TRUST BOARD MEETING IN PUBLIC (PART 1) AGENDA · Sir Simon Wessely 7KH%RDUGDJUHHGWKDWWKH7...

TRUST BOARD MEETING IN PUBLIC (PART 1) To be held in the Trust Headquarters, Armstrong Way, Southall

on Wednesday 14th March 2018 - from 9.30 to 12.00hrs

AGENDA

Approx. Timing

Agenda No.

Title Lead Enclosed or Verbal

Item

9.30 1 Opening & Welcome

Chairman Verbal

2 Apologies for Absence

Chairman Verbal

3 Declaration of Interests If any member of the Board has an interest in any item on the agenda, they must declare it at the meeting, and if necessary withdraw from the meeting.

Chairman Verbal

MINUTES & ACTION SCHEDULE

9.35 4 Draft minutes of 14th February 2018 meeting To approve the minutes from the last meeting

Chairman Enclosed

5

Board Action Schedule & Matters Arising To note updates on actions arising from previous meetings.

Chairman

Enclosed

ITEMS FOR DISCUSSION

9.45 6 Chairman’s Report To note the Chairman’s report, including updates on NEDs’ activities in the period since the last meeting.

Chairman Enclosed

7 Chief Executive’s Report To note the Chief Executive’s report.

Chief Executive Enclosed

8 Integrated Performance Report To receive the monthly integrated performance report.


9

9.1

9.2

Director of Finance’s Report

Month 10 Finance report To receive a report from the Director of Finance, including the monthly financial performance report.

Interim budget 2018/19 To approve the 2018/19 budget, pending the final agreement of income contracts and submission of the financial plan to NHSI in April 2018.

Director of Finance

Enclosed

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10.30 10

10.1 10.1.1

10.2

10.3 10.4 10.5

10.6

Executive Directors’ Reports To receive reports from executive directors, including:

Medical Director’s Report Medical Director’s Report – Appendix 1 Director of Nursing’s Report, including:

• Triangle of Care implementation update Director of Local Services’ Report Director of High Secure & Forensic Services’ Report Director of Workforce & OD’s report including:

• Workforce Performance Report Director of Communications & Engagement’s report

Directors Enclosed

11.10 11 Nurse and Health Care Assistant Staffing Levels – Exception Report To note the exception report on safe staffing levels in the period.

Director of Nursing

Enclosed

12 Night Time Confinement (NTC) – quarter 3 report To note the quarterly update and support the continuance of Night Time Confinement as an intervention

Director of HSS & WLFS

Enclosed

13 Estates strategy – update To receive an update on the implementation of the Trust’s Estates Strategy

Director of Finance

Enclosed

14 Level 1 Risk Register and Board Assurance Framework update To receive an update on the management of the most significant risks, on the level 1 risk register, and to receive an update on assurances provided on the effectiveness of controls.


REPORTING COMMITTEES 11.50 15

15.1 15.2 15.3

Quality Committee Approved minutes from meeting held on 24 January Chairman’s report from meeting held on 21 February Draft minutes from meeting held on 21 February

Committee Chair

Enclosed

16 16.1 16.2

Workforce & OD Committee Approved minutes from meeting held on 31 January Chairman’s report from meeting held on 21 February

Committee Chair

Enclosed

17 17.1 17.2

Finance & Performance Committee Approved minutes from meeting held on 31 January Chairman’s report from meeting held on 28 February

Committee Chair

Enclosed

18 18.1 18.2

Trust Management Team Approved minutes from meeting held on 31 January Draft minutes from meeting held on 28 February

Committee Chair

Enclosed

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19 19.1 19.2

Audit Committee Approved minutes from meeting held on 17 January Chairman’s report from meeting held on 7 March

Committee Chair

Enclosed

20

20.1 20.2

Broadmoor Hospital Redevelopment Programme Board Agreed minutes of meeting held on 7 February Verbal update of meeting held on 7 March

Committee Chair

Enclosed Verbal

21 21.1

Local Services Transformation Board Agreed minutes of meeting held on 7 February

Committee Chair

Enclosed

ANY OTHER BUSINESS

12.00 22 Any Other Business To consider any additional items of business previously notified to the Chairman.

Chairman Verbal

INVITATION FOR QUESTIONS FROM THE PUBLIC

22 Questions from Members of the Public

Chairman Verbal

RESOLUTION

The Board is invited to adopt the following: “The trust hereby resolves that the remainder of the meeting shall be held in private because publicity would be prejudicial to the public interest, by reason of the confidential nature of the business to be transacted.”

Date of Next Trust Board Meeting in Public: Wednesday 11th April 2018 Time: 09.30hrs Venue: Trust Headquarters

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DRAFT MINUTES OF THE TRUST BOARD MEETING (PART 1) Held on Wednesday 14th February 2018

In Learning & Development Centre, Broadmoor Hospital Present: Mr Tom Hayhoe Chairman

Ms Carolyn Regan Chief Executive Professor Paul Aylin Non-Executive Director Ms Stephanie Bridger Director of Nursing and Patient Experience Mrs Wendy Brewer Director of Workforce and OD Professor Sally Glen Non-Executive Director Hassaan Majid Non-Executive Director Miss Leeanne McGee Director of High Secure & Forensic Services Mr Neville Manuel Non-Executive Director Ms Elizabeth Rantzen Non-Executive Director Dr Jose Romero-Urcelay Medical Director Mr Paul Stefanoski Director of Finance & Business / Deputy CEO

Attending: Mr Peter Jenkinson Trust Secretary (minutes)

Ms Sally Sykes Director of Communications and Engagement Ms Helen Mangan Associate Director, Local Services

Mr Jai Jayaraman NExT Director participant (observing) Ms Lucy Bubb Deloitte LLP (observing)

Mr Wil Bevan Deloitte LLP (observing) Items were discussed in the sequence they are recorded in the minutes Ref: Discussion: Action: 20/18 Item 1

OPENING & WELCOME Mr Hayhoe welcomed everyone to the meeting, including Ms Bubb and Mr Bevan who were observing the meeting as part of the Well-Led Review, and Jai Jayaraman, observing the meeting as a member of the NExT Director scheme. Mr Hayhoe reported that, as the meeting was being held at Broadmoor Hospital, the Board would meet a patient to hear their experience of the Trust’s services following the Board meeting. Mr Hayhoe stated that the Board’s public (part 1) meeting would be followed by a further, confidential (part 2) meeting to discuss confidential items.

21/18 Item 2

APOLOGIES FOR ABSENCE Apologies were received from Moriam Bartlett, Non-Executive Director, and Sarah Rushton, Director of Local Services.

22/18 Item 3

DECLARATIONS OF INTEREST No conflicts of interests were declared against any of the items of business to be discussed.

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Ref: Discussion: Action: 23/18 Item 4

MINUTES OF THE LAST MEETING The minutes of the meeting held on Wednesday 10th January 2018 were agreed to be a correct record, subject to agreed amendments: 10/18 Item 10: to amend the sentence ‘The Board did not accept the findings, noting its serious concerns at the analysis, timeliness and inaccuracy of data underpinning these…’. 12/18 Item 12: to amend the sentence ‘The Board noted the improved NHS Improvement financial risk rating, which had moved from three to two, but noted that the nationally reported position through the model hospital portal had not been updated since July 2017. 13/18 Item 13.1: to amend the sentence ‘The Board noted receipt of the formal, and positive, report from NHS Health Education England…’

24/18 Item 5

BOARD ACTION SCHEDULE & MATTERS ARISING The Board considered the action schedule and noted the completed actions which would now be archived. The Board noted that the staff communications around the staff survey results would include a reminder to staff to report incidents and noted that job descriptions for associate Speak-Up Guardians were currently being considered and would be taken forward by Prof Glen and Mrs Brewer. Matters Arising There were no matters arising from the minutes of the last meeting.

25/18 Item 6

CHAIRMAN’S REPORT Mr Hayhoe presented his report which provided an update on his activities over the period since the last meeting. He reported the resignation of Moriam Bartlett as non-executive director with effect from 31 March 2018. The Board thanked Ms Bartlett for her contribution to the Trust and wished her well. Mr Hayhoe reported that the recruitment process had commenced for a replacement, with interviews scheduled for 10th April; the person specification published included experience in public involvement and / or organisational development. Mr Hayhoe also reported that there had been a positive response to the advertisement for a non-executive director to replace Sarah Cuthbert and that he was confident that an appointment would be made. The Board noted that Steve Russell and Dean Spencer, NHS Improvement, had been invited to attend the Board meeting in March to continue the discussion regarding the outcome of the NHS Improvement’s segmentation review. The Board also noted other non-executive directors’ activities during this period. The Board noted that the Chief Executive and Prof Glen had attended a Mental Health providers’ meeting and had noted the

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Ref: Discussion: Action:

independent review of the Mental Health Act being led by Professor Sir Simon Wessely. The Board agreed that the Trust’s response to the review would be considered at the April Board meeting, following discussion by the medical advisory committees and mental health act committee. Mr Manuel reflected on his visit to Lakeside and noted the parking issues at the unit which made it difficult for both patients and staff. It was noted that a review of staff parking across the organisation was current being undertaken and the recommendations from that would be presented to the Trust Management Team. The Board noted the Chairman’s report.

Medical Director

26/18 Item 7

CHIEF EXECUTIVE’S REPORT Ms Regan introduced her report highlighting developments in the external health care environment, nationally and within London. She highlighted the publication of planning guidance by NHS England and NHS Improvement, including Mental health funding to be protected and additional funding of £1.05bn, some of which would be spent on ongoing improvement to mental health, cancer and primary care. The mental health investment standard would be audited by the Clinical Commissioning Group. However NHS England would only be funding 1% of the government’s promised raise in salaries. The Board noted that NHS Improvement had confirmed that they would fund the post of interim and part-time Improvement Director, and that Stanley Riseborough would start in post the following week. The Board noted the update on NHS benchmarking and agreed that this should be added to the work plan for Quality Committee to consider opportunities for quality improvement arising from benchmarking information. Ms Regan reported that a Gold Command major incident had occurred in the last period, referred to in the Director of Nursing’s report, and thanked Dr Romero-Urcelay for his leadership of the event. The Board noted the update on the Trust’s development of its business intelligence reporting through the West London Business Intelligence(WBLI), a new data warehouse and data visualisation platform based on market leading software Tableau. Mr Manuel welcomed the development of the Trust’s information reporting capability and requested that this be made available to non-executive directors. Ms Regan confirmed that this would be considered along with development of provision of access to commissioners. Mr Majid also welcomed the development and noted the importance of the Trust being prepared to deal with data quality issues arising from publishing the data.

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The Board noted the update on the Well-led Review and the appointment of Deloitte as external reviewers, noting that the Director of Finance was also a member of the procurement panel. The Board noted the process and timeline to be followed in the review. The Board noted NHS Improvement’s publication of their report on Care Hours per Patient day across all in-patient wards in the Trust and discussed the data. Ms Rantzen queried whether the aspiration to increase the percentage of contact time from 33% to 50%, raised in one of the Listening Events, was sufficient and Prof Aylin suggested that the amount of time spent on admin and data entry highlighted an opportunity for reduction of admin time and increased contact time. Ms Regan reported that the benchmarking exercise in community services would identify any opportunities for increased productivity and would inform the work of the transformation programme in local services. Prof Glen noted the feedback from the Listening Event in Claybrook Centre regarding workload and reflected on concerns raised with her through Speak-Up referrals about excessive workloads and the impact on patient caseloads. Ms Regan reported that the executive directors would be meeting with clinical directors on 9th March to discuss quality improvement priorities for 2018/19; one of the options to be discussed would be a focus on community services. The Board agreed that a session on benchmarking and increasing productivity in clinical services would be included in a future board development session. The Board noted the Chief Executive’s report.

Trust Secretary

27/18 Item 8

INTEGRATED PERFORMANCE REPORT (IPR) The Board received and considered the IPR for month 9, and noted that it had been considered by the Finance and Performance Committee in January. The Board considered the exceptions highlighted in the report, noting that performance against the CPA 7 day follow up target had reduced and noting the importance of monitoring performance given previous serious incidents and sustained improvements. Dr Romero-Urcelay noted that this was a good example of where access to service line data in Tableau would assist in addressing specific performance issues. The Board acknowledged and welcomed the sustained overall improvement in performance, in finances, operational and quality. The Board noted the ongoing work to review the metrics in the IPR for the

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coming year, being led by the Finance and Performance Committee with input from the Quality Committee. It was noted that the refreshed IPR would include community health performance indicators. Mr Majid suggested that performance indicators regarding timely completion of serious incident investigations should be included on the main dashboard and that the target for outstanding complaints should be zero rather than four, including appropriate escalation processes. Prof Aylin reported that the Quality Committee had considered the quality of physical assessments being completed and that Dr Romero-Urcelay was currently reviewing this and would be reporting back to the Committee. Ms Rantzen noted that the report from the last CQC inspection had identified supervision of bank staff as an issue and suggested that the Board should have oversight over improvements in this area. Ms Bridger reported that run-charts were being developed to include this and that action was being taken to improve in this area. She highlighted that the challenge was supervision of bank staff who worked in a number of different areas of the Trust and that some trusts had employed a clinical supervisor to run the bank in order to provide supervision. It was agreed that this would be discussed further at the Workforce Committee. The Board noted the Integrated Performance Report.

Director of Workforce

28/18 Item 9

DIRECTOR OF FINANCE’S REPORT Finance Report The Board received and considered the month 9 financial performance report to the Board, noting that this had been discussed in detail by the Finance and Performance Committee. The Board noted the improved year-end forecast and discussed the proposed change to the year-end forecast to increase the Trust’s projected surplus. The Board noted that NHS Improvement had agreed to match-fund any additional surplus achieved, which would be used to mitigate additional costs associated with the Broadmoor Hospital redevelopment programme. The Board noted the reasons for the additional surplus achieved, including improved performance in CIPs and expenditure controls, increased benefit from land sales and lower capital costs due to revaluation of buildings, as well as underspends on the Broadmoor Hospital redevelopment programme. This would result in a projected year-end surplus of £8m, an additional £2.6m over the original year-end projection. The Board agreed the proposed change in year-end projection and confirmed its confidence in the budget and financial management arrangements, noting that the additional surplus was due to changes

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in circumstances such as the delays in the Broadmoor Hospital redevelopment and greater progress than expected made in bed management in local services. The Board noted the importance of clear communication to staff to explain the additional surplus and to ensure that focus remains on financial performance in the next year. Ms Rantzen noted the additional benefit arising from income and stressed the need to focus on recurrent CIPs in 2018/19. It was agreed that the CIPs target for 2018/19 would not change. The Board noted that the Trust’s cash position was very positive and confirmed the commitment to invest in estates, however noted the current constraint on expenditure through the current capital resource limit. The Trust would be applying to NHs Improvement to increase this limit to allow greater expenditure. The Board noted that NHS Improvement had set the revised control total for the Trust for 2018/19, of £4.5m, including £2m from the Sustainable Transformation Fund (STF) funding. This was in comparison to the planning assumption of a £5.6m surplus, including £1.4m from STF funding. The Board welcomed this movement as recognition of the Trust’s performance in previous years, but noted that contracts had not yet been agreed with commissioners and therefore the position was not yet certain. It was agreed that the NHS Improvement notice regarding the control total would be circulated to Board members. The Board discussed the planning timetable for 2018/19, noting a revision to the timetable which meant that contracts would not be agreed until 23rd March and therefore the plan submission would not be until April 2018. The Board agreed that an interim budget would be presented to the Board in March, with any subsequent variation to be agreed by the Finance and Performance Committee.

Director of Finance Director of Finance

29/18 Item 10.1

EXECUTIVE DIRECTORS’ REPORTS Medical Director’s Report The Board received and noted the Medical Director’s report, noting the Medical Director’s activities in the month. The Board noted in particular the issues regarding maintaining safe on-call rotas, with significant vacancies in both Core Trainees and Specialist Trainees establishments, and the impact on medical agency usage. The Board noted the letter sent to all Trainees to reflect on the circumstances surrounding a recent High Court ruling (GMC - v - Bawa-Garba case) regarding the use of supervision notes and reflections in prosecutions of professional staff. The Board noted the significant potential impact on all professional staff, noting its concern that this would reinforce a blame culture contrary to the Trust’s efforts to embed an open culture, and agreed that the letter should be sent to

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Ref: Discussion: Action: Item 10.2 Item 10.3

all clinical professionals. The Board noted the approval of a Quality Improvement central budget and the commencement of the recruitment process for the role of Head of Quality Improvement to support the programme and the roll-out of the methodology. Mr Manuel endorsed the progress being made in quality improvement and suggested that a case study should be presented to a future board development session to showcase the quality improvement methodology, following the appointment of the Head of Quality Improvement. The Board also noted and agreed its support for the proposals to establish a Trust Clinical Ethics Committee. The Board noted that the proposals discussed at the previous meeting for non-executive directors to be involved in medical appraisals had been agreed in principle by the Chairman and that formal proposals would now be developed. Prof Glen supported the approach being taken regarding safeguarding and suggested that a similar model could be used to support the mental health act. It was agreed that Dr Romero-Urcelay would consider this in discussion with Prof Glen. Director of Nursing & Patient Experience’s Report The Board received and noted the Director of Nursing’s report, noting the overview from the CQC follow-up inspection of the Trust’s PICU and adult acute wards. The Board noted that the report was currently in draft and the Trust would be submitting factual accuracy comments prior to its publication. The Board noted the positive feedback from the inspection, including the comments on the Trust’s bed management, but also noted the issues raised regarding estates maintenance, incident reporting and seclusion data. These issues would be addressed through the CQC working group. Director of Local Services’ Report The Board received and noted the Director of Local Services’ report, noting that inpatient bed capacity remained good but also the need to monitor the number of people staying over 50 days and refresh the list of interventions. The Board noted that transformation work had commenced in this area. The Board noted the update on the telemedicine project, working in partnership with London Central and West Unscheduled Care Collaborative (LCW) to submit a proposal to deliver a new pan-North West London telemedicine support service for Care Homes with advanced nurse assessors. Ms Regan added that this had been presented to the Finance & Performance Committee. The Board also noted the update on funding for the Liaison psychiatry

Trust Secretary Medical Director

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Ref: Discussion: Action: Item 10.4 Item 10.5

service. The Board welcomed the confirmation received from the CCGs on the funding to support the provision of the model of care outlined within the Liaison Psychiatry Service 24/7 bid to NHS England agreed during 2017-18, but noted the importance of ensuring that this was included in contracts recurrently. Director of High Secure & West London Forensic Services’ Report The Board received and noted the Director of High Secure & West London Forensic Services’ report, noting developments in high secure services and forensic services. The Board noted the confirmation from the Head of Mental Health Programme of Care, Specialised Commissioning at NHS England, that Broadmoor Hospital has an assurance rating “Green – Substantial Rating”. The Board noted the risk to the library services for forensic services on the Ealing site following the collapse of Carillion, but noted that London Borough of Ealing would take back the library services for a period of time until a decision would be made on the future management of this service within the Borough. The Board also noted the update on the purchase two additional beds within the WEMS service by commissioners. Director of Workforce & OD’s report including workforce performance report The Board received and considered the Director of Workforce & OD’s report, including the workforce performance report. The Board noted no significant movement in indicators in-month, but noted the reduction in agency spend compared with the same period in 2016/17. The Board noted the Trust’s response to recommendations arising from the NHS Improvement review of the progress being made in reducing agency usage. The Board noted the update on mandatory training, noting that the executive directors would focus on trust-wide performance in all mandatory training subjects, and a monthly report was considered by the executive team. The Board noted the introduction of charges for ‘did not attends’ at training sessions, to be levied on service units. The Board noted the Workforce report.

Item 10.6

Director of Communications and Engagement’s report The Board received and noted the Director of Communications and Engagement’s report, noting an update on the proposed renaming of the Trust. The Board also noted the launch of the NHS70 Parliamentary Awards scheme, with nominations being considered.

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NURSE AND HEALTH CARE ASSISTANT STAFFING LEVELS – EXCEPTION REPORT The Board received and noted the quarterly exception report on safe staffing levels, and noted the need to increase the reporting of incidents. The Director of Nursing confirmed that an incident report was raised when staffing levels were below that required.

31/18 Item 12

LEVEL 1 RISK REGISTER & BOARD ASSURANCE FRAMEWORK The Board received and noted the latest Level 1 risk register and Board Assurance Framework (BAF), noting the summary of points relating to the BAF raised at sub committees since the Board’s last review and assurances provided regarding the controls in place. The Board noted that a quarterly review of the BAF was currently being conducted with executive owners and any recommended changes to risk ratings arising from this would be presented to the next meeting. It was noted that the risk relating to the Broadmoor Hospital redevelopment would be reviewed as part of this review. The Board noted that proposals for the further development and strengthening of the Trust’s assurance framework would be presented to the next Audit Committee meeting. The Board noted the latest Level 1 risk register and BAF.

Trust Secretary

32/18 Item 13

MORTALITY DATA The Board received and noted the Learning from Deaths Dashboard for Quarter 3 2017/18. Prof Aylin asked that the report contained greater narrative to explain and to triangulate the data, noting that two unavoidable deaths had been reported but without explanation. The Board also agreed that the current report should be compared with other mental health trusts to seek best practice in format and narrative reporting, although it was noted that the Trust was currently ahead of other trusts.

Medical Director

33/18 Item 14

QUALITY COMMITTEE The Board received and noted the chairman’s report from the meeting held on 24th January 2018, and the approved minutes from the meeting on 22nd December 2017. The Board noted the discussion at the Quality Committee regarding the proposals for changes to the format of the Committee, the concerns raised regarding the data quality issues and the challenges noted regarding non-compliance with mandatory training in fire safety.

34/18 Item 15

FINANCE AND PERFORMANCE COMMITTEE The Board received and noted the chairman’s report from the meeting held on 31st January 2018, and the approved minutes from the meeting on 29th November 2017.

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TRUST MANAGEMENT TEAM The Board received and noted the draft minutes from the meeting held on 31st January 2018, and the approved minutes from the meeting on 29th November 2017.

36/18 Item 17

AUDIT COMMITTEE The Board received and noted the chairman’s report from the meeting held on 17th January 2018, and the approved minutes from the meeting on 1st November 2017. The Board noted the discussion at the meeting regarding the internal audit review of the Trust’s readiness to submit the Information Governance Toolkit at the end of March 2018, and the issues currently faced in the Trust’s information governance resources. Mr Jenkinson updated the Board on actions being taken to mitigate these risks, including the appointment of an interim Information Governance Manager.

37/18 Item 18

BROADMOOR HOSPITAL REDEVELOPMENT PROGRAMME BOARD The Board received and noted the approved minutes of meetings held on 6 December 2017 and 8 January 2018 and received a verbal report from the meeting held on 7th February 2018. Ms Regan reported that, in response to recommendations from the independent review of governance, Simon Waters had attended the Programme Board as an external advisor from Community Health Partnerships. The Board agreed to the recommendation to appoint him to membership of the Programme Board. Andrew Bray, Independent Project Manager from Ridge & Partnerships LLP also joined the programme board and would be in attendance at future Programme Board meetings. Work had started on reviewing job descriptions of the direct line reports to the Programme Director and ‘Role descriptions’ had been proposed for each of the major project roles described in PRINCE2 project management, namely the Executive, Project Board, Project Manager, Senior User, and Senior Supplier. Ms Regan provided an update on operational commissioning, with action plans being reviewed with services on a monthly basis.

38/18 Item 19

ANY OTHER BUSINESS The Board noted the importance of its oversight over transformation and agreed that the minutes from the Transformation Board should be presented to Board.

Trust Secretary

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QUESTIONS FROM MEMBERS OF THE PUBLIC There were no members of public in attendance.

DATE OF NEXT MEETING IN PUBLIC Wednesday 14th March 2018 Trust Headquarters Armstrong Way Southall

Signed: _____________________________________ Date: _______________________

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/17

Item

6T

rust n

am

e: T

he

Bo

ard

reso

lve

d to

ag

ree

to th

e

reco

mm

en

de

d n

am

e c

ha

ng

e, W

est L

on

do

n

NH

S T

rust, w

ith th

e a

im o

f imp

lem

en

ting

the

ch

an

ge

from

Ap

ril 20

18

, bu

t ag

ree

d th

at

sta

ke

ho

lde

rs, in

clu

din

g s

erv

ice

use

rs a

nd

We

st

Lo

nd

on

CC

G, s

ho

uld

be

info

rme

d o

f this

inte

ntio

n.

Dire

cto

r of

Stra

teg

y &

Dire

cto

r of

Co

om

un

ica

tion

s

Ma

r-18

Actio

n c

om

ple

te.

Co

mp

lete

13

-De

c-1

73

61

/17

Item

8T

rian

gle

of C

are

: Th

e B

oa

rd a

gre

ed

tha

t

an

oth

er u

pd

ate

wo

uld

be

pro

vid

ed

in M

arc

h

20

18

, inclu

din

g a

n a

sse

ssm

en

t of a

dd

ition

al

reso

urc

es re

qu

ired

.

Dire

cto

r of

Nu

rsin

g

Ma

r-18

Actio

n c

om

ple

te. O

n th

e a

ge

nd

a fo

r the

Ma

rch

me

etin

g

Co

mp

lete

08

-No

v-1

73

38

/17

Item

10

Inte

gra

ted

Pe

rform

an

ce

Re

po

rt:Fo

cu

s o

n

me

etin

g th

e 7

da

y fo

llow

up

targ

et in

fore

nsic

se

rvic

es v

ia p

roce

ss re

vie

w, a

imin

g to

red

uce

furth

er

Me

dic

al D

irecto

rM

ar-1

8D

iscu

sse

d w

ith s

erv

ice

, with

info

rma

tics

su

pp

ort fro

m T

ab

lea

u to

ide

ntify

are

as

for im

pro

ve

me

nt.

Co

mp

lete

08

-No

v-1

73

44

/17

Item

16

Bo

ard

Assu

ran

ce

Fra

me

wo

rk:T

o fo

cu

s

de

ve

lop

me

nt o

f BA

F o

n th

e u

se

of th

e

fram

ew

ork

to e

va

lua

te th

e le

ve

l of a

ssu

ran

ce

s

be

ing

rece

ive

d b

y B

oa

rd a

nd

co

mm

ittee

s.

Tru

st S

ecre

tary

Ma

r-18

Actio

n c

om

ple

te. In

clu

de

d in

the

pro

po

sa

ls fo

r the

stre

ng

the

nin

g o

f the

Tru

st's

assu

ran

ce

fram

ew

ork

pre

se

nte

d

to th

e A

ud

it Co

mm

ittee

.

Co

mp

lete

11

-Oct-1

73

15

/17

Item

17

Me

nta

l He

alth

Act re

po

rt: leve

l of S

13

6

pre

se

nta

tion

s to

be

mo

nito

red

with

in L

oca

l

Se

rvic

es, in

ligh

t of th

e le

gis

latio

n c

ha

ng

es, a

nd

exce

ptio

ns re

po

rted

.

Dire

cto

r of L

oca

l

Se

rvic

es

Ma

r-18

Su

pe

rce

de

d b

y a

ctio

n 0

7/1

8. R

ep

ort to

be

pre

se

nte

d to

Bo

ard

in A

pril.

Clo

se

.

Co

mp

lete

08

-No

v-1

73

35

/17

Item

7N

igh

t Tim

e C

on

fine

me

nt a

nn

ua

l rep

ort:

To

ad

d h

isto

ric d

ata

from

co

mp

ara

tive

wa

rds

be

fore

the

po

licy w

as im

ple

me

nte

d in

ord

er to

pro

vid

e a

mo

re a

ccu

rate

be

nch

ma

rk o

f

pro

gre

ss.

To

de

ve

lop

a n

arra

tive

aro

un

d th

e b

en

efits

of

the

po

licy w

ith R

am

pto

n a

nd

Ash

wo

rth h

osp

itals

.

Dire

cto

r of H

SS

& W

LF

S

Ja

n-1

8M

ar-1

8A

ctio

n c

om

ple

te. O

n th

e a

ge

nd

a fo

r the

Ma

rch

me

etin

g

Co

mp

lete

KE

Y

INC

OM

PL

ET

E &

OV

ER

DU

E

CO

MP

LE

TE

D - o

n tim

e

CO

MP

LE

TE

D - la

te

Item 5: Action Schedule -March 2018

Page 15 of 308

TR

US

T B

OA

RD

ME

ET

ING

AC

TIO

N S

CH

ED

UL

E

WE

ST

LO

ND

ON

ME

NT

AL

HE

AL

TH

NH

S T

RU

ST

ME

ET

ING

DA

TE

MIN

UT

E

NU

MB

ER

AG

EN

DA

ITE

M

AG

RE

ED

AC

TIO

NA

CT

ION

LE

AD

BY

WH

EN

(en

d o

f)

RE

VIS

ED

DA

TE

UP

DA

TE

ON

PR

OG

RE

SS

ST

AT

US

14

-Fe

b-1

82

5/1

8Ite

m 6

Ch

airm

an

's re

po

rt: Tru

st's

resp

on

se

to th

e

ind

ep

en

de

nt re

vie

w o

f the

me

nta

l he

alth

act to

be

co

nsid

ere

d a

t the

Ap

ril bo

ard

me

etin

g,

follo

win

g d

iscu

ssio

n b

y th

e m

ed

ica

l ad

vis

ory

co

mm

ittee

an

d m

en

tal h

ea

lth a

ct c

om

mitte

e

Me

dic

al D

irecto

rA

pr-1

8W

IP

14

-Fe

b-1

82

6/1

8Ite

m 7

Ch

ief E

xe

cu

tive

's re

po

rt: Th

e p

rovis

ion

of

acce

ss to

Ta

ble

au

to n

on

-exe

cu

tive

dire

cto

rs to

be

co

nsid

ere

d a

s w

ell a

s to

co

mm

isio

ne

rs.

Dire

cto

r of

Fin

an

ce

Ma

y-1

8W

IP

14

-Fe

b-1

82

6/1

8Ite

m 7

Ch

ief E

xe

cu

tive

's re

po

rt: A b

oa

rd d

eve

lop

me

nt

se

ssio

n o

n th

e u

se

of b

en

ch

ma

rkin

g to

imp

rove

pro

du

ctiv

ity in

clin

ica

l se

rvic

es to

be

arra

ng

ed

.

Dire

cto

r of

Fin

an

ce

TB

CW

IP

14

-Fe

b-1

82

9/1

8Ite

m 1

0M

ed

ica

l Dire

cto

r's re

po

rt: To

pre

se

nt th

e q

ua

lity

imp

rove

me

nt m

eth

od

olo

gy u

sin

g a

ca

se

stu

dy,

follo

win

g th

e a

pp

oin

tme

nt o

f the

He

ad

of

Qu

ality

.

Me

dic

al D

irecto

rT

BC

WIP

14

-Fe

b-1

82

9/1

8Ite

m 1

0M

ed

ica

l Dire

cto

r's re

po

rt: To

dis

cu

ss w

ith P

rof

Gle

n th

e a

pp

roa

ch

to s

up

po

rting

imp

lem

en

taito

n

of th

e m

en

tal h

ea

lth a

ct u

sin

g a

sim

ilar m

od

el a

s

use

d fo

r sa

feg

ua

rdin

g.

Me

dic

al D

irecto

rA

pr-1

8W

IP

14

-Fe

b-1

83

2/1

8Ite

m 1

3M

orta

lity d

ata

da

sh

bo

ard

: To

ad

d g

rea

ter

na

rrativ

e to

exp

lain

an

d to

trian

gu

late

the

da

ta

pro

vid

ed

.

Me

dic

al D

irecto

rM

ay-1

8W

IP

10

-Ja

n-1

80

6/1

8Ite

m 6

Bu

sin

ess P

lan

nin

g u

pd

ate

: Th

e B

oa

rd a

gre

ed

tha

t the

Tru

st’s

stra

teg

y w

ou

ld b

e re

vie

we

d a

nd

refre

sh

ed

at th

e B

oa

rd’s

aw

ay-d

ay in

Ju

ne

20

18

, in th

e c

on

text o

f the

de

ve

lop

me

nt o

f the

H&

F A

CS

an

d N

orth

We

st L

on

do

n S

TP

.

Dire

cto

r of

Stra

teg

y

Ju

n-1

8W

IP

10

-Ja

n-1

80

6/1

8Ite

m 6

Bu

sin

ess P

lan

nin

g u

pd

ate

: Th

e B

oa

rd n

ote

d

tha

t the

form

at o

f the

cu

rren

t rep

ort w

ou

ld b

e

revie

we

d b

y D

r Hilto

n, in

ord

er to

en

su

re b

ette

r

stra

teg

ic a

lign

me

nt w

ith o

the

r trust s

trate

gie

s

an

d S

TP

pla

ns, to

pro

vid

e b

ette

r assu

ran

ce

to

the

Bo

ard

wh

ile a

vo

idin

g d

up

lica

tion

.

Dire

cto

r of

Stra

teg

y

Ap

r-18

WIP

10

-Ja

n-1

80

7/1

8Ite

m 7

Lo

ca

l Se

rvic

es T

ran

sfo

rma

tion

Pro

gra

mm

e: T

he

Bo

ard

ag

ree

d th

at a

n u

pd

ate

on

ch

an

ge

s to

the

se

ctio

n 1

36

‘pla

ce

of s

afe

ty’ w

ou

ld b

e p

rese

nte

d

to B

oa

rd in

Ap

ril 20

18

.

Dire

cto

r of L

oca

l

Se

rvic

es

Ap

r-18

WIP

10

-Ja

n-1

80

7/1

8Ite

m 7

Lo

ca

l Se

rvic

es T

ran

sfo

rma

tion

Pro

gra

mm

e: T

he

Bo

ard

ag

ree

d th

at fu

ture

rep

orts

wo

uld

inclu

de

trackin

g o

f pro

gre

ss a

ga

inst p

rog

ram

me

mile

sto

ne

s to

pro

vid

e th

e B

oa

rd w

ith a

ssu

ran

ce

reg

ard

ing

de

live

ry.

Dire

cto

r of L

oca

l

Se

rvic

es

Ap

r-18

WIP

11

-Oct-1

73

08

/17

Item

7

Sp

ea

k u

p G

ua

rdia

n a

nn

ua

l rep

ort: th

e

exe

cu

tive

to w

ork

with

Pro

fesso

r Gle

n to

ag

ree

the

ap

po

intm

en

t of a

dd

ition

al c

ha

mp

ion

s to

su

pp

ort h

er ro

le.

Dire

cto

r of

Wo

rkfo

rce

& O

D

No

v-1

7M

ar-1

8U

pd

ate

Ja

n-1

8: R

ecru

itme

nt o

f

ad

ditio

na

l ch

am

pio

ns to

co

mm

en

ce

in

Ja

nu

ary

20

18

.

Up

da

te F

eb

-18

: job

de

crip

tion

s fo

r

asso

cia

te s

pe

ak-u

p g

ua

rdia

ns b

ein

g

co

nsid

ere

d. T

o b

e ta

ke

n fo

rwa

rd b

y

Dire

cto

r of W

ork

forc

e a

nd

Sp

ea

k-U

p

Gu

ard

ian

.

WIP

10

-Ma

y-1

71

59

/17

Item

12

.1M

ed

ica

l Dire

cto

r's R

ep

ort: D

r Ro

me

ro-U

rce

lay

to a

lign

pu

blic

atio

ns w

ith s

erv

ice

line

s in

the

list

of p

ub

lica

tion

s fo

r futu

re y

ea

rs

Me

dic

al D

irecto

rM

ay-1

8W

IP

WO

RK

IN P

RO

GR

ES

S

Page 16 of 308

TR

US

T B

OA

RD

ME

ET

ING

AC

TIO

N S

CH

ED

UL

E

WE

ST

LO

ND

ON

ME

NT

AL

HE

AL

TH

NH

S T

RU

ST

ME

ET

ING

DA

TE

MIN

UT

E

NU

MB

ER

AG

EN

DA

ITE

M

AG

RE

ED

AC

TIO

NA

CT

ION

LE

AD

BY

WH

EN

(en

d o

f)

RE

VIS

ED

DA

TE

UP

DA

TE

ON

PR

OG

RE

SS

ST

AT

US

11

-Ja

n-1

79

/17

Item

9B

AF

: sch

ed

ule

Bo

ard

de

ve

lop

me

nt s

essio

n to

un

de

rsta

nd

rela

tion

sh

ip b

etw

ee

n IP

R a

nd

BA

F.

Tru

st S

ecre

tary

TB

CW

IP

Item 5: Action Schedule -March 2018

Page 17 of 308

Report summary Trust board meeting: Part 1 (in public) March 2018

Report title:

Chairman’s Report

Executive lead:

n/a

Report authors:

Tom Hayhoe, Chairman

Report discussed previously at:

n/a

Purpose and action required

For approval ✓

For discussion / decision

To note ✓

Relates to? Strategy & Planning ✓

Quality & Safety ✓

Performance & Activity

Legal & Governance ✓

Relationship to board assurance framework? Are any existing risks in the Board Assurance Framework affected?

No

If yes, insert relevant risk reference:

N/A

Do you recommend a new entry to the Board Assurance Framework (i.e. Trust-wide level 1 risk) is made?

No

Item

6: C

hairm

an's

Boa

rdR

epor

t - M

arch

201

8

Page 18 of 308

Relationship to trust strategic objectives? Outstanding We coordinate and collaborate – to deliver holistic care

We innovate – to turn research into practice ✓

Improving quality

We invest – in people, estates, technology We listen and learn – from patients, carers, staff, the public

✓

Compassionate care

We work together – and implement the principles of recovery We are recommended – by patients, carers, friends and families

✓

Summary The report contains updates on recent activity undertaken by the Chairman and non- executive directors.

Supporting documents and/or further reading

Page 19 of 308

Trust board meeting (Part 1): 14th February 2018

Chairman’s Report

1 Activities undertaken 1.1 Since preparing my report for the 14th February meeting of the Board, I have:

- Attended meetings of the Quality Committee, Finance & Performance

Committee, Workforce and Organisational Development Committee and the Broadmoor Hospital Redevelopment Programme Board

- Undertaken annual appraisals of two non-executive directors - Chaired the interview panel for the appointment of a non-executive

director, and spoken to potential candidates for the second non-executive director vacancy on the board

- Been interviewed by the Deloitte consultants retained by the Trust to undertake the Well Led Review

- Chaired the interview panel for the appointment of a consultant to the women’s enhanced medium secure service at The Orchard

- Presented certificates of achievement to patients studying at the Broadmoor Recovery College

- Joined nurses from the Hammersmith and Fulham CAT team for early evening service user visits and then shadowed the duty nurse supporting Charing Cross A&E for the first part of his night shift

- Visited Parkland and Garnet Wards at The Ochard - Sung with the St Bernards Choir and shared my perspective on the

operation of the Voices of Broadmoor with the Newbury Therapy staff - Alongside several other board members, attended the presentations made

by the 4th cohort of the BME Leadership Programme - In the company of the chief executive, hosted a visit to Thames Lodge by

Dr Onkar Sahota, the GLA member for Ealing and chair of the GLA health committee

- Met with the Deputy Medical Director to discuss non-executive involvement in medical appraisal and revalidation

- Attended a meeting of the NHSI/CQC Chairs’ Advisory Board - Attended the NHS Providers Mental Health Leaders’ Forum - Attended a meeting of the Southern NHS Trust Chairs’ Forum with the

chair of NHS Improvement - Attended the first anniversary event of the Hounslow’s Promise scheme,

hosted by Seema Malhotra MP at the House of Commons

1.2 Since my last report to the Board, the non-executive directors have undertaken various activities in addition to attending board committees: Moriam Bartlett attended a seclusion review and met the chairman of NACRO on a visit to the Wells Unit; Sally Glenn attended the NHS Providers Mental Health Leaders’ Forum, chaired the Rostering Task Group and visited the Cassel; Hassaan Majid visited the Hammersmith & Fulham Recovery and Early Intervention in Psychosis teams at the Claybrook Centre; Neville Manuel was interviewed by the Deloitte consultants undertaking the Well Led Review; and Elizabeth Rantzen had visited the Hammersmith & Fulham CAMHS service, joined the visit by the chairman of NACRO to the Wells Unit and was also interviewed by Deloitte. The non-executive directors will report verbally at the Board on any other activities

Item

6: C

hairm

an's

Boa

rdR

epor

t - M

arch

201

8

Page 20 of 308

undertaken in the past month and, alongside the chair, will be happy to answer any questions.

2 Board membership 2.1 Interviews were held on 2nd March for the appointment to fill non-executive

director vacancy created by Sarah Cuthbert’s resignation. We are awaiting a response from the Appointments Committee of NHSI to recommendation of the interview panel.

Tom Hayhoe Chairman

6th March 2018

Page 21 of 308

Report summary Trust board meeting: Part 1 (in public)

March 2018

Report title: Chief Executive’s report to the board

Executive lead: Chief Executive

Report authors: Chief Executive

Report discussed previously at: N/A


For approval


To note ✓



Performance & Activity ✓



No


N/A


No

Item

7: C

EO

's B

oard

Rep

ort

Mar

ch -

201

8

Page 22 of 308



Improving quality


✓

Compassionate care


✓

Summary


Thank you from Carolyn Regan.msg

Page 23 of 308

Trust board meeting (Part ): March 2018

Chief Executive’s Report

1 Purpose 1.1 The report aims to highlight recent key activities and to draw the Board’s attention

to a number of recent developments.

2 Recommendations 2.1 The board is asked to note the content of the report.

3 Issues 3.1 NATIONAL ISSUES

3.1a CQC report on 28th February 2018: http://www.cqc.org.uk/provider/RKL/inspection-summary#mhpsychintensive

The key findings from a recent publication by the Care Quality Commission on their annual review of monitoring the Mental Health Act 2016/17 are listed below.

These include:

• CQC has found limited or no improvement in key areas of concern raised in previous years, including patient involvement in care planning; clinical consideration of least restrictive options for care; improving the number of patients who receive physical health checks; and improving the number of patients being referred to advocacy services and informed of their legal rights on admission.

• CQC’s findings, along with the hypotheses generated from its recent report exploring potential reasons for the rise in detentions under the Mental Health Act, will help inform the current Independent Review of the Mental Health Act, led by Professor Sir Simon Wessely.

• CQC will also conduct during 2018 a collaborative evaluation with patients, providers and experts of the way the MHA Code of Practice (2015) has been implemented to inform the Independent Review.

The Trust is considering this report as part of the local CQC action plan and all

areas listed are the subject of trust wide actions. As previously agreed, we are aiming to respond to the Mental Health Act review.

Item

7: C

EO

's B

oard

Rep

ort

Mar

ch -

201

8

Page 24 of 308

3.2 NORTH WEST LONDON ISSUES 3.2a Recruitment of a single Accountable Officer for NW London – Update

The NW London Collaboration of CCGs has held discussions with NHS England & Improvement about the specific remit of the above role. That discussion has now concluded and it has been agreed that the STP leadership component will be removed from the position. The recruitment process will now progress. In parallel NHSE & I will set out their plans for the STP leadership role and where that will sit within the NW London system.

3.2b Sustainability and Transformation Plan (STP) Director Mark Easton has joined NW London as the STP Director and will be leading the Strategy & Transformation directorate. Mark is initially on a three month contract. Mark brings with him a wealth of experience, having worked across a number of high profile roles within the NHS, and most recently heading up the South East London STP.

3.3 TRUST ISSUES 3.3a NHS Improvement Undertakings We are making good progress on this work.

• We have appointed Deloitte to carry out a Well-led review of the Trust’s governance arrangements. This is well underway with individual Board Director, Clinical and Service Director interviews; staff focus groups and a range of site visits arranged.

• Stanley Riseborough, interim Improvement Director, has taken up his role on a three day week basis for three months, fully funded by NHS improvement.

• Work on the medium term financial plan continues with the aim of sign off in the next month.

• Agency staffing: we are making good progress with a range of recruitment and retention initiatives, an improved employee offer and a faster recruitment process. These include joining the 18 month capital nurse programme, which aims to decrease variation in education and practices across London, reduce nursing attrition rates and retain nursing staff. We have also launched a new partnership with Buckinghamshire New University to deliver a nursing degree apprenticeship, reflecting the blend of theoretical, technical and vocational skills required in nursing. We are one of the first Trusts in London to offer this degree level opportunity.

• Following discussion at the Performance Oversight meeting, NHSI have advised that they still require from the Trust: a clear plan which maps our actions to outcomes which is demonstrated on a timeline which achieves compliance against the Agency target; evidence of ongoing compliance against the agency rules and that the changes we have put in place have been embedded and tested. The Trust has confirmed to NHSI that we will

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include the agency plan with the overall plan submissions; and that our weekly returns meet NHSI requirements.

More detail is included in the Director of Workforce and OD Board Report. 3.3b Nursing Conference 2nd March 2018 at Twickenham Stadium These and many other achievements were highlighted at the recent nursing

conference, which drew on many examples of good practice, e.g.:

• The provision of support and development through reflective practice and supervision so all our nurses feel positive about learning and growing in their roles. This excellent progress was noted by the CQC in their recent re-inspection of our acute adult wards and PICU.

• Seeking to ‘grow our own’ through career development so that all healthcare assistants have clear career pathways into nursing.

• As a mental health trust, we have led the way in integrating physical healthcare with mental health via, for example, introducing a mandatory physical healthcare assessment within 24 hours for all patients and increasing our expertise in patients managing co-morbidities with their mental health conditions.

• Safewards and reducing restrictive interventions

• User experience of the Cassell Hospital.

3.3c Staff Survey Results

• These were released on the 6th March and management and staffside enjoyed a presentation from Quality Health, which noted improved staff engagement scores across the board. As a Trust we have improved in 52 out of 65 questions. We have still got some areas to improve but have moved positively across the board and in some areas we are in the top 10 of mental health trusts.

• This was the second year running and builds on a number of strategies, including revised learning and development aimed at supporting middle managers and clear objective setting based on individual and team development. These results include improvements in senior management and leadership, motivation and involvement scores drawn from the comprehensive survey questions.

• Also of note was a high score for job satisfaction, with appraisals and development support both well above the national average, and enhanced reporting by staff of errors and incidents. As noted at the Workforce Committee, further action is required on equality and diversity. The percentage of staff reporting good communications between senior management and staff, as well as support from line managers, is in the top scores nationally.

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• Another area requiring focus is the ongoing violence, harassment and bullying, including by staff towards staff.

There are action plans being developed to address all of these outstanding areas.

3.3d Senior Staff changes

• Trust Board Secretary, Peter Jenkinson, is moving to take on the Board secretary and governance role at Imperial College Healthcare Trust. Peter joined us in October last year and has worked as Trust Secretary, overseeing the secretariat at a time of change. He led the ‘well led’ analysis, currently being assured by Deloitte. He has been headhunted to this similar role in a large acute trust and will leave us on April 13th 2018.

Peter’s post is out to advert and will be interviewed for by Wendy Brewer (Workforce Director) and Moriam Bartlett (Non-Executive Director) and me, pre-ceded by a stakeholder panel.

• Sally Sykes, Director of Communications and Engagement, who joined us in April 2017, is going to a post as Director of Communications and Marketing at the University of Manchester, her home city.

Sally has made a significant contribution in her short time with the trust, helping us to, amongst other projects, instigate our name change and strategy consultation, publicise our estates strategy and raise the profile of the trust in the national media and through prestigious awards for our work. Sally will leave at the end of May and arrangements are in hand to consider how best to fill the role. Elizabeth George has been appointed the interim Head of Communications for a period of at least six months, whilst we consider the best solution for the trust’s communications needs.

4 Visits and Meetings 4.1 EXTERNAL MEETINGS 4.1.1 North West London

• Most activity has been with NW London CCG Collaboration, including meeting the Chairs and CE’s to discuss the Trust response to CQC reports and next steps; transformation priorities for 18/19 and the Trust's view of how we see ourselves as part of integrated care developments.

• I participated in the NW London seminar to review and reset the Health and Social Care STP Programme Board, including overall purpose and governance.

• I contributed to a review of the mental health programme, delivery area 4 of the STP, Like Minded. These discussions will continue after agreement of the second year of the contract with local CCG‘s for 2018/19 and include modelling the impact of inpatient reconfigurations on community teams.

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• We have recently received support from local commissioners for a wave 2 perinatal service to extend the existing service.

• I met with Sheila Lock, Chair Ealing Safeguarding Adults Board, following her presentation to the board. She reported that significant progress has been made on a number of fronts regarding joint working and improved communications between the two organisations.

• I was invited by Professor Tim Kendall, MH National Clinical Director for NHS England and NHS Improvement, to participate in the National Mental Health Medical Directors Network as a panel guest speaker to talk about the topic of the joint Green Paper for Children & Young People, on a panel with Professor Dame Sue Bailey, Chair of the Children & Young People's Mental Health Coalition and Dr Prathiba Chitsabesan Consultant Child and Adolescent Psychiatrist and CAMHS Strategic Lead, Pennine Care NHS Foundation Trust among others.

4.2 VISITS TO THE TRUST

• Dr. Onkar Sahota, GLA member for Ealing and Hillingdon, Chair of the GLA Health Committee and a Hanwell GP, with the Trust Chair, to Ealing local services (Wolsey wing and the SPA) and Thames Lodge.

• Sir David Behan CBE, Chief Executive of the Care Quality Commission, to Broadmoor Hospital and a tour the new hospital.

• The High Sheriffs of the Thames Valley sponsored the staff awards ceremony at Broadmoor Hospital. A verbal update will be given.

• Other award winners this month included: Karen Spick, Team Secretary at Broadmoor, in the Administrative Staff Leader of the Year category, of the national Unsung Hero Awards 2018. The Unsung Hero Awards are the only national awards for non-medical/non-clinical NHS healthcare staff and volunteers who go above and beyond the call of duty. The Trust’s Portering Team at St Bernard’s Hospital were also shortlisted for ‘Team of the Year’ in the Ancillary Staff category respectively.

• Two employees of the month jointly won this month’s award: Gaganjot Sidhu, Resourcing Lead for Local Services in HR corporate

services and Wendy Pickford, Domestic Assistant at Broadmoor Hospital 4.3 INTERNAL VISITS AND ACTIVITIES

4.3.1 I joined the LGBTQ+ group in Hounslow CAMHS; gave two employees of the month their awards; and held two listening events for staff at Cafe on the Hill, St Bernard’s with the Director of Nursing and Patient Experience, and at the Hammersmith and Fulham Claybrook Centre with the Director of Finance. Issues raised included:

• Assaults on patients and staff. There are two liaison police officers for the St Bernard’s site and a regular police liaison meeting is held in each borough.

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• Anonymous complaints. Several anonymous complaints have been received recently. These are difficult to follow up as they do not include enough detail to investigate. The Trust takes all complaints seriously and we need to think about what prompts people to make complaints anonymously. Staff were reminded that information is available on the Exchange on how to raise complaints and about speaking up.

• Supporting staff to take safeguarding action. Training is provided but staff should take the opportunity to raise at supervision and take responsibility for making safeguarding referrals.

• Linking IR1s with RiO. At the moment reporting is duplicated and this is being looked into.

• Healthy eating advice for patients. Discussed looking to source local options for healthy food.

• Bank shifts and bank staff. Ward staff have first pick for bank shifts on e-Roster. Staff can take advantage of this to work on other wards. Staff who only work on the bank should ensure they receive clinical supervision.

• Out of date DBS checks. Work is in hand to address this backlog.

• Disabled staff accessing the LDC at Ealing. There are discussions around an alternative location for the LDC.

4.3.2 I attended presentations by the 4th cohort BME Leadership Development

Programme with the Trust Chairman on restrictive practices, favouritism and staff retention.

5 Recommendation(s) 5.1 The board is asked to note the content of the report.

Carolyn Regan Chief Executive

March 2018

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Appendix 1 – CEO message on the Exchange Dear colleagues, Although I’ve already written this month’s CEO blog – and it’s a busy round up with many important events and milestones for the Trust – I did want to issue a further special thanks to staff who have gone to great lengths to support our patients and each other during the recent spell of bad weather. People in the main managed to get into front line work locations or work from home during the bad weather. Colleagues in Estates and Facilities and operational staff worked hard to ensure patients’ needs were met – in the face of difficult challenges, ranging from heating failures and water loss in Tony Hillis Wing, boiler issues at Broadmoor and a water leak at the Claybrook Centre to a ceiling collapse at Armstrong Way caused by burst pipes. We managed to hold our Nursing Conference on Friday 2 March with a good attendance and an almost full roster of speakers. So, I wanted to say thank you to all of you who have worked above and beyond to keep our patients safe during challenging weather conditions. Carolyn Carolyn Regan Chief Executive

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Report summary Board Meeting: Part I (in Public) March 2018

Report title:

Integrated Performance Report

Executive lead:

Paul Stefanoski - Director of Finance & Business

Report authors:

Babs Dhillon – Head of Knowledge Management


N/A


This report summarises the Trust performance compliance against statutory targets and internally set priorities at Month 6 (September 2017) and identifies areas of underperformance that are being investigated and monitored. The Board is asked to review performance and discuss key issues raised.

For approval

✓

To note

✓

Summary Within the Areas of concern: Performance improvement has been noted for the following metrics:

• KPI 001 : Admissions via CRHT Gatekeeping – April 2017 to January 2018 achieving target

• KPI002 : DToC rate of 3.8% in January, the lowest in over 2 years. This is a provisional figure subject to sign off by local authorities.

• KPI015: Level 1 Incidents commissioned –There were four reviews commissioned in January. The indicator has had a sustained downward shift since May 2017.

• KPI 021: % Risk assessments within 72 hours of admission – achieved 97.4%.

• KPI022A: Physical Health Assessment within 24 hours – has achieved the target with trust-wide compliance at 95.6% showing a massive improvement in performance since the 24hr target was introduced.

Concerns :

• KPI 019: CPA 7 day follow up – performance did not meet the target in January and

Item

8.1

: M10

Inte

grat

edP

erfo

rman

ce R

epor

t Sum

mar

y

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only achieved a compliance of 94.7%. Workforce and Finance performance are reviewed within respective reports.


We innovate – to turn research into practice

Improving quality


✓

Compassionate care


✓

Relationship to board assurance framework (risks)? Are any existing risks in the board assurance framework affected?

Yes

If yes, insert relevant risk reference: Various

Do you recommend a new entry to the board assurance framework (i.e. trust-wide level 1 risk) is made?

Acronyms / terms used in the report SPC Statistical Control Chart

DToC Delayed Treatment of Care

KPI Key Performance Indicator

F&P Finance and Performance Committee

Supporting documents and/or further reading https://improvement.nhs.uk/uploads/documents/Single_Oversight_Framework_published_30_September_2016.pdf

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Inte

gra

ted

Perfo

rman

ce

Rep

ort (IP

R)

Ja

nu

ary

20

18

Item 8.2: M10 IntegratedPerformance Report

Page 33 of 308

Su

mm

ary

of o

ve

rall p

erfo

rma

nce

is s

et o

ut b

elo

w

Ind

ica

tor D

es

crip

tion

Ke

y H

igh

ligh

tsT

arg

et

Pre

vio

us

Mo

nth

Cu

rren

t

Mo

nth

KP

I00

1: In

patien

t adm

ission

s Gatekep

tP

erform

ance in

Janu

ary was 1

00

%. A

sustain

ed sh

ift in p

erform

ance co

ntin

ues w

ith ab

ove 9

5%

com

plian

ce since A

pril 2

01

7.

>=

95

%1

00

.0%

10

0.0

%

KP

I00

2: D

elayed Tran

sfers of C

are Th

e Trust level D

ToC

was 3

.8%

in Jan

uary , th

e low

est in last 3

4 m

on

ths.

<=

7.5

%4

.3%

3.8

%

KP

I00

8: N

ew C

om

plain

ts received in

perio

d

A to

tal of 2

5 co

mp

laints w

ere received d

urin

g Janu

ary 20

18

, wh

ich sh

ow

s an in

crease of 6

com

pared

with

the p

reviou

s mo

nth

19

25

KP

I00

9: N

um

ber o

f com

plain

ts no

t

respo

nd

ed to

with

in agreed

timefram

e

(Op

en)

There w

ere 3 co

mp

laints n

ot resp

on

ded

to w

ithin

agreed tim

eframe, o

ne in

Access &

Urgen

t Care, o

ne in

Prim

ary & P

lann

ed an

d o

ne in

High

Secure Services

04

3

KP

I01

4: Level 2

Incid

ents co

mm

ission

ed

There w

ere two

Level 2 review

s com

missio

ned

in Jan

uary, o

ne in

Prim

ary and

Plan

ned

Care an

d o

ne in

CA

MH

S. YTD average o

f level 2

incid

ents th

is year is 2.

2

2

KP

I01

5: Level 1

Incid

ents co

mm

ission

ed

Fou

r Level 1 in

ciden

ts were co

mm

ission

ed in

Janu

ary. A sm

all sustain

ed d

ow

nw

ard sh

ift can b

e ob

served d

urin

g the last 1

1 m

on

ths. YTD

Level 1 in

ciden

ts in A

ccess and

Urgen

t Care service rem

ain h

ighest (3

0) fo

llow

ed b

y Prim

ary and

Plan

ned

Care (1

1).

4

4

KP

I01

9: C

PA

7 d

ay follo

w u

pTh

e 95

% target h

as been

breach

ed fo

r the seco

nd

mo

nth

. There w

ere five breach

es, 2 in

A&

UC

, 2 in

WLFS an

d 1

in H

igh Secu

re. Trust Q

3

perfo

rman

ce pu

blish

ed b

y NH

SE is at 95

.9%

pu

tting u

s fou

rth fro

m b

otto

m co

mp

ared to

oth

er Lon

do

n Tru

sts. >

=9

5%

93

.75

%9

4.7

0%

KP

I02

1:In

patien

t risk assessmen

ts with

in

72

ho

urs

There w

ere 3 b

reaches o

ut o

f 11

3 ad

missio

ns in

Janu

ary with

com

plian

ce at 97

%.

>=

95

%9

7.0

%9

7.4

%

KP

I02

2A

: % o

f Inp

atients P

hysical h

ealth

check w

ithin

24

hrs ad

missio

n

Janu

ary 20

18

data sh

ow

s that p

hysical h

ealth assessm

ents (P

HA

) with

in 4

8 an

d 7

2 h

ou

rs of ad

missio

n are b

oth

at 98

%, w

ith 9

6%

of p

atients

havin

g a PH

A w

ithin

24

ho

urs.

>=

95

%9

6.0

%9

5.6

%

1.0

Areas o

f Co

ncern

D

ata Mo

nth

10

(Jan 2

01

8)

Page 34 of 308

Co

mm

en

ts: A

s a resu

lt of th

e rep

ortin

g and

reco

rdin

g imp

rovem

en

ts, we

have ach

ieved a co

mp

liance o

f 99.5%

for Q

3. Perfo

rman

ce in Jan

uary w

as 100%. A

sustain

ed sh

ift in p

erform

ance co

ntin

ues w

ith

abo

ve 95%

com

plian

ce since A

pril 2

017

. A n

ew d

ashb

oard

to give services o

n d

eman

d access to

this K

PI h

as bee

n d

evelop

ed an

d ro

lled o

ut.

Ove

rview

C

RH

T Gatekee

pin

g is a key target with

in th

e NH

S Imp

rovem

en

t Single O

versight Fram

ewo

rk with

a target of 95%

. Gatekee

pin

g has rem

ained

abo

ve the target o

f 95% sin

ce Ap

ril follo

win

g review

of p

rocesses earlier in

20

17.

