agenda - Heart of England NHS Foundation Trust
Transcription
agenda - Heart of England NHS Foundation Trust
AGENDA for a meeting of the Board of Directors of Heart of England NHS Foundation Trust to be held in the Education Centre, Birmingham Heartlands Hospital on 6 January 2016 at 12.30pm 12.30PM – 2.30PM: Indicative Timings (Minutes) 1. APOLOGIES (JS/KS) 1 (Oral) 2. DECLARATIONS OF INTEREST (JS) 1 (Enclosure) 3. MINUTES (JS) – 7 Oct & 4 Nov 2015 2 (Enclosure) 4. MATTERS ARISING & DECISIONS/RECOMMENDATIONS TRACKER (KS) 2 (Enclosure) 5. CHAIR’S UPDATE (JS) 5 (Oral) 6. CHIEF EXECUTIVE’S UPDATE (DJM) 10 (Oral) 7. PERFORMANCE REPORT (KB/HG) 10 (Enclosure) 8. CLINICAL QUALITY REPORT (AC/DR) 10 (Oral) 9. CARE QUALITY REPORT, INCL. INFECTION CONTROL (SF) 10 (Enclosure) 10. FINANCE REPORT (JM) 10 (Enclosure) 11. OPERATIONAL STRUCTURES (KB) 10 (Oral) 12. BOARD STRUCTURES (JS/KS) 5 (Enclosure) 13. BOARD ASSURANCE FRAMEWORK AND RISK REGISTER (SF) 5 (Enclosure) 14. ANNUAL SAFEGUARDING REPORTS (SF) 10 (Enclosure) 15. BOARD COMMITTEE MINUTES & REPORTS 15.1 Audit Committee (25.11.15) (AL) 15.2 Donated Funds Committee (20.11.15) (KS) 15.3 Monitor Standing Committee (29.10.15) (KS) 5 16. 17. POLICIES FOR APPROVAL Consultant and SAS Job Planning Policy (AC) (Enclosure) (Enclosure) (Enclosure) (Enclosure) ANY OTHER BUSINESS PREVIOUSLY ADVISED TO THE CHAIR Date of next meeting – 2 March 2016 Harry Hollier Lecture Theatre, Good Hope Hospital. PRESS AND PUBLIC ARE WELCOME TO ATTEND THIS MEETING AS OBSERVERS ONLY EXCLUSION OF THE PRESS AND PUBLIC The Board will be asked to resolve “That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”. REGISTER OF DIRECTORS and REGISTER OF DIRECTORS’ INTERESTS VOTING DIRECTORS NAME DATE OF APPOINTMENT INTEREST (if any) DATE OF NOTIFICATION Mr Jonathan Brotherton 04.03.15 Nothing to declare 04.03.15 Mr Darren Cattell 19.01.15 Director & Shareholder - Mill Street Consultancy Limited. 19.01.15 Dr Andrew Catto 01.03.14 (Interim CEO 14.11.14 to 16.02.15) 01.10.14 Nothing to declare. 01.03.14 Couch Perry & Wilkes. In receipt of annuity following business sale until May 2019. 01.10.14 Nothing to declare. 01.09.13 Professor / Head of School, University of Birmingham Senior Fellow, NIHR School for Social Care Research Member of Birmingham Health Partners Executive Group 01.10.15 Nothing to declare. 04.03.15 CEO of Criminal Cases Review Commission Part time judge Social Entitlement Chamber Fitness to Practise Member for General Dental Council Director (unremunerated) of BRAP, an equalities think tank. 01.10.14 Mr Andrew Edwards Mrs Sam Foster 01.09.13 Prof Jon Glasby 01.10.15 1. 1. 2. 3. Ms Hazel Gunter 04.03.15 Mrs Karen Kneller 01.10.14 1. 2. 3. 4. Mr David Lock 01.07.13 1. Practising barrister and a member of 2. 3. 4. 5. 6. 7. 8. 9. Landmark chambers. Providing legal advice and representation to a wide range of individuals, NHS organisations, local authorities, charities and commercial organisations mainly on public law issues. These frequently involve issues concerning the rights of patients to NHS treatment as well as structural and management issues involving NHS bodies. Member of Amnesty International. Member of the BMA Ethics Committee (unremunerated). Member of the Labour Party and occasional legal advice to Labour Party and elected Members of Parliament on NHS policy issues. Mr Lock’s wife, Dr Bernadette Gregory, is a medical doctor employed by Redditch and Bromsgrove Clinical Commissioning Group and is Clinical Lead for the Worcestershire Integrated Care Project. Chairman of Innovation Birmingham Limited. Representing NHS England in relation to specialised services. Receives instructions from the CQC from time to time. Receives instructions from NHS England from time to time DATE OF TERMINATION OF INTEREST 01.10.15 01.10.15 01.10.14 01.10.14 01.10.14 Updated Jan 14 01.07.13 01.07.13 01.07.13 01.07.13 Oct 2015 05.11.13 06.01.14 04.07.14 07.10.15 Oct 2015 NAME Ms Alison Lord DATE OF APPOINTMENT 01.05.13 INTEREST (if any) 1. 2. 3. 4. Dame Julie Moore Dr Jammi Rao Rt Hon Jacqui Smith CEO and Shareholder of Allegra Ltd. Voluntary role as a business mentor for the Prince's Trust. In her professional capacity as a 'turnaround executive' Ms Lord has relationships from time to time with major accountancy firms, legal firms, banks and venture capital providers. Company Secretary - Adente Limited (unremunerated). DATE OF NOTIFICATION 01.05.13 22.01.14 13.05.14 26.10.2015 1. Birmingham Systems Ltd 2. Innovating Global Health China Ltd 3. Member of Birmingham Business School Advisory Board 4. Court of the University of Birmingham 5. Governor – Birmingham City University 6. Non-Executive Director – Precision Medicine Catapult (PMC) 7. CEO – University Hospitals Birmingham NHS Foundation Trust 01.07.13 1. Sole director of Gorway Global Ltd. a private company and owning 50% of its share capital. A consulting company offering management support, training and bespoke public health analytical support to public sector organisations involved in health, well-being and health care. 2. Board Director of Welcome CIC - a Community Interest Company supporting minority and disadvantaged communities by working with statutory and other agencies. 3. Trustee of the Faculty of Public Health as an elected General Board Member. Term of office from 2010 to July 2013. 4. Visiting Professorship in Public Health in the School of Health, Staffordshire University. 01.07.13 1. 2. 01.12.15 01.12.15 01.12.15 3. 4. 5. Chair – The Precious Trust Chair – Public Affairs Practice for Westbourne Communications Associate – Cumberledge Eden & Partners Associate, Global Partners Governance. Chair – University Hospitals Birmingham NHS Foundation Trust DATE OF TERMINATION OF INTEREST 01.07.13 01.07.13 01.07.13 01.12.15 01.12.15 01.12.15 Jul 2013 Minutes of a meeting of the Board of Directors of Heart of England NHS Foundation Trust held in Partnership Learning Centre, Good Hope Hospital on 7 October 2015 at 9.30am PRESENT: L Lawrence (Chair) J Brotherton D Cattell A Catto A Edwards J Glasby H Gunter K Kneller D Lock A Lord J Rao IN ATTENDANCE: M Cooke (Dir. of Strategy) K Eccles (Head of Comms) S Hyland (Dep. Chief Nurse) I Philp (Dep. Medical Director) K Smith (Co. Secretary) Governors and the Public R Hughes (Lead Governor) Members of the public A Hudson (minutes) 15.134 APOLOGIES & WELCOME L Lawrence welcomed Professor Jon Glasby to his first Board meeting as a Non-executive Director. Apologies had been received from P Cadigan, A Foster, S Foster and D Whittingham. 15.135 DECLARATIONS OF INTEREST The declarations of interests were received and the following amendments noted: D Lock’s wife was no longer employed by Redditch & Bromsgrove CCG, nor Clinical Lead for the Worcestershire Integrated Care Project (no.5), and D Lock no longer represented NHS England in relation to specialised services (no.7) but did represent them in relation to other matters from time to time. J Rao was no longer a trustee of the Faculty of Public Health, nor an elected general board member (no. 3). 15.136 2020 VISION – HEFT STRATEGY M Cooke presented the staff and public version of the 2020 Vision draft launch document which outlined the strategy for the Trust over the next five years and contained references to the Trust’s patient-centred approach, and its focus on partnership working and integration of services. The document had been developed as a result of a comprehensive engagement process with both internal and external stakeholders over the summer and subsequent work and feedback from Executive and Non-executive Directors. Page 10 ‘Investing for the future’ had appeared in error and would be removed. Page |2 M Cooke noted that there was considerably more detail behind the strategy than that outlined in the launch booklet that would continue to be developed in the coming months. D Lock thanked M Cooke and his team for the work undertaken to produce the document. In response to a question from A Edwards, M Cooke advised that the document would be published in booklet format which would be distributed with payslips to all staff; also that it would be discussed further at future staff engagement events. M Cooke was working with Communications on a communications plan for the public. In response to a question from J Glasby, H Gunter confirmed that the Trust’s values had been generated through staff engagement events held over the summer and they would continue to be embedded through upcoming staff engagement events. L Lawrence recorded his thanks to M Cooke and his team for the work undertaken to produce the strategy. The Board agreed to the publication of the 2020 Vision public and staff document, subject to formatting and minor corrections. 15.136 SOLIHULL URGENT CARE CENTRE – MEMORANDUM OF UNDERSTANDING D Cattell apologised for the lateness in circulating the papers to Board members. He then gave a brief overview of the history. The Solihull Urgent Care Centre (UCC) concept had been jointly developed between the Trust and Solihull CCG over a two year period. Prior to and following major public consultation there had been significant clinical, operational and financial commitment from the Trust to work with Solihull CCG to support the programme which would shortly be at the stage of finalising both the facility development and the service procurement approach. Finalisation of a Memorandum of Understanding (MoU) was an outstanding issue for the Trust and Solihull CCG. The MoU would not be legally binding but aimed to set out the framework for the strategic relationship between the Trust, Solihull CCG and any third party service providers. In response to a question from A Lord, D Cattell advised that the capital spend would be around £3.5m, which would be recovered over time. D Cattell confirmed that should the Trust need to borrow money to fund the capital, interest accrued over the term of the loan would also be recovered. D Lock advised that he had been involved in reviewing the documentation and recognised the amount of work done by all of the teams involved to get to the current position. He was supportive of the recommendations and saw this as an interesting opportunity to take a strategic role in the provision of services in Solihull. The Board agreed to the completion of the MoU in principle and delegated authority to the Director of Finance & Performance to agree specific pricing detail on behalf of the Trust. The Board delegated authority to the Chief Executive to sign the MoU on behalf of the Trust. 15.137 INTEGRATED QUALITY AND PERFORMANCE REPORT S Hyland presented the quality aspects of the report. The number of injurious falls and the falls rate had continued to reduce, which correlated with the introduction of ‘open visiting’; work to progress improvement would continue. C.diff incidence was on target. There had been one case Page |3 of MRSA due to non-compliance of screening; this had been addressed. The number of avoidable grade 2 pressures ulcers had continued to decrease but the number of grade 3 pressure ulcers had increased; further work around education would continue. The Trust was compliant with its Unify nursing and HCA workforce return. There were 146 newly qualified nurses due to start across September and October with 22 additional offers made. In addition around 34 nurses were planned to start in theatres over the next two months. The overall vacancy position was reducing. Bank and agency spend had reduced. A Catto reported that the Trust had recently received unexpected correspondence from the Joint Advisory Group (JAG) indicating that the Trust’s JAG accreditation for the three Endoscopy units was being withdrawn. The Trust had responded and been in active discussion with JAG to address this. Whilst a full patient service would continue, the loss of JAG accreditation may have an impact on commissioning, and therefore income, in the future. In response to a question from D Lock, A Catto advised that until the Trust could ascertain why the accreditation had been removed, action plans to reinstate it couldn’t be developed. J Rao advised that the last Quality Committee (QC) had received a very positive report on the Trust’s Endoscopy services. H Gunter reported that Workforce had been concentrating on reducing the use of bank and agency staff. The number of appraisals to be completed to achieve target remained high. Mandatory training performance had improved. Sickness had reduced for the month of August at 3.96%, reducing the moving annual average to 4.63% against a target of 4.51%. Voluntary turnover had reduced slightly. Time to hire had increased due to the additional time required for newly qualified nurses to receive their pins and the longer lead time for overseas recruitment. J Brotherton gave an update on operational performance; he noted that there were three main areas of concern 4-hour A&E, RTT, including diagnostics, and cancer waits. The urgent care pathway had experienced a decline in performance against target and recovery trajectory in August compared to July. The Trust had missed the 4-hour A&E trajectory three weeks out of four in August. There had been an increase in ED attendances at both Heartlands and Good Hope hospitals (compared to the same period in 2014). The non-delivery of trajectory in early August had coincided with the changeover of junior doctors and over-reliance on locums. There had also been an increase in AMU cycle time at both Heartlands and Good Hope compared to the previous month. Cancer two week waits had shown early signs of improvement with the Trust on or just above trajectory; demand remained high. 62 day cancer waits had deteriorated but were now back on track. The Trust had agreed with CCGs that it would deliver the 85% standard by December 2015. D Cattell advised that the Trust had an unsustainable financial situation that had been impacted by the way it set about improving quality and performance. The Executive Directors were now focussed on plans to reduce expenditure but without compromising patient care. J Brotherton confirmed that additional capacity for elective pathways and ward based care had impacted on costs. Pay costs had been above Plan and the Trust was behind Plan on identifying and delivering Service Improvement Efficiency Plans (SIEP), sometimes referred to as Cost Improvement Plans (CIP). Divisional recovery plans had been developed but needed focus to achieve delivery. The unmitigated (or ‘do nothing’) projection indicated a deficit for the full year of around £63m; D Cattell explained that mitigating actions could see this deficit reduce to around £30m but action needed to be taken soon with immediate impact. Monitor had initiated an investigation into the Trust’s sudden unplanned financial deterioration. In response to a question from the Chair, A Catto advised that actions were in hand to involve divisional colleagues in weekly meetings to manage the financial recovery and open and honest messaging was being developed to cascade to all staff. The messaging would be multi-channel Page |4 with the Executive team working with Communications and OD to ensure that staff were engaged with the key cost reduction messages and initiatives. In response to a question from J Rao regarding medical overspend, D Cattell confirmed that agency costs had risen by 75% year on year and there was currently medical overspend of around £1.6m per month. D Lock gave an overview of the recent F&PC meeting which went through the figures in detail and was satisfied that the Executives had serious focus and plans to address the position. The messaging to staff was late starting but F&PC was pleased to see it was ramping up. The Trust had serious issues with non-compliance with financial controls (e.g. excessive recruitment outside of controls). D Lock was clear that the Trust had a duty to deliver the best care available within its financial envelope – i.e. affordable care. It was recognised that this might not sit well with all clinicians; therefore controls and compliance were necessary. The new plan was based on running at break even for the remainder of year which would be very difficult but needed to be done; however he noted that the level of challenge should not be underestimated. In response to a question from L Lawrence, D Cattell was unable to advise the financial outturn for September yet. D Cattell advised that information was being cascaded to staff to enable them to understand what actions had resulted in penalties being levied against the Trust. J Brotherton believed that the move from the JMRA to the PbR contract would allow staff to have greater visibility of actions and consequences. More rigour in conjunction with clear protocols and monitoring systems for bank and agency spend for nursing and clinical staffing were now in place on wards. A Catto confirmed that the concept of ‘safe staffing’, that was fairly well understood in nursing, was less well developed for medical staffing but the same rigour would be applied to medical staffing going forward. The challenge of moving from short term measures to longer term strategic actions and ‘business as usual’ was noted. The Board endorsed the recommendations set out in the finance section of the report. 15.138 INTEGRATED IMPROVEMENT PLAN A Catto advised that the report reflected the continued stable position. The IIP programme board had met on 16 September; the plan was largely on track. Five of the seven programmes were green rated; two were red rated (urgent care and surgery reconfiguration). Verbal update sessions had been held weekly by the PMO and provided an opportunity for all IIP programme leads, Executive directors and operational staff to report against progress and highlight any risks and issues; these meetings had now ceased as part of the transition to service but reporting would continue by way of the standard reporting tool in place. A Catto went on to give a brief update on each of the programme work streams and it was noted that: The key issue around the reporting of Doctor Foster mortality data had been resolved. A Board development session on mortality was scheduled for later in the day. The Governance Recovery Programme was on track to deliver. Page |5 IM&T had been discussed at the recent Monitor PRM meeting and Monitor was content with the high level strategic intent. Scheduled Care remained green and would move to ‘business as usual’. Culture and Engagement work would continue notwithstanding changes in the team. Surgery Reconfiguration – a detailed response had been sent to the Clinical Senate addressing all of the initial concerns that had been raised. The second round of Clinical Senate feedback had wanted more information on staff engagement. Cataract surgery had been removed as this was likely to be available locally. More clarity was required on emergency pathways. The Trust had again responded to each of the issues raised. A Lord welcomed the update on culture and staff engagement and the Board’s commitment to deliver the Plan. H Gunter advised that there had been some feedback from staff around concerns that staff engagement would stop when A Foster left; she reassured the Board that the message to staff was that staff engagement was a Board policy delivered by A Foster not an individual’s policy and it would therefore continue. D Lock noted that the staff engagement and culture agenda was recognised as an issue before A Foster arrived and confirmed that it should continue after he left. 15.139 DATE OF NEXT MEETING 4 November 2015, St Johns Hotel, Solihull. 15.140 ANY OTHER BUSINESS There was none. The Board resolved “That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”. PART TWO ....................................... Chairman Minutes of a meeting of the Board of Directors of Heart of England NHS Foundation Trust held at St. Johns Hotel, Warwick Road, Solihull on 4 November 2015 at 9.30am PRESENT: L Lawrence (Chair) J Brotherton D Cattell A Catto A Edwards S Foster J Glasby H Gunter K Kneller A Lord J Moore J Rao IN ATTENDANCE: M Cooke (Dir. of Strategy) K Eccles (Head of Comms) A Hussain (DIPC) J Smith (Chair Designate) K Smith (Co. Secretary) Governors and the Public R Hughes (Lead Governor) J Thomas (Governor) Members of the public A Hudson (minutes) 15.151 APOLOGIES & WELCOME L Lawrence welcomed Dame Julie Moore and Rt Hon Jacqui Smith to the Trust and Julie Moore to her first Board meeting as Interim Chief Executive. Jacqui Smith would become interim Chair on 1 December 2015. The Chair explained that P Cadigan had resigned with effect from 30 October 2015 and recorded thanks and best wishes from the Board for his contribution during his term of office. Apologies had been received from D Lock and D Whittingham. Governors were invited to remain for the item of the private Board session regarding the Financial Recovery Plan. 15.152 DECLARATIONS OF INTEREST The declarations of interests were noted. 15.153 CHIEF EXECUTIVE’S REPORT J Moore explained that she had been delighted by the welcome that she had received from the Executive team and clinical colleagues, and was impressed with the dedication shown by a large number of staff. 15.154 INTEGRATED PERFORMANCE REPORT S Foster presented the quality aspects of the report. There had been no new cases of MRSA bacteraemia in September; there had been five cases of post 48 hour toxin positive C. Diff, giving the Trust 23 against a year to date target of 32 cases. There had been a total of 90 avoidable grade 2 pressure ulcers against a maximum threshold of no more than 185 for the year, and 26 Page |2 avoidable grade 3 pressure ulcers against a threshold of 29; there was an element of lack of record keeping that had resulted in the rise. A review of current reporting and changes to the performance framework had commenced and all divisions would now formally report any incidences of pressure ulcers and lessons learned. The number of falls incidences remained low which coincided with open visiting. The CCG had undertaken a falls themed review at Good Hope and Solihull hospitals that included looking at the times of falls to see if there was any correlation to breaks and handovers. The increase in the number of HCAs seemed to be having a positive impact. A review on the Heartlands site would take place in November. There had been 94% positive responders for the Inpatient Friends & Family Test (FFT) which was 2% below the national average. The complaints improvement plan had been presented to the Quality Committee and was being presented to the Governor led site based groups. The revised policy for complaints was also going through the committee structure for comment and ultimately approval. A Catto reported that a briefing on mortality to educate the Board had been held in October. The HSMR mortality rate for the first quarter of 2015/16 was 91, the lowest for three years with data demonstrating sustained improvement. The January to December 2014 SHMI was below 1 which was within the expected band 2; however that period had included some inaccurate data due to the previous PMS2 input errors, this would reduce over time. There was one CQC mortality outlier alert in relation to gastrointestinal haemorrhage that was being reviewed. H Gunter gave an update on Workforce. It was noted that sickness for registered nurses at 4.03% was the lowest for 18 months; the moving annual average was 4.56% against a target of 4.46%. Changes to rostering could see upwards of 200 additional nursing shifts. Around 160 qualified nurses due to join the Trust over the coming two months resulting in a vacancy position of 100 posts compared to 200 at December 2014. A key priority had been to continue to support the improvement of the financial position by ensuring resources were used efficiently and effectively. The time to hire had increased from 11 weeks to 14.32 due to the length of time taken to recruit newly qualified and overseas nurses. J Brotherton gave an update on performance. There had been good progress in a number of areas for patient access, including RTT and cancer. Progress against the 4-hour A&E target had reached a plateau. The RTT admitted backlog reduction was on trajectory for September; the incomplete pathway for September was at 87.64% and speciality recovery plans were under review. Diagnostics had seen improvement at 94.1% and continued to improve, there were some challenges and capacity was at maximum. Cancer 2 week wait performance for October was 90.15%, the best year to date this equated to a 10% increase on the prior year despite a 15% growth in referral numbers. 62 day performance had deteriorated to 76.36% as projected owing to the backlog reduction; there were focussed pathway improvement projects in place and a remedial action plan had been agreed with CCGs. The 4 hour A&E performance was 90.9% for September, 3% below the agreed ‘best case trajectory’. ED activity was above the assumed levels in the trajectory and the 3.5% Delayed Transfer of Care target was running 49% above target. The new ED had opened on the Heartlands site creating an expanded and improved space. The new AMU at Good Hope was due to open on the 5 November. The Trust was opening and reconfiguring as much capacity as possible on wards to cope with increased activity from the seasonal spike. D Cattell reported on the financial position. The Trust had received the draft Monitor s.106 undertakings following the completion of Monitor’s investigation into the Trust’s deteriorating financial position. The Trust’s financial sustainability risk rating was 2. There had been a marginal improvement in month 6 with a reduction in overspend from £7m for the month down to £6.4m. The year to date deficit was a £35.9m. The nursing efficiency programme had begun to deliver improvement however the medical efficiency programme had seen a slower start. A financial recovery plan had been developed and agreed by the Board and Monitor; implementation of the Page |3 plan had commenced. Ernst & Young (EY) had commenced within the Trust to support the implementation of the recovery plan. The plan predicted a revised deficit of £32.8m at the end of 2015/16. Quality Impact Assessments on any financial recovery actions would be undertaken and signed off by the Medical Director and Chief Nurse. A number of financial controls had been put in place and EY were supporting those actions including managing debtors and creditors, increased controls/ authorisation processes, improving recording to enable billing for all activity and review of capital expenditure. J Rao noted that staff should be commended for maintaining standards in challenging times and noted reporting updates were received by the Quality Committee. In response to a question from A Edwards, J Brotherton advised that demand and capacity planning meetings had taken place and investments made to better cope with winter demand, including the opening of additional base wards on each of the three sites, staff recruitment and he was confident that the actions taken would enable the Trust to respond in a more effective way than the previous winter; although there was no guarantee that this would be enough and the Trust was heavily reliant on its partners in the local health economy. In response to a question from L Lawrence, J Brotherton confirmed that more intervention from social care was required in order to ease hospital pressures; discussions were being held with CCG and social services colleagues. In response to a question from K Kneller, H Gunter advised that 37% of front line staff had received the flu vaccine and all new nursing staff would receive it. In response to a question from J Glasby about avoidable pressure ulcers and whether the measures were sufficient, S Foster advised that every grade 2 and 3 pressure ulcer was subject to a root case analysis and the key causes were dressings and the positioning of patients. These gave rise to staff performance management measures. Nursing endeavoured to record properly and take the right action. In response to a question from J Glasby as to why the target for mandatory training in particular resuscitation training was only 85%, H Gunter, advised that the figure was set by the CCGs as part of contract negotiation but it took into account term sickness and maternity leave. A Catto added that he had personally attended resuscitation training sessions, where a DVD was used to deliver training but a member of staff was on hand to deliver training and correct technique, where necessary J Moore explained that some mandatory training was transferable but not all; reporting on mandatory training would be improved going forward. 15.155 INTEGRATED IMPROVEMENT PLAN A Catto advised that the report reflected the continued stable position. The IIP programme board had met on the 15 October 2015 and the intention was to transition all work streams to business as usual. There were 4 green and 2 red rated work streams (Urgent Care and Culture and Engagement). The Board had approved a decision to pause the Surgical Reconfiguration Programme until further notice and agreed to remove it from the IIP; each of the Executive Leads went on to give a brief update on each of the programme work streams. A Catto advised that there were no major issues with the Mortality programme which was progressing well. S Foster noted that Governance Recovery Programme focussed on the Deloitte governance review and remained on track to deliver; the pre-circulated slide pack gave an overview of the Page |4 programme. There was some residual work going through Board committees in relation to the Kennedy work stream. Governor Engagement was being led by K Smith and had transitioned to business as usual. J Brotherton advised that Urgent Care was red rated due to the 4-hour A&E performance against trajectory; the milestones had largely been delivered and activity was now owned by the Divisions. D Cattell reported on IM&T; PMS2 was in place and had been tested, there were still a number of issues to be resolved including staff training. A review of the internal function of ICT was underway. H Gunter reported that Culture and Engagement was now red rated in respect of leadership; engagement and values work was due to commence. H Gunter was due to meet with T Jones from UHB to look at how HEFT could mirror UHB’s practice, once a way forward had been agreed a budget would be required. In response to question from J Glasby, H Gunter confirmed that the leadership work had been held back in order to discuss it with the new leadership team. M Cooke advised that although the Surgical Reconfiguration Programme had been paused, those components that related to safety had been passed back to the Divisions for action. J Brotherton advised that Scheduled Care was progressing and rated green; work to identify gaps and subsequent business cases had been progressed. The financial challenge had focussed attention and was driving efficiencies including the tightening up of internal processes. In response to a question from L Lawrence, J Brotherton advised that the Trust continued to work through the System Resilience Group, however there were various levels of quality of input and he was not confident that the Trust would see any reduction in demand; despite continually raising concerns with its partners. The Chair reminded the meeting that the programme had been agreed with Monitor; and the Trust was only one part of the wider health economy. D Cattell confirmed that the Trust was working through the benefits realisation to ensure the benefits flowed from the actions taken. The PMO was planned to transition to a Project Management Assurance role and assist the Divisional delivery. J Glasby observed that the Culture and Engagement Programme seemed to have paused to take on a small number of key people and suggested that this needed to be an organisation wide function. J Moore confirmed that engagement was everyone’s job and that she would be reviewing this. 15.156 BOARD COMMITTEE – TERMS OF REFERENCE K Smith reported that the following the presentation of draft terms of reference (ToR) at the 8 September 2015 Board meeting the draft ToR had been referred back to committee chairs for further review and were now presented for Board ratification. A Lord advised that the Audit Committee had not yet reviewed its terms of reference and went on to note her concerns on the low attendance of Non-Executive Directors at meetings. The meeting considered the possible need to increase the NED membership and quorum of the Audit Committee. J Moore advised that a full review of the Board committee structure would be undertaken shortly and that the need to review the membership of the Audit Committee would be included. After due consideration the terms of reference for the following committees were approved, pro tem: Finance and Performance Page |5 IM&T Quality Research Workforce The terms of reference for Audit Committee would remain outstanding for review and referral back to the Board. 15.157 MINUTES 8 September 2015 The minutes of the meeting held on 8 September 2015 were received and the following changes were noted: 15.118 First sentence, penultimate paragraph – delete the word ‘properly’ from the end of the sentence. 15.131 paragraph 16 – replace the words ‘innovation framework’ with the words ‘Divisional delivery framework’ 15.131 Third sentence, paragraph 18 – replace the words ‘show results sooner’ with the words ‘take effect sooner’. Subject to the foregoing revisions the minutes were approved as a true record. 15.158 BOARD ASSURANCE FRAMEWORK S Foster referred to the pre-circulated paper noting that it reflected work done at the Board ‘Away Day’ in July and the assistance received from Deloitte. It highlighted the risks to the current strategic objectives, key controls, sources of assurance, gaps and potential mitigation actions. This was the first draft of the new style Board Assurance Framework that would evolve over the coming months. Following discussion it was agreed that this was an improvement on what had previously been brought to the Board but it would be subject to further review and regularly be bought back to the Board. 15.159 EMERGENCY PLANNING J Brotherton referred to the pre-circulated paper and reported that the Trust had met all of the required standards with no concerns. The report was received with approval. 15.160 ANNUAL INFECTION PREVENTION AND CONTROL REPORT 2014/15 Dr Abid Hussain, Director of Infection Prevention and Control, joined the meeting to present the annual report. Overall the Trust had performed well over the 12 months ended March 2015 compared to other trusts within the region. During 2014/15 there had been 1 post-48 hour case of MRSA, which had been identified as avoidable, against a target of 0; there had been 75 post-48 hour C. Diff cases against a target of Page |6 78; E coli was being investigated in more detail following the rise in the number of cases in the community. MRSA screening rates had not been as good as they should have been but it was thought that this may have been a coding issue, which was now being addressed. A Hussain commented that there were lessons to be learned from the Salmonella outbreak in June 2014, as highlighted by Professor Bolton’s subsequent report. He confirmed that the source came from outside of the Trust but staff needed to carefully follow Trust policies and procedures to avoid the spread of such diseases. J Moore confirmed that management would be having tough conversations with any staff that didn’t comply. The outlook so far for 2015/16 included 2 post-48 hour cases of MRSA, 25 cases of post-48 hour C. Diff against a target of 38 and some sporadic cases of CPE which was likely to become the focus of the TIPC going forward. J Rao congratulated A Hussain for the work he and the team had done. The meeting questioned what action could be taken with primary care and GPs to mitigate the increase in the number of bacteria resistant to antibiotic treatment; it was noted that discussions were already taking place to educate these groups. 15.161 BOARD COMMITTEES Audit Committee A Lord referred to the pre-circulated minutes of the meeting held on 29 July and advised that there had been a further meeting on 30 September, also that recent meetings had focussed on adding value. Finance & Performance Committee L Lawrence, on behalf of D Lock, advised that the last two meetings had focussed on financial controls. There had been a presentation from Solihull Community Services that had highlighted the issues created by the rolling forward of budgetary deficits. Colleagues had been reminded of the importance of CIP/ SIEP in financial control. Dr Phil Bright had attended the last meeting and given a presentation on aspects of clinical spend that he was investigating. There was a need to ensure that demand capacity and job planning for senior medical staff were right, especially during the transition from JRMA to PbR. Information Management & Technology Committee A Edwards referred to the minutes of the meeting on 7 July 2015. The October meeting had been rescheduled for November. He had met with J Rex, in the interim, to discuss the recording of data on PMS2 in the context of accurate PbR invoicing; staff training was underway in this regard. There had also been a wider discussion about potential ICT system changes, investment permitting. Monitor Standing Committee The committee had met on 29 October 2015 to approve the quarter 2 return to Monitor. Quality Committee The minutes of the meetings held 31 July, 21 August and 16 September were noted. The committee was focussed on mortality, patient experience and complaints, as well as promoting good quality care. There had been a discussion around the national audit and whether the Trust was able to review and analyse its own data before the publication of the national results. Two ‘never events’ had been reported. Page |7 J Brotherton noted that he was not a member of the committee and should therefore not be recorded as sending apologies. Research Committee M Cooke commented on the 2 October meeting on behalf of P Cadigan; the minutes were noted. Two years earlier the Trust experienced a serious incident that was investigated by the MHRA; the investigation had now closed with the Trust’s process used as an exemplar. The Trust was still one of the largest recruiters to clinical trials within the West Midlands; there were several large trials due to commence. Workforce Committee K Kneller advised that a meeting had been held on the 30 September. It had been a challenging first year for the committee with a number of changes due to the lack of clarity in the role of the committee, this had now been resolved and there was confidence in its future working. 15.162 ANY OTHER BUSINESS The Chair noted that this would be his last Board meeting and formally thanked Executive and Non-executive colleagues for their support during his time at the Trust; he hoped that the Trust would continue its journey of improvement and build on the work already done. 15.163 DATE OF NEXT MEETING 6 January 2016; venue to be confirmed. The Board resolved “That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”. PART TWO ....................................... Chairman BOARD OF DIRECTORS Matters Arising & Decisions/Recommendations Tracker Date raised 7 Oct 2015 Minute No 15.141 Detail Report back on financial modelling for and progress with Priority Programme for Frailty Action IP Due Feb 2015 Status Completed HEART OF ENGLAND NHS FOUNDATION TRUST BOARD OF DIRECTORS WEDNESDAY 6 JANUARY 2016 Title: Performance Indicators Report Attachments: From: Kevin Bolger, Interim CEO - Improvement 1 To: Board of Directors The Report is being provided for: Decision N Discussion Y Assurance Y Endorsement Y The Committee is being asked to: Note the content of the report and note the action being taken to achieve compliance with the Trust’s performance indicators. Review the paper (Attachment 1) which provides an assurance statement on the Trust position against the ‘NHS Preparedness for a Major Incident Statement of Readiness (Gateway ref 04494) Key points/Summary: Exception summaries have been provided where there are current or future risks to performance for targets and indicators included in Monitor’s Risk Assessment Framework, national and contractual targets and internal indicators. The Trust’s position against the ‘NHS Preparedness for a Major Incident Statement of Readiness (Gateway ref 04494) is one of assurance. Recommendation(s): The Board of Directors is requested to: Accept the report on progress made towards achieving performance targets and associated actions and risks. Note the Trust’s position against the ‘NHS Preparedness for a Major Incident Statement of Readiness (Gateway ref 04494). Assurance Implications: Strategic Risk Register Resource/Assurance Implications (e.g. Financial/HR) Identify any Equality & Diversity issues N Performance KPIs year to date Y Y Information Exempt from Disclosure None N Outline how any Equality & Diversity risks are to be managed Which other Committees has this paper been to? (E.g. F & PC, QRC etc.) None Page 1 of 17 HEART OF ENGLAND NHS FOUNDATION TRUST BOARD OF DIRECTORS WEDNESDAY 6 JANUARY 2016 PERFORMANCE INDICATORS REPORT PRESENTED BY INTERIM CEO - IMPROVEMENT 1. Purpose This paper summarises the Trust’s performance against national indicators and targets, including those in Monitor’s Risk Assessment Framework, as well as local priorities. Material risks to the Trust’s Monitor Provider Licence or Governance Rating, finances, reputation or clinical quality resulting from performance against indicators are detailed below. In addition this month the paper provides an update on the Trust position against the ‘NHS Preparedness for a Major Incident Statement of Readiness (Gateway ref 04494) - Attachment 1 2. HEFT Key Performance Indicators The Trust has a suite of Key Performance Indicators that includes national targets set by the Department of Health (DH) and local indicators selected by the Trust as priority areas, some of which are jointly agreed with the Trust’s commissioners. This report is intended to give a view of overall performance of the organisation in a concise format and highlight key risks particularly around national and contractual targets as well as an overall indication of achievement of key objectives. The Trust currently rates indicators as either green – meeting the target or red - failing the target. For this report all indicators that are failing to achieve compliance with targets have been reported on. The report also contains a short overview of performance against the Solihull Community Contract. 3. Material Risks The DH sets out a number of national targets for the NHS each year which are priorities to improve quality and access to healthcare. Monitor tracks the Trust’s performance against a subset of these targets under its Risk Assessment Framework. The remaining national targets that are part of the Everyone Counts document from the DH but not in Monitor’s Risk Assessment Framework are included separately. 3.1 Monitor Of the 13 indicators currently included in Monitor’s Risk Assessment Framework (RAF), 9 were on target in the most recent month. 2 cancer Page 2 of 17 targets (reported a month in arrears); the A&E 4 hour wait target and the 18 week RTT incomplete pathways target were not met. 3.1.1 A&E 4 Hour Waits Performance against the 4 hour A&E target in November was 87.38% similar to the performance of 87.34% in October. There were no 12 hour trolley breaches. Attendances during November were 8% higher (for BHH and GHH) compared with the same month last year and admissions from the Emergency Department were 12% higher. Alongside this there has been a significant increase in the number of delayed transfers of care, with significant issues relating to failed discharges due to patient transport delays. There is a need to revisit the improvement trajectory with the Systems Resilience Group (SRG) given these factors and the current performance. Actions being taken to improve performance include: • • • • • Expansion of the majors and minors ED areas at BHH to support increased demand. Opening an expanded AMU department at GHH, co-located with the Short Stay Unit. Expanded Ambulatory Emergency Clinics (AEC) to further reduce avoidable admissions. New Medical Rotas to better match patient demand profiles. Opened full discharge lounge provision at BHH and GHH. A full review of the winter plan has been undertaken in December and additional contingency measures put in place in light of the above plan activity being seen. A financial penalty of £120 for every breach under the 95% target applies within the Trust contract. The impact of this in November was £209,880 3.1.2 Cancer Targets In October the Trust missed 2 of the national cancer targets. The cancer 2 week wait from referral to appointment and the 62 day urgent GP referral to first treatment target. 62 day standard Performance against the 62-day standard deteriorated slightly in October to 79.29% which is below the operational standard. This was expected, as the directorates continued to tackle patient backlogs that had developed earlier in the year and prioritised patients who have been waiting the longest amount of time. This is in Page 3 of 17 line with the Trust’s improvement trajectory which has been agreed with the commissioners as part of the Remedial Action Plan (RAP). November’s unvalidated position is showing an improvement in performance to 86.79%, above the 85% target. It should be noted that this performance may not be sustained through December as more patients from the backlog are treated. Urology remains a significant concern and further work is being undertaken to improve the position. Table 1: Cancer Performance against Target and Planned Trajectory for 62 day cancer target Target Cancer – 62 day urgent GP referral October Performance October Trajectory Target Resolution Date 79.29% 79.20% 85% January 2016 Table 2: 2015/16 Year to Date 62 day GP Cancer Performance by Tumour Site Tumour Site Breast Gynaecology Haematology Lower GI Head & Neck Lung Skin Upper GI Urology Oct-15 88.9% 88.2% 60.0% 94.7% 62.5% 50.0% 93.6% 70.0% 76.9% YTD 15/16 92.0% 83.7% 87.2% 86.5% 44.4% 60.4% 98.7% 54.7% 70.1% Total 79.3% 80.6% 2 week cancer wait Performance against the cancer 2 week wait referral from GP to first appointment was 90.09%, a slight decrease against September’s performance of 90.50%. November’s unvalidated performance is showing an improved performance of 93.06%. The Trust hasn’t achieved the 93% standard since December 2013. The Trusts trajectory to recover performance against the 2ww operational standard is December so this may be achieved a month early. Conversely performance against the 2 week wait for breast symptom patients was achieved in October, 93.55%, however November’s unvalidated position is currently showing performance at 90.69%. This is primarily due to a persistent fault with the mammography machine at Solihull; this resulted in patients needing to come back for Page 4 of 17 a second appointment impacting on capacity. The fault, on the 6 month old machine, has now been rectified and the backlog of patients has been cleared. Performance against the national cancer targets continues to be associated with a contractual penalty in 2015/16 if they are not achieved over the quarter. This equates to £1000 per additional patient below the 62 day target and £200 for the 2 week target. The year to September penalty for the 2 week cancer targets is £114,200 and for the 62 days standard £39,000. 3.1.3 Referral to Treatment Time Incomplete pathway performance improved to 91.34% in November, which although just below the national target of 92%, is an improvement on October’s position of 88.75%. Performance for the former Referral to Treatment Time (RTT) targets for admitted and non-admitted patients is 78.6% and 89.7% respectively. A significant amount of work has been undertaken to deliver the improvement in the Trust’s performance these include an increase in theatre utilisation, an increase in the number of patients being seen earlier in their pathway in out-patients and validation with a strong focus on clinical and pathway administration. This improvement is set in the context of a vast reduction in the use of private sector capacity. The contractual penalty for the incomplete target in November is £157,932. 3.2 National Targets Monitored Locally Through CCG Contract Of the 15 national targets that are not included in Monitor’s Risk Assessment Framework but are included in the CCG contract the Trust is on target for 9 and not delivering against 6. The Trust has 1 Remedial Action place with the CCG in relation to the diagnostics indicator 3.2.1 6 Week Diagnostics In November the Trust’s performance against the 6 week diagnostic target was 97.97%. (233 breaches). There has been a significant improvement in delivery of this target in the last 3 months, in September the Trust performance was 94.1% (663 breaches) The underperformance against this target sits within the endoscopy diagnostic group and a separate delivery trajectory is in place for this. They are currently slightly under delivering against trajectory but are showing a month on month improvement in performance. There is a risk to delivery of the 99% standard in December as per the RAP and trajectory. Page 5 of 17 This is a contractual target with an associated financial penalty which in 2015/16 is £200 per additional patient below target. The penalty associated with November performance will be £24,200. 3.2.2 Ambulance Handover Due to discrepancies between the Trust and West Midlands Ambulance Service (WMAS) data a validation process for over 60 minute breaches has commenced from November. In November there were 11 breaches reported by WMAS, the Trust has validated this to 7 breaches for the 60 minute target. The Trust achieved 94.28% for the 30 minute handover target (353 breaches) against 95.03% in October. There were 328 breaches in November 2014. This is a contractual target with an associated penalty of £1,000 per over 60 minute handover and £200 per handover longer than 30 minutes. Based on the validated figures the Trust’s total penalty in November will be £77,600 3.2.3 Safer Staffing Table 3 shows the Divisional break down for the November 2015 monthly nurse staffing level information for adult inpatient ward areas, including critical care. This information is published on the NHS Choices website for all Trusts with adult inpatient services and is reported to NHS England as part of the monthly UNIFY return Table 3: Divisional Breakdown of Staffing Levels BHH GHH SOL W&C TRUST % fill rate Qualified Days 99% 96% 103% 100% 99% % fill rate Unqualified Days 102% 98% 117% 90% 101% % fill rate Qualified Nights 97% 98% 100% 98% 99% % fill rate Unqualified Nights 113% 104% 112% 92% 103% All areas were compliant with staffing during November 2015. Where there are individual clinical areas within a division that are not compliant the Head Nurse submits an exception report to the Chief Nurse that articulates risk mitigation and assurance of safe care. Further information is provided in the Care Quality Report. All staffing compliance is measured weekly and is discussed with the CN or DCN. This includes ‘flex’ areas enabling decisions to be made about the safety of opening additional beds at times of high demand. Page 6 of 17 Workforce reviews have been undertaken for all in patient areas and AMU’s which highlighted no areas of concern. These will be repeated again in February 2016. The most significant challenge for safer staffing is the number of vacancies that there are for registered nurses and midwives across the Trust. Further detail is provided in section 4.8 of this report. 3.2.4 Consultant Upgrade Performance against this indicator deteriorated in month from 75.4% in September to 64.29% in October. There were 8 breaches in total 7 lung 1 urology. Pathway improvement groups are in place for both Lung and Urology and action plans to improve the overall pathway to mitigate any process or capacity delays have been developed. 3.2.5 Sleeping Accommodation Breach There was one sleeping accommodation breach in November affecting 5 of patients (1 female and 4 male). This occurred in where there was a 9 hour delay in locating a side room for a Type 1 patient who was fit for transfer from ITU. This is a contractual target with an associated penalty of £250 per patient this equates to £1,250 in month. 3.2.6 Urgent Operations cancelled for the second time There were 2 breaches of this indicator in November relating to trauma patients. Both were operated on within 24 hours of the second cancellation. A review of the classification of patients that fall into this category is being undertaken, the Trust will liaise with other local Trusts to gain an understanding of how they monitor compliance with this contractual target. This is a contractual target with an associated penalty of £5000 per patient equating £10,000 in month. 3.2.7 52 week breach In line with the Trust's zero tolerance to 52 week breaches, there have been no genuine 52 week breach patients due to a prolonged clinical pathway. There was one incomplete pathway 52 week breach (Urology) who is a legacy patient from the previous open clock cohort. The financial penalty for this breach in November is £5000. Page 7 of 17 3.2.8 Duty of Candour The requirements for reporting Duty of Candour changed for this contractual year. The Commissioners agreed that the Trust could have time to put in place processes to meet the requirements with reporting to begin from September, reported 2 months in arrears. Performance will be reported from December. 3.2.9 Never Event There was one never event in November at Solihull where a patient due to undergo a left anterior cruciate ligament repair had a right sided nerve block administered by the anaesthetist. The error was identified prior to surgery and correct side then blocked. The Trust has had 3 never events year to date. There are financial penalties associated with never events whereby the commissioner can recover the costs of the procedure or episode (or, where these cannot be accurately established, £2,000) plus any additional charges incurred by the commissioner for any corrective procedure or necessary care in consequence of the Never Event. The financial penalty for this patient is still to be calculated. 4. Local Indicators – contract/local Local indicators continue to be monitored that reflect the Trust’s priorities and contractual obligations. Of the Trust’s 53 local contract indicators, 22 are reported monthly, of these 16 (73%) are currently on target, 6 (27%) are below target. Details of those indicators failing to meet the target are provided below: 4.1 Babies at risk of TB receive vaccination Current performance for November was 35.06% against a target of 98%. There has been a national shortage of the vaccination which has impacted on performance. The Trust have now received a supply of the vaccine and have been holding a number of ‘catch up’ clinics to clear the backlog of children who were unable to be vaccinated earlier in the year. The last of which is being held on 19 December, it has been agreed with NHSE that any child not attending the clinics will be vaccinated by their GP. The Trust has a supply of the vaccine and is generally able to vaccinate babies at birth. However as one vial of the vaccine can be used for a number of babies, in order to make the most effective use of the supply, where numbers of babies requiring vaccination are small, e.g. at GHH, babies are being asked to come back to the ward 2-3 days post-delivery to be vaccinated. It is anticipated that performance will be back on track by the end of December, assuming the supply of the vaccine continues. Page 8 of 17 4.2 Breast feeding rates The definition of this target is the percentage of mothers who have initiated breast feeding or babies who received expressed breast milk within 48hours of delivery. In month performance has improved to 68.51% against a target of 72%. The Trust has not met this target all year, there is a remedial action plan in place with the CCG and the Trust has delivered all of the agreed actions including the development of HCA breast feeding support workers and an enhanced breast feeding team. The Women’s and Children’s Division believe that it is unlikely that they will achieve the target due to our high number of patients from ethnic backgrounds who will not culturally put their babies to the breast in the first 48 hours. They will however continue to work with commissioners to identify ways of improving compliance. 4.3 Compliance with nursing care indicators (tissue viability/SSKIN bundle) – total score and repositioning frequency adhered to for 3 days. The overall performance against this indicator is measured against an aggregated score of 3 sub-indicators. Poor performance against repositioning frequency adhered to for 3 days had a detrimental impact on the overall performance. Current performance is at 81% against an expected score of 90%. There has been a review of trust wide reporting and mandatory actions against a revise performance framework. Any area underperforming for repositioning will be referred to the Chief Executives RCA forum for action from January 2016. 4.4 Appraisal rates The appraisal rate remains below the target of 85%. The rate has risen slightly from the previous month and is now level with the appraisal rate from last year. The low appraisal rate indicates missed opportunities to enhance engagement with staff and the ability to communicate objectives and provide constructive feedback as well as listening to staff concerns before they escalate. Divisional Human Resources Managers in all areas have been asked to ensure that the Divisions have plans in place to achieve the target by the end of the year. The Appraisal Policy has been updated to provide more clarity on those employees that are included /excluded in the appraisal figures (e.g. new starters, staff on maternity leave etc.). Page 9 of 17 4.5 Mandatory Training The Trust is delivering its overall mandatory training performance. However it has been noted that Information Governance Training is not currently one of the Trust’s mandatory training requirements. This is deemed to be a risk for the Trust and the workforce department have been asked to include this going forward. In order to mitigate the risk the Information Governance (IG) Team have completed a training needs analysis for 2015/16, which forms the basis of the training plan for IG and which has been approved by the IG Committee. Local Indicators - Internal The Trust has a number of internal KPIs that it reviews on a monthly basis, these are classed under the headings of workforce and quality and safety Details of those not being achieved are provided below: 4.6 Staff in post v budget established (excluding nursing) The target is between 95% - 100% and currently stands at 91.5% in November. In some part this is due to new control processes for approving non-clinical posts being introduced resulting in a reduction of appointments to these posts. This KPI includes medical vacancies. The current level of medical vacancies as at the end of November 2015 stands at 61.1 wte. This is split between 41.54 consultants and 19.56 non-consultant posts. This vacancy level has improved throughout the year from its highest point in June 2015 when the vacancy level was 100.30 wte. 4.7 Nursing staff in post v budget established Nursing vacancies continue to decline following successful and ongoing nurse recruitment. This has focused on local and EU recruitment campaigns. There are currently 156 registered nursing vacancies across all adult inpatient and AMU areas. There are a further 41 planned starters over December and January with an average attrition rate of 11 registered nurses per month. Theatres continue to face significant challenges with their recruitment with a further EU campaign currently being undertaken. Emergency Department recruitment is progressing however there are challenges within these departments due to the lack of experienced nurses resulting in large numbers of newly qualified nurses being recruited and requiring intensive support and development. There is ongoing Midwifery recruitment; however this continues to be insufficient for demand. The possibility of EU recruitment is currently being considered. Page 10 of 17 The Chief Nurse and Director of Workforce are currently considering a potential solution for the provision of fit for purpose nurses from Romania over the longer term (circa 100 per year). This is being scoped as a collaborative project with UHBT. 4.8 Average time to recruit – hiring manager and total time to recruit Performance against this target has improved during November to 13.7 weeks compared with 14.1 weeks in October. This is against a Trust target of 11 weeks. The key area to focus on is time to hire in order to speed up the improvement in overall staffing levels thus reducing reliance on bank, agency and locum bookings. The central recruitment team and Divisional teams continue to focus on their processes in order to meet time to hire targets. This target is likely to improve as the newly qualified nurses that have started receive their PIN numbers. 4.9 Voluntary turnover The level of voluntary turnover is steadily reducing with performance in November at 8.99% against 8.86% in October and a Trust target of 8.70%. The Trust is going through a period of change which could potentially have an impact on staff morale. Turnover levels and reasons for leaving will be monitored closely over the next few months to assess any impact. Operational Human Resources staff continue to work with Divisions to identify issues, hotspots and problems and find solutions. As well as supporting longer term issues the Workforce Directorate are also focusing on developing a positive experience for new starters 4.10 Trust wide Agency Spend The Trust continues to overspend against its Trust wide Agency Spend indicator. The in-month position is 8.76% against last months of 9.45%. Work to address this is being undertaken through the finance recovery programme. 4.11 Delayed Transfers of Care The reporting specification for Delayed Transfers of Care (DToC) has been revised to ensure it is in line with the methodology set by NHS England. Levels of DToC have been above the 3.5% target and the revised stretch target of 2.5% for some months. Current performance is 5.6% against current improvement target of 5.5% A plan has been agreed with the System Resilience Group (SRG) which will focus on the following: The immediate implementation of the new patient choice/bed utilisation policy Page 11 of 17 4.12 Demand and capacity planning for the Trust and Local Authority staff involved in complex discharge Streamlining of the Continuing Healthcare process Reduction of length of stay in enhanced assessment beds Increased provision of reablement capacity Daily Multiagency review of all patients referred into the discharge hubs MRSA Emergency Screening Rates (% patients screened) MRSA emergency screening performance remains below the 90% target at 82.54% in November. A number of actions have been implemented to improve overall compliance in MRSA Emergency Screening. These include pocket reminder cards for staff, inclusion in mandatory training and ward based teaching. The MRSA policy is currently being reviewed as part of Trust’s two yearly policy review process. The updated policy will include details of the revised procedure for emergency screening but no other changes to the policy are planned. 4.13 Patients receiving their first definitive treatment for cancer within 100 days of GP or dentist urgent referral for suspected cancer There are currently five patients without confirmed treatment dates that have been waiting longer than 100 days (2 Breast patients, 2 Urology patients, 1 Lung patient). This cohort is down from 9 patients last month as directorates continue to tackle their longest waiting patients. All of these patients are complex cases, some spanning multiple providers and having significant complex needs. There have also been a number of patient-initiated delays. A weekly patient level update is now sent from the Lead Cancer Clinician to MDT Leads to ensure that all appropriate steps are in place. In line with the recent ‘Cancer Backstop Policy’ issued by Monitor and NHS England, the Trust is required to establish a process for undertaking both an RCA and a Potential Clinical Harm Review for any cancer patient waiting longer than 104 days. Cancer Services are currently in the process of scoping such a process, although it should be noted that every patient is already tracked and reviewed as soon as cancer is suspected. 4.14 Operations cancelled on the day In November there were 88 operations cancelled on the day of surgery for non-clinical reasons. Performance against the 0.8% target was 1.05% in November. There have been no breaches of the contractual target requiring patients to have surgery within 28 days of cancellation of surgery since August. 4.15 Nursing Metrics – quality of care Performance dipped in November to 94% from 95% in October. During November there was a rotation in nominated auditors to ensure senior ward sisters were following process. Page 12 of 17 The two indicators that reduced the score for November were: Adherence with repositioning patients as per frequency suggested Fluid balance completion particularly 6hrly input /output totals and cumulative balance. Action to date: Implementation of mandatory tasks to ensure improved compliance with reposition frequency. Revised fluid balance charts to be implemented by January 2016. 4.16 Admissions, Discharges and Transfers (ADT) recorded within 2 hours The Trust has a requirement for 90% of ADTs to be recorded within 2 hours performance in November was 76.48% Solihull have recently commenced a pilot of improving ADT’s to real time of 10 minutes, there is no data as yet to measure the impact although as a site the overall performance is higher than both BHH and GHH with admission at 84% and transfers at 93%. Focus for quarter 4 is to understand why compliance is poor during core hours and for all clinical areas to develop actions to improve compliance which are monitored through site. 4.17 Dementia CQUIN Trust performance against the dementia CQUIN indicator of the percentage of eligible patients aged over 75 asked the dementia question was 87.41% deterioration on October’s position of 88.66%. The Trust has only achieved this target in two months year to date. A daily e-mail is circulated to all consultants identifying those patients that have not been screened. 5. CQUINs The Trust currently has 12 CQUINs ( 7 relating to the Acute Contract, 3 to the Specialised Services Contract, 1 to the Solihull Community Contract and 1 to the Public Health Contract. All CQUINs were delivered for Q2 For Q3 the Trust is currently confident of delivery of the maternity safety thermometer and cancer survivorship framework in gynaecology. There are risks to the delivery of all others CQUINs for Q3 with a full risk value of £2.57m Further detail on CQUINs is provided in the in Care Quality Report Page 13 of 17 6. Solihull Community Contract The Solihull Community Services contract has a value of approximately £20 million, commissioned by Solihull Clinical Commissioning Group (CCG), Solihull Metropolitan Borough Council (SMBC) and NHS England. In total there are over 40 Services, ranging from Health Visiting, Community Paediatrics, Community Respiratory, Speech & Language Therapy to the You + shop that provides advice and health care checks. As part of the 2015/16 contract, the Trust currently submits the following information on working day 20 each month to the Commissioners: Solihull CCG 37 key performance indicators (KPIs), 83 information requirement reports (IR) Health visiting 17 KPIs SMBC 37 KPIs, 12 IR. Solihull SMBC / CCG 6 KPIs, 8 IR The KPIs and Information requirements are a mixture of monthly, quarterly or annual reports. The majority of the performance requirements are locally agreed rather mandated by national targets, however Community Paediatrics is included in the Trusts 18 weeks submission because it is a consultant led service. This contract is reported a month in arrears in October a short overview of performance against the contract is provided below: 6.1 Community Service KPIs - Solihull CCG The only exception was staff receiving appraisal / PDR, 66.04% during Q2 vs. a target of 85%. Work to improve performance against this indicator is as reported for the acute contract above. 6.2 Solihull Metropolitan Borough Council (SMBC) The SMBC KPI targets are all quarterly, in Quarter 2 there were two targets that Trust failed to achieve: Breastfeeding initiation for Solihull residents (66.72%) was below the 70% target. A detailed action plan was created by the Service to improve the performance in future months, this was presented to the Commissioners at the Maternity LIG meeting 29.41% of the weight management patients achieving 5% weight loss at 3 months, this was below the >30% target in Q2; however the performance increased to 40% in October. Page 14 of 17 7. NHS Preparedness for a Major Incident Statement of Readiness (Gateway ref 04494) Dame Barbara Hakin, National Director of Commissioning Operations at NHS England, has requested via Public Trust board an assurance statement against 4 specific elements identified with her letter dated 9th December 2015 (gateway ref no: 04494). This is in addition to the annual Emergency Preparedness, Resilience and Response (EPRR) core standards assurance that was accepted at board in November 2015. The paper (Attachment 1) provides assurance to the 4 elements requested and an overarching final statement of readiness 8. Recommendations The Board of Directors is requested to: 8.1 Accept the report on progress made towards achieving performance targets and associated actions and risks. 8.2 Confirm that they are assured on the Trust’s against the ‘NHS Preparedness for a Major Incident Statement of Readiness (Gateway ref 04494) Kevin Bolger Interim CEO – Improvement Page 15 of 17 Attachment 1 NHS Preparedness for a Major Incident Statement of Readiness For Trust Board 6th January 2016. (Publications Gateway Reference No.04494) 1. Introduction This paper provides details of the Heart of England NHS Foundation Trusts readiness for a major incident in light of the tragic events in Paris on 13th November 2015. The threat level for the UK remains unchanged since 29th August 2014 and therefore remains at SEVERE; this means that an attack is highly likely. SEVERE is the second highest level with CRITICAL being the highest. CRITICAL means an attack is imminent. Dame Barbara Hakin, National Director: Commissioning and Operations, NHS England has written to all Trust asking them to provide a statement of readiness to their Public Boards against the following areas:- 2. • You have reviewed and tested your cascade systems to ensure that they can activate support from all staff groups, including doctors in training posts, in a timely manner including in the event of a loss of the primary communications system; • You have arrangements in place to ensure that staff can still gain access to sites in circumstances where there may be disruption to the transport infrastructure, including public transport where appropriate, in an emergency; • Plans are in place to significantly increase critical care capacity and capability over a protracted period of time in response to an incident, including where patients may need to be supported for a period of time prior to transfer for definitive care; and • You have given due consideration as to how the trust can gain specialist advice in relation to the management of a significant number of patients with traumatic blast and ballistic injuries. HEFT readiness against the identified areas above Our call in cascade system (confirmer) is tested quarterly across the trust and following the Paris events has been reviewed. A new mass casualty specific cascade will be in place imminently which will have all medical staff populated within it. Confirmer itself has 3 layers of resilience in addition to our communications systems which also has 3 layers of resilience. Confirmer also has the benefit of being able to be activated by either ICT or telecommunication lines and from both internal and external lines which means unless we lose both internet and telecoms we are still able to use our cascade system. Loss of all Page 16 of 17 communications, whilst possible, is mitigated against to the best of our ability. In the event of a total loss we would utilise the communications department media management plan and get messages out to staff via local TV and radio stations. Arrangements are already in place as part of our Cold Weather and Fuel plans to utilise Trust shuttle buses to assist with staff getting to work along with the reallocation of staff to their nearest sites as opposed to base sites where appropriate. With the activation of NHS England’s incident response plan we also have plans to work in liaison with West Midlands Police and arrange rendezvous points for staff collection and transportation if required and will be identified at the time. All of our emergency incident plans have been reviewed in 2015 and link into NHS England West Midlands – Birmingham, Solihull & Black Country Incident Response Plan. A strong emergency preparedness, resilience and response (EPRR) network within our area ensures we both liaise and work well with other local trusts. Our mass casualty plan (part of the Heartlands Major Incident Plan) details how we will expand our critical care capacity and capability during such incidents. These plans are due their annual review in the first quarter of 2016 and will be done in line with the latest NHS England Assurance Framework published in November 2015. Due to our strong EPRR network acute providers have a presence not only within the NHS England Incident Control Centre but also within the Police Events Control Suite. These provide us with direct access to many specialists from whom we can gain any specialist advice required depending on the incident. This includes the trauma network, critical care network and military liaison officers as well as Public Health England and Hazardous Area Response Teams etc. 3. Assurance statement Having reviewed and taken into account all of the current plans following the tragic events in Paris Heart of England NHS Foundation Trust can provide assurance that it is ready, to the best of its ability, to respond in the event of a major incident. Paper prepared by Kellie Jervis Head of Emergency Planning & Business Continuity Page 17 of 17 HEART OF ENGLAND NHS FOUNDATION TRUST BOARD OF DIRECTORS WEDNESDAY 6 JANUARY 2016 Title: Care Quality Board Report Attachments: 0 From: Sam Foster To: Trust Board The Report is being provided for: Decision N Discussion The Committee is being asked to: Y Assurance Y Endorsement N Note the content of the report and the required onward actions. Key points/Summary: This paper summarises the Trust’s performance against national quality indicators and targets including those in Monitor’s Risk Assessment Framework as well as local priorities. It outlines the current position with performance and actions required in six key areas to build on the care provided to patients in our hospitals: Infection Control: Performance remains within trajectory for Clostridium Difficile with 2 Trust attributable MRSA bacteraemia YTD Patient Experience: Friends and Family test (FFT) All areas remain within or slightly below the national picture, with Maternity and Emergency Departments as the current focus for improvements. Complaints: following the external review previously reported to Trust Board, the revised process for recording, grading and responding to complaints is now live; the Board should expect to see an improvement in closure of complaints within 25 working days over the coming months. Harm: 15/16 performance YTD for both harm from falls and pressure ulcers has improved- the paper details specific improvements required to further reduce harm from pressure ulcers. Discharge: The local Health and Social Care economy for HEFT share concerns in respect of the deteriorating position of delayed transfers of care and have indicated commitment to resolve this through an agreed 7 point action plan. The report details a current DTOC position of circa 6% against an existing 3.5% target with a higher number from February 2015 with a higher proportion attributable to Health. Nursing and Midwifery staffing: All areas reported compliance with their planned vs. actual staffing levels. The Trust vacancy position is improving with circa 100 wte vacancies as of December – an improved picture to this time last year with circa 200 Vacancies. Particularly difficult to recruit to specialties are Theatres, Emergency Department and Midwifery – where planning is currently taking place to scope options. CQUIN Delivery: Q2 delivery was achieved, with a financial plan to achieve 75% in Q3&4 areas of focus are detailed in the report. Recommendation(s): Note the content of the report and the required onward actions. Assurance Implications: Strategic Risk Register N Performance KPIs year to date Y Resource/Assurance Implications (e.g. Financial/HR) Identify any Equality & Diversity issues N Information Exempt from Disclosure Nil Which other Committees has this paper been to? (E.g. F & PC, QRC etc.) None N HEART OF ENGLAND NHS FOUNDATION TRUST BOARD OF DIRECTORS WEDNESDAY 6 JANUARY 2015 CARE QUALITY BOARD REPORT PRESENTED BY THE CHIEF NURSE 1. Purpose This paper summarises the Trust’s performance against national quality indicators and targets including those in Monitor’s Risk Assessment Framework as well as local priorities. It outlines the current position with performance and actions required in key areas to build on the care provided to patients in our hospitals. 