7th October 2015 - Dudley and Walsall Mental Health Partnership

Transcription

Dudley and Walsall Mental Health
Partnership NHS Trust
Papers for the Trust Board Meeting
Wednesday 7th October 2015
1.00pm-2.45pm
Board Room, Canalside
Abbotts Street, Bloxwich, Walsall WS3 3BW
PUBLIC MEETING OF THE TRUST BOARD
13:00pm, Wednesday 7th October 2015
Boardroom, Canalside House, Abbotts Street, Bloxwich, Walsall WS3 3BW
AGENDA
Culture and Conduct Protocol
We are a values-led Board. We place quality of care and safeguarding the needs of our patients at the heart of
everything we do. We work consciously as a team to support and constructively challenge each other in the best
interests of service users, their carers and families. We champion the interests of staff and acknowledge that they are
working well in challenging times. We seek to ensure value for money at all times through efficient use of our
resources in the delivery of services and achievement of standards. We welcome the rigour of debate with fellow
Board members, drawing upon a range of different experiences and perspectives and applying the Nolan principles of
Selflessness, Integrity, Objectivity, Accountability, Openness, Honesty and Leadership.
ITEM
1.
Purpose
Board Lead
Apologies
Format
Timings
Oral
1.00pm
Minutes of the Previous Meeting
2.
To approve the minutes of the Board meetings held
on Wednesday 2nd September 2015
Approval
Ms Oum
Enc 1
3.
Summary Report of Confidential session of Trust
Board held on Wednesday 2nd September 2015
Information
Ms Oum
Enc 2
4.
Matters Arising
Continuity
Ms Oum
Enc 3
5.
Notification of Items of Any Other Business
6.
Declarations of Interests
For Board members to declare any relevant interests
in items on the agenda.
7.
Questions from Members of the Public
8.
Occupational Health to announce formal launch of flu
vaccination campaign
Information
Assurance
Ms Ingram
Oral
1.05pm
9.
Chair’s Comments
Information
Ms Oum
Enc 5
1.10pm
10.
Chief Executive Officer’s Overview (including written
summary of strategic publications and headlines)
Information
Mr Graham
Enc 6
1.15pm
11.
QUALITY, SAFETY, EFFICIENCY &
EFFECTIVENESS
11.1
Trust Integrated Performance Dashboard (Month 5)
• Contract Performance Report
• Finance Report
• Quality Report
• Workforce Report
Assurance
Mr Axcell
/Ms
Pugh/Ms
Ingram
Enc 7
1.25pm
11.2
Medical Directors’ Report
Assurance
Dr Gingell
/Dr Weaver
Enc 8
1.50pm
Oral
All
Enc 4
Oral
ITEM
Purpose
Board Lead
Format
Timings
11.3
Nurse Director’s Report, including Safeguarding
Annual Report.
Assurance
Ms Pugh
Enc 9
1.55pm
11.4
Monthly Ward Staffing Levels Report
Assurance
Ms Pugh
Enc 10
2.00pm
12.
LEADERSHIP, CULTURE & WORKFORCE
12.1
Fit and Proper Persons Policy
Approval
Ms Ingram
Enc 11
2.05pm
13.
STRATEGIC DEVELOPMENT & DIRECTION
Approval
13.1
Board Statements for Monitor and TDA - Month 5
(following
Chair’s
action)
Mr Axcell
Enc 12
2.15pm
13.2
FT Update
Information
Mr Graham
Oral
2.20pm
13.3
Trust Wide Risk Register
Approval
Ms Pugh
Enc 13
2.25pm
14.
FOR ASSURANCE
14.1
Quality and Safety Committee Chair’s Report
Assurance/
Information
Dr Murphy
Enc 14
2.30pm
14.2
Finance and Performance Committee Chair’s Report
Assurance/
Information
Mr Higgs
Enc 15
2.35pm
14.3
MExT Chair’s Report
Assurance/
Information
Mr Graham
Enc 16
2.40pm
15.
ANY OTHER BUSINESS
16.
DATE AND TIME OF THE NEXT MEETING
Wednesday 4th November 2015, 13.00 hrs,
Conference Room 1, 2nd Floor, Trafalgar House,
47-49 King Street. Dudley, DY2 8PS
2.45pm
Enc 1
MINUTES OF THE TRUST BOARD MEETING OF
DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUST
Held on Wednesday 2nd September 2015
Conference Room 1, 2nd Floor, Trafalgar House, Dudley, DY2 8PS
PUBLIC SESSION
Present
Ms D Oum
Ms M Ingram
Ms W Pugh
Mr M Axcell
Dr K Gingell
Dr M Weaver
Mr M Higgs
Mrs G Cooper
Mr D Matthews
Mr P Rana
Mrs O Clymer
Chair
Director of People and Corporate Development/Deputy CEO.
Director of Operations, Nursing and Estates
Director of Finance, Performance, IM and T
Joint Medical Director
Joint Medical Director
Non Executive Director
Associate Non Executive Director
Associate Non Executive Director.
In Attendance
Ms M Edwards
Mrs P Roberts
Mr S Johnson
Mr M Hyroons
Mrs J Wright
Mr P Lewis-Grundy
80.
FT Project/Company Secretary Consultant
Minute Taker
Staff Engagement Officer (Item 90.1 only)
Staff Engagement Champion (Item 90.1 only)
Staff Workplace Adviser (Item 90.1 only)
Member of the public – new substantive Company Secretary
APOLOGIES
ACTION
Apologies were received from, Mr G Graham, Chief Executive Officer,
and Dr S Murphy, Non Executive Director.
81.
MINUTES OF THE PREVIOUS MEETING
The minutes of the meeting held on 5th August 2015 were agreed as an
accurate record, with the following exceptions:
Page 3, item 73, top of page to add “Mrs Cooper agreed the letter was a
holding position pending the meeting with Monitor.”
Page 12, item 77.2, amend the first sentence to read “Mr Higgs took the
Board through the Finance and Performance Committee”
Amend the second sentence to read “the organisation had taken its eye
off”.
Amend second paragraph to “£14m cash in the bank”.
Page 4, item 75.1, under performance, last part of first paragraph to read
“however that had been rectified”.
Page 1 of 230
Last sentence under performance to read “the Board would be updated
in line with the implementation date for each KPI”.
Page 5, item 75.1, first paragraph to add at the end of the sentence “now
that CIP’s were getting harder”.
The minutes were approved and would be signed by the Chair
following the completion of the above amendments.
82.
SUMMARY REPORT OF CONFIDENTIAL SESSION OF TRUST
BOARD
The Board noted the summary of the business transacted in the
confidential session of the Trust Board held on 5th August 2015.
83.
MATTERS ARISING
The schedule of matters outstanding was discussed and an update was
provided on those actions, where appropriate:
Item 75.6, this matter arising was to be removed as existing national
evidence correlated the points.
84.
NOTIFICATIONS OF ITEMS OF ANY OTHER BUSINESS
There were no notifications of any other business.
85.
DECLARATIONS OF INTEREST
Members were asked to disclose any interest they may have, direct or
indirect, in any of the items being considered during the course of the
meeting and to note that those members declaring an interest would not
be allowed to participate in the consideration, discussion or vote on any
issue relating to that item.
No interests were declared in addition to those already recorded on
the Register of Interests.
86.
QUESTIONS FROM MEMBERS OF THE PUBLIC
Mr Lewis-Grundy was in attendance as a member of public and had no
questions for the Board.
Ms Edwards advised the Board that a member of the public had emailed
a question to the Board as they were not able to personally attend. The
Question was from Leslie Johnson as follows:
“I note from the declarations of interest that the Trust Chairperson is also
the Director of Skills and Partnerships at a national charity as well as
holding other part time roles. As this charity role is a full time one how
does the Chairperson manage to complete that role and her other
responsibilities and commit 3 days per week to the Trust?
Is the NHS paying the Chair (using tax payers funds) but not receiving
the appropriate time she should be providing in return?
Page 2 of 230
Are all members of the Trust Board satisfied that the Chair is investing
an appropriate time commitment into the Trust?”
Mrs Cooper stated that as Vice Chair it would be more appropriate for
her to lead on this matter as the question directly involved the Chair.
Mrs Cooper suggested the course of action to be that the first two
matters should be referred to the TDA as the Trust did not appoint the
Chair.
She added that the third question was a direct question to the Board.
However as the full Board was not present at the meeting and the
agenda was full, Mrs Cooper recommended that the full Board discussed
the matter outside of the meeting and formally wrote a response to Leslie
Johnson.
Mr Higgs seconded Mrs Cooper’s recommendation with the caveat that
the matter was disused within a private Board meeting.
The Board agreed the recommendation.
87.
CHAIR’S COMMENTS
The Chair provided the Board with an updated report which the Board
took as read and further highlighted that the main item undertaken in
month was work on the MERIT Vanguard application.
Mr Axcell would be representing the Trust with the presentation and had
been working with the representatives of the other Trusts involved. The
Chair of the Black Country Partnership and Medical Director of Coventry
and Warwickshire would undertake a presentation, following which Mr
Axcell and Mr Short, Chief Executive from Birmingham and Solihull
would answer questions. The Chair commented that this was a good
example of working collaboratively.
The Chair highlighted that she had spent the previous afternoon with
Fran Steele from the TDA looking at patient services at Bushey Fields
Hospital. Ms Steele was very impressed with the passion, commitment
and care and sense of calm of the site. The Chair added that Ms Steele
went away with a very positive impression of the Trust. The Chair stated
that she would be personally emailing all staff who were met with herself
and Ms Steele.
The Board received the Chair’s update for information and
assurance.
88.
CHIEF EXECUTIVE OFFICER’S OVERVIEW
Ms Axcell took the Board through the key points of the strategic overview
and horizon scan report, which summarised recent important
publications and information, including items requiring action.
Mr Axcell commented that the past month had been focussed on
partnership and working on the Vanguard bid. Mr Axcell added that
there had been a very positive meeting with Dudley CCG in August.
Page 3 of 230
Mr Axcell advised the Board that he had completed a teleconference that
morning regarding the new unitary authority.
The Chair commented that as part of the partnership work some
Executives had been meeting with people within the Local Authorities
and had agreed to become more involved with their Health Scrutiny
Committees. The Trust had received its first invitations from both Dudley
and Walsall Health Scrutiny Committees and the Chair would be
attending the meeting in Walsall and Ms Ingram and Mr Axcell would be
attending the meeting in Dudley.
The Chair asked if NED colleagues particularly Committee Chairs, could
attend these meetings where ever feasible.
Action – Circulate both Dudley and Walsall Health Scrutiny
Committee dates all Board members.
Ms Ingram
The Board received the CEO’s overview for information and
assurance.
89.
QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS
89.1
Trust Integrated Performance Dashboard – Month 4
Mr Axcell took the Board through the key points, issues, and risks, as set
out within the Dashboard Report and the Performance Report. The
following additional information was noted:
- CPA indicators continued to improve after some challenges and
older adults had continued to improve with month 4 being 94.5%.
The Trust had sustained improvement with CPA’s.
- Home treatment was amber, which was seasonally always amber
at the current time of year as was linked to school holidays and
general holiday timings.
- The Trust was showing a very strong position in activity against
contract, particularly on community activity, however the Trust
was significantly down on impatient bed activity.
The Chair highlighted that whilst copies of care plans were improving,
she had heard that they had dipped slightly within the month.
Mr Axcell stated that they had not dipped.
Ms Pugh commented that stretching the target was discussed at the
Finance and Performance Committee but it had not dipped.
Mrs Clymer questioned if the Board would be receiving further details
regarding days left on care plans.
Ms Pugh stated that the performance team would be gathering the data
regarding days and the quality impact would be investigated.
Performance Report
Mr Axcell took the Board through the performance report and highlighted
that there were three amber metrics regarding PbR with Dudley and
Walsall. He stated that the Trust was reviewing the ambers and
confirmed that there were no fines which would be incurred with regard
to these. The issues would be monitored by the Finance and
Performance Committee at their October meeting.
Page 4 of 230
Finance Report
Mr Axcell took the Board through the finance report and the following
was highlighted:
- The Trust’s financial position at the end of month 4 was £167k
surplus.
- The Trust was £176k behind plan.
- Total expenditure was £172k ahead of the planned position.
The Trust had seen large levels of activities within community, however
there had been a dip in acute and older adults. This had been a focus of
the Finance and Performance Committee and the following had been
created:- Dailey targets, to ensure the exact daily bed number was known.
- Looking at how the funds flowed.
- Gatekeeping and marketing beds to external CCG’s.
Early indications for August showed that the number of bed days for
acute had risen. Older adults remained a challenge, therefore a paper
would be presented to the Finance and Performance Committee
regarding delivery of this.
Mr Axcell added that £200k of the Trust’s CIP was linked to acute and
older adults capacity therefore challenges were being seen with these.
Mr Matthews referred to the earlier detailed Board development session
regarding CIP’s and the suggestion that although there were red ratings,
the end of year position would be improved. It was suggested that a
year end RAG rating should be added.
Mr Axcell added that a forecast outturn for each CIP should be added to
the report, showing the true level of gap between the present rating and
the year end rating.
Action – Expected year end position to be added to October’s CIP
report
Mr Axcell
Quality Governance Report
Ms Pugh took Board through the quality governance report and
highlighted the following:
The acute service line had shown a rise in incidents for medicine
management. All incidents were being reviewed in detail and would be
reported to the Quality and Safety Committee. The Trust would see an
increase in reporting due to improved pharmacy involvement and the
development of a health reporting culture.
Ms Pugh stated that incidents within acute concerning violence and
aggression resulted in a difficult weekend with out of area patients, which
required police involvement.
The Chair questioned if out of area patents would generally be more of a
risk as they were not known to the Trust.
Ms Pugh commented that the case had not disclosed forensic history
prior to admission and was only discovered following admission, which
caused the high risk.
The Chair commented that Ms Steele from the TDA had asked staff a
Page 5 of 230
direct question of “Do you ever feel so unsafe that you wish you had
security guards on site? The response was that most staff felt they could
diffuse the situation with their own skills and expertise better than on site
security.
Mr Rana questioned the acute service medication change and the
change in the way pharmacy services were provided and did this imply
that there was a change in recording.
Ms Pugh stated that the Trust had a larger pharmacy department, which
was undertaking a more integral role, which was previously missing.
With regard to the community and recovery service, since the SMS
contract was withdrawn and closure of Grasmere, a large dip in incidents
had been seen as they were the main recorders of incidents.
Serious incidents were around absconding and the Quality and Safety
Committee were due to receive a report reviewing the provision of leave
policy. The framework for multiple incidents would also be reported to
the Quality and Safety Committee in September.
Deprivation of Liberty had seen an increase which was expected, and for
assurance, the Mental Health Act Scrutiny Committee would be keeping
a close eye on activity and capacity.
Ms Pugh commented that safeguarding with regard to vulnerable adults
categories were quite complex.
Mrs Cooper questioned that Dudley Local Authority had recently been
questioned about safeguarding children in their care and was there any
issues for the Trust.
Ms Pugh stated that nothing had come through to her about this at
present.
Workforce Report
Ms Ingram took the Board through the workforce report highlighting the
key messages which included:
The Trust underline turnover rate was at 11.1%.
With regard to vacancies, the Trust had seen a significant amount of
recruitment and new starter activity within July. The pace of recruitment
may have been optimistic on the original trajectories, however the overall
position was improving.
Ms Ingram explained the vacancy position and gave details of the way
vacancies were captured and reported. The view was to possibly
amend reporting so a truer picture of the actual number of posts being
recruited to was shown, as apposed to number of technical vacancies.
Mrs Cooper questioned how the view to reporting would affect the
percentage.
Mr Ingram commented that the vacancy rate of 10% at year end may
need to be amended to 10% of vacancies being recruited to and not 10%
of technical recruitment.
The Chair questioned why recruitment took as long as it felt slow.
Ms Pugh commented that for nurses the Trust recruited twice a year for
Page 6 of 230
people who had recently qualified.
The Chair further questioned the process, asking if there were any
internal blockages inhibiting the recruitment process, and Ms Ingram
confirmed that there were specific external aspects to the recruitment
process which did take some time, however there were no internal
blockages to the recruitment process.
Ms Ingram highlighted temporary workforce spend and the
announcement on 1st September regarding caps on agency nurse
budgets. Trusts had been set a celling on nursing agency spend and the
Trust’s was 8% with a view to it reducing to 6% in 2016/17, 4% in
2017/18 and 3% in 2018/19.
Mrs Clymer questioned where the greatest turnover area was and did it
correlate with agency spend.
Ms Pugh commented that the inpatient areas would always have a
higher turnover rate due to newly qualified staff beginning their career in
this area and then moving onto other areas.
Action – Temporary workforce review trajectory to be brought to
October Board with an update on progress within the trajectory to
November Board.
Ms Ingram /
Ms Pugh
The Board noted the performance of the Trust as at month 4.
89.2
Medical Directors’ Report
Dr Gingell took the Board through the Medical Directors’ report and
highlighted the following:
- The issue of the 7 day working government focus was going to be
part of the Vanguard proposals, which was being taken forward
within the MERIT bid.
- The Trust was working with CCG colleagues with regard to
funding for CAMHS and eating disorders, to ensure the Trust
could access the funding.
- Delays within recruitment were due to the very complex and
specialist staff which the Trust required. The CAMHS and
Learning Development consultant posts were included within this
specialist staff.
- The lead doctor for Children and Safeguarding had stepped down
from their role and recruitment was planned to commence in
September.
The Chair questioned what would happen if the Trust could not recruit to
the roles.
Dr Gingell commented that the Trust had managed using locums and
other people had stepped up and filled gaps, however this may not be
sustainable.
Mrs Cooper questioned if there would be a gap between departure from
the current lead for safeguarding and the new recruit beginning.
Ms Pugh stated that there would possibly be a gap, however the Trust
had a very effective safeguarding team and any exceptions would be
escalated to Dr Gingell or Dr Weaver.
Dr Weaver commented on the nationally reported suicide review and that
Page 7 of 230
the research had focussed on the predictors of suicide.
The Board received the update for information and assurance.
89.3
Nurse Director’s Report
Ms Pugh took the Board through the main points within the Nurse
Director’s report and highlighted that there had been a whole remit and
raft of regulations and guidance on nurse staffing which the Trust would
need to review and evaluate.
90.3
Nursing Strategy
Ms Pugh took the Board through the Nursing Strategy and the main
areas to highlight were as follows:
- The strategy was an ambitious 5 year strategy.
- The strategy had been developed to support the implementation
of the national nursing strategy and the delivery of the 6 C’s which
were “Care, Compassion, Communication, Commitment,
Competency and Courage”. The Strategy was underpinned by
the refreshed values and strategic objectives of the Trust.
- There was a focus within the report on nurse revalidation and
learning and development.
- There was a focus on new ways of working and work with the
university, of which the Trust’s first five trainees would begin in
November.
Mrs Clymer questioned if the Trust ensured the trainees committed to
the Trust for a set number of years due to the investment put into them.
Ms Ingram commented that she would have to investigate what other
Trusts put in place so not to disadvantage the Trust.
Action - Briefing sheets on Nursing Strategy and DIPC annual
report to be provided to the Company Secretary for circulation to
the Board.
Ms Pugh
The Board approved the Nursing Strategy.
89.4
Monthly Ward Staffing Levels Report
Ms Pugh informed the Board on the monthly ward staffing report and
commented that there were no exceptions to report to the Board.
Ms Pugh added that the Trust would be looking to launch the e-rostering
in November.
The Board noted the data, and were assured of safe staffing levels
for July data 2015.
89.5
Director of Infection Prevention & Control Annual Report
Page 8 of 230
Ms Pugh took the Board through the annual report and explained the
following areas:- The report reflected an overview of all aspects of the Trust.
- During 2014/15 the Trust continued to comply with all regulations.
- There were zero cases of MRSA, C-Diff and E-coli.
- The TDA assessed the DIPC Committee and gave very positive
feedback.
- There would be a strong focus on compliance with mandatory
training going forwards to prevent the quarter 4 rush and also the
target had to be increased.
- There was a need to ensure that decontamination was
appropriate and the Trust had a new SLA in place.
The Chair questioned if staff were having the same infection prevention
mandatory training every year.
Ms Pugh commented that inpatient staff’s yearly update would contain
new relevant information. For staff outside of inpatient areas the training
would not change unless there was a significant change.
Mr Matthews stated that the report was a comprehensive report and he
questioned the vacancy of the Infection and Prevention Control Nurse.
Ms Pugh commented that the Trust had two vacancies and they were
able to recruit to the higher banded post. The Lower banded post could
not be recruited to even with working with the TDA, therefore the Trust
invested and secured a higher grade. Unfortunately, the Trust did fill the
post but the candidate was offered a higher grading with their current
organisation.
Mr Matthews questioned whether the Trust should be setting a target for
the decontamination of equipment as it had been red since 2011/12.
Ms Pugh stated that the Trust had a very small amount of equipment
which would need to undergo the decontamination process. The Trust
had joined up with an acute Trust who had undertaken an audit and
there was a plan that this would turn green quite soon.
Action – Quality and Safety Committee to review the trajectory for
decontamination equipment to ensure it moves from red to green
Ms Pugh
Mr Axcell questioned the flu vaccine and increasing the vaccination rate
and encouraging staff to come forward with ideas.
Ms Pugh advised that this was currently being lead through Occupation
Health.
Ms Ingram stated that flu vaccine role was out being worked up through
MExT.
The Board approved the annual report and received the update for
information.
89.6
Q1 Service Experience Quarterly Report
Mrs Ingram provided the Board with an update and stated that the report
was a quarter 1 report on all aspects of service experience.
Page 9 of 230
The Trust had received the raw results of the 2015 community survey
and were currently negotiating a date to present to the Board with
headlines being taken to the Quality and Safety Committee in
September.
Mr Matthew questioned what was being undertaken to rectify the amount
of complaints responses being breeched as it remained high.
Ms Ingram advised that the pool of investigators was to be expanded to
include non clinical staff.
Dr Gingell stated that the Quality and Safety Committee endorsed that
the Trust wanted to gain feedback from its patients and capacity for
investigations needed to be allowed. The process needed to ensure that
complaints were investigated without taking clinicians away from doing
their clinical job.
Mrs Cooper commented on a trajectory to reduce the rates.
Ms Ingram suggested a discussion outside of the meeting as a trajectory
was more difficult with complaints, however an action plan could be
worked up.
Ms Ingram
Action – Action plan to improve the complaints process to be
brought to the Board via the Quality & Safety Committee.
90
LEADERSHIP CULTURE & WORKFORCE
90.1
Staff Engagement Programme Quarterly Report
Mr Johnson presented to the Board and provided an update on the staff
engagement plan, he highlighted the following:- The action plan was mostly on track and the stalled “Speak up”
was now complete and had since been launched last week.
- The policy element had been stalled due to changes in HR and
the date had been extended with Board agreement.
Mr Hyroons provided the Board with an update from an engagement
champion perspective. Mr Hyroons commented that this was a new role
and the main focus had been agreeing and selecting the values.
Meetings had been undertaken to go through suggestions and to reduce
them from 50/60 to 4 from each of the different groups to come back and
choose from. The work included developing what was meant by values
and specific behaviours with the do’s and don’ts.
Mr Johnson highlighted the values and commented that the values would
be launched and then could be used in appraisals and personal
development. The planned launch for the values would be week 4th
October to 10th October and the plan would be to reach out to all areas
and capture all shifts.
Mr Higgs drew attention to the presentation 12 months ago where the
background work had come under criticism from outside sources that the
Board did not see the initial rough plans. Mr Higgs asked the Board if
Page 10 of 230
there was a need for the Board to see the preliminary work and detail
behind the values work.
Mr Johnson advised that there may not be a need to see the plans
behind the values work as it was taken from staff voting results and then
the engagement champions were tasked with taking this forward.
Mr Johnson added with regard to the previous work, the comment from
Monitor was with regard to his rough data.
The Chair reminded Board colleagues that following the Board
dicussions on the subject in the aftermath of the Monitor meeting, the
preliminary work with regard to values had been circulated to the Board.
Dr Weaver questioned in terms of the values and values based
recruitment, how did the Trust ensure that the values were embedded in
doing and not just saying.
Mr Johnson commented that the values would be competency based. In
terms of recruitment the panel would have a set of questions with the
values incorporated. Also in terms of appraisals the values should be
linked.
Mr Johnson added that the values would only be successful if managers
and the Board demonstrated the behaviours. They should translate into
appraisals at all levels by asking appraisers to go through behaviours
and identify those values that could be demonstrated.
Mrs Cooper requested that all outputs from the up coming focus groups,
which would be shared with MExT, should also be shared with the
Board.
Mr Johnson commented that he would share with the Board.
Ms Ingram added that the Board should see the verbatim write up and
the raw data.
Mrs Wright updated the Board as a workplace adviser and commented
that the role built on the caring emphasis and offered staff an impartial
support network when they did not want to go through the official route.
The role gave staff advice and guidance whilst pointing out Trust policies
and moving towards a solution. The role was solution focused without
being coercive to pushing people down a certain route. The role could be
seen as different from engagement champions as the workplace adviser
was waiting for people to come to them and therefore staff needed to be
made more aware that the workplace advisors were available. There
were plans in place to do this.
Mr Rana questioned how mature the process was and how would the
Trust make the engagement stick.
Mr Johnsons stated that it was in the early stages of trying to change the
culture within the organisation and NHS culture. The engagement was
not yet sticking, however in the future it could stick but would only
happen if difficult conversations were undertaken with the people who
did not believe in the values. It would take time but some fantastic
improvement had already been seen.
Mr Matthews commented on the revised target for the bullying and
Page 11 of 230
harassment policy. The policy on the intranet was dated 2013 and
therefore was out dated and was the revised target of November realistic
for an updated policy.
Mr Johnson stated that the policy was in the final stage, however the
policy could not be changed until all the underlining actions such as
values were in place which took time. If the policy were to come sooner,
it may be necessary to revisit the strategy again.
The Chair commented that it would be worth waiting to get the policy
right, however would not want to let it slip.
The Chair thanked Mrs Wright and Mr Hyroons for attending Board and
asked in terms of colleagues and peers involved in the roles, what was
the spread over the organisation and where was everyone working.
Mr Hyroons explained that there were gaps, more so on the clinical side.
The Chair questioned what levels the staff where at.
Mr Johnson explained that there were people up to a band 6 and also
band 3 admin in the roles. He added that the original plan was not to
recruit people at a too senior level. There were gaps, however the Trust
was encouraging people and people were saying positive things and
were starting to enquire and have more interest in the roles.
Mrs Wright explained that there were less workplace advisors as it was a
more specialist role.
90.2
Equality and Diversity Annual Report
Ms Ingram outlined the annual report to the Board and explained that it
had been previously presented to the Quality and Safety Committee. Ms
Ingram added that it was a very compressive document which explained
specific aspects of Equality and Diversity work. The Trust had also been
selected as a partner on the NHS Employers Equality and Diversity
programme.
Mr Matthews commented that it was a very good report, however he
questioned section 3.4 on page 8 that the final grading on EDS had not
improved and was this still on track.
Ms Ingram stated that the EDS was a long term improvement plan and
the Trust remained on track.
The Chair reminded the Board that there were some forthcoming
development sessions which would enable the Board to look at equality
and diversity in greater depth.
91.
STRATEGIC DEVELOPMENT & DIRECTION
91.1
Board Statements for Monitor and TDA - Month 4
The Board noted the content of the submissions, which set out the Board
statements and declarations regarding the Trust’s performance as at the
Page 12 of 230
end of month 4 2015/16. The Finance and Performance Committee had
endorsed the returns at its meeting on 1st September 2015. The Board
declarations had already been signed off for submission to the TDA on
the 31st August 2015 as a Chair’s action.
The Board endorsed and ratified the submission for month 4.
91.2
Foundation Trust Update
Mr Axcell reminded the Board of the forthcoming arranged meeting with
Monitor on Friday 4th September to discuss the content of their letter and
their decision. Mr Axcell would update the Board following this meeting.
91.3
BAF and Annual Plan Q1 update
Ms Ingram introduced the BAF to the Board and commented that it was
a huge piece of work and the primary change was regarding the
presentation of the draft strategic risk register.
Draft Strategic Risk Register
Ms Edwards stated that after the series of development sessions, the
Trust identified the top strategic risks and have identified them into
words. Ms Edwards added that each quarter, going forwards, she
would liaise with Service and Executive leads with regard to the strategic
risk register as well as the BAF to ensure the two documents would be
kept live and aligned.
Ms Edwards commented that in conjunction with Governance leads Mr
Jinks and Mr Tong, the strategic risks had been separated from the Trust
wide risk register. The Trust wide risk register would continue to be
presented to Board with the high level operational risks, which the
Finance and Performance and Quality and Safety Committees would
continue to review.
Ms Ingram questioned if there would be movement from the Trust wide
risk register to the strategic risk register.
Ms Edwards commented that movement between the two registers
would be very unlikely.
Action - Board Development In February 2016 to include a review of
the BAF and Strategic Risk Register
Mr Matthews questioned if dates should be added to the strategic risk
register.
Action – End dates to be added to the Strategic Risk Register,
where applicable if risk is not ongoing
Ms Edwards
Ms Edwards
BAF
Ms Ingram highlighted to the Board that the BAF was a quarterly position
on progress against the Trust’s objectives within year.
Ms Edwards commented that there were no objectives with negative
Page 13 of 230
assurance, some had moderate, however this was related to the Trust’s
position at present.
The Chair commented that her view was that some of the sources of
assurance were not Board level sources of assurance which they
needed to be. She added that some of the areas on the BAF had clear
gaps in assurance and there was a need to identify where to plug those
gaps.
Ms Ingram raised a caution as the Trust received extremely positive
feedback from the auditors regarding the BAF. Ms Ingram suggested
using colour coding to differentiate between Board level assurance and
other sources of assurance.
Ms Edwards
Action – Ms Edwards, Ms Ingram and Ms Oum to meet to discuss
levels of assurance within the BAF and update the Board within the
Q2 report.
The Board approved the Board Assurance Framework and Annual
Plan Quarter 1 update
91.4
Ms Pugh highlighted that once the strategic risk register was confirmed
this would reflect within the Trust wide risk register. Ms Pugh suggested
that as the risks were being looked at in a new way, there was a need for
explanatory narrative behind the register. The first draft of the new Trust
wide risk register would be available for the October Board meeting.
The current Trust wide risk register showed no movement, however the
responsible Committees continued to look at their risks and take forward.
Action – Draft of revised Trust Wide Risk Register and updated
narrative regarding the changes to be presented to October Board.
Ms Pugh
The Board approved the Trust Wide Risk Register.
91.5
Monitor new Risk Assurance Framework
Mr Axcell provided the Board with an overview of the new risk assurance
framework and the changes within the calculations of the continuity of
service rating. The Trust had previously remained at 4 or a 3 with their
continuity of service rating.
Mr Higgs commented that the impact on the Trust would be minor as
after calculating the new continuity of service rating score, the Trust
would have a overall rating of 3 plus.
92.
FOR ASSURANCE
92.1
Quality and Safety Committee Chair’s Report
Page 14 of 230
Mrs Cooper took the Board through the Quality and Safety Committee
Chair’s report, and highlighted that it was a positive meeting which
benefited from not having a large agenda and gave more time to debate.
The Committee discussed reporting and also the increase in the number
of incident reporting on older adults.
Mrs Cooper highlighted the Committee’s recommendations to the Board
which included the following:
- To approve Service Incident and Embedding lessons report and
Service experience report
- To accept the reporting of medication incident
- To accept the review of abscond incidents
- To accept the review of quality risk associated with under 18
admissions
- To accept the need to positively provide feedback from service
users and families though the complains/concerns procedures.
The Board accepted the report for assurance and endorsed the
decisions and recommendations made by the Committee.
92.2
Finance and Performance Committee Chair’s Report
Mr Higgs provided the Board with a verbal update which highlighted the
following:
- Volume and bed days had been seen as problematic, with acute
moving in the right direction, however older adults needed more
work and would be further discussed at the next meeting on 28th
September.
- There was a cost reduction programme plan in place if required
- The Committee discussed the TDA stretch target and what the
Trust would need going forwards.
92.3
MExT Chair’s Report
Mr Axcell took the Board through the MExT Chair’s report and
highlighted the following areas:
- The meeting on 4th August concentrated on the business case for
the consultant model and closing off the number of CIP schemes.
- The meeting on18th August received an update on water
management, a tender for finance bureau and undertook
discussion around the TDA stretch target.
92.4
Mental Health Act Scrutiny Committee Chair’s Report
Mrs Cooper took the Board through the report and highlighted that the
Committee, with the support of the Board, would meet bi monthly going
Page 15 of 230
forwards due to the volume of the work.
Mrs Cooper commented that there was a partnership group meeting with
the police and ambulance and other key professionals within the
partnership. Much positive work had been completed with the
partnership, however there were some areas which partners raised
concerns. These concerns were with regard to the place of safety and
the police were not happy that the 136 suite was not staffed at all times.
This was a senior area for debate which had yet to be resolved.
The Police also had plans to escort potential patients to 136 suite and to
discharge them to the Trust’s care the moment they arrived at the suite.
The Trust was not in agreement and would like the police to stay until the
assessment was completed as they may not come into the Trust care.
The Committee would be looking to complete more detailed work within
KPI’s to give Board assurance and demonstrate work and progress of
the Committee.
92.5
Nomination & Remuneration Committee Chairs Report
The Chair took the Board through the Nominations and Remuneration
Committee report and took the report as read. The Chair highlighted that
the Committee was concerning annual appraisals and very senior
managers pay.
93.
ANY OTHER BUSINESS
No items of any other business were raised.
94.
DATE AND TIME OF NEXT MEETING
Wednesday 7th October 2015, 1pm, Boardroom, Canalside House,
Walsall
Signature……………………………………………………….. Date…………….
Ms D Oum, on behalf of the Dudley and Walsall Mental Health Partnership NHS Trust Board
Page 16 of 230
Board meeting date:
7th October 2015
Report Title:
Agenda Item number:
3
Enclosure:
2
Summary of Confidential session of Trust Board held on 2nd
September 2015
Accountable Director:
Danielle Oum, Chair
Author (name & title):
Mandy Edwards, Interim Company Secretary
Purpose of the report:
Best practice in corporate governance requires that business
considered in private session is reported into the public
session as soon as possible. Given the arrangement of the
Board meetings, the earliest opportunity is at the public
session of the following month.
This report outlines the business considered in private at the
meeting of the Board held on 2nd September 2015.
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information




What other Trust Committee or
Group has considered the key
elements of this report?
Committee: None
Date reviewed: N/A
Key points or recommendations
from Committee:
Strategic Objective(s) to which this paper relates:
High quality
Inclusive
Leadership
services
partnerships
culture



The CQC domains that this report relates to
are:
Caring
Responsive
Responsible
workforce
Supporting
strategies
Effective/efficient
resources