Data

Sou

rce: RiO

as at 1

1 Febru

ary 20

18

1.1

-K

PI0

01

: Ad

missio

ns C

RH

T Gatekeep

ing

Data M

on

th 1

0 (Jan

20

18

)


Page 35 of 308

Ove

rviewTh

e natio

nal target fo

r Delayed

Transfer o

f Care (D

ToC

) set by th

e Single

Ove

rsight Fram

ewo

rk is 7.5%. Th

e trust's o

verall D

ToC

% h

as bee

n u

nstab

le ove

r the last 2 1/2 years an

d h

as breach

ed

con

sistently b

etwee

n Jan

uary to

Septem

ber 201

7). Local services (A

&U

C an

d C

IDS) in

particu

lar are experien

cing in

creased p

ressures acro

ss the th

ree m

ain Lo

cal Au

tho

rities/CC

Gs (Ealin

g, H&

F,

Ho

un

slow

). There h

as bee

n a m

ore rigo

rou

s app

roach

to rep

ortin

g and

the d

etails of d

elayed p

atients h

ave b

een

verified

with

ou

r lead co

mm

ission

ers and

local au

tho

rities in th

e mo

re recent

mo

nth

s.

No

tes:

- Data rep

orted

here is m

on

th en

d sn

apsh

ot p

ositio

n b

efore Lo

cal Au

tho

rity sign o

ff and

may b

e differen

t from

final su

bm

itted d

ata to N

HS En

gland

- Bro

adm

oo

r patien

ts on

trial leave or th

ose o

n th

e MO

J waiters are n

ot req

uired

to b

e repo

rted o

n D

ToC

un

der th

e ‘safe’ for d

ischarge d

efinitio

n, an

d are rep

orted

here fo

r local p

erform

ance m

on

itorin

g on

ly.

1.2

-K

PI0

02

: De

layed Tran

sfers o

f Care D

ata Mo

nth

10

(Jan 2

01

8)

Page 36 of 308

Co

mm

ents:

In Jan

uary th

e Trust level D

ToC

was at 3.8%

, low

est in last 34

mo

nth

s. Significan

t imp

rove

men

t has b

een

ob

served

across th

ree m

ain Lo

cal Au

tho

rities (Ealing, H

&F an

d H

ou

nslo

w) an

d Fo

rensic

ove

r last 4 m

on

ths as a resu

lt of jo

int D

ToC

sign o

ff with

Local A

uth

ority co

lleagues.

Trust w

ide, 'So

cial Care' attrib

ute acco

un

ted fo

r 43%

of Eq

uivalen

t DTO

C b

eds (11 o

ut o

f 26). This p

rop

ortio

n h

as redu

ced co

nsid

erably in

Local Services sin

ce local au

tho

rities and

com

missio

ners

have

started to

sign o

ff the d

elays. As a resu

lt delays attrib

utab

le to So

cial Care h

ave redu

ced fro

m 78%

in A

pril to

43% in

Janu

ary. The b

iggest reason

for d

elayed b

eds th

is mo

nth

was 'A

waitin

g

pu

blic fu

nd

ing' (33%

of th

e total D

TOC

mo

nth

ly reason

s) follo

wed

by 'A

waitin

g furth

er no

n-acu

te NH

S Care' (23%

of th

e total D

TOC

mo

nth

ly reason

s).

Ou

t of 16 p

atients d

elayed acro

ss WLFS, 4 each

in M

ale Med

ium

Secure an

d M

ale Low

Secure an

d Lo

w Secu

re Pre-D

ischarge, 1 in

WEM

MS an

d 3 in

Wo

men

’s Med

ium

Secure. B

iggest reason

for

delay in

WLFS th

is mo

nth

was 'A

waitin

g pu

blic fu

nd

ing' (36

% o

f the to

tal) follo

wed

by 'A

waitin

g Care H

om

e placem

ent o

r availability' (24%

of th

e total).

Ho

un

slow

, Ealing an

d H

&F LA

s qu

eried/ d

ispu

ted th

e histo

rical reason

for d

elayed p

atients. Th

ese ad

justm

ents h

ave n

ow

bee

n agree

d an

d a revised

sub

missio

n w

ill go to

Un

ify wh

en th

e revision

win

do

w is o

pen

ed in

May 201

8.

Data So

urce: M

anu

al data su

bm

itted b

y services as at 2

1 Feb

ruary 2

018


Page 37 of 308

Co

mm

ents

• A to

tal of 2

5 co

mp

laints w

ere received

du

ring Jan

uary 201

8, w

hich

sho

ws an

increase o

f 6 co

mp

ared w

ith th

e previo

us m

on

th

• The tru

st is 100

% co

mp

liant ackn

ow

ledgin

g the co

mp

laint w

ithin

three w

orkin

g days

• High

Secure Services receive th

e high

est nu

mb

er of co

mp

laints, 3

1%

(n=98

) of th

e trust to

tal 317

from

1st A

pril 201

7 to

date

• To d

ate the m

ain th

eme is 'all asp

ects of clin

ical treatmen

t' wh

ich acco

un

t for 3

2%

(n=10

0) of th

e com

plain

ts, follo

we

d b

y 'attitud

e of staff' w

hich

has received

30%

(n=94

)

• Of th

e total 2

5 co

mp

laints raised

, 2 we

re from

1 p

atient. 1

1 co

mp

laints w

ere raised

by fam

ily mem

bers, 9

by p

atients, 2 fro

m an

extenral so

urce. 1 fro

m SEA

P, 1

from

the C

QC

, 1 from

a solicito

r

• Ke

y them

es are furth

er analysed

and

repo

rted o

n in

:

o Th

e we

ekly patien

t experien

ce data su

mm

ary pro

du

ced fo

r the D

irector o

f Nu

rsing an

d P

atient Exp

erience

o Th

e mo

nth

ly Bein

g Op

en rep

ort w

hich

is presen

ted at th

e Clin

ical Go

vernan

ce Co

mm

ittee M

eetin

g

o Th

e qu

arterly patien

t experien

ce repo

rt presen

ted at th

e Service User an

d C

arer Sub

- com

mittee

Data So

urce

: Ce

ntral G

ove

rnan

ce : C

om

plain

ts System (Exch

ange) as at 29 Jan

uary 2018

Ove

rview

C

om

plain

ts can b

e received verb

ally, by telep

ho

ne, letter o

r email. A

n ackn

ow

ledgem

ent is sen

t to th

e com

plain

ant w

ithin

three w

orkin

g days o

f receipt p

rovid

ing an

overview

of th

e main

issues

and

the tim

escale for th

e investigatio

n. Th

emes fro

m co

mp

laints are an

alysed to

iden

tify key areas fo

r action

.

Ke

y them

es are furth

er analysed

and

repo

rted o

n in

:

o Th

e we

ekly patien

t experien

ce data su

mm

ary pro

du

ced fo

r the D

irector o

f Nu

rsing an

d P

atient Exp

erience

o Th

e mo

nth

ly Bein

g Op

en rep

ort w

hich

is presen

ted at th

e Qu

ality Matters C

om

mittee

o Th

e qu

arterly patien

t experien

ce repo

rt presen

ted at th

e Service User an

d C

arer Sub

- com

mittee

o A

recom

men

datio

n fro

m th

e ann

ual p

atient exp

erience rep

ort is fo

r service lines to

pro

vide fee

db

ack on

imp

rovem

ents/actio

n b

eing taken

to ad

dress areas o

f con

cern raised

wh

ich w

ill be

inclu

ded

in th

is com

men

tary

1.3

-K

PI0

08

: Ne

w C

om

plain

ts received in

perio

d D

ata Mo

nth

10

(Jan 2

01

8)

Page 38 of 308

Co

mm

ents

Data So

urce

: Ce

ntral G

ove

rnan

ce : C

om

plain

ts System

(Exchan

ge) as at 2

9 Jan

uary 2

01

8

Overview

Th

e investigatio

n resp

on

se will b

e requ

ired b

y a spe

cified d

ate wh

ich is agree

d w

ith th

e co

mp

lainan

t at the start o

f the p

rocess. H

ow

ever this w

ill no

t exceed 30 d

ays from

receipt o

f

com

plain

t, un

less a lon

ger timescale is req

uired

du

e to

exceptio

nal circu

mstan

ces wh

ich sh

ou

ld n

ot exceed

35

days.

If an exten

sion

is agreed

and

signed

off b

y the

Directo

r of N

ursin

g and

Patien

t Experien

ce and

Executive D

irector th

e exten

sion

sho

uld

be fo

r a maxim

um

of 10 d

ays, and

there sh

ou

ld b

e a

maxim

um

nu

mb

er o

f extensio

ns gran

ted p

er co

mp

laint, w

hich

mu

st no

t exceed th

ree.

A w

eekly su

mm

ary of p

atient exp

erien

ce data in

clud

ing o

verdu

e co

mp

laints is p

rovid

ed to

the D

irector o

f Nu

rsing an

d P

atient Exp

erience fo

r discu

ssion

at the Execu

tive Directo

rs mee

ting, th

e

mo

nth

ly Bein

g Op

en

repo

rt presen

ted at th

e Q

uality M

atters Co

mm

ittee, an

d th

e q

uarterly p

atient exp

erience rep

ort p

resented

at the Service U

ser and

Carer Su

b- co

mm

ittee. A

recom

men

datio

n fro

m th

e an

nu

al patien

t experien

ce repo

rt goe

s to each

service line

s to p

rovid

e feed

back o

n im

pro

vemen

ts/action

be

ing taken

to ad

dress areas o

f con

cern.

The

data w

as draw

n fro

m th

e live system

at 09

35hrs o

n 29

th Jan

uary 201

8 an

d sh

ow

ed th

at 3 com

plain

ts are overd

ue

with

ou

t an agree

d exten

sion

date.

• 1 in A

ccess & U

rgen

t Care relatin

g to ‘ad

missio

ns, d

ischarge

and

transfer arran

gemen

ts’

• 1 in P

rimary &

Plan

ne

d relatin

g to ‘attitu

de

of staff

• 1 in H

igh Secu

re Services relating to

‘ho

tel services’

Reaso

ns p

rovid

ed fo

r overd

ue

com

plain

ts are as follo

ws:

Access &

Urge

nt C

are - Ch

ange o

f investigato

r du

e to

previo

us in

vestigator go

ing o

n lo

ng term

sick

Prim

ary & P

lann

ed

Care - In

vestigator h

as leave

High

Secure Services - C

om

plain

t has b

een

chased

and

escalated

1.4

-K

PI0

09

-N

um

ber o

f com

plain

ts no

t respo

nd

ed to

with

in agreed

timefram

e(o

pen

) Data M

on

th 1

0 (Jan

20

18

)


Page 39 of 308

Co

mm

en

tsD

urin

g Janu

ary 20

18

there w

ere 2 Level 2

reviews co

mm

ission

ed, o

ne in

Prim

ary and

Plan

ned

Care an

d o

ne in

CA

MH

S. YTD average o

f level 2 in

ciden

ts this year is 2

.

An

alysis of in

ciden

ts year to d

ate sho

ws P

&P

C h

ave the h

ighest n

um

ber o

f incid

ents (8

) follo

wed

by A

&U

C (5

). Patien

t death

incid

ents are th

e largest Level 2 in

ciden

t type an

d acco

un

t for 7

8%

of

the to

tal level 2 in

ciden

ts this year.

Wo

rk is un

derw

ay to im

pro

ve pro

cesses and

systems to

captu

re and

repo

rt data m

ore accu

rately and

con

sistently.

Data So

urce

: Cen

tral Go

vernan

ce - IR

1 (Exch

ange) as at 09 Fe

bru

ary 2018

Ove

rview

The n

ature, severity an

d co

mp

lexity of serio

us in

ciden

ts vary on

a case-by-case b

asis and

therefo

re the level o

f respo

nse is d

epen

den

t on

and

pro

po

rtion

ate to th

e circum

stances o

f each sp

ecific

incid

ent. Level 2

incid

ents co

mm

ission

ed req

uire co

mp

rehen

sive intern

al investigatio

n an

d in

clud

e all the elem

ents o

f a credib

le investigatio

n. Level 2

reviews are co

nd

ucted

wh

ere there are

com

plex issu

es with

generally m

od

erate to severe level o

f harm

. These are m

anaged

by a m

ultid

isciplin

ary team, an

d in

volve exp

erts and

/or sp

ecialist investigato

rs.

1.5

-K

PI0

14

: Leve

l2 In

cide

nts co

mm

ission

ed

D

ata Mo

nth

10

(Jan 2

01

8)

Page 40 of 308

Co

mm

en

tsLevel 1 in

ciden

ts com

missio

ned

in Jan

uary 20

18 remain

ed u

nch

anged

from

last mo

nth

(4 co

mm

ission

ed in

Decem

ber), Level 1 in

ciden

ts have sh

ow

n a sm

all sustain

ed d

ow

nw

ard sh

ift on

last 11

mo

nth

s' ob

servation

s and

last 7 mo

nth

s' average (5) is h

alf of last 3 years' o

bservatio

ns (10

). 'Patien

t death

', 'Self-inju

ry to P

atient' an

d 'B

ed O

ccup

ancy Levels' are th

e largest type o

f level 1

incid

ents co

mm

ission

ed an

d acco

un

t for 20

%, 18%

and

13%

of th

e YTD in

ciden

ts respectively. YTD

Level 1 incid

ents in

Access an

d U

rgent C

are service remain

high

est (30) fo

llow

ed b

y Prim

ary and

Plan

ned

Care (11

).

No

te: That d

ate of in

ciden

t may n

ot b

e same as co

mm

ission

ed d

ate and

som

e incid

ents th

at hap

pen

ed in

previo

us m

on

ths m

ay app

ear this m

on

th b

ased o

n co

mm

ission

ed d

ate.

Data So

urce

: Ce

ntral G

ove

rnan

ce - IR

1 (Exch

ange

) as at 09

Feb

ruary 2

01

8

Ove

rview

Level 1 Incid

ents C

om

missio

ned

requ

ire con

cise intern

al investigatio

n an

d in

clud

e the essen

tials of a cred

ible in

vestigation

. Level 1 reviews are co

nd

ucted

for less co

mp

lex incid

ents, w

here th

e

level of h

arm is gen

erally no

ne/lo

w/m

od

erate.

These are m

anaged

by in

divid

uals o

r a small gro

up

at a local level extern

al to th

e team.

1.6

-K

PI0

15

: Level 1 In

ciden

ts com

missio

ned

D

ata Mo

nth

10

(Jan 2

01

8)


Page 41 of 308

Ove

rview

Th

e natio

nal target fo

r CP

A 7

day fo

llow

up

is 95

%. Th

is key target had

bee

n u

nd

erperfo

rmin

g since Ju

ne 2016 w

ith th

e exceptio

n o

f few m

on

ths.

The accu

racy of re

cord

ing an

d re

po

rting h

as imp

roved

follo

win

g a com

pre

hen

sive revie

w o

f pro

cesses. Better tim

ely w

eekly rep

orts an

d th

e efforts o

f the D

ata Qu

ality man

ager have p

roved

effective.

We h

ave missed

the 9

5%

target for th

e last two

mo

nth

s (93.8%

and

94.7% in

De

c and

Jan re

spectively). Th

ere we

re 5 breach

es (ou

t of 95 d

ischarges) in

Janu

ary. Qu

arter 3 perfo

rman

ce as per

NH

S Englan

d p

ub

lished

data is ju

st abo

ve target at 95.9%

wh

ich p

uts u

s fou

rth fro

m b

otto

m co

mp

ared to

oth

er Lon

do

n Tru

sts.

Un

til Au

gust 2

017, th

is KP

I was m

on

itore

d fo

r CP

A d

ischarges o

nly (exclu

ded

patie

nts w

ho

we

re n

ot o

n C

PA

at the tim

e o

f disch

arge). From

Au

gust 2017, as a stretch

target, all disch

arges are

bein

g mo

nito

red

against th

e 7 d

ay follo

w u

p co

mp

liance b

ut as th

e NH

S Englan

d gu

idan

ce on

ly req

uires fo

r CP

A d

ischarges, n

on

CP

A d

ischarges are n

ot rep

orted

.

Ou

t of 5

bre

aches in

Janu

ary, 2 w

ere

in A

ccess & U

rgent C

are, 2

in W

est Lon

do

n Fo

ren

sic Service and

1 in H

igh Secu

re Service.

Ou

t of tw

o b

reaches in

WLFS, o

ne w

as patie

nt o

n leave w

hen

disch

arged an

d fo

llow

up

was co

mp

leted o

n th

e day o

f disch

arge (instead

of th

e day after d

ischarge) an

d o

ther fo

llow

up

did

n't

take place. Staff h

ave bee

n rem

ind

ed o

f the C

PA

7 D

ay Follo

w u

p p

roced

ure

.

Data So

urce

: RiO

as at 11

Janu

ary 20

18

Co

mm

en

ts:

1.7

-K

PI0

19

: CP

A 7

day fo

llow

up

D

ata Mo

nth

10

(Jan 2

01

8)

Page 42 of 308

Co

mm

en

tsTh

ere were 3 b

reach

es ou

t of 113 ad

missio

ns th

is mo

nth

(97.4%). Th

e bre

akdo

wn

by service

as follo

ws : A

&U

C (9

7.1%, 3 b

reach

es, 2 in H

OU

GR

OSV

ENO

R an

d 1

in H

&F R

AV

ENSC

OU

RT), C

ID (100%

),

P&

PC

(100%),W

LFS (100%

)

Two

ou

t of th

ree b

reach

es this m

on

th d

id h

ave a risk assessmen

t in m

on

th (o

utsid

e 72 ho

urs).

High

Secure

data is n

ot in

clud

ed in

this an

alysis bu

t will b

e add

ed in

futu

re.

Ove

rview

Tru

st has a 95%

target for co

mp

leting an

initial risk assessm

ent w

ithin

72 ho

urs o

f adm

ission

to an

inp

atient w

ard. Tru

st has b

een

com

plian

t excep

t in 3

instan

ces sin

ce A

pril 2015. Th

is ind

icator

do

es no

t pro

vide a m

easure

of th

e qu

ality or co

mp

leteness o

f the risk assessm

ent carried

ou

t.

Data So

urce

: RiO

as at 05

Feb

ruary 2

01

8

1.8

-K

PI0

21

: % R

isk Asse

ssme

nt w

ithin

72

hrs ad

missio

n

Data M

on

th 1

0 (Jan

20

18

)


Page 43 of 308

Co

mm

en

ts:

Overview

9

5%

of in

patien

ts sho

uld

have a p

hysical h

ealth assessm

ent w

ithin

24

ho

urs o

f adm

ission

(previo

usly 7

2 h

ou

rs). The n

ew target w

ent live m

id A

pril 2

01

7.

Furth

er mo

nito

ring o

f the n

ew target w

ill con

tinu

e with

focu

s on

ind

ividu

al services and

ward

s and

trainin

g as the n

ew target is em

bed

ded

. There is also

wo

rk plan

ned

arou

nd

the evalu

ation

of

the n

ew p

hysical h

ealth p

ortal regard

ing u

sage and

feedb

ack.

This in

dicato

r do

es no

t pro

vide a m

easure o

f the q

uality o

r com

pleten

ess of th

e ph

ysical health

assessmen

t carried o

ut.

Data

Sou

rce: RiO

as at 05 Feb

ruary 2

018

Janu

ary 20

18

data sh

ow

s that p

hysical h

ealth assessm

ents (P

HA

) with

in 4

8 an

d 7

2 h

ou

rs of ad

missio

n are b

oth

at 98

%, w

ith 9

6%

of p

atients h

aving a P

HA

with

in 2

4 h

ou

rs. PH

A can

be co

mp

leted

befo

re adm

ission

and

this is taken

into

accou

nt w

hen

calculatin

g com

plian

ce.

There w

ere 11

3 ad

missio

ns in

Janu

ary across th

e Trust, 1

08

of th

em h

ad a P

HA

with

in 2

4 h

ou

rs of ad

missio

n. Th

ere were 5

breach

es, all in A

&U

C:

- Two

assessmen

ts com

pleted

ou

tside 2

4 h

ou

rs of ad

missio

n b

ecause p

atients refu

sed an

assessmen

t initially, O

ne reco

rdin

g issue w

here alth

ou

gh assessm

ent co

mp

leted w

ithin

24

ho

urs b

ut w

as

entered

after 31

ho

urs o

f adm

ission

, On

e adm

ission

on

ly lasted 5

ho

urs an

d staff d

id n

ot get a ch

ance to

record

an assessm

ent w

hile p

atient w

as on

the w

ard w

hile o

ne reco

rd sh

ow

s no

eviden

ce

of P

HA

attemp

t with

in 2

4 h

ou

rs.

Of th

e 5 b

reaches (2

4 H

r PH

A M

easure) th

is mo

nth

, 3 (6

0%

) wen

t on

to receive a P

hysical H

ealth A

ssessmen

t with

in 7

2 h

ou

rs, 1 h

ad P

HA

77

ho

urs after ad

missio

n w

hile 1

adm

ission

has n

o P

HA

record

ed at th

e time o

f repo

rting th

is data. P

erform

ance b

y Service is as follo

ws; A

&U

C 9

5%

, CID

10

0%

, WLFS 1

00

%.

Data exclu

des B

road

mo

or reco

rds as th

ey are record

ed o

n EM

IS.

1.9

-K

PI0

22

A: %

of P

hysical h

ealthassessm

ent w

ithin

24

hrs o

f adm

ission

Data M

on

th 1

0 (Jan

20

18

)

Page 44 of 308

KP

I #A

ccess and

Waitin

g Time

Stan

dard

sExe

c

Lead

Plan

Qtr2

16

/17

Qtr3

16

/17

Qtr4

16

/17

Qtr1

17

/18

Qtr2

17

/18

Qtr3

17

/18

Au

g-17

Sep

-17

Oct-1

7N

ov-1

7D

ec-1

7Jan

-18

vs. Last

Mo

nth

Tren

dC

om

me

nts

KP

I07

9

% o

f Peo

ple exp

eriencin

g a first episo

de o

f psych

osis

treated w

ith a N

ICE ap

pro

ved care p

ackage with

in

two

weeks o

f referral - ove

rall Trust le

vel

SR5

0%

66

.0%

54

.2%

62

.7%

50

.8%

53

.2%

48

.7%

40

.0%

53

.0%

36

.0%

60

.0%

50

.0%

40

.0%

KP

I07

9A

Nu

mb

er of P

eop

le waitin

g mo

re than

two

weeks to

enter th

e Susp

ected First Ep

isod

e Psych

osis P

athw

ay -

EIS

SR1

66

81

01

61

0

KP

I07

9B

Nu

mb

er of P

eop

le waitin

g mo

re than

two

weeks to

enter th

e Psych

osis P

athw

ay - CA

MH

SSR

00

0

KP

I07

9C

Nu

mb

er of P

eop

le waitin

g mo

re than

two

weeks to

enter th

e Psych

osis P

athw

ay - Re

cove

rySR

13

11

12

12

11

11

KP

I08

0

IAP

T - % o

f referrals that fin

ish a co

urse o

f

treatmen

t in th

e repo

rting p

eriod

wh

o received

their

first treatmen

t app

oin

tmen

t with

in 1

8 w

eeks of

referral

SR9

5%

99

.9%

10

0.0

%9

9.7

%9

9.7

%9

9.9

%9

9.7

%9

9.9

%9

9.9

%9

9.4

%9

9.9

%9

9.7

%1

00

.0%

KP

I08

1

IAP

T - % o

f referrals that fin

ish a co

urse o

f treatmen

t

in th

e repo

rting p

eriod

wh

o received

their first

treatmen

t app

oin

tmen

t with

in 6

weeks o

f referral

SR7

5%

96

.1%

95

.9%

94

.0%

90

.5%

93

.5%

93

.7%

93

.4%

94

.1%

95

.6%

94

.9%

90

.5%

90

.1%

KP

I08

2A

vg Waitin

g times R

eferral to A

ssessmen

t (Ro

utin

e) -

Local Services (W

eeks)SR

4 w

ks4

.64

.25

.05

.54

.94

4.4

34

.33

.74

.14

.14

.6

KP

I05

0Elective In

patien

t: Bro

adm

oo

r Referral to

adm

ission

>12

wks (N

o o

f patien

ts)LM

12

wks

23

43

20

11

00

03

KP

I08

4N

um

ber o

f referrals accepted

to th

e service (Ealing

Ho

me W

ard)

SR1

23

31

36

91

40

21

06

81

09

81

28

63

52

38

83

96

44

14

49

46

3

KP

I08

5N

um

ber o

f claimed

avoid

ed ad

missio

ns (Ealin

g

Ho

me W

ard)

SR5

00

58

91

00

88

51

82

06

45

28

62

70

20

72

05

23

32

17

KP

I #Q

uality - C

linical Effe

ctiven

ess

ind

icators

Exec

Lead

Plan

Qtr2

16

/17

Qtr3

16

/17

Qtr4

16

/17

Qtr1

17

/18

Qtr2

17

/18

Qtr3

17

/18

Au

g-17

Sep

-17

Oct-1

7N

ov-1

7D

ec-1

7Jan

-18

vs. Last

Mo

nth

Tren

dC

om

me

nts

KP

I00

1%

Ad

missio

ns C

RH

T Gatekeep

ing

SR9

5%

92

.0%

91

.9%

94

.2%

97

.3%

99

.6%

99

.5%

10

0.0

%9

8.9

%9

8.5

%1

00

.0%

10

0.0

%1

00

.0%

KP

I00

2%

Delayed

Transfer o

f Care (Sitrep

) - All reaso

ns

SR&

LM<7

.5%

5.5

%6

.0%

8.5

%9

.2%

8.6

%4

.9%

9.1

%8

.4%

6.2

%5

.0%

4.3

%3

.8%

Th

is is a pro

vision

al figure su

bject to

sign o

ff by lo

cal auth

orities.

KP

I00

5D

ata com

pleten

ess: iden

tifies MH

SDS

SR>=9

7%

90

.4%

99

.3%

99

.2%

99

.2%

99

.2%

99

.3%

99

.2%

99

.3%

99

.2%

99

.3%

99

.3%

99

.3%

KP

I00

6D

ata com

pleten

ess MH

SDS: O

utco

mes fo

r Pts o

n C

PA

SR>=5

0%

51

.9%

52

.1%

51

.1%

51

.3%

50

.8%

51

.0%

50

.8%

50

.6%

50

.4%

51

.0%

51

.0%

51

.0%

A

verage of H

oN

OS 12 M

on

th R

eviews (71.1%

), CP

A p

atients in

Settled A

ccom

mo

datio

n (71.0%

)

and

CP

A p

atients in

Emp

loym

ent (9.0%

)

KP

I01

1%

Overall Tru

st Co

mm

un

ity DN

A rate (A

ll HC

Ps)

SR<1

5%

16

.0%

15

.8%

14

.7%

14

.5%

15

.0%

14

.9%

15

.0%

14

.7%

14

.8%

15

.0%

15

.0%

14

.4%

R

ecovery team

s 17%, EIS 19%

KP

I01

3%

Inp

atient R

eadm

ission

Rate fo

r Acu

te Local C

SU

(All ages an

d w

ards) (3

0 D

ays)SR

<8.1

%8

.3%

7.5

%6

.2%

3.8

%6

.1%

6.8

%6

.7%

5.8

%3

.2%

7.9

%1

1.3

%6

.3%

7 read

missio

ns w

ithin

30 days o

f disch

arge, 6 of th

em w

ere emergen

cy readm

ission

s.

KP

I #Q

uality - P

atie

nt Exp

erien

ceExe

c

Lead

Plan

Qtr2

16

/17

Qtr3

16

/17

Qtr4

16

/17

Qtr1

17

/18

Qtr2

17

/18

Qtr3

17

/18

Au

g-17

Sep

-17

Oct-1

7N

ov-1

7D

ec-1

7Jan

-18

vs. Last

Mo

nth

Tren

dC

om

me

nts

KP

I00

8N

um

ber o

f new

Co

mp

laints received

in p

eriod

(Trust)

SB

92

12

81

29

10

71

03

82

40

30

37

26

19

25

KP

I00

9N

um

ber o

f com

plain

ts no

t respo

nd

ed to

with

in

agreed tim

eframe (O

pen

)A

LL0

71

11

67

24

52

16

43

KP

I01

0N

um

ber o

f com

plain

ts respo

nd

ed to

ou

tside agreed

timefram

e (closed

) A

LL0

44

38

56

46

32

17

10

93

68

7

KP

I01

2%

Overall Tru

st Can

cellation

rate (All H

CP

s)SR

<5%

3.0

%3

.5%

3.8

%3

.0%

2.4

%2

.6%

2.1

%2

.5%

2.8

%2

.6%

2.4

%2

.9%

C

ID 6.4%

and

Eating D

isord

ers 7.3%

Qu

arterly Pe

rform

an

ce Tre

nd

2.0

Trust Su

mm

ary Scorecard

20

17-1

8

Data M

on

th 1

0 (Jan

20

18

)


Page 45 of 308

KP

I #Q

uality - P

atie

nt Safe

ty ind

icators

Exec

Lead

Plan

Qtr2

16

/17

Qtr3

16

/17

Qtr4

16

/17

Qtr1

17

/18

Qtr2

17

/18

Qtr3

17

/18

Au

g-17

Sep

-17

Oct-1

7N

ov-1

7D

ec-1

7Jan

-18

vs. Last

Mo

nth

Tren

dC

om

me

nts

KP

I01

4N

um

ber o

f Level 2 In

ciden

ts com

missio

ned

SB

68

54

13

46

12

11

2

KP

I01

5N

um

ber o

f Level 1 In

ciden

ts com

missio

ned

SB

33

22

26

20

13

15

36

38

44

KP

I01

6N

um

ber o

f Level 2 in

ciden

ts repo

rts overd

ue

ALL

01

31

31

21

58

99

88

89

8

KP

I01

7N

um

ber o

f Level 1 in

ciden

ts repo

rts overd

ue

ALL

02

63

03

53

95

51

55

14

53

KP

I01

8N

um

ber o

f Co

mm

un

ity Suicid

esJR

&SB

03

44

35

22

10

02

2

KP

I01

9C

PA

7 d

ay follo

w u

pSR

>95

%9

4.6

%9

3.5

%9

5.0

%9

5.8

%9

5.2

%9

5.8

%9

4.3

%9

4.9

6%

96

.4%

97

.1%

93

.8%

94

.7%

5 b

reaches o

ut o

f 95 'in sco

pe' d

ischarges. O

nly C

PA

disch

arges are repo

rted h

ere altho

ugh

trust

aims to

follo

w u

p all d

ischarges as a stretch

target.

KP

I02

0Service u

ser CP

A review

12

mo

nth

sJR

>95

%9

5.3

%9

5.5

%9

5.7

%9

5.5

%9

4.7

%9

2.0

%9

4.9

%9

4.1

%9

2.9

%9

2.0

%9

2.0

%9

5.0

%

Sou

rced fro

m M

HSD

S pu

blish

ed d

ata. Local D

Q rep

orts p

rod

uced

for o

peratio

nal m

on

itorin

g of

perfo

rman

ce sho

w im

pro

vemen

t from

Jan 2018

KP

I02

1%

of In

patien

t Risk A

ssessmen

t with

in 7

2 h

rs

adm

ission

BM

>95

%9

5.4

%9

6.8

%9

6.1

%9

6.5

%9

8.1

%9

6.7

%9

6.0

%1

00

.0%

96

.3%

96

.9%

97

.0%

97

.3%

3 b

reaches in

Access an

d U

rgent C

are

KP

I02

2A

% o

f Inp

atients P

hysical h

ealth assessm

ent w

ithin

24

hrs o

f adm

ission

JR&

SB>9

5%

n/a

n/a

n/a

70

.1%

80

.7%

94

.0%

76

.8%

94

.3%

92

.5%

93

.1%

96

.3%

95

.6%

A

bo

ve 95% target fo

r the seco

nd

con

secutive m

on

th. Th

ere were 5 b

reaches in

Jan, all in

A&

UC

.

KP

I02

3N

um

ber o

f Safeguard

ing A

du

lt Referrals m

ade to

Local au

tho

ritiesJR

13

62

32

13

71

41

13

51

41

60

35

64

50

27

48

KP

I #W

orkfo

rce Ind

icators

Exec

Lead

Plan

Qtr2

16

/17

Qtr3

16

/17

Qtr4

16

/17

Qtr1

17

/18

Qtr2

17

/18

Qtr3

17

/18

Au

g-17

Sep

-17

Oct-1

7N

ov-1

7D

ec-1

7Jan

-18

vs. Last

Mo

nth

Tren

dC

om

me

nts

KP

I02

4%

staff wh

o h

ave Ob

jectives Set for th

e finan

cial yearW

B9

0%

71

%7

9%

80

%3

8%

87

%8

8%

90

%9

0%

88

%8

8%

87

%8

8%

KP

I02

5%

Vacan

cy rateW

B<=1

0%

17

.1%

16

.9%

17

.0%

17

.0%

16

.3%

15

.8%

16

.1%

16

.5%

15

.5%

15

.7%

16

.1%

16

.3%

KP

I02

6%

Sickness rate

WB

<=4.1

%3

.8%

4.4

%4

.2%

3.7

%4

.1%

4.1

%3

.9%

4.0

%4

.0%

3.9

%4

.5%

5.2

%

KP

I02

7%

Spen

d A

gency

WB

<=5%

12

.5%

10

.9%

11

.7%

9.3

%8

.7%

8.0

%8

.4%

9.5

%8

.8%

8.4

%6

.8%

8.4

%

KP

I02

8C

om

plian

ce Overall M

and

atory Train

ing

WB

>85

%8

5%

85

%8

3%

86

%8

9%

88

.9%

88

.9%

89

.0%

88

.9%

89

%8

9%

90

%

KP

I02

9D

ignity at W

ork rep

orted

(new

cases)W

B0

01

00

11

01

01

00

KP

I03

0Tu

rno

ver rate (rollin

g 12

mo

nth

s)W

B1

2%

13

.9%

14

.0%

14

.2%

14

.9%

14

.7%

14

.9%

14

.5%

15

.3%

14

.8%

14

.9%

15

.1%

15

.1%

KP

I03

1A

verage Nu

mb

er of W

eeks to fill a vacan

cyW

B1

5 w

ks1

4.5

12

.61

5.0

11

.11

1.8

11

.11

2.0

9.4

7.4

11

.01

5.0

17

.0

The tim

e to h

ire has b

een

high

du

e to th

e ho

liday p

eriod

and

chan

ges with

in th

e team

KP

I #Fin

ance In

dicato

rsExe

c

Lead

Plan

Qtr2

16

/17

Qtr3

16

/17

Qtr4

16

/17

Qtr1

17

/18

Qtr2

17

/18

Qtr3

17

/18

Au

g-17

Sep

-17

Oct-1

7N

ov-1

7D

ec-1

7Jan

-18

vs. Last

Mo

nth

Tren

dC

om

me

nts

KP

I03

2Fin

ancial Efficien

cy - I&E Su

rplu

s Margin

(%)

PS

1.5

%0

.7%

0.8

%1

.4%

-1.4

%-0

.8%

0.2

%-1

.0%

-0.8

%-0

.4%

0.1

%0

.2%

2.2

%

KP

I03

3C

ash p

ositio

n versu

s plan

P

S+/- 1

0%

-1

6%

-7%

26

%5

1%

32

%5

8%

35

%3

2%

72

%7

5%

58

%7

5%

KP

I03

4C

apital sp

end

v plan

ratings

PS

+/- 10

%

28

%-2

4%

-24

%-3

5%

-43

%-4

6%

-43

%-4

3%

-44

%-4

5%

-46

%-4

7%

KP

I #Exte

rnal A

ssessm

ent in

dicato

rsExe

c

Lead

Plan

Qtr2

16

/17

Qtr3

16

/17

Qtr4

16

/17

Qtr1

17

/18

Qtr2

17

/18

Qtr3

17

/18

Au

g-17

Sep

-17

Oct-1

7N

ov-1

7D

ec-1

7Jan

-18

vs. Last

Mo

nth

Tren

dC

om

me

nts

KP

I03

7N

HSI - Fin

ancial R

isk Ratin

gP

S>3

33

33

32

23

22

22

KP

I08

3C

QC

- Warn

ing n

otices (En

forcem

ent A

ction

s)SB

00

00

10

00

00

00

0

KP

I04

1C

om

plian

ce with

IGT v1

4SB

Level 2l

Level

1

l

Level

1

l

Level

1

Aw

aiting

2017-18

too

lkit

Too

lkit

bein

g

po

pu

lated

Too

lkit

bein

g

po

pu

lated

Too

lkit bein

g po

pu

lated

Ke

y : lC

om

plian

t lR

isk of n

ot m

eeting target l

No

n-

Co

mp

liant

Pred

icted

Page 46 of 308


March 2018

Report title:

Finance Report month 10

Executive lead:


Report authors:




For approval


To note ✓






5889 / 8023



No

Item

9.1

: Dire

ctor

of F

inan

ce's

Rep

ort

Page 47 of 308



Improving quality


✓

Compassionate care


✓

Summary This paper provides the Committee with a summary of the financial performance for month 10 2017/18. The position for M10 is an improvement on the planned year to date position and shows

an underspend of £4,389k in month. The year to date position is a £4,725k underspend as

compared to a planned position of £568k. The improved position is the result of land sales

income being received earlier than anticipated in the Trust plan.

For the current month overall expenditure was better than the anticipated level, mainly due

to additional CIPs being achieved. It is planned that a continuation on this trajectory will

ensure both achievement of the 17/18 plan and a sustainable recurrent position moving

into 18/19.

It is now expected that the year-end target as set at month 3 will be over achieved. In

addition, following the annual asset revaluation, there is expected to be a significant

reduction in the cost of capital charges as compared to plan, as a result, the forecast

position shows an underspend of £8,007k.

It is still important that the financial recovery plans must continue to be closely monitored

through the Financial Oversight & Leadership Group which takes place monthly.

Page 48 of 308

WLM

HT B

alan

ced

dash

bo

ard 2

017

-18

Finan

cial - inco

me

and

Expe

nd

iture

Re

lated

CQ

C

Q&

R

Strategic

Aim

sFram

ew

ork

Target

Tren

dQ

tr 1

12

/13

Qtr 2

12

/13

Qtr 3

12

/13

Qtr 4

12

/13

Jan-1

3Fe

b-1

3M

ar-13

Ap

r-13

May-1

3Ju

n-1

3Ju

l-13

Au

g-13

Sep

-13

Oct-1

3N

ov-1

3Jan

-16

Feb

-16

Mar-1

6A

pr-1

6M

ay-16

Jun

-16

Jul-1

6A

ug-1

6Se

p-1

6O

ct-16

No

v-16

De

c-16

Jan-1

7Fe

b-1

7M

ar-17

Ap

r-17

May-1

7Ju

n-1

7Ju

l-17

Au

g-17

Sep

-17

Oct-1

7N

ov-1

7D

ec-1

7Jan

-18

Finan

cial Efficiency - I&

E Surp

lus M

argin (%

)SA

31

.5%

1.2

%1

.5%

1.7

%1

.6%

1.7

%1

.6%

1.6

%1

.0%

0.9

%0

.8%

0.9

%1

.0%

1.2

%1

.2%

1.3

%2

.2%

2.2

%2

.2%

2.2

%2

.2%

2.2

%2

.2%

2.2

%2

.2%

2.2

%2

.2%

2.2

%2

.2%

2.2

%2

.2%

2.2

%2

.2%

-1.4

%-1

.2%

-1.0

%-0

.8%

0.0

%0

.1%

0.2

%2

.2%

Cash

po

sition

versus p

lan

SA3

-10

% A

mb

er;

-30

% R

ed+8

%+1

4%

+36

%-1

%+2

%-4

%-1

%-1

%-6

%-9

%-1

4.0

%-2

%-4

9%

-51

%-5

3%

34

%-3

7%

34

%1

9%

23

%9

%-9

%-6

%-1

6%

14

%2

0%

-7%

24

%2

3%

26

%4

9%

51

%5

1%

45

%3

5%

32

%7

2%

75

%5

8%

75

%

Cap

ital spen

d v p

lan ratin

gsSA

3

+/-10

%

Am

ber; +/-

30

% R

ed

-44

%-2

6%

-31

%-2

%-2

3%

-19

%-2

%-6

7%

-46

%-3

9%

-33

%-3

4%

-31

%-3

5%

-30

%-1

0%

-8%

-7%

-43

%-4

4%

-26

%-2

5%

-27

%-2

8%

-26

%-2

4%

-24

%-2

3%

-24

%-2

4%

-57

%1

8%

-35

%-4

0%

-43

%-4

3%

-44

%-4

5%

-46

%-4

7%

CQ

UIN

- Linked

to In

com

e Loss *

Outco

me

05SA

4C

CG

s<=

5 % in

c. loss

Met

Met

Met

Met

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

tbc

Extern

al Asse

ssme

nt in

dicato

rs

CQ

C

Q&

R

Ou

tcom

e

s

Strategic

Aim

sFram

ew

ork

Target

Tren

dQ

tr 1

12

/13

Qtr 2

12

/13

Qtr 3

12

/13

Qtr 4

12

/13

Jan-1

3Fe

b-1

3M

ar-13

Ap

r-13

May-1

3Ju

n-1

3Ju

l-13

Au

g-13

Sep

-13

Oct-1

3N

ov-1

3Jan

-16

Feb

-16

Mar-1

6A

pr-1

6M

ay-16

Jun

-16

Jul-1

6A

ug-1

6Se

p-1

6O

ct-16

No

v-16

De

c-16

Jan-1

7Fe

b-1

7M

ar-17

Ap

r-17

May-1

7Ju

n-1

7Ju

l-17

Au

g-17

Sep

-17

Oct-1

7N

ov-1

7D

ec-1

7Jan

-18

FT mo

nito

r Finan

cial Risk R

ating**

SA3

>3n

/a4

44

44

44

33

34

44

44

44

NH

SI - Finan

cial Risk R

ating

SA3

TDA

Green

n/a

n/a

n/a

n/a

44

4n

/aA

mb

erA

mb

erA

mb

erA

mb

erA

mb

erA

mb

erA

mb

erA

mb

erA

mb

erA

mb

ern

/a3

33

33

33

33

33

33

33

23

22

22

% Sp

end

Agen

cy%

Spen

d A

gency

Outco

me

05SA

4<=5

%5

%6

%6

%7

%6

%7

%6

%6

%6

%6

%7

%7

%1

1%

13

%1

3%

11

%1

1%

12

%1

2%

13

%1

2%

12

%1

2%

12

%1

2%

12

%1

2%

10

%1

0%

9%

8%

8%

9%

8%

8%

6%

8%

Item 9.1.2: Board FinanceReport M10 - 2017/18

Page 49 of 308

Ex

ec

utiv

e S

um

ma

ry

Su

mm

ary

Ne

t I&E

Po

sitio

n

Pla

nA

ctu

al

Varia

nce

Pla

nned F

ore

cast

Fore

cast

Stre

tch fo

recast

Positio

nC

hang

e

Curre

nt

fore

cast

£000s

£000s

£000s

£000s

£000s

£000s

£000s

£000s

Sp

ecia

list &

Lo

ca

l Se

rvic

es

19

,71

21

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Page 50 of 308

BALANCE SHEET MOVEMENTS

PSPP

AGED DEBT POSITION

CASH FLOW POSITION

CAPITAL

Budget Actual Variance

Redevelopment capital 17,420 10,163 7,257

Operational capital 12,619 5,625 6,994

Trust agency usage

Balance Sheet and Cash flow position

Month 10 January 2017

Month 10 shows an upward movement on the balance sheet of £4.3m from month 9. This is mainly related to the disposal of Cricketfield Grove in month.

The Trust PSPP results remain strong to date with performance above target in 3 out of 4 areas. The average number and value of NHS invoices paid was 97% and 99%

respectively and the average number and value of non NHS invoices was 93% and 96% respectively. The PSPP target is 95%.

Since M10, the total value of NHS debt over 90 days has increased by £356k whilst total Non-NHS debt over 90 days has increased by £1.3m. Main reasons for the NHS

increase include queries from; Hounslow CCG re Dementia Liaison invoices (£135k); Ealing and Harrow CCG's re Glyn ward invoices (£117k) and NCA activity invoices

across several other CCG's (£104k). Of the Non-NHS figure over 90 days, over £1m relates to a contract variation re Safe/Brighter futures with the London Borough of

Ealing. £103k of this balance relates to salary overpayments.

The closing cash balance for M10 is £78m which is significantly above plan. The key reason is lower than expected expenditure on capital ytd. The expectation is that the

capital spend will be lower than plan for the remainder of 2017/18. As a result the end of year cash balance is forecast to be higher than anticipated and reduce in 2018/19 in

line with an increased capital programme.

Capital budget for 2017/18 is £34.5m. Capital expenditure as at M10 is £15.8m against a ytd budget of £30m. This represents a 47% ytd underspend. Broadmoor

Redevelopment is underspent as the programme is not running to plan. Medway Lodge is underspent by £3.6m.

Notes

High Secure redevelopment is currently not running to plan.

Projects currently underspending are Medway Lodge £3.6m, Environmental Improvement £696K,Ligature

reduction £390K,Compliance & regulation £317K,backlog £955k,Business as usual £352K, IT £644K and £240K

Brentford Lodge.

We over-delivered by £21k to end month 10 against our QCIPs target of £6,937k. The target for the year is £9.4m.

The Trust wide agency spend in M10 was 8.2%, (the same as the previous month). The Trust spent £1.2m on agency in January. The majority of expenditure continues to be

in Specialist and Local Services, £10.6m ytd.

Cost Improvement Programme (CIPs)

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Target Actual

Item 9.1.2: Board FinanceReport M10 - 2017/18

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Finance Month 10, January 2018

Summary Income & Expenditure as at 31st January 2018 Table 1

( £ '000 ) Current month Year to date Forecast Forecast

Budget Actual Variance Budget Actual Variance Budget Actual

Operating income (20,949) (11,156) 9,792 (210,315) (215,443) (5,128) (252,122) (260,304)

Operating Expenditure

Pay 14,760 15,442 682 147,760 152,245 4,485 177,249 177,363

Non-pay 3,100 (11,746) (14,847) 28,455 24,419 (4,035) 40,686 42,688

Total Operating Expenditure 17,861 3,695 (14,165) 176,215 176,665 450 217,935 220,051

EBITDA (3,088) (7,461) (4,373) (34,101) (38,779) (4,678) (34,188) (40,253)

Non-Operating Income/Expenditure

Interest Receivable (6) (23) (17) (61) (107) (46) (73) (140)

Interest Payable 207 207 0 2,072 2,072 0 2,764 2,792

Impairment 0 0 0 0 0 0 0

Discount unwound 0 0 0 2 0 (2) 2 2

Restructuring 0 0 0 0 0 0 0 0

Depreciation 1,049 1,049 0 10,548 10,548 0 16,017 12,666

PDC dividend 1,375 1,375 0 13,411 13,411 0 15,477 16,926

Net surplus/ deficit (463) (4,853) (4,390) (8,129) (12,854) (4,725) (0) (8,007)

Balance Sheet as at 31 January 2018 Table 2

( £ '000 ) 30/12/2017 31/01/2018Mvmt in

monthForecast Outturn ( £ '000 ) 30/12/2017 31/01/2018

Mvmt in

month

Forecast

Outturn

Fixed Assets 572,455 572,573 118 466,913 Financed by

Current Assets 105,089 99,134 (5,955) 58,896 Public Dividend Capital 392,444 392,444 400,605

Current Liabilities (57,552) (47,275) 10,277 (19,876) Revaluation Reserve 190,079 182,277 (7,802) 98,641

Total Assets Less Current Liabilities 619,992 624,432 4,440 505,933 I&E Reserve (47,670) (35,478) 12,192 (76,830)

Long term creditors (inc. loans) (83,605) (83,605) (81,817)

Provisions for Liabilities & Charges (1,534) (1,584) (50) (1,700)

Total Assets Employed 534,853 539,243 4,390 422,416 Total Capital & Reserves 534,853 539,243 4,390 422,416

15 Month Cash flow Table 3

Table - 4 Table - 5

Annual CIPs

allocated Annual forecast

CIPs allocated

to date

Achieved to

date Variance to date

Specialist & Local Services 4,477,357 3,619,155 3,245,918 3,006,214 (239,704) In Month Cumulative

High Secure services 1,343,643 790,000 1,147,690 785,025 (362,665) High Secure Services CSU (492) 813

West London Forensic services 2,849,000 1,530,958 2,126,213 1,217,774 (908,439)

Specialist & Local Services CSU (299) 1,817

Estates & Facilities 351,000 139,011 313,250 114,910 (198,340)

Other Corporate 397,000 3,324,000 103,686 1,833,686 1,730,000 West London Forensic services 405 4,266

CIPS managed centrally 0

undidentified CIPs 0 0 Clinical Service Units (386) 6,896

Estates & Corporate 748,000 3,463,011 416,936 1,948,596 1,531,660 Estates and Facilities 12 1,359

TOTAL 9,418,000 9,403,124 6,936,757 6,957,609 20,852 Other corporate (86) (645)

Land sales profit (3,321) (3,321)

Corporate & Estates (3,395) (2,607)

Central budgets (609) (9,014)

Operational (under)/o'spend (4,390) (4,725)

Budget (under)/o'spend (4,390) (4,725)

Run Rate 39.3% 2.2%

Director of Finance & Business

Cost improvement progress to date

Net Operational Income and Expenditure Budget Variances (£ 000s)

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

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Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Plan Actual

Capital Programme Expenditure Profile £000s Table 6

30,000

40,000

50,000

60,000

70,000

80,000

Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19

Forecast (annual plan) Actual

Page 52 of 308


March 2018

Report title:

2018-19 opening budgets

Executive lead:


Report authors:




For approval ✓


To note






5889 / 8023



No

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Improving quality


✓

Compassionate care


✓

Summary The purpose of this paper is to approve the 2018/19 budget for the Trust in advance of the start of the financial year, pending the final agreement of income contracts and submission of the financial plan to NHSI in April 2018. This paper outlines the 2018-19 anticipated income and expenditure budgets, along with the 2018-19 capital plan and the principles underpinning the budget setting process, which was approved by the Trust TMT in November 2017. The 2018-19 budget plans to deliver a £4.5m surplus, which includes £2m SFT funding. The figures provided in this paper reflect the annual plan which is expected will be submitted to NHSI in April 2018. The Trust is anticipating an income base of £258m, which includes net growth as per the national guidance. It should be noted that at the time of writing, both contract negotiations are still under negotiation and as such, further adjustments to the budget will be required pending the final outcome of these negotiations. The Trust has applied a £8.6m cost reduction target for 2018-19. The plan assumes the identified CIPs are delivered in full. Additionally, the plan assumes that we will continue to deliver the CIS service and it also assumes at this point in time 1% pay uplift for 2018/19.

Supporting documents and/or further reading Appendix A – I&E Appendix B – Capital plan

Trust board meeting (Part 1): March 2018

Page 54 of 308

Budget setting 2018-19

1 Purpose 1.1 The purpose of this paper is to provide the Board with an overview of the

anticipated 2018-19 income and expenditure budgets and capital plan including QCIP progress and outline the 2018-19 budget-setting principles. In addition to this it should be noted that the NHSI annual plan submission due in April 2018 is based on the assumptions contained within this paper.

2 Recommendations 2.1 The Board is asked to note the income and expenditure budgets along with the

principles underpinning the 2018-19 budget setting process. At the time of writing, both NHS England and CCGs contracts were under negotiation and as such, further adjustments to the budget will be required pending the final outcome.

2.2 Therefore a revised paper outlining the actual Income and expenditure budget will

need to be presented to the Board for approval once the negotiations have been concluded in line with the Trust’s Standing Orders, which requires Director of Finance to prepare and submit details of the Trust’s income and expenditure budgets to the Trust Board prior to the start of each financial year.

3 Introduction 3.1 The statutory duty of the Trust is to deliver a break-even position; however there is

an expectation that all Trusts should be planning for a surplus and hold a contingency to ensure they can continue to operate, without any external financial support, in the event of unforeseen cost pressures.

3.2 The Trust was notified in 2016 that a control total for 2018/19 of £5.5m surplus had

been set. However, further correspondence in February 2018 has advised that this target has been reduced to £4.5m as a result of national policy to support providers that had accepted and forecast to achieve their control totals for 2017-18.

3.3 In light of the above, the proposed budget contained within this paper includes a

planned £4.5m surplus. This assumes that the contact negotiation will deliver an income of £258m; furthermore it assumes that the CSUs/corporate services will deliver £8.6m of QCIPs and the all services will manage within their individual control total limits.

4 Income budgets 4.1 Contract Income 4.1.1 The Trust is anticipating a Service Level Agreement (SLA) income base of £258m.

This includes the 2% national efficiency savings and 2.1% cost inflation funding for 2018-19 on both CCGs and NHS England contracts.

4.1.2 It assumes that the Trust will continue to provide the CIS service for 2018/19.

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4.1.3 The budgeted income is made up income SLA block and cost per case income to

support patient activities, income from Service Increment for Teaching (SIFT), Postgraduate Medical Education (PGME), non-patient related income such as rent and recharges and Interest received. These are shown in Table 1a and Table1b:

Table 1a: Anticipated income for 2018-19

2018-19 anticipated income £’000

Operating Income from patient activities 245,388

Income from non-patient activities 12,543

Financing income (interest) 144

Total anticipated income for 2018-19 258,075

Table 1b: Anticipated income for 2018-19 shown by CSUs/areas

CSU/directorates 2018-19 anticipated income

£’000

West London Forensic service CSU 47,533

High Secure Service CSU 73,859

Specialist & Local Services CSU 123,996

Other Income 10,701

STF 1,986

Total anticipated income for 2018-19 258,075

4.2 Inflation uplift assumptions 4.2.1 Contract negotiations for the two main SLAs for 2018-19 (Forensic, High Secure,

and Specialist & Local Services) are on-going at the time of writing .Table 1 reflects the anticipated income values, which the NHSI annual plan submission is based on.

4.2.2 The forecast requirement for the Trust in 2018-19 is that all inflationary costs are

contained within the 2.1% inflation funding. However, these costs can only be funded if services deliver the required QCIPs. These costs include:-

• The national agreed pay changes including, pay awards and incremental drifts.

• The Inflation funding needed to cover specific non pay costs and inflation on external contracts. There will not be a general allocation of non-pay inflation across the Trust. This will only be allocated to specific non pay expenditure over which the Trust has no means of mitigating. This is in line with agreed budget setting principles.

Page 56 of 308

4.2.3 The proposed budget assumes that commissioners will continue to contribute 2% of the total contract value to support CQUIN schemes.

5 Expenditure budgets

5.1 The Trust is anticipating closing 2017-18 with a £8m surplus. In April 2017, the Board signed off a financial plan to deliver a £5.3m surplus. However, in quarter 3 it became apparent that the Trust would be in a position to deliver a bigger surplus as a result of underspend on capital charges and additional profit received on the planned land sale leading to a £8m forecast surplus.

5.3 Moving into 2018-19 the plan assumes a gross reduction in agency expenditure

(£3.3m) for the year compared to 2017/18 and is based on the agency cap of £12.6m set by NHSI. The current run rate of agency spend has improved from the start of 2017/18 so some of the necessary year on year reduction will be offset by existing actions and an improvement in the vacancy rate.

6 Capital plan 2018-19

6.1 We anticipate that the outturn position for the 2017/18 capital programme will be c£26m against an original plan of c£34.5m. Of this original plan £19m related to the High Secure redevelopment programme, £7m related to the Medway Lodge and £8.5m to operational capital. The underspend reflects £6.5m due to delays on the redevelopment programme and £2m on operational projects.

6.2 The capital plan for 2018/19 is £33.9m which has been submitted to NHSI for

approval. The plan consists of £17.5m for the High Secure redevelopment (including £6.5m underspend from 17/18, £8m for Medway Lodge with the remainder allocated to operational capital which will address some CQC issues raised to date. Details of the capital plan are shown in appendix b.

7 Budget-Setting Principles 2018-19

7.1 The budget setting principles was presented and agreed by the TMT in November 2017; these have been outlined below;

o The budget setting process is not an opportunity to bid for additional

resources internally to resolve overspends but a process to identify budgetary changes that will need to take place to better reflect changes to services and ensure the optimum allocation of resources.

o The recurrent budgets will be “rolled over” as the start-point for every

Directorate/CSU and will then be amended to reflect any anticipated or known SLA changes.

o Any cost pressures, no matter when they arise, that are not funded from the

inflation uplift in the SLA, or by specific agreement by Commissioners will

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need to be handled within the overall budget envelope of the directorate/service in which they occur.

o Any requirements for safer staffing or similar initiatives cannot result in

additional costs unless external funding is secured. If this is not possible there will need to be an adjustment to the level of service provided in order to maintain balance.

o Pay awards will be funded from within the SLA inflation uplift allocation.

o The budgets for CSUs are based on the services funded through the SLAs.

Unfunded services should not be provided unless the Trust Board has explicitly agreed such a position.

o The increase in capital charges where it is not related to a specific funded

business case will be funded from within the allocation in the SLA uplift inflation.

o The Trust needs to ensure income budgets are set at deliverable levels,

particularly in view of the financial pressures faced by commissioners. Income reductions need to be matched by corresponding expenditure budget reductions.

o The CSUs and corporate directorates are responsible for identifying

recurrent CIPs in line with the targets set by the Board.

o Where previous years efficiency targets have only been met non- recurrently or not met at all, those targets will still remain with that specific directorate/ service to address recurrently.

o Use of reference cost analysis has been developing and will be used to help

target cost efficiencies and ensure services represent value for money.

o It is for each Directorate/CSU to address and remove any negative budget lines within their service/CSU budgets.

8 Quality Cost Improvement Programme 2018-19 8.1 The Trust has applied a £8.6m cost reduction in 2018-19; this includes the 2%

national efficiency savings target on the total overall Trust budget plus any previously unmet QCIP targets. Therefore, a 2.8% cost reduction has been applied to the individual CSUs/corporate budgets, which also accounts for any exclusions from cost reductions such as capital charges and long term contracts.

8.2 Table 2 outlines the QCIPs target by each area. The plan assumes that the

identified QCIPs and the gap are found in full. Table 2: Financial efficiency plans by service

Page 58 of 308

Directorate 2018-19

CIPs QCIPs relating to previous years

Total

Specialist and Local Services 2,597 1,697 4,294

West London Forensic Services 825 684 1,509

High Secure Services 969 1,000 1,969

Estates & Facilities 308 105 413

Corporate 457 457

Total 5,156 3,486 8.644

8.3 Each QCIP scheme is required to be assessed and signed off by the Medical

Director and/or Director of Nursing and approved by the Trust Management Team (TMT). The Trust continues to hold a month Finance oversight leadership group which is chaired by the Chief executive and attended by all Executive and clinical directors who have overall responsibility for delivery of QCIPs and are held accountable for progress on each of their schemes. On-going assurance of their delivery will be monitored through the Finance and Performance Committee. This will ensure that corrective action is taken as soon as any variance arises. The findings of this committee will are shared with the Board.

9 Proposed Revenue Budget 2018-19

9.1 Appendix A shows the overall anticipated income and expenditure for 2018-19 9.2 The overall budget includes £14.7m of centrally held budgets including the £2.5m

surplus required net of STF funding. Pay and non-pay reserves will be allocated to the CSUs and corporate directorates during the year to fund specific unavoidable pressures as they materialise.

9.3 It should be noted that the 2018-19 pay uplift has not been published as yet,

therefore for planning purposes there is an assumed a 1% increase. This amount will be covered through the pay reserve which also includes reserves for consultant incremental drift and medical awards, which has not been announced at the time of writing.

9.4 The breakdown of the centrally held budgets is detailed below in Table 3 Table 3: centrally held budgets breakdown

9.5 The centrally held budget includes a minimum level of reserves to cover known

commitments, such as pay (including the pension change), non-pay inflation, and increase in interest payable.

Centrally-held budgets: Forecast overspend - WLFS 4,000

Pay reserves 4,000

Non-pay inflation 1,500

Contingency 2,822

Surplus (excluding STF) 2,470

Total 14,792

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9.6 If a new cost pressure arises expenditure can only be committed once the source of funding (i.e. the real reduction in expenditure) is also identified. It is not sufficient to simply identify why the over-spending arose - sufficient action will need to be taken to mitigate it.

9.7 The overall responsibility for every budget manager/director is to breakeven at year

end. Financial plans are a means to that end not an end in itself. The financial plans are a way of breaking down the task into manageable and measurable tasks.

10 Risk & Impact

10.1 All fully developed efficiency plans are evaluated and rated in relation to the financial risk i.e. the likelihood of it being delivered.

10.2 The locally managed risks are the inevitable unavoidable cost pressures that arise

in year. As a general principle as unavoidable cost pressures arise services need to identify how to manage them. If no additional funding from commissioners is available to cover a cost pressure, then the CSU/ directorate should plan to manage cost pressures from within their existing budget. This will mean prioritising expenditure, and making sufficient savings to meet these costs prior to authorising any expenditure. It is important that such savings are not only identified but also delivered, and that only the level of savings realised are utilised on the cost pressures.

10.3 In addition to cost pressures there are also risks that may arise in year and will

need to be managed across the Trust. The table below showing the key high level risks and mitigations has been agreed by the Executive Directors

Risk to Financial Plan Risk management/mitigation

2018-19 Contract outcome are not as planned

Negotiations on-going with CCGs and NHSE any reductions agreed will be linked to corresponding service reductions. Review the allocation of 2018-19 to the risk reserves until outcome is known.

Agreed QCIP are not delivered in full

All plans risk assessed Further cash releasing QCIPs are developed in order that the full efficiency target is delivered in year. Monthly monitoring of position and proactive intervention (special performance measures). Finance Director/Deputy Finance Director monthly meetings for any area judged to be high risk. Ensure that work streams are set up to review any partnership schemes are owned by the relevant CSUs/services.

Reduction in agency Weekly submission made to NHSI with reference to breach

Page 60 of 308

expenditure by £3.3m against agency cap TMT to review agency spend, recruitment activity and turnover rates

11 Conclusion 11.1 The Trust is anticipating income from SLAs to the value of £258m. 11.2 The Trust will begin 2018-19 with a recurrent balanced budget by utilising its

resources to meet the priorities of the organisation, and has planned to deliver a £4.5m surplus, however this is reliant on the Trust delivering £8.6m QCIPs and the CSUs managing within their budget. Furthermore it is dependent on the outcome of the 2018-19 contracting round and assumes any SLA reduction can be managed with a corresponding service/cost reduction and contained within the CSU allocated budget.

12 Recommendation(s) 12.1 The Board is asked to approve the revenue budgets detailed in Appendix A and the

capital plan in Appendix B

Paul Stefanoski Executive Director of Finance and Business

March 2018

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17

/18

20

18

/19

20

18

/19

20

18

/19

20

18

/19

20

18

/19

% o

f T

rust

N

on

ad

ditio

na

lre

duction

s to

Savin

gs

infla

tion

Expe

nd

iture

Fore

ca

st

Bud

ge

t R

ecu

rren

texpe

nd

iture

bu

dg

etexpe

nd

iture

bu

dg

et

Iden

tified

costs

bu

dg

et

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

West

Lon

do

n F

ore

nsic

CS

U36

,446

31

,560

87

3-4

88

35

432

,299

13

%

Hig

h S

ecu

re S

erv

ices C

SU

40

,533

38

,460

-1,4

69

1,3

93

-44

04

31

38

,375

15

%

Spe

cia

list &

Loca

l S

erv

ices C

SU

10

0,2

10

93

,798

-1,5

34

3,5

35

-72

7-1

,36

79

39

94

,644

37

%

Sub

to

tal

17

7,1

89

16

3,8

18

-3,0

03

5,8

01

-72

7-2

,29

51,7

24

16

5,3

18

64

%

Esta

tes a

nd

Facili

ties

18

,525

17

,382

-13

76

84

-30

32

85

17

,911

7%

Esta

tes a

nd

Facili

ties

18

,525

17

,382

-13

76

84

0-3

03

28

517

,911

7%

Corp

ora

te s

erv

ices

25

,130

24

,537

-22

41

50

0-5

00

20

124

,164

9%

Corp

ora

te s

erv

ices

25

,130

24

,537

-22

41

50

0-5

00

20

124

,164

9%

Cap

ital ch

arg

es/d

ep

recia

tion

25

,130

31

,494

-45

49

20

0-7

26

20

131

,435

12

%

Cen

trally

-he

ld b

ud

ge

ts4,9

63

9,6

36

2,2

30

3,3

42

-41

70

14

,791

6%

Tota

l e

xpe

nd

iture

25

0,9

37

24

6,8

67

-1,5

88

10

,897

-72

7-4

,24

12,4

11

25

3,6

19

98

%

(Su

rplu

s)/

Defi

cit

-8,0

07

-5,3

27

7,7

81

-1,1

68

3,5

55

-8,6

44

-65

3-4

,45

62

%

W

ES

T L

ON

DO

N N

HS

TR

US

T A

pp

en

dix

A

INC

OM

E &

EX

PE

ND

ITU

RE

FO

RE

CA

ST

20

18

-19

20

18

/19

In

co

me

20

18

/19

Ex

pe

nd

itu

re

Item

9.2

.1: A

ppen

dix

A -

Rev

enue

Page 62 of 308

Five Y

ear C

apital P

lan Y

ear 2

20

18

/19

AP

PEN

DIX

B

Sum

mary

Detail

201

8/19

plan

£K

N

otes / ju

stification

for n

eed

ing to

incu

r capital sp

en

d in

18/19

Bro

adm

oo

r Develo

pm

ent

Bro

adm

oo

r Red

evelop

men

t 1

7,34

6

Final year o

f schem

e, nee

ds to

be in

curred

in o

rder to

com

plete th

e

pro

ject h

aving alre

ady in

vest c£250m

. Had

pre

viou

sly anticip

ated

land

sale rece

ipt w

ou

ld b

e available in

year to co

ver this b

ut n

ow

nee

d to

use Tru

st cash to

cover tim

img d

ifference

and

therefo

re n

eed

add

ition

al

CR

L to allo

w th

is expen

ditu

re.

Med

way Lo

dge

Med

way Lo

dge P

roje

ct8

,000

A

s with

Bro

adm

oo

r the p

roje

ct has alre

ady started

and

it was in

tend

ed

that it w

ou

ld b

e covered

by sale rece

ipt b

ut n

ow

nee

ds to

be co

vered b

y

the tru

st from

its cash b

ut n

eed

s the C

RL in

ord

er to d

o th

is. The p

roje

ct

nee

ds to

be co

mp

leted d

urin

g 2018/19 in

ord

er that w

e main

tain o

ur

licen

ce to

pro

vide m

ediu

m secu

re service

s.

Land

sale S3 En

ablin

gLan

dsale en

ablin

g wo

rks 200

Sale o

f surp

lus lan

d o

n St B

ernard

s site will gen

erate cash fo

r futu

re

capital sp

end

, will re

du

ce b

acklog an

d o

ngo

ing m

ainten

ance

costs an

d

run

nin

g costs b

ut w

ork n

eed

s to start o

n p

rep

aring fo

r this in

ord

er that

we are in

aa po

sition

to m

arket the site o

nce

services are all re

located

.

Local Service

s Acco

mm

od

ation

C

IDS A

ccom

mo

datio

n St B

s 365

C

QC

reco

mm

end

ation

feb 17 - Th

e trust m

ust en

sure

that th

e ward

enviro

nm

ent an

d in

form

ation

pro

vided

to p

atients m

eets the n

eed

s of

patien

ts with

dem

entia o

r oth

er cogn

itive imp

airmen

ts. (CQ

CR

38).

Ward

Re-co

nfigu

ration

s HFM

HU

100

CQ

C fin

din

g feb 2017 - To

make service

s safer and

mo

re su

itable, th

is

inclu

des m

ovin

g an o

lder p

erson

s ward

to th

e grou

nd

floo

or to

imp

roved

accom

od

ation

and

facilitating im

pro

vemen

ts to th

e Clo

zapin

e services.

Bre

ntfo

rd Lo

dge

35

Trust is m

ovin

g servcies from

ren

ted acco

mm

od

ation

into

the b

uild

ing

ow

ned

by th

e trust th

ereby savin

g on

ren

ts and

maxim

ising th

e use o

f

existing estates b

ut so

me w

ork to

adap

t the site is n

eed

ed. Th

e pro

ject

com

men

ced

in 17/1

8 and

will co

mp

lete in M

ay 18.

Backlo

g / Regu

latory / En

viron

men

t P

LAC

E 300

CQ

C fin

din

g Janu

ary 18 - The tru

st sho

uld

ensu

re m

ino

r new

wo

rks and

imp

rovem

ents are carried

ou

t timely w

ay to p

rom

ote co

nd

usive

enviro

nm

ents fo

r the p

rom

otio

n o

f well b

eing o

f service u

sers.

Red

ecoratio

n P

rogram

me (5 year cycle)

150

CQ

C fin

din

g Feb 2017 - Th

e trust sh

ou

ld co

ntin

ue to

pro

vide lo

ng term

plan

s to en

sure

the p

atient en

viron

men

t pro

mo

tes the w

ell bein

g and

reco

very of service

users.

Min

or En

viron

men

tal Imp

rovem

ents

100

CQ

C fin

din

g Feb 2017 - Th

e trust sh

ou

ld co

ntin

ue to

pro

vide lo

ng term

plan

s to en

sure

the p

atient en

viron

men

t pro

mo

tes the w

ell bein

g and

reco

very of service

users.

Fire Safety

300

Co

mp

liance

imp

rovem

ent w

orks fro

m fire

risk assessmen

t

reco

mm

end

ation

s to p

rovid

e a safe enviro

nm

ent.

Listed B

uild

ings

200

Co

mp

liance

imp

rovem

ent w

orks to

adh

ere to re

qu

irem

ent in

the u

pkee

p

of listed

bu

ildin

gs and

english

heritage.

Item 9.2.2: Appendix B -Capital

Page 63 of 308

Backlo

g Main

tenan

ce: Lo

nd

on

900

C

om

plian

ce an

d im

pro

vemen

ts to en

sure

safe, suitab

le and

sufficien

t

enviro

nm

ents fo

r the p

ub

lic, staff and

service u

sers.

Backlo

g Main

tenan

ce: B

road

mo

or

800

Co

mp

liance

and

imp

rovem

ents to

ensu

re safe, su

itable an

d su

fficient

enviro

nm

ents fo

r the p

ub

lic, staff and

service u

sers.

Ligature

Red

uctio

n

300

To co

ntin

ue to

red

uce

the risk o

f suicid

e by re

mo

ving risks fro

m th

e

ligature

risk register in

line w

ith th

e Do

H d

rive to "Zero

Suicid

es".

Do

ors, Secu

rity, Fixture

s and

Fittings

100

To carry o

ut secu

rity and

safety wo

rks to th

e men

tal health

enviro

nm

ent

to en

sure

that service

users an

d staff are kep

t safe and

secure

in th

e

enviro

nm

ent in

wh

ich th

ey abid

e.

Wash

roo

m Im

pro

vemen

ts 100

C

QC

com

men

ts Feb 2017 - Th

e trust sh

ou

ld co

ntin

ue to

pro

vide lo

ng

term p

lans to

ensu

re th

e patien

t enviro

nm

ent p

rom

otes th

e well b

eing

and

reco

very of service

users.

S136 Imp

rovem

ent W

orks (N

ew

Stand

ards)

100

To carry o

ut co

mp

liance

wo

rks to m

eet the req

uire

men

ts of 136

Facilities.

CQ

C H

FMH

U Seclu

sion

Ro

om

s 330

CQ

C fin

din

g Feb 2017 -Th

e trust m

ust en

sure

that th

e Ham

mersm

ith an

d

Fulh

am m

ental h

ealth u

nit seclu

sion

roo

ms are lo

cated so

they can

be

used

safely and

that p

atient tran

sfer to seclu

sion

facilities do

es no

t

com

pro

mise th

e patien

t’s privacy an

d d

ignity. (C

QC

R6)

CQ

C K

estrel Seclu

sion

Ro

om

, Lakeside

110

CQ

C fin

din

g Feb 2017 - Th

e trust m

ust en

sure

that Lakesid

e seclusio

n

roo

ms are lo

cated so

they can

be u

sed safely an

d th

at patien

t transfer to

seclusio

n facilities d

oes n

ot co

mp

rom

ise the p

atient’s p

rivacy and

dign

ity.

(CQ

CR

6)

CQ

C 136 Su

ite Imp

rovem

ents Lakesid

e50

C

on

tinu

ation

of w

orks to

pro

vide ven

tilation

and

coo

ling to

com

ply w

ith

the 136

Facility reco

mm

end

ation

s.

CQ

C C

IDS En

viron

men

tal Imp

rovem

ents

100

CQ

C fin

din

gs Feb 2017 - Th

e trust sh

ou

ld en

sure

that w

ards are w

ell

deco

rated, w

ell main

tained

and

free fro

m o

do

urs. Sp

ecific wo

rks in all

CID

S ward

s, inclu

din

g deco

ration

s, enviro

nm

ental im

pro

vemen

ts, access

and

han

drails.

Wells U

nit R

efurb

ishm

ent

100

Imp

rovem

ent w

orks to

meet co

mp

liance

in th

e pro

vision

of h

ot an

d co

ld

water service

s, seclusio

n facilities an

d th

e ward

enviro

nm

ent

Oth

er85

THW

Enviro

nm

ental Im

pro

vemen

ts TH

W En

viron

men

tal Imp

rovem

ent P

roje

ct 400

C

QC

find

ing Feb

2017 - The tru

st mu

st loo

k at the p

hysical en

viron

men

t

in th

e Ton

y Hillis W

ing to

see if chan

ges can b

e mad

e to im

pro

ve the

safety and

qu

ality of th

e enviro

nm

ent. Th

is inclu

des th

e redu

ction

of

ligature

anch

or p

oin

ts and

access to

sufficien

t toilets an

d b

athro

om

facilities.

Bu

siness Tech

no

logy

Bu

siness Tech

no

logy P

roje

cts1

,500

see sep

arate pap

er

Bro

adm

oo

r Retain

ed Estate

Bro

adm

oo

r Retain

ed Estate P

roje

cts 500

To

pro

vide a co

mp

liant en

viron

men

t.

Oth

er pro

jects

Oth

er small in

year pro

jects

776

THQ

Re-lo

cation

and

/or o

ccup

ancy m

aximisatio

nSo

urcin

g suitab

le alternative acco

mm

od

ation

for likely n

eed

s50

Pad

do

ck Refu

rbish

men

ts P

add

ock re

furb

ishm

ent p

roje

cts inc w

ind

ow

s500

Totals

Totals

33,8

97

Page 64 of 308

Report summary Trust board meeting: Part 1 (in public) Part 1

March 2018

Report title:

Medical Director

Executive lead:

Dr Jose Romero-Urcelay

Report authors:

Medical Director


N/A


For approval ✓


To note ✓

Relates to? Strategy & Planning

Quality & Safety


Legal & Governance




No


Item

10.

1: M

edic

al D

irect

or's

Rep

ort -

Mar

ch 2

018

Page 65 of 308


Improving quality


Compassionate care


Summary This report is to provide the Trust Board with an update on:-

• Medical Management

• Medical Education

• Safeguarding

• Research and Development

• Quality Improvement


Page 66 of 308

Trust board meeting (Part 1): 14th March 2018

Medical Director’s Report

1. Purpose 1.1. To inform the board regarding particular developments related to the Medical Director’s

portfolio of responsibilities.

2. Recommendations

2.1. The board is asked to note the report.

3. Areas of responsibility 3.1. Medical Management

Management of the Trainee Doctors on-call rotas continues to present a significant challenge. There are significant vacancies particularly in the Specialist Trainees rotas from April 2018. Medical HR and I have held several meetings with Specialist Trainees representatives and have also met the chairs of the Medical Advisory Committees. Any decision is likely to have a significant impact on consultants who will be likely be required to step down to cover the ST rota gaps. As a consequence it is more than likely than clinical day activities will be affected. I have convened an extraordinary consultants meeting on 21st of March to present to consultants the magnitude of the challenge, proposed options to cover gaps and seek their views. Wendy Brewer and Sarah Rushton have been invited to attend the meeting. The trust has received the NCISH Safety Scorecard (National Confidential Inquiry into Suicide and Homicide by People with Mental Illness)

West London Mental Health NHS Trust.docx

3.2. Medical Education Progress is being made with the HEE action plan and the Streamlining Project HEE has received the Trust’s return for consultant trainer accreditation – the DME is working prospectively with newly appointed consultants to ensure their completion of the required training to enable their accreditation to be trainers A programme of work is underway to re-develop 50% HEE funded CT posts within WLFS within other CSU’s and to also maximise CT post offers within AUC inpatient services. These posts are at risk of decommission by HEE due to trainer capacity issues and changing programme demands, the potential to maximise fill into new posts will bring considerable advantage to our manpower, on call and training offer and this work is attracting strong interest from HEE

Item

10.

1: M

edic

al D

irect

or's

Rep

ort -

Mar

ch 2

018

Page 67 of 308

The GMC Regional Liaison Adviser will co-host an event in May with the DME for trainees to address issues raised by the Bawa-Garba case A strategy for the inclusion of Foundation2 trainees in the first on call rota is in development Trainee feedback remains generally positive

3.3. Safeguarding The Trust has completed self-assessment audits against compliance with Section 11 of the Child Act for both the boroughs of Hounslow and Ealing. These audits have been presented to the Local Safeguarding Boards and there are plans in place to develop safeguarding in the Trust further in keeping with these audits. No areas of concern were identified. A similar audit is being prepared for Broadmoor for the LSCB.

The Trust has completed and presented a self-assessment audits for safeguarding adults to Ealing and Hounslow Boards.

There has been no notice as yet for similar audits in respect of services in Hammersmith.

The safeguarding team have established safeguarding clinics in all three boroughs to support staff with safeguarding practice. Further support to staff in respect of the principles of making safeguarding personal is also being emphasised through safeguarding team members joining community meetings on the wards in local services to empower service-users users.

No specific progress on SCR’s and learning reviews – progress is being made and publication expected in March and April.

The Local Authority of Hammersmith and Fulham is resuming sovereign authority and exiting the arrangements previously shared with the Boroughs of Kensington and Chelsea and Westminster from the 1st of April. This has no impact on safeguarding arrangements or practice for Trust staff members in respect of safeguarding service-users. Safeguarding Board arrangements will be reviewed with stakeholders in due course but remain unaltered at present.

3.4. Research and Development

Dr. Scholtz will be presenting the proposed R&D strategy at the March board meeting for consultation and approval. This will be an opportunity for the board to comment on the planned diversification and expansion of research across the Trust. Recommendations and findings from the Noclor audit of the research delivery service are being reviewed and implemented as necessary. Recruitment figures show a promising rise with the introduction of the R&D clinical studies officers. The posts for research manager of the research delivery service and Research lead for Mood and Psychosis will be recruited to in early April.

3.5. Quality Improvement

The Head of Quality Improvement post has been advertised nationally. Interviews are scheduled for the 20th of March. On 7th of March we held the Graduation Ceremony for the 3rd cohort of QSIR (Quality, Service Improvement and Redesign) training. To date approximately 120 staff have attended the training programme. Cohort 4 is due to start training during March

Page 68 of 308

4. Recommendation

The Board is asked to note the content of this report.

Dr Jose Romero-Urcelay Medical Director

March 2018

Item

10.

1: M

edic

al D

irect

or's

Rep

ort -

Mar

ch 2

018

Page 69 of 308

the national confidential inquiry into suicide and homicide by

people with mental illness

Professor Louis Appleby

PO Box 86,

Manchester M20 2EF

Tel: 0161 275 0700/1 Fax: 0161 275 0712

www.manchester.ac.uk/nci

26 February 2018

Dear Dr Romero-Urcelay,

Re: National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH)

Safety Scorecard

Please find attached the NCISH Safety Scorecard for your trust, accompanied by an information sheet for you to consider.

The NCISH Safety Scorecard has been developed in response to the request from our commissioners, the Healthcare

Quality Improvement Partnership (HQIP), for benchmarking data to support quality improvement. Also, trusts often ask

us how their figures compare to other trusts around the country. We are therefore providing this information for you to

consider internally - we will not give this information directly to any other organisation. Whilst considering the NCISH

Safety Scorecard you may wish to refer to our ten key elements of safer care in mental health services from our latest

annual report - key safety measures that trusts can make, which you can download from our website

www.manchester.ac.uk/nci

The information in the scorecard is based on data that we hold for you, provided by you. The scorecard consists of 6

indicators that relate to the work of NCISH: suicide rate, homicide rate, rate of sudden unexplained death (SUD), patients

under the Care Programme Approach (CPA), staff turnover and NCISH questionnaire response rate. The CPA and staff

turnover figures are taken from NHS Digital data, which in turn are taken from individual trusts.

The figures show the range of results across trusts in England in addition to your own position that is represented by an

‘X’. If you would like to see the actual score for your trust, place the cursor over the “X”.

We will contact you in 4-6 weeks to ask for brief feedback on the NCISH Safety Scorecard, and whether you have found

this information useful within your trust.

Yours sincerely,

Professor Louis Appleby

Director, NCISH

Item

10.

1.1:

Med

ical

Dire

ctor

'sR

epor

t - A

ppen

dix

1

Page 70 of 308

Trust Scorecard: West London Mental Health NHS Trust

The figures give the range of results for mental health providers across England, based on the most recent available figures: 2013-

2015 for suicides, homicides and sudden unexplained deaths (SUD), 2016-17 for people on the Care Programme Approach (CPA), 31

October 2016 – 31 October 2017 for non-medical staff turnover and 2012-17 for trust questionnaire response rates. ‘X’ marks the

position of your trust. Rates have been rounded to the nearest 1 decimal place and percentages to whole percentage numbers.

Suicide rate The suicide rate in your Trust was 5.88 (per 10,000 people under mental health care) between 2013-15.

Homicide rate The homicide rate was 0 (per 10,000 people under mental health care) between 2013-15.

Sudden unexplained deaths (SUD) The SUD rate was 5.5 (per 10,000 hospital admissions) between 2013-15.

% on CPA The % of patients on CPA was 10% in 2016-17.

Staff Turnover Non-medical staff turnover was 15% between 31 October 2016 – 31 October 2017.

NCISH questionnaire response rate You have returned 95% of NCISH questionnaires between 2012-17.

Median = 7.10

0.0 5.0 10.0 15.0

Suic

ide

s

Rate

Median = 0.24

0.0 0.2 0.4 0.6 0.8

Ho

mic

ides

Rate

Median = 0.00

0.0 1.0 2.0 3.0 4.0 5.0 6.0

SUD

Rate

Median = 10%

0% 10% 20% 30% 40% 50% 60%

CP

A

% on CPA

Median = 15%

10% 15% 20% 25% 30% 35%% Turnover

Staf

f Tu

rno

ver

(No

n M

edic

al)

national rate 98%

85% 90% 95% 100%Response rate

Qu

esti

on

nai

re

resp

on

se r

ate

Page 71 of 308

National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH) Safety Scorecard:

FAQs

Why have you sent us this information?

This information has been collected in response to the request from our commissioners, the Healthcare Quality Improvement Partnership (HQIP), to provide benchmarking data to support quality improvement in mental health trusts. We have also received requests directly from mental health service providers for similar information. What will this scorecard be used for? The NCISH Safety Scorecard has been prepared for your information only, to support quality improvement in your trust. We will not share the information directly with any other organisation. The NCISH Safety Scorecard consists of 6 indicators that relate to the work of NCISH: suicide rate, homicide rate and rate of sudden unexplained death (SUD), patient under CPA, non-medical staff turnover, and NCISH suicide, homicide and SUD questionnaire response rate. Why do you use these indicators? Suicide, homicide and SUD cases are the core data collections of NCISH. We send questionnaires to clinicians in trusts for detailed information on these cases, and trust response rates are based on the questionnaire returns. A number of mental health reports have indicated CPA is underused to safeguard patients. Our own research on suicide in the post-discharge period has shown that being under CPA was a protective factor for service users. In a recent report, we also found that non-medical staff turnover was associated with increased suicide rates. The report can be accessed via the link: http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/serv_features.pdf Where do you get the data from? Suicide and homicide

Suicide and homicide data are collected as part of NCISH for individuals aged 10 years and older who died by suicide or

who were convicted of homicide (murder, manslaughter and infanticide) in England. These data are provided by the

Office for National Statistics (ONS).

A proportion of these individuals had been in contact with mental health services in the 12 months prior to death or

homicide (i.e. patient suicides, patient homicides). Based on the information from your trust, we identify the clinicians

who had been caring for the patient and collect detailed clinical information about their care. Therefore, the data given

in the NCISH Safety Scorecard represents patients who had been in contact with your services in the 12 months prior to

death or homicide, notified to us by your trust.

Sudden Unexplained death (SUD)

All individuals who die on an in-patient mental health ward are identified from the Hospital Episode Statistics (HES)

database. From these data, we identify the clinician who had been caring for each patient. Based on the information

from the clinician, we determine whether the patient meets the criteria for inclusion in the study. Where the patient

meets the criteria, detailed clinical information about their care is collected.

CPA and staff turnover

CPA data and staff turnover data provided by your Trust are obtained from NHS Digital (formerly the Health and Social

Care Information Centre (HSCIC)). Non-medical staff is defined as all staff excluding doctors. CPA data are available from

the Mental Health Services Data Set (MHSDS formerly Mental Health and Learning Disabilities Data Set (MHLDDS)).

MHLDDS was superseded by the MHSDS on 1 January 2016. CPA figures for the financial year 2016-17 here are

therefore based on estimates using MHLDDS methodology prior to the instigation of the MHSDS. CPA and staff turnover

data are in the public domain on the NHS Digital website http://content.digital.nhs.uk/mhldsreports.

Denominator data

Denominator data used to calculate patient suicide and homicide rates are obtained from the MHSDS (formerly

MHLDDS). These are the number of people in contact with adult and elderly secondary mental health services which are

submitted to NHS Digital by the trust. Denominator data for SUD rates are the number of admissions per hospital.

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NCISH questionnaire response rate

This provides the current rate of response between 2012-2017 for suicide, homicide and SUD questionnaires in your

trust, in comparison to the national average. We would like to emphasise that these are not response rates for

individual consultants but apply to the trust as a whole.

If you feel the data presented in the NCISH Safety Scorecard for your trust are incorrect please contact the person

within your trust responsible for returning data. You can inform us that you are looking into data quality issues by

emailing us at [email protected]

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Report title: Director of Nursing and Patient Experience’s Report

Executive lead: Stephanie Bridger, Director of Nursing and Patient

Experience

Report authors:

Stephanie Bridger, Director of Nursing and Patient Experience


N/A


For approval


To note ✓




Legal & Governance

Relationship to Board Assurance Framework? Are any existing risks in the Board Assurance Framework affected?

✓


BAF 7838


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Relationship to Trust strategic objectives? Outstanding We coordinate and collaborate – to deliver holistic care


Improving quality


✓

Compassionate care


✓

Summary

A standing report is given on the matters of note relating to the responsibilities of the Director of Nursing and Patient Experience. This report notes matters arising since the February 2018 Board meeting.

Supporting documents and/or further reading N/A

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Trust Board meeting (Part 1): 14th March 2018

Director of Nursing & Patient Experience’s Report

1 Purpose 1.1 This report gives the Board an update on matters relating to the responsibilities of the

Director of Nursing and Patient Experience. 2 Recommendation 2.1 The Board is asked to note the contents of this paper. 3 Issues and activity 3.1 Since the last Board I have undertaken a number of clinical visits. In Local Services I

have visited both Lakeside and Hammersmith and Fulham Mental Health Units. I visited the Orchard with the Executive Director for High Secure and Forensic services and also facilitated an informal visit with the CQC at the Tony Hillis Wing.

3.2 I have attended a listening event with the CEO at the Cafe on the Hill at St Bernard’s

site on Monday 19th February. 3.3 I attended a nursing recruitment event for final year nursing students where a

significant number of nurses attended despite the weather; 34 positions were offered. The other 20 students who were not able to attend will be followed up. I spoke to nurses who were keen to work on both Meridian and Jubilee Wards and also Horizon which is hugely positive given the challenges we have recruiting to these specific areas.

3.4 I will also be attending the London wide Mental Health Directors of Nursing Group. 4 Care Quality Commission Quality Improvement Plan 4.1 Progress relating to the CQC Quality Improvement Plan continues to be discussed on

a monthly basis at the CQC Working Group and Quality Committee. 4.2 The report for the re-inspection for the adults of working age wards and PICU was

published on Wednesday 28th February 2018. The re-inspection was not rated however it was noted there was good progress being made in all areas, particularly our bed management and capacity. There remains in place 5 regulatory notices, the action plans to address these need to be completed by the 26th March. Work is already underway to address the areas identified.

4.3 This re-inspection will allow the trust to take stock of, and review the current CQC

Quality Improvement plan. Service lines have been asked to write summary reports for their local improvement plans. This will allow for a transition period between a move to the run charts and exception reporting for key quality and patient safety indicators.

4.4 A stand alone Estates and Facilities plan will be pulled together covering all service

lines. This will link to the existing Estates Strategy with clear timelines for delivery

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around CQC compliance areas. A review of ligature anchor points and risk assessments has been undertaken by the Head of Health and Safety and a further review of lines of sight. Outstanding work will have an agreed timeline for delivery.

4.4 During my meeting with the CQC on 1st March I was informed that the lead inspectors have all been asked to collate information about inpatient deaths since the 1st September 2017. The request is to double check the accuracy of the information the inspector already has. This request is already being dealt with and a response is required by the end of March.

4.5 During this meeting I was also informed that the CQC have been asked to provide additional reports relating to Broadmoor of progress towards compliance and outstanding requirement notices to the National Oversight Group on a quarterly basis. Dates have been provided when additional information will be requested and the Executive Director for High Secure and Forensic Services has been made aware of this.

4.6 I was also informed that the lead inspector Victoria Hart and her direct line manager Emily Weston have requested to attend the Trust Board meeting in May 2018.

5 Quality Risk ProfileTool (QRPT) 5.1 Following further discussions amongst external stakeholders (commissioners, CQC,

HEE, NHSI and NHSE) regarding the previously raised quality, patient safety and safeguarding concerns raised in 2017, it has been proposed that the QRPT review should transition from an ‘assessment’ phase, to a ‘monitoring’ phase.

5.2 The six areas that were identified for continued vigilance, following the QRPT review,

were themed under the following descriptors:

• Safety and learning from incidents

• Improving the environment

• Developing clinical pathways

• Reducing delayed transfers of care

• Implementing the plan following the CQC inspection

• Developing and securing the workforce and associated staffing

5.3 Stakeholders and commissioners have informally reported that there has been positive progress made in many of the areas identified. This progress has also been evidenced in the recent CQC re-inspection report, and the latest HEE feedback. It has been stressed by all parties that although good early progress is being made, the need for sustainability and momentum remains the priority.

5.4 Following discussions between stakeholders and the Trust, it has been suggested that each of the above ‘themes’ should be supported and monitored in order to seek assurance through the provision of credible evidence and oversight. Ealing CCG, as the lead commissioner will take the lead on monitoring and supporting the Trust, with the expectation that specialist stakeholders will assist when requested.

5.5 The details specific to the priority, frequency and format of on-going monitoring and

oversight remain to be agreed with Ealing CCG. However, it is likely that they will link closely to the Trust CQC Action Plan, and that the vehicle(s) for monitoring will include

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monthly CCG–led Clinical Quality Groups, topic specific assurance meetings with commissioners, and supportive clinical visits where appropriate.

6 Capital Nurse Foundation Programme 6.1 We are planning on establishing a 3rd Cohort of Capital Nurses to commence in

September 2018. The Nursing Directorate provides central oversight of the programme, which requires considerable co-ordination, monitoring, support and ongoing evaluation and development.

6.2 During 2017/18 these oversight and development functions have been achieved with

funding from Health Education England. An update is expected from Health Education England in April 2018 on the outcome of our application for further funding for 2018/19.

6.3 A recruitment event took place on 1st March where 34 third year nursing students were

offered jobs within the Trust. As outline in the ‘issue and activities’ section of the paper some nurses had specifically asked to work in what are hard to recruit areas.

7 Nursing Degree Apprenticeship 7.1 Staff from the Trust and Central and North West London NHS Foundation Trust

(CNWL) have joined together with Bucks New University to launch a new Nursing Degree Apprenticeship.

7.2 This exciting new programme gives healthcare support workers the opportunity to

pursue a career in nursing through a fully funded apprenticeship programme. Together with CNWL, we are one of the first trusts in London to offer this degree level opportunity.

7.3 Each trust held its own individual assessment centre to select from the huge amount

of interest they received. Those that passed the first stage of selection came together at the university selection event, which included talks from the university staff, literacy and numeracy assessments, group interviews and individual interviews, ensuring the apprentices received the same selection process as all other degree level students.

7.4 The trust have selected 13 staff to go forward for the Nursing Degree Apprenticeship.

Work is underway to agree the host wards/teams for the apprentices and once the university confirms the staff places on the apprenticeship programme, we will have a launch and welcome event on 29th March 2018.

8 Allied Health Professional (AHP) update

8.1 Plans are underway for a student AHP conference on 9th April 2018. This is being used as a way of continuing to build on existing relationships with our health education institution (HEI) partners. It will also be an excellent continuing professional development (CPD) opportunity for the AHP students who come to the Trust for their clinical placements. Ian Merrick (Professional Lead Occupational Therapist, Community Mental Health) and Sarah Kramer (Speech and Language Therapy Manager), have led on this development and should be thanked for their hard work with this.

8.2 On Wednesday 7th March a group of senior AHP staff facilitated a debate at Brunel University for their AHP undergraduate students. The debate is on the theme of Ite

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extended roles and working beyond existing AHP scopes of practice. It is hoped this will encourage student AHPs to think about their roles within the multi-disciplinary team (MDT); what their current offer is; what their unique skills are and what they could offer beyond this that would support the work of the MDT and reduce duplication of processes for patients and carers. This is the first time the Trust has facilitated such an event and is an innovative approach to strengthening our relationships with Brunel University. Leah Madnick has co-ordinated this event as part of her Darzi Fellowship.

8.3 Early discussions have begun with our neighbouring Trusts CNWL and Hounslow, Richmond Community Healthcare NHS Trust (HRCH) about working in partnership to procure a HEI to deliver the occupational therapy apprenticeship degree programme which is in the final stages of its development. There is precedent in that this is a similar arrangement developed for the nursing apprenticeship. It is not therefore envisaged there will be any significant challenges with moving this forward and there is definite interest across the STP footprint in ensuring that Trusts are able to utilise the apprenticeship levy for the benefit of the AHPs. Further updates will be provided going forward.

9 Service User and Carer Involvement 9.1 The service user and carer strategy continues to need further work to give more detail

to the underlying principles set out in the initial draft. This will enable us to develop a clear delivery plan. It is hoped that this will be done by the latest May 2018.

9.2 An initial review of the trusts recovery strategy has been undertaken this is being

presented to the Service User and Carer sub-committee on 13th March. It is hoped that this will enable us to review achievements so far, and identify what further work needs to be undertaken.

9.3 The formal contract for West London Collaborative is nearly ready for sign off. I have

regular meetings with the CEO and we are currently in the process of discussing projects for the forthcoming year.

10 Triangle of Care (ToC) 10.1 We continue to work towards submitting our stage one progress report to the Carers

Trust. The submission is due on 13th March 2018, however, we have requested a further extension, of up to three months, to help us achieve greater service user and carer engagement in authoring the final submission report as well as provide our partner service user and carer groups with more time to shape this work.

10.2 Additional time to provide the stage one report is also in keeping with the fact the trust

has had a larger than average number of self-assessments to complete and report upon in stage one (with a total of 51 inpatient wards and 3 crisis teams).

10.3 The request for an extension is fully supported by the trust ToC Working Group

membership, inclusive of service users and carers. If an extension is agreed, this would not delay the commencement of stage two, which sees the roll out of self-assessments throughout community services from April 2018.

10.4 As previously reported, our trust ‘Carer Awareness Training’ will be piloted in March

2018 and evaluated by service users, carers and staff before roll-out Trust wide. The roll-out of the training will require a number of staff, service users and carers to be trained as facilitators. The training will be offered locally within services to ease the

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release of staff. The training has incorporated and builds upon the existing Carer Awareness Training developed within HSS last year.

10.5 I continue to work with an Ealing carer on a collaborative pair’s project, this relates to

the implementation of the Triangle of care. The project a present is focused on Ealing West Community Recovery Team. I also attended an Ealing Carers meeting on 13th March.

11 Nursing Conference 2018 – Celebrating Good Practice 11.1 The trust wide nursing conference took place at Twickenham Stadium on Friday 2nd

March. Despite the poor weather over a hundred staff attend the conference. 11.2 The conference was focused on celebrating good practice and staff health and well

being. 11.3 There were a variety of ‘bite-size’ good practice sessions. These were:

• Nursing role in early intervention in psychosis – Experience of setting up a nurse-led physical health clinic

• The NEWs score in intermediate care

• Nursing achievements within Cognitive Impairment and Dementia Services

• Where is Wally the wheelchair – Improving the safe management of wheelchairs in the trust

• Changing the culture in an intensive care unit – Cranfield Ward, Broadmoor Hospital

• Implementation of ‘Safe Wards’ in West London Forensic Services

• What is it like living in a psychosocial psychodynamic community? – from a nursing and patient perspective – the Cassel

• Capital Nurse one year on: What have we learned? 11.4 There were also wellbeing sessions which included massage and mindfulness.

Unfortunately Laughter Yoga – Hands on at Work were unable to make it, however we had a lively Zumba session after lunch. We were also able to facilitate two stadium tours. Initial feedback from the day was extremely positive. The conference will be formally evaluated and the findings used to inform future events.

12 Emergency Planning Response and Resilience (EPRR) 12.1 The EPRR Lead for the Trust James Harris provided severe weather impact

assessment during the severe weather that was experience during the week commencing the 26th February 2018.

12.2 The Tony Hillis/Wolsey Wing (Ealing) experienced heating problems in some wards.

Estates took action to resolve a boiler issue however a number of additional electric heaters had to be purchased to enable ward temperatures to reach an acceptable level.

12.3 There was water reported to be leaking from Derby to Solaris Ward on Friday 2nd

March and water leaking in Trust Head Office. Both issues were addressed by estates.

12.4 During the weekend (3rd March) there were further heating issues reported on Bevan

Ward, estates managed to address the issue however there needs to be a further

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discussion about where we would decant patients from this unit in an emergency. A debrief took place regarding the earlier incident on Monday 5th March.

12.5 Staffing issues were also reported in the severe weather impact assessment. There

were some staff shortages however teams were checking shifts in advance to make sure they had clinical areas covered. For the community where there were staff shortages urgent home visits were prioritized.

13 Suicide Prevention Strategy 13.1 The trust has developed a new Suicide Prevention Strategy for 2017-2020 based on

the cross-Government National Suicide Prevention Strategy (NSPS) for England and the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH).

13.2 The trust’s strategy objectives reflect those of the National Suicide Prevention Strategy

(NSPS) and aim to reduce the suicide rate in the population of individuals that come into contact with our services and to provide better support for those bereaved or affected by suicide.

13.3 The trusts Suicide Prevention Strategy 2017-2020 was ratified by the Quality Matters

meeting (now the trust wide Clinical Governance Group) on the 6th November 2017. An update on the strategy and next steps, detailed below, was presented to the trust Quality Committee on 21st February 2018. Next steps:

• To ensure service leads for suicide prevention develop the initial action plans

• Establish and embed governance structures to evaluate and monitor progress -

utilising existing assurance frameworks and meetings, with the appropriate

membership, to support effective information sharing and to manage any risks

identified

• Build on local engagement to ensure meaningful overlap between the trust action

plans and local borough based strategies and planning

13.4 The Quality Committee (21st February 2018) commented that the LSS leads need to link with the local health and wellbeing boards and that local action plans need to reference the respective borough strategy implementation plans. These comments are being taken forward for action.

Stephanie Bridger Director of Nursing and Patient Experience

5th March 2018

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Report summary Trust board meeting: Part 1 (in public) 14

th March 2018

Report title: Trustwide report on the Triangle of Care

Implementation

Executive lead: Stephanie Bridger Director of Nursing & Patient Experience

Report authors:

Gillian Kelly Deputy Director of Nursing (Corporate)


n/a


For approval


To note


Quality & Safety


Legal & Governance


Yes

If yes, insert relevant risk reference: BAF 4217


No. However, actions may need updating in relation to this risk.

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Improving quality


Compassionate care


Summary The paper provides an update on the overarching delivery plan and risk log for the Triangle of Care (ToC). This update report provides a summary of:

what we have achieved to date

what we expect to achieve going forward

risks to project delivery and actions being taken to reduce these risks

gaps in mitigation/control of risks Although progress continues to be made in implementing the ToC, there remain risks to project delivery. Actions to reduce these risks are being implemented, however, there are gaps in controls. The risks to delivery with significant gaps in controls are:

Project Management Resource and Local Leadership Capacity

Stakeholder Engagement

Training

Financial Resources

Supporting documents and/or further reading Appendix 1 Quality Priorities for 2017–2019 (Triangle of Care is a Quality Priority 6 for all services), Quarter 1-4, Reporting Month: June 2017

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Trust Board – Part 1 14

th March 2018

Trustwide Report on the Triangle of Care Implementation

_____________________________________________________________________

1 Background and Introduction 1.1 The Trust joined the Triangle of Care membership scheme in September 2016,

following an initial workshop in August 2017. The workshop agreed that a Trustwide Triangle of Care Working Group be formed to become a meeting for sharing good practice and ideas, and to take forward two Trust wide key areas for development – communications strategy and policy guidelines.

1.2 As part of the Triangle of Care membership scheme, the trust has committed to undertake its ‘Stage 1’ self-assessments and submit a progress report.

1.3 We continue to work towards submitting our ‘Stage 1’ progress report to the Carers Trust. The submission is due on 13 March 2018, however, we have requested a further extension, of up to 3 months, to help us achieve greater service user and carer engagement in authoring the final submission report as well as provide our partner service user and carer groups with more time to shape this work.

1.4 Additional time to provide the stage one report is in keeping with the fact WLMHT

has had a larger than average number of self-assessments to complete and report upon in ‘Stage 1’ (with a total of 51 inpatient wards and 3 crisis teams).

1.5 The request for an extension was supported by the WLMHT ToC Working Group on

26 February 2018. If an extension is agreed, this would not necessitate delaying the commencement of ‘Stage 2’.

1.6 ‘Stage 2’ is the roll out of self-assessments throughout community services within

an additional two year period. The stages, number of stars awarded at each stage and target completion dates are set out in the table below:

Stage 1

Inpatients and CRHTs

March 2018 (Extension requested)

Stage 2

Community Teams March 2020

1.7 The Trust has also developed its Quality Priorities for 2017–2019, and the implementation of the Triangle of Care is a Quality Priority 6 for all services (at Appendix 1), except for Liaison and Long Term Conditions who will look to implement equivalent standards during 2018 – 2019 as this was not identified as a

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key area for the service. It is noted that work is required to align the Quality Priorities key milestones with the Carers Trust ToC Accreditation requirements and timelines.

1.8 In March 2017, the Deputy Director of Nursing (Corporate) was identified as the Triangle of Care Project Lead and work begun on establishing local leadership, and agreeing governance arrangements. The Project Lead chairs the Triangle of Care Working Group.

1.9 It was agreed that the local Service User and Carer Experience meetings would provide governance for the individual ward, team or service self-assessments (including corresponding action plans once available), and that progress would then be reported to the Trust wide Service User and Carer Experience meeting.

2.0 Achievements to date 2.1 WLMHT is committed to implementing the Triangle of Care. Significant progress

has been made towards achieving ‘Stage 1’ of the Triangle of Care membership scheme. These achievements are summarised below:

Board ‘Carer Champion’ appointed

Project leads identified (trust wide and local leads, however, capacity limited)

Project governance structure agreed and risk analysis completed

WLMHT consistently represented and engaged in the ToC London and South East Region meetings

Project launched, communications strategy developed and delivery of the communications strategy is well underway. For example; posters, leaflets and a film have been developed and an intranet site with resources went live in November 2017

WLMHT Triangle of Care working group established (includes leads and service user and carer members) with corresponding sub-groups (co-produced task and finish approach) for the communications strategy and policy guidelines aspects of the project

Stakeholder briefings provided to key groups

Team/Ward Triangle of Care self-assessments – completed 52/54

Team/Ward Triangle of Care champions identified and training being developed to support the champion role

Data collection and triangulated experience / outcome measures being developed for the ‘stage 1’ progress report

Co-production of Information Sharing with Carer Guidelines – ratified by the Trustwide Service User and Carer Experience Meeting - 14 November 2017

Summary version (leaflet) of the Information Sharing with Carer Guidelines developed and content agreed at the ToC Working group - 26 February 2018

Co-production event held to design our trust Carer Awareness Training. The event was well attended (approx. 40 attendees) with service users, carers and professionals all well represented

Carer Awareness Training pilots scheduled in March 2018. The pilot will be evaluated by service users, carers and staff before roll-out trustwide

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R

AG

Marc

h 1

8 -

Co-p

roduced n

ew

ToR

for

meeting

follo

win

g w

ork

shop.

New

ToR

appro

ved in F

ebru

ary

2018. C

o-c

hair

arr

ang

em

ent to

be e

sta

blis

hed.

Polic

y s

ub-g

roup (

task a

nd f

inis

h)

to c

o-

pro

duce g

uid

elin

es f

or

info

rmation s

haring

w

ith c

are

rs

Octo

ber

2017

DD

oN

(corp

) D

raft

guid

elin

es c

om

ple

te. G

oin

g to T

W

SU

CE

for

ratification. T

o b

e launched w

ith

sum

mary

and c

onfidentialit

y m

yth

-buste

r.

Marc

h 1

8 -

Guid

elin

es a

nd s

um

mary

le

aflet com

ple

ted. F

inal vers

ions to b

e

launched in M

arc

h 2

018 to c

om

ple

te t

his

action.

Sub-g

roup n

ow

fin

ished.

R

Com

munic

ations s

ub

- g

roup (

task a

nd

finis

h)

to c

o-p

roduce a

nd d

eliv

er

com

munic

ations s

trate

gy

Decem

ber

2017

DD

oN

(corp

) S

trate

gy c

om

ple

te. Im

ple

menta

tion

underw

ay.

Pro

ject la

unched

with

associa

ted p

ress r

ele

ase a

nd c

om

ms.

Leaflets

, poste

rs a

nd film

com

ple

ted.

Intr

anet and w

ebsite p

ages launched in

Nov 1

7.

Marc

h 1

8 -

Sub-g

roup n

ow

fin

ished –

any

ong

oin

g w

ork

to b

e a

ddre

ssed in T

oC

w

ork

ing g

roup.

G

4

Tra

inin

g

C

SU

Recovery

Colle

ges / L

eads t

o c

o-

pro

duce a

nd d

eliv

er

care

r aw

are

ness

train

ing f

or

sta

ff.

April

2018

HS

S -

W

LF

S-

LS

S –

AH

Appro

ach n

eeds t

o b

e form

ally

agre

ed for

HS

S/W

LF

S.

Marc

h 1

8 –

Tra

inin

g c

onte

nt

has b

een c

o-

pro

duced. P

ilot

sessio

ns r

unnin

g o

n 6

th

and 2

9th M

arc

h 2

018 f

or

WLF

S a

nd L

SS

. F

eedback t

o info

rm s

essio

ns g

oin

g

forw

ard

. R

oll-

out pla

n to b

e d

evelo

ped

aft

er

the p

ilot

– to inclu

de T

TT

for

sta

ff a

nd

care

r fa

cili

tato

rs.

NB

: th

is tra

inin

g h

as b

uilt

upon w

ork

already d

one in H

SS

.

WIP

Cham

pio

n tra

inin

g t

o b

e p

rovid

ed b

y T

oC

pro

ject

leads

Febru

ary

2018

CS

U T

oC

Leads

HS

S h

ave p

rovid

ed s

om

e tra

inin

g to

cham

pio

ns a

nd t

his

is b

ein

g r

olle

d o

ut

within

WLF

S.

Explo

ring

capacity t

o

develo

p 2

hr

to learn

for

ToC

cham

pio

ns.

G

Page 87 of 308

T

ask N

am

e

Tasks

Targ

et

Date

R

esponsib

le

Pers

on

Pro

gre

ss U

pdate

R

AG

Marc

h 2

018 –

Co-p

roduction p

rocess led

to a

gre

em

ent th

at th

is tra

inin

g w

ill b

e

incorp

ora

ted w

ithin

the C

are

r A

ware

ness

Tra

inin

g.

5

Reso

urc

es /

Care

rs t

rust

too

lkit

s

To b

e a

vaila

ble

via

ToC

exchang

e p

ag

e a

nd

on e

xte

rnal w

ebsite f

or

care

rs

Decem

ber

2017

DD

oN

(corp

)

&

Com

ms

Dra

ft intr

anet pag

e d

evelo

ped. T

o g

o liv

e

in N

ovem

ber

2017. E

xte

rnal w

ebsite

hold

ing

pag

e in p

lace

Marc

h 1

8 –

Intr

anet page liv

e.

Exte

rnal

pag

e t

o d

evelo

p f

urt

her

over

tim

e.

G

6

Sta

ge 1

:Self

-A

ssessm

en

ts

Com

ple

te s

elf-a

ssessm

ents

within

inpatient

ward

s a

nd c

risis

team

s (

sta

ge 1

) usin

g t

he

ToC

self-a

ssessm

ent to

ol

31

st

Novem

ber

2017

CS

U T

oC

Leads

66%

SA

s c

om

ple

ted.

Marc

h 1

8 -

52/5

4 (

96%

) te

am

s c

om

ple

ted

(WLF

S w

ith x

2 o

uts

tandin

g –

Dam

son a

nd

The W

ells

). T

oC

work

ing g

roup r

eq

ueste

d

for

dis

cussio

n a

t S

UC

E.

R

7

Imp

lem

en

t th

e

To

C s

tan

dard

s

Develo

p t

eam

/ward

level action p

lans t

o

addre

ss g

aps identified v

ia s

elf-a

ssessm

ent

pro

cess

(actions r

ela

ting

to the C

are

rs A

ct; e

nsuring

jo

ined u

p C

are

rs A

ssessm

ents

need to b

e

reflecte

d a

t boro

ug

h/s

erv

ice level)

31

st M

arc

h

2018

CS

U T

oC

Leads

45%

com

ple

ted

24 o

f 53 w

ard

s/ te

am

s c

om

ple

ted

. M

arc

h 1

8 –

Deta

iled u

pdate

to b

e

req

ueste

d fro

m leads this

month

with

deadlin

e f

or

com

ple

tion

A

8

QI

Co

llab

ora

tive

Pair

s

Com

ple

te Q

I colla

bora

tive p

airs p

roje

ct th

at

support

s T

oC

im

ple

menta

tion –

messag

es

to s

upport

culture

change

30

th M

ay

2018

DoN

&P

E

&

Care

r re

p

Executive D

irecto

r of

Nurs

ing

and P

atient

Experience w

ill b

e w

ork

ing w

ith o

ne o

f our

trust

care

r re

pre

senta

tives o

n a

colla

bora

tive p

airs Q

I pro

ject th

at W

est

London C

olla

bora

tive a

re c

o-d

eliv

ering

in

part

ners

hip

with t

he K

ings F

und a

nd

CLA

HR

C N

WL.

Pro

ject

pla

n a

nd tim

elin

e t

o b

e c

onfirm

ed

Marc

h 1

8 –

Pro

ject te

am

have m

et and

att

endin

g s

essio

ns a

t th

e K

ing

s F

und.

Furt

her

update

to follo

w.

WIP

9

Sta

ge 1

p

rog

ress r

ep

ort

S

ubm

it S

tag

e 1

pro

gre

ss r

eport

to t

he

Care

rs T

rust (D

raft t

o T

W S

UC

E f

or

ratification in F

ebru

ary

2018)

13

th M

arc

h

2018

DD

oN

(corp

) B

aselin

e d

ata

to s

upport

report

is b

ein

g

colla

ted o

n c

are

r re

late

d c

om

pla

ints

, via

C

are

Opin

ion c

om

ments

and c

om

plim

ents

and o

ther

feedback s

ourc

es i.e

. lo

cal

WIP

Item

10.

2.1:

Tru

stw

ide

Tria

ngle

of C

are

Del

iver

y P

lan

Page 88 of 308

T

ask N

am

e

Tasks

Targ

et

Date

R

esponsib

le

Pers

on

Pro

gre

ss U

pdate

R

AG

surv

eys.

Marc

h 2

018 –

work

pro

gre

ssin

g o

n o

ur

Sta

ge 1

pro

gre

ss r

eport

to t

he C

are

rs

Tru

st. T

he s

ubm

issio

n is d

ue o

n 1

3 M

arc

h

2018,

how

ever,

we h

ave r

eq

ueste

d a

fu

rther

exte

nsio

n,

of

up to 3

month

s, to

help

us a

chie

ve g

reate

r serv

ice u

ser

and

care

r eng

ag

em

ent

in a

uth

oring t

he f

inal

subm

issio

n r

eport

as w

ell

as p

rovid

e o

ur

part

ner

serv

ice u

ser

and c

are

r g

roups w

ith

more

tim

e to s

hape t

his

work

. T

his

was

support

ed b

y t

he T

oC

Work

ing G

roup –

26

th F

ebru

ary

2018.

10

Co

mm

en

ce

Sta

ge 2

D

evelo

p s

tag

e 2

pro

ject pla

n

31

st M

arc

h

2018

DoN

&P

E

Marc

h 2

018 –

to d

iscuss a

t T

oC

work

ing

g

roup.

WIP

Ac

tio

n P

rog

res

s K

ey:

W

ork

in P

rogre

ss

not

yet

due (

WIP

) O

ver

Due

(R)

On T

arg

et

(A)

Com

ple

ted

(G)

Page 89 of 308

4.0

R

isk L

og

4

.1

The

ris

k lo

g b

elo

w b

roa

dly

su

mm

arise

s k

ey r

isks t

o a

ch

ievin

g t

he

pro

ject

ob

jective

s a

nd

sets

ou

t m

itig

atin

g a

ctio

n to

redu

ce

th

ese

ris

ks.

A

rea o

f R

isk

Lik

elih

oo

d

(1-5

) S

everi

ty

(1-5

) R

isk R

ati

ng

(L

ikelih

oo

d x

Severi

ty)

Mit

igati

ng

Acti

on

/ C

on

tro

ls

Pro

ject

Man

ag

em

en

t R

eso

urc

es

N

o dedic

ate

d pro

ject

manag

em

ent

resourc

e,

pro

ject

leaders

hip

capacity/t

ime

curr

ently

limited a

nd t

here

is a

ris

k t

hat

we a

re n

ot

able

to

id

entify

and

develo

p

suff

icie

nt

ward

/team

based

care

r cham

pio

ns

to

lead

necessary

culture

chang

e

3

3

9

Tru

st pro

ject

lead (

DD

oN

- corp

) pro

vid

ing

som

e

briefing

s to k

ey p

rofe

ssio

nal gro

ups / s

takehold

ers

re:

pro

ject re

quirem

ents

and im

ple

menta

tion p

lans (

tim

e

perm

itting)

Work

ing

with C

SU

leads to identify

local support

needs

Lia

isin

g w

ith C

are

rs T

rust T

oC

National Lead to s

ee if

they c

an o

ffer

furt

her

support

Explo

ring

resourc

es for

cham

pio

n tra

inin

g

Marc

h 2

018 –

cham

pio

ns tra

inin

g t

o b

e incorp

ora

ted

into

Care

r A

ware

ness T

rain

ing

Sta

keh

old

er

en

gag

em

en

t

(Serv

ice U

sers

/ C

are

rs / M

DT

/ O

pera

tional)

3

3

9

Tru

st pro

ject

lead (

DD

oN

- corp

) is

pro

vid

ing s

om

e

briefing

s to k

ey p

rofe

ssio

nal gro

ups / s

takehold

ers

re:

pro

ject re

quirem

ents

and im

ple

menta

tion p

lans (

tim

e

perm

itting)

Self

-assessm

en

t R

isk t

o t

imely

com

ple

tion o

f self-a

ssessm

ents

and

that

self-a

ssessm

ents

do

not

pro

vid

e

appro

priate

evid

ence a

gain

st T

oC

sta

ndard

s

2

3

6

Deadlin

e a

gre

ed f

or

com

ple

tion o

f self-a

ssessm

ent

is

31

st N

ovem

ber

2017

96%

com

ple

te t

o d

ate

Assura

nce o

f self-a

ssessm

ents

is v

ia T

W S

UC

E

Curr

ently r

evie

win

g r

eport

ing

tools

to e

nsure

necessary

evid

ence is b

ein

g s

ubm

itte

d to S

UC

E.

Marc

h 2

018 -

RA

G table

bein

g p

roduced to p

rovid

e

overv

iew

Tra

inin

g r

eso

urc

es

C

apacity

issue

re:

pro

vis

ion

of

Care

r A

ware

ness

Tra

inin

g

and

Care

r C

ham

pio

n

Tra

inin

g n

eeded t

o s

upport

culture

chang

e.

No

dedic

ate

d

fundin

g

or

resourc

es

req

uirin

g

4

3

12

Recovery

Colle

ges to b

e c

onsid

ere

d t

o s

upport

tr

ain

ing.

LS

S a

nd W

LF

S R

ecovery

Colle

ge

s a

re

com

mencin

g c

o-p

roduction o

f C

are

r A

ware

ness

Tra

inin

g

Explo

ring

capacity t

o d

evelo

p o

f 2hrs

to learn

sty

le

Item

10.

2.1:

Tru

stw

ide

Tria

ngle

of C

are

Del

iver

y P

lan

Page 90 of 308

Are

a o

f R

isk

Lik

elih

oo

d

(1-5

) S

everi

ty

(1-5

) R

isk R

ati

ng

(L

ikelih

oo

d x

Severi

ty)

Mit

igati

ng

Acti

on

/ C

on

tro

ls

train

ing

to

be

develo

p

and

deliv

ere

d

via

exis

ting

resourc

es

ToC

Cham

pio

n tra

inin

g

Marc

h 2

018 –

Conte

nt co-p

roduced.

Pilo

t tr

ain

ing t

o

run in M

arc

h 2

018

Roll-

out

via

TT

T / c

ascade locally

will

need t

o

consid

er

local capacity

Fin

an

cia

l re

so

urc

es

Ris

k o

f in

suff

icie

nt

rem

unera

tion f

or

short

and

long

te

rm

rem

unera

tion

of

co

-pro

duction

ele

ments

of

the p

roje

ct

(meeting

att

endance,

travel, tra

inin

g)

3

3

9

5k c

entr

al fu

ndin

g s

ecure

d t

o s

upport

a p

roport

ion o

f C

are

r paym

ent (w

ithin

conte

xt

of

s19 p

olic

y)

Furt

her

costing

s for

pro

ject

deliv

ery

to b

e c

om

ple

ted

Mem

bers

hip

sch

em

e -

su

bm

issio

ns

Failu

re

to

dem

onstr

ate

pro

gre

ss

in

imple

menting

th

e

ToC

and

associa

ted

risks

(reputa

tional,

sta

ff

mora

le,

serv

ice

user

and

care

r experience,

pro

ject cre

dib

ility

)

2

3

6

Deadlin

es a

gre

ed (

31/1

1/1

7)

to s

upport

tim

ely

analy

sis

of

self-a

ssessm

ent

data

(in

c. evid

ence)

and

report

auth

ors

hip

Revie

wed a

nd u

pdate

d C

SU

report

ing t

ools

Patient

Experience L

ead a

dapting

report

ing to

support

baselin

e d

ata

colle

ction a

nd e

nable

outc

om

e

measure

s

Deadlin

es t

o s

upport

evid

encin

g a

ction p

lannin

g

Marc

h 2

018 -

Furt

her

exte

nsio

n r

eq

ueste

d follo

win

g –

th

is w

as s

ugg

este

d b

y t

he C

are

rs T

rust T

oC

lead –

g

iven o

ur

hig

her

than a

vera

ge inpatient w

ard

s a

nd

the n

eed t

o f

urt

her

eng

ag

e c

are

r gro

ups in t

he

pro

cess.

Ris

k R

ati

ng

Key:

Ris

k I

mp

act

Lo

w

(1-3

) M

od

era

te

(4-6

) H

igh

(8

-12

) E

xtr

em

e H

igh

(1

5-2

5)

Page 91 of 308

5. Gaps in mitigating risks to project delivery 5.1 The risk log provides details of mitigating actions against a number of the risks. Gaps in

controls do exist where resources required exceed those currently available to the project. The risks with the most significant gaps in controls remain unchanged and are set out below:

1. Project Management Resource and Local Leadership Capacity 2. Stakeholder Engagement 3. Training Resources 4. Financial Resources

6. Conclusion 6.1 WLMHT is committed to implementing the Triangle of Care. Significant progress has been

made towards achieving ‘Stage 1’ of the Triangle of Care membership scheme and further work is planned.

6.2 We continue to work towards submitting our ‘Stage 1’ progress report to the Carers Trust.

The submission is due on 13 March 2018, however, we have requested a further extension, of up to 3 months, to help us achieve greater service user and carer engagement in authoring the final submission report as well as provide our partner service user and carer groups with more time to shape this work.

6.3 It is of note that risks to delivering the project objectives have been identified. Actions to

reduce these risks are being implemented. However, there remain gaps in controls that could impact on successful delivery of the Triangle of Care project. The risk ratings and gaps in controls remain unchanged since the last update.

Gillian Kelly Deputy Director of Nursing (Corporate)

March 2018

Item

10.

2.1:

Tru

stw

ide

Tria

ngle

of C

are

Del

iver

y P

lan

Page 92 of 308

AP

PE

ND

IX 1

Q

ua

lity

Pri

ori

tie

s 2

01

7/1

9:

Qu

art

er

1-4

R

ep

ort

ing

Mo

nth

: J

un

e 2

017

The

se

rvic

e lin

es h

ave

all

de

ve

lop

ed

qu

alit

y im

pro

ve

me

nt p

lan

s t

o s

up

po

rt d

eliv

ery

of

the

qu

alit

y p

rio

ritie

s f

or

2017

/19 in

th

e fo

llow

ing a

rea

s

Pa

tie

nt

Safe

ty, W

ell

Led

, E

ffe

ctive

, R

espo

nsiv

e,

Carin

g.

B

elo

w a

re t

he

se

rvic

e lin

es q

ua

lity p

rio

ritie

s f

or

Carin

g, w

hic

h a

re T

ria

ngle

of C

are

. T

he

tab

le b

elo

w s

ho

uld

pro

vid

e a

hig

h le

ve

l qu

alit

y a

ssu

ran

ce

po

sitio

n a

ga

inst th

ese

pla

ns q

ua

rterly.

T

he

tab

le s

ho

uld

als

o o

utlin

e t

he n

ext

ste

ps a

nd

de

scrib

es t

he

chan

ge

s t

hat

ha

ve

be

en

im

ple

men

ted

. A

ss

ura

nce

de

fin

itio

ns

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Page 94 of 308

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Page 95 of 308

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Page 96 of 308


March 2018

Report title:

Executive Director Report – Local Services

Executive lead:

Sarah Rushton, Executive Director of Local Services

Report authors:

Sarah Rushton


n/a


For approval


To note ✓




Legal & Governance


no



Item

10.

3: D

irect

or o

f Loc

alS

ervi

ces'

Rep

ort -

Mar

ch 2

018

Page 97 of 308



Improving quality


✓

Compassionate care


✓

Summary The report updates the Board on events and issues related to Local Services.


Page 98 of 308


Executive Director Report - Local Services

1 Purpose

1.1 The purpose of this report is to inform the Board of key issues not covered in other

specific reports.

2 Recommendations 2.1 The Board is asked to note the report

3 Delayed transfers of care update

3.1 Local Services has been delivering a DToC improvement plan management with each of its three main CCG’s as a part of an NHSE drive to reduce DToC to a rate of 3.5%. These plans, primarily driven by a joint working group with Ealing CCG, have involved a number of internal process improvements

3.2 Performance Improvement:

3.3 Performance on DToC has been on a sustained improvement trajectory since the

implementation and embedding of the action plans. In December, as a total figure

across Local Services we were within the contracted DToC threshold for the first

time since June 2015. In January all three boroughs were below the 7.5%

threshold.

3.4 Because the level of DToC has a direct impact on the inpatient capacity, with a high

level DToC putting pressure on ability to maintain capacity, it is imperative to

maintain this performance in order to support inpatient flow.

Item

10.

3: D

irect

or o

f Loc

alS

ervi

ces'

Rep

ort -

Mar

ch 2

018

Page 99 of 308

3.5 To ensure oversight of patients across all three sites including the recovery house/

Jubilee ward and the forensic service, a detailed spreadsheet is updated weekly by

the discharge coordinators. Included in this spreadsheet is our pre-DToC list of

patients on our acute wards. This has proved very helpful for both commissioners

and local authority social care staff. We also hold weekly calls with the three local

authorities and CCG’s to discuss where there are blockages with specific cases.

3.6 At a recent workshop with CCG/ LA and trust it was agreed that 5 pathway delay

cases from Q3/4 be process mapped to show the delay reasons - reviewing recent

delays to develop a representative list of actions that we would need to work on.

3.7 The joint workshop also agreed to develop a new process for earlier placement

sourcing during the inpatient admission, for a subset of known patients. This would

require increased joint working using a trusted assessor process to identify the

needs of the individuals.

4 Serious incident backlog

4.1 There are 14 overdue SIs.

Stage Comment PPC AUC CIDS LLTC

1 Ongoing 0 6 1 1

2 1st draft 0 0 0 0

3 Draft has been reviewed and

returned to panel for clarification

0 2 0 0

4 Quality assurance 0 3 0 1

5 Submitted to ED and CD for final

approval for submission

0 0 0 0

Total: 14 0 11 1 2

4.2 Last month, I reported on the 46 reports submitted where there are outstanding

multiple queries from the CCG. A meeting has been set up to try and find a pragmatic solution. A project has also been initiated on the 11 historical cases where detailed discussion is required to ascertain whether a report is required or not. The Trust will provide the CCG with a detailed synopsis of each of these cases by the end of March so they can be discussed in more detail and acted on accordingly.

Page 100 of 308

4.3 Overdue SIs for Access and Urgent Care will now be supported by the new Head of Quality to enable a more robust process for quality assurance and timeliness of providing future reports.

5 Hammersmith & Fulham family support service tender 5.1 The Hammersmith & Fulham CAMHS were successful in winning a bid for an

element of this tender. The service will deliver group based provision to support young people with special educational needs and disability (SEND) with targeted needs associated with: staying safe, preventing youth crime, healthy living, progressing successfully into post-16 education, employment or training and engaging young people in achieving within education.

5.2 The delivery will be in the form of group sessions which will focus on the needs of a

particular group of young people, or on particular outcomes, including: understanding of consequences, behaviour and self-control, self-esteem and personal resilience and awareness of how to seek help from targeted and specialist support services. Session delivery will be tailored to meet the particular characteristics and needs of the young people engaged.

5.3 A total of 150 group sessions will need to be delivered with an average of 75%

attendance of the total sessions delivered. Other KPIs will include CYP qualitative feedback and evidence of positive outcomes (target 85%).

5.4 The service will make use of existing practice already in place within the H&F

Community CAMHS team, a team that has a successful history in delivering group work to this age range, to include Tree of Life resilience, strength-based groups and mindfulness groups to younger children and adolescents. The service will work closely with partners in the borough to support this group delivery in the community, making use of accessible venues such as schools and children and community centres.

5.5 The contract value is: £146,821 recurrently and the proposed staffing is a band 4

Child Wellbeing Practitioners & band 7 CAMHS practitioner.

6 Other service delivery information

6.1 The inpatient service has maintained a positive and stable level of bed capacity

throughout February. Bed occupancy remains around 85% and we have been able

to generate income through sale of a small number of beds. We currently have 4

out of area patients within the service.

6.2 Access and Urgent Care have completed their senior management restructure and

Sonya Clinch has been appointed as Head of Operations and Suzanne McMillan

has been appointed as Head of Quality. These new roles will enable better

oversight of operational delivery across the crisis care pathway and strengthen the

clinical governance and quality standards work within the service line.

Item

10.

3: D

irect

or o

f Loc

alS

ervi

ces'

Rep

ort -

Mar

ch 2

018

Page 101 of 308

6.3 Hammersmith & Fulham Mental Health Unit implemented the generic ward configuration on 1st March. This removes the distinction between assessment and treatment wards and therefore reduces the handoffs. It is envisaged that this should have a positive impact on lengths of stay. Lakeside will go live on 19th March. This ties in with the rota changing. Ealing already operates in this way as there are only single male and female wards.

Sarah Rushton Executive Director Local and Specialist Services

March 2018

Page 102 of 308

Report summary Trust board meeting: Part 1 March 2018 Report title:

Monthly update from High Secure and West London Forensic Services

Executive lead:

Leeanne McGee, Executive Director of High Secure & Forensic Services

Report authors:

Leeanne McGee


n/a


For approval


To note ✓


Quality & Safety




No



N/a

Item

10.

4: D

irect

or o

f Hig

hS

ecur

e S

ervi

ces

- W

LFS

Page 103 of 308



Improving quality

We invest – in people, estates, technology We listen and learn – from patients, carers, staff, the public ✓

Compassionate care


✓

Summary Feedback on activities and visits to Broadmoor Hospital and West London Forensic Services.


Page 104 of 308


Monthly Update from High Secure and West London Forensic Services

1 Purpose 1.1. To update the Board on matters of fact within the High Secure Services CSU and West

London Forensic Services CSU.

2 Recommendations 2.1. The Board is asked to note the contents of this report.

3 Introduction 3.1. The details in this report are to make the Board aware of clinical and salient issues

affecting the services and recommendations, where applicable, of action required or taken.

4 Issues Relating to High Secure and Forensic Services 4.1. General Issues - High Secure Services 4.1.1. The High Sheriffs of Berkshire, Buckinghamshire and Oxfordshire held a high Sheriffs

award ceremony at Broadmoor hospital on 12th March to honour the outstanding work undertaken by our staff. The winners of the awards were Ken Wakatama, Clinical Nurse Specialist; Sheila Hale, Patients Benefits Manager; Wendy Pickford, Domestic Assistant; Paul Robertson, Assistant Practitioner; Venus Kan, Vocational Services Manager; and Charles [Bob] Gordon, Speciality Grade Doctor.

4.1.2. The hospital held an annual celebration of achievement in the Recovery College.

Certificates were presented by Tom Hayhoe and 42 patients achieved one or more certificates in a wide range of subjects.

4.1.3. On 26th February Broadmoor Hospital hosted a visit by three Portuguese visitors who

were in the UK for the faculty of Forensic Psychiatry Annual Conference. They requested a professional visit as Broadmoor is considered a world reference in the field of forensic hospitals. The visitors were Consultant Psychiatrist with a special interest in Forensic Psychiatry; a Clinical Coordinator at the Regional Forensic Service in Lisbon with involvement in the Portuguese National Institute of Legal Medicine; and a member of the committee that is setting up the Forensic Psychiatry Subspecialty within the Portuguese College of Psychiatry who also works at the Regional Forensic Service in Lisbon and is on the supervising committee of the Portuguese Mental Health Act.

Item

10.

4: D

irect

or o

f Hig

hS

ecur

e S

ervi

ces

- W

LFS

Page 105 of 308

4.1.4. During the extreme weather conditions at the beginning of March, staff made every attempt to get to work at Broadmoor. The hospital provided 4 x 4 vehicles to assist staff where necessary. With the help of staff across all disciplines, the hospital continued to function well in difficult conditions.

4.1.5. Broadmoor hospital has submitted its 3 yearly S11 audit in terms of safeguarding on

2nd March and will receive feedback from the Pan Berks Panel within 20 working days to support the mid review return

4.1.6. Broadmoor Procedure for the Use of Mechanical Restraints H5p, has been updated to

reflect the circumstances when mechanical restraints may be required in an emergency situation. The amended section is as follows:

5.3.1. Authorising Emergency Use If it is decided during the management of an emergency situation as above or

during a major incident that fast straps or the mechanical restraint or the recovery stretcher are required to bring about a safe resolution, then arrangements for their use will be detailed in the management plans and approved following the major incident command and control structure. If the emergency situation is not deemed a ‘major incident’ then the approval of any form of mechanical restraint will be approved by the Clinical Director and Executive Director of High Secure and Forensic Services in office hours. Outside of office hours discussion will take place with the on call Responsible Clinician, On Call Manager and On Call Executive Director. This may necessitate the RC and On Call manager attending site. The PPE advisor will offer advice and support throughout. Any emergency authorization must be followed up in writing within 12 hours of approval.

4.2. General issues – Forensic Services 4.2.1. Following a national recruitment campaign Dr Diomidis Antoniadis was appointed to

the post of Consultant Psychiatrist for the WEMSS service. He has taken up post. 4.2.2. WLFS was informed of the outcome of the FCAMH’s bid on 9th March 2018. 4.2.3. Mark Landy has been appointed to the role of Managing Director for the North London

Partnership for New Models of Care. 4.2.4. The Tony Hillis and Wolsey Wings were affected by problems with heating in late

February and early March which was managed through the trust business continuity plan. A debrief was held on 5th March and a Local Team Review has been commissioned to learn lessons from the event. Goodwill payments have been offered to those patients affected.

4.2.5. Service users within WLFS attended a Focus Group relating to the Independent

Review of the Mental Health Act on 22nd February with DH colleagues. 4.2.6. In the early hours of 2nd March, flooding occurred on two wards in the Tony Hillis Wing,

resulting in emergency repairs being carried out by Estates & Facilities staff. It was necessary to switch off the hot water. Despite the inclement weather and some staff shortages, patient care at WLFS remains unaffected.

Page 106 of 308

5. Conclusion 5.1. The Board is asked to note the contents of this report.

6. Recommendation(s) 6.1. The Board is asked to note the contents of report and agree the proposed actions.

Leeanne McGee Executive Director

High Secure & Forensic Services March 2018

Item

10.

4: D

irect

or o

f Hig

hS

ecur

e S

ervi

ces

- W

LFS

Page 107 of 308


(March) 2018


For approval


To note ✓

Relates to?

Strategy & Planning ✓



Legal & Governance

Relationship to board assurance framework?

Are any existing risks in the Board Assurance Framework affected?

✓


7808 4186 4127 5563


No

Relationship to trust strategic objectives?

Outstanding We coordinate and collaborate – to deliver holistic care We innovate – to turn research into practice

Improving quality


Report title:

Director of Workforce and OD monthly report

Executive lead:

Director of Workforce and OD

Report authors:

Wendy Brewer


N/A

Item

10.

5: D

irect

or o

fW

orkf

orce

& O

D's

Rep

ort -

Page 108 of 308

Compassionate care


✓

Summary

This workforce report provides:

• Key points to note in the workforce performance report

• Detail of the NHSI agency recommendations and the Trust’s response

• A report on the NHSI retention programme visit

• A report on a visit to Mersey Care to hear about their work on developing a Just Organisation


Page 109 of 308

Trust board meeting (Part 1): (14th March) 2018

Director of Workforce Update

1 Purpose 1.1 To update the trust board on workforce issues and on progress with the implementation of

the workforce strategy.

2 Recommendations 2.1 The board is asked to note the contents of the paper.

3 Workforce performance report 3.1 There was no material difference in the key workforce indicators in January 2018. The

seasonal increase in sickness absence, noted in December, has continued with 39% of all absence being due to coughs, colds and influenza.

3.2 Under the leadership of the newly appointed Assistant Director of Workforce and following

the visit to Mersey Care in November, the Trust will be reconsidering its approach to managing employee relations cases and in particular the management of conduct cases. It is planned to hold a seminar led by Capsticks in April to reconsider our approach.

3.3 Agency expenditure 3.3 As anticipated in the February board report, expenditure on agency staff in January has

reverted to November levels. The reduction seen in December expenditure was in part a result of slow processing of invoicing in December and is a regular seasonal occurrence. Good progress has been made regarding a sustained reduction in agency expenditure overall as compared with 2016/17 levels of expenditure. This reduction has been supported by a series of deep dive meetings regarding expenditure in Local Services accompanied by focused recruitment. The newly appointed recruitment lead for Forensic and Local Services has been very well received and is making a good impact in some fairly intractable areas of vacancy; Gaganjot Sidhu was awarded employee of the month in March for her work.

3.4 It remains the case, however, that the gaps in the allocation of doctors in training from

February will put significant pressure on agency expenditure and increase the likelihood of breaches in expenditure caps.

3.5 Recommendations from NHSI re agency usage 3.6 There was a thorough discussion of agency usage, the recommendations from the NHSI

agency team and the Trust’s response at the Provider Oversight Meeting that took place on 21st February. NHSI agreed with the Trust’s responses to the recommendations and noted that there was evidence that the programme of work in place to reduce agency expenditure was having a positive impact. Confirmation in writing has been received that the remaining actions for the Trust are to produce a forecast plan for agency expenditure for 2018/19 and to ensure that weekly returns remain compliant with NHSI agency rules.

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4. Reform to Local Clinical Excellence Awards 4.1 NHS Employers have advised all NHS trusts of progress with national negotiations over the

consultant contract regarding Local Clinical Excellence Awards. The key points are that in

the period from April 2018 – March 2021:

• trusts must run annual awards rounds

• the investment ratio of new awards will be 0.3 per eligible consultant

• awards rounds must be conducted in line with current agreed policies, subject to any

changes reached in agreement with your LNC

• existing LCEA (those granted before April 2018) will be retained and will remain

pensionable and consolidated

• new CEA (those granted after April 2018) will be non-pensionable and non-consolidated

• where national awards are withdrawn, there will be a mechanism based on current

scoring allowing reversion to a local level award.

4.2 The move to a non-consolidated performance scheme will mean that organisations will be able to incentivise productivity improvements in return for making future awards contractual. In the longer term, the agreement will allow employers to shape the performance pay scheme in a way that better meets their organisational needs and encourage the pay review body to support greater flexibility in linking pay to performance.

4.3 WLMHT have continued to maintain Local Clinical Excellence Awards in recent years

where other trusts have not necessarily done so. This means that WLMHT is not exposed by the outcome of the recent ruling.

5. Nursing Degree Apprenticeships 5.1 The Trust have selected to work with Buck New University as the provider or our Nursing

Degree Apprenticeships. 5.2 Staff from the Trust held local assessment events and from those, 15 staff were selected to

attend the BNU selection day. 5.3 Feedback has been very positive and we have been able to select 13 staff to progress onto

the Nursing Degree Apprenticeship that commences in April 2018 and will be made up of a joint cohort of staff from both WLMHT and CNWL.

6 Mandatory training - Charging for Did Not Attend (DNA).

6.1 From April 2018 the Trust will be charging £50 per DNA on the top 5 courses that we receive DNAs that include the following courses.

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Course Title DNAs 1st January to 31st December 2018

Basic Fire Awareness 763

Automated External Defibrillation 379

Information Governance 296

Breakaway 293

6.2 The charge is preventable if members of staff cancel in advance of the training taking

place. Where this is not done, a charge will be made to the budget of the service. The funds received will enable additional courses to be provided to ensure capacity can be maintained.

7 Staff Survey Update 7.1 Quality Health presented the Staff Survey summary findings at a joint management and

staff side meeting. The meeting was positive showing improvements in a number of areas but continues to highlight concerns with H&B and discrimination although a downward trend was noted. Quality Health reported that, of those trusts that Quality Health support, WLMHT is the only trust that has only seen positive movements in question responses.

7.2 The nationally benchmarked staff survey report is attached. The Trust has made very

good progress in many areas and especially in overall engagement. There is a significant programme of work that underpins this progress which is managed through the workforce strategy action plan and reported to the Workforce Committee. There will be a Board development session in April to provide a more detailed view of the findings.

7.3 The progress made in many areas of staff engagement highlights that the Trust still has

much work to do to tackle discrimination and bullying where, although we have seen improvement, the responses give cause for concern. The Trust will continue to focus on these areas through the diversity strategy, which includes the BME development programme, the deployment of diversity champions and the BME forum and through specific actions to tackle bullying including ensuring clarifying processes for shift allocation, reviewing our approach to formal disciplinary action and the Lead by Example programme. We will develop a clear communications strategy to underpin this work including publicising internal promotions and sharing the leadership challenges faced by senior leaders within the Trust.

8 Talent Management 8.1 The Recruiting and Retaining Talent Scheme will be added to the April 2018/2019

PDR/Appraisal which will launch on Tuesday 6th March 2018. 8.2 The first Talent Steering group meeting took place in February and has good

representation from across the services and disciplines.

9 Open Days – Promoting Our Development Opportunities 9.1 The Learning and Development team will be hosting 2 Open Days to promote the wide

range of development opportunities available at the Trust.

These are popular with both staff and managers as they provide an opportunity to review t he development available and make the PDR discussions and developing planning process more effective.

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Broadmoor Open Day - 21st March 2018 - 11.00am – 3.00pm Ealing Open Day - 22nd March 2018 - 11.00am – 3.00pm

Places can be booked during various timeslots via the Exchange.

Wendy Brewer

Director of Workforce March 2018

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2017 National NHS staff survey

Brief summary of results from West London Mental Health NHSTrust

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Table of Contents

1: Introduction to this report 3

2: Overall indicator of staff engagement for West London Mental Health NHS Trust 5

3: Summary of 2017 Key Findings for West London Mental Health NHS Trust 6

4: Full description of 2017 Key Findings for West London Mental Health NHS Trust(including comparisons with the trust’s 2016 survey and with other mental health /learning disability trusts)

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1. Introduction to this report

This report presents the findings of the 2017 national NHS staff survey conducted in WestLondon Mental Health NHS Trust.

In section 2 of this report, we present an overall indicator of staff engagement. Full details of howthis indicator was created can be found in the document Making sense of your staff surveydata, which can be downloaded from www.nhsstaffsurveys.com.

In sections 3 and 4 of this report, the findings of the questionnaire have been summarised andpresented in the form of 32 Key Findings.

These sections of the report have been structured thematically so that Key Findings are groupedappropriately. There are nine themes within this report:

• Appraisals & support for development

• Equality & diversity

• Errors & incidents

• Health and wellbeing

• Working patterns

• Job satisfaction

• Managers

• Patient care & experience

• Violence, harassment & bullying

Please note, two Key Findings have had their calculation changed and there have been minorchanges to the benchmarking groups for social enterprises since last year. For more detail onthese changes, please see the Making sense of your staff survey data document.

As in previous years, there are two types of Key Finding:

- percentage scores, i.e. percentage of staff giving a particular response to one, or aseries of, survey questions

- scale summary scores, calculated by converting staff responses to particularquestions into scores. For each of these scale summary scores, the minimum scoreis always 1 and the maximum score is 5

A longer and more detailed report of the 2017 survey results for West London Mental HealthNHS Trust can be downloaded from: www.nhsstaffsurveys.com. This report provides detailedbreakdowns of the Key Finding scores by directorate, occupational groups and demographicgroups, and details of each question included in the core questionnaire.

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Your Organisation

The scores presented below are un-weighted question level scores for questions Q21a, Q21b,Q21c and Q21d and the un-weighted score for Key Finding 1. The percentages for Q21a – Q21dare created by combining the responses for those who “Agree” and “Strongly Agree” comparedto the total number of staff that responded to the question.

Q21a, Q21c and Q21d feed into Key Finding 1 “Staff recommendation of the organisation as aplace to work or receive treatment”.

Your Trustin 2017

Average(median) for

mentalhealth

Your Trustin 2016

Q21a "Care of patients / service users is my organisation'stop priority"

77% 73% 75%

Q21b "My organisation acts on concerns raised by patients /service users"

77% 75% 73%

Q21c "I would recommend my organisation as a place towork"

57% 57% 55%

Q21d "If a friend or relative needed treatment, I would behappy with the standard of care provided by thisorganisation"

56% 61% 53%

KF1. Staff recommendation of the organisation as a place towork or receive treatment (Q21a, 21c-d)

3.67 3.67 3.57

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2. Overall indicator of staff engagement for West London Mental Health NHS Trust

The figure below shows how West London Mental Health NHS Trust compares with other mentalhealth / learning disability trusts on an overall indicator of staff engagement. Possible scores rangefrom 1 to 5, with 1 indicating that staff are poorly engaged (with their work, their team and theirtrust) and 5 indicating that staff are highly engaged. The trust's score of 3.82 was average whencompared with trusts of a similar type.

OVERALL STAFF ENGAGEMENT

This overall indicator of staff engagement has been calculated using the questions that make upKey Findings 1, 4 and 7. These Key Findings relate to the following aspects of staff engagement:staff members’ perceived ability to contribute to improvements at work (Key Finding 7); theirwillingness to recommend the trust as a place to work or receive treatment (Key Finding 1); andthe extent to which they feel motivated and engaged with their work (Key Finding 4).

The table below shows how West London Mental Health NHS Trust compares with other mentalhealth / learning disability trusts on each of the sub-dimensions of staff engagement, and whetherthere has been a significant change since the 2016 survey.

Change since 2016 survey Ranking, compared withall mental health

OVERALL STAFF ENGAGEMENT Increase (better than 16) Average

KF1. Staff recommendation of the trust as a placeto work or receive treatment

(the extent to which staff think care of patients/service usersis the trust’s top priority, would recommend their trust toothers as a place to work, and would be happy with thestandard of care provided by the trust if a friend or relativeneeded treatment.)

Increase (better than 16) Average

KF4. Staff motivation at work

(the extent to which they look forward to going to work, andare enthusiastic about and absorbed in their jobs.)

No change Above (better than) average

KF7. Staff ability to contribute towardsimprovements at work

(the extent to which staff are able to make suggestions toimprove the work of their team, have frequent opportunitiesto show initiative in their role, and are able to makeimprovements at work.)


Full details of how the overall indicator of staff engagement was created can be found in thedocument Making sense of your staff survey data.

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3. Summary of 2017 Key Findings for West London Mental Health NHS Trust

3.1 Top and Bottom Ranking Scores

This page highlights the five Key Findings for which West London Mental Health NHS Trustcompares most favourably with other mental health / learning disability trusts in England.

TOP FIVE RANKING SCORES

KF2. Staff satisfaction with the quality of work and care they are able to deliver

KF4. Staff motivation at work

KF27. Percentage of staff / colleagues reporting most recent experience of harassment,bullying or abuse

KF8. Staff satisfaction with level of responsibility and involvement

KF18. Percentage of staff attending work in the last 3 months despite feeling unwellbecause they felt pressure from their manager, colleagues or themselves

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For each of the 32 Key Findings, the mental health / learning disability trusts in England were placed in order from 1(the top ranking score) to 26 (the bottom ranking score). West London Mental Health NHS Trust’s five lowest rankingscores are presented here, i.e. those for which the trust’s Key Finding score is ranked closest to 26. Further detailsabout this can be found in the document Making sense of your staff survey data.

This page highlights the five Key Findings for which West London Mental Health NHS Trustcompares least favourably with other mental health / learning disability trusts in England. It issuggested that these areas might be seen as a starting point for local action to improve as anemployer.

BOTTOM FIVE RANKING SCORES

! KF23. Percentage of staff experiencing physical violence from staff in last 12 months

! KF28. Percentage of staff witnessing potentially harmful errors, near misses orincidents in last month

! KF20. Percentage of staff experiencing discrimination at work in the last 12 months

! KF26. Percentage of staff experiencing harassment, bullying or abuse from staff in last12 months

! KF22. Percentage of staff experiencing physical violence from patients, relatives or thepublic in last 12 months

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3.2 Largest Local Changes since the 2016 Survey

This page highlights the five Key Findings where staff experiences have improved at WestLondon Mental Health NHS Trust since the 2016 survey. (This is a positive local result.However, please note that, as shown in section 3.3, when compared with other mental health /learning disability trusts in England, the scores for Key findings KF23, and KF28 are worse thanaverage).

WHERE STAFF EXPERIENCE HAS IMPROVED

KF23. Percentage of staff experiencing physical violence from staff in last 12 months

KF30. Fairness and effectiveness of procedures for reporting errors, near misses andincidents

KF28. Percentage of staff witnessing potentially harmful errors, near misses orincidents in last month

KF10. Support from immediate managers

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Because the Key Findings vary considerably in terms of subject matter and format (e.g. some are percentage scores,others are scale scores), a straightforward comparison of score changes is not the appropriate way to establish whichKey Findings have improved the most. Rather, the extent of 2016-2017 change for each Key Finding has beenmeasured in relation to the national variation for that Key Finding. Further details about this can be found in thedocument Making sense of your staff survey data.

KF9. Effective team working

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3.2. Summary of all Key Findings for West London Mental Health NHS Trust

KEY

Green = Positive finding, e.g. there has been a statistically significant positive change in the Key Finding since the2016 survey.Red = Negative finding, e.g. there has been a statistically significant negative change in the Key Finding since the2016 survey.Grey = No change, e.g. there has been no statistically significant change in this Key Finding since the 2016survey.For most of the Key Finding scores in this table, the higher the score the better. However, there are some scoresfor which a high score would represent a negative finding. For these scores, which are marked with an asteriskand in italics, the lower the score the better.

Change since 2016 survey

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KEY

Green = Positive finding, e.g. there has been a statistically significant positive change in the Key Finding since the2016 survey.Red = Negative finding, e.g. there has been a statistically significant negative change in the Key Finding since the2016 survey.Grey = No change, e.g. there has been no statistically significant change in this Key Finding since the 2016survey.For most of the Key Finding scores in this table, the higher the score the better. However, there are some scoresfor which a high score would represent a negative finding. For these scores, which are marked with an asteriskand in italics, the lower the score the better.

Change since 2016 survey (cont)

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KEY

Green = Positive finding, e.g. better than average.Red = Negative finding, i.e. worse than average.Grey = Average.For most of the Key Finding scores in this table, the higher the score the better. However, there are some scoresfor which a high score would represent a negative finding. For these scores, which are marked with an asteriskand in italics, the lower the score the better.

Comparison with all mental health in 2017

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KEY

Green = Positive finding, e.g. better than average.Red = Negative finding, i.e. worse than average.Grey = Average.For most of the Key Finding scores in this table, the higher the score the better. However, there are some scoresfor which a high score would represent a negative finding. For these scores, which are marked with an asteriskand in italics, the lower the score the better.

Comparison with all mental health in 2017 (cont)

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KEY

Green = Positive finding, e.g. better than average, better than 2016.

! Red = Negative finding, e.g. worse than average, worse than 2016.'Change since 2016 survey' indicates whether there has been a statistically significant change in the KeyFinding since the 2016 survey.

-- No comparison to the 2016 data is possible.* For most of the Key Finding scores in this table, the higher the score the better. However, there are some

scores for which a high score would represent a negative finding. For these scores, which are marked with anasterisk and in italics, the lower the score the better.

Change since 2016 survey Ranking, compared withall mental health in 2017

Appraisals & support for development

KF11. % appraised in last 12 mths Increase (better than 16) ! Below (worse than) average

KF12. Quality of appraisals No change Above (better than) average

KF13. Quality of non-mandatory training, learning ordevelopment


Equality & diversity

* KF20. % experiencing discrimination at work in last 12mths

No change ! Above (worse than) average

KF21. % believing the organisation provides equalopportunities for career progression / promotion

No change ! Below (worse than) average

Errors & incidents

* KF28. % witnessing potentially harmful errors, nearmisses or incidents in last mth

Decrease (better than 16) ! Above (worse than) average

KF29. % reporting errors, near misses or incidentswitnessed in last mth

No change Average

KF30. Fairness and effectiveness of procedures forreporting errors, near misses and incidents


KF31. Staff confidence and security in reporting unsafeclinical practice


Health and wellbeing

* KF17. % feeling unwell due to work related stress inlast 12 mths

No change Below (better than) average

* KF18. % attending work in last 3 mths despite feelingunwell because they felt pressure

No change Below (better than) average

KF19. Org and mgmt interest in and action on healthand wellbeing


Working patterns

KF15. % satisfied with the opportunities for flexibleworking patterns


* KF16. % working extra hours No change ! Above (worse than) average

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3.3. Summary of all Key Findings for West London Mental Health NHS Trust (cont)

Change since 2016 survey Ranking, compared withall mental health in 2017

Job satisfaction

KF1. Staff recommendation of the organisation as aplace to work or receive treatment


KF4. Staff motivation at work No change Above (better than) average

KF7. % able to contribute towards improvements atwork


KF8. Staff satisfaction with level of responsibility andinvolvement


KF9. Effective team working Increase (better than 16) Average

KF14. Staff satisfaction with resourcing and support No change Average

Managers

KF5. Recognition and value of staff by managers andthe organisation


KF6. % reporting good communication between seniormanagement and staff

No change Average

KF10. Support from immediate managers Increase (better than 16) Above (better than) average

Patient care & experience

KF2. Staff satisfaction with the quality of work and carethey are able to deliver


KF3. % agreeing that their role makes a difference topatients / service users


KF32. Effective use of patient / service user feedback No change Above (better than) average

Violence, harassment & bullying

* KF22. % experiencing physical violence from patients,relatives or the public in last 12 mths


* KF23. % experiencing physical violence from staff inlast 12 mths

Decrease (better than 16) ! Above (worse than) average

KF24. % reporting most recent experience of violence No change ! Below (worse than) average

* KF25. % experiencing harassment, bullying or abusefrom patients, relatives or the public in last 12 mths


* KF26. % experiencing harassment, bullying or abusefrom staff in last 12 mths


KF27. % reporting most recent experience ofharassment, bullying or abuse


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1Questionnaires were sent to all 3214 staff eligible to receive the survey. This includes only staff employed directly by thetrust (i.e. excluding staff working for external contractors). It excludes bank staff unless they are also employed directlyelsewhere in the trust. When calculating the response rate, questionnaires could only be counted if they were receivedwith their ID number intact, by the closing date.

4. Key Findings for West London Mental Health NHS Trust

West London Mental Health NHS Trust had 1368 staff take part in this survey. This is aresponse rate of 43%1 which is below average for mental health / learning disability trusts inEngland (52%), and compares with a response rate of 47% in this trust in the 2016 survey.

This section presents each of the 32 Key Findings, using data from the trust's 2017 survey, andcompares these to other mental health / learning disability trusts in England and to the trust'sperformance in the 2016 survey. The findings are arranged under nine themes: appraisals andsupport for development, equality and diversity, errors and incidents, health and wellbeing,working patterns, job satisfaction, managers, patient care and experience , and violence,harassment and bullying.

Positive findings are indicated with a green arrow (e.g. where the trust is better than average, orwhere the score has improved since 2016). Negative findings are highlighted with a red arrow(e.g. where the trust’s score is worse than average, or where the score is not as good as 2016).An equals sign indicates that there has been no change.

Appraisals & support for development

KEY FINDING 11. Percentage of staff appraised in last 12 months

KEY FINDING 12. Quality of appraisals

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KEY FINDING 13. Quality of non-mandatory training, learning or development

Equality & diversity

KEY FINDING 20. Percentage of staff experiencing discrimination at work in the last 12months

KEY FINDING 21. Percentage of staff believing that the organisation provides equalopportunities for career progression or promotion

Errors & incidents

KEY FINDING 28. Percentage of staff witnessing potentially harmful errors, near missesor incidents in last month

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KEY FINDING 29. Percentage of staff reporting errors, near misses or incidents witnessedin the last month

KEY FINDING 30. Fairness and effectiveness of procedures for reporting errors, nearmisses and incidents

KEY FINDING 31. Staff confidence and security in reporting unsafe clinical practice

Health and wellbeing

KEY FINDING 17. Percentage of staff feeling unwell due to work related stress in the last12 months

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KEY FINDING 18. Percentage of staff attending work in the last 3 months despite feelingunwell because they felt pressure from their manager, colleagues or themselves

KEY FINDING 19. Organisation and management interest in and action on health andwellbeing

Working patterns

KEY FINDING 15. Percentage of staff satisfied with the opportunities for flexible workingpatterns

KEY FINDING 16. Percentage of staff working extra hours

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Job satisfaction

KEY FINDING 1. Staff recommendation of the organisation as a place to work or receivetreatment

KEY FINDING 4. Staff motivation at work

KEY FINDING 7. Percentage of staff able to contribute towards improvements at work

KEY FINDING 8. Staff satisfaction with level of responsibility and involvement

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KEY FINDING 9. Effective team working

KEY FINDING 14. Staff satisfaction with resourcing and support

Managers

KEY FINDING 5. Recognition and value of staff by managers and the organisation

KEY FINDING 6. Percentage of staff reporting good communication between seniormanagement and staff

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KEY FINDING 10. Support from immediate managers

Patient care & experience

KEY FINDING 2. Staff satisfaction with the quality of work and care they are able todeliver

KEY FINDING 3. Percentage of staff agreeing that their role makes a difference to patients/ service users

KEY FINDING 32. Effective use of patient / service user feedback

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Violence, harassment & bullying

KEY FINDING 22. Percentage of staff experiencing physical violence from patients,relatives or the public in last 12 months

KEY FINDING 23. Percentage of staff experiencing physical violence from staff in last 12months

KEY FINDING 24. Percentage of staff / colleagues reporting most recent experience ofviolence

KEY FINDING 25. Percentage of staff experiencing harassment, bullying or abuse frompatients, relatives or the public in last 12 months

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KEY FINDING 26. Percentage of staff experiencing harassment, bullying or abuse fromstaff in last 12 months

KEY FINDING 27. Percentage of staff / colleagues reporting most recent experience ofharassment, bullying or abuse

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Nursing Degree Apprenticeship ProgrammeStaff from West London Mental Health NHS Trust (WLMHT) and Central and North West London NHS Foundation Trust (CNWL) joined forces at Bucks New University to launch a new Nursing Degree Apprenticeship.

This exciting new programme gives healthcare support workers the opportunity to pursue a career in nursing through a fully funded apprenticeship programme. Together with CNWL, we are one of the first trusts in London to offer this degree level opportunity.

Deputy Director of Nursing Gillian Kelly said: “We wanted to start with a small group of students so that we could ensure they receive the very best possible support and education experience. We collaborated with CNWL to present a joint cohort of students to make the programme viable.”

Assistant Director of Workforce Ali Webster said: “The opportunity to grow our own future nursing workforce is something we are really passionate about and the benefits are clear. We now have the opportunity to ensure that our future nurses receive the same high quality university education but also gain valuable on the job training so that they are working to our Trust values and gaining experience while they learn.”

Each trust held its own individual assessment centre to select from the huge amount of interest they received.

Those that passed the first stage of selection came together at the university selection event, which included talks from the university staff, literacy and numeracy assessments, group interviews and individual interviews, ensuring the apprentices received the same selection process as all other degree level students.

Jayne Francis-Shama – BNU Programme Lead for Nursing Degree Apprenticeship said “We were so impressed with the high calibre of the West London Mental Health staff who had all prepared well for their interviews and led the way in the group discussions.”

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rpo

rate

Se

rvic

es h

as a

lso

se

en

a d

ecre

ase

fro

m 6

.8%

in

De

ce

mb

er,

to

6.5

% in

Ja

nu

ary

.

Va

ca

ncy r

ate

fo

r a

ll o

the

r C

SU

s h

ave

in

cre

ase

d; H

igh

Se

cu

re h

as in

cre

ase

d b

y 1

.1%

, E

sta

tes b

y 0

.4%

an

d F

ore

nsic

Se

rvic

es s

aw

an

in

cre

ase

of

0.2

%.

VA

CA

NC

IES

Va

ca

nc

y r

ate

by C

SU

SP

EC

IAL

IST

& L

OC

AL

SE

RV

ICE

S

FO

RE

NS

IC S

ER

VIC

ES

HIG

H S

EC

UR

E S

ER

VIC

ES

CO

RP

OR

AT

E S

ER

VIC

ES

CO

MM

EN

TA

RY

Th

e v

aca

ncy r

ate

fo

r Ja

nu

ary

ha

s in

cre

ase

d b

y 0

.2%

co

mp

are

d to

th

e p

revio

us m

on

th a

nd

is 6

.3%

ab

ove

th

e T

rust ta

rge

t

of

10

%. V

aca

ncy r

ate

fo

r re

gis

tere

d n

urs

es h

as in

cre

ase

d m

arg

ina

lly, fr

om

24

.1%

to

24

.2%

an

d u

nre

gis

tere

d n

urs

ing

ha

s

de

cre

ase

d f

rom

14

.7%

in

De

ce

mb

er

to 1

3.8

% in

Ja

nu

ary

. T

he

nu

mb

er

of

fun

de

d p

osts

in

Ja

nu

ary

wa

s 3

78

3.9

WT

E a

nd

the

nu

mb

er

of

sta

ff in

po

st w

as 3

16

8.7

WT

E o

r 3

34

4 h

ea

dco

un

t.

ES

TA

TE

S &

FA

CIL

ITIE

S

TR

US

T W

IDE

6%

8%

10

%

12

%

14

%

16

%

18

%

20

%V

acan

cy R

ate

(%

)

20

16

-17

20

17

-18

Targ

et

0%

5%

10

%

15

%

20

%

25

%

SPEC

IALI

ST &

LO

CA

LSE

RV

ICES

FOR

ENSI

C S

ERV

ICES

HIG

H S

ECU

RE

SER

VIC

ESC

OR

PO

RA

TESE

RV

ICES

ESTA

TES

&FA

CIL

ITIE

S

Vac

ancy

Rat

e (%

) b

y C

SU

CSU

Targ

et

3

Item

10.

5.3:

Wor

kfor

ceP

erfo

rman

ce R

epor

t - J

an

Page 141 of 308

No

v-1

7D

ec

-17

Ja

n-1

8

18.0

3%

18.5

0%

18.5

7%

9.1

3%

9.2

9%

9.4

7%

16.8

2%

16.6

7%

16.6

5%

15.3

0%

16.3

5%

15.9

8%

9.1

6%

8.0

3%

7.2

8%

14.9

4%

15.1

3%

15.0

8%

Invo

lun

tary

R

eti

rem

en

t

SP

EC

IALIS

T &

LO

CA

L S

ER

VIC

ES

12.9

2%

3.3

9%

2.2

6%

18.5

7%

FO

RE

NS

IC S

ER

VIC

ES

7.5

7%

0.8

6%

1.0

3%

9.4

7%

HIG

H S

EC

UR

E S

ER

VIC

ES

11.9

6%

2.1

2%

2.5

7%

16.6

5%

CO

RP

OR

AT

E S

ER

VIC

ES

12.4

3%

1.4

2%

2.1

3%

15.9

8%

ES

TA

TE

S &

FA

CIL

ITIE

S4.0

0%

1.4

6%

1.8

2%

7.2

8%

TR

US

T W

IDE

10.8

3%

2.2

7%

1.9

8%

15.0

8%

Sta

ff i

n p

os

t

HC

Le

ave

rs H

CV

olu

nta

ry

Tu

rno

ve

r

23

626.3

7%

21

524.0

0%

21

523.4

4%

22

522.4

7%

22

522.3

9%

Sta

ff i

n p

os

t

HC

Le

ave

rs H

CV

olu

nta

ry

Tu

rno

ve

r

10

329.7

5%

10

329.2

7%

11

328.1

3%

12

325.9

0%

12

324.8

3%

To

p 5

dep

art

men

ts w

ith

th

e h

igh

est

vo

lun

tary

tu

rno

ver

rate

s

Dep

art

men

t -

(reg

iste

red

nu

rses o

nly

)

222 1

0555 S

heff

ield

Ward

222 1

2193 W

ells

Unit N

urs

ing

222 1

4492 D

over

Ward

222 1

0555 S

heff

ield

Ward

222 1

2135 B

err

y W

ard

(T

om

Main

)

CO

MM

EN

TA

RY

Dep

art

men

t -

(all s

taff

)

222 1

0170 S

andow

n W

ard

222 1

3871 L

illie

Ward

222 1

4492 D

over

Ward

The tota

l T

rust tu

rnover

rate

for

rolli

ng 1

2 m

onth

s h

as m

arg

inally

decre

ased this

month

to 1

5.0

8%

,

whic

h is 3

.08%

above the c

urr

ent ta

rget of

12%

, and 0

.05%

low

er

than the p

revio

us m

onth

.

Aft

er

the p

ositiv

e d

eclin

e in turn

over

rate

for

leavers

with less than 1

year

serv

ice

betw

een M

ay

2017 a

nd J

uly

2017, th

ere

was a

slig

ht in

cre

ase in A

ugust to

Se

pte

mber.

We a

re n

ow

seein

g

anoth

er

positiv

e d

eclin

e b

etw

een S

epte

mber

2017 a

nd D

ecem

ber

2017.

The 5

depart

ments

curr

ently w

ith the h

ighest volu

nta

ry turn

over

rate

s a

re s

how

n to the left

. T

his

inclu

des d

epart

ments

with m

ore

than 2

0 s

taff

only

for

all

sta

ff g

roups a

nd d

epart

ments

with m

ore

than 1

0 s

taff

only

for

regis

tere

d n

urs

es, and is a

n a

vera

ge o

ver

the p

ast 12 m

onth

s.

222 1

2142 B

evan W

ard

222 1

0170 S

andow

n W

ard

TUR

NO

VER

The b

elo

w d

ata

pre

sents

the turn

over

rate

s f

or

rolli

ng 1

2 m

onth

s b

y C

SU

alo

ng w

ith leavers

with less than 1

years

serv

ice

CS

UV

olu

nta

ry

Tu

rno

ver

Oth

er

Tu

rno

ver

Gro

ss

Tu

rno

ver

Gro

ss t

urn

over

CS

U

SP

EC

IALIS

T &

LO

CA

L S

ER

VIC

ES

FO

RE

NS

IC S

ER

VIC

ES

HIG

H S

EC

UR

E S

ER

VIC

ES

CO

RP

OR

AT

E S

ER

VIC

ES

ES

TA

TE

S &

FA

CIL

ITIE

S

TR

US

T W

IDE

11

%

12

%

13

%

14

%

15

%

16

%

Ap

rM

ayJu

nJu

lA

ug

Sep

Oct

No

vD

ecJa

nFe

bM

ar

Gro

ss T

urn

ove

r R

ate

(%

)

20

16

-17

20

17

-18

Targ

et

3.0

0%

3.2

0%

3.4

0%

3.6

0%

3.8

0%

4.0

0%

Feb

-17

Mar

-17

Ap

r-17

May

-17

Jun

-17

Jul-

17A

ug-

17Se

p-1

7O

ct-1

7N

ov-

17D

ec-1

7Ja

n-1

8

Gro

ss t

urn

ove

r ra

te (

%)

- Le

aver

s w

ith

less

th

an 1

yea

r se

rvic

e

4

Page 142 of 308

WT

EH

CW

TE

HC

Ad

d P

rof

Scie

ntific a

nd

Te

ch

nic

0.8

10

.51

Ad

ditio

na

l C

linic

al S

erv

ice

s1

8.0

19

7.6

9

Ad

min

istr

ative

an

d C

leri

ca

l4

.85

4.5

5

Alli

ed

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alth

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fessio

na

ls2

.02

0.6

1

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tes a

nd

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cill

ary

0.0

00

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Me

dic

al a

nd

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nta

l4

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1.4

2

Nu

rsin

g a

nd

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wife

ry R

eg

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4.0

41

0.6

11

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de

nts

0.0

00

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nd

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tal

33

.63

52

5.2

29

WT

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CW

TE

HC

SP

EC

IAL

IST

& L

OC

AL

SE

RV

ICE

S1

6.8

18

11

.31

4

FO

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NS

IC S

ER

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5.0

53

.54

HIG

H S

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UR

E S

ER

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8.8

99

.09

CO

RP

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AT

E S

ER

VIC

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3.0

31

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ES

TA

TE

S &

FA

CIL

ITIE

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0.0

0

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US

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IDE

33

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52

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Star

ters

an

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MM

EN

TA

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35

ne

w s

taff

me

mb

ers

jo

ine

d t

he

Tru

st

in J

an

ua

ry a

nd

29

le

ft (

this

in

clu

de

s s

ub

sta

ntive

an

d F

TC

sta

ff).

4 R

eg

iste

red

Nu

rse

s (

an

d 3

Nu

rse

s a

wa

itin

g p

in)

join

ed

th

e T

rust

an

d 1

1 le

ft.

Th

e m

ajo

rity

of

Sta

rte

rs in

Ja

nu

ary

we

re A

dd

itio

na

l C

linic

al S

erv

ice

s s

taff

.

ST

AF

F G

RO

UP

ST

AR

TE

RS

JA

N-1

8L

EA

VE

RS

JA

N-1

8

CS

US

TA

RT

ER

S J

AN

-18

LE

AV

ER

S J

AN

-18

20

30

40

50

60

70

80

90

10

0H

ead

cou

nt

of

Star

ters

an

d L

eave

rs (

Tru

st)

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ters

(H

C)

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(H

C)

05

10

15

20

25

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adco

un

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f St

arte

rs a

nd

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ave

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Re

gist

ere

d N

urs

es)

Star

ters

(H

C)

Leav

ers

(H

C)

5

Item

10.

5.3:

Wor

kfor

ceP

erfo

rman

ce R

epor

t - J

an

Page 143 of 308

Oc

t-1

7N

ov-1

7D

ec

-17

Ja

n-1

8D

EP

AR

TM

EN

TS

taff

in

po

st

HC

Sic

kn

es

s r

ate

%

3.5

0%

3.0

8%

3.2

4%

3.8

8%

22

2 1

56

10

Do

me

stic S

taff

(B

HA

)5

01

9.6

1%

4.2

7%

4.3

5%

5.8

6%

6.0

1%

22

2 1

21

42

Be

va

n W

ard

22

18

.33

%

5.7

2%

5.7

7%

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9%

6.8

9%

22

2 1

05

55

Sh

eff

ield

Wa

rd2

21

4.9

0%

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9%

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6%

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6%

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7%

22

2 1

26

21

Le

a W

ard

(R

ollo

Ma

y)

23

14

.54

%

3.1

0%

4.4

2%

4.9

6%

6.7

6%

22

2 1

01

70

Sa

nd

ow

n W

ard

23

14

.14

%

3.9

9%

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4%

4.5

0%

5.1

5%

% o

f a

ll e

pis

od

es

Oc

t-1

7N

ov-1

7D

ec

-17

Ja

n-1

83

9.1

0%

1.9

0%

1.4

3%

1.3

8%

2.2

2%

12

.20

%

6.6

3%

5.9

0%

6.2

4%

5.7

6%

8.5

0%

3.2

0%

2.8

8%

3.3

1%

6.3

3%

7.8

0%

2.6

7%

3.9

4%

4.9

6%

3.3

0%

5.6

0%

4.0

2%

4.7

2%

5.2

0%

7.0

2%

% o

f a

ll W

TE

Da

ys

Lo

st

0.0

0%

0.0

0%

0.0

0%

0.0

0%

24

.70

%

1.1

2%

1.5

8%

1.8

2%

2.1

6%

17

.30

%

3.7

3%

4.1

2%

5.2

9%

5.1

8%

10

.80

%

0.0

0%

0.0

0%

0.0

0%

0.0

0%

8.7

0%

3.9

9%

3.9

4%

4.5

0%

5.1

5%

7.5

0%

Alli

ed

He

alth

Pro

fessio

na

ls

Esta

tes a

nd

An

cill

ary

He

alth

ca

re S

cie

ntists

S1

0 A

nxie

ty/s

tre

ss/d

ep

ressio

n/o

the

r p

sych

iatr

ic illn

esse

s

S1

2 O

the

r m

uscu

loske

leta

l p

rob

lem

s

S2

8 In

jury

, fr

actu

re

S1

3 C

old

, C

ou

gh

, F

lu -

In

flu

en

za

TO

P 5

RE

AS

ON

S B

Y N

UM

BE

R O

F W

TE

DA

YS

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ST

S2

8 In

jury

, fr

actu

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S2

5 G

astr

oin

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al p

rob

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s

Me

dic

al a

nd

De

nta

l

Nu

rsin

g a

nd

Mid

wife

ry R

eg

iste

red

Stu

de

nts

TR

US

T W

IDE

S1

3 C

old

, C

ou

gh

, F

lu -

In

flu

en

za

Th

e s

ickn

ess a

bse

nce

ra

te f

or

Ja

nu

ary

wa

s 5

.15

%, w

hic

h is 1

.05

% a

bo

ve

th

e

Tru

st ta

rge

t o

f 4

.1%

, a

nd

0.6

5%

hig

he

r co

mp

are

d to

th

e p

revio

us m

on

th.

Th

e W

ork

forc

e &

Ad

vis

ory

Te

am

co

ntin

ue

s to

pro

vid

e s

up

po

rt to

ma

na

ge

rs in

reg

ard

s to

ma

na

gin

g s

ickn

ess a

bse

nce

ca

se

s.

Th

e ta

ble

be

low

lis

ts th

e f

ive

de

pa

rtm

en

ts w

ith

th

e h

igh

est sic

kn

ess a

bse

nce

rate

du

rin

g J

an

ua

ry 2

01

8, a

s w

ell

as a

bre

akd

ow

n o

f th

e to

p 5

re

aso

ns f

or

ab

se

nce

, b

oth

by th

e n

um

be

r o

f e

pis

od

es a

nd

th

e n

um

be

r o

f d

ays lo

st.

TO

P 5

RE

AS

ON

S B

Y N

UM

BE

R O

F E

PIS

OD

ES

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MM

EN

TA

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KN

ESS

S2

5 G

astr

oin

testin

al p

rob

lem

s

S1

0 A

nxie

ty/s

tre

ss/d

ep

ressio

n/o

the

r p

sych

iatr

ic illn

esse

s

S1

2 O

the

r m

uscu

loske

leta

l p

rob

lem

s

SIC

KN

ES

S B

Y C

SU

SP

EC

IAL

IST

& L

OC

AL

SE

RV

ICE

S

FO

RE

NS

IC S

ER

VIC

ES

HIG

H S

EC

UR

E S

ER

VIC

ES

CO

RP

OR

AT

E S

ER

VIC

ES

ES

TA

TE

S &

FA

CIL

ITIE

S

TR

US

T W

IDE

SIC

KN

ES

S B

Y S

TA

FF

GR

OU

P

Ad

d P

rof

Scie

ntific a

nd

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ch

nic

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ditio

na

l C

linic

al S

erv

ice

s

Ad

min

istr

ative

an

d C

leri

ca

l

3%

4%

5%

6%

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-16

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Sick

ne

ss R

ate

(%

) -

Jan

uar

y 2

01

6 t

o J

anu

ary

20

18

Sick

ne

ss R

ate

%Ta

rget

6

Page 144 of 308

CO

MM

ENTA

RY

Sic

kn

es

s r

ate

Tu

rno

ve

r R

ate

-

12

Mo

nth

5.1

2%

15.2

0%

2.8

3%

17.8

3%

4.2

2%

20.5

4%

4.7

1%

16.6

8%

3.7

3%

17.1

5%

4.1

5%

15.3

2%

1.8

7%

17.1

6%

4.1

2%

15.0

9%

3.8

4%

12

.63

%

4.9

3%

16.8

7%

Me

nta

l H

ea

lth

an

d L

ea

rnin

g D

isa

bil

ity T

rus

ts

WO

RK

FOR

CE

BEN

CH

MA

RK

ING

Sick

nes

s d

ata

sho

wn

is f

rom

Oct

ob

er 2

01

7. C

om

par

ed t

o o

ther

Men

tal H

ealt

h &

Lear

nin

g D

isab

iliti

es t

rust

s in

Lo

nd

on

, WLM

HT

had

a h

igh

er t

han

ave

rage

sic

knes

s ra

te.

The

aver

age

sick

nes

s ra

te f

or

Lon

do

n T

rust

s is

3.8

% c

om

par

ed t

o W

LMH

T si

ckn

ess

rate

of

4.1

%. T

he

top

gra

ph

re

pre

sen

ts s

ickn

ess

rate

s fo

r Tr

ust

s A

-G, r

epre

sen

tin

g th

e gr

ou

p

of

Men

tal H

ealt

h &

Lea

rnin

g D

isab

ility

tru

sts.

Th

e Tr

ust

's s

ickn

ess

rate

was

low

er

than

the

nat

ion

al r

ate

for

Men

tal H

ealt

h &

Lea

rnin

g D

isab

ility

tru

sts

in O

cto

ber

, at

4.9

%.

The

bo

tto

m g

rap

h s

ho

ws

the

com

par

iso

n o

f tu

rno

ver

rate

s fo

r th

e sa

me

gro

up

of

Lon

do

n M

enta

l Hea

lth

& L

earn

ing

Dis

abili

ties

tru

sts

(exc

lud

ing

jun

ior

med

ical

sta

ff)

in

No

vem

ber

20

17

. Th

is is

th

e to

tal t

urn

ove

r ra

te in

clu

din

g al

l lea

vers

(vo

lun

tary

resi

gnat

ion

s, r

eti

rem

ents

, en

d o

f fi

xed

ter

m c

on

trac

ts e

tc.)

. WLM

HT

had

a h

igh

er t

han

aver

age

turn

ove

r co

mp

ared

to

th

e gr

ou

p (

12

mo

nth

s to

en

d N

ove

mb

er 2

01

7)

at 1

5%

.

Stab

ility

in W

LMH

T in

No

vem

ber

20

17

was

hig

her

th

an t

he

Lon

do

n a

vera

ge.

**A

s w

ith

all

ben

chm

arki

ng

info

rmat

ion

, th

is s

ho

uld

be

use

d w

ith

cau

tio

n. T

rust

s w

ill

use

ESR

dif

fere

ntl

y d

epen

din

g o

n t

hei

r o

wn

loca

l pro

cess

es a

nd

may

no

t co

nsi

sten

tly

app

ly t

he

app

roac

hes

.

This

ben

chm

arki

ng

info

rmat

ion

co

mes

fro

m iV

iew

, th

e In

form

atio

n C

en

tre

dat

a

war

eho

use

to

ol a

nd

is t

he

mo

st r

ece

nt

dat

a av

aila

ble

.

Tru

st

G

West

London M

H

Avera

ge

London M

enta

l H

ealth &

Learn

ing D

isabili

ty

Natio

nal M

enta

l H

ealth &

Learn

ing D

isabili

ty

Tru

st

A

Tru

st

B

Tru

st

C

Tru

st

D

Tru

st

E

Tru

st

F

0%

1%

2%

3%

4%

5%

6%

Tru

st A

Tru

st B

Tru

st C

Tru

st D

Tru

st E

Tru

st F

Tru

st G

Wes

tLo

nd

on

MH

Ave

rage

Lon

do

nM

enta

lH

ealt

h &

Lear

nin

gD

isab

ility

Nat

ion

alM

enta

lH

ealt

h &

Lear

nin

gD

isab

ility

Sick

ne

ss r

ate

0%

5%

10

%

15

%

20

%

25

%

Tru

st A

Tru

st B

Tru

st C

Tru

st D

Tru

st E

Tru

st F

Tru

st G

Wes

tLo

nd

on

MH

Ave

rage

Lon

do

nM

enta

lH

ealt

h &

Lear

nin

gD

isab

ility

Nat

ion

alM

enta

lH

ealt

h &

Lear

nin

gD

isab

ility

Turn

ove

r ra

te-

12

Mo

nth

7

Item

10.

5.3:

Wor

kfor

ceP

erfo

rman

ce R

epor

t - J

an

Page 145 of 308

Str

ess / a

nxie

ty

/ d

ep

ressio

n

Bu

llin

g &

hara

ssm

en

t

SP

EC

IALIS

T &

LO

CA

L S

ER

VIC

ES

43

73

59

16

50

11

5

FO

RE

NS

IC S

ER

VIC

ES

CS

U1

85

18

15

65

06

7

HIG

H S

EC

UR

E S

ER

VIC

ES

CS

U1

31

11

87

10

41

CO

RP

OR

AT

E S

ER

VIC

ES

*6

12

00

00

9

ES

TA

TE

S &

FA

CIL

ITIE

S7

21

23

60

03

0

TR

US

T W

IDE

87

16

78

35

35

11

0262

CO

MM

EN

TA

RY

CS

US

ho

rt T

erm

Sic

kn

ess %

Lo

ng

Term

Sic

kn

ess %

To

tal sic

kn

ess

%

% W

ork

Rela

ted

WT

E

Days L

ost

SP

EC

IALIS

T &

LO

CA

L S

ER

VIC

ES

1.4

3%

2.4

5%

3.8

8%

1.5

7%

FO

RE

NS

IC S

ER

VIC

ES

CS

U1.8

7%

4.1

4%

6.0

1%

0.6

3%

HIG

H S

EC

UR

E S

ER

VIC

ES

CS

U3.1

2%

3.7

7%

6.8

9%

9.8

6%

CO

RP

OR

AT

E S

ER

VIC

ES

*1.4

0%

2.3

7%

3.7

7%

0.0

0%

ES

TA

TE

S &

FA

CIL

ITIE

S3.1

8%

3.5

8%

6.7

6%

0.8

2%

To

tal

2.0

1%

3.1

3%

5.1

5%

3.4

9%

* in

clu

din

g C

apital P

lannin

g &

Redevelo

pm

ent

CO

MM

EN

TA

RY

Sic

kness a

bsence in J

anuary

is b

roken d

ow

n a

s 2

.01%

short

term

and 3

.13%

long term

. H

igh S

ecure

Serv

ices h

ad the h

ighest sic

kness r

ate

s n

ote

d. T

he h

ighest le

vel of

work

rela

ted s

ickness in J

anuary

was s

een in H

igh S

ecure

Serv

ices (

9.8

6%

of

all

WT

E d

ays lost in

Hig

h S

ecure

CS

U),

com

pare

d to 1

7.6

% in D

ecem

ber.

OC

CU

PA

TIO

NA

L H

EALT

HT

he b

elo

w d

ata

show

s the n

um

ber

of

Occupational H

ealth r

efe

rrals

for

January

2018 b

y C

SU

TO

TA

LO

CC

UP

AT

ION

AL

HE

AL

TH

Man

ag

em

en

t

refe

rrals

in

itia

l

ap

pt

-

AT

TE

ND

ED

OH

self

refe

rrals

init

ial ap

pt

-

AT

TE

ND

ED

Ph

ysio

thera

py

assessm

en

ts

& t

reatm

en

ts-

AT

TE

ND

ED

Co

un

sellin

g

assessm

en

ts -

AT

TE

ND

ED

Co

un

sellin

g

sessio

ns -

AT

TE

ND

ED

WO

RK

-RE

LA

TE

D S

TR

ES

S

RE

PO

RT

ED

Belo

w d

ata

show

short

and long term

(above 2

1 d

ays

) sic

kness r

ate

s a

long w

ith the w

ork

rela

ted s

ickness p

er

CS

U.

Work

-rela

ted s

tress n

arr

ative: T

he them

es f

or

Local serv

ices inclu

de w

ork

load, la

ck o

f support

fro

m c

olle

agues / m

anager,

and u

nder

investigation / m

onitoring. B

roadm

oor

HS

S them

es inclu

de u

nder

investigation / m

onitoring. T

hem

es f

or

Fore

nsic

Serv

ices inclu

de lack o

f support

form

colle

agues / m

anager,

under

investigation / m

onitoring,

work

load, and r

ela

tionship

s a

t w

ork

. N

o them

es r

ecord

ed f

or

Esta

tes &

Facili

ties S

erv

ices o

r C

orp

ora

te S

erv

ices.

0%

1%

2%

3%

4%

5%

Sho

rt T

erm

Sick

ne

ss %

Lon

g Te

rmSi

ckn

ess

%

8

Page 146 of 308

Nu

rsin

g es

tab

lish

men

t W

TEC

OM

MEN

TAR

Y

CSU

Ap

r-1

7M

ay-1

7Ju

n-1

7Ju

l-1

7A

ug-

17

Sep

-17

Oct

-17

No

v-1

7D

ec-1

7Ja

n-1

8

Fore

nsi

c C

SU5

02

.25

02

.25

02

.25

03

.25

03

.25

03

.25

03

.25

03

.25

03

.25

03

.2

Hig

h S

ecu

re S

ervi

ces

CSU

48

6.7

48

6.7

48

6.7

48

9.0

48

8.4

48

8.0

48

7.9

48

9.4

49

2.3

49

2.3

Spe

cial

ist

& L

oca

l Ser

vice

s C

SU8

15

.88

22

.58

18

.58

18

.58

12

.78

10

.58

10

.28

10

.28

11

.38

07

.7

Gra

nd

To

tal

18

04

.71

81

1.4

18

07

.41

81

0.8

18

04

.31

80

1.7

18

01

.31

80

2.9

18

06

.81

80

3.2

Nu

rsin

g St

aff

in P

ost

WTE

CSU

Ap

r-1

7M

ay-1

7Ju

n-1

7Ju

l-1

7A

ug-

17

Sep

-17

Oct

-17

No

v-1

7D

ec-1

7Ja

n-1

8

Fore

nsi

c C

SU4

15

.64

15

.04

15

.04

16

.04

17

.34

19

.94

27

.14

26

.14

20

.24

16

.9

Hig

h S

ecu

re S

ervi

ces

CSU

40

4.6

40

2.2

40

6.4

40

5.8

40

7.2

40

8.8

42

1.0

42

3.8

41

8.8

41

9.3

Spe

cial

ist

& L

oca

l Ser

vice

s C

SU6

06

.16

04

.26

01

.06

00

.85

95

.35

97

.15

97

.26

01

.86

03

.66

07

.2

Gra

nd

To

tal

14

26

.21

42

1.4

14

22

.31

42

2.5

14

19

.81

42

5.7

14

45

.31

45

1.7

14

42

.51

44

3.3

Nu

rsin

g V

acan

cy r

ate

CSU

Ap

r-1

7M

ay-1

7Ju

n-1

7Ju

l-1

7A

ug-

17

Sep

-17

Oct

-17

No

v-1

7D

ec-1

7Ja

n-1

8

Fore

nsi

c C

SU1

7.2

%1

7.4

%1

7.4

%1

7.3

%1

7.1

%1

6.6

%1

5.1

%1

5.3

%1

6.5

%1

7.2

%

Hig

h S

ecu

re S

ervi

ces

CSU

16

.9%

17

.4%

16

.5%

17

.0%

16

.6%

16

.2%

13

.7%

13

.4%

14

.9%

14

.8%

Spe

cial

ist

& L

oca

l Ser

vice

s C

SU2

5.7

%2

6.5

%2

6.6

%2

6.6

%2

6.8

%2

6.3

%2

6.3

%2

5.7

%2

5.6

%2

4.8

%

Gra

nd

To

tal

21

.0%

21

.5%

21

.3%

21

.4%

21

.3%

20

.9%

19

.8%

19

.5%

20

.2%

20

.0%

Nu

rsin

g Si

ckn

ess

rate

s

CSU

Ap

r-1

7M

ay-1

7Ju

n-1

7Ju

l-1

7A

ug-

17

Sep

-17

Oct

-17

No

v-1

7D

ec-1

7Ja

n-1

8

Fore

nsi

c C

SU3

.6%

4.7

%4

.5%

4.4

%4

.2%

3.5

%4

.8%

5.2

%7

.0%

6.7

%

Hig

h S

ecu

re S

ervi

ces

CSU

5.8

%7

.8%

6.7

%8

.8%

7.2

%8

.4%

7.3

%6

.7%

7.5

%7

.8%

Spe

cial

ist

& L

oca

l Ser

vice

s C

SU2

.6%

3.0

%3

.2%

3.5

%4

.2%

4.1

%4

.1%

3.5

%4

.2%

3.4

%

Gra

nd

To

tal

3.8

%4

.9%

4.6

%5

.3%

5.1

%5

.2%

5.2

%4

.9%

6.0

%5

.6%

Nu

rsin

g vo

lun

tary

tu

rno

ver

CSU

Ap

r-1

7M

ay-1

7Ju

n-1

7Ju

l-1

7A

ug-

17

Sep

-17

Oct

-17

No

v-1

7D

ec-1

7Ja

n-1

8

Fore

nsi

c C

SU8

.2%

8.3

%8

.3%

8.3

%6

.7%

7.1

%7

.1%

6.9

%6

.6%

7.1

%

Hig

h S

ecu

re S

ervi

ces

CSU

12

.1%

12

.3%

12

.4%

12

.7%

13

.5%

15

.4%

14

.2%

13

.5%

12

.8%

13

.1%

Spe

cial

ist

& L

oca

l Ser

vice

s C

SU1

3.1

%1

2.6

%1

2.6

%1

3.1

%1

1.5

%1

1.8

%1

1.0

%1

0.3

%1

0.6

%1

0.6

%

Gra

nd

To

tal

11

.4%

11

.3%

11

.3%

11

.6%

10

.7%

11

.5%

10

.8%

10

.2%

10

.1%

10

.3%

* R

egis

tere

d n

urs

es in

clu

de

the

NM

C r

egis

tere

d s

taff

no

t w

ork

ing

on

war

ds

Th

e v

aca

ncy r

ate

is a

bo

ve

th

e T

rust's t

arg

et

of

10

% a

nd

ha

s d

ecre

ase

d b

y

0.2

% c

om

pa

red

to

th

e p

revio

us m

on

th.

Sic

kne

ss r

ate

de

cre

ase

d t

o 5

.6%

an

d

is a

bo

ve

th

e T

rust's t

arg

et

of

4.1

%.

Vo

lun

tary

tu

rno

ve

r h

as in

cre

ase

d t

o 1

0.3

%

in J

an

ua

ry,

co

mp

are

d t

o 1

0.1

% in D

ece

mb

er.

NU

RSI

NG

WO

RK

FOR

CE

PR

OFI

LE

Th

is d

ata

sh

ow

s a

mo

re d

eta

iled

vie

w o

f o

ur

nu

rsin

g w

ork

forc

e (

bo

th

regis

tere

d a

nd

un

regis

tere

d).

4 r

egis

tere

d n

urs

es*

an

d 1

4 u

nre

gis

tere

d n

urs

es jo

ine

d t

he

Tru

st

in J

an

ua

ry,

wh

ere

as 1

1 r

egis

tere

d n

urs

es*

an

d 6

un

regis

tere

d n

urs

es h

ave

le

ft.

0%

5%

10

%

15

%

20

%

25

%

Vac

ancy

rat

eSi

ckn

ess

rat

eV

olu

nta

ry t

urn

ove

r

9

Item

10.

5.3:

Wor

kfor

ceP

erfo

rman

ce R

epor

t - J

an

Page 147 of 308

CS

U

Le

ng

th o

f

va

ca

nc

y a

dve

rt

fro

m v

ac

an

cy

po

sti

ng

to

ad

ve

rtis

ing

clo

se

Ave

rag

e t

ime

fro

m

va

ca

nc

y a

dve

rt

clo

sin

g t

o

forw

ard

ing

lo

ng

lis

t to

hir

ing

ma

na

ge

r -

KP

I 1

da

y

Ave

rag

e t

ime

for

Re

cru

itin

g

Ma

na

ge

r to

sh

ort

lis

t -

KP

I

3 d

ays

Ave

rag

e t

ime

fro

m s

ho

rtlis

t

no

tifi

ca

tio

n t

o

invit

es

fo

r

inte

rvie

w -

KP

I

1 d

ay

Ave

rag

e t

ime

Fro

m In

terv

iew

Invit

ati

on

se

nt

to in

terv

iew

da

te

Ave

rag

e t

ime

fo

r

Re

cru

itin

g L

ine

Ma

na

ge

r to

ma

ke

ve

rba

l o

ffe

r &

re

turn

ou

tco

me

in

form

ati

on

to R

ec

ruit

me

nt

- K

PI 2

da

ys

Ave

rag

e

tim

e f

or

off

er

lett

ers

to

be

se

nt

ou

t b

y

Re

cru

itm

en

t -

KP

I 1

da

y

Fro

m

Co

nd

itio

na

l

Off

er

se

nt

to

ID

ap

po

intm

en

t

bo

ok

ed

by

ca

nd

ida

te -

KP

I 5

da

ys

Fro

m

Co

nd

itio

na

l

Off

er

se

nt

to

da

te o

f ID

Ap

po

intm

en

t

att

en

de

d -

KP

I

5 d

ays

Fro

m

Co

nd

itio

na

l

Off

er

se

nt

to

1s

t R

efe

ren

ce

req

ue

st

se

nt

-

KP

I 1

da

y

Fro

m D

ate

of

ID

Ap

po

intm

en

t

att

en

de

d t

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cess.

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o H

ire t

his

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ire h

as b

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igh in a

ll are

as

due t

o t

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olid

ay p

eriod ,

changes w

ithin

the t

eam

and 2

mem

bers

of

sta

ff leavin

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t th

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nd

of

the y

ear.

F

or

local serv

ices,

there

was a

technic

al err

or

due t

o a

clo

ned v

acancy f

rom

Febru

ary

2017 w

hic

h h

as p

ulle

d t

hro

ugh t

o J

anuary

2018 a

nd led t

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h t

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14.6

44.9

10

Page 148 of 308

Cap

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at

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ne

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LA

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ELA

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BY

CSU

-

Jan

uar

y 2

01

8

SPEC

IALI

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L

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ES

FOR

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ERV

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CSU

HIG

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SER

VIC

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CSU

CO

RP

OR

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In t

he

mo

nth

of

Ja

nu

ary

th

e n

um

be

r o

f d

iscip

lina

ry c

ase

s in

cre

ase

d f

rom

12

to

18

.

Tru

stw

ide

. T

he

nu

mb

er

of

Dig

nity a

t W

ork

ca

se

s r

ed

uce

d f

rom

2 t

o 0

.

Th

ere

we

re n

o G

rieva

nce

ca

se

s a

cro

ss a

ll D

ire

cto

rate

s.

Th

ere

we

re 2

ca

pa

bili

ty c

ase

s

rep

ort

ed

in

th

e m

on

th o

f Ja

nu

ary

(co

nsis

ten

t w

ith

De

ce

mb

er

sta

tistics)

Th

ere

we

re 5

ne

w D

iscip

lina

ry c

ase

s in

th

e m

on

th o

f Ja

nu

ary

an

d a

n in

cre

ase

of

29

sic

kne

ss a

bse

nce

ca

se

s t

ha

t h

ave

mo

ve

d in

to t

he

Re

d a

s p

er

the

Bra

dfo

rd s

co

ring

syste

m (

ove

r 3

00

).

In J

an

ua

ry 2

01

8 t

he

re w

ere

6 s

taff

su

sp

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ty a

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th

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ba

se

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st

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e.

Of

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su

bse

qu

en

tly b

ee

n

dis

mis

sed

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Th

e W

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forc

e p

art

ne

ring &

Ad

vis

ory

se

rvic

e c

on

tin

ue

to

wo

rk w

ith

ma

na

ge

rs in

ad

vis

ing,

co

ach

ing a

nd

su

pp

ort

ing t

he

m t

o a

dd

ress issu

es a

t a

n e

arly s

tage

, in

clu

din

g

sic

kne

ss a

bse

nce

ca

se

s,

ho

we

ve

r, s

om

e c

ase

s in

evita

bly

re

qu

ire

fo

rma

l a

ctio

n d

ue

to

the

na

ture

of

the

co

nce

rns

11

Item

10.

5.3:

Wor

kfor

ceP

erfo

rman

ce R

epor

t - J

an

Page 149 of 308

n/a

n/a

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Th

era

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c E

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ag

em

en

t a

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pp

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ed

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se

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tio

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86%

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77%

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70%

84%

91%

92%

97%

83%

88%

The J

anu

ary

score

card

show

s 1

3 incre

asin

g,

7 c

ours

es r

em

ain

ing t

he

sam

e a

nd 4

cours

es d

ecre

asin

g.

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stw

ide 1

4 c

ours

es a

re r

epo

rtin

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t 9

0%

and a

bo

ve w

ith 1

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ours

es r

epo

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.

There

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ne s

erv

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es (

Corp

ora

te &

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tes a

nd F

acili

ties )

repo

rtin

g in R

ED

for

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ty U

pda

te -

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nsic

s, th

is r

ela

tes to 2

sta

ff r

epo

rtin

g a

s n

on c

om

plia

nt.

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rses a

bove h

ighlig

hte

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lue a

re a

vaila

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via

eLe

arn

ing a

nd

as a

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ld a

ll be

90

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nt.

T

his

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ein

g c

losely

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y E

Ds b

ut de

spite a

rang

e o

f com

munic

ation a

nd

the

ab

ility

for

all

sta

ff to a

chie

ve c

om

plia

nce in th

ese s

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cts

, 4 c

ours

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em

ain

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r th

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are

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ff fail

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show

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train

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y h

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289 D

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's w

ere

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h s

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n incre

ase fro

m 2

75 in D

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ber.

K

ey o

utlie

rs a

re

Basic

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e A

ware

ne

ss, A

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ce, a

ll of

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re r

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nce b

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w 9

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.It is im

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the

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or

sta

ff a

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the

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All

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re a

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ire

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ieve

d t

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ta

rge

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Man

dat

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Tra

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Page 150 of 308

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Page 151 of 308

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Page 155 of 308


March 2018

Report title:

Monthly communications and engagement report

Executive lead:

Sally Sykes, Director of Communications and Engagement

Report authors:

Sally Sykes, Director of Communications and Engagement Elizabeth George, Head of Communications


N/A


For approval


To note ✓




Legal & Governance


N/A



N/A

Item

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6: D

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Page 156 of 308



Improving quality


✓

Compassionate care


✓

Summary This paper summarises the recent communications and engagement activity carried out by the Communications and Engagement Team.

Supporting documents and/or further reading In the last month, the communications team has produced a range of materials to support the Trust’s activities, including:

• We have not self-produced new videos in this period but we have supported the production of a video for the nursing conference. Some filming has been undertaken for the Broadmoor historical film which we plan to release when the new hospital opens.

• Body worn camera posters (x2) – attached • Collateral for the Nursing Conference on 2 March

• Promotional items for Learning and Development: Congratulation cards (your new job, your achievement, your new role)

• Induction banners (x5)

• CAMHS Eating Disorders Service banner

• A range of posters (x6) to promote National Apprenticeship Week – example attached

• Broadmoor redevelopment: Central building services booklet for patients – attached

Page 157 of 308

Trust board meeting (Part 1): Wednesday 14 March 2018

Communications and engagement activity 1 – 28 February 2018

1 Purpose 1.1 To update the Board on the work of the Communications and Engagement Team.

This report covers the period since the previous board meeting in February. 2 Executive summary 2.1 The board is asked to note the contents of this report, to provide feedback and indicate any

other areas they may wish to see included. 3 Key issues 3.1 External media 3.1.1 The communications team has engaged with external media on the following issues:

• Issued press releases including: o The Care Quality Commission’s unannounced inspection of our acute wards and

psychiatric intensive care unit o Karen Spick, Team Secretary at Broadmoor Hospital, winning an Unsung Hero

Award for ‘Leader of the Year.’ This was covered by the print edition of Bracknell News.

o Trust responds to Health and Social Care Secretary’s ‘zero suicide’ ambition

• The communications team prepared media lines for a number of incidents and issues including the sad death of a patient who went missing while on leave from one of our units; court cases; a high profile patient; and our response to tweets about a sectioned patient.

• We have continued to engage with media within BME communities. Dr Jayshree Pithia, CBT Therapist for Ealing Improving Access to Psychological Therapies (IAPT) was interviewed live on Westside Radio talking about the Ealing IAPT service.

• Chief Executive Carolyn Regan was interviewed about our role in relieving winter pressures, at a recent mental health leaders’ event -https://nhsproviders.org/nhs-winter-watch/week-11

3.2 Social media 3.2.1 The Communications Team uses Twitter as its primary social media platform. Between 1

and 28 February 2018, the Trust’s Twitter following has grown by 89 to a total of 3,595. In addition it has earned:

• 56,200 impressions (this is the number of people who have seen our social media content)

• 132 retweets (onward sharing of our content)

• 183 likes (a further measure of engagement)

• 209 clicks on links through to additional content.

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3.2.2 NHS Improvement has tweeted out links to our thought leadership case study highlighting

the Trust’s work to improve bed management and patient flow within inpatient wards in Local Services. This was published by NHS Improvement here. This builds on action the Board requested to ensure our success stories are profiled in key system bulletins to demonstrate our innovation and delivery.

3.2.3 NHS England showcased the work of the Trust’s Hammersmith and Fulham IAPT service

(Back on Track) published here. 3.2.4 Chief Executive Carolyn Regan was interviewed about our role in relieving winter pressures,

at a mental health leaders’ event and NHS Providers tweeted about this: https://nhsproviders.org/nhs-winter-watch/week-11

3.2.5 During this period our tweets included:

• Congratulating Karen Spick, Team Secretary at Broadmoor Hospital, who won a 'Leader of the Year' award in the Admin and Clerical category in the Unsung Hero Awards.

• Promoting our film on embedding the Triangle of Care across the Trust to make sure that carers are included in the treatment of their loved ones.

• Sharing the Ealing Council consultation related to funding cuts at the One You Ealing

Smokefree service. • Sharing new research as reported in journals and in the media

• Tapping into awareness days and festivals such as Self-harm Awareness Day, World Thinking Day, Chinese New Year and Valentine’s Day.

3.2.6 A tweet highlighting a new study that revealed having pets improved mental wellbeing

gained the highest impressions (3,294) across February and received 15 retweets and 20 likes.

3.3 Website 3.3.1 The Trust’s website is constantly being updated with new content, news stories and links to

significant content or microsites. Below are some overall statistics for visitors to the Trust’s site and other microsites the Communications Team runs.

• During this period, we have had 25,678 sessions, 76% of which were new visitors to the website.

• More than half of visitors came to the site via a search tool, such as Google.

• The careers site had 2,054 sessions in the same period – most of which resulted in a job search. The use of mobile devices continues to increase, with almost half of all visitors accessing the site using a mobile phone or tablet.

3.4 Exchange and internal communications 3.4.1 February saw Director of Finance and Business Paul Stefanoski take over the guest blog

slot with a straight talking piece on the Trust’s finances. The blog post received 2,637 hits with 11 comments from staff.

3.4.2 The Communications team promoted a range of events and stories to staff, notably LGBT

History Month, the Trust’s Nursing Conference, and the Cassel Speakers’ Programme. 3.4.3 An analysis of the most read news stories on the Exchange shows the most popular in

February were (most popular first):

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Band 5 nursing recruitment for Sept 2018

Secondment: Low secure and forensic community Senior Nurse

Gaganjot Sidhu named Employee of the Month

Level 3 severe cold weather alert issued

Join us to celebrate LGBT History Month 2018

3.5 Patient and carer engagement 3.5.1 The Communications Team has supported communication with patients and carers by:

• Producing a Triangle of Care video that informs audiences about the project’s aims: https://youtu.be/TkgRWdSvqyU

• Working to revamp a Carers Information Guideline document as part of the Triangle of Care project.

• The Head of Communications attended the West London Collaborative’s community forum in February where attendees discussed mapping sources of information on access to benefits.

3.6. Staff engagement 3.6.1 During this time, the communications team organised a listening event with Chief Executive

Carolyn Regan and Director of Nursing and Patient Experience Stephanie Bridger for staff at St Bernard’s Café on the Hill. A summary of the event was published on the Exchange.

3.6.2 February’s employee of the month awards went to Wendy Pickford, Domestic Assistant at

Broadmoor hospital and Gaganjot Sidhu, Resourcing Lead for Local Services, Armstrong Way.

3.6.3 We put out a call for staff to be on the judging panel for the Quality Awards 2018. 3.6.4 We highlighted the Ealing Council consultation related to funding cuts at the One You

Ealing Smokefree service and encouraged staff to contribute and support the service. 3.7 Service line communications - High secure and forensic services 3.7.1 The Communications Team has undertaken a number of service line specific activities:

• The communications team has worked with the Prevention and Management of Violence and Aggression (PMVA) to develop a video to highlight PMVA techniques to the reference group for the National Standards for Restrictive Practice. A draft is with the group for comment.

• Following the Board’s decision to decommission the Broadmoor sirens, the communications plan to inform local residents and communicate the replacement alert system with Thames Valley Police is being implemented.

• Broadmoor redevelopment: o The latest Broadmoor redevelopment staff newsletter has been produced. o Web pages have been updated with the latest images of patient and staffing areas. o A member of the redevelopment team will be attending the March staff forum to

update staff. o The latest images of patient areas will be included in patient community meeting

presentations. o A new patient leaflet on the Central Building has been produced.

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3.8 Service line communications – Local and specialist services 3.8.1 The Communications Team has undertaken a number of service line specific activities

• Updated staff on the results of the Care Quality Commission (CQC) inspection in early January via an article on the Exchange.

• The Head of Communications supported the Executive Director of Local Services at a residents’ meeting ahead of service move to Brentford Lodge.

• Contributed to the review of Trust handling of communications of the service disruption at Hammersmith and Fulham Mental Health Unit as a result of flooding in West London.

3.9 External stakeholder engagement 3.9.1 The Communications team supported Chief Executive Carolyn Regan’s participation in a

discussion with senior clinicians in NHS England on the Green Paper on Children’s services at the request of Professor Tim Kendall, National NHS Director for Mental Health.

3.9.2 The Communications team supported the visit of Dr Onkar Sahota, who is a London

Assembly Member with a special interest in health, chairing the Assembly’s Health Committee. Dr Sahotra met with Chairman Tom Hayhoe and Chief Executive Carolyn Regan and visited the SPA, Wolsey Wing and Thames Lodge.

3.10 Communications and engagement staffing 3.10.1 Sally Sykes will be leaving the Trust at the end of May to take up a new post as Director of

Communications and Engagement at the University of Manchester. Recruitment to this role is being planned and in the meantime, recruitment to the permanent Head of Communications has been put on hold. Elizabeth George, interim Head of Communications, has been offered a six month fixed term contract. Matt Barnfield, Web and Design Manager, is leaving the Trust in mid-March to take up a new role and Kofo Nolla Omidiran, currently working in the communications team at One Housing, has been recruited to cover the role on an interim basis.

Ends/

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“I have seen a few occasions where theincident had deescalated and believe thisto have been helped by the camera beingturned on.”

Body Cameras at WLMHT

www.calla.co

The nurse turns the camera on and makes it clear he is recording

Nurse comes across a situation that warrants turning the camera on.

Nurse continues to deal with situation as normal until is resolved.

Nurse uploads Calla footage to secure cloud account.

Scan to view Northamptonshire Healthcare NHS Foundation Trust

Body worn cameras at WLMHT

Nurse comes across a situation that warrants turning the camera on.

The nurse turns the camera on and makes clear they are recording.

Nurse continues to deal with the situation as normal until resolved.

Nurse uploads camera footage to a secure cloud account.

Scan to view an example of the cameras being used at another trust.

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Promoting hope and wellbeing

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2 West London Mental Health NHS Trust

Contents Page Number

Ground Floor:

Welcome 3Travellers’ Rest (café) 4The Junction (shop) 4Barnets (hairdressers) 5Physical Healthcare 6Woodcraft 7Enterprises 8Pottery and silver clay 8

First Floor:

Multi-Faith Sanctuary 9Art therapy 10Occupational therapy 10-11Occupational therapy kitchen 12Recovery College 13Centralised Groupwork Service 14Patient work opportunities 15

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Central Building Services Information Booklet 3

Thank youWe would like to thank the patients and staff of Broadmoor Hospital for their contribution to the Central Building design and production of this information booklet.

WelcomeThe Central Building has been designed to support your recovery by offering all therapeutic activities and services in one place. Once inside the building, you’ll be able to make your own way to therapy sessions, appointments or work areas.

Referrals will be made by your clinical team and attendance based on an assessment of your readiness, motivation and risk.

The Central Building opening hours:

Daily sessions Monday to Friday 9am - 5pm

Evening sessions Tuesday to Thursday 5.30pm - 8pm

The Central Building will also be open during some weekends to support other activities.

As well as all the services listed on page 2, you can also access the following Central Building areas:

Ground Floor: ECT suite, medicines information and family and non-contact visits suite.

First Floor: tribunal suite.

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The Travellers’ Rest A café style facility providing opportunities for social engagement with others, Travellers’ Rest can be used weekly, as part of your timetabled programme. This is usually at the same time as you visit the Junction (patient shop). If you’re on ground access there are also fixed times for you to come and enjoy the café facilities.

Offering a range of drinks and light snacks, there is also a takeaway window, located in the Central Garden, serving hot and cold drinks, ice lollies and cakes. This window is only open when there are no patients in the café.

Providing space for larger social events, Travellers’ Rest also offers selected times for patients at higher risk and/or requiring support to do their shopping.

The JunctionA shopping facility which takes into account the ethnic, religious and dietary diversity at Broadmoor Hospital, The Junction also provides a refreshment service as part of the patients’ social activities.

You’ll be encouraged to visit The Junction during your designated session. If you’re unable to attend you can submit a requisition form, which must be signed by you on your shopping day, then authorised by either your Team Leader or Clinical Nurse Manager.

Requisitions for CDs, DVDs or items supplied from catalogues used by The Junction (e.g. Argos and Amazon) can be submitted at any time. Orders for items

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from other catalogues must be entered on separate requisition forms (online requisition forms will also be available).

Barnets:Barnets Hairdressers delivers a quality service to all patients. Staff make sure they stay up to date with new products, styling techniques and high street trends.

Barnets wide range of treatments includes: • styling • colouring• perming • hair and scalp treatments

Appointments can be made via ward staff and you will be escorted to the salon. A clipper service is available for any patients too unwell to leave their ward.

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Physical HealthcareResponsible for maintaining your physical wellbeing, this team work alongside a larger network of healthcare specialists to ensure you receive the right care for any physical illnesses.

on-going services visiting services

• GP / nurse-led clinics • optician

• dentist • diabetes specialist nurse and consultant

• podiatrist • general surgeon

• dietician clinic • pain specialist

• physiotherapy clinics • audiology and ear, nose and throat (ENT)

To book an appointment, speak to a member of ward staff.

The staff are really down to earth and easy to get on

with.

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WoodcraftGet involved, learn new skills and choose from a range of creative projects. Here you’ll learn basic to advanced carpentry and how to use a full range of tools; such as saws, chisels and machinery correctly.

Projects include bird boxes, stands and jewellery boxes. You’ll then progress onto small projects, like tables, followed by larger projects such as benches and rocking horses. There are a number of group activities to support you and others working together on larger items.

Staff will also help you produce a personal portfolio that includes training records, skills gained and photographs, which you can take with you when you move on.

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EnterprisesA friendly work area offering an opportunity to engage and take ownership of projects, here you’ll learn new skills and/or enhance existing ones. You’ll be trained to use tools and resources to help you take on various projects including; decorating boxes, canvas painting, costume jewellery, ceramic painting and other activities.

You’ll also develop problem solving, creativity and team work skills, so you’ll experience feelings of accomplishment, increased confidence and improved social awareness.

Pottery and Silver Clay unitsPottery introduces you to the art of pottery making from clay selection to firing, while silver clay supports you to make objects and jewellery with clay then fire with a torch or kiln, turning the object into pure silver.

Form, shape, mould, cut and texture the materials using your own hands and various tools. This is your chance to learn new hobbies, skills and develop future job opportunities. Staff will support you to express your creativity, and develop self-awareness as you create items for personal use or commissioned by others.

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Multi-Faith SanctuaryThe Spiritual and Pastoral Care Service (SPCS) offers a safe environment, together with high quality and responsive care on an individual or group basis. The service accepts and supports you, at all stages of your recovery journey.

It also offers an outreach service, where chaplains visit wards, meet patients and work with clinical teams. Group work, either on the wards; or in another agreed area is also available. Other religious leaders are available on request; such as Quaker, Rabbi and Buddhist Monk.

The work gave me a way of distracting myself from problems with my mental health at the same time as learning a skill and letting me enjoy life again.

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Art TherapyA form of psychotherapy which uses drawing, painting and making objects, models etc. to communicate thoughts, ideas, experiences and feelings, Art therapy helps you look deeper into personal problems and worries, and address troublesome habits that you find difficult.

Therapy can be provided in groups or individually. Staff encourage you to explore past and present experiences by experimenting and playing with art materials and imagery. In addition, time and space will be provided to talk in a safe and supportive setting, similar to traditional ‘talking psychotherapy’.

This is not a recreational activity or ‘art lesson’, so no previous experience, knowledge or expertise in drawing, painting and making things is needed.

Occupational TherapyOccupational Therapy (OT) uses activity, or occupation, to promote good mental health, assist recovery and help you to achieve meaningful outcomes. These include everyday activities such as self-care, work and leisure, all of which give meaning and value to lives. Occupational deprivation can worsen mental ill health, but being able to participate in the right occupation at the right time can improve mental health and wellbeing.

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Examples of sessions offered:

• life skills groups • interaction skills

• improving communication groups

• daily living support on wards

• task based groups • moving on groups

• cooking sessions

The service also welcomes patient suggestions about other sessions they would like to see available.

I have been able to develop

skills which have helped me to

engage in voluntary roles. I have been

able to access project based work, like the Millennium Falcon Group. Here, I have

been able to gain skills which will help me to get back to working and build

friendships with patients on Rehabilitation Wards before

I move there.

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Occupational therapy kitchenThe occupational therapy kitchen is part of your therapist’s risk assessment, allowing them to assess your suitability for referral onto the Rehabilitation Therapy Service (RTS) areas (see page 3-8). Treatment activities such as a cooking group promote and encourage teamwork, sharing, compromise and healthy eating.

Encouraging you to make edible meals and snacks, the service will also help you increase your self-esteem and self-confidence whilst improving your cooking skills.

Food frequently requested by patients to be cooked/baked during these sessions include curries, bolognese, pizzas, lamb koftas, stuffed peppers, large cakes for sharing on the ward, smoothies, pancakes and omelettes. The importance of a healthy balanced diet forms the basis of all sessions.

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Recovery CollegeThe Recovery College offers a wide range of courses and learning opportunities. We aim to meet the needs of our diverse patient population by providing courses from basic to advanced levels of education.

Courses include:• art • English as a Second Language (ESOL)

• food hygiene • Information Technology (IT)• literacy • music• numeracy • Open University courses

Recovery College tutors also offer further support to complete assignments or extra tuition if required.

This includes:• access to a virtual campus • one to one teaching• private study • Recovery courses• teaching on ward • themed events

The College also manages the hospital’s Koestler Arts Awards scheme. This yearly competition, run by the Koestler Charity encourages creativity amongst those detained in secure hospitals and prisons.

The competition comes to a close each September, with an exhibition of award winning entries, where entrants have the chance to sell their work.

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The Centralised Groupwork Service (CGS)

CGS provides a structured and safe environment offering psychological group therapy where you can discuss a range of needs related to mental health issues and offending behaviour. Attendance is based on individual assessment of readiness, need, motivation and risk, carried out by a member of the CGS team and your multidisciplinary team (MDT). The CGS accepts and supports you at each stage of your recovery journey, from admission through to transfer.

Group therapy offered includes:Groups to enhance coping and promote recovery:• challenging stigma and promoting recovery• cognitive skills group• understanding mental illness• understanding personality disorder

Mental health restoration:• anger treatment programme• cognitive behavioural therapy for psychosis• dialectical behavioural therapy• family and relationship skills • leavers group• mentalisation based treatment

Risk reduction• fire setting • homicide • sex offending • substance misuse• understanding relationships skills • violence

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Patient vocational training opportunitiesAll Central Building work opportunities are available to patients referred by their clinical team and assessed as suitable.

The Travellers’ Rest Supported by the staff, all café workers receive training on a variety of catering skills including food and hygiene certificate. Once successfully completed, workers will be supervised to cook orders, wash up and keep the food server area clean.

BarnetsThis role will include shampooing, general housekeeping and supporting the hairdresser.

The Junction This role provides patient workers with a wide range of ‘similar to real life’ work opportunities and experiences such as serving customers, stock replenishment, use of the till and handling money.

The Multi-Faith Sanctuary This role provides opportunities to support the care taking of the Multi-Faith Sanctuary. Duties including maintaining a high level of cleanliness and making sure relevant text and books are stored neatly and correctly.

When you arrive here you hand over responsibility and you HOPE that one day it will be handed back to you in better shape

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Website

wlmht.nhs.uk

Switchboard

020 8354 8354Email

[email protected]@

24 hour helpline (single point of access)

0300 1234 24424/7

If you need this information in another format, such as Braille, large print, Easy Read or another language, please ask a member of staff.

If you have questions or concerns about any of our services, please contact the patient advice and liaison service (PALS) on 0800 064 3330 or [email protected].

You can give feedback about any of our services at www.patientopinion.org.uk or on 0800 122 31 35.

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Promoting hopeand wellbeing

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Apprentices in ActionDebbie, joined the Broadmoor L&D team in February 2017, as the apprentice in the Learning & Knowledge assistant’s role which involves:- • The accurate recording of attendance to training • Collating information for reports• Communicating with staff about training provision• Demonstrating excellent customer service when answering or /dealing with queries, both face to face and via the telephone• There is also the requirement each month to prepare all information for new starters attending the induction.

Meet Debbie:

Email [email protected] for information on other apprenticeships on offer at the Trust

The apprenticeship was attached to the advertised job role, which was really good for me as I had no previous qualifications in administration.This was a perfect way for me to learn the correct skills for my new role. I sometimes found dividing my time between work and studying difficult to prioritise. Although work did allocate me time to do my training, I found it better to study at home where I could concentrate properly. One of the benefits is that I now have a qualification in business and admin, which is useful in respect of furthering my career. I have learnt many useful new skills, as well as brushing up on the basics of correct grammar, maths and customer service skills.Completing my training early was also a personal achievement.

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2f0274ce-2fbb-426b-9cb9-0717016e26a8 Page 1 of 7


Report title: Nurse and Health Care Assistant Staffing Levels –

Exception Report to the March 2018 Trust Board meeting, which includes January 2018 data

Executive lead: Stephanie Bridger Director of Nursing & Patient Experience

Report authors:

Stephanie Bridger Director of Nursing & Patient Experience Gillian Kelly Deputy Director of Nursing (Corporate)


n/a


For approval


To note ✓




Legal & Governance


No



No

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Improving quality


✓

Compassionate care


✓

Summary The March 2018 safer staffing report to the Board sets out the January 2018 data. The red rated shifts being reported do not suggest a significant change in Nurse and Health Care Assistant staffing numbers available. The number of patients requiring an escorted leave of absence continues to be a pressure on resource management at Broadmoor. The Board can be assured there is local monitoring and oversight of staffing. The Board can also be assured that the Nursing Directorate, in collaboration with operational and profession leads, has undertaken a review of our safe staffing monitoring arrangements in light of the National Quality Board’s (NQB’s) Safe, sustainable and productive staffing - An improvement resource for mental health - Draft (NQB, 2017) An action plan to enhance and standardise our monitoring and reporting arrangements has been developed. The next full safe staffing report to the Board is expected in May 2018.

Supporting documents and/or further reading Full details of all red rated shifts are reported within section 4 (below) and Trustwide Nurse and Health Care Assistant staffing fill rates are provided in Appendix 1.

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Trust board meeting (Part 1): March 2018 Registered Nurse and Health Care Assistant Staffing

Levels – Exception Report: January 2018

1 Purpose

1.1. The purpose of this exception report is to advise the Board of shifts within the Trust’s in-patient areas, where Nurse and Health Care Assistant staffing levels fell below planned requirements and due to being regarded as having an impact on care or being potentially unsafe, were escalated to senior nurses or site managers who employed contingency plans.

2 Recommendation(s)

2.1 The Board is asked to note the contents of this paper.

3 Introduction

3.1 This report is provided in accordance with the expectations set out in the National Quality Board Guidance (2013 and 2017) that Trust Boards take full responsibility for nursing and care staffing capacity and capability.

3.2 In February 2018, the Nursing Directorate, in collaboration with operational and profession leads, undertook a review of our safe staffing monitoring arrangements in light of the National Quality Board’s (NQB’s) ‘Safe, sustainable and productive staffing - An improvement resource for mental health’ – Draft, (NQB, 2017). An action plan to enhance and standardise our monitoring and reporting arrangements has been developed. The next full safe staffing report to the Board is expected in May 2018.

3.3 All 51 in-patient areas within the Trust have reported the details of their staffing levels on a shift by shift basis for the month of January 2018.

3.4 Managers are required to report their planned numbers of registered nurses and

health care assistants on duty, against the numbers actually present on shift. Each shift was then RAG rated as follows:

Green Staffing meets planned requirement

Amber Staffing does not meet planned requirement but is safe

Red Staffing does not meet planned requirement and this has been escalated to a senior nurse or site manager

3.5 This exception report provides details of all shifts that were RAG rated red during

January 2018. On the basis of three shifts per day (early, late and night) for 31 days on 51 in-patient areas, there were a total of 4,743 shifts. Of those, 28 (0.6%) were RAG rated as red, this is a small increase from December 2017 when 24 (0.5%) of shifts were RAG rated as red.

3.6 Full details of red rated shifts are reported in section 4, along with reasons given for

not meeting the planned staffing. Where details of mitigation and impact on quality

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have been provided, these have been noted. Trustwide Nurse and Health Care Assistant staffing fill rates by hour and site are provided in Appendix 1.

3.7 Safe staffing reports are published on the Trust website monthly; promoting transparency and providing assurance in relation to the Trust monitoring of safe staffing. Our fill rates are reported via monthly UNIFY submission; a requirement of all NHS providers.

4 Analysis 4.1 Of 4,743 shifts within in-patient areas during January 2018, 28 (0.6%) were RAG

rated red. These figures indicate a small increase from December 2017 when 24 (0.5%) of shifts were RAG rated as red.

4.2 Chart 1 below shows percentage red RAG rated shifts for the past year from February 2017 to January 2018.

4.3 Chart 1: Trust - percentage red RAG rated shifts month by month

4.4 Chart 2: Red RAG rated shifts from February 17 to January 18 by CSU

1.21%

1.03%

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0.63%

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1.20%

1.40%

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4.5 Chart 2 above shows the number of red rated shifts reported per month by CSU. It is difficult to draw a conclusion from this data as reporting is also influenced by the reporting culture as much as the incidence of short staffed shifts.

4.6 Full details of all red rated shifts are provided in Chart 3 below along with reasons given for not meeting the planned staffing.

4.7 Chart 3: Red RAG rated shifts for January 18 breakdown by ward

4.8 The overall sickness rate of registered and unregistered nursing staff in January

2018 was 5.6%.

4.9 Newly available figures from the Corporate Scorecard include the nursing vacancy rates for January 2018. The vacancy rate of registered and unregistered nursing staff was 20%. Vacancy levels remain variable across all wards even with the recent initiatives in respects to recruitment and retention.

4.10 Detailed workforce information is available and triangulated via the workforce

committee and includes nursing establishment WTE, nursing staff in post WTE and nursing voluntary turnover figures.

4.11 A total of 21 incident forms were raised during January 2018 for staffing level

concerns; 14 were received from high secure services, 5 from local and specialist services and 2 from forensic services. It is of note that incident forms have not been completed for all red RAG rated shifts.

RMN HCA RMN HCA

Newmarket Ward Mens Admission 12 2 AM 3 4 2 3 Unable to cover shortfall

PM 3 4 4 1 Unable to cover shortfall

AM 3 4 2 3 Unable to cover shortfall










Epsom Ward Mens MI High dependancy 12 1 PM 3 5 2 4 Unable to cover shortfall









PM 4 3 2 3 Unable to cover shortfallW L F S Barron Ward Mens - Low secure 16 1 PM 2 3 1 2 Unable to cover shortfall - UC Supported

Hope Ward Women's Admission 1 PM 3 2 2 1 Unable to cover shortfall - UC Supported

AM 3 3 3 2 Unable to cover shortfall - UC Supported

AM 3 3 3 2 Unable to cover shortfall - UC Supported

PM 2 1 1 1 Unable to cover shortfall - UC Supported

PM 2 1 1 1 Unable to cover shortfall - UC Supported

28

5

Cranfield Ward+B8Mens High Dependency 12 3

Woburn Ward Mens High Dependency 14 2

Ascot Ward Mens MI High dependancy

Unit (HDU)

12 7

Chepstow Mens PD High dependancy 12

212Mens AdmissionSandown Ward

ActualRED RATED

SHIFTS

JAN 2018

Ward Type

No

of

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ds

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pti

on

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4.12 Chart 5: Staffing Incident Forms completed for January 2018

4.13 It should be noted that high secure services have to deploy staff for a significant

number of escorts. A breakdown of these escorts is provided in Chart 6 below. 4.14 Chart 6 High secure staff on escort January 2018

5 Mitigation and impact of short staffing 5.1 Mitigation plans remain in place as previously detailed to the board of directors. 5.2 The impact of short staffing at Broadmoor Hospital continues to be closely

monitored following feedback from the CQC on the risk to quality.

6 Conclusion 6.1 The data available supports the view of staff, managers and the executive team,

that recruiting high quality registered nurses, whilst also remodelling establishments to ensure sustainable staffing, is top priority. The Director of Nursing will provide more analysis on trends overtime and confidence intervals.

7 Recommendations

7.1 Staff to be kept fully informed of newly recruited staff and when they are coming into

post and where. This is now happening in Monday Matters. 7.2 The executive team to continue to monitor very closely the impact of the recruitment

strategies in place and to continue to progress the plans to improve retention. 7.3 The executive team will continue to support an improved use of e-Rostering in order

that the available resource can be used more efficiently and effectively.

Stephanie Bridger

Director of Nursing and patient Experience

23 Patients, 25 episodes

Total number of shifts staff were out on LOA duties 650

Total number of shifts patients were out on LOA duties 148

Average staff per escort 4.4

Page 186 of 308

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Page 187 of 308

Report summary Trust board meeting: Part 1 (in public) February 2018

Report title:

Night Time Confinement [NTC] – Broadmoor Hospital

Executive lead:

Leeanne McGee Executive Director of High Secure & Forensic Services

Report authors:

Alice Foyle, Service Director, HSS


High Secure Senior Management Team Meeting on 22 February 2018


To note the content of this paper

For approval

To note

✓

Summary



Improving quality


✓

Compassionate care


✓

Relationship to board assurance framework (risks)? Are any existing risks in the Board Assurance Framework affected?

No

If yes, insert relevant risk reference: No


No

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Corporate impact assessment: assurance against Legal and regulatory implications Yes

Financial implications No

Equality and diversity No

Public, service user and carer No

Performance management No

Communication No

Relevance of report to Monitor’s quality governance framework Strategy None

Capabilities and culture None

Processes and structure None

Measurement None

Acronyms / terms used in the report NTC Night Time Confinement

Supporting documents and/or further reading None

Page 189 of 308


Update on Night Time Confinement at Broadmoor Hospital

1. Purpose

1.1 Following a night time confinement conference for the High Secure hospitals, hosted

by Broadmoor CSU in 2012, considerable liaison work was undertaken with Ashworth

and Rampton colleagues in order to identify core work streams to support the

implementation of Night Time Confinement (NTC) at Broadmoor Hospital.

2. Introduction

2.1 The pilot of NTC arrangements was introduced to two wards in 2012. This followed a

period of preparation, including awareness raising and information sharing with staff

and patients on the two wards. Ward and hospital business continuity plans were

revised and the respective ward operational policies updated to reflect the changes.

2.2 This paper identifies the Patient Activity data from April 2016 to December 2017, the

incidents from 2011 during the hours of NTC compared to incidents during 2017. In

addition complaints will be highlighted from the Q1 – Q3 and the patient survey results

from January 2018 following a patient focus group will be discussed.

3. Patient Activity

3.1 It had been proposed that the amount of ‘day time’ patient activity offered would be

increased following the introduction of NTC arrangements.

3.2 The mean level of activity offered to patients on NTC Wards is 35.56 hours from April

2016 to March 2017 (based on contracted bed numbers); this exceeds the Trust and

CSU target of 25 hours.

3.3 From April 2017 to December 2017 mean level of activity offered to patients on NTC

Wards increased to 43.51 hours (based on contracted bed numbers); this exceeds the

Trust and CSU target of 25 hours.

Ward Contracted Beds Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Mean Apr

16 - Mar

17

Ascot Ward 12 39.69 43.11 41.19 53.98 53.08 37.55 46.08 49.2 40.1 37.6 34.8 56.7 44.42

Chepstow Ward 12 72.80 81.04 80.48 82.02 86.43 49.93 58.40 47.8 53.6 34.5 40.6 49.8 61.45

Cranfield Ward 11 26.49 20.00 21.51 36.96 13.55 20.33 41.09 35.0 30.9 33.2 22.7 32.0 27.82

Epsom Ward 12 35.27 38.97 19.16 17.48 7.91 16.64 21.33 41.2 38.1 41.8 25.2 55.6 29.88

Kempton Ward 12 29.53 30.63 36.87 28.99 28.51 26.91 22.55 37.7 30.4 35.8 29.5 33.3 30.88

Newmarket Ward 12 39.32 43.07 36.62 24.56 16.03 22.54 25.20 14.1 13.7 15.3 14.9 43.3 25.71

Sandown Ward 12 14.92 20.93 37.91 60.14 54.64 54.51 59.14 64.9 47.1 36.5 32.9 27.4 42.58

Woburn Ward 15 18.65 20.92 16.61 21.66 19.26 23.53 20.40 12.0 25.7 32.4 28.7 21.4 21.77

Grand Total 98 34.58 37.33 36.29 40.72 34.93 31.49 36.77 37.73 34.96 33.37 28.66 39.93 35.56

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4. Night Time Staffing

4.1 Night staffing levels reduced by a total of 24 as a result of implementing NTC

arrangements.

5. Incidents during NTC Hours

5.1 The graphs below show that between January 2011 and December 2011 in High

Secure Services there were 2765 incidents reported in total (not including medication

incidents) of which 521 (18.84%) were reported during the hours of NTC, compared to

January 2017 to December 2017 when there have been 3613 incidents reported in

total of which 466 (12.90%) were reported during the hours of NTC, again with

medication incidents omitted.

Ward Contracted Beds Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17

Mean Apr

17 - Dec

17

Ascot Ward 12 62.39 39.53 34.52 65.94 50.44 46.34 62.60 67.50 51.90 53.46

Chepstow Ward 12 80.13 82.70 51.91 21.38 32.61 34.60 44.00 30.60 45.90 47.09

Cranfield Ward 11 64.54 48.12 44.85 57.36 53.27 47.33 52.65 59.00 61.60 54.30

Epsom Ward 12 47.47 27.96 28.26 29.44 21.35 38.28 40.70 60.00 56.40 38.87

Kempton Ward 12 25.92 45.43 26.94 39.09 33.61 28.19 58.50 38.20 50.10 38.44

Newmarket Ward 12 32.78 43.07 33.03 24.45 34.52 27.67 26.00 32.50 42.20 32.91

Sandown Ward 12 26.95 26.78 28.55 52.56 59.41 72.56 42.70 66.20 60.10 48.42

Woburn Ward 15 31.35 34.58 37.00 37.08 37.31 35.66 23.30 36.80 38.10 34.58

Grand Total 98 46.44 43.52 35.63 40.91 40.32 41.33 43.81 48.85 50.79 43.51

Page 191 of 308

5.2 The graph below shows incidents at night during 2011 and 2017 by month, excluding

medication incidents. This shows the number of incidents reported during the hours of

NTC has decreased by 55, despite the number of incidents reporting as a whole

increasing in 2017.

5.3 The mean level of incidents occurring on NTC Wards during the hours of NTC is 32

from January 2016 to December 2016 for non NTC wards. The mean for the same

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period is 15.92, it is expected that NTC wards would have a greater number of

incidents due to the nature of the wards (Admissions, ICU, High Dependency).

Type Jan

-16

Fe

b-1

6

Mar-

16

Ap

r-16

May-1

6

Ju

n-1

6

Ju

l-16

Au

g-1

6

Se

p-1

6

Oc

t-16

No

v-1

6

De

c-1

6

Gra

nd

To

tal

Mean

Non NTC ward 19 15 19 18 10 16 30 17 11 20 6 10 191 15.92

NTC Ward 30 26 39 34 30 27 23 40 30 40 29 36 384 32.00

Grand Total 49 41 58 52 40 43 53 57 41 60 35 46 575 47.92

5.4 The mean level of incidents occurring on NTC Wards during the hours of NTC is 23.58

from January 2017 to December 2017 for non NTC wards the mean for the same

period is 11.58. It is expected that NTC wards would have a greater number of

incidents due to the nature of the wards (Admissions, ICU, High Dependency). This is

a reduction in the number of reported incidents compared to the previous year.

Area Jan

-17

Fe

b-1

7

Mar-

17

Ap

r-17

May-1

7

Ju

n-1

7

Ju

l-17

Au

g-1

7

Se

p-1

7

Oc

t-17

No

v-1

7

De

c-1

7

Gra

nd

To

tal

Mean

Non NTC Ward 9 13 6 7 23 15 12 11 7 12 17 7 139 11.58

NTC Ward 28 22 25 25 33 24 23 15 28 19 23 18 283 23.58

Grand Total 37 35 31 32 56 39 35 26 35 31 40 25 422 35.17

5.5 The most pre-dominate type of incident occurring on NTC wards (excluding

medication) are assault non-physical to staff, security and damage to property

6. Non-compliance with NTC Arrangements

6.1 In Q1 there were 2 patients who are normally subject to NTC that were exempt on the

grounds of risk to self.

Patient 1 – 5 nights

Patient 2 – 1 night

6.2 In Q2 there were 2 patients who are normally subject to NTC that were exempt on the




6.3 In Q3 there was 1 patient who is normally subject to NTC that was exempt on the



6.4 These patients were managed with therapeutic engagement and supportive

observations by staff during the nights when they were not locked in their rooms.

Page 193 of 308

7. Complaints

7.1 During Q1 and Q2 there were 3 complaints registered relating to NTC from 1 patient:

The complainant was concerned about his safety following the termination of NTC

because his door was left unlocked when he was still asleep/in bed. The investigation

found that it was appropriate for staff to unlock patients’ bedroom doors following the

termination of NTC as to relock them would be in breach of the MHA Code of Practice

and the complaint was not upheld. There were several recommendations made which

have now been implemented

7.2 The complainant complained that his bedroom door was not locked following the

commencement of NTC and it had left him feeling scared and vulnerable that people

may have tried to break into his room. The investigation found that the patients’

bedroom door was not locked on the commencement of NTC and this occurred

because the room next to this patients’ bedroom was unoccupied at that time and the

staff had thought they had locked the correct bedroom, therefore the complaint was

upheld. There were several recommendations made which have now been

implemented

7.3 There were no complaints recorded regarding NTC during Q3.

8. Patient Experience Survey

8.1 On the 3rd January 2018 a patient focus group was organised and attended by 8

patients, the Service Director and Nurse Consultant. At this focus group the patients

identified key areas to be highlighted within a patient survey, which would be sent to all

patients in the Hospital.

8.2 Surveys were circulated to all wards and were given a three week period to complete

and return, 67 (35%) surveys were returned.

8.3 The survey responses were reviewed and analysed by the Service Director, Nurse

Consultant and a member of the Advocacy service.

68%

21%

11%

Did/do you feel safe under NTC

Yes

No

N/A

87%

9% 4%

Have you been subject to NTC

Yes

No

N/A

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8.4 58 patients (87%) who responded to the survey have been subject to NTC, of these 44

patients (68%) felt safe under NTC. With 33 patients (51%) agreeing that they felt

supported whilst under NTC. 36 patients (56%) felt they could access staff if they

needed to during NTC. In addition 20 patients (31%) felt they had an improved

sleeping pattern under NTC.

8.5 In total 47 comments were received, 29 comments expressed concern which included

NTC being a backward step for rehabilitation patients, with limited support for transition

to a lower secure environment (medium secure unit). In addition there were concerns

surrounding the negative impact on a patient’s mental health, limited access to phone

calls and an environment comparable to a prison. It was noted that these comments

were predominately received from the rehabilitation patients.

8.6 9 comments received did highlight positive aspects of NTC which included the benefits

of a quieter environment and an improved sleep pattern. A further 6 comments were

ambivalent to the whole process of NTC, a further 3 comments gave limited

information.

8.7 Following the focus group held in January 2018 there have been no further complaints

in Q3 regarding NTC, however this could potentially change following the introduction

of NTC in the new hospital for the rehabilitation patients. There is also the potential that

rehabilitation patients may see this as an erosion of their patient rights and which could

51%

37%

12%

Did/do you feel supported under NTC

Yes

No

N/A 56%31%

13%

Did/do you feel you could access staff if you needed to

during NTC

Yes

No

N/A

31%

44%

25%

Did/do you feel your sleeping pattern improved with NTC

Yes

No

N/A

Page 195 of 308

in turn lead to an increase in complaints in this area. This was also highlighted by the

Independent Advocate.

9. Conclusion

9.1 The benefits of NTC have been a reduction in incidents during the hours of NTC; in

2011, 521 incidents (18.84%) were reported compared to 466 hours (12.90 %) in 2017.

There have been no major incidents during the hours of NTC since its implementation.

9.2 The mean level of activity offered to patients on NTC Wards has increased from 35.56

in 2016 to 43.51 hours in 2017 (based on contracted bed numbers). This exceeds the

Trust and CSU target of 25 hours.

9.3 From a patients perspective it has been reported that 68% do feel safe whilst under

NTC. It was noted that the 31% of patients who do not feel supported, this will be

discussed further in community meetings, patient forum and the ward CIG meetings.

9.4 Following the commissioners perspective of the NTC report which was discussed at

the National Oversight Group it was highlighted that NTC has not prevented or

diminished the overall aim of high secure hospitals in treating and reducing risk for

patients in their care. Furthermore, they also noted that the current staffing challenges

would have been far greater if NTC had not been implemented.

9.5 The less positive aspects of NTC which have been previously outlined in this report is

the impact that moving into the new hospital for the rehabilitation patients will be. They

view NTC as a backward step, simulating a restrictive environment that would have

limited benefits for an individual’s mental health.

10. Recommendation(s)

10.1. The board is asked to note this paper and support the continuance of Night Time

Confinement as an intervention.

Alice Foyle

Service Director, HSS

9 February 2018

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Report summary Trust board meeting: Part 2

March 2018

Report title:

WLMHT Estates Strategy - Update

Executive lead:

Paul Stefanoski, Director of Finance & Business

Report authors:

Paul Stefanoski, John Atkins


September 2017 Trust Board Meeting


For approval


To note ✓






yes


8024


no

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Improving quality


✓

Compassionate care


Summary This paper presents an update on the Estate Strategy and the associated actions.


Page 198 of 308


WLMHT Estates Strategy - Update

1 Purpose 1.1 The purpose of this paper is to provide a bi annual update to the Trust Board on the

Estate Strategy and the actions that have been taken since the strategy was presented and approved by the Trust Board in March 2017.

2 Recommendations 2.1 The Board is asked to:

• Note the progress made on the short and medium terms issues.

3 Introduction 3.1 Following meetings with a wide range of stakeholders, including strategic estates

input from the CCGs, the Board approved and adopted a new Estate Strategy in March 2017.

3.2 This approval also covered a number of short and medium term issues which were

identified as requiring progression/resolution and are covered in the table below. 3.3 The Strategy continues to form the basis for future estate-related decisions – be it

reconfiguration, investment or disinvestment.

4 Progress to Date 4.1 The table below demonstrates the progress that has been made and planned to

address the issues identified in the Strategy. 4.2 The Trust will continue to ensure that it is fully engaged in discussions taking place

across North West London in order to take advantage of any opportunities that may present themselves including the development of the health hubs mentioned in the table below. It is believed that this Strategy forms a sound evidence-base on which to progress these discussions.

4.3 In order to provide oversight and assurance to the Board regarding revisions to the

Strategy and version control, it is recommended that the Finance & Performance Committee should receive such changes and make recommendations to the Board. It is recommended that the Trust Board shall receive an update on the Strategy in the autumn.

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Page 200 of 308

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Item

13:

Est

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pdat

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Mar

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Page 201 of 308

P

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8

Page 202 of 308


Report title:

Level 1 Risk Register & Board Assurance Framework

Executive lead:

Carolyn Regan, Chief Executive

Report authors:

Peter Jenkinson, Trust Secretary


Quality Committee, 21st February 2018 Workforce & Development Committee 21st February 2018 Finance & Performance Committee, 28th February 2018 Trust Management Team, 28th February 2018 Audit Committee, 7th March 2018


For approval


To note ✓






Yes


See paper

Do you recommend a new entry to the Board Assurance Framework

See paper

Item

14:

BA

F

Page 203 of 308

(i.e. Trust-wide Level 1 risk) is made?



Improving quality


✓

Compassionate care


✓

Summary

The Board last reviewed the BAF and Level 1 risk register at its meeting on 14th February 2018. Following discussion at meetings of the Quality Committee, Workforce & Development Committee, Finance & Performance Committee, TMT and Audit Committee, the Board is asked to consider the latest Level 1 Risk Register (attached at Appendix 1). The Board is invited to consider the latest BAF and Level 1 risk register and consider the assurance it receives relating to the management of the most significant risks to the Trust’s achievement of strategic objectives.


The full entries for the BAF and Level 1 Risk Register are available on request from the Board Secretariat, and are presented to Board committees at their respective meetings.

Page 204 of 308


Level 1 Risk Register & board assurance framework

1 Introduction 1.1 The effective application of board assurance arrangements to produce and maintain

the board assurance framework (BAF) helps management and the Board to gain assurance using a formal process that promotes good organisational governance and accountability.

2 Level 1 Risk Register 2.1 The latest version of the level 1 risk register and BAF is attached at the Appendix

(current as at 7th March 2018), with the highest rated risks appearing first. The total number of risks currently stands at 23.

2.2 There have been no additions to the level 1 risk register since the Trust Board meeting

on 14th February 2018. The latest quarterly review of the BAF and risk register with executive owners is currently ongoing and proposed changes from this review will be presented to TMT in March and then Board in April.

2.3 The following is a summary of the other points relating to the BAF raised at sub committees since the Board’s last review:

Audit Committee – 7th March

2.4 The Committee received and considered the latest version of the BAF, including the level 1 risks to the Trust, noting changes arising from the review of the BAF by other committees – no new risks have been added to the register and there have been no changes to risk ratings.

2.5 The Committee discussed the continual improvement of the effectiveness of the BAF,

given the internal audit review of its effectiveness, the Trust Secretary’s observations and the discussion at the December board meeting regarding the robustness of assurance being provided to board sub-committees, in light of the findings of the external fire safety report. The Committee considered proposals for the strengthening of the existing Board Assurance Framework and developing additional assurance mechanisms for the Board regarding the overall control framework for the Trust.

2.6 The outcome of those discussions and recommendations to the Board are included in the Chairman’s report to the Board from that meeting.

Quality Committee – 24th January

2.7 As reported in the Committee Chairman’s report to the Board, the Committee reviewed the quality-related risks on the BAF, including a walk-through of the BAF risk relating to timely completion of serious incident investigations. The Committee welcomed the reduction in the backlog of serious incident investigations as positive assurance that the controls put into place were effective, but was concerned that the backlog did not increase again, noting the identification of process issues that prevented timely

Item

14:

BA

F

Page 205 of 308

completion and sign off of investigations. The Committee referred to the presentation given to the Committee by Jane Carthey and her advice regarding the strength of actions and recommendations, and the possible benefits of having standing panels to investigate serious incidents. With continued leadership oversight such as that which led to the reduction in the backlog and the actions being taken to address system issues, the Committee expects to reduce the current backlog further.

2.8 The Committee also noted the ongoing work by the Director of Nursing with the CCG

to reduce the number of outstanding queries submitted by them in relation to completed investigations.

2.9 The Committee considered whether this risk should be merged with the BAF risk 4217 relating to learning lessons from patient feedback and incidents. While there is a connection between the two risks, in that timely completion of investigations is important to enable organisational learning, it was felt that the two risks should be kept separate for the time being so that focus could be maintained on improving the timeliness of completion of investigations. . Finance & Performance Committee – 28th February

2.10 The Committee reviewed the finance and performance-related risks on the BAF. Trust Management Team – 28th February

2.11 TMT received and noted the latest version of the BAF and the level 1 risk register, noting no significant change in current risk ratings or assurance levels.

3 Recommendations 3.1 The Board is invited to consider the latest BAF and Level 1 risk register and consider

the assurance it receives relating to the management of the most significant risks to the Trust’s achievement of strategic objectives. The full entries for the BAF and level 1 Risk Register are considered by the respective Board sub-committee.

Peter Jenkinson Trust Secretary

March 2018

Page 206 of 308

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SA

3 T

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Item

14:

BA

F

Page 207 of 308

BA

F8

252

Paul S

tefa

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ay lose s

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Safe

W

ell

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d

BA

F4

182

Paul S

tefa

noski

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r fire

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k that

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428

Wendy B

rew

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Wendy B

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Jose R

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h R

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Page 208 of 308

Safe

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Cari

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R

esp

on

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BA

F8

407

Sara

h R

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in

patient

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apacity, th

en

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tefa

noski

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st

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ts tota

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at support

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develo

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mm

es, either

at th

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e

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ay b

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re

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ssocia

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SA

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serv

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ari

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esp

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ell

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F8

429

Wendy B

rew

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If the T

rust fa

ils t

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ngage w

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em

bers

of sta

ff, th

is

could

le

ad t

o p

oor

levels

of m

otivatio

n a

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oor

qualit

y

of care

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tefa

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If the T

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igital m

atu

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ks its

abili

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in o

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ain

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ms a

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rust's

abili

ty t

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deliv

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its s

trate

gy.

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ell

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F8

431

Wendy B

rew

er

If the T

rust cannot support

the p

eople

change

managem

ent

aspects

of org

anis

ation t

ransfo

rmatio

n,

the r

equired p

atie

nt care

and q

ualit

y im

pro

vem

ents

will

not

occur

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of

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F4

198

Ste

phanie

Brid

ger

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obust e

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ency p

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ontin

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roto

cols

in p

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will

be a

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k t

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taff d

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217

Ste

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Brid

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are

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safe

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Item

14:

BA

F

Page 209 of 308

of 308

MINUTES OF THE QUALITY COMMITTEE MEETING Held on Wednesday 24th January 2018

Present: Prof Paul Aylin Non-Executive Director (Chair) Dr Chris Bench Clinical Director, Planned & Primary Care Services

Ms Wendy Brewer Director of Workforce & Organisation Development Ms Stephanie Bridger Director of Nursing and Patient Experience

Dr Claire Dillon West London Forensics Services Mr Tom Hayhoe Trust Chairman

Dr Vijay Parkash Clinical Director, CAMHS Dr Jose Romero-Urcelay Medical Director

Dr Angharad Ruttley Clinical Director, Liaison & Long-Term Conditions Mr Paul Stefanoski Director of Finance and Business

Attending: Mr Peter Jenkinson Trust Secretary Mr Jai Jayaraman Associate non-executive director (NExT

Programme) Dr Khin-San Linn Junior Doctor Miss Iscelyn Richards Deputy Trust Secretary Miss Jinelle Rodrigues Trust Secretariat Assistant Ms Samatha Scholtz Bariatric Consultant Liaison Psychiatrist Ms Sally Sykes Director of Communications and Engagement Agenda items are recorded in minutes in the sequence they were considered

Item

Discussion Action

1. 1.1

INTRODUCTION & WELCOME Prof Aylin welcomed everyone to the meeting and a round of introductions was made.

2. 2.1

APOLOGIES FOR ABSENCE Apologies for absence were received from the following: Ms Moriam Bartlett, Non-Executive Director Ms Leeanne McGee, Director of High Secure and Forensic Services Ms Carolyn Regan, Chief Executive Dr Nevil Cheesman, Clinical Director, Cognitive Impairment and Dementia

3. 3.1

MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on Wednesday 20th December 2017 were agreed to be a correct record subject to some minor amendments and corrections. Item 13.2 to omit from minutes, necessary changes have been made to the minutes

J Rodrigues

Item

15.

1: Q

ualit

y C

omm

ittee

Min

utes

- J

anua

ry 2

018

-

Page 211 of 308

Item

Discussion Action

4. 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.13 4.14

ACTION SCHEDULE & MATTERS ARISING Action Schedule The Committee reviewed the action schedule and noted the completed actions. The following updates were provided: 22/12/17: item 9.4 Responsible Officer’s Report Outcome of Job Planning audit: This has been presented to the Board. 22/11/17: item 13.2 Rio/Sytmone Update: Action Closed 20/12/2017: 5.1.1 CAMHS New Models of Care/Quality Matrix (F&P Action): This has been raised with Programme Board and an update will be provided in February’s meeting. 20/12/17: 5.2.1 Quality of Physical Health Assessments: To review quality of health assessment and 24hr check-ups. This had been discussed with Linda Nazarko. The Committee agreed to close the action, but to receive an update in April 2018. 20/12/17: 8.2: Responsible Officers Report: JRU confirmed that the Board had agreed to start including NED’s as lay representatives in medical revalidation appraisals. 21/06/17: item 6.36 Service line deep dives: It was agreed to implement template provided to the Committee, as part of taking forward the change in format for the meeting. 22/11/17: item 7.4 Estates and Maintenance: It was noted that revised processes for minor works and maintenance had been agreed, and a programme of works was in place to address estates issues. 22/11/17: item 16.2 H&F Site TV Technical Issues: Ms Sykes to provide an update at February’s Quality Committee meeting. 19/07/17: item 15.1 Clinical Governance Group ToR: It was agreed that this action, to complete the review of the Clinical Governance Group, would be completed as part of the implementation of changes to the format of this Committee. Matters Arising DRAFT PROPOSALS FOR THE QUALITY COMMITTEE WORKPLAN 2018/19 (ITEM 20 ON AGENDA) The Committee agreed to take this item under matters arising. Mr Jenkinson provided a verbal update on the background to discussions on the future format of Quality Committee meetings and the proposals for the changes. The Committee noted that the key driver for change was the need to ensure adequate and appropriate time for the Committee to discuss and understand key quality issues as well as receive formal assurance regarding the achievement of quality improvement strategies and quality performance objectives.

J Rodrigues

Page 212 of 308

Item

Discussion Action

4.15 4.14 4.15 4.16 4.17 4.18 4.19

Mr Jenkinson presented and explained the proposals to include the use of quality seminars to allow more time for the Committee, and other Board members, to focus on deep dive reviews of quality issues. The meetings and seminars would be held on alternate months and the seminars would have a larger audience such as the Board and other committees that may want to attend, however the Quality Committee members would attend both. The Committee discussed the proposals presented in the briefing paper. The Committee welcomed the proposed use of quality seminars to allow more time for the Committee, and other Board members, to focus on deep dive reviews of quality issues and annual reviews of quality at service line level, to allow better triangulation of quality themes and issues. The Committee discussed how the reporting from serious incident investigations might fit into these proposals and received an update from the Medical Director on the development of a SI synopsis report for Board which will include a summary of serious incidents reported and thematic review of findings from investigations so that the Board receives assurance regarding trust-wide learning from incidents. The Quality Committee will receive assurance from the Clinical Governance Group that serious incidents are investigated and recommendations implemented, as well as providing oversight at service-level through the service level presentations. The Committee discussed the format and purpose of the service-line ‘deep dives’ and the definition of ‘deep dive’, noting that the purpose of these reviews would be to provide the Committee with a 30 minute overview of quality in each service line, rather than an extensive 2-3 hour detailed review. Dr Parkash suggested that the Committee agreed what it needed from the reviews and it was agreed that the presentations should provide the Board with assurance regarding the quality improvement priorities and leadership, as well as identifying examples of best practice and risks. Ms Sykes suggested that the work plan should refer explicitly to CQC compliance. Ms Bridger stated that CQC was part of Quality Analysis.

The Committee agreed the proposals in principle and agreed that it would consider more formal proposals at the next meeting, with a view to implementing the change from April 2018. The proposals will include the purpose of each of the items on the work plan and each session so that the purpose of each item is clear – board-level assurance, agreeing strategy, sharing best practice, greater understanding of trust-wide quality issues etc. The Committee noted the need for the work plan for the Committee meetings and quality seminars to be dynamic so that emerging themes or issues could be prioritised during the year, as appropriate.

P Jenkinson

Item

15.

1: Q

ualit

y C

omm

ittee

Min

utes

- J

anua

ry 2

018

-

Page 213 of 308

Item

Discussion Action

5. 5.1

ACTIONS REMITTED BY THE BOARD OR OTHER COMMITTEES No actions had been remitted by the Board or other committees since the Committee had last met.

6. 6.1 6.2 6.3

Q3 QUALITY PRIORITIES ASSURANCE REPORT & QUALITY ACCOUNT UPDATE The Committee received an update on the timeline and sign off process for the Quality Account for 2017/18 and the progress made in achieving the quality priority targets set out for Quarter 2. It was noted that the paper had been presented to the Trust Clinical Governance Group, and the Committee noted the assurance being provided by service lines to support the delivery of the targets set out in Q2 for 2017/18. In particular the amber rating for HSS was noted, due to the delays in the opening of the new hospital.

The Committee discussed the content format of the report, and agreed that greater assurance and evidence of progress against the priorities would be beneficial in future reports. It was also noted that the RAG ratings were self-assessment of progress against the agreed priorities in the Quality Account and not reflective of CQC compliance ratings. Dr Parkash highlighted that one of the priorities surrounding CAMHS was based around KPI’s without commission. Dr Romero-Urcelay explained this issue would be resolved by the inclusion of narrative explanations in the report and that this suggestion would be followed up.

Dr Romero-Urcelay

7. 7.1 7.2 7.3

QUALITY AND COST IMPROVEMENT PLAN UPDATE The Committee received a summary of current CIPs identified for 2017/18, including an assessment of the risk rating and potential quality impact. Mr Stefanoski reminded the Committee of the process undertaken in respect to assessing the quality impact of CIPs, noting that each CIP Project Implementation Document included a Quality Impact Assessment (QIA) where both current and residual risks to Clinical effectiveness, Patient safety and Patient experience were RAG rated by the project lead and clinical lead. The Medical Director, Director of Nursing and QAC provided scrutiny of the QIA prior to CIP sign off. The Committee welcomed the assurance provided to the Committee from the QCIP process, including the role of the QCIP panel, chaired by a non-executive director, in reviewing and challenging the potential quality impact assessments completed for all CIP schemes.

8. 8.1 8.2

QUALITY IMPROVEMENT UPDATE, INCLUDING QUALITY AND PERFORMANCE DASHBOARD The Committee received and reviewed the CQC action plan and progress against the plan and considered the newly created dashboards showing compliance in a number of quality standards across different clinical service lines. The Committee noted that the format of the report continued to be

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8.3 8.4 8.5

developed, to provide more trust-wide assurance regarding quality standards rather than specific actions, and noted that the newly appointed Associate Director of Clinical Governance would support in this work once he takes up his post on 29 January. The Committee noted and endorsed the development of the report but stressed the need to continue the progress in developing this report in a timely way.

The Committee discussed data quality issues encountered in producing the reports, including different data held locally to that held centrally, for example in HSS, and noted the risk of underreporting on adverse incidents due to the lack of a user-friendly incident reporting system. The Committee noted the concern that these data quality issues posed risks to the quality of reporting and the accuracy of the dashboards being presented to the Committee, and agreed the need to have a central system of capturing data in order to build resilience and accurate data.

Ms Bridger provided an oral update from the recent CQC inspection of acute adult wards and PICU, focussed on responsiveness. The Committee noted the informal feedback received following the inspection and welcomed the positive feedback received regarding the progress made in care planning and bed management. The CQC had picked up on some issues regarding safeguarding, to be confirmed, and fridge temperatures at Hammersmith. Issues with outstanding minor estates maintenance work had also been identified by staff; areas of non-compliance regarding ligature points had also been identified at Lakeside. Ms Bridger confirmed that these issues were being addressed. The Committee noted the report and agreed that feedback from the CQC inspection would be presented at the next Trust Board meeting.

9. 9.1 9.2

Q3 QUALITY GOVERNANCE (COMPLAINCE. QUALITY IMPROVEMENT, BEING OPEN & WELL LED)

The Committee received the quarterly update on quality governance, noting the assurance provided in CQC compliance (including MHA visits and themes), CQC complaints, notifications and incidents reported to the CQC, internal and external inquiries, National External inquiries and a summary of Being Open incidents. The Committee noted the level of data included in the report but agreed that the format of the report needed to be reviewed to increase the level of data analysis and triangulation and to introduce a summary of action taken in response to the data. Prof. Aylin recommended the introduction of greater triangulation of data from service lines in the next quarter’s report.

S Bridger

10. 10.1 10.2

REDUCING RESTRICTIVE PRACTICE REPORT Ms Bridger presented a draft strategy for reducing restrictive practice, explaining that the purpose of the strategy was to pull together the various implementation plans already in existence in service lines and to articulate a trust-wide vision for reducing restrictive practice. The Committee noted and endorsed the strategy, and thanked Ms

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12. 12.1 12.2 12.3

RISK DEEP DIVE – ESTATES MAINTENANCE Mr Stefanoski provided an oral report on the actions being taken to mitigate the risk regarding estates maintenance, highlighting the link with ensuring compliance with CQC standards. He reported that he was working towards discarding rechargeable mechanisms and prioritizing resources on the outstanding minor maintenance work required. The Committee agreed that it would receive a formal report on action being taken to improve responsiveness and standards at the next meeting. Dr Bates advised that there was an ongoing delay in the rebuilding of Broadmoor Hospital which was leading to increased risk to the quality of care being provided.

Mr Stefanoski

13. 13.1 13.2

BOARD ASSURANCE FRAMEWORD AND LEVEL 1 RISKS The Committee reviewed the quality-related risks on the BAF and noted no significant changes to the risk ratings or assurance levels for the risks included. The Committee discussed the format of the BAF, noting that further work was underway to consider how to strengthen the assurance role of the framework. It was also agreed that the purpose and validity of the tolerance levels in the BAF would be considered as part of this exercise.

P Jenkinson

14. 14.1 14.2

CLINICAL GOVERNANCE GROUP Ms Bridger provided an update that the mortality review dashboard would include a review group on rotation. The Committee noted the ratified minutes of the meeting held on 4th December 2017 and the draft minutes of the meeting held on 8th January 2018.

15. 15.1 15.2

SUCE SUB COMMITTEE Ms Bridger advised that a draft SUCE strategy was submitted for comments and will go to Trustwide Clinical Governance Group in a couple of months The Committee noted the ratified minutes of the meeting held on 14th November 2017 and the draft minutes of the meeting held on 9th January 2018.

Ms Bridger

16. 16.1

CLINICAL DESIGN GROUP The Committee noted the agreed minutes of the meeting held on 7th November 2017.

17. 17.1

PHYSICAL HEALTH STEERING GROUP The Committee noted the ratified minutes of the meeting held on 1st December 2017.

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Ms Bridger updated the Committee the Physical Health Steering Group was still working on the structure and strategy. Physical Health Policy to be circulated in early February 2018.

S Bridger

18. 18.1 18.2 18.3

FIRE SAFETY STEERING GROUP The Committee noted the ratified minutes of the meeting held on 4th December 2017. Ms Bridger raised concerns on the non-compliance with mandatory Fire Training and that 164 employees throughout the Trust had either cancelled or did not attend the mandatory training. Ms Brewer agreed to take this up to the Workforce Committee for discussion.

Ms Brewer

19. 19.1

ANY OTHER BUSINESS There being no other business the meeting was declared closed at 1045hrs.

20. 20.1

QUALITY COMMITTEE WORKPLAN 2017/18 The workplan was noted.

DATE & TIME OF NEXT MEETING Wednesday 21st February 2018 0900 to 1100 hrs, White Rooms A&B

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Chairman’s report from Quality Committee – February 2018

1. The Quality Committee met on 21 February 2018. Below is a summary of the key points

discussed.

SUCE representation

2. The Committee continues to support the principle of service user and carer participation at the

Committee meetings. We have a nominated service user representative who does not currently

attend, so we have agreed that the Trust will circulate an invitation to express an interest with a

view to recruiting at least two representatives to join the Committee. We also agreed that the

executive will consider the management of service user participation across the Trust.

Quality committee format and draft work plan 2018/19

3. Following on from our discussion at the January meeting, the Committee considered more

detailed proposals for the change in format of the Committee meetings, including a draft work

plan for 2018/19 reflecting the introduction of quality seminars. As part of the quality seminars

we have agreed a schedule of service line reviews, through which the Committee will review

quality at a service line level.

4. The Committee noted that the Trust’s Safeguarding Committee currently reports to the Trust-

wide Clinical Governance Group and an annual report is presented to the Quality Committee.

We have agreed that, due to the importance of oversight in this area, the Committee will now

receive quarterly reports as well as the annual report. We also agreed that the quality issues

arising from the New Models of Care for Forensics should be included in the work plan.

5. The Committee agreed to implement the change in format from April 2018.

CQC Quality Improvement Plan and performance dashboard

6. The Committee received and reviewed the CQC action plan and progress against the plan and

considered the performance dashboards showing compliance in a number of quality standards

across different clinical service lines.

7. We considered the level of compliance with the supervision standard across the Trust, noting

that Clinical Health Psychology was an outlier due to issues in recording the data. We also noted

similar issues in IAPT due to supervision being recorded through a different system. We were

assured that supervision was ongoing and welcomed the action being taken to address the

recording issue through the implementation of new systems. The Committee also suggested

that the staff survey results could be used to triangulate and validate the improvements in

supervision. The Committee noted that the area of greatest risk in supervision was relating to

bank staff who worked in different areas of the trust. Again, we welcomed the action being

taken to introduce new systems to ensure regular structured supervision for all members of

staff, including bank staff.

Suicide prevention strategy

8. The Committee received an update on the implementation of the Trust’s suicide prevention

strategy, noting that the Trust-wide Clinical Governance Group was overseeing the

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implementation of the strategy through local plans. We agreed that an executive summary

would be developed to help the communication of the strategy.

9. The Committee welcomed the multi-agency approach adopted by the Trust, the local boroughs

and the Health and Wellbeing Boards, and recommended that the local action plans should

include explicit reference to these partnerships.

Health and Safety – quarter 3 update

10. The Committee received an update on health and safety issues and noted the status on a

number of the issues reported, but we are assured that action is being taken to address those.

We will receive a further update at the next meeting, to include the actions being taken to close

the loop on issues identified.

Physical health policy

11. The Committee received the final draft version of the physical health policy and noted that the

policy would be launched. The launch is currently being planned and will have comms support.

We welcomed this significant step in the Trust’s approach to physical health and noted that a

trust strategy would also follow. However we also noted the risk in current resources, with a

single point of resource providing training and guidance across the trust. We noted that this risk

would be managed by the Physical Health Steering Group.

12. The Committee discussed various aspects of physical healthcare, including provision of dental

health. We noted the risk of the Trust not being able to recruit physicians across the Trust which

would impact on the provision of trust-wide healthcare, although we also noted the need to

utilise existing resources better. This will be reflected in the next update to the BAF risk.

13. The Committee received the minutes from the last Physical Health Steering Group meeting,

noting the ongoing discussion regarding the use of MEWS across the Trust but with a focus on

community services. We also noted the concerns raised by the Group regarding a consultation

launched by Ealing Borough, proposing to stop their provision of a smoking cessation service.

The Trust will be responding to the consultation to raise its concerns.

14. We have agreed that we would include a more detailed review of physical health, aligned with

the development of the physical health strategy, in the Committee’s work plan.

BAF risk ‘deep dive’ – Serious incidents

15. The Committee reviewed the quality-related risks on the BAF and considered a review of the

BAF risk relating to timely completion of serious incident investigations and welcomed the

reduction in the backlog of serious incident investigations as positive assurance that the

controls put into place were effective.

16. The Committee however is concerned that the backlog does not increase again, noting the

identification of process issues that prevented timely completion and sign off of investigations.

We referred back to the presentation given to the Committee by Jane Carthey and her advice

regarding the strength of actions and recommendations, and the possible benefits of having

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standing panels to investigate serious incidents. With continued leadership oversight such as

that which led to the reduction in the backlog and the actions being taken to address system

issues, the Committee expects to reduce the current backlog further.

17. The Committee also noted the ongoing work by the Director of Nursing with the CCG to reduce

the number of outstanding queries submitted by them in relation to completed investigations.

18. The Committee considered whether this risk should be merged with the BAF risk 4217 relating

to learning lessons from patient feedback and incidents. While there is a connection between

the two risks, in that timely completion of investigations is important to enable organisational

learning, it was felt that the two risks should be kept separate for the time being so that focus

could be maintained on improving the timeliness of completion of investigations.

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DRAFT MINUTES OF THE QUALITY COMMITTEE MEETING Held on Wednesday 21st February 2018

Present: Prof Paul Aylin Non-Executive Director (Chair) Ms Moriam Bartlett Non-Executive Director

Dr Chris Bench Clinical Director, Planned & Primary Care Services (Representing Dr Vijay Parkash)

Ms Stephanie Bridger Director of Nursing and Patient Experience Mr Tom Hayhoe Trust Chairman

Mr Neville Manuel Non-Executive Director Ms Leeanne McGee Executive Director of High Secure and WLFS (Representing Dr Robert Bates & Dr Claire Dillon) Ms Carolyn Regan Chief Executive

Mr Stanley Riseborough Director of Improvement Dr Jose Romero-Urcelay Medical Director Dr Angharad Ruttley Clinical Director Liaison and Long Term Conditions Mr Gordon Turner Associate Director of Clinical Governance Attending: Mr Peter Jenkinson Trust Secretary Ms Jinelle Rodrigues Secretariat Assistant (Minutes) Ms Sally Sykes Director of Communications and Engagement Mr Wil Bevan Deloitte Representative (observing) Miss Lucy Bubb Deloitte Representative (observing) Agenda items are recorded in minutes in the sequence they were considered

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1. 1.1

INTRODUCTION & WELCOME Prof Aylin welcomed everyone to the meeting and a round of introductions was made.

2. 2.1

APOLOGIES FOR ABSENCE Apologies for absence were received from the following: Dr Robert Bates, Clinical Director of High Secure Services (HSS), Ms Wendy Brewer, Director of Workforce & OD, Dr Nevil Cheesman Clinical Director, Cognitive Impairment and Dementia Services (CIDS), Ms Gillian Kelly, Deputy Director of Nursing, and Ms Sarah Rushton, Director of Local & Specialist Services

3. 3.1

MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on Wednesday 21st June 2017 were agreed to be a correct record subject to some minor amendments and corrections.

Jinelle

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4. 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9

ACTION SCHEDULE & MATTERS ARISING Action Schedule The Committee reviewed the action schedule and noted the completed actions. The following updates were provided: 5.1.1 CAMHS New Models of care/Quality Matrix (F&P Action): Ms Regan stated that the CAMHS New Models of Care contacts had not been devolved to providers but were held centrally by NHS England; the Trust therefore had little ability to influence the metrics within the contract. This issue had been raised with the London Specialised Commissioning Board and action would be taken forward through that forum to provide assurance regarding the quality aspects of the contract. 7.4 Estates and Maintenance: Ms Bridger reported that a process for the management of requests had been reviewed and revised to improve responsiveness, and a central budget had been assigned to estates maintenance. The Committee noted the assurance mechanisms in place and agreed to close this action. 21/06/17: item 6.36 Service line deep dives: The Committee noted that the template for service line reviews had been circulated and agreed to close the action. Clinical Governance Group Terms of Reference: Ms Bridger stated that the Terms of Reference had been redrafted and would be circulated by end of March. Update on Service User and Carer Involvement Review: The Board noted the update on the development and implementation of the SUCE strategy and delivery plan and agreed to review the plan in May 2018. Fire Safety Steering Group Training: The Committee noted that non-compliance with mandatory training was now regularly reported to line managers and monitored through the executive directors’ meeting. In addition the EDs had approved the implementation of a £50 penalty to be levied on operational units for non-attendance at training sessions. The Committee noted the assurance mechanisms in place and agreed to close the action. BAF & Level 1 Risks: Mr Jenkinson stated that proposals for the strengthening of the trust’s assurance framework would be presented to the Audit Committee in March. Action closed. Q3 Quality Priorities Assurance Report & Quality Account Update: Dr Romero-Urcelay noted that Clare Harris would meet with Dr Parkash to discuss the narrative regarding CAMHS. Matters Arising 16.2 H&F Site TV Technical Issues: Ms Sykes presented an update on the issues experienced in updating the content of the screens and advised that the cost of replacement would be prohibitive. The Committee agreed that standard videos would be used on all screens.

Director of Nursing Director of Nursing

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4.10

18/10/17: item 9.5 SUCE Lay representation: The Committee noted that a job specification for the SUCE Lay Representative had been developed and would be published as an invitation to express an interest in participating. The Committee agreed that there should be more than one service user representative, where possible representative of the services provided by the Trust. The Committee discussed the Trust’s approach to service user participation and noted the need for a central register of service user representatives. It was agreed that the Director of Nursing, Director of Communications and Director of Workforce would agree how to take this forward.

Director of Nursing / Director of Communications / Director of Workforce

5. 5.1

ACTIONS REMITTED BY THE BOARD OR OTHER COMMITTEES No actions had been remitted by the Board or other committees since the Committee had last met.

17. 17.1 17.2 17.3 17.4 17.5 17.6

QUALITY COMMITTEE WORKPLAN 2018/19 – PROPOSALS The Committee agreed to bring this item forward as it revolved around the future plans of the Quality Committee. Mr Jenkinson provided a verbal update on the background to discussions on the future format of Quality Committee meetings and the proposals to reformat the Quality Committee in order to give time for service line deep dives which would be presented in the quality seminars and meetings would take place on a bimonthly basis. The Committee considered the detailed proposals for the change in format of the Committee meetings, including a draft work plan for 2018/19 reflecting the introduction of quality seminars. As part of the quality seminars the Committee agreed a schedule of service line reviews, through which the Committee will review quality at a service line level.

The Committee noted that the Trust’s Safeguarding Committee currently reports to the Trust-wide Clinical Governance Group and an annual report is presented to the Quality Committee. It was agreed that, due to the importance of oversight in this area, the Committee would receive quarterly reports as well as the annual report. The Committee also agreed that the quality issues arising from the New Models of Care for Forensics should be included in the work plan.

The Committee agreed the proposed change to the work plan to reflect the change in format, and agreed commencement in April 2018, but noting that the work plan would be dynamic so that the Committee could prioritise issues during the year. The Committee confirmed that quality seminars would be minuted to ensure an audit trail of discussion

Trust Secretary Trust Secretary

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6. 6.1 6.2 6.3 6.4

CQC QUALITY IMPROVEMENT PLAN UPDATE REPORT The Committee received and reviewed the CQC action plan and progress against the plan and considered the performance dashboards showing compliance in a number of quality standards across different clinical service lines.

The Committee considered the level of compliance with the supervision standard across the Trust, noting that Clinical Health Psychology was an outlier due to issues in recording the data. The Committee also noted similar issues in IAPT due to supervision being recorded through a different system. The Committee were assured that appropriate supervision was taking place and noted the action being taken to address the recording issue through the implementation of new systems. The Committee also suggested that the staff survey results could be used to triangulate and validate the improvements in supervision. The Committee noted that the area of greatest risk in supervision was relating to bank staff who worked in different areas of the trust. The Committee noted the action being taken to introduce new systems to ensure regular structured supervision for all members of staff, including bank staff.

7. 7.1 7.2 7.3

UPDATE ON SUICIDE PREVENTION Ms Bridger presented an update on suicide prevention and stated that the draft strategy has been discussed at the Trust Wide Clinical Governance group. The seven key principles had been agreed, along with a lead for each borough, who would then be linking in with local authorities. The Committee agreed to a suggestion by Dr Romero-Urcelay to include issues around playground and social media bullying into the policy. It also agreed to a recommendation from Ms McGee that an executive summary should be developed to help the communication of the strategy. The Committee noted the update and thanked Ms Bridger, noting that the Trust-wide Clinical Governance Group would oversee the implementation of the strategy through local plans. The Committee welcomed the multi-agency approach adopted by the Trust, the local boroughs and the Health and Wellbeing Boards, and recommended that the local action plans should include explicit reference to these partnerships.

Director of Nursing / Director of Communications S Bridger

8. 8.1

HEALTHCARE SAFETY AND WELFARE UPDATE Q3 The Committee received an update on health and safety issues, noting that the update contained an early view of the Trust by the newly appointed Head of Risk, Health & Safety, including observations and data on a number of different issues. Ms Bridger assured the Committee that action was being taken to address those issues, and agreed to provide a further update at the next meeting, to include the actions being taken to close the loop on issues identified.

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9. 9.1 9.2 9.3 9.4 9.5

9.10

PHYSICAL HEALTHCARE POLICY The Committee received the final draft version of the physical health policy and noted that the policy would be launched. The launch is currently being planned and will have communications support. The Committee noted and endorsed this significant step in the Trust’s approach to physical health and noted that a trust strategy would also follow. The Committee also noted the risk in current resources, with a single point of resource providing training and guidance across the trust. The Committee also noted the risk of the Trust not being able to recruit physicians across the Trust which would impact on the provision of trust-wide healthcare, although we also noted the need to utilise existing resources better. It was agreed that this risk should be reflected in the next update to the BAF risk and should be managed by the Physical Health Steering Group, and escalated as appropriate if required.

The Committee discussed various aspects of physical healthcare, including provision of dental health. Mr Riseborough questioned if there was a provision present in Forensics about prompts on dental care in community. Ms McGee stated that this issue was raised several times by carers and the Committee agreed to include prompts on dental care into the policy. Dr Romero-Urcelay raised the possibility of having a mobile application for all junior doctors featuring standards and aspects of Trust, NICE guidelines, inpatient protocols, etc. to maintain standards in inpatient services including community services. The Committee agreed that this should be considered, including research as to whether any other trusts have implemented such applications. The Committee agreed My Hayhoe’s suggestion that an update on physical health care be presented at a future board development session.

Dr Romero Urcelay Dr Romero-Urcelay Trust Secretary

10. 10.1 10.2 10.3

BAF8026 – SERIOUS INCIDENTS Ms Bridger presented the deep dive on behalf of Ms Rushton - named lead for the report. The Committee reviewed the quality-related risks on the BAF and considered a review of the BAF risk relating to timely completion of serious incident investigations and welcomed the reduction in the backlog of serious incident investigations as positive assurance that the controls put into place were effective.

The Committee however noted its concern that the backlog did not increase again, noting the identification of process issues that prevented timely completion and sign off of investigations. The Committee reflected on the presentation given to the Committee by Jane Carthey and her advice regarding the strength of actions and recommendations, and the possible benefits of having standing panels to investigate serious incidents. The Committee agreed that with continued leadership oversight such as that which led to the reduction in the backlog and the actions

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10.4 10.5 10.6 10.7

being taken to address system issues, the expectation should be to reduce the current backlog further.

Ms Regan reported the key actions in respect of this risk, as agreed by executive directors, including ensuring a process was in place to close down outstanding queries from CCG regarding completed investigations, and ensuring a robust investigation process to ensure the backlog did not increase again. The Committee noted the ongoing work by the Director of Nursing with the CCG to reduce the number of outstanding queries submitted by them in relation to completed investigations.

The Committee considered whether this risk should be merged with the BAF risk 4217 relating to learning lessons from patient feedback and incidents. While there is a connection between the two risks, in that timely completion of investigations is important to enable organisational learning, it was felt that the two risks should be kept separate for the time being so that focus could be maintained on improving the timeliness of completion of investigations. Mr Riseborough questioned about the forward graph projections [4.1 (ii)] and Ms Bridger explained that the graph has to feature a fall in serious incidents and not a rise in the future reports. Dr Romero-Urcelay suggested that the report should be multifactorial and the target for serious incidents should be zero. The Committee noted the suggestions from members and thanked Ms Bridger for the report.

11. 11.1

BAF AND LEVEL 1 RISKS The Committee reviewed the quality-related risks on the BAF and noted no significant changes to the risk ratings or assurance levels for the risks included, but that a quarterly review of the risks was currently being completed with executive owners of risks.

12. 12.1 12.2

SUCE SUB COMMITTEE The Committee noted the ratified minutes of the meeting held on 14th November 2017. Ms Bridger stated that there has been no meeting since November 2017 and that the next meeting will be held in March 2018.

13. 13.1 13.2 13.2

PHYSICAL HEALTH STEERING GROUP The Committee received the minutes from the last Physical Health Steering Group meeting, noting the ongoing discussion regarding the use of MEWS across the Trust but with a focus on community services. The Committee also noted the concerns raised by the Group regarding a consultation launched by Ealing Borough, proposing to stop their provision of a smoking cessation service. The Trust would be responding to the consultation to raise its concerns. Prof Aylin questioned about the news feed to inpatients and Dr Romero-

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Urcelay stated that this issue is integrated in the Physical Healthcare Report that the news feed works fine in some places while others still possess technical glitches.

14. 14.1

FIRE SAFETY STEERING GROUP The Committee noted the approved minutes of the meeting held on 4th December 2017 and agreed that the minutes from the recent meeting would be presented at the next meeting.

15. 15.1 15.2

CLINICAL GOVERNANCE GROUP The Committee noted the approved minutes of the meeting held on 5th February 2018. Ms Bridger stated that the ratified minutes would be presented at the next meeting.

16. 16.1

ANY OTHER BUSINESS There being no other business the meeting was declared closed at 1045hrs.

DATE & TIME OF NEXT MEETING Wednesday 21st March 2018 0900 to 1100 hrs, White Rooms A&B

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MINUTES OF THE WORKFORCE AND DEVELOPMENT COMMITTEE Held on Wednesday 1 November 2017

In White Room A Trust Headquarters, Armstrong Way, Southall UB2 4SA

Present: Prof Sally Glen Non-Executive Director (Committee Chair)

Mrs Sarah Cuthbert Non-Executive Director

Mrs Wendy Brewer Director of Workforce and OD

Ms Sarah Rushton Director of Local and Specialist Services

Mr Tom Hayhoe Chairman

Ms Moriam Bartlett Non-Executive Director

Ms Stephanie Bridger Director of Nursing & Patient Experience

Ms Katie Lynn Harfield Team Leader, High Secure Services

Ms Alice Foyle Service Director, High Secure Services

Ms Dawn Harwood Service Director, Women’s and Adolescent Services

Attending: Mr Peter Jenkinson Trust Secretary

Mrs Alison Webster Assistant Director of Learning and Development

Mrs Gillian Kelly Deputy Director of Nursing

Mrs Maninder Walia Lead Workforce Partner

Mrs Gillian Henry Deputy Trust Secretary (minutes)

Ref:

Discussion: Action:

1. WELCOME AND APOLOGIES

1.1 1.2

Prof Glen welcomed everyone to the meeting. Apologies for absence were received from Mrs Jo Smith, Deputy Director of Finance Ms Leeanne McGee, Director of High Secure and Forensic Services Dr Jose Romero-Urcelay, Medical Director

2. 2.1

DRAFT MINUTES OF THE PREVIOUS MEETING 2 AUGUST 2017 The minutes of 2 August 2017 were agreed to be a correct record of the meeting.

3.1 3.1.1 3.2 3.2.1

ACTION SCHEDULE The Committee discussed the action schedule, noting the completed actions which will now be archived. MATTERS ARISING There were no matters arising.

4. 4.1

ACTIONS FROM BOARD AND/OR OTHER COMMITTEES

The Committee noted an action from the Audit Committee meeting held on 1 November 2017, where a query was raised about a tender waiver for the use of Harvey Nash to support the overseas

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recruitment of staff. The Audit Committee has asked whether Harvey Nash was the only supplier of this service and whether there had been any inquiries made to ensure the contract provided value for money. Mrs Brewer confirmed that this supplier had been selected due to their experience in other trusts, and that she was looking at the possibility of adding the client to the national procurement framework.

5. 5.1

5.2

5.3

5.4 5.5

DRAFT WORKFORCE STRATEGY ACTION PLAN Mrs Brewer presented the interactive workforce strategy action plan which included the key areas of focus within the workforce strategy and the key initiatives and targets within each area. The key areas of focus in the strategy are:

• Recruitment and retention

• Fair and diverse workforce

• Leadership development

• Workforce development

• Engagement and transformation

• Workforce efficiency The Committee discussed the development of defined career pathways, one of the issues identified in staff exit interviews, and noted that well-established career pathways already existed into nursing but that more work was required to develop similarly well-defined pathways in clinical roles, research, AHPs, social work and non-clinical disciplines such as estates and administration. These pathways should include development of the role as well as potential routes of promotion and would be included in the recruitment documentation for any role.

The Committee discussed the Trust’s retention initiatives around the career progression for Band 2 HCAs to Band 3 upon completion of a Care Certificate. The Committee noted a varied implementation of this scheme across the Trust and agreed the need for a consistent approach so that all staff had similar opportunities.

Ms Webster said that buy-in was needed from all areas to identify pathways and that it was important for the key message to be relayed to the services that clear pathways were required, so that people could see the benefit of joining the organisation. The Committee noted its concern regarding the current vacancy rate and the risk that this would compromise patient safety. It therefore agreed the importance of retaining staff. The Committee therefore noted the update and agreed the need for a consistent, competency-based approach across the Trust, and will review this again at the next meeting.

W Brewer / S Rushton

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6. 6.1 6.2 6.3

WORKFORCE PERFORMANCE REPORT

The Committee received the latest workforce performance report, and noted that while the fill rate for recruitment was improved, there was also an increase in turnover rate and vacancy rate as well as a slight increase in sickness absence. As the current recruitment rate was only just covering the turnover rate, the Committee noted the importance of focusing on retention of staff.

The Committee considered the latest agency figures and breaches to the national cap, noting five shifts by one individual during the last period. The Committee noted that the Director of Finance was aware of the individual involved and the Committee will monitor action being taken to address this breach. The Committee also noted a high level of vacancies in the Broadmoor estates team, noting the ongoing restructure of the team as the reason for the high vacancy rate. The Committee noted the report.

7. 7.1 7.2 7.3 7.4

EXIT SURVEY DATA ANALYSIS

The Committee received a presentation from external consultants, Great with Talent, summarising the analysis of exit surveys completed by 47 staff leavers in the last quarter June to September 2017. The survey, an anonymous questionnaire, was issued to all leavers during this period. The figure of 47 completed questionnaires represented around 40% of leavers during this period and although the size of the dataset was small, the analysis gave the Committee a good insight into the reasons why staff were leaving the Trust. The analysis data was considered by demographics and by professional discipline. The Committee noted, in particular, the level of staff leaving within their first 24 months working in the Trust. Some of this was due to career progression and was probably reflected in the 53% of respondents who were ‘happy leavers’ and the 55% of respondents who would recommend the Trust as a place to work. The Committee agreed that this cohort of leavers were important ambassadors for the Trust and should be managed as alumni of the Trust, with the aim of attracting them back to the Trust at a later stage in their careers. The Committee also noted the importance of being a local employer in the reasons given for joining the Trust and agreed that a focus on the reasons why staff choose the Trust to work would strengthen the Trust’s future recruitment campaigns. It was agreed that there was a need to celebrate the career development opportunities within the Trust, including the number of internal promotions. The Committee noted the results from the exit survey and agreed to receive similar analysis on a quarterly basis in order to monitor trends,

A Webster W Brewer

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with an update coming to the May 2018 meeting, and the Trust commissioned Great with Talent to run a similar exercise with staff who have stayed on at the Trust, to compare the differences between those staff who elect to leave versus those who stay.

A Webster

8. 8.1 8.2

8.3 8.4

RISK STEP THROUGH: RISK REF 8428 Mrs Brewer presented the step through of risk ref 8428 (‘if external education funding is reduced, the supply of undergraduate staff to the Trust may be significantly reduced and the opportunities for skill development for the current workforce may reduce’), noting the dependency on external factors, such as national policy, and the controls in place to mitigate the risk. It noted that the Trust was working with Health Education North West London to develop the London response to the HEE strategy on the future of the mental health workforce. The Committee discussed the impact of reduced funding for training for AHPs and the need to identify other methods of training and development, such as AHP apprenticeships. It was also noted that Helen Lycett was currently looking at improving retention. The Committee agreed that an update on the development of AHP apprenticeships and retention initiatives would be presented to the Committee at its February meeting. The Committee agreed to maintain the risk ratings as per the current version of the BAF, but agreed that a target date should be given for reduction of the current risk to the target risk rating. Mr Jenkinson agreed to meet with Ms Brewer to discuss. The Committee noted the risk step through.

A Webster / H Lycett P Jenkinson/ W Brewer

9. 9.1 9.2

BOARD ASSURANCE FRAMEWORK The Committee reviewed the workforce related risks on the BAF and associated controls and agreed that the current risk ratings remained the same. The Committee noted that it would be useful for a narrative description of the impact of the risk to be included in the BAF. It was agreed that the Trust Secretary would consider this recommendation as part of his review of the format and content of the BAF.

The Committee noted the update.

P Jenkinson

10. 10.1

LEARNING & DEVELOPMENT UPDATE The Committee received an update on learning and development, including an update on the numbers of staff attending Trust induction as a result of a successful recruitment campaign. The Committee welcomed the improvement in attendance at mandatory training in some subjects but noted concern over the level of compliance with Information Governance training, currently at 86% against a target of

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10.2 10.3

90%, and the level of staff not attending fire safety and information governance training when booked onto courses. The Committee noted that a new system had been implemented for tracking compliance with mandatory training requirements that would enable managers to be alerted if staff members are non-compliant. The new system would also advise staff members of available spaces on courses to improve access to training. The update was noted by the Committee.

11. 11.1 11.2 11.3

NURSING DEGREE APPRENTICESHIPS The Committee noted and welcomed Trust Management Team’s decision to move ahead with establishing a nursing degree apprenticeship scheme, and discussed the draft curriculum for the scheme. The Committee noted that the curriculum would remain as per the current BSc Mental Health Nursing or Adult pathway but would be delivered in a different way, enabling it to be delivered as an apprenticeship and in doing so, enable the organisation to train the future nursing workforce whilst benefiting from having them working in the Trust for large amounts of time. The Committee noted that the tendering process for the course provider was currently ongoing, and that numbers for each cohort across the different areas of the Trust were to be confirmed. The Committee also noted the possibility of arranging joint arrangements with CNWL which would allow placements across both organisations, and noted LNC validation of the programme. The Committee agreed to monitor progress in the establishment of the scheme. The update was noted by the Committee.

12. 12.1 12.2

UPDATE ON LONG SERVICE AWARDS

The Committee noted the launch of long service awards for staff, noting that around 120 were expected to attend the inaugural ceremony on 17 November 2017 at The Stoop. The Committee noted that the criterion for being awarded a long service award was 25 years continual service within the Trust. The Committee noted the update.

13. STAFF SURVEY UPDATE The Committee received an update on the staff survey, noting that the survey had been circulated to staff, with a response rate to date of 27%.

14. 14.1

REVIEW OF COMMITTEE’S EFFECTIVENESS The Committee considered a proposed template for the self-assessment of the Committee’s effectiveness and agreed that any

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comments on the format and questions used in the template should be forwarded to the Trust Secretary. The Committee agreed that it would review the results of the effectiveness review at its next meeting.

P Jenkinson

15. 15.1

TRUST PARTNERSHIP FORUM The Committee received and noted the approved minutes from the Trust Partnership Forum meeting held on 13 July 2017. The Committee also noted that September’s meeting had been cancelled due to a high number of apologies.

16. 16.1

APPRENTICESHIP STEERING GROUP MEETING The Committee received and noted the draft minutes from the meeting held on 3 August 2017.

17. 17.1 17.2

ANY OTHER BUSINESS

Talent Management The Committee received an update on the implementation of a talent management framework, following approval by the Trust Management Team. The framework would be launched in April 2018 as part of the personal development review. The Committee endorsed the importance of transparency and fairness in the process and will appoint a subset of the Committee to review the nominations and calibrate the proposed participants in May 2018. There would also be an appeals process. The Committee noted the next steps were to agree the critical posts to be included in the scheme and then Trust-wide communications to explain the process. As this was Gillian Henry’s last meeting, Prof Glen thanked her for her contribution to the Workforce agenda and the development of this committee, and wished her well for the future.

Date & Time of next meeting Wednesday 21 February 2018 0900 – 1100 White Room A, Armstrong Way

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Chairman’s report from Workforce & Development Committee – 21 February 2018

The Workforce and Development Committee met on 21 February 2018. Below is a summary of the key points discussed. Workforce Strategy action plan 1. The Committee received a verbal update on the workforce strategy action plan, with focus on

the following areas:

• Diversity

• Talent Management

• Bullying

• Disability 2. The Committee discussed ways to improve staff retention and discussed the ways in which the

Trust has been managing diversity noting the investment in BME leadership and movement towards supporting employees with disabilities. It was recognised that WLMHT should be viewed as ‘leaders’ in supporting employees with mental health issues particularly given our status as a mental health Trust.

3. The Committee received a positive report on the progression of staff reporting bullying by

colleagues and line managers. The bullying at work policy has been revised, as has the approach to managing shifts fairly. It was recognised that a plan needs to be created in conjunction with Communications and Engagement team to re-educate managers on the impact of their management styles on those who they manage.

WLMHT Agency Recommendations and Responses 4. The Committee discussed the Trusts response to the letter received from NHSI. The deep dive

has been helpful for reducing agency spend. However, it was determined that there will always remain a need for agency AHP and medical staffing. The Chair offered commendation to the Committee and Ms Brewer for the improvements noted over the last 18 months.

5. The Committee considered an approach to reducing agency spend which includes long term

locums and the use of Nurse Practioner, the Committee recognises a shortage of nurses. It was recognised that steps further could be taken to encourage junior doctors into the high yield learning environment that WLMHT offers. The Committee considered inviting focus group representatives from the under staffed areas to learn how we can encourage more applicants, how to best market the vacancies to prospective staff and what they are looking for in a good employer.

On Boarder Questionnaire Information and Response 6. The On Boarder questionnaire received a response rate of 35%, or 79 participants. 82% of the

participants felt very good about the overall recruitment process, they felt that they had been treated with respect. The participants also felt that job descriptions were clear and they had an understanding of organisation. The Committee heard that the participants were attracted to WLMHT by the nature of the work and the opportunities for learning and development. However the questionnaire flagged that 32% of new starters are already considering leaving the Trust, which requires further investigation.

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7. Following on from the results of the On Boarder questionnaire, the provision of staff handbook has greatly improved; it is now available in electronic format and accessible from mobile phones. The handbooks highlight the employee benefits. There has also been an employee handbook created for the nursing staff arriving into the Trust through the Philippines initiative.

Gender Pay Gap Report 8. The Committee discussed the Trust position in relation to the requirements of the Equality Act

2017, and our proposed actions to address the gender pay gap. It was acknowledged that there remains a gender pay discrepancy within the Trust. However, a proportion of this finding is likely to be due in part to a greater period of continuous service for amongst male employees. The report also flagged that there appears to be a disproportionate amount of men in senior roles within the Trust; staff from Black and Minority Ethnic backgrounds have highlighted the need for transparency, particularly in regards to ‘acting up’ and secondments.

AHP Workforce Strategy 9. The Strategic Trust Lead for AHP presented to the Committee an update on the Allied Health

Professions development pathway which offered a high level overview of the initiatives being developed and implemented to support the recruitment and retention of Allied Health Professionals (AHPs). The Committee learnt that there has been a significant decrease from 20% to 13% in AHP vacancies. In addition, the survey response indicated that the band 5 and 6 AHPs have shown encouraging interested in the bespoke training which started in January.

10. The second focus following on from the survey is AHP development. This has presented a

challenge due to the niche specialisms within AHP; which has led to creation of the career development pathway. This will eventually become an interactive platform which will enable to exploration of different career pathways.

11. The Committee learnt that there has been a drop in undergraduate enrolment, this is likely not to be recurrent; pre-registration for the AHP apprenticeship is currently awaiting commissioning from providers.

Retention Action Plan for NHSI 12. Committee learnt of the voluntary engagement that the Trust had with NHSI which consisted of

submission of retention plans, and attendance at a conference on topic in January. It was determined that the exercise offered a good opportunity to identify retention issues.

Talent Management

13. The first Talent Management steering group will be taking place this month. Following on from

consultations with The Leadership Academy, the group will be renamed the ‘Recruiting and

Retraining group ’.

14. The steering group has obtained funding to train line managers in the appraisal process; funding

has also been sourced for short appraisal training videos. The Learning Academy will also be

funding unconscious bias training.

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Workforce Performance Report – December 2017

15. The Committee was informed that agency spend was reduced this month. There was a peak in

sickness absence as expected over the winter period. The Committee noted that staff turnover

appeared to be high. Particularly in nursing, with the amount of leavers near matching the

amount of joiners.

16. An update was given to the Committee regarding the Philippines nursing initiative. 200 offers

have been made, with an estimated 20-30 new nurses expected to join the Trust owing to

anticipated challenges. Development of a group is currently in motion to provide specific and

personalised support in terms of accommodation, induction and peer support.

Nursing degree apprentice

17. Over 60 applications submitted for the nursing degree apprenticeship that is being offered by

WLMHT alongside CNWL, 15 applicants have been accepted. Buckinghamshire New University

has been appointed as our provider.

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MINUTES OF THE FINANCE AND PERFORMANCE COMMITTEE Held on Wednesday 31 January 2018

In the White Room A Trust Headquarters, Armstrong Way, Southall UB2 4SA

Present: Mr Tom Hayhoe Non-Executive Director (Chairman)

Mr Neville Manuel Non-Executive Director (Committee Chair)

Ms Elizabeth Rantzen Non-Executive Director

Dr Jose Romero-Urcelay Medical Director

Ms Sarah Rushton Director of Specialist & Local Services

Mr Paul Stefanoski Director of Finance & Business

Attending: Ms Carolyn Regan Chief Executive

Ms Wendy Brewer Director of Workforce and Organisational Development

Ms Angela Dolan Deputy Director of High Secure Services

Ms Pamela Farrow Head of Costing

Mr Peter Jenkinson Trust Secretary

Mr Peter Milliken Head of Finance & Business Performance (Local Services)

Mr Trevor Nelms Director of IM&T

Ms Hannah Parsons Head of Business & Finance, WLFS

Mr Jim Phillips Head of Finance

Ms Iscelyn Richards Deputy Trust Secretary (Minutes)

Ms Lesley Soden Deputy Director of Business Items were discussed in the sequence they are recorded in the minutes

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1. WELCOME AND APOLOGIES

1.1.1 1.1.2

Mr Manuel welcomed everyone to the meeting. Apologies were received from Mr Chris Hilton, Director of Business & Strategy Mr Hassaan Majid, Non-Executive Director Ms Leeanne McGee, Director of High Secure and Forensic Services Dr Jose Romero-Urcelay, Medical Director

2. 2.1.1 2.1.2

DRAFT MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on 29 November 2018 amended to reflect apologies of Tony Hayhoe. Action to prepare and disseminate an action plan to reduce agency spend for 2018/19 not captured. Ms Richards to add to the action log for completion by Ms Brewer, March 2018.

Iscelyn Richards/ Wendy Brewer

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3.1 3.1.1 3.1.2 3.1.3 3.1.4 3.1.5 3.1.6 3.1.7 3.1.8 3.1.9 3.1.10 3.1.11

ACTION SCHEDULE AND MATTERS ARISING The Committee discussed the action schedule, noting the completed actions which will now be archived. 29.11.17:Broadmoor Estates and Facilities: The Committee agreed to receive a briefing on the planning for the transition from old to new hospital at the next meeting. Action brought forward to February Committee. Action closed. 29.11.17 Monthly Trust position (CIPs): The Committee noted that some CIPs on the list would not be delivered and should be removed from the list. Action closed. 29.11.17 Monthly Trust position: The Committee noted the reported reduction in education and training expenditure and asked for assurance that this would not impact on quality. Action closed. 29.11.17 Monthly position - London E&F: The Committee asked for assurance that budget had been allocated to resolve the issues highlighted in the fire safety review. Action closed. 29.11.17 IPR (risk assessments): The Committee noted that the Medical Director would be reviewing compliance levels at a service level and would also be considering reducing the target time for completion of risk assessments from 72 hours. Action closed. 26.4.17 Monthly Position: To check again in Q2 as to whether the control processes are working and making the necessary difference to the financial trajectory. Action closed. 29.3.17 NMOC CAMHS Tier 4 business case: A review to be held to ensure KPIs were being met. This was reviewed by the Committee in November. Action closed. 22.3.17 Estates Portfolio Risk Step Through: (a) The long term approach to maintenance and planning to be remitted to the Finance & Performance Committee for consideration: (b) Mr Stefanoski to update the BAF entry. Action closed and remitted to Quality Committee due to the Estates maintenance risk and impact of patient experience. 27.9.17 Monthly Position - Local Services: Ms Regan to include the achievement of medical staff in maintaining gatekeeping in her blog. Action closed. 28.6.17 WLFS Expenditure Deep Dive: To look at whether the common line items across all the services, i.e. IT and telephony, reflect divided procurement because it gives us better value for money. Action to be brought forward as agenda item for March Committee.

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3.2 3.2.1

Matters Arising Item 3.1.9 to be remitted to the Quality Committee to review at next meeting.

4. 4.1

ACTIONS FROM BOARD AND/OR OTHER COMITTEES No actions remitted.

5. 5.1.1 5.1.2 5.1.3 5.1.4 5.1.5 5.1.6 5.1.7

MONTHLY POSITION - TRUST The committee received an update on the M9 position, noting that the Trust was reporting underspend of £336k. An anticipated spike in M10 due to recruitment growth spend. Mr Stefanoski reported the stretch target for Q.1 was set at 50% and is confident that this will not be surpassed for 2017/18. The inpatient position has improved measurably due in part to additional funding for WEMSS beds from NHS England. Significant inroads have been made into reducing agency spend, in relation to CIPs the Trust has identified £9.4m worth of from the budget. There has been a 70:30 unexpected split due to less non-recurrent, which will lead to a positive impact on CIPs for 2018/19. Two thirds of CIP targets for 2018/19 have been identified, the current objective is to identify and meet 100% of the CIP target for 2018/19 by February 2018. Mr Stefanoski commended the Committee for the efforts undertaken to meet financial targets from 2017/18. Capital charges have gone down by approximately £3m for 2017/18. This is partially due to the delay in the development of the new Broadmoor site. The Trust has reached an overachievement on control targets; this presents an opportunity for a return of at least 1:1 from NHS I. This funding, which would stem from the STF incentive, could be utilised as additional funding for KIA towards compensation, and the cost of events. Mr Stefanoski informed the Committee of his intention, subject to approval, to present this information to NHS I soon as possible. Mr Stefanoski asked the members to consider whether the finance and performance committee felt that it would be appropriate to declare the over achievement for M10 to NHS I. There would be a risk in regards to internal communication and staff perception as this overachievement is a non-reoccurring benefit. In addition another risk would be the implications for ongoing negotiations between WLMHT and a) the local CCG’s and b) NHS E in the wider context of delivery of performance achievement. The committee agreed that the decision for approval would be taken at the next TMT meeting 28 February 2018, with sign off at the next Board 14

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5.1.8 5.1.9

March 2018. It was raised by Mr Manuel that the surplus from the capital charges and potentially NHS I could be used for estate risks. Mr Stefanoski informed the committee that the Trust has a healthy cash balance at the moment therefore he would be happy for the Trust to invest in estates, however as we are not a Foundation Trust we would be restricted by the upper limits. Mr Stefanoski is prepared and confident that we can make the argument to NHS I to increase our capital resource limit, because it is a quality issue. Mr Manuel reflected the earlier sentiments of Mr Stefanoski in commending the committee for the hard work over the last financial year. Ms Rantzen suggested that more communications be offered to NEDs in regards to the Trust finance updates.

6. 6.1.1 6.1.2

Monthly position – Local Services Ms Rushton was pleased reported to the committee that bed availability has been sustained over January, despite winter pressures. Length of stay of 75 days is slowly increasing, working on reducing this. Ms Rushton has passed on her gratitude to Mr Stefanoski and team for the strong financial position that the Trust is in. The stretch team has done a great job in bringing in income.

7 7.1.1 7.1.2 7.2.1 7.2.2

Monthly Position - HSS & West London Forensic Services Ms Parsons reported a M9 overspend, and is anticipating M10 spend is also likely to be high due to increase in hospital expenditure. The year-end forecast of overspend is £560k is due to staff overspend, drugs, medical vacancies and ward expenditure. Mr Stefanoski is not anticipating a breach within HSS in M10 or M11.Mr Neville proposed that the 60% £1.3m reduced spend from agency fees would allow for break even, and will account for overspend. Ms Dolan reported that in 2015 there was a 70-75% head count vacancy. The vacancy was due to acuity and staff were not engaging in bank. Currently recruitment is good and retention is poor. Acuity and retention issues in addition to a unforeseen activities such as a recent roof top protest by patients necessitates the need for staff who possess PPI training. There is also the need to ensure that at all times we have enough staff members to create and maintain ‘calm’ within the wards. Overtime by ward indicates higher agency spend within our intensive care wards and Epsom. The higher agency spend is due to the nature

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7.2.3. 7.2.4 7.2.5 7.2.6 7.2.7 7.3.1 7.3.2

of the ward, Ms Dolan is working on reducing vacancies. As it currently stands, there are 58 vacancies across two wards. Ms Dolan will review recruitment around the March and April period, as this has been identified as the best time to attract newly qualified nurses. Retention improvements expected due to improvements to work conditions. Stringency has been implemented around band 6 and band 7 overtime. Overtime will now only be authorised in advanced, and authorisation will come only from the Service Director. Ms Dolan has begun looking at engaging additional bank staff through options for retired staff to work bank, and encouragement of flexible working to allow for better retention. Additionally, reducing staffing numbers on the wards where beds are empty. Mr Neville queried the report findings that overtime remains consistent, whilst the usage of bank staff is increasing which indicates that overtime is being incurred when not necessary. Mr Neville highlighted the requirement for controls to be maintained. Ms Dolan responded to the query by advising that the reasons for this are justified, offering the example of a patients being offsite and requiring the assistance of 20 specialised staff. Also, over the January period 31 members of staff were absent due to illness and existing vacancies. Ms Dolan recognises that this is something that requires rectification and is also looking at behavioural changes within the hospital. Ms Rantzen asked the committee what the incentive was for Ward Managers to keep the expenditure down, committee informed that the staffing expenditure was monitored through performance clinics with their Service Managers and direct managers for the scrutiny of overtime usage. If it was found that expenditure was not managed appropriately, it would lead to capability issues. There are currently no capability issues in the management of staff expenditure. Where staffing is short, attempts to mitigate this are implemented such as cancelled, reduced or reviewed patient activities. The committee heard reports of £440k overspend for M9, This position is currently £165K behind the plan that was set at the start of the year for how WLFS intends to feed into the wider Trust position. Within the next three months we should be adverse against our plans. By April 2018 the department should have admitted into the extra beds in WEMSS service, following on from this we will be in a position to invoice NHS E. This will be then rolled into next year’s contract. The committee noted the successes attributed to reduction in agency

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7.3.3 7.3.4

spend for West London Forensic Services. The agency spend within West London Forensic Services tends to be low due to meticulous exercise of reducing spend line by line. The committee discussed recent bank staff trends; many bank staff prefer to work at WLFS due to the nature of the hospital. Ms Rushton has now begun allocating shifts to bank staff with the intention of encouraging each staff member to build a relationship with specific units. Mr Hayhoe noted that the encouragement of relationship building with specific units would also assist in assuring consistent supervision. Mr Stefanoski is currently working on maintaining the overspend of £4m for construction of Meadow Lodge and the sale of additional wards in 2020. The Trust will be entering into a new relationship with North London Forensic Services. Mr Stefanoski is hoping to mitigate the overspend whilst we assess what the new partnership may bring. Is anticipated to be resolved fairly quickly.

8 8.1.1 8.2.1

Monthly Position – Estate & Facilities Ms Parsons declared vacancy savings and a small overspend in M9, as well as predicted year end overspend. Mr Milliken reported to the committee that London is forecasted to meet the 50% stretch. The existing issues with the stretch relate to rents and rates which Mr Millikan will try and resolve as part of the budget setting process. Mr Milliken is currently budgeting to mitigate against potential short fall, however no drain to overall position of stretch. Chair, in agreement with Mr Stefaniski agreed that no deep dive will be necessary for the financial year 2018/19.

9 9.1.1

Monthly Position – Corporate Committee informed of HMRC refund of £75k, underspend planned for financial year 2017/8. There has also been a reduction in agency spend.

10 10.1.1 10.1.2

Financial ‘deep dive’ – Medical Expenditure The Committee noted the apologies of Dr Romero-Urcelay. This item will be discussed at the next Financial and Performance Committee, 28

February 2018. Mr Jenkinson to advise Dr Romero that this agenda item is to be brought forward to next month.

Peter Jenkinson

11 11.1.1

Agency expenditure Ms Brewer informed the Committee that conversations are ongoing with NHS I regarding the deep dive into local services; there has been good progress so far.

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11.1.2 11.1.3

Ms Brewer informed the committee that we have been reporting our agency spend through invoicing methods, which has led to an overstatement of our financial position, in comparison to other organisations where there have been understating. Ms Regan highlighted the concern from NHS I that WLMHT are not reporting in accordance, in the manner to which they have stipulated. This concern has led to an amendment to process since January 2018.

12 12.1.1 12.1.2

Publication of Reference Cost Index 2016/17 Good news in relation to Local Services due to changes in reporting methods. We are doing well in comparison to other London Trusts. Mr Neville commented that the strong financial trajectory that we are now achieving, the competitive reference costs that are being achieved in local services, and the KPI’s that we are looking at around quality and local services demonstrates that we can achieve the current financial position and drive up quality at the same time.

13 13.1.1

2017/18 STF Incentive Scheme The letter from NHS I forms the rationale behind reporting our M10 position under the STF incentive Scheme which will allow the basis for negotiation with NHS I for the 1:1 funding. The Committee supports the proposed approach to seek approval at Board in February regarding the decision whether or not to report underspend.

14 14.1.1 14.1.2 14.1.3

5 year Capital Plan Update The update offered to the committee a line by line comparison to the previous finance year and the formalisation of the delay in the sale of current Broadmoor site by approximately of 2 years. Mr Stefanoski informed the committee that he has budgeted additional money for IMT. The 5 year capital plan update does not include the Limes and Jubilee, which accounts for approximately £10m. Currently our cash balance is approximately £17m The Chair suggested that we should provide more of an explanation regarding the remaining secure wards. The Chair invited the Committee to consider driving up the bar, by scrutinising the good progress currently engaged.

15 15.1.1

Budget and SLA review 2018/19 Mr Stefanoski informed the committee that we have received no offer from any local Clinical Commissioning Group or NHS E as yet for financial year 2018/19.

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16 16.1.1 16.1.2 16.1.3 16.1.4

Integrated Performance Report The committee agreed on the need to gain an understanding from the Commissioners of what success looks like to them, to give focus and direction within the Trust. Ms Regan expanded further, suggesting that the scrutiny is inclusive of IAPT, EIS and dementia mapped against the Five Year Forward View steered towards investment and prioritising NHS benchmarking, starting with the Mental Health dashboard. The committee agreed to discuss further at the next committee. The Committee discussed reaching a more diverse community as a public health ambition; the committee will seek to establish whether or not the KPI’s are to be reported on a monthly or quarterly basis. Questions were raised as to what KPI’s the committee should be focusing on and prioritising. The committee agreed that further discussion is required at TMT to allow a realignment of the issues that the committee reflects on in line with measures that the commissioners would recognise. Item to be discussed for information at the next Quality Committee on 21 February 2018. Item to be discussed at TMT on 28 February 2018 for consideration.

17 17.1.1 17.1.2 17.1.3 17.1.4

BAF and Risk Register No changes to level 1 risk registers. Mr Jenkinson declared no significant changes and informed the committee that there will be a quarterly review this month. Mr Jenkinson will report back to the Audit Committee in March, as it was recognised that there was further work to be carried out in terms of strengthening the assurance aspects of the BAF. The report to the March audit committee will include a proposal outlining how the assurance levels will be met. The Integrated nature of a combined risk register and assurance framework potentially results in a loss of strength in risk. In regards to the Well-Led review, Mr Jenkinson has be informed by the auditors that our BAF is fit for purpose, but we should continue to promote the development of the BAF. Mr Manuel highlighted the importance of including a deep dives into specific risks onto the Finance and Performance work plan for 2018/19.

Peter Jenkinson

18 18.1.1

Capital and Asset Planning Management Group meeting Noted. No amendments made to minutes.

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19 19.1.1 19.2.1 19.3.1

FOLG Noted. No amendments made to minutes. FOLG meeting held this morning, therefore no minutes available. Ms Regan provided oral update to committee on the recent FOLG meeting. The current financial position was examined, time was spent discussing the usage of NHS benchmarking, and considering the clinical engagement and narrative. There was a further session on costings.

20 20.1.1

Consider If Any New Risks Were Identified Or Changes To Risks Proposed No new risks identified.

21 21.1.1 21.1.2 21.1.3

Actions Remitted to Other Committees 2017/18 STF Incentive Scheme has been remitted to Board, 14 February 2018 The Integrated Performance Report has been remitted to TMT, 28 February 2018 Previous Finance and Performance committee action ‘22.3.17 Estates Portfolio Risk Step Through’ remitted to Audit Committee,7 March 2018

22 22.1.1 22.1.2 22.1.3

Any Other Business

Liz raised concerns over the lack of employment service level agreements and short term commitments to staff. Should be flagged as a risk within Chairman’s report, or more formally. Mr Stefanoski flagged that the lack of contracts are undermining our ability to carry our CIP obligations. Submitting a plan in advance of offers mitigates our risk. Mr Stefanoski suggested that the agenda for February committee is kept light in order to review the work plan for 2018/19. It was suggested that a period of 30 minutes is allocated for this.

Date & Time of next meeting Wednesday 28 February 2018 1300 – 1500 White Rooms A & B, Armstrong Way

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CHAIRMAN’S REPORT – FINANCE & PERFORMANCE COMMITTEE 28 February 2018 1. SUMMARY – M10 POSITION The position for M10 is an improvement on the planned year to date position and shows an

underspend of £4,389k in month. The year to date position is a £4,725k underspend as compared to

a planned position of £568k. The improved position is the result of land sales income being received

earlier than anticipated in the Trust plan.

The total variance in budget for month 10 and year to date is made up of the following:

M10

position

YTD

position

‘£000 ‘£000

Specialist and Local services -299 1,817

West London Forensic Service 405 4,266

High Secure services -492 813

Estates and Facilities 12 1,359

Corporate 85 -645

Subtotal CSU/directorate

position -289 7,610

Funding to cover overspend -333 -3,333

Planned Surplus -51 -513

Centrally held budgets e.g.

innovation fund and

underspend on planned capital

charge

1 -4,772

Trust net underspend -4,389 -4,725

For the current month overall expenditure was better than the anticipated level, mainly due to additional CIPs being achieved. It is planned that a continuation on this trajectory will ensure both achievement of the 2017/18 plan and a sustainable recurrent position moving into 2018/19. The establishment of a stretch target was agreed at month 3. It is now expected that this target will

be over achieved at year-end. In addition, following the annual asset revaluation, there is expected

to be a significant reduction in the cost of capital charges as compared to plan.

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2. LOCAL SERVICES SUMMARY Local Services CSU closed month 10 £1,818k overspent; with a forecasted year end of £1.9m overspend. The position at month 10 is due primarily to additional income being recognised, outside of main contractual income streams. Key drivers for the current year to date overspend were a high use of private acute beds through Q1 and Q2, which ceased in Q3 and additional staffing requirements on inpatient wards due to safer staffing and productivity requirements. This has reduced in recent months as ward capacity has led to a reduced need for additional staffing due to acuity. Local Services have set a revised planned year-end outturn of £1.9m overspent with a potential upside forecast of £1.75m overspent. The forecast outturn at M10 has improved on the previous forecast due to improvements on income position and realisation of previously identified and outlined mitigating actions. Additional actions which could improve position and support the CSU stretch target include further reduction in the use of agency, seeking to generate additional income through billable patients outside of contract, and marketing and sale of spare bed capacity.

3. WEST LONDON FORENSIC SERVICES (WLFS) SUMMARY West London Forensic Services (WLFS) closed month 10 with an in-month overspend of £405k; the year end forecast remains £5.1m. Month 10 performance is driven by ward expenditure within the 3 ward areas.

Nursing development incurred an overspend of £9k driven by unmet CIPs targets. The monthly overspend in Women & Adolescent services driven by unmet CIP and ward over expenditure driven by observations and long term sickness. Additionally, the Wells unit moved from Women’s services to Male Medium secure in month 10, the Wells Unit overspent by £25k in month 9.

Agency usage Increased by £5k in month 10 but remains on course to reduce agency usage by £500k (40%) year on year. Agency costs are split between qualified nursing roles, Medical, AHP, Psychology and HCA roles.

WLFS is facing a significant challenge as an operational service. In order to reduce expenditure there need to be continued focus on staffing levels and e-rostering as well as income generation and collaboration with NHS England to progress QIPP discussions. The Trust’s involvement in the Forensic NMOC, national service reviews, and 2018/19 contracting round will provide the opportunity to “reset” some of these fundamental issues. If this is not possible, then although in the short term the Trust is able to cover the loss, it will need to consider the possibility of having to give notice on some or all of the services.

4. HSS SUMARY High secure services (HSS) underspent in month 10 by £492k. This was driven by additional profit on the sale of cricket field grove (£750k). The underlying position for HSS was an overspend of £258k. Year to date HSS have overspent by £813k. This forecast to increase to £1.1m by year end. Ward areas overspent by £198k in month 10, this was consistent with month 9 and brings the year to date overspend across the wards to £1,584k. The overspend is attributed to high levels of leave of absence and escorts required during January.

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HSS have overspent by £813k year to date, and forecast an overspend of £1.1m by year end. This is based on the assumptions that overspending within ward areas continues until year end. Controls need to be implemented to reduce expenditure on a recurrent basis to deliver a balanced position in future years.

5. CORPORATE SUMMARY The Corporate directorate underspent by £84k in month 10, which is a positive position, and the year to date position is a £645k underspend (excluding the impact of land sales). Including land sales, the position in month was £3,405k underspent and year to date £3,966k.

6. BROADMOOR E&F SUMMARY Broadmoor estates and facilities overspent by £14k in month 10, as a result of vacancy savings and reduced expenditure in laundry operational capital reported an overspend of £10k and E&F London overspent by £15k so the combined total was £12k overspent. Broadmoor estates & facilities are reporting an overspend of £43k year to date and a year-end forecast overspend of £79k. The forecast has been revised downwards to reflect recent confirmation that the disturbance allowance will be paid before year end. This has a £50k favourable impact on the year end position. The E&F restructure is currently out for consultation, the aim is for recruitment into the new structure to take place during 2018/19. There are a number of risks associated with this forecast, and financial performance in 2018/19, which are currently being managed within budget but these need to be monitored closely and outcomes of the staffing consultation and contract retendering will need to be reflected in the forecast once known.

7. LONDON E&F SUMMARY London estates and facilities reported an overspend of £15k in month 10 and a year to date overspend of £1,156k. London E&F are forecasting an overspend of £1.1m in 2017/18 this is an improvement on the stretch forecast produced at Q1. The forecast includes an assumption that rental costs recharged to commissioners are recovered in full by the end of Q4 2017/18. This is a risk of £200k.

8. GENERAL DISCUSSION Capital – quarterly update The financial position of the Capital Programme as at month 9 was presented to the committee. The ‘Broadmoor Hospital Redevelopment’ project underspent by £4.6m. The ‘Total Operational Capital’ projects underspent by £6.6m due to the Medway Lodge project showing an underspend to date(£3.3m), as well as the varying stages of tender or works in progress for the ‘Brentford Lodge’ project, patient environmental projects, backlog maintenance project lines and business as usual project lines. It is expected that the majority of this particular expenditure will “catch-up” by year end. Total capital outturn for 2017/18 is projected to have an underspend of £6.9m, of which Broadmoor redevelopment is expected to underspend in year by £5.3m. Contracts and budget setting 2018/19 update The Committee noted that the Trust had not yet received SLA offers from commissioners for 2018/19 and noted the risk of the Trust having to submit a financial plan for 2018/19 without

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confirmation of the contract. The Committee will consider the draft financial plan at its next meeting.

8. INTEGRATED PERFORMANCE REPORT The Committee also considered the month 10 performance improvements, noting in particular Admissions via CRHT Gatekeeping, reduction in DToC rate, sustained downward trend in Level 1 Incidents commissioned and the achievement of the target percentage of risk assessments completed within 72 hours of admission. It was also noted that the Trust had achieved the target for completion of Physical Health Assessment within 24 hours, with trust-wide compliance at 95.6%, showing a massive improvement in performance since the 24hr target was introduced. CPA 7 day follow up was raised as a concern to the committee this month, as performance did not meet the target in January.

Finance and Performance Committee have reasonable assurance that the 2017/18 financial forecast will be achieved.

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MINUTES OF THE TRUST MANAGEMENT TEAM MEETING Held on Wednesday 31st January 2018 In White Room, Trust Headquarters,

Armstrong Way, Southall UB2 4SA from 1000 to 1200hrs

Present: Carolyn Regan Chief Executive (Chair) Paul Stefanoski Director of Finance & Deputy Chief Executive Dr Rob Bates Clinical Director, High Secure Services Dr Chris Bench Clinical Director, Planned and Primary Care Wendy Brewer Director of Workforce & OD Stephanie Bridger Director of Nursing Angela Dolan Deputy Director of High Secure Services Dr Claire Dillon Clinical Director, West London Forensic Services Dr Estelle Moore Strategic & Professional Lead for Psychological Therapies Trevor Nelms Director of Business Technology Dr Vijay Parkash Clinical Director, CAMHS Dr Jose Romero-Urcelay Medical Director Sarah Rushton Executive Director, Local Services Dr Angharad Ruttley Clinical Director, Liaison and Long Term Conditions Attending: David Cochrane Head of Forensic Social Work Kalwant Grewal Financial Controller Peter Jenkinson Trust Secretary Peter Milliken Head of Finance and Business Performance Barbara Wood Redevelopment Programme Manager (for item 12)

Matthew Wilding Deputy Director of Nursing, WLFS Jim Tighe Local Security Management Specialist (for item 14)


1. 1.1

WELCOME & APOLOGIES Mr Stefanoski welcomed everyone to the meeting. Apologies were noted from: Dr Nevil Cheesman, Dr Chris Hilton, Leeanne McGee, Gillian Kelly, Dr Fintan Larkin, Helen Lycett, Dr Johan Redelinghuys, Jo Smith and Sally Sykes.

2. 2.1

MINUTES OF THE LAST MEETING The minutes of the meeting held on Wednesday 29th November 2017 were agreed to be an accurate record.

3. 3.1

ACTION SCHEDULE The TMT received updates to the action schedule: 26-Jul-17 Lone working policy: TMT noted that progress had been made in implementing the policy, with an increase in uptake to

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40%. TMT agreed the award of a contract for the new provider of lone working devices to SoloProtect Ltd, and noted that this should lead to increased availability given additional staff support and take up of the lone working devices.Ms.Regan asked about user engagement in the procurement process and Ms Rushton responded that there had been CPN input to the preparation work. It was agreed that a further update would be provided in March 2018. Fire safety: TMT noted that the Fire Safety Steering group had held its second meeting earlier that week. Progress was noted in achievement of the priorities agreed at the inaugural meeting, including the approval to recruit a Head of Fire Safety and the identification of a software package to assist in the trust-wide management of fire risk assessments. TMT supported the continued need for all departments and units to ensure that fire risk assessments were up to date.

J Tighe ALL

4. 4.1 4.2

MATTERS ARISING Purchases from suppliers not on the Trust approved suppliers list TMT noted the risks inherent in purchasing from non-approved suppliers and endorsed the principles outlined in the paper. It was agreed that the principles would be communicated to all staff involved in the purchasing of goods and services for the Trust, to be cascaded by Executive Directors. TMT noted the issue raised regarding joint projects where the Trust did not hold the order. It was agreed that Mr Stefanoski would review the process with procurement. Proposed contract award for the rental of Washing Machines and Washing Dryers TMT considered and approved the recommended award of the contract for the rental of washing machines and washing dryers. TMT discussed the process for selection panels of potential suppliers, and the input from staff or patients / carers into the process. It was noted that in this instance patients and staff had been involved in the procurement process, but it was agreed that Mr Stefanoski would consider the procurement process to ensure that it was standard practice to consider staff, patient and carer involvement as appropriate.

Executive Directors

Mr Stefanoski Mr Stefanoski

5. 5.1

ACTIONS FROM BOARD &/OR OTHER COMMITTEES No actions were remitted from the Board and/or other Committees.

6. 6.1

PRESENTATION – SOCIAL WORK UPDATE TMT received a presentation from David Cochrane, Head of Forensic Social Work, including an update on the ongoing work to

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develop a joint strategy with other local partners. TMT received an update on the various perspectives on social work provision in the neighbouring local authorities, their concerns and their respective responses to suggestions for a joint approach. Mr Cochrane also updated on the Trust’s provision of social work services, including current challenges faced in recruiting social workers, in the context of the wider social work environment. TMT noted that the CQC were reviewing local health and social care systems in 20 local areas, with the interim report highlighting system issues and partnerships. TMT discussed the key issues arising from the presentation, including the recruitment issues and how to use the ‘Think Ahead’ recruitment initiative. TMT acknowledged the potential benefits of participating in the initiative but recognised the need to provide physical space and engagement. In particular the concerns of local boroughs were noted. It was agreed that Mr Cochrane and Dr Bench would discuss how to take this initiative further, including resolving space issues. TMT also noted the need to evaluate the impact of social workers coming out of Hounslow local borough arrangements and consideration of potential models of management and service delivery. It was also noted that section 75 agreements were expected to be in place by mid-February.

D Cochrane / C Bench S.Rushton April 18

7. 7.1 7.2

FINANCE UPDATE Finance Report – month 9 TMT received and noted the month 9 financial performance summary, noting that performance was currently ahead of plan to achieve a year-end surplus and that the Trust was confident of achieving the year-end target. Mr Stefanoski also reported the completion of the sale of Cricket Field Grove and the unexpected reduction in capital charges, both of which would provide a non-recurrent benefit. Mr Stefanoski explained the STP incentive scheme published by NHS Improvement, whereby they would match any surplus reported by trusts. It was noted that the additional cash benefit from this scheme, should the Trust Board agree to enter into the scheme, would help mitigate against any additional legal costs and compensation events relating to the Broadmoor Hospital redevelopment. TMT noted that the Trust would be meeting with NHS Improvement later that week to discuss the Trust’s medium term financial plan, including the two year financial plan to 2019/20.

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Ms Regan congratulated and thanked all teams across the trust for their level of engagement in the CIP process and their delivery, which had led to this much improved position compared with earlier in the year. Formal noting of outputs from FOLG meeting, 31st January TMT noted the oral summary provided from the FOLG meeting held prior to this meeting. TMT agreed and noted the following points:

• Benchmarking – FOLG had received a presentation on benchmarking, including a summary of the 14 benchmarking exercises completed or planned in 2017/18. FOLG agreed the importance of developing responses to this benchmarking data, identifying good practice and opportunities for improved efficiency, including a clear narrative. Clinical and managerial input was required..

• CIPs performance – FOLG had considered the summary of CIP performance as at month 9 and the forecast year end delivery, noting the Trust had achieved the requisite CIPs to achieve the year-end financial target. Planning gaps had been mitigated during the year through non-recurrent CIPs to ensure year-end achievement of the target. £6.1m of CIPs had been identified for 2018/19.

• Patient Level Costings (PLICS) – FOLG had received a presentation on the benefits of PLICS and the ongoing work being done to implement PLICS as one of three roadmap partners working with NHS Improvement to implement PLICS in mental health trusts.

8.1 8.1.1 8.1.2 8.1.3

INTEGRATED PERFORMANCE REPORT (IPR) TMT considered the monthly performance report for month 9, noting exceptions in performance. TMT noted continued improvement in the compliance levels regarding completion of Physical Health Assessment within 24 hours. TMT also noted concerns in CPA 7-day follow up, with performance not meeting the target in December, with a compliance level of 93.75% reported. TMT noted that this issue had been picked up in relation to earlier follow up of patients at 2 days and would continue to be addressed by Helen Mangan. TMT reviewed the format and content of the IPR and agreed that the London mental health indicators should be added to the dashboard – EIS, dementia and IAPT. TMT also discussed other new indicators which might be added to the dashboard, including a

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‘key risk’ indicator relating to community services and other quality indicators such as suicide prevention. It was agreed that additional indicators would be considered and proposed additions agreed by TMT ahead of the new financial year.

P Stefanoski

8.2 8.2.1 8.2.2 8.2.3

WORKFORCE PERFORMANCE REPORT TMT received and noted the workforce performance report for month 9, noting exceptions. TMT noted a reduction in the use of agency, noting the outputs from the successful ‘deep dive’ reviews of agency usage by service line held in November. These reviews had led to a greater understanding of the issues and would continue. It was also noted that the Trust was now able to report actual usage on a weekly basis, rather than reporting based on invoices received. TMT also noted the decision by Executive Directors to impose a financial penalty on the appropriate unit for staff failing to attend for pre-booked mandatory training sessions. TMT also noted a marginally increased vacancy rate.

9 9.1 9.2

AGENCY TRAJECTORY UPDATE TMT noted the reduction in agency expenditure and the actions being taken as outlined in the workforce performance report. TMT noted the ongoing risks regarding junior doctor coverage and psychiatrists that impacted on the use of agency. It was noted that risks regarding rota coverage needed to be managed, and therefore there would be a patient safety need for some agency. TMT therefore welcomed the achievement of better controls in the use of HCA agency. TMT noted the high risk areas in the Trust and other initiatives being considered to attract permanent staff, including staff accommodation and provision of nursery facilities. TMT noted that the Trust target remained at keeping agency expenditure to £1m per month.

10.

BUSINESS DEVELOPMENT UPDATE COMMERCIALLY CONFIDENTIAL

11. 11.1

BAND 3 PAYMENTS (BROADMOOR HOSPITAL) TMT considered proposals for the introduction of enhanced allowances for staff to promote recruitment and retention of band 3 nurses, including various options for the enhancement. TMT considered the financial impact of these options and the potential benefits in staff recruitment and retention. TMT agreed that the proposals made the case in long–term

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savings achievable and agreed in principle to the enhanced allowance, but agreed that it would need to consider the impact on other bands of staff and other areas within and across the Trust. It was noted that the staff-side representatives had already noted inconsistency in application of allowances across the Trust. TMT discussed the potential impact of this initiative on overtime usage at Broadmoor and noted that it was hoped that such an initiative would increase recruitment and retention and therefore reduce the need for overtime. It was also noted that the new Broadmoor Hospital would be an attraction to potential new staff, but that this would not be for another year. TMT therefore agreed that Rob Bates, Angela Dolan and Wendy Brewer should review and consider this proposal in the context of the potential impact on other staff grades, including consideration of a similar allowance for band 4 staff and setting the allowance at £2,300 in line with other nurse retention allowances. It was agreed that the proposal from this review could be circulated outside of the meeting for agreement, due to the urgency required in decision.

A Dolan / W Brewer

12. 12.1 12.2 12.3 12.4

STAFF CONSULTATION – RESTRUCTURE OF BROADMOOR ESTATES AND FACILITIES TMT considered the consultation document for the proposed restructure of the Broadmoor Capital Estates & Facilities Department (CEF), to enhance the ability to deliver compliant, consistent, high quality and responsive services to support the new Broadmoor high secure hospital. The ED’s had asked that all proposals be sustainable and affordable. TMT noted that the proposed restructure incorporated the recommendations from an external independent review undertaken in 2016 by Sussex Community NHS Foundation Trust. TMT noted feedback received to date from the consultation, in particular from the HSS SMT, that the structure was too management-heavy, but acknowledged the need for greater senior assurance and oversight over contracts and processes. It was noted that feedback from staff side had been positive. TMT discussed the affordability and sustainability of the proposed structure and noted the projected increased cost of the structure of £44,000. It was noted that the consultation was due to conclude on 16th February, after which consideration of the comments received would be presented to the HSS SMT.

B Wood

13. 13.1

WELL-LED REVIEW OF TRUST GOVERNANCE

TMT noted the approach and timetable for the Trust’s well-led

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13.2 13.3

review of governance, including the use of an external reviewer to support the review and validate the Trust’s developmental action plan. TMT noted the timescales for the review, including board member interviews, observation at key trust meetings and meetings with clinical service line management during February and March. TMT also discussed the expected level of involvement of clinical directors and service line management in the review. It was agreed that the Key Lines of Enquiry (KLOEs) to be used in the review would be circulated to all clinical directors, to be considered ahead of the interviews and staff meetings.Mr. Jenkinson was available for further advice and support.

P Jenkinson

14. 14.1 14.2 14.3

BODY WORN VIDEO PILOT TMT considered a proposal for the introduction of a pilot project, testing the use of body worn cameras in support of violence reduction. TMT noted the proposed timescales for the roll-out of the pilot and the training to be provided. TMT agreed to support the trial, and noted that following the pilot an evaluation report would be submitted to the respective Strategic Management Teams, Clinical Governance Group and Trust management team for further consideration. A research paper would also be produced. TMT noted that details of the trial would be presented to the Patients Forum and at the Community Meetings for the wards concerned.

15. BOARD ASSURANCE FRAMEWORK (BAF) TMT received and noted the latest version of the BAF and the level 1 risk register, noting no significant change in current risk ratings or assurance levels.

16. 16.1

HIGH SECURE SERVICES’ SENIOR MANAGEMENT TEAM TMT received and noted the ratified minutes of the High Secure Services SMT meeting held on 26 October 2017.

17. 17.1

FORENSIC SERVICES’ SENIOR MANAGEMENT TEAM TMT received and noted the ratified minutes of the Forensic Services SMT meetings held on 1 November 2017 and 6 December 2017.

18. 18.1

LOCAL SERVICES SENIOR MANAGEMENT TEAM TMT received and noted the ratified minutes of the meeting held on 20 October 2017.

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19. 19.1

PSYCHOLOGICAL THERAPIST GROUP TMT received and noted the draft minutes from the meeting held on 9 January 2017.

20. 20.1

CLINICAL DESIGN GROUP TMT noted and ratified the minutes of the meeting held on 7 November 2017.

21. 21.1

CAPITAL ESTATES & FACILITIES SENIOR MANAGEMENT TEAM TMT received and noted the draft minutes from the meeting held on 30 November 2017.

22. 22.1

STRATEGIC TECHNOLOGY INVESTMENT GROUP TMT noted and ratified the minutes from the meeting held on 2 November 2017.

23. 23.1

MEDICAL EDUCATION COMMITTEE

TMT received and noted the Draft minutes of meeting held on 4 December 2017.

24. 24.1 24.2

ANY OTHER BUSINESS Ms Regan thanked Dr Jo Dow and Dr Amrit Sachar for their contributions as clinical directors, and thanked Lesley Soden for her contribution as Deputy Director of Business & Strategy. TMT noted that the funding for LPS had now been confirmed by commissioners and a letter was expected to this effect.

Date & Time of Next Meeting Wednesday 28th February 2018, 10.00hrs to 12.00hrs, White Room (A&B)

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DRAFT MINUTES OF THE TRUST MANAGEMENT TEAM MEETING Held on Wednesday 28th February 2018

In White Room, Trust Headquarters, Armstrong Way, Southall UB2 4SA from 1000 to 1200hrs

Present: Carolyn Regan Chief Executive (Chair) Dr Rob Bates Clinical Director, High Secure Services Dr Chris Bench Clinical Director, Planned and Primary Care Angela Dolan Deputy Director of High Secure Services Dr Claire Dillon Clinical Director, West London Forensic Services Dr Chris Hilton Director of Strategy Trevor Nelms Director of Business Technology Dr Vijay Parkash Clinical Director, CAMHS Dr Johan Redelinghuys Deputy Medical Director for Dr. Jose Romero Sarah Rushton Executive Director, Local Services Paul Stefanoski Director of Finance & Deputy Chief Executive Attending: David Cochrane Head of Forensic Social Work Nathan Christie-Plummer Associate Director of Workforce for Wendy Brewer Peter Jenkinson Trust Secretary Helen Lycett Strategic Lead for OT & AHP Estelle Moore Strategic & Professional Lead for Psychological Therapies Hannah Parsons Head of Business & Finance, Forensics Pippa Lee Head of Safety and Security, shadowing Leeanne Mc Gee John Elbake, Internal Audit for item 6


1. 1.1

WELCOME & APOLOGIES Ms Regan welcomed everyone to the meeting. Apologies were noted from: Dr Rob Bates, Dr Fintan Larkin, Stephanie Bridger, Wendy Brewer, Dr Jose Romero-Urcelay, Dr Angharad Ruttley, Dr Claire Dillon. Carolyn welcomed Dr. J. Rxxxxx, Nathan Cxxx-P and Pippa Lee.

2. 2.1

MINUTES OF THE LAST MEETING The minutes of the meeting held on Wednesday 31st January 2018 were agreed to be an accurate record.

3. 3.1

ACTION SCHEDULE The TMT received and noted updates to the action schedule, and agreed the closure of actions due in February 2018.

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4. 4.1

MATTERS ARISING 31-Jan-18 Band 3 payments (Broadmoor Hospital staff) TMT noted that the proposals for enhanced payments for A&C staff to support recruitment and retention had been reviewed, following discussion at the previous meeting, and revised proposals had been circulated to TMT outside of the meeting. Mr Jenkinson confirmed that a quorum of TMT had approved the revised proposals by email; TMT therefore confirmed the approval of the revised proposals for payment as of 1st April.

5. 5.1

ACTIONS FROM BOARD &/OR OTHER COMMITTEES No actions were remitted from the Board and/or other Committees.

6. 6.1

INTERNAL AUDIT – 2018/19 DRAFT AUDIT PLAN Ms Regan welcomed John Elbake, Internal Audit Manager, RSM, to the meeting. Mr Stefanoski introduced the discussion with an explanation of the process undertaken to develop and approve the internal audit plan, including prior discussion with the executive team and final approval required by the Audit Committee. TMT noted the importance of the plan being risk-based in order to focus on the key risks faced by the organisation and to provide assurance regarding the Trust’s management of these risks. Mr Elbake presented the draft plan for 2018/19, highlighting the key areas of focus in the plan and the rationale for the inclusion of the areas of audit in the plan, and highlighting the amendments made to the plan following discussion with executive directors. TMT considered the draft plan, noting:

• GDPR: the timing of the GDPR audit would need to be confirmed, bearing in mind the planned audit of data protection arrangements by the Information Commissioner’s Office in November 2018.

• Lone working: the need to complete a follow up audit of lone working. This was not currently in the plan, therefore it was agreed that internal audit would consider how to incorporate it into the plan for 2018/19 or early in 2019/20.

• Physical Health: the scope of the audit to be considered to ensure the value added from auditing this area.

• Cyber security: the timing of the audit to be confirmed, and IT resources required, once the scoping of the audit was confirmed.

• New Models of Care (NMoC): to bring forward in the plan to ensure that lessons learnt from the audit review of CAMHS could be applied to the Forensics NMoC work.

• Transformation: It was agreed that this should be discussed at the Local Services Transformation Board, to confirm the

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external assurance mechanisms already in place for the programme and to agree whether the audit should be a joint audit with commissioners.

The TMT agreed the draft plan, subject to these amendments, and agreed for the plan to be presented to the Audit Committee for approval. TMT noted that the scoping and timing of the audits would be confirmed in due course.

Services Director of Finance / Internal Audit

7. 7.1 7.2 7.3

PRESENTATION – PSYCHOLOGICAL THERAPIES Estelle Moore presented a comprehensive update on psychological therapies, including psychology, arts therapies, clinical nurse specialisms, psychotherapy and family therapies. TMT noted a summary of the services provided across the organisation, noting that the workforce in these services made up approximately 16% of the Trust’s workforce. TMT considered a SWOT analysis of each of the services, and the planned activities for 2018 to ensure continual improvement across those services. TMT discussed the opportunities to join up services across acute sector and community services especially in relation to people with long term conditions like diabetes, and opportunities to expand services with the provision of physical health services.

8. 8.1 8.2

ESR SELF-SERVICE Ms Regan welcomed Nathan Christie-Plummer, Associate Director of Workforce, to the meeting. TMT received a presentation, outlining the functionality available via the ESR self-service, the benefits and the status of the implementation of the service trust-wide. TMT noted the positive feedback from a pilot implementation in four areas of the Trust and in other trusts, and noted confirmation of user support available from the Trust’s contact centre. TMT noted the intention to roll-out the service trust-wide from April 2018. TMT noted concerns raised regarding access to the system after leaving the Trust, as the system required login via Trust email. It was agreed that this would be considered. TMT also agreed that the proposed retention period of 5 years should be considered as it was felt to be too short. TMT noted that the implementation of the self-service system would eliminate the need for hard-copy pay slips, with savings reflected in the Equiniti contract. However it was noted that there was a risk that staff would print their pay slips from the self-service system, which would negate the savings. This would need to be monitored.


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TMT agreed to the proposed roll-out trust-wide and agreed that staff communications and a FAQ factsheet would support the implementation, including briefings to staff forums, including Trust Partnership Forum, that included examples of where this had been implemented elsewhere in the NHS and the feedback from the pilot areas. It was noted that a link between this system and electronic expenses system was currently being developed.

Director of Workforce / Director of Communications

9. 9.1 9.2 9.3 9.4 9.5

FINANCE UPDATE Finance Report – month 9 TMT received and noted the month 10 financial performance summary, noting an improvement on the planned position of an underspend of £568k with a year to date underspend of £4.7m. The improvement was mainly due to receipt of land sales profit of £3.8m from the sale of Cricket Field Grove. Mr Stefanoski reported that this performance exceeded the targets set in July 2017 for the financial recovery, leading to an year-end forecast of £8m surplus against the control total set of £5.2m. The improved year-end forecast was driven by increased profit from land sales, reduced capital charges due to property revaluation and improved financial management by CSUs. TMT noted that the result of this improved performance was a reduced CIP target for 2018/19, from £9.4m to £8.4m, and the ability to access additional £2m in funds from NHS Improvement that would be used to improve the trust estate, subject to approval by NHS Improvement of an increase to the Trust’s capital resource limit. There were a number of maintenance issues requiring attention, including those noted in the CQC reports. TMT also noted that another benefit of the improved performance was a reduced control total for 2018/19, access to increased transformation funding and an increased agency expenditure target. TMT recognised that external factors had contributed to the improved financial position, as well as improved financial control and that there was therefore a need to continue the focus on financial control. It was agreed that communications would be published to explain the year-end position and the need to continue with the focus. It was noted that the planning assumptions and draft budget for 2018/19 would be presented to the FOLG in March and then to the Board. Further work was required on the development of the forensics new model of care across North London, the opening of Medway Lodge and the ongoing issue of the WEMS beds. The opening of Broadmoor Hospital was also key and continued

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9.6

breakeven and transformation in local services TMT discussed the issue of the positive contribution from Broadmoor that currently supported the Trust’s financial position and noted that the bridging from the current position to where the Broadmoor contribution would no longer be required, would be developed and used in discussion with specialised commissioners. This would be addressed in the medium term financial plan.

10.1 10.1.1 10.1.2 10.1.3

INTEGRATED PERFORMANCE REPORT (IPR) TMT considered the monthly performance report for month 10, noting exceptions in performance. TMT noted in particular the positive performance in DTOC, with the lowest rate ever being reported, due to the Trust’s ongoing working relationship with local boroughs and other partners. However TMT noted caution around the gradual increase in length of stay being reported, and agreed that this would need to be actively monitored. TMT noted the ongoing review of the content of the IPR and discussed other KPIs that should be included in the IPR. It was agreed that the London mental health indicators should be added to the dashboard – EIS, dementia and IAPT. TMT also considered adding a metric to reflect physical health screening, such as QRisk scores, and waiting times for young people with eating disorders. It was noted that it was important to identify any problem areas with waiting times for treatment, as opposed to access to the service. It was agreed that other priority areas should be identified and would feed into the proposed changes to the IPR, to be presented to Finance & Performance Committee.

Director of Finance

10.2 10.2.1 10.2.2 10.2.3

WORKFORCE PERFORMANCE REPORT TMT received and noted the workforce performance report for month 10, noting exceptions. TMT noted in particular an increase in sickness absence and continued use of agency, noting the continuation of the ‘deep dive’ reviews of agency usage by service line, which were agreed as useful. The target for agency spend in 18/19 was £12M. TMT also noted the actions being taken to reduce the time taken to hire new staff. TMT noted the particular increase in sickness in estates and administration and agreed that more analysis was required to understand the reasons for this. TMT noted an increase in staff suspensions and noted that a QSIR project would be looking at ways to resolve such cases. TMT noted that the comparative data for the staff survey would be available from 6th March. It was noted that the initial results from the survey showed improvement across all areas, with the Trust achieving top decile scores in some areas. TMT noted, however,


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remaining issues in diversity and staff feeling under pressure to come to work, as well as the ongoing work to identify incidents related to staff assaults on other staff.

11. 11.1 11.2

AGENCY TRAJECTORY UPDATE TMT noted the current agency expenditure, noting the ongoing work to ensure the continued reduction in expenditure on top of the £0.5m monthly savings achieved to date. TMT noted that the service line level reviews of agency expenditure continued and were proving very helpful in understanding the reasons for agency expenditure and identification of further controls. TMT noted the need to reduce the average monthly expenditure from £1.1m to below £1m in order to achieve the NHS Improvement target, and agreed that the focus would be on medical locums and rota management, as well as continued and sustained focus on recruitment and retention. TMT noted the recommendations made by NHS Improvement following their review of agency expenditure, and the Trust’s response.

12.

BUSINESS DEVELOPMENT UPDATE COMMERCIALLY CONFIDENTIAL

13. 13.1

PROPOSED CONTRACT AWARD FOR THE NURSING DEGREE APPRENTICESHIP (NDA) TMT received an update on the development of the nursing degree apprenticeship programme (NDA), noting the procurement process used for the NDA Tender. TMT approved the recommendation that Bucks New University (BNU) be appointed as the provider for the Trust’s first cohort of NDAs (trust-wide) commencing in April 2018. TMT noted that the government’s apprenticeship levy, used to fund the cost of the training, was guaranteed.

14. 14.1 14.2

GENERAL DATA PROTECTION REGULATIONS (GDPR) - BRIEFING TMT received and considered a briefing paper on the General Data Protection Regulations (GDPR) that were required to be implemented nationally by 25 May 2018, noting the new requirements and the current status of preparation for the new requirements. The TMT considered the current risk to the Trust from non-compliance of the standards and agreed that a new risk should be added to the Board Assurance Framework to reflect this. A key control to managing the risk would be ensuring adequate resources to drive the change programme across the organisation and TMT endorsed the decision by the executive team to appoint an interim

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Information Governance Manager to lead this programme.

15. 15.1

BOARD ASSURANCE FRAMEWORK (BAF) TMT received and noted the latest version of the BAF and the level 1 risk register, noting no significant change in current risk ratings or assurance levels. TMT noted that the BAF was being reviewed with executive director risk owners and an updated BAF with increased assurance, including the addition of the GDPR risk, would be presented at the next meeting.

Trust Secretary

16. 16.1

HIGH SECURE SERVICES’ SENIOR MANAGEMENT TEAM TMT received and noted the ratified minutes of the High Secure Services SMT meeting held on 25 January 2018.

17. 17.1

FORENSIC SERVICES’ SENIOR MANAGEMENT TEAM TMT received and noted the ratified minutes of the Forensic Services SMT meetings held on 3 January 2018.

18. 18.1

LOCAL SERVICES SENIOR MANAGEMENT TEAM TMT received and noted the ratified minutes of the meeting held on 17 November 2017. TMT noted that a meeting had taken place on 23 February 2018.

19. 19.1

STRATEGIC TRUST-WIDE ALLIED HEALTH PROFESSIONALS GROUP TMT received and noted the ratified minutes from the meeting held on 10 January 2018.

20. 20.1

STRATEGIC TRUST-WIDE ALLIED HEALTH PROFESSIONALS GROUP TMT received and noted the draft minutes from the meeting held on 23 January 2018.

21. 21.1

PSYCHOLOGICAL THERAPISTS GROUP TMT noted and ratified the draft minutes of the meeting held on 9 January 2018.

22. 22.1

CAPITAL ESTATES & FACILITIES SENIOR MANAGEMENT TEAM TMT received and noted the draft minutes from the meeting held on 30 November 2017.

23. 23.1

STRATEGIC TECHNOLOGY INVESTMENT GROUP TMT noted the ratified minutes from the meeting held on 3 November 2017.

24. 24.1

ANY OTHER BUSINESS The meeting noted the London Borough of Ealing consultation on stopping the smoking cessation service.

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Date & Time of Next Meeting Wednesday 28th March 2018, 10.00hrs to 12.00hrs, White Room (A&B)

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MINUTES OF THE AUDIT COMMITTEE MEETING Held on Wednesday 17 January 2018

Present: Mr Hassaan Majid Non-Executive Director (Chair) Neville Manuel Non-Executive Director Attending: Mr Paul Stefanoski Director of Finance & Business Ms Carolyn Regan Chief Executive

Dr Jose Romero-Urcelay Medical Director Ms Stephanie Bridger Director of Nursing & Patient Experience Ms Karanjeet Basra KPMG (external audit) Mr John Elbake RSM (internal audit) Ms Lianna Parker-Carn RSM (local counter fraud service manager) Mr Jim Phillips Head of Financial Services Mr Kalwant Grewal Financial Controller Mr Peter Jenkinson Trust Secretary

Item Discussion Action

1. 1.1

INTRODUCTION & WELCOME Mr Majid welcomed everyone to the meeting.

2. 2.1

APOLOGIES FOR ABSENCE No apologies for absence were received.

3. 3.1

DRAFT MINUTES OF LAST MEETING It was agreed that the minutes of the meetings held on 1 November 2017 were an accurate record, subject to recording Sally Glen’s attendance.

4.1 4.1.1 4.2 4.2.2

ACTION SCHEDULE The Committee discussed the action schedule, noting updates provided and the completed actions which would now be archived. MATTERS ARISING The Committee noted updates on matters arising from previous meetings: 5-Jul-17 4.1 Broadmoor Redevelopment Programme The Committee noted that the independent review of the programme governance undertaken by Arcadis had been completed and the findings and recommendations presented to the Trust Board. The recommendations had been agreed and implementation would be overseen by the programme board, including the recommendation to appoint a lay member to the programme board with experience of large scale building programmes.

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1-Nov-17 11.1 Fire safety The Committee received an update on actions being taken in response to the recommendations arising from the internal audit review of fire safety. The Committee noted that a trust-wide fire safety steering group had been established with agreed terms of reference that would report to the Trust’s Fire, Health & Safety Committee. The Trust Management Team would also oversee progress. Recruitment was ongoing to the fire safety team to increase resource and the group would oversee trust-wide compliance with fire risk assessments.

5. 5.1

ACTION FROM BOARD OR OTHER COMMITTEES No items had been remitted to the Committee this month.

6. 6.1 6.2 6.3

BOARD ASSURANCE FRAMEWORK The Committee received and considered the latest version of the BAF, including the level 1 risks to the Trust, noting changes arising from the review of the BAF by other committees. The Committee noted that no new risks have been added to the register and no changes to risk ratings. The Committee discussed the continual improvement of the effectiveness of the BAF, given the internal audit review of its effectiveness, the Trust Secretary’s observations and the discussion at the December board meeting regarding the robustness of assurance being provided to board sub-committees, in light of the findings of the external fire safety report. The Committee agreed the need to develop and strengthen the assurance mapping in place and to consider the development of the BAF as an assurance tool. It was agreed that the Trust Secretary would develop proposals to be considered at the Committee’s next meeting, with a view to presenting proposals to the Board in April. The Committee reviewed the schedule of risk deep dives being conducted by board sub-committees, and agreed that the deep dive review of the estates risk ‘If the trust does not adequately manage its estate portfolio this will compromise the safety and quality of service delivery’ should be presented to Quality Committee, given the impact of the risk on quality.

Trust Secretary

7. 7.1 7.2

Q2 TENDER WAIVERS The Committee reviewed a summary of tender waivers applied in the last period. The Committee noted an overall reduction in the level of waivers being used since the last period, and noted the additional assurance being provided to the Committee regarding the steps taken to ensure value for money in these contracts. The Committee considered whether the current financial limits were

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7.3

still appropriate for the tendering process, noting that the limits had been kept low in the past to ensure appropriate control in the procurement process. The Committee noted that the controls appeared to be more robust, and agreed that it would be appropriate to review the limits set out in the standing financial instructions at the meeting in July 2018. The Committee also discussed the Trust’s approach to procurement and its procurement strategy, and agreed to recommend that the Finance and Performance Committee review the strategy, to consider the impact of the proposed joint working with CNWL.

Director of Finance Director of Finance

8. 8.1

STANDING ORDERS / STANDING FINANCIAL INSTRUCTIONS – CHANGES The Committee noted that no changes to either Standing Orders or Standing Financial Instructions had been proposed.

9. 9.1 9.2 9.3 9.4

CLINICAL AUDIT PROGRESS REPORT The Committee received a six-month update on clinical audit. The Committee noted the progress being made towards implementing new processes to monitor clinical audit activity within the Trust and track the implementation of actions which lead from clinical audit projects. The Committee also noted an update on the progress made towards establishing our compliance to NICE guidelines which have been scoped as relevant to the Trust.

The Committee noted changes had been made to the reporting process for clinical audit, to strengthen the reporting arrangements for clinical audit. Local Clinical Audit Groups would now report directly to the Trust Clinical Governance Group (formerly known as Quality Matters) through an exception report. Local Services Clinical Audit Group would have their own exception report and the two Forensic Clinical Audit Groups (West London Forensic Audit Group and Broadmoor Audit Group) would be combined into one exception report. The reports would be produced quarterly but on alternative months. The Committee received the first of these exception reports, for Local Services, including a summary of audits completed and the actions arising from the audits. The findings and recommendations from a recurring quarterly audit of Children’s safeguarding and an audit of nutritionally vulnerable inpatients were noted. The Committee also noted the development of a physical health strategy that would mitigate the risks in physical health. The Committee sought assurance on the effective tracking of actions leading from clinical audits, and received the assurance that all actions would be logged on a central database and the Central

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9.5

Governance Team would monitor the implementation of actions through the clinical audit leads. The Committee endorsed this approach and stressed the need to close the loop in order to ensure the transference of learning from audit into quality improvement action. The Committee noted the concerns raised by the Clinical Effectiveness and Quality Improvement Team to the Trust Clinical Governance Group that there was limited assurance of the compliance or otherwise with many NICE guidelines and other clinical guidelines and some Service Lines had reported an overwhelming amount of guidance had been released and scoped as relevant to their Service Lines over the past financial year. The Committee noted the action being taken to address this gap - the Clinical Effectiveness and Quality Improvement Team would compile of list of relevant guidance for each of the Service Lines and would meet with them individually to go through the priority guidance and assess the evidence available to support the compliance level.

10. 10.1 10.2 10.3 10.4

INTERNAL AUDIT PROGRESS REPORT The Committee reviewed progress against the internal audit plan for the year and the plan for the remainder of the year. The Committee noted continued good progress in completion of management actions in response to audit recommendations and a good level of management engagement in audits and draft reports, noting in particular progress in implementing the recommendations arising from the audit of Local Services Lone Working. The Committee also received final reports from internal audit reviews of:

• Information Governance Toolkit – The Committee noted the findings from this advisory audit, reviewing the trust readiness for submission of the IG toolkit at year-end. The Committee noted the gaps identified, but were assured that these will be closed by year-end and noted that the trust had made the baseline submission in October as required. The Committee discussed the risk arising from the absence of the Trust’s information governance manager, due to illness, in particular the lack of expert data protection advice in the trust. The Committee noted the actions being taken to mitigate this risk and agreed to monitor the impact of the risk.

• Payments to staff – feeder systems – the Committee

welcomed the reasonable assurance provided and noted the progress being made in improving process and systems, resulting in reduced level of staff overpayments compared with the previous year. The Committee reviewed the findings

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10.5

and recommendations and considered the direct link between good budget management and effective controls in staff payments.

• Financial ledger and feeder system – the Committee

welcomed the substantive assurance provided from the audit of the financial ledger and feeder systems, including access to systems and system security measures.

11. 11.1 11.2

LOCAL COUNTER FRAUD SPECIALIST (LCFS) REPORT The Committee received the quarterly report from the LCFS including a progress report against the annual work plan and activities completed or underway, and a summary of referrals and ongoing investigations. The Committee received assurance from RSM that the number of referrals and investigations being conducted in the trust was average for the size of trust. The Committee noted the ongoing review of compliance with NHS CFA guidance, with compliance exercises ongoing in procurement, finance and human resources. It also noted planned activities for the remainder of the year, including a proactive exercise in pharmacy, and a staff survey to test staff awareness. The Committee also noted an ongoing quality assurance exercise being conducted in the LCFS, with a self-assessment due to be completed by end of March. We noted the mid-year assessment rating of Amber, but noted that work was ongoing and the forecast for the year-end assessment was currently Green.

12. 12.1

EXTERNAL AUDIT PROGRESS REPORT The Committee received an update from the external auditors, including an update on audit planning for year end. The Committee noted in particular that the external auditors had signed off the annual accounts for the Trust’s charitable fund. It was noted that the auditors were currently on site completing an interim audit, including the quality account indicators. It was also noted that a draft audit plan for 2018/19 was currently being considered by the executive and this would be circulated to committee members once agreed.

Director of Finance

13. 13.1

LOCAL SECURITY MANAGEMENT SPECLIALIST (LSMS) PROGRESS REPORT The Committee received an update from the Trust’s LSMS, noting the assurance provided by the internal auditor regarding progress being made against recommendations from their audit. The Committee agreed that it would receive a further update at the next meeting, including consideration of security at St. Bernard’s Hospital site.

LSMS

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14. 14.1

ANY OTHER BUSINESS The Committee discussed the approach to the Committee’s annual review of effectiveness and agreed that the results of the survey would be presented at the next meeting. The Committee also discussed the approach to the Committee’s cycle of reviews with internal audit, external audit and LCFS and agreed to continue with the current arrangements.

Trust Secretary

15. 15.1

CONFIDENTIAL ITEM The Committee excused Internal Audit, the LCFS and the other attendees from the meeting in order to have a private meeting with External Audit.

DATE OF NEXT MEETING 9.00am on 7 March 2018, at THQ.

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Chairman’s report from Audit Committee – 7 March 2018

The Audit Committee met on 7 March 2018. Below is a summary of the key points discussed.

Board Assurance Framework

1. The Committee considered the latest version of the BAF. The number of risks on the level 1 risk registers remains at 23, with no new risks added to the register and no changes to risk ratings reported. We noted that the BAF was currently being reviewed with executive risk owners and any updates from that review will be presented to Board. We discussed the usefulness and accuracy of the forecast risk ratings and tolerance levels and agreed that the forecast ratings needed to be updated to reflect the target rating and a date by when the target rating was expected to be achieved. The tolerance ratings should reflect the Board’s agreed risk appetite – this needs to be discussed and agreed at a future Board meeting.

2. The Committee also considered proposals for the development of the trust’s assurance

framework, to ensure the continual improvement of the effectiveness BAF and to support the Board in its overall assurance regarding the Trust’s control framework. We noted that the Internal Audit review of the BAF concluded that that the BAF is a robust and important mechanism in providing assurance to the Trust Board on the management of the principal risks including in depth assurance on how those key risks are being managed and mitigated. The Committee could therefore be assured that the BAF, as currently formed, is fit for purpose.

3. While the Internal Audit review of the BAF identified some areas of good practice, such as the mapping of risks to strategic objectives and deep dive reviews of individual risks, the review found that assurances on the effectiveness of the controls to manage the risks were missing in some cases or lacking evidence, and that the gaps in assurance were not identified or addressed through action plans.

4. The Committee therefore considered and agreed recommendations to strengthen the existing

BAF, including:

a. The revision of the reporting template for risk ‘walk throughs’ to ensure a focus on

the different levels of assurance and the identification of action plans to address

gaps in assurance

b. The categorisation of sources of assurance using the three lies of assurance, to

assess the strength of assurances

c. The development of a committee map for the Trust so committees can track the

assurances they should be receiving from subgroups

d. The introduction of chairmen’s report from each group or committee reporting to

the Board or sub-committee of the Board.

5. The Committee also agreed to a recommendation to introduce Board level assurance

statements every six months, adopting the KLOE template used for the self-assessment within

the well led review, to support the Board’s assurance in respect of the overall control

framework for the Trust and therefore the Board’s approval of the Annual Governance

Statement.

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Quality governance – Quarter 3 update

6. The Committee noted the Q3 report and identified that there were no significant changes to

risk.

Losses and special payments report

7. The Committee received an update on the losses and special payments made by the Trust April

2017 to December 2017. The number of cases has increased by 3 for Broadmoor, and reduced

by 4 for London compared to last year. There were no significant items of concern.

Accounting policies update

8. The Committee received an update on the revised accounting policies and disclosures as per the HM Treasury FReM and DH Group Accounting Manual. 2017/18 will be the first year where NHS organisations will take responsibility for submitting the audited accounts rather than the external auditors. Additionally, as per HM Treasury direction, the rate for early retirements and injury benefits has changed to 0.10% (0.24% in 2016/17).

9. IFRS 15 introduces a 5 step process that emphasises the recognition and satisfaction of performance obligations. It has been indicated that the overall impact in the NHS could be limited given that healthcare obligations are short term in nature and transactions are generally not complex.

10. IFRS 16 will bring most leases on to Balance Sheet. All entities that lease assets for use in their

business will see an increase in reported assets and liabilities the new standard will affect most commonly used financial ratios and performance metrics, including an increase in gearing ratios and a decrease in capital ratios. Typically Broadmoor own most equipment, and nothing in current policies to suggest that the Trust is at risk in terms of operating leases.

Internal audit

12. RSM provided an opinion of reasonable assurance to the Committee within their verbal update.

It was noted that the main issues had related to staff capacity and lack of resources within the

cash handling area to offer greater segregation of duties, which increases the potential risk of

fraud. A new patient bank manager is now in post and started in January 2018 – this extra

resource will increase the capacity of the team to enable appropriate segregation of duties

within all processes. Additionally, an Interim IG Manager is now in post leading the data

processing review.

13. The Committee were advised that Trust is forecasting a surplus of £8.007m against the

budgeted £5.3m there are risks to the individual Directorate/CSU positions where there is a

forecasted overspend total of £8.718m. The overspends on the overall CSU Directorates have

been predominantly offset by the profits received on land sales and the £4m funding used to

cover overspends. It was confirmed that the Trust continues to have an appropriately designed

control framework in place for the ongoing monitoring of budgetary performance.

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12. Fire safety: Fire safety policies and procedures are being updated to reflect appropriate

processes such as the local issues identified through site visits i.e. non-identification of fully

trained up fire marshals, incomplete risk assessments and fire log books accuracy.

13. Temporary staffing: Improvements were required to ensure compliance with the Temporary

Workers policy to provide clear guidance to staff. A number of compliance issues against

Standing Financial Instructions and the policy were identified around our testing on bookings

and cancellations of agency staff.

Local Counter Fraud Service quarterly report

14. RSM presented findings to the Committee and provided assurances that the 18/19 Trust

standards are in line with the Counter Fraud Authority standards, the committee is on track for

full compliance by year end. It was highlighted that there were a few changes between 17/18

and 18/19 standards, namely the removal of one ‘hold to account’ standard and slight variance

in the wording. RSM provided assurances that the changes to the standards for 18/19 are not so

significantly different that it would present a threat to existing time frames.

External audit

15. The Committee received an update from the external auditors; the audit found that IR1 forms

were not being approved within the 48 hours period stated within policy. Those that were

approved contained accuracy errors, indicating thee approval control is not operating

effectively. KPMG recommended that the remedial actions consisted of additional training to

ward staff and approvers.

16. The audit flagged a change in the following risks, sustainable resource deployment: financial

resilience, as well as valuation of land and buildings has increased. Whereas, the risk associated

with recognition of NHS and non- NHS income has decreased. The other risks remain stable.

17. The committee learnt that Materiality has been set at £4.5 million (PY £4.5 million) which is

approximately 1.8% of total revenue. We design our procedures to detect individual errors at

£3.35 million (PY £3.35 million) for the year ended 31 March 2018, and we have some flexibility

to adjust.

Local Security Management Service (LSMS) quarterly update

18. Implementation of lone worker process is still in process, 2 project workers have been

appointed. From June 2018 there will be extra support offered through e-learning. The Lead for

LSMS is currently engaged in discussion with Learning and Development regarding an annual 15

minute training module, the ambition is for this module to become a part of mandatory

training.

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Broadmoor Hospital Redevelopment Programme Board 7

th February 2018, 14:00 – 16:00

Eton Room, Broadmoor LDC

Approved Minutes

Membership Title Present

Apologies

Carolyn Regan (CAR) Chief Executive Officer and SRO

Paul Stefanoski (PS) Director of Business & Finance (in the Chair)

Dr Rob Bates (RB) Clinical Director (arrived at item 3)

Angela Dolan (AD) Deputy Director of High Secure Services

Mark Edmond (ME) High Security Mental Health Commissioning and Oversight Manager, NHS England

Tom Hayhoe (TH) Trust Chairman

John Hourihan (JH) Director of Security

Leeanne McGee (LMcG)

Executive Director of High Secure Services (arrived at item 3)

Neville Manuel (NM) Non-Executive Director

David Phillips (DP) Redevelopment Programme Director

Sally Sykes (SS) Director of Engagement & Communication

Simon Waters (SW) Programme Manager - Community Health Partnerships (external advisor to Programme Board)

Barbara Wood (BW) Estates & Facilities Lead – Service & Business Change

In attendance Title Present Apologies

Ben Stephenson (BS) Kier (by invitation - item 4.2 only)

James Carpenter (JC) Kier (by invitation - item 4.2 only)

Andrew Bray (AB) Project Manager, Ridge & Partners LLP

Jo Murfitt (JM) Regional Director Specialised Commissioning (London), NHS England

Tony Cloke (ARC) Business & Performance Manager

Vanessa Lee (VL) Redevelopment Programme Manager – Property & Land Sales

Neil Montgomery (NM)

Design & Construction Manager (by invitation items 4.1 & 4.2 only)

Lisa Upton (LU) Operational Commissioning Manager

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Julie Vowles (JV) Executive Support Officer (Minutes)

Item Discussion

Action Date

1. Apologies & Matters Arising

1.1. Apologies for absence were received from CAR, ARC & ME. PS chaired the meeting on behalf of CAR and welcomed Simon Waters who had been appointed to the Programme Board membership as an external advisor from Community Health Partnerships following the independent review of governance. Andrew Bray, Independent Project Manager from Ridge & Partnerships LLP was also welcomed and would be in attendance at future meetings (see section 6.9 below for further detail).

2. Minutes of the previous meeting

2.1. The minutes and confidential minutes of the meeting held on 8th January 2018 were agreed as an accurate record.

3. Matters Arising / Action List

The meeting reviewed the Action Log. Updates on ‘work in progress items’ were noted as follows:

3.1. (09/01/17, Item 7.3) Jubilee House – Patient Privacy for Windows

Although a solution had been agreed in principle, the issue of funding needs to be resolved. A timetable to complete the privacy for patient windows would be prepared.

DP Mar 18

07.02.18 – Information pack issued to Pagabo framework members before Christmas and responses being analysed. NM to confirm the deadline for responses. It was thought the deadline would be Friday, 9th February 2018.

3.2. (13/01/14, Item 4.8) DH Gateway Review 4

Progress reports to come to Programme Board meetings to ensure project is on target for this review.

ARC Sep 18

07.02.18 – No further change. Due September 2018.

3.3. (06/03/17, Item 15.1) Business Continuity Plan

A Business Continuity Plan to be agreed and written for the new hospital.

Action Closed

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Item Discussion

Action Date

order to develop the Business Continuity Plan which would be part of business as usual and could be closed off from the project action plan.

3.4. (06/09/17, Item 4.1.9) Design & Construction

ME & PS to discuss the transfer of transitional funding to the following year.

PS/AD Mar 18

07.02.18 – AD advised that the Trust was in the process of agreeing the contract for next year. AD was in liaison with ME regarding the matter. The completion date was revised to the end of March 2018.

3.5. (06/12/17, Item 5.3.5) Design & Construction – Time & Money

PS to have a discussion with the Finance Director at Kier Group PLC (the parent company) to explain the situation presented to the Trust and find out more information in regards to their cash flow situation…

Action Closed

07.02.18 - The action regarding cash flow was closed. Offer made by PS with Trust Board approval and rejected by Kier.

3.6. (04/10/17, Item 3.11) Property & Land Sales OBC

ARC would provide a response to NHS Improvement on the Outline Business Case queries.

Action Closed

07.02.18 - See item 9 below.

3.7. (01/11/17, Item 4.12) Design & Construction Report

DP to consider how best to present the detail of Compensation Events to Trust Board.

DP On-going

This remained ‘work in progress’. Refer to confidential minutes for further detail.

3.8. (01/11/17, Item 6.9) Steering Group Chair’s Report – Issue identified with maintenance costs.

PS would ask Jo Smith, (Deputy Director of Finance), upon her return to work to review the business case in order to explore the gap in maintenance costs.

BW May 18

07.02.18 – An indicative maintenance costs report had been submitted to SMT and the Steering Group. More accurate costs would be available in May 2018 after the tendering exercise for the MEP contract.

3.9. (06/12/17, Item 12.2) IL20 – Broadmoor E&F – readiness for service

The E&F consultation would go to EDs for sign-off on

Action Closed

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19th December 2017. It was expected to go to TMT thereafter and to the Programme Board for information.

07.02.18 – See item 10 on the agenda. Action closed.

3.10. (06/12/17, Item 4.8) Arcadis review of Governance

TH would make some enquiries about appointing a non-executive with a large capital delivery background to the membership of the Programme Board for external assurance to Trust Board.

Action Closed

07.02.18 – Community Health Partnerships had nominated Simon Waters and he attended this meeting. SW had been invited to attend all future meetings of the Programme Board; a meeting between SW and CAR had been tentatively arranged to take place immediately after the March meeting of the Programme Board.


Kier would be invited to attend future meetings of the BHR Programme Board. The meeting would be split into two parts in order for Kier to attend the first part to update the Programme Board on construction progress.

Action Closed

07.02.18 – Kier had been invited to present progress at this meeting. See item 4.2 below.


Current processes for reporting programme progress would be reviewed by DP and a report would come to the February 2018 meeting of the programme board.

DP On-going

07.02.18 - This remained ‘work in progress’ and was a standing agenda item. An update was provided to the Programme Board, see item 6 below. Date changed to ‘on-going’.

3.13. (08/01/2018, Item 10.4) Issues Log IL23 – Delay in moving into the new hospital; impact on operation of the existing hospital.

The monthly update to the High Secure SMT would be brought to the Steering Group for information from January 2018 onwards.

Action Closed

07.08.18 – BW to report at future Steering Group meetings. Action closed.

4. Design & Construction

4.1. Design & Construction Progress Report

4.1.1. DP presented his current report on the progress of the

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design and construction elements of the BHR scheme.

Commercially sensitive information noted, please see confidential minutes.

4.2. Kier Presentation

4.2.1. Commercially sensitive information noted, please see confidential minutes.

5. Programme & Progress Report – Operational Commissioning and Transitional Planning

DP presented the report on the progress of the operational commissioning and transition planning elements of the BHR scheme on behalf of LU.

5.1. Summary Programme

Action plans continued to be reviewed with services on a monthly basis with a verbal update on progress given to the Transition Planning & Development Group (TPDG).

5.2. Staff Engagement

During December 2017, site visits booked via the Exchange had been suspended until February 2018, but bespoke visits had been facilitated for 50 members of staff from the following teams:

Nursing

Medical

Trust Board

Security

Infection Control

E&F Management

E&F Catering

A number of external visits had also been hosted:

Local MP

CQC

NHSI

Bracknell Academy (Education)

5.3. Communication with Staff and Patients

Bespoke visits for staff would allow teams to focus on ward LOPs and walkabouts of the current wards to assist with the de-cluttering would restart in preparation for the transition to the new hospital.

Each CNM would be given an information folder which would contain guidance and information on de-cluttering,

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new equipment and the move day itself. Nearer to the move date, additional information would be provided for inclusion in the folder as and when required.

During the month of December, action plan meetings were put on hold but would resume during January.

The Redevelopment Technical team presented an update on the Redevelopment at the December staff forum.

5.4. Local operational procedures (LOPs) / Contingency planning

A focus for the Central Building was to carry out individual visits with managers to walk through the LOPs in relation to the day to day running of services. A final review of LOP’s would be carried out prior to any presentation at TPDG. A table top exercise had been scheduled for next week.

The final review of supervised movement would take place through a table top exercise within CBOM, followed by invitations to operational staff to join the meetings and promote working together with other services.

5.5. Equipment

The Wybone bin was awaited and would be fixed in Jubilee basement for ESOPDG/PMVA to review the fixing and testing of it.

The weighted Ryno chair sample for the visits room had been approved by security and clinical staff. It would be ordered in colours to complement the curtains in the rooms where they would be located.

The work on procuring group 3 and 4 items continued. The equipment for the “garden on the move” group would be purchased in conjunction with RTS so the group could commence following the closure of the kitchen gardens. The staff cutlery had also been purchased and received by security in readiness to be engraved.

Orders for high value items such as food trolleys and domestic equipment had been placed with support of the procurement department to avoid imminent cost rises.

An agreement had been made with the supplier that they would hold those items until the buildings were “handed over” to the Trust; at which time, the Trust would then take delivery of the items. The items would be made available to E&F at the time of delivery.

Warranties; it was reported that any equipment procured as a group 1 item (i.e. through Kier’s contract), would be

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covered by them through the 104 week defect period and commence on completion (which on programme rev 38 is 6th April). The pharmacy robot and gym equipment was shared as good examples of group 1items. Any group 3 items procured via Kier through the additional arrangements to the contract would also be covered in the same way. All equipment would be maintained in accordance with manufacturer’s recommendations throughout the defect period by the Trust.

An extract from the contract below clarified the response times to a defect and was shared with the Programme Board:

Remaining Group 4 items that were low of value but high in volume would be purchased. If covered under a warranty, it would be effective from the point of delivery to site. Examples of those items were patient and staff tableware, cookware and other small items of equipment.

5.6. Training & Familiarisation

The November meeting of the TPDG had agreed the proposed approach to the training and familiarisation programme, and the Redevelopment Team had begun to move into the next phase of planning which included detailing all key holders and the level of training required for each individual member of staff.

5.7. Removals Planning

Quotations from Removals contractors who had surveyed the site were awaited.

5.8. Transitional Events

The program of transitional events was scheduled to take place during 2018 and awaited full hospital agreement on identified dates. Events had been organised to avoid any service moves within the 15 week period. Once confirmation had been made on the dates, the program would be advertised in the hospital and departmentally wide in February 2018.

5.9. Telephony

The first stage of the telephone list for all areas and staff in the new hospital had been completed. A large piece

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of work had been carried out to ensure that those who wanted to transfer their numbers would go to the right desk/office/area; new numbers to all other areas/offices allocated and certify no duplication.

Work continued on the Ascom zoning and naming for the Paddock Centre.

5.10. The Programme Board noted the updates provided.

5.11. Transition Planning – Table Top Exercises

AD tabled a paper to inform the Programme Board of the preparation that had taken place for the move to the new hospital and provide assurance to Programme Board regarding transition planning.

5.12. A series of table-top exercises had been carried out over the past year to test the resilience of the planning that had taken place. A total of five table top exercises had been carried out to date. Details of each exercise were shared within the report. Further exercises were scheduled to take place during 2018.

5.13. The Programme Board noted the report.

6. Independent Review of Governance - Update

6.1. DP presented an update on the action plan to address the recommendations of the Arcadis independent review of governance.

6.2. At the last meeting in January 2018, the programme board had reviewed and approved the RACI matrix. It had also been reported at that meeting that work had begun on reviewing the job descriptions of those people reporting directly to the Programme Director.

6.3. Seven recommendations had been made, and updates were provided against each as set out below. The Programme Board noted this as on-going work.

6.4. Recommendation 1 – Roles

The process had begun to review the job descriptions of those who reported directly to the Programme Director.

A further piece of work was being carried out to review the job descriptions against the 19 core roles identified in the Government’s Project Delivery Capability Framework.

‘Role descriptions’ had been proposed for each of the major project roles described in PrInCE2 project management, namely the Executive,

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Project Board, Project Manager, Senior User, Senior Supplier, etc.

6.5. Recommendation 2 – Reporting

The programme board previously agreed its preferred format for progress reports from Kier and also invited representatives from Kier to attend future meetings.

The Redevelopment team had worked with the cost advisor, Capita, to produce a more detailed budget report to allow easier monitoring of the budget (see the budget report at item 11).

6.6. Recommendation 3 – Resources

The Redevelopment team would recruit a technical commissioning manager.

6.7. Recommendation 4 – Change Control

A report would be brought to the March meeting on change control.

ARC/DP Mar 18

6.8. Recommendation 5 – Delivery Reviews

A report would be brought to the March meeting on delivery reviews.

ARC/DP Mar 18

6.9. Recommendation 6 – Assurance

The Trust had agreed to further support the Programme Board through the provision of an experienced and independent individual, who would act as a ‘critical friend’ to the Board, and additionally provide strategic support to the Trust’s Programme Director.

Simon Waters, London & South Programme Manager from Community Health Partnerships (CHP) had been put forward to fulfil the role. Simon was described as one of CHP’s most experienced programme managers, with an extensive work history covering both main contracting and client side operations.

The programme board recommended to Trust Board the formal appointment of Simon Waters as a member of the BHR Programme Board.

Independent project manager (Andrew Bray from Ridge & Partners LLP) would also attend future meetings but not as a member of the programme board.

6.10. Recommendation 7 – Commercial Capability & Knowledge

The Design & Construction Manager (also the NEC3 Supervisor under the contract with Kier) had been

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booked on NEC3 project manager training, and this would strengthen the trust’s position for the section 2 works under the contract.

6.11. The programme board noted the on-going work to implement the action plan following the independent governance review.

7. Steering Group Chair’s Report

LMcG presented the Steering Group Chair’s report from the meeting held in January 2018. Highlights from the report were as follows:

7.1 Construction programme

Rev 38 had been rejected on 19th December 2017 due to non-compliance with the contract.

Kier had reported to the Redevelopment team that section 1 completion for 6th April 2018 was still achievable.

7.2 Defects

The overall number of defects had increased. The scope of time for defect resolution was not clear.

7.3 Entrance Building Room Inspections

Room inspections within the Entrance Building were scheduled to take place week commencing 15th January 2018 but did not materialise. It was rescheduled for the following week commencing 22nd January 2018.

7.4 Structural Issues – Capita Report

The Capita report on structural issues was shared and discussed at Steering Group. Further work would be required with regards to identified cracking as detailed within the report. It was reported that meetings had been arranged with Kier to discuss the matter further.

7.5 IT Hub

The Business Technology department had requested to use some equipment in the two Core Network Hub rooms to assist with the Trust network strategy; a formal request for a quotation was submitted to Kier on 6th December 2017 to establish if there would be any cost or programme implications associated.

Kier provided a response on 22nd December 2017 confirming there would likely be a range of issues and ‘complications’ which required clarification, and that it was likely that there would be cost and programme implications. A response to Kier would be provided as

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soon as possible – the final decision on the way forward would be made by Programme Board (see item 4.1 Design & Construction report).

7.6 The Paddock Centre Visits

Plans to commence work were estimated for the end of May 2018.

7.7 Maintenance costs of new hospital

An update on more accurate costs would be provided in May 2018.

7.8 Operational Commissioning Programme

The operational commissioning programme was progressing well.

7.9 ASCOM devices

Steering Group approved 100 ASCOM devices to be fitted with additional telephone functionality.

7.10 Issues and risks

No new risks or issues were raised. Risk Ratings were confirmed.

7.11 Programme Board noted the report from Steering Group.

8. Patients’ Forum Chair’s Report

LMcG presented the combined Chair’s report from the meetings held in November and December 2017. Highlights from the meetings were reported as follows:

8.1. Richard Kelly from Department of Health had been invited to attend the Patients’ Forum in February 2018.

8.2. A multi-use games court with rubberised surface would be included in Phase 2 of the redevelopment; sand had previously been requested but would not be suitable for multi-use.

8.3. The Redevelopment Operational Commissioning Manager had attended in November to provide an update on construction progress. Patients had been informed that a video showing the fitness and music suite was in progress and would be shown when ready.

8.4. Representatives from redevelopment had reassured patients that an area of their new rooms could accommodate photos whilst being shielded from general view.

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8.5. Becky Martin and Pat McKee attended the December meeting to update on redevelopment progress. It had been anticipated to have additional information about the music and fitness suite in the new year.

Some patient representatives had expressed an interest in the transitional events group; some had joined already. Pat McKee would continue to liaise with patients with regards to their involvement.

8.6. Programme Board noted the report from Patients’ Forum.

9. Land Sales

9.1 Cricket Field Grove

VL provided the Programme Board with a verbal update.

9.1.1 The sale of Cricket Field Grove completed on 19th January 2018.

9.1.2 A Masterplanning Workshop had been arranged for 13th March 2018.

9.1.3 Commercially sensitive information noted, please see confidential minutes.

9.2 Broadmoor Main Property & Land Sales OBC

DP presented a report on behalf of ARC to update the Programme Board on progress with NHS Improvement (NHSI) on the Broadmoor main property and land sales outline business case (OBC).

9.2.1 The first draft of the OBC had been submitted to NHSI in August 2017. Following an initial review NHSI had requested further information from the Trust in certain areas, and the Trust had responded to all further information requested in mid-December 2017.

9.2.2 On 4th January 2018, NHSI had confirmed that the responses had not yet been reviewed, and therefore a meeting had been arranged at Trust Headquarters on 12th January 2018 to discuss how the responses should be reflected in an amended draft of the OBC.

9.2.3 The meeting had taken place on 12th January 2018 as planned; Paul Stefanoski and Tony Cloke represented the trust, and Liz Lloyd-Kendall and Charith Cabraal represented NHS Improvement. The meeting was short and positive in tone. A summary of the points discussed/agreed is set out below:

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9.2.4 Content

NHSI confirmed that the further information supplied in December, if included in an updated OBC, should provide a sufficient level of information for NHSI to consider the OBC for approval in due course.

9.2.5 Restrictions on use of land & buildings

NHSI had checked restrictions of use with its own advisor and agreed the proposed disposal made sense in the light of the current restrictions. The disposal was not regarded as ‘contentious’.

9.2.6 Contract/s

Although NHSI agreed that the trust could not provide a draft contract at this stage, it did expect to see significant contract provisions (e.g. heads of terms – with any restrictions, such as shared utilities, use of cranes near high secure site, easements, etc.) set out in the commercial case in the OBC.

9.2.7 OBC v FBC options

The proximity of the SPA prevented planning permission for residential (and the OBC was predicated on that assumption). NHSI agreed that, if the Trust mentioned in the OBC the potential for challenging that restriction, it would be sufficient if any challenge was successful and the Trust would include ‘residential’ as the preferred option in the FBC.

9.2.8 Timing

The Trust would submit an updated OBC in May 2018 (current estimate), after Section 1 completion of the new hospital in April and when firmer timescales could be included in the OBC.

9.2.9 Further work would be done on the next draft of the OBC in the next couple of months, with a view to re-submitting it to the Trust Board early in May 2018 for approval to re-submit to NHSI.

9.2.10 Programme board noted the progress to date regarding the main property and land sales OBC.

10. E&F Consultation Document – For information

10.1. ED’s had approved the E&F consultation document on 9th January 2018; it had then been communicated to all staff on 16th January 2018.

The consultation period had originally been planned to close on 16th February 2018, but BW explained that the

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consultation had been extended for a further week and it was anticipated that the E&F final structure would be ready by the end of February 2018.

The consultation paper was shared with the Programme Board for information.

11. Financial Updates – Budget Report

DP presented the revised budget report to the Programme Board.

11.1 The budget report showed a number of separate items which, taken together, showed the ‘whole picture’.

11.2 There were two continuing cost pressures which could not reasonably have been foreseen:

The shift in programme whereby Section 1 completion was now about 13 months later than originally planned (i.e. people were being paid for longer); and

Expenditure on expert NEC contract advice to assist in the validation of CEs.

11.3 One of the recommendations from the independent review of governance had focussed on reporting requirements and ensuring outputs were fit for purpose.

11.4 The Redevelopment team had worked with the cost advisor, Capita, to produce a more detailed budget report to ensure easier monitoring of the budget. The general approach had been to identify budgeted amounts, forecast amounts and, thus, the difference between the two, i.e. forecast expenditure in excess of the budget amount (this could be either an overspend or ‘unfunded’ expenditure).

11.5 The new Table 1 within the report showed many more categories than previous reports and gave a more comprehensive picture of the amount and type of expenditure for items within the business case.

11.6 Table 2 showed expenditure on items outside of the full business case with similar detail.

11.7 The figures were reported as illustrative and unsubstantiated, and ‘real’ figures would be included in the report to the March meeting once the Programme Board had agreed the preferred format for the report.

11.8 The Programme Board agreed the layout of the new report and welcomed the prospect of updated figures at the next meeting.

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12. Issues

DP presented the issues log on behalf of ARC as follows:

12.1 IL19 – Jubilee House – Patient privacy (Stratford ward)

The deadline to submit tenders was 9th February. A conference call to evaluate the tenders had been arranged for 13th February with the interview of the preferred bidder (or bidders if two are tied after evaluation) scheduled for 15th February.

12.2 IL20 – Broadmoor E&F: readiness for service

On agenda – see item 10.1.

12.3 IL22 – Delay in moving into the new hospital: communication with stakeholders

It had previously been agreed at the Steering Group that the Trust ‘line’ would be, “The patient moves will take place in 2018.”

Rev 38 of the programme had been rejected by the trust as not being compliant with the requirements of the contract, namely “The contractor’s plans which it shows are not practicable”. Rev 39 was being reviewed and in the absence of an accepted programme, there would be no change to the agreed communications for the present moment.

12.4 IL23 – Delay in moving into the new hospital: impact on operation of the existing hospital

Monthly updates continued to be reported to SMT.

BW On-going

12.5 IL24 – Construction Quality

There was now a total 383 defects. Room inspections in the Entrance Building commenced but had ceased due to minor issues being identified. Kier had begun addressing the minor issues and formal notification for the Entrance Building to be re-inspected was awaited.

Jubilee House room inspections were due to commence in the week beginning 5th February.

No rooms had yet been signed off.

12.6 IL25 – Maintenance costs

The initial report discussed at the Steering Group had contained indicative costings, and the shortfall identified was £921,000. More detailed costs would be provided in May 2018.

BW May 18

12.7 IL26 – Damage to furniture and equipment

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No further change to that reported at the January 2018 meeting.

12.8 IL27 – Central network hubrooms – early access

The programme board previously added a new issue to the log about the potential cost associated with early access to the central network hub rooms and the potential impact on the Trust’s IT strategy if this did not happen.

No further update was provided as the issue remained on-going with a response to Kier in the pipeline. (Please note confidential minutes section 4.3.17.)

13. Risks

13.1 DP presented the managed risk register on behalf of ARC as set out below:

8034 – Gateway 4 review …

The due date for planning for Gate 4 Review had been put back to the end of May (to reflect the new review date of September 2018).

6841 – Failure to deliver service change …

The due dates for the Benefits Management Plan actions had been moved back (these were not reflected in the copy of the circulated register, but had been done on the Exchange).

13.2 The Programme Board confirmed the current and forecast ratings for all the ‘managed’ risks.

13.3 SW asked whether financial risks in relation to land sales had been identified and added to the risk register. SW was informed that land sales had identified risks as part of the Board Assurance Framework (risk 5972) and was noted on the project BAF risk 5917 which was a standing agenda item for the Programme Board.

13.4 It was clarified that there were three areas of risk to monitor, that of the land sales, the impact of the delay and the project risks.

13.5 SW asked whether financial risks regarding Compensation Events should be added to the project risk register. This was agreed by the Programme Board.

Action: DP/ARC to add a new risk to reflect the potential financial impact of prolongation costs.

DP/ARC Mar 18

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Programme Board.

Action: DP to report on highlights of Early Warning Notices as part of his update to the Programme Board.

DP

Mar 18

14. BAF risk 5917

14.1. It was previously reported that LMcG had worked with the Trust Board Secretary, Peter Jenkinson, to review this BAF risk.

14.2. The proposed change was as set out below:

“If we do not move patients into the redeveloped Broadmoor Hospital in a timely fashion in 2017/18, there will be an adverse impact on patient progress and an impact on the Trust’s overall financial position for the year and the NWL control total”.

14.3. The revised wording was agreed by the programme board and recommended for approval by TMT.

14.4. The Programme Board also noted that the risk owner had left the rating at 5 x 5 (Red) and gave positive assurance on the risk, endorsing both the risk management approach being taken by the risk owner and the risk rating.

15. Communications update

SS presented the Communications report. Highlights from the report were noted as follows:

15.1 External updates

15.1.1 A letter had been sent out informing all affected Cricket Field Grove residents about the completion of the land sale.

15.1.2 The Trust Board would consider the Broadmoor memorabilia book proposal at its next meeting on 14th February.

15.1.3 The Trust had responded to the report from the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment.

The report was originally based on a visit to Broadmoor, Ashworth and a number of other UK high secure, immigration and custody facilities in March and April 2016 and had been published in 2017. The trust’s response included a statement from the CEO that:

“The new Broadmoor Hospital will open in late 2018 and will transform the settings patients are cared for in and

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create a much more therapeutic environment. It will also enable us to put in place a new clinical model that will further enhance the care and treatment that patients receive.”

15.2 Internal Updates

15.2.1 The winter edition of the Patients’ newsletter had been produced; it contained articles about transitional event plans, the trust’s work with the fire brigade, and new equipment arrivals.

15.2.2 Updated ward images of the new hospital had been shared with the existing wards. The Exchange pages had been updated and included details of the transition events.

15.2.3 Staff visits had resumed on Tuesday, 6th February and would take place on Tuesdays, Wednesdays and Thursdays.

15.2.4 A calendar of attendance had been drawn up for redevelopment presentations at the staff forum. The team would continue to attend monthly and present bi-monthly. The redevelopment focus for this year would centre on operational commissioning and staff from the technical team would assist with presentations as and when necessary.

15.2.5 The Trust Board had agreed to the decommissioning of all hospital sirens. In accordance with the communications plan, all distribution messages had been drafted. A comprehensive list of residents’ associations, community websites and Facebook groups had been produced and would be used to ensure the Trust communicated key decommissioning messages widely.

15.2.6 Exhibition boards had been produced for display at the National Employment Careers Fair which took place in Aldershot on Thursday, 25th January.

15.3 Forthcoming Activities

15.3.1 The filming of The Paddock Centre extension had been put on hold and would take place at a later date. The team were exploring alternative areas of interest to patients that could be filmed.

15.3.2 The Eastern Lane residents meeting would take place on Thursday, 8th February. The Redevelopment Team and Kier would update local residents on the next steps in construction.

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15.3.3 Following agreement of transition events dates at the January Transition Events meeting and subsequent discussion at the March meeting of the Patients’ Forum, details of events and dates would be communicated.

15.3.4 Additional car parking spaces at Broadmoor had been created and staff would be advised.

15.3.5 Members of the Redevelopment Team would attend the next meeting of the Carers’ Forum.

15.4 The Programme Board noted the content of the report.

16. Any other business

16.1 No items were raised.

17. Items for Chair’s report

17.1 Items for Part 1:

Independent review of governance – on-going

Operational Commissioning update

BHR Steering Group - chair’s report

Budget

Land Sales - Cricket Field Grove/OBC updates

X1 new risk

E&F consultation – structure to be confirmed by the end of February 2018.

BAF – wording agreed for recommendation to TMT

Commercially sensitive items – Part 2:

Programme – including update from Kier.

Approval from Programme Board to obtain costs for site security of buildings post section 1 completion until secure fence tie in.

Defects

17.2 Statement on assurance

Incomplete assurance was provided to the Trust Board in respect of time (delay in the programme), cost (number and size of compensation events) and quality (defects).

18. Date and time of next meeting

All To note

18.1 The next meeting was scheduled for 7th March 2018,

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14:00-16:00, in the Eton Room, Broadmoor LDC.

Future meetings:

Date Time Paper deadline Venue

07 Mar 2018 14:00-16:00 26 Feb 2018 Eton Room, Broadmoor LDC

04 Apr 2018 14:00-16:00 26 Mar 2018 Eton Room, Broadmoor LDC

02 May 2018 14:00-16:00 23 Apr 2018 Eton Room, Broadmoor LDC

06 Jun 2018 14:00-16:00 28 May 2018 Eton Room, Broadmoor LDC

04 July 2018 14:00-16:00 25 Jun 2018 Eton Room, Broadmoor LDC

01 Aug 2018 14:00-16:00 23 Jul 2018 Eton Room, Broadmoor LDC

05 Sep 2018 14:00-16:00 27 Aug 2018 Eton Room, Broadmoor LDC

03 Oct 2018 14:00-16:00 24 Sep 2018 Eton Room, Broadmoor LDC

07 Nov 2018 14:00-16:00 29 Oct 2018 Eton Room, Broadmoor LDC

05 Dec 2018 14:00-16:00 26 Nov 2018 Eton Room, Broadmoor LDC

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Paper for Item 2

West London Mental Health Transformation Board

Friday 19th

January 2018 Minutes – Approved by Transformation Board on 02 March 2018

PRESENT

Alina Latar AL Consultant H&F CAMHS, WLMHT

Ann Kirkpatrick AK RiO Transformation Programme Manager, WLMHT

Annabel Crowe (Co-Chair) AC GP Mental Health Lead, Hounslow CCG

Benn Keaveney BK Hammersmith and Fulham, MIND

Carol Lambe CL Head of Planned Care and Mental Health, Hammersmith and Fulham

Chris Bench CB Clinical Director for Primary and Planned Care , WLMHT

Dominic Benson DB Head of Communication, WLMHT

Elizabeth Rantzen ER Non-Executive Director, WLMHT

Godwyns Onwuchekwa GO Engagement Lead, HealthWatch, Central West London.

Helen Mangan HM Associate Director/Business Planning, WLMHT

James Moore JM Head of Delivery, NHS Improvement(in observation capacity)

John Wicks JW Interim Deputy Director Mental Health Transformation Programme , Like Minded

Karishma Soba KS Transformation Team Administrator, WLMHT(Minutes)

Lisa Burrage LB Interim CAMHS Project Manager, WLMHT

Martin Waddington MW Director, Joint Commissioning, Hounslow

Nathan Christie-Plummer NC-P Assistant Director of Workforce, WLMHT

Neetika Mahan NM WL MH Transformation Programme Director, WLMHT , Ealing/ Hounslow/ H&F CCGs

Paulette Ranaraja PR Carer Representative, Ealing

Sarah Rushton (Co- Chair) SR Executive Director, Local Services, WLMHT

Tessa Sandall TS MD, Ealing CCG (via Tele-Conference)

Val Wilson VW Mental Health Commissioner, Ealing Council /Ealing CCG

Wendy Lofthouse WL H&F Mental Health Commissioner, H&F CCG

Apologies

Beverley McDonald BM GP Mental Health Lead, H&F CCG

Cath Attlee CA Head of Integrated Commissioning, Ealing Council/Ealing CCG

Cathy Phippard CP Local Service Transformation Project Manager, WLMHT

Deirdre McLellan DM Carer Representative, Ealing

Ebru Oliver EO Mental Health Transformation Programme ,Like Minded

Fintan Larkin FL Clinical Director for Access & Urgent Care, WLMHT(on sick leave)

Gillian Kelly GK Corporate Deputy Director of Nursing, WLMHT

Jane Mcgrath JMcG CEO, West London Collaborative

Jonathan Scott JS Chief Clinical Information Officer (CCIO), West London Mental Health Trust

Lina Christopoulou LC Implementation Lead, NWL Mental Health and Wellbeing Programme

Nevil Cheeseman NC Clinical Director CIDS, WLMHT

Paul Meechan PMe Associate Director, Local Services, WLMHT

Paul Skinner PS GP, Brook Green Surgery

Pauline Mason PMa Transformation Manager, Urgent Care & Access, WLMHT

Phil Morris PM Service Manager CIDS, WLMHT

Renuka Wickramaratne RR Service User Representative , H&F

Rhona Hobday RH Implementation Lead– Mental Health and Wellbeing Strategy and Transformation Team

Roseanne Connolly RC Carer Representative, Hounslow

Sally Sykes SS Director of Engagement and Communication, WLMHT

WEST LONDON MENTAL HEALTH TRANSFORMATION BOARD

Transforming the way we care: An integrated Programme for West London Local Services

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Serena Foo SF GP, MH Lead, Ealing CCG

Sharon Wellington SW Implementation Lead, NHS North West London Collaboration of Clinical Commissioning Groups

Susan Roostan SRo Deputy Managing Director, NHSH&F CCG

Toni Camp TC Mental Health Commissioner, Hounslow

Trevor Nelms TN Director IM&T, WLMHT

Vijay Parkash VP Clinical Director for CAMHS, WLMHT

Item Comment Document

1

Introduction, welcome and apologies AC welcomed the group and introduced James Moore from NHSI who was observing the meeting. Apologies were noted (as above)

2 Minutes from the 24th

November 2018 were noted as an accurate record.

3

Action Log Update (Please see attached action log for all open and closed actions) Action: Ref 3 - WL to look into support worker role and improving the support offered to carers in H&F. Wendy to hold discussion with Cath Attlee to understand the approach in Ealing. Update: CLOSED - there is a 2 year contract in place for the MH carers group. Hammersmith and Fulham service will be provided for all carers. When the contract is re-tendered in the future; the user engagement and any learning from other models will be incorporated. Action: Ref 12 - TS to seek clarity on funding status of Perinatal Services with Hounslow and H&F CCG MDs and feed back to LG and Sarah Rushton. Update: CLOSED – this is now complete, further clarity on funding status of Perinatal Services was provided. Action: Ref 20 - JW to identify who is working on developing common data sets (in the CWHHE and BHH Quality/ contract teams) and reporting for SPA across NWL ; and arrange a meeting with the WLMHT and CNWL trust/commissioners in order to streamline these data sets. Update: OPEN – Action to be bought back to the March Transformation Board. It was previously agreed to review CNWL and WLMHT scorecards and look for common elements and consistent definitions. JW to take forward the action and progress this with SW. Action: Ref 6 - CB/CP to provide a refreshed list of internal and external resources available to service users and carers in the community for each borough. CB to work with the communication team (DB) to help complete this and have it put up on the WLMHT trust intranet. Update: CLOSED – List of internal and external resources available to service users has been shared by CP with the OT’s, Cathy to share list with DB and work towards getting it published on the WLMHT intranet. Action: Ref 5 - Like-minded team to draw up a one page leaflet/communication material specific for SPA. Update: OPEN - Each team is to provide a list of communication materials to be incorporated on a leaflet specific to SPA. DB to follow this up with LC and bring back to share at the Transformation Board taking place in March. Action: Ref 1 - NM to include the point in the local response regarding asking HLP for impact analysis proposed sites will be based. Update: CLOSED - NM included changes in the local response and sent back to HLP (collated for WLMHT & CNWL by Like Minded Crisis Pathway Lead Sharon Wellington). Action: Ref 2 - SW and DB to work together regarding communication and engagement for HBPOS work.

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Update: OPEN, DB and SW to work together with NWL to produce this and provide an update at the next Transformation Board taking place in March. Action: Ref 4 - FL to incorporate readmissions data in Inpatient Transformation Workstream highlight report. Update: OPEN - Data on readmissions had not been added to the highlight report, to be added in time for the Transformation Board taking place in March. Action Ref 5: VW to work with the voluntary sector to recruit a voluntary sector rep to be present at all Transformation Board. Update on this work to be provided at the next Transformation Board. Update: CLOSED - VW reported Ben Keaveney will represent MIND from Hammersmith and Fulham at all forthcoming Transformation Board. VW also reported the Healthwatch representative (who was representing Ealing, Hounslow and Hammersmith and Fulham) has left. A new voluntary sector representative will now be required to represent Healthwatch, further clarity will be required if they will be representing all three boroughs. VW to take this action forward. ER and VW to meet and identify. Update to be provided at the March Transformation Board. Action: VW to identify a replacement Health Watch Representative Action Ref 6: CB/CP to include the risk mitigation used regarding disruption of care for patients that are due to be discharged in the next 6 months (while teams work in new pathways) as part of the risks and mitigation section of the Planned and Primary Care highlight report Update: CLOSED - Risk and mitigation has been added to the PPC Highlight Report. Action Ref 7: CB/ CP to monitor the impact of training programme on waiting times and provide an update at the next Transformation Board. Update: CLOSED - Training is organised and has been being taking place, these training sessions have not impacted waiting times as waiting times continue to decrease. Action Ref 8: CP to provide feedback on the Early Interventions options timelines at the next Transformation Board Update: CLOSED - Early Interventions options were discussed at the last CQG. A meeting for detailed discussions is due to take place. Action Ref 10: SR to meet with NC to discuss future attendance of CID'S team at the Transformation Board Update: CLOSED – SR met with PM and NC with regards to future attendance of CID’s at Transformation Boards. Action Ref 11: KS to add older People Mental Health Service Review to the next Transformation Board agenda Update: CLOSED - item on older people Mental Health Service review was added to the agenda however, was not covered in the meeting on January 2018. To add it to the March meeting agenda. Action Ref 12: PM/NC to amend the risk register on the CID’s highlight report to reflect the ongoing issues in the recruitment of clinical posts in Hounslow Update: CLOSED - PM made amendments to the risk register on the CID’s highlight report to reflect the ongoing issues in the recruitment of clinical posts in Hounslow.

5b Update from last Crisis Care Concordat meeting and Health Place Base of Safety (including proposed NWL capital bids)

(Please see attached document for full information) The Transformation Board welcomed John Wick who has taken over from Jane Wheeler as the

Item 4 Update from last Crisis Care Concordat meeting and Health Place Base of Safety.pptx

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Programme Director for Mental Health and Wellbeing Likeminded programme. JW gave an update from last Crisis Care Concordat meeting and Health Place Base of Safety including proposed NWL capital bids. Main highlights reported were: Update from the Crisis Care Concordat Meeting Held on 8

th December 2017

1) A table top exercise was completed to define long list of priorities in relation to crisis

pathway. Further work is being done to pull out key themes. 2) The CAMHS crisis care strategy has been launched and representatives from the

service have been invited to join the membership of the Crisis Care Concordat Group. 3) Pathway links with Urgent and Emergency Care are increasingly being highlighted as a

key aspect. Links are being followed up to have representation on to the group Timelines from HLP re their proposed site reconfiguration are not clear, SW is currently working on a NWL level options paper, and this will be ready by the end of January 2018. JW stated that £15 million worth of Capital grants funding has become available nationally for the Beyond Place of Safety Grant Scheme. Grant scheme initiatives are expected to support the reduction in use of A&E and inpatient settings and by providing alternative pathways, this bidding process is only for capital aspects of these initiatives. Three applications are considered from NWL. These are:

CYP pre-admission step up support(based at CNWL, but available for all 8 NWL borough residents)

Psychiatric Decision Units(for CNWL)

Crisis calming room(at Charing Cross site) JW stated that the process for sign off is being completed at present; some issues have been picked up within this process and will need to be addressed. JW also stated that the bids have been developed by providers SR mentioned the Like-Minded teams should promote equity in NWL, and expressed some disappointment at the decision to not take WLMHT CYP bid forward. The Board noted that revenue impact of bids would need to be carefully considered, especially in relation to CNWL’s PDU bid. The Board noted issues in the governance and sign off process followed for these bids.

5a Inpatient Transformation Workstream Including Update on 7 Day Standards

HM presented a brief update on the Inpatient Transformation Workstream including an update on 7 Day Standards. It was noted that AUC (Access and Urgent Care) Clinical Director Dr Fin Larkin is currently on sick leave. (Please see the attached Highlight Report for full report) Main headlines reported: Co-Produced Model of Care

The coproduced vision and standards were presented to West London Transformation Board on

13th

October 2017. Opportunity to comment on the standards closed on 31st

October. The

standards have been further refined and rationalised and form a key component of the

Item 5a Inpatient Transformation Workstream.docx

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Inpatient Clinical Specification. The next phase in this work is the development of an

implementation plan. Currently the service is undertaking a baseline assessment on each ward

against the standards. Suzanne McMillan (Head of Inpatient Care) is leading on this work. Staff,

patients and carers are taking part in this assessment process, which has been signed off by the

Director of Nursing and Patient Experience. This will help prioritise key areas of focus during

development of the implementation plan. The methodology of the baseline assessment has

been designed in conjunction with the Modern Matrons in each mental health unit.

HM agreed to present Co - Produced standards baseline assessment findings at the next Transformation Board taking place in March 2018.

7 Day Standards

A staff event that was held on 13th

December bringing together staff from both AUC and PPC

(Planned and Primary Care) service lines to discuss lessons learnt and next steps, including any

changes to the standards. The event was an opportunity for clinicians across both service lines

to come together, build on our existing relationships, particularly cross-borough relationships,

and share current challenges and positive developments.

There was a particular focus on:

Reviewing progress and effectiveness of the 7 Day Standards discharge planning initiative across inpatient and recovery teams.

Identifying any issues/barriers to delivery of 7 day discharge planning meetings, based on the local experience, workshopping developing ideas and solutions for successful implementation.

The session also developed options for an integrated RiO solution which will enable early

identification of barriers to discharge, notification to Recovery Teams and planning/slotting in

the 7 day discharge planning meeting. Staff will have the opportunity to co-design and input

into the RiO solution with the developers and RiO lead at a future session on RiO.

Ealing and H&F CCGs/LAs are working with the Trust on delivering against detailed action plans

regarding the Ealing, H&F and Hounslow DToCs. West London Transformation Board had

previously requested that reporting against the delivery of the trajectories should form part of

the highlight report. HM reported DToC figures were moving in the right direction and continue

to show improvement. Admissions were noted to be high but discharges have outnumbered

admissions. The Transformation Board congratulated HM and the Access and Urgent team on

their hard work to get to this position.

SR confirmed the WLMHT had a CQC visit in January and an inspection of key acute wards was carried out. A Full report is due in six weeks from now; this will include all finding from adult acute wards. Informal feedback received was that the CQC was impressed with the remarkable change that has taken place since their last visit. Actions around estates and timeliness will also be outlined in the final report. Action: HM/SMcM to Present the co - produced standards baseline Assessments at the next Transformation Board taking place in March 2018.

5b Continued Development of Crisis and Urgent Care Workstream

HM presented an brief update on the Continued Development of Crisis and Urgent Care Workstream (Please see the attached Highlight Report for full report)

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Main headlines reported:

Work continues on SPA/CATT scorecard. The scorecard was discussed at 11th January CQG and the Trust has been asked to add definitions and set performance thresholds. This is due for completion and final sign off at FIG on the 25th January. The scorecard will then be discussed at the regular Access and Urgent Care Steering Group.

HM stated that there is incorrect information re vacancy rates in CATT at Hammersmith and Fulham. HM will check with Access and Urgent Care Team to ensure all details in the highlight report are accurate before it is sent out. There are 16 posts in the service and out of the 16 there are 11 staff in post.

NTW completed the Recovery House evaluation which was noted and discussed by the Access and Urgent Care Steering Group. The group consensus that whilst the report was welcome, and the service user experience of the Recovery House is very positive, it is unclear from the findings as to whether the service achieves good value for money. This will be taken back for further discussion to the next Access and Urgent Care Steering Group.

The Recovery House contract is currently held by the Trust. Operational Leads need to use contractual management levers to understand and improve value for money for this service.

It was confirmed the Recovery House Evaluation will bought back to a later Board meeting.

Action: HM to check vacancy rate figures in the AUC highlight reports in the future.

Action: HM to bring back an update on Recovery House Evaluation and next steps to the May 2018 meeting.

5c

Planned and Primary Care Transformation Workstream

CB gave an update on the Planned and Primary Care Transformation Workstream

(Please see the attached Highlight Report for full report)

Main headlines reported:

A detailed plan is in place to maximise the numbers transferred under SSoC. At month 9, all 3 Boroughs are meeting the planned trajectory. In Hounslow West, the new discharge coordinator and additional support from an experienced Band 7 nurse has increased transfers dramatically in December. In addition, the PCMHS Team Manager and the Service Manager have met with all of the teams to develop a better awareness of the PCMHS. The PCMHS stakeholder workshop on 29.11.17 was attended by over 50 people.

Caseloads have now plateaued or are decreasing all Recovery teams.

In H&F and Hounslow, the services have moved into smaller pathway specific multi-disciplinary teams. In Ealing, there has been a meeting with the leaders and a date set for the 15

th of January when the Ealing teams will move into pathways. Work

continues to discharge or recluster all patients on cluster 3 and 4 across the Recovery Teams. The teams are also working to align caseloads and pathways; this will take place over a 6 month period to ensure there is as little disruption to service users as possible. Work continues on the details of the pathways and a comprehensive training plan for staff has been developed and is being implemented.

On 13th

December, there was a large workshop involving staff from AUC and PPC to work on interfaces and standards. The main aim of the workshop was to ease flow through the system.

A secondary care Service Specification has jointly been developed by the CCG and WLMHT. This was discussed at the last tri-borough PPC/SSoC Workstream Delivery Group, feedback has been collated.

CB reported that there is a big shift of cluster 3&4’s from Recovery Teams caseloads.

Item 5c Planned and Primary Care Transformation Workstream.docx

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5d Cognitive Impairment and Dementia Service (CIDS) Workstream including:

Update on Older People Services Review

PM was not able to attend the meeting due to an incident on the unit.

AC asked the group to note the highlight report for CIDS


Main headlines reported were:

The Board agreed that representation from a member of the CID’s team is needed at future Transformation Board meetings.

AC requested that the CID’s highlight report needs to include trajectories and actual numbers of patients transferred from CIDS to the dementia link workers in Hounslow and Ealing to see how well each borough is achieving

CID’s service to give an update on recruitment in Hammersmith & Fulham. Action: CID’s highlight report to include trajectories and actuals to see how well each borough is achieving in all boroughs.

Item 5d Cognitive Impairment and Dementia Service.doc

5e Workforce Workstream

NC-P presented a update on noted the Workforce Workstream (Please see the attached Highlight Report for full report) Main Headlines reported were:

Current average vacancy rates across the 3 boroughs were reported as follows: follows:

Band Vacancies

Band 2 &3 32%

Band 4 51%

Nursing band 5 38%

Nursing band 6 6%

Nursing Band 7 9%

NC-P confirmed current vacancies are high but there are measures in place to reduce these vacancies. These are mainly been done thorough rolling adverts, additional resources in place to bring this down.

The NC-P highlighted that the trend is relatively flat. Retention of staff remains essential. National retention rate is similar to the Trusts.

SR outlined that an agency use deep dive in each service line has taken place. Each service now has actions associated.

ER confirmed there was a lot of creative thinking going on but this report to Transformation Board does not include that.

Action: NC-P to provide a summary report outlining Trusts recruitment and retention challenges, work done to date and progress made so far. This report to also include trajectories showing target figures.

Item 5e Workforce Worksteam.docx

5f CAMHS Transformation Workstream


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LB presented an update on the CAMHS Transformation Workstream. Main Headlines reported were:

The CAMHS Transformation Plan across NWL has been refreshed and has been submitted to NHSE. Currently awaiting feedback on submission

The Eating Disorder Service is running well and is reported be one of the best performing against targets in London. NWL Eating Disorder Evaluation has derived actions with clear measures to highlight what is being planned for the future of the service, what is being measured with a plan for further review on the service for the future.

The Crisis Pathway work is progressing well. Savings from NMOC project will be reinvested in Crisis Pathway.

Workforce work led by Like-Minded has had a positive Impact. This will also help with waiting lists.

LB confirmed the CAMHS service would like to work closely with commissioners to recruit band 5.

The service is looking at a new way of working and is looking to buy new software for ADHD and roll it out in Hammersmith and Fulham.

LB also stated that a pilot will be launched that aims to reduce waiting lists using DORMA along with Assistant Psychologist to help work towards bringing down DNA rates.

CAMHS data capturing has improved. An Assistant Psychologist has recently been recruited and is working to focus on data quality work.

The Board noted it was important to know what was being measured to see the impact of transformation initiatives. This will need to be incorporated into the highlight report. LB to add this information into the next Transformation Board papers.

A report is being drawn up that summarises work that has been done in relation to work in schools.

Clinician to Clinician meetings are fully established and will adopt a thematic approach.

GP Leads for CYP mental health together with clinicians from CAMHS, A&E and

paediatrics are attending with the aim of ensuring there is robust clinical expertise to

underpin the Transformation Programme. The last meeting on 3rd

November focused

on ASD. HLP mapped pathways will now be validated by all services. Next meeting will

examine the issue of transition on 23rd

February 2018.

A new service delivery framework to ensure CYP have access to the right treatment at the right time is in development. A multi-agency workshop took place on 4

th of July

which cantered on early intervention and prevention. The aim was to identify strategies to build community resilience, improve access to early intervention and redesign the pathway into CAMHS. This work is ongoing and a further report will be circulated by the Mental Health and Wellbeing Strategy and Transformation Team in due course

Action: LB to circulate a summary of Eating Disorder evaluation to the Transformation Board. Action: LB to add CAMHS dashboard /relevant metrics in highlight reports in the future. Action: LB to share waiting times deep dive with the Transformation Board.

5g Digital Transformation Workstream


AK presented an update on the Digital Transformation Workstream Main Headlines Reported:

Item 5g Digital Transformation Workstream.docx

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As previously noted, the Digital Transformation program replaced local CQUINS, and comprises of 4 sub projects:

1. Clinical Summary Portal (CSP) – a revised overview page on the electronic patient record (RiO) enabling much improved access to core clinical information for each patient and automatic generation of letters, including to primary care.

2. Extending availability of the summary care record (SCR) in WLMHT, which has information on prescribing by GPs and allergies.

3. Extending availability of the diagnostic cloud in WLMHT. 4. Inpatient Discharge Summary – improving the summary to primary care

Clinical Summary Portal: The CSP will impact every clinician and every patient so the method of putting it into practice needs to be thoroughly tried and tested with a full risk management plan in place to run alongside the roll out. The plan presented to the Board in September last year described the process of taking the CSP through a series of incremental pilots to evaluate the functionality and inform the next stage of the roll out plan.

First phase pilot: 15 Crisis & Home Treatment Team clinicians tested key elements of the CSP on 2 or 3 patients each with the following results:-

o Overall the feedback was positive. o Refinements were identified and put in place, some essential and others more

cosmetic. o 2 of the 3 teams involved in the initial pilot want to deploy the CSP across the

whole team as soon as possible.

Second phase pilot: For phase 2, the pilot was to be extended into inpatient wards at Hammersmith & Fulham and incorporate all elements of the CSP. Extensive training and workshops took place in December. Overall feedback was positive and resulted in a reviewed approach for the phase 2 pilot. Given the broader extent of this phase, it became apparent that better assurance and risk mitigation could be achieved by breaking down the components of the CSP into 3 areas of focus:-

o New Risk Assessment: A plan to switch from the current risk assessment to the new forms will be presented to the Trust Clinical Governance meeting (in February if a slot is available). Cutting over to the new forms will mean that a new risk assessment will have to be created for every patient. By doing this now rather than incorporating into the CSP roll out it means there can be a clean cut over rather than having to try to manage 2 forms for the duration of the CSP roll out.

o Immediate Care Actions (previously the To Do List): The risk is that actions will not be closed in a timely manner which would completely invalid this feature. Immediate Care Actions look to be a good fit to support the ‘Red to Green’ and 7 Day Standards/Discharge Planning currently being piloted at H&F making these projects ideal for focussed testing. DToC will be incorporated to ensure maximum benefit for the users and teams involved in testing. Estimates are that by moving these projects onto RiO wards may save up to 3 hours a week in admin.

o Full take up of CSP: To achieve this, a solution for managing discharge medications is required. There are 2 proposals on the table and a pharmacy workshop has been arranged for early February to determine the best solution to support the process requirements. As soon as this is achieve, the discharge summary may be automated which will provide sufficient advantages to justify the changes to practice and specifically, the additional effort required by doctors to manage patients’ medication on RiO on an ongoing basis. H&F and Hounslow CAT teams have both requested to roll out the CSP comprehensively, as soon as possible.

AK confirmed management of the pilot and testing the whole service would prove difficult so this piloting is being carried out on a smaller scale.

JS will work with junior docs and pharmacies to gain a wider knowledge on testing.

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A proposal for new risk summary is going to be taken to Quality Committee in February 2018.

Immediate Care Actions: this was noted to be a good feature and will enable clinicians to compile a list that can be actioned for patients. 7 day standards and Red to Green work will be combined with this piece of work and could prove beneficial. A meeting to progress this will be arranged to see what work can be done on ground level to make it work effectively.

With 7 days standards, as soon as the patient is admitted, the clinicians will be able to look at the immediate care actions. This way different spreadsheets will not be required. SR stated that both Red to Green and 7 day discharge standards require significant ongoing engagement and great progress has been made by the teams. The RiO functionality will enable the work and should not be seen as a replacement for joint team working.

April 2018 has been proposed for soft rollout, but the full rollout will be in May 2018.

CAMHS is part of this pilot and this will be piloted in the Crisis Care Service.

5h Communication and Engagement Workstream (Please see the attached Highlight Report for full report) Main Headlines Reported were:

Transformation newsletter

The communications team has worked with the Programme Director to develop a new transformation e-newsletter for staff within local services at the Trust and interested stakeholders (particularly Heads Up). The e-newsletter will also be made available on the Trust’s website and produced on a bi-annual basis going forward.

Wider narrative work

The amended transformation narrative was attached as an annex to the paper; it includes feedback received from the Board members. The communications team will make this document available on the Trust’s website.

Item 5h Communication and Engagement Workstream.docx

6 AOB

James Moore who observed the meeting commented positively on the progress being made. The Board noted DM will be leaving the Trust at the end of January 2018 while substantive recruitment takes place. Elizabeth George will cover as an interim. The Board thanked DM for all his hard work and dedication and wished him success in his future role.

7 Forward Planner: 02

nd March 2018 meeting to cover:

Inpatient Co-Produced Vision and Standards Baseline Assessments – Dr Fin Larkin , Suzanne McMillan and Julia Renton

NWL Mental Health and Wellbeing priorities – John Wicks

25

th May 2018 meeting to cover:

Future Model of Specialist Rehab Service – Dr Chris Bench and Lina Christopoulou Update on implementation of Triangle of Care – Gillian Kelly

Draft Transformation Dashboard – Neetika Mahan

Recovery House Evaluation and Next Steps - Helen Mangan

8 Date of Next Meeting: Date: Friday 02

nd March 2018

Time: 9.30am to 11.30am

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Item Comment Document Venue: Meeting Room 1 & 2, 3rd Floor, Ealing CCG, Perceval House , Longfield Ave, London W5 2HL

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TRUST BOARD MEETING IN PUBLIC (PART 1) To be held in the Trust Headquarters, Armstrong Way, Southall

on Wednesday 14th March 2018 - from 9.30 to 12.00hrs

AGENDA

Approx. Timing

Agenda No.

Title Lead Enclosed or Verbal

Item

9.30 1 Opening & Welcome

Chairman Verbal

2 Apologies for Absence

Chairman Verbal

3 Declaration of Interests If any member of the Board has an interest in any item on the agenda, they must declare it at the meeting, and if necessary withdraw from the meeting.

Chairman Verbal

MINUTES & ACTION SCHEDULE

9.35 4 Draft minutes of 14th February 2018 meeting To approve the minutes from the last meeting

Chairman Enclosed

5

Board Action Schedule & Matters Arising To note updates on actions arising from previous meetings.

Chairman

Enclosed

ITEMS FOR DISCUSSION

9.45 6 Chairman’s Report To note the Chairman’s report, including updates on NEDs’ activities in the period since the last meeting.

Chairman Enclosed

7 Chief Executive’s Report To note the Chief Executive’s report.


8 Integrated Performance Report To receive the monthly integrated performance report.


9

9.1

9.2

Director of Finance’s Report

Month 10 Finance report To receive a report from the Director of Finance, including the monthly financial performance report.

Interim budget 2018/19 To approve the 2018/19 budget, pending the final agreement of income contracts and submission of the financial plan to NHSI in April 2018.

Director of Finance

Enclosed

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10.30 10

10.1 10.1.1

10.2

10.3 10.4 10.5

10.6

Executive Directors’ Reports To receive reports from executive directors, including:

Medical Director’s Report Medical Director’s Report – Appendix 1 Director of Nursing’s Report, including:

• Triangle of Care implementation update Director of Local Services’ Report Director of High Secure & Forensic Services’ Report Director of Workforce & OD’s report including:

• Workforce Performance Report Director of Communications & Engagement’s report

Directors Enclosed

11.10 11 Nurse and Health Care Assistant Staffing Levels – Exception Report To note the exception report on safe staffing levels in the period.

Director of Nursing

Enclosed

12 Night Time Confinement (NTC) – quarter 3 report To note the quarterly update and support the continuance of Night Time Confinement as an intervention

Director of HSS & WLFS

Enclosed

13 Estates strategy – update To receive an update on the implementation of the Trust’s Estates Strategy

Director of Finance

Enclosed

14 Level 1 Risk Register and Board Assurance Framework update To receive an update on the management of the most significant risks, on the level 1 risk register, and to receive an update on assurances provided on the effectiveness of controls.


REPORTING COMMITTEES 11.50 15

15.1 15.2 15.3

Quality Committee Approved minutes from meeting held on 24 January Chairman’s report from meeting held on 21 February Draft minutes from meeting held on 21 February

Committee Chair

Enclosed

16 16.1 16.2

Workforce & OD Committee Approved minutes from meeting held on 31 January Chairman’s report from meeting held on 21 February

Committee Chair

Enclosed

17 17.1 17.2

Finance & Performance Committee Approved minutes from meeting held on 31 January Chairman’s report from meeting held on 28 February

Committee Chair

Enclosed

18 18.1 18.2

Trust Management Team Approved minutes from meeting held on 31 January Draft minutes from meeting held on 28 February

Committee Chair

Enclosed

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19 19.1 19.2

Audit Committee Approved minutes from meeting held on 17 January Chairman’s report from meeting held on 7 March

Committee Chair

Enclosed

20

20.1 20.2

Broadmoor Hospital Redevelopment Programme Board Agreed minutes of meeting held on 7 February Verbal update of meeting held on 7 March

Committee Chair

Enclosed Verbal

21 21.1

Local Services Transformation Board Agreed minutes of meeting held on 7 February

Committee Chair

Enclosed

ANY OTHER BUSINESS

12.00 22 Any Other Business To consider any additional items of business previously notified to the Chairman.

Chairman Verbal

INVITATION FOR QUESTIONS FROM THE PUBLIC

22 Questions from Members of the Public

Chairman Verbal

RESOLUTION

The Board is invited to adopt the following: “The trust hereby resolves that the remainder of the meeting shall be held in private because publicity would be prejudicial to the public interest, by reason of the confidential nature of the business to be transacted.”

Date of Next Trust Board Meeting in Public: Wednesday 11th April 2018 Time: 09.30hrs Venue: Trust Headquarters

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TRUST BOARD MEETING IN PUBLIC (PART 1) AGENDA · Sir Simon Wessely 7KH%RDUGDJUHHGWKDWWKH7...

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