2. Infection Control The annual objective for Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia is zero avoidable cases. There have been two Trust apportioned bacteraemias so far this financial year. The annual objective for Clostridium difficile infection (CDI) for 2015/16 is 64 cases all of which will be calculated as Trust apportioned. C.Diff cumulative post 48 hours toxin positive Trust performance until November 2015 was a total of 32 reported cases, seven of which were deemed avoidable. Reasons for these occurrences being deemed avoidable include inappropriate sample testing and antimicrobial prescribing. These 32 cases were reported to Public Health England (PHE) in accordance with Department of Health guidance. All of these cases were reviewed jointly with the commissioners monthly to ascertain avoidability, based on clinical and antibiotic reviews. Page 2 of 20 2.1 Actions to improve performance of CDI and MRSA 2.2 Increased education and observational audit of health care worker’s hand hygiene, in particular medical staff, as well as Personal Protective Equipment (PPE). A different method of MRSA screening has been introduced in the Trust to improve laboratory diagnosis. This will require an extensive campaign of training and blended education. Decolonisation bundles are to be reinvigorated to allow prompt prescription and administration. Careful attention to device insertion, both through appropriate prophylaxis and documentation, as well as intensive training on aseptic non-touch technique. The current antimicrobial stewardship programme has maintained an improving compliance with antimicrobial stop dates and indications. Continue with current post infection reviews (PIR) of Trust apportioned cases as well the monitoring of clinical areas where concurrent infections has occurred through the period of increased incidence (PII) process. This involved a rapid review by a Consultant Microbiologist and a Senior Infection Control Nurse. Relaunch of octenisan anti-microbial hair and body wash for all adult inpatients not colonised with MRSA Award of a £210,000 research grant from the Health Foundation investigating factors that may modify hand washing behaviour. Outbreaks There have been no outbreaks of diarrhoea and/or vomiting so far this financial year that have resulted in ward closures. In line with the PHE national toolkit on the screening and diagnosis of Carbapenemase-producing Enterobacteriaceae (CPE) there have been two defined outbreaks across HEFT this financial year. Each outbreak involved transmission between two different groups of patients, with three patients in each group. The index cases were defined on identification of a CPE from a clinical specimen. There was no failure of screening patients in line with the Trust policy. Action plans were devised and reviewed jointly with the commissioners and PHE. The outbreaks area reflection of the complexity of patients admitted to HEFT as well the multiple transfers between different clinical areas. Page 3 of 20 3. Patient Experience 3.1 Friends and Family (FFT) Test November 2015 3.1.1 Positive responses The graph below shows the proportion of both positive and negative responders by service area in November 2015. The yellow diamonds represent national performance. Proportion of Friends & Family Test positive and negative responders for November 2015 Comparison with national performance All areas are either consistent with or below national standards for both positive or negative responders. Areas of concern are in Maternity and ED as they are reporting an under compliance with national standards for both positive and negative responders. Actions to improve Patient experience is a key driver and measure within the provision of high quality healthcare. To enable improvements in the number of positive responders there is a focus on the hotspot areas within each of the divisions as follows (i)Emergency Department Birmingham Heartlands Hospital (BHH) A high number of responders have identified concerns with long waits along with staff attitude. To address this and improve personal interactions with staff there has been a focus on leadership with a change in uniform for the Shift Leaders and Matron clearly identifying the Nurse in Charge role. (ii)Emergency Departments-All Divisions Benchmarking against top performing organisations to observe and implement good practice and behaviours around communication with patients and families. Page 4 of 20 (iii) Maternity Services The introduction of SMS response service in Quarter 3 whereby patients can respond by text message and commentary for improvements. Two additional actions include a newly formed Patient Community Panels for each division. The panels will be working with the triumvirates on key projects to improve the patients experience, an example of this is mock CQC visits and actions required. Secondly there has been the introduction of a Patient Experience dashboard which provides FFT data at ward, site and trust level. 3.1.2 Response Rates The graph below shows response rates for each service area. Response rate by service area The internal trust target for responders for all areas is at 30%. In-patient areas are currently over performing all other areas are underperforming. Actions to improve this include: (i) Emergency Departments-All Divisions Response cards have been introduced in the newly formed minors area at BHH to encourage on the spot responses that can be monitored by the staff in the department. Initial discussions have taken place with regards to increasing the number of volunteers in all divisions to assist with data collection on the day of care (ii) Maternity Services The introduction of a new SMS service to encourage the number of responses in a timely manner was introduced in quarter 3. Early indicators have shown an improved number of responses. (ii) Outpatient Services Focused work commenced in October to ensure that staff were tracking the number of response cards received each day; this has resulted in a slight improvement in November s results. It is clear that in the three areas discussed above there is a need for improvement in FFT response rate and positive responders. This will be a priority in quarter 4 Page 5 of 20 3.2 Complaints The graph below shows the number of formal complaints received by month (line) and the proportion of these complaints based on their initial grading (bars). Formal complaints received by month The graph below shows the number of complaints responded to within 25 working days. Number of complaints responded to within 25 working days The updated complaint policy with agreed timeline for complaint responses is awaiting ratification. Weekly escalation of complaint progress against timescale to Divisional leads has been implemented. Overdue complaints are now escalated to Executive level for action. The trajectory for improvements in complaint response rates, agreed with Monitor, is 40% of complaints responded to within negotiated timeframe by March 2016, 50% by November 2016 and 60% by March 2017. The top seven complaint themes during the previous 12 months were clinical care, poor communication, staff attitude, nursing care, delays or cancellations in OPD and inpatient areas and admission and discharge. Page 6 of 20 Top seven complaints themes *as at 18th December 2015 3.2.1 Actions to Improve (i) Corporate actions There has been an introduction of a weekly complaints meeting where all open complaints are discussed and required actions are coordinated. Following this meeting the escalation of complaints is circulated to the divisions for action including highlighting current position of complaints per site and speciality. Complaints overdue by 30 days are escalated to the Chief Executive for action. In addition to this there has been an introduction of a monthly complaint meeting with each of the Divisional Head Nurses to discuss outstanding complaints. A new complaint policy has been drafted and is expected to be ratified at the newly formed Chief Executive Advisory Group (CEAG) in January 2016. A Quality assurance process has been implemented to ensure that accurate and timely responses are coordinated. A newly formed Chief Executive Officer response letter has been implemented with a requirement for embedded with lessons learnt identified. (ii) Divisional Requirements To ensure that this new process is embedded divisions must adhere to these requirements and have a clear understanding of how to embed lessons learnt from complaints and poor patient experience from ward to board level. Page 7 of 20 Currently there are action plans available as a result of trust wide complaints, however, there is limited assurance that the actions have been completed and shared to ensure improvements in the patients experience across all divisions. 3.2.2 New and Open Cases to Ombudsman (PHSO) In November the Trust was notified of 5 new referrals to the PHSO. The PHSO also issued 2 final reports relating to HEFT complaints. Both of these complaints were not upheld. The table below shows the numbers of referrals to the PHSO and the numbers of cases upheld. Indicator Apr May Jun Jul Aug Sep Oct Nov No of referrals to ombudsman 0 2 1 2 0 1 2 5 No of complaints upheld/partially upheld by Ombudsman 0 2 0 0 0 2 0 0 Number of referrals to PHSO and number of cases upheld The below gives detail of the one current PHSO case where actions remain outstanding. Ref Division Directorate 13.15400 BHH Elderly Action required Acknowledge failings identified. Apologise for the impact these had. Action plan by 05.01.16. PHSO cases with action outstanding 3.3 CQC Maternity Survey 2015 The CQC have released the 2015 Maternity Survey which benchmarks each trust against other trusts. There are three overarching categories which are labour and birth, staff during labour and birth and care in hospital after birth. Two hundred and seven women who gave birth in February 2015 out of a possible responded to the survey. Out of those who responded it can be clearly seen that HEFT has been benchmarked with other organisations as being about the same. The scores range from 9.4 out of 10 to 5out of 10 with most scores being in the 8 out of 10 range. Page 8 of 20 Areas to celebrate are partners being involved as much as they wished in the Intrapartum period, and 9.1 out of 10 for being treated with respect and dignity and 9.3 out of 10 for being spoken to in a way they could understand during labour and birth. Areas that scored the lowest 7.1 out of 10 for being left alone by midwives or doctors at a time that worried them and 6.9 out of 10 for length of stay and the lowest score of 5 out of 10 for feeling like their Partner who was involved in their care was able to stay with them as much as they wanted. It is disappointing that HEFT received a required improvement when the majority of scores were around 8 out of 10. There is always room for improvement and the team will continue to work on the key areas. 4. NHS Safety Thermometer The National Safety Thermometer is a point prevalence audit to measure harm in four key areas: Pressure Ulcers, both hospital and non-hospital acquired Falls within the preceding 72hrs of the audit being completed Urinary Tract Infection and Urinary Catheter use Venous Thromboembolism (VTE) Measuring assessment, appropriate prophylactic treatment and the development of a PE or DVT. Within HEFT the audit data incudes both acute and community care. The current month position for November 2015 demonstrates HEFT achieved 93.6% that is just below the national average of 94.3%. Although a national data collection tool the purpose of this methodology was to be as a local improvement tool and not as national benchmarking and these are the principles of how it is utilised across the organisation. Proportion of patients receiving harm free care Whilst harm from pressure ulcers remains our biggest cause of harm within this data set, November achieved 4.19%, which is in line with national reporting average of 4.20%. There was increase for November of catheterised patients developing a urinary tract infection this rose from 0.77 Page 9 of 20 to 1.77 with the national average at 0.71.Whilst, this is a harm to patients the value in actual number of patients rose from 8 in October to 14 in November. On completion of the safety thermometer the data is translated from a Trust wide to site and most importantly down to ward based scorecard so the local improvement can be implemented and lessons learnt. 5. Inpatient Falls Trust wide work continues to reduce the overall numbers of patients falling. The Trust 2015/16 year end trajectory is set at 6.36 against 1000 occupied bed days (OBD). Current performance demonstrates compliance within the agreed trajectory with November achieving 6.13 this has been sustained through quarter 1 and quarter 2 achieving 6:24 and 6:12.respectively. It is felt that the introduction of open visiting has improved our patient’s opportunities to eat, drink and move, therefore having a positive effect on falls reduction. . Trust Falls rate per 1,000 occupied bed days 5.1 Injurious Falls All falls have the potential to be injurious and cause significant harm to patients and whilst we have data to demonstrate this with year to date this being a total of 49 where patients have sustained a head injury or fracture compared with 55 for the same reporting timeframe of 2014/15. All injurious falls are subjected to an RCA process which is presented at local site forum and then additional quality assurance is undertaken at corporate level to ensure all lessons learnt have been captured and acted upon. 5.2 Repeat Fallers Whilst falls are considered unpredictable events many patients can be prevented from falling and certainly from having repeat falls by ensuring appropriate interventions are embedded into practice. In 2014/15 for quarter one and two 234 patients had more than one fall Page 10 of 20 whilst receiving inpatient at HEFT in some instances patients had in excess of 4 falls. For this reporting year significant emphasis has been placed on reducing the number of repeat fallers and this has achieved almost 30% reduction for the same period. 5.3 Falls Metric The nursing care indicators measure compliance with the falls bundle and assessment every month using the 10 patient sample size. Overall falls metric score and compliance with falls bundle level 1 and level 2 are reportable each month through the HEFT Contract to the CCG. The year-end target is to achieve 95% or above in all three components. Year to date for bundle 1 is 96% and Falls Bundle level 1 is currently at 93%. Overall falls metric currently at 94%. All elements achieved 95% by year end for 2014/15. Both elements were achieved. 5.4 Falls Practitioner Role The lead nurse for falls prevention is supported by two falls practitioners who are site based at Good Hope and Solihull. The role is to support the clinical areas in falls prevention and provide resources when dealing with complex patients as well as ward based education. The site based practitioners are posts which have been established within the financial year and have made a significant impact to the reduction of falls and reducing patient harm. 6. Pressure Ulcers The priority for HEFT is to reduce the overall number of patients who acquire avoidable pressure ulcers whilst in hospital during the 2015/2016 financial year. The agreed reduction trajectory for HEFT, set with the commissioners, was to achieve a 10% reduction for avoidable hospital acquired grade 2 pressure ulcers and a 50% reduction for avoidable hospital acquired grade 3 and necrotic pressure ulcers based on the Trust’s overall performance in these areas for 2014/2015. In addition to this the following three KPI’s are outlined within the contract; documented repositioning, actual repositioning and daily skin inspection, all of which are to achieve compliance of 90% in the overall metrics by the end of Quarter 2 and 95% by the end of quarter 4. Whilst it is important to achieve the target the priority is to ensure that incidents of patient harm caused by pressure ulcers is minimised through robust root cause analysis and shared learning. 6.1 How is the priority monitored and what has been achieved? Data is monitored daily by a ‘harm alert’ that provides all clinical areas with an overview of pressure ulcers that have been reported in the Page 11 of 20 preceding 24 hour period. Monthly pressure ulcer compliance within nursing care indicators are recorded across all adult inpatient areas. The overall score for the nursing care metrics from the end of Quarter 2 has been sustained at 94% up until November 2015. Performances against the three KPIs are: Compliance with documentation for the frequency of repositioning at the end of Quarter 2 was 95%Trust wide and has improved to 96% in November 2015. Compliance with the frequency of actual repositioning at the end of Quarter 2 was 79% Trust wide and has improved slightly to 81% in November 2015. Compliance with daily skin inspections at the end of Quarter 2 was 91% Trust wide and has improved to 93% in November 2015. These results show that improvement is required in performance against the KPI for the frequency of actual repositioning as this currently sits at 81% compliance. There are Divisional Tissue Viability Steering Groups held monthly to discuss areas of non-compliance and share good practice providing updates to all clinical areas. The divisional Tissue Viability leads then attend a monthly Trust Tissue Viability Steering Group chaired by the Deputy Chief Nurse. At this forum, each Division submits their monthly divisional performance against the overall trajectory, KPI’s performance data is discussed, and the Deputy Chief Nurse assigns recommendations and actions to divisions. Through this structure and at the end of Quarter 2 the Deputy Chief Nurse has mandated the implementation of three practice changes across each of the three divisions to ensure improvement in compliance with actual repositioning of patients. These are: 6.2 The introduction of repositioning clocks above each patients bed on those wards where compliance improvement with actual patient repositioning is required Daily metrics on actual repositioning to be completed and checked by the nurse in charge and the metrics results are presented to the Deputy Chief Nurse through the Trust Tissue Viability Steering Group Those wards that are achieving 90% or above on their actual patient repositioning metrics are undertaking a daily safety huddle to ensure performance is sustained Performance to date The following graphs outline performance to date against avoidable hospital acquired grade 2 pressure ulcers and avoidable hospital acquired grade 3 and necrotic pressure ulcers. Page 12 of 20 6.2.1 Grade 2 Pressure Ulcers Current performance at the end of November 2015 for Trust wide avoidable hospital acquired Grade 2 pressure ulcers equates to 120 against a target of 187. Performance against numbers last year has improved from 141 in November 2014 compared to 120 in November 2015. Avoidable hospital acquired grade 2 pressure ulcers 6.2.2 Grade 3 Pressure Ulcers Performance against hospital acquired grade 3 and necrotic pressure ulcers is 39 against a target of 29 breaching the trust trajectory. This breach is indicative of the current poor compliance with the actual repositioning of patients and the implementation of the three mandatory practice changes at the end of Quarter 2 were expected to improve compliance with this trajectory. This trajectory is broken down by division, during August and September this was breached however is compliant in November. The divisional breakdown of total numbers is as follows: Heartlands- Total 24, Good Hope- Total 8, Solihull - Total 7. Performance against numbers last year has improved from 41 in November 2014 to 39 in November 2015 Page 13 of 20 Avoidable hospital acquired grade 3 and necrotic pressure ulcers 6.3 Initiatives Implemented in Quarter 3 2015 A 12-month tissue viability re-energising campaign commenced in September 2015 with a different focus of pressure ulcer prevention each month supported by our media and communications team. A review of current reporting mechanisms and changes to the performance framework commenced in November 2015, whereby all clinical areas of concern are formally presenting incidents of avoidable pressure ulcers and lessons learnt to encourage shared learning and peer confirm and challenge. Any concerns with continued poor compliance will be referred to the Chief Nurse for consideration at the CEO RCA Meeting commencing January 2016 Continuation of bespoke ward and speciality based training where there are trends that are causing concern or complex education needs for the management of patient devices Mandate that daily skin checks are carried out before midday to encourage contemporaneous documentation Page 14 of 20 7. Discharge / Delayed Transfers of Care The local Health and Social Care economy for HEFT share concerns in respect of the deteriorating position of delayed transfers of care and have indicated commitment to resolve this through an agreed 7 point action plan. The deteriorating position is reflected in the graph below which shows a current DTOC position of circa 6% against an existing 3.5% target with a higher number from February 2015 with a higher proportion attributable to Health. A recent review of the DTOC position (weekly snap shot 30/10/15) provided an overview and baseline from which to start discussions with partner agencies. This informed the discussions at SRG meeting on 10/11/15 with key partner agencies. The snap shot showed: Over 50% of delays for social care relate to placement and 28% relate to assessment Only 15% of the overall delays are within HEFT’s gift to resolve independently 46% delays sit with Local Authorities – BCC and SMBC predominantly but not exclusively 29% sit with other Health providers The apportionments of the delays for each organisation were: 15% HEFT (1.76% if compared to OBD) 46% LA’s 29% CCG- other health providers A further analysis over a longer period of time is provided below and shows the increased level of health related delays across 3 sites over the last 12 month period and demonstrates the need for system wide commitment to an improvement plan and supportive actions to realign performance to 3.3% and then achieve the expected stretch target of 2.5% Page 15 of 20 The 7 point improvement plan agreed at SRG is: 1. A number of HEFT plans- demand and capacity modelling for appropriate staffing including Social Workers (SW) and Complex Discharge Nursing Service (CDNS) 2. Develop triage and reject for inappropriate requests and integrated working/pathways, integration of the CDNS service into the Discharge Hubs at BHH and GHH 3. 13 virtual beds- BCF funded scheme 4. Increase home based enablement capacity 5. Action plan from EAB session on 16 November to plan for reduction in LOS and reviewing processes and responsibilities for initial assessment 6. Daily board round for all patients on Transfer of Care 7. Involvement of senior colleagues from community health and social care on daily board rounds for min 4 weeks All HEFT actions are in progress. Whilst in comparison the HEFT attributable delays are low, the available analysis from UHB would suggest that actions in relation to Discharge Hub and TOC had a high impact in reducing overall delays to <2% therefore the HEFT specific plans will play a significant part in the delivery of the improvement plans generally. Current performance is circa 6% against a target of 3.5% - 90 patients delayed for a target of 49. NHSE are applying a stretch target of 2.5% (35 patients) Page 16 of 20 Suggested overall improvement trajectory 8. Safe Staffing The table below shows the Divisional break down for the November 2015 monthly nurse staffing level information for adult inpatient ward areas, including critical care. This information is published on the NHS Choices website for all Trusts with adult inpatient services and is reported to NHS England as part of the monthly UNIFY return. % fill rate Qualified Days 99% 96% 103% 100% % fill rate Unqualified Days 102% 98% 117% 90% Heartlands Good Hope Solihull Women & Children TRUST 99% 101% Divisional breakdown of nurse staffing levels % fill rate Qualified Nights 97% 98% 100% 98% % fill rate Unqualified Nights 113% 104% 112% 92% 99% 103% All areas were compliant with staffing during November 2015. Where there are individual clinical areas within a division that are not compliant the Head Nurse submits an exception report to the Chief Nurse that articulates risk mitigation and assurance of safe care. All staffing compliance is measured weekly (and with a look back at the previous six months) and is discussed with the Chief Nurse or Deputy Chief Nurse. This includes flexible additional areas enabling decisions to be made about the safety of opening additional beds at times of high demand. Workforce reviews have been undertaken for all in patient areas and AMU’s as per national guidance which highlighted no areas of concern. These will be repeated again in February 2016 and biannually. Page 17 of 20 The most significant challenge for safer staffing is the number of vacancies that there are for Registered Nurses and Midwives across the Trust. The Nursing vacancy position continues to improve following the implementation of a robust recruitment workforce strategy. This has focused on local and EU recruitment campaigns. There are currently 156 registered nursing vacancies across all adult inpatient and AMU areas. There are a further 41 planned starters over December and January with an average attrition rate of 11 Registered Nurses per month. Adult theatres continue to face significant challenges with their recruitment with a further EU campaign currently being undertaken. Emergency Department recruitment is progressing however there are challenges due to the lack of experienced nurses resulting in large numbers of newly qualified nurses being recruited and requiring intensive support and development. There is on-going Midwifery recruitment; however this continues to be insufficient for demand. The possibility of EU recruitment is currently being considered. The Chief Nurse and Workforce Lead Nurse are currently considering a potential solution for the provision of fit for purpose nurses from Romania over the longer term (circa 100 per year). This is being scoped. 9. CQUINS – Q2 targets were delivered with a number of actions required to meet Q3/4 Performance- there is a financial plan to deliver 75% in Q3/4 AKI – requires junior doctors training to complete information on discharge summaries and IT work to be competed enabling discharge summaries to collect data regarding AKI stage. Sepsis screening and antibiotic administration- requires % of patients screened and antibiotics administered within 1 hour of presentation to be improved from the current % (screening 22%, Antibiotic administration 54%) to screening 50% and AA and 70%. Dementia screening targets have been achieved for Q2 but focus needs to continue including within the community. COPD- GHH site has difficulties in access to COPD specialist support on site affecting the ability for all COPD patients to receive specialist review and all elements of the discharge bundle. AEC- Work is on-going to resolve data recording issues with Solihull to ensure all AEC activity can be captured in SUS. Page 18 of 20 Page 19 of 20 Page 20 of 20 Attachments: 0 Title: Quarter 3 COMPLIANCE AND ASSURANCE REPORT From: Sam Foster To: Board of Directors The Report is being provided for: Assurance Y Decision N Discussion Y Endorsement Y The Committee is being asked to: Accept this report as assurance on the internal and external compliance processes of the Trust Key points/Summary: The Trust has been rated as ‘Requires Improvement’ by the CQC. The action plan has been presented to the Executive Management Board monthly The Trust is currently doing a further audit of risk registers in preparation for the internal audit which will take place from January 2016. The central compliance team was not notified of any external inspection during Quarter 3. 97 % compliance against NICE Technical Appraisals. Recommendation(s): Accept this report as assurance on the internal and external compliance processes of the Trust Assurance Implications: Strategic Risk Register Y Resource/Assurance N Implications (e.g. Financial/HR) Identify any Equality & Diversity issues Performance KPIs year to date N Information Exempt from Disclosure N Outline how any Equality & Diversity risks are to be managed Which other Committees has this paper been to? (e.g. F & PC, QRC etc) None 1. SUMMARY The purpose of this paper is to provide the Board with an update on internal and external compliance as at December 2015. 2. INTERNAL ASSURANCE Quality Reviews During quarter 3 the Trust has continued to implement its rolling programme of quality reviews on wards and department using the quality review tool (based on CQC Regulations and Key Lines of Enquiry). Action plans continue to be monitored via the divisional quality and safety meetings. There are currently no exceptions to report to Board in quarter 3. Patient Safety Walkabouts The existing programme of patient safety walkabouts has been reviewed and a revised programme established. This will commence as of Friday 18th December at Solihull hospital. It is envisaged that this report going forward will provide by exception any issues that arise with mitigation plans to address them. NICE Guidance The Trust has a process in place to implement, review and record decisions where recommendations are not being met. The current compliance against NICE Technology Appraisals (TA) is 97%, the following presents the 2 TA exceptions: Both are being monitored by the Clinical Effectiveness group Ref TA345 Published Jul 15 Directorate Gastroenterology Title Naloxegol for treating opioid-induced constipation TA335 Mar 15 Cardiology Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome Reason for Non-Implementation Discussed at the October 2015 Area Prescribing Committee (APC). Concerns raised relating to the use of naloxogel in therapy. No decision was made regarding its position on the formulary. APC to write to NICE with concerns. TA335 has been considered, but the senior consultant team not willing to use the drug based on the single trial to which NICE refer. Reference also made to the European Society of Cardiology 2015 ACS guidelines to which the British Cardiovascular Society are aligned which makes no firm statement regarding the drug’s use, but do refer to the trial. Risk Register Audit A quarter 3 audit of risk registers in accordance with compliance against the Risk Management policy is currently being finalised. A further update will be provided in Q4 aligning to the outcome of the Risk/BAF internal audit which commences on the 11th January. Meanwhile, compliance with the Risk Management policy continues to be monitored via the weekly risk forum. 3. EXTERNAL ASSURANCE Care Quality Commission The action plan from the latest CQC inspection (December 2014) has been presented monthly to the Executive Management Board for review. The Trust was rated overall as ‘Requires Improvement’, with 11 requirement notices, 16 must do actions and 22 should do actions. An update on the overall action plan has been presented on a separate paper to the Board. In future, exceptions against the plan will be included in this report. A mock inspection to test the embedding of the actions is planned for January 2016. CQC Themed Review The Solihull team were included in the CQC themed review of End of Life Care in November 2015. The teams were commended by CQC for their passion and commitment to this work and the focus on patient centred care. Highlighted areas for improvement included, improvements to silo working and the IT infrastructure to support the sharing of information more effectively. The final report is still awaited and any exceptions will be included in the next compliance/ assurance update. IMR The CQC has confirmed that they will no longer be completing the Intelligent Monitoring Report (IMR) for Trusts. External Visits The Trust has a process in place to ensure that there is coordination of actions arising from external agency visits. No external visits have been reported to the central compliance team in Quarter 3. Internal and External Audit The safety and governance team lead on a number of the quality audits which are part of the annual internal audit programme. There are no updates for quarter 3 however, the team are currently preparing for the quarter 4 audits of the Risk and BAF and the CQC compliance process. 4. RECOMMENDATION(S) The Board of Directors is asked to accept this report. Title: ACTIONS FROM THE CARE QUALITY COMMISSION (CQC) INSPECTION From: Sam Foster Attachments: 1 To: Board of Directors The Report is being provided for: Decision N Discussion Y Assurance Y Endorsement Y The Committee is being asked to: The Board of Directors is asked to receive this update on the actions following the CQC inspection. Key points/Summary: The Care Quality Commission (CQC) completed an unannounced inspection at the Trust on the 7th/8th December 2014. The draft and then final reports were received by the Trust in June 2015. The action plan has been presented monthly to the Executive Management Board There are a number of actions where further work is required in order to provide full assurance of compliance (Attachment 1) Recommendation(s): The Board of Directors is asked to receive this update on the actions following the CQC inspection. Assurance Implications: Strategic Risk Register Y Resource/Assurance N Implications (e.g. Financial/HR) Identify any Equality & Diversity issues Performance KPIs year to date N Information Exempt from Disclosure N Outline how any Equality & Diversity risks are to be managed Which other Committees has this paper been to? (e.g. F & PC, QRC etc) None 1 HEART OF ENGLAND NHS FOUNDATION TRUST BOARD OF DIRECTORS WEDNESDAY 6th JANUARY 2016 ACTIONS FROM THE CQC INSPECTION 1. Introduction The Care Quality Commission (CQC) completed an unannounced inspection at the Trust on the 7th/8th December 2014. The draft and then final reports were received by the Trust in June 2015. The CQC inspected urgent and emergency care, maternity, medicine, surgery and outpatients on all three acute sites and stated that although there was some evidence of progress since the last inspection, in other areas there were no improvements or deterioration. The key findings are summarised as follows: • • • • • • • • • • • • Widespread learning from incidents needed to be improved. Appraisals for staff were not widely undertaken. Staffing sickness and attrition rates were impacting negatively on existing staff. Patient flow mainly in BHH and GHH was having negative impacts across all the core areas inspected. Referral to treatment times were not always met for people. Discharge arrangements required improvement; only 35% of patients were discharged on or before their planned date of discharge. The care of the deteriorating patient was generally managed well. Arrangements for patients with reduced cognitive function were not always effective. This meant that some patients did not receive the level of care and support they required. The culture within the trust was one of uncertainty due to the number of changes which had occurred. Staff could not communicate the Trust vision and strategy. Governance arrangements needed to be strengthened to ensure more effective delivery. IT systems required improvement to ensure reporting was accurate. The ability of the Trust to report against activity was not always available for use at Trust level or to the Commissioners. Areas of outstanding practice were identified as follows: On the Acute Medical Unit (AMU) at Birmingham Heartlands Hospital (BHH) local complaints resolution was very responsive to patient’s needs. The complainant was invited to a meeting and given a recording of the discussion. This appeared to resolve complaints quickly. • AMU, Ambulatory Care, wards 10, 11 and 24 on the BHH site provided excellent local leadership, services were well organised, responsive to patients individual needs and efficient which resulted in excellent patient outcomes. 2 • The Practice Placement team provided excellent links between the Trust and the University in supporting more than 600 student nurses across all three hospital sites. • Sexual health team demonstrated how they used information such as audit and patient feedback to improve services to patients. • Caring was good across the Trust. 2. Ratings The ratings are summarised as follows: Heartlands Emergency Care Medicine Surgery Maternity Outpatients Overall Safe Requires Improvement Requires Improvement Not rated Requires Improvement Requires Improvement Requires Improvement Responsive Inadequate Requires Improvement Not rated Requires Improvement Requires Improvement Requires Improvement Well-led Inadequate Requires Improvement Not rated Requires Improvement Requires Improvement Requires Improvement Safe Requires Improvement Requires Improvement Not rated Requires Improvement Requires Improvement Requires Improvement Responsive Requires Improvement Requires Improvement Not rated Good Requires Improvement Requires Improvement Well-led Requires Improvement Requires Improvement Not rated Requires Improvement Requires Improvement Requires Improvement Safe Requires Improvement Requires Improvement Not rated Requires Improvement Good Requires Improvement Responsive Requires Improvement Requires Improvement Not rated Good Good Requires Improvement Well-led Requires Improvement Requires Improvement Not rated Requires Improvement Requires Improvement Requires Improvement Good Hope Emergency Care Medicine Surgery Maternity Outpatients Overall Solihull Emergency Care Medicine Surgery Maternity Outpatients Overall Overall the Trust was rated as ‘Requires Improvement’ 3. Areas identified for improvement The Trust received 11 requirement notices and a range of ‘must do’ and ‘should do’ actions. The requirement notices are outlined as follows: 1. Lack of robust incident reporting and feedback which could result in learning opportunities being lost; 3 2. 3. 4. 5. 6. Management of patient handover, overcrowding and timely assessments in ED; Patients waiting over 30 minutes in recovery; Service delivery in OPD with the use of management reporting data; Availability of emergency medication in maternity and staff unaware of its whereabouts; Within ED cleaning practices need to be improved and staff not adhering to infection control policies; 7. Lack of equipment and faulty equipment not being replaced in a timely fashion; 8. Safeguarding was not in place for patients wearing mittens within the Trust; 9. Nursing staff was insufficient in places having a direct impact on patients, for instance the second obstetrics theatre at Good Hope; 10. The appraisal rate for staff within the Trust was 38%. This rate had the potential to impact on the level of care patients received. Managers also lost the opportunity to support staff and identify where additional support was required; and 11. The visibility of the Head of Midwifery continues to be an issue. 4. Action Plan The attached quality improvement plan (Appendix 1) sets out the actions as identified. It shows the actions that still require further work. All leads responsible for the assigned actions have been required to provide monthly updates and submission of evidence of completion as appropriate. Monitoring has been on a monthly basis via the executive management team 5. Next Steps Actions owners will continue to be monitored and supported to deliver against their action by the Trusts compliance team. Where there is no movement ,by exception this will continue to be escalated to the lead executive director and the divisional triumvirates. A programme of internal mock CQC inspections, focussing on the key areas is planned for January 2016. 6. Recommendations The Board of Directors is asked to receive this update on the actions following the CQC inspection. 4 Regulated Activity/Must Do/Should Do Operational Lead CQC Finding Current Measures in Place Further action identified Lack of robust incident reporting and feedback which could result in learning opportunities lost Much work has been undertaken over the last few years to support learning and organisation feedback from incidents. This includes; Development of multimodal cascade system for sharing lessons learnt from incident and errors SUI: At a Glance” and “Lesson of the Month” cascade processes (including Nurse induction programmes and junior doctors’ “Risky Business” Forums) Targeted sharing of incidents (for examples re: inpatient diabetes care in “Diabetes June”) Development of Patient Safety boards on a number of wards and also in the education centre. Learning lessons survey (April 2015) to evaluate learning lessons initiatives and identify gaps - Collaboration with Warwick University on research into what factor most strongly affects the efficacy of implemented learning initiatives at HEFT using the safety board concept More recently: Phase 1 of project to reduce IR1 backlog underway. This will include ward by ward visits to all staff and high level feedback on incident trends 1) Further communications will be sent out to Directorates and Departments reinforcing the importance of incident reporting and learning from incidents 2) A report summarising the previous 12 months trends in incident reporting will be sent to all wards and departments to support learning 3) Implementation of Phase 1 of the project to reduce IR1 backlog . This will include ward by ward visits to all staff and high level feedback on incident trends will be undertaken. 4) Implementation of be-spoke training to areas of percieved high risk or where additional training has been requested, will be implemented. 5) Review of Datix System Capacilities to improve userbility at ward level and enable greater feedback to reporters. 6) Implementation of Phase 2 of the IR1 Project focusing on departmental training and awareness. 7) Incident Reporting Policy will be revised and raified with roll out to ward areas. 8) Continue work with Director of Education & Clinical Tutor to provide feedback to junior doctors who report incidents 9) A new Datix front page will be developed to incorporate more information on how to get feedback and also link to organisational feedback in the form of “SUI:At a Glance” and “Lesson of the Month” Clinical Holding (Restraint) Policy. Safegaurding Policy Quarterly Audit cycles. 1) An MCA and DOLS Task and Finish Group will be implemented reviewing and implementing best practice processes across the organisation 2) Clinical Holding (restraint) Policy will be revised and include reference to the use of mittens 3) Following ratification the new policy will be implemented and rolled out within the organisation. 4) A review of the Safegaurding Audit Programme will be undertaken to include more regular review of restraint. November update: Clinical holding policy has been revised, approved and the policy launched.Launch has been led by Beverly Chew which has included site walkarounds, stands, roadshows etc. In depth audits to take place in Jan/Feb 2016. MCA DOLs and task finish group to be established in Feburary. Quality Reviews to test DOLs awareness and the appropriate use of clinicial restraint. Lorraine Longstaff The hospital must improve the information available to departments to ensure that these are monitored and action taken to improve services through audit, trending and learning. Implementation of Performance Management Framework. November update: The PMF process has been established. Unfortunately the first round of meetings were cancelled due to finance pressures. The framework is in place but requires exec suport to implement and embed Diane Povey MUST DO An external audit of hand hygiene practice has been carried out in clinical departments throughout the Trust. The hospital must take steps to improve Hand hygiene education and re-enforcement of adherence to infection control processes to compliance with six step technique and WHO five ensure the safety of patients. This includes moments carried out in identified clinical areas e.g the monitoring of hand outbreak ward. washing practices and the bare below elbows policies. This includes hand hygiene roadshows on wards, implementation of “Chain Reaction” and teaching of medics in surgery and AE. 1) Staff from the audited areas to attend hand hygiene forum, support will be given to cascade the learning to their departments. A re-audit of hand hygiene practice will be carried out in the same clinical departments at the end of 2015. 2) Hand hygiene road shows will be carried out across all three hospital sites during summer 2015. This will be supported by GOJO supplier of hand hygiene products. 3) Further programme of actions will be developed as part of the planned activity on the IPCT away day on 16.06.2015. 4) Increased hand hygiene education will be delivered as part of the doctors induction programme in August 2015. 5) Hand hygiene audit of medical staff in August and October 2015 in order to demonstrate sustained compliance. 6) There will be a Re-launch of “Major Handwash” twitter feed and communications campaign to reinforce hand hygiene messages. External audit of hand hygiene practice carried out in selected clinical departments at three hospital sites during October 2015. Slight improvement in hand hygiene compliance was noted in some but not all areas although all staff were observed to be bare below the elbow. The main area of non compliance was failure to decontaminate hands following contact with patient environment. Pocket reminder cards for staff are currently in development which include a reminder relating to hand hygiene practice. Infection control sessions are now included in the new nurse induction programme and a trainign video has been developed relating to MRSA screening. MUST DO The trust must address the ambivalence held by staff about reporting incidents as they may be under reporting and trust could miss important trends. MUST DO The trust must ensure all patients requiring items of restraint such as hand control padded mittens are supported with a mental capacity assessment, a DoLS and are regularly reviewed by the MDT which is recorded in the patient’s notes and mittens are replaced when soiled. A consistent practice must be adopted across the trust. MUST DO All patients treated at the Trust have a designated The trust must ensure patients are not consultant who is responsible for their care and clinical labelled with a condition unless a diagnosis management. Other members of the multidisciplinary has been confirmed by a medic. team, including nurses, therapists and other clinical support staff will contribute to the diagnostic process Regulation 17 (2(b)(f)): Good Governance Regulation 13(4)(b) (5) : Safeguarding service users from abuse and improper treatment MUST DO Safeguarding processes were not in place for people wearing mittens within the trust. Adult Updates on progress Since the start of this project the pre-April backlog has reduced from just over three and a half thousand to just under a thousand The total number of incidents awaiting review has decreased from just under five thousand to just over three and a half thousand (two and half thousand of which are over a month old) The remaining pre-april incidents will be devolved to head nurse and triumvirate leads as well as the current backlog (all incidents a month old) which has recently started to increase Agreement of revised incident reporting process and responsibilities will be agreed with chief nurse and triumvirate leads with appropriate supportive resources rolled out Revised process and performance monitoring framework to be embedded in January. Exec Monitored by Lead Evidence Req Timescale RAG Quality Committee Project TOR/Outline Project updates/Data Analysis Evidence of ward visits /teaching Jan-16 A/G SF Adult Safegaurding Committee Revised Policy Minutes from Adult Safegaurding Committee Minutes from Tak and Finish Group and Action Plan Audits Education packs/programmes schedule of visits. Feb-16 A/G JB EMB / CEO meetings PMF Framework and schedule of dates Feb-16 A Gill Abbott SF Infection Control Committee Evidence of Audit Teaching packs/sessions IPC Committee papers evidencing active learning and review Dec-15 A/G See above. Enforcement notice for Regulation 17 Lisa Pim/Louise Rudd SF Project TOR/Outline Phase 2 IR1 IIP Programme Board Project updates/Data Analysis Project December Evidence of ward visits /teaching 2015 A/G See above. Enforcement notice for Regulation 13 Lorraine Longstaff SF Adult Safegaurding Committee Feb-16 A/G Clive Ryder CR Exceptions to the Trust quality forums Apr-16 A Monitoing of complaints, incidents and patient / carer feedback will identify areas where tis is not being delivered Lisa Pim/Louise Rudd SF Audits to be carried out. Minutes of quality forums and Board reports MUST DO MUST DO The trust must ensure that staff are clear about clinical responsibility for patient’s awaiting handover by Ambulance services. 1) An AHO will be funded to support ambulance handovers. 2) An SOP will be written to support standardised practice in the Rapid Assessment Area. 3) The SOP will be rolled out. 4) Practice will be audited to ensure compliance. November update BHH Site only: Head nurses receiving daily reports on the patients waiting over 15 minutes in recovery Theatre matron and associate head nurse are working together to minimise delays as there are improvements to be made on both sides. It is discussed regularly with the surgical SWSs Bleeps have been ordered for each ward to have, once received and programmed an automatic bleep will be sent to the appropriate ward informing them that their patient has arrived in recovery therefore giving them approx 1/2 hour advance notice of the patient being ready to return. An escalation process has been developed for recovery to follow should they encounter barriers to returning the patient(s). There are some situations where the delays will not be easily prevented - for example when a patient is sent to theatre with no clearly identified receiving ward/when the patient has different surgery to that planned which requires a different exit location (eg planned for DSU or HDU, but due to a change in procedure requires a ward bed). November update for GHH site only – head Nurse receiving daily updates regarding delays for Patients waiting over 15 minutes in Recovery . AHN , Matrons and Ward Mangers for Surgery / T/O working closely together to monitor , minimise delays and make improvements . 0800 – Surgical / TO meeting held on ward 17 daily with SWS , Matrons and Surgical Bed Coordinator to discuss daily Theatre list / Trauma List and Bed Capacity issues . Surgical Coordinator aware of who is the point of Contact for each ward and who in Recovery is Charge so there is a single point of contact between areas . Initiative to be started at Bed Meetings is to highlight any delays in Recovery , There are situations where delays as BHH describes which not easily be prevented . Recovery delays are discussed at 1-1 s with Matron by AHN for planned care . Patients waiting over 30 minutes in recovery MUST DO The trust must review the operation of rapid assessment of patients to improve its consistency and effectiveness. MUST DO The trust must take effective action to achieve consistent staff compliance of infection control procedures MUST DO (GHH&BHH) The trust must take effective action to address the crowding in the majors area of Estate rationalisation Project Workstream the ED department and ensure that staff Major/Minors Re-design on duty can see and treat patients in a timely way. SHOULD DO The trust should ensure staff are given training how to report poor staffing levels via incident reporting software. The trust should ensure that patient’s with complex needs such as mental ill health, dementia or learning disability are SHOULD DO (GHH&BHH) appropriately supported through their experience of emergency department services. AHO is funded to support ambulance handover ED team have written operational policy for Rapid Assessment area (RAT) which clarifies responsibility ED redesign porject should help to support effective and timely handover Urgent Care Improvement Programme - Workstream 1 See above. Line 6 The theme of overcrowding with patient handover and timely assessments will be adressed by ensuring capacity and flow through the department, ensuring safe and efficient care delivery . The actions have therefore been forcused on improving the capacity through the department to achieve the outcomes required; 1) The works to move minors to an alternative environment will be completed. 2) The upgrade and expansion of Majors will be completed. 3) A working establishment will be devised (incorperating medical and nursing and support service models) 4) Safer placement of patients review will be undertaken to improve efficiencies and engagement with process. 5) Re-launch process re Safer Placement of Patients Process 6) Commence Escalation Card Process. The current ED expansion project at BHH is on schedule. New Minors Dept opened several weeks ago, Majors B (old minors) has been refurbished, Majors A has been refurbished. The resus area is currently closed so that the floor can be replaced. Resus cubicles have been re-provided in the Majors A area. Therefore all of the planned ED redesign and improvement work will be complete, additional Majors cubicles will be functioning • Safer Patient Placement is in place, site continues to embed this • Discharge Lounge , numbers increasing gradually and planning to open earlier to support SPP. Pilot planned to commence 2nd Nov with Pharmacy to evaluate the impact of putting Pharmacy resource into DL to prevent delays in transfer to DL from wards due to TTO issues • Site Safety Huddle at 0800am in Site office commenced – daily overview and briefing of priorities for the day • Site is continuing to support AHO in order to manage timely ambulance handovers See above. Regulation 17 1) Appropriate Assessment Areas will be provided for patients requiring this specialist intervention 2) Cohesive working will be evidenced working with the MH Trust/RAID to share best practice and improve patient care. New MH assessment room provided in New Minors area – fully compliant with MH requirements Engagement with MH trust and commissioners regarding additional support for winter period Increased engagement and collaboration with RAID services Elderly In reach to ED provided by Elderly Care team (Sally Jones & Niall Fergusson) Nov-15 A Dec-15 A Dec-15 R Evidence of Audit Teaching packs/sessions IPC Committee papers evidencing active learning and review Dec-15 A Pending meeting with CQC Action Plan Lead Nov-15 A Ben Richards SF/AC IIP Board BHH site- Louise Everett GHH site - Emma Harthill SF Ben Richards SF/AC IIP Board Gill Abbott SF Infection Control Committee Ben Richards SF/AC IIP Board Lisa Pim/Louise Rudd SF Project TOR/Outline Phase 2 IR1 IIP Programme Board Project updates/Data Analysis Project December Evidence of ward visits /teaching 2015 A/G Ben Richards SF IIP Programme Board A/G Weekly breach position to be Evidence of pilot study and Audit monitored on devliery Results unit dashboard SHOULD DO The trust should take steps to address staff Complaints procedure understanding of the value of learning from patient’s complaints and better promoting the engagement groups public engagement methods already in place. Patient 1) Commence monthly complaints review process with Divisional Heads of Nursing - reviewing live complaints and handling. 2) Add patient experience data to the current Nurse Quality Dashboard. This will include complaints data - improving data visibility and enabling ward managers to review at a glance specific data fields. 3) Ensure that Patient User Groups have the appropriate direction and governance arrangements in place to support their work. 4) Peer Review to be undrtaken to review trust processes in respect to patient complaints and handling - where possibel generating improvement in efficiencies and practice. 5) Following the review an action plan will be generated. This will be monitored through Quality and Risk Committee to ensure completion. 6) A business case will be develped to support devolved patient complaint handling - ensuring better ownership at local levele and improving engagement in the process. 7) To implement performance reporting to Quality and Risk Committee to ensure overarching review and monitoring. November update: Framework for patient engagement with governance and term of reference for newly configured patient panels. Peer Review Complaints process and subsequent action plan. Business case development to support devolved complaints handling. Web based computer handling database comissioned. Assurance performiance framework implemented reporting to Quality and Risk. HoPS involvement in Quality Champion programme. Use of EBD methodology to highlight messages contained in Patient Experience information/feedback to front line staff. Updated Complaints policy is drafted, in preparation for circulation to the Trust and other stakeholders for comment. Business case requirement for the department going forward have been firmed up in readiness for discussion with finance and formal request for consideration of business case. ToRs for Patient Panels are finalised and launched Patient Experience Advisory Group Committee to be established, draft ToRs circulated (sub group of Quality Committee) Datix implementation action plan underway, for completion end of December 15 Jamie Emery SF Quality committee. Weekly Complaints Review. Monthly HON Complaints Review. Weekly and Monthly Complaints. Quality and Risk Reports. Peer Review. Business Case. Jan-16 A/G BHH Division Regulated Activity/Must Do/Should Do Regulation 17 (2(b)(f)): Good Governance SHOULD DO SHOULD DO CQC Finding Management of patient handover, overcrowding and timely assessments undertaken in ED The hospital should consider improving the information available on delays for patients and consider what actions are taken to alleviate these to ensure a responsive service that meet the needs of patients. The trust should improve the connectivity with the iPads in use within anaesthetics. Current Measures in Place Estate rationalisation Project Workstream Major/Minors Re-design All patients have a predicted date of discharge (PDD) within 48 hours of admission and this is monitored via the daily Jonah board rounds Further action identified The theme of overcrowing with patient handover and timely assessments will be adressed by ensuring capacity and flow through the department, ensuring safe and efficient care delivery . The actions have therefore been forcused on improving the capacity through the department to achieve the outcomes required; 1) The works to move minors to an alternative environment will be completed. 2) The upgrade and expansion of Majors will be completed. 3) A working establishment will be devised (incorperating medical and nursing and support service models) 4) Safer placement of patients review will be undertaken to improve efficiencies and engagement with process. 5) Re-launch process re Safer Placement of Patients Process 6) Commence Escalation Card Process. 1) Communication with patients regarding discharge arrangements will be improved. 2) A patient leaflet will be devised informing patients of their discharge arrangements/requirements. ICT Director prioritising all requests for front line improvements. Updates on progress Staffing Plan has been completed this incorperates both nursing and medical workforce models. Ongoing recruitment plan in place - escalation plan in place to cascade staff from other areas should ED staffing be insufficient to ensure that all cubicles are open at all times. Escelation cards ahve been signed off and circulated and are in active use by management - site wide email remainded to go out from GR in early Jan 15 • The current ED expansion project at BHH is now complete - all capacity opened, there are now additional majors and high dependency cubicles in place. The site has also agreen a handover process with WMAS where patients are cohorted ans there is a designated individual in place (usually 1st POD) who is designated to provide nursing cover to the corridor should surge occur • Safer Patient Placement is in place, site continues to embed this • Discharge Lounge , numbers increasing gradually and planning to open earlier to support SPP. Pilot commenced 2nd Nov with Pharmacy to evaluate the impact of putting Pharmacy resource into DL to prevent delays in transfer to DL from wards due to TTO issues • Site Safety Huddle at 0800am in Site office commenced – daily overview and briefing of priorities for the day • Site is continuing to support AHO in order to manage timely ambulance handovers A Patient leaflet wasdrafted to go to every patient outlining the process and expectations of their stay and how they can plan their discharge with their families, however as the new Bed Utilisation policy has been implemented the leaflet has been replaced with a series of letters to patients which are consistent through the patient journey. The process was lauched across the BHH site at the Clinical Engagement Meeting on 29th October 2015 and therefore is currently becoming embedded and will be reviewed and monitored Awaiting final update/assurance from Leads November 2015 Operational Lead Ben Richards Ragu Sally Caren RG/CH/SQ- Stuart Dale Exec Lead Monitored by Evidence Req Timescale RAG Dec-15 A/G Ward Metrics and spot audits of Carl Holland availablilty. In Letter process in place, Sarah future when improved patient feedback on Quinton available, will be discharge arrangement s monitored by JONAH Nov-15 A/G RG/CH/SQ Stuart Dale General manager for Critical care and Anaesthetics Nov-15 SF/AC IIP Board Project Plan Staffing establishments/plan Safer Placement Review Escalation cards Pending Meeting Pending Meeting with CQC with CQC Action Action Lead Lead GHH Division Regulated Activity/Must Do/Should Do MUST DO SHOULD DO SHOULD DO CQC Finding Current Measures in PlaceFurther action identified Improve the environment of the transfer corridor used to transport patients and dispose of refuse appropriately. The trust address the ambivalence held by staff about the impact reporting incidents has on learning and improving the quality and safety of the service. The trust should ensure that staff working in the ED department are For further detail: see Urgent Care made aware of a vision and strategy for programme IIP workstream 6 the service and their contribution to achieving it. Updates on progress 1) Maintaining the decluttering of corridors 2) Safety Survey of the corridor will be undertaken for transferring patients (mainly children)access to telephones, cables, electrics. 3) Re-decoration of the corridor will take place to make it child friendly and less intimidating (Painting of floors/walls) 4) Contact will be made with "speight of the art" to provide further artwork. 5) Spot Audit checks will be undertaken to review the environment regularly. 6) To investigate the addition of medical equipment and telephones in the corridors November Update: Decluttering and cleaning of the corridors completed and being maintained. Schools are working on the themes identified by staff. Speight agreed to take on project will commence as soon as some funding has been agreed. Byron Batten Fire and Safety issues escalated to Dave Smith- Estates GHH- costing Julie Taylor obtained from estates and project lead. Update will be presented at Mona Cambell November STEER Co. See Trust wide action: Regulation 17 The Trust will ensure that engagement events are held with staff working within A&E on changes to the department and strategy going forward. Operationa l Lead October Update - There have been several away days and engagement events for all ED staff across three sites to discuss and debate the vision for Emergency Care at HeFT. The first on 6.7.15 and subsequent internal events for the wider ED team. On 14.07.15 – the vision was presented by the CD to the wider Trust at clinical engagement session. Work is in now in progress to work through the finer detail of the future plans , before meeting with key stakeholders to develop a health economy wide emergency strategy to align with the wider Urgent Care strategies. November update: Service plans for Emergency Medicine is currently under develpoment, along with a workforce strategy, first draft to be presented to BHH site team in Jan 16 November 2015 Exec Lead Monitored Evidence Req by Timescale RAG AR/JT/CS Divisional Committee Meeting Spot Audits of environment. Formal environmental audits Safety Survey STEER Committee Minutes Feb-16 A/G Lisa Pim/Louise Rudd SF IIP Project TOR/Outline Project updates/Data Analysis Evidence of ward visits /teaching Phase 2 IR1 Project December 2015 A Ola Efi, Raghu Urgent care Group Mar-16 A Agreed Strategy document and roll out plan Solihull Division Regulated Activity/Must Do/Should Do SHOULD DO SHOULD DO CQC Finding The trust should consider using assessment rooms fit for purpose at the AMU ground floor service and not admin offices or bereavement rooms. Exec Lead Further action identified AMU – Currently site is trying to manage flow through the department to reduce congestion in the department and reduce the length of time patients spend in the department. This facilitates use of designated triage cubicle Quality Review undertaken on the 26/08/15. Action Plan put in place - Divisional Clinical Governance Forum for review and monitoring on the 13/08/15. Action plan includes requirement to address issues relating to RAID Room so is fit for patient contacts. This includes removal of clutter Options paper AMU - There is a potential opportunity to and ensure appropriate equipment in place. Quality Review Undertaken Short Term Actions review AMU physical location and layout in the Commenced early phase of ambulatory care AEC Performance Data 31/10/2015 Long context of the Urgent Care Review proposals. which is facilitating identification of patients who General Manager for Options to Solihull Site VW/AC/VS produced weekly. These need to be explored by the site team can be assessed in alternative clinical areas. Transformation Board Term Actions June Ambulatory Care Model and Trust to establish whether there are November update: RAID assessment room has 2016 Process and Pathways. viable alternative options (See abov improved but still isn't totally free from clutter. Audit Spot Checks To be discussed with Ward Manager December update: Assoc Head Nurse to implement check and challenge process immediately which includes weekly review of the AMU assessment rooms to ensure they are fit for purpose. A A Quality Review was undertaken of AMU in August 2015 which has highlighted a lot of the AMU - There is a potential opportunity to detailed issues the dept needs to address. review AMU physical location and layout in the Delivery of the Quality Review recommendations / context of the Urgent Care Review proposals. requirements will be monitored through the sites These need to be explored by the site team Clinical Governance forum - Matron and CD for and Trust to establish whether there are Medicine are identified leads. Night walk around viable alternative options (See above) conducted by Corporate Senior Nurses on the Wards (ward 17, 18 & 20B templates)– Work 15/09/15. Management of flow and capcity to to be undertaken with wards to establish reduce volume of patients in the department ‘LEAN’ processes for storage requirements; during the overnight period reducing noise levels. Work to reduce occupied bed days to Substantiating additional ward (20B) and EJONAH continue, with a view to providing opportunity Programme of work to suuport wards with to reduce number of beds per ward and reducing lengths of stay. create opportunities for improved storage November update: FFT score for noise level at solutions night has not improved. Work ongoing to improve this. December update: Assoc Head Discussion has taken place with infection Nurse to carry out observations in AMU as Prevention who have recently provided LEAN previous work has not improved the situation. A training to site Housekeepers - request has robust action plan will be implemented to reduce been made for a 2nd session focusing on SWS. noise/confidential information being overhead. Work to improve the flow through out the hospital is ongoing. A AMU: currently site is trying to manage flow through the department to reduce The trust should ensure reducing the congestion in the department and reduce noise level and improve the length of time patients spend in the communicating (verbal) confidential department information at the AMU ground floor service. Wards (ward 17, 18 & 20b templates) Updates on progress Operational Lead Current Measures in Place November 2015 Monitored by AMU: Options to Site Board VW/AC/RS VW/AC/VS Wards: Site walk arounds Evidence Req Quality Review paper including recommendations and Action plan Evidence of walk arounds Daily SBARs which refelct numbers of patients in AMU Site LOS Information. Timeline RAG Solihull Division SHOULD DO The trust should ensure that identified risks and shortfalls in compliance relating to Solihull Hospital ED are specifically addressed in action plans for improvements. Urgent Care Improvement Programme Workstream 1 December update: Risk presented by Governance lead to risk forum on 11th December. 1. Safe sustainability of the MIU service at Solihull Hospital – score 15 -ENP anxiety has reduced slightly with only limited and manageable vacancies present with current staff having benefited from official MIU status/advertisement.GP cover 5 days with phased 7/7 working from 2016. Review of incidents planed for January with an improved picture anticipated. Lead /Group agreed to review risk score once the review of incidents has been completed and UCC development is clarified. 2. Compromise to care of Critically Ill Children at Solihull A&E – score 12 - Further comms exercise to parents in January advising . Incident audit due in January. Refresher training in paediatric advanced life support for staff providing the GP service is being provided by Trusts advanced life support trainers. As a new quality ans safety initiative , resuscitation and anaesthetic staff at SOH carry bleeps to advise them immediately of any sick child that may require their specialist support / medical input to stablise prior to transfer. This is also transmitted to the on call ED/MIU consultant who will attend in and out of hours , when required. New concerns are around the Paediatric ENP who is leaving in Feb and the challenges to recruitment . UCC " on hold" . Agreement with WMAS to ensure appropriate 999 transfers is currently working well and operating as planned. November 2015 Ben Richards RG/CH/SQ IIP Board Action Plan Under review - to be clarified when further information is known re UCC at SH A Solihull Division SHOULD DO The trust should ensure that locum doctors in the ED have the expertise Urgent Care Improvement Programme Workstream 1 that they need at hand at all times including overnight, to manage any Doctor Rotas - ED patient condition that may present. 1) The Trust will review its rota trustwide consider the adoption of further night cover being undertaken by current substantive Locum doctors. 2) The Trust will undertake a workstream reviewing a "blended front door approach", increasing the support of specialty doctors within busy ED's to give patients timely and appropriate access to specialty doctors promoting better decision making, movement of patients to appropriate specialty areas and discharge where appropriate. 3) As aprt of the workstream specialties will submit plans of how they will support the ED Directorate. November update: GP now in place 7 days per week thereby restricting locum usage to OOH periods allowing use of more experienced locum drs. A business case for the use of this service as a substantive basis has been submitted by the Directorate and approved. Discussions ongoing surrounding management of the service. December update: 1. Expansion of the GP in MIU service has enabled a small core group of locum doctors to provide consistent rota cover during the night time shifts. This has reduced the requirement for ad hoc and unknown locums , improving quality and safety in the department. Rotas are developed 8 weeks in advance , gaps are identified and ample opportunity is given to requesting bank/ internal locums to fill the gaps, On occasions where the shift cannot be filled with a known locum ( usually short notice absence) the locum CV is reviewed by the CD or on call Consultant to ensure that the Doctor has the necessary qualifications, skils and capabilities to work in the MIU, before they are booked. 2. Ongoing development of the AEC to include speciality input to patients attending MIU ,will include pathways by which MIU can refer directly to AEC. 3. Please refer to developments outlined above with reference to sick children. November 2015 Ben Richards Ragu RG/CH/SQ IIP Board Rota in place Work stream evidence Specialty plans Dec-15 A/G Maternity Regulated Activity/Must Do/Should Do Regulation 17 (2(b)(f)): Good Governance Regulation 15(1)(f):Premises and equipment Regulation 18(1)(2)(a) :Staffing CQC Finding Lack of robust incident reporting and feedback which could result in learning opportunities lost Operational Lead Current Measures in place Further action identified Updates on progress • Lessons are fed back in a variety of forums including: - Labour Ward Forum - Women’s Health Governance Committee - Women’s Risk and audit committee - Perinatal Mortality Meetings Safety Briefs at handovers - Women’s and Children’s Quality and Safety Committee - HoM Meeting - Consultant meetings - Band 7 meetings - Obstetric training day - 8B Lead Midwife for Governance in place and also a lead Obstetrician with a governance team in place supporting her. - Team Stepps supporting the directorate in safety improvement projects - Circulation of Newsletter Matty chat - SUI at a glance 1) A Quality Safety Review will be undertaken at Birmingham Heartlands Hospital - an element of this will be focused on incident reporting /learning 2) Evidence of Safety Briefs is to be captured across BHH and GHH 3) The Maternity Newletter will be revised to make the content more safety focused capturing lessons learnt 4) The Structure of the Womens Governance Team will be revaluated including the reevaluation of job roles and responsibilities strengthening local governance systems. 5) Unit Meetings will be set up on each site. A structured aganda incorperating learning from incidents will be implemented. 6) Training sessions will be delivered around DOC and learning from incidents. TOR devised for safety review BHH. Safety Reviews Commenced - Timescale for completion to be determined. Safety Briefs underway and evidenced. Newsletter has got evidence of learning currently but is under review - New newsletter anticipated deadline of December. Katherine Barber Unit Meetings in place - Governance lead to Clinical Director review if minutes are being recorded. Joy Payne HoM Presentation prepared - sessions underway Shalini Patni (4/6 seesions already delievered) Lead Obstetrician for Governance November update: Actions above all Janet Pollard Lead underway and are ongoing. Systems and Midwife Governance processes in place. Two new consultant and Quality midwives recently in post to embed Liz Howland Lead processes. Obstetrician GHH Site Equipment Folders in place - however these Lack of equipment and faulty equipment were not accessible to clinical staff and not being replaced in a timely fashion. knowledge of these folders by clinical staff were poor. Nursing staffing was insufficient in places having a direct Risk identified on the risk register. impact on patients. For instance not Business cases previously submitted for being able to staff increased staffing requirements. the second obstetrics theatre in maternity. 1) Equipment logs will be maintained by ward managers/ matrons in each designated area 2) A review of compliance with locally held ward equipment logs will be undertaken by the Associate Head of Nursing for Midwifery and Childrens Services. 3) Accountability in relation to equipment will be discussed at the away days, band 7 meetings and unit meeting. 4) Accountability for equipment will also be included in the monthly newsletter for September. 5) Spot checks of compliancee with expected standards will be undertaken by the Matrons. 6) Spot checks of equipmeny in clinical areas will be undertaken by the matrons. 7) Quarterly report of equipment compliance will be presented at the Womens Health Committee. 1) Staffing requirements will be rescoped in conjunction with Dr E Walker Consultant Anaesthetist. 2) Risk assessment to be reviewed on risk register 3) A Gap Anaylsis paperwill be undertaken to outline the risks and identify the gap between current staffing levels and recommended staffing levels with and the shortfall will form the basis of a businss case for additional staffing 4) The trust will review and approve the required funding and resource. 5) Training and competency based assessment will be provided to midwives and maternity support workers on scrub technique and circulating practitioner duties. Exec Lead Meetings in place monthly so on going in practice SF Folders in place. Spot checks to ensure folders accessible and up to date are in place. Spot checks of equipment are to be instigated and evidenced. Quarterly reports continue to be embedded as common practice by all sites. November update: spot checks underway, quarterly reports ongoing, list of equipment needed collected and this will be used to compile a priority list of equipment to be purchased. Problems with CERC under discussion. Maternity investigating own store of equipment. New BP machines being delivered by 20/11/15. Equipment folders in place and in use. Joy Payne/Tracey Nash A business case has been developed and been taken to Executive Management Board. The risk assessments for both sites have been updated and the risk score of 16 agreed at the Divisional Quality and Safety Group. Katherine Barber The risk has been presented at the Trust Risk Clinical Director AND Joy Payne Head of Forum. Pending approval on the business Midwifery case. Programme of training has commenced. it is Janet Pollard anticipated that this will be an elongated Lead Midwife process due to the requirement to backfill Governance and Quality staff in order to enable training. November update: Business case is going through the trust processes, currently at executive level. CSS division are supporting the staffing standards. Programme of training midwives is ongoing in the meantime. November 2015 Katy Hogan Monitored by Evidence Req SF Safety Briefs Matrons via governance July 2015 Women's Health Governance Committee Meeting Minutes Agendas Example of revised news letter. Evidence of Quality safety Review Evidence of Governance Team Review, Evidence of training sessions. Safety Briefs and sign in sheets.TOR for Safety Review Random Spot check by Operational Deputy Tracey Nash and Matrons Minutes of WHG Committee Spot Audit Documentation and Action Plans Timescale RAG Nov-15 A/G. Nov-15 A/G. Dependent on Business Case approval A Women’s Health Governance committee SF Women’s and Children’s Quality and Safety Committee Women’s and Children’s Divisional Board Scoping Exercise Risk Assessment Committee and Board papers Business Case TNA Training and competency package. Maternity Katherine Barber Clinical Director AND Joy Payne Head of Midwifery MUST DO The trust must provide sufficient staff to operate the second obstetrics theatre at night, and prevent delays occurring. Janet Pollard Lead Midwife Governance and Quality See above line 5 Women’s Health Governance committee SF Women’s and Children’s Quality and Safety Committee Scoping Exercise Risk Assessment Committee and Board papers Business Case Dependent on Business Case A Nov-15 A/G. Dec-15 A Women’s and Children’s Divisional Katy Hogan Maternity: Site Matrons Maggie Coleman Lorna Foster MUST DO The trust must replace or repair essential equipment in a timely manner. The trust should review the number of SHOULD DO (BHH)syringe drivers and blood pressure cuffs to meet the needs of women in maternity. See above line 4 Maternity: Ward managers and Matrons should ensure equipment logs are maintained and monitored in each ward delivery suite or community team. Equipment should be purchased on an annual rolling programme or as required. Equipment library in use The Associate Head of Nursing and Midwifery, Women's Services is in the process of actioning compliance with that there are equipment logs in each clinical area. Compliance will be monitored through the Women's Health Governance Committee Meeting Accountability in relation to equipment is discussed at the away days, band 7 meetings and 1) Please review actions accordingly in respect to unit meeting. In addition, this will be included in management of equipment (Regulation the September Maternity Newsletter 15(1)(f):Premises and November update: spot checks underway, equipment) quarterly reports ongoing, list of equipment 2) Priority list of equipment purchases will be compiled needed collected and this will be used to compile 3) Equipment will be purchased a priority list of equipment to be purchased. Problems with CERC under discussion. Maternity investigating own store of equipment. New BP machines being delivered by 20/11/15. Equipment folders in place and in use. November 2015 Joy Payne/Tracey Nash SF JP/PL SF Women's Health Random Spot check Governance by Operational Deputy Committee Meeting Tracey Nash Minutes of WHG Committee Spot Audit Documentation and Action Plans Womans Health Governance Committee Audits Annual equipment logs Clinical Support Services Regulated Activity/Must Do/Should Do Regulation 17 (2(b)(f)): Good Governance CQC Finding Patients waiting over 30 minutes in recovery Current Measures in Place Operational Lead Exec Lead Monitored by Evidence Req November update: BHH Site: head nurses receiving daily reports on the patients waiting over 15 minutes in recovery Theatre matron and associate head nurse are working together to minimise delays as there are improvements to be made on both sides. It is discussed regularly with the surgical SWSs Bleeps have been ordered for each ward to have, once received and programmed an automatic bleep will be sent to the appropriate ward informing them that their patient has arrived in recovery therefore giving them approx 1/2 hour advance notice of the patient being ready to return. An escalation process has been developed for recovery to follow should they encounter barriers to returning the patient(s). Safer patient placement to be There are some situations where the delays will not be easily prevented - for example when a patient is sent to theatre BHH site- Louise extended to surgery. with no clearly identified receiving ward/when the patient has different surgery to that planned which requires a Everett Louise Everitt Associate Head different exit location (eg planned for DSU or HDU, but due to a change in procedure requires a ward bed). GHH site - Emma Nurse BHH and Debra Jones Harthill Theatre Matron to lead. November update for GHH site: head Nurse receiving daily updates regarding delays for Patients waiting over 15 minutes in Recovery . AHN , Matrons and Ward Mangers for Surgery / T/O working closely together to monitor , minimise delays and make improvements . 0800 – Surgical / TO meeting held on ward 17 daily with SWS , Matrons and Surgical Bed Coordinator to discuss daily Theatre list / Trauma List and Bed Capacity issues . Surgical Coordinator aware of who is the point of Contact for each ward and who in Recovery is Charge so there is a single point of contact between areas . Initiative to be started at Bed Meetings is to highlight any delays in Recovery , There are situations where delays as BHH describes which not easily be prevented . Recovery delays are discussed at 1-1 s with Matron by AHN for planned care . AC/SF See updates section Recovery breach data in TMIS Further action identified Updates on progress November 2015 Timescale RAG Ongoing A/G Title: Finance Report to 30 November 2015 Attachments: From: Interim Director of Finance To: Board of Directors (6 Jan 2016) The Report is being provided for: Decision N Discussion Y Assurance Y Endorsement N The Board is being asked to: Receive the Finance Report for the period ending 30 November 2015. Key points/Summary: The Trust has reported an I&E deficit of (£5.4m) in Month 8 leading to a year to date deficit of (£45.9m) which is (£38.5m) above plan. The current forecast year end deficit is between (£53.0m) and (£64.0m) dependent upon the delivery of recovery actions and other upside / downside movements. The cash balance is £50.3m at 30 November 2015. The Financial Sustainability Risk Rating has fallen to 1. Recommendation(s): The Board of Directors is requested to: Receive the contents of this report. Note the range anticipated for the reforecast year end trajectories for 2015/16. Assurance Implications: Strategic Risk Register Y Performance KPIs year to date Y Resource/Assurance Y Implications (e.g. Financial/HR) Identify any Equality & Diversity issues Information Exempt from Disclosure N/A N Outline how any Equality & Diversity risks are to be managed N/A Which other Committees has this paper been to? (e.g. F & PC, QRC etc) None 0 HEART OF ENGLAND NHS FOUNDATION TRUST BOARD OF DIRECTORS WEDNESDAY 6 JANUARY 2016 FINANCE REPORT FOR THE PERIOD ENDING 30 NOVEMBER 2015 PRESENTED BY THE INTERIM DIRECTOR OF FINANCE 1. Introduction This report covers the first eight months of the 2015/16 financial year (1 April 2015 to 30 November 2015). The report summarises the Trust’s year to date financial performance and includes information on healthcare activity, expenditure variances and Cost Improvement Programme (CIP) delivery. During the planning for the 2015/16 financial year, using the information available at the time, it was anticipated that the underlying financial position would be a (£9.9m) deficit and this was submitted to Monitor on 31 March 2015, in line with the national timetable. In June 2015 (backdated to the start of the financial year), the CCG commissioners imposed a change from the Jointly Managed Risk Agreement (JMRA) to Payment by Results (PbR) on the Trust. No change to the Monitor plan was anticipated or submitted as a result of this change whilst it did introduce additional risk including marginal rates for a number of areas of growth. The impact of this change to PbR is currently being reassessed. Year to date, the Trust is reporting a deficit of (£45.9m), an adverse variance of (£38.5m) against the plan at this point in the year. The adverse variance is partially driven by Medical staffing (£10.0m) and Nursing staffing (£7.7m) with a number of different reasons behind the expenditure including Quality Initiatives, growth in activity/capacity constraints and premium rate cover. Other key drivers of the adverse variance are the use of the Private Sector (£3.2m) and slippage against CIP delivery (£19.1m) which includes both current and prior year targets. The process of recovery has started to deliver small improvements in the monthly financial position but further work is required to identify robust and recurrent plans which will reduce the deficit further. Currently the year end forecast is expected to be within the range of (£53.0m) deficit as a best case and (£64.0m) deficit as a worst case. 2. Income & Expenditure Year to Date Summary The Trust’s year to date income and expenditure position as at the end of November is a (£45.9m) deficit against a plan of (£7.4m), an adverse variance of (£38.5m). Table 1 below details the actual income and expenditure deficit compared to the planned trajectory produced at the start of the year. Table 1: I&E - Actual vs Plan 2015/16 I&E - Actual vs Plan 0.0 (5.0) (10.0) (15.0) (20.0) £m's 2.1 (25.0) (30.0) (35.0) (40.0) (45.0) (50.0) Apr May Jun Jul Aug Sep Cumulative Planned Trajectory Oct Nov Dec Jan Feb Cumulative Actual Table 2 below summarises the Trust’s income and expenditure position at the end of November with analysis of expenditure in section 2.3 and operating revenue in section 2.6 below. Mar Table 2: YTD Income and Expenditure Plan vs Actual YTD Plan YTD Actual Variance Nov Nov £m £m £m 424.6 433.2 8.5 (415.7) (463.4) (47.7) 8.9 (30.3) (39.1) (11.5) (11.4) 0.1 0.2 0.1 (0.0) (0.2) (0.2) 0.0 (4.6) (4.0) 0.5 (0.0) 0.0 0.0 (7.2) (45.7) (38.5) (0.2) (0.1) 0.0 Operating Revenue Operating Expenses EBITDA Depreciation Interest Receivable Interest Payable PDC Dividend Other Finance Costs Surplus/(Deficit) Gain/(Loss) on Asset Disposal Total Surplus/(Deficit) (45.9) (38.5) Monthly Run Rate The monthly deficit from the start of the financial year is demonstrated in table 3 below. Table 3: Deficit by Month Compared to Plan I&E Deficit versus Monitor Plan 1,000,000 0 (1,000,000) (2,000,000) £'s 2.2 (7.4) (3,000,000) (4,000,000) (5,000,000) (6,000,000) (7,000,000) (8,000,000) Apr-15 May-15 Jun-15 Jul-15 Aug-15 I&E Actual Deficit Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Monitor Plan The Trust has been delivered an average monthly deficit of (£5.7m) for the year to date against a planned average monthly deficit of (£0.9m). Although there has been an improvement since the recovery programme commenced in September, the deficit during November was (£0.9m) above the prior month due primarily to lower NHS clinical income in the period. 2.2.1 Ernst & Young Recovery Support As part of the recovery process, EY has been commissioned to provide two 6 week programmes. The first was to support the Trust in developing and implementing a short term recovery plan. This process has aided in the identification of recovery actions totalling a best case delivery of £20.4m in the 2015/16 financial year broadly split as follows: Nursing Medics Income schemes Reduction of Private Sector Usage Other Non-Pay Other Pay - £5.4m £2.4m £4.4m £1.1m £5.7m £1.4m Table 4 below details the anticipated trajectory with the delivery and implementation of rectification and recovery plans. Table 4: Improvement Trajectory Forecast Trajectories as at End of October 2015 (40.0) (45.0) (50.0) £m's (55.0) (60.0) (65.0) (70.0) (75.0) Oct-15 Cumulative Do Nothing Forecast Nov-15 Dec-15 Cumulative Worst Case Forecast Jan-16 Feb-16 Cumulative Likely Case Forecast Mar-16 Cumulative Best Case Forecast The second 6 week programme, currently in progress and due to run until early Jan 2016, involves quantifying the underlying recurrent baseline deficit position (following these recovery actions) moving into 2016/17 financial year, improving financial controls and starting to look at longer term productivity and efficiency opportunities. 2.3 Expenditure Analysis The adverse expenditure variance of (£47.1m) against plan can be broken down as detailed in table 5 below. Table 5: Breakdown of Variance Against Plan YTD Plan Nov £m PAY Medical Staff Nursing Scientific & Technical Other Total Pay NON PAY Drugs Clinical Supplies & Services Unidentified CIP Private Sector Usage Other Total Non Pay GRAND TOTAL YTD Actual Variance Nov £m £m 75.1 106.9 38.3 55.3 275.6 85.1 114.6 39.4 54.6 293.7 (10.0) (7.7) (1.1) 0.7 (18.0) 45.6 42.6 (19.1) 4.2 83.1 156.3 432.0 44.4 46.0 0.0 7.4 87.5 185.4 479.0 1.2 (3.4) (19.1) (3.2) (4.5) (29.0) (47.1) The main areas of pay and non-pay variance are explored further in sections 2.4 and 2.5 below. 2.4 Pay Analysis The drivers behind the pay variance are predominantly Medical and Nursing staffing. 2.4.1 Medical Staffing Table 6 below details the average monthly expenditure in the first seven months of the year compared to the month 8 period expenditure. Table 6: Change in Average Medical Expenditure Consultant Consultant Total Non Consultant Agency Locum Substantive Agency Locum Substantive Non Consultant Total WLI's WLI's WLI's Total Grand Total Average Monthly Expenditure Expenditure in Change Months 1-7 Month 8 £000's £000's £000's 541.2 498.3 42.9 291.7 204.8 87.0 4,765.0 4,874.0 (108.9) 5,597.9 5,577.0 21.0 744.4 655.7 88.7 384.2 395.0 (10.9) 3,541.8 3,727.2 (185.4) 4,670.4 4,777.9 (107.5) 370.1 257.1 113.0 370.1 257.1 113.0 10,638.4 10,612.0 26.4 It is clear that the recovery plans for medical expenditure are taking some time to gain traction. However, the following actions should result in improvements in future months: The phased removal of a number of unfunded posts between October and December. Introduction of Confirm and Challenge meetings where the use of locum cover is evaluated on a shift by shift basis starting in early December. A change in the authorisation process for use of external locums. Review of medical efficiency and productivity prioritising areas of concerns. 2.4.2 Nursing Table 7 below details the average monthly expenditure on nursing compared to the month 8 period expenditure. Table 7: Change in Average Nursing Expenditure Qualified Qualified Total Unqualified Agency Bank Substantive Agency Bank Substantive Unqualified Total Grand Total Average Monthly Expenditure Expenditure in Months 1-7 Month 8 £000's £000's 850.1 1,044.0 1,080.6 711.1 9,783.4 9,856.3 11,714.2 11,611.5 55.9 9.1 436.3 326.7 2,142.2 2,194.4 2,634.5 2,530.2 14,348.6 14,141.7 Change £000's (193.9) 369.5 (72.9) 102.7 46.8 109.7 (52.2) 104.3 207.0 The nursing position is showing some improvement, despite additional unfunded beds being opened, as a result of the following initiatives being implemented in the latter part of the year: 2.5 Substantive recruitment to posts previously covered by temporary staff. Weekly Confirm and Challenge meetings. Reconfiguration of wards at GHH to allow the cohorting of patients suitable for discharge. Introduction of dementia and delirium outreach team at Solihull. Removal of enhanced bank rates. Removal of use of off-framework agencies eg. Thornbury. Some take up of frontline shifts by CNS and Faculty nurses. Non Pay Expenditure 2.5.1 CIP Delivery Table 8 below details the breakdown of the undelivered CIP target. Table 8: Breakdown of Unidentified CIP Unachieved CIP 2015/16 Cash Releasing Run Rate Reductions 2015/16 Unachieved CIP Prior Years Grand Total Mth 8 In Month £m 0.8 (0.3) (1.4) (0.8) Mth 8 YTD £m (5.0) (2.8) (11.3) (19.1) The month 8 position shows an over-recovery of £0.8m against target for the 2015/16 programme largely as a result of back-dated income over-performance. However the prior year targets are contributing a (£1.4m) deficit per month to the position. The CIP delivery and year end forecast will be analysed further in section 3 below. 2.5.2 Clinical Supplies and Services The deficit on clinical supplies is largely driven by increased activity levels. 2.5.3 Private Sector Usage The early part of the financial year has seen the use of the private sector in order to support the Trust’s performance against Referral to Treatment Targets. The Trust is now ahead of trajectory to achieve 18 weeks by March 2016 and so the use of the private sector has largely stopped. The referrals to the private sector have been reducing on a weekly basis and now average around 5 cases per week. This should deliver an improved financial position in future months whilst monitoring continues to ensure the reduction in usage does not adversely affect the waiting lists. 2.6 Income Analysis 2.6.1 Total Operating Income Total operating income is £8.5m above plan at the end of November as shown in table 9 below. Table 9 – Income against Plan Clinical - NHS Clinical - Non NHS Other TOTAL YTD Plan Nov £m (381.1) (6.8) (36.7) (424.6) YTD Actual YTD Variance Nov £m £m (391.3) 10.3 (6.7) (0.2) (35.1) (1.6) (433.2) 8.5 NHS Clinical Income currently indicates over-performance of £10.3m year to date, however, it should be noted that contract payment challenges have been received from commissioners totalling circa £10.5m to the end of September. Although the Trust disputes the majority of these a bad debt provision has been made where appropriate. The over-performance on other income is predominantly from the NHS Lease Car Scheme and Sale of Goods and Services. 2.6.2 NHS Clinical Income/Activity - Inpatients Table 10.1 below details the monthly admitted patient care (APC) spells against target to the end of November. Table 10.1: Trust Inpatient Activity Admitted Patient Care 2015/16 - Actual vs Target (PbR) 8,000 7,500 Spells 7,000 6,500 6,000 5,500 5,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month Emergency Spells - Actual Emergency Spells - Target Daycase & Elective Spells - Actual Daycase & Elective Spells - Target The in-month activity position reflects an increased level of demand for Emergency pathways. There was an increase in the number of patients being seen in A&E of 4.0% compared to plan which has converted into a 3.9% increase in emergency inpatients and an 11.3% increase in assessment activity. Year to Date A&E activity is 0.2% above plan, contributing to a 0.5% increase in emergency inpatient but a (3.4%) reduction in assessment activity against plan. The in-month planned inpatient activity was 11.6% above plan and 2.4% above the year to date plan. 2.6.3 NHS Clinical Income/Activity – Outpatients Table 10.2 below details the monthly outpatient attendances compared to target to the end of November. Table 10.2: Trust Outpatient Activity Outpatients 2015/16 - Actual vs Target 78,000 76,000 74,000 Attendances 72,000 70,000 68,000 66,000 64,000 62,000 60,000 58,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Month Outpatient Attendances - Actual Outpatient Attendances - Target The Outpatient activity in month is 7.3% above plan which brings the year to date performance to 0.3% above plan. The main areas of over-performance in Outpatients in month are Paediatrics (691 attendances, 38.6%), Respiratory Medicine (477 attendances, 27.4%) and ENT (681 attendances, 25.4%). Main areas of over-performance year to date against plan are Endoscopy (2,344 attendances, 13.2%), ENT (2,470 attendances, 10.9%) and Respiratory Medicine (1,541 attendances, 10.5%). 2.6.4 2016/17 Commissioning Intentions The LDP process for 2016/17 has begun with the Trust submitting a letter highlighting proposed counting and coding changes. An initial response has been received from commissioners and the detailed negotiations will commence in January. 3. Cost Improvement Programmes The Trust’s 2015/16 financial plan includes a total efficiency savings target of £24.0m. Against an equal 12ths year to date target of £16m, the Trust has delivered £11.0m (68.7%). Of this year to date delivery (£3.6m) is nonrecurrent for which recurrent alternatives need to be identified going into 2016/17. Mar The delivery in the period of November shows over-performance against target of £0.8m predominantly due to some back-dated activity overperformance. The current year end forecast delivery is expected to be £19.1m, 79.8% of the target. The delivery by Division is detailed in table 11 below. Table 11: CIP Delivery by Division Division Heartlands Hospital Corporate Directorate Clinical Support Services Trustwide Education Services Facilities Good Hope Hospital Solihull Hospital Womens & Childrens GRAND TOTAL November - In Month Year to Date Target Actual Actual Non Variance Target Actual Actual Non £000's Recurrent Recurrent £000's £000's Recurrent Recurrent £000's £000's £000's £000's 623.8 249.7 91.4 (282.7) 4,990.0 1,793.3 1,521.4 117.3 54.8 0.0 (62.5) 938.0 463.0 0.0 436.5 465.7 1,112.4 1,141.7 3,491.7 1,248.3 1,498.1 7.8 7.8 0.0 0.0 62.0 62.0 0.0 116.7 118.9 2.1 4.3 933.3 897.1 16.7 183.3 117.2 0.0 (66.1) 1,466.7 678.5 5.9 289.8 238.4 62.2 10.8 2,318.3 1,654.3 446.6 225.0 288.7 28.1 91.8 1,800.0 580.3 125.9 2,000.0 1,541.2 1,296.2 837.4 16,000.0 7,376.8 3,614.5 Year End Forecast Variance Annual Forecast Variance £000's Target £000's Actual £000's £000's (1,675.3) 7,485.0 5,030.0 (2,455.0) (475.0) 1,407.0 735.8 (671.2) (745.3) 5,237.5 5,906.9 669.4 0.0 93.0 93.0 0.0 (19.6) 1,400.0 1,397.8 (2.2) (782.4) 2,200.0 1,542.1 (657.9) (217.4) 3,477.5 3,394.8 (82.7) (1,093.8) 2,700.0 1,044.6 (1,655.4) (5,008.8) 24,000.0 19,145.0 (4,855.0) Quality Impact Assessments have been completed, and signed off by Divisional Associate Medical Directors and Head Nurses, for 360 schemes with 97 currently overdue. Corporate QIA’s have been reviewed and are now with Execs for final sign off. This is expected by the end of December. The overall percentage of QIA’s complete has reduced from previous months following the addition of new schemes. 4. Statement of Financial Position The Statement of Financial Position (Balance Sheet) shows the value of the Trust’s assets and liabilities. The upper part of the statement shows the net assets after deducting short and long term liabilities with the lower part identifying sources of finance. Table 12 below summarises the Trust’s Statement of Financial Position as at 30 November 2015. Table 12: Statement of Financial Position Audited Mar-15 £m Non Current Assets: Property, Plant and Equipment Intangible Assets Trade and Other Receivables Other Assets Total Non Current Assets Current Assets: Inventories Trade and Other Receivables Other Financial Assets Other Current Assets Cash Total Current Assets Current Liabilities: Trade and Other Payables Borrowings Provisions Tax Payable Other Liabilities Total Current Liabilities Non Current Liabilities: Borrowings Provisions Other Liabilities Total Non Current Liabilities TOTAL ASSETS EMPLOYED Financed by: Public Dividend Capital Income and Expenditure Reserve Donated Asset Reserve Revaluation Reserve Merger Reserve TOTAL TAXPAYERS EQUITY Actual Nov-15 £m Plan Nov-15 £m Annual Plan Mar-16 £m 245.3 3.6 1.1 4.2 254.2 248.0 3.7 1.4 4.1 257.3 239.7 11.8 1.1 4.0 256.6 266.4 12.9 1.1 4.0 284.4 8.5 23.5 0.0 8.5 87.7 128.2 10.6 30.0 0.0 16.6 50.3 107.6 8.5 19.9 0.0 8.5 71.9 108.8 8.5 21.9 0.0 8.5 49.1 88.0 (73.7) (0.5) (8.7) 0.0 (6.5) (89.4) (102.2) (0.5) (7.6) 0.0 (7.8) (118.1) (67.6) (0.5) (7.7) 0.0 (7.6) (83.3) (79.1) (0.5) (7.0) 0.0 (6.5) (93.1) (4.0) (6.7) 0.0 (10.7) 282.3 (3.8) (6.5) 0.0 (10.3) 236.4 (3.7) (6.7) 0.0 (10.4) 271.6 (3.5) (6.7) 0.0 (10.3) 269.1 215.3 19.4 (0.2) 47.7 0.0 282.3 215.3 (25.3) (0.2) 46.6 0.0 236.4 215.3 13.2 (0.2) 43.3 0.0 271.6 215.3 11.8 (0.2) 42.1 0.0 269.1 5. Capital Expenditure (Non-Current Assets) The approved capital plan for the 2015/16 year is £50.4m which includes £20.4m of schemes brought forwards from 2014/15. The expenditure in November 2015 was £0.8m, to take it to £14.0m year to date which is underspent against plan by £3.0m but is on track against forecast. The variance is explained by a £2.5m underspend on ICT schemes and a £0.6m underspend on site strategy schemes. The capital forecast was revised at the October Capital Planning Group to £21.4m and subsequently to £19.5m on 9 November. 6. Current Assets The Trust’s total current assets (excluding cash and inventories) amount to £46.7m at 30 November 2015, (£18.2m) higher than plan. Table 13: Analysis of Current Assets (excluding Inventories and Cash) YTD Actual YTD Forecast November 2015 November 2015 £m £m 39.1 26.0 (11.2) (8.4) 2.1 2.4 30.0 19.9 3.4 2.5 3.4 2.5 13.2 6.0 13.2 6.0 Trade Receivables Bad Debt Provision Other Receivables Trade and Other Receivables Accrued Income Other Financial Assets Prepayments Other Current Assets TOTAL 46.7 28.4 Analysis of the age profile of Trade Receivables (unpaid invoices issued by the Trust) is summarised in table 14 below. Table 14: Aged Debt Analysis Aged Trade and Other Receivables for Nov 2015 40% 35% % of Debt 30% 25% 20% 15% 10% 5% 0% 0-30 30-60 60-365 1 Year+ Of the over 30 day debt, there are 3 debts in the region or in excess of £1m: Burton Hospitals Foundation Trust (£1.7m > 30 days, £2.0m total) – this has increased by £0.1m as new maternity pathway invoices was issued. There have been no payments since July. There is still £1.5m outstanding in respect of maternity pathways debt, including £0.9m in respect of 2013/14 activity, for which Burton refuse to pay. Sandwell and West Birmingham Trust (£0.9m > 30 days, £1.2m total) – this has increased by £0.1m in month. The majority of this debt (£1.1m) is for maternity pathways which have been escalated alongside other maternity debt. Other recharges for £0.1m are being chased by the debtor’s team and additional information has been provided so payment is expected to be made by mid-January. University Hospitals Birmingham (£1.1m > 30 days, £1.1m total) – the majority (£0.8m) is due to maxillofacial services with a further (£0.2m) being for ministry of defence HIV services. These accounts are under review with an expectation that the queries can be resolved within the next month. The Trust transactions team is working with Ernst and Young to implement new debtors chasing policies which include the following; Chasing actions to make sure debt is paid on its due date (this has already been in place for mandate payments for 12 Months) Chasing all debts over a set value that are over 30 days Sending letter from the FD to all larger debts Employing additional credit controllers for a short period of time to chase outstanding debt. 7. Cash Flow 7.1 Current Position The cash balance at the end of November 2015 was £50.3m, an increase of £3.7m in month. The variance to plan is (£21.6m) which is a £3.3m improvement on the October variance of (£24.9m). This improvement against plan variance is due to the working capital measures that have been put in place including the following; Only paying creditors when they have chased and not before the payment date. An improved collection rate on debtors. Weekly production of a rolling cashflow forecast based on known factors. As a result of the rate of payment to suppliers being slowed, performance against the Better Payment Practice Code target of 90% will not be hit in 2015/16, with October and November’s performance being 64% and 61.9% respectively. It is important to note that whilst working capital measures have been taken to improve the cash position in the short term, the ongoing reduction in cash will only slow if the recovery/rectification plans take effect and the income and expenditure deficit reduces. 7.2 Forecast Year End Cash Balance The graph below shows the impact on cash over the rest of the financial year of delivering the best, likely and worst case forecasts as at 7 December 2015 with a capital forecast of £19.5m. Table 15: Cashflow Forecast Month End Cash Flow Forecast 60.0 50.3 50.0 50.3 £m's 40.0 37.0 36.8 30.8 34.7 33.5 30.0 26.3 23.0 20.0 15.1 10.0 0.0 End Nov 15 27 Nov Rolling Forecast End Dec 15 End Jan 16 Best Case Forecast End Feb 16 Likely Case Forecast End Mar 16 Worst Case Forecast 8. Monitor Financial Sustainability Risk Rating Monitor has replaced the previous Continuity of Services Risk Rating with a new Financial Sustainability Risk Rating (FSRR) from August 2015. The four criteria evaluated, the weighting placed on each of them and the scoring rationale is detailed in table 16 below. Table 16: Scoring Mechanism for FSRR FSRR Metric Capital Service Cover Liquidity I&E Margin I&E Margin Variance Weight 25% 25% 25% 25% 4 2.50 0.0 1% 0% 3 1.75 (7.0) 0% (1%) 2 1.25 (14.0) (1%) (2%) 1 <1.25 <(14.0) <(1%) <(2%) The Trust planned to achieve an FSRR of 2 as at both month 8 and the year end. However due to the large income and expenditure deficit, three of the four criteria are rated as 1 bringing the actual FSRR at month 8 down to a weighted average of 1. The fourth criteria Liquidity is now rated as a 2, down from 3 in September, with the continued deterioration in the Trust’s net current liability position. 9. Conclusion The Trust is declaring an overall deficit of (£45.9m) for the first eight months (April – November) of the 2015/16 financial year, representing a (£38.5m) adverse variance against the Monitor plan of (£7.4m) deficit. The Trust’s cash balance as at 30 November 2015 is £50.3m which is (£21.6m) below the planned cash balance at this point in the year. Work on rectification plans continues with the yearend forecast income and expenditure position expected to be between (£53.0m) deficit as best case and (£64.0m) as worst case. As plans become more robust it is anticipated that this range can be reduced. 10. Recommendations The Board of Directors is requested to: Receive the contents of this report. Note the range anticipated for the reforecast year end trajectories for 2015/16. Julian Miller Interim Director of Finance 21 December 2015 Title: Board Structures From: Chair and Company Secretary The Report is being provided for: Decision Y Discussion Y The Board is being asked to: Attachments: To: Board Assurance N Endorsement N Consider and, if thought appropriate, approve changes to Board structures, including disestablishment of certain assurance committees and revising the membership of remaining committees. Key points/Summary: The interim Chair and interim Chief Executive have reviewed the Trust’s Board structures and believe that they should be streamlined to improve efficiency. The authority to make the changes contemplated rests with the Board. Recommendation(s): The Board is recommended to approve the proposed changes. Assurance Implications: Strategic Risk Register N Performance KPIs year to date N Resource/Assurance N Implications (e.g. Financial/HR) Identify any Equality & Diversity issues Information Exempt from Disclosure N/A N Outline how any Equality & Diversity risks are to be managed N/A Which other Committees has this paper been to? (e.g. F&PC, QRC, etc.) None 2 HEART OF ENGLAND NHS FOUNDATION TRUST BOARD OF DIRECTORS WEDNESDAY 6 JANUARY 2016 BOARD STRUCTURES 1. BACKGROUND The interim Chair and interim Chief Executive have reviewed the Trust’s Board structures and believe that they should be streamlined to improve efficiency and accountability. This is supported by and subject to the simultaneous review of operational structures that is also being brought to the Board. Given concerns about performance and governance, it is appropriate at this time to maintain direct sight of key operational and performance issues at Board level and to reserve to the Board the issues currently contained within the terms of reference for the related committees. The expectation is that the new operational structures will deliver a clearer and more robust accountability framework that will enable the Directors to receive assurance at Board meetings in relation to the majority of operational matters. It is therefore recommended that the following Board committees are disestablished with immediate effect: Finance & Performance Committee Information Management & Technology Committee Research Committee Workforce Committee The Chair will review the annual cycle of Board business to ensure that statutory responsibilities are fulfilled and key issues and decisions are appropriately brought to the Board and bring the Board Business Plan 2016/17 to the Board for approval in March 2016. The role of the Quality Committee will be re-focussed, so that, rather than the Board delegating its responsibility for clinical quality to that Committee, the role of the Committee becomes one of supporting and providing continuity for the Board in relation to its responsibility for ensuring that the care provided by the Trust is of an appropriate quality. It is intended that this Committee will meet on a bimonthly basis. The members of this Committee will be all of the Non-Executive Directors, including the Chair, the Chief Executive, the Medical Director, the Chief Nurse and the Director of Operations. Other officers of the Trust, including other members of the Executive Team, may be invited to attend the Committee as and when required. It is further recommended that the Appointments Committee is amalgamated into the Nominations Committee, the membership of which will be all of the NonExecutive Directors, including the Chair, and the Chief Executive (save when the matters before the Committee concern the Chief Executive). The revised terms of reference are attached and recommended for approval. There are no immediate plans to disestablish the following Board Committees: Audit Committee Donated Funds Committee Monitor Standing Committee The membership of these committees is proposed to be revised as per the attached schedule with immediate effect. The Board will undertake a review of these new arrangements in six months. The authority to make the changes contemplated rests with the Board. 2. RECOMMENDATION The Board is recommended to approve the proposed changes as described above. Rt Hon Jacqui Smith Chair Kevin Smith Company Secretary Board Committees – Membership proposal – January 2016 Audit Committee Chair Alison Lord Donated Funds Committee Chair Paul Hensel NEDs Andy Edwards Jon Glasby Karen Kneller David Lock Jammi Rao ED & Senior Mgr support Andrew Catto/ Clive Ryder Sam Foster/ Alison Fuller Julian Miller/ Angeline Jones NEDs Angeline Jones Jacqui Smith Kevin Smith Governor Albert Fletcher Monitor Standing Committee Chair NEDs Jacqui Smith Nominations Committee Chair Jacqui Smith Quality Committee Chair Jacqui Smith Remuneration Committee Chair Jacqui Smith David Lock Alison Lord Jammi Rao EDs (and Senior Mgr support) Sam Foster/ Alison Fuller Julian Miller Julie Moore NEDs Andy Edwards Jon Glasby Karen Kneller David Lock Alison Lord Jammi Rao EDs Julie Moore NEDs Andy Edwards Jon Glasby Karen Kneller David Lock Alison Lord Jammi Rao EDs Jonathan Brotherton Andrew Catto Sam Foster Julie Moore NEDs Andy Edwards Jon Glasby Karen Kneller David Lock Alison Lord Jammi Rao ED support Hazel Gunter Julie Moore NOMINATIONS COMMITTEE TERMS OF REFERENCE (Approved by the Board on 3 6 January 20126) All powers and authorities exercisable by the Board, together with any delegation of such powers or authorities to any committee or individual, are subject to any limitations imposed by the Constitution or by Monitor or by the National Health Service Act 2006. Due regard will also be had to any Code of Governance issued from time to time by Monitor. Any reference to “Director” shall be to formally appointed directors of the Trust Board and, unless otherwise specified, not to personnel who carry the word “Director” as part of their title. 1. 2. MEMBERSHIP 1.1 Members of the Committee shall be appointed by the Board and shall be made up of at least three members. At least one third of the membership shall be independentcomprise all of the Non-Executive Director(s), including the Chair, together with the Chief Executive, except that the Chief Executive shall not participate in any matters relating to her/ his own role. 1.2 The Chairman of the Board and the Chief Executive shall be members of the Committee. An independent non-executive director shall be the third member. 1.32 Only members of the Committee have the right to attend Committee meetings. However, other individuals, including external advisers, may be invited to attend for all or part of any meeting, as and when appropriate. 1.43 The Board shall appoint the Committee Chairman who should be either the Chairman of the Board or an independent Non-Executive Director. In the absence of the Committee Chairman or a deputy nominated by the Chairman and appointed by the Board (who shall also be an independent Non Executive Director), the remaining members present shall elect one of their number to chair the meeting. The Chairman of the Board shall not chair the Committee when it is dealing with the matter of succession to the chairmanship. SECRETARY 2.1 The Company Secretary shall be Secretary to the Committee and shall attend all meetings and provide appropriate support to the Chairman and Committee members. 2.2 The Secretary's duties will include: 2.2.1 agreement of the agenda with the Chairman, collation and circulation of papers; 2.2.2 minuting the proceedings and resolutions of all meetings of the Committee including recording the names of those present and in attendance. Minutes shall be circulated promptly to all members of the Committee; 2.2.3 keeping a record of matters arising and issues to be carried forward; and 2.2.4 3. QUORUM 3.1 4. 6. The Committee shall meet at least twice a year and at such other times as the Chairman of the Committee shall require. NOTICE OF MEETINGS 5.1 Meetings of the Committee shall be summoned by the Secretary of the Committee at the request of the Chairman of the Committee. 5.2 Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed, shall be forwarded to each member of the Committee and any other person required to attend no later than 5 working days before the date of the meeting. Supporting papers shall be sent to Committee members and to other attendees as appropriate, at the same time. ANNUAL GENERAL MEETING 6.1 7. The quorum necessary for the transaction of business shall be three, onetwo of whom must be an independent Non-Executive Directors. A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee. FREQUENCY OF MEETINGS 4.1 5. advising the Committee on pertinent areas. The Chairman of the Committee shall attend the Annual General Meeting prepared to respond to any questions on the Committee's activities. DUTIES 7.1 The Committee shall: 7.1.1 regularly review the structure, size and composition (including the skills, knowledge and experience) required of the Board compared to its current position and make recommendations with regard to any changes; 7.1.2 give full consideration to succession planning for Directors, taking into account the challenges and opportunities facing the Trust, and what skills and expertise are needed on the Board in the future; 7.1.3 keep under review the leadership needs of the organisation, both executive and non-executive, with a view to ensuring the continued ability of the Trust to compete effectively in the marketplace; and 7.1.4 keep up to date and fully informed about strategic issues and commercial changes affecting the Trust and the market in which it operates; 7.2 The Committee shall also be responsible to a Committee of the Board comprising the Chairman, the Chief Executive and all Non-Executive Directors for: 7.3 7.2.1 identifying, shortlisting, interviewing and recommending for approval candidates to fill Executive Director (whether voting or non -voting) vacancies as and when they arise; 7.2.2 recommending for approval the reappointment of any Executive Director who becomes subject to the periodic reappointment cycle having due regard to their performance and ability to continue to contribute to the Board in the light of knowledge, skills and experience required; and 7.2.3 any matters relating to the continuation in office of any Executive Director at any time including the suspension or termination of service of an Executive Director as an employee of the Trust subject to the provision of the law and their service contract. The Committee shall also make recommendations to the Council of Governors concerning: 7.3.1 formulating plans for succession for Non-Executive Directors; 7.3.2 the appointment of any Non-Executive Director; 7.3.3 the re-appointment of any Non-Executive Director at the conclusion of their specified term of office having given due regard to their performance and ability to continue to contribute to the Board in the light of the knowledge, skills and experience required; and 7.3.4 any matters relating to the continuation in office of any Non-Executive Director at any time including the suspension or termination of any Non-Executive Director. 7.4 8. 9. REPORTING RESPONSIBILITIES 8.1 The Committee Chairman shall report formally to the Board on its proceedings after each meeting on all matters within its duties and responsibilities. 8.2 The Committee shall make whatever recommendations it deems appropriate on any area within its remit where action or improvement is needed. 8.3 The Committee shall make a statement in the Annual Report about its activities. OTHER MATTERS 9.1 10. The Committee shall also make recommendations to the Board concerning membership of the Audit and Remuneration Committees, in consultation with the Chair of those Committees. The Committee shall, at least once a year, review its own performance and Terms of Reference to ensure it is operating at maximum effectiveness and recommend any changes it considers necessary to the Board for approval. AUTHORITY 10.1 The Committee is authorised to seek any information it requires from any employee of the Trust in order to perform its duties. 10.2 The Committee is authorised to obtain, at the Trust's expense, outside legal or other professional advice on any matters within its Terms of Reference. Attachments: Title: BOARD ASSURANCE FRAMEWORK From: Sam Foster To: Board of Directors The Report is being provided for: Assurance Y Decision N Discussion Y Endorsement Y The Committee is being asked to: 1 Review the revised BAF and identify any gaps in controls and assurance. Key points/Summary: The existing BAF has been revised by the relevant leads and is attached Risks have been mapped to the relevant strategic priority The BAF continues to be work in progress and further work is underway to ensure that the corporate risk register is integrated further to ensure that operational risks are recorded on the strategic risk register, where appropriate specifically for the risks that have been raised by the CEO/Chair to both Board members and Monitor. Once this revised process is fully established, it will also be cross checked with the performance report to ensure that all risks are captured on the relevant Executive risk register There are currently 3 red risks, 5 Amber risks and 1 Yellow (8) risk Recommendation(s): Review the revised BAF and identify any gaps in controls and assurance. Assurance Implications: Strategic Risk Register Y Resource/Assurance N Implications (e.g. Financial/HR) Identify any Equality & Diversity issues Performance KPIs year to date N Information Exempt from Disclosure N Outline how any Equality & Diversity risks are to be managed Which other Committees has this paper been to? (e.g. F & PC, QRC etc) None DRAFT Heart of England NHS Foundation Trust Board Assurance Framework 2015/16 Dec-15 Safe, Caring & Compassionate, Empowering and Effective DRAFT Heart of England NHS Foundation Trust - Board Assurance Framework - Summary (Q3-2015/16) QUALITY - Setting out our future clinical strategy through clinical leadership in partnership with whole system working to achieve continuous improvement in the quality of patient care that we provide Current Assurance Level Failure to have in place a sustainable governance infrastructure for all divisions, set against the Trust's quality and safety strategy and assurance frameworks. 12 Failure to deliver access standards owing to rising volume of routine secondary care work, delayed TOC, rising ED attendances, gaps in community provision, lack of impact from better care fund and rapidly rising two week wait 16 Breach of terms of Monitor Provide Licence /Material non-compliance with external regulators -with particular reference to capacity, finance and CQC inspection follow up action plan. 16 WORKFORCE - We will be a great place to work with a highly-engaged, motivated and skilled workforce who are supported to deliver high-quality care Current Assurance Level Failure to have in place the leadership skills and capacity at all levels to deliver new ways of working and appropriate ways of leading 12 Failure to maintain staff engagement 8 Inability to recruit sufficient numbers of appropriately skilled,trained and competent staff due to reduced workforce availability. 9 INTEGRATION - We aim to provide care as close to home as possible and patients will see a coordinated seamless approach to their care Current Assurance Level Failure to deliver an agreed vision within the Birmingham economy to deliver a fully integrated health and social care service 12 Inability to deliver the infrastructure metrics, workforce, information system, financial modelling and payment methods are not in place or sufficiently well-understood to deliver the programme of change 12 AFFORDABILITY - We will make the best use of every pound, developing services for the long term. Quality will be the key driver to affordability Significant deterioration in the Trust's underlying financial position resulting in the inability to deliver the Financial Recovery Plan against insufficient income. Current Assurance Level 20 DRAFT Note: for Q2 as this is the first report in the new format a trajectory has not been included This assurance framework assesses the most important risks that the Trust faces and which have the highest potential for external impact. These risks differ in magnitude and complexity to operational (day-to-day) risks and typically require comprehensive risk mitigation plans which span a longer time than most operational risks. The Trust defines strategic risk as a strategic control issue that could close down a service(s):1. Seriously prejudice or threaten the achievement of one or more of our strategic objectives. 2. Threaten the safety of service users. 3. Threaten the reputation of the Trust / the NHS. 4. Lead to significant financial imbalance and / or the need to seek additional funding to achieve resolution and / or result in significant diversion of resources. Strategic risk will be reviewed as part of the Trust’s annual business planning cycle and, if required, as identified during the year. The risks are managed to minimise the potential impact and / or likelihood of the risk occurring. The purpose of the BAF is to provide assurance to the Board of Directors that strategic risks are being fully and effectively identified, managed, mitigated and reported with clear ownership and accountability within the organisation. A risk score is attributed to each risk based on scores for impact (the effect the risk occurring would have on the organisation) and likelihood (of the risk occurring). Successful mitigating actions should lead to a reduction in one or both of these scores. The Trust uses the following matrix for scoring its risks. DRAFT Quarter 3 Board Assurance Framework Report Objective What is the Trust's objective? 1. CLINICAL QUALITY Setting out our future clinical strategy through clinical leadership in partnership with whole system working to achieve continuous improvement in the quality of patient care that we provide Risk Principal Risk ID Risk Describe the risk which threatens the Ref achievement of the objective 1.1 Failure to have in place a sustainable governance infrastructure for all divisions, set against the Trust's quality and safety strategy and assurance frameworks. Risk Owner Key Controls Individual What existing controls and processes that are in place to manage ultimately the risk accountable for managing the risk CN Good Governance Institute Review Key roles & responsibilities at Divisional and Directorate level triumvirates Divisional Committee structure Monthly Performance Framework reporting through to divisional review Trust Board reporting Sources of Assurance Where can we gain evidence that our controls/systems on which we are placing reliance are effective CQC Action Plan Board reports Minutes of Groups and Committees aligned to Divisions and corporate accountability Current Assurance Level RAG Rating Target Score Gaps in Assurance/Control Target RAG Where we are failing to pull Rating post controls/systems in place. Where we are mitigation plan failing in making them effective Current governance systems not fully mature within Directorates and Divisions to ensure the delivery robust clinical governance. 12 6 No clear route of escalation for risk from ward to Board Demand and capacity group involving all divisions and corporate services. DoP Trust Board Report. Performance against national target and waiting list size through Forecast activity for 2015/16. performance reports to divisional meetings, exec meeting and Board of Identified bed and theatre requirements overseen by business case Directors review group. 16 9 16 9 No transformational programme in place that is aligned to strategic objectives / projected activity in terms of efficiency / productivity / redesign Activity, income and performance reviews 2. WORKFORCE We will be a great place to work with a highlyengaged, motivated and skilled workforce who are supported to deliver high-quality care Breach of terms of Monitor Provide Licence /Material non-compliance with 1.3 external regulators -with particular 4.1 reference to capacity, finance and CQC inspection follow up action plan. CoSec Failure to have in place the leadership 2.1 skills and capacity at all levels to deliver the organisational objectives DoW 2.2 Failure to maintain staff engagement 2.3 Inability to recruit sufficient numbers of appropriately skilled,trained and competent staff due to reduced workforce availability. IIP and other regulatory frameworks. Monitor update Timescale What further action (if any) is necessary to address the gap? Dates/notes on slippage or controls assurance failing Work force review of corporate governance services to wrap round Directorates and strengthen the resilience and capacity of the local governance arrangements. To implement Executive-led risk group to ensure ward to Board accountability Divisional restructure Feb-16 Sustained clinical engagement Available information flow and analysis for monitoring Capacity demand modelling undertaken to right size capacity. Winter plan Failure to deliver access standards owing to rising volume of routine secondary care work, delayed TOC, rising ED 1.2 attendances, gaps in community provision, lack of impact from better care fund and rapidly rising two week wait referrals. Actions/Planned Updates EMB, Trust Board and PMO - CQC action plan Mature governance systems and processes Divisions working to implement the capacity requirements as identified via BCRG. Alternative / collaborative (community) models of care for ward based capacity Divisional activity monitoring through range of forums. Aligned to Quarterly reviews of activity and growth. All plans presented to Exec Team. Activity and capacity plan for 2016/17 to be presented early February as year 1 of 5 sustainable plan (all as 16/17 Monitor planning guidance) Transformation plan will be derived from this in response to the capacity / financial requirement On-going Review of governance framework as described in 1.1 and 4.1 On-going Trajectory to reduce datix backlog DoW Managed through the new executive team meetings currently and Weekly Execs Trust Board. Structures including accountability currently being worked on and will be implemented early 2016. Good Governance Minutes of and reports to Trust Board Institute commenced work with the Board. Quarterly engagement scores. National staff survey results. Communications with staff via range of communications from Chief Executive Extensive recruitment activity has resulted in circa 160 nurses joining the Trust in October and December 2015. Pastoral support is in place to support and improve attraction and retention DoW 12 6 Leadership programmes for senior leaders Discussions to be held with the new CEO aligned to the in the organisation have not been financial envelope. identified. 8 6 Sustained defined Staff Engagement programme 9 6 Sustaining an affordable integrated quality To continue to evaluate the current workforce position set workforce within the current financial against the Trust corporate objectives. envelope set against clinical activity 12 6 Fully agreed vision at Executive level with reference to short-term winter plan and medium-term priorities Jan-16 Staff Engagement Steering Committee Reports to Trust Board Teambrief events have been set across each main site plus the Chest Clinic, Lyndon Place and a number of community locations, delivered by the CEO. These will be held each month from January 2016 Jan-16 Weekly and monthly monitoring of recruitment trajectories. Weekly monitoring via Finance Medical Efficiency Programme incorporating medical vacancies and Recovery Board job planning Dec-15 Trust Board Discussions taking place between HEFT and partners including the GP Federations, East and North Birmingham 3. INTEGRATION We aim to provide care as close to home as possible and patients will see a coordinated seamless approach to their care Failure to deliver an agreed vision within 3.1 the Birmingham economy to deliver a fully integrated health and social care service DOP Service model discussions with UHB and City and Sandwell The clinical model discussed and clarification sought with Birmingham Community Healthcare using a shared approach to post-acute care Integrated Care and Social Services (ICASS)Programme management structure Trust Board EMB Systems Resilience Group To monitor discussions through existing Governance arrangements Direct discussion with CEOs Jan-16 DRAFT Inability to deliver the infrastructure metrics, workforce, information system, 3.2 financial modelling and payment methods 4.1 are not in place or sufficiently wellunderstood to deliver the programme of change Solihull Vanguard Project to address the issues relating to the infrastructure Gaining full assurance that BCF is fit for purpose Trust Board DOP Plans to roll this model out into Birmingham economy once recognised 12 6 ICASS Systems Resilience Group Sustained collaborative working with the CCGs To continue to strengthen the programme and change management capacity within the financial envelope and work collaboratively with key stakeholders Jan-16 Additional resource provided to support the programme Trustwide rapid cost reduction programme Controls reviewed and updated 4. AFFORDABILITY We will make the best use of every pound, developing services for the long term. Quality will be the key driver to affordability. Expenditure across the Trust has significantly exceeded the income received leading to a rapid deterioration in the Trusts cash position. Despite the financial 4.1 recovery plan there is likely to be a requirement for ongoing central financial support in early 2016/17. This may reduce the Trusts ability to determine its own use of resources Financial Recovery Programme established Availability and transparency of financial information Directorate accountability through divisional monitoring Unidentified savings within 2015/16 cost improvement programme Financial Recovery Tracking Framework Financial Recovery Framework agreed and issued internally DoF External support with plan (Ernst&Young) now in place Short term Financial Recovery Plan agreed by the Board of Directors and Monitor Longer term Financial Recovery Plan to be developed and submitted by 11 April 2016 Financial Recovery Programme Board 20 12 Widespread communications strategy Fully-implemented job planning (Demand & Capacity) Divisional recovery meetings Clarification of staff terms and conditions Weekly Ernst&Young report Maximise transition to PBR (getting paid for the activities performed) Monthly finance report to the Board of Directors Understanding of financial baseline / robustness of financial plan for 2015/16 Support from Ernst Young Cash and capital expenditure review Trustwide finance communications plan Endoscopy 7-day working consultation Nursing efficiency programme Medical efficiency programme (focus on locums & job planning) Workforce redesign Trustwide activity and income entitlement project (counting and coding) SLR programme being tested and rolled out Ongoing Title: Annual Safeguarding Report Attachments: 2 From: Sam Foster Chief Nurse To: Trust Board The Report is being provided for: Decision N Discussion Y Assurance Y Endorsement Y The Board is being asked to: Note the activity of the Children’s’ Safeguarding Boards across Birmingham, Solihull and Staffordshire – and be assured that The Trust is satisfied that it has the internal and partnership processes in place to monitor the effectiveness of safeguarding arrangements within the organisation and can identify areas of strength and areas for further development during 2015-16. Key points/Summary: Heart of England NHS Trust sees and treats over 132, 000 UNDER 16’s. The Trust has an established Specialist Safeguarding Team reporting to the Executive Lead for Safeguarding (Chief Nurse) and internal governance processes to oversee the effectiveness of safeguarding arrangements within the Trust. The Trust reviews the compliance with CQC safeguarding regulations and Section 11 quarterly There is external scrutiny of the safeguarding arrangements within the Trust through the CCGs, LSCBs, the CQC and monitor. The Trust has completed a capacity review of Specialist Safeguarding Resource in view of growing demands and new ways of working (including Multi-agency Safeguarding Hubs). Recommendation(s): For the Board to receive the Annual report and to receive assurances on current position and proposed activity of the safeguarding team. Assurance Implications: Strategic Risk Register N Performance KPIs year to date Y Resource/Assurance N Implications (e.g. Financial/HR) Identify any Equality & Diversity issues Information Exempt from Disclosure nil N Outline how any Equality & Diversity risks are to be managed n/a Which Committees has this paper been to? (E.g. F&PC, QC, etc.)External safeguarding boards, Internal safeguarding committees, Partner Agency Annual Safeguarding Report 2014/15 To the Local Safeguarding Children’s Board To provide assurance and to contribute to the LSCB Annual Report Evaluating the Effectiveness of Safeguarding arrangements in Birmingham, Solihull and Staffordshire. Partner Agency: Heart of England NHS Foundation Trust Report Author: Maria Kilcoyne 1 Executive Summary Effectiveness of safeguarding arrangements in your organisation with evidence The Trust has an established Specialist Safeguarding Team reporting to the Executive Lead for Safeguarding (Chief Nurse) and internal governance processes to oversee the effectiveness of safeguarding arrangements within the Trust. The Trust reviews the compliance with CQC safeguarding regulations and Section 11 quarterly There is external scrutiny of the safeguarding arrangements within the Trust through the CCGs, LSCBs, the CQC and monitor. The Trust has completed a capacity review of Specialist Safeguarding Resource in view of growing demands and new ways of working (including Multi-agency Safeguarding Hubs). Progress made in improving safeguarding practice and outcomes for C&YP in 2014/15 in your organisation During 2014-15 the Trust has: Expanded the scope of supervision to include the large group community midwives and increased the amount an frequency of supervision to the health visitors Increased compliance with the safeguarding learning and development strategy Responded to the latest requirements in relation to Child Sexual Exploitation and developed and commenced delivery of in house Child Sexual Exploitation (CSE) Training; a communication strategy to promote awareness of CSE and how it may present to health staff; arrangements to capture use of the CSE screening tool Introduced the new multi-agency referral forms from Birmingham and Solihull and maintained a focus on the quality of information transferred at referral Implemented a number of audits to track the effectiveness of information sharing at points of transition Sought the views of families following safeguarding referrals and gained an understanding of how they experienced this process Tracked both good practice and learning through implementation of the ‘patient story’ template using this to highlight both good practice and areas for improvement. This has in many cases illustrated the contribution of HEFT staff in achieving safety for children through application of assessment and multi-agency processes. Increased CAF initiation in maternity and health visiting services Emerging themes and areas for improvement for your organisation in 2015/16 The Trust has identified the following areas for further improvement: Sharing of information – particularly at transition points is an area that will feature in audit activity in 2015-16 to ensure that the Trust can be satisfied that information sharing is reliable and ensures that children can be safeguarded. This includes a continued and relentless focus on the quality of information shared in multi-agency referral forms (MARFs) with further improvement required The Trust will commence rotation into the Multi-agency Safeguarding Hub in 2015-16 and will aim to improve the interface between acute care and the MASH. Recruitment is underway. Supervision – the Trust plans to maintain compliance with supervision targets whilst expanding provision in the Emergency Ensuring that user experience continues to inform practice Consistency of application of safeguarding knowledge and processes -Ensuring the consistent application of safeguarding assessments with 16-18 year olds and for adults presenting with problems with substances, mental health issues or domestic abuse Early Help -The Trust will be seeking to increase use of the appropriate assessment to help families access early help in health visiting, maternity, neonates and clinical nurse specialisms in paediatrics Challenges to be addressed in 2015/16 by your organisation Completion of a capacity review and consideration of a Business Case for Safeguarding Specialist Resource in quarter 1 2015-16 Full implementation of recommendations following the Lampard and Marsden report into the NHS following the Investigations into Jimmy Saville Illustrating improved consistency in the safeguarding assessment for 16-18 year old and adult presentations suggesting parenting capacity could be compromised Establishing a consistent and skilled response to young people at risk of child sexual exploitation wherever they present in the organisation. Enhancing the communication skills of practitioners when they are raising safeguarding concerns Maintaining momentum in the assessment of families for early help Maintaining compliance and expanding the remit of specialist child safeguarding supervision Expanding the voice of the child and service user in the safeguarding arena Refreshing the understanding of key staff in relation to Right Service Right Time and thresholds. 2 Introduction Heart of England NHS Foundation Trust is large provider of a wide variety of child and family’s services for residents of Birmingham, Solihull, Staffordshire and other neighbouring areas. The Trust provides the following services to patients: Emergency Care, Maternity and Neonatal Services, Acute Services for Adults and Children, Community Services within Solihull. The Trust, annually, sees and treats 1.2 million people and has 250,000 attendances to the Emergency Departments. The Trust employs approximately 10,000 staff. Due to the geographical area covered by the Trust there are relationships with three Local Authorities and three Safeguarding Children Boards (Birmingham, Solihull and Staffordshire). Although it should be noted that the Trust does not sit as a formal member of the Staffordshire Board currently. Birmingham City Council has also been continuing its improvement journey in relation to safeguarding children and the BSCB published it plan ‘Getting to Great’ in 2014 which highlights 3 priority areas: • The voice of the child • Early Help • Safe systems Birmingham Local Authority has during 2014-15 altered arrangements at its ‘front door’ to ensure that there is multi-agency screening of referrals, prior to decision making. This new arrangement is part of the safe systems work stream and is known as MASH (multi-agency safeguarding hub) and these arrangements have been replicated elsewhere in the West Midland and will be implemented in Solihull in quarter 2 of 2015-16. The Trust will be required to commit safeguarding specialists to both MASH arrangements and is working to increase capacity within the Team to facilitate this. The national agenda and media coverage in relation to child safeguarding within the NHS has been dominated by two main issues during 2014-15: Themes from the investigations into Jimmy Saville within the NHS and high profile exposés of system wide, inadequate responses to child sexual exploitation. The Trust has developed responses to both issues and will continue a focus on implementation in these areas into 2015-16. 3 Effectiveness of Safeguarding Arrangements Section 11 ‘Duty to safeguard’ o Outcomes for your agency from BSCB S11 Peer Challenge event The Trust has self-assessed against section 11 during 2014-15 and participated in a peer challenge event. The Trust judged itself to be overall 85% compliant with the requirements. In 2014-15 the main areas for HEFT development were: Expansion of specialist safeguarding supervision Increasing service user involvement and feedback in relation to safeguarding. Reviewing restraint Increasing access to information on how to stay safe for children and young people using our services Increasing use of the Common Assessment Framework The Trust is in the process of undertaking a review of Section 11 compliance with the new BSCB tool and anticipates that this will be completed by the end of May 2015. o Progress on implementing actions from 2014 audit. The table below highlights progress on implementation from the audit completed in 2014-15. Element of the S11 audit Expansion of specialist safeguarding supervision Progress Increasing service user involvement and feedback in relation to safeguarding Increasing children’s awareness of how to stay safe Reviewing recruitment of volunteers Early help – delivery enhanced through use of the CAF Restraint Business case completed to allow community midwives to participate in safeguarding supervision Increased the frequency of provision for health visitors from 2015-16 Evaluation of supervision undertaken in Community Services Patient Experience Team encouraged to get involved with families at the point of referral Small scale telephone survey completed with families who have experienced safeguarding processes Patient stories completed Digital patient stories incorporated into training of frontline staff Links between the safeguarding team/ patient experience and complaints reviewed Trust internal and external websites developed with key messages for children and young people. Packs developed for in patients adolescents exhibiting mental health problems or risky behaviours Key display areas promote how to stay safe and the Child Line number is promoted within the Trust The Trust Safeguarding Team tweet and have links to the wider Trust circulation – this allows contact with parents regarding e-safety and the ‘Underwear Rule’. Status Community midwives receive supervision All completed Completed This was reviewed and decision made for enhanced checks on all volunteers CAF initiation increased in Maternity and Health Visiting Completed Training reports received in relation to the any service offering physical restraint. Awareness raising completed in relation to the policy Completed Completed . o Internal assurance of our safeguarding effectiveness? • There is a Safeguarding Children Committee which meets bi-monthly to review progress against all statutory and regulatory requirements • This group reports to the Governance and Risk Committee (a formal sub group of the Trust Board) • The Trust has an annual safeguarding audit programme which tests out the effectiveness of safeguarding arrangements in response to reviews/ incidents and this programme is particularly focussed on information sharing at transition points in a child’s life. • The Trust has a robust Safeguarding Learning and Development Strategy (updated in 2014) and monitors progress in relation to compliance with the strategy on a quarterly basis. • Safeguarding supervision is available to staff in line with the policy and again compliance with the framework is monitored quarterly. • The Trust works closely with partners in police, social care, other health organisations and with the LSCBs and CCGs to continuously strive for best practice in relation to safeguarding. • The Trust monitors safeguarding children activity and quality of information shared on referrals to Children’s Social Care The Trust implementing recommendations from the Children’s Looked After and Safeguarding Inspections carried out by the CQC. Safeguarding Performance NB: Please note that Education and Development is covered under section 6 – workforce development Safeguarding Children Referral Activity The Trust has seen a year on year increase in the numbers of children referred each quarter since 2010 as illustrated in the table below. Average Referral rates per quarter year on year for children are: 2010-11 2011-12 2012-13 2013-14 2015-16 150 445 446 601 653 The graph below illustrates the referrals completed each quarter during 2014-15 Quality of referrals is continuously monitored with feedback provided to staff. Level 3 Safeguarding Children Training focuses on the quality of information shared at the point of training. Quality issues are identified most frequently with ED referrals and additional targeted training is being delivered within that Department, commencing in May 2015. The introduction of new referral forms by Local Authority partners has been welcomed as having potential to improve information shared at the point of referral. However whilst the Solihull web based tool has been easily implemented the trust has experienced difficulties with the Birmingham MARF and is unable to send referrals electronically due to lack of secure email in many areas. This has been raised as a risk within the organisation. The form is not liked by ED staff who find it difficult to fill in and report issues with the ‘drop down’ sections and access to computers. However, as more referrals are being typed this has improved legibility. Referrals due to concerns regarding adult behaviours are monitored quarterly. The table below reports the numbers of referrals citing adult concerns. Acute Services Community Services Domestic Abuse 608 Substance Misuse 366 Mental Health Problems 692 24 13 19 Whilst the information in the table above demonstrates that professionals ‘think family’ and provides some assurance of this the Trust has also conducted audits which demonstrate that consideration of safeguarding of children is not consistent when adults present with problems. This is an area for further development. Referrals per Local Authority: The graph below illustrates the percentage of referrals to Local Authorities. Overall percentage rates of referrals to Local Authorities fluctuated slightly during 2014-15 with referral rates to Birmingham Local Authority at 70 % compared to 77% in the previous year and referrals to Solihull increasing to 24% from 17%. Feedback from referrals This remains a problematic area with feedback not being received in particular from Birmingham Local Authority who have asked that we do not request it and that they will send to the individual referring practitioners. We remain in discussion with them as individual practitioners often will not be able to marry the outcome up with the child’s records due to their work patterns/ nature of work and also few of our staff have secure emails to send this information to. We are continuing discussions as we are keen that this information is sent to a central point (Safeguarding Team) for internal dispersal and to ensure that records can be updated. Outcome unknown increased during quarter 4 to the highest ever level as previously this has consistently been between 20 and 30% See table below in relation to feedback from referrals during quarter 4 2014-15. Already open – passed to SW Section 47 & Strategy Meeting Social Work Single Assessment Family Support Signposted for CAF Signposted other Outcome Unknown No further Action 15% 5% 13% 5% 0.4% 4% 38.5% 19% Child Sexual Exploitation During 2014-15 the Trust commenced monitoring of the numbers of referrals made by staff due to concerns regarding CSE. This monitoring commenced in quarter 2 and the table below illustrates the relevant referral activity. It should be noted that the Trust has started to deliver targeted CSE Training to key staff groups and this commenced in Quarter 4. Quarter Quarter 2 Number of Referrals related to CSE 2 CSE screening tool at the time of the referral 0 Quarter 3 8 3 Quarter 4 17 5 Referring Department 1xCAMHS 1x Sexual Health 2 x ED 1x Maternity 1 x other 3 x Sexual Health 1 x CAMHS 3 x ED 1x HV 3 x Maternity 1 x Paediatrics 9 x Sexual Health CAF The Trust has also seen an increase in use of CAF to drive early help with both Maternity and Health Visiting increasing their use of CAF during 2014-15 (maternity produced 68 CAFs and Health Visiting 64). Staff report that they have found this work beneficial and the Trust will continue to monitor use of CAF in these areas during 2015-16. Supervision The Trust has supervision in place for the highest risk areas including: Paediatrics Health Visitors School Nurses Specialist and Community Midwives The Trust has struggled to achieve and maintain the 90% target set in relation to compliance with the supervision policy. This is due to capacity within the specialist safeguarding workforce and was exacerbated by some sickness. The Trust continues to work with consultant paediatricians to tweak the format for their ‘peer review’ to meet their needs. For acute services the average compliance with supervision policy was 82% during 2014-15 For Community Services the average compliance with supervision policy was 86%. The Trust has been asked to develop supervision within the ED during 2015-16. All Named Professionals receive supervision and for Acute services 93.75% compliance was achieved. For community services this was 87.5% The Trust provided supervision to two groups of staff during 2014-15 that have transferred out of the Trust for 2015-16 . These include high risk areas of sexual health services and CAMHS. Quality of safeguarding practice Audit Activity in the Trust is driven by the Inspection and review processes (completed as part of the Serious Case review Process or the Domestic Abuse Process). Key areas of focus are ‘Think Family’, Transition and Information Sharing. The table below provides a brief flavour of areas looked at that the results Area of Audit Findings Further Action Maternity Liaison Audit – Some delays, found, good Introduction of electronic transfer of information from compliance with transfer and recording of maternity to Health Visitor completion of paperwork transfer of information. by midwives but lack of Area for further audit in evidence of how they were 2015-16 sent Maternity Due Date Audit Poor compliance (60%) On-going live audit in place with transfer of with remedial action if nondocumentation relating to compliance found. safeguarding issues to the Workshops for new child’s record at birth and midwives. to the transfer of alert to the child’s electronic record Domestic Abuse routine Improved compliance with Subject to on-going inquiry routine inquiry x 3 monitoring Genogram audit in Compliance with Communicated to staff and paediatrics and community genograms variable (better for further review services in acute than community records). Self-Harm Audit to look at 0-16 year olds presenting 16-18 year old assessment safeguarding response. with self-harm all had paperwork updated and Audit of 0-16 years and 16- consideration of their 18 years completed safeguarding needs, multiagency discussion and admission for support in relation to self-harm behaviours. ‘Invisible Child’ Audit Quality of referrals 16-18 years olds often had limited assessment of safeguarding needs Variable response to the assessment of child safeguarding needs when adults present with mental health problems Variable quality, many referrals not explicit enough about nature of concern. Paediatric Audit of stepping down in safeguarding concern Highlighted that there was infrequent discussion between ED and Paed doctors Audit of checks with other hospital when children are investigated for nonaccidental injury 100% compliance not achieved safeguarding assessment enhanced. Training planned for the adult ED workforce who assess 16-18 year olds Further training and support for staff indicated and underway. Messages sent to all staff. Training in place, mechanisms in place to provide additional information when required. Improvements noted in paediatrics and maternity Process changed in view of the findings to ensure discussion between ED and Paediatric Consultants when a case is stepped down Supervision used to oversee this requirement. Patient Stories During 2014-15 the Trust has completed a number of patient stories, many highlighting good practice including staff that had appropriately identified safeguarding issues, contributed to the multi-agency processes and effectively ensured a safe outcome for children. Areas for development that have arisen in relation to some patient stories are: Ensuring that the history of complex cases is fully explored by health visitors following the transfer in of cases from out of area. Promoting the escalation process to staff when they are unhappy with threshold decisions Ensuring staff are confident with thresholds for intervention Ensuring that staff are active in pursuing information that they need shared from other agencies. Reminding staff about referral responsibilities. The patient stories have enabled us to capture and ‘celebrate’ good practice with our staff who in many instances have been at the forefront of the identification and articulation of concerns. Learning from complaints and compliments Learning from complaints and compliments during 2014-15 has consistently highlighted one main finding and that is that communication at the time that safeguarding concerns emerge, during and post the referral process is critical. One family drew attention to a nurse who was identified by name who the family had said was a ‘caring and empathic nurse who explained the safeguarding process and pathway clearly and effectively’. The family contrasted this nurse with other professionals involved in the process who they felt had been abrupt, uncommunicative and in some instances had appeared judgemental. Another family likened the fact that they had been notified of a safeguarding concern, in what they felt was unnecessarily blunt terms, before the full assessment had been completed to being told ‘you had cancer before all the diagnostic tests had been carried out’. Communication was the dominant theme from safeguarding complaints and discussions are underway about to ensure that this finding is most effectively relayed to staff (via digital patient stories) and how staff skill in this area can be enhanced. A digital patient story is used in Level 3 training currently. Summary of work to engage with and listen to children and young people and the learning from this. The Trust commenced work this year in the form of a telephone survey to understand some of their views of the child protection process. This work has highlighted the importance of very clear communication throughout the process. It has really captured the views of parents and carers rather than young people. The views of young people on the care they receive whilst inpatients is captured using ‘Fabio the Frog’ and the Trust has links with school groups which enable consultation with young people on the development of services. Young people make a clear contribution to the decisions made about their clinical care when they are assessed to have capacity. Their views are also taken into account during multiagency meetings. Where adolescents have expressed strong desires about where they wish to reside or be discharged to there are examples of where staff have advocated for them to ensure their views are taken into account. Number of serious incidents involving children and young people and outcomes from reviewing them The Trust has reported a total of 5 significant Incidents: 2 obstetric, 2 paediatric and one paediatric prevented never event Serious Incidents during to 2014-14 have led to an increased focus within the trust on the SUDIC process as a number of SIs highlighted poor compliance with the process. This has been refreshed with key staff in paeds/ neonates and ITU. Findings from Internal Reviews and action taken Internal reviews have highlighted the following learning: During 2014-15 the Trust has been in the process of implementing learning from a SCR which highlighted the need for increasing staff awareness in relation to substance misuse, domestic abuse and other risk factors, enhancing assessment tools and documentation in the health visiting service, reviewing supervision processes for health visitors and exploring the liaison between maternity and health visiting services. The Trust has completed a number reviews as part of the domestic homicide process this year that highlighted the need for staff to adhere to self-harm pathways, the domestic abuse policy, to ensure that adults presenting with ‘Toxic Trio’ type presentations have consistent consideration of the safeguarding needs of any children in the family. All training provided during 2014-15 has been updated to ensure that relevant messages are embedded. The audit programme reflects these key areas for further exploration. Findings from External Inspections and Reviews and action taken The Trust has been subject to a CLAS inspection as part of the health economy in Birmingham during 2014-15 and has learning to implement around: Ensuring the safeguarding assessment of 16-18 years olds is consistent Consistent application of ‘Think Family’ principles Ensuring compliance with the assessment of safeguarding risks in paediatric Emergency Department Ensuring assessment in maternity reflects social factors and routine inquiry Review of ED discharge information Summary analysis of the effectiveness of safeguarding arrangements o Strengths The Trust has an established specialist safeguarding team and clear arrangements in place for governance in relation to safeguarding. The Trust has a workforce that are identifying children with safeguarding concerns and can evidence they follow safeguarding processes. The Trust has improved the CAF initiation rates amongst midwives and health visitors during 2014-15 and will continue to work on this in 2015-16 to drive early help to families as soon as needs emerge. See section 6 below on workforce development – the Trust has a robust Education and Development plan in place and staff report feeling confident in identifying and referring concerns and knowing who to contact for help. The Trust has an audit programme annually for safeguarding which is driving some key improvements and identifying areas for further work and audit. Areas for improvement The safeguarding assessment of 16-18 year olds particularly in relation to CSE The consistency of assessment of safeguarding needs of children related to adults with toxic trio type presentations The span of safeguarding supervision to include the ED The quality of referral information – particularly from the ED The transfer mechanism for referrals to Birmingham Increase and consistency in the use of the of the CSE screening tool Increase in the use of CAF and the initiation of early help in key services Documentation in the ED in relation to safeguarding assessment and whether safeguarding alerts exist Communication at the point of referral and following referral is an area for development User involvement requires further development Summary of lessons learnt, actions taken and impact on practice / multi-agency working / outcomes for C&YP. The escalation process is being highlighted to all staff in response to learning from patient stories and reviews. There is evidence that staff are using this with confidence to advocate for children and young people. Safeguarding Supervision opportunities have been increased for health visitor, school nurses and community midwives and effective monitoring is in place to ensure that all staff receive this on a quarterly basis from 2015-16. This increases opportunities for reflection and oversight of cases. Peer review is in place for medical staff working in paediatrics and is continuously being reviewed to meet the needs of the doctors. Across the organisation there have been improvements to the information shared at points of transition and this is focus of all audit activity to maintain an emphasis on this. The quality of information on referrals remains a high priority for 2015-16. 4 Responding to emerging issues How our organisation is developing its agency contribution to early help and monitoring the quality of input into fCAF/Integrated Support plans and Child in Need plans I. The Trust has incorporated the Right Service Right Time guidance into all safeguarding training in the Trust with a particular emphasis on this in Level 3. This is in the process of being ‘refreshed’ in line with the latest training materials from the BSCB and a delivery plan has been developed to ensure that all relevant staff receive a face to face update in relation to RSRT. II. The Trust Safeguarding Policy was amended in 2013 to reflect the requirement for staff to support access to early help for families III. IV. V. VI. VII. The threshold guidance “Right Service, Right Time” – Delivering effective support for children and families in Birmingham has been disseminated throughout the relevant areas of the organisation. The Trust has identified the key staff groups who will participate in fCAF, ISPs and Child in Need Plans. The Trust has refreshed training for staff in health visiting and midwifery services in 2014-15 and maintains monitoring processes in relation to CAF training other key groups of staff including school nurses, neonatal, paediatric and specialist nurses. The Trust has participated in a CQIN with the CCG during 2014-15 to encourage use of CAF. Although the target was not achieved the health visiting and maternity services achieved over 60% of the required CAF implementation. This is a significant shift in maternity practice in particular. Monitoring will continue in 2015-16. There will be an audit of the health visiting records / intervention for a cohort of CIN cases during 2015-16 How our agency is monitoring the quality of and outcomes from referrals to MASH I. The Trust Safeguarding Team review all safeguarding children referrals sent through to partners II. Where additional information is required this is done as soon as possible directly to MASH III. There is a mechanism to provide feedback in relation to the quality of referrals to staff. IV. There is core training at level 3 internally on how to complete good quality referrals , additional training is being targeted at specific areas identified as needing additional support (this includes the Emergency Departments) V. The RSRT developed materials in relation to quality of referrals is used and disseminated widely to support practitioners with this aspect of their work VI. Data is captured in relation to the quality of information shared including whether demographic details are correct and concerns adequately explained. The Trust is looking at aligning the quality judgement with the ones used in MASH. A report on the quality of referrals is captured quarterly within the Safeguarding Referral Report which goes to Safeguarding Committee VII. Data is captured in relation to outcomes received centrally however this continues to be a problematic area with outcomes to a third of referrals remaining unknown. How our organisation is embedding “Strengthening Families and the West Midlands Child Protection Protocol” into your organisational practice I. Key staff have been identified and received training in relation to Strengthening Families II. Report templates have been made available to staff III. Internally supervision documentation reflects a strengthening families approach to identify risk and protective factors. How our agency is improving attendance at Initial child Protection case conferences, core groups and review conferences I. Attendance at Case Conferences and Core Groups is a high priority for staff and managers within the Children’s Workforce at HEFT II. Solihull LA share information with the Trust in relation to requests to attend so that staff can be supported and any non –attendance in Solihull is reported so that is can be investigated and remedied. III. In some instances nonattendance is linked to late invitations or poor communication and so we are working with local authorities to improve these processes. IV. Birmingham is more problematic as we do not yet receive information per individual provider but this has been requested. 5 Partnership Working The Trust continues to work with the LSCBs and maintains over 80% attendance at LSCBS and sub groups. The Trust contributes to a number of sub groups responsible for developing joint working (Policy and Procedures, Education and Development, CSE Strategic Groups and CMOGs). The Trust makes a considerable contribution in manpower to the Solihull Training Pool. The Trust participates in a wide variety of multi-agency reviews including reviews undertaken as part of the serious Case review Process The Trust staff regularly attend Strategy Meetings carried out as part of Child Protection Investigations, MACE meetings carried out in relation to CSE and a variety of other case specific multi-agency meetings. The Trust is currently recruiting staff to ensure that they can participate in MASH in Solihull and Birmingham. 6. Workforce Development A summary of your involvement in multi-agency safeguarding training / learning and development activity The Trust makes a considerable contribution in manpower to the Solihull Training Pool and has a Training Matrix clarifying the staff groups who are required to attend multi-agency training Single agency safeguarding training / learning and development activity During 2014-15 the Trust updated its Learning and Development Strategy for Safeguarding and it is compliant with both Working Together 2013 and the RCPCH competences for health care staff issued in 2014. Current training Figures are illustrated in the table below: Level of Safeguarding Total Number of Staff Total percentage of the Training required to be trained at workforce trained at this this level level Level 1 9736 98.55% Level 2 6467 88.42% (93.2% of community staff) Level 3 1358 83.5% PREVENT Health 9736 42.38% Training Level 1 safeguarding training includes identification and referral and is delivered through a video and updated via annual leaflets and communications. Level 2 is delivered through face to face training and updated through a moodle package. Level 2 training is delivered to all clinical staff at induction. Level 3 training is delivered via face to face sessions in house and multi-agency. Inhouse level 3 focuses on enhanced recognition and response to safeguarding and includes multi-agency processes. Staff from key groups are encouraged to access multi-agency training from the selection provided by the LSCBs. Solihull LSCBs share this information with us so that it can be logged on our internal safeguarding training database. Bespoke CSE Training has been developed within the Trust and delivery commenced in January 2015. Training evaluations are positive in terms of the impact on the learning. See details below: Level 2 safeguarding Children and Adults Total number of sessions = 151 Total number of attendees = 2355 Completed evaluation forms = 2094 (89%) Responses from evaluation forms 2014-15 1400 1200 1000 800 yes 600 yes 400 part 200 No N/A 0 what Categories of Know how to Understanding Know what to Know what to Did you find constitutes abuse for seek advice of information do - about do - adult the session child and adult children and and support sharing child abuse abuse useful? abuse adults Attendees are asked to record in a free text box information received that has enhanced their understanding of safeguarding and what they will take back to the work place. Responses are categorised in the table below Level 3 Safeguarding Children Total number of sessions = 28 Total number of attendees = 387 Total number of completed forms = 269 (69.5%) Responses from evaluation forms During 2014-15 there have been 2 ‘survey monkey’ surveys and a moodle learning questionnaire developed. Both were designed to see how confident and knowledgeable staff have felt in relation to safeguarding. Survey activity was small (particularly in relation to level 3) and will be repeated with larger cohorts in 2015-16 Level 2 staff indicated some inconsistency in the understanding of ‘Think Family’ messages in relation to identifying the needs of children where there are parental concerns and this has been identified in other audits during the year. The level 3 workforce results highlighted staff know where to get help within the organisation, had confidence in speaking to families about concerns, all could make referrals and knew how to do this although some found the process difficult and complicated and stated that they were required to re-refer in some instances to MASH. Safer recruitment requirements and referrals to the LADO The Trust has a DBS and Safe recruitment Policy in place and is fully compliant with all legislation in relation to regulated activity. DBS checks are carried out on all volunteers working within the Trust. The Trust carried out 4250 DBS checks on staff within the Trust between April and the end of March 2015 as part of the 3 yearly review of DBS status. This is an on-going process managed by HR. Where positive DBS results are returned the Trust has a process to ensure that they are reviewed and risk assessed by senior staff with consideration given to the implications for their role and to the need for onward referral to professional bodies and the barring authority. Referrals to LADO from HEFT during 2014-15 were 9 (1 from Community Services and 8 from Acute services) Conclusion The Trust is satisfied that it has the internal and partnership processes in place to monitor the effectiveness of safeguarding arrangements within the organisation and can identify areas of strength and areas for further development during 2015-16. Executive Summary Annual Report 2014 –15 Foreword I am happy to present this Executive Summary of the Birmingham Safeguarding Children Board Annual Report (2014-15) for publication. The full report which is available on www.lscbbirmingham. org.uk gives a full description and robust analysis of the activity of the Board collectively over that year. people, their families and for the staff working with them. The new model for establishing how staff should respond to need, (‘Right Services, Right Time’), and the In April 2014 Safeguarding we publishedHub this (MASH) three year Strategic Plan Multi-Agency Williams Serious Case Review, the Local Governmen are both excellent examples of the changes safeguarding arrangements Government we are making as is our much enhanced Review led by Ju Ofsted Inspection in March 2014. It work. meant the previous pla performance and quality assurance to a three Strategic Planstill andtoan There is of year course much more do.annual Business an Plan for 2014/15 included the action being We are ambitious for the city’s children. taken in respons They deserve the best and we are central This revised was agreed Birmingham Safegua to helping theplan city’s services beby thethe best in after a review of the previous year’s performance and the country rather than some of the worst. commitment to driving forward a strong plan for achieving th We need to build on the progress in 2014improvement over the next two years of the plan up to 31s 15, increase pace, and taking action that some firm foundations and ensured that the basic requirem is, if necessary, The place. It is now radical time to and buildinnovative. on this foundation over years tw challenges ahead undoubtedly remain very great. In particular weretain need to We have agreed to oursupport three priorities as a Boar the great work to coordinate, elements to theunderway “safer systems” priority. We will obsess co extend and develop early help in the everything else – far do. That does not mean we stop doing City, rapidly improve our responses more on what life is like for a single to vulnerable child living in Child Exploitation and address the every Sexual child’s life for the better. issues for children who are missing from home, school, caretoand those children not that all professio We must continue unequivocally ensure receiving or accessing and with families knownormal when universal to act to safeguard the vulne city andeducation what to do they are worried about a possib health, or when early years services. they walk inwe theneed shoes of a much child, simpler and see the world throug In addition to find something might affect the a child for the better. W ways to do that things, different wayslife toofbecome the children and young people they serve, more effective on less money, to share our and for the su child’s needs. Wemore musttogether support, rather supervise resources and do than and train those but excellently, based on what works and what the evidenc separately. Most importantly we need to not everyone to account for how they do it. As only build the confidence of children, younga Board, we mu also hightheir challenge for our children. We wa people, familiesand and aim theirhigh communities support, great training and great challenge. that we can make them safer, we need to ensure that those children, young people, In two years’ time I want us all to hear children tell us tha families and communities shape what have made their lives better. It is our responsibility as a Bo we do, and challenge us to do better. how we will get to that point Introduction As Chair of the Board from October 2011 the report covers my fourth year in the role, setting out the effectiveness of the Board itself and the effectiveness of the work of Board partners in safeguarding children and promoting their welfare in the City. The Report presents a positive picture of progress over that year in most aspects of the Board’s work. There is clear evidence that as a result of the hard work put in by the local authority, and all other partners to the Board, especially the NHS (in all its organisational forms) and West Midlands Police, children are safer in Birmingham, and the most vulnerable are getting a better response. In addition there is a lot of good work happening across the city, undertaken by front line professionals from every agency who are quietly ‘getting on with the job’ and doing above and beyond what is necessary to meet individual children’s needs which should be recognised and celebrated. This is imperative if the children and young people of the city are to get the services they deserve, achieve their potential, remain safe and become fully rounded and responsible adults. I also continue to believe we owe it to the children of the city and their families and communities to be as open, honest and transparent as possible about our progress, our effectiveness and our inadequacies. The Executive Summary covers the first year of “Getting to Great”, the Board’s new Strategic Plan 2014-17. We have made steady progress across all three of our priorities and we can see the differences we are making for children and young JaneHeld Held Jane Independent Chair Independent Chair Birmingham Safeguarding Children Birmingham Safeguarding Children Board Board 23rd June 2015 2015 •••• 2 Introduction This Executive Summary provides an overview of the full Birmingham Safeguarding Children Board Annual Report 2014–15. The full report is available on the Birmingham Safeguarding Children Board (BSCB) website ( www.lscbbirmingham.org.uk ) as are the 16 appendices that accompany the report. This summary includes all the key information in a shorter and more accessible form, which allows the people of Birmingham to easily read about the improvements that have taken place over the year. In addition a two page summary for children and young people is being developed and will be available by the end of 2015. Working Together (2015) requires each Local Safeguarding Children Board to produce and publish an Annual Report evaluating the effectiveness of safeguarding in the local area. The guidance states that the Annual Report ‘should provide a rigorous and transparent assessment of the performance and effectiveness of local services. It should identify areas of weakness, the causes of those weaknesses and the action being taken to address them as well as other proposals for action’. The Report should: •Recognise achievements and progress made as well as identifying challenges •Demonstrate the extent to which the functions of the LSCB are being effectively discharged The Executive Summary focusses on the key priorities the Board set itself in 2014, and on the statutory objectives and functions of the BSCB as set out in Working Together to Safeguard Children 2015. The BSCB is a statutory body established under the Children Act 2004. It is independently chaired (as required by statute) and consists of senior representatives of all the principle stakeholders working together to safeguard children and young people in the City. Its statutory objectives are to: •Include an account of progress made in implementing actions from Serious Case Reviews •Provide robust challenge to the work of the Children’s Trust Board This Executive Summary summarises the progress made by Birmingham LSCB in 2014-15 through and with its partners and analyses the effectiveness of: • Safeguarding arrangements in the city •Co-ordinate local work to safeguard and promote the welfare of children and young people •The LSCB itself in supporting and coordinating safeguarding arrangements and in monitoring and challenging those who provide them. • To ensure the effectiveness of that work •••• 3 Context and key facts about Birmingham Birmingham, is the largest unitary authority in Europe with a population of 1,085,400 is one of the youngest, with approximately 280,000 0-17 year olds (312,000 0-19). It is one of the most diverse cities in the UK with almost 50% of the population from a Black and Minority Ethnic (BME) community. As a major regional city it has areas of considerable wealth and areas of great deprivation. 47.7% of the population is under 30 (nationally this averages at 36.8%) and 32.4% of children in the city are children living in poverty (nationally 20.1%). The annual Birmingham child wellbeing survey indicates that there are declining rates of physical health in children in the city and ongoing high levels of significant behaviour problems and emotional ill health. About 82% of children and young people report feeling safe at home, about 50% feel safe at school and about 45% feel safe in their neighbourhoods. The Birmingham Child Poverty Commission is working to understand how best to change the pattern and the impact of poverty in the city and is due to report in 2016 1,976 children in care and 1,251 children the subject of a child protection plan. 93.8% of care leavers were in suitable accommodation at the end of February 2015 and 67 out of 157 care leavers were NEET. In terms of complexity of services in December 2014 there were: Commissioned and funded by Birmingham City Council, The Birmingham Commission for Children was run by The Children’s Society. The Commission examined what life should be like for children and young people in Birmingham in ten years’ time and how the city council and other organisations might go about making their vision for Birmingham’s young people a reality. It’s Report, “It takes a City to raise a child” found that children and young people said that: The BSCB commissioned a full analysis of what life is like for most children in the city from the Department of Public Health in the council (“Understanding the needs of children and young people in Birmingham”) which provides a rich source of information about need in the City. In 2014-15, ethnicity, faith and diversity became a more dominant element of the work of the Board and of all its partners. Two major issues, one of which (Trojan Horse as it is known) sparked significant national and governmental attention, created concerns about how well children and young people from the wide and diverse range of communities in the city were safeguarded and getting their needs met and their wellbeing promoted. •441 schools in the city, comprising a mix of academies, free schools, and maintained schools. •Of the total school population 34,088 have special educational needs. •There are 73 children’s centres (of three different types) •20 youth settings, based in areas of high levels of multiple indices of deprivation. •Relationships are the most important thing in the lives of children and young people, especially relationships with their families. •12,618 different young people aged 11-25 received a youth service and 64% of them were from BME backgrounds. •Children and young people from every group, and from every part of Birmingham, want to feel safer in the city. They feel they lack safe, affordable spaces and activities that allow them to be with friends and family. •The Youth Offending Service provided more than 8,833 programmes during the year. •There are 3 Clinical Commissioning Groups (CCGs) in the city with 268 GP practices, with 1,096 GPs. •Children and young people want to have a say in the issues that matter to them, they want their voices to be heard and acted upon. •There are five child development centres five Accident and Emergency Units and nine NHS trust hospitals. •Children were positive about school and valued the opportunities that education gave them. • There are 10 BCC children’s homes in the city. •The Board estimates that the total workforce in daily contact with children and young people just in the statutory sector is above 85,000. •Young people wanted knowledge and skills that were useful for getting a job and being a good citizen. They valued their community and their sense of place. As a consequence outcomes for children and young people are very mixed. By the end of March 2015, 2,614 16-19 year olds were not in education, employment or training (NEET) (6.9%), there were •Children and young people wanted a positive story to be told about Birmingham and young people’s achievements. •••• 4 Partnerships The Board agreed and implemented a new three year Strategic Plan, “Getting to Great 2014-17” in 2014. The Board’s priorities reflected the three key issues highlighted in previous years as most needing to be improved. This Plan is underpinned by a strong focus on business excellence. The previous partnership infrastructure in relation to Children’s Services was dismantled at the beginning of 2014-15 and a new structure was not put back in place to replace it. Instead of the Children’s Trust partnership the Council led a series of multiagency topic based “think tanks” over the year. This increased the risk of, and at times real experience of BSCB continuing to act as a “proxy” for service design, delivery and operational detail. That said, two effective and focused council led programme boards, the MASH Board and the Early Help Board, included a range of partners and BSCB was represented on both. In addition the multi-agency outcomes from these two boards were reported to and signed off by BSCB in the absence of any other “full system” body. It did, however, lead to confusion at times. The BSCB Strategic Priorities •The voice of the child – central to everything we do • We provide early help –when problems first arise •We run safe systems – to ensure children are properly safeguarded The Strategic Plan also highlights the underpinning behaviours expected of anyone who works with children, young people, their families and their communities. However, as the year progressed, Lord Warner’s views, plus strong debate at BSCB, partially stimulated by the Governance Review, as well as challenges from individual partners led, by March 2015 to a clear recognition by the Council as the lead agency, of the need to address the problem of partnership and governance confusion, and to develop a new partnership landscape and architecture for the city in relation to children and young people. This coincided with the City Council’s decision to review all its partnership arrangements, but by the end of March 2015 exactly how those two strands of work fitted together was still not clear. The Birmingham Basics • The child comes first • Do simple things better • Never do nothing • Do with, not to, others • Have conversations, build relationships Plans and Improvement Programmes Partners were asked to build the Birmingham basics into their own strategic plans and expectations. In addition the Council drew up and implemented two key strategic plans for improving services for children and young people. The first, in response to Government directions was overseen by Lord Warner (the appointed Children’s Commissioner) and was fully implemented by March 2015. The BSCB priorities contributed to key elements of this improvement plan. Following the “Trojan Horse” events, a second External Commissioner, Sir Mike Tomlinson, was appointed. An Education Improvement Plan was developed and agreed and is progressing under the External Education Commissioner’s leadership. A third Commissioner, Bob Kerslake, reviewed and the whole Council’s performance and a third improvement plan, the ”Future Birmingham” has been put in place. Finally a multi-agency Early Help Strategy was developed and agreed by March 2014 which will underpin the work of all partners in designing and developing appropriate integrated early help services. This will ensure children and young people get support and help “early in the life of a problem” rather than wait until they need statutory child protection interventions. Partnership relationships with the Community Safety Partnership and Adult Safeguarding Board remained informal, built on the shared agreements made in 2012-13 about which partnership body should lead on which cross cutting issue and informed by the increasingly close working drive through the MASH initiative. In 2015 the challenge for the lead agency, Birmingham City Council, with every partner will be to design and implement a new partnership framework for multi-agency co-operation, co-ordination, and commissioning of services to meet children’s needs. This will need to also feed into the “Future Birmingham” process. The challenge for the Board will be to fully cease to act as a proxy for partnership working and to create meaningful relationships with the new models for partnership, including the new Birmingham Education Partnership (BEP), to inform and influence their work and hold them to account. •••• 5 Organisational change across partnership As well as the impact of the improvement programmes and agendas the Council did not have a stable permanent senior leadership team for children’s services throughout the year. However, the impact of this was minimised through the presence of strong interim leaders. In addition, the City Council was not the only organisation where there was significant change and organisational churn. Change also occurred to: The whole of 2014-15 was (as was 2013-14) characterised by substantial change, in many of the statutory partner agencies, with the resultant churn in staff, services and stability of practice, and the challenges arising from such churn. Much of what happened during the first half of the year was imposed from outside Birmingham itself, with significant Central Government and Inspectorate activity taking place, often all at once. This meant that it was extremely difficult for partners to steer a steady course and build on the areas for improvement identified by the council and BSCB in 2013-14, and the additional and new requirements identified by Ofsted in their report. • The Probation Service and West Midlands Police. • Heart of England NHS Foundation Trust • Birmingham and Solihull Mental Health NHS Trust • NHS England underwent All of these changes had an immediate impact on the BSCB Board in terms of changing membership. The Board was appraised of the changes appropriately and the impact was less challenging than it would have been, as the governance review facilitated good discussion about the safeguarding functions and accountabilities of organisations through a period of change. Organisation change and its impact remained on the BSCB Risk Register over the whole year and action taken to adjust the mitigation each time the Risk Register was reviewed. By the end of 2014-15 the City Council and its partners were dealing with the requirements set by Lord Warner, as the External Commissioner for Children’s Services Improvement, Sir Mike Tomlinson Education Commissioner, and his Deputy Commissioner, Colin Diamond, all commissioned by the Department For Education, and those set for the whole of the City Council by Sir Robert Kerslake, commissioned by the Department for Communities and Local Government. The effectiveness of safeguarding arrangements in Birmingham Engagement with Children and Young People in some limited cases had a strong impact on service provision. The Board’s collective work with partners in terms of listening to, engaging with and responding to children and young people’s views, wishes, and experiences in 2014-15 continued to be limited. Despite this we became increasingly aware of the range, depth and breadth of work that was being done by different agencies across the city. In November 2014 work commenced to map agencies methods of engagement with children and young people. Once this work is completed in 2015-16, it will provide the Board with a fuller picture of the excellent work undertaken by the city to engage children and young people whilst providing the Board with a platform to engage children and young people in its work. All participant partners (all of whom are members of BSCB as well) agreed to sign up to seven principles for engagement with and providing services to children, young people, and their families: •We need to design services which respond to the public (as opposed to public services) •Do nothing without us (design and deliver nothing without involving children and young people) • Always act (never do nothing) •Engage in an ongoing relationship (every contact counts and every contact is an opportunity) • Embrace technology and new methodologies In March 2015 the City Council, working with INLOGOV held the last of its series of “Think Tank” events and focussed on the voice of the child, the report of the Birmingham Commission and work across the city. The event addressed the question of “What is our commitment to listening to, hearing and acting on the voices of children and young people. Overall it was clear that during 2014-15 the collective amount of energy going into involving children and young people was significant, and it has • Listen, listen, listen! •Recognise the opportunity of the experience for young participants (“giving back”, “belonging” and “it’s your city”) It would be fair to say however that the Board did not progress its first key priority as far as it wished. The work is continuing into 2015-16. •••• 6 The key challenge is to find ways of harnessing the energy and activity across the city in involving children and young people and build on that to inform, influence and set direction for the Board, as well as to find ways to directly engage with children and young people in the work of the Board. CCG and South Central CCG). Unlike Ofsted, CQC do not provide an overall grade or judgement in these inspections. Nor do they arrive at a general conclusion. Good practice was observed in the provider services and the safeguarding leadership of the Clinical Commissioning Groups was praised. GPs were identified as making a strong contribution to safeguarding in the city. 42 recommendations were made, and the report overall demonstrated that serious consideration was given to ensuring effective safeguarding practice by NHS Organisations across the city. A challenge for the City Council through the Place Directorate is to work with children, young people, communities and partner agencies to significantly reduce the expressed sense of being unsafe in public spaces articulated so strongly by the children and young people of the city. An aggregate report on six inspections focused on protecting children was published by Her Majesty’s Inspector of Probation in August 2014. The then Staffordshire and West Midlands Probation Trust was not inspected and the findings and recommendations now need to be seen in the context of the Transforming Rehabilitation (TR) agenda cumulating in the formation of two district operations which made up the former Probation Trust. Staffordshire West Midlands Community Rehabilitation Company (SWM CRC) is the provider responsible for the supervision of low/medium risk of harm offenders, while the National Probation Service (NPS) has responsibility for high risk of harm offenders, MAPPA arrangements and providing advice to Courts. The NPS and CRC have provided assurance that the report’s four recommendations will be taken forward within Birmingham by providers of Probation Services. External Inspections and Reviews As well as implementing and addressing the requirements of the Ofsted Single Inspection and Review of the LSCB (http://www.ofsted.gov.uk/ inspection-reports/find-inspection-report ) published in May 2014, we began to receive Inspection Reports relating to all our partner agencies and monitor the implementation of relevant recommendations by each agency in 2014-15. This has provided a more comprehensive understanding of practice across the whole system and supported the identification of key common themes and challenges. Ofsted undertook a review of the Birmingham Multi-Agency Safeguarding Hub (MASH). This was a helpful review, which provided valuable advice about areas for development and improvement (including timeliness, delay, and the approach to domestic violence contacts) but also praise for the strong front door and multi-agency nature of the MASH. West Midlands Police were subject to a safeguarding Inspection between 2 and 13 June 2014 as part of their new National Child Protection Inspections. The conclusion of the Inspection Report was that “West Midlands Police has demonstrated a commitment to improving child protection services. The move to build increased capability and capacity is testament to this as is the focus on child protection within the force’s strategic change programme. However, at the time of the inspection, not all children at risk of harm were sufficiently protected by West Midlands Police and it is too soon to judge whether the changes underway will deliver the level of improvement required. Ofsted also undertook a significant number of inspections of early years providers and schools in 2014-15, particularly following the initial phase of the period after the publication of the Trojan Horse material, and subsequent inquiries. The Care Quality Commission (CQC) also undertook a range of inspections in the city in 2014-15. The full inspection reports are available to download at the Care Quality Commission website; http:// www.cqc.org.uk/. This included a full review of health services for Children Looked After and Safeguarding in Birmingham undertaken in September and October 2014. This review included key provider services (Heart of England NHS Foundation Trust; Birmingham Children’s Hospital NHS Foundation Trust; Birmingham Community Healthcare NHS Trust; Birmingham Women’s NHS Foundation Trust, Birmingham and Solihull Mental Health NHS Foundation Trust; University Hospitals Birmingham NHS Foundation Trust; Sandwell and West Birmingham Hospitals Trust) and two of the three CCGs in the city (Birmingham Cross City The report covered all seven local authority areas but much reflected the experience in Birmingham. This report included 20 recommendations and WMP have been proactive and energetic in addressing them. By the end of 2014-15 the transformation programme was beginning to show dividends although it became very clear over the year that as the police addressed the issues identified, and the MASH in Birmingham began to have a major impact, the allocation of resources to the Birmingham Safeguarding Service was still inadequate to meet need. •••• 7 Birmingham Youth Offending Service were informed by and involved in a thematic inspection of resettlement led by Her Majesty’s Inspector of Probation in July 2014 and an Ofsted Inspection of Community Safety and Public Protection Incidents. We have during 2014-15 been able to gain a much better understanding of the collective views of external regulators across the city about the strengths, areas for development and competence of all partners in relation to their safeguarding practice, and the way their work improves the welfare of children and young people. •Each agency should regularly review and monitor progress on the implementation of the audit action plan •The audit findings and action plans should be disseminated and progress monitored through existing agency management structures that have responsibility for safeguarding •Agencies should ensure that all relevant documents providing evidence of their judged compliance with each level should be uploaded to the online audit and management system Partner Compliance The learning points for BSCB are that: Each year all the Board’s statutory partners undertake a self-assessment of their effectiveness in terms of how well they are safeguarding children and young people and promoting their welfare. Known as the Section 11 audit it is part of their responsibilities under Section 11 of the Children Act 2004. In Birmingham the Board asks for a copy of every statutory partner’s audit in order to analyse the overarching strategic, operational, practice and workforce themes and achieve a sound understanding of the current quality of what is happening as well as the emerging issues for the city. The aim of a Section 11 audit is to provide the board with reassurance that organisations have good structures and processes in place to safeguard children and to provide a benchmark of current performance to enable organisations to monitor progress and quantify improvement in safeguarding practice for children and young people over time. •The learning points around action plans are the same as the last 2 years which is a concern to the board in that the section 11 process is not being embedded into agencies safeguarding standards. •BSCB needs to be assured that agencies are completing their Section 11 Audits and are following up on their action plans to implement the actions they have identified to improve their compliance with safeguarding standards •The BSCB need to ensure that agencies have access to the appropriate training for domestic violence and child sexual exploitation. In summary, whilst there has been some improvement in the response from partner agencies on last year’s audit, we still need to be assured that, for all partners which have identified areas for development from the audit have an action plan in place to resolve the areas of concern. We also need to ensure partners provide better evidence of progress and facilitate the sharing of good practice identified thorough the audit process and through the peer review. One agency has not completed the section 11 audit and a further three agencies have not completed action plans this year. The action plan is key to improving the safeguarding in agencies and as such all agencies should have an action plan that is being regularly reviewed and updated. The local authority have completed four separate section 11 audits rather than of one for the whole of the local authority. The West Midlands Ambulance Service complete a standard section 11 for the whole of the West Midlands and is not specific for the Birmingham. A well received peer review event was held in November 2014 where partners reviewed each other’s section 11s against other agencies. This helped agencies gain an understanding of how to apply the grades in their agency. Further independent validating of the section 11 audit is still required. In addition to the Section 11 audits, Board asked formally for each statutory partner to submit an annual report to the Board accompanied by an assurance letter from the Chief Executive or Chair of the organisation for the first time in 2013-14. The quality, consistency and depth of the returns in 2013-14 was very variable. As a consequence partners were given a framework within which to report. This asked organisations to report as follows: • Executive Summary of progress over the year • Introduction to the service •Their evaluation of the effectiveness of their safeguarding arrangements Analysing the Section 11 returns overall there are a number of key learning points to inform our work in 2015-16. The learning points for agencies include: •Their organisational governance and arrangements for evaluating their effectiveness •Each agency needs to be required to submit a detailed Action Plan to evidence how audit findings will be taken forward •Their safeguarding performance and arrangements for quality assurance, audit and learning from practice •••• 8 •A summary of the work undertaken to engage with and listen to children and young people, and the learning from this The challenge for the Board in 2015 is to improve the span of agencies driving the priorities forward, and the consistency of their focus and “ownership” of the issues, and to share the work across partner agencies more effectively, reducing “silo” working. •The number of serious incidents they had had and the learning from them Joint Commissioning •The findings from internal reviews and the action taken Another area where the absence of clarity about roles, responsibilities, functions and accountabilities across partnership arrangements was important related to joint commissioning activity and priorities (0-25 service; drugs and alcohol services; school nursing). Whilst an LSCB has no direct responsibility for joint commissioning activity, a good LSCB can influence what happens, what is a priority, and what should change through its regular performance reports and quality assurance activity. In 2014-15 recommissioning of relevant children’s services was led by the joint commissioning Sub-Group of the Health and Wellbeing Board (HWB) •The findings from external inspections and reviews and the action taken •A summary analysis of the effectiveness of their arrangements in terms of strengths, areas for improvement, and the impact of lessons learnt on practice •The organisation’s response to emerging issues and Board priorities (early help, fCAF, integrated support plans and child in need plans; MASH, attendance at Initial Child Protection case conferences, core groups and reviews, strengthening families protocol and west midlands child protection protocol In Birmingham for the third year running the Board had limited direct influence and was not consulted sufficiently well in identifying priorities or developing new commissioning programmes. The risks were to a degree mitigated by all the other scrutiny, challenge, review and quality assurance activity taking place, and by the fact that the BSCB Vice Chair was Chair of the Children’s Joint Commissioning Sub-Group. • Partnership working •Training and workforce development (single and multi-agency) This framework broadly covered the Board’s priorities and business plan in 2014-15. Returns were significantly better this year with greatly improved consistency and focus. This has allowed for a far greater understanding of exactly what the common themes are, where there are challenges, and how well learning is being demonstrably used to improve practice. In addition more returns were received with only two who did not respond. However, the work of the Joint Commissioning group was in fact extremely positive over the year. The Children’s Joint Commissioning Board oversaw a significant amount of work on behalf of the key partners during 2014-15. Progress was made in: 1. Early Help: 2.Services to Vulnerable Young People – especially the 0-25 mental health service Overall it is important to recognise that the reports collectively provided sound evidence that in 2014-15 the Board’s priorities were recognised and were informing individual agency practice, that key areas of work are genuinely rolling out from the board to the front line, that learning is being applied to practice and compliance with requirements improving. None of this in itself improves the safeguarding experience in an individual case but it is clear there is an increasingly shared understanding of what is required, to what standard and how we can use what we do to improve practice. The majority of reports were analytical, open and evidenced. The returns demonstrate significant forward progress, particularly on compliance, process and delivering the Board priorities. The impact of this is demonstrable through the data in the annual performance report. It is a positive sign of real progress and improvement. 3. Looked After Children Joint Commissioning Priorities during 2015-16 include: 1.Early Help – implement the recommendations contained within the Early Help strategy. 2.Safeguarding/MASH – build on the work to date and deliver a fully functioning MASH including ensuring CSE is part of the new arrangements and that the HUBS are operating effectively. 3.SEND – Continue to deliver on the requirements of the guidance in this area including the development of a more coordinated funding arrangement as contained within the Sect 75 agreement •••• 9 4.0 – 25 – mobilise the new service and implement the evaluation process as planned and work closely with other stakeholders including schools to deliver on recent guidance to create a whole system approach to emotional wellbeing would make them feel safer. However, although the findings are captured from a relatively small target audience, they clearly reinforce the key themes identified in the Child Wellbeing Survey 2013-14 and forms part of the information collated to capture the ‘voice of the child’. In addition, as part of the quality assurance process established by the Board through the Performance and Quality Assurance Sub-Group all audits now include at least a question or a section on the voice of the child. 5.Work to engage the schools through the Birmingham Education Partnership and initially through the Ladywood Pathfinder project. 6.Children in care – reduce the numbers of children in care and increase the proportion placed with families in order to promote better outcomes and deliver improved value. How well have we done it? The audit work on Initial child Protection conferences (ICPC) in October identified as its main concern that the Voice of the Child is not being heard. Recommendations were made in the report to include more work on the Voice of the Child in BSCB training. All of these will assist in improving the whole safeguarding and wider welfare system positively The Annual Performance Report Evaluating the child’s journey through the safeguarding system. The Board agreed a new and comprehensive Performance and Quality Assurance Framework “Improving Safeguarding Standards and Assuring the Quality of our Service Delivery in Birmingham” in March 2014. This was refreshed in February 2015 and updated to reflect a wider range of datasets. The audit identified in four out of the five cases that the Voice of the Child was not clearly present and that opportunities for partners other than social workers to talk to young people were not always taken. Another area of concern was the identification of cultural background /ethnicity of the child and family on the CareFirst forms including the A1 form which is the initial point at which a referral is recorded on the system. The lack of ethnicity here was perpetuated through other forms within CareFirst. Consequently issues around honour based violence, forced marriage, FGM could be missed. The recommendations from the ICPC audit will be followed up later in 2015, to assess progress against the recommendations. The Board was able to report against all three Board priorities at each Board and Executive Meeting over the year, although there were some changes over that period to the key data sets and overall dashboard as the Performance and Quality Assurance Sub-Group improved the range contribution and depth of its work. As a consequence the Board was able to take a full Annual Performance Report for the first time in four years. The annual performance report examined each BSCB Priority in terms of our three dimensions: ‘how much are we doing?’; ‘how well are we doing it?’; and ‘what did we learn and change as a result?’ The audits of re-referrals and child protection for 2015 also include a question/section on the voice of the child. Currently 97% of Looked After Children participate in their reviews. Priority 1 – Voice of the Child What did we learn and change as a result? How much have we done? The audit work on ICPC has already been incorporated into the training provided to child protection chairs and further work is ongoing with them to ensure the Voice of The Child is clear in the conference. The Early Help Brokerage Support Team on 7 October 2014 held a youth conference called ‘Protect Yourself’. In line with the theme of the conference the following questions were posed: a) what makes you feel unsafe when you’re outside in your neighbourhood or at school, and b) What could be done to make you feel safer. Out of the 13 key issues identified in relation to what makes young people feel unsafe; groups were highlighted as the highest concern (22%) with strangers and inadequate street lighting being cited as the next main concern (13%). In respect of what would make young people feel safer; 33% identified that there should be an increased Police Officer presence on the streets before and after school, with 17% of the young people stating that more CCTV Priority 2 – Early Help How much have we done? A priority action for the Board last year was to develop a definition for Early Help and to develop an early help strategy. The definition was approved at the Board meeting on 13 May 2014 and the strategy was approved on 31 March 2015. As part of the work on early help it was agreed in the performance and quality assurance sub-group to use the fCAf (family •••• 10 Common Assessment Framework), family support plans and health visitor active interventions as a proxy measure for early help. Figure 1 below shows a clear increase in the early support work being carried out by all agencies with fCAF and health visitors’ active interventions. The increase in health visitor active interventions may be as a result of the increase in the number of health visitors which is seen in the staffing data later this has resulted in an overall drop in caseload for health visitors. Figure 1 Rate of Early Help Assessments initiated 35 100 20 80 Health Visitor – active intervention – rate of cases opened in last quarter per 10,000 population per month Family support plan rate per 10,000 population per quarter 2014/15 Q4 2014/15 Q3 2014/15 Q2 2014/15 Q1 0 2013/14 Q4 0 2013/14 Q3 20 2013/14 Q2 5 2013/14 Q1 40 2012/13 Q4 10 2012/13 Q3 60 2012/13 Q2 15 CAF rate per 10,000 population per quarter Family Support Plan rate 120 2012/13 Q1 CAF and Health Visitor Active Interventionn rate Rate of Early Help Assessments initiated 30 How well have we done it? Birmingham has now come to the end of phase 1 of the Think Family Programme. Despite extremely strong performance over the final year, delays at the beginning of the programme meant that the final target for families where outcomes have been achieved was missed by a narrow margin (figure 2). Nevertheless entry into the expanded Troubled Families phase 2 has been secured and DCLG is extremely satisfied with the progress that has been made in the city. Figure 2 Key Targets Actual Target Identified Think Family cases 7,449 families 4,180 families Families worked with 6,200 families 4,180 families Families where outcomes have been achieved (families “turned around”) 3,984 families 4,180 families What did we learn and change as a result? Over the last three years the programme has achieved: A major long term national evaluation exercise is under way covering both phases of the programme and for which Birmingham has already supplied a large amount of data, although findings from this will not be available for some time. Locally there are indications of the effectiveness of the whole family approach, although this is an area which would definitely benefit from further analysis. It is intended to carry this out once more analytical capacity is created within the Think Family Team. – 424 families where adults have found sustained employment – 2,320 families where children have improved school attendance – 752 families where youth offending has ceased or significantly reduced – 844 families where anti-social behaviour has ceased (note families may have achieved more than one outcome). •••• 11 Priority 3 – Safe Systems a degree of early assurance that changes to early help, better identification of concerns and earlier intervention are having an impact. Despite significant efforts to address and deal with substance abuse in the under 18 population we are not yet seeing a significant downturn in presentations to hospital. This however does not mean that every young person presenting has significant problems. The system for identifying and supporting children and young people who present more than once is improving as awareness of the issues of risk and sexual exploitation improves. How much we do? How well do we do it? As part of Safe systems Performance and Quality Assurance have reviewed data from all agencies Health Organisations and Police provided data to assist in identifying areas of concern. It is clear that, in line with national trends, there is an increasing level of self- harm in the under 18 population. The changes to the 0-25 mental health service should impact on these figures in 2015-16 onwards. However the mental health of children and young people is an increasing concern, particularly in our schools. Overall the levels of crime against children has stayed reasonably stable over the year. 60% are for child cruelty/neglect which would suggest the majority of offences are committed by a parent or someone in care and control of the child. Sexual offences then account for the vast majority of the remainder. It is clear that there has been some reduction in the numbers of children presenting at hospital with unexplained or non accidental injuries which provides Volume of CSE Reports for the West Midlands Figure 3 200 178 280 250 142 240 142 141 125 118 120 103 95 100 84 70 200 50 10 4 20 0 17 6 13 1 24 16 16 10 23 23 9 9 19 8 12 6 6 104 90 84 71 63 56 48 40 92 62 62 42 12 7 21 10 21 11 21 15 3 4 14 5 4 4 5 5 14 -14 Y-14 -14 -14 -14 -14 T-14 13 R-13 -13 -13 -1 -13 -13 -13 -13 -1 V-1 C-1 N-1 B-1 AR-1 RR N UL UG EP A A JUN JUL AUG SEP OCT NOV DEC JAN FEB J JU S FE OC NO DE JA A M MA AP M M R- AP Volume of CSE Reports for the West Midlands Missing Children •The orange line in figure 3 shows the total number of referrals with a CSE “Special Interest Marker” force wide – the blue line shows the number for the Birmingham LPUs. Figure 4 Misper Age Range 01/01/2015 – 30/04/2015 95 56 •The data is over two years to show the substantial increase in the number of referrals from May 2014 onwards when the new tools for identification and assessment of risk of CSE were introduced. U 12 758 1136 12-18 YRS 18-60 •Figure 4 shows a four month snapshot of missing persons data by age and local policing unit area. During this period 386 children under the age of 18 years were reported missing. Over 60 Related to CSE is the issue of missing children Police data (figure 4) shows that the majority of children and young people reported to them as missing from home or care in 2014-15 were between 12 and 18 years old. A significant number were however over 18, which is a relevant issue for adult safeguarding practice. All these areas of concern indicate areas for increased focus and the targeting of expertise and resources in 2015-16. More about what we were doing to address these areas of concern are set out below. •••• 12 Identification; referral and assessment of need: Multi-Agency Safeguarding Hub in fewer single assessments being initiated. Whilst performance has dipped slightly (appropriate) reduced demand will result in improved timescales and more importantly improved quality in working with the family. During 2014-15 the Birmingham Multi-Agency Safeguarding Hub (MASH) began operating on 28 July 2014. MASH is a fully integrated and co-located multi-agency team based in the centre of Birmingham. The team focuses on receiving referrals for children believed to be at risk of significant harm, including domestic violence. MASH was agreed as the strategic multi-agency response to reaching and meeting high levels of unidentified risk as articulated by Ofsted, Le Grand, Kerslake and Lord Warner. All single assessments should be completed within 45 days. Those over 45 days are out of time, as at 31 March 2015, 223 single assessments were out of time, this has dropped from 517 as at 4 March 2015. A task and finish group was established in June 2014 to audit referrals into the “Front door” of children’s social care. The audit has identified that the quality of the referrals being made over the latter part of the year has shown generally a consistent improvement. The audits have been spread across a number of agencies and further work is intended next year to identify the quality of referrals from particular agencies. Next year’s audit will review re-referrals. Each agency within the MASH has access to their own systems and shares information as appropriate with key partners. This enables partners to gain a much more timely and comprehensive understanding of the current situation, together with any relevant historical information. The team jointly discusses and assesses the risk and needs of the child and agrees what action needs to be taken. MASH works because the partners are sitting together, sharing information and taking joint action. Child Protection Processes At the end of March 2013 there were 1,149 children who were the subject of a child protection plan. At the end of March 2014, there were 844 children with a child protection plan. Reaching a low of 806 in December 2013 but rising to 1301 by 31st March 2015. These numbers indicated that Birmingham was significantly below the national average during 2013 and raised concerns that too many children may have been at risk of harm without appropriate protection plans in place. However, a significant number of these led to no further action (NFA) which became a major concern for the Board by March 2014. The number of section 47s NFA was 160 in March 2014 and by September 2014 this had dropped to 31 and by March 2015 it was 29. Part of the problem was identified as a lack of coding in CareFirst and consequently a number of staff were using it inappropriately, new coding was introduced. At the beginning of 2015 it was identified there were 930 S47 cases open. MASH is embedded within the Birmingham ‘Right Service, Right Time’ model. The key determination within Right Service, Right Time is that MASH responds to all children with additional needs and complex/significant needs. Following the introduction of MASH there was a significant increase in the number of contacts, however, this not only coincides with the start of MASH on 28 July 2015 but also 1 August was the point at which police started sending in information regarding domestic violence, which accounts for an additional 1,100 contacts approximately per month. These contacts do not usually become referrals as the majority are referred to other agencies. Hence the conversion from contact to referral rate appears to have dropped over this period. At the start of last year the Board identified an issue with the number of single assessments not allocated to a social worker. At 31 March 2014 there were 457 unallocated single assessments, during the year this went up to 763 on 1 July 2015. Areas of children’s social care developed a triage system for managing the unallocated single assessments. The directorate carried out some focused work in the south of the city which had the biggest number of unallocated single assessments. As at 31 March 2015 there were 68 unallocated single assessments. From 1 April the directorate established teams in all three areas to manage referrals that are rated “amber” in the MASH which are then referred to the area. The area then decides whether an assessment is required and the nature of the assessment. This has resulted In March 2014 a new child protection conference process was introduced known as “Strengthening Families”. This new approach involves the chair being sent reports from agencies prior to the conference to provide the chair with an overview of the case before hand. The chair then facilitates the meeting between professionals, families and young people identifying: • • • • • • • Danger/risk factors Child and Family history Grey Areas/Complicating Factors Child’s Views Parental Views Family strengths/protective factors Safeguarding statement •••• 13 An improvement in performance in relation to the number of children and young people appropriately made the subject of a child protection plan took place as a consequence. The results of the referral audits were fed into the development of the new multi-agency referral form which was rolled out to agencies in March 2015. Further work is still required to improve referrals from some agencies. The Board was concerned about poor attendance by partners at Initial Child Protection Conference with no agency achieving a 100% attendance to the conferences they have been invited to. The data identifies a significant improvement in police attendance over the last 12 months primarily as a result of the police establishing a small team of officers who are responsible for attending conferences. There remain some significant challenges. We have, for example, still not improved the case conference system processes enough to facilitate a strong understanding of multi-agency attendance at child protection case conferences. However, it is clear that there has been sufficient improvement for us to focus far more on the quality of what is being done to safeguard children and promote their welfare rather than on the processes being used. Timeliness of ICPCs was also inconsistent over the last year. At the end of quarter 3 there was a significant problem in the Child Protection Review Service in that a significant number of chairs where either on leave or off sick, resulting in a large number of conferences being cancelled. This resulted in a backlog. At the same time a lack of suitable conference venues was identified to resolve these issues two additional chairs have been temporarily employed and temporary additional conference space identified in the city centre. The key challenge in 2015-16 is for the Board in monitoring effectiveness is to develop robust ways of assuring quality of practice, and to create a learning culture across agencies to allow our understanding of quality to improve practice and make a measurable difference to children’s lives. Right Service, Right Time National guidance ‘Working Together to Safeguard Children’ published in March 2013 requires LSCBs to publish threshold guidance setting out the process for early help, criteria to determine levels of need and when cases should be referred to social care for assessment and statutory intervention. It further stipulates that the guidance must be understood and consistently applied by all professionals and ultimately lead to services that deliver the right help at the right time. Unfortunately during this period the service received a high volume of late ICPC requests. These late notifications delayed the booking of conferences within the 15 working day statutory requirement. Improvements in conference timescales were seen in by March 2015 rising to 45% compared to 8% in January 2015. Staffing levels in both social care and health visiting were a major concern over the last year. The number of health visitors has increased significantly following a national drive to increase the numbers in the last three years. In line with this the average caseloads of health visitors has dropped significantly from 696 in 2012-13 quarter 1 to 368 in quarter 3 2014-15. Social care at March 2015 still had significant permanent vacancies with over 35% of full time posts filled by agency staff. We do not currently have the police data for staffing. Social work caseloads are hovering around the average of 24. The Ofsted Inspection in 2012 highlighted fragility and inconsistency in professional understanding and application of thresholds of need across the city. In response the BSCB published Right Service, Right Time (RSRT) threshold guidance in May 2013 and carried out a six month evaluation of progress the findings of which were presented to the Board in January 2014. Disappointingly the finding from an employee survey found that only 53% of frontline staff across organisations in Birmingham were aware of RSRT. During the same period the quality of fCAF and referrals to children’s social care remained problematical. The Ofsted inspection in 2014 rightly highlighted concerns about how widely it was understood and applied. What did we learn and change as a result? As a result of the concerns surrounding the Unallocated Single Assessments the process for dealing with amber rated referrals at MASH has been amended. Amber rated referrals are now assigned straight to an area team who assess the referral and decided whether an assessment should be carried out. Consequently there has been a significant reduction in the number of unallocated assessments. In 2014-15 the Board’s most significant programme of work was the redevelopment and dissemination of the “Right Service, Right Time Threshold model” (RSRT) in response to these concerns. The refresh was led by a multi-agency task and finish group, working closely with the MASH Programme Board and the •••• 14 Early Help Programme Board on its development. The key principles are that every child needs and receives universal services, and that at times they may also need more input, varying in its types and intensity, depending on the type of need, its complexity and potential to cause harm. It allows for movement between categories without any implication of a progression “upwards” towards the most serious intervention. It expects professionals to intervene early in the life of a problem or expressed need and to seek to meet that need with and through the family or carers of the child. It is predicated on agencies being prepared to accept and work with a degree of risk, and to ensure families are as far as possible supported to find their own solutions and ways to meet their own needs. The successful introduction of RSRT and MASH have restored confidence but resulted in a huge amount of work being escalated to social care, when it could be better dealt with in other ways. The development of early help is a key to achieving this change in 201516, as is greater clarity about when family support under s17 is an appropriate response and when it is appropriate to move to a s47 investigation. RSRT provides a strong platform to support that drive. Early Help At the beginning of the 2014-15 year early help was not sufficiently well developed, co-ordinated or understood within the council and across the partner agencies. The BSCB Board developed and consulted on a “definition” of what we mean by early help in Birmingham (which was congruent with the RSRT refresh). This was to ensure that being assessed as “child in need” (under S17 of the Children Act 1989) and provided with social care services was not seen by partners as the only way in which children receive “early help”. It was also designed to underpin and support the BSCB Neglect project and campaign being led by the Board with partners and the NSPCC. As part of the Warner led Year 1 Improvement plan in the Local Authority the Early Help Programme Board was established to develop the multi-agency early help strategy. This strategy was supported by the BSCB Board, widely consulted on and debated across a range of services. The strategy outlines the vision, principles and approach for Early Help and identified seven strategic priorities. The revised model was launched with an extensive programme of awareness raising events and a comprehensive single and multi-agency training programme, utilising training for the trainers and an implementation pack for each partner agency. Early adoption of the refreshed model means that the MASH referral pathways and the whole early help strategy are based on the application of the model. The impact of the revised model will be evaluated in the autumn of 2015-16. However it is clear from a range of data sources that the model has provided a common conceptual framework for all partners, and a shared language to use when considering, assessing and meeting need. 1. Leadership Partnership Working and Governance 2.Strengthen and clarify the Early Help and Safeguarding front door pathway 3. Assessment and Interventions 4. Information Sharing 5. Localities and Pathways 6.Workforce 7.Commissioning The Early Help Programme Board has now (2015-16) become integrated into the Birmingham Early Help and Safeguarding Partnership Board (BEHSP). The BEHSP is accountable to the new Strategic Leaders Forum and will report on Early Help performance to the BSCB. The Board have agreed clear ‘success criteria’ for the refreshed model, which will inform the overall evaluation and impact assessment that will be presented to the Board on 15 December 2015. What is also clear is that the RSRT threshold model has not yet had sufficient impact on cultural behaviours across the system. The degree to which the child protection system was failing in 2009 to 2014 undermined confidence in practitioners and drove a culture of pushing things up to social care repeatedly when they had real and genuine concerns. Children in care and young people leaving care Children and young people in care, young people and care leavers continue to be recognised as a vulnerable group in society, despite the attention over recent years paid towards improving outcomes for them. This •••• 15 was not a priority for the Board in 2014-15. However the Board was aware that there were significant issues with the volume, quality and approach to care in the city. As part of the year 1 Improvement Plan a major programme of work took place. This culminated in a new strategy for Corporate Parenting, agreed and published in March 2015 and subsequently scrutinised by the BSCB Board. A comprehensive programme of training has been developed for schools building on the work commissioned by BCSB during 2014. These sessions are aimed at all schools regardless of designation and currently are attended by 65% of schools across the City. Work for 2015-16 has identified the need to widen further the access to these events for all schools. Private fostering The cascade of Right Services, Right Time has been coordinated through the Education plan as part of the work of schools relating to the MASH. In conjunction with the BSCB a set of training and cascade tools have been produced and an audit and impact process identified to measure how schools brief all their staff on the threshold model. To date 60% of schools have received this training with three additional sessions booked for September 2015. In addition a programme has been put into place to ensure schools are aware of their responsibilities under the new Prevent Duty and Equalities legislation. Prevent training continues to be delivered into schools, with take up now at 71%, and the LA supports the delivery of two theatre in education programmes around Prevent aimed at key stage 2 and 3, both of which evaluate extremely well. The Children Act 1989 defines a privately fostered child as: “A child under the age of 16, or 18 if the child is disabled, who is cared for (or will be cared for) and provided with accommodation by someone who is not a parent, a close relative or someone who has no parental responsibility for the child for a continuous period of 28 days or more. If the period of care is less than 28 days but there is an intention that it will exceed 28 days it is considered to be private fostering. There is a duty placed on anyone involved in a private fostering arrangement to notify the local authority. Local authorities do not formally approve or register private foster carers On 3 April 2015 there were 28 private fostering arrangements known to the council. This was a reduction of four from 32 at 31 March 2013. The database has been revised to show 26 children are currently living in private fostering arrangements. Given the size of Birmingham this is under reported and is an area of risk which requires some focus over the next 12 months. The UNICEF Rights Respecting Schools Award is being promoted as a way of engaging the children’s rights agenda within the curriculum with 71 schools registered within the first 3 cohorts. A key element of work that is being progressed within the plan is engaging with faith and supplementary settings with a safeguarding tool kit that these organisations can sign up to too ensure good practice and a safe environment for the children. This work was initially led by the LADO service and commissioned from Faith Associates. Safeguarding in schools At the beginning of the 2014-15 year, the BSCB in partnership with the newly formed Birmingham Education Partnership (BEP) funded a 6 month secondment to look at how best to improve safeguarding practice and improve the focus of schools on promoting welfare as well as safeguarding children. This work was also supported by the local authority. The decision at the end of the secondment was that there needed to be increased capacity within the system to support schools with these expectations and requirements. The local authority funded two posts on an interim basis – the Schools Safeguarding Advisor and the Schools Resilience Advisor. At the same time Sir Michael Tomlinson, the External Commissioner for Education in Birmingham reported on what needed to be done to improve education overall, including to improve safeguarding practice. This led to the development of an Education Plan (a companion to the Early Years and Safeguarding Improvement Plan). Finally work is being undertaken to identify and support schools which need additional support with safeguarding practice. Completion of the Section 175 self-assessment has been monitored through the plan and schools which have not completed or only partially completed will be supported in the next academic year. A programme of safeguarding reviews have been established with a supporting monitoring tool for safeguarding and one for the single central register to ensure that good practice is identified and support offered where required. Data around safeguarding will be provided to the Education Dashboard and is seen as a key element in the cross cutting reviews of schools around whom concerns are expressed. Every school is expected to undertake a selfassessment of their safeguarding practice annually, report it to their governing body and act on the •••• 16 findings. This is referred to as the Section 175 report. The Safeguarding in Education audit (Section 175) has been carried out in the city for the last three years and there has been steady improvement in return rates and compliance. In 2012-13 63% completed; 2013-14 97% completed; Compliance with submitting the audit on 10 July 2015 was 97.6%. At the deadline for submission of 31 May 2015 89% of schools had started the audit (54/489 schools not including Children Centres and Further Education colleges). The largest groups not completing the audit were Independent schools (46%), All Through Schools (43%), Secondary Schools without 6th forms (29%), 12% of outstanding schools and 23% of Edgbaston schools (this district has the most Independent schools at 21%). c) E-safety support and training for parents – Only 75% of schools responded to say they gave training or support to parents on e-safety. There were 70 schools who did not respond to this question. Independent schools did worst in this area with only 29% of them providing e-safety support and training to parents. 83% of Selly Oak schools supported parents in this way but only 46% of schools in Lady Wood and 29% of Independent schools did. Each school is expected to have an action plan in place to address areas for improvement. A separate analysis of the training elements within the audit has been completed to support the strategic development of a safeguarding in education training plan for the city. There are some key learning points arising from this analysis. For the Board there is still significant work to do to ensure schools are complying with the expectations laid on them, particularly in the independent sector. Key factors from the 2014-15 audit are that there has been an increased response rate across all schools even with an increase in the number of schools contacted to submit. But within this Independent schools have a significant lack of engagement. For the Local Authority the learning from the audits includes the need to develop: The key areas which schools are responsible for within safeguarding have high response rates that they comply with requirements i.e. 95% of schools report that they have robust governance arrangements in place, 97% report that they follow statutory guidance, 99% complete risk assessments for offsite activities, 100% of schools responding report that they have systems of reporting safeguarding concerns, they respect and value their students, that DSLs make staff aware of policies and procedures, schools have made appropriate action when students are persistently absent, keep records of low level concerns, have a person designated to attend CP meetings and have a regularly maintained SCR. a)A strategic plan to address the training needs identified in the attached training report b)A clear information and tracking system to capture safeguarding concerns and information from schools i.e. which young people are missing from education, what are the contact details in each school of their DSL and LAC teacher, which schools have high levels of non-compliance and need additional support in line with the draft strategy currently being developed by the CSE Strategic Sub-Group and the Child Sexual Exploitation and Missing (CMOG) operational group. c)Develop a clear “In Birmingham” message about expectations on all schools and how schools can fulfil those expectations focused on low compliance areas. Areas which had low rates of responding that the school had areas in place were: a) Action Plans – 57% of schools who responded reviewed and submitted safeguarding action plans to Governors although 73% of schools responded that they had completed a safeguarding action plan. Of the schools responding to say that they did not review 14% were schools whose Ofsted result was Requires Improvement (RI) whereas Outstanding schools only had 4% who did not review their action plans. For schools the learning from the audits includes the need to: a) Ensure ongoing compliance to reporting to the BSCB b) Make appropriate information returns to the local authority c) Ensure governors/responsible bodies have the correct information and understanding of safeguarding practice within their schools in order to be able to fulfil their statutory duties b) Anti-bullying – 22% of schools reported not reviewing their anti-bullying policy with children and young people, 24% of schools did not complete an anti-bullying survey. 92% of Sutton Coldfield schools completed an annual survey, compared to only 60% of Edgbaston, Erdington and Hall Green schools. Only 33% of Independent schools complete an annual bullying survey. d) Put in place a ‘Safeguarding in Education’ Action Plan to monitor progress on addressing the areas for development identified in the Audit which is annually reviewed with Governors. •••• 17 The Local Authority Designated Officer (LADO Service) •Including WRAP as the Learning and Development offer accessed through a central point •Developing trainer capacity across the council to meet need. •Safeguarding support and co-delivery of services with Birmingham Education Partnership This service fulfils the Local Authority Statutory Duties under Working Together to Safeguard Children (2015) and sections 10 to 11 of the Children Act 2004.Local authorities should have a Local Authority Designated Officer (LADO) to be involved in the management and oversight of individual cases. The LADO should provide advice and guidance to employers and voluntary organisations, liaising with the Police and other agencies and monitoring of cases to ensure that they are dealt with as quickly as possible, consistent with thorough and fair processes. Key vulnerable groups in the City Child Sexual Exploitation (CSE) has been a major focus in 2014-15. We know that there are a significant number of children and young people who have been exploited or are at risk of exploitation in the city. The Birmingham Local Authority Problem Profile in October 20141 and the Education and Vulnerable Children Overview and Scrutiny Report in December 2014 both make it clear that the evidence base about CSE in the city is not good enough. There is still a significant lack of information about the numbers of children and young people who are at risk of CSE and underreporting of those who are victims of CSE. There is also a lack of information that allows us to identify the root causes. In 2014-15 there were 1,076 referrals to the Birmingham LADO this year as compared to 864 last year, which represents an increase of 24.5%. Of these referrals 211 were taken forward to managing allegations meetings. This compares to 219 meetings held last year. A large number of referrals will be closed as advice only. Of the total number of referrals during 2014/2015 the number that were closed as advice only was 839 cases as compared to 606 last year which suggests that on balance the same proportion of referrals are dealt with at source commensurate to the overall number of referrals. This may well indicate significantly heightened awareness of safeguarding issues within the workforce across most organisations. Earlier in the year the BSCB CSE Sub-Group contributed to the regional assessment of the nature and scale of child sexual exploitation across the West Midlands for the period January till June 2014. The findings ‘Tackling Child Sexual Exploitation’ were published in March 2015 and provided a valuable overview of risk at that time and helped inform the development of our CSE strategy. The largest number of referrals were received from education and this continuous a year on year trend. The figures for this year are 331 as compared to 270 last year. A significant number of these referrals were received as parental complaints from Ofsted. The referrals from education are now broader and will not just involve staff members but may also include referral about education transport and possibly voluntary agencies that may be using the school site. This reflects a greater understanding about the role of the LADO and schools’ willingness to refer anyone of concern that has any connection with the school. The issue of allegations in relation to physical restraint within schools and residential homes continues to feature in the referral base and the police are involved in a great many of these cases. We (at 16 March 2015) also know that: •There were 340 Children and young people identified as at risk of Child Sexual Exploitation in the City. •177 were assessed as Children in Need, and have a child in need plan in place •75 were high risk and the subject of Child Protection Plans and • 88 were in Care of the Local Authority. •Since February 2014 to date there have been 284 referrals with CSE as presenting issue and 423 Single Assessments (incl. S47) have been undertaken with CSE as a contributing factor. The second largest numbers of referrals are received from Early Years partners with referrals about residential children’s services featuring as significant as well. There has been an increase of over 100% in the referrals received from Early Years partners this year 136 as compared to 65 captured last year. •There have been 67 (MASE) meetings held in last 4 months (Nov 2014-Feb 2015). •80% of referrals to MASE are initiated from Children in Care, Safeguarding and Family Support Teams; the other 20% is via MASH and other Agencies. Including Youth Service and third Sector Aquarius Key challenges for 2015-16 •Workforce development and the mandatory inclusion of the Prevent Duty in training 1 “We Need to Get it Right – A Health Check into the Council’s Role in Tackling Child Sexual Exploitation – Birmingham City Council Dec 2014 •••• 18 •There have been 18 C(M)OG meetings (Nov 2014Feb 2015). A total of 98 Victim discussions and 106 Perpetrator discussions have been held within CMOG during the reporting period. These include reviews of progress and agreeing action pending completion. than through a proper needs analysis. Our current position is that Birmingham is doing some important and bold things as part of our shared approach to tackle CSE. Despite the failure of partners to contribute to and drive the way in which CSE was being responded to in the City progress is being made. There is a strong commitment by all partners and a lot of energy going into it. We are building the necessary structures, processes, and services to identify children and young people at risk of CSE, ensure there are the right interventions and services to support them and their families and to protect then, and to pursue perpetrators. This snapshot of the current situation represents a significant increase in the numbers of children and young people identified at risk of CSE since last reported in November 2014. This is very positive and a direct consequence of the more effective structures put in place over the last year and greater awareness across the partnership. However it is probable that it is still an underestimate about the actual extend of CSE and the risk of CSE in the city. However, we are only a few steps along the road to dealing with it comprehensively and are still learning how much we have got to do ahead of us. We know that the scale of CSE in the West Midlands is greater than initially identified, that CSE is a regional and national issue and that victims of CSE come from all parts of the city and all walks of life. We now need to better understand prevalence, ethnicity, age and gender issues for offenders and victims, and the patterns of risk and offending across the city, the key areas for strategic focus, the scale of the investment needed and the impact and effectiveness of what we have done. We also need to start to involve children and young people, especially victims, in the design and development of our services. The BSCB approved a new CSE Strategy in January 2014, following the establishment of a CSE Strategic Sub-Group in 2013. However the complexities and pressures of a range of external reviews of Birmingham, organisational change for the West Midlands Police, the impact of setting up a MultiAgency Safeguarding Hub in Birmingham have all had an impact on the delivery of this strategy. There was a considerable focus on CSE over the 201415 year which has ensured awareness of CSE has risen across the whole City. Some very good and innovative work has taken place over the year, but much has been despite rather than because of a coherent local strategic approach. This has largely been due to the lack of effective work by the BSCB Strategic SubGroup, which lacked the drive, capacity, coherence, contribution from and commitment of partners with a number of changes of chair leading to an absence of continuity. This is made more obvious by contrast with the MASH Programme Board, Early Help Programme Board and Troubled Families Partnership Board despite the importance of the issue. CSE has been everybody’s problem and none in many ways. As a consequence of the lack of strategic drive to develop and improve CSE services the Board agreed a new Strategy in March 2015. This included a set of key principles to govern what we do collectively and individually, as practitioners, managers and senior staff in each agency, as partners and as the BSCB in responding to CSE. Two major achievements have had an impact over the year. Firstly the local authority successfully applied to the court for a civil remedy to disrupt the perpetrators of CSE in a specific case. Secondly an innovative new DVD, BAIT, was commissioned, led by young people and distributed to secondary schools across the City for use with students. Whilst this has been less important over the year as services develop and the whole system becomes increasingly complex a bottom up approach ceases to be either effective or safe. A number of complexities have made achieving strategic coherence difficult. The Regional Preventing Violence against Vulnerable People Programme has driven much of the work that has been done, and it has at times been difficult adapting the regional approach to fit the Birmingham context. Capacity to respond to CSE has been increased by the local authority, and significantly increased by West Midlands Police, but in the absence of a strong strategic set of drivers additional multi-agency capacity has not been scoped, or commissioned. The size of the dedicated CSE team has grown incrementally and opportunistically rather In addition work is now underway to better integrate CSE into “business as usual” in order to equip practitioners in every aspect of multi-agency children’s services to recognise and respond to the risk of or actual CSE as part of their case work rather than transfer it to a small centralised specialist team. This is driven by both the principles in the strategy and by the work underway to rebalance the system to ensure the majority of work takes place at as low a level as possible, and in the areas, and local communities children and young people live in. •••• 19 In 2015 there is however a major challenge to the strategic leaders’ forum, early help and safeguarding partnership and BSCB to assertively and decisively strengthen the work of the CSE Strategic Sub-Group, agree a programme delivery plan behind it and deliver the new CSE Strategy. In addition there is a corporate challenge for the local authority as a whole to get a better collective “grip” on how CSE and other safeguarding issues across the whole council are appropriately led and co-ordinated across departments and partnership bodies. By July 2014 and the start of MASH there had been a significant increase in the number of police incident reports moving from a previous average of 11,000 children per year to 13,500 in 2013/2014. The increase was influenced by police service redesign and pro- active training in respect of domestic abuse with police frontline colleagues. The resulting increase in volume was not matched by resource and as a result a significant backlog of cases accumulated during the 12 months. Ofsted cited this as a major risk for the city in their 2014 inspection and the January improvement visit. It has subsequently been dealt with. Missing Children is another area which saw very significant slippage in 2014-15. The challenge for 2015 is for the multi-agency partnership, through the MOG, to develop an integrated approach to identifying responding to and intervening with children missing from home, care, school and from view. This should include the development of a shared database, some simple accessible systems and processes and the ability to ensure appropriate early help or statutory interventions are put in place with each individual child. Early in 2014 the BSCB Board convened a meeting of the Community Safety Partnership, WMP, NHS representatives and the Adult Safeguarding Board and BSCB to discuss how best to respond to the increasing concerns about the need to better address the issue of Female Genital Mutilation (FGM). The meeting agreed FGM should be led by the BSCB rather than the other Boards. It also agreed to ask BAFGM to become part of the partnership governance structure of BSCB. BAFGM is now an affiliated group to the Board, which has also agreed to underwrite some of its budget. The Board signed off the action plan, and takes reports from BAFGM every six months. Domestic Violence has a significant impact on children’s lives and as such is part of the Board’s work, although it is clearly led by the Community Safety Partnership. The Birmingham multi-agency screening process of child risk in domestic violence has been in place in the city since 2009. In addition the newly defined criteria which includes the 16-18 year old age group has further emphasised the role that safeguarding plays in trying to improve the future safety and wellbeing of children and young people under 18 years of age. For the past 18 months the BSCB has required 6 six monthly reports on the progress of the joint screening teams and the learning for the city in respect of the trends and outcomes of the screening process. Significant progress was made over the year, largely due to the efforts of BAFGM and its inspirational chair, the Police Sentinel Programme, the commitment of the NHS providers and the support of the Regional PVVP. This was helped by new government legislation and guidance. The model provides a clear opportunity for BSCB with the Community Safety Partnership and the Adult Safeguarding Board to support similar arrangements for other emerging issues and concerns, where community and practitioner led initiatives can be much more effective that statutory arrangements. With the advent of the Multi Agency Safeguarding Hub (MASH) the joint screening process now is part of the integrated arrangements in MASH. The first anniversary of MASH in July 2015 has seen the historic backlog of cases removed, resources improved and the use of MASH staff flexibly to meet demand. Processes for responding to high risk have changed and now any incident where the police deem the adult to be at high risk is screened within 24 hours. All high and medium adult risk cases are therefore screened within a working day. There is now assurance for MARAC that the screening of child risk will inform their discussions. A database tracks the numbers of cases screened daily and a weekly report allows managers constant oversight of the volumes and outcomes of screening. MASH audit programmes will encompass domestic abuse outcomes. Another emerging issue over the year was the impact of radicalisation both nationally and locally in Birmingham. The Board took a presentation from the Counter Terrorism Unit on radicalisation and its impact on children and young people at the beginning of the year. It took an update report on the joint radicalisation and prevent hub at the end of the year. Prevent is led by the Community Safety Partnership rather than by BSCB and has little impact until relatively recently on the work of the Board. It has latterly highlighted some significant gaps between the two Boards in terms of a common understanding of each other’s responsibilities, priorities and strategies, agreements about shared initiatives and shared •••• 20 priorities. It is clear that there is a major gap in relation to the BSCB’s relationships with the very wide range of faith communities across the City, and its ability to communicate with them, set expectations, support them to develop safeguarding systems and to better respond to risks including those as a result of radicalisation. Partnership’s areas of concern. This relates too to the need for a corporate council led approach to the whole safeguarding agenda, and has implications for the “Future Birmingham” programme in terms of the partnership landscape for safeguarding in the future. The challenge in 2015-16 is for the Community Safety Partnership, the Adult Safeguarding Board, the Health and Wellbeing Board and the BSCB Board to agree a protocol governing the relationship between them, address the issue of who leads on what, agree shared priorities and a shared work-streams within the context of the Future Birmingham Programme. Other emerging issues that the Board has not yet addressed but needs to consider are modern day slavery, trafficking, honour based violence and forced marriage. These also fall with the Community Safety The effectiveness of the Birmingham Safeguarding Children Board This part of the report deals with how effective the BSCB Board, Executive and Sub-Groups have been in fulfilling their statutory objectives and functions. It covers the delivery of the Board priorities, the governance of the Board, its business arrangements, budget and major programmes of work. The Board complies with the requirements of ‘Working Together to Safeguard Children 2015’, with its independence built upon individual and collective responsibility for holding organisations to account, by evaluating how effectively they work together to safeguard children. The Chief Executive of Birmingham City Council is responsible for the appointment and removal of the Independent LSCB Chair with the agreement of statutory partner Chief Executives and lay members. Membership of the Board comprises of 42 members, of whom there are 27 statutory board partners, 2 lay members, 2 participant observers, with Sub-Group chairs and professional advisors making up the remaining 11 representatives. The diversity of the city is reflected by the make-up of membership of the Board, with a gender ratio of 56% female and 46% male representatives from different faiths, cultures and communities. The key focus of the BSCB is to provide independent strategic oversight of partnership working to safeguard and promote the welfare of children in Birmingham. The BSCB is responsible for collectively leading, co-ordinating, developing, challenging and monitoring the delivery across the city of effective safeguarding practice by all local agencies. It is not responsible or accountable as a Board for actually delivering safeguarding services. That is the responsibility of each of the local agencies separately and collectively. Figure 5 Our structure in 2015 Birmingham Safeguarding Children Board Structure Birmingham Safeguarding Adult Board Education and Vulnerable Children Overview and Scrutiny Committee Chief Executive BSCB Strategic Board Birmingham Community Safety Partnership Health and Wellbeing Board BSCB Executive Group FGM Sub Group Safeguarding Learning & in Education Development Sub Group Strategic Child Sexual Exploitation Child Sexual Exploitation Operational Group Practice Standards & Procedures Missing Children Operational Group •••• 21 Performance & Quality Assurance Serious Case Child Death Overview Panel Comms & Public Engagement During 2014-15 the Board met on five occasions, supported by the Executive Group schedule bimonthly meetings. The geographical boundary of the Board’s strategic responsibility is coterminous with that of Birmingham City Council and includes all those statutory agencies that operate within this area. The Board’s span of influence and collaboration extends to both a regional and national level, focused on utilising finite resources to maximum effect on tackling safeguarding issues that have no boundaries, such as Child Exploitation, Trafficking and Female Genital Mutilation. All the Terms of Reference (for each body) were redrafted, along with new membership role descriptions, statements of responsibility, appointment terms, membership contracts and individual objectives for agreement at the November 2014 Board. Each statutory partner was asked to sign up to a statement of accountability and commitment to the Board and its requirements. The previous Executive oversaw the changes, negotiated new appointments and commissioned a piece of work to provide the required governance material. At the same time the executive put out to tender a Board Development programme to support the first year of operation. The Executive Group managed the smooth transition to the new Governance arrangements and the establishment of the new Sub-Group structure in place for the new financial year. The Board have commissioned the Executive Group to monitor implementation of the new governance arrangement in 2015. The Independent Chair utilises a Practitioners Forum to consult front-line professionals across a range of agencies to test, challenge and develop new safeguarding initiatives and seek feedback on the embedding on practice. This network has 80 members with approximately half attending the five consultation events chaired by the Independent Chair, Jane Held. The feedback from frontline professionals contributed significantly to the board’s work over the year. For example, the final version of Right Service, Right Time, with members also volunteering to be involved in multi-agency case file audits during the year. The Board discharges its statutory functions through an Executive Group and six established Sub-Groups. During 2015 implementation of the governance review findings saw the creation of two new SubGroups, Safeguarding in Education and Practice Standards and Procedures. The Board also provides strategic oversight and direction for the Birmingham against Female Genital Mutilation Group. Governance Review In January 2014 the Independent Chair commissioned a review of its governance arrangements to improve the Board’s ability to deliver on the aims and objectives set out in the three year strategy ‘Getting to Great’ 2014-2017 and the Business Improvement Plan 2014-15. The review took account of the findings of Ofsted Inspections and the Independent Chair’s Reports to the Parliamentary Under Secretary of State. It also ensured compliance with statutory guidance set out in Working Together to Safeguard Children. The review was also cognisant of the emerging direction of travel of Lord Warner’s intervention to improve safeguarding of children in Birmingham. Implementation of the Business and Improvement Plan 2014/2015 is predominantly delivered through the Sub-Group structure and approved Work Programmes. The role of Sub-Group Chairs is crucial to the successful delivery of safeguarding priorities. The Independent Chair, Vice Chair and Board’s Business Manager ratify the appointment of SubGroup Chairs and Vice Chairs and there is an effective succession planning process in place. In 2015 the Board Induction Programme was revamped focusing on core roles, functions and expectations of Chairs and new members. In order to improve, radical changes were needed to the Board membership arrangements, governance mechanisms and arrangements, organisational accountabilities, business and administrative arrangements. The chairing arrangements appropriately reflect the requisite expertise, seniority from a range of key stakeholders: 1.Practice Standards and Procedures Sub-Group – West Midlands Police The report makes 50 recommendations which were all accepted. The Board, the Executive and the SubGroups were all dissolved on 31 December 2014 and reconstituted the following day (1 January 2015) under the new arrangements, with new membership of the Board, the Executive and all Sub-Groups, as well as newly appointed Sub-Group chairs and vice chairs. In addition the new meeting cycle began in from 1 January 2015. 2.Child Death Overview Panel – Public Health 3.Strategic Child Sexual Exploitation – Birmingham City Council 4.Serious Case Review Sub-Group – Birmingham South Central CCG 5.Learning and Development Sub-Group – Birmingham City Council •••• 22 6.Communications and Public Engagement SubGroup – NHS Communications and Engagement Service support delivery on safeguarding priorities set out in the agreed work programme which is subject to regularly monitoring by the Board. Each of the SubGroup completes a concise annual report identifying progress, improvements practice and outcomes; emerging themes and areas for improvement and a record membership, representation and attendance. 7.Performance and Quality Assurance – Birmingham City Council The Independent Chair and Business Manager meet on a bi-monthly basis with Sub-Group Chairs and Programme Managers to monitor progress on Sub-Group agreed work programmes and to resolve issues that impact on the implementation of the BSCB Business and Improvement Plan. Some agencies attendance at Sub-Groups has continued to fail to meet the Board’s high expectations. Sub-Group Chairs are provided with an analysis of attendance data by agency to enable non-attendance to challenge and escalated when required. Board Attendance, Representation and Engagement Attendance and representation at Board (figure 6) and Executive Level is good, during 2014-15 all statutory agencies achieved attendance targets. Within that overall picture however some agencies with 100% attendance had a significant churn in membership itself, particularly the Local Authority with changes in year to the Strategic Director and to the professional advisers. This necessarily impacted heavily on that Agency’s ability to contribute effectively and consistently to the Board. Each Sub-Group has a clearly defined function, dedicated programme management support to Figure 6 BSCB Attendance May 2014 - March 2015 - 5 meetings + development session 100% 80% 70% 60% 50% 40% 30% 20% 10% Organisation Represented Non Attendance No Identified Member •••• 23 Membership Ceased Lay Member Lay Member Third Sector Assembley Cabinet Member, People’s Directorate Designated Nurse Chair of Child Death Overview Panel Chair of Communications and Public Engagement Chair of Learning and Development Sub Group Chair of Child Sexual Exploitation Steering group Chair of Performance and Quality Assurance Chair of Policy and Procedures Sub Group Chair of Serious Case Reviews Sub Group BSCB, Business Manager NHS England Designated Doctor Cross City CCG Heart of Englands NHS Foundation Trust Birmingham & Solihull Mental Health Foundation Trust Birmingham Children’s Hospital/ CAMHS Birmingham Community Health Care Trust Birmingham South and Central CCG West Midlands Police Youth Offending Service National Probation Service Rep: Nursaries Sandwell and West Birmingham CCG Staffordshire and West Midlands CRG Rep: Special Schools Rep: Primary Head Teachers Attended Rep: Secondary Head Teachers Rep: Adults and Communities BSCB Independent Chair 0% People’s Directorate, Strategic Director Safeguarding and Development, Peoples Directorate Education and Commissioning. Strategic Director Place Directorate Attendance Percentage 90% Figure 7 - Agency Attendance by Sub-Group between April 2014 – March 2015 Green: The named member attended 80% or more of the meetings Blue: The named or nominated members attend 80% or more of the meetings Red: The named or nominated members attended less than 80% of the meetings Pink: The organisation joined the Sub-Group Yellow: The organisation’s membership at the Sub-Group ceased Board Comms CDOP CSE L&D P&QA SCR People Directorate Place Directorate Legal Directorate BSCB Primary Schools Secondary Schools Special Schools Nurseries West Mids Police Probation CRC Vol / Third Sector Youth Offending Public Health SC CCG CC CCG SWB CCG BCH / CAMHS BCHC BSMHFT BWH HEFT ROH WMA WMF A dedicated Business Support Unit supports the work of the Board and is currently hosted by the City Council, but funded by key statutory partners. In April 2014 the Board appointed three dedicated programme managers and an additional administrator to reflect the expansion of the safeguarding structure and address concerns in relation to capacity and management resilience within the Unit. The changes have made a significant impact in driving forward the Board’s Business and Improvement Plan and the SubGroup work programmes. The Business Support Unit is directly managed by the Independent Chair, increasing its independence. The Business Manager provides the Independent Chair with regular performance updates on the efficiency administrative systems that impact on the effectiveness of the Sub-Group Structure. •••• 24 Business Plan performance must be included in the routine work of the BSCB. The Birmingham Safeguarding Children Board Business Plan 2014-15 reinforced the continued focus on four key business priorities from the previous year. Key business tasks for 2014-15 were: These four areas remain a priority and have been integrated into the Business and Improvement Plan from 2015-16. The Board remains concerned that despite effective delivery of much of the plan it still needs further reassurance of the impact on frontline practice. Against the performance measures we set for 2015 we delivered as follows: •Ensuring that multi-agency frontline practice focuses on the experiences and life of children •Understanding and assuring the quality and consistency of front line practice through strong data and multi-agency audit By March 2015, we will know that: 1.The number or re-referrals and children made subject to a protection plan for the second time are both reducing year on year. We have the data to demonstrate activity. Re-referrals are now within the national norm. However we cannot demonstrate the total target we set ourselves. •Using quality assurance information, review of child deaths, SCRs complaints and other activity to inform a comprehensive learning and development strategy •Creating a multi-agency workforce development programme which supports excellent practice through practical tools and learning opportunities 2.Children and families are assessed and receive services within statutory timescales. We are not yet fully achieving timescales across the Board but have made significant progress. What is more important now timescales are reasonable and most cases allocated quickly is the quality of the assessments, plans and outcomes achieved. •Influencing and supporting multi-agency strategic planning, integrated commissioning and integrated service delivery •Creating the capacity as a Board Business Support Unit to effectively support the system 3.Where children are the subject of a protection plan the family can tells us they know what has to happen why and by when, and what will happen if this isn’t achieved. There is still some distance to go to deliver fully on this measure. It identified 96 specific actions. Throughout the year the Board closely monitored implementation of these themes and tasks and actively intervened to address under performance where necessary and ensured the completion of work within the agreed timescales. At the end of the year 53% (51) of actions were completed and 22% (21) of actions were progressing, but not finalised. The outstanding actions were reviewed as part of the Board’s formal end of year review of progress and effectiveness 21% (20) of actions had been deferred until 2015-16. There was significant slippage in the below areas: 4.All our statutory agencies are able to demonstrate how well their safeguarding systems are functioning, what needs to be improved and what action they are taking to achieve this. This has been achieved. Risk Register As part of the strategic planning framework, the Board periodically undertakes environmental scanning to identify risks and focus partnership intervention to mitigate the potential impact. The Board’s Executive Group is working in partnership with Birmingham South Central Clinical Commissioning Group to further refine and develop the management of risk utilising good practice from the NHS. •Work with, and utilise, existing opportunities for children and young people to help develop a programme of engagement in the Board’s work. We are building on young people’s feedback from the seminar in October 2014. •Agree with the scrutiny committee the theme we will undertake a joint scrutiny exercise on in 201415 and then undertake it The key risks and mitigation action focused on: •Implement a full annual Quality Assurance Programme, implement and utilise the outcomes to inform learning and development •Children’s safeguarding arrangements in Birmingham continue to fail to keep children safe •Children continue to be invisible to practitioners, managers, senior managers, strategic planners and system governors •Work with partners to develop good quality collection and collation of data on missing children so that partners have a full understanding of the risks to these children and can identify what actions they need to take to minimise these risks. Scrutiny of challenge to this data and related •Lack of tangible evidence of trajectory on improvement journey •The impact of publication of Serious Case Reviews in undermining public confidence •••• 25 • Impact of MASH and Early Help developments A Zero Based Budget exercise recommended an increase agency contributions, which resulted in a total BSCB budget for the financial year 2014/2015 amounted to £834,615. The below chart (figure 8) provides a breakdown of the components of the budget detailing individual agencies contributions (£659,267), income generation (£7,830) and a carry from the 2013-14 budget (£167,518). Figure 9 provides details of expenditure during 2014-2015 which concentrated on five core business areas. •Lack of clarity about Early Help model delivery and coordination of multi-agency services for Universal, Universal Plus and Additional Needs •Lack of assurance of the effectiveness partnership intervention to combat child sexual exploitation •Impact on safeguarding capacity and delivery during a period of austerity The future development of the Board’s risk assessment model will be incorporated with its strategic and business planning process from 2016 Figure 8 Breakdown of BSCB budget and agency contributions 2014-15 £167,518 20% £7,830 1% Birmingham City Council £550 0% Health £15,176 2% West Midlands Police Staffordshire & West Midlands Probation CAFCASS Income Generation £39,837 5% Carry Forward from 2013/14 £447,964 54% £155,740 18% Figure 9 Breakdown of BSCB Expenditure 2014-15 40% Safeguarding Business Support Unit Infrastructure Supplies & Services Professional Fees relating to Serious Case Reviews Independent Chair Arrangements Delivery of Multi-Agency/Campaigns/Projects 28% 10% 5% 4% Birmingham City Council also continues to make a significant contribution in kind, by the provision of office accommodation, IT, Legal, Financial and HR support for the BSCB Business Support Unit. •••• 26 Performance Management and Quality Assurance Sub-Group (P&QA) children and young people. The Assistant Director Education and Skills has been appointed to chair the new Safeguarding in Education Sub-Group which commenced in June 2015 following the recommendations of the Governance Review. The Group provide a conduit between the 445 education establishments and the LSCB. This Sub-Group moved forward significantly during 2014-15. All statutory partners completed the annual Section 11 safeguarding audit return. Since June 2014 a Front Door Reference Group has been running as a small Sub-Group of the P&QA. This group had audited 66 referrals by the end of March 2015. The data has been regularly reported to the group, the MASH Board and the BSCB, the information to date indicates that there has been some improvement in the quality of the referrals since last June. In 2015 the Sub-Group will concentrate on supporting the development and co-production of a safeguarding assurance, improvement and development ‘offer’ for education establishments in order to: •Improve the welfare and safety of children and young people (through the delivery of support, training, audit processes and education improvement offer.) The PQMA Sub-Group completed four audits of Initial Child Protection Conferences (ICPCs) in October 2014. The findings have been acted upon to enhance training of child protection chairs and the ICPC process. These audits identified that the Voice of the Child is still missing in the child protection conference process with only one case identified as good. The BSCB will seek further assurance of improvement in the conference process during 2015-16. •Provide assurance for establishments and the LSCB of the effectiveness of safeguarding arrangements and practice (through the Section 175) audit process, support visits, external inspections and reviews. We are starting to see positive outcomes on the stronger relationship, which is evidenced by the 97% completion rate for the Safeguarding in Education Audit 2014. Head Teachers and Designated Safeguarding Leads have contributed to the design and rolled out programme of new on-line Section 175 Audit process. The new Chair of Safeguarding in Education Sub-Group is a participant member of the Board alongside Head Teacher representation form Secondary, Primary, Special and Early Years settings on behalf of the relevant schools forum. Towards the end of the year a multi-agency audit pool was developed, with professionals from a range of organisation being trained to undertake joint child protection audits. The audits are due to be completed by the end of June and a final report produced on the outcome of the audits in July. Practice Standards and Procedures Sub-Group The Board tendered for a supplier to undertake the detailed work of procedures and Tri-Ex was appointed. They worked on a total revision of procedures which were launched in September 2014. The Practice Standards and Procedures SubGroup is a newly established Sub-Group as part of the Governance Review, and is chaired by a Superintendent from West Midlands Police. The SubGroup is focusing on the continued development and dissemination of multi-agency practice standards, protocols and practice requirements. The Sub-Group is also overseeing the development and maintenance of the Tri-Ex on-line procedures that provide the children’s workforce with instant access to current national, regional and local guidance. Work is being undertaken at regional level to develop local multiagency protocols, standards, and service pathways for the West Midlands region. Communication and Public Engagement Sub-Group During the last year good progress has been made on establishing a foundation for good communications and focused work on: •The Voice of the Child – working with and utilising existing opportunities for children and young people to develop a programme of engagement: Whilst it is acknowledged that progress on this key objective has been restricted an initial mapping exercise was undertaken in November 2014 to scope and map who is leading on participation within the city. This objective will be carried forward into the 2015-16 work programme. •A re-fresh of Right Services, Right Time information campaign was delivered right across all agencies in Birmingham to help professionals understand how to access right support at the right time and to improve quality of referrals (Right Services, Right Time) – this included delivering nine briefing sessions for 1,492 professionals to raise awareness of the threshold guidance model. Safeguarding in Education Sub-Group During the last year the Board has worked closely with the Local Authority, Schools and Birmingham Education Partnership to ensure processes are in place to support schools to own and fully engage with statutory responsibilities for safeguarding •••• 27 •Launch of new way of working in Birmingham – 2014 saw substantial support for the launch of a new Multi-Agency Safeguarding Hub (MASH) in August 2014 – this included delivering 15 briefing sessions for over 2,750 professionals to raise awareness around forthcoming changes. the 5,915 delegates who attended training during the 2013-14 year, this was due to a reduction in capacity to commission training, with 19 less courses than the previous year. The L&D Sub-Group have been fully committed to the delivery and implementation of the Sub-Group Work Programme 2014-2015 and key achievements include: • Awareness raising campaigns – this year saw: •Delivery of a full multi-agency campaign in partnership with the NSPCC for raising awareness around neglect and monitoring public and professional response – this included supporting the delivery of a multi-agency conference for 200 professionals. •All commissioned training material reflects, ’The Voice of The Child’ • Standard Induction Programme developed. •Attendance and satisfaction with training deliver remains high, with low levels of non-attendance and cancellation. •Commencement of a safer sleeping campaign to raise awareness of the importance, perception and social views on sleeping arrangements with roll out and implementation expected in 2015-16. •Development of ‘Right Service, Right Time’ training materials/trainer’s pack produced to support a programme of train the trainer events. •Public Information – the newly designed BSCB website has continued to be maintained as a key gateway with up to date information. However, there are limited metrics available about the usage of the BSCB website. This will be remedied in 2015-16. •Commissioned a programme of training and briefing during 2014-15. Training courses remain full, with representation from different agencies enhancing the learning experience. Fewer courses were cancelled due to non-attendance and the importance of attending training has been reinforced through charges for non-attendance. •Agreeing communications protocols and joint working between agencies for media and campaigns so an effective multi-agency response is managed. The Sub-Group now has in place a Learning and Development Strategy, Learning and Improvement Framework and Training Plan. Work will continue to implement the Learning and Improvement Framework, to ensure that we build learning from serious case reviews and learning lesson reviews into future commissioned training activities. The SubGroup is actively working in partnership with Research in Practice on a number of initiatives including developing an evaluation framework. Learning and Development Sub-Group There are approximately 75,000 front line staff in the city who work with children or with adults who also have children. This creates a significant challenge in ensuring the Board effectively commissions multiagency safeguarding training and targets its finite resources at those professionals who can make the maximum impact on safeguarding children and young people across the city. The Board’s Training Offer compliment and builds upon each agencies safeguarding training, however there are particular issues in every agency in delivering with sufficiency in terms of skilled practitioners, recruitment and, more importantly, retention. The training module for RSRT was recognised as good practice and will act as an exemplar for the development of future training courses in relation to Early Help, FGM, CSE and Strengthening Families Framework. The Sub-Group assisted in developing briefing sessions to prepare and inform the workforce of the practical application of the assessment of needs model in March 2015. During 2014-15 the Learning and Development SubGroup commissioned and delivered multi-agency safeguarding training to 2,524 delegates across the children’s workforce. This is significantly fewer that Further achievements include: Figure 10 Number of Training Courses/Conferences •Four year procurement framework established to secure delivery of multi-agency training programme. 140 120 100 •Course utilisation has decreased by 1% from 93% during 2013-14 to 92% during 2014-15. 80 123 60 40 69 20 87 104 59 0 2010/11 2011/12 2012/13 2013/14 2014/15 •••• 28 •The number of training courses excluding conferences has remained stable during 2014-15 at 124, an increase of one course on the previous year. •Develop specific training activities around Early Help. •To continue to support, commission and quality assure RSRT training. •Implementation and usage of charging policy to maximise attendance and therefore justify expenditure. •Review, revise and evaluate existing training courses and use intelligence to inform future, commissioning intentions. •Delivery of key components within the 2014-15 L&D Work Programme. •Commission bespoke and multi-agency training specific to target groups. •A number of new training courses are currently under development and will be delivered during the forthcoming year, including learning from SCR, FGM and CSE. •Explore the application of e-learning for target group 1 and 2. •Review, revise, evaluate and develop training around Strengthening Families Framework. •A review of training courses has taken place, leading to a number of courses being revised and updated. •Develop and implement a multi-agency evaluation framework. •Develop a ‘core offer’ of training activities that is fundamental to what we do. The training courses delivered have increased the knowledge, skills, confidence and understanding of the children’s workforce as outlined by course evaluation sheets; however we recognise the need to further develop an Evaluation Framework that will demonstrate the impact that learning and development activities are having at different levels throughout the organisation. •Develop a robust process for the commissioning, delivery and evaluation of training activities. •Clearly identify and establish the meaning of multiagency training. Work is ongoing to develop courses as a direct result of lessons learnt from SCR, DHR and DV’s as well as other sources including section 175 and section 11 audits. Work will be undertaken in the forthcoming year to revise and update the Cancellation and Charging Policy; however, course take up rates from the Voluntary/Private and Independent sector have improved, showing a significant reduction in nonattendance and cancellation. Course utilisation remains above 90% even though there has been a reduction in the number of courses commissioned. During the coming year work will be undertaken to review and revise the existing course booking process. Strategic Child Sexual Exploitation Sub-Group Earlier in the year the Sub-Group contributed to the regional assessment of the nature and scale of child sexual exploitation across the West Midlands for the period January till June 2014. The findings ‘Tackling Child Sexual Exploitation’ were published in March 2015 and provided a valuable overview of risk at that time and helped inform the development of our CSE strategy. During 2014/2015, 57 courses were delivered with 1,385 training places available and 1,350 training places were actually achieved which equates to 97.47% places filled. Overall delegates satisfaction with the content of the courses was 98.31% and 98.23% rated as very good and good the delivery of the training. Training has been updated throughout the year to reflect changing structures in Birmingham, in particular the introduction of MASH in July 2014 and new ‘Working Together’ guidance 2015. The Board are ensuring the continued development of services takes account learning from the Rotherham Review, Birmingham City Council review ‘We need to get it Right’ and the emerging regional approach being driven by the Home Office supported initiative ‘Preventing Violence against Vulnerable People’. In August 2014 the Sub-Group on behalf of the Board contributed to Office of the Children’s Commissioner national review of ‘Gangs or Groups’. The 2015-16 L&D Work Programme will further develop and embed the key themes contained within the Strategic Plan around; the voice of the child, early help and safe systems. Therefore our key priorities for the forthcoming year are: The Sub-Group have also contributed to the development of a protocol for hotels; this approach is to become the ‘Gold Standard’ for the hospitality industry in Birmingham. •To ensure safeguarding child protection training at levels 1-3 are delivered via the sub-group. •••• 29 The Sub-Group commissioned a training needs analysis specifically focused on equipping participants within the new CSE framework as well as the broader children’s workforce. Interim findings were presented to the group in May 2015 and this will be a key feature of the work programme for 2015-16. We have participated in a regional awareness raising campaign to help parents, young people and communities to spot signs of abuse http://www.seeme-hearme. org.uk. In partnership with Birmingham Community Safety Partnership, Birmingham City Council and Birmingham Community Healthcare NHS Trust we have produced a resource pack to help support delivery of the PHSE curriculum in Secondary Schools and Further Education Colleges to enhance 14-17 year olds’ awareness and understanding of the dangers of CSE. The BAIT Resource pack which included a DVD, Work Book and posters was launched on 10 March 2015 with a screening of the film at Cineworld on Broad Street, Birmingham. The resource pack has been sent to every secondary school and Further Education College in the city. The resource pack is receiving recognition as good practice at both regional and national level. •Deliver a programme of CSE training that enhances staff skills, knowledge, professional competence and confidence to address CSE. Engagement in National and Regional Networks to share good practice. •To lead and continue to participate in a regional and local awareness raising campaign to help parents, young people and communities to spot signs of abuse. •Work with the Performance and Quality Assurance Sub-Group to develop the CSE dataset to meet local priorities and facilitate regional comparison of performance. •Evaluate the impact on young people of the BAIT educational recourse pack to be undertaken in December 2015. The findings to be shared with Headteachers, School Governors, Governing bodies and the Safeguarding in Education Sub-Group. The Child Death Overview Panel (CDOP) The Birmingham Safeguarding Children Board has a statutory duty to review and enquire into the deaths of all children under the age of eighteen. The Child Death Overview Panel (CDOP) oversaw the review of the 165 deaths that occurred between 1 April 2014 and 31 March 2015. The responsibility for determining the cause of death rests with the coroner or the doctor who signs the medical certificate of the cause of death and is not therefore the responsibility of the Child Death Overview Panel. The Panel’s role, under a chair that is independent of service provision responsibilities, is to: In March 2015 the Board ratified the revised Child Sexual Exploitation Strategy 2015-17 to tackle Child Sexual Exploitation. The strategy is built around four key strands, prevention, protection, disruption and prosecution. Successful implementation will be closely monitored by the Board and is embedded within ‘Getting to Great’ the Board’s three year Strategic Plan. Emerging Themes & Areas for Improvement 2015-16 •Classify the cause of death according to a national categorisation scheme; The Strategic CSE Sub-Group will concentrate on ensuring the effective implementation of the priorities set out in first year of the two year CSE Strategy ratified by the Board in March 2015. The Chair will closely monitor performance and provide regular progress reports to the Board. The main focus in year one will be: •Identify factors in the pathway of death, service/ environmental/behavioural, which if modified would be likely to prevent further such deaths occurring; then •Consider recommendations on these factors for action to the Safeguarding Children Board, who then arrange to ensure any appropriate actions agreed with partners. •Explore the feasibility of co-locating the dedicated CSE Team within the Multi-Agency Safeguarding Hub based at Lancaster House. Figure 11 below provides a comparison of the number of child deaths and serious case reviews commissioned between 1 April 2007 and 31 March 2015. Each year the Board publishes statistical analysis of the causes of child deaths and emerging learning. •Establish and embed the Missing Operational Group to improve our data collection systems to better identify the most vulnerable children so we can intervene earlier to make a difference. •Strengthen the pathways between CSE Operation Group and the Multi-Agency Safeguarding Hub to secure the requisite expertise earlier in identified cases of CSE. •••• 30 Figure 11 Comparison of Child Deaths to SCR’s in Birmingham between 2007 - 2015 Number of Deaths Number of Deaths 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0 Number of SCRs 184 175 171 160 171 165 157 144 4 2007/2008 5 2008/2009 3 2009/2010 4 2 2010/2011 2011/2012 1 2012/2013 2 2013/2014 2 2014/2015 Year A separate detailed analysis of the learning from the review process is commissioned and overseen by the Board through the Child Death Overview Panel (CDOP). A separate annual report analysing why children die is published by the Board. The report provides a detailed overview of the work of CDOP and the associated work of the Sudden Unexpected Death in Childhood (SUDIC) Team. a systematic bias in recording ethnicity. However the proportion of deaths is higher for Asian Pakistanis children than British White children. This can be attributed to the proportionately higher number of births to Asian Pakistani women. Serious Case Reviews and Learning Lessons Reviews The Sub-Group oversees the commissioning of the independent reviews process when a child dies or is serious injured and child abuse is suspected of being a contributing factor. The Sub-Group also monitors and ensures that the learning and action plans have been fully implemented. The findings from the CDOP Annual Report are referred to the Director for Public Health and the Health and Wellbeing Board in order to inform their work particularly in terms of the on-going issues relating to higher incidents in certain populations in the city. During the year two Serious Case Reviews were commissioned. The first Serious Case Review relates to a family of nine children who suffered sexual abuse at the hands of family members. The other is in relation to a Looked After Child who was sexually abused after absconding from a residential unit. In past reports we have been concerned about the influence of premature births upon the pattern of deaths, particularly the perinatal category. There were 100 neonatal deaths in 2014-15, 31 of these were born at less than 22 weeks of pregnancy. The mortality rate in this group is 100%, despite all the technological expertise available. The reviews undertaken by the panel, using our current resources and processes, cannot demonstrate any missed opportunities to prevent these births. The impact of these very premature and inevitable fatal births on families and service providers is, however, significant. Also during this reporting period six Learning Lessons Reviews were commissioned. The first of the Learning Lessons Reviews is in relation to a child who survived a house fire; the child’s mother was suffering from mental health issues and died suddenly after the fire. The second was in relation to a family who previously lived in Birmingham and moved to another Local Authority, court proceedings were taking place and the Judge requested that BSCB look into the circumstances of why the children were placed with the parents after Birmingham Social Care had previously had involvement. The third case was into a Looked After Child, and it was felt that his care was not managed appropriately. The fourth case was a young person who committed suicide, it was not felt In view of Birmingham’s cultural diversity it is important to understand any demonstrable differences in the patterns of deaths in different ethnic groups. The recording of the ethnic group of children overall is not complete (25%) but slightly better than in previous reports, particularly in the neonatal and infancy groups. The children whose ethnicity is unrecorded are spread proportionately across all the age groups which suggests that there has not been •••• 31 Published Serious Case Reviews that this case me the criteria for a SCR but it was felt that there would be learning that could be established from a Learning Lessons Review. The fifth case is of a baby whose arm was fractured by her father. She was only four weeks old at the time of the incident. This review only involves two agencies. The sixth case involves a baby who died suddenly and was remitted from the Child Death Overview Panel due to both parents being deaf and information that mother had not been provided with safer sleeping advice. The Board completed and published the findings from one serious case review, the tragic death of Harli Delves Reid who died at the hands of her father who pleaded guilty to causing the death and was subsequently convicted of manslaughter on 4 November 2013. He was sentenced to three years and nine months imprisonment. The full report is publically available through BSCB website at www. lscbbirmingham.gov.uk (BSCB 2010-11/2). Serious Case Review Sub-Group were notified of serious injuries to two children, this case was referred on to the Domestic Homicide Review Steering Group as the mother had been murdered by the father who subsequently went on to try to murder the children. Serious Case Review Sub-Group reviewed the Terms of Reference to ensure that the safeguarding arrangements for the children were included. Homicide Investigation Report The SCR Sub-Group has been involved in reviewing the death of Christina Edkins who was killed during an unprovoked attack by a stranger who was convicted of manslaughter on the grounds of diminished responsibility in October 2013. He was detained without a time limit in a secure psychiatric hospital. Birmingham and Solihull Mental Health NHS Foundation Trust were required to investigate the circumstances of Christina’s death and did so in conjunction with their lead commissioner, Birmingham Cross City Clinical Commissioning Group. Early on in the course of the review it was identified that a number of partner agencies external to health organisations had been involved and a collaborative approach was taken to maximise learning. BSCB agreed that this review fulfilled the requirements of safeguarding legislation. The full report is available through www.bhamcrosscityccg.nhs.uk. Work has taken place with the NSPCC and Sequeli to produce a Serious Case Review manual for practitioners, which will assist them in the completion of reports and chronologies, provide guidance on the differing types of review that can be undertaken, set out the expectations of BSCB board and SCR subgroup members and be a resource for independent reviewers and report authors. This piece of work will be finalised in the forthcoming year. During the year, BSCB also commissioned Birmingham University to undertake a thematic review of Serious Case Reviews and Learning Lessons Reviews over the previous five years; this was not completed by the year end and will be carried forward. Key learning points from the published SCRs and Homicide Reviews The key learning identified through the review processes inform policy development, training delivery, communication and public engagement and audit activity to evidence learning has been effectively implemented. The Disclosure policy has been developed by SCR Sub-Group and ratified and disseminated. The scoping document, sent to agencies requesting preliminary information about cases, was not always submitted in a format which allowed considered decisions to be made by the Sub-Group. It has, therefore, been revised to ensure that the Sub-Group has more accurate and complete evidence on which to make decisions. The key messages are: •Lack of focus on the children in frontline and management practice. •Domestic violence, mental health and substance misuse all featured which is a recurring theme in national reviews. •Lack of in depth assessment and insufficient support, guidance and explanation of how to safely care for a baby. There has been a significant amount of work performed by BSCB to ensure that SCRs that are nearing completion are quality assured and reflect the guidance in Working Together 2013, and looking ahead will need to reflect the 2015 revision. This has resulted in a revision of timescales to reflect the new requirements. •Insufficient attention given to emotional impact of event upon the parents. •Lack of information sharing between health professionals. •••• 32 •Organisations failed to listen to and respond to carers and significant others consistently and adequately. to these reviews. This has been particularly noticeable in recent very complex cases where organisations have to gather and analyse high volumes of material whilst continuing to deliver services which are already under scrutiny within Birmingham. •The accessing and sharing of information between key agencies was ineffective. •Organisations’ information recording and storage were not robust enough to allow good management and care. In some circumstances a statutory review may not be required but does raise issues about safeguarding in its widest sense. This is particularly the case where children are seriously injured, perhaps as the result of an accident, where supervision is of concern but there does not appear to be overt neglect or abuse or concern about the way in which agencies have worked together. These cases lead to substantial debate amongst Sub-Group members. This also requires consideration of the relationship between the SCR Sub-Group with that of the Child Death Overview Panel and Public Health. An example would be serious injuries of children due to falls from open windows which would not result in a CDOP review and do not require an SCR or LLR. Clearly, there are important safety messages that need dissemination and it will be important to develop better links to ensure this happens. •Services need to be more proactive in making it easier for a person with mental health issues to engage with them. Ensuring lessons are learnt The Birmingham Safeguarding Children Board closely monitors timely implementation and compliance with the key learning from Serious Case Review. Each agency provides regular reports detailing how learning has been embedded into front-line practice. Six other SCRs are still in the process of being finalised: on completion they will be submitted to the Department for Education and the findings published. A detailed performance overview is presented to the BSCB on a quarterly basis and an executive summary is provided. Themes that are emerging are the increasing number of cases involving families who have moved to the UK from mainland Europe and may have unrecognised or unmet needs. The Sub-Group have also considered how lessons from SCRs and LLRs are disseminated and will be taking this work forward, with the Learning and Development Sub-Group, to ensure that frontline staff can access learning in the most effective way recognising that this may be through use of a variety of formats. Reflection of the work of the Sub-Group For each case that is discussed at the Sub-Group there can be considerable debate about the type of review that should be conducted. There has been substantial deliberation about the reviews that may be required and their proportionality in ensuring important lessons are identified whilst balancing this with the capacity within organisations to commit significant resources in order to contribute effectively Summary, conclusions and whole system analysis This Executive Report sets out the work of the Birmingham Safeguarding Children Board in 201415. It addresses both the effectiveness of what is done in the city by partners to safeguard children, and the effectiveness of the Board itself in delivering its statutory objectives and 14 functions. The report shows that there has been significant progress by the BSCB Board through and with partners across the whole of the Board’s functions and objectives, delivering on much of the Business Plan for the year, and on the Ofsted requirements whilst adapting to changing policies and expectations nationally and locally. and service improvements that have been underway during the year. It has been drafted in line with national guidance on what a good report should contain. However this Executive Report fundamentally addresses six key questions. It assesses the Board’s work objectively against the evidence and against the guidance provided by guidance as to what a Board must do. It evaluates the quality of what we are doing against the criteria for what constitutes a “good” Board, and against the evidence we have of the impact of our work. The conclusions are short, and framed in the context of what the work of 2014-15 tells us about what we need to be doing next, the priorities for 2015-16 and the challenges we are setting. The full Report is long, largely because of the need to provide strong evidence of that progress, and to set out the range of activities, projects, programmes •••• 33 What is it like to be a child growing up in Birmingham? We have a high performing youth offending service, an excellent “Think Family Programme” and some strong NHS services in place. West Midlands Police have reorganised services specifically to build their capacity to respond to children at risk of harm and abuse. New approaches to key services, in particular the 0-25 Mental Health Service and the planning for an early start service (involving early years services and health visiting) will contribute to that process. We also have good evidence of the increased ownership of and responses to their safeguarding responsibilities from the majority of partners on the Board, with more investment in services as well as specialist safeguarding staff, and a much stronger approach to dissemination of material, development of learning and practice compliance. The rapidly improving engagement by and with schools, and the demonstrable areas of improvement in the way safeguarding is being built into school improvement work is another positive indicator of progress. We now have much better information about what life is like growing up in Birmingham. The Children’s Commission Report, ‘It takes a City to raise a Child’ has provided an in-depth analysis, and demonstrates that the Board’s preoccupations are not necessarily those of the children and young people living in the City. We also now have in-depth and sophisticated data available to us about the extent and depth of need in the City, both met and unmet. There has been a demonstrable increase in engagement and participation work with the children and young people using services across the partnership which we now need to capitalise on and use to inform our own Board work. In 2015-16 the BSCB Board will monitor progress generally by the Council and its partners against the recommendations of the Children’s Commission Report, “It takes a City to Raise a Child” as well as against our formal performance data set and other scrutiny activity. However it is clear that children and young people most want to feel safe in open spaces and on public transport. Clearly the City Council through the Place Directorate needs to lead work with children, young people, communities and partner agencies to significantly reduce the expressed sense of being unsafe in public spaces articulated so strongly by the children and young people of the City. However that is just the start of the long process of creating a city where children grow up happy, safe, and well, with good futures ahead of them. Paradoxically, although focussing on the children who are most unsafe has acted as a spur it has taken attention away from services to support families to keep children safe themselves, from the cooperation and coordination needed across the partnership in creating effective early help services, and from multi agency ownership of the need to respond early to emerging problems rather than pass the problems on to someone else. Challenge 1: Improving the safety of children’s lived experiences in their communities presents a significant challenge to the Council and its partners. Are children safer in the City? The much used “safeguarding is everybody’s responsibility” mantra is still a long way from being realised. Indeed the creation of strong centralised multi-agency safeguarding activity, whilst both very welcome and very necessary at the “front door” into statutory interventions is acting as a draw, rather than a filter, pulling everything up into a level of response higher than may realistically be needed. Partners have not yet fully developed cohorts of strong confident multi-agency staff in every service, school or setting, who can respond to need quickly and effectively, and who have the support, training and capacity to do it well. Neither is there a welldeveloped range of service “offers” they can draw on to create the right support packages. However partners are engaging strongly and willingly with the new Early Help Strategy. Overall the data and other evidence combine to demonstrate that by the end of 2014-15 children and young people were demonstrably safer. This does not of course mean they are safe, and indeed we can never guarantee the safety of every single child. In addition we have made significant progress in understanding the degree of need there is for services to support vulnerable children in the city. We know those most at risk are now getting a speedier and more consistent response to their needs, and professionals are clearer about what to do when they are concerned about a child or young person through the new Right Services, Right Time Threshold Model. The significant increase in contacts and referrals to the MASH, the numbers of children and young people getting assessments from social care, the number who are the subject of child protection plans, court proceedings and in care have all increased, and timescales diminished in terms of drift. Over 2015-16 onwards there needs to be a multiagency focus on to how best to appropriately and safely reduce the amount of work going through the MASH when it can be better dealt with at Right Service, Right Time (RSRT) Additional Needs and Universal Plus needs levels. This needs to be done •••• 34 without undermining agency confidence or the momentum gained by the successful development of the MASH. In addition the rebalancing of the relationships between the highly centralised City wide service (MASH) and the three local area service delivery model agreed with Lord Warner will be a challenge. This needs to be achieved within the context of reducing capacity across the partnership so needs to demonstratbly realign resources as a consequence of success. through providing data and intelligence, high support and high challenge. There is a long way to go however. Across all agencies service redesign has taken place without early engagement with partners. This affects multi-agency working. Challenge 4: There is a major challenge ahead for the new partnership bodies established to lead children’s services across the city, in establishing new ways of working, developing real cooperation across the system, rather than cooperation on specific issues, and to ensure the most effective ways of delivering services as resources reduce, capacity shrinks, and demand increases. Challenge 2: The major challenge for partners is to retain the confidence brought into the system through the work done in 2014-15, whilst ‘rebalancing’ resources, investment, staff capability and capacity so early help takes precedence over child protection for the majority of children and young people needing support. This applies equally to the overall partnership framework across the City, and to the simplification and rationalisation of the multiplicity of boards with overlapping responsibilities, and increasingly shared priorities. The BSCB Board has made limited progress in 2014-15 in terms of developing clearer and more effective strategic relationships with the Health and Wellbeing Board, Community Safety Partnership and Adult Safeguarding Board although some discussions have taken place about this with the Adult Safeguarding Board and, to a lesser extent the Health and Wellbeing Board. The LSCB Board has also not yet addressed the relationship that needs to be developed between the Board and the BEP. Whilst there are understandable reasons for this it is time to sort it out. Are we making sufficient progress with our strategic objectives? Overall the Board has made some significant progress in demonstrating it is more explicitly working with partners to co-ordinate local work to safeguard and promote the welfare of children and young people. By the end of the year it was also appropriately and positively withdrawing from over-engagement in co-ordinating activity that was more properly the responsibility of others. Significant challenges remain, partially reflecting the internal incoherence in Working Together in relation to our statutory functions as opposed to our statutory objectives. CSE for example is currently being led by the local authority, by West Midlands Police, by the PVVP and by the LSCB leading to a significant degree of overlaps, contradictions confusions for front line staff, middle managers and service providers. It is possible that there are far better ways of delivering some of the BSCB statutory functions than through the LSCB. Challenge 5: The Board’s challenge in 2014-15 of developing stronger, clearer and more mutually robust and accountable relationships with all key partnership bodies remains a challenge in 2015-16. Challenge 6: The Board welcomes the focus of the Council’s Future Council Programme on the quality of partnership working across the city. The Board hopes that this work, led by the Director of Public Health will assist the Community Safety Partnership, the Adult Safeguarding Board, the Health and Wellbeing Board and the BSCB Board and others to agree protocols governing the relationship between them, address the issue of who leads on what, agree shared priorities flowing from a common vision and shared work-streams. Challenge 3: This is of course a national as well as local debate. However, there is no reason why the BSCB should not build on its experiences of the last few years by challenging itself to think radically together as partners in terms of examining what functions should be led by whom, how and where in order to be far more effective in contributing to and supporting the co-ordination of what is done collectively. Challenge 7: This work combined with the continued partnership work by InLoGov in Children’s Services has given the Board the space to stop acting as a proxy for partnership working, and create meaningful relationships with the new models for partnership, in order better to inform and influence their work and hold them to account. This new role will test the Board in the coming year. As confidence grew about the MASH Board’s programme of work across the partnership, the Early Help Programme Board engaged in extensive multiagency consultation, and discussions began about a new partnership landscape, the Board has been able to redefine its role to better support service planning, service design, and service commissioning •••• 35 There have also been new challenges in terms of the dynamics between national departmental policy, regional work and local partnerships thrown up by the work of the Preventing Violence against Vulnerable People, which have helped to highlight the issues locally. Whilst strong leadership of the children’s agenda has assisted in making progress the multiplicity of national policy agendas and Departments involved, plus complexities locally have meant that at times there has been duplication, overlapping work streams and confused accountabilities as well as gaps in activity. This has been particularly the case in relation to emerging issues and the role of the community safety partnership. There is no central shared safeguarding group or collaborative arrangement within the council to address common council wide issue. and the revised fCAF material and MASH tools. This work will now be taken forward by one of the new partnership’s work streams. In terms of our ability to monitor the effectiveness of what is done to safeguard children and promote their welfare we have made significant progress. Increased capacity to support this work within the Board’s Business Unit coupled with a strong Sub-Group chair in the performance and quality assurance Sub-Group, and a clear willingness by partners to focus on this work have all paid dividends. Do we have sufficient assurance about the practice of all statutory partners? In addition to the challenges identified in the BSCB 2014-15 Annual Report, the Ofsted Inspection of the LSCB identified a number of areas for improvement. Progress has been made on the majority of them. In terms of an expectation that each partner agency urgently develops and can demonstrate stronger and more effective accountability within its organisation for their roles and responsibilities in safeguarding children and young people in Birmingham particularly at middle and frontline manager level we made significant progress over the year in our assurance and challenge systems. Evidence includes the Section 11 Peer challenge event, the development of multiagency audit, and the independent chair’s audits, as well as the analysis of Section 11 audits (and follow up visits) and the requirements of the Annual Assurance Letter and Annual Report. In addition we are evaluating and testing the effectiveness of “roll outs” of major policies. This impacts on the City Council’s relationships and leadership of the overall safeguarding agenda with partners. Improvement is dependent on the Council’s progress in developing new frameworks for partnership working, within the context of the Future Birmingham Programme as well as on partner organisations committing to the new frameworks as part of their own strategic and operational planning. Challenge 8: The challenge for the lead agency, Birmingham City Council with every partner will be to design and implement a new whole council partnership framework for multi-agency cooperation, co-ordination, and commissioning of services to meet children’s needs. This will need to also feed into the “Future Birmingham” process. Ofsted expected us to ensure that partners urgently agree a definition of early help and drive the implementation of the Early Help Strategy so that partners are fully engaged in the work to achieve and deliver this. The definition is agreed and in use through is still not fully embedded and used by individual agencies in their own agency early help work. A strong multi-agency strategy was developed over the year and agreed by the beginning of 201516. Assurance and Annual Reports demonstrate a variable engagement in early help although every agency is now involved in developing services. The BSCB Early Help Working Group undertook three key pieces of work over the year; an audit and analysis of the range of assessment tools currently in use in the city) (over 300); an examination of national evidence about interventions and what works; and the development of a proposed outcomes evaluation tool to use in the city. In addition it agreed an ideal model for a coherent system of integrated common pathways, processes, and tools to use for all forms of early help within the RSRT model. We also contributed to the development of the strategy We were required by Ofsted to ensure that single and multi-agency audits are undertaken, analysed and evaluated and that findings are used to help to improve standards of practice in all agencies. We developed new frameworks, systems and process for this over the year and it was underway by the year end. Significant progress has been made. The Assurance and Annual Reports demonstrate this and provide evidence to support the evidence from the P&QA Sub-Group. A multi-agency audit pool is in place and auditing, the Front Door Reference Group is working well and having a direct impact and themed multi-agency audits were undertaken over the year. There is good evidence of the outcomes being applied to changes in practice, action plans being implemented and learning applied. However now systems are in place we need to focus on developing the quality of practice rather than just our compliance with statutory requirements. The City Council as lead agency has been under intensive supervision with Lord Warner as Commissioner for the improvement plan. Although •••• 36 Challenge 9: The challenge to the Board and its partners in 2015-16 is to improve the span of agencies driving the priorities forward, and the consistency of their focus and “ownership” of the issues, and to share the work across partner agencies more effectively, reducing “silo” working. only one year through the plan, the council has made significant investment into services and Lord Warner has overseen the Council’s re-engagement with partners. Its programme with inLoGov has been a constructive approach to helping agencies consider how they work with others rather than just decide how to structure working arrangements. This challenge and review mechanism will start to be tested over the next year and this will be important for the development of further partnerships. The BSCB was also expected to ensure that a range of mechanisms, platforms and processes are in place to support schools to own and fully engage with their statutory responsibilities for safeguarding children and young people. This has been achieved with good evidence to support positive comments on progress. The Section 175 audit provides rich evidence as to where compliance is still an issue, and a focus on those settings follows. Termly briefings, the School Noticeboard, the re-established education SubGroup, and locality based DSL networks are all now in place. The development of the local authority “quartet” model of improvement has ensured a really strong grip on the local authority’s improvement programmes across social care, early help and education. It has at times meant partners have felt excluded or uninvolved but without it the progress would have been less effective. The BSCB was also required to work with partners urgently to develop and implement systems and processes to ensure that they fully comply with safeguarding audit requirements. The Annual Assurance process and Annual Report demonstrate the variable degrees to which this has been achieved, but it is now underway and the BSCB has presented some important challenges to agencies at a practice level over the year. The Section 11 Audit indicates there is still much to do in some agencies to properly embed the Section 11 cycle of audit, action plan, change, compliance, assurance that is required although increase in number of agencies delivering better on compliance expectations. In address we are monitoring agency progress towards compliance, with a requirement to complete regular audits which are routinely tested and reported regularly to BSCB. We have had a series of reports from key services such as the Child Protection Service over the year as a result. Alongside this the BSCB was required to provide robust challenge and scrutiny to ensure that the arrangements between schools and their partners, especially the local authority, are secure and progress on these arrangements should be reported routinely to the safeguarding board. This has been achieved to a degree but at times deflected by the internal improvement agenda over the year. There have been some issues about multiple scrutiny for schools. Reports should now coming to the Board via the Education Sub-Group. Senior ownership of this issue still developing but is quickly being established in 2015-16. There is a potential risk of the BEP transfer deflecting attention from this and the BEP will report to the BSCB to mitigate against the risk. The Board and the lead partners have completely failed to deliver a programme of work with partners to develop good quality collection and collation of data on missing children so that partners have a full understanding of the risks to these children and can identify what actions they need to take to minimise these risks. Over the year there were various attempts to address it but inconsistent leadership grasp and a focus on getting CSE sorted deflected attention too often. This is a high priority and a challenge for 2015-16. The BSCB were asked to improve the degree to which partners at the Board use their role to properly influence their own strategic and corporate governance, and to ensure the Board’s work is integrated into their own strategic, operational and business as well as workforce development. Progress has been made with majority of agencies as demonstrated in the Annual Assurance Letters and Reports. This is more challenging for regional organisations working on a regional basis that are accountable to a number of LSCBs. This has also been a significant challenge for the City Council who have not yet shown that it can address assurance across all its range of functions outside of social care and schools which has not yet been addressed. Clearly scrutiny of challenge to this data and related performance must be included in the routine work of the BSCB. This was not done over 2014-15. Challenge 10: The challenge for 2015 is for the multi-agency partnership, through the Missing Operational Group, to develop an integrated approach to identifying responding to and intervening with children missing from home, care, school and from view. This should include the development of a •••• 37 shared data base, some simple accessible systems and processes and the ability to ensure appropriate early help or statutory interventions are put in place with each individual child. Work on improving the attendance of partners at SubGroups and ensuring that Sub-Groups are resourced appropriately to undertake the tasks and actions that are required, and that they maximise learning from their work is underway although it has taken a lot longer than planned. Governance arrangements between the local authority and its partners to achieve effective and coherent strategic relationships has only really begun in the latter part of the year but is now developing well and discussions are beginning about redefining accountabilities and responsibilities to ensure the Board has the resilience and flexibility to relate to new service design and delivery models agreed between the LA and partners. What impact is the Board having? This report demonstrates that the Board is increasingly effective and has had a direct impact on most aspects of Children’s Services across the whole system over the year. However this has not yet had a big enough impact on the strength, depth and quality of front line practice. Challenge 11: The Board needs to build on the impact the Board has made in 2014-15 and increase the degree to which to Board supports the improvements underway in the City in terms of safeguarding children and promoting their welfare. The Governance Review has successfully addressed the need to improve the attendance of partners at Sub-Groups and assure that Sub-Groups are resourced appropriately to undertake the tasks and actions that are required and that they maximise learning from their work. This has been strengthened by the bi-monthly Sub-Group chairs meetings. SubGroup performance is still however far too variable. A lot depends on the leadership of each group and the capacity and authority of Chairs to drive performance, as well as on the understanding, capacity and willingness as well as ability of members to do the required work. What progress is the Board making in improving its own effectiveness? Getting to the point when we became an effective Board was a major priority in the 2014-15 Business and Improvement Plan, as part of year one of delivering “Getting to Great”. This Report demonstrates that progress has been made on all of these challenges. Good progress has been made in terms of the Board’s own governance, membership, systems and processes. Participation by statutory partners is more variable. Limited engagement with three NHS Trusts continues but the safeguarding teams within those Trusts are now engaged with the Board’s work. We also need to ensure that learning from serious case reviews is used effectively to inform practice and that audit work is beginning to demonstrate that learning is having an impact on improving practice across partner agencies. Similarly we need to find far better ways to use audits and other quality assurance information, learning lessons reviews, serious incidents, complaints, and Serious Case Reviews as well as reviews of good practice to improve our practice. It would be fair to say that a learning culture has not been developed and embedded across the partnership or in the Board. We are still too focussed on process and who is responsible for what rather how we will learn grow and develop. The 2013-14 Report also set the BSCB Partnership a series of challenges. The key and primary challenge was to ensure that the Board works collectively and collaboratively, holds the whole system to account and delivers on its statutory requirements, both as a Board and as individual partners. There is substantial evidence that good progress has been made in this respect. In addition there is also good evidence that each partner agency has developed and can demonstrate stronger and more effective accountability within its organisation for their roles and responsibilities in safeguarding children and young people in Birmingham, particularly at middle and frontline manager levels. Our Learning and Improvement Framework is relatively limited and we are prone to defensive or blaming behaviours at times. Although we talk about providing high support and high challenge we have not yet consistently modelled the behaviours associated with such an approach. We have a huge amount still to do. We have some good examples of application and impact in some of the individual Agency Assurance Annual Reports and in our relatively new audit activity. When monitoring effectiveness the Board needs to develop robust ways of assuring quality of practice, and to create a learning culture across agencies to allow our understanding of Whilst the Board has not been successful in strengthening governance arrangements between the BSCB and other Boards, it has however improved the degree to which partners at the Board use their role to properly influence their own strategic and corporate governance, and to ensure the Board’s work is integrated into their own strategic, operational and business plans as well as their workforce development. •••• 38 quality to improve practice and make a measurable difference to children’s lives. strategy was not completed until after year end. This, like much of what has been so impressive in 201415 is due to highly committed individuals working together. The PVVP leadership has supported and to a large extent driven this although at times it has created tensions, confusions and complexities. Increased investment by the LA has also had a significant impact. The OCS Report provided another impulse to focus on delivery. Ofsted also expected us to develop and implement a comprehensive programme of multi-agency child protection training (levels 1, 2 and 3) with clear arrangements for evaluation of impact to inform future training needs. Unfortunately this was not delivered in 2014-15. The matter was the subject of debate throughout year at the Learning and Development Sub and an early presentation of options made to the Board. However debate has stimulated better discussions within agencies and the project will be delivered by the end of 2015-16. Challenge 12: In 2015 there is also a major challenge for the strategic leaders forum, local authority and BSCB who together need to assertively and decisively strengthen the work of the CSE Strategic Sub-Group, agree a programme delivery plan behind it and deliver the new CSE Strategy, as well as continue to improve and develop services to support children and young people at risk of CSE and to disrupt and pursue the perpetrators. Summary Overall the Board has achieved a significant part of last years’ priorities and Ofsted’s requirements and the impact is evidenced. In addition it is clear that overall progress in improving the effectiveness of safeguarding children is occurring across the city on a multi-agency and a single agency basis. Work with schools has been intensive, multi-faceted and important over the year despite the complexities and the majority of schools now appropriately look to the BSCB for advice. They also understand their responsibilities better, are engaging more and better understand the system. There is no doubt that the MASH has had a transformational impact on this and the over performance of MASH by the year end testifies to how effective it has become (and therefore highlighted the emerging challenge of much more rapidly developing and providing effective early help across every agency and collectively at universal plus level as well as at additional needs). Lord Warner’s challenge to the NHS was uncomfortable but ultimately helpful and the Police have invested heavily in the MASH. Lord Warner himself saw MASH as having been a touchstone moment in changing the way the city’s partner agencies work together. Priorities for the 2015-16 work programme are to: •Continue to focus on and improve the delivery of effective practice in relation to the voice of child, early help and safe systems (adding children in care to child protection and court processes) •Clarify the governance arrangements for and deliver a more coherent strategic approach to CSE ,support the development of an effective operating model and implement the strategy The Board’s work on systems and processes has underpinned this and the refresh and re-launch of RSRT has also been very important, creating a fully agreed, accepted and disseminated framework for people to use in judging how best to respond to identified need. Work on the West Midlands Protocol and Strengthening Families was also important in underpinning and providing consistency to child protection work in the MASH as well as at ICPC’s and through the CP system. The material on how to make good referrals and the focus of the FDRG has assisted in improving referral practice and creating a better understanding about when to seek advice and make contact with MASH and when to make a referral. By year end there was good evidence of better localised partnership working through the Safeguarding Hubs. •Address the gap in relation to missing children •Strengthen still more our challenge and scrutiny functions and the use of our intelligence to inform partner and single agency priorities for service delivery, practice improvement • Intensify and extend our multi-agency audit work •Deliver even stronger accountability and challenge relationships with each agency and use that to inform collective strategic activity •Facilitate the development of a much better learning culture and reduce unnecessary processes in relation to LLR’s and SCR’s •Support and challenge the development of a new partnership landscape between partners and Children’s Services and corporately We have also made significant progress in tackling CSE, to a degree despite rather than because of coherent multi agency leadership locally as the Strategic CSE Sub-Group struggled and the new •Address the question of what a “new” approach to scrutiny, challenge, coordination, performance •••• 39 and quality assurance, learning from practice and from what good practice looks like in order to agree how best to approach these requirements across the system by April 2016 •A rigorous and transparent assessment of our performance and effectiveness, as a board and across local services The fact remains we will remain inadequate as a Board if we cannot demonstrate that we understand the experiences of children and young people or fail to identify where service improvements can be made. Whilst we have made significant progress in both these areas it is not yet secure, embedded or wide reaching enough. Conclusions and sufficiency statement: In terms of the five dimensions of a Board’s responsibilities set out by Ofsted, we are now meeting our statutory responsibilities, with varying degrees of effectiveness with the exception of missing children. We are able to provide substantial evidence as to how we have worked to support and co-ordinate the work of statutory partners in helping, protecting and caring for children, and we are able to demonstrate how we monitor effectiveness. It is appropriate to say that overall the Board’s arrangements are increasingly sufficient to meet our basic responsibilities and to ensure children are safer in the City. The biggest challenge of all is to explore whether there are better ways to achieve the same ends within an overarching statutory framework. Children are getting a better service, but it could be much better if we allow ourselves to think more radically about how we work together and as a Board. We are not yet however monitoring multi-agency training for its effectiveness and evaluating its’ impact on practice. In fact although we have continued to provide significant amounts of training we have not yet created a learning and workforce development approach to multi-agency workforce training and learning. We do check that policies and procedures and thresholds for intervention are applied properly through our audit programme and the work of the Front Door Reference Group. Whilst partners can be quite challenging of each other in meetings they do not consistently demonstrate how they challenge practice and audit casework in their own agency and across the partnership. Challenges in 2015-16 The challenges we are setting for 2015-16 are: To the Board: The Board needs to find the best ways to engage with and involve children and young people, their families and their communities in the work of the Board and in providing high support and high challenge as critical friends of what we do. We cannot as yet demonstrate that we meet the criteria for a good LSCB. In fact we are still quite a long way from that, and we certainly require improvement to be able to get to good. However we can demonstrate progress against the criteria in terms of: The BSCB should build on its experiences of the last few years by challenging itself to think radically together as partners in terms of examining what functions should be led by whom, how and where in order to be far more effective in contributing to and supporting the co-ordination of what is done collectively. •The priority given to safeguarding by statutory LSCB Members and how that is demonstrated both through Section 11 assessments, sound financial contributions (although how sound varies) and contributions to the audit and scrutiny activity of our Section 11 The Board’s challenge in 2014-15 of developing stronger, clearer and more mutually robust and accountable relationships with all key partnership bodies remains a challenge in 2015-16. •Our policies and procedures, and the way we review these. In addition the Board needs to stop acting as a proxy for partnership working, and create meaningful relationships with the new models for partnership, in order better to inform and influence their work and hold them to account. •Case file audits and the use of data and audit evidence to determine priorities for the board, the challenge we put into the system and the assurances we seek. •Our contribution to and influence in informing senior leaders, and supporting planning and commissioning activity The Board needs to ensure that the Community Safety Partnership, the Adult Safeguarding Board, the Health and Wellbeing Board and the BSCB Board can agree a protocol governing the relationship between them, address the issue of who leads on what, agree shared priorities and shared work-streams. •The provision of a high level of high quality training •••• 40 The Board needs to improve the span of agencies driving the priorities forward, and the consistency of their focus and “ownership” of the issues, and to share the work across partner agencies more effectively, reducing “silo” working. In 2015 there is also a major challenge for the strategic leaders forum, local authority and BSCB who together need to assertively and decisively strengthen the work of the CSE Strategic Sub-Group, agree a programme delivery plan behind it and deliver the new CSE Strategy, as well as continue to improve and develop services to support children and young people at risk of CSE and to disrupt and pursue the perpetrators. The Board needs to build on the impact the Board has made in 2014-15 and increase the degree to which to Board supports the improvements underway in the City in terms of safeguarding children and promoting their welfare. To the Council with its’ partners: Improving the safety of children’s lived experiences in their communities presents a significant challenge to the Council and its partners. The challenge for the lead agency, Birmingham City Council with every partner will be to design and implement a new whole council partnership framework for multi-agency co-operation, coordination, and commissioning of services to meet children’s needs. This will need to also feed into the “Future Birmingham” process. To the Strategic Leaders Forum and Early Help and Safeguarding Partnership: The major challenge for partners is to retain the confidence brought into the system through the work done in 2014-15, whilst ‘re-balancing’ resources, investment, staff capability and capacity so early help takes precedence over child protection for the majority of children and young people needing support. There is a major challenge ahead for the new partnership bodies established to lead children’s services across the city, in establishing new ways of working, developing real cooperation across the system, rather than cooperation on specific issues and to ensure the most effective ways of delivering services as resources reduce, capacity shrinks, and demand increases. The challenge for 2015 is for the multi-agency partnership, through the Missing Operational Group, to develop an integrated approach to identifying responding to and intervening with children missing from home, care, school and from view. This should include the development of a shared data base, some simple accessible systems and processes and the ability to ensure appropriate early help or statutory interventions are put in place with each individual child. •••• 41 Birmingham Safeguarding Children Board Room B54 Council House Extension Margaret Street Birmingham B3 3BU Tel: 0121 464 2612 Fax: 0121 303 8427 Web: www.lscbbirmingham.gov.uk Solihull Local Safeguarding Children Board Statutory Annual Report 1st April 2014 until 31st March 2015 The effectiveness of partners’ work to safeguard and promote the welfare of children in Solihull. 1 About this report Every year, the LSCB (Local Safeguarding Children Board) publishes a report accounting for our work. This is our account for 2014-2015. In this report we aim to provide a rigorous and transparent assessment of performance and effectiveness of local services to safeguarding children. We aim to describe the challenges we have identified and their causes. We set out what we are doing about them and what we have learned from our reviews of practice across all our participating agencies. The report begins by analysing our progress in relation to the priorities set by the LSCB in 2013/2014. This led directly to our work in 2014/2015. These priorities were to safeguard children at risk of sexual exploitation and those living with neglect. An analysis of key child protection performance indicators for the year 2014 - 2015 is then provided, followed by our overall analysis of the current LSCB effectiveness and future challenges. At the date of publication of this report i.e. this year, (2015-2016) partners are continuing to account to their colleagues on the Board, led by our Independent LSCB Chair. Partners are working on performance measured against their current organisational arrangements in relation to their safeguarding duties. This ongoing analysis informs our current priorities for 2015/2016. The business plan for 2015/2016 is at the end of the report along with the budget for 2015/2016. Contents 1 FORWARD By Independent Chair ........................................................................................... 3 2 About Solihull ........................................................................................................................... 4 3 LSCB Effectiveness; Progress on priorities set for 2013/2014 ................................................. 6 4 LSCB Effectiveness; priorities set for 2013/2014 ................................................................... 10 5 Performance analysis; The data on Child Protection ............................................................. 12 6 Regulation 5 ........................................................................................................................... 21 7 Statutory partners safeguarding responsibilities .................................................................... 28 8 Solihull LSCB: A summary of our strengths and weaknesses 2014/2015 .............................. 41 9 The business plan 2015-2016 ................................................................................................ 42 10 LSCB Budget and Spending 2014/2015 ............................................................................... 48 11 LSCB Attendance at Board Meetings 2014/15...................................................................... 49 2 FORWARD from our Independent Chair I am delighted to introduce the Annual Report of Solihull Local Children Safeguarding Board covering our period of activity from April 2014 to March 2015 and commenting on our plans for our future work in 2015. This has been a busy year for the Board. We have focused on addressing those priorities we know will support children and families best. Amongst other priorities, we have listened to your feedback and we have refocused our training offer. We have also been working in partnership to continue to improve the way we listen to children and young people and children’s services practitioners. Building on what we have learnt this year we will continue to improve our work in the future, not only by working on our priorities but by engaging with our community more. We hope that this report will be useful to you and that you will take it back into your organisations to inform your work. If you have any comments or questions about this report, I shall be pleased to hear from you. I would be particularly pleased to hear how we could improve future annual reports so that they could be more helpful. If you have any comments please write to me at edwina.grant@solihull.gov.uk I am grateful to all our partners and supporters who have contributed to the work of the Board during the year. I am particularly grateful to the LSCB Board staff who work so hard behind the scenes to ensure that our programme works efficiently. I look forward to working with you again next year. Edwina Grant OBE 3 2. Facts about Solihull 2.1 Solihull is a broadly affluent borough characterised by above-average levels of income and home ownership. A high proportion of residents (50%) are classified as belonging to the Prosperous Suburbs socio-demographic classification. 22 of the Borough’s 133 Lower Super Output Areas (LSOAs) are in the most 20% deprived areas in the country and just 2 are in the bottom 5%. 2.2 Solihull has significant geographic and infrastructure advantages, lying at the heart of the West Midlands motorway network, with excellent public transport connections with the Birmingham city conurbation and linked to European and global markets by Birmingham International Airport. Economically, this supports a strong service sector economy with a thriving Solihull town centre and key regional strategic assets, for example the NEC complex, Land Rover and the Birmingham & Blythe Valley Business Parks. 2.3 Solihull is challenged by a prosperity gap, with performance indicators in the Regeneration Area, framed by the wards of Chelmsley Wood, Kingshurst & Fordbridge and Smith’s Wood to north of Birmingham International Airport, significantly lagging the rest of the Borough. The Regeneration Area contains the 20 most deprived LSOA neighbourhoods in Solihull, with 24 of the areas 29 LSOAs in the bottom 25% nationally. The impacts of this are felt across a broad range of outcomes including educational attainment, employment, crime and health. We therefore take care in the Board to understand the postcode variations. Solihull is in the midst of dynamic and rapid sociodemographic change. The Black and Asian Minority Ethnic (BAME) population has more than doubled since the 2001 Census and now represents nearly 11% of the total population. Yet the Borough is less diverse than England as a whole and significantly less so than neighbouring Birmingham, but with BAME groups representing a relatively higher proportion of young people in Solihull (over 15% of those aged 15 and under) this representation is set to increase. 2.4 Whilst Solihull’s population is ageing, the age profile of the North Solihull regeneration wards is significantly younger than the rest of the Borough. 29% of the population in north Solihull are aged 19 years and under and 20% aged 20-34 years, compared to 23% and 15% respectively in the rest of the Borough. At the other end of the spectrum 4 just 14% of the North Solihull population is aged 65 and over and 1.4% is aged 85+, compared to 20% and 3% in the South. 2.5 This difference in age profile is important in our deliberations about the development of services. Particularly as they relate to the development of early help support to families. 5 3. LSCB Effectiveness; evaluation of progress on priorities set for 2013/2014 Safeguarding children from sexual exploitation (CSE) 3.1 A collective, concerted ambition has made a difference to children in Solihull on this priority. We know this because the community at large, children and young people and their families and the professional community as well as local politicians are telling us that they are now more aware of CSE. We have taken care to create a web of support and enable early identification and a swift, timely and robust response to concerns. Solihull has led the west midlands region in identifying and helping children at risk of sexual exploitation. In March 2015, 34 children had been helped by the local arrangements with demonstrable reduction in risks to them seen during the course of our work with them. These results arise as a result of the following elements; 3.2 Leadership comes from the highest level. Solihull’s Chief Executive (CEO) provides the CEO lead and Solihull’s Director of Children’s Services (DCS) provides the DCS lead on CSE across the West Midlands region. This involvement and leadership ensures sound local direction and accountability. The Council’s portfolio holder for Children’s services is an active member of the CSE steering group and has led in ensuring that ward members can be informed of general progress and issues specific to their ward. 3.3 A clear governance structure, (see diagram below) enables development through strategic, tactical and operational levels. 3.4 Multi-agency Sexual Exploitation (MASE) meetings are a part of our routine response to children at risk. Their effectiveness is seen through the reduction of risks to individual children, some moving from level 3 to level one as a result of partnership effort and specialist support. 3.5 The CSE and Missing Operation Group (CMOG) is a multi-agency task group which meets to direct medium and long term actions to safeguard, disrupt and reduce opportunity for children to be harmed through sexual exploitation and missing episodes. We track this work closely and can see that it has had effect for individuals. 3.6 The CSE steering group , a sub group of the LSCB is chaired by the Detective Chief Inspector for Coventry and Solihull, who is the Child Abuse Lead in the Police Public Protection Unit. This group ensures sound governance and links with regional developments and provides overall strategic direction to the work. It has delivered on a comprehensive action plan for 2014/2015. The recently developed “Problem profile” shares local intelligence and is used by the CMOG group to target preventative interventions. The Police have identified a range of civil and criminal avenues to disrupt potentially offending behaviours. 3.7 The Local Authority is re-structuring its teams to enable a better offer for early help. 3.8 The police have re-structured the public protection unit, creating additional posts to respond to CSE. 3.9 Awareness-raising involves dissolving the myths as well as clarifying the facts; • The majority of our schools have “safe and healthy relationships” as part of the PHSE curriculum and training for governors regularly features in schools safeguarding programmes. 6 • The police have visited over 141 establishments in order to raise awareness and encourage a response to concerns. • Politicians have also received briefings on CSE, including a full Council meeting. We will continue to brief ward members in the future to support their representational role because they are so close to their communities. • CSE training has been successful, and at the time of writing , a total of 698 professionals from a wide variety of agencies, including the voluntary sector, are receiving high quality awareness-raising and skills acquisition training. The police public protection unit have re-structured to provide additional officers to deliver on CSE. • Taxi-drivers will be targeted to ensure that CSE training is a condition of license renewal. • For CSE awareness day in March 2015, Solihull Youth Service had displays and awareness raising activities in most venues including: • • In Chelmsley Wood Adventure Playground healthy relationships bite-sized programme of work was started with the first session looking at consent and the grooming line. • In “Safe Time Out” a group for young people with learning difficulties started a targeted 8 week programme about healthy & safe relationships delivered in partnership with the NHS. • Kingshurst Youth Centre carried out a session based around the NWG helping hands campaign. • Evolution and Outdoor Ed alternative education provision ran awareness raising sessions as part of their PSHE on-going programmes. A small group of young people from Solihull, including representation from the Youth Council and Children in Care Council were supported to attend the West Midlands CSE conference organised by West Midlands Police and Birmingham Youth Service. These young people then informed the ideas and development of a future conference. A sound operational core; 3.10 Solihull has established a CSE Team, liaising closely with the Public Protection unit of the police and the Youth Offending Team. 3.11 It provides information, advice and guidance to workers and teams on CSE and a robust data set is maintained to inform service planning. Specialist training is delivered and creative ways to engage families designed. 3.12 In addition, the team has two case-workers who offer direct specialist long-term support to young people at risk of CSE. The CSE team operate within the CSE governance structure and attend all MASE meetings, the CMOG and the LSCB CSE steering group. 7 3.13 The team regularly revises QA arrangements, refining KPI’s to ensure high quality engagement with professional staff and with a focus on outcomes for children and young people. 3.14 We know that all these activities require good coordination across agencies. We also know that good prevention of CSE requires us to work across our geographical boundaries which is why we have decided to be so active in supporting the work of the West Midlands region. 3.15 We keep in mind at all times that accountabilities need to be clear and we have set out the accountability structure for our partnerships on the next page. 8 Safeguarding Adults Board Health and Wellbeing Board Regional CSE Group LSCB Strategic overview LSCB Executive sub group (Chairs) Performance Activity LSCB CSE Steering Group CSE Team Delivering LSCB CSE Strategy Whole borough training, communications and intelligence gathering. CMOG (CSE and Missing Operational group). Overview, support and challenge on a number of cases MASE Multi agency sexual 9 exploitation meetings (case specific) Community Safety Partnership CSE next steps 3.16 We shall work to further combine intelligence to ensure sound analysis of children who go missing from home or from care. Soon this will lead to an even deeper understanding of their views and experiences. This will then help the CSE steering group to more proactively plan and to inform services working directly with the young people and develop even better educational and awareness raising programmes. 3.17 The CSE strategy for 2015/2016 has been revised following the government response to the Rotherham report and our local and national experience, including the experience of our young people. A very simple but relevant set of measurable objectives for 2015/2016 has been devised. The police experience in using civil as well as criminal interventions has been included in our performance measures. 3.18 Young people at risk of CSE maturing into adulthood will be prioritised by the group in 2015/2016. 3.19 A new multi-agency case audit tool will assess the quality of interventions to children at risk of CSE. 3.20 A training review highlighted the high quality of CSE training provision. This has been improved and will be continually reviewed by the CSE steering group to ensure sound multi-agency workforce development in this area. This will be informed by a practitioner led safeguarding learning faculty described below. 4. LSCB Effectiveness; evaluation of progress on priorities set for 2013/2014 Neglect 4.1 A serious case review, while as yet unpublished at the time of writing, generated awareness of a range of activities to be worked on by the LSCB as a group. There were also lessons learned for their own agencies built on individually by board partners to deliver better practice. We have already introduced some changes building upon lessons learned. 4.2 Linked to the learning ,a new neglect strategy was developed in consultation with a range of practitioners and managers. The use of the graded profile was approved by partners in the LSCB. Training on neglect was provided and continues to feature strongly in the current 2 day course. A series of seminars provided practitioners and managers with information on lessons learned from this SCR and included learning from national experience. The LSCB carried out a whole systems review of training. While evaluations show that training continues to be of a high quality, consultation with over 400 practitioners, showed a demand for re-modelling training around the skills needed to identify non-and false compliance in families and to recognise and act on drift and delay. This has led to a radical new model of training, with new competencies based on partnership communications and negotiation skills. This model also includes the use of the graded care profile. After a gap for recruitment, a new training officer has now been appointed to deliver this programme. 4.3 Case audits carried out in this period were designed to address the early lessons from the serious case review and to test out practice around the following; child focus, thresholds, assessment and planning, core group work, information sharing and 10 management oversight. This informed the Board that work was yet to be done to embed the threshold document in practice. Recently a leaflet setting out what needs to be considered to be important was produced and widely disseminated via board members to all practitioners. The leaflet is also actively promoted in training. This has provoked discussion and challenge throughout the partnership system in relation to the Early Help initiative. Further testing of practitioners’ use of the threshold document will be carried out via our improved case audit tool. The audits also demonstrate recent improvements in positive practice around assessments, including actively engaging the child. Partners engage more effectively at key points in decision making. We know that there remain pockets where engagement of practitioners working with adults needs improving and we are actively engaged in working to achieve this. 4.4 Working with our colleagues in the Adult’s Safeguarding Board, we recognised that there was a need for the safeguarding training review to incorporate adults’ services’ safeguarding training needs. The new training strategy provides for a modular approach with a curriculum which aligns the common safeguarding training needs of adults and children’s practitioners. Core group working continues to need improvement, in terms of timeliness and recording. Progress on this will be assessed by future case audits. We have learnt that assessing the quality of management oversight and supervision has been challenging due to the diverse cultures across agencies. In response to this, simple common standards are, at the time of writing, being developed by the newly focussed case audit group to provide a basic measurement tool and more realistic expectations. 4.5 Overall, recent multi-agency case audits have showed positive practice in multi-agency working and communications with a continued need to improve the use of practical tools, such as chronologies and the need to improve understanding of the various available assessment tools, such as the graded care profile and the DA assessment tools. The use of these tools has been included in the training strategy and the practice and procedures group will continue work on this in 2015 to provide clarity and consistency. 4.6 An audit of agencies’ compliance with domestic abuse standards was also initiated and was reported to the LSCB at its meeting in July 2015. 4.7 This audit work will culminate in a rigorous Section 11 audit due to be completed in the Autumn of 2015, combining the learning from the above and including key messages from case audits to inform further work. This will include further assurance on partner member’s progress on their SCR action plans. 4.8 On analysis, the LSCB has created new priorities around neglect for 2015/2016 recognising the intrinsic relationship with domestic violence, substance misuse and parental mental health problems. Also the importance of understanding the experience of the child living with one or all of these features as an aspect of family life. We are aware that the need to continue on this work will be brought into focus by the publication of our first Serious Case review in Solihull expected in the Autumn. As a result the Board has prioritised children living with any or all of these features for attention in 2015/2016. Our set of objectives with key performance indicators alongside them will measure progress. 11 5. Performance analysis; the data on Child Protection 5.1 This section of the annual report accounts for child protection performance, the core of the LSCB business. Data has been selected from the Local Authority quality assurance data set and independently analysed. This data is regularly used to inform the LSCB overall performance analysis and the LSCB performance dashboard. This performance analysis involves strategic review of trends and, for this report, where relevant, the last 5 years performance is used as a comparison to help understand trends and explain performance trajectories. Each performance indicator is taken in turn; some are combined to help understand trend analysis. Overall performance is summarised at the end. The data selected corresponds to the referral pathway, the child’s journey. Referral rates per 10,000 Year SN 10/11 500.20 11/12 508.30 12/13 421.80 13/14 472.10 14/15 England 556.80 533.50 520.70 573 Solihull 728.81 634.58 527.21 492.7 400 Referral rates per 10,000 1000 800 600 400 200 0 10/11 SN 5.2 England 11/12 Solihull 12/13 13/14 14/15 Year Referral rates appear to have come down in comparison to previous years. However, in that time there have been several changes in definitions and so this would impact on the results. In previous years, all contacts to social care were counted. This year, only those that are considered to meet the relevant threshold of need (level 4 of the threshold procedures) are now counted resulting in these figures. Historically, there was a lack of clarity around threshold definitions and therefore a lack of application of thresholds in practice. Recent communications with all agencies and the reissuing of the thresholds guidance has led to widespread debate and engagement in the early help agenda. Local demographics in Solihull suggest a resilience to societal economic fluctuations and an associated expectation of increased family resilience overall. This would explain the referral rates being lower than statistical neighbours. Widespread communication, awareness raising and campaigning by the LSCB on issues around lessons learned from serious case reviews, neglect and the toxic trio are likely to result in an increase in contacts and referral rates. This will almost certainly result in increased activity in demand for early help services, which are at the time of writing being reconfigured and improved. 12 Percentage of referrals that are repeat referrals within 12 months SN 27.4% 27.5% 25.3% 23.5% 10/11 11/12 12/13 13/14 14/15 England 25.6% 26.1% 24.9% 23.4% Solihull 27.3% 22.6% 22.1% 12.6% 14.3% Percentage of referrals that are repeat referrals within 12 months 40% 35% 30% 25% 20% 15% 10% 5% 0% 10/11 11/12 SN 5.3 12/13 Year England 13/14 Solihull Fewer referrals are repeat referrals than was the case 2 or 3 years ago. The rate is currently lower that the England and statistical neighbour average but has increased slightly in 14/15. There will always be a cohort of children who need referral for a second time. A low rate of repeat referrals may indicate that more children are being directed to other services, preventing the need for formal statutory intervention. Our multi agency reviews will test this assumption. 13 NI 68 (Proportion) proceeding to assessment or S47 Year SN England 10/11 66.5% 71.5% 11/12 69.2% 74.6% 12/13 75.9% 74.4% 13/14 75.9 74.4 14/15 Not published Not published Solihull 54.3% 75.5% 74.8% 89.6% 83.6% Source: CPPID N168 (Proportion) proceeding to assessment or S47 100% 80% 60% 40% 20% 0% 10/11 11/12 12/13 13/14 14/15 Year SN 5.4 England Solihull The proportion of referrals proceeding to initial assessments or S 47 has increased. When combined with a low referral rate and low repeat referral rate, this reflects a high degree of assessment activity by social care acting as a single agency filter. This was brought to our attention by an external peer review as well as from our own observations. Work to address this has already begun and this rate is predicted to reduce to statistical neighbour rates early in the financial year 2015/2016. 5.5 Increasing application of the thresholds guidance will reduce this figure to SN and England average or lower, as cases will be diverted to improved early help services without the need for a formal social work assessment. 5.6 In addition, the Local Authority has made significant investment in early help, restructuring to ensure more effective delivery. These plans combine to ensure sustainable delivery of effective filtration and so improvement in performance. 14 No of children subject to s47 enquiry initiated year to date per 10,000 population under 18 SN England Solihull 10/11 77.1 101.1 59.77 11/12 97.1 109.9 98.26 12/13 96.7 111.5 83.70 13/14 112.9 124.1 131 14/15 Not published Not published 125.7 Source: CPPID No of children subject to s47 enquiry initiated year to date per 10,000 population under 18 140 120 100 80 60 40 20 0 10/11 11/12 SN 12/13 Year England 13/14 14/15 Solihull 5.7 This figure is in line with the England average and above the average rate for statistical neighbours and has been increasing year on year. 5.8 When accompanied by a low rate of referral, low re-referral rate and a high proportion proceeding to assessment, the identified need for checking that we have effective communications becomes clear. 5.9 We conclude that the right numbers of children are getting s47 investigations but getting to this point involves using scarce social work resources to filter cases through. This is a process that would be more efficiently delivered through multi-agency triage. In 2015 we shall continue to work on the opportunity for a MASH and to improve interagency debate about this issue. 15 NI 64 Child Protection Plans lasting 2 years or more 10/11 11/12 12/13 13/14 14/15 SN England Solihull 7% 8.3% 4.5% 5.4% Not published 6% 5.6% 5.2% 4.5% Not published 1.3% (2/154 plans) 9% (18/200 plans) 3.7% (8/214 plans) 10.4% (27/260) 7.4% (21/284) Source: CPPID NI 64 Child Protection Plans lasting 2 years or more 20% 15% 10% 5% 0% 10/11 11/12 12/13 13/14 14/15 Year SN England Solihull 5.10 National and local experience shows the importance of monitoring drift and delay. This indicator is a high level Key performance indicator for the LSCB in relation to monitoring practice around neglect. This is with particular reference to children living with domestic abuse, parental mental health problems and or parental substance misuse. 5.11 There will always be a cohort of children whose needs indicate that they need the formal child protection system longer than most. If this figure is too low, it means there is a risk that child protection plans cease too soon. This eventually leads to a higher figure for children with repeat child protection plans. If the number is too high, it can indicate that there is drift and delay in supporting the children. 5.12 Reflecting on this in the LSCB, action has been taken to prevent any drift and delay. This has included the use of senior level reviews with reference to the recently reissued threshold guidance. More work will be ongoing in the autumn of 2015 to test the thresholds are effective. 5.13 Children in Need cases are reviewed at the 9 month stage and children with child protection plans at 15 months. 5.14 We conclude that the evidence is that this supportive challenge is already beginning to address drift and delay. So whilst this indicator has seen swinging changes in the last 5 years, it is now stabilising. The outcome is that it has reduced from 10.2% to 7.3% in the last year (2014/2015) indicating a steady and sustainable change with a positive trajectory for 2015/2016. 16 5.15 This is an early indication that the LSCB is delivering on lessons learned around SCR’s both locally and nationally. 5.16 We will monitor this key performance indicator closely to ensure the trajectory is sustained. 17 NOS of Children with child protection plans per 10,000 SN England Solihull (source: (source: (source: CPPID) LAIT) LAIT) 10/11 30.9 38.7 43.78 11/12 35.7 37.8 48.89 12/13 34.5 37.9 48 13/14 39.5 42.1 46 14/15 48.43 Not Not published published NOS of Children with child protection plans per 10,000 60 50 40 30 20 10 0 10/11 11/12 12/13 Year Solihull 13/14 14/15 5.17 The rates of children with child protection plans is in line national and statistical neighbour averages. 5.18 In 2015/2016 we shall continue to monitor this indicator and to look for outliers e.g. very young children with child protection plans and their time on plan. Also those in families that move across our geographical boundaries. 18 NI65 Children becoming the subject of CP Plan for second or subsequent time SN England Solihull 10/11 11/12 12/13 13/14 14/15 Source: CPPID/DFE 15.2% 14.0% 13.3% 14.0% 15.1% 14.9% 16.3% 15.8% Not published Not published 9.9% 5.9% 9.4% 16.3% 21.03% NI 65 Children becoming the subject of CP plan for second or subsequent time in their lifetime. 5.19 This has increased since 13/14. 5.20 This is an issue that we will keep in focus. However, the challenge relating to the validity of assessing performance in relation to this key performance indicator has been evaluated by local authorities’ safeguarding leads at regional level. In areas with low population denominators, such as Solihull, the value of this indicator in assessing performance is reduced as small fluctuations in family size can sometimes artificially inflate the numbers. 5.21 Evaluation is also distorted by the possible 18 year timeframe. For example, a child born and provided with a child protection plan, and having a repeat plan at 16 years is included in this indicator. This reduces the effectiveness of this KPI in evaluating overall performance. Regionally safeguarding leads have agreed that measuring the proportion of these children who have a repeat plan within 2 years of ceasing their original plan is a more effective evaluation of the validity and effectiveness of the original plan and so of overall effectiveness of safeguarding arrangements. Solihull’s performance is good on this measure as the percentage of repeat plans which occur within 2 years is low in comparison to available benchmarking data. 19 NI65A Proportion of children becoming subject of a CP plan for the second time within 2 years of the original plan. WM average England Solihull 13/14 14/15 10.3% 14.9 Not published Not published Source: CPPID 7.8% 9% 5.22 Regional benchmarking and local targeting show a positive trajectory. In Solihull 9% of children with CPP for a second time have a CPP within 2 years of their original plan. The remaining 12.3% of those with repeat plans in their lifetimes can be attributed in part to one or two large families and also in part to historical inheritance of unclear thresholds and poor filtration which we have begun to address (see earlier comments). CCP x 2 and 2 year analysis 5.23 These two indicators, when analysed together can help evaluate the pace and quality of decision making within the child protection system. If too many children have child protection plans for too long, this informs us that decision making is slow and that there is delay. If at the same time the rate of children with repeat child protection plans is lower than our expectation, this tells us that overall and retrospectively, children are in the system for too long and there is too much drift and delay. Conversely, if very few children have child protection plans for 2 years or more and there are excessive numbers have repeat plans, this tells us that there is a pattern of ceasing plans too early. These two indicators, therefore, have to be analysed together to aid our understanding of practice around the timeliness and quality of decision-making. 5.24 Our analysis over the last five years shows that these indicators have been volatile, with swinging changes until the last 2 years where performance has begun to settle down. Recent work on re-publishing thresholds should ensure that a positive trajectory is sustained with appropriate balance between these two performance indicators. These will be regularly monitored by the LSCB and the social care quality assurance programme. % of Children on Child Protection Plan by Category 70.0% 60.0% Em otional 50.0% Neg lect 40.0% Mult i 30.0% 20.0% Sexual Abuse 10.0% Physical 20 May-15 Apr-15 Mar-15 Jan-15 Feb-15 Dec-14 Oct-14 Nov-14 Sep-14 Aug-14 Jun-14 Jul-14 May-14 0.0% 5.25 Local Authority audit findings in autumn 2014, reported to the LSCB, show that use of the Emotional Abuse category in child protection procedures is effectively linked with understanding of emotional impact upon children where domestic abuse is present in the household. This was discussed at a meeting of Child Protection Conference Chairs to provide an opportunity for them to reflect on and adjust their practice. This was to ensure that the category of Child Protection Plan (CPP) is focused on and reflective of the primary issue of significant concern. The picture regarding the distribution of CP Plans in terms of category is now, in Solihull, increasingly comparable to the national picture, with neglect being predicted to overtake the emotional abuse category towards the end of the year. This evidences progress as a result of the focus of the learning and analysis from the serious case review and ensuing work by the LSCB on clarifying neglect, as explained above. Conclusions 5.26 Overall the pattern of year on year swinging data changes in Solihull seen up to 3 years ago is settling down. Our analysis suggests that there is a need to improve filtration to ensure children get the services they need and that social workers concentrate on safeguarding those children who need it. We are aiming for them not to be distracted by inappropriate referrals. 5.27 Work to hone in on performance around children with CPP for 2 years in their lifetime and those with CPP for 2 years or more is proving to have a positive impact. Performance is improving and has stabilised in the last 2 years and there has been considerable improvement in this year. Next steps 5.28 We know that performance in 2014/2015 has improved on previous years. We know that we need to do more. The key area of weakness in performance identified in more recent analysis is around the need to deliver on effective filtration. The Local Authority has taken the lead in working with partners on plans to deliver a multi-agency safeguarding hub (MASH) and an aligned efficient triage for police notifications of domestic violence incidents. At the time of writing this work is ongoing. Significant investment in re-structuring to align local authority and partners services to deliver early help is well developed at the time of writing. An early help performance framework has been created to monitor impact with particular reference to impact on workflow. The LSCB has agreed that Early Help is a priority for 2015-2016 and will aim to use a high level performance monitoring process to assess progress. 6. Regulation 5 and the LSCB Functions 6.1 Regulation 5 of the Local Safeguarding Children Boards regulations 2006 sets out the functions of the LSCB in relation to its objectives under Section 14 of the Children Act 2004. This is an account of those functions. Policy development; (Regulation 5 1(a)) 6.2 The following procedures were updated during 2014/15:• Multi-agency guidance on threshold criteria to help support, Children, Young People and their Families in Solihull • Information Sharing and Confidentiality Protocol 21 • • • • • • • • • • • • • • • Referrals Social Work Assessments The Child Protection Plan – Including Lead Social Worker and core Group Responsibilities Safeguarding children and Young People from Child sexual Exploitation: West Midlands Metropolitan Area Child Sexual Exploitation Procedures West Midlands Metropolitan Area Child Sexual Exploitation Disruption Toolkit Domestic Violence and Abuse procedures Fabricated or induced illness Forced Marriages and Honour based violence Neglect Toolkit Serious Case Review Guidance Local Protocol for Children’s Assessments Joint procedures for the Assessment of Housing and support needs of homeless 16 and 17 year olds Solihull Community Housing and Children’s Social Work Services Joint protocol for the Assessment of Accommodation and Support Needs of homeless 16/17 Year Olds Joint Assessment of Accommodation and support needs of homeless 16/17 year olds flowchart West Midlands Metropolitan Area child Sexual Exploitation Framework (incorporating the See Me, Hear Me Framework) Thresholds; (Regulation 5 1(a) (i)) 6.3 A revised threshold document was agreed by the Board and promoted through the dissemination of a leaflet summarising the levels of need. It is available on the LSCB website. The document is also embedded in training programme. Communications on raising awareness of the document will continue into the autumn period (2015). Case audits will seek to identify the degree of professionals understanding of the application of the thresholds locally. Training (Regulation 5 1(a) (ii)) 6.4 A comprehensive training review was carried out February to March 2015 in order to assess the quality of current provision, governance and commissioning arrangements. 6.5 This review involved over 400 practitioners and also took views from local Children “Looked After”. At that time, a joint training sub-committee managed the training developments of both the LSCB and the Safeguarding Adults Board (SAB). The review recognised that whilst the current training was high quality with very positive evaluations, it also recommended alternative means to ensure training was effectively evaluated and delivered. 6.6 The joint committee was replaced by a Safeguarding Learning faculty, an open forum of practitioners and managers from adults and children’s services, working together on curriculum design and content. In addition a new set of core multi-professional competencies was produced based on the experience of the recent serious case review and national research on homicide reviews. These competencies are based on the skills needed to deliver effective and safe practice in safeguarding children in a multi-agency environment. 22 6.7 The outcome of this work is therefore an improved training offer with increased emphasis on how a professional navigates thresholds and negotiates with partners on the appropriate services a child needs. 6.8 Focussed competencies are now established for the range of practitioners and managers, including those working in the newly developed Early Help arrangements. The programme also includes the competencies of senior managers supporting staff with, for example, escalation procedures, challenge and arbitration. 6.9 The aim of these improvements is to promote these skills across the workforce overall, enabling sound judgement and decision making among partners at practice, tactical and strategic levels in the infra-structure. After a gap for recruitment, the LSCB has appointed a full time trainer to ensure delivery of high quality multi-agency training. We now need to focus on evaluating the impact of this change and to make further revisions based on what partners tell us. 23 Attendance at LSCB training courses in Q1- 4 2014/15 (1 April 2014 - 31 March 2015) SMBC Other Staff Youth Offending Service, Youth Services & Solihull Specialist Careers Service HoEFT Community Services HoEFT Acute Services Solihull NHS Clinical Commissioning Group Birmingham and Solihull Mental Health NHS Foundation Trust WM Police Community Rehabilitation Company National Probation Service Solihull Community Housing Schools and Colleges Early Years CAFCASS UK Visas & Immigration Voluntary/Third Sector Other (e.g. Private business/ out-of-borough organisations) Grand Total PROBATION Adult Social Care HEALTH Childrens Social Care SMBC LEVEL 2 Working Together to Safeguard Children and Young People (2 days) [11 courses] 24 1 25 7 20 0 0 2 8 1 1 7 59 32 0 0 41 12 240 LEVEL 2 Refresher (half-day) [2 courses] 1 0 0 5 2 0 0 0 0 0 0 0 16 7 0 0 2 3 36 LEVEL 3 Child Sexual Exploitation Awareness (halfday) [3 courses] 9 0 0 8 10 0 0 1 0 0 0 0 8 1 0 0 3 5 45 LEVEL 3 Understanding & Responding to Child Sexual Exploitation (1 day) [1 course] 6 0 3 0 2 0 0 0 3 0 0 0 1 0 0 0 1 0 16 LEVEL 3 Skills for Working With Vulnerable Young People (1-day) [1 course] 5 0 0 3 5 0 0 3 0 0 0 0 1 0 0 0 1 0 18 LEVEL 3 Skills in Recognising & Responding to Signs of Physical Abuse (half-day) [2 courses] 8 1 0 2 6 0 0 4 0 0 0 0 5 2 3 0 2 1 34 LEVEL 3 Working with Highly Resistant Families (1 day) [1 course] 0 1 0 0 7 0 0 0 0 1 0 0 5 0 0 0 3 0 17 LEVEL 3 Working With Neglect (1 day) [3 courses] 2 0 4 0 25 0 0 0 0 1 0 0 7 1 0 0 9 0 49 LEVEL 3 Practitioner Forum (half-day) [1 course] 3 0 5 2 13 0 0 0 0 0 3 2 1 0 0 0 6 1 36 LEVEL 3 Domestic Abuse (1 day) [2 courses] 8 0 3 1 16 1 0 1 1 0 0 2 5 0 3 0 5 2 48 LEVEL 3 Female Genital Mutilation (half-day) [1 course] 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 2 LEVEL 4 - Learning from Serious Case Reviews (half-day) [4 courses] 31 1 9 4 8 0 0 0 0 3 0 7 31 0 0 0 1 2 97 LEVEL 4 Managing Allegations Against Staff (halfday) [2 courses] 2 0 5 0 2 0 0 1 0 0 0 0 9 20 0 0 2 1 42 LEVEL 4 Managing Allegations Against Staff (halfday) (Early Years Only) [1 course] 0 0 0 0 0 0 0 0 0 0 0 0 0 18 0 0 0 0 18 Total 99 4 54 32 116 1 0 12 12 6 4 18 148 81 6 0 78 27 698 24 Local Authority Designated Officer (LADO) report (Regulation 5 1(a) (iii) and (IV)) 6.10 Since February 2014, the LADO has been supported by officers of the Child Protection and Review Unit to manage referrals, chairing of Position of Trust (POT) meetings, and, provision of advice. The details of the changes to the LADO were circulated widely and this was supported by the LSCB. The LADO annual report on the period January 2014January 2015 was provided to the LSCB in May 2015. 6.11 The report provided detailed analysis of the numbers of allegations in that period, (43) and a profile of agencies with the concern, the majority being from the Local Authority and the Education provider sectors. The report noted that there were no referrals from health and enquiries were made into the reasons why and referrals have been encouraged and monitored. As a result of this the Board was assured that health agencies have tested awareness in-house, having used LADO’s in neighbouring areas and that there was no deficit in training or processes. The LADO provided 3 training sessions to 72 attendees on managing allegations. Private fostering (Regulation 5 1(a) (v)) 6.12 At the time of writing, there are seven children known to the local authority currently in private fostering arrangements in Solihull. All of them received a visit within 7 days of the LA being informed. Private fostering is managed through one of senior social workers in the fostering service. 6.13 Publicity materials on private fostering are on the Council website and promoted to schools via Designated Members of Staff (DMS) training .Most recently at the time of writing in November 2014 for DMS in schools and for GPs in July 2014. Training was also offered to the wider community via foster carers (newsletter July 2015). Briefings have been delivered to Social Work teams to make sure they are aware. The LSCB communications function (Regulation 5 1(b) 6.14 The LSCB’s role is to communicate to persons and bodies in the area of the authority the need to safeguard and promote the welfare of children, raising their awareness of how this can best be done and encouraging them to do so. 6.15 Key highlights for work carried out in 2014/2015 are as set out below; 6.16 The threshold leaflet has been designed and delivered to practitioners through their member agency representative on the Board. It has also been a key focus for training and is included in the LSCB website. 6.17 Seminars for practitioners were held to raise awareness about lessons learned from national and local experience of case reviews. 6.18 As part of the training review; over 400 practitioners engaged in a survey to express their views about training resulting in a new training strategy. 6.19 The community, schools, politicians and the workforce received awareness raising on CSE as described above. 25 Communications; Next steps 6.20 A revised whole systems communication strategy will be delivered in the autumn of 2015. Using a new LSCB website, a range of communications will deliver messages more effectively to the frontline. This will include a conference to be held in November to bring key stakeholders together to consolidate lessons learned from serious case reviews, early help provision and the neglect strategy as well as raising awareness on private fostering. 6.21 Communications on the new training strategy and programme will promote the training. 6.22 CSE communications will also include messages for parents. The LSCB is a learning organisation (Regulation 5, 1 (c)) 6.23 A new Learning and Improvement framework has been created in order to reflect the learning experience of the Board in this period. We aimed to provide a clear understanding of how the LSCB improves practice from learning. This provides the rationale for members’ decisions and priority setting. A new quality assurance framework has been created, linking the Boards’ priorities directly to key performance indicators and including data shared from partner agencies. 6.24 This helps Board members focus and analyse progress in relation to outcomes for children and young people and represents a shift in emphasis from the Board’s processes to productivity in terms of impact. The Local Authority continues to provide the raw data on child protection, and this is analysed above. 6.25 This data, and data from partners is used to inform performance on overall priorities and objectives. The aim of this new arrangement was to de-clutter the process to allow increased visibility and transparency and therefore enable ownership of the progress made. Data is analysed by the LSCB executive group and items for further analysis are examined by the full Strategic LSCB and sometimes entered on the risk log so providing opportunities for challenge and improvement. Source We learned in 2014/2015 Serious case review Intrinsic relationship between neglect and the toxic trio. We will prioritise children living with any or all of these features. We need to improve LSCB communications. Training review (and practitioners views) Case audit Therefore in 2015/2016 we will; Deliver the neglect strategy Promote the graded care profile Use simpler performance tools to measure progress. Focus on outcomes, not process Devise new training competencies. Devise new communications strategy and LSCB website. We need to shift the emphasis to Provide clear training strategy outlining partnership skills development. partnership competencies. Enable practitioners to identify Ensure training on graded care profile. and respond to drift and delay, Relentless focus on outcomes for the and providing healthy challenge child, not processes. and to use escalation procedures. Engage practitioners in training design. Need to improve core group Improve case audit methodology. working, audit supervision and Re-audit core group working, management oversight, supervision and auditing children living repeatedly disseminate with domestic abuse, neglect and the thresholds leaflet, and improve toxic trio, those at risk of CSE and 26 case audit methodology, challenge drift and delay. CDOP Co-sleeping awareness campaign Risk assessment of mothers with High BMI those receiving early help services. E-enable communications to reach a wider audience faster. Monitor children with child protection plans for 2 years or more as part of QA framework. Ensure all lessons are in training. Continuing awareness campaigns in health agencies. Information includes risk assessment included in “Red Book”. 6.26 A learning log is maintained by the LSCB business unit to ensure lessons learned are captured and used in the LSCB’s various initiatives. Below are examples from the learning log which provides key highlights of how we learn from experience; LSCB participating in planning of services for children; (Regulation 5 (d)) 6.27 During the year we began to explore further the way we work with other partnerships and Boards to better effect. Work to align our training priorities took place with the Adult Safeguarding Board. We have developed protocols for our work with other Boards and are currently exploring how we can improve these further with specific tasks to be identified to improve outcomes. Serious case reviews (Regulation 5,1(e)) 6.28 A serious case review was commissioned in March 2013. There has been a delay in publication due to legal reasons outside the control of the LSCB. Work on engaging the family and the completion of the report was suspended for these legal reasons. Partner agencies therefore proceeded to deliver on their action plans to ensure that lessons were learned quickly and the LSCB action plan has been completed. Initial learning from the SCR, though not published or complete, influenced training and priority setting for the LSCB. This work is likely to be completed in the autumn of 2015, generating the high level communications strategy described above. Child Death Overview Panel (CDOP) ;( Regulation 5, (2) 6.29 13 deaths were notified and 12 reviewed between April 2014 and March 2015. 5 were neonatal deaths, 5 were sudden and unexpected deaths and 3 were expected deaths from limiting conditions. 8 had identifiable modifiable factors and 4 had non-modifiable factors. Age 5 0 3 2 3 6.30 Aged 0-28 days 29-364 days 1-4 years 5-9 years 10-17 years* Gender 7 Male, 6 Female Ethnicity 7 White English 4 Asian 2 “Other” Key Highlights: • Following the review of an 11 year old who died prematurely from Cystic Fibrosis, CDOP referred the case to the LSCB chair to consider whether the case meets the 27 criteria for serious case review. It was agreed that it did. CDOP suggested that parental neglect was a contributory factor in the child’s death. • Following the review of a neonatal death where there was a perceived delay in the ambulance attending to transfer the patient to a Level 3 hospital, CDOP wrote to West Midlands Ambulance Service to ascertain how the service was to sustain its attendance targets with increased demands being placed on the service. In this particular case the target time was found to be met and CDOP was reassured by the response received, i.e. the plans in place to recruit 400 paramedic students over the following year, ordering additional vehicles and introducing additional shifts to provide more flexibility during peak demands. • A high maternal BMI was found to be a contributory factor in 2 neonatal deaths reviewed. This is more significant when grouped with Coventry and Warwickshire CDOPs as we work as a sub-region; i.e. a high maternal BMI was found to be a contributory factor in 4 neonatal deaths reviewed at Coventry CDOP and 3 neonatal deaths reviewed at Warwickshire CDOP, taking the total to 9. A raised BMI has featured as a contributory factor in previous years. CDOP sought reassurance that expectant mothers with a high BMI were being referred to the Maternal and Early Years Obesity Pathway. It was ascertained that this referral service stopped in 2014 and it is a commissioning decision whether to reinstate. CDOP sought to learn more about ‘Lighten Up’, a Birmingham service weight loss programme • Solihull CDOP reviewed a further SIDS death during 2014-2015 where modifiable factors were identified. Parent(s) not following safe sleeping advice is a recurring theme. Together with Coventry and Warwickshire, Solihull Health Visiting Service has agreed to utilise a risk assessment model to identify any factors which increase the risk of SIDS. This will be undertaken at the primary (home) visit. The proposal is to have the risk assessment bound into the Personal Child Health Record (red book) and a draft has been forwarded for printing which will then be circulated for consultation with Midwifery and Health Visiting services. Children Missing Education 6.31 Schools rigorously monitor children who are not regularly in school with particular reference to the child’s safety. This includes children who are persistently absent, children whose attendance has dropped below the national average figures and continues to slip, and children who are not attending but have not been removed from school roll. Schools are also supported to use a Behaviour and Attendance tool (https://extranet.solgrid.org.uk/schoolissues/BehaviourAttendance/Shared%20Document s/Forms/AllItems.aspx) to promote good attendance. This applies to all vulnerable groups, including those in need of safeguarding, at risk of CSE or in need of early help. A specialist Children Missing Education Team supports schools in working to ensure children missing education are safe and that procedures are followed. School Improvement Advisors discuss and challenge attendance/persistent absence termly and during their annual safeguarding visit. 7. Statutory partners safeguarding responsibilities 7.1 Each partner member of the LSCB is accountable to all members for their safeguarding responsibilities. This section provides a summary of statutory partners account in 2014/2015. 28 West Midlands Police 7.2 West Midlands Police (WMP) force has made significant strides forward in the understanding of the threat relating to CSE across the Force and this is a key area that has advanced over the last period. Police now have a force CSE perpetrator team who look to target the most risky groups around CSE and, at the time of writing, there are a number of live operations running across the force area. 7.3 In Solihull, the force has reduced the number of victims from over 70 to around 40 with few high risk victims. These have all been managed and reviewed through CMOG and sit with the LA, CSE team and the WMP CSE co-ordinator. There have been some significant interventions and partnership work around all of the victims based on their level of risk. 7.4 WMP has set up a local CSE team led by a Detective, (DS) who manages the CSE coordination and utilises local police resources where necessary. Front line training has been implemented around the use of civil interventions (Child Abduction Warning Notices) and disruption tactics. A CSE tasking group is led by a DCI to ensure aspects are gripped around victim, offenders and locations. Return interviews are conducted and a robust intelligence sharing process has been developed. The force are receiving a lot of ‘bite size chunks’ from partners through this system helping to fill intelligence gaps. 7.5 A missing and absent pilot, (Coventry and Solihull PPU) began on 1st July which will ensure absent children are entered into the police software, allowing an automatic referral to Local Authority colleagues to ensure no victims slip through the net. 7.6 The force continues to support the Early Help process and attend Domestic Abuse (DA) screening meetings whilst managing the MARAC process via a DI. Also the force is currently looking to finalise the recruitment for MARAC support through the LA. Through the voice of a child work, the force is also dip sampling our Domestic Abuse (DA) crimes to ensure the children are being seen and checked 100% for DA incidents and that the relevant referrals are submitted. 7.7 WMP are committed to the anticipated delivery of a Solihull MASH unit and are working with partners around the foundation of early help which is vital to the implementation of a child MASH and to ensure we can manage the demands. This discussion is on-going through the MASH governance structures. 7.8 Future developments are looking around digital capability around CSE and child investigations through a specialist trained officer. This is embedded within the team. WMP are progressing the training and awareness raising through the CSE sub group and trying to tackle the adolescent issue where a child becomes 18 years of age and so may fall through the gaps during this transition. NHS Solihull Clinical Commissioning Group (NHS CCG) Achievements 7.9 We are active members and work closely with Solihull Safeguarding Adults & Children’s Boards, Safer Solihull, Birmingham Community Safety Partnership, Solihull Health & Wellbeing Board, Solihull Special Needs & Disabilities Board, Solihull Youth Offending 29 Board, West Midlands Police, Solihull Multi-agency Public Protection Arrangements (for example, via MAPPA Panels level 2 & 3), Solihull Domestic Abuse Priority Group and Solihull Prevent Forum. 7.10 Solihull CCG (SCCG) appointed on behalf of NHS England a 0.8 week time equivalent Named Professional for Primary Care during the autumn of 2014. The post holder commenced in December 2014. During January to March 2015 the Named Professional for Primary Care completed practice based audits in respect of: implementation of the domestic homicide reviews and serious case review recommendations, as well as the wider test for compliance in regards to: implementing safeguarding policies and procedures; information sharing guidance; and application of the threshold documents (LSCB and SSAB). 7.11 NHS CCG continue to support practices through the establishment of the Practice Safeguarding Leads Network Meetings and giving planned opportunities for practice members to attend Solihull CCG safeguarding workshops and multi-agency training. Where we can, we combine partnership resources and opportunities to enable multiagency learning events for example, the Protecting Young People and Vulnerable Adults at Risk: Domestic Abuse allied to vulnerabilities conference held on 2nd October 2014 at The National Motorcycle Museum. Child Protection Conferences 7.12 Piloting telephone conferences in respect of child protection conferences was in progress during March & April 2015. Findings, analysis and recommendations are being built on and evidence shows that this has improved input to these meetings. 7.13 During 2014/15 we have reviewed the vetting & barring requirements and our entire workforce continue to meet the criteria. There have been no referrals to the Disclosure & Barring Service. In respect of safeguarding adults & children’s learning and development we have reviewed compliance with all courses taking account of the Care Act 2014, Children and Families Act 2014, Safeguarding Children and Young People: roles and responsibilities for health care staff (2014), Solihull Domestic Abuse Workforce Strategy (updated February 2015), Solihull Joint SSAB & LSCB Learning and Development Strategy 2013-15 and the respective professional learning and development competency frameworks (e.g. NHS England Prevent competency framework). Benchmarking against current 2015 standards and competency level as mentioned above, during 2014/15 we have achieved an uptake of: • 89% compliance for Governing Body (16 out of 18 members have received executive learning & development for safeguarding adults, children, and domestic abuse awareness). • 64.7% compliance (80% on 7/7/2014) for Safeguarding children, level 1 (equivalent to SSAB/LSCB Foundation Level (33 out of 51). • 100% compliance for levels 2 safeguarding adults and/or children (equivalent to SSAB/LSCB Level 1). • 100% compliance for higher levels including level 3, 4 & 5 for Safeguarding Adults & Children. • 81.8% compliance for Prevent/ WRAP training (45 out of 55 paid staff). 30 • During May 2015 SCCG Senior Management Team is revisiting the mandatory requirement for inductions and documentation for annual appraisals. Assurance- summary 7.14 Within the past year we have continued to strengthened assurances from health providers and from local authority that commission and/or deliver services on our behalf. The CCG continues to use contractual mechanisms to reinforce or raise queries with our providers. Key specifications continue to be included in the NHS Commissioning Board 2015/16 NHS Standard Contract – Service particulars and any care placements it commissions are safe, with mitigating action against potential concerns when they arise. All of our contracts, including third sector contracts reference our safeguarding policies, which are linked to the multi-agency agreed standards and procedures. For 2015/16 we have issued, via our SCCG contracts and performance team, a comprehensive learning and development dashboard to all providers we contract with. The purpose is to obtain a current stock check mapped against the existing polices, standards, new legislation and competency frameworks. 7.15 During 2014/15, we have had two Commissioning for Quality & Innovations (CQUINs) in place in relation to experiences of staff and service users via capturing safeguarding stories (safeguarding adults and children) and improving the common assessment framework compliance for health professionals. 7.16 Future challenges for safeguarding and actions: • Getting better at protecting people from harm to include: early and/or preventive help for those at risk of abuse, including the local priorities given to child sexual exploitation, domestic abuse’ & neglect. • Giving every child the best start in life, this includes children with disabilities, looked after children, children & families meeting the local authority thresholds of intervention and those subject to child protection plans . • Embedding and implementing the Children & Families Act 2014, Working Together to Safeguard Children (March 2015), Promoting the Health and Well-Being of Looked after Children (March 2015), Care Act 2014, and the Mental Capacity Act 2005. • Continue to ensure the programme of action to transform care is in place. This will ensure that people no longer live or remain in hospital inappropriately, but are cared for in line with best practice, in ways which place their individual needs and families views at the heart of support and planning. • To continue to support and strengthen system wide safeguarding quality assurance, including monitoring visits; assisting with evidencing best practice and improvements are making a difference to improving the safety and welfare of our most vulnerable residents. Partner Agency: Heart of England NHS Foundation Trust. Heart of England Foundation Trust 7.17 The Trust has an established Specialist Safeguarding Team reporting to the Executive Lead for Safeguarding (Chief Nurse) and internal governance processes to oversee the 31 effectiveness of safeguarding arrangements within the Trust. Compliance with CQC safeguarding regulations and Section 11 duties is carried out quarterly. 7.18 There is external scrutiny of the safeguarding arrangements within the Trust through the CCGs, LSCBs, and the CQC. The Trust has completed a capacity review of Specialist Safeguarding Resource in view of growing demands and new ways of working (including Multi-agency Safeguarding Hubs). 7.19 7.20 During 2014-15 the Trust has: • Expanded the scope of supervision to include the large group community midwives and increased the amount and frequency of supervision to health visitors. • Increased compliance with the safeguarding learning and development strategy. • Commenced delivery of in house Child Sexual Exploitation (CSE) training and a communication strategy to promote awareness of CSE and how it may present to health staff and arrangements to capture use of the CSE screening tool • Introduced the new multi-agency referral forms maintaining a focus on the quality of information transferred at referral. • Implemented a number of audits to track the effectiveness of information sharing at points of transition. • Sought the views of families following safeguarding referrals and gained an understanding of how they experienced this process. • Tracked both good practice and learning through implementation of the ‘patient story’ template using this to highlight both good practice and areas for improvement. • Increased Common Assessment Framework (CAF) initiation in maternity and health visiting services Key areas of improvement for the Trust in 2015/16 • Sharing of information – particularly at transition points is an area that will feature in audit activity in 2015-16. This includes the use of multi-agency referral forms (MARFs) with a view to continuing practice improvement. • The Trust will commence rotation into the Multi-agency Safeguarding Hub in 2015-16 and will aim to improve the interface between acute care and the MASH. Recruitment is underway. • Supervision – the Trust plans to maintain compliance with supervision targets whilst expanding provision in the Emergency Department. • Expanding the voice of the child and service user in the safeguarding arena. • Ensuring the consistent application of safeguarding assessments with 16-18 year olds and for adults presenting with problems with substances, mental health issues or domestic abuse. 32 • Early Help -The Trust will be seeking to increase use of the appropriate assessment to help families’ access early help in health visiting, maternity, neonates and clinical nurse specialisms in paediatrics. • Completion of a capacity review and consideration of a Business Case for Safeguarding Specialist Resource in quarter 1 2015-16 • Full implementation of recommendations following the Lampard and Marsden report into the NHS following the Investigations into Jimmy Savile. • Establishing a consistent and skilled response to young people at risk of child sexual exploitation wherever they present in the organisation. • Maintaining compliance and expanding the remit of specialist child safeguarding supervision. • Refreshing the understanding of key staff in relation to Right Service Right Time and thresholds. Birmingham and Solihull Mental Health NHS Foundation Trust Summary: 7.21 In 2014, Birmingham and Solihull Mental Health Foundation Trust’s Executive Director for safeguarding commissioned an external review of the safeguarding team in order to discern how improvements could be made to service delivery. The review suggested that the safeguarding team needed additional staffing capacity and an improved governance structure. The Trust appointed a new Head of Safeguarding and agreed to increase the number of staff to improve the capacity of the safeguarding team. During this financial year the Trust responded to an unprecedented number of investigations, such as serious case reviews and domestic homicide reviews. Changes related to commissioning, a revision of children’s safeguarding arrangements and the introduction of the Care Act have all impacted upon the workload of the safeguarding team, as has the political landscape of austerity on public service provision. 7.22 As a result of the above 2014/15 was a challenging year, however the safeguarding team are now settling into new ways of working. They are not as yet fully staffed, but now have a full time trainer and two safeguarding facilitators, one for adults and one for children. The named nurse provision had increased from 2 nurses to 3. Training: 7.23 In 2014 it was identified that training provision was hampered by a lack of staff capacity. From November 2014 we have employed a full time trainer and have reviewed and rewritten our training package to comply with Intercollegiate (2014) requirements and Working Together 2015. 7.24 We deliver safeguarding training at level 1, 2 and 3 (level 3 training was introduced in January 2015). At level 3 we offer 45 places per month to external candidates, most of which come from early help services. The purpose of this was to comply with intercollegiate guidance and to improve BSMHFT staff understanding of early help and partnership working. 33 7.25 Training includes “Think Family” SCIE 30 Guidance and aims to incorporate “the voice of the child”. This meets our section 11 peer challenge to improve training provision. The Safeguarding Team have recently commissioned a training needs analysis to determine specific areas for targeted training above and beyond statutory requirements. An evaluation exercise is due to be conducted in July. Evaluations to date are very positive. However, we are aiming to assess the impact of training on staff competency this year. 7.26 Training Compliance at end of Quarter 4 2014/15 Safeguarding Children Level 1 Level 2 Level 3 Training % 94.0% 70.5% Σ62.5% Audit: 7.27 We have conducted an audit in Solihull to ascertain how staff identify children with young carer responsibilities and who may be in need of support due to limited parenting capacity. 7.28 Planned improvements for 2015/16 are: • Improving our understanding of the safeguarding experience of children and service users. We have engaged with patients within Trust youth services to produce a safeguarding leaflet. We have offered to make this available in other languages (there has been no demand for this to date). Our new training package has more emphasis on “the child’s voice”. A 2015 priority is to develop this aspect of service delivery. • Implementing a new supervision policy. In 2014/15 we offered supervision in the form of Action Learning Sets to targeted areas with a high proportion of young service users or where there were significant numbers of children on Child Protection Plans. However, the Trust has undergone some service changes and therefore a new approach needs to be introduced. The Trust’s external review has recommended that all appropriate staff are trained in NSPCC supervision – this is planned for 2015/16. • Domestic Abuse. We will be recruiting a Domestic Abuse Named Nurse and implementing a domestic abuse strategy. • Improving data collection and retrieval. The system used in 2013/14 was reviewed and was not fit for purpose. Currently we are able to flag children known to be on child protection plans on our alert system. We are able to record numbers of referrals via our incident reporting system. We are not able to accurately measure families with child in need or early help plans. We aim to review our data retrieval systems within the next eighteen months. Schools and education providers 7.29 The LSCB now incorporates the safeguarding in education group as a sub-group. The chair of that group is also a member of the LSCB executive and the full LSCB board. Schools have made a significant contribution to the board’s priority on Child Sexual 34 Exploitation with the majority of schools attending training for governors and staff on CSE and e-safety is incorporated into the PHSE curriculum of all schools, with many schools also raising awareness for parents and the local community. 7.30 The revised Safeguarding children in Education guidance (Keeping Children Safe in Education, 2015) has been disseminated via regular forums for safeguarding children developments, including a head teacher “Breakfast” meeting, Solihull Schools Strategic Accountability Board, school collaborative groups and training for Designated Members of Staff. Regular information on national and local safeguarding issues, including serious case reviews is disseminated widely through this sub-group and using these forums. 7.31 Solihull schools have a clear referral process for PREVENT to refer any concerns about radicalisation and violent extremism. Three workshops to raise awareness of PREVENT have been delivered to PREVENT leads. 43 education providers have been trained and 24 school governors have attended governor sessions. 7.32 All schools and education providers receive an annual visit from the education improvement advisors to establish their compliance with Section 175 or 157 of the Education Act 2002. As a result of this work, the LSCB is assured that schools now have a clear oversight of pupils at risk of harm and are responding appropriately to need and engaging key partners in line with statutory duties. This results in continual improvement across the schools sector. This year a vulnerability profile was produced indicating the numbers of children in schools who had additional vulnerabilities around child protection or looked after or with other additional needs. This profile was shared with the LSCB executive group and aligns with the demographic profile of the borough described in section 2 of this report. There are more children with additional needs in the north of the borough, with a concentration on the B36 and B37 postcode, than in the south. This will help schools to work with the Early Help initiative on workforce and capacity planning and informs schools concerns to prioritise the improvement of mental health services to children and young people. 7.33 Bullying has been identified as a specific safeguarding priority by schools; the following are key highlights of findings from the Health Related Behaviour Questionnaire (2014) to schools. This explains its priority . • 89% of schools that responded to the questionnaire identified bullying, including cyberbullying, as a top-five priority. • 32% of these identified bullying as their number one priority. • Three quarters of pupils surveyed (Years 4 and 6) report that their school takes bullying seriously • Specific gender issues are apparent and begin in Year 2 • Pupils are over three times more likely to have been picked on or bullied for their size or weight if they would like to lose weight than if they are happy with their weight as it is. • When responding to “If you had a problem with bullying, with whom would you share it first?”, respondents are more likely to keep it to themselves 35 • 5% of pupils, Years 4 and 6 (just over 200) report having been bullied through their mobile phone, whilst 7% (286 pupils) have received nasty or threatening emails or online messages. Ongoing progress on addressing this will be reported to the LSCB in 2015 as set out below.. 7.34 The managing allegations policy has been revised, and managing allegations training is regularly provided to all school leads by the LADO and HR. A new safer recruitment training package has been developed and training is currently being rolled out to all education providers. Work is underway to sustain child protection foundation level 1 training in schools through organisational change. 7.35 Priority setting for this sub-group therefore involves borough wide concern to address mental health issues, and to support anti-bullying work in schools including cyberbullying. It also includes taking the lead on the LSCB priority around neglect and delivering on CSE and toxic trio objectives. In addition this group will deliver on the core business of safeguarding children in education settings, and align working with any MASH and Early Help developments. Solihull Community Rehabilitation Company (CRC) 7.36 On 9th May 2013, the government announced its aim to “transform the way we manage offenders in the community to achieve a reduction in the rate of re-offending whilst continuing to protect the public”. This means that in the near future, the majority of offender services will be delivered by a range of contracted private and voluntary organisations. 7.37 Staffordshire and West Midlands Probation Trust came to an end on the 31st of May, with staff transferring to either the new public sector National Probation Service (NPS) cluster of Warwickshire, Coventry and Solihull, or the new Staffordshire & West Midlands Community Rehabilitation Company (CRC) cluster of Coventry and Solihull. The SWM CRC remains under contract to the National Offender Management Service until share sale is completed (anticipated to be 1st February 2015). 7.38 The key aspects of the Coalition’s Transforming Rehabilitation reforms are: • • • • • • A new public sector National Probation Service has been created. Every offender released from custody will, in due course, receive statutory supervision and rehabilitation in the community. Legislation will extend this statutory supervision and rehabilitation to all 50,000 of the most prolific group of offenders – those sentenced to less than 12 months in custody. Currently, these offenders have no statutory involvement with the probation service. A nationwide ‘through the prison gate’ resettlement service will be put in place, meaning most offenders are given continuous support by one provider from custody into the community. The prison service is to re-organise the prison system so that most offenders are held in a prison designated to their area for at least three months before release (a resettlement prison). The market will be opened up to a diverse range of rehabilitation providers in the voluntary and private sectors, at the local as well as national level. New payment incentives for market providers will be introduced, giving providers freedom from bureaucracy and flexibility to do what works, but only paying them in full for significant reductions in reoffending. 36 The Community Rehabilitation Company 7.39 The Coventry and Solihull Probation cluster of the SWM Community Rehabilitation Company (CRC) is led by Kobina Hall. 7.40 The Community Rehabilitation Company is responsible for: • • • • • the supervision of all cases assessed to present a low risk of harm or medium risk of harm delivery of Community Payback delivery of accredited programmes (group work with offenders except for sex offenders) delivery of other interventions e.g. Employment training and Education support and services; non-accredited group work programmes; and a range of interventions addressing issues such as finance, accommodation and substance misuse issues Integrated Offender Management (IOM) 7.41 In October 2014, The Reducing Reoffending Partnership was announced as the preferred bidder for the Staffordshire and West Midlands CRC. This partnership between Ingeus, St Giles Trust and Crime Reduction Initiatives was also successful in securing preferred bidder status for the Derbyshire, Leicestershire, Nottinghamshire and Rutland CRC. 7.42 Ingeus UK is a leading provider of employment and training, including the government’s Work Programme amongst other employability services. The company works alongside one hundred partner organisations from the public, private and voluntary sectors. 7.43 St Giles Trust is a registered charity that aims to break the cycle of prison, crime and disadvantage and create safer communities by supporting people to change their lives. Their services put offenders at the heart of the solution by training them to put their skills and experience to use in providing peer support and mentoring. Interestingly about a third of St Giles Trust’s staff are ex-offenders who now support others towards living independent lives, according to the following needs: Somewhere to live; “Something to live for”; Support from someone who has been there; Positive relationships. 7.44 Crime Reduction Initiatives is a recovery oriented substance misuse service that works with service users to inspire them towards appreciating the benefits of abstinence for their health and wellbeing. CRI works from the basis of respect for user choice and so by being non-judgemental, will work with service users on longer term treatment journeys. 7.45 Further information: http://www.justice.gov.uk/transforming-rehabilitation and http://www.rrpartnership.com/ 7.46 The contracts for the sale of the CRC to RRP were signed on 18th December 2014 and the transition date to new ownership is 1st February 2015. The contract is set to run for 7 years with a possible extension period of a further 3 years. 7.47 February 1st coincides with the enactment of the Offender Rehabilitation Act and the implementation of the new provisions for supervision of short sentence prisoners whose offences are committed on or after this date. The CRC will then have twelve weeks put in place its provisions for the Through the Gate service. 37 7.48 The work of the CRC under RRP’s ownership will be underpinned by a payment by results (Payment by Results (PbR) framework which combines a ‘fee for service’ element with payments by results, increasing potentially over the life of the contract which are payable only if there are demonstrable and incremental reductions in reoffending by the offender cohorts supervised. It is anticipated that the first cohort of offenders subject to the PbR arrangements will commence supervision in October 2015, with the first payments under PbR due to be made from late 2017. 7.49 Setting up the new service out of the probation trust has entailed a huge amount of work however safeguarding children has remained a priority for all staff in the CRC. Training requirements have been met and CRC staff have continued to contribute to multi-agency procedures including Early Help initiatives. Solihull probation has contributed to the LSCB Audit Group’s work and the learning from that exercise has been taken forward with the team. In summary, the following has occurred: 7.50 We have signed people up to appropriate safeguarding training and will continue to monitor this; • • • • • A case audit for the Audit Group revealed gaps in inter-agency communication at referral, assessment and case conference stages which we are seeking to address through training and, inputs from partners Probation staff have received input around thresholds including an input from Betty Lynch re the general context; this linked well with the identified need re communication We are establishing closer links with Solihull Families First and will shortly roll out a case information form re potential familial involvement at case allocation stages; We will shortly be undertaking orientation work with Solihull CMHT and would like to pursue similar cross fertilisation opportunities with social care; We continually stress the importance of HVs and requirement for professional curiosity and a more reflective approach to staff supervision is underway Solihull Metropolitan Borough Council 7.51 Organisational change to improve children’s social work provision, addressing concerns around practice and performance as well as caseloads size, workforce recruitment and retention have been completed and the resulting structure is currently being embedded. All of the actions outlined in the SCR action plan have been delivered. The local authority has invested significantly in the creation of early help services, working with partners on effective arrangements to deliver. As a result, early help is a LSCB priority for 2015-2016 with an associated performance framework to demonstrate impact on filtration and workflow volume. It is too early to assess impact but the LSCB will retain a focus on improved outcomes during and after organisational change. A summary of developments; 7.52 The large number of CiN cases was reviewed and, as a consequence, reduced as a large proportion of those children did not meet the threshold for statutory intervention. A dedicated team is now ensuring robust plans deliver identified outcomes. 7.53 To support workforce development a bespoke training programme for managers has been commissioned from the Virtual Staff College and the development needs of core operational teams have been assessed by an external consultant resulting in a detailed workforce training programme. The consultant also identified a lack of clarity regarding 38 thresholds for services and interventions. This helped explain why, at the time only 47% of s47s were progressing to ICPC. The revised LSCB Threshold document is now being applied by all teams, especially the Referral Team and this has now improved. 7.54 A new Quality Assurance Framework has been agreed, with the first report due to go to children’s services Divisional Leadership Team meeting in July. 7.55 CSWS staff have taken the lead, working with partners on creating a local MASH. 7.56 All first assessments and s47s are undertaken by one team to ensure consistency and quality. 7.57 A specialist CP and Court team is responsible for these key areas of work. There are no unallocated CP cases. 7.58 The division also includes the specialist CSE Team and oversees our responsibilities for Missing Children. The Missing processes are subject to revision to ensure all staff understand and comply with expectations. The CSE team continue to function well and the future role of the team is subject to current review by their head of service. 7.59 Positive impact on outcomes is seen as follows; • A simple organisational structure aligned to key operational activities provides clarity around accountabilities and responsibilities. • A new quality assurance framework allows for increase challenge and transparency on performance throughout the infra-structure. • Staff caseloads have reduced and performance is more closely monitored by managers. • Performance in areas of past concern, such as assessment timeliness and care leaver • The Child Protection and Review Unit, provides regular challenge and scrutiny to operations. Solihull Community Housing 7.60 Solihull Community Housing (SCH) is an Arm’s Length Management Organisation (ALMO), which provides landlord and other housing services on behalf of Solihull MBC. In addition to providing traditional landlord services for Council tenants, SCH delivers a cross-tenure anti-social behaviour service on behalf of the Solihull Partnership, housing options and homelessness services on behalf of the Council and Solihull Independent Living (SIL), which provides support and adaptations to those in need of such assistance (including adaptations for the benefit of disabled children). 7.61 2014/15 saw significant changes within SCH. The senior management team has been restructured with two key appointments, the Chief of Operations and the Chief of Commercial Activity, replacing the previous Service Director roles. 7.62 SCH continues to be committed to safeguarding, having been a member of the LSCB since 2006. The importance of housing within a framework of effective multi-agency 39 safeguarding activity is reflected by our involvement in a range of joint working arrangements including, for example, the LSCB Audit Sub Group and the strategic and operational groups working towards the establishment of a Solihull MASH. 7.63 SCH’s Delivery Plan for 2015/16 sets out what will deliver in the coming year on behalf of the Council. The Plan is aligned with the Council’s four key priorities: • • • • Improve Health and Wellbeing Managed Growth Build Stronger Communities Deliver Value 7.64 The associated Service Development Plan includes specific actions to review our safeguarding training needs and to ensure that our internal policies and procedures are fit for purpose and complement the LSCB’s key priorities. Youth Offending Services 7.65 Over the period of time there have been changes within the service which have been a consequence of a) reducing numbers of young people being dealt with, either on a statutory court ordered intervention or pre court basis, b) our court services moving to Birmingham, c) as well as developments within the team. To respond to these changes the youth offending service restructured and sought to improve practice and outcomes for children, young people, families and communities that we work are engaged with across the borough. This has included development of our Restorative Practice and work with Victims be that direct or indirect reparation activities, as well as implementing the findings in respect of the HMIP (Her Majesty’s Inspectorate of Probation) Audit which had been undertaken in the early months of 2014. 7.66 Performance over the period has been very positive and equally so when compared with our regional partners, family group comparators and national averages. At the end of 2014 to 2015 financial year the information is as follows:• First Time Entrants to the Criminal Justice System - At the end of quarter 4, the number of First Time Entrants to the criminal justice system had shown considerable reductions as measured from January to December 14 as opposed to the same time period, the previous year. • Re-Offending - Similarly binary (actual) rates of re-offending, measured from a period in 2012/2013 as opposed to the previous year continued to demonstrate significant reductions in re-offending. Albeit there was a slight increase in the frequency of reoffending, the baseline was significantly lower for Solihull in comparison to others. • Use of Custody following Sentence – Albeit there had been a slight increase in the number of young people sentenced to custody between April 2013 and March 2014 against the following financial year 2014 and 2015 (which was one young person,) baseline information identifies that per 1,000 of the 10 to 17 population Solihull has a considerably lower use of custody than our regional neighbour, family averages and national averages. 7.67 Moving forward into 2015 and 2016, the service both statutory and preventative provision (Youth Inclusion Support Programme) will become a part of the Early Help Service currently being developed, for implementation in October of this year. The will mean key 40 changes to staff within both statutory and preventative teams, but the Service will become part of a much larger provision to support children, young people, families and communities within Solihull, to target, intervene and address issues at an early stage. The management of this change process, inclusive of staff development, and continued delivery of services and outcomes will form a key aspect of transition during the forthcoming year. 8. Solihull LSCB: A summary of our strengths and challenges 2014/2015 8.1 CSE: Strengths; the National profile of CSE and the success of local arrangements in Solihull have energised local practitioners and managers to continually improve outcomes for children and young people, breaking new ground and not accepting compromise. Further work will inform the CSE steering group about the experience of children who go missing from home or care, helping to shape services to meet their needs. Challenges; more work is needed to explore how children at risk of CSE who are reaching maturity can be safeguarded. 8.2 SCR and other lessons learned from audit: 8.3 Strengths; lessons from the Serious Case Review and ongoing work on serious case reviews both locally and nationally, continue to inform and influence the LSCB activities and direction. Case audits have identified strengths around positive partner engagement in assessments and direct work with the child. 8.4 Challenges; there remain some weakness around core group working, information sharing and the consistent application of thresholds. These areas are a major focus for training with the new strategy identifying new partnership competencies with clear practical skill set to equip practitioners to operate safely in a partnership environment. Re-audits will help the board to assess the rate of improvement. Whole systems communications needs further development to ensure the LSCB messages reach a wider audience and do so faster. 8.5 Building on what we know about our strengths and challenges: This learning has driven the development of the learning and improvement strategy review as well as the training review. Developing a continual culture of learning from multi-agency case audit is now embedding awareness at practitioner level of standards and expectations. The creation of a new safeguarding learning practitioners’ faculty will ensure training is in touch with contemporary practice. 8.6 Major organisational change in the Local Authority to ensure continuing improvement in social work practice is already showing benefits in terms of improved outcomes around timeliness and consistency. Significant transformation is ongoing to deliver early help services to provide the foundation for change, is resulting in effective partner engagement and this work is governed by the LSCB. It will be the LSCB which evaluates effectives following implementation in autumn 2015. Data analysis already demonstrates the need for improvements in filtration and triage and plans to deliver this have been agreed through the MASH arrangements. 8.7 Our priorities are therefore around improving outcomes for children and not process. We try to ensure that our evidence is informed from practice experience and case audit and review. We are increasingly informed by the views of children and young people and practitioners although we need to bring this work together into a more coherent strategy for engagement. 41 Conclusions and summary 8.8 The opportunity of a look from fresh pair of eyes from our new independent chair and the appointment of an interim business manager with rich experience in other Councils has provided an insight into the development of the LSCB. 8.9 A shift in emphasis has been seen as members are challenged to retain a focus on outcomes for children and not to allow this to be obscured by bureaucracy and process. The challenges from our lay members has helped us with this and help to keep our thoughts close to the community. At the time of writing, the Independent Chair is seeking to meet with the representatives of the faith communities to see if we can engage them more. 8.10 Partners have been called to account on several levels. Schools accounted for their S157 and S175 responsibilities. The Police accounted on their HMIC inspection and resulting organisational changes. Health agencies provided a full account of their arrangements for the purposes of this report as have the 2 agencies providing probation services. 8.11 Agencies have been called to account on their Domestic Abuse responsibilities. Challenge is provided in and out of meetings and a challenge log keeps track of challenges and how they have been dealt with. 8.12 This approach has created a shift in emphasis from process to outcomes. 8.13 Meetings are now becoming forums for engaging in analysis on contemporary concerns, with agenda setting collaboratively agreed. This reduced bureaucracy in and out of meetings, accompanied by a direct approach enables clear visibility and transparency across the partnership, encouraging challenge in a safe environment. The accompanying alignment of priority setting, derived from the learning and improvement framework provides the rational for clear priorities. The new uncluttered performance framework has provided a focus on priorities and increasingly there will be an even greater focus on the child’s experience and improving outcomes. 8.14 In summary, this report and its analysis provides the rationale for the priorities agreed by the LSCB going forward into 2015-2016 which are; • To help children at risk of sexual exploitation • To promote positive practice on neglect, including a focus on children living with domestic abuse, a parent with mental health problems and/or substance misuse. • To support the delivery of Early Help services 8.15 The remainder of this report is the business plan, showing how the Board plans to take these priorities forward and what resources it has to do this. 9. The business plan 2015-2016 9.1 This business plan explains how the LSCB will deliver on its priorities. It shows a set of objectives, using the priorities as headings in simple table format. These tables also act as a performance monitoring tool for the LSCB, the executive group and sub-group so 42 that they can clearly see progress being made and address any areas that are not progressing as they should. 9.2 The first table is an overall LSCB action plan. This shows how the LSCB priorities will be delivered by each of the LSCB sub-groups. This is followed by a table on each of the priorities. 9.3 Child protection data will continue to be monitored by the executive group. 9.4 Finally, a budget statement is provided to aid understanding of how the priorities and activities will be resourced. 9.5 The budget plan is subject to fluctuations in the event of emerging imperatives, such as further serious case reviews or national policy directives. The budget deficit is well known and understood and at the time of writing discussions are being led by the Independent Chair to seek ways to resolve this. 43 Group/ Workstream LSCB work plan in sub-groups LSCB priorities for 2015/2016 Neglect /toxic trio Ensure SCR finalised and impacts on practice Ensure delivery of neglect strategy. LSCB MAKES DECISIONS S11 Audit CSE Early Help Communications Full LSCB Analyse and challenge CSE Analyse impact on work strategy (In addition to reports volume and links with Ensure LSCB is all of below) MASH. participating in planning. Maintain a risk and challenge log Training faculty Ensure high quality CSE Ensure high quality training on neglect, All training to include Training review. training is provided to (including neglect strategy and graded care thresholds and early help Training strategy, appropriate professionals profile), information sharing, toxic trio and developments and Evaluation. Training non-compliance is provided to appropriate MASH needs analysis. Deliver professionals. training and evaluate quality. Case Audit Carry out case audit Case audit involving neglect, adult mental Analysis of case audits Carry out annual audit group involving CSE cases. health and substance misuse and domestic to include early help plan and abuse. issues. Report to LSCB CSE Analyse return interviews. Exec group: CO-ORDINATES Campaigns on CSE in Highlight reports to Target Children at risk using Agree on agendas, ensure the right issues schools and in the wider LSCB. the problem profile. are dealt with in the right forum. community. Receive reports on CSE All sub-groups report to Exec and on to training. Engage the SAB in LSCB. work on children at risk who All chairs are members of the LSCB are reaching maturity. Analyse performance data set and highlight to LSCB. Safeguarding Raise awareness/evaluate Lead on neglect strategy, ensuring schools Engage in early help Engage in the in schools impact of awareness raising access multi-agency training which development, including safeguarding faculty. group on CSE in schools includes neglect, info sharing and the toxic CAF and thresholds Provide an annual trio, and promoting the strategy through a work. report on safeguarding LSCB conference. children in schools. P&P Ensure CSE policies are up Revise range of DA tools, including signs Support Early Help Ensure all policies and to date. Deliver MASH and of safety and DASH. Ensure policy on non- policy and protocol procedures are up to DA triage protocols. compliance is sound. developments. date. Annual reports from CDOP, LADO and Private fostering. *Read vertically for actions on priorities and LSCB core functions, read horizontally for tasks for sub-groups. 44 Performance framework 2015-17 Solihull Local Safeguarding Children Board Priority: Neglect Lead: Education Providers and Early Years sub-group This data informs the LSCB about the impact of the neglect strategy using high level key performance indicators. Data on the impact of communications and training is provided. The majority of children with child protection plans will be living with domestic violence, substance misuse and/or parental mental health problems violence. Data on children with child protection plans for 2 years or more provides insight into drift and delay. A downward performance trend on this indicator should prompt further enquiry. LSCB objective To promote the neglect strategy through training and communications Ensure high quality training on neglect including the impact of domestic violence, substance misuse and parental mental health. Assess the impact of supervision in enabling reflective practice and challenge. Monitor indicators to ensure sound multiagency decision making and reduce risk of drift and delay. Data Owner Key Performance indicator 2014Q1 15 Nos of professionals reached through communications. Q2 LSCB Trainer Denise Lewis Nos of professionals reached through LSCB training on neglect. monitored by the executive group Practitioner evaluation. Q3 Q4 Qualitative reports to EXEC. Impact of training strategy assessed. Simon Stubbs; _______ Simon Stubbs AD Safeguarding __________ Jim Edmunds Case audit. Nos of Children with CPP Qualitative reports to EXEC. ENG Children with child protection plans for 2 years or more Nos of police incidents involving children. 45 SN 201415 Q1 Q2 Q3 Q4 March 2016. Performance framework 2015-17 Solihull Local Safeguarding Children Board Priority: Early Help Lead; Tina McGrath Interim Assistant Director Early Help, Children’s Services “The LSCB should; critically evaluate the effectiveness of early help and publish these findings in the LSCB annual report” (Whose responsibility? Ofsted 2015) Increased early help provision and a sound understanding of the threshold document will reduce workflow volume through social care while ensuring children get the services they need. LSCB objective Data Key Performance indicator 2014Q1 Q2 Q3 Q4 Target Owner 15 March 2016. Deliver high quality early Tina Nos of early help assessments. N/A N/A help assessments. McGrath Evaluation report to LSCB, March 2016 Assess the impact of early help on volume of referrals to social care. Assess the quality of management oversight and supervision in relation to early help. Evaluate the effectiveness of the LSCB threshold document Simon Stubbs Simon Stubbs Inappropriate referral rates to social care Referral rate to social care Eng SN Re referral rate to social care Eng SN Proportion of referrals proceeding to S47 enquiries Eng SN Proportion of S47 enquiries proceeding to child protection conference LSCB Case audit programme Eng SN Qualitative reports Simon Stubbs LSCB case audit programme Practitioner survey 46 CSE Solihull Local action plan 2015-2016 SOLIHULL LSCB CSE strategic objective one: Children and young people have an increased awareness of safe and healthy relationships. Action Lead KPI’s (the local CSE QA data set) as at March 2015- 4th Quarter Raise awareness Safeguarding Percentage of secondary schools where health and safety relationships is delivered as among children and in schools sub- part of the PHSE curriculum. young people about group Percentage of secondary schools where governors have had training on; 1) CSE; 2) Online safe and healthy Lorraine Lord safety; relationships, including (Chair) on line safety. 3) Relationships and sex education CSE strategic objective two; Increase community awareness about CSE Action Lead KPI’s Raise awareness in Shabnam Nos of businesses reached business Beattie establishments (Police) Provide leaflets for parents. CSE strategic objective three: Children and young people who are being sexually exploited are effectively supported ( March 2015) Action Lead By age KPI’s Nos at risk of CSE; 11yrs 12yrs = 13yrs = = By gender: M = F = With CPP, 14yrs = CLA 15yrs = With CIN plan 16yrs = 17yrs= 18yrs = Target children at risk CMOG chair By ethnicity: of CSE using the Jim Edmonds regional problem profile and local intelligence. Assess quality of help CMOG chair Nos Risk level Level to these children by Jim Edmonds ensuring the risks are reduced. Missing children. Shelley Ward Nos missing Nos missing LAC Nos missing age, gender, ethnicity location CSE strategic objective four: Perpetrators are disrupted and/or held to account using appropriate criminal and/or civil interventions Action Lead KPI Use available criminal Police No of harbouring notices and civil interventions No of those on remand to disrupt local Other civil interventions. perpetrator activities. No of arrests No of criminal investigations/prosecutions 47 LSCB BUDGET AND SPENDING 2014/2015 Contributions Made Solihull MBC – Children's Services Schools Forum Solihull Partnership West Midlands Police Child Death Grant Solihull Clinical Commissioning Group Heart of England Foundation NHS Trust Solihull Specialist Careers Service CAFCASS Solihull Community Housing Safer Solihull Partnership Youth Offending Service Staffordshire and West Midlands Probation Trust External Income Serious Case Review funded by Solihull MBC Carried Forward from previous year Shortfall - met by SMBC TOTAL 2014/15 Summary Pay and Overheads Training Professional fee’s - SCR Office Expenses including car allowance, general office expenses, furniture, IT Equipment, ICT, building maintenance and telephones Other fees - CDOP Other fees - Independent Chair Grants and Subscriptions and advertising/publicity Internal Room Hire (including Training venues) Total Expenditure Income Net Underspend 48 2013-14 £ 115,273 14,250 21,565 19,600 0 67,165 4,600 2,299 550 4,000 1,995 1,862 3,000 1,565 20,000 63,272 11,214 352,210 2014-15 £ 151,520 13,540 0 12,400 0 67,160 12,400 2,190 550 10,000 19,600 1,770 3,000 0 0 0 0 294,130 Budget 207,830 25,000 0 Actual 180,688 28,556 250 13,000 7,955 13,000 18,000 7,500 2,000 286,330 -286,330 0 13,000 14,044 907 5,088 250,488 -294,130 -43,642 LSCB Attendance at Board Meetings 2014/15 Attendance by Designated LSCB Representative Agency attendance 33% 100% 33% 100% 100% 100% 100% 100% 83% 100% 100% 100% 83% 83% 83% 83% NHS England 17% 17% Third Sector 100% 83% UK Visa and Immigration 50% 67% West Midlands Police 100% 100% Attendance at LSCB meetings 2014/15 (1st April 2014 – 31st March 2015) Birmingham & Solihull Mental Health NHS Foundation Trust Solihull Clinical Commissioning Group CAFCASS Heart of England NHS Foundation Trust Solihull Metropolitan Borough Council Solihull Community Housing National Probation Service Community Rehabilitation Company Also the Lead Member for children and young people is a participant observer and attended 50% of meetings in 2014/15 49 lscb@solihull.gov.uk www.solihull.gov.uk/staysafe 50 DRAFT AUDIT COMMITTEE Minutes of a meeting of the Audit Committee held in the Board Room, Devon House, Birmingham Heartlands Hospital on 25 November 2015 at 10.00am PRESENT: Alison Lord (Chair) David Lock Jammi Rao IN ATTENDANCE: Richard Bacon (PwC) Lorna Barry (Deloitte) Kate Eccles (Head of Comms – part meeting) Alison Fuller (Deputy Director Governance) Carl Holland (Head of Ops, BHH – part meeting) Angie Hudson (minutes) Angeline Jones (Chief Financial Controller) Gus Miah (Deloitte) Julian Miller (Interim Director of Finance) Jessica Seymour (Deloitte) Natalie Shaw (PwC) Kevin Smith (Company Secretary) Claire Whittle (Acting Deputy Dean of Faculty) 15.065 APOLOGIES A Lord welcomed everyone to the meeting and introduced Andrew Corbett-Nolan and Hannah Campbell from Good Governance Institute who were observing the meeting. Apologies had been received from Sam Foster and Hazel Gunter (Claire Whittle was attending on behalf of H Gunter). 15.066 MINUTES OF LAST MEETING & MATTERS ARISING The minutes of the meetings held on 30 September 2015 were approved as a true record. Matters Arising 15.058 Send communication to line managers reminding them of their responsibilities regarding leavers. C Whittle advised that the action had been completed and payroll would monitor the responses. 15.058 Include commentary in LCFS update on ‘hot spots’ in payroll processes that apply when staff leave the Trust. L Barry advised that the doctor concerned had refunded the overpayment and that the LCFS investigation had therefore been closed. There was e-mail evidence to show that the revalidation manager had been advised that the doctor had left the Trust (although not the line manager); it was understood that Clive Ryder and Alison Money (HR) would be undertaking an internal investigation. A Lord indicated that the wider implications should be considered by the IA Payroll review. Page |2 15.067 FINANCE REPORT A Jones outlined the main points of the report. There had not been any feedback following the Monitor consultation on the ARM; it was hoped this would be received before the end of December 2015. The Finance team had commenced preparation for the 2015/16 reporting year with the month 6 submission going as expected with no surprises. Preliminary progress had begun on the fixed asset revaluation and the fee (£20k) for the work had been agreed with GVA; a programme of work had been agreed in order to achieve the March valuation date. The preliminary values for the two new builds were expected to be available in January 2016. Significant work had been undertaken to reduce the outstanding IA recommendations; some were now being referred to other committees, which A Jones was attending, where necessary. The IA reviews on key internal controls had been completed. The PwC position regarding an admin and clerical review was being reconsidered. The cost of Ernst & Young (EY) work programme was £650k plus VAT (recoverable). J Miller advised that the business case for the second part of the work had been submitted to Monitor and a decision was awaited. The focus for the first phase had been on cash control, pay controls and quick wins; Monitor was keen to understand how much improvement was EY related, versus other factors implemented by the Trust. The second phase of the EY work would be around rebasing costs. Deloitte had not received any additional instructions since the last meeting. A Lord questioned what progress had been made in the tender process for the appointment of external auditors. A Jones advised that the framework had been revisited in order to avoid unnecessary long list interviews and that the Trust needed to move to tender shortly in order to appoint by 1 April 2016. The tender documentation was complete, subject to approval by the Finance Director following which it would be submitted to the Council of Governors Audit Appointments Committee; following its decision, a recommendation would be presented to the full Council of Governors for approval of the appointment. ACTION – A Jones to keep A Lord apprised of progress on appointment process for external auditors. 15.068 INTERNAL AUDIT 15.068.1 Progress Update G Miah presented the Progress Report. There were three deep dives on budgetary control, where work was already underway and expected to be complete by Christmas: Budgetary control fieldwork had been completed and initial findings fed back to management; a report would be presented to the next meeting. Quality Indicators - RTT 18 Weeks fieldwork was due to be completed by the end of December 2015. The ToRs for the Workforce Planning and Recruitment Controls review had been agreed and fieldwork was due to commence. Work had continued to reduce the number of outstanding actions; progress was noted. Page |3 There were two high priority actions; IG Toolkit and Medical Revalidation, action was being taken to ensure resolution of these. J Rao noted that Quality Committee was sighted on Medical Revalidation and that the system of utilising outcomes for medical revalidation and as part of appraisal process was a national problem; this was less of an issue for surgical outcomes where the data was more widely available. The Trust was in line with other trusts with the exception of a couple of specialities; PROMS data was not published nationally and was difficult to use. J Rao was comfortable that the Trust wasn’t an outlier. 15.068.2 Updated Strategic Internal Audit Plan G Miah advised that, following the discussion at the last audit committee meeting, further consideration of critical recovery work streams had been undertaken by the Exec team and a revised internal audit plan for the balance of 2015/6 was now being proposed. This included the three budgetary control related reviews already referred to, balanced by a deferral of the Fixed Asset Management audit to 2016/17, which had been rated as a low priority in the current year, and deferral of the 18 Weeks RTT follow up review in order to extend the scope and allow controls to be embedded within the follow up review in 2016/17 (some testing would be undertaken as part of the PwC external audit). The Governance Review was also deferred as much work was still on-going in this area, not least the involvement of the GGI, so it was too early to review progress as yet. Taken together this meant there was no change to the total number of days included in the work plan. It was noted that the Waiting List Initiatives review was separate from the RTT review and was a priority. D Lock wanted to ensure that conflicts of interest were considered as part of the Waiting Lists Initiatives review The meeting referred to the findings of the theatre utilisation review in the previous year and the need to improve theatre capacity and questioned what action had subsequently taken place to achieve this. it was noted that this was intended to be addressed as part of the Surgery Reconfiguration exercise but that programme was now on hold. J Miller noted that work around theatre efficiency was reported to EMB and embedded into the EY financial recovery work. The Committee requested J Miller provide a brief update to the next meeting on what current and planned activity there was in this regard. ACTION - KS to e-mail interim Medical Director to ascertain whether theatre utilisation and associated systems had improved; also to report on this to the Finance & Performance Committee Meeting at the end of November. ACTION – J Miller to provide a brief update to the next meeting on current and planned activity around theatre efficiency improvement 15.068.3 Cash Management, Income & Debtors, Payments & Creditors The Terms of Reference for these reviews had been agreed in early summer and the reviews completed during September so they predated more recent concerns around financial performance. G Miah advised that he had undertaken a post completion review in each area and provided some updated conclusions. The Cash Management review had focused on the controls around cash movement and Page |4 access and had received a substantial assurance rating with one medium priority and two low priority recommendations. The deteriorating cash position brought greater emphasis to the importance of cash flow management where it was noted that although controls were in place, greater focus and tighter controls around cash maximisation were now being implemented. Income and Debtors had received a substantial assurance rating with two medium and two low priority recommendations – some of the procedures had been out of date, so needed updating. Chasing of aged debts required improvement as it appeared that all correct procedures were followed and finance staff chased outstanding amounts to the extent that they were able but once reported up to Exec level, nothing seemed to happen. Day to day debtors were generally up to date but large debts arose where there was confusion or lack of agreement with the other party over contractual terms and these generally required very senior level, DoR to DoR, intervention before settlement could be reached. Previously this has had not been a priority but had now become so and Darren Cattell had taken responsibility for agreeing some of the larger balances in the last week or two. D Lock confirmed that these matters were reported to FP&C on an on-going basis. Payment and creditors had received a substantial assurance rating with four medium and two low priority recommendations. Controls were in place but written procedures were not always reflective of what happened in practice; these needed to be updated. It was noted that there were self-authorisation rights for ordering in some areas (Obstetrics and Renal) to facilitate urgent ordering of consumables for theatre but no limits were set eg by product or requisition type. J Miller commented that this type of “urgent’ ordering as not required at UHB and he would seek to stop it at HEFT if there was no evidence to support it being necessary here. G Miah stated that it was important in the current financial environment to stop the practise of paying suppliers earlier than was required under their contractual terms and J Miller advised that work was on-going to delay payments as appropriate to conserve cash. G Miah observed that, overall, controls were in place but procedures did not reflect current practice or the current financial position and should be updated accordingly. Reporting to committees (e.g. F&PC) was in place but needed to be more robust to improve the effectiveness of controls and actions. The meeting discussed debtors further and J Miller assured the meeting that work was underway on debt recovery including FD to FD dispute resolution conversations. 15.068.4 Charitable Funds G Miah reported that a full assurance rating had been given. The Committee recorded its thanks to the team for its adherence to controls. 15.068.5 Payroll A substantial assurance rating had been received with one medium priority and two low priority recommendations. In relation to overpayments, it was noted that managers might not always understand why an overpayment had been made because the policy of crediting the overpayment as soon as the recipient had been invoiced was unhelpful in this regard and consideration should be given to changing the process or, at least, writing to the manager to ensure that they understood what had gone wrong. The meeting discussed the wider issue around the lack of consequences where staff did not adhere to policies. J Miller Page |5 and H Gunter would discuss this and bring a proposal back to the next meeting. D Lock noted his concern that locums were being hired against non-existent budgets; J Miller believed this was due to a lack of accountability and cultural issues, which were being reviewed. ACTION – J Miller/ H Gunter to bring back proposal for consequences for failure to adhere to payroll policies and procedures. R Bacon confirmed that there were no concerns from PwC regarding the underlying financial systems for the purposes of the external audit. 15.069 LCFS UPDATE L Barry presented the LCFS progress report and highlighted that to date 62.75 days had been delivered across the four key areas of the work plan. There had been nine further fraud referrals bringing the total to 22. The changes to the plan had been driven by the number of referrals. The e-rostering review was almost complete. L Barry was working with the Deputy Director of Governance to progress the ‘Sunshine rule’ which was an area of concern due to the amount of work involved. L Barry had written to a number of pharmaceutical companies and initial results had shown areas of concern. K Smith reminded the Committee that the Code of Conduct policy already covered the requirement on staff to declare conflicts of interest and hospitality and that Workforce had undertaken to include a requirement in the appraisal process to question staff’s compliance with the Code in the annual appraisal process from spring 2016. Following a discussion J Miller agreed to look with others at ways to raise its profile and bring back proposal to a future meeting. ACTION – J Miller to look at how to raise the profile of the obligations of staff to report conflicts of interest and hospitality in accordance with the Code of Conduct and appropriate consequences for failure to report and report back to the next meeting. J Rao commented that he was particularly concerned diagnostic/ medication creep, where doctors could go unquestioned when they requested tests or prescribed ‘preferred’ drugs. The meeting considered the referrals and noted that around half related to staff allegedly working whilst on sick leave. L Barry explained that latest advice suggested these cases could be difficult to prosecute because alternative activities could sometimes be regarded as therapeutic. The key was earlier intervention by occupational health to help manage the situation and potentially vet requests to undertake alternative activities. Generally it was agreed that more rigour was required around the rules for working when on sick leave. L Barry confirmed that the current wording within the policy regarding working elsewhere whilst on sick leave was appropriate. It was agreed that Workforce should issue a message to all staff and report back on this to the next meeting on progress. J Miller observed that ownership of the issue at local management level was key. ACTION: Workforce to issue message to all staff highlighting the correct processes around sanctioning any work undertaken whilst on sick leave and report back to the next meeting on progress. H Gunter/ C Whittle. Page |6 15.070 EXTERNAL AUDIT – DRAFT PLAN R Bacon presented the draft external audit plan for 2015/16 and referred to the context described therein. The audit for 2014/15 had gone very well and there was no reason to expect anything different for 2015/16. Materiality limits would be assessed at the year end. The Deloitte controls review would be important. The economy, efficiency and effectiveness opinion was likely to be qualified again and the Quality Account position would be considered again, both as in 2014/15. The Risk Assessment Framework for NHS Foundation Trusts had been updated in August 2015 and reflected the challenging financial context foundation trust were operating in and strengthened Monitor’s regulatory regime to support improvements in financial efficiency across the sector. The risks affecting the trust were discussed and noted. The Committee was reminded of its obligations regarding fraud. The proposed base audit fee was slightly below last year. Estimates had been included for the revaluation and VFM work. Once the scope of the work was known, the final fees could be agreed. It was noted that N Shaw was due to go on maternity leave in March 2016 and Joanna Watson would take over from her. 15.071 FIRST ED QUARTERLY DATA QUALITY AUDIT REPORT Carl Holland joined the meeting and presented an update based on the IA review of the Emergency Department undertaken the previous year. There had been concerns around lack of controls to alter times on transfer of patients from ED that could have led to alteration of performance around the 4–hour target time. All recommendations set out in the report had been actioned, including the removal of staff access and ability to alter times. The meeting discussed ‘clock starts’ i.e. when a patient presented in the ED department, currently the clock commenced when the patient was booked in. In response to a question from D Lock, C Holland advised that a breach review was taken for all relevant cases and only where it was clearly documented in the notes that a patient had not breached would revalidation take place. A Lord questioned the number of patients who were discharged just prior to the 4-hour deadline, C Holland advised that staff continually chased discharges but noted that targets did drive behaviour; 4-hour performance was reviewed daily. The Committee agreed no further updates were required at present. C Holland left the meeting. 15.072 PLAN FOR ENHANCED DECLARATIONS IN APPRAISALS FROM 2016/17 Claire Whittle referred to the pre-circulated paper that set out how a mandatory declaration of interests and hospitality would be required in the annual appraisal documentation for all staff from April 2016. The appraisal process rolls out over the six months following April. It was agreed that a communications plan was needed to ensure all staff were aware of the Code of Conduct and revised appraisal process. Page |7 15.073 FEEDBACK ON O/S RECOMMENDATIONS FROM CLINICAL REVIEWS K Smith explained that the Committee had requested a report on progress in addressing outstanding recommendations from IA clinical reviews. There were 5 actions outstanding and these were already known to the committee, having been discussed when reviewing outstanding audit actions generally. 15.074 ANNUAL REPORT & ACCOUNTS 2015/16 - PLAN Kate Eccles joined the meeting and explained that the outline plan for the Annual Report & Accounts (AR&A), including the Quality Account, for 2015/16 essentially followed the previous year’s plan. The Communications team were awaiting Monitor guidance before revising this. This was consistent with the approach being taken by UHB. It was noted that it was important to agree an early date for PwC’s review of the document in final draft form and for the Executive lead to attend the Audit Committee earlier in the process to confirm that the Executive team was content with the messaging and content. It was also noted that the stories needed to be balanced and accurate. ACTION - J Miller undertook to ascertain who would be the Executive lead for the AR&A 2015/16. ACTION – K Eccles would bring a detailed timetable and key themes back to the January 2016 meeting in conjunction with the Exec lead. 15.075 QUALITY ACCOUNT UPDATE A Fuller referred to the pre-circulated update on the priorities for 2015/16; Reduction of grade 2 hospital acquired pressure ulcers Reduction of incidence of patients who have multiple falls in hospital Improvement in response rates and overall scores for Friends and Family Tests in ED An improvement in response rates to stroke A Lord noted that the content of quality accounts was largely prescribed but requested that a simple key be introduced to make it clear whether or not improvements were being made for each priority (e.g. RAG rating). D Lock noted that there was a potentially very positive story to be told on the Heartlands HASU and stroke outcomes. 15.076 ANY OTHER BUSINESS A Lord had invited the Governors to send an observer to future meetings if they wished to do so. It was noted that the next meeting was scheduled for 27 January 2016 but would re- Page |8 scheduled to 20 January. A Lord thanked everyone for their attendance and contribution. There was no further business so the meeting closed. ....................................... Chair Minutes of a meeting of the Donated Funds Committee of Heart of England NHS Foundation Trust held in the Boardroom, Devon House, Birmingham Heartlands Hospital on 20 November 2015 15.034 PRESENT: P Hensel (Chair) A Fletcher A Jones (part meeting) L Lawrence K Smith IN ATTENDANCE: J Creba E Hale A Hudson (minutes) M Hammond (QEHB Charity – observing) M Turner (Investec – part meeting) APOLOGIES AND WELCOME P Hensel welcomed Mike Hammond, Queen Elizabeth Hospital Birmingham Charity, who was observing the meeting and undertaking a review of the HEFT Charity. P Hensel noted that it was L Lawrence’s last meeting and thanked him for his contribution to the Committee over the last three years. A Fletcher seconded the vote of thanks. 15.035 MINUTES OF PREVIOUS MEETING The minutes of the meetings held on 29 July 2015 were approved as a true record. 15.036 MATTERS ARISING 15.003 Trust-wide communication exercise. E Hale advised that she had met with Fiona Alexander, Director of Communications at UHB, to discuss how fundraising would be supported by Communications going forward; a report would be presented to the next meeting. (Action: EH) 15.037 FUNDRAISING REPORT E Hale reported that Q2 fundraising performance was slightly ahead of Q1 and year to date was slightly ahead of previous year to date but was still behind plan. Good Hope and Heartlands fetes had been delivered but lost money. Due to the large number of planned community and staff engagement events a Community Fundraising Strategy had been developed that would encourage the focus on lower risk and higher return initiatives. E Hale then presented the community fundraising strategy that set out the objectives and targets for community based fundraising up to December 2018. In the past some charity led events arranged had cost more than had been raised. There had been a decline in the amount of fundraising income, despite additional resources put in place within the fundraising team and it was anticipated that fundraising income would fall significantly below the planned target and previous year’s performance. The current target was to raise £150,000 through Page| 2 community fundraising, however this would not be achieved within the current strategy and a review was required. It was suggested that the fundraising department would cease delivering charity led events until it had increased it supporter base and had focussed its efforts on third party event delivery. A benchmarking exercise had indicated that there was potential to increase income, but there was sufficient recourse within fundraising to recruit and steward fundraisers whilst the team were engaged in the delivery of charity led events. An order had been raised for the outright purchase of new payment kiosks for the baby scan facilities in the maternity department at each hospital and a commissioning plan was being rolled out. There was a large amount of work underway to expedite the installation of the machines including new Chip and Pin requirements; subject to estates facilitation works the machines were due to be commissioned in March 2016. It was felt that this would provide a rigorous system and see an increase in revenue. A £277k grant submission to the Sutton Coldfield Charity had been approved at a value of £200k for prostrate equipment; the trust had 12 months in which to spend the grant; associated revenue costs for the equipment and the process for ordering were being examined. This would be the Charity’s largest grant to date. .E Hale recorded a vote of thanks to L Lawrence and A Catto for their support in reassuring the Sutton Coldfield Charity following the latest Monitor enforcement action. A new cancer services appeal was being developed. The current cancer fundraising focussed around ward 19 at BHH; however other cancer services would be included as set out in the presentation pack included in the papers. The new fund would be administered through a committee which will act as joint fundholder. The need for consistent branding was noted. The presentation on the Cancer Services Fund was noted. More generally there were a lack of suitable projects for funding applications; it was understood that Project Pelican and the Infusion Unit were now unlikely to proceed. Other income was slightly up both year on year and against plan. The content of the dashboard was noted. A Jones joined the meeting. In response to a question from P Hensel on the likely full year out turn, E Hale explained that HEFT had taken a decision to terminate all agency staff and put permanent recruitment on hold which only left one colleague in the Fundraising Team 9and a second on maternity leave. A Jones confirmed that this was about preserving cash within the Group and that it came as a recommendation from EY, who were assisting HEFT with its short term financial recovery plan. K Smith reported that D Cattell, Finance Director, had confirmed that the SLA would need to be adjusted to reflect a lower level of service being delivered to the Charity. A Fletcher observed and others agreed that this supported the Charity’s case for greater independence. L Lawrence noted that the decision was dismissive of the Charity and was a concern to the Committee. It was agreed that P Hensel should meet with D Cattell to get a better understanding of the reasoning behind the decision and the options available to the Charity. (Action: P Hensel) 15.038 FINANCE REPORT A Jones outlined the key financial information for the 7 months to October 2015 stating that Page| 3 total income received was £699k, £334k below plan, expenditure was £862k, £163k below plan, there was a loss on revaluation of £257k, resulting in a net deficit of £420k, £609k worse than plan. The value of the fund at 31 October was £7,263k. A Jones also referred to the following: There was £387k cash on deposit with RBS at a rate of 0.92%. Three main funds may take a sizable hit because of the revised policy on realised gains/losses. Large receipts had been received from Friends of Solihull (£3.6k), Learning beyond Commissioning (£3k) and a grant from Sutton Coldfield Charities (£200k). Large payments had been made for a CPAP breathing system at Heartlands (£29k); a cellcheck specular microscope for Solihull Ophthalmology (£16.5k), a patient hoist for ward 10, GHH (£5k) and an electro therapy kit for GHH physiotherapy (£5k). Bequests to the value of £61k had been received; there were £224k legacies pending. There had been a loss on the value of investments managed by Investec that equated to an approximate loss of £257k on revaluation as at 31 October 2015. The year end cash forecast was £272k J Creba advised that fund holders had been encouraged to provide spend plans and it was anticipated that funds may be spent more quickly than previously, due to the Trust’s current financial situation. There was a plan to consolidate unrestricted funds if no spending plans were submitted. It was noted that restricted legacies or monies donated for a specific purpose were exempt from the planned consolidation. The large receipts and payments were noted. A Jones advised that there was a further potentially large payment to be noted; D Cattell had advised that consideration was being given to funding the Christmas lunch for all staff from the three main site charitable funds. The value was unknown at the present time. The meeting discussed the decision at length and it was noted that P Hensel would discuss this with D Cattell when they met. (Action: P Hensel) The summary of the 303 group funds was noted. 15.039 DRAFT INTERNAL AUDIT REPORT A Jones reported that a full assurance Internal Audit report had been received and formally thanked Alison Evans, Jeff Creba, Maria Lloyd and Janet Gray for their contributions to achieving this. 15.040 OPERATIONS COMMITTEE K Smith commented on the Operations Committee Actions Log and noted an e-mail had recently been received from the Good Hope League of Friends to advise that their charity would be wound up and the £2,027 they were holding would be transferred to the GHH General Fund. 15.041 REVISED FUNDRAISING POLICY E Hale advised that the Fundraising Policy had been reviewed and updated in line with the HEFT policy review process. Changes and updates had included recommendations made by the Marsden Review following the Saville investigation. HEFT had developed its own VIP/ Visitor policy that was reflected in the document, as was the requirement for all visual materials for Page| 4 marketing and PR to comply with branding guidelines. In response to a question from P Hensel, E Hale advised that there had been a communications exercise when the policy was first launched three years previously. The policy was regularly referred to and generally understood. The revised Fundraising Policy was approved. 15.042 FUNDHOLDER SPENDING PLANS AND CASH IMPACT A Jones advised that D Cattell had written to fundholders and asked for their spending plans; advising that their plans would be bought to the Committee for review. Responses had been received from 144 with overall plans to spend £3.5m of total funds of £7.3m (of which £1.7m was restricted and £5.6m unrestricted). £2.1m of the plans indicated spend in the current financial year. Fund holders who had not yet responded would be reminded that plans for spending were required. P Hensel noted a slight governance concern that the letter had come from the Finance Director and it needed to be ensured that the right governance was being followed for identifying spend for donated funds. The meeting discussed the purpose/objectives of the Charity to spend money for the benefit of patients and staff and that due to the current financial climate there may be capital plans that would not be funded by HEFT but could be funded by the Charity. A Jones clarified the current SFI authorisation expenditure limits: £1- 10K fund holder £10k - £50k fund holder and Finance Director £50k+ Donated Funds Committee. A Fletcher noted that the number of positive responses was to be celebrated. It was agreed that A Jones would to bring back a list of equipment with spending plans for consideration by the Committee. It was agreed for reasons of administrative convenience to delegate approval of those plans and the associated expenditure to any 3 from 5 members of the Committee by circulating resolution. (Action: A Jones/ K Smith) A Jones left the meeting. 15.043 INVESTEC INVESTMENT REPORT M Turner, Investec, joined the meeting to report on the performance for the six months to 30 September 2015 and tabled his presentation. Prior to receiving the report P Hensel explained the Charity’s plans to receive spending plans from fund holders and initial indications showed that these could be in the order of £2m in the remainder of the current financial year. It was agreed to confirm a more accurate estimate as soon as possible. M Turner confirmed that the current investment strategy remained appropriate and that with the exception of property, all other classes of investment were ‘daily dealing’ so quick disinvestment wouldn’t be problematic. The value of the fund at 30 September 2015 was £7,578k and at 17 November 2015 was £7,718k. Performance was on track to delivery £200k of income for the full year. Page| 5 Performance was noted as: Q1 Q2 6 months HEFT -1.2 -3.4 -4.5 Benchmark -2.2 -2.4 -4.5 Property had offset weakness seen elsewhere in the market. Q3 to date 2.3 2.4 Investec still believed that bonds were overvalued and would fall, particularly longer dated bonds. They were continuing to rise but this was not sustainable. The Chinese slowdown had impacted but was likely to re-balance. There was concern over pace and size of the expected increase in US interest rates. Commodity prices were falling causing a negative impact on inflation. In response to a question from P Hensel, M Turner advised that Investec’s expectations included more volatility in the market and a US interest rate rise. The account signatories were confirmed; K Smith agreed to complete and return the revised forms. (Action: KS) The report from Marlborough was received and the summary noted. The pre-circulated paper from Marlborough was noted. It confirmed that Investec had delivered a one year return of around 5.1% against benchmark of 4.9% and 7.1% against benchmark of 9.3% since inception (31 March 2014) in a very difficult period in which to outperform, given the volatile nature of the markets. K Smith reminded the Committee that Marlborough’s role was to provide an element of expert independent scrutiny to Investec’s performance. 15.044 HEFT REVIEW BY QEHB CHARITY CEO P Hensel thanked M Hammond for undertaking the review of the HEFT Charity and looked forward to receiving his report upon completion of the review. 15.045 ANY OTHER BUSINESS There was none. 15.046 DATE OF NEXT MEETING 29 January, 2016; Boardroom, Devon House, Birmingham Heartlands Hospital. ........................................ Chairman Minutes of a meeting of the Monitor Standing Committee of the Board of Heart of England NHS Foundation Trust held in the Board Room, Devon House, Birmingham Heartlands Hospital on 29 October 2015 at 8.00am 15.22 PRESENT: Mr L Lawrence Mr D Cattell Dr A Catto (by phone) Mr A Foster Mr D Lock (by phone) (Chair) IN ATTENDANCE: Mr K Smith Mrs A Fuller (Company Secretary) APOLOGIES Apologies were received on behalf of Mr Foster (Dr Catto was in attendance on his behalf), Mrs Foster (Mrs Fuller was in attendance on her behalf) and Dr Rao. 15.23 APPROVAL OF MONITOR QUARTER 2 RETURN Mr Cattell confirmed that the Monitor quarter 2 return had been completed in accordance with the Risk Assessment Framework. The meeting reviewed the pre-circulated papers. The Board was expected to sign the combined Governance Statement. This would confirm three things: • The board anticipates that the trust will continue to maintain a Continuity of Service risk rating of at least 3 over the next 12 months; • the board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards; and • the board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework page 21, Diagram 6) which have not already been reported. Governance The Trust has failed to achieve the four hour A&E waiting target for the thirteenth consecutive quarter. Recovery work on this target was being led through the Integrated Improvement Plan (‘IIP’). Improvement was on the most likely trajectory, however, was below the best trajectory. The Trust expected to consistently meet the target from quarter 1 2016-17. In line with national reporting deadlines, the Trust’s performance against cancer targets had not yet been fully validated for the quarter. The results in the return were provisional and fully validated results would be notified in November. At this stage, however, it was known that the Trust would not hit the two week targets for both breast and other cancers. The Trust was committed to deliver the two week wait cancer targets and it had been agreed with stakeholders that this would be consistently achieved from quarter 4 2015-16. The Trust had recognised in year demand increases and recognised the potential for increased demand as a result of the latest NICE guidance which may provide further challenges. As disclosed in the previous quarter, the ‘Cancer 62 Day Waits for first treatment (from urgent GP referral) - post local breach re-allocation’ target would not be achieved. This was due to a flood in Endoscopy at Solihull Hospital in quarter 1. This led to a loss in cystoscopy capacity, blocking the 2 week wait pathway in Urology and resulted in sharply reduced volumes achieving the 62 day pathway. Delivery of the standard was expected from January 2016. Also as previously disclosed the Trust failed to hit the 18 week RTT target in the quarter. The Trust has agreed with a wider stakeholder group a trajectory to return to compliance with the RTT targets by quarter 1 2016-17; this was part of the IIP. The Trust also provided supplementary governance information to Monitor. Amongst other things it includes information on serious untoward incidents (‘SUIs’), contacts with the CQC, information governance breaches, dealings with the Coroner and exchanges with other regulatory organisations such as the Health and Safety Executive. Finance The Trust’s Financial Sustainability Risk Rating was 2, reflecting deterioration in financial performance between quarters 1 and 2. The Trust remained subject to Monitor enforcement undertakings. The Trust had developed the IIP over the last several months. The IIP identified trajectories, agreed with stakeholders, for performance improvement. There was some evidence that the Trust was meeting those trajectories. This has come at a financial cost higher than planned as significant investment in services has been made to meet trajectory targets and improve clinical quality. It was clear that the current cost of improvement was unaffordable. Urgent work was in progress in order for the Trust to re-establish a sustainable financial position while maintaining improvements in operational performance. This work had been agreed by the Board and Monitor and included support from Ernst & Young. In the quarter 2 the Trust had reported a deficit of £21.3m, £19.7m adverse to Plan. The year to date deficit of £35.9m was £26.8m adverse to the Plan. . In quarter 2 overall operating income of £160.8m was £0.5m favourable to Plan, year to date income of £324.1m was £5.9m above Plan. NHS Clinical Income of £145.3m outperformed the Plan by £1.5m contributing to half year over-performance of £5.7m. The Trust was recognising income under full Payment by Results (‘PbR’) terms and conditions using the Enhanced Tariff Option (‘ETO’). However, a bad debts provision of £2.6m year to date was included in the position, relating to ongoing payment queries from the CCGs and risks associated with moving to PbR. The modest favourable variance on operating income was offset by an overspend of £20.5m on operating expenses of £180.7m in the quarter. At the half year operating expenses of £356.9m were £33.2m over Plan. Notable year to date overspends against Plan were recorded on employee expenses £11.2m (unfilled vacancies, extended enhanced bank rates, additional WLI work, high levels of agency nurses and locum doctors), drugs, including pass through expenses £3.3m (activity driven predominantly in CHONC and Gastroenterology), clinical supplies £2.4m (activity driven notably in T&O, extra focus on performance notably in A&E and on 18 weeks RTT), non-clinical supplies £2.3m (extra capacity still open impacting on laundry, cleaning and security), purchase of healthcare services £0.3m (18 week RTT backlog driven) and other non-pay expenses £13.8m (including extra governance costs, impairment of receivables, consultancy for project management office, contingencies). There had been a reduction in the Trust’s liquidity. Cash and investment balances of £34.1m were below Plan by £37.5m. Lower than planned operational performance has resulted in adverse to plan cash flows of £18.7m for the quarter, £25.9m for the half year. Changes in 2 working capital balances were £3.5m worse than planned for the quarter, £14.7m for the half year. Cash capital additions were £2.8m below Plan for the quarter and for the half year. Urgent work had already been undertaken and would continue to preserve cash balances over the remainder of the financial year. Mr Lock confirmed that the return was consistent with the deliberations at the Finance & Performance Committee meeting the previous week. The Committee noted that it would have to highlight in the Governance Statement any exceptions to the confirmations noted in a similar way to the previous quarter and delegated authority to Mr Cattell to complete this by reference to failure to meet the 4-hour A&E target, the 18 week RTT target and the 2 week cancer targets, the financial Plan and the agreed trajectories for compliance. After due consideration and subject to the foregoing the quarter 2 return was approved and two directors were authorised to sign it on behalf of the Trust. 15.20 ANY OTHER BUSINESS There was none. 15.21 DATE OF NEXT COMMITTEE MEETING 29 January 2016. ……………………………… Chairman 3 Heart of England NHS Foundation Trust Consultant and SAS Job Planning Policy and Procedure Ratified Date: Ratified By: JLNC, HR Committee Review Date: Accountable Directorate: HR Consultancy Corresponding Author: HR Business Consultant 1 Paper Copies of this Document If you are reading a printed copy of this document you should check the Trust’s Policy website (http://sharepoint/policies) to ensure that you are using the most current version. Insert Footer For copyright insert “©Heart of England NHS Foundation Trust” include year document was created. (If this document has been adapted from another source acknowledgements must be inserted or replace copyright marker with owning organisation copyright marker) 2 Meta Data Document Title: Consultant and SAS Job Planning Policy and Procedure Status Active Document Author: HR Business Consultant Source Directorate: Human Resources Consultancy Date Of Release: December 2015 Approval Date: December 2015 Approved by: JLNC Ratification Date: December 2015 Ratified by: JLNC Review Date: December 2018 Related documents Medical and Dental terms and conditions Superseded documents Job Planning Policy March 2010 Relevant External Standards/ Legislation Key Words Job planning 3 HEART OF ENGLAND FOUNDATION NHS TRUST CONSULTANT AND SAS JOB PLANNING POLICY AND PROCEDURE 1.0 Circulation This polices apples to all Consultants and SAS staff employed by the Trust directly and those on honorary/clinical academic contracts. 2.0 Scope of Policy A job plan is designed to be a prospective agreement that sets out a Consultant’s/SAS duties, responsibilities, accountabilities, objectives and expected outcomes for the coming year. Both consultants who have remained on the ‘old’ contract and those appointed on the ‘new’ contract are expected to participate in job planning. The two contracts have different arrangements for scheduling and timetabling of activities and the currency for the ‘old’ contract is Notional Half Days (NHDs) and, for the ‘new’ contract, Programmed Activities (PAs). Similarly, all Specialty and Associate Specialist doctors, whether on the 2008 or pre-2008 national contracts, are expected to participate in job planning. This policy supersedes any previous policies relating to job planning. 3.0 Definitions The Trust is aware that there are some Consultants, Staff Grades and Associate Specialists who have elected to remain on their previous terms and conditions. However, for the purposes of this policy, the term ‘programmed activities’ will also denote ‘sessions’, acknowledging that the period denoted by a session is in accordance with those terms and conditions. PAs Programme Activities DCC Direct Clinical Care SPA Supporting Activities APAs Additional Programmed Activity NHD Notional Half Day (old consultant contract) A standard job plan will be based on 10 Programmed Activities (PAs), which will comprise of: 4 Direct Clinical Care activities (DCCs) Supporting Professional Activities (SPAs). Additional NHS Responsibilities (ANRs) External Duties Additional Programmed Activities (APAs) up to a maximum of 2 (and maximum total of 12 PAs) can be offered, subject to the agreement of the Associate Medical Director or Deputy Medical Director. These will be offered on a temporary basis. Part-time substantive contracts will be advertised and paid at a Maximum of 9 PA’s for those not undertaking private practice Maximum 8 PA’s for those undertaking private practice Consultants who work privately are required to offer first call on their ‘spare time’ to the NHS and may be requested to work 1 additional PA (e.g. 11 PA’s total) or their pay progression maybe withheld in accordance with the Terms and Conditions – Consultants (England) 2003. Pre Consultant Contract 2003 5-7 3.0 Fixed Sessions (DCCs) Flexible Sessions (Patient admin and SPAs) The SPA allocation for part time doctors will be pro rata to the number of PAs worked. No job plan will exceed 12 PAs. Clinical Directors and General Managers must ensure a consistent and flexible approach is taken to the job planning process. 4.0 Reason for Development The purpose of this document is to introduce a clear procedure for job planning that will ensure job plans are linked to the needs of the service and development needs of the doctor. The process will be led by the Associate Medical Director, Clinical Director and Operations Manager/General Manager for the service. Individual or team job planning meetings will be conducted between the doctor(s) and the appropriate clinical director (and service lead if appropriate) and operations or general manager. 5.0 Aims and Objectives This policy and procedure aims to provide a uniform and equitable approach to the job planning process. 5 6.0 Job Planning The job plan will set out the duties, responsibilities and expected outcomes for DCC, SPA and any additional PAs awarded to the doctor. The job plan will include any duties for other NHS employers, HEE or external agencies and must also identify any regular private practice work undertaken. All job plans should include an agreed annual amount of clinical activity and supporting professional activity that is relevant and appropriate to the doctor’s role and not necessarily related to direct patient contact. 1.5 PAs of SPA will be offered to Consultants and a minimum of 1PA of SPA will be offered to SAS doctors. More details of SPAs can be found in section 5 of Procedure for Job Planning. The job plan will be reviewed every year or more frequently where working arrangements and responsibilities change. Job planning should take place between Jan – Mar each year and must be aligned to the service plan. At the job planning meeting the expected personal objectives and outcomes agreed in the previous job plan will be discussed. At the same time the consultant’s/SAS doctor’s expected personal objectives and outcomes for the coming year will be agreed. Annual leave requests should also be discussed at the job planning meeting where possible. All consultants/SAS doctors must develop and seek to agree an individual job plan, based on either a regular cycle (weekly, monthly etc.) or on an annualised basis. In some specialties a team approach to job planning may be developed. In such cases, each individual must still agree a schedule of commitments and ‘sign-up’ to the job. 7.0 Appraisal The appraisal process will provide an important opportunity to draw together information and data from which the job plan and a work programme are shaped. The Appraisal process will support revalidation and Clinical Excellence awards and should be conducted in line with National Appraisal and Good Medical Practice frameworks. The appraisal should precede job planning and should be held separately from the job planning meeting. The appraisal must be undertaken by an appropriate individual who has received the necessary training to undertake appraisals. The following appraisal/job planning cycle should be used: Appraisals of all consultants/SAS doctors to be completed Apr - Sep Job Plans of all consultants/SAS doctors reviewed and agreed Jan – Mar 6 As business planning usually occurs in the autumn season each year, this will ensure that the agreed job plan can take into account service requirements for the following financial year. Clear objectives and outcomes should be outlined within the job plan. These should be achievable and must support the needs of the service and personal development of the consultant. 8.0 Responsibilities Medical Director/Deputy Medical Director Undertake performance and job plan review for Associate Medical Directors. Ensure all Associate Medical Directors have agreed job plans for consultants/SAS doctors within their area on an annual basis. Ensure the job plans of all consultants/SAS doctors meet the needs of the service. Identify key objectives to be delivered by the consultant workforce. Chairs Appeals panel for disputes concerning job plans/pay awards. Associate Medical Director Undertake performance and job plan review of all Clinical Directors within their area annually. Ensure all consultants/SAS doctors within their area receive an appraisal and job plan review each year. Review the directorate summary report of job plans to ensure the needs of service are delivered. Approve/Not approve PAs awarded above 10. Mediate job planning disputes. Mediate disputes against pay award. Clinical Director/Operations/General Manager Ensure all appraisals and job plans are conducted for each consultant/SAS doctor within their area of responsibility on an annual basis. Ensure the job plans deliver the needs of the service. Ensure objective setting is aligned to the needs of the service. Ensure consultants/SAS doctors deliver agreed objectives and outcomes. Submit an annual summary report to the Associate Medical Director following completion of job plan reviews. Complete change forms and notify Employee Services as appropriate. 7 7.0 Monitoring and Review This policy will be monitored and reviewed by the Workforce Director and updated as necessary and amended through the JLNC.PROCEDURE FOR JOB PLANNING 1.0 Introduction This procedure sets out the Trust process for Consultant and SAS Job Planning. Annual job planning is a contractual obligation for all Consultant and SAS Medical Staff (both substantive & honorary), irrespective of the contract type held. An IT infrastructure will be implemented which will support the job planning framework and allow a consistent application to be used. All doctors’ job plans will be entered into the IT framework supplied for this purpose and job planning meetings will utilise this IT framework. Reports on allocation of PAs and other service planning, capacity and activity information will be generated by the system and reviewed by the Clinical Directors and Associate Medical Directors as required to support and facilitate service development 2.0 Job Planning Principles A Job Plan is a prospective agreement that sets out a consultant’s / SAS doctor’s duties, accountabilities, objectives and outputs for the coming year, with the identified support and resources to be provided by the Trust to facilitate the delivery of agreed work. The job plan must include any duties for other NHS employers and must identify any regular private practice work undertaken. The job planning process will be led by the Associate Medical Director, Clinical Director and Operations/General Manager for each service area. Job Planning will be based on a partnership with the consultant/SAS doctor. A standard full time job plan will contain ten Programmed Activities. Additional PAs above the standard 10 PA’s may be offered to consultants and SAS doctors for additional clinical activity subject to a maximum of 12 PAs. Where agreed, the additional PAs will be an addendum to the substantive contract and will be reviewed on an annual basis. Additional PA’s may be terminated by mutual agreement, at the end of a fixed term period or by 3 months’ notice. Part-time substantive contracts will consist of a: Maximum of 9 PAs for those not undertaking private practice Maximum 8 PAs for those undertaking private practice 8 The SPA allocation for part time doctors will be pro rata to the number of PA’s worked. The job plan will be reviewed every year and at this review meeting the expected personal objectives and outcomes agreed in the previous job plan will be discussed. At the same time the consultant’s/SAS doctor’s expected personal objectives and outcomes for the coming year will be agreed. All consultants/SAS doctors must develop and seek to agree an individual job plan, based on either a regular cycle (weekly, monthly etc.) or on an annualised basis. In some specialties a cumulative or team based approach to job planning may be developed. In such instances there may have been “team” job planning of some elements of the timetable, for example, on-call, emergency cover, departmental SPA, patient related admin time for specified clinical activities and it is inadvisable for this to be revisited on an individual basis. In such cases, each individual must still agree a schedule of commitments, outputs and ‘sign-up’ to the job plan. If there is a significant change in any aspect of the job plan during the year it might be necessary to have an interim job plan review. A Programme Activity (PA) will have a working allocation of 4 hours in standard time unless it falls within 7pm to 7am Monday to Friday, weekends or bank holidays when premium time applies and 1PA has a working time allocation of 3 hours. A Consultant/SAS doctor can agree with the Clinical Director and Operations/General Manager to allocate a PA to work flexibly, and where this occurs, additional work may be undertaken on an ad hoc basis to ensure efficient use of resources e.g. additional cover whilst a colleague is away. Flexible work must be recorded and agreed output measures must be achieved to ensure the obligations for work and payment are met. If it is agreed that a PA may be worked flexibly they will automatically be counted as being a standard PA (4 hours in time) regardless of when the work is undertaken unless otherwise agreed with the clinical director. 3.0 Objectives As part of the job planning review all consultants and SAS doctors will be set objectives for the forthcoming year. Clinical Directors and Operations/General Managers must ensure that objectives and outcomes are agreed and recorded on the supplied IT system. The objectives and outcomes should be reviewed annually or sooner if there is a significant change in role. Objectives and outcome measures must be aligned to the needs of the service and objectives of the Trust and the allocation of supporting programme activity. A standard job plan will comprise of: 9 Direct Clinical Care activities (DCCs) Supporting Activities (SPAs). Additional NHS Responsibilities External Duties The job plan will include appropriate and identified personal objectives and outcome measures that have been agreed between the doctor and the Clinical Director/General Manager. The personal objectives and outcome measures will depend in part on the specialty but may include: Quality improvement Activity and efficiency Clinical outcomes Clinical standards Local service objectives Management of resources, including efficient use of NHS resources Service development Multi-disciplinary team working Continuing professional development and continuing medical education Output required from additional SPA activity Supporting Activities must be aligned to service needs/objectives where appropriate. Objectives may refer to protocols, policies, procedures, number of meetings to attend, outcomes from audit and work patterns to be followed. Where objectives are set in terms of output and outcome measures, these must be reasonable and agreement reached. Consultants may also be asked to undertake corporate roles outside of their specialty. The SPA allocation will be agreed in discussion with the Clinical Director and Deputy Medical Director/AMD. 4.0 Direct Clinical Care Direct clinical care means work that directly relates to the prevention, diagnosis or treatment of illness. It may include the following: Emergency duties (including work carried out or arising from on call) Operating Sessions including pre-operative and post-operative care Ward rounds Outpatient Activities Clinical diagnostic work Other patient treatment Public Health Duties Multi-disciplinary meetings about direct patient care 10 Patient related administration linked to clinical work i.e. directly related to the above (primarily but not limited to, notes letters and referrals) In order to maintain a consistent approach to the job planning process Directorates should where possible agree standard times to undertake direct clinical care activities for example a ward round may equate to 1 PA per week or clinical administration may equate to 0.5PA per week The allocation of direct clinical care activities will depend upon the specialty and must be agreed between the Clinical Director, Operations/General Manager and Consultant/SAS doctor. External benchmarking data should be used where possible. Administrative Time If timetabled administrative time beyond that included within Direct Clinical Care PA time is required, the nature of these tasks should be detailed and recorded within the Job Planning process The same ‘evidence based’ approach regarding SPA time should be applied to this area. The proportion of administrative time to DCC should be discussed as part of the preliminary Team Job Planning session 5.0 Supporting Activities The Trust is committed to paying for reasonable, agreed amounts of SPA activities which are as defined in the contracts. It is not expected that all doctors will undertake all of these activities. It is likely, therefore, that the SPA time within job plans will vary. It is also likely that time allocated to SPA will alter as activities change throughout the course of a consultant/SAS doctor’s career. It is a fundamental requirement that SPAs are directly relevant to the individual consultant/SAS doctor and to the Trust. The consultant contract currently provides for a typical weekly split of 7.5 DCC to 2.5 SPA. The SAS contract provides for a typical weekly split of 9 DCC to 1 SPA. However this is neither a universal allowance nor an entitlement and the job planning process should develop a range of SPA activities for individuals linked to personal continuing professional development (CPD) requirements and the agreed needs of the team of doctors and the service. Therefore, there may be a variation in the number of SPAs, and in the range of activity, within individual job plans. Consultants will receive up to 2.5 PA, with a minimum of 1.5 PA in order to revalidate and an additional jointly negotiated 1PA for agreed clinical objectives. Up to one additional SPA can be awarded for additional responsibilities (see section 5.1) at the discretion of the CD or Clinical Service Lead where appropriate, with an expectation of 2 PAs on average per consultant per directorate. This could be increased in exceptional circumstances. The SPA will be allocated at a basic level to cover the following: 11 Quality Improvement, Audit and Governance programmes Continuing Professional Development Local clinical governance activities including mortality and morbidity review meetings Participation in essential training including mandatory and statutory training Formal teaching Appraisal and Revalidation Job Planning Personal administration Team/service/directorate business meetings Given that these activities are required of all doctors. This must be documented in the job plan Monday to Friday, although for some activities the actual location and timing can be at the consultant’s discretion. For the avoidance of doubt participating in audit and quality improvement includes: Participating in mortality and morbidity reviews Attending audit/quality improvement meetings Contributing data and to its analysis Implementing agreed audit recommendations in your own practice Where consultants/SAS doctors undertake work for other NHS Trusts, SPA time should be split pro rata to the DCC activity undertaken for that organisation. SPA activity should be scheduled within the job plan, although by agreement may be worked flexibly subject to the outcome measures being agreed. 5.1 Additional SPA activity Additional SPA allocation up to a maximum of 1PA can be for specific lead roles. Examples include: Corporate Roles as agreed with the Clinical Director and Deputy Medical Director including Case Investigation Role or Case Manager role Lead roles in Clinical Governance/Quality Improvement Activities o o o o Audit or guideline development Service Development Risk Management Research Service lead roles 12 Where SPA time is allocated for research this should be reviewed annually by the Trust Research and Development committee chaired by the Medical Director. It should be noted that Audit is not a research activity and should not be counted as such. Education and training roles o Post Graduate o Undergraduate Educational work should have measurable outcomes which could include; Definite Objectives if in a formal education role Attendance at timetabled teaching sessions Number of students and trainees taught and supervised current timetables and programmes of work Feedback from students and trainees or end of placement feedback evaluations E-portfolio evidence of use and number of work placed based assessment carried out Audit/research outputs with trainees and undergraduates General Teaching Commitments Clinicians are expected to participate in education as part of their employment. It is important to recognise that time spent teaching in clinics and ward rounds is not additional, it is part of those fixed clinical units of PA (DCC). It is recognised that workplace based teaching may affect the volume of activity which can be undertaken within a clinical session. Variations in activity will be identified and accommodated as part of the job planning process. Undergraduate teaching – this relates to specific undergraduate teaching in SPA time and is separate from contact time during a fixed activity such as a clinic. The amount of SPA time for this activity will be individually negotiated as part of the job planning process with the involvement of the Directorate and the Undergraduate Department of Education through an evidenced based approach. Postgraduate Education and Training Postgraduate Doctors in training should have an assigned Educational Supervisor along with a Named Clinical Supervisor, the Trust acknowledges the roles and time that Consultants will take delivering their commitment to train and supervise. An average of 0.25 SPA per recognised training post in each specialty may be allocated per trainee. The Clinical Director will need to agree with the consultants how the Educational Work will be provided. Individual job plans will reflect the explicit allocated time. Trainees can only have one nominated educational supervisor at a time. It is acknowledged that in some departments, the role of Assigned Educational Supervisor is undertaken by different Consultants at different times during a Training Placement. Where this is the case the allocation 13 of SPA time associated with this work should be agreed at Specialty Level and the total time allocated must not exceed 0.25 SPA per week for each trainee in the specialty. Consultants appointed as Trust Specialty Tutor or College Tutor should be allocated adequate time to perform the role. The time required should be agreed on a case by case basis and should be based on the objectives the individual is required to achieve. This time can either be recorded as SPA time or Additional Responsibilities As a guideline the Deanery suggests that Consultants performing this role be allocated 0.5 PA/week in specialties with up to 10 trainees (excluding Foundation Trainees, for whom appropriate arrangements are already in place), 1 PA/week in specialties with over 10 trainees The Trust will also support other educational roles such as STC chairs, Regional Advisers and Training Programme Directors. PAs allocated for supporting these roles will be included in job plans. Doctors are required to seek and obtain the support of their clinical director before putting themselves forwards for these roles. The Trust expects these roles to add value to education and training in the organisation and the Education Faculty will provide advice to the doctor about the Trust’s expectations. Further guidance on STC roles is contained within Appendix A. Undergraduate Education Consultants performing the role should be allocated adequate time to perform this role. Consultants appointed as the module lead for each of the Universities should be allocated a maximum of 0.5 SPA/week, but will be asked to maintain a diary over the course of the year to assess the actual time spent performing this role. In both cases specific measurable objectives should be agreed and included in the Consultants Job Plan Objective setting around SPA time could include preparation of teaching materials usable by others, utilisation of student feedback, planning/managing teaching courses. Such evidence should be discussed at the annual job planning and appraisal Acting as a medical appraiser The Trust recognises the contribution that Appraisers make to ensuring that colleagues and the Trust are able to meet their obligations for Revalidation. Appraisers will be allocated 0.2 SPA per week for the role in entirety and are expected to undertake a minimum of 4 and a maximum of 12 (an average of 6) appraisals per annum. In addition, the appraiser will also be expected to attend any appraiser training and update sessions as required and organised by the Trust throughout the year. The time and place where additional SPAs (i.e., those over and above the 1.5 per week allocated to all Consultants) are performed must be clearly documented in the Job Plan. These activities should be performed on Trust sites unless an explicit agreement is made to the contrary with the Clinical Director. Supporting resources such as office space and appropriate access to a computer will be provided by the Trust to facilitate this. 14 The Clinical Director and Operations/General Manager must agree with the consultant/SAS doctor the activity to be undertaken and the outcome to be achieved. For example a consultant undertaking the role of Quality Improvement Lead must agree the output to be delivered which could include: agreement on the number of audits meetings to be undertaken within the directorate the audit programme to be delivered Engagement agreement with the Governance Department. The outcome must be evidenced in the appraisal documentation and job planning review. It is important that activities are not counted twice. Any of the activities outlined above undertaken during DCC time cannot be taken into account. For instance teaching during a ward round or theatre session or slide reporting, cannot be counted as SPA. Likewise missing a DCC activity like theatre or out-patient clinic and attending a management meeting cannot be counted separately. In the event that a full time consultant/SAS doctor does not wish to work more than 1.5/1 SPA, then an agreement can be made to either convert the PA into a DDC activity or alternatively a reduction in the contractual value of the contract can be made. The factor underpinning job planning with regard to SPAs is transparency in the activity that occurs during this time. Supporting activities should be linked to the delivery of service objectives or personal development. Evidence may need to be provided during the course of the year. Consultants/SAS doctors must be able to demonstrate that the time spent on SPAs is needed for the identified activities and that these activities are undertaken. The supporting evidence can come from two sources: The Trust asks consultants to keep a work diary which includes details of SPA activities. The output from this SPA time (for example research outputs, articles, evidence of teaching sessions & preparation, audit project outputs etc.) will be reviewed and discussed at the Job Planning session Consultants/SAS’s have an obligation to attend key sessions (such as audit meetings, teaching sessions or clinical governance activities) unless they are on annual leave, study leave or a substitute activity is agreed with the relevant Clinical Director. Consultants are also expected to comply with 100% of mandatory training. Job plans will be selected at random for review by Internal Audit to ensure there is compliance with the policy and procedure. 6.0 Management Responsibilities These will vary between consultants; an appropriate PA allowance will be negotiated at the time of the Clinical Director’s job planning. 15 For a part-time Associate Medical Director a substantial part of the job plan will be taken up by management component of the job plan with less time for clinical activities. The job plan should allocate and timetable programmed activities within the total working week accordingly. 7.0 Additional NHS Responsibilities/External Duties If a Consultant/SAS Doctor is asked to take on a wider NHS role that is likely to have a significant impact on the job plan, discussion must take place with the Clinical Director and Operations/General Manager and colleagues and this should be agreed by the Associate Medical Director prior to accepting this role. Examples of special responsibilities may include being a clinical audit lead, governance lead, undergraduate dean, postgraduate dean, clinical tutor, regional education adviser, cancer service work and other similar roles. This must be agreed with the Clinical Director prior to accepting the role. The consultant/SAS doctor must be able to fully account for these activities in terms of interest to the Trust, Professional Society, College or wider NHS. Time should be allocated for such activities in the overall weekly job plan after discussions between the Clinical Director and Operations/General Manager undertaking the job plan review and the consultant/SAS doctor, if these are undertaken over and above the agreed job plan commitments with the Trust. The Trust will not pay for travel or expenses claims for the external duties. A consultant may not take annual leave from PA’s assigned to the Trust for any leave accrued through external PA’s in an individual job plan. Where a consultant/SAS doctor wishes to perform an additional NHS responsibility on an ad hoc basis they must first discuss this with the Clinical Director and must provide at least 6 weeks’ notice where a scheduled commitment may be missed. Where the commitment which is displaced for a different category of PA the displaced activity should be paid back in time allocated to the PA category of the commitment undertaken. 8.0 Private Practice and Fee paying Services The consultant/SAS doctor is responsible for ensuring that the provision of Private Professional Services or Fee Paying Services for other organisations does not: Result in detriment of NHS patients or services Diminish the public resources that are available for the NHS 16 The Consultant/SAS doctor must inform the Clinical Director and Operations/General Manager of any regular commitments in respect of private professional services or fee paying services. This must include the planned location, timing and broad type of work involved and must be documented on the job plan. Where a Consultant/SAS doctor undertakes Private Practice it is agreed that the 11th PA is offered to the Trust first. Where the doctor declines the 11th session pay progression will be withheld. All private practice must be arranged and undertaken within the requirements of the Private Practice Code of Conduct. Consultants/SAS doctors must not undertake any Private Practice work when they are contracted to work at HEFT including when the consultant/SAS doctor is on call for NHS emergency work. Where a concern arises that private work has been undertaken when the Consultant/SAS doctor was required to fulfil contractual obligations as agreed in the job plan the Trust will notify the Counter Fraud department and may implement MHPS. If a Consultant/SAS doctor wishes to undertake fee paying service duties in NHS time the express permission of the Clinical Director or Operations/General Manager is required. Permission should be sought a minimum of six weeks in advance. If such duties are undertaken in a doctor’s own time, they keep the fee: in NHS time, they must remit the fee to the Trust with the exemption of cremations and family planning fees. Where a Doctor currently undertakes such duties on a regular basis the Clinical Director or Operations/General Manager must demonstrate how the Direct Clinical Care PAs will be delivered on an annual basis. Time shifting is the process whereby one activity e.g. fee paying work is carried out during the scheduled time for another activity e.g. DCC. Time shifting of DCC/SPA can only be done with the expressed agreement of the Clinical Director and Operations/General Manager. Time shifting of a PA will not be authorised to enable a consultant/SAS doctor to undertake private practice. All time shifting requests must be recorded and monitored. Where time shifting has been agreed the equivalent amount of missed activity will be carried out at another time. 17 9.0 Study Leave and Professional leave Study Leave The total amount of study leave granted is a maximum of 30 days over a 3 year period which can be taken as 10 study days a year. This includes: Study, usually but not exclusively or necessarily on a course or programme. Taking examinations Visiting clinical and attending professional conferences Undertaking specialist training skills Note the difference between the SPA allocation and study leave is that the SPA allocation is used to underpin direct clinical care activities and is of benefit to the service whereas study leave should be used to develop the skills of a consultant and the service offered to our patients. Study leave should be identified with the PD. Study leave that is not contained within the PDP may not be authorised. Professional Leave Professional leave is discretionary and must be approved by either the Clinical Director, Clinical Service Lead, or General Manager prior to the Consultant/SAS doctor agreeing to the commitment. It is expected that the individual will minimise the impact on direct clinical care activities. The consultant should attempt to schedule duties outside the Trust so as to minimise loss of commitments such as clinics, operating lists, on call etc. Any leave granted is subject to the need to maintain the service and where possible should be factored into the job planning process for example, a consultant who has a regular external commitment that falls on Tuesday pm which also coincides with a clinic scheduled for Tuesday pm must ensure that the clinic is moved to another time to ensure activity is not lost. Professional leave can be granted for the following: Teaching or lecturing outside the Trust e.g. on ALS or ATLAS courses, MSc or Conferences. Examining outside the Trust for Medical Schools, Royal Colleges, others. Duties as an officer, committee member or member of a working party of a Royal College, Faculty, Professional or Scientific Society or NICE. Attendance as a college Assessor at an Advisory Appointments Committee inside/outside the Region Attendance at officially constituted bodies giving advice to the department of Health Attendance at external appeals committee 18 Duties as a member of the Medical Research Council Duties in relation to Postgraduate educational activities outside the Trust If a consultant/SAS doctor is considering taking up a significant external position (e.g. Regional Training Advisor etc.) they must discuss this with the Clinical Director and General Manager and gain approval prior to taking up the role. Where the leave is granted the consultant/SAS doctor, must not undertake any other paid work during the leave of the period without the Clinical Director’s approval. Consultants/SAS doctors may not claim expenses from the Trust for participation in professional activities. The following activities are regarded as official duties and do not form part of the study/professional leave and can count toward SPA allocation: Attendance at Coroners inquests Specialist Cancer Network Meetings e.g. Cancer, Cardiology Meetings with local commissioners Where the requirement for professional or study leave is known in advance, this should be included within the job plan. Otherwise 6 weeks’ notice should be given to minimise the impact on direct clinical care. 11.0 Special Leave Special leave for circumstance such as time off to care for a dependant, attending jury service or domestic emergency should be taken and paid in agreement with the Time off Work policy which can be accessed via the Trust intranet. 12.0 Job Planning Process – Pre 2003 Consultant Contract The job planning process for consultants employed on the pre 2003 contract will be the same as defined above with the exception of the following: Consultants employed on the pre 2003 contract may be classed as whole time, maximum part time or part time. Job Plans are based on a minimum of 10 Notional Half Days (NHD’s) A Notional Half Day (NHD) equates to 3.5 hours. They comprise of fixed and flexible commitments: 19 Fixed commitments consist of clinical wards rounds, theatre lists are counted as DCC’s under the new contract. These commitments are normally at the same time/day each week, but this can be varied and should normally account between 5 - 7 NHD’s depending for whole and max part time. (Source Medical and Dental Whitley Council Duties of Practitioners, section 30 9d). Flexible commitments which consist of patient admin (this is a DCC in the new contract), research, audit and medical management. A Maximum Part time consultant is paid ten elevenths of the whole time salary and of any distinction award if applicable. The minimum work commitment is equivalent to ten national half days (35 hours). The split between Fixed/Flexible NHD’s will be as follows: Those employed on a whole time contract/Max part time: 5 - 7 Fixed NHD’s 3 Flexible NHD’s (note this includes patient admin) Those employed on part time basis will receive NHD’s on a pro rota basis. 13.0 Travel Time Where a doctor is expected to spend time on more than one site during the course of the day, traveling time to and from their main base to other sites will be included as working time within the programmed activity. It is therefore more effective use of a doctor’s time to schedule activities at one base for a working day. However it is acknowledged this may not be possible in a number of cases. Travelling time between a doctor’s main place of work and home or private practice premises will not be regarded as part of working time with the exception of a Consultant/SAS who is called back to work premises whilst on call. 14.0 On Call Consultant New Contract There are three requirements in relation to the consultant on call which need to be determined in job planning: Determination of the frequency rota commitment i.e. 1 in 4 or 1 in 8 This is simply done by referring to the number of doctors on the rota. Determination of the category of consultant on call duties 20 This is done by considering the nature of the calls typically taken by a consultant in determining whether: CATERGORY A: The consultant is typically required to return immediately to site when called OR has to undertake intervention with a similar level of complexity to those normally taken when on site. CATERGORY B: The consultant can typically respond by giving telephone advice and/or by returning to work later. Determination of the average amount of time a consultant is likely to spend on unpredictable emergency work when on call and the time of day this work takes place. These must be counted towards Direct Clinical Care PAs and will normally be up to one programmed activities per week. Directorates must assess and agree the category and time allocated for on call. The Clinical Director/Lead will assess with the doctor on a prospective basis the number of programmed activities that are to be regarded for these purposes, as representing the average weekly volume of unpredictable emergency work arising from a doctor’s on call duties. The following calculation provides an example of how the on call can be assessed and allocated: Average number of hours spent in hospital per day out of hours (audited over a 1 month period twice a year) divided by the number of people on the rota multiplied by 7 (to get the hours per week per consultant) divided by 3 (the number of OOH hours for 1 PA). Where this work exceeds 2 PAs in an average week the Clinical Director/Lead must review this with the consultant and either: Re-organise other Direct Clinical Care Activities during weeks of on call Explore recognition of this work via time off or additional remuneration It is the Trust’s expectation that the former of these options will provide a mutually acceptable solution in the majority of cases. Where unpredictable emergency work occurs between 7am and 7 pm the following allocations should be made: Average emergency work per week likely Possible allocation to arise from on call duties Activities (PA’s) ½ hour of Programmed 1 PA every 8 weeks, or half a PA every 4 21 weeks 1 hour 1 PA every 4 weeks, or half a PA every 2 weeks 11/2 hours 3 Pas every 8 weeks 2 hours 1 PA every 2 weeks, or half a PA every one week 3 hours 3 PA’s every 4 weeks Where unpredictable emergency work occurs between 7pm and 7am the following allocations should be made: Average emergency work per week likely Possible allocation to arise Out of Hours from on call duties Activities (PAs) of Programmed ½ hour 1 PA every 6 weeks, or half a PA every 3 weeks 1 hour 1 PA every 3 weeks 1 ½ hours 1 PA every 2 weeks, or a half PA per week 2 hours 2 PAs every 3 weeks 3 hours 1 PA per week 4 hours 3 PAs every two weeks 6 hours 2 PAs per week Where on call work averages less than 30 minutes per week, compensatory time will be deducted from normal Programmed Activities on an ad hoc basis. SAS On Call New Contract There are two requirements in relation to SAS on call which need to be determined in job planning: Firstly the determination of the frequency rota commitment i.e. 1 in 4 or 1 in 8 This is simply done by referring to the number of doctors on the rota. 22 The on call availability supplement is as follows: Frequency Percentage of Basic Salary More frequent than or equal to 1 in 4 6% Less frequent than 1 in 4 or equal to 1 in 8 4% Less frequent than 1 in 8 2% Secondly the expected average amount of time that a doctor is likely to spend on unpredictable emergency work each week whilst on call and directly associated with on call duties will be treated as counting towards the number of Direct Clinical Care programmed activities. This will normally take up to a maximum of two programmed activities per week. The Clinical Director/General Manager must assess with the doctor on a prospective basis the number of programmed activities that are to be regarded for these purposes, as representing the average weekly volume of unpredictable emergency work arising from a doctors on call duties during a period between one and eight weeks. Where unpredictable emergency work occurs between 7am and 7 pm the following allocations should be made: Average emergency work per week likely to arise from on call duties Possible allocation of Programmed Activities (PA’s) ½ hour 1 PA every 8 weeks, or half a PA every 4 weeks 1 hour 1 PA every 4 weeks, or half a PA every 2 weeks 11/2 hours 3 Pas every 8 weeks 2 hours 1 PA every 2 weeks, or half a PA every one week 3 hours 3 PA’s every 4 weeks 4 hours 1 PA per week 23 6 hours 1 ½ PA’s per week, or 3 Pas every 2 weeks 8 hours 2 PAs per week Where this work exceeds 2 PA’s the Clinical Director/General Manager must review this with the doctor and either: Re-organise other Direct Clinical Care activities during weeks of on call Explore recognition of this work via time off or additional remuneration It is the Trusts expectation that the former of these options will provide a mutually acceptable solution in the majority of cases. Where unpredictable emergency work occurs between 7pm and 7am the following allocations should be made: Average emergency work per week likely to arise Out of Hours from on call duties Possible allocation of Programmed Activities (PAs) ½ hour 1 PA every 6 weeks, or half a PA every 3 weeks 1 hour 1 PA every 3 weeks 1 ½ hours 1 PA every 2 weeks, or a half PA per week 2 hours 2 PAs every 3 weeks 3 hours 1 PA per week 4 hours 3 PAs every two weeks 6 hours 2 PAs per week Where on call work averages less than 30 minutes per week, compensatory time will be deducted from normal Programmed Activities on an ad hoc basis. 24 15.0 Annualisation Annualisation is an approach to job planning in which a doctor contracts with the Trust to undertake a particular number of PAs or activities on an annual, rather than a weekly, basis. Annualisation of all or part of job plans or agreed annual numbers of certain activities for example clinics can enable employers and doctors to match variations in demand with the available resources. Others may want to arrange their work so that they can spend the maximum amount of time at home with their families and would like, for example, to have as much leave during school holidays as possible. As with all aspects of job planning the decision whether to annualise a job plan or not must be by mutual agreement as the needs of the service must be delivered. At the outset the doctor and their Clinical Director must agree that activity relates to measurable outputs and that arrangements reflect the professional nature of the consultant contract the doctor’s continuing responsibility for care as described in the GMC’s Good Medical Practice. At the same time the Trust should clarify a doctor’s responsibilities when they are not scheduled to work and not undertaking any other planned activity, on-call or when they are on leave, for example whether they are required to return to work in the event of an emergency. Key principles of annualisation Annualisation is a flexible working arrangement which needs to meet both the needs of the individual and the Trust. Consultants/SAS doctors work an agreed annual total of programmed activities instead of the same number each week. An alternative approach is for there to be an agreement as to the number of specific activities, for example out-patient clinics, to be delivered over the year. Either arrangement must be compatible with the Consultant/SAS doctors’ contract and job planning best practice. This provides for working time measured in programmable activities and also for paid leave. The arrangement must be agreed. As for job plans, this agreement is between the doctor and their Clinical Director. Agreement must be reached on how many programmed activities or specific activities are to be done in a year. For programmed activities this is usually expressed as a mean number per week multiplied by the number of weeks in the working year. For example, on a 10PA fully annualised contract, this would be the number of weeks in the working year multiplied by ten. 25 For individual components (e.g. clinics, lists) this is usually expressed as the number normally undertaken in a week multiplied by the number of weeks in the working year. The number of weeks in the working year is not a fixed number. It is equal to 52 less the number of weeks granted as leave (annual, study, professional). This number will vary for Consultants/SAS doctors and cannot be assumed to be 42 or any other fixed number. The Annual leave policy for Medical and Dental staff outlines the annual leave entitlement by grade and years service. This will identify the number of weeks leave that will be taken. If during the year it becomes apparent that significantly more or less leave than anticipated will be taken then the annualised total should be reviewed and adjusted as appropriate. All parties should agree on the outputs and outcomes expected from activity in the job plan, and the means by which they will be measured and reported. Agreement will be reached regarding the arrangements by which Consultants/SAS doctors will notify the Clinical Director/Operational Manager when objectives or agreed levels of activity are not being met. These arrangements may form part of a wider system of review which tracks progress against objectives; are able to take into account changing circumstances and other external factors and allow for agreed modifications to the job plan where necessary. Programmed activities do not always run to the scheduled time and a professional approach should be taken to this. In the short term such variances will often balance out but if an activity consistently lasts longer or for less time than the PA time allowed then an interim job plan review should be held. Both the Consultant/SAS doctor and the Clinical Director must keep a record of the work undertaken against their annualised total. In some circumstances, a minimum number of PAs per week or month may need to be agreed for annualised plans so that activity can be delivered in a predictable manner. There should also be agreement on the frequency and nature of reporting arrangements so that any issues arising can be dealt with within a timeframe that allows reasonable changes to be made. It is important that the delivery of annualised clinical activities aligns to patient demand/waiting times and the capacity of the service to deliver. It is important, therefore, that agreement is reached on when the annualised activities will be delivered to meet these. There is no one agreed or recommended way of annualising a job plan. Different methods will work for different situations. Examples of how job plans can be annualised are given in Appendix B. The examples share an adherence to the principles set out above. 26 16.0 Job Planning Process The Clinical Director or Clinical lead and Operations/General Manager for each division will take the lead in the job planning process. Job Planning will be based on a partnership approach. Preparatory work is necessary to ensure the job planning process is meaningful and helpful to both the doctor and the Clinical Director or Clinical Lead/Operations Manager. The Clinical Director or Clinical Lead must undertake robust preparation for the job planning process. This must include reviewing demand for clinical activities to ensure that the directorate can apply sufficient resource to deliver a good service. For service specialisms, this may be easy to predict e.g. theatre sessions require a single anaesthesiologist. For response specialism this can be predicted often using historic occurrences. The Doctor will be responsible for providing a draft job plan based on their current timetable of activities to the Clinical Director/Service Lead for discussion. Listed below is a checklist of suggested information to assist the planning process. Preparation by Doctor Last year’s job plan List of main clinical duties to the Trust Timetable of private practice commitments List and schedule of any fee paying commitments CPD/CME requirements Personal Development plan List and time commitment of other duties and responsibilities e.g. trade union etc Clinical audit and clinical governance dates and issues to be addressed An idea of required additional support to be provided by the Trust Ideas for improvements to service, quality range or performance Evidence to demonstrate achievement of agreed objectives and outcome measures Preparation by Clinical Director/ Operations Manager Quantity and quality targets for the directorate and performance against them by the team and individually last year Knowledge of the relevant priorities within the local delivery plan Changes in services being require of, or offered by the directorate Clinical audit and clinical governance data and issues affecting the directorate and the individual 27 17.0 Knowledge of the resource base of the directorate including numbers of staff changes in skill mix and those services, space and equipment available Understanding of current and new initiatives within the directorate or Trust Details of study leave taken within the last year Changes in practices and/or services of other providers National clinical audit or clinical governance issues Changes in the health provision requirements of the local health community The requirements of related medical schools The needs of doctors in training Feedback from trainees The Job Planning Discussion This is a suggested format for the meeting to agree the job plan Discussion about last year’s plan – the positive and negative issues from both the individual’s and Clinical Directors/General Manager’s perspective What service needs or individual development needs are there to be addressed e.g. offer of additional PA Private Practice: what are the details of current regular contracts and the impact of work scheduling What could the schedule look like Are there any service implications or additional pay as a result of this plan The job plan will include appropriate and identified personal objectives and expected outcomes that have been agreed between the doctor and the Clinical Director or Clinical Lead and Operations/General Manger. Job plans should be reviewed by the Clinical Director or Clinical Lead and Operations/General Manager and consultant/SAS on an annual basis or sooner if there is a significant change in role/service needs. Consultants/SAS doctors may bring a work colleague to the job planning review meeting if required. Following the job planning review, the Clinical Director or Clinical Lead/Operations Manager will sign off the job plan and inform the Associate Medical Director whether the consultant/SAS doctor has: Made every reasonable effort to meet the service commitments in his/her job plan Met the personal objectives and delivered the agreed outcomes in his/her job plan or whether this was not achieved for reasons beyond the individual consultant’s control and he/she has made every reasonable effort to do so. 28 Participated satisfactorily in annual appraisal, job planning and objective setting. Agreed the prospective job plan for the year ahead. Worked towards any changes identified as being necessary to support achievement of the Trust’s service objectives in the last job planning review. Met the criteria for pay progression. If a consultant fails to meet the agreed objectives then these should be reviewed and an agreed structure put in place to support the achievement of these. Further advice can be sought from the HR consultancy team. 18.0 Submission to Associate Medical Director Upon completion of the job planning process Including Clinical Director and Operations/General Manager sign-off, the job plan will be submitted to the appropriate Associate Medical Director for sign-off. The Clinical Director and Operations/General Manager will also provide a report outlining Existing and proposed Job Plans for all consultants/SAS in the directorate, including those choosing to remain on the old contract. A summary of the implications in terms of: o Programmed Activities required for individual consultants in excess of 10 PAs and the justification in each case. o Identify the service improvements to be achieved throughout the year. o Achievement of the Corporate Business Plan: Waiting times, including cancer targets Patient Booking Length of stay Use of day case facilities Discharge of patients Clinical Governance 29 Financial Balance 19.0 Changes to the impact on inter-dependant directorates e.g. Anaesthetics, Radiology and the outcome of discussion with Clinical Directors/Leads of those services. An explanation of the physical resources required to fulfill the job plan, specifically the clinical, theatre and other treatment facilities required in each of the Trust sites. Mediation In the event that a job plan cannot be agreed between the Consultant/SAS doctor and the Clinical Director/Operations/General Manager the following Mediation process will be used. The Mediation and Appeal Process applies equally to those Consultants/SAS doctors on both the old and new contracts. The consultant/SAS doctor, may refer the matter to the Associate Medical Director, or to a designated other person if the Associate Medical Director is one of the parties to the initial decision. Since the Clinical Directors’ job plans will be reviewed by the Associate Medical Director, the role of mediator will be taken on by another Associate Medical Director or the Medical Director/Deputy Medical Director of the Trust. If a consultant/SAS doctor is employed by more than one NHS organisation, a designated employer will take the lead (in the case of a disputed Job Plan, a lead employer should have already been identified). The purposes of the referral will be to reach agreement if at all possible. The mediation process should be used where the two parties have failed to reach an agreement. If a doctor/Clinical Director feels that the panel is biased then they can request that the panel be revised to include either an Associate Medical Director from a different area or the Medical Director. The party making the referral will set out the nature of the disagreement and his or her position or view on the matter. Where the referral is made by the doctor, the Clinical Director and Operations/General Manager responsible for the job plan review will set out the employing organisation’s position or view on the matter. 30 Where the Clinical Director/Operations/General Manager makes the referral, the consultant/SAS doctor will be invited to set out his or her position on the view or matter. The mediator or an appropriate nominated person will convene a meeting, normally within four weeks of receipt of the referral, with the doctor and the responsible Clinical Director/Operations/General Manager to discuss the disagreement and to hear their views. If agreement is not reached at this meeting, then the mediator (in most cases the Associate Medical Director) will decide the matter in the case of a decision on the Job Plan or on whether the criteria for a pay threshold has been met. 20.0 Appeals In an event that a consultant/SAS doctor are not satisfied with the outcome of a mediation job planning and pay progression disputes a formal appeal should be lodged in writing to the Medical Director soon as possible and in any event within two weeks, after the outcome of mediation process. On receipt of a written appeal with points in dispute and the reasons for the appeal, the Medical Director will convene an appeal panel to meet within four weeks. A formal appeal panel will be convened to set out points in dispute and the reasons for the appeal. The parties to the dispute will submit their written statements of case to the appeal panel and to the other party one week before the appeal hearing. The appeal panel will hear oral submissions on the day of the hearing. Management will present its case first explaining the position on the Job Plan, or the reasons for deciding that the criteria for a pay threshold have not been met. The doctor may present his or her own case in person, or be assisted by a work colleague or trade union or professional organisation representative, but legal representatives acting in a professional capacity are not permitted. Where the consultant/SAS doctor or the panel requires it, the appeals panel may hear expert advice on matters specific to a specialty. It is expected that the appeal hearing will last no more than one day. The appeal panel will make their decision and will confirm it in writing within 5 days of the hearing. No disputed element of the Job Plan will be implemented until confirmed by the outcome of the appeals process. Any decision that affects the salary or pay of the consultant/SAS will have 31 effect from the date on which the consultant/SAS doctor referred the matter to mediation or from the time he or she would otherwise have received a change in salary, if earlier. In the case of a job planning appeal from a Medical Director, mediation would take place via a suitable individual, for example, a Non-Executive Director. If a doctor/Clinical Director feels that the panel is biased then they can request that the panel is revised to include the Medical Director, CEO or Non-Executive Director. 32 Appendix A Trust position on Consultant Staff undertaking regional education roles Health Education West Midlands appoints consultant grade staff to various educational roles at a regional level. These positions include Specialist Training Committee Chairs (STCs). Over a period of time the posts move around the region such that each trust will be called on to support particular posts for a limited period of usually 3 years. STC Chairs run the training programmes for specialities and are an important part of the delivery of education and training. As such they are highly prestigious posts and the Trust supports and encourages its staff to undertake these roles. HEWM requires the Trust to support individuals in undertaking the role of STC Chair by providing time in job plans and effectively supporting the role financially. The Trust support should be reflected in job plans as a reduction in clinical commitment, changes to SPA responsibilities or additional PAs within the Trust maximum. The Trust should reimburse directorates for this support. Activity in this role should be reflected in the consultant’s annual appraisal supported by their annual HEWM appraisal by the relevant Head of School. Because of this cost it is reasonable that the Trust has certain expectations of individuals undertaking these roles; Individuals wishing to apply for the role of STC Chair should first discuss and get the approval of their Clinical Director for the time commitment. In the case where the CD does not agree then the potential applicant should appeal to the Director of Medical Education who will discuss the case with the relevant Associate Medical Director. STC Chairs within the Trust will be expected to lend their expertise working with the Trust’s Education Lead in the relevant speciality helping to ensure that the training programmes delivered are of the highest calibre. The STC Chair is expected to contribute to the Trust’s wider educational environment by regular attendance at the medical education management committees as required by the DME The STC Chair brings to the Trust a greater understanding of education and training at a regional (HEWM) and sometimes national level. The STC Chair will be expected to provide advice to the Medical Director and DME in issues affecting training and service delivery where appropriate Undertaking these roles assists in developing the individual with leadership and other transferable skills that are then available to the Trust. 33 Appendix B Annualisation of job plans – examples Example A: Term time working Doctor A wishes to spend as much time during the school holidays at home. He or she then arranges their job plan on an annualised basis so that all their elective direct clinical care (DCC) and emergency work is carried out during term time. Supporting Professional Activities (SPAs) are worked partly during term time and partly during the school holiday periods. This is how the job plan is worked out. Assumptions Doctor A does 1PA of unpredictable on-call work per week and 6.5 elective direct clinical care work. Doctor has a weekly ratio of 7.5 DCC and 2.5 SPA Programmed Activities. There are 35 weeks of term time per year and 17 weeks of school holiday time. All annual leave (6 weeks plus 2 weeks of bank holidays and extra days = 8 weeks) will be taken during the school holidays. A week of professional leave will be taken to teach on a postgraduate course. That leaves 43 weeks during which Doctor A must work – 430PAs per year (based on a 10PA contract). Doctor A will work all their DCC programmed activities (PAs) in the 35 weeks of term time. SPAs will be worked over both term time and school holiday time. Study leave will be handled on an ad-hoc basis. On-call duties falling during school holidays will be swapped as they would be for annual leave. The detail Weekly equivalent (52 weeks) School holidays (18 weeks) (PA per week) Term time (34 weeks) (PA per week) Direct Clinical Care (DCC) 7.5 0 9.45 Supporting Professional Activities (SPA) 2.5 3.5 1.4 34 Total Programmed Activities (PAs) per week 10 Total Programmed Activities (PAs) per year 3.5 11.9 63 369 During term time Doctor A will work on average an 11.9PA week consisting of 9.45 DCC and 1.4 SPAs. During the school holidays and during leave Doctor A will do just 3.5PA per week of SPA only. These proportions can be adjusted to the needs of both Doctor A and the Trust. Over the year, Doctor A will deliver a total of 432PAs. Example B Doctor B works 5 DCC PAs per week but would like to work this out on an annualised basis. Doctor B takes a total of eleven weeks (55 days; 110 half-days) of approved leave (for bank holidays, annual leave, study leave, professional leave, sick leave). This leaves 41 weeks so that means that 205 PAs should be carried out during the rest of the year. SPAs can be worked out in a similar way. Example C The consultants and the Trust agree that workload for acute medicine is greater during the winter months and therefore, on average three months are spent working a 12PA week. During the summer months, workload is eased and thus the consultant works three months at 10 PAs per week. The consultant’s salary is maintained at 11 PAs across the year. This is a simple form of annualisation which may be useful for specialties with a seasonal variation in workload. 35 Example D An agreement is reached that a consultant who nominally undertakes two out-patient clinics per week and has a working year of 42 weeks, to deliver 84 clinics per year. Flexibility is provided by the Trust that this can at times be delivered at different times in the week than may have been nominally indicated on the weekly timetable. Without this flexibility, this annualisation would not have led to a different outcome than a rigid weekly job plan. 36