Please give brief details:
Best practice in corporate governance requires that
business considered in private session is reported into
the public session.
Effective
Well-led
Safe
Page 17 of 230
Title
Summary of Confidential session of Trust Board held on 2nd
September 2015
Introduction
This report outlines the business considered in the private at the meeting of the Board held on
2nd September 2015.
Summary of key points, issues and risks
Nurse Director Confidential Update
The Board were provided with an update regarding water management from Ms Musson and
Mr Koumi, the Trust authorising engineer.
Mr Koumi provided the Board with an update of the journey to date and the current water
management position. The Board were assured that procedures had been followed and
clinical risk assessments put in place to ensure patient safety.
Ms Pugh provided the Board with further updates as follows:
• The recent death of an inpatient. A serious case review and strategy meeting would
occur on Thursday 3rd September.
• A Serious Untoward Incident, relating to an individual known to Trust services who had
been charged in court.
• Recommendations from a multi agency Serious Case Review and the two
recommendations for the Trust to consider.
Tender for Finance Bureau Service
The Board agreed to the recommendations provided within the paper and the award of the
contract to Capita who were the current providers.
Chief Executive Officers Overview
Mr Axcell highlighted to the Board that the TDA’s increased stretch target had been reviewed
by the organisation and a response sent to the TDA confirming the Trust’s intention to achieve
the new target.
The Board were also provided with an update concerning the MERIT Vangaurd bid and that
the Trust, together with partner organizations, had been shortlisted to present on 7th
September.
Patient Story
It was agreed to circulate the transcript of a patient story that was due to be played, after the
meeting for the Board to consider.
Page 18 of 230
CIP PMO and Service Transformation Report
Mr Axcell presented the report acknowledging that CIP, PMO and Service Transformation
plans and progress had been discussed in depth as part of the preceding Board development
session.
Service and Business Development PMO Report
Mr Axcell appraised the Board of an announcement, currently embargoed, confirming that the
Trust had won a recent tender.
FT Update
Mr Axcell confirmed there was nothing further to add to the update that had been provided in
the public session.
Medical Directors’ Confidential Update
The Medical Directors’ confirmed there was nothing to raise, in addition to that already
reported in the Public Board session.
For Assurance
The Board noted the minutes of the Finance and Performance Committee meeting held on 27th
July 2015, the Quality and Safety Committee held 8th July 2015, MExT held on 4th August 2015
and Mental Health Act Scrutiny Committee held 11th June and 13th August 2015.
Recommendation
The Board is invited to note the business transacted in the private session held on 2nd
September 2015.
Board action required
The Board is asked to receive this report for information.
Page 19 of 230
Enc 3
MATTERS ARISING FROM PUBLIC MEETINGS
Item
No.
Date
Added
th
23.7
6 May
2015
st
60
1 July
2015
Action
Review the amalgamated
‘External enquiry report’ action
plan in November to ensure
the Board continues to have
direct sight of actions &
progress.
Trust paper in response to the
Mental Health Taskforce
Strategy to be prepared.
Responsibility
Due
Date
Ms Ingram /
Ms Pugh
4th Nov
2015
Dr Gingell
2nd Sept
2015
Update
Not expected to report until
October
TBC
st
61.1
1 July
2015
st
63.1
1 July
2015
th
75.1
75.2
75.5
5 Aug
2015
5th Aug
2015
5th Aug
2015
th
75.7
5 Aug
2015
Staff wellbeing work to be
reported to the Finance and
Performance Committee in
September and any issues
highlighted to the Board.
Coversheet template for Trust
Board reports to be revised to
indicate which quality priority
each report is aligned to.
Bed Review Report (inc. U18
activity) commissioned by F&P
to be presented to October
Board
Profile of patients involved in
multiple incidents to be
presented to Q&S Committee
in September
Workforce
Recommendation for revised
vacancy rate target to be
presented to F&P in October
and Board in November
Consider development of local
research to establish evidence
base for reasons for the
Trust’s lower than average
suicide rates
1st Draft Benefits realisation
measures relating to
overarching Francis/
Winterbourne/Cavendish/
Keogh/Berwick action plan
with other priorities (as agreed
in private board)
Ensure future Duty of Candour
reports more clearly indicate
whether all required actions
were fully met
Ms Ingram
Sept
2015
Ms Edwards /
Mr Jinks
2nd Sept
2015
2nd Dec
2015
Mr Axcell/Ms
Pugh
7th Oct
2015
4th Nov
2015
Ms Pugh
16th
Sept
2015
Ms Ingram
4th Nov
2015
Dr Gingell/Dr
Weaver
4th Nov
2015
Ms Pugh/Ms
Ingram
2nd Dec
2015
Dr Murphy/Ms
Pugh
4th Nov
2015
On agenda for September
F&P Committee
Reprioritised. To be taken
forward by new Co Sec
once they have started in
post.
Discussed at F&P on 28th
September, further work
identified to go back to
October F&P and
presented to November
Board.
Page 20 of 230
Item
No.
76.4
Date
Added
5th Aug
2015
th
77.3
5 Aug
2015
88
2nd
Sept
2015
89.1
2nd
Sept
2015
89.5
2nd
Sept
2015
89.6
2nd
Sept
2015
90.3
2nd
Sept
2015
91.3
2nd
Sept
2015
Due
Date
Update
Action
Responsibility
Proposal for Communication
and Engagement Strategy
outcome measures to
demonstrate successful
implementation to be
presented to October Board
Trust’s very positive 2014/15
Quality Account to be more
widely publicised and
celebrated within the Trust
Circulate both Dudley and
Walsall Health Scrutiny
Committee dates to all Board
members
Finance
Expected year end position to
be added to October’s CIP
report.
Ms Bytheway
7th Oct
2015
4th Nov
2015
Will form part of the
Q2 communications
bulletin and dashboard to
November Board
Ms Bytheway
1st Oct
2015
Has been shared and
highlighted within Team
Brief
Ms Ingram
7th Oct
2015
Complete
Mr Axcell
7th Oct
2015
Ms Ingram /
Ms Pugh
7th Oct
2015 &
4th Nov
2015
4th Nov
2015
Workforce
Temporary workforce review
trajectory to be brought to
October Board with an update
on progress within the
trajectory to November Board
Quality and Safety Committee
to review the trajectory for
decontamination equipment to
ensure it moves from red to
green
Action plan to improve the
complaints process to be
brought to the Board via the
Quality & Safety Committee.
Briefing sheets on Nursing
Strategy and DIPC annual
report to be circulated to the
Board
Board Development in
February 2016 to include a
review of the BAF and
Strategic Risk Register
Ms Pugh
Ms Ingram
4th Nov
2015
Ms Pugh
7th Oct
2015
Ms Edwards
Feb
2016
End dates to be added to the
Strategic Risk Register, where
applicable if risk is not ongoing
Ms Edwards
7th Oct
2015
Will be presented with the
Q2 BAF
Ms Edwards, Ms Ingram and
Ms Oum to meet to discuss
levels of assurance within the
BAF and update the Board
within the Q2 report.
Ms Edwards
4th Nov
2015
Meeting arranged for 5th
October
Complete, circulated on
28th September
Page 21 of 230
Item
No.
Date
Added
nd
91.4
2
Sept
2015
Action
Responsibility
Due
Date
Draft of revised Trust Wide
Risk Register and updated
narrative regarding the
changes to be presented to
October Board
Ms Pugh / Mr
Jinks
7th Oct
2015
Update
This action replaces
previous item 76.3 ‘Date
for final board development
risk session to be agreed’
Page 22 of 230
Enc 4
7th October 2015
REGISTER OF INTERESTS
CURRENT
DIRECTORS
Date of
appointment
to the Board
Post
Declared Interests
Ms Danielle Oum
08.09.14
Chair



Non-Executive Director, Optima Community
Trust
West Midlands Committee Member, National
Housing Federation
Director of Skills and Partnerships, TCV
Non-Executive Director of Extra Care Trust

Nothing to declare




Trustee – Frederick Pearson Fisher Charity
Serving Justice of the Peace – Dudley Bench
Chair, Sandwell Local Improvement Finance
Trust Company Ltd
Director – Design, Implementation and
Platform
Operations,
Network
and
Telecomms, Fujitsu
Nothing to declare

Nothing to declare

Nothing to declare

Nothing to declare

Nothing to declare

Nothing to declare

Trustee – A Child of Mine Charity

Michael Higgs
01.10.08
David Matthews
20.09.10
Gill Cooper
01.06.13
Dr Simon Murphy
02.02.15
Pawiter Rana
02.02.15
Olivia Clymer
15.04.15
Gary Graham
01.09.08
Dr Kate Gingell
01.10.12
Marsha Ingram
23.03.12
Wendy Pugh
01.10.08
Dr Mark Weaver
01.10.12
Mark Axcell
28.04.14
Non-Executive
Director
Non-Executive
Director
Non-Executive
Director
Non-Executive
Director
Associate NonExecutive
Director
Associate NonExecutive
Director
Chief Executive
Joint
Medical
Director
Director of
People and
Corporate
Development
Director of
Operations &
Nursing
Joint Medical
Director
Director of
Finance and
Performance

Page 23 of 230
Board meeting date:
7th October 2015
Report Title:
Agenda Item number:
9
Enclosure:
5
Chair’s Comments
Danielle Oum, Chair
To advise the Board on recent and forthcoming activities and
events undertaken by the Chair and Non-Executives. To note
key aspects of stakeholder engagement and areas of strategic
relevance.
Decision / Approval
Gain assurance
Discussion
Information




What other Trust Committee
or Group has considered the
key elements of this report?
Committee: None
Date reviewed: N/A
Key points or
recommendations from
Committee:
High quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources






The CQC domains that this report
relates to are:
Caring
Stakeholder engagement and strategic leadership are
important elements of a Chair’s role in ensuring strong
governance and a responsive organisation.
Responsive
Effective
Well-led
Safe
Page 24 of 230
Title
Chair’s Comments
Introduction
This paper forms the Chair’s monthly report to the Board regarding Chair, Non-Executive and
Board activities undertaken during the previous month, together with a forward look at
programmed work.
During September, my main focus has been on the NED recruitment campaign and the MERIT
Vanguard bid. Also, continued progression of the development of strong stakeholder
relationships and partnership working.
In summary, the things I have been involved in and my key learning points are:
1. Foundation Trust Assessment
I attended the post FT assessment meeting with Monitor on the 4th September,
accompanied by Gill and Mark. Details of the discussions have been circulated by Mark to
Board colleagues for information.
2. NED Recruitment Campaign
Three strong candidates have been shortlisted for interview and these are scheduled to take
place on Monday 28th September. I will feedback to the Board once the interviews are
completed.
3. Partnership and Stakeholder Engagement
During September I met with the Chair of Walsall Healthcare NHS Trust. I also visited
Coventry and Warwickshire Partnership Trust to meet the Chair and new Chief Executive.
Both Trusts are interested in exploring partnership work, particularly around the Carter
Review.
4. Mental Health Vanguard Discussions
I participated in planning sessions for the presentation to the bid panel and have
subsequently met with the chair of BCPFT and BSMHFT to discuss the governance
arrangements of the Mental Health Vanguard.
5. Trust Internal Affairs
I have continued to direct the Board’s development programme, and the sharpened focus
on our approach to growth.
Page 25 of 230
6. Next Month
Over the coming month my plan is to focus on continued partnership working and staff
engagement.
Recommendation
It is recommended that: the Board notes the Chair’s update and comments.
The Board is asked to receive this report for information and assurance.
Page 26 of 230
Board meeting date:
7th October 2015
Report Title:
Agenda Item number:
10
Enclosure:
6
CEO Strategic Overview and Horizon Scan
Gary Graham, Chief Executive
This report summarises recent publications and information, which
are of relevance or interest to the Trust. It sets out the key points of
each item and identifies the officer accountable for any action
required and appraising the Board where appropriate.
Decision / Approval
Gain assurance
Discussion
Information




Committee: N/A
Date reviewed:
Key points or
Committee:
High quality
services
Inclusive
partnerships
Leadership
culture
Accountable
workforce
Supporting
strategies
Effective/efficient
resources






relates to are:
Caring
The report provides information regarding latest news
and relevant strategic developments that may impact all
5 CREWS domains.
Responsive
Effective
Well-led
Safe
Page 27 of 230
Introduction
This report provides a summary of recent information, publications and news items of interest and
relevance to the Board. It identifies the Trust officer accountable for any action the Trust may be
required to take and for appraising the Board where appropriate.
Summary of key areas for action:
Accountable Officer
Monitor – Nursing Agency new rules
Director of Nursing, Operations and
Estates
Monitor – Strategy in practice workshops
Chief Executive
DoH – Consultation on the role of the National Data
Director of Finance, Performance &
IM&T/Caldicott Guardian
Guardian for health and social care.
NHS England – Results of Mental Health Taskforce:
Director of Nursing, Operations and
Estates/Joint Medical Directors
Engagement Report
NHS England – £5million plan to improve the health of NHS Director of People and Corporate
Development
staff
NHS England – Self Care Week’s message for healthy
Director of People and Corporate
Development
living
NHS Employers – Creating healthy workplaces – A toolkit
Development
for the NHS
NHS Employers – Effective management of temporary
Development
staffing
NHS Employers – Government confirms plan to cap exit
Development
payments
NHS Employers – CQC creates national guardian role Director of People and Corporate
Development
have your say
NHS Providers – Community Healthcare: Highlighting its
Director of Operations, Nursing and
Estates
impact and harnessing its potential
Mental Health Foundation – Launch of IAPT Positive
Joint Medical Directors
Practice Guide for Learning Disabilities
The Centre for Mental Health and Safety – Practical
solutions for preventing suicide in healthcare settings
The Mental Health Network - Understanding the legislative Director of Nursing, Operations and
Estates
landscape in mental health
CQC - Give us your views on the new National Guardian role Director of People and Corporate
Development
Recommendation
It is recommended that the Board note and discuss the information contained within this report.
Page 28 of 230
The Board is asked to:
• Note the information contained within the report.
• Agree the Accountable Officer identified within the report and any specific action required.
Page 29 of 230
Strategic Overview and Horizon Scan Report
October 2015
This report summarises recent important publications and information items, setting out the key points
of each item and identifying an accountable officer/Board lead for each item.
Accountable Officers are responsible for reviewing each item, ensuring appropriate action is taken
where required and reporting relevant information to the Board.
Trust Internal News
th
Vanguard Bid Success – It was announced on 25 September that the Mental
Health Alliance for Excellence, Resilience, Innovation and Training (MERIT),
which comprises of DWMH Trust along with Birmingham and Solihull Mental
Health Foundation Trust, Black Country Partnership NHS Foundation Trust and
Coventry and Warwickshire Partnership NHS Trust, had been successful in its
application to NHS England’s New Care Models Vanguard programme.
Accountable Officer
For information
The organisations have come together in a unique new healthcare alliance to
transform the way acute mental health services are provided. The purpose of this
programme is to develop new models for acute care collaboration to put the Five
Year Forward View into action.
Black Country Partnership CEO Retires – Karen Dowman has announced her
intention to retire from BCPFT who has served as CEO for 20 years. Karen has
agreed to remain in her role, allowing the process for the appointment of her
successor to take its course, alongside her continuing leadership and direction.
Trust AGM and Wellbeing Fair – Took place on 24th September with a good
amount of public and staff attending. The wellbeing fair had various information
stalls from local organisations, which included:• Central Therapies offering Reiki
• Wellbeing advise
• Walsall CCG
• Healthwatch Walsall
There was also a 5 ways to wellbeing seminar which took place before the AGM
was launched with an opening talk by one of the Trust’s EBE’s.
Trust staff survey to be launched – This year, for the first time, some staff will
receive the survey on-line with the remaining staff via the traditional paper
version.
Trust values to be launched – Following the refresh of the Trust values they will
be launched in October. Sessions will be held with all staff across the Trust.
Trust shortlisted for HSJ Award – The trust has been successfully shortlisted
for the mental health category of the Health Service Journal awards for its
innovation in developing App technology.
Page 30 of 230
Monitor
Website link: https://www.gov.uk/government/organisations/monitor
Monitor reveals governance and structural details of NHS Improvement
Further details of NHS Improvement, the agency name for the recently announced
Monitor-NHS TDA merger, have been unveiled ahead of Monitor’s board meeting
on 30 September.
Its board meeting papers have revealed the programme structure of the merger,
set to be in operation from April 2016. At the top of its power structure will sit a
Monitor/TDA board and ministers from the Department of Health, to whom NHS
Improvement’s chair, Ed Smith, will report.
Accountable Officer
For information
More information can be found at:
https://www.gov.uk/government/publications/monitor-board-papers-for-30september-2015-meeting
and an article by the National Health Executive at:
http://www.nationalhealthexecutive.com/Health-Care-News/monitor-revealsgovernance-and-structural-details-of-nhs-improvement
Nursing Agency new rules
New rules were announced on nursing agency spend from Monitor and the TDA
for NHS foundation trusts and NHS trusts. The new rules came into effect on 1st
September 2015 and apply to agency spend on registered nursing, midwifery and
health visiting staff only; rules on other agency staff will follow.
The new rules will see:
• An annual ceiling for total agency spend for each trust between 2015/16 and
2018/19; trusts are being sent individual ceilings and will have the opportunity
to apply for exceptions if there are specific local needs.
• Mandatory use of frameworks for procuring agency staff
• Limits on the amount individual agency staff can be paid per shift, which will be
implemented later in the year after further work by the two organisations
Director of Nursing,
Operations and Estates
More information on the rules and guidance can be found at:
https://www.gov.uk/government/publications/nursing-agency-rules
Monitor launches an investigation into Black Country Partnership NHS
Foundation Trust
Monitor has launched an investigation into the financial sustainability of Black
Country Partnership NHS Foundation Trust.
Marianne Loynes, Regional Director at Monitor said:
“We have launched this investigation to find out more about the financial situation
at the trust and to establish what can be done to improve things for those who use
its services.” “No decision has been taken about whether further regulatory action
is required and an announcement about the outcome of the investigation will be
made in due course.”
For information
https://www.gov.uk/government/news/monitor-launches-an-investigation-intoblack-country-partnership-nhs-foundation-trust
Page 31 of 230
Monitor
Website link: https://www.gov.uk/government/organisations/monitor
More needs to be done to promote patient choice across the NHS
A survey published on 16th September shows that too few NHS patients say that they
are being offered a choice about where they receive care, indicating that more work
needs to be done to promote patient choice across the NHS.
For information
Alongside NHS England, Monitor state that they will continue to support the sector to
use these findings and increase the number of patients exercising their right to
choose providers of healthcare.
https://www.gov.uk/government/publications/survey-results-are-patients-offered-achoice-on-where-they-receive-care
and
https://www.gov.uk/government/news/more-work-needed-to-make-the-nhscommitment-to-choice-a-reality-for-all-patients-survey-suggests
Strategy in practice workshops
Monitor is hosting workshops in various locations from 29th September 2015 – 15th
October 2015.
This is a practical workshop for anyone looking to refresh or recreate their
organisation’s strategy and engage the trust, board and wider stakeholders in the
process. Monitor will draw on their strategy development toolkit and real life
examples to give the knowledge, tools and resources to lead the strategic
planning process and to develop a robust plan for the organisation.
Chief Executive
http://www.eventbrite.co.uk/e/strategy-in-practice-workshops-registration18292919615
Moving healthcare closer to home
Monitor have published guidance and support for providers and commissioners to
make evidence-based appraisals of how the benefits compare with the costs of
various approaches to move care closer to home.
For information
https://www.gov.uk/guidance/moving-healthcare-closer-to-home
Department of Health (DoH)
Website link: https://www.gov.uk/government/organisations/department-of-health
First ever mental health champion for schools unveiled
Natasha Devon MBE, the Department for Education’s first ever mental health
champion for schools will help to raise awareness and reduce the stigma around
young people’s mental health. This includes launching 2 organisations which give
young people practical tips on dealing with mental health and body image
concerns.
Accountable Officer
For information
Page 32 of 230
https://www.gov.uk/government/news/first-ever-mental-health-champion-forschools-unveiled
Consultation on the role of the National Data Guardian for health and social
care.
Consultation closes on 17th December 2015.
The consultation seeks views on the responsibilities of the statutory National Data
Guardian for health and social care. The responses will form a major part of the
development for more detailed proposals to establish the National Data Guardian
for health and social care on a statutory footing. The National Data Guardian for
health and social care will help to ensure that personal confidential data is held
and used to support better outcomes from health and care services, at the same
time providing confidence that there are thorough safeguards in place to protect
personal confidential data.
Director of Finance,
Performance &
IM&T/Caldicott Guardian
More information on how to respond can be found at:
https://www.gov.uk/government/consultations/the-role-of-the-national-dataguardian-for-health-and-social-care
The National Data Guardian, Dame Fiona Caldicott, sets out her priorities and
encourages responses to the consultation, which can be found at:
https://www.gov.uk/government/speeches/national-data-building-trust-acrosshealth-and-social-care
NHS England
Website link: http://www.england.nhs.uk
Results of Mental Health Taskforce: Engagement Report
The results were published on 2nd September.
More than 20,000 people have given their views on the top priorities for reshaping
mental health services as part of a drive to develop a five year national NHS
strategy for people of all ages.
The results can be found at:
http://www.england.nhs.uk/mentalhealth/taskforce/
And a various news articles on the subject at:
• http://www.england.nhs.uk/2015/09/02/mh-priorities/
• http://www.england.nhs.uk/2015/09/02/new-era-mh/
£5million plan to improve the health of NHS staff
NHS England Chief Executive Simon Stevens announced a major drive to
improve and support the health and wellbeing of 1.3million health service staff, at
the Health and Innovation Expo 2015 conference in Manchester on 2nd
September. He set out how NHS organisations will be supported to help their
staff stay well. This will include serving healthier food, promoting physical activity,
reducing stress, and providing health checks covering mental health and
musculoskeletal problems – the two biggest causes of sickness absence across
the NHS.
Accountable Officer
Operations and
Estates/Joint Medical
Directors
Director of People and
Corporate Development
Page 33 of 230
http://www.england.nhs.uk/2015/09/02/improving-staff-health/
Flagship helpline aids thousands in mental health crisis
Thousands of people in mental health crisis have been able to access the urgent
care they need quickly and directly thanks to a flagship £1million crisis helpline in
the North East. People with mental health issues, who might previously have
attended A&E, have been able to use a single telephone number set up by
Northumberland, Tyne and Wear NHS Foundation Trust (NTW).
For information
http://www.england.nhs.uk/2015/09/03/flagship-helpline/
Self Care Week’s message for healthy living
NHS staff, patients and carers are being urged to support and help raise
awareness of Self Care Week next month.
The theme for the week, running from 16th to 22nd November, is ‘Self Care for Life’
and aims to help people understand what they can do to better look after their
own health and that of their family, as well as living as healthily as possible.
http://www.england.nhs.uk/2015/09/09/self-care-week/
Is this a new era for dementia?
News article by Professor Alistair Burns and Professor Martin Rossor regarding
the raised profile of Dementia in recent months.
For information
The full article can be found at:
http://www.england.nhs.uk/2015/09/15/alistair-burns-martin-rossor/
NHS Employers - Workforce Bulletin
Website link: http://www.nhsemployers.org/about-us/our-communications/nhs-workforce-bulletin
Creating healthy workplaces – A toolkit for the NHS
This new toolkit aims to support NHS organisations to improve the staff health,
wellbeing, effectiveness and productivity by providing practical, step-by-step
information on how to implement the six pieces of workplace guidance from the
National Institute for Health and Clinical Excellence (NICE)
Accountable Officer
http://www.nhsemployers.org/news/2015/09/creating-healthy-workplaces-a-toolkitfor-the-nhs
Effective management of temporary staffing
60 HR professionals from across the NHS have shared their top tips on how
organisations can manage their temporary staff more effectively and reduce their
reliance and spend on agency workers.
http://www.nhsemployers.org/case-studies-and-resources/2015/09/effective-
Page 34 of 230
management-of-temporary-staffing
Government confirms plan to cap exit payments
The government has confirmed it plans to introduce a public sector exit payment
cap of £95,000 for public sector workers, which includes the NHS. The Enterprise
Bill 2015 contains a provision to cap exit costs for employees working for public
sector organisations.
http://www.nhsemployers.org/news/2015/09/consultation-on-restricting-publicsector-exit-payments
Seasonal influenza vaccination advanced service
From September 2015 certain at-risk adult patients (aged 18 or over at the time of
vaccination) will be able to access their free seasonal influenza vaccination from
community pharmacies if they wish to do so. The service will run from 1
September to the end of February each year. Pharmacy contractors will be paid
£7.64 for each vaccination provided, with an additional £1.50 per vaccinated
patient in recognition of costs related to providing the service, including collection
of clinical waste, staff training and revalidation.
For information
http://www.nhsemployers.org/your-workforce/primary-care-contacts/communitypharmacy/seasonal-influenza-vaccination-advanced-service
CQC creates national guardian role - have your say
NHS Employees are seeking views on the establishment of the new national
guardian role for the NHS. This will feed into NHS Employees response to
the Care Quality Commission's (CQC) public consultation A National Guardian for
the NHS – your say; improvement through openness. To ensure they fully
represent employers, they are asking for thoughts and comments by Friday 27th
November 2015.
Further information on how to respond can be found at:
http://www.nhsemployers.org/news/2015/09/cqc-consultation-on-the-nationalguardian-have-your-say
Flu fighter launches mythbusting Mondays
Flu fighter HQ has launched mythbusting Mondays to help dispel common myths
about the flu virus and the vaccination. They have picked up on some of the
myths that are circling this season, and will be sharing a mythbuster every
Monday during the flu season. Look out for the fact vs fiction tweets and images,
which can be shared across social media channels to help spread the message.
For information
http://www.nhsemployers.org/news/2015/09/flu-fighter-mythbusting-mondays-ontwitter
Page 35 of 230
NHS Providers
Full newsletters can be obtained from helen.king@dwmh.nhs.uk
Community Healthcare: Highlighting its impact and harnessing its potential
NHS Providers launched its publication Community Health Services – A Way of
Life on 16th September. This is a new publication and infographic, with supporting
blog, which sets out a new vision to recognise and expand the role of NHS
community health services.
Accountable Officer
The publication can be found at:
http://www.nhsproviders.org/resource-library/community-health-services-a-way-oflife/
This week next week – 4th September Issue Main highlights:
• Secretary of state promotes full patient access to records by 2018. Dame
Fiona Caldicott will lead a review of data security, and the CQC will be given
new responsibilities for monitoring providers on data-security measures.
• NHS England announces £5m drive to improve health of workforce.
Plans include exercise regimes, regular checks for muscular skeletal and
mental health conditions and healthier catering.
• Regulators confirm controls on agency staff. There are new limits on
maximum spend but price caps for hourly rates are delayed. Separately, some
trusts move away from national agreements paying senior staff a 1% increase.
• Mental health taskforce publishes its engagement report. The exercise,
led by Mind and Rethink Mental Illness on behalf of the taskforce heard from
over 20,000 people on the priorities for reshaping mental health services.
• Concerns raised about medication for people with learning difficulties.
Over the last 10 years 33,000 adults with learning difficulties are found to have
been inappropriately prescribed antipsychosis drugs.
For information
http://nhsproviders.cmail1.com/t/ViewEmail/t/B1A4F4EBD1869059/7A3E0527A55
B85E7C68C6A341B5D209E
This week next week – 11th September 2015 Main highlights:
• Secretary of state sees CQC ratings as "definition of success". The health
secretary suggests trusts with a “good” or “outstanding” rating could be
awarded greater freedoms.
• Workforce shortages and finance are barriers to reform, say urgent and
emergency care vanguards. Several are struggling to attract staff to support
new skill mixes, and need funds to "'double run" services.
• Concerns raised over immigration rules. Writing to the home secretary,
NHS Employers and ten trusts ask for non-EU nurses’ work requests to be
prioritised to cope with demand this winter.
For information
http://nhsproviders.cmail1.com/t/ViewEmail/t/0EE28CF76824AE49/7A0573B753B
4807E6A4D01E12DB8921D
Page 36 of 230
This week next week – 18th September 2015 Main highlights:
• NHS faces the “hardest decade ever”, say think tanks. Leading health
think tanks' submissions ahead of the forthcoming spending review offer a
bleak assessment of the pressures facing the health service.
• Being clear about cost can reduce missed appointments. Texting the cost
of missed appointments to patients was found to increase attendance.
Government plans to introduce similar systems across England.
• More needs to be done to promote patient choice, finds survey. Just 40%
of patients in the NHS England and Monitor survey said they had been offered
a choice, compared to 38% last year.
For information
http://nhsproviders.cmail20.com/t/ViewEmail/t/2A3ABE87F81535CB/D96816C9F
C555F3B6A4D01E12DB8921D
Mental Health Foundation
Website link: http://www.mentalhealth.org.uk
World Mental Health Day 10th October
Joining organisations all over the world including the World Federation of Mental
Health and the World Health Organisation, the Mental Health Foundation are
raising awareness of what can be done to ensure that people with mental health
problems can live with dignity.
Accountable Officer
For information
http://www.mentalhealth.org.uk/our-work/world-mental-health-day/world-mentalhealth-day-2015/
Launch of IAPT Positive Practice Guide for Learning Disabilities
The guide provides useful information regarding how best to support people with
learning disabilities to access their local IAPT service, including numerous
practical examples of how to make reasonable adjustments to achieve this.
http://www.mentalhealth.org.uk/our-news/news-archive/2015/IAPT-PPG-learningdisabilities/?view=Standard
World Mind Matters Day 2015: call for greater awareness of the mental
health needs of refugees
The Mental Health Foundation has added its support to World Mind Matters Day
which is launching a programme for training psychiatrists to care for the mental
health issues affecting refugees and migrants. The Foundation is calling for
greater awareness of the mental health needs of refugees, in particular those who
have experienced trauma.
For information
http://www.mentalhealth.org.uk/our-news/news-archive/2015/15-09-04-worldmind-matters-day-2015/?view=Standard
Page 37 of 230
Media statement on the inappropriate use of psychotropic drugs
The Mental Health Foundation and the Foundation for People with Learning
Disabilities comment on the inappropriate use of psychotropic drugs in people
with a learning disability. The study has lead researchers to suggest “that, in some
cases, these drugs are being used to manage other presentations, such as
challenging behaviour, rather than for mental illness.”
For information
http://www.mentalhealth.org.uk/our-news/news-archive/2015/statementinappropriate-use-psychotropic-drugs/?view=Standard
Mental Health Foundation launches new supporter-led programme
The launch of Friends of the Foundation’; a supporter-led programme to generate
funding for and promote work which is focused on prevention and aims to ensure
better mental health for all.
For information
http://www.mentalhealth.org.uk/our-news/news-archive/2015/friends-of-thefoundation/?view=Standard
The Centre for Mental Health and Safety
Website link: http://www.bbmh.manchester.ac.uk/cmhs
Practical solutions for preventing suicide in healthcare settings
Webinar by Professor Nav Kapur, University of Manchester
Accountable Officer
Professor Kapur is the Head of Research at the Centre for Suicide Prevention at
the University of Manchester and is a member of the UK Department of Health’s
National Suicide Prevention Strategy advisory group.
Professor Nav Kapur's webnar can be viewed at:
https://www.youtube.com/watch?v=iWPEVhrWZS0
The Kings Fund
Website link: http://www.kingsfund.org.uk
Increasing access to Mental Health Conference – sessions
The Kings Fund hosted a conference on increasing access to mental health and
the sessions included:
• Promoting good mental health across the population
• Preparing for new standards
• Providing mental health care in non-mental health settings
• Innovative approaches to access
Accountable Officer
For information
The sessions and presentations can be viewed at:
http://www.kingsfund.org.uk/events/increasing-access-mental-health-care
Page 38 of 230
National Health Executive
Website link: http://www.nationalhealthexecutive.com
Labour leader creates new cabinet-level mental health post to ‘tackle crisis’
Labour leader Jeremy Corbyn has created a post in his shadow cabinet designed
to address mental health issues in the NHS. The new shadow minister for mental
health, Luciana Berger MP, will work solely on mental health and assess how the
NHS and the government and can address and prioritise its issues.
Accountable Officer
For information
http://www.nationalhealthexecutive.com/Mental-Health/labour-leader-creates-newcabinet-level-mental-health-post-to-tackle-crisis
Norman Lamb to chair new mental health commission
Norman Lamb MP, the former minister for community and social care, has been
appointed chair of a new West Midlands commission on mental health. The
commission proposal was announced in July when the emerging West Midlands
Combined Authority put forward plans to establish three major independent
commissions to help shape the future of the region.
For information
http://www.nationalhealthexecutive.com/Mental-Health/norman-lamb-to-chairnew-mental-health-commission
Thousands of mental health patients forced to travel to find a bed
More than 2,000 mental health patients had to travel outside their local region for
an inpatient bed in May, according to new data by the Health and Social Care
Information Centre (HSCIC). The figures – made public for the first time – showed
that 2,107 mental illness sufferers were assigned a bed at a provider that was not
the usual provider for their local CCG.
For information
http://www.nationalhealthexecutive.com/Mental-Health/thousands-of-mentalhealth-patients-forced-to-travel-to-find-a-bed
NHS Benchmarking Network
Website link: http://www.nhsbenchmarking.nhs.uk/index.php
Information on the NHS Benchmarking Network website includes:
• Launch of NHS Benchmarking Network Survey to gain feedback on their
service and views on next year’s Network work programme.
Accountable Officer
For information
http://www.nhsbenchmarking.nhs.uk/news.php
NHS Benchmarking August newsletter gives an update on the 2015/16 work
programme, upcoming publications, and conferences and events that members
can attend.
For information
Page 39 of 230
Upcoming events include:
• Benchmarking & Good Practice in Mental Health Services Conference
Venue: London
Date: 06 Nov 2015
The event will present the findings from 2015 benchmarking and also present
a range of good practice in Mental Health services
• Child and Adolescent Mental Services (CAMHS) Findings Event
Venue: London
Date: 01 Dec 2015
The event will present the findings from 2015 benchmarking and also present
a range of good practice in CAMHS services.
http://www.nhsbenchmarking.nhs.uk/CubeCore/.uploads/EmailFunction/Newslette
r/NewsletterAugust2015.pdf
NHS Confederation
Website link: http://www.nhsconfed.org
• Report from Monitor looks at potential savings from moving care into the
community
• The World Health Organisation looks at effect of economic crisis on health
systems
• NHS Confederation response to 2016/17 national tariff proposals
• A culture of stewardship: The responsibility of NHS leaders to deliver better
value healthcare
• Further details on nursing agency spend caps from TDA and Monitor
Accountable Officer
For information
More information on each of the headings above can be found at:
http://www.nhsconfed.org/resources
Understanding the legislative landscape in mental health
The Mental Health Network have produced a briefing called ‘Horizon scanning:
The legislative landscape in mental health’ aimed at bringing members up to
speed on some of the legal developments relevant to mental health which have
taken place in the last twelve months as well as some of the legislative proposals
currently under consideration.
http://www.nhsconfed.org/news/2015/09/mhn-publishes-briefing-on-thelegislative-landscape-in-mental-health
Health Service Journal (HSJ)
Website link: http://www.hsj.co.uk
Information from the HSJ includes the following:
Accountable Officer
For information
Page 40 of 230
• Low staff morale and high use of restraint at mental health trust, CQC
says
Low staffing levels and an ‘unacceptable variation’ in the use of restraint at
West London Mental Health Trust has caused the Care Quality Commission to
call for the trust to make improvements.
• NHS agency controls unveiled, but price cap pushed back
Price caps on the hourly rate the NHS can pay agency nurses may not take
effect until December, after regulators received more than 100 responses to a
consultation on the controversial plans.
• Thousands of mental health patients still detained in police cells
Almost 4,000 people detained under the Mental Health Act are still being
forced to stay in police cells rather than a hospital, despite a 54 per cent fall
over the last three years.
Further information can be found at:
http://www.hsj.co.uk/news/mental-health/
Care Quality Commission (CQC)
Website link: http://www.cqc.org.uk
Give us your views on the new National Guardian role
CQC are seeking views on the new role of a National Guardian, who will be
responsible for leading local ambassadors across the country so that staff feel
safe to raise concerns and confident that they will be heard.
Accountable Officer
More Information can be found at:
http://www.cqc.org.uk/content/give-us-your-views-new-national-guardian-role
Secretary of State asks CQC to review NHS data security
Jeremy Hunt has asked CQC to review the effectiveness of current approaches to
data security by NHS organisations when it comes to handling patient-confidential
data.
For information
More Information can be found at:
http://www.cqc.org.uk/content/secretary-state-asks-cqc-review-nhs-data-security
Page 41 of 230
Board meeting date:
Agenda Item number:
Enclosure:
7th October 2015
11.1
7
Trust Integrated Performance Dashboard Month 5 (August 2015/16)
Report Title:
Mark Axcell - Director of Finance and Performance
Makhan Singh (Principal Consultant, Information & Performance)
To update the Board on all aspects of Trust performance at month 5
of 2015/16
•
•
•
•
•
Quality and Safety
Service User Experience
Efficiency
Resources
Monitor and Trust Development Authority
Decision / Approval
Gain assurance
Discussion
Information




Committee:
•
•
Quality and Safety Committee considered elements from
within the Quality and Safety domain, and the Service User
Experience domain.
Finance and Performance Committee considered elements
from the Efficiency, Resource and Quality and Safety Domains
Date reviewed
• Finance and Performance Committee – 28th September 2015
Key points or
Committee:
High quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources






Page 42 of 230
What impact or implications does
this report have on any of the
following:
Caring
The report provides an update on the performance in
relation to Quality and Safety, Service User Experience,
Efficiency and Resources
Responsive
Effective
Well-led
Safe
Page 43 of 230
Trust Integrated Performance Dashboard Month 5 (July 2015)
Title
Introduction
•
This paper presents the Trust’s performance at the end of month five 2015/16 financial year.
•
The 2015/16 Integrated Dashboard allows comparison and triangulation across Quality and
Safety, Service User Experience, Efficiency, and Resources to give a comprehensive picture of
the performance of the Trust.
•
The 2015/16 Integrated Dashboard also includes performance, and exception commentary, by
service line, so that the Board is better able to see achievements as well as any adverse
performance within the overall aggregate level.
•
Sickness - Trust Sickness for August 2015 is 4.74%, compared to 4.89% as reported in July
2015.
•
Copies of Care Plan – the Trust remains above the agreed 95% target (96.5%).
•
The overall finance risk rating for the month remains green with a score of 3.7.
•
Our overall governance risk rating for the month is green with a score of 0.
Further detail
Please see enclosed Integrated Performance Dashboard and underpinning reports for finance,
contractual performance, quality and workforce.
Recommendation
•
It is recommended that the Board note the performance of the Trust as at month five and debate
accordingly.
•
Debate the content of the reports accordingly.
Page 44 of 230
Trust Integrated Performance Dashboard
Month 5 (August)
Presented at Trust Board 7th October
Page 45 of 230
Page 46 of 230
Trust Level Integrated Dashboard – Exception Commentary
Quality and Safety Domain
• The number of serious incidents has slightly decreased to 3 in August (4 were reported in July). From the 3 serious incidents reported in month five, 1 related to
Homicide, 1 is in relation to an attempted suicide and 1 is in relation to a failure to return from leave. The number of incidents reported in month five has slightly
increased to 330 (325 were reported in July). Of the 330 incidents, 140 relate to Patient Safety Incidents.
• CPA Formal Review and Copies of Care Plan – the Trust continues to remain above the agreed 95% target.
Efficiency Domain
• Activity against contract (NHS Activity) – NHS contracted activity remains above the target as at month five. In August, the Trust is reporting 139,422 units of
activity against a target of 131,757. Within this there is over performance in community activity and a significant underperformance on inpatient activity. This
reduction in inpatient activity is driving the income underperformance.
Resources Domain
• Cost Improvement Programme (CIP) - The Trust’s CIP target for the year is £2,147k. As at month five the YTD CIP target of £794k is behind plan by £94K. The Trust
has identified sufficient schemes to deliver the whole CIP target on a recurrent basis. In the year to date £1,871k has been devolved to budget areas, leaving
£276k to be supported non recurrently from reserves until the schemes are implemented in year. Of the schemes devolved a total of £1,233k has been
transacted, £98k of schemes are not due to start until later in the financial year and £914k are running behind plan (including £470k regarding Activity CIPs).
• PDR's % in Date (Data in ESR) - Appraisal Data Capture has decreased to 75.60% as at the end of August 2015 (76.41% reported in month four).
• The Trust Sickness rate has slightly decreased to 4.74% in month five (4.89% reported in month four). Long Term Sickness accounts for 65.3% of Sickness in month
five. Regular case review meetings are on-going with the Occupational Health service to address the sickness rates.
• The 12 month rolling sickness % has decreased slightly from 4.93% in month four to 4.86% in month five. Long Term Sickness accounts for 65.3% of this sickness.
• The Trust Mandatory Training rate has slightly decreased to 82.20% in month five but remains above the 70% target (82.75% reported in month four).
Page 47 of 230
Service Line Summary
•
•
•
•
Acute & Access Service incident figures have shown an increase when compared to the
previous month. (161 reported in July to 197 recorded in August).
This service line has underspent by £15k in August. The true underlying underspend is
approximately, £20k greater, but masked by prior-month costs (e.g. agency staff shifts
not booked/reported through AVA system in July). The true in-month position comprises
breakeven on Acute ward staffing (but includes an overspend of £15k on Ambleside
ward), plus an underspend generated by various non-ward vacancies (in psychology,
management posts and CRHT).
Acute Income performance remains low but recent months have shown an improved
position
Acute Services sickness in-month has decreased to 7.39% in month five (8.07% reported
in month four). 12 month sickness has slightly increased to 7.33% (7.28% reported in
month four). Mandatory Training has slightly increased from 75.63% in month four to
76.30% in month five.
Page 48 of 230
• CPA Formal Review and Copies of Care Plan – this service has remained above target for
the past five consecutive months.
•
Activity against contract continues to remain above the target for month five.
•
Community & Recovery Services position to month five 2015/2016 was £118k
underspent. The underspend is driven by vacancies within the Psychological Therapy Hub
which offsets the agency costs within CRS. Recruitment to current vacancies will support
cost reduction and increase activity. Vacancy slippage attributed to skill mix changes and
the uncertainty of Grasmere is being offset by the closure of Walsall SMS. Grasmere's
position has been matched off with the reduction in Income this month.
•
Community Services and Recovery have seen a slight decrease in sickness – 4.20%
reported in month five in comparison to 4.30% reported in month four. 12 month rolling
sickness slightly decreased to 5.40% in month five (5.52% reported in month four).
Mandatory training has seen a decrease in month five to 80.10% - 84.78% reported in
month four).
Page 49 of 230
• Copies of Care Plan – this service has remained at or above target for the past three
months.
•
Incident numbers for the this service have decreased in August. 18 recorded for July and 13
were reported in August.
•
This service line is overspent up to month five by £227k. There are high risk cost pressures
on this service line, especially around the non – recurrent agency support in CAMHS and
other CAMHS income streams. CAMHS has contributed £287k of overspend towards the
position. A recruitment drive has been implemented to gradually reduce down the use of
temporary agency usage (13 posts). This has resulted in the use of agency slowing where
substantive posts will replace their activity. The use of locums for the CAMHS Tier 3+
service has been implemented at risk in preparation for taking on the service recurrently.
The Primary Care teams are currently generating an underspend of £55k which is
attributed to vacancy slippage within the service. An urgent review of agency usage in EI
has been implemented
Early Intervention sickness has seen a slight increase to 3.49% in month five (2.21% in
Page 50 of 230
month four). The 12 month sickness has slightly decreased from 5.13% reported in month
four to 4.87% at month five.
•
•
CPA Formal Review and Copies of Care Plan– there has been an increase in Performance
and this service is now reporting above the 95% target.
•
The Older Adult Services have shown a decrease in the number of incidents reported for
August. 105 reported in month five in comparison to 131 reported in July.
•
Activity against contract continues to remain below the target as at month five.
Inpatient activity is significantly down against contract
•
This service line has overspent by £63k in August. This overspend in primarily on bank
and agency. The service line is also showing significantly reduced inpatient activity
compared to last year. A review of staffing against activity levels has now been
commenced
•
Older Adults sickness has decreased to 5.61% (6.99% in month four). The 12 month
sickness has slightly decreased from 5.77% in month four to 5.67% in month five. PDR’s
Page in
51month
of 230 four.
has seen a decrease in month five to 78.10% - 83.80% reported
Trust Performance Report
Month 5
2015/16
Page 52 of 230
1
Part 1 – Contractual Quality Requirements - Trust
KPI
No
1
2
3
4
5
6
7
8a
8b
9a
9b
10
11
12
13
14
15
16
KPI Detail and Target
Trust
Percentage of non-admitted Service Users starting treatment within a maximum of 18 weeks from Referral. (Target:
Above 95%)
Percentage of Service Users on incomplete RTT pathways (yet to start treatment) waiting no more than 18 weeks from
Referral. (Target: Above 92%)
Care Programme Approach (CPA): The percentage of Service Users under adult mental illness specialties on CPA who
were followed up within 7 days of discharge from psychiatric in-patient care. (Target: Above 95%)
Completion of a valid NHS Number field in mental health and acute commissioning data sets submitted via SUS
(Target: Above 99%)
Completion of Mental Health Minimum Data Set ethnicity coding for all detained and informal Service Users. (Target:
Above 90%)
Completion of IAPT Minimum Data Set outcome data for all appropriate Service Users. (Target: Above 90%)
Delayed Transfer of Care (All Reasons). (Target: Below 7.5%)
IAPT - Proportion of people who complete treatment who are moving to recovery. (Target Dudley: Above 50.5%)
IAPT - Proportion of people who complete treatment who are moving to recovery. (Target Walsall: Above 50.4%)
IAPT - number of people who receive psychological therapies. (Target Dudley: Annual TBC. Interim metric 4825 pa;
402 per month)
IAPT - number of people who receive psychological therapies. (Target Walsall: 4328 pa; 361 per month)
Percentage of patients who are provided a copy of their care plan. Target: Above 95%)
Number of home treatment episodes by crisis teams. (Target Walsall only: 608 pa; 51 per month)
Average Length of Stay for cluster 19 -21. (Target: TBC - following baseline in Q1)
Average Length of Stay (all other clusters). (Target: TBC - following baseline in Q1)
Percentage of urgent referrals contacted within 1 operational day. (Target: TBC - following baseline in Q1)
Percentage of routine referrals contacted within 2 weeks. (Target: TBC - following baseline in Q1)
Percentage of people experiencing a first episode of psychosis will be treated with a NICE approved care package
within two weeks of referral. (Target: Q1 - no target; Q2 - 40%; Q3 - 45%; Q4 - 50%)
100%
100.0%
95.4%
99.6%
92.9%
99.1%
0.8%
47.8%
51.8%
432
445
96.5%
65
53
48.5
96.3%
97.8%
---
17
The proportion of people that wait 6 weeks or less from referral to their first IAPT treatment appointment against the
number of people who enter treatment in the reporting period. (Target: Q1 - no target; Q2 - 50%; Q3 - 60%; Q4 - 75%)
97.2%
18
99.7%
23
The proportion of users on CPA who have had a review within the last 12 months. (Target:Q1 - no target; Q2 - 75%; Q3
- 85%; Q4 - 95%)
The completeness of ethnicity reporting. (Target: Above 90%)
The proportion of users on CPA with a crisis plan in place. (Target: Q1 - no target; Q2 - 75%; Q3 - 85%; Q4 - 95%)
The proportion of users with a valid ICD10 diagnosis code recorded. (Target: Q1 - no target; Q2 - 80%; Q3 - 90%; Q4 100%)
Proportion of in-scope patients assigned to a cluster. (Target: Q1 - no target; Q2 - 75%; Q3 - 85%; Q4 - 95%)
24
Proportion of initial cluster allocations adhering to red rules. (Target: Q1 - no target; Q2 - 60%; Q3 - 70%; Q4 - 80%)
25
26
27
28
Proportion of patients within cluster review periods. (Target: Q1 - no target; Q2 - 75%; Q3 - 85%; Q4 - 95%)
Sleeping Accommodation Breach
Publication of Formulary
Duty of Candour
19
20
21
22
96.4%
96.0%
95.4%
75.0%
93.7%
30.8%
47.5%
0
--Page 53 of 230 ---
2
Part 1 – Contractual Quality Requirements – Dudley CCG
KPI
No
1
2
3
4
5
6
7
8a
9a
10
12
13
14
15
16
Dudley CCG
Above 95%)
(Target: Above 99%)
Above 90%)
IAPT - Proportion of people who complete treatment who are moving to recovery. (Target Dudley: Above 50.5%)
IAPT - number of people who receive psychological therapies. (Target Dudley: Annual TBC. Interim metric 4825 pa;
402 per month)
100%
100.0%
90.2%
99.7%
91.5%
99.3%
0.0%
47.8%
432
95.6%
37
44.5
95.7%
94.9%
---
17
98.4%
18
99.7%
23
- 85%; Q4 - 95%)
24
25
26
27
28
Duty of Candour
19
20
21
22
96.7%
95.9%
93.9%
83.1%
94.2%
37.8%
40.1%
0
--Page 54 of 230 ---
3
Part 1 – Contractual Quality Requirements – Walsall CCG
KPI
No
1
2
3
4
5
6
7
8b
9b
10
11
12
13
14
15
16
Walsall CCG
Above 95%)
(Target: Above 99%)
Above 90%)
IAPT - Proportion of people who complete treatment who are moving to recovery. (Target Walsall: Above 50.4%)
IAPT - number of people who receive psychological therapies. (Target Walsall: 4328 pa; 361 per month)
Number of home treatment episodes by crisis teams. (Target Walsall only: 608 pa; 51 per month)
100%
100.0%
100.0%
99.9%
95.6%
98.8%
1.1%
51.8%
445
97.7%
65
73.5
56.7
96.9%
100%
---
17
96.5%
18
99.5%
23
- 85%; Q4 - 95%)
24
25
26
27
28
Duty of Candour
19
20
21
22
96.5%
96.5%
97.2%
69.6%
94.6%
28.1%
55.7%
0
--Page 55 of 230 ---
4
2015/16 DWMHPT Finance Report Month 5
Page 56 of 230
Trust Board
meeting date:
7th October 2015
Title
Agenda Item number:
11.1
Enclosure:
7
DWMHPT Finance Report, Month 05, 2015/16
Mark Axcell, Director of Finance and
Performance
Mark Banks, Deputy Director of Finance
Action
required
from the
Committee:
Decision /
Approval

What other Trust
Committee has
considered this
report?
Purpose of
the report
Gain
assurance
Committee
None
Discussion

Date reviewed
Information

Key points or
recommendations
Not available for this
report
To present to members the financial position as at 31st August
2015, for Dudley and Walsall Mental Health Partnership NHS
Trust
Page 57 of 230
2
Recommendation(s)
to Trust Board
Trust Board members are asked to note the contents
of the report
Which key standards
or assurances does
this report relate to?
State specific standard / outcome or BAF risk
CQC
TBC
NHSLA
TBC
Board Assurance
Framework
TBC
Strategic
Objective(s)
to which
this paper
relates:
/
High
quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective &
efficient
resources

IMPACTS & IMPLICATIONS
Patient safety & experience
The financial position of the Trust and the
capital programme could have a direct impact
on patient safety and experience, both
adversely and positively
Financial (revenue & capital)
Contained within the report
Equality & Diversity
Not directly applicable
OD/Workforce
Establishment against budget and temporary
staffing spend contained within the report
What patient & public
involvement has there been in
this issue?
Service user feedback used to inform some
revenue and capital investment decisions
Page 58 of 230
2015/16 DWMHPT Finance Report Month 5
Page
•
Key Messages
5
•
Overall Summary and RAG Assessment
6-7
•
Trust Income Statement: Functional Analysis
8-11
•
Capital Programme
12-13
•
Financial Performance Metrics
14
•
TDA Key Financial data: Month 5
15
•
Cash Flow Statement
16
•
Debtor and Creditor Performance
17
•
Cost Improvement Target Achievement
18
•
Statement of Financial Position (Balance Sheet)
19
Page 59 of 230
Key Messages
Financial Position
Expenditure – Pay
£192k
surplus
•
The Trust has delivered a cumulative surplus of £192k as of Month 5.
•
However, this is £218k behind the planned surplus for the year to date (£410k plan), based on the revised ‘stretch’ target of £1.267m for the year.
£1k
favourable
variance
•
Pay expenditure is £1k in surplus against budget YTD (£20,615k budget against £20,614k actual).
•
Bank & Agency spend equates to £668k in month (£706k in Month 4) and £3,753k YTD (£3,084k in Month 4), but is being negated in part by slippages
on vacancies.
•
Whilst pay is underspent overall, there are considerable cost pressures against budget in Corporate areas and the Early Intervention service line.
Expenditure – Non
Pay
£268k
favourable
variance
•
Non-Pay expenditure is £268k in surplus against budget YTD (£5,382k budget against £5,114k actual).
•
The largest area of surplus at Month 5 relates to balances on Trust Non-Pay Reserves of £413k.
Income & Activity–
2015/16 outturn
(£487k)
•
The Trustwide Activity position for Month 5 is an under-performance of £536k and is explained as:
Adverse
variance
(incl (£536k)
contract
activity under
performance)
CIP plans delivered
for 2015/16
Expenditure - Capital
£103k behind
plan
£396k spend
YTD
•
Dudley CCG has under-performed by £179k (incl. U18 income) – moved adversely £62k in month
•
Walsall CCG has under-performed by £152k (incl. U18 income) – moved adversely £69k in month
•
NCAs are under-performing against plan by £12k
•
The activity in the Detox beds at Bushey Fields is under recovering by £25k.
•
Sandwell, B’ham Cross City and Cannock CCG’s are also over-performing by £18k, £4k and £5k respectively
•
The Net position is an under-performance of £340k, however, after taking account of the impact of the CIP target that has been applied to activity
(£470k FYE), overall performance to date is significantly behind target.
•
Bed days for Acute and Older Adults are still showing the most significant movement away from plan year to date. Although acute activity has
improved in Month 5 Older Adults activity still remains a challenge with low activity levels and costs remaining at constant levels.
•
To note though the Community Income Generation element of the £470k CIP is currently being achieved within the Activity position (an overperformance of £177k compared to CIP of £104k). This has not been transacted as an achieved CIP at this stage due to the issues with in-patient
activity.
•
The Trust’s Cost Improvement Target for the year is £2,143k.
•
As at Month 5 the YTD CIP target of £849k is behind plan by £103k.
•
The Trust has identified sufficient schemes to deliver the whole CIP target on a recurrent basis. In the year to date £1,871k has been devolved to
budget areas, leaving £276k to supported non-recurrently from reserves until the schemes are implemented in year.
•
Of the schemes devolved a total of £1,233k has been transacted (£1,193k recurrently and £40k non-recurrently), £97k of schemes are not due to start
until later in the financial year and £817k are running behind plan (incl. £470k re Activity CIPs).
•
YTD spend is currently behind plan - £396k spend against £1,083k plan YTD.
•
The Capital Programme has been revised in part to support the additional financial ‘stretch’ target in year.
Page 60 of 230
Overall Summary and RAG Assessment
Statement of Comprehensive Income - Financial Position to 31st August 2015
Annual
Plan
£000
Revenue From Activities
Revenue-NHS Clinical
Revenue-Non NHS Clinical
Total Revenue From Activities
Income
Plan
In Month
Actual
Variance
£000
£000
£000
59,353
910
4,970
35
4,809
36
60,263
5,005
4,845
Commentary
Plan
Year To Date
Actual
Variance
£000
£000
£000
(161)
1
24,911
668
24,400
642
(510)
(26)
(159)
25,579
25,043
(536)
Revenue Position
Other Operating Revenue
Revenue-Employee Benefits
Revenue-Education & Training
Revenue NHS Non-Clinical
Other Revenue
399
1,613
621
526
70
178
39
34
67
156
80
40
(3)
(22)
41
6
166
674
280
219
213
687
284
202
47
13
4
(17)
Total Other Operating Revenue
3,159
321
343
22
1,339
1,386
47
Total Revenue
63,421
5,325
5,188
(137)
26,917
26,429
(489)
Expenditure
Pay
Clinical Supplies and Services
Expenditure Reserves
CIP Target
Other Costs
(48,116)
(1,733)
(509)
484
(9,500)
(4,040)
(137)
(148)
19
(749)
(3,986)
(170)
(6)
0
(798)
54
(33)
143
(19)
(49)
(20,436)
(751)
(324)
199
(4,080)
(20,355)
(746)
430
0
(4,452)
81
5
755
(199)
(373)
Total Operating Expenditure
(59,375)
(5,056)
(4,959)
97
(25,392)
(25,123)
269
4,046
269
229
(41)
1,525
1,306
(219)
(1,342)
(236)
2,468
(1,263)
40
22
1,267
(81)
(21)
167
(105)
3
0
65
(81)
(21)
127
(105)
4
0
25
0
0
(41)
0
0
(0)
(40)
1,267
65
25
(40)
(541)
(87)
897
(526)
17
22
410
0
410
(541)
(87)
678
(526)
18
22
192
0
192
0
0
(219)
0
1
0
(218)
0
(218)
•
The Trust is reporting a Month 5 surplus position of £192k, which
is £218k behind the expected ytd plan.
•
Total Income after taking account of the impact of the applied CIP
(£470k FYE) is reflecting an under-performance of £536k
•
Total Expenditure is £269k ahead of the planned position and is
being supported by Trustwide Reserves.
(further detail is shown on Pages 6 – 10)
CIP 2015/16 Delivery
•
Most CIP targets have been devolved to the appropriate
management levels and slippage is covered by reserves at
present.
•
There are however several schemes that have a risk of nonachievement in year.
•
Current performance reflects a 57.42% achievement of schemes
delivered against the annual target of £2.143m
(further detail is shown on Page 11)
EBITDA
Budgetary Reserves
Depreciation
Amortisation
Net Operating Surplus
PDC
Interest Receivable
P/L Disposal
Net Surplus /(Deficit)
Technical Adjustment
Technical Surplus
•
As at Month 5 the Trust has a balance of £1.3 million in reserves.
This will change as in year commitments arise and as CIP
schemes are implemented and targets devolved accordingly.
•
There is a balance of £276k CIP not achieved which is currently
being covered by reserves.
(further detail is shown on Page 16)
Page 61 of 230
Overall Summary and RAG Assessment Continued
Run Rate 2015/16
Capital Programme 2015/16
1,400
1,000
Cumulative
'Stretch'
Revised Run
Rate
800
600
400
Actual Run
Rate
200
0
2,500
Cumulative
Planned Spend
2,000
£'000
1,200
£'000
3,000
Cumulative
'Original'
Planned
Run Rate
1,500
Cumulative
Actual Spend
1,000
500
0
CIP 2015/16
Transacted full
year value
2,205
Transacted
part year
effect
1,807
CIP Target
2,143
0
1,000
2,000
£'000
3,000
Page 62 of 230
Trust Summary Income & Expenditure Statement Including Functional Analysis
Annual Plan
NHS Revenue-Activities
Revenue from LAs
Total Revenue from Activies
In Month
Year to Date
FOT M5
2015/16
Plan
Actual
Variance
Plan
Actual
Variance
Var
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
59,353
4,970
4,809
(161)
24,911
24,400
(510)
(238)
910
35
36
1
668
642
(25)
8
60,263
5,005
4,845
(159)
25,579
25,043
(536)
(230)
(12,317)
(1,026)
(1,030)
(5)
(5,276)
(5,406)
(130)
(171)
Corporate Functions
Corporate Departments
Central Reserves
Total Corporate Functions
(509)
(148)
(6)
143
(324)
106
430
529
(12,826)
(1,174)
(1,036)
138
(5,600)
(5,300)
300
358
Commentary
•
The Trust is showing an under-performance
against contracted activity levels which is
resulting in an adverse position of £536k. It
should be noted that £196k relates to the
CIP target for 2015/16.
•
The under performance against contract
activity targets mainly relates to in-patient
activity.
•
Acute and Older Adult Services are £104k
underspent, which is made up of Acute InPatients overspending and Older Adults
services showing an underspend.
•
Community services are showing an
overspend of £101k, most of which relates
to the use of agency staff in Early
Intervention services (CAMHs), which is
being covered partly by contractual overperformance.
•
The overall Trust wide position is being
delivered by an underspend year to date on
Trust reserves of £430k and £529k forecast
outturn.
Operational Services
Total Acute & Older Adults
(19,024)
(1,589)
(1,617)
(28)
(8,094)
(7,990)
104
36
Total Community Services
(13,913)
(1,093)
(1,083)
10
(5,990)
(6,092)
(101)
(164)
Medical Services
(12,009)
(982)
(983)
(1)
(4,974)
(4,960)
14
0
Total Operational Services
(44,947)
(3,664)
(3,683)
(19)
(19,058)
(19,042)
17
(128)
Total Expenditure
(57,773)
(4,838)
(4,719)
119
(24,659)
(24,342)
317
230
2,490
167
127
(40)
920
701
(219)
0
Sub Total
Interest Receivable
40
3
3
0
17
18
1
0
(1,263)
(105)
(105)
0
(526)
(526)
0
0
Net Surplus/(Deficit)
1,267
65
25
(40)
410
192
(218)
0
Technical Adjustment
0
0
0
0
0
0
0
1,267
65
(40)
410
192
(218)
0
PDC Dividend
Technical Surplus
25
Page 63 of 230
Trust Income Statement – Income
Annual Plan
In Month
Year to Date
FOT M5
2015/16
Plan
Actual
Variance
Plan
Actual
Variance
Var
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
Commentary
•
The Trust is now operating on a mixture
of cost per case and block contract
agreements with its host whilst
neighbouring CCGs remain on block
contracts.
•
Month 5 Trustwide activity has shown an
under-performance in both Dudley and
Walsall, which in the main is due to
under activity within ‘Admitted’ areas.
•
The level of NCA activity has achieved
the planned levels in month but remains
at an overall under-performance to date.
•
In patient detox service at Bushey Fields
are also under-performing at £25k
against the expected activity levels to
date.
•
CIP of £470k has been applied to activity
which means a required overperformance of £39k each month in order
to deliver the target. As of Month 5 this
target of £196k had not been fully met only a contribution of £104k from
Community Income Generation
elements such as CAMHs and Primary
Care over-performance is helping .
•
Overall the Trust is under-performing to
the value of £536k in Month 5.
Revenue From NHS Activities
Dudley CCG
26,868
2,266
2,203
(62)
11,357
11,178
(179)
(44)
Walsall CCG
27,317
2,275
2,206
(69)
11,393
11,241
(152)
(44)
NHS Walsall
0
0
0
0
0
0
0
0
Sandwell & West Birmingham CCG
1,891
156
161
4
796
814
18
20
Wolverhampton CCG
306
26
26
0
128
128
0
0
Birmingham Cross City CCG
352
29
29
(0)
147
151
4
0
Birmingham South Central CCG
61
5
5
0
25
25
(0)
0
South East Staffs & Seisdon CCG
232
19
19
0
97
97
0
0
Cannock Chase CCG
126
11
16
5
53
58
5
0
Stafford & Surrounds & E Staffs CCGs
2
0
0
0
1
1
0
0
0
Total Staffs CCGs
360
30
35
5
150
156
6
Redditch & Bromsgrove CCG
21
2
2
0
9
9
0
0
Wyre Forrest CCG
33
3
3
0
14
14
0
0
NHS South Worcester CCG
19
2
2
(0)
8
8
(0)
0
Total Worcester CCGs
73
6
6
0
30
31
0
0
Income Generation CIP
470
39
0
(39)
196
0
(196)
(470)
Budget for Under Recovery
0
0
0
0
0
0
0
0
300
NCAs
270
23
22
(0)
113
101
(12)
CAMHs Deaf
1,384
115
115
0
577
577
0
0
Total NHS Revenue-Activities
59,353
4,970
4,809
(161)
24,911
24,400
(510)
(238)
Revenue - Local Authorities
Walsall MBC
585
8
8
(0)
532
532
0
0
Dudley MBC
120
10
10
0
50
50
(0)
0
Sandwell MBC
0
0
0
0
0
0
0
10
Wolverhampton MBC
0
0
0
0
0
0
0
0
Stafford MBC
0
0
0
0
0
0
0
0
Detox Beds
205
17
19
2
85
61
(25)
(7)
Dudley CRI
0
0
0
0
0
0
0
0
NCA - Other HC
0
0
(0)
(0)
0
(0)
(0)
5
Total Revenue from LAs
910
35
36
1
668
642
(25)
8
Total Revenue from Activies
60,263
5,005
4,845
(159)
25,579
25,043
(536)
(230)
Page 64 of 230
Trust Income & Expenditure Statement - Corporate Functions
Annual
Plan
In Month
Year to Date
FOT M5
2015/16
Plan
Actual
Varian
ce
Plan
Actual
Varianc
e
Var
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
Chief Executive
(685)
(53)
(48)
6
(282)
(246)
36
111
Corporate Affairs
(773)
(47)
(77)
(30)
(325)
(363)
(38)
(52)
Commentary
•
Corporate Functions
•
•
Corporate Human Resources &
Dev. & People
(1,405)
(138)
(43)
95
(632)
(630)
2
(71)
Corporate Medical
(1,165)
(96)
(96)
0
(494)
(522)
(28)
(67)
Corporate Estates
(2,652)
(222)
(271)
(49)
(1,127)
(1,250)
(123)
(45)
Corporate Operations
(1,990)
(164)
(170)
(6)
(838)
(820)
17
(16)
Corporate Finance
(1,141)
(88)
(92)
(4)
(488)
(497)
(9)
(34)
Corporate Performance & IT
(2,506)
(217)
(234)
(17)
(1,090)
(1,077)
12
3
Total Corporate Functions
(12,317)
(5)
(5,276)
(5,406)
(130)
(171)
(1,026) (1,030)
•
•
CEO – Overspends generated by Acting
CEO arrangements/PA Agency
cover/Board to Board
costs/membership fees offset by the
vacancy slippage in Liaison & Diversion.
Corporate Affairs – Consultancy costs
partially offset by Business
Development slippage. Expecting to
utilise all NP.
Dev & People – Redundancy costs now
moved over to reserves (67k) from HR
and vacancy slippage on Development
and People vs. continued usage of
Agency to backfill until posts are
recruited to in the new structure.
Estates overspends relate to slippage
on old year CIP delivery of Estates
Rationalisation and Sustainability PODs.
Plans are in place to complete the
savings for 14/15. Water
Quality/Management/ Security for
Bloxwich/Vehicle Maintenance/
Continued costs for Falcon House/
Structural Surveys all are cost pressures
for the service.
IM&T – NR Budget realignment B7 ESR
post to ESR.
Page 65 of 230
Trust Income & Expenditure Statement - Operational Services
Annual Plan
In Month
Year to Date
FOT M5
2015/16
Plan
Actual
Varianc
e
Plan
Actual
Variance
Var
£'000
£'000
£'000
£'000
£'000
£'000
£'000
£'000
Management and Administration
(994)
(86)
(66)
20
(439)
(340)
99
193
Acute Services
(8,778)
(749)
(734)
15
(3,820)
(3,784)
36
21
Acute Estates
(2,682)
(206)
(206)
(0)
(1,102)
(1,096)
7
0
Older Adults
(6,571)
(548)
(611)
(63)
(2,732)
(2,770)
(37)
(178)
Total Acute & Older Adults
(19,024)
(1,589)
(1,617)
(28)
(8,094)
(7,990)
104
36
Commentary
•
Operational Services
Acute and Older Adults
•
•
Community Services
Community Estates
(732)
(59)
(60)
(1)
(310)
(301)
9
(5)
Management and Administration
(172)
(13)
(15)
(2)
(72)
(73)
(1)
(15)
Community Services & Recovery
(5,645)
(406)
(369)
37
(2,513)
(2,395)
118
222
Early Intervention
(7,364)
(616)
(639)
(23)
(3,095)
(3,322)
(227)
(366)
Recovery Services
0
0
0
0
0
0
0
0
Total Community Services
(13,913)
(1,093)
(1,083)
10
(5,990)
(6,092)
(101)
(164)
Medical Services
(12,009)
(982)
(983)
(1)
(4,974)
(4,960)
14
0
Total Operating Services
(44,947)
(3,664)
(3,683)
(19)
(19,058)
(19,042)
17
(128)
•
•
Acute & Older Adult services overspent by £28k in
August. The true position for August was more or
less breakeven, as the overspend has arisen from
late costs for prior months: £10k costs for 6.00
wte HCAs who started in post on the wards on 1st
July, but – due to lack of paperwork – were not
paid until August; £20k costs for prior month
inpatient agency work not booked/ reported
through the AVA system. After taking this into
account, the Acute wards were in line with budget
overall (within this, Ambleside overspent by
£15k), whilst the OA wards overspent by £38k
(mainly Malvern £19k and Linden £18k), and there
were various savings generated by psychology,
management, CRHT, OA CMHT and day centre
vacancies.
Medical service costs did not vary significantly
from budget in August .
Community Estates – Based upon the occupancy
of buildings and the errors created by NHS
property services, I anticipate a small underspend
for the service. This is still ongoing and we will be
having further meetings towards the end of the
month. Further work needs to be done by the
trust and NHS Property Services/CHP on the
bookable areas within buildings.
Community Services – The Walsall SMS service
currently stands at (4k)/ Walsall Grassmere Unit
has now been capped with income at 34k ytd.
The other contributing factors to the in-month
change are vacancy slippage within the
Psychological Hub/ CRS/ Employment services.
Early Intervention – Vacancy slippage within EI/PC
is offset by the agency usage within the CAMHS
main teams and the project areas. This is being
mitigated by a targeted plan of reduction to
agency costs within CAMHS. This is an on-going
process but started 6-8 weeks ago.
Page 66 of 230
Capital Programme
Commentary
•
There has been very little capital expenditure YTD
(£396k against planned expenditure of £1,083k).
•
In addition, the Capital Plan has been revised in
Month 5 to help deliver the organisation’s ‘stretch
target’ in part via depreciation and amortisation in
year. The revised FOT for 2015/16 is £2,406k
Page 67 of 230
Capital Programme (continued)
Commentary
Page 68 of 230
Financial Performance Metrics
Current Month Metrics
Risk Ratings
Financial Metric
TRU FORM
REFERENCE
Sub
Code
Historic
Year to 31Mar-15
(mc 01)
£000s
Forecast Outturn Metrics
Actual /
Forecast Variance
(mc 03) (mc 04)
£000s
£000s
Plan
(mc 02)
£000s
Actual /
Forecast Variance
(mc 06) (mc 07)
£000s
£000s
Plan
(mc 05)
£000s
Continuity of
Services Risk
Rating
Commentary
•
Monitor published in 2013 a new financial assessment
tool, called the Continuity of Service Metric, which
incorporates two metrics: Capital Service Capacity
(Revenue available for Debt service and or Capital
service) and Liquidity (Cash for Liquidity relative to
turnover).
•
At Month 05 the Trust is reporting a Liquidity Ratio of
55 days, with a forecast outturn of 59 days. A score of
zero or higher gives a maximum metric score of 4.
•
The Capital servicing capacity score for Month 05 is
2.6. A score of 2.5 or above will deliver a maximum
metric score of 4.
•
The two metrics are therefore combined to give a
combined metric of score of 4 for the year to date and 4
for the forecast outturn.
Working Capital comprising:
Total Current Assets
TRU02 sc230
16,140
16,511
16,447
(64)
14,565
15,574
1,009
Total Current Liabilities
TRU02 sc320
(7,047)
(7,367)
(6,930)
437
(5,984)
(5,934)
50
Inventories
TRU02 sc160
0
0
0
0
0
0
0
Non Current Assets Held for Sale
TRU02 sc220
390
390
250
(140)
0
0
0
PFI Prepayments, Current Portion
TRU02 sc510
0
0
0
0
0
0
0
Derivatives, Current Portion
TRU02 sc520
0
0
0
0
0
0
0
TRU02 sc530
0
0
0
0
0
0
0
Current Assets held for Sale by Charitable Funds
TRU02 sc540
0
0
0
0
0
0
0
Current Liabilities held for Sale by Charitable Funds
TRU02 sc550
0
0
0
0
0
0
0
8,703
8,754
9,267
513
8,581
9,640
1,059
Liquidity Ratio Financial Assets Available for Sale
(days)
SUB TOTAL: WORKING CAPITAL BALANCE
371
Annual Operating Expenses comprising:
Operating Expenses
TRU01 sc100, 110
63,177
25,471
25,751
280
61,184
60,904
(280)
Add back: Amortisation
TRU01 sc420
(229)
(108)
(87)
21
(256)
(213)
43
Depreciation
TRU01 sc410
(1,321)
(616)
(541)
75
(1,483)
(1,441)
42
Impairments
TRU01 sc425,570,580
(302)
(5)
0
5
(20)
0
20
SUB-TOTAL: ANNUAL OPERATING EXPENSES
Liquidity Ratio Days (Working Capital Balance /
Annual Operating Expenses)
372
61,325
24,742
25,123
381
59,425
59,250
(175)
373
51
53
55
2
52
59
7
Liquidity Ratio Metric
374
4
4
4
0
4
4
0
239
Revenue Available for Debt Service comprising:
Capital
Servicing
Capacity
(times)
EBITDA
TRU01 sc490
3,527
1,643
1,350
(293)
3,912
4,151
Restructuring Costs
TRU01 sc500
0
0
0
0
0
0
0
Normalised EBITDA
TRU01 sc510
3,527
1,643
1,350
(293)
3,912
4,151
239
Interest Receivable
SUB-TOTAL: REVENUE AVAILABLE FOR DEBT
SERVICE
TRU01 sc430
375
Annual Debt Service comprising:
Finance Costs (including interest on PFIs and Finance
Leases)
TRU01 sc440
Dividends
TRU01 sc460
Public Dividend Capital repaid in year: PDC Capital & TRU04 sc427, 441,
Revenue
442
Loans repaid to DH - Capital Investment Loans
Repayment of Principal
TRU04 sc480
Loans repaid to DH - FT Liquidity Loans Repayment of
Principal
TRU04 sc490
Loans repaid to DH - Revenue Support Loans
Repayment of Principal
TRU04 sc492
Capital element of payments relating to PFI, LIFT
Schemes and finance leases
TRU04 sc495
Other Borrowings Repaid (inc Other Loans and
Working Capital Facility)
TRU04 sc429, 500
(44)
(16)
(18)
(2)
(40)
(43)
(3)
3,571
1,659
1,368
(291)
3,952
4,194
242
0
0
0
0
0
0
0
1,201
525
526
1
1,263
1,251
(12)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
SUB-TOTAL: ANNUAL DEBT SERVICE
Capital Servicing Capacity (times) (Revenue
available for Debt Service / Annual Debt Service)
376
1,201
525
526
1
1,263
1,251
(12)
377
3
3
3
(1)
3
3
0
Capital Servicing Capacity metric
378
4
4
4
0
4
4
0
Continuity of Services Risk Rating for Trust
379
4
4
4
0
4
4
0
Liquidity ratio (days)
50
4
3
2
1
0
-7
-14
<-14
Capital servicing capacity
50
4
3
2
1
2.5
1.75
1.25
<1.25
%
%
Page 69 of 230
TDA Key Financial Data: Month 5
Commentary
Key Metrics
(A) Accountability Framework
Variance
by Month
Current Month Metrics
Sub
Code
Sign
Plan
(mc 01)
Actual /
Forecast
(mc 02)
Variance
(mc 03)
£000s
£000s
£000s
RAG
Rating
(mc 04)
RAG By
Month
May
(mc 05)
Jun
(mc 06)
Jul
(mc 07)
£000s
£000s
£000s
May
(mc 16)
Jun
(mc 17)
Jul
(mc 18)
•
The Trust has plans in place
to deliver the £2.1million CIP
plan. At Month 5, schemes to
the value of £276k have been
retained centrally and are
covered by reserves,
however several of the CIP
schemes are running behind
plan and this is reflected
here.
•
The Trust is currently behind
plan to deliver the revised
£1,267k planned surplus but
is still forecasting to deliver
as expected this target at
outturn.
•
Continuity of Service scores
are at a maximum of 4.
NHS Financial Performance
1a) Forecast Outturn, Compared to Plan
100
+/-
950
1,267
1b) Year to Date, Actual compared to Plan
150
+/-
410
192
(218)RED
317GREEN
20
0
0GREEN
GREEN
GREEN
2
(57)
(178)GREEN
AMBER
RED
RED
RED
Financial Efficiency
2a) Actual Efficiency recurring/non-recurring
compared to plan - Year to date actual compared to
plan
200
+/-
- Total Efficiencies for Year to Date compared to Plan
210
+/-
986
883
(103)
0
(50)
(94)
- Recurrent Efficiencies for Year to Date compared to
Plan
215
+/-
986
746
(240)
(52)
(140)
(210)
2b) Actual Efficiency recurring/non-recurring
compared to plan - Forecast compared to plan
220
+/-
- Total Efficiencies for Forecast Outturn compared to
Plan
225
+/-
2,430
2,430
0
0
0
3
- Recurrent Efficiencies for Forecast Outturn
compared to Plan
230
+/-
2,430
2,238
(192)
(195)
(129)
(192)
3) Forecast Underlying surplus / (deficit) compared to
Plan
250
+/-
2,248
2,565
317GREEN
0
Cash and Capital
4) Forecast Year End Charge to Capital Resource
Limit
350
+/-
2,811
2,016
795RED
0
5) Permanent PDC/Interim RWCSF accessed for
liquidity purposes
400
+/-
Trust Overall RAG Rating
455
RED
AMBER
AMBER
AMBER
AMBER
AMBER
22
0GREEN
GREEN
GREEN
0
0GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
RED
GREEN
AMBER
AMBER
Underlying Revenue Position
0
(B) Continuity of Service Risk Ratings
Year to Date Rating
460
+/-
4.00
4.00
0.00GREEN
0
0
0GREEN
GREEN
GREEN
Forecast Outturn Rating
465
+/-
4.00
4.00
0.00GREEN
0
0
0GREEN
GREEN
GREEN
Page 70 of 230
Cash Flow Statement
Commentary
Cash Flow
•
The Trust has made an operating surplus of £701k in 2015/16
and received cash of £627k in respect of depreciation and
amortisation
•
Trade and Other Receivables increased over the period (a
negative impact on cash)
•
Trade and Other Payables decreased over the period (a
negative impact on cash)
•
The Trust has received £18k of interest, and spent £944k on
capital (£550k on reducing capital payables from the 2014/15
year end and £394k on 2015/16 capital expenditure). Total
capital expenditure in cash terms was more than the cash
received for depreciation and amortisation (a negative impact
on cash)
•
The impact of all these movements was to increase the
Trust’s cash balance YTD by £95k
Page 71 of 230
Payables Performance & Aged Debt
Aged Debt as of August 2015
Better Payment Practice Code
Non-NHS
Mth 01
Mth 02
Mth 03
Mth 04
Mth 05
Non-NHS YTD
<75%
NHS
Mth 01
Mth 02
Mth 03
Mth 04
Mth 05
NHS YTD
<75%
75% - 95%
31-60 days
61-90 days
91-120 days
120+ days
23.0%
3.7%
>95%
93.81%
96.27%
94.07%
91.98%
93.24%
93.71%
75% - 95%
Current
Transactions by
Number
Value
Agreed Tolerances
95.38%
97.11%
95.86%
92.59%
95.44%
95.13%
66.6%
16.4%
-9.7%
Debt Profile and Value
>95%
92.59%
95.83%
96.15%
100.00%
100.00%
97.14%
99.65%
90.87%
99.94%
100.00%
100.00%
98.61%
Commentary on Payables
Better Payment Practice Code
•
The Trust meets the 95% target across all but the Non-NHS by Number indicator both
in month and YTD.
•
100% of NHS invoices were paid on time in the month again in August.
•
Non-compliance continues to be as a result of IAS transactions not being appraised or
approved on a timely basis by Requisitioners or Budget Holders. Financial Services
department continue to contact those responsible for late payments to offer assistance
and further training if required.
Current
£000
£465
31-60 days
£000
-£68
61-90 days
£000
£114
>20%
>10%
Agreed Tolerances
10% - 20%
5% - 10%
91-120 days
£000
£26
121+ days
£000
£160
Total
£000
£698
% of Total
Debt
<10%
<5%
Value
£000
£186
£160
Aged Debt
Over 91 days
Over 120 days
26.7%
23.0%
Commentary on Aged Debt
Aged Debt Profile by Value
•
57% of outstanding invoices were aged 60 days or less at the month end (this figure
was 55% at the end of July).
•
27% of debt was aged 90 days or older at the end of July (this figure was 31% at the
end of the previous month).
•
Debt over 90 days old relates in the main to a 2014/15 CQUIN invoice. Negotiations
are ongoing with Dudley CCG and it is hoped that it will resolved shortly.
Page 72 of 230
Cost Improvement Programme
Cost Improvement Programmes (by POD)
Annual
Schemes
Schemes
Delivered
Delivered
Plan
Devolved
Held Centrally
Recurrently
Non-Rec
Variance
Profiling
£'000
£'000
£'000
£'000
£'000
£'000
(due date)
POD 078 - Night Co-Ordinators
19.2
19.2
0.0
0.0
8.0
11.2
Apr'15
POD 079 - Dudley Chaplaincy
12.0
12.0
0.0
1.0
0.0
11.0
Apr'15
POD 080 - Psychiatric Liaison
17.8
17.8
0.0
17.8
0.0
0.0
Apr'15
POD 081 - Acute Bed Capacity (Cat A Income)
100.0
100.0
0.0
0.0
0.0
100.0
Apr'15
POD 082 - OA Bed Capacity (Cat A Income)
100.0
100.0
0.0
0.0
0.0
100.0
Apr'15
POD 083 - Taxi Usage
10.0
10.0
0.0
10.0
0.0
POD 084 - Estates Rationalisation
POD 085 - Catering Review
50.0
50.0
50.0
50.0
0.0
0.0
3.0
0.0
0.0
0.0
0.0
47.0
Apr'15
Oct'15
50.0
Oct'15
POD 086 - Postage
10.0
10.0
0.0
10.0
0.0
0.0
Apr'15
POD 087 - Care Home Post
7.0
7.0
0.0
5.8
1.2
0.0
Apr'15
POD 088 - Corporate Clinical Leadership Structures
263.0
263.0
0.0
263.0
0.0
-0.0
Apr'15
POD 090 - Staff Side
18.2
18.2
0.0
18.2
0.0
0.0
Apr'15
POD 091 - L&D
43.4
43.4
0.0
43.4
0.0
0.0
Apr'15
POD 092 - Back Office functions
200.0
200.0
0.0
200.0
0.0
0.0
Apr'15
POD 093 - Agile Working (Mobile Phones)
43.0
0.0
43.0
0.0
0.0
43.0
Apr'15
POD 094 - Agile Working (Landlines)
15.0
3.2
11.8
3.2
0.0
11.8
Apr'15
POD 096 - Business Mileage
POD 097 - Corporate Savings
41.9
170.4
41.9
170.4
0.0
0.0
16.5
170.4
9.4
0.0
16.0
0.0
Apr'15
Apr'15
POD 098 - Pay Awards
250.0
250.0
0.0
250.0
0.0
0.0
Apr'15
POD 100 - Demand & Capacity (Cat A Income)
250.0
250.0
0.0
0.0
0.0
250.0
Apr'15
POD 101 - IT Helpdesk calls
18.8
18.8
0.0
0.0
0.0
18.8
Jul'15
POD 102 - Teleconferencing
6.0
6.0
0.0
0.0
0.0
6.0
Apr'15
POD 103 - DNA in OA Clinics (Cat A Income)
20.0
20.0
0.0
0.0
0.0
20.0
Apr'15
POD 104 - Journals and Subscriptions
22.5
22.5
0.0
22.5
0.0
0.0
Apr'15
POD 105 - Procurement and Tendering
200.0
61.1
138.9
61.1
0.0
138.9
Apr'15
POD 106 - Salary Exchange
16.0
0.0
16.0
0.0
0.0
16.0
Apr'15
POD 107 - Staff Flow
66.0
POD 108 - Long Acting Injections
POD 109 - Patients own drugs
50.0
5.0
0.0
50.0
66.0
0.0
0.0
50.0
0.0
0.0
66.0
0.0
Apr'15
Apr'15
5.0
0.0
5.0
0.0
0.0
Apr'15
POD 110 - Clozapine Clinic
17.0
17.0
0.0
0.0
8.5
8.5
Apr'15
POD 111 - Aripiprazole
50.0
50.0
0.0
37.5
12.5
0.0
Apr'15
POD 044 - CAMHs SpR
4.9
4.9
0.0
4.9
0.0
0.0
Apr'15
2,147.0
1,871.2
275.8
1,193.2
39.6
914.2
Total CIPs
In relation to Activity CIPS as at Month 5 only Demand & Capacity elements are currently reflecting a level of over-performance and thus a contribution towards CIP
Full Delivery
1,372.2
Part Delivery
91.0
Part Shortfall
185.6
Not Delivering
478.6
RAG
Commentary
•
Target for 2015/16 = £2,143k.
•
2015/16 Month 5 YTD = £1,871k
schemes devolved to appropriate
budget areas and £276k is being
managed centrally in reserves.
•
The schemes currently managed
through reserves need to be
allocated out to the appropriate
budget areas and delivered as
soon as possible.
•
Schemes transacted and delivered
equate to £1,233k (split £1,193k
recurrent and £40k non-recurrent),
which is 57.42% achievement.
•
Schemes not delivering to plan or
not due to start till later in the year
equate to £914k or 42.58% of the
target for the year. The majority of
this relates to the £470k Activity
CIP but there is a level of overperformance that is contributing
around £104k towards the YTD
target of £196k – this has yet to be
transacted.
•
TDA CIP target is £2,430k, but the
Trust has reviewed its
commitments for 2015/16, and
agreed a internal target of
£2,143k.
•
Work is ongoing to ensure 2016/17
schemes begin to deliver cash
reductions from 1st April 2016.
Plans and milestones need to be
in place to ensure delivery is
achieved for the start of the new
financial year.Page 73 of 230
Statement of Financial Position
Commentary
Non Current Assets
•
Depreciation and amortisation exceed capital expenditure
in 2015/16 but this is to be expected as this years Capital
schemes get under way
•
Final outturn against capital schemes is reviewed later in
this report
Current Assets
•
Receivables have increased by £352k in 2015/16.
•
Cash is £95k higher than the balance at 31 March 2015.
This is due to the surplus building prior to the 6 monthly
payment of PDC scheduled for September.
•
An analysis of cash flows can be seen elsewhere in this
report.
Current Liabilities
•
Payables have reduced by £148k in the financial year.
•
The increase in provisions relates to additional NHSLA
excesses being provided for in the new year (£20k relates
to the flood at DPH).
Tax Payers’ Equity
•
The Current Year I&E figure reflects the surplus for the
year to date of £192k. This is £218k behind the original
plan YTD.
•
The transfer between reserves relates to a small
revaluation reserve held in the accounts in respect of Rose
Cottage at the point of it’s sale.
Page 74 of 230
Section 1
Summary of Trust Incidents and
Serious Incidents
Page 75 of 230
Section 1 - Trust Summary
Quality and Safety Report September
2015
1.2 - Actual Impact and Duty of Candour
Table 1.2.1
All Trust Incidents Level of harm & Duty of Candour
Chart 1.2.1 - All Trust Incident, compared to reportable Patient Safety
Incidents and Reportable Security Incidents
Trust Patient Safety
Incidents (PSI)
Actual Impact
350
Acute &
Access
Older
E.I.
Community
& Recovery
300
1 No Harm
82
58.99%
63
14
3
2
250
2 Low Harm
52
37.41%
31
16
4
1
200
3 Moderate Harm
1
0.72%
1
0
0
0
4 Severe Harm
0
0.00%
0
0
0
0
5 Death
1
0.72%
1
0
0
0
Ungraded
2
1.44%
2
0
0
0
PSI
139
Duty of
Candour
150
100
50
0
Sep
Oct Nov Dec
Jan
Feb Mar Apr May Jun
2014
Jul
Aug
2015
SIRS
PSI
All Incidents
Duty of Candour
From the Number of Patient Safety Incidents shown in Table 1.2.1;
During August there have been 2 cases where duty of candour has been considered. Only one of these cases has been considered appropriate for the Duty of Candour process.
The case below is being consider for Duty of Candour.
2015/28652 this incident occurred on 28/08/2015 and has subsequently been formally logged on the 01/09/2015 and therefore will be included in next months SI figures:
A strategy meeting is to be held on 03/09/2015 regarding this case. Details of this case are still emerging but an informal patient has been found deceased in their car whilst on leave from our care, the death
is believed to be Suicide. The Trust currently hold s no Next of Kin details, this appears to be at the patient's request due to complex family dynamics. Actions from the strategy meeting will be to contact GP
and further contact with the coroner to identify the next of Kin.
Page 76 of 230
Quality & Safety Exception
Report
Section 1
Summary of Trust Incidents and Serious Incidents
1 August 2015 to 31 August 2015
326 INCIDENTS
REPORTED
3 SIs*
42.94% of incidents were Patient Safety
Incidents (140 of 326 incidents)
0 Never
Events
Service Line
57 SIRS**
No.
Incidents
Older
103
E.I.
13
Comm & Rec
9
Other
6
DisDisruptive / Aggressive Behaviour
Pat
164
Patient Accident
32
Clinical Care, Assessment And MHA
Clin
29
Ser
Serious Harming Behaviour
22
Hea
Health & Safety
20
Access, Admission, Transfer
18
Medication
11
Security
9
Consent, Communication And
6
Equipment
6
Documentation
3
Infection Control Incident
3
Fire Incident
2
Skin Integrity
1
326 Total Incidents
Reported
Disruptive / Aggressive Behaviour: Top Causes
1
Behavioural - Aggressive
47 incidents
2
3
Behavioural - Disruptive
23 incidents
Behavioural - Destructive / Damage To Property
19 incidents
Patient Accident: Top Causes
Incidents by Cause
195
Service Lines
Acute
No.
Incidents
Cause Group
1
Fall - Unobserved Fall Mobilising Alone
7 incidents
2
Patient - Faint/ Fit / Unwell
7 incidents
3
Fall - Observed Fall Mobilising Alone
5 incidents
1
Clinical Care, Assessment And MHA: Top Causes
Death - Natural Causes/Expected
8 incidents
2
Clinical - Treatment / Care Related
7 incidents
3
Clinical - Lack Of Clinical Or Risk Assessment
3 incidents
Serious Harming Behaviour: Top Causes
1
Attempted Suicide - Ligature
4 incidents
2
Self Harm - Self Injury
4 incidents
3
Attempted Suicide - Medication Overdose
3 incidents
Health & Safety: Top Causes
1
Clinical Waste / Environment
6 incidents
2
Non Patient Slip Trip & Fall
5 incidents
3
NOTE: The skin Integrity Incident relates to Acute Services.
A patient was transferred back to the inpatient ward from
WMH following physical health issues wIith a pressure
identified which had been omitted from the discharge
summary. This was a low grade 2 pressure sore. Details
have been forwarded onto WMH Safeguarding Lead.
* SI: Serious Incidents
** SIRS: Security Incidents Reporting System
Page 77 of 230
Section 2
Individual Operational
Service line Reports
Page 78 of 230
Section 2 - Service Line Reports
Quality and Safety Report September
2015
2.1 - Acute & Access Service Line
Commentary
Chart 2.1.1 - Total Acute & Access incident numbers received by the Trust during the last 12
months
100%
190
80%
170
150
60%
130
40%
110
90
20%
70
50
The monthly (mean) average for incidents relating to Acute & Access Services (calculated using
data from the last 12 months) is 145.17
Bed Occupancy
210
0%
Acute and Access Services
12 Monthly Average
Mean + 2S.D.
Mean - 2S.D.
Acute Bed Occupancy
Table 2.1.1 - Total Acute & Access incidents by Cause Group and showing a position on the
Trend analysis
Incident Cause Group
Disruptive / Aggressive Behaviour
Access, Admission, Transfer Discharge
Patient Accident
Current
Month
94
17
21
16
12
Position on previous
month
54

18

14

16

9

Medication
Health & Safety
Security
Consent, Communication And Confidentiality
9
13
3
3
23
10
5
3




Fire Incident
Skin Integrity
Documentation
Equipment
2
1
1
1
7
1
0
1




2
0

195
161

Grand Total
Last 12 months
•Chart 2.1.1 shows the incident numbers for Acute & Access Services have increased since the
previous month, and remain above the 12 month average.
• Chart 2.1.1 also offers a comparison of the bed occupancy for acute inpatient services during
this period.
•Table 2.1.1 shows the total number of incidents broken down by cause group.
•The most reported Incident categories are Disruptive / Aggressive Behaviour & Clinical Care
and assessment.
Exceptions/Trends
There has been an increase in the number of incidents since the previous month. the chart
below shows that there has been in increase in the number of incidents on the Walsall Wards;
in particular Langdale wards. This increase was noticed in the previous month and was
documented to be in relation to specific patients and difficult presentation.
The increase in Clinical care and assessment incidents appear to be in relation to a hand full of
incidents from Langdale and refer to difficulties in transferring patients. 2 patients have been
highlighted and there appear to be a cluster of incidents in relation to the transfer of 2 patients
between ourselves and a PICU unit. This has been raised with the commissioners . Risk Plans
are in place to mitigate potential for harm to patients and staff.
80
70
60
50
40
30
20
10
0
Acute - Inpatient incidents
Langdale Ward
Ambleside Ward
Kinver Ward
Wrekin Ward
Clent Ward
Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
2014
2015
Page 79 of 230
Quality and Safety Report September 2015
2.2 Older Adults Service Line
Chart 2.2.1 - Total Older Adults incident numbers during the last 12 months
200
Table 2.2.1- Total Older Adults Level of harm & Duty of Candour
90%
70%
150
60%
50%
100
40%
30%
50
20%
10%
0%
0
Older
12 Monthly Average
Mean - 2S.D.
Older Adults exc Leave
Patient Accident
Health & Safety
Security
Medication
Skin Integrity
Equipment
Documentation
Fire Incident
Grand Total
Current
Month
66
19
6
3
3
2
0
0
1
2
1
0
0
0
103
1 No Harm
14
2 Low Harm
16
3 Moderate Harm
0
4 Severe Harm
0
5 Death
0
Ungraded
0
Mean + 2S.D.
Table 2.2.2 - Total Older Adults incidents by Cause Group and showing a position on the
previous months figures
Trend analysis
Position on previous
month
75

28

8

2

3

4

2

3

5

1

0

0

1

0

132

Bed Occupancy
80%
Last 12 months
PSI
30
Duty
of
Candour
SIRS
4
Commentary
The monthly (mean) average for incidents relating to Older Adults Services (calculated using data
from the last 12 months) is 114.67
• Chart 2.2.1 shows there has been a reduction in the number of Incidents for the Older adults
service line.
• Table 2.2.1 shows information about the level of harm and Duty of Candour. This table also offers
number of reportable Patient Safety Incidents (PSI) and Security Incidents (SIRS). All of the incident
reported were considered either No, or Low Harm.
• Table 2.1.2 shows the total number of incidents broken down by cause group.
The most reported Incident categories are Disruptive / Aggressive Behaviour & Patient Accident
Exceptions/Trends
The increase in overall incidents is in relation to the 2 functional wards. this is in relation to specific
patients who are displaying challenging behaviour in relation to their current mental health
presentations. Both patients have careplans in place which are reviewed regularly by the senior
clinical lead.
Page 80 of 230
2.3 Early Intervention Service line
Table 2.3.2 - Total Early Intervention incidents by Cause Group and showing a position
on the previous months figures
Medication
Security
Health & Safety
Patient Accident
Documentation
Equipment
Fire Incident
Skin Integrity
Grand Total
Early Intervention
Current Previous month Last 12
Month
months
3
1
2
0
2
3
0
0
1
0
1
0
0
0
3
5
4
0
3
0
2
0
1
0
0
0
0
0














13
18

Chart 2.3.1 - Total Early Intervention incident numbers during the last 12 months
25
20
15
10
5
0
Sep-14
Oct-14
E.I.
Nov-14
Dec-14
Jan-15
Feb-15
12 Monthly Average
Mar-15
Apr-15
May-15
Mean + 2S.D.
Jun-15
Jul-15
Aug-15
Mean - 2S.D.
Commentary
The monthly (mean) average for incidents relating to E.I. Services (calculated using data from the last 12 months) is 10.42
• Chart 2.3.1 shows this month has seen a slight decrease in the number of Incidents for the Early Intervention service line, with 13 incidents reported
for the month.
Exceptions/Trends
All incidents relate to individual services and the incidents have no specific trend.
Page 81 of 230
2.4 Community & Recovery Service line
Chart 2.4.1 - Total Community & Recovery incident numbers during the last 12 months
Table 2.4.2 - Total Community & Recovery incidents by Cause Group and
showing a position on the previous months figures
40
Walsall SMS Contract End
35
Medication
Security
Health & Safety
Patient Accident
Documentation
Equipment
Fire Incident
Skin Integrity
Grand Total
Community & Recovery
Last 12
Current
months
Previous
Month
month
0
3

4
1

1
2

0
1

0
0

0
0

1
0

0
0

0
0

2
0

1
0

0
0

0
0

0
0

9
7
30
25
20
15
10
5
0
Community & Recovery Service
12 Monthly Average

Commentary
The monthly (mean) average for incidents relating to Community & Recovery (calculated using data from the last 12 months, and as a combination of the previous individual Services) is 19.75
• Chart 2.4.1 shows the incident figures which have shown a slight increase since the previous month.
Exceptions/Trends
All incidents relate to individual services and the incidents have no specific trend.
Page 82 of 230
Section 3
Serious Incidents
Page 83 of 230
Table 3.1 - List of Serious Incident raised during the month of July 2015
SI Number
Date of Incident
Service Line
2015/25940
30/07/2015
Acute
2015/27839
19/08/2015
2015/27935
19/08/2015
Incident Description
DoC applicable
Level of response
Current status
Low
No
STEIS - Level 1 Clinical Review
Ongoing
Moderate/High
No
STEIS - Level 1 Full Investigation
Ongoing
High
No
STEIS - Level 1 Full Investigation
Stop the clock pending
Police investigation
Failure To Return From Leave
Community & Recovery Attempted Suicide - Ligature
Acute
Level of Risk
Homicide Actual Or Attempted
Chart 3.2 - Total number of Serious Incidents during the last 12 months
Chart 3.1 - Summary of the Serious Incident types during the last 12 months
5%
12
3% 3%
2%
Access Admission Transfer Discharge
10
8
13%
6
40%
Patient Accident
4
Clinical Care Assessment And MHA
2
34%
0
Security
Health & Safety
Serious Incidents
Trust Average
Mean + 2S.D.
Mean - 2S.D.
Commentary
The monthly (mean) average for serious incidents across the Trust (calculated using data
from the last 12 months) is 5.58
Table 3.1 Shows a list of the serious incident logged on STEIS during the previous
month, this includes details of the service line and nature of the incident
• The 3 Serious Incidents are linked to 2 Service lines
Chart 3.2 shows that the number of Serious Incidents is above the 12 monthly average
Chart 3.1 illustrates the types of the Serious Incidents that have been reported over the
previous 12 months.
Incident Summary
2015/25940 - This is the case of a patient who failed to return from agreed leave. Whilst safe and well at home
patient was under section and refusing to return to the ward. There are elements of this case in relation to
social care and housing and there are multi-agencies involved in this patients care.
2015/27839 - This is in relation to a patient in crisis who contacted the HTT to inform them of their intention
to end their life by hanging. Emergency Services were contacted and attended the property to find the patient
un responsive but breathing. Patient has since made a full physical recovery, and is now being supported for his
mental health needs. A Clinical Review is underway.
2015/27935 - This is the case of a patient known to our service who has been arrested and charged in
connection with the death of a 20yr Female. A strategy meeting has been held in relation to this case, with
multiple agencies involved and will become a Serious Case review. Whilst this case is currently with the police,
initial investigations are underway within the Trust to look into this patients access with our service.
Page 84 of 230
Section 4
National Guidance:
Safety Alert Broadcasts (SAB's)
Page 85 of 230
Quality and Safety Report
August 2015
Section 4 - CAS Alerts
Table 4.1 – Summary of Alerts received during August 2015
Type of Alert
MDA
MHRA
CMO
DDL
EFN
DH – EFA
DH
NHS – PSA
Total
Number of
Alerts in Aug
5
Action not
Required
5
1
13
1
13
1
20
19
Assessing
Relevance
Action
Required
Circulated for
Information
1
1
 During August 2015 there were 20 alerts issued via the Central Alerting System, of these 20 alerts:
o 19 Alerts required no action taking.
o 1 Alert required circulating for information and was circulated accordingly
o 0 Alerts are currently being assessed for relevance, the full details of which are outlined below.
 The table below (4.2) outlines a summary of the alerts issues and any action taken.
Table 4.2 –Alerts issued during August via the Central Alerting System
Alert
Number
Alert
Date
Description of Alert
Status
Notes / action taken / assurance
EFN/2015/13
03-Aug2015
High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - Switchgear & Cowans - RAE4
- Ring Main Unit
Action Not
Required
EFN/2015/14
04-Aug2015
High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - Long & Crawford - T3GF3 Ring Main Unit
Action Not
Required
MDA/2015/028
04-Aug2015
Action Not
Required
EFN/2015/15
05-Aug2015
Automatically retracting safety syringes, including insulin syringes, manufactured by Medicina Ltd.
The manufacturer is recalling these devices due to two problems: there is a risk of needle stick injury as they
may not automatically retract and the shelf life stated on the devices is incorrect, compromising the sterility of
the product.
High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - Schneider Electric - RN2c Ring Main Unit
The Trusts authorising officer acknowledged
receipt of the alert and that no action was required
by the Trust
by the Trust
The Trust has no history of having purchase / used
any of these devices
MDA/2015/030
05-Aug2015
06-Aug2015
Shiley neonatal and paediatric tracheostomy tubes, manufactured by Medtronic (previously Covidien):
specific product and lot numbers are affected.
High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - South Wales Switchgear D8/12X - Circuit Breaker
Action Not
Required
Action Not
Required
10-Aug2015
High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - Merlin Gerin - Genie EVO Circuit Breaker
Action Not
Required
EFN/2015/16
EFN/2015/17
Action Not
Required
by the Trust
The Trust does not use these particular devices
by the Trust
by the Trust
Page 86 of 230
Alert
Number
Alert
Date
EL (15)A/07
12-Aug2015
EFN/2015/18
Description of Alert
Status
Notes / action taken / assurance
Action Not
Required
by the Trust
17-Aug2015
Drug alert class 4, for information, teva uk limited, pregabalin 75mg capsules
Teva UK Limited has notified us of a printing error on some blisters of Pregabalin 75mg capsules from one
batch only. The strength is printed incorrectly, as 25mg, in one position on the foil for approximately 1 in 3
blisters
High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - Areva T&D Automation
& Information Services - MiCOM P123 - Protection Relay
Action Not
Required
by the Trust
EFN/2015/19
18-Aug2015
High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - GEC Alsthom - VMX Circuit Breaker
Action Not
Required
NHS/PSA/Re/
2015/007
18-Aug2015
Addressing antimicrobial resistance through implementation of an antimicrobial stewardship programme
MDA/2015/031
18-Aug2015
Home-use blood glucose monitoring system: Accu-Chek Mobile meter and Accu-Chek Mobile test cassette –
manufactured by Roche Diabetes Care
Action
Required:
Ongoing
Action Not
Required
by the Trust
The Trust is to signpost the toolkits to relevant
staff to support the NHS in improving antimicrobial
stewardship.
The Trust has no history of having purchase / used
any of these devices
EFN/2015/20
19-Aug2015
Low Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - Eaton Electric - Eaton
Capitole 40 - Switchboard
Action Not
Required
by the Trust
EFN/2015/21
20-Aug2015
High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - FKI - Eclipse - Circuit
Breaker
Action Not
Required
EFN/2015/22
24-Aug2015
High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - Whipp & Bourne - CV - Circuit
Breaker
Action Not
Required
EFN/2015/23
25-Aug2015
High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - Reyrolle - ROKSS Ring Main Unit
Action Not
Required
MDA/2015/032
25-Aug2015
Charging base for surgical hair clippers. Manufactured by Medline Industries
Action Not
Required
by the Trust
by the Trust
by the Trust
EFN/2015/24
26-Aug2015
High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - Reyrolle - LM23T - Circuit
Breaker
Action Not
Required
by the Trust
MDA/2015/033
26-Aug2015
Sterile electrosurgical forceps and electrodes. Manufactured by Zethon Limited and Ross Electro Medical
Limited.
Action Not
Required
EFN/2015/25
27-Aug2015
High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - Whipp & Bourne DV40 - Circuit Breaker
Action Not
Required
by the Trust
Page 87 of 230
DWMHT Safeguarding Performance Framework
2015/16
Section 1
• Safeguarding Training Compliance
Section 2
• DoL's
• Domestic Violence
Section 3
• Safeguarding Children
LAC - CAMH's
•
Page 88 of 230
Section 1
Safeguarding Training Compliance
Page 89 of 230
Section 1 - Training Summary
Adult
Safeguarding Performance
Framework for August 2015
Dudley
Walsall
Trust
YTD
YTD
YTD
Level 1 Safeguarding Adults Level 1 - 3 Years
83.11%
85.23%
82.72%
74.86%
80.30%
75.81%
98.97%
99.35%
99.22%
Dudley
Walsall
Trust
Children
YTD
YTD
YTD
Level 1 Safeguarding Children Level 1 - 3 Years
87.24%
89.39%
86.81%
77.11%
82.95%
79.48%
98.97%
99.35%
99.22%
Dudley
YTD
Walsall
YTD
Trust
YTD
Compliance with MCA and DoLs Training (%)
76.88%
77.78%
77.20%
Prevent Training
12.66%
16.62%
15.04%
Exceptions / Commentary
This section looks at Training compliance with the Safeguarding and Vulnerable Adults. This isnformation is broken down by Service locality
and provides a overall Trust Complaince (NB. there is a variance on the overall trust figures which includes corporate teams, not specific to
individual locations).
PREVENT training.
The Trust has delivered basic awareness across all clinical areas which was included in the PREVENT leaflet and also incorporated within the
safeguarding adults and information governance training. The % compliance relates to the face to face health wrap 3. There is a training
delivery plan in place to ensure appropriate compliance figures are achieved.
Data Quality Assurance
There continues to be data quality checks in relation to the information contained on the ESR System. Work is being conducted to review the
current compliance figures against the requirements of the clinical workforce.
Page 90 of 230
Section 2
Deprivation of Liberty (DoL's)
&
Domestic Violence
Page 91 of 230
Safeguarding Performance Framework for August 2015
Section 2 - DoL's and Domestic Violence
2.1 Deprivation Of Liberties (DOL's) - This shows the total number of active cases of DOL's,
broken down by Locality
Dudley
DOL's Active
DOL's Closed
Walsall
DOL's Active
DOL's Closed
Total Cases
2015
2014
Sep Oct Nov Dec Jan Feb Mar Apr May Jun
1
4
1
3
1
1
3
1
2
2
3
4
1
1
5
1
1
1
4
4
4
1
2
2
3
3
3
3
6
1
3
1
2
4
1
9
1
8
10
3
6
1
5
9
2
2
2
Jul Aug
2
3
2
3
7
6
1
9
2
1
1
5
Grand
Total
19
5
14
42
10
32
61
Commentary
10
3
6
3
5
1
4
3
6
4 10
Table 2.1
This table shows the activity in relation to cases of Deprivation Of Liberties (DOL's). This information is broken down
by locality and shows the current number of Active cases, and activity for the last 12 months.
There are currently 15 active cases of DoL's across the Trust
2.2 Domestic Abuse
Total number of cases of Domestic Violence for the current month,
these include cases reported within the Trust and Externally notified
by MARAC (Multi-Agency Risk Assessment Conference)
Dudley
Walsall
Open To
Open To
Cases
Cases
Mental
Mental
Checked
Checked
Health
Health
DART
MARAC
N/A
152
17
1029
64
Safeguarding Cases Internally reported as
Domestic Abuse
Alert Only
Referral
126
18
Aug-15
24
7
Further information relating to Older Adults, health related legal restrictions / provisions
• Dudley - 8 patients (5 DoL's & 3 under MHA)
• Walsall - 15 patients (10 DoL's and 5 under MHA)
Table 2.2
Domestic abuse cases are reported as separate figures to display the prevalence within the service. Case figures are
also shown for MARAC (multi agency risk assessment conference), these figures demonstrate how many cases are
heard at MARAC where the victim, perpetrator or children are open cases to mental health.
• The first table provides information on Cases reported Externally of the Trust which are then checked to see if
these Patients are open to Dudley and Walsall Mental Health.
• It is to note that we do not have Dudley DART data, we continue to request this information however the Police
currently are looking to resolve data issues in order to support this request.
• The second table provides information on Domestic Abuse cases which have been reported internally into our
Trust
Page 92 of 230
Section 3
Safeguarding Children
&
Vulnerable Adults
Page 93 of 230
Safeguarding Performance Framework
for August 2015
3.1 Safeguarding Children
Graph 3.1 - This graph provides information relating to the last 12 months and shows a breakdown of Safeguarding cases which are just for alert only and those which have been progressed
to be continued under Safeguarding
Table 3.1 -This shows that the number of Safeguarding cases broken down by case type and showing the locality . This also shows infor mation on whether the case is for alert only or if it
has been referred for further investigation to another agency.
There was a notable decrease in July of referrals being made to Children's Services due to the alerts not reaching the thresh old for referral and will continue to be monitored by Mental
Health Services.
Table 3.1.1
This table provides information in relation to Looked after Children (LAC), who have been referred or in receipt of our servi ces.
Table 3.1 Total number of Safeguarding
Children cases for the current month
Child Safeguarding Case
Position of Trust
Under 18 Admission
Under 18 Death
Grand Total
Referral
Dudley
Alert Only
Referral
Walsall
Alert Only
Grand
Total
11
0
0
0
11
4
0
0
0
4
12
1
0
0
13
9
0
0
0
9
36
1
0
0
37
30
25
20
15
10
Table 3.1.1 Looked after Children (LAC)
Total number of cases of Looked after Children
Total
Graph 3.1 - Total number of Safeguarding Children
incidents reported during the last 12 months
5
Dudley
Walsall
Number of Looked after
Children
Number of Looked after
Children
85
79
0
Grand
Total
164
2014
Alerts
2015
Referral
Page 94 of 230
Safeguarding Performance Framework
for July 2015
3.2 Vulnerable Adults
Graph 3.2 -This graph provides information relating to the last 12 months and shows a breakdown of Vulnerable Adults Cases which are just for alert only and those which have been
progressed to be continued under Safeguarding
• The Alerts have decreased when compared to the previous month.
Table 3.2
This shows that the number of Vulnerable Adults cases broken down by case type and showing the locality. This also shows information on whether the case is for alert only or if it has
been referred for further investigation to another agency .
Graph 3.2 Total number of Vulnerable Adults incidents
reported during the Last 12 Months
Table 3.2 - Total number of Vulnerable
Adults incidents for the current month
Adult
Patient Considered High Risk
Position Of Trust (Adult)
Grand Total
Dudley
Walsall
Referral
Alert Only
Referral
Alert Only
Grand
Total
9
1
2
12
34
1
1
36
17
2
0
19
52
5
1
58
112
9
4
125
180
160
140
120
100
80
60
40
20
0
2014
2015
Alerts
Referral
Page 95 of 230
Trust Board
Workforce Report
2015/16 Month 5
Page 96 of 230
Workforce Report - Contents
Page
Key Messages
3
Workforce Dashboard
4
Recruitment
5-6
Turnover
7
Sickness
8
Appraisal
9-10
Mandatory Training
11
Page 97 of 230
2
Key Messages
Vacancies – There are currently 181 FTE contracted vacancies across the Trust at a vacancy rate of 16.5%. A Recruitment Plan
has been developed and agreed with a target of reducing the Trust vacancy rate to below 10% by the end of 2015-16. HR
continue to work in partnership with each Service to deliver the implementation of the plan. 34.4 FTE staff started with the
Trust in Month 5, which is another significant increase to the Trust headcount. A new vacancy reporting tool has been
developed that adjusts contracted vacancies to vacancies that are recurrently available for recruitment.
Turnover – The 12 Month Turnover rate has reduced to 17.8%, due to the Jul-14 MARS leavers being now being excluded from
the calculation. The rate continues to be high and is attributable to the departure of individuals under the MARS and TUPE.
Turnover excluding MARS and TUPE employees is 11.1%.
Sickness Absence – Sickness has reduced from 4.89% to 4.74 % in Month 5. 12 Month sickness has reduced to 4.86%.
Appraisal – Reported compliance has remained static at 76% in Month 5. Concerted efforts have been made in Acute Services
to achieve Trust target and a significant increase is expected by the end of September. Update reports have been sent to Exec
Directors and Heads of Service in September to support the achievement of the Trust target.
Mandatory Training - The Trust has achieved an overall compliance rate of 83% for Month 5, which exceeds the Trust’s target
of 70%. Information Governance is tracking at 90% as at the end of Aug-15 and is below the Trust target of 95%. All other
competencies are above Trust target. A training plan and trajectory for PREVENT has been developed to ensure that targets
are met by the end of the Financial year and performance is included in this report.
Page 98 of 230
3
Workforce Dashboard
Aug-15
445 Dudley and Walsall Mental Health Partnership NHS Trust
Staff in Post
Target
Headcount
Funded Establishment
Staff in Post FTE (Contracted)
No of Vacancies
Vacancy %
Worked FTE (Substantive)
Worked FTE (Temp)
Worked FTE (Total)
Turnover % (12 Months)
10.0%
Sep-14
1047
1114.9
945.7
169.1
15.2%
Oct-14
1011
1115.4
911.9
203.5
18.2%
Nov-14
1006
1118.0
907.3
210.7
18.8%
Dec-14
1010
1126.0
912.0
214.0
19.0%
Jan-15
1009
1127.7
913.8
213.9
19.0%
Feb-15
1014
1127.0
918.8
208.2
18.5%
Mar-15
1018
1128.0
922.3
205.7
18.2%
Apr-15
1012
1118.0
916.0
202.0
18.1%
May-15
1013
1141.1
916.8
224.2
19.7%
Jun-15
1017
1143.4
922.3
221.1
19.3%
Jul-15
983
1101.6
903.6
198.0
18.0%
Aug-15
1006
1099.6
918.5
181.1
16.5%
8-14%
946.9
180.3
1,127.2
16.20%
911.7
179.7
1,091.4
17.27%
912.0
189.2
1,101.2
17.48%
908.8
197.8
1,106.6
17.12%
904.5
205.9
1,110.4
17.27%
918.9
218.8
1,137.7
17.17%
919.9
256.5
1,176.4
15.75%
920.3
225.9
1,146.2
15.74%
910.1
197.1
1,107.2
15.73%
921.2
208.5
1,129.7
18.55%
890.7
192.9
1,083.6
18.27%
916.4
204.6
1,121.0
17.82%
Target
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
£4.07m
£3.55m
£0.59m
£4.14m
-£69K
£4.00m
£2.66m
£0.72m
£3.38m
£624K
£3.99m
£3.35m
£0.65m
£4.00m
-£14K
£4.08m
£3.72m
£0.77m
£4.49m
-£413K
£4.13m
£3.53m
£0.77m
£4.30m
-£171K
£4.15m
£3.31m
£0.82m
£4.13m
£20K
£4.16m
£3.44m
£0.94m
£4.37m
-£213K
£4.11m
£3.42m
£0.77m
£4.19m
-£87K
£4.15m
£3.44m
£0.72m
£4.16m
-£5K
£4.26m
£3.47m
£0.71m
£4.18m
£85K
£3.94m
£3.38m
£0.69m
£4.07m
-£128K
£4.08m
£3.42m
£0.62m
£4.04m
£35K
Sep-14
4.91%
1,393
163
Oct-14
4.63%
1,308
176
Nov-14
5.40%
1,472
184
Dec-14
5.70%
1,614
204
Jan-15
4.80%
1,358
180
Feb-15
4.11%
1,056
141
Mar-15
4.98%
1,420
186
Apr-15
5.08%
1,395
158
May-15
4.76%
1,346
148
Jun-15
4.21%
1,167
158
Jul-15
4.89%
1,366
131
Aug-15
4.74%
1,344
143
£111K
2.09%
5.34%
74.1%
£101K
2.03%
5.36%
73.0%
£116K
2.21%
5.37%
72.5%
£136K
2.12%
5.39%
72.2%
£116K
2.06%
5.28%
70.5%
£86K
2.04%
5.15%
70.6%
£120K
2.13%
5.12%
69.5%
£110K
2.15%
5.06%
68.5%
£102K
2.12%
5.05%
69.9%
£92K
1.93%
4.99%
69.0%
£113K
2.04%
4.93%
68.2%
£113K
1.68%
4.86%
65.3%
£1.56m
£1.54m
£1.52m
£1.53m
£1.50m
£1.46m
£1.45m
£1.41m
£1.39m
£1.36m
£1.34m
£1.32m
Sep-14
634
948
66.9%
79.9%
39.9%
Oct-14
602
899
67.0%
80.3%
41.8%
Nov-14
571
871
65.6%
79.7%
44.5%
Dec-14
564
871
64.8%
79.9%
46.5%
Jan-15
574
877
65.5%
79.8%
47.7%
Feb-15
586
881
66.5%
80.0%
49.8%
Mar-15
615
889
69.2%
81.5%
50.8%
Apr-15
618
868
71.2%
83.2%
54.9%
May-15
646
857
75.4%
82.8%
55.4%
Jun-15
673
874
77.0%
83.0%
66.8%
Jul-15
657
838
78.4%
82.7%
73.1%
Aug-15
645
853
75.6%
82.2%
73.9%
Pay Spend
Funded £
Substantive Spend £
Temp Spend £
Total Pay Spend £
Varaince - Budget to Actual £
Absence
Sickness % (Month)
Sickness Days Lost FTE (Month)
No of Sickness Episodes (Month)
Cost of Sickness (Month)
Maternity % (Month)
Sickness % (12 Months)
Long Term Sickness % (12 Months)
Cost of Sickness (12 Months)
Target
4.68%
4.68%
Developm ent
Target
Appriasals Completed
Appraisals Required
Appraisal %
Mandatory Training %
Essential Skills Training %
85%
70%
70%
Page 99 of 230
4
Recruitment Summary
The table below details the vacancy position by Service as at the end of Aug-15. As at the end of Month 5 there are 181 FTE
contracted vacancies across the Trust, which has reduced from 224 FTE in May-15. There are 98 vacancies in the current
Recruitment Pipeline, 63 at pre offer stage and 35 at post offer stage. Please note that the number of vacancies are now
adjusted for secondments, acting up arrangements, rotations, temporary changes in hours and known leavers.
The table below details the vacancy position by Staff Group
Page 100 of 230
5
Recruitment Forecast
Recruitment Plan
Standard Recruitment
Junior Doctors Rotation
Nurse Band 3 Campaign
Replacement Recruitment
Total
Recruitment Actuals
Standard/Replacement Recruitment
Junior Doctors Rotation
Total
Vacancy Position (Forecast)
Funded FTE
Staff in Post
Recruitment Plan
Projected Leavers
No of Vacancies (Forecast)
Vacancy % (Forecast)
2015-16
Target 10%
DWMH Recruitment Plan
Monthly Performance
Apr-15
May-15
Jun-15
Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015-16
2.7
4.7
6.0
3.0
3.0
3.0
5.7
2.0
3.0
9.7
7.0
16.0
3.0
2.0
7.0
15.0
6.0
5.0
8.6
9.3
1.0
7.0
2.0
7.0
2.0
0.8
11.4
6.8
0.6
16.7
1140
916
6
6
224
19.6%
1140
919
10
7
221
19.4%
1143
928
16
7
215
18.8%
1102 1099
910
943
15
41
7
7
192
156
17.5% 14.2%
1140
916
224
19.6%
1141
917
224
19.6%
1143
922
221
19.3%
1102 1099
904
918
198
181
18.0% 16.5%
1
1
-2.7
-1.3
-4.6
-5.9
14.5
13.2
5.0
1.0
7.0
40.7
Variance
In Month Plan v Actuals
Cumulative Plan v Actuals
12.0
15.0
3.0
6.0
14.0
7.0
39.0
8.0
1.0
7.0
31.0
9.0
7.0
19.0
1.0
1.0
7.0
8.0
2.0
7.0
10.0
1.0
63.8
7.0
8.0
7.0
7.0
34.0
25.0
73.0
209.0
55.9
13.2
18.8
12.4
100.3
The number of va ca nci es a cros s the Trus t ha s
reduced from 224 to 181 i n 5 months ., wi th the
va ca ncy ra te reduci ng from 19.6% to 16.5%
34.4 FTE s ta ff commenced empl oyement wi th the
Trus t i n Aug-15 a ga i ns t a pl a n of 40.7 FTE. Thi s
i ncl udes Juni or Doctors rota ti on.
Pred
13.2
13.2
8.0
34.4
Vacancy Position (Actuals)
Funded FTE
Staff in Post
No of Vacancies
Vacancy %
Commentary
1.7
-4.2
13.8
2.0
8.0
23.8
0.0
0.0
0.0
0.0
0.0
0.0
1099
975
39
7
124
11.2%
1099
999
31
7
100
9.1%
1099
1011
19
7
88
8.0%
1099
1012
8
7
87
7.9%
1099
1015
10
7
84
7.6%
1099
1016
8
7
83
7.5%
1099
1016
7
7
83
7.5%
209
83
The i n Month a ctua l s were -6.3 v pl a n a nd the YTD
pos i ti on i s -10.5 v pl a n.
There a re 23.8 FTE predi cted s ta rters i n Sep-15
a ga i ns t a ta rget of 39. The rea s on for the
predi cted under perfora mnce i s tha t s ome s ta rt
da tes ha ve s l i pped i nto l a ter months . Al s o the
number of pos ts tha t a re i n the pi pel i ne i s bel ow
the requi red number.
As a t the end of Aug-15 There a re currentl y 918
FTE i n the Trus t. If a l l of the 92 va cna ci es i n the
recrui tment pi pel i ne were recrui ted s ucces s ful l y,
the Trus t Wi de pos i ti on woul d i ncrea s e to 1010
FTE, wi thout a ny s ta ff l ea vi ng the Trus t.
Ba s ed upon a projected 7 FTE l ea vers a month for
7 months , the Trus t Wi de pos i ti on woul d reduce
to 967 FTE a t a projected va ca ncy ra te of 12.6% a t
the end of the Fi na nci a l Yea r.
-6.3
-10.5
Page 101 of 230
6
Turnover
DWMH Turnover % by Month
23.0%
18.0%
13.0%
8.0%
3.0%
Lower Target
Sep-14
8.0%
Oct-14
8.0%
Nov-14
8.0%
Dec-14
8.0%
Jan-15
8.0%
Feb-15
8.0%
Mar-15
8.0%
Apr-15
8.0%
May-15
8.0%
Jun-15
8.0%
Jul-15
8.0%
Aug-15
8.0%
Turnover %
16.2%
17.3%
17.5%
17.1%
17.3%
17.2%
15.8%
15.7%
15.7%
20.1%
18.3%
17.8%
Upper Target
14.0%
14.0%
14.0%
14.0%
14.0%
14.0%
14.0%
14.0%
14.0%
14.0%
14.0%
14.0%
Service
445 ACU Acute Services Level 3
445 AOMGT Acute & Older Adults Management Level 3
445 CAF Corporate Affairs Level 3
445 CDP Corporate Development and People Level 3
445 CHX Chief Executive Level 3
445 COM Community Services Level 3
445 EIN Early Intervention Level 3
445 FIN Finance Level 3
445 HR Human Resources Level 3
445 MED Medical Level 3
445 OAS Older Adults Level 3
445 OPS Operations Level 3
Starters FTE Leavers FTE Turnover %
(Month)
(Month) (12 Months)
6.00
1.00
15.05%
0.00
0.00
7.26%
0.00
0.00
9.42%
0.00
0.00
25.00%
0.80
0.00
13.62%
4.00
0.80
32.58%
4.40
1.00
9.57%
1.00
0.00
11.78%
0.00
0.00
58.51%
15.20
11.60
19.19%
2.00
0.57
12.88%
1.00
2.77
18.74%
34.40
17.75
17.82%
The 12 Month turnover rate has reduced
from 18.2% in Month 4 to 17.8% in Month
5.
Turnover continues to remain high as it
includes the staff that left the Trust due to
MARS and TUPEs
Turnover excluding employees that left due
to MARS and TUPE is 11.1%.
Page 102 of 230
7
Sickness
Sickness Absence % v Trust Target
6.00%
5.50%
5.00%
4.50%
4.00%
3.50%
3.00%
Target
Sep-14
4.68%
Oct-14
4.68%
Nov-14
4.68%
Dec-14
4.68%
Jan-15
4.68%
Feb-15
4.68%
Mar-15
4.68%
Apr-15
4.68%
May-15
4.68%
Jun-15
4.68%
Jul-15
4.68%
Aug-15
4.68%
Sickness %
4.91%
4.63%
5.40%
5.70%
4.80%
4.11%
4.98%
5.08%
4.76%
4.21%
4.89%
4.74%
Service
Jul-15
Aug-15
8.07%
2.22%
8.99%
0.81%
7.02%
4.30%
2.21%
0.00%
4.80%
4.04%
6.99%
3.29%
4.89%
7.39%
1.44%
10.20%
4.03%
6.12%
4.20%
3.49%
0.22%
8.58%
3.62%
5.61%
2.84%
4.74%
Sickness %
(12 Months)
7.33%
1.53%
4.99%
0.87%
2.24%
5.40%
4.87%
1.58%
6.27%
2.72%
5.67%
2.70%
4.86%
Sickness has reduced from 4.89% in
Month 4 to 4.74% in Month 5.
12 month rolling sickness has decreased
sickness is 4.93% in Month 4 to 4.86% in
Month 5. 12 month sickness was 5.39%
in Dec-14, so there is a considerable
overall improvement in 2015.
Sickness levels in Acute Services and
Older Adults continues to track above
Trust target.
Page 103 of 230
8
Appraisal
Appraisal % v Trust Target
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
Target
Sep-14
85.0%
Oct-14
85.0%
Nov-14
85.0%
Dec-14
85.0%
Jan-15
85.0%
Feb-15
85.0%
Mar-15
85.0%
Apr-15
85.0%
May-15
85.0%
Jun-15
85.0%
Jul-15
85.0%
Aug-15
85.0%
Appraisal %
66.9%
67.0%
65.6%
64.8%
65.5%
66.5%
69.2%
71.2%
75.4%
77.0%
76.4%
75.6%
Service
Appraisals
Required
168
31
10
3
8
112
150
28
19
77
146
101
853
Jul-15
Aug-15
+/-
60%
80%
60%
100%
71%
83%
92%
81%
86%
74%
84%
60%
76%
64%
81%
70%
100%
63%
83%
91%
86%
89%
69%
78%
59%
76%


Appraisal compliance has remained static at
76% in Month 5.










There are 208 employees in the Trust that
haven't had an appraisal in the last 12 months.
Appraisal plans and trajectories have been
developed to track performance in 2015-16.
Based upon information provided by Managers
across the Trust.

Page 104 of 230
Appraisal Trajectory
Jun-15
Service
445 ACU Acute Servi ces Level 3
Jul-15
No
Booked Completed
Total
(Month)
(Month)
Completed Req'd
59
16
93
156
%
60%
Aug-15
Booked Completed
Total
No
(Month)
(Month)
Completed Req'd
17
13
96
161
%
60%
23-Sep-2015
Booked Completed
Total
No
(Month)
(Month)
Compelted Req'd
6
7
108
168
%
No
No
Compelted Req'd
64%
137
166
%
83%
445 AOMGT Acute & Ol der Adul ts Ma na gement Level 3
2
1
26
31
84%
2
0
24
30
80%
1
2
25
31
81%
25
31
81%
445 CAF Corpora te Affa i rs Level 3
1
0
8
10
80%
3
0
7
10
70%
0
1
7
10
70%
9
10
90%
1
3
3
100%
0
0
3
3
100%
0
0
3
3
100%
3
3
100%
445 CHX Chi ef Executi ve Level 3
4
1
5
8
63%
0
0
5
7
71%
1
0
5
8
63%
5
8
63%
445 COM Communi ty Servi ces Level 3
23
13
118
147
80%
3
9
98
118
83%
0
2
93
112
83%
91
112
81%
445 EIN Ea rl y Interventi on Level 3
20
16
137
150
91%
4
10
141
154
92%
9
8
136
150
91%
128
149
86%
445 FIN Fi na nce Level 3
4
2
22
27
81%
3
1
22
27
81%
1
3
24
28
86%
23
27
85%
445 CDP Corpora te Devel opment a nd Peopl e Level 3
445 HR Huma n Res ources Level 3
3
2
16
17
94%
0
1
18
21
86%
0
1
17
19
89%
17
18
94%
445 MED Medi ca l Level 3
10
11
68
87
78%
7
0
58
78
74%
5
2
53
77
69%
50
78
64%
445 OAS Ol der Adul ts Level 3
23
11
121
137
88%
2
11
119
142
84%
12
11
114
146
78%
110
146
75%
445 OPS Opera ti ons Level 3
29
11
56
101
55%
9
8
61
101
60%
4
0
60
101
59%
54
98
55%
DWMH
178
85
673
874
77%
50
53
652
852
77%
39
37
645
853
76%
652
846
77%
As at the end of Month 5, Appraisal compliance is at 76% against a target of 85%.
There has been significant improvement in performance in Acute Services and as of 23rd September their Appraisal rate has
increased to 83%.
Targeted emails have been sent to Heads of Service and Executive Directors regarding outstanding appraisals. Another 67
appraisals are required for completion to achieve 85% Trust Wide.
Page 105 of 230
Mandatory Training
Aug-15
Training Com pliance
Com petence
Target
Com pleted
Jul-15
Required
%
Com pleted
Aug-15
Required
%
+/-
70%
6143
7424
82.7%
6289
7648
82.2%
Essential Skills
70%
3014
4124
73.1%
3128
4235
73.9%
Combined Training %
70%
9157
11548
79.3%
9417
11883
79.2%



Target
Com pleted
Jul-15
Required
%
Com pleted
Aug-15
Required
%
+/-
Mandatory Training
Mandatory Training
Com petence
Safeguarding Adults Level 1
90%
770
928
83.0%
795
956
83.2%
Safeguarding Children Level 1
90%
807
928
87.0%
824
956
86.2%









Target
Com pleted
Jul-15
Required
%
Com pleted
Aug-15
Required
%
+/-
70%
488
630
77.5%
503
650
77.4%






Equality & Diversity
70%
742
928
80.0%
753
956
78.8%
Fire Safety
70%
729
928
78.6%
759
956
79.4%
Health & Safety
70%
744
928
80.2%
758
956
79.3%
Infection Control (Clinical)
70%
497
646
76.9%
519
669
77.6%
Infection Control (Non Clinical)
70%
239
282
84.8%
245
287
85.4%
Information Governance
95%
834
928
89.9%
848
956
88.7%
Moving & Handling
70%
781
928
84.2%
788
956
82.4%
Essential Skills
Com petence
Mental Capacity Act
Prevent
70%
96
646
14.9%
171
669
25.6%
90%
706
928
76.1%
717
956
75.0%
90%
492
496
99.2%
491
502
97.8%
90%
740
928
79.7%
756
956
79.1%
90%
492
496
99.2%
490
502
97.6%
Page 106 of 230
Mandatory Training – PREVENT
Service
Acute Servi ces
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Booked Completed Booked Completed Booked Completed Booked Completed Booked Completed Booked Completed Booked Completed Booked Completed
107
22
39
34
4
0
2
0
1
Acute & Ol der Adul ts Ma na gement
0
13
0
0
8
16
2
0
5
Corpora te Affa i rs
6
0
0
0
0
0
4
0
2
Corpora te Devel opment a nd Peopl e
0
0
0
0
0
0
4
0
0
Chi ef Executi ve
0
0
0
8
0
4
1
0
3
Communi ty Servi ces
0
0
42
52
5
26
4
0
0
Ea rl y Interventi on
21
5
86
20
41
0
0
0
0
Fi na nce
0
1
0
0
10
0
0
14
9
Huma n Res ources
0
0
0
3
0
0
11
8
0
MED Medi ca l
5
3
9
30
29
22
7
0
0
Ol der Adul ts
0
19
95
28
38
0
0
3
0
Opera ti ons
DWMH
0
1
0
139
64
271
13
0
188
46
0
181
13
0
81
25
0
60
7
0
32
8
0
28
0
Page 107 of 230
Board meeting date
7th October 2015
Report Title:
Agenda Item number:
11.2
Enclosure:
8
Joint Medical Directors’ Update
Dr Gingell and Dr Weaver, Joint Medical Directors
Dr Gingell and Dr Weaver, Joint Medical Directors
To update the Board on matters pertaining to the joint medical
directors’ portfolio that are of relevance and interest to the
Board. This will include, but is not limited to, strategic
implications of national and regulatory guidance and
publications, together with local matters including risk and
governance issues.
Decision / Approval
Gain assurance
Discussion
Information




What other Trust
Committee or Group has
considered the key
elements of this report?
Key points or
Committee:
Committee: N/A
Date reviewed: N/A
N/A
High quality
Inclusive
Leadership
Responsible
services
partnerships
culture
workforce

relates to are:
Caring
Responsive
Effective
Well-led
Safe


Supporting
strategies
Effective/efficient
resources


Page 108 of 230
Title
Joint Medical Directors’ Update
National and Regulatory guidance
Provide brief overview of national and regulatory guidance together with summary of key
implications of relevance to the Board.
Recent Publications and Hot Topics
Provide overview of the key points/issues/risks raised by the item.
Proposed changes to doctors’ contracts
Further to the detailed update in last months MD report to board, the issue of contractual
changes in relation to junior doctors remains an issue prominent on the national agenda and
unresolved with no sign of a resolution.
.
Local Matters
Provide overview of key points and strategic or governance issues/risks raised by any local
matters for example stakeholder/commissioner relationships, partnership working, service line
activity, medical establishment.
Clinical Director Post EI/ CAMHS/Primary Care
Further to financial and vacancy panel approval expressions of interest have been sought for
this CD post which has been vacant for a few months. The portfolio will either include all the
clinical teams in line with the Head of Service or depending on expressions of interest be
divided into separate portfolios of EI/CAMHS or Primary Care mental health. All service areas
within this portfolio are the subject of current and planned major developments so it is hoped
and anticipated that the post will be filled by November and well ahead of our CQC inspection.
Appointment to trust fixed term locum posts
Discussions have recently taken place within the medical directorate and HR concerning the
appointment to trust fixed term locum posts. We have been fortunate that several doctors often
our previous trainees approach us for locum work or in relation to substantive middle grade
posts which nationally are very difficult to recruit to. In the case of fixed term locum posts a
clear and consistent process for advertising the posts on NHS jobs has now been agreed so
that the process is transparent and consistent and will allow us to appoint in a timely manner
so that we can continue to keep our use of agency locums to a minimum and respond
Page 109 of 230
effectively when we become aware that there is interest in our vacant short term appointments
from those willing to work on trust terms and conditions.
General Adult medical team configuration in Walsall Locality
The Clinical Director in Community services has continued to lead the work on the
reconfiguration of Walsall locality consultant general adult medical teams to bring them into
line with the model in Dudley. The purpose of this work has been to promote a more equitable
distribution of work, provide more robust cover to EAS and the new planned primary care
model, and hopefully to allow consultants to more flexibly use programmed activities to lead
new service projects. Consultation with those affected has taken place and implementation
planned for mid to late October. This plan is to be implemented within existing budget.
Consultant care clusters
For the past two months the medical directorate has agreed to fund the admin support to
improve the central inputting of the consultant team care clustering performance. Although
there has been improvement and a strong performance on cluster and diagnostic identification
within several consultant teams there is still some work to do to achieve an acceptably high
level (>95% clustered) across all consultant teams. The issue has been raised again at the
recent consultant away day at the end of September with a presentation from members of the
performance/ cluster team so that we can identify the limiting steps in achieving full compliance
and a sequential and clear process that all medical teams can apply consistently and with
sufficient admin support and task identification.
Admin Pressures
High activity levels across many medical teams and long term absences of medical secretaries
has created some backlogs of letters in some medical teams. This is being addressed by
increasing admin support on a temporary basis, though agency solutions to this in the short
term are not always available. We are therefore looking to explore other ways to address and
mitigate this back log focusing on the teams which are most affected.
Staffing
Two trust fixed term locums have recently been appointed and plans in place to set up AAC for
vacant CAMHS posts shortly.
Service development and Growth plans
A leadership and engagement event was coordinated and facilitated by Oliver Nyumbu at the
consultant away day (end September) focusing amongst other areas within the program, on
senior effective engagement and sharing of ideas in relation to service growth and
development. The session was productive and well received and produced some informative
proposals for the achievement of objectives in relation to three service development ideas in
particular , PICU, Older Persons Challenging behavior unit, and Eating Disorder service. The
Page 110 of 230
information has been collated and will be brought to the project teams discussions in due
course when firmer plans are confirmed around these proposals.
Consultant Concerns and Triumphs
Nil to report during the month of September.
Recommendation
This report is provided for information only as there are no recommendations to put forward
currently.
Page 111 of 230
Board meeting date:
Agenda Item number:
Enclosure:
7th October 2015
11.3
9
Director of Operations and Nursing Update
Report Title:
Wendy Pugh – Director of Operations and Nursing
Rosie Musson – Head of Nursing, Quality and Innovation
To update the Board on matters pertaining to the Director of
Operations and Nursing portfolio that are of relevance and
interest to the Board. This will include, but is not limited to,
strategic implications of national and regulatory guidance and
publications, together with local matters including risk and
governance issues.
Decision / Approval
Gain assurance
Discussion
Information




Key points or
Committee:
Committee: N/A
Date reviewed: N/A
N/A
High quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources





relates to are:
Caring
Responsive
Effective
Well-led
Safe
Page 112 of 230
Title
Director of Operations and Nursing Update
Recent Publications and Hot Topics
Local Matters
E- Rostering
A Business Case for the implementation of Allocate’s e-rostering package was presented to and
approved by the Trust Board in July 2015, subject to further clarity on what was in scope and a
challenge to reduce the cost of the contract.
Additionally a proposal to roll out ESR Self Service was presented to MEXT in August 2015.
The Executive Team requested that the two projects were reviewed for key interdependences. A
further paper was presented to MEXT paper outlines the outcome of the commercial negotiations that
have taken place with Allocate and the proposed strategy for implementation.
MExT supported the proposal which
•
•
•
Outlined the positive outcome of the commercial negotiations that have taken place with
Allocate and the proposed strategy for implementation.
Provided an overview of the cross over functionality with manager self-service and agreed
Allocates Healthroster would be used for all Time & Attendance and Absence Management
Trust Wide.
Clarified resources required to support implementation
The project implementation group is now being established with view developing a full project
implementation plan which will be presented to MEXT.
Annual Safeguarding Report 2014/15
This report sets out the work conducted by Dudley and Walsall Mental Health Partnership Trust in the
work of safeguarding vulnerable adults, young people and children. The report explains its approach to
governance, partnerships, quality and performance together with setting out performance activity. This
includes the number of referrals and type of safeguarding activity undertaken. The report explains the
work which has been conducted in terms of a competency framework to underpin job roles so that all
staff are clear about their roles and responsibilities in relation to safeguarding policy and practice.
Key achievements over the year 2014/15 are set out and future priorities identified for 2015/16.
The report concludes that the Trust has continued to make considerable progress in all areas of
practice and this work continues to be embedded within service lines and within its quality priorities
going forward.
Recommendation
As a result of the above the Board are asked to receive the update from the DONs portfolio
Page 113 of 230
Page 114 of 230
CONTENTS
FOREWORD .............................................................................................................. 2
EXECUTIVE SUMMARY ........................................................................................... 3
1
INTRODUCTION ................................................................................................. 4
2
PARTNERSHIP WORKING ................................................................................ 6
3
SAFEGUARDING GOVERNANCE ..................................................................... 7
3.1 Roles and Responsibilities ............................................................................... 7
3.2 Safeguarding Governance Structures ............................................................. 8
3.3 Safeguarding Governance Processes ............................................................. 9
4.0 QUALITY & PERFORMANCE .......................................................................... 10
4.1 Performance Indicators ................................................................................... 10
4.2 Serious Case Review, Domestic Homicide Review and Lessons Learned 10
4.3 Audit ................................................................................................................. 11
4.4 Safeguarding Performance ............................................................................. 12
4.4.1
Adult Safeguarding Activity 2014/15 ....................................................... 13
4.4.2
Child Safeguarding Activity 2014/15 ....................................................... 14
4.4.3
Domestic Abuse Activity .......................................................................... 15
4.4.4
Mental Capacity Act and Deprivation of Liberty Safeguard .................. 16
4.4.5
Looked After Children (LAC) .................................................................... 17
4.4.6
Drug and Alcohol Service......................................................................... 17
5.0 SAFEGUARDING COMPETENCY AND TRAINING ........................................ 19
6.0 SUPERVISION .................................................................................................. 24
6.1 Safeguarding and Human Resources ............................................................ 24
7.0 KEY ACHIEVEMENTS 2013/14 ........................................................................ 25
8.0 FUTURE PRIORITIES - (APRIL 2015 – MARCH 2016) ................................... 26
9.0 CONCLUSION................................................................................................... 27
APPENDICES .......................................................................................................... 28
Appendix 1:
Dudley CAMHS & Looked After Children ................................... 29
Appendix 2:
Walsall CAMHS & Looked After Children .................................. 32
Page 1 of 34
Page 115 of 230
FOREWORD
The Trust has ensured that safeguarding vulnerable people is an imperative part of
its core business and continues to develop and embed systems for capturing,
governing, responding and reporting on safeguarding activity for vulnerable adults
and children. As Executive Lead for Safeguarding, and with Trust Board
accountability, I am committed to ensure that our governance procedures are robust
and transparent and that we are able to uphold our duty of candour. To this end
partnership working is at the centre of our work including working with the police,
Clinical Commissioning Groups and both adult and children’s services within the
local authorities to continually improve referral pathways. My safeguarding team are
dedicated to supporting frontline staff to work alongside and provide protection,
guidance, education and support to people whose circumstances make them
vulnerable to abuse, neglect or radicalisation.
I am confident that our progress and continued high quality work in this area to
include our priorities as set out in this report for 2015/16, will not only help to protect
the vulnerable but also ensure that our staff are well supported with this challenging
area of their work and that service users will be supported to live their lives in safety
I am pleased to endorse this Safeguarding Annual Report for 2014/2015.
Wendy Pugh
Director of Nursing, Quality and Operations
Executive Lead for Safeguarding
Page 2 of 34
Page 116 of 230
EXECUTIVE SUMMARY
This report sets out the work conducted by Dudley and Walsall Mental Health
Partnership Trust in the work of safeguarding vulnerable adults, young people and
children. The report explains its approach to governance, partnerships, quality and
performance together with setting out performance activity. This includes the number
of referrals and type of safeguarding activity undertaken. The report explains the
work which has been conducted in terms of a competency framework to underpin job
roles so that all staff are clear about their roles and responsibilities in relation to
safeguarding policy and practice.
Key achievements over the year 2014/15 are set out and future priorities identified
for 2015/16.
The report concludes that the Trust has continued to make considerable progress in
all areas of practice and this work continues to be embedded within service lines and
within its quality priorities going forward.
Following a review by the Care Quality Commission in February 2014 they reported
that “the Trusts quality and governance systems were seen as robust and ran
through the Trust at every level; the leadership of governance and quality was
outstanding” and that “safeguarding processes were embedded across all of
the teams in the trust.”
Page 3 of 34
Page 117 of 230
1
INTRODUCTION
The Trust demonstrates effective leadership, multi-agency working and dedication to
safeguarding for all patients and their families who access our services.
The Trust has a safeguarding team who are dedicated to supporting frontline staff to
work alongside and provide protection, guidance, education and support to people
whose circumstances make them vulnerable to abuse, neglect or radicalisation.
The Trust ensures that the safeguarding agenda is at the heart of all it delivers.
Over the past three years it has become more evident for the NHS to ensure robust
systems are in place following the high profile historical abuse and convictions of
celebrities who had power to abuse women and children; national serious case
reviews of terrible abuse to children; Winterbourne view hospital exposed abuse and
the Keogh and Francis reports that highlight the need for all NHS Trusts to have
effective governance and to act with candour and transparency.
All NHS Trusts have statutory responsibilities under Section11 of the Children’s Act
2004 to make arrangements in discharging the functions they have with regards to
safeguard and promoting the welfare of children.
The Care Act 2014 stipulates statutory responsibilities and outlines the duties of
health services around safeguarding all service users, and providing additional
support for people who are less able to protect themselves from harm or abuse.
It is the requirement of the Health and Social Care Act that organisations give
assurance that safeguarding is embedded in every day practice and applied
consistently across services. Dudley and Walsall Mental Health Partnership NHS
Trust (“the Trust”) is formally registered with the Care Quality Commission (“CQC”)
without conditions and has remained compliant with Outcome 7 – Safeguarding
people who use services from abuse.
This report provides a declaration to the Trust Board about how the Trust has
continued to comply with the current safeguarding duties and also identifies priorities
for 2015/16.
The Trust is committed to safeguarding all its service users across the range of
services delivered by the organisation. The success of safeguarding is ensuring it is
embedded into the values of the organisation to promote a positive service user
experience. The commitment is further supported by a range of safeguarding policies
giving regard to how the Trust meets the vulnerability needs of children and adults.
Page 4 of 34
Page 118 of 230
The Trusts safeguarding strategic objectives are:
•
To identify those vulnerable children and adults who are in need of protection
and apply appropriate procedures/processes.
•
To identify those children and adults who may present a risk to others and
apply the appropriate procedures/processes.
The Trust continues to achieve these objectives whilst continuously working to
improve safeguarding across Trust services. This involves close partnership working
to deliver the requirements of Children’s and Adult Safeguarding Boards across
Dudley and Walsall.
During 2014/15 a considerable amount of activity has been carried out with regards
to safeguarding. This report provides an opportunity for reflection and retrospective
analysis on the previous year, to recognise success and identify priorities to sustain
and build on our achievements. Progress is demonstrated under the following
headings:
•
Partnership working
•
Safeguarding Governance
•
Quality and performance overview
•
Education and Training
•
Supervision
•
Future Priorities
•
Conclusion
Page 5 of 34
Page 119 of 230
2
PARTNERSHIP WORKING
The Trust has maintained its commitment to working with all partner organisations
and voluntary services to continue to deliver the safeguarding agenda.
Dudley & Walsall Partnership NHS Trust Board of Directors, Heads of Service,
Medical Directorate, Safeguarding Team, Governance and Managers are committed
to ensuring that safeguarding and the assessment of mental capacity of our service
users is given the highest priority. By asking direct questions and embedding the
‘Think Family approach’ at an early stage the Trusts clinicians assist service users to
recognise abuse and work with them therapeutically as well as referring and
involving other partners address the holistic needs and safeguarding action required.
The Trust remains an active member of the Safeguarding Adults and Children’s
boards across the boroughs of Dudley and Walsall and takes active participation the
sub groups of each Board. It is also aligned to the Safer Partnership Board and
Prevent agendas.
The Trust recognises its responsibility to work with other partners in safeguarding
activities during 2014/15. This is demonstrated through:
•
Ensuring that safeguarding procedures and practice are aligned to changes
within Local Authority processes and governance arrangements
•
Maintaining attendance and contribution to the Safeguarding Boards and subgroups
•
Ensuring that the Trusts on-going service transformation takes account of
safeguarding responsibilities
•
Commitment to participation in complex strategy meetings
•
Working in partnership with police
•
Delivery of performance indicator requirements to the CCGs
•
Multi-agency audit
•
Participation in serious case review/domestic homicide activity
•
Multi-agency training
•
Participation with vulnerability forums
•
Working in partnerships with children’s services on pathways for referrals
•
Active contribution to channel panels and the radicalisation agenda across the
boroughs
The Trusts policies are aligned to the safeguarding Boards with clear links to multi
agency procedures
The Safeguarding Team is proactively engaged in multi-agency working to enhance
relationships and strengthen processes for our service users and their families.
Page 6 of 34
Page 120 of 230
3
SAFEGUARDING GOVERNANCE
3.1
Roles and Responsibilities
During 2014/15, the Trust has contributed to strengthen the safeguarding agenda
across all clinical areas and continued to embed safeguarding as ‘everyone’s
business.’ Roles and responsibilities are clearly defined within the Trusts policies
and procedures and reinforced through continual targeted training that is delivered
by the Safeguarding Team.
VULNERABLE ADULTS & CHILDREN’S
Fig 1 shows the
structure of the Trust Safeguarding Team.
SAFEGUARDING
ORGANISATION CHART
Chair
Chief Executive Officer
Executive Director
Development
Non-Executive Director
Executive Director
Operations and Nursing
Head of Nursing, Quality
and Innovation
Vulnerable Adults &
Children’s Lead
Named Doctor for Adult Safeguarding
Head of Adult Social Care
Named Nurse for Children’s Safeguarding
Named Doctor for Children’s Safeguarding
Vulnerable Adults & Children’s
Specialist Practitioner
Senior Administrator
Vulnerable Adults & Children’s Safeguarding
Vulnerable Adults & Children’s
Specialist Practitioner
Senior Administrator
Apprentice
Fig. 1
Page 7 of 34
Page 121 of 230
The Trust has continued to embed the developed competency framework for
vulnerable adults and children in line with all staff member’s roles and responsibilities
in the organisation. The competency levels reflect:
•
•
•
•
Competency Level
Competency Level
Competency Level
Competency Level
-
Foundation
Intermediate
Specialist
Strategic
3.2
Safeguarding Governance Structures
The safeguarding agenda and governance structures are fully aligned to the Trusts
overarching governance targets.
The safeguarding annual work programme is overseen by the Trusts Safeguarding
Strategic Group, which has the Trusts Executive Lead for Safeguarding (Director of
Operations and Nursing) and a Non-Executive Safeguarding Lead on its
membership.
The role of this Group is to oversee and monitor safeguarding policies, procedures
and processes. Assurance and activity is provided monthly to the Trusts Quality and
Safety Committee and to the Trust Board. Regular reports are also overseen by the
CCG’s in Dudley and Walsall and the Safeguarding Boards.
Fig 2 shows the Trusts governance arrangements for safeguarding.
Trust
Board
Quality & Safety
Commitee
Safeguarding
Strategic Group
Service Line
Quality Meetings
Team
Department
Meetings
Fig. 2
Page 8 of 34
Page 122 of 230
3.3
Safeguarding Governance Processes
The Trust has made safeguarding part of its core business and has developed and
embedded robust systems for capturing, governing, responding and reporting on
safeguarding activity for vulnerable adult and children safeguarding concerns across
all clinical areas.
The safeguarding team work closely with patient’s safety team to examine and
respond to all incident reports, enabling safeguarding to be a seamless thread
across all activity.
The safeguarding data is reported on a monthly basis to the Trusts Quality and
Safety Committee and as part of the performance indicators through the CCG to the
Clinical Quality Review meetings.
Safeguarding is also embedded into the Trusts monthly triangulation meetings along
with incidents and complaints to ensure any trends or themes are responded to
appropriately.
The Safeguarding Lead is also an active member of the Mental Health Act Scrutiny
Committee and the Embedding Lessons from serious incidents to scrutinize and
response to reports and actions.
Page 9 of 34
Page 123 of 230
4.0 QUALITY & PERFORMANCE
4.1
Performance Indicators
The Trust has worked with the CCG’s for Dudley and Walsall in relation to delivering
a set of safeguarding performance indicators that are reported on. Those indicators
and activity are also shared with the Quality and Performance sub groups of the
Safeguarding Boards.
4.2
Serious Case Review, Domestic Homicide Review and
Lessons Learned
The Trust continues to have representation on both serious case reviews and
domestic homicide review panels which are aligned to the Safeguarding Boards.
During 2015/15 the Trust actively contributed information relating to one Serious
Incident Learning Process (SILP) and one Serious Case Review/Domestic Homicide
Review. The lessons learned for the Trust relating to these reviews was for:
1.
A review of the domestic abuse training to ensure it included
controlling/cohesive behaviour
2.
A review of the Trusts DNA (did not attend) policy to ensure it informed other
agencies when there had been an awareness of safeguarding activity.
The Trust has addressed both of these activities with monitoring taking place from
the Safeguarding Boards.
During 2014/15, additional resources were agreed within the Trusts Safeguarding
Team to enhance the domestic abuse agenda.
The Trust carries out serious incident investigations in line with root cause analysis
and complaint investigations. All of these investigations include a review of
safeguarding, least restrictive practice and mental capacity practice. The outcomes
have led to increased work and emphasises the importance of ensuring adult mental
health services access and consider the impact on children; the strengthening of
policies, procedures and governance arrangements around areas of practice to
ensure it is delivered in the least restrictive manner and the importance of continually
assessing decision specific capacity in line with safeguarding allegations.
Page 10 of 34
Page 124 of 230
4.3
Audit
Clinical Audit
Safeguarding activity continues to be part of the Trust annual clinical audit
programme. The internal audit activity has included:

The Voice of the Child and Outcomes of Care

The mental capacity of the adult where safeguarding concerns are noted or
allegations made

Actions following self-neglect

Awareness and escalation response of domestic abuse
The Trust continues to meet the requirement of the Children’s Safeguarding Boards,
in line with the Children’s Act to complete the Section 11 audit.
An action plan has been formulated to address the required improvements across all
services provided by the Trust. The actions are summarised as follows:
Children’s Safeguarding Boards – Section 11 Audits
The Section 11 action plan is monitored through the Trusts Safeguarding Strategic
Group.
An action plan has been formulated to address improvements following the audit.
The actions are summarised as:



Review and audit of clinical documentation to capture Voice of the Child and
outcomes
Review children’s experience of service
Embedding training for potential mental health and early help.
In March 2015, the Trust received recommendations in line with the Lampard Report.
An action plan was formulated against all the relevant NHS provider requirements for
the Trust and is monitored through the Trust Board for assurance and compliance.
The Trust has formulated an action plan to address areas of improvement, these
include:



Review of policies for visitors and celebrity access
Review of Social Media Policy
Review of Contractors across the services in line with safeguarding requirements
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Adult Safeguarding Annual Assurance
A review and audit of adult safeguarding practices was undertaken for the Dudley
Adult Safeguarding Board in January 2015.
The audit examined policies and procedures in place to capture, record and action
safeguarding activity. The culture of the Trust in alerting and responding to
safeguarding, across all service lines was also audited in line with the west midlands
policy and Board expectations.
The results of this audit gave assurance that the Trust has safeguarding embedded
within its governance and quality processes and procedures.
The recommendation from this review was to look at additional ways to capture the
outcomes of safeguarding activity for the individuals, in line with requirements within
the Care Act. This activity has been added to the Trusts work plan for 2015/16.
4.4
Safeguarding Performance
The Trust has continued to work with both Dudley and Walsall local authority and the
CCG’s in relation to providing accurate and timely data relating to all safeguarding
activity undertaken and outcomes for the adults and children within the organisation
and the wider family, in line with the ‘Think Family’ approach.
The adoptions of the West Midlands pan procedures and continued looking to
Working Together 2013/15 has produced a greater local consistency.
The Trust has a dedicated safeguarding database that is aligned to the Trusts
incident reporting system. This allows for scrutiny and response to the safeguarding
alerts and embedding the early help agenda along with enabling triangulation of data
and trend analysis.
Over the past 3 years there has been a significant increase in safeguarding alerts
being raised by Trust staff, this is attributed to an investment in the Safeguarding
Team to work with all staff on promotional information, early intervention, reporting
and training. This increase in alerts evidences the safeguarding agenda being
embedded across both the adult and children’s service lines.
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Figure 3 evidences the amount of safeguarding alerts collated within the Trust over a
3 year period.
Fig. 3
4.4.1 Adult Safeguarding Activity 2014/15
Trust Wide Adult Safeguarding Activity
During 2014/15 a total of 1165 vulnerable adult alerts were raised via the Trust
safeguarding system.
Of the 1165 alerts raised 283 resulted in safeguarding processes led by the Trust.
All the alerts received are scrutinised by the safeguarding team and early
intervention actions and sign posting evidenced on the database.
Data on all cases taken through adult safeguarding processes are shared with the
local authorities.
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Figure 4 indicates the types of allegations made.
Types of Allegations Made
Vulnerable Adults - Physical
Vulnerable Adults Emotional/Psychological
Vulnerable Adults - Domestic
Abuse
Vulnerable Adults - Sexual
Vulnerable Adults Financial/Material
Vulnerable Adults - Neglect
And Act Of Omission
Vulnerable Adults - Neglect
Meds Mismanagement
(blank)
Fig. 4
The activity during 2014/15 has been collated in localities for the purpose of
reporting to the Safeguarding Boards. The activity relates to clients in hospital,
placements or living in the community.
Dudley Borough Safeguarding Activity
During 2014/15 there were a total of 548 adult safeguarding alerts raised for clients
where the Trust holds responsibility for overseeing their care. Of the 548 alerts
raised, 126 resulted in safeguarding activity.
Walsall Borough Safeguarding Activity
During 2014/15 there were a total of 617 adult safeguarding alerts raised for clients
where the Trust holds responsibility for overseeing their care. Of the 617 alerts
raised 157 resulted in safeguarding activity.
4.4.2 Child Safeguarding Activity 2014/15
Trust Wide Child Safeguarding Activity 2014/15
The Trusts safeguarding database also captures activity relating to children. This
information includes alerts and also referrals that have been made into children’s
services due to identified child concerns. These can be further reported to when a
children’s services referral has been made due to concerns relating to parental
mental health.
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During 2014/15 there was a total of 311 alerts received relating to child concerns. Of
the 311 concerns raised 162 were from the Dudley locality, and 148 were from the
Walsall locality.
Of the 311 concerns raised 129 originated from the Trusts Early Intervention Service
line, which includes Primary Care, CAMHs and Early Intervention Services. The 182
remaining were reported through adult mental health services. The continued
activity reflects the on-going embedding of ‘Think Family’ across service lines.
Figure 5 shows the percentage of concerns raised between adult mental health and
Early Intervention.
41%
Adult Mental Health
59%
E.I.
Fig. 5
4.4.3 Domestic Abuse Activity
During the last year, Domestic abuse has been addressed within the Trust by firstly
the compilation of a Domestic abuse policy. This has been ratified and implemented
within the trust. Roles and responsibility training has been delivered to all managers
and leads and support has been provided for staff in utilising the Safe Lives
(CAADA) risk assessment to identify the risk associated with domestic abuse.
Robust pathways have been put in place for reporting and responding to domestic
abuse.
An audit has been completed regarding domestic abuse and phase two of the audit
is near completion. Work is on-going with a production of a bulletin which will be
made available to all staff across the trust which will aid them to recognise and
respond to domestic abuse safely and appropriately.
The Trust attends both Dudley and Walsall Multi Agency Risk Assessment
Conference (MARAC). An information sharing process is in place for the Domestic
Abuse Response Team (DART).
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The Trusts safeguarding database has been further developed to report on internal
domestic abuse alerts to ensure all areas of safeguarding and sign posting to other
agencies are collated and clinicians supported in this process.
During 2014/15 there were 304 internal domestic abuse alerts received.
Figure 6 demonstrates the alerts received by borough.
180
160
140
120
100
NHS Dudley
80
NHS Walsall
60
40
20
0
Domestic Abuse
(Adult)
Domestic Abuse
(Child)
Fig. 6
4.4.4 Mental Capacity Act and Deprivation of Liberty Safeguard
During 2014/15 the Trust has reviewed Trust policies and procedures to further
embed MCA across all activity, assessment and review processes.
The Trust developed a specific screening tool to assist in identifying DoLS and has
aligned its safeguarding database to accurately capture record and report DoLS
activity across the services.
During 2014/15 the Trust had 50 service users under DoLS.
Figure 7 demonstrates DoLS activity reported by borough.
2014
2015
Apr
May
Jun
Jul
Sep
Oct
Nov
NHS Dudley
1
3
2
5
1
4
NHS Walsall
4
7
1
1
2
1
1
Grand Total
5
10
3
6
3
5
1
Dec
Jan
Total
Feb
Mar
1
3
1
21
4
2
3
3
29
4
3
6
4
50
Fig. 7
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4.4.5 Looked After Children (LAC)
Looked After Children (LAC) across Dudley and Walsall boroughs within the Trust
pan service is demonstrated in Appendix 1 and 2. As part of the safeguarding
training and updates the private fostering agenda remains a key priority for all
services in the Trust.
4.4.6 Drug and Alcohol Service
Lantern House is part of Dudley and Walsall Mental Health Partnership NHS Trust
and provides Tier 3 Treatment for people with substance misuse problems residing
(or under the care of a GP) in Walsall.
Throughout 2014/2015 the service continued to develop and grow with Lantern
House having a robust safeguarding team with their primary role being around
safeguarding both vulnerable adults and children in direct or indirect contact with the
service. This includes attendance at Vulnerable Adult Safeguarding meetings and
investigations, all child protection meetings from Children in Need to Case
Conference, LAC reviews and family court if required and the provision of
appropriate reports for these.
The Team provides training, advice and supervision both internally and externally to
partnership agencies in cases where substance use is known or thought to be a
contributing factor that is increasing the risk for vulnerable adults or children. The
team work alongside partnership agencies helping inform the safeguarding process
to help enable accurate and comprehensive risk management plans.
Cases are allocated to workers within the safeguarding team in line with their
specialist roles but there will inevitably be instances where cases escalate and deescalate and there is some crossover of caseload. Where ever possible a single
worker will work with the client throughout the part of their treatment journey that
involves children’s services, helping to ensure that services for vulnerable people in
Walsall have access to timely and dedicated support with regard to issues of
substance misuse.
Lantern House has formed robust links with partnership agencies and developed
strong care pathways helping to contribute to the assessment process and the
delivery of a package of interventions for families at risk.
This is in line with the national drug strategy ‘Drugs: protecting families and
communities’ – 2008 and Working Together 2013’ and contributes significantly to the
following key strategic actions.

Ensure prompt access to treatment if assessed as appropriate for all drugmisusing parents who may become or are problematic drug/alcohol users.
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
Early Help – Providing Early Help is more effective in promoting the welfare of
children than reacting later. Early help means providing support as soon as the
problem emerges, at any point in a child’s life from the foundation years
through to the teenage years. Early help can also prevent further problems
arising, for example, if it is provided as part of a support plan where a child has
returned home to their family from a care setting.

Effective early help relies upon local agencies working together to identify
children and families who would benefit from early help, undertake an
assessment of need and provide targeted early help services to address the
assessed needs of a child and their family which focuses on activity to
significantly improve the outcomes for the child.

If children are identified as being at risk ensure their parents have rapid access,
and all assessments taking account of the needs of families.

Deliver a package of interventions for families at risk, to improve parenting
skills, helping parents to educate their children about the risks of drugs,
supporting families to stay together and breaking the cycle of problems being
transferred between generations, learning from innovative programmes and
providing intensive interventions when needed.

Supporting carers, such as grandparents caring for children of substance
misusing parents, by exploring extensions to the circumstances in which local
authorities can make payments to carers of children classified as ‘in need’,
backed up by important information for carers and guidance for local authorities

Support parents with substance misuse problems so that children do not fall
into excessive or inappropriate caring roles.
Providing a family focus ensures that the needs of children and families are given a
greater priority.
As part of the role of the safeguarding team within Lantern House, information is
collated around all children known to our service users, including name, date of birth
and whether there is any social care involvement either currently or historically. This
information helps to inform decision making around risk assessment and potential
referral.
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5.0
SAFEGUARDING COMPETENCY AND TRAINING
The strategic framework for training defines the approach to safeguarding training
across Dudley and Walsall Mental Health Partnership NHS Trust. Its aim is to
ensure that all staff are alert to the need to safeguard and promote the welfare of
children and vulnerable adults and are appropriately skilled and competent in
carrying out their responsibilities for safeguarding appropriate to their role.
This framework is informed by statutory and national guidance and the safeguarding
learning and improvement frameworks in operation across Dudley and Walsall
Boroughs.
Principles
This framework is founded on the following principles:
•
That all staff are trained and competent to be alert to potential indicators of
abuse and neglect, know how to act on these concerns and to fulfil their roles
and responsibilities for safeguarding in line with local procedures and national
guidance such as Working Together 2015.
•
That all training emphasises the importance of working together and equips staff
to work collaboratively with others, communicating and sharing information.
•
That staff comply with the legal requirements of the Mental Capacity Act 2005
and understand confidentiality and information sharing within the Act.
•
That staff understand and are able to demonstrate least restrictive practice and
are aware of their responsibilities when there is a Deprivation of Liberty.
•
That staff are aware of their responsibilities and comply with safeguarding duties.
•
That all training embodies the Think Family approach.
•
That training underpins delivery of the national PREVENT strategy.
•
That all training provided respects diversity, promotes equality and encourages
the participation of children, families and adults in the safeguarding process.
Purpose of Safeguarding Training
The purpose of safeguarding training is to achieve better outcomes for vulnerable
adults, children and young people by promoting:
•
A shared understanding of the tasks, processes, principles and roles and
responsibilities outlined in national guidance and local arrangements for
safeguarding vulnerable adults, children and young people and promoting their
welfare.
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•
More effective and integrated services at both the strategic and individual case
level.
•
Improved communications between professionals including a common
understanding of key terms, definitions, and thresholds for action.
•
Effective working relationships, including an ability to work in a multi-disciplinary
way.
•
Sound decision making based on information sharing, thorough assessment,
critical analysis and professional judgement.
•
Learning lessons from serious case reviews/critical incident reviews and
implementing changes to practice based on recommendations from local and
national cases.
Trust Internal Training Activity 2014/15
Type of Training
Safeguarding Vulnerable Adults - Mandatory
Safeguarding Adults Assessor’s/Investigator’s - Practitioner’s role and application
Safeguarding Adults training/briefings for Consultant Psychiatrists & Doctors
Safeguarding Vulnerable Adults – Roles and Responsibilities training
Mental Capacity Act Training for Ward Managers/Deputies.
Applying the Mental Capacity Act/DoLS
Health Care Assistants Safeguarding and Potential Mental Health
Parental Mental Health training/ briefings for Consultant psychiatrists & Doctors
Chairing Adult Case Conferences
PREVENT
Safeguarding Children and Young People – Mandatory
Safeguarding Children & Young People training/briefings for Consultant Psychiatrists &
Doctors.
Domestic Abuse Training
Trust Board Safeguarding Responsibility
Trust staff also have the opportunity to access multi agency training programmes
appropriate offered by Safeguarding Boards in both boroughs.
Methods of Delivery
The Trust commissions safeguarding training to all staff working within the Trust as
well as communicating multi-agency training from the safeguarding boards.
There is a clear expectation that all clinical staff complete mandatory safeguarding
training through face to face sessions and that non clinical staff complete mandatory
safeguarding training through e-learning.
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There is a range of learning methods in use to match the breadth of training
requirements. These are designed to ensure learning is effective, cost efficient,
flexible to ensure timely updates and diverse to appeal to individual learning styles.
Examples are:
•
Classroom sessions
•
E-learning
•
Targeted training sessions (specific subjects for specific roles)
•
Briefings and leaflets
•
Mechanisms for supervision
•
Reflection through completion of the competency framework
•
Learning from Serious Case Reviews
•
Multi agency training events
Evaluation and Impact
All classroom based training will be subject to on the day course evaluation to
measure the usefulness of training and to collect immediate feedback on its
effectiveness. This will be reviewed by the trainer and periodically reviewed by the
Workforce Team.
Where possible post event feedback will be sought and used to measure the impact
of learning on practice.
Further learning and impact will be reviewed through supervision discussions and for
clinical staff through demonstrating evidence of competency through completion of
the Safeguarding Competency Framework.
Individual compliance with safeguarding training will be reviewed through annual
Appraisal and through professional revalidation processes.
Reporting trends (for example increasing numbers of safeguarding alerts) will be
monitored and used to inform training content. The outcomes and recommendations
from investigations and Serious Case Reviews will be used to inform training content
and the design of further learning processes.
Safeguarding Competency Framework for frontline clinical and management roles
This strategic framework for safeguarding training is underpinned by a competency
framework developed by the Trust, used to develop and demonstrate the
competency of staff in delivering services that safeguard and protect vulnerable
adults, children and young people. It is for use with all staff in who come into contact
with vulnerable adults, children, young people and families within their role as well as
managers who have responsibility for reviewing and making decision about issues
that might affect the organisations procedures and practice in relation to
safeguarding.
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Its purpose is to define competency requirements, to ensure managers are confident
about the safeguarding competency of individual members of staff within their teams.
In completing the framework any gaps in knowledge or understanding can be
addressed and the impact of learning can be fed back and reflected upon.
Different staff groups require different levels of competence depending on their role
and degree of contact with individuals, the nature of their work and their level of
responsibility. The competency framework has been split into four distinctive
competency groups (Foundation, Intermediate, Specialist and Strategic
Management) to reflect competency requirements by role.
The Trust has a responsibility to ensure that temporary workers, contractors, agency
staff, trainees and students coming into services delivered by the Trust also undergo
training relevant to their role. An induction pack has been developed to ensure that
consistent written information, including safeguarding leaflets (PREVENT,
Safeguarding Adults and Young People and Domestic Abuse) is passed on to all
such workers upon the Trust.
Contractors and agencies used to supply staff to the Trust are required to ensure
their staff are up to date with relevant Safeguarding training. This is reviewed
through the contracting process and included within eligibility criteria. Contractors
and agency staff will also receive the induction pack referred to above.
Training Compliance
Safeguarding vulnerable adults and safeguarding children and young people remain
mandatory requirements within the Trust.
Figure 7 shows the monthly breakdown of training compliance during 2014/15.
Mandatory Training
Safeguarding Adults Level 1 & 2 - %
Safeguarding Children Level 1 & 2 - %
Target
70%
70%
Apr 14
84%
85%
May 14
83%
83%
Jun 14
81%
82%
Jul 14
80%
81%
Aug 14
79%
79%
Sep 14
78%
78%
Oct 14
77%
78%
Nov 14
78%
77%
Dec 14
79%
76%
Jan 15
79%
78%
Feb 15
78%
78%
Fig. 8
Raising Awareness of Safeguarding
The Trust continues to work alongside the Boards and sub-groups to participate in
single agency and multi-agency responses and build on awareness and
understanding of safeguarding.
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Mar 15
78%
76%
Internally, the Trust has:

Contribution to Safeguarding Board training and business plans and priorities.

Updating staff leaflet.

Development of patient leaflet relating to safeguarding.

Delivered bespoke training in response to competency framework requirements.

Development of a safeguarding website on the Trust intranet. This holds all
relevant information, advice, contacts and documentation, and links the Trust
staff to the relevant Safeguarding Board websites.

Delivered roles and responsibility training to managers and leads across all
clinical areas and medical colleagues.

Delivered specific training on domestic abuse and controlling behaviours

Developed a specific training package for the Health Care Assistants.

Participation with public events to raise awareness on safeguarding

Commissioned specific safeguarding adults and children’s training to meet level
1, 2, and 3 requirements.

Attendance and delivery of training alongside the health economy at GP events.
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6.0
SUPERVISION
The Trust continues to recognise the importance of supervision and has reviewed
the supervision policy to ensure it has robust and explicit reference to safeguarding
supervision.
The Trust has named and designated safeguarding staff who can be accessed for
supervision on complex cases and attend multi-disciplinary discussions and
reflective practice. Supervision for designated roles is received both internally and
externally to the Trust to ensure that there is clear transparency and is in line with
role expectations.
6.1
Safeguarding and Human Resources
Disclosure and Barring Compliance
The Trust continues to meet its requirements for disclosure and barring compliance.
This is monitored through the workforce directorate and enhanced checks are
completed on a three yearly basis.
94% of the workforce has a DBS clearance check. The remaining 6% do not require
a DBS clearance check for their role.
Position of Trust
The Trusts designated director for ‘people in a position of trust’ remains the Director
of People and Corporate Development.
The Vulnerable Adults and Children’s Lead works directly for the Trust Director and
the local authority Heads of Safeguarding and Leads to ensure all processes and
referrals are dealt with appropriately.
The Trust has a specific ‘Position of Trust’ policy and all procedures are embedded
within the safeguarding process.
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7.0
KEY ACHIEVEMENTS 2013/14
During 2014/15, the Trust has continued to make progress in developing, delivering
and embedding safeguarding processes and procedures across the organisation.
The Trust Board of Directors, Safeguarding Team and staff have worked to deliver
the Trusts safeguarding objectives. The highlights of this work programme were:Work Programme
1. Continued monitoring and compliance
against Outcome 7, in line with CQC
recommendations.
2. Integration of quality outcomes for
safeguarding within the performance
dashboards.
3. Development of a process to embed
and monitor the safeguarding
competency framework across all
clinical areas.
4. Further alignment of safeguarding into
governance processes to enhance the
Trusts quality report.
5. Delivery of safeguarding performance
indicators agreed with commissioners
6. Review of clinical assessment tools to
ensure they address specific areas for
safeguarding and early help.
7. Improvement of the management of
service users experiencing domestic
abuse.
8. Review of safeguarding policies and
training in line with national guidance.
9. Review of policies and procedures to
address all area of least restrictive
practice
10. Development of processes to capture
and report DoLS applications across
the Trust.
11. Development of a joint working protocol
between children’s mental health and
adult mental health services.
12. Triangulation process to robustly
scrutinise and review safeguarding with
incidents and complaints.
13. Continued raising awareness of the
safeguarding profile across the health
and social care economy.
Outcomes
The Trust remains compliant in standards
for safeguarding vulnerable adults from
abuse.
Service line performance and quality
monitored for safeguarding.
Embedded competency framework and
monitored through Learning and
Development.
Safeguarding is fully embedded within the
Trusts quality report and monitored on a
monthly basis.
Performance indicators integrated into the
Safeguarding Quality Report and
monitored monthly by clinicians.
Clinical assessment tools incorporate all
required areas to capture safeguarding
activity.
The Trusts investment in Safeguarding
personnel to respond to domestic abuse.
Policy, procedures and recording in place
to monitor and report domestic abuse
activity.
Safeguarding policies and procedures are
up to date with national and local guidance.
The Trust has a suite of policies and
procedures to address least restrictive
practice.
DoLS activity and monitoring is embedded
within the Trusts safeguarding and
governance procedures.
The Trust has ratified the joint working
protocol which is embedded across all
service lines.
Monthly triangulation meetings are in place
in order to scrutinise Trust activity.
The Trust has a robust Safeguarding Team
who work across both health and social
care.
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8.0
FUTURE PRIORITIES - (APRIL 2015 – MARCH 2016)
The Trusts Safeguarding Strategic Committee and Safeguarding Team have
developed the following objectives for the year 2015/16. These objectives will be
monitored by the Safeguarding Strategic Committee and reported to the Trust Board.
These were as follows:
To ensure ongoing monitoring and compliance against Outcome 7 in
line with CQC recommendations
2.
To continue to monitor the safeguarding competency framework across
clinical areas
3.
To ensure that there is effective clinical supervision processes in place
specific to safeguarding
4.
To implement/ monitor the recommendations from internal and external
SCR/DHR investigations and reviews relating to safeguarding
5.
To deliver targeted safeguarding training and briefings in line with the
Trusts safeguarding strategy including local and national requirements
6.
To develop processes to capture and collate outcomes and feedback
from service users and carers, specific to safeguarding, in line with the
Care Act 2014 and Working Together 2015
7.
To complete a review of clinical processes to demonstrate that Mental
Capacity, Best Interests and Deprivation of Liberty Safeguards is
central to the safeguarding process
8.
To deliver the Safeguarding Performance Framework across both the
Dudley and Walsall Borough.
9.
To deliver the PREVENT agenda across the Trust in line with statutory
responsibilities.
10. To deliver the FGM (Female Genital Mutilation) across the Trust in line
with statutory responsibilities.
1.
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9.0 CONCLUSION
Whilst this report details the significant work that has been undertaken in the past
year, the Trust also acknowledges that there continues to be developments and
challenges within the Safeguarding agenda that will require further Trust focus in the
period to follow. This report summarises the key safeguarding activities and
achievements during this reporting period.
Supporting staff in day to day practice through the delivery of high quality training
has been essential, underpinned by a robust database; case management and
support and advice from the Safeguarding Team.
The Trust has robust safeguarding arrangements in place, the strengths of which are
recognised throughout this report.
Safeguarding practice is evidenced through both internal and external scrutiny and is
noted to be embedded throughout the Trust as ‘Safeguarding is everyone’s
business.’
The Trust continues to keep safeguarding of adults and children as an integral part
of its monitoring and recognises its responsibilities to respond to the continual
changes and risk elements of safeguarding practice.
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APPENDICES
Appendix 1:
Dudley CAMHS & Looked After Children
Appendix 2:
Walsall CAMHS & Looked After Children
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APPENDIX 1
DUDLEY CAMHS AND LOOKED AFTER CHILDREN (LAC)
Referral screened by the Duty Management Team
Discharged
(Not
appropriate)
Choice
appointment
Consultation (Social
Worker)
Discharged
LAC Consultation (not
a diagnostic clinic)
Kept in LAAC
Consultation
Choice Appointment
Choice appointment
(Choice Plus)
Discharged
Partnership
with Keyworker
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Dudley CAMHS and Looked After Children (LAC)
Referrals for Looked After Children follow the same referral pathway as other
children referred to Dudley CAMHS and are seen by the members of the CAMHS
team using the Choice and Partnership Approach (CAPA) model which Dudley
CAMHS implemented in 2008.
After Dudley CAMHS has received a referral on an LAC the referral will be screened
by the CAMHS Duty Manager using a screening form where the outcome of the
screening is documented.
Several outcomes are possible depending on the nature of the referral. One outcome
could be that the LAC is put directly into the CAMHS Choice clinic and at this stage a
CAMHS professional undertakes a screening assessment with the aim to establish
whether the LAC will need further assessment and input via CAMHS through the
partnership assessment or whether the LAC needs can be met within the primary
care setting.
In more complex presentations a CAMHS Choice Plus assessment might be
conducted before a decision is made.
Another option is that the Duty Manager will put the LAC referral into a Social
Service (SS) Consultation slot which is held every Monday from 11.30 AM to 12.30
PM and the child’s referrer will be invited to attend this consultation meeting in order
to establish the background of the child and what intervention have already been
provided.
Following the SS Consultation the outcome will be either for the child to be seen by a
CAMHS professional as part of the CAPA set up or recommendations can be made
what work is necessary with the child to be under taken prior to CAMHS accepting
this referral.
The third option offered by the Duty Manager is to offer the professional network
around the child an LAC Consultation which is provided by CAMHS professionals
with a special interest in LAC at Dudley CAMHS as a Tier 3 clinic on a Thursday
afternoon and this service has been running since 2002.
The outcome of this consultation could be that the child and his/her needs will
continue to be discussed within the LAC Consultation setting or if necessary the child
could be offered a CAMHS Choice appointment as part of the CAPA assessment.
Following a CAMHS Choice assessment the LAC will be offered a Partnership
assessment by a CAMHS professional if a specific need was identified as part of the
screening assessment and this CAMHS worker will stay involved as the LAC
keyworker and will coordinate the child’s CAMHS management.
As LAC are seen as part of generic CAMHS the data of specific LAC assessments
and their outcomes is not easily accessible and would need to be requested via the
Oasis information team.
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Professionals who are part of the LAC Tier 3 Consultation service keep their own
record (LAC booking diary) which then will be fed in to the Oasis system via the
CAMHS LAC Consultation clinic secretary.
The Dudley CAMHS LAC Consultation service has currently 32 cases open to the
LAC Consultation clinic. Between April 2014 and March 2015 52 LAC Consultations
took place on a Thursday afternoon (13.00PM until 16.30 PM) and two consultation
slots are available during this time period. A total of 13 new patients were discussed,
73 follow up consultations took place, 17 LAC Consultations were cancelled by the
professional network and 2 were not attended
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APPENDIX 2
WALSALL CAMHS AND LOOKED AFTER CHILDREN (LAC)
Referral screened by the Duty Management Team
Discharged
(Not appropriate)
Priority Choice
LAAC Consultation
(not a diagnostic
clinic)
Choice Plus
Appointment
Partnership
Appointment
Discharged
Partnership
Appointment
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Walsall CAMHS and Looked After Children (LAC)
Walsall CAMHS – summary of pathway for Looked after Children (LAC) and
those young people subject to Child Protection Plans (CPP)
All routine and priority appointments are managed through the single point of entry.
Referrals are screened every day, where further clarification is required regarding
the status of a child the admin team will contact Children’s Services directly to clarity.
Once it is established the referral is for an LAC or child on a CPP, the allocated
Social Worker is contacted, usually by telephone, to arrange a Choice appointment.
Referrals for LAC and those on a CPP are handled by a designated member of the
administration staff for continuity. The Choice appointments are usually arranged at
a mutually convenient time between the Social Worker and CAMHS clinician. This
appointment is a consultation to gather and share information prior to meeting the
child and family.
Delays can occur where there are difficulties arranging appointments with the
allocated Social Worker due to absence. At times there is no response or call back
from messages left for the allocated Social Worker. Should this be the case it will be
documented that the Social Worker failed to respond and after a number of attempts
with no response the case would be discharged from the service. At this point a two
week discharge with correspondence letter will be sent to the Social Worker and GP
giving them the opportunity to contact clinic before we close the case. If there is no
response the case is then closed.
Choice appointments are conducted with the Clinical Nurse Specialist / CAMHS
Social Worker for LAC. This meeting establishes beginnings of a plan for the child
and if necessary a Choice Plus appointment is offered, where we can gain further
information including background information, reports etc. At the end of the Choice
appointment a robust plan is agreed regarding further assessment and treatment.
The assessment appointment is when we see the child / parent / carer for a
Partnership appointment.
Treatments for psychological trauma and distress and psychiatric disorders in
childhood are provided by a range of disciplines within the service who deliver
interventions according to NICE guidance. All children have access to appropriate
treatment.
The majority of LAC referrals come directly from the Social Worker or Paediatrician
following LAC health reviews. A number of LAC/CPP referrals miss the pathway as
it is not clear from the referral, often when sent by General Practitioners.
Page 33 of 34
Page 147 of 230
Total LAC-CPP referrals to CAMHS for
108
Period April 2014-March 2015 including
Other Authorities Children placed in Walsall
Average time in total days from initial referral 63.3
to first consultation/assessment appointment
Number of referrals seen as priority
4
Average time in total day to first appointment 31.2
for priority appointments
Number of referrals discharged prior to first
2 (Walsall LA)
consultation/assessment due to failure by
SW to respond to opt-in
Referrals discharged for other reasons
4
*includes family absconding, moving placement out of area and transfer to Under 5s clinic
These figures can be compared with figures from the period 2013-14
Total LAC-CPP referrals to CAMHS for
Period April 2013-March 1014 including
Other Authorities Children placed in Walsall
Average time in total days from initial referral
to first consultation/assessment appointment
Number of referrals seen as priority
Average time in total day to first appointment
for priority appointments
Number of referrals discharged prior to first
consultation/assessment due to failure by
SW to respond to opt-in
Referrals discharged for other reasons
111
59.4
2
12
1 (all Walsall LA)
5*
As can be seen from the figures only a very small number of LAC referrals meet the
threshold (based primarily on immediate risk to self or others) for priority choice.
Anecdotally and not accounted for in these figures are LAC/CPP children who
presented on the children’s wards and were taken via a next working day
assessment. That is not recorded on the DSH referral database and may be
something we need to consider for future stats.
Page 34 of 34
Page 148 of 230
Board meeting date:
Agenda Item number:
Enclosure:
7th October 2015
11.4
10
Report Title:
Enhancing Quality through Safer Staffing Levels
- Monthly Exception Report
Wendy Pugh – Director of Operations, Nursing & Estates
Rosie Musson – Head of Nursing Quality and Innovation
Makhan Singh – Principal Consultant, Informatics and
Performance
This report aims to provide the Trust Board with:
Purpose of the
report:
1. The summary report of planned and actual staffing which has been
submitted to NHS Choices as part of a national staffing return
2. Exception reporting regarding variances provided by Heads of
Service
3. Trend analysis reporting monthly average fill rate
4. Update on regional and national direction
Decision / Approval
Gain assurance
Discussion
Information


Committee:
Date reviewed:
Key points or
Committee:
High quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources






The CQC domains that
this report relates to are:
Caring
Responsive
Effective
Well-led
Safe
Ensuring staffing levels are responsive to meeting patient need
Ensuring staffing levels are adequate to deliver safe care
Page 149 of 230
Title
Safe Staffing on Inpatient Wards
Introduction
There is now a requirement post publication of the Francis Report 2013 and following the
publication of Hard Truths that Trusts fulfill key commitments regarding publishing staffing data.
This report aims to provide the Trust Board with:
•
•
•
the summary report of planned and actual staffing which has been submitted to NHS Choices as
part of a national staffing return and is available on the Trust’s website.
exception reporting for variances
trend analysis monthly average fill rate
All Trusts are required to submit data, by ward, which shows planned against actual staff fill rates for
inpatient wards. This is provided by total hours for both day and night shifts. The data is broken down
by registered nurse and care staff.
Trust Boards are asked to receive this published data monthly. The Board will be informed by exception
of those wards where staffing fell short, the reasons for the gap, the impact and the actions taken to
address this gap.
There has currently been no agreement on RAG rate for this data for shortfalls, or oversupply of staffing
nationally, although further guidance on this tolerance is expected. However the report has used a
rating based on the provisional Information Centre range thresholds which were used to identify outliers
from the first submission in May 2014.
This set of data indicates sustained improvement in data quality. As reported in last month’s report this
information is collected manually and further systems have been introduced to improve data quality and
reduce the risk of double counting bank and agency staff.
Across the inpatient areas the overall fill rates are 99.5%, with 96.4% for registered staff and 101.2%
for care staff.
Typically where our care staff rates exceed the planned numbers significantly, this is due to temporary
staff being used to support patient observations or changes in skill mix.
There is one ward to note as an exception, whereby staff fill in part is within the lowest category
(Holyrood). An impact assessment has been completed that provides assurance safe staffing levels
have not been compromised, and during August there were no reported incidents of unsafe staffing
levels.
Trend analysis included in report, which are regularly monitored nursing teams. Variance predominately
attributed to initial data quality. Trends will continue to be monitored.
Page 150 of 230
The Board are asked to note that work is currently underway to enable more detailed analysis of related
to planned bank and actual agency usage.. In the longer term the Trust is working to introduce e rostering which will enable more effective triangulation of data and aim to improve the efficiency of
rostering.
Recommendation
To note and discuss the monthly data return submitted providing details of planned and actual staffing
at ward level. Data represents August 2015 and a monthly trend analysis for a 12 month period.
To note
• the work underway to enable more detailed analysis of staffing data and the current
complexities.
• the Trust continues to be engaged in the regional projects relating to the development of safe
staffing tools
• The Trust is in the process of taking forward e- rostering.
The Board of Directors are asked to:
•
To note and discuss the monthly data return submitted, providing details of planned and actual
staffing at ward level. Data represents August 2015 and a 12 month trend analysis.
Page 151 of 230
1. Nursing and healthcare staffing fill rates August 2015
The data submission was made on 14th September 2015 of August data
The following table provides a summary of the planned verses actual staffing levels on the inpatient wards.
Day
RMN
Cedars
Linden
Ambleside
Langdale
Clent
Kinver
Wrekin
Holyrood
Malvern
Grand Total
Night
Care Staff
Actual
RMN
Planned
Actual
Planned
937.5
930
985.5
972.5
785.5
877.5
833.25
712.5
945
7979.25
862.5
877.5
976
949.25
785.5
810
795.75
615
915
7586.5
1395
1447.5
666.5
2310
2330
666.5
1890
1890
659.75
1294.5
1299.5
637
1440
1440
354.75
1507.5
1571.5
333.25
859.25
855.25
333.25
1897.5
1995
333.25
2111.5
2134
666.5
14705.25 14962.75 4650.75
Planned
Lowest range – less than 80%
Day
Care Staff
Actual
Planned
Actual
655.75
655.75
649
612.75
354.75
344
333.25
333.25
648.25
4586.75
333.25
999.75
1150.25
842.25
1021.25
1128.75
720.25
1540.25
1343.75
9079.75
344
1010.5
1150.25
841
1021.25
1128.75
720.25
1537.25
1354.5
9107.75
Average fill rate registered
nurses/midwives
(%)
92.0%
94.4%
99.0%
97.6%
100.0%
92.3%
95.5%
86.3%
96.8%
95.1%
Average fill rate care staff (%)
103.8%
100.9%
100.0%
100.4%
100.0%
104.2%
99.5%
105.1%
101.1%
101.8%
Night
Average fill rate Average fill rate registered
care staff (%)
nurses/midwives
(%)
98.4%
103.2%
98.4%
101.1%
98.4%
100.0%
96.2%
99.9%
100.0%
100.0%
103.2%
100.0%
100.0%
100.0%
100.0%
99.8%
97.3%
100.8%
98.6%
100.3%
Highest range – greater than 150%
Low range – greater than 80% but less than 90%
High range – greater than 120% but less than 150%
Greater than 90% but less than 120%
Across the inpatient areas the overall fill rates are 99.5%, with 96.4% for registered staff and 101.2% for care staff. The overfill
result is as expected, as most of the inpatient wards do not have planned staff levels built into their rotas for increased levels of
patient observation and complexity. Typically where our care staff rates exceed the planned numbers significantly, this is due to
temporary staff being used to support patient observations.
Page 152 of 230
2.
Exception Report on Variance – August 2015
For August 2015, the Trust has one exception to report to the Trust Board.
Exceptions
Holyrood Ward – Bushey
Fields Hospital
86.3% Day – Average fill rate –
Registered Nursing (low range)
Rationale
Average fill rate for registered
nurse differed from planned
staffing
Impact
Safe staffing levels maintained,
no reported incidents
Remedial Actions
No action required
Ward used additional care staff
(105.1%) staffing levels to
ensure clinical risk was kept to
a minimum.
Page 153 of 230
3.
Trend Analysis average fill rate
The following table shows a monthly trend of the total average fill rates planned verses actual for the Trust. It shows the
improvement in the data quality and significant understanding of the capturing of planned hours of working.
Page 154 of 230
Board Meeting date:
7th October
Report Title:
Agenda Item number:
12.1
Enclosure:
11
Fit and Proper Persons Test Policy and update
Danielle Oum, Chair
Ashi Williams, Associate Director of People
This paper outlines the action the Trust has taken to meet
the workforce requirements of the “fit and proper persons”
standard. It sets out:
• The requirements of the fit and proper person
requirements regulation 5
• A summary of the CQC guidance and standards
expected of the regulation
• An update on how the Trust meets these requirements
Decision / Approval
Discussion
Gain assurance
Information


Key points or
Committee:
Committee: MExT
Date reviewed: 31/03/2015
•
•
Note the actions taken
Approve the fit and proper persons policy
High quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources






relates to are:
Caring
Responsive
Effective
Well-led
Safe
Fit for purpose Leadership team
Page 155 of 230
Title
Fit and Proper Persons Test policy and update
Introduction
New fundamental standards for all care providers are incorporated into the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2014 and came into force for all providers on
1 April 2015.
Within the new regulations, the duty of candour (regulation 20) and the fit and proper person
requirements for directors (regulation 5) came into force earlier (from 27 November 2014) for
NHS bodies than other providers
The introduction of the fit and proper persons requirement, via the above regulations, aims to
strengthen corporate accountability in the light of issues identified at Mid Staffordshire
Foundation Trust.
Previously providers had a general obligation to ensure that they only employed individuals
who were fit for their role and they were required to assess the fitness of nominated individuals
(organisationally determined, but usually Directors) to ensure that they were of good
character, were physically and mentally fit, had the necessary qualifications, skills and
experience for the role, and could supply certain information (including a Disclosure and
Barring Service (DBS) check and a full employment history).
The new fit and proper person requirement for Directors has a wider impact, in both the scope
of its application and the nature of the test. It makes it clear that individuals who have authority
in organisations that deliver care are responsible for the overall quality and safety of that care
and, as such, can be held accountable if standards of care do not meet legal requirements.
It is the responsibility of the Chair to ensure that all directors (or equivalents) in post and all
future appointments meet the fitness test and do not meet any of the “unfit” criteria.
It applies to all Directors and “equivalents” of provider organisations registered with the CQC
including non–voting directors. This includes both Executive and Non-Executive Directors of
NHS Trusts and Foundation Trusts. This is defined as individuals “performing the functions of,
or functions equivalent or similar to the functions of a Director”. The test will therefore apply to
some senior managers who exercise function similar to the directors of the Trust, attending the
Board event thought they are not members.
In addition to the usual requirements of good character, health, qualifications, skills and
experience as detailed below, the regulation goes further by barring individuals who are
prevented from holding the office (for example, under a directors disqualification order) and
significantly, excluding from office people who:
"have been responsible for, been privy to, contributed to or facilitated any serious misconduct
or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity,
or discharging any functions relating to any office or employment with a service provider."
Page 156 of 230
This is a significant restriction which, it is stated, would enable the Care Quality Commission
(“CQC”) to decide that a person is not fit to be a Director on the basis of any previous
misconduct or incompetence in a previous role for a service provider. This would be the case
even if the individual was working in a more junior capacity at that time, or working outside
England.
Requirements
The CQC has issued Guidance on what is required of Trusts in meeting these new duties. The
guidance is not enforceable but the CQC have stated that this will be taken into account in all
its regulatory decisions.
The regulations require the Chair to:
•
confirm to the CQC that the fitness of all new directors has been assessed in line with
the regulations; and
•
declare to the CQC in writing that they are satisfied that they are fit and proper
individuals for that role.
The CQC will cross-check notifications about new Directors against other information that they
hold or have access to, to decide whether they want to look further into the individual’s fitness.
They will also have regard to any other information that they hold or obtain about directors in
line with current legislation on when convictions, bankruptcies or similar matters are to be
considered ‘spent’.
Where a Director is associated with serious misconduct or responsibility for failure in a
previous role, the CQC will have regard to the seriousness of the failure, how it was managed,
and the individual’s role within that. There is no time limit for considering such misconduct or
responsibility. Where any concerns about an existing Director come to the attention of the
CQC, they may also ask the Trust to provide the same assurances.
Should the CQC use their enforcement powers to ensure that all Directors are fit and proper
for their role, they will do this by imposing conditions on the provider’s registration to ensure
that the provider takes the appropriate action to remove the director.
Standards
To meet the requirements of this regulation, the Trust must carry out all necessary checks to
confirm that persons who are appointed to the role of Director in an NHS trust or NHS
foundation trust are deemed “fit”. This requires that individuals must:
•
be of good character (Schedule 4, Part 2 of the regulations);
•
have the appropriate qualifications, are competent and skilled (including that they
show a caring and compassionate nature and appropriate aptitude);
•
capable by possessing the relevant experience and ability (including an appropriate
level of physical and mental health, taking account of any reasonable adjustments
under the Equality Act 2010 ); and
•
exhibit appropriate personal behaviour and business practices.
Page 157 of 230
•
have not been responsible for, or known, contributed to or facilitated any serious
misconduct or mismanagement in carrying on a regulated activity.
•
have not been prohibited from holding the position under any other law for example
the Companies Act or the Charities Act.
The CQC does recognise that a provider may not have access to all relevant information
about a person, or that false or misleading information may be supplied to them. However,
they expect providers to demonstrate due diligence in carrying out checks and that they have
made every reasonable effort to assure themselves about an individual by all means available
to them.
Assurance
An audit of Directors’ personal files has recently been completed to establish compliance with
the fit and proper persons checklist. A copy of this will be provided to the confidential session
of the Board for assurance.
A Fit and Proper Persons Test Policy has been developed which describes how the Trust will
meet its regulatory requirements to ensure that all Executive Directors and people performing
“the functions of, or functions equivalent or similar to the functions” of an Executive Director
are fit and proper individuals to carry out their roles, which includes compliance with the ‘duty
of candour’ and the Nolan principles. The policy outlines a number of key topics around Fit
and Proper Persons, including:
• Roles and responsibilities of the Board, HR and Executive Directors/equivalent
positions
• Processes and procedures around Fit and Proper Persons
• Appeals processes
• Regulatory requirements
Further detail
The table at appendix A identifies the specific requirements of the fit and proper persons test
and sets out, alongside those requirements, how the Trust assures itself about the suitability of
individuals.
The new Fit and Proper Persons policy is attached at Appendix B.
Recommendation
The Board is asked to
• Note the contents of the report and progress to date
• Approve the Fit and Proper Persons Policy
Page 158 of 230
RECRUITMENT
Action
Responsibility
Timescale
•
Update Recruitment & Selection Policy to include
o F&PP Test
o Duty of Candour
o Update DBS Process
Recruitment
•
Revise ED and associated director contracts of
employment and Reference request templates to
include F&PP and Duty of Candour
Associate Director of
People
End of June 2015
•
Revise ED and associated director Job Descriptions to
include F&PP and Duty of Candour
People
End of June 2015
People
End of April 2015
Recruitment
End of April 2015
•
Identify existing ED & associated director postholders
and issue declaration to existing ED & associated
director postholders
• Ensure system in place to re-issue annual
• declarations
APPRAISALS
Action
• Revise Appraisal Paperwork to refer to F&PP & Duty
of Candour
Responsibility
Learning & Development
Manager
End of August 2015
Timescale
End of Aug 2015
Update
R&S Policy updated (in draft)
and with HR Policy group for
consultation to be ratified Oct
2015
DBS Process updated, Trust
signed up to DBS Update
service.
Consultation commenced with
EDs completion expected Sept
2015 due to absence of CEO
and interim CEO continuing
work.
NED contract’s held with TDA
to be updated
Consultation commenced with
EDs completion expected Sept
2015 due to absence of CEO
and interim CEO continuing
work.
NED JD’s held with TDA to be
updated
Completed April 2015
Completed to be re-issued
April 2016
Appraisal Policy updated (in
draft) with HR policy group to
Page 159 of 230
•
be consulted on before
ratification. Likely to be ratified
end of Oct 15.
Ensure competence framework incorporates F&PP &
Duty of Candour
VALUES
Action
Embed Trust values in Policy and processes ie:
o Recruitment
o Appraisal
o HR Polices and Processes
HR POLICIES
Action
• Update HR Polices to include F&PP Duty of Candour
ie
o Disciplinary
•
Responsibility
People /Staff
Engagement lead
Timescale
Dec 2015
Responsibility
Senior HR Manager
Timescale
End of Dec 2015
Completed
In progress – Appraisal Policy,
R&S and Disciplinary Policy
currently being consulted on.
Page 160 of 230
Appendix A
Standard
Assurance
Evidence
Providers should make every effort to ensure that all
available information is sought to confirm that the
individual is of good character as defined in
Schedule 4, Part 2 of the regulations.
Employment checks are undertaken in accordance
with NHS Employers pre-employment check
standards and include:
At appointment
(Sch.4, Part 2: Whether the person has been
convicted in the United Kingdom of any offence or
been convicted elsewhere of any offence which, if
committed in any part of the United Kingdom, would
constitute an offence.
Whether the person has been erased, removed or
struck-off a register of professionals maintained by a
regulator of health care or social work
professionals.)
References
Other pre-employment checks
DBS checks where appropriate

Two references, one of which must be most
recent employer

qualification
checks

right to work checks

identity checks

occupational health clearance

DBS checks (where appropriate)
and
professional
registration
Signed declarations from applicants
Register search results
In addition, we also carry out:

Declarations of fitness by candidates

Search of insolvency and bankruptcy register
(*)

Search of disqualified directors register (*)
Page 161 of 230
Standard
Assurance
Where a provider deems the individual suitable
despite not meeting the characteristics outlined in
Schedule 4, Part 2 of these regulations, the reasons
should be recorded and information about the
decision should be made available to those that
need to be aware.
This would be the subject of debate at the
Remuneration and Nominations Committee.
Evidence
Record due process was followed
Minutes of meetings.
The Chair would take advice from internal and
external advisors as appropriate.
Decisions and reasons for decisions recorded in
appropriate minutes
Where specific qualifications are deemed by the
provider as necessary for a role, the provider must
make this clear and should only employ those
individuals that meet the required specification,
including any requirements to be registered with a
professional regulator.
This requirement is included within the job
description for relevant posts and is checked as part
of the pre-employment checks and references
regarding qualifications.
Person specification
The provider should have appropriate processes for
assessing and checking that the individual holds the
required qualifications and has the competence,
skills and experience required, (which may include
appropriate communication and leaderships skills
and a caring and compassionate nature), to
undertake the role; these should be followed in all
cases and relevant records kept.
Employment checks include a candidate’s
qualifications and employment references.
Recruitment policy and procedure
The recruitment process also includes qualitative
assessment
Checks undertake in line with the Trust’s
recruitment and selection policy and procedure (
and associated appendices)
Interview scoring notes
Decisions and reasons for appointments recorded in
panel notes
NB the reference to qualifications, skills and
experience is relevant to NED appointments
Page 162 of 230
Standard
Assurance
The provider may consider that an individual can be
appointed to a role based on their qualifications,
skills and experience with the expectation that they
will develop specific competence to undertake the
role within a specified timeframe.
Any such decision would be discussed by the
Remuneration and Nomination Committee and
would be minuted.
Evidence
Minutes of meetings
Appraisal framework
Record of appraisals
Actions would be subject to follow-up as part of on
going review and appraisal.
Follow up as part of continuing review and appraisal
When appointing relevant individuals the provider
has processes for considering a person’s physical
and mental health in line with the requirements of
the role.
All post-holders are subject to clearance by
occupational health as part of the pre-employment
process.
Occupational health clearance
Signed self declaration form
Signed self declaration form
Wherever possible, reasonable adjustments are
made in order that an individual can carry out the
role.
Signed self declaration of adjustments required
NHS pre-employment check standards via
Equality & Diversity Policy and Sickness Policy and
supporting guidance for managers
This is already included in the Trust’s Sickness
absence Policy
If a provider discovers information that suggests an
individual is not of good character after they have
been appointed to a role, the provider must take
appropriate and timely action to investigate and
rectify the matter.
The Trust’s Disciplinary policy, procedure and
guidance provides for such investigations and
sanctions as appropriate
Revised contracts allow for termination in the event
of non-compliance with regulations and other
requirements.
Contracts of employment (for EDs and directorequivalents)
Terms and conditions of service agreements (for
NEDs) – TDA role
Disciplinary policy and procedure
Page 163 of 230
Standard
Assurance
Evidence
The provider has processes in place to assure itself
that the individual has not been at any time
responsible for, privy to, contributed to, or facilitated,
any serious misconduct or mismanagement in the
carrying on of a regulated activity; this includes
investigating any allegation of such potential
behaviour. Where the individual is professionally
qualified, it may include fitness to practise
proceedings and professional disciplinary cases.
Specific declaration as part of the pre-employment
process.
ED/NED Recruitment Information pack
The consequences of false or inaccurate or
incomplete information is included in the recruitment
process
Reference Request for ED/NED (NED recruitment is
managed by the TDA)
(“Responsible for, contributed to or facilitated”
means that there is evidence that a person has
intentionally or through neglect behaved in a
manner which would be considered to be or would
have led to serious misconduct or mismanagement.
Pre-employment checks completed
Self - declaration
Revised reference request template for all director
and director-equivalent posts.
“Privy to” means that there is evidence that a person
or
was
aware
of
serious
misconduct
mismanagement but did not take the appropriate
action to ensure it was addressed.
“Serious misconduct or mismanagement” means
behaviour that would constitute a breach of any
legislation/enactment CQC deems relevant to
meeting these regulations or their component
parts.”)
Page 164 of 230
Standard
Assurance
The provider must not appoint any individual who
has been responsible for, privy to, contributed to, or
facilitated,
any
serious
misconduct
or
mismanagement (whether lawful or not) in the
carrying on of a regulated activity; this includes
investigating any allegation of such potential
behaviour. Where the individual is professionally
qualified, it may include fitness to practise
proceedings and professional disciplinary cases.
Specific declaration as part of the pre-employment
process.
Only individuals who will be acting in a role that falls
within the definition of a “regulated activity” as
defined by the Safeguarding Vulnerable Groups Act
2006 will be eligible for a check by the Disclosure
and Barring Service (DBS).
DBS checks are undertaken only for those posts
which fall within the definition of a “regulated
activity” or which are otherwise eligible for such a
check to be undertaken.
The consequences of false or inaccurate or
incomplete information is included in the recruitment
process
Evidence
NED Recruitment Information pack
Reference Request for ED/NED (NED recruitment is
managed by the TDA)
Revised reference request template for all director
and director-equivalent posts.
DBS checks for eligible post-holders
Recruitment and selection policy and procedure
(CQC recognises that it may not always be possible
for providers to access a DBS check as an
individual may not be eligible.)
As part of the recruitment/appointment process,
providers should establish whether the individual is
on a relevant barring list.
Eligibility for DBS checks will be assessed for each
vacancy arising.
DBS checks for eligible post-holders
Recruitment and selection policy and procedure
Page 165 of 230
Standard
The fitness of directors is regularly reviewed by the
provider to ensure that they remain fit for the role
they are in; the provider should determine how often
fitness must be reviewed based on the assessed
risk to business delivery and/or the service users
posed by the individual and/or role.
Assurance
Post-holders undertake annual declarations of
fitness to continue in post.
Evidence
Annual self - declaration
Assessed via NED appraisal process
Checks of insolvency and bankruptcy register and
register of disqualified directors to be undertaken
each year as part of the appraisal process. (*)
Assessed via ED appraisal process
Board decisions ratified and minuted
Minutes of meetings
The provider has arrangements in place to respond
to concerns about a person’s fitness after they are
appointed to a role, identified by itself or others, and
these are adhered to.
The Trust’s Disciplinary policy, procedure and
guidance provides these arrangements, and revised
contracts (for EDs and director-equivalents) and
agreements (for NEDs) incorporate maintenance of
fitness as a contractual requirement allow for
termination in the event of non –compliance with the
regulations.
Disciplinary policies
The provider investigates, in a timely manner, any
concerns about a person’s fitness or ability to carry
out their duties, and where concerns are
substantiated, proportionate, timely action is taken;
the provider must demonstrate due diligence in all
actions.
This will be undertaken in line with the appropriate
HR policy if concerns are identified and revised
contracts provide for termination if individuals fail to
meet necessary standards.
Revised employment contracts for ED and
NEDs/addendum letter for existing postholders
Where a person’s fitness to carry out their role is
being investigated, appropriate interim measures
may be required to minimise any risk to service
users.
This would be reviewed when concerns are
identified. The appropriate core HR policy would
apply.
Core HR policies applied and action taken as
necessary
Checks recorded
ED contracts of employment
NED agreements
Page 166 of 230
Standard
Assurance
The provider informs others as appropriate about
concerns/findings relating to a person’s fitness; for
example, professional regulators, CQC and other
relevant bodies, and supports any related
enquiries/investigations carried out by others.
This would be reviewed when concerns are
identified. The appropriate core HR policy would
apply if any concerns were identified.
Evidence
Referrals made to other agencies if necessary.
(*) indicates newly-introduced requirements to address the regulations
In the table above, unless the contrary is stated or the context otherwise requires, “ED” means executive directors and director-equivalents
Page 167 of 230
Appendix B
Pre-employment and annual declaration for director and
Director-equivalent posts
DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUST (“the
Trust”)
“FIT AND PROPER PERSON” DECLARATION
1.
It is a condition of employment that those holding director and director-equivalent
posts provide confirmation in writing, on appointment and thereafter on demand,
of their fitness to hold such posts. Your post has been designated as being such
a post. Fitness to hold such a post is determined in a number of ways, including
(but not exclusively) by the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2008 (“the Regulated Activities Regulations”).
2.
By signing the declaration below, you are confirming that you do not fall within
the definition of an “unfit person” or any other criteria set out below, and that you
are not aware of any pending proceedings or matters which may call such a
declaration into question.
Regulated Activities Regulations
3.
Regulation 5 of the Regulated Activities Regulations states that the Trust must
not appoint or have in place an individual as a director, or performing the
functions of or equivalent or similar to the functions of, such a director, if they do
not satisfy all the requirements set out in paragraph 3 of that Regulation.
4.
The requirements of paragraph 3 of Regulation 5 of the Regulated Activities
Regulations are that:
(a)
the individual is of good character;
(b)
the individual has the qualifications, competence, skills and experience
which are necessary for the relevant office or position or the work for
which they are employed;
(c)
the individual is able by reason of their health, after reasonable
adjustments are made, of properly performing tasks which are intrinsic to
the office or position for which they are appointed or to the work for which
they are employed;
(d)
the individual has not been responsible for, privy to, contributed to or
facilitated any serious misconduct or mismanagement (whether unlawful
or not) in the course of carrying on a regulated activity or providing a
service elsewhere which, if provided in England, would be a regulated
activity; and
(e)
none of the grounds of unfitness specified in Part 1 of Schedule 4 apply to
the individual.
Page 168 of 230
5.
The grounds of unfitness specified in Part 1 of Schedule 4 to the Regulated
Activities Regulations are:
(a)
the person is an undischarged bankrupt or a person whose estate has
had sequestration awarded in respect of it and who has not been
discharged;
(b)
the person is the subject of a bankruptcy restrictions order or an interim
bankruptcy restrictions order or an order to like effect made in Scotland or
Northern Ireland;
(c)
the person is a person to whom a moratorium period under a debt relief
order applies under Part VIIA (debt relief orders) of the Insolvency Act
1986;
(d)
the person has made a composition or arrangement with, or granted a
trust deed for, creditors and not been discharged in respect of it;
(e)
the person is included in the children’s barred list or the adults’ barred list
maintained under section 2 of the Safeguarding Vulnerable Groups Act
2006, or in any corresponding list maintained under an equivalent
enactment in force in Scotland or Northern Ireland;
(f)
the person is prohibited from holding the relevant office or position, or in
the case of an individual for carrying on the regulated activity, by or under
any enactment.
I acknowledge the extracts from the provider license, Regulated Activities Regulations
and the Trust’s constitution above. I confirm that I do not fit within the definition of an
“unfit person” as listed above and that there are no other grounds under which I would
be ineligible to continue in post. I undertake to notify the Trust immediately if I no longer
satisfy the criteria to be a “fit and proper person” or other grounds under which I would
be ineligible to continue in post come to my attention.
Name:
___________________________________
Signed:
___________________________________
Position:
___________________________________
Date:
___________________________________
Page 169 of 230
Appendix C
Additional clauses for inserting into Chairman’s appointment letter
Basis of appointment
It is a condition of your continuing engagement that you remain a fit and proper person
as required by the Health and Social Care Act 2008 (Regulated Activities) Regulations
2014 and the guidance issued by the Care Quality Commission (including any
amendments of either from time to time).
Early Termination of Appointment
You may resign from office by giving notice in writing to the Company Secretary.
You will be disqualified from continuing in office if:
a) you have been adjudged bankrupt or your estate has been sequestrated and (in
either case) you have not been discharged;
b) a moratorium period under a debt relief order applies in relation to you (under
Part 7A of the Insolvency Act 1986);
c) you have made a composition or arrangement with, or granted a trust deed for,
your creditors and have not been discharged in respect of it;
d) you are (or have been within the preceding five years) convicted in the British
Islands of any offence if a sentence of imprisonment (whether suspended or not)
for a period of not less than three months (without the option of a fine) is imposed
on you;
e) you are subject to an unexpired disqualification order under the Company
Directors’ Disqualification Act 1986; or
f) you are otherwise disqualified in law from holding the office of non-executive
director of a Trust; or
g) you are or become an unfit person for the purposes of the Trust’s Monitor
Licence or if Monitor determines that the Trust is in breach of its Licence or
exercises its powers to require the Trust (either directly or through an
enforcement undertaking from the Trust) to remove you from office as a nonexecutive director of the Trust, or to suspend or disqualify you from office or any
other action Monitor considers necessary; or
h) you are the subject of conditions from the CQC requiring your removal from office
as a non-executive director of the Trust or your suspension or disqualification
from office or any other action the CQC considers necessary; or
i) you fail to satisfy the fit and proper person requirements of the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2014 and the guidance issued
by the Care Quality Commission..
j) If you are or become disqualified from continuing in office on any of the grounds
set out in paragraphs (a) to (i) above you must notify the Company Secretary and
you will cease to hold office with immediate effect.
Duties
As Chairman you are responsible for ensuring that the fitness of all directors has been
assessed in line with the fit and proper person test as required by the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2014 and the guidance issued by the
Care Quality Commission. You will be required from time to time to make this
declaration in writing to the Board, the CQC and/or Monitor.
Page 170 of 230
Declaration
I confirm that I satisfy the requirements of the fit and proper person test and that I am of
good character, have the qualifications, skills and experience to carry out the position,
am capable by reason of health of properly performing tasks which are intrinsic to the
position, have not been responsible for any misconduct or mismanagement previously
and am not prohibited from holding office. Should any matters arise which impact upon
the requirement of the fit and proper test, I confirm that I shall notify the Vice Chairman
and/or Company Secretary of such matters.
Name:
___________________________________
Signed:
___________________________________
Position:
___________________________________
Date:
___________________________________
Page 171 of 230
Document Title
Fit and Proper Persons Test Policy
Document Description
Document Type
Human Resources
Service Application
Trust Wide
Version
1.0
Reference Number
Lead Author(s)
Ashi Williams
Associate Director of People and Workforce Development
Change History – Version Control
Version
Date
Comments
1.0
16/09/15
Sent for comments and Staff Partnership Forum
Link with National Standards
National Health Service Litigation Authority
√
Care Quality Commission
√
National Institute of Clinical Excellence (NICE) Guidance
National Patient Safety Agency
√
West Midlands Quality Review
Essence of Care
√
Aims Standards
Key Dates
Day
Month
Year
Ratification Date
Review Date
Page 172 of 230
Executive Summary Sheet
Document Title: Fit and Proper Persons Test Policy
Please tick ()
as appropriate
This is a new document within the Trust
This is a revised document within the Trust

What is the purpose of this document?
This policy describes how the Trust will meet its regulatory requirements to ensure that all
Executive Directors and people performing “the functions of, or functions equivalent or similar
to the functions” of an Executive Director are fit and proper individuals to carry out their roles,
which includes compliance with the ‘duty of candour’ and the Nolan principles.
What key issues does this document explore?
This policy outlines a number of key topics around Fit and Proper Persons, including:
• Roles and responsibilities of the Board, HR and Executive Directors/equivalent positions
• Processes and procedures around Fit and Proper Persons
• Appeals processes
• Regulatory requirements
Who is this document aimed at?
This policy is aimed at all employees and Board Members within Dudley and Walsall Mental
Health Partnership NHS Trust
What other policies, guidance and directives should this document be read in conjunction with?
• Whistleblowing Policy
• Safeguarding Policy
• Aggregating Data and Learning from Incidents, Serious Untoward Incidents, Complaints
and Claims Policy
• Incident, Near-miss and Serious Untoward Incident Policy
• Recruitment & Selection Policy
• Disciplinary Policy
How and when will this document be reviewed?
Every 3 years or as and when legislation changes.
Appendix 1 List of equivalent positions currently identified (subject to annual review)
Page 173 of 230
Contents
1.0
INTRODUCTION ............................................................................................................... 4
2.0
POLICY OBJECTIVES .......................................................................................................... 4
3.0
SCOPE.............................................................................................................................. 4
4.0
ROLES & RESPONSIBILITIES .............................................................................................. 5
5.0
GENERAL PRINCIPLES ....................................................................................................... 6
6.0
POLICY PROCEDURES ....................................................................................................... 7
7.0
EQUALITY AND DIVERSITY ................................................................................................ 9
8.0
SUPPORTING REFERENCES ............................................................................................... 9
9.0
TRAINING ...................................................................................................................... 10
10.0 APPENDICES .................................................................................................................. 10
Page 174 of 230
1.0
INTRODUCTION
As a Health service provider, the Trust currently has a general obligation to ensure that
only individuals who are fit for their role are employed. The Health & Social Care Act 2008
(Regulated Activities) Regulations 2014 has introduced an additional fit and proper
persons requirement for Executive Directors (FPPR) and people performing “the functions of,
or functions equivalent or similar to the functions” of an Executive Director.
The
th
regulation came into force on 17 November 2014.
It will be the ultimate responsibility of the Chair to discharge the requirement placed on the
Trust to ensure that all E x e c u t i ve D irectors and ‘equivalents’ meet the fitness test and
do not meet any of the unfit criteria.
2.0
POLICY OBJECTIVES
The policy objectives are;
• To define the minimum standards for determining the fitness and propriety of
individuals on appointment and on an ongoing basis [a ‘Fit & Proper Person’] to serve in their
respective position within the Trust.
• To explain to external regulators how the Trust intends to comply with the Regulations.
• To define the individuals and/or roles to which this policy applies
• To describe the procedures in relation to the policy
• To outline the evidence required to demonstrate statutory obligations
• To promote stakeholder confidence in the Trust and its officers
3.0
SCOPE
This policy applies to Executive Directors and people performing “the functions of, or
functions equivalent or similar to the functions” of a director. For the purposes of this policy
the positions detailed in Appendix 1 within the Trust are defined as within the scope of
this policy.
Any other new position specifically designated by the CEO or the Nominations and
Remuneration Committee of Trust Board as being a role which requires the performing of
“functions of, or functions equivalent or similar to the functions” of an Executive Director;
such a position is likely to involve:
i.
ii.
iii.
iv.
High level decision making
Implementing strategies and policies approved by the Board
Developing and implementing processes or systems that identify, assess, manage
and monitor risks related to regulated activities and operations; or
Monitoring the appropriateness,
adequacy
and effectiveness
of
risk
management systems
Page 175 of 230
4.0
4.1
ROLES & RESPONSIBILITIES
Chair
The Chair has overall responsibility for compliance with the FPPR and will be required to
confirm to the CQC that:
• the fitness of all new Executive Directors has been assessed in line with the regulations; and
• Declare to the CQC in writing that they are satisfied that all individuals within the scope of
FPPR are fit and proper individuals for their role.
4.2 Nominations and Remuneration Committee of Trust Board
• Review this policy to ensure it is fit for purpose
• Receive an annual report on the application of FPPR to ensure ongoing compliance
4.3
Director of People and Corporate Development (DPCD)
The Director of People and Corporate Development is responsible for:
• Administering the policy; and
• Ensuring compliance with relevant obligations described within the Regulations and any
changes to the requirements and recommending the appropriate policy amendments to
the Nominations and Remuneration Committee of the Trust Board
• Ensuring that all appropriate documentation is completed, stored and available to the Care
Quality Commission for inspection upon request.
4.4
Affected Individuals
Individuals who fall within the policy are responsible for:
• The provision of their consent to the checks described in Appendix 4 on request for the
purposes of this policy
• The signing of the declaration that they are a fit and proper person at Appendix 2 on
appointment and on an annual basis
• The provision of evidence of their qualifications, experience and identity documents on
appointment or on request to confirm the competencies relevant to the position at Appendix
4
• The identification of any issues which may affect their ability to meet the statutory
requirements on appointment and bringing their issues on an ongoing basis to the Chief
Executive (for Executive and other Directors) and the Chairman for NEDs. The Chair should
raise any issues with the NHS Trust Development Authority (TDA).
4.5
Members of Staff
Raise issues of concern via appropriate processes and/or policies i.e. Whistleblowing
Policy or directly to Director of People and Corporate Development or Associate Director of
People and Workforce Development.
Page 176 of 230
5.0
5.1
GENERAL PRINCIPLES
What is a “fit & proper person”?
Regulation 5 of the Health & Social Care Act 2008 (Regulated Activities) Regulation 2014
sets out the criteria that a director and/or equivalent must meet. They must:
• Be of good character;
• Have the qualifications, skills and experience necessary for the relevant position.
• Be capable of undertaking the relevant position, after any reasonable adjustments under
the Equality Act 2010;
• Not have been responsible for any misconduct or mismanagement in the course of any
employment with a CQC registered provider;
• Not be prohibited from holding the relevant position under any other law, eg under the
Companies Act or the Charities Act.
5.2
Who approves a person as ‘Fit & Proper’?
For a person to be “fit and proper” for the purposes of this policy, the Board, delegate to
individuals listed below to satisfy themselves that individuals are a “fit & proper person”. The
following table sets out the delegations: (appendix 1)
Identified Position
Chair
Who (the delegate) with authority to
approve a person as “fit & proper”
NHS Trust Development Authority
Non-Executive Director (excluding Chair)
Chair
Executive Directors
5.3
Fit & Proper Person test
This is defined in Schedule 4 of the Health & Social Care Act 2008 (Regulated Activities)
Regulations 2014 in two parts; good character(part 2) and unfit persons test (part 1) and its
purpose is to ensure that the Trust is NOT managed or controlled by individuals who present
an unacceptable risk to the organisation or to patients.
Under Schedule 4, Part 1, a director will be deemed unfit if they:
• Have been sentenced to imprisonment for three months or more within the last five
years, although CQC could remove this bar on application;
• Are an undischarged bankrupt;
• Are the subject of a bankruptcy order or an interim bankruptcy order;
• Have an undischarged arrangement with creditors;
Page 177 of 230
• Are included on any barring list preventing them from working with children or
vulnerable adults.
Under Schedule 4, Part 2 a director will fail the ‘good character’ test, if they:
• Have been convicted in the United Kingdom of any offence or been convicted
elsewhere of any offence which, if committed in any part of the United Kingdom, would
constitute an offence;
• Have been erased, removed or struck off a register of professionals maintained by a
regulator of health or social care.
5.4
The Nolan Principles
It is anticipated that this policy is operated alongside the Nolan principles. Board members
and equivalents are expected to promote and support these principles by leadership and
example (Appendix 6 - List of Nolan Principles)
6.0
POLICY PROCEDURES
Director and Equivalent Positions
All appointments will require appropriate approval for persons detailed in Section 6.2 prior to
confirmation of offer of employment/office. An agreed signed off process with all
relevant checks (Appendix 4) will be carried out prior to final checking by the designated
person (see section 6.2 above) and unconditional offer. All conditional offers will be
conditional on meeting the statutory requirements.
Disqualification
A failure or refusal by a candidate for appointment to comply with any of the procedures
set out in this policy will immediately disqualify that person from the proposed
appointment.
Decisions for Candidates
The Director of People and Corporate Development will notify any prospective candidate for
appointment as soon as is practicable if that person is determined to be ineligible under this
Policy.
Existing Staff
Investigation
If a concern regarding an individual is brought to the attention of the Trust, an appropriate
investigation will be carried out by an appropriate person/body dependent on the particular
circumstances.
Page 178 of 230
Where an individual’s fitness to carry out their role is being investigated, the CQC states that
“appropriate interim measures may be required to minimise any risk to service users”. This
may mean that an individual’s duties may need to be temporarily varied or closely
supervised pending investigation and in some cases suspension may be considered.
Any failure by an affected individual to co-operate with such an investigation without an
acceptable (as defined by the Trust Chair) explanation, will result in suspension without
pay/payment of fee until the matter is concluded.
If an investigation has concluded that an individual carrying out an identified position under
this policy may no longer meet the requirements of the “fit and proper person test” the
following 2 stage procedure will be applied:
Fit & Proper Person Hearing
If there is sufficient evidence that an individual carrying out one of the identified positions
under this policy may no longer be a fit and proper person and the evidence is such that
formal action may be required, then that person will be invited to a hearing to give them
the opportunity to test the evidence and/or offer an explanation for consideration of the
panel.
Fit & Proper Person Appeal Hearing
If an individual carrying out one of the identified positions under this policy has been
determined to no longer be a fit and proper person, then that person may appeal that
decision in writing within 10 days of receipt of notification of Trust’s decision.
Evidence
The regulations require certain information to be available as evidence in respect of persons
employed or appointed by the Trust. The information required is described in Schedule 3 of
the Regulations (see appendix 3).
Based on the regulations and cross-referenced with the guidance provided by the CQC a
simple check sheet (see appendix 4) has been developed in order to ensure all
appropriate information has been gathered and is available for inspection.
Confidentiality
All information provided by a person in accordance with this Policy will be kept confidential in
accordance with the terms of the Trust’s confidentiality and privacy policies. However, a
person seeking to demonstrate that they are a ‘fit and proper person’ in accordance with this
policy consents to the Trust disclosing, to Regulators, the extent that is necessary any
personal information (as per Data Protection Act 1988) and confidential information for the
purpose of undertaking the checks required by this policy and for the related purposes of this
policy.
Page 179 of 230
7.0
EQUALITY AND DIVERSITY
The Trust is committed to an environment that promotes equality and embraces diversity both
within our workforce and in service delivery. This policy will be implemented with due regard
to this commitment.
An Equality Impact Screening Assessment will be completed.
8.0
SUPPORTING REFERENCES
CQC Guidance for NHS Bodies
November 2014
Health & Social Care Act 2008
(Regulated Activities) Regulations
2014
NHS Guidance
Regulation 5: Fit & Proper persons: directors and Regulation
20:duty of candour
SI 2014/2936, reg 20; SI 2014/2936, reg 5
Professional Standards Authority
Standards November 2013
Charities Commission Guidance
2013/14
NHS Employers Employment Checks etc
Disclosure & Barring identity Check
July 2014
Guidance
Equality & Human Rights Commission Employment Statutory Code of Practice
NHS Standard Contract 2014/15:
Updated Technical Guidance (Appendix 5:
Contractual requirements relating to duty of
Candour
NHS Patient Safety Agency, being
Provision of guidance on communicating about patient
Open Framework
safety incidents with patients, families and carers
National Patient Safety Agency, Seven Definitions of levels of harm
Steps
to Patient Safety
CQC (Registration requirement)
Regulations 16-18 outline the notifications required by CQC
Regulations 2009
NHS Litigation Authority
Saying Sorry
General Medical Council Guidance
Good Medical Practice 2001, Guidance on ‘duty of candour’
Trust policies
Whistleblowing Policy
Safeguarding Policy
Aggregating Data and Learning from Incidents, Serious
Untoward Incidents, Complaints and Claims Policy
Incident, Near-miss and Serious Untoward Incident Policy
Recruitment & Selection Policy
Disciplinary Policy
Fit and proper persons requirements for NHS Chairs and
non-executive directors 4th Dec 2014
Page 180 of 230
9.0
TRAINING
The approved policy will be promoted via the Trust intranet for all staff and detailed
briefings will be carried out with all affected individuals.
Coaching will also be available to managers on a 1-2-1 basis for individual cases.
10.0 APPENDICES
Appendix 1 – List of equivalent positions currently identified (subject to annual review)
Appendix 2 – Self-declaration form as per schedule 4. To be completed by all applicants
Appendix 3 – Schedule 3: information required in respect of persons employed or appointed for
the purposes of a regulated activity
Appendix 4 – Individual Check Sheet
Appendix 5 - CQC guidance on evidence to meet FPPR regulations
Appendix 6 – list of Nolan principles
Page 181 of 230
APPENDIX 1 - LIST OF EQUIVALENT POSITIONS CURRENTLY IDENTIFIED (subject to annual
review)
All Executive Directors in attendance at Trust Board irrespective of voting rights:
•
•
•
Chair
Non-executive Directors
Executive Directors
Page 182 of 230
APPENDIX 2 – SELF-DECLARATION FORM AS PER SCHEDULE 4. To be
completed by all applicants.
“FIT AND PROPER PERSON” DECLARATION
1.
It is a condition of employment that those holding director and director-equivalent
posts provide confirmation in writing, on appointment and thereafter on demand, of
their fitness to hold such posts. Your post has been designated as being such a post.
Fitness to hold such a post is determined in a number of ways, including (but not
exclusively) by the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2008 (“the Regulated Activities Regulations”).
2.
By signing the declaration below, you are confirming that you do not fall within the
definition of an “unfit person” or any other criteria set out below, and that you are not
aware of any pending proceedings or matters which may call such a declaration into
question.
Regulated Activities Regulations
3.
Regulation 5 of the Regulated Activities Regulations states that the Trust must not
appoint or have in place an individual as a director, or performing the functions of or
equivalent or similar to the functions of, such a director, if they do not satisfy all the
requirements set out in paragraph 3 of that Regulation.
4.
The requirements of paragraph 3 of Regulation 5 of the Regulated Activities
Regulations are that:
(a)
(b)
(c)
(d)
(e)
5.
the individual is of good character;
the individual has the qualifications, competence, skills and experience which
are necessary for the relevant office or position or the work for which they are
employed;
the individual is able by reason of their health, after reasonable adjustments
are made, of properly performing tasks which are intrinsic to the office or
position for which they are appointed or to the work for which they are
employed;
the individual has not been responsible for, privy to, contributed to or facilitated
any serious misconduct or mismanagement (whether unlawful or not) in the
course of carrying on a regulated activity or providing a service elsewhere
which, if provided in England, would be a regulated activity; and
none of the grounds of unfitness specified in Part 1 of Schedule 4 apply to the
individual.
The grounds of unfitness specified in Part 1 of Schedule 4 to the Regulated Activities
Regulations are:
(a)
(b)
the person is an undischarged bankrupt or a person whose estate has had
sequestration awarded in respect of it and who has not been discharged;
the person is the subject of a bankruptcy restrictions order or an interim
bankruptcy restrictions order or an order to like effect made in Scotland or
Northern Ireland;
Page 183 of 230
(c)
(d)
(e)
(f)
the person is a person to whom a moratorium period under a debt relief order
applies under Part VIIA (debt relief orders) of the Insolvency Act 1986;
the person has made a composition or arrangement with, or granted a trust
deed for, creditors and not been discharged in respect of it;
the person is included in the children’s barred list or the adults’ barred list
maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006,
or in any corresponding list maintained under an equivalent enactment in force
in Scotland or Northern Ireland;
the person is prohibited from holding the relevant office or position, or in the
case of an individual for carrying on the regulated activity, by or under any
enactment.
I acknowledge the extracts from the provider license, Regulated Activities Regulations and
the Trust’s constitution above. I confirm that I do not fit within the definition of an “unfit
person” as listed above and that there are no other grounds under which I would be ineligible
to continue in post. I undertake to notify the Trust immediately if I no longer satisfy the
criteria to be a “fit and proper person” or other grounds under which I would be ineligible to
continue in post come to my attention.
Name:
…………………………………………………………
Signed:
…………………………………………………………
Position:
…………………………………………………………
Date:
…………………………………………………………
Page 184 of 230
APPENDIX 3 - SCHEDULE 3: INFORMATION REQUIRED IN RESPECT OF PERSONS
EMPLOYED OR APPOINTED FOR THE PURPOSES OF A REGULATED ACTIVITY
1. Proof of identity including a recent photograph.
2. Where required for the purposes of an exempted question in accordance with section
113A(2)(b) of the Police Act 1997, a copy of a criminal record certificate issued under
section 113A of that Act together with, after the appointed day and where applicable,
the information mentioned in section 30A(3) of the Safeguarding Vulnerable Groups
Act 2006 (provision of barring information on request).
3. Where required for the purposes of an exempted question asked for a prescribed
purpose under section 113B(2)(b) of the Police Act 1997, a copy of an enhanced
criminal record certificate issued under section 113B of that Act together with, where
applicable, suitability information relating to children or vulnerable adults.
4. Satisfactory evidence of conduct in previous employment concerned with the provision
of services relating to—
(a) health or social care, or
(b) children or vulnerable adults.
5. Where a person (P) has been previously employed in a position whose duties involved
work with children or vulnerable adults, satisfactory verification, so far as reasonably
practicable, of the reason why P’s employment in that position ended.
6. In so far as it is reasonably practicable to obtain, satisfactory documentary evidence of
any qualification relevant to the duties for which the person is employed or appointed to
perform.
7. A full employment history, together with a satisfactory written explanation of any gaps
in employment.
8. Satisfactory information about any physical or mental health conditions which are
relevant to the person’s capability, after reasonable adjustments are made, to properly
perform tasks which are intrinsic to their employment or appointment for the purposes
of the regulated activity.
9. For the purposes of this Schedule—
(a) “the appointed day” means the day on which section 30A of the Safeguarding
Vulnerable Groups Act 2006 comes into force;.
(b) “satisfactory” means satisfactory in the opinion of the Commission;
(c) “suitability information relating to children or vulnerable adults” means the
information specified in sections 113BA and 113BB respectively of the Police
Act 1997.
Page 185 of 230
APPENDIX 4 – INDIVIDUAL CHECK SHEET
On appointment
Pre-employment Checks
New Starter Form
Identity checks including photo
(retain copies)
Right to work checks
Employment history and reference checks
Professional registration and required
qualifications checks
Criminal Record (Enhanced DBS) and
Barring Checks
Occupational Health & Exposure Prone
Procedures (EPP)Clearance
Health Declaration form
Self-declaration
Existing Staff
Enhanced DBS Check (annual)
Self-declaration (annual)
Appraisal Information
Absence Record (Occ Health referral as
necessary)
Compliance with appropriate policies e.g.
FPPR, Incidents, safeguarding etc
Professional Registration Check
Recruitment & Selection
Recruitment & selection based on values as
well as qualifications, skills etc
Conditional Offer Letter (subject to above
checks)
Unconditional Offer Letter
Contract to include additional FPPR
requirements
Provider Checks
Provider Checks e.g. provider whose
registration has been suspended/cancelled,
public inquiry reports about provider,
disqualification from professional regulatory
body, serious case reviews, homicide
investigations for mental health trusts,
criminal prosecutions against provider,
ombudsman reports, CQC inspection
reports & actions taken
Unfit Person Criteria Checks
Check for bankruptcy, sequestration,
insolvency, insolvency and arrangements
with creditors
Check that not prohibited from holding office
e.g. Companies Act 2006 or Charities Act
Where any evidence found which suggests
person unfit, evidence should be reviewed
and decisions documented.
As appropriate i.e. on new role
Mutual variation of the contract: Contract to
include additional FPPR requirements
Where any evidence found which suggests
person unfit, evidence should be reviewed
and decisions documented.
Page 186 of 230
APPENDIX 5 – CQC GUIDANCE ON EVIDENCE TO MEET FPPR REGULATIONS
Component of the regulation
5(3)(a) the individual is of good character
On appointment
NHS Employment Checks
Previous employer references (last 3
years) DBS Checks
Values Based Recruitment & Selection
Self-declaration (appendix 2)
5(3)(b) the individual has the
qualifications, competence, skills and
experience which are
necessary for the relevant office or
position for which they are employed
Evidence to confirm individual meets
‘Person specification’, original to be seen,
signed off
and copies retained
Check of relevant professional register
Values Based Recruitment & Selection
Appraisal information from
previous/current employer where
Occupational Health Clearance
5(3)(c) the individual is able by reason of
their
health, after such reasonable adjustments
are made, of properly performing tasks
which are intrinsic to the office or position
for which they are appointed or for the
5(3)(d) the individual has not been
responsible for, been privy to,
contributed to
or facilitated, any serious misconduct or
mismanagement (whether unlawful or
not) in
the course of carrying on a regulated
activity or providing a service elsewhere
which, if provided in England, would be a
regulated
References covering last 3 years
employment to cover serious misconduct
or
mismanagement
Provider Checks e.g. provider whose
registration has been
suspended/cancelled,
public inquiry reports about provider,
disqualification from professional
regulatory body, serious case reviews,
Existing Personnel
NHS Employment Checks (on file)
Previous employer references (last 3
years) –
on file (where not available –
appraisal documentation)
DBS Checks (annual?)
Check that individual meets documented
‘Person specification’
Professional registration
checks
Appraisal information
Occupational Health referral as necessary
Absence record
Appraisal information
Compliance with Trust policies including:
• FPPR Policy
• Safeguarding Policies
• Incidents Policy
Incidents/concerns raised via:
• Whistleblowing Policy
• Professional registration Referrals
Page 187 of 230
5(3)(e) none of the grounds of unfitness
specified in Part 1 of Schedule 4 apply to
the
individual
5(6) where an individual holds an
office or position referred to in para
2(a) or (b) no
longer meets the requirements in para (3)
the service provider mustTake such action as is necessary &
proportionate to ensure that the office
or position in question is held by an
individual who meets such
requirements &
(b) if the individual is a health
care professional social worker
20(1) a health & service body must act in
an open and transparent way with
relevant
persons in relation to care & treatment
provided to the service users in carrying
on a regulated activity
20(2) As soon as is 20(2) As soon as is
reasonably practicable after becoming
ombudsman reports, CQC inspection
reports
& actions taken
Professional Registration/Regulator checks
DBS Checks
DBS Checks
Check for bankruptcy, sequestration,
insolvency, insolvency and arrangements
with
creditors
Check that not prohibited from holding
office e.g. Companies Act 2006 or
Charities Act Where any evidence found
which suggests person unfit evidence
DBS Checks
Self-declaration
Professional registration checks
References covering last 3 years
Incidents & Openness Policy
FPPR Policy
Safeguarding
Policies Disciplinary
policy
Whistleblowing
DBS Checks
Professional Registration Checks
DBS Checks
Self-declaration (annual)
Professional registration
checks
DBS Checks
Self-declaration
Professional registration checks
Appraisal
Any relevant investigation & outcome to
be properly recorded with any relevant
interim
measures
Appropriate review, monitoring and follow
up
Page 188 of 230
that a notifiable safety incident has
occurred a health service body must–
(a) notify the relevant person that the
incident
has occurred in accordance with paragraph
(3)and
20(3) The notification to be given
under paragraph (2)(a) must–
(a) be given in person by one or more
representatives of the health service
body, (b) provide an account, which to
the best of
the health service body’s knowledge is
true, of all the facts the health service body
knows
about the incident as at the date of
the notification,
(c) advise the relevant person what further
enquiries into the incident the health
service body believes are appropriate,
20(2) As soon as reasonably practicable
after becoming aware that a notifiable
safety
incident has occurred a health service
body must–
(b) provide reasonable support to the
relevant person in relation to the incident,
20(4) The notification given under
paragraph (2)(a) must be followed by a
written notification given or sent to the
relevant person containing—
• The provider must ensure that
written notification is given to the
relevant person following the
Pre-employment checks
References
Self-declaration
relation to:
Incidents
Policy FPPR
Policy
Safeguarding Policies
DBS Checks
Professional Registration Checks
Self-declaration
Provider Checks
Professional registration Check
FPPR policy self-declaration
Incidents Policy
Professional registration Checks
FPPR policy self-declaration
N/A
Compliance with following policies:
• FPPR Policy
Page 189 of 230
person, even though enquiries may not
yet be complete.
The written notification must contain all the
information that was provided in person
including an apology, as well as the results
of any enquiries that have been made
since the notification in person.
(a) the information provided under
paragraph
(3)(b),
(b) details of any enquiries to be
undertaken in accordance with
paragraph (3)(c),
(c) the results of any further enquiries into
20(5) But if the relevant person cannot be N/A
contacted in person or declines to speak
to the representative of the health service
body–
(a) paragraphs (2) to (4) are not to apply,
and
(6) The health service body must keep a
copy
of all correspondence with the relevant
Compliance with following policies:
• FPPR Policy
• Safeguarding Policies
Compliance with Incidents Policy
Page 190 of 230
APPENDIX 6 – LIST OF NOLAN PRINCIPLES
The Seven Principles of Public Life, known as the Nolan Principles, were defined by the
Committee for Standards in Public Life. They are:
1. Selflessness: Holders of public office should act solely in terms of the public interest.
They should not do so in order to gain financial or other benefits for themselves, their
family or their friends.
2. Integrity: Holders of public office should not place themselves under any financial or
other obligation to outside individuals or organisations that might seek to influence
them in the performance of their official duties.
3. Objectivity: In carrying out public business, including making public appointments,
awarding contracts, or recommending individuals for rewards and benefits, holders of
public office should make choices on merit.
4. Accountability Holders of public office are accountable for their decisions and actions
to the public and must submit themselves to whatever scrutiny is appropriate to their
office.
5. Openness: Holders of public office should be as open as possible about all the
decisions and actions that they take. They should give reasons for their decisions and
restrict information only when the wider public interest clearly demands it.
6. Honesty: Holders of public office have a duty to declare any private interests relating to
their public duties and to take steps to resolve any conflicts arising in a way that
protects the public interest.
Leadership Holders of public office should promote and support these principles by
leadership and example.
Page 191 of 230
Appendix 7 – Personal File Checklist
Personal File Checklist
Fit and Proper Person Requirement
This checklist must be retained on the personal file of all Directors, Non-Executive
Directors and senior managers determined to fall within the scope of the FPPR by the
relevant Director.
Name ………………………………………
Criteria
Proof of identity including a recent photograph
Evidence on
file
YES / NO
Evidence of right to work in the UK
YES / NO
Two detailed references including one from the most
recent employer
YES / NO
Contract/appointment letter confirming requirement
to be a fit and proper person as detailed in legislation
YES / NO
PDR in last 12 months
YES / NO
Evidence of required qualifications, skills and
experience as detailed in person specification for
Executive Director including professional registration
check) if relevant
YES / NO
DBS check within previous 12 months 1
YES / NO
Evidence of check for undisclosed
bankrupt/sequestration awarded in respect of it and
who has not been discharged
YES / NO
Evidence that the employee is not a person to whom
a moratorium period under a debt relief order applies
under Part VIIA (debt relief orders) of the Insolvency
Act 1986(40)
YES / NO
Date checked
1
Check must be clear or detail evidence of appropriate consideration and assessment of suitability of individual for the
post where convictions are recorded
Page 192 of 230
Evidence that the employee is not on the disqualified
directors register
Occupational Health clearance from recruitment
process
YES / NO
FPPR signed self-declaration in last 12 months
YES / NO
Is there any evidence in the file that the individual
has been responsible for, privy to, contributed to or
facilitated any serious misconduct or
mismanagement in the course of carrying out a
regulated activity?
YES / NO
YES / NO
Completed by:
Date:
Page 193 of 230
Equality Impact Assessment
Form A – Policy Screening Impact Assessment
Fit & Proper Person Test Policy
The completion of appropriate checks to ensure that new appointments and existing
personnel is essential to ensure that the statutory requirements (Health & Social Care
Act 2008 (Regulated Activities) Regulations 2014) are met and that members of the
Board and equivalent positions are carried out by fit and proper persons to safeguard
quality of care.
Name and details of those
involved in the screening
equality impact assessment
Date of screening assessment
Negative Impact
Could the policy or strategy have a significant negative impact on any of
the protected characteristics? Could the policy or strategy:
• Presenting any problems or barriers to any staff, community or group
• Excluding people as a result
• Worsening existing discrimination and inequality
• Having a negative effect on relations with staff or the community
All equality strands listed below
Age
Disability
Gender Reassignment
Marriage and Civil Partnership
Pregnancy and maternity
Racial Group
Religion or Belief
Sex
Sexual Orientation
Please give any relevant information / details:
Positive Impact
Could the policy or strategy have a significant positive impact on equality
by reducing inequalities that already exist? Could the policy or strategy
help meet our duty to:
• Promoting equality of opportunity
• Eliminating discrimination and harassment
• Promoting good community relations
• Promoting positive attitudes towards disabled people
• Encouraging participation of disabled people
• Considering more favourable treatment of disabled people
• Promoting and protecting human rights
All equality strands listed below
Age
Yes
No










Yes
No


Page 194 of 230








Disability
Gender Reassignment
Marriage and Civil Partnership
Pregnancy and maternity
Racial Group
Religion or Belief
Sex
Sexual Orientation
Please give any relevant information / details
Evidence
What is the evidence for the above
What does any research say
What additional research is required to fill any gaps in
The implementation of the policy is required to ensure that the statutory obligations
introduced by the Health & Social Care Act 2008 (Regulated Activities) Regulations
2014 are met.
Full impact assessment
In light of the above does the policy or strategy require a full equality
impact assessment (refer to the flowchart on page 3)
Is a full Equality Impact Assessment required
Please rate the priority High / Medium
LOW
/ Low
Yes
No

Page 195 of 230
Board meeting date:
7th October 2015
Agenda Item number:
13.1
Enclosure:
12
Trust Development Authority Self Certification Documents
Monthly report (Month 5)
Report Title:
Mark Axcell – Director of Finance, Performance, and IM&T
Makhan Singh (Principal Consultant, Information & Performance)
As part of the NHS Trust Development Authority Accountability
Framework for NHS Trust Boards, a self-certification process has
been set up. As a provider organisation we are required to provide
the NHS Trust Development Authority with two monthly selfcertifications in relation to the Foundation Trust application process.
The self-certification process consists of two forms as per its
introduction in 2013/14:
•
•
Monitor Licensing Requirements
Trust Board Statements
Both submissions are included in this enclosure, and have already
been reviewed by the Chief Executive Officer and the Trust
Chairman to approve submission to the Trust Development
Authority.
Decision / Approval
Gain assurance
Discussion
Information




Committee: Finance and Performance Committee
Date reviewed: 28th September 2015
Key points or
Committee:
High quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources






Page 196 of 230
What impact or implications does
this report have on any of the
following:
Caring
Responsive
Effective
Well-led
Safe
Page 197 of 230
Trust Development Authority Self Certification Documents
Monthly report (Month 5)
Title
Introduction
•
This paper presents the Trust’s compliance with Monitor Licensing Requirements at the end of
month five, 2015/16 financial year, together with Board statements on compliance with
fundamental standards of:
o Clinical quality
o Finance
o Governance
•
Governance Risk Rating (GRR) remains 0 with 0 being the best rating possible.
•
Monitor Continuity Service Rating remains 4 with 4 being the best rating possible. The overall
FRR is rating is therefore Green.
•
The Board is required by the NHS TDA to provide and return the oversight self-certification
governance declarations no later than close of play on 30th September 2015.
•
Late submissions will be over-ridden to a red governance risk rating.
Recommendation
•
It is recommended that the Board note the performance of the Trust as at month five, and the
fact that these documents have been approved for submission by the Finance and Performance
Committee and the Chairperson and Chief Executive.
•
The Board is asked to ratify the submitted Board statements and Monitor licensing requirements
declarations.
Page 198 of 230
NHS TRUST DEVELOPMENT
AUTHORITY
OVERSIGHT: Monthly self-certification requirements - Compliance Monitor
Monthly Data.
CONTACT INFORMATION:
Enter Your Name:
Makhan Singh
Enter Your Email Address
makhan.singh@dwmh.nhs.uk
Full Telephone Number:
01384325020
Tel Extension:
5020
SELF-CERTIFICATION DETAILS:
Select Your Trust:
Dudley And Walsall Mental Health Partnership NHS Trust
Submission Date:
30/09/2015
Select the Month
Reporting Year:
2015/16
April
May
June
July
August
September
October
November
December
January
February
March
COMPLIANCE WITH MONITOR LICENCE REQUIREMENTS FOR
NHS TRUSTS:
Page 199 of 230
1. Condition G4 – Fit and proper persons as Governors and Directors (also applicable to those
performing equivalent or similar functions).
2. Condition G5 – Having regard to monitor Guidance.
3. Condition G7 – Registration with the Care Quality Commission.
4. Condition G8 – Patient eligibility and selection criteria.
5.
6.
7.
8.
9.
Condition
Condition
Condition
Condition
Condition
P1
P2
P3
P4
P5
–
–
–
–
–
Recording of information.
Provision of information.
Assurance report on submissions to Monitor.
Compliance with the National Tariff.
Constructive engagement concerning local tariff modifications.
10. Condition C1 – The right of patients to make choices.
11. Condition C2 – Competition oversight.
12. Condition IC1 – Provision of integrated care.
Further guidance can be found in Monitor's response to the statutory consultation on the new NHS provider licence:
The new NHS Provider Licence
COMPLIANCE WITH MONITOR LICENCE REQUIREMENTS FOR
NHS TRUSTS:
Comment where non-compliant or
at risk of non-compliance
1. Condition G4
Fit and proper persons as
Governors and Directors.
Yes
N/A
Timescale for compliance:
2. Condition G5
Having regard to monitor
Guidance.
Yes
N/A
3. Condition G7
Registration with the Care
Quality Commission.
Yes
30/09/2015
30/09/2015
N/A
30/09/2015
4. Condition G8
Patient eligibility and
selection criteria.
Yes
N/A
30/09/2015
Page 200 of 230
5. Condition P1
Recording of information.
Yes
N/A
6. Condition P2
Provision of information.
Yes
N/A
7. Condition P3
Assurance report on
submissions to Monitor.
Yes
Yes
30/09/2015
N/A
8. Condition P4
Compliance with the
National Tariff.
30/09/2015
30/09/2015
N/A
30/09/2015
9. Condition P5
Constructive engagement
concerning local tariff
modifications.
Yes
N/A
30/09/2015
Page 201 of 230
10. Condition C1
The right of patients to
make choices.
Yes
N/A
11. Condition C2
Competition oversight.
Yes
N/A
12. Condition IC1
Provision of integrated
care.
Yes
30/09/2015
30/09/2015
N/A
30/09/2015
Submit
Page 202 of 230
NHS TRUST DEVELOPMENT
AUTHORITY
OVERSIGHT: Monthly self-certification requirements - Board Statements
Monthly Data.
CONTACT INFORMATION:
Enter Your Name:
Makhan Singh
Enter Your Email Address
makhan.singh@dwmh.nhs.uk
Full Telephone Number:
01384325020
Tel Extension:
5020
SELF-CERTIFICATION DETAILS:
Select Your Trust:
Dudley And Walsall Mental Health Partnership NHS Trust
Submission Date:
30/09/2015
Select the Month
Reporting Year:
2015/16
April
May
June
July
August
September
October
November
December
January
February
March
BOARD STATEMENTS:
Page 203 of 230
CLINICAL QUALITY
FINANCE
GOVERNANCE
The NHS TDA’s role is to ensure, on behalf of the Secretary of State, that aspirant FTs are ready to proceed for
assessment by Monitor. As such, the processes outlined here replace those previously undertaken by both SHAs
and the Department of Health.
In line with the recommendations of the Mid Staffordshire Public Inquiry, the achievement of FT status will only
be possible for NHS Trusts that are delivering the key fundamentals of clinical quality, good patient experience,
and national and local standards and targets, within the available financial envelope.
BOARD STATEMENTS:
For CLINICAL QUALITY, that
1. The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard
to the TDA’s oversight model (supported by Care Quality Commission information, its own information on
serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), the trust has,
and will keep in place, effective arrangements for the purpose of monitoring and continually improving the
quality of healthcare provided to its patients.
1. CLINICAL QUALITY
Indicate compliance.
Yes
30/09/2015
RESPONSE:
N/A
Comment where noncompliant or at risk of noncompliance
BOARD STATEMENTS:
Page 204 of 230
2. The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality
Commission’s registration requirements.
2. CLINICAL QUALITY
Yes
30/09/2015
RESPONSE:
N/A
BOARD STATEMENTS:
3. The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing
care on behalf of the trust have met the relevant registration and revalidation requirements.
3. CLINICAL QUALITY
Yes
30/09/2015
RESPONSE:
N/A
BOARD STATEMENTS:
Page 205 of 230
For FINANCE, that
4. The board is satisfied that the trust shall at all times remain a going concern, as defined by the most up to
date accounting standards in force from time to time.
4. FINANCE
Yes
30/09/2015
RESPONSE:
N/A
BOARD STATEMENTS:
For GOVERNANCE, that
5. The board will ensure that the trust remains at all times compliant with the NTDA accountability framework
and shows regard to the NHS Constitution at all times.
5. GOVERNANCE
Yes
30/09/2015
RESPONSE:
N/A
BOARD STATEMENTS:
Page 206 of 230
6. All current key risks to compliance with the NTDA's Accountability Framework have been identified (raised
either internally or by external audit and assessment bodies) and addressed – or there are appropriate action
plans in place to address the issues in a timely manner.
6. GOVERNANCE
Yes
30/09/2015
RESPONSE:
N/A
BOARD STATEMENTS:
7. The board has considered all likely future risks to compliance with the NTDA Accountability Framework and
has reviewed appropriate evidence regarding the level of severity, likelihood of a breach occurring and the plans
for mitigation of these risks to ensure continued compliance.
7. GOVERNANCE
Yes
30/09/2015
RESPONSE:
N/A
BOARD STATEMENTS:
Page 207 of 230
8. The necessary planning, performance management and corporate and clinical risk management processes
and mitigation plans are in place to deliver the annual operating plan, including that all audit committee
recommendations accepted by the board are implemented satisfactorily.
8. GOVERNANCE
Yes
30/09/2015
RESPONSE:
N/A
BOARD STATEMENTS:
9. An Annual Governance Statement is in place, and the trust is compliant with the risk management and
assurance framework requirements that support the Statement pursuant to the most up to date guidance from
HM Treasury (www.hm-treasury.gov.uk).
9. GOVERNANCE
Yes
30/09/2015
RESPONSE:
N/A
BOARD STATEMENTS:
Page 208 of 230
10. The Board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing
targets as set out in the NTDA oversight model; and a commitment to comply with all known targets going
forward.
10. GOVERNANCE
Yes
30/09/2015
RESPONSE:
N/A
BOARD STATEMENTS:
11. The trust has achieved a minimum of Level 2 performance against the requirements of the Information
Governance Toolkit.
11. GOVERNANCE
Yes
30/09/2015
RESPONSE:
N/A
BOARD STATEMENTS:
Page 209 of 230
12. The board will ensure that the trust will at all times operate effectively. This includes maintaining its register
of interests, ensuring that there are no material conflicts of interest in the board of directors; and that all board
positions are filled, or plans are in place to fill any vacancies.
12. GOVERNANCE
Yes
30/09/2015
RESPONSE:
N/A
BOARD STATEMENTS:
13. The board is satisfied that all executive and non-executive directors have the appropriate qualifications,
experience and skills to discharge their functions effectively, including setting strategy, monitoring and
managing performance and risks, and ensuring management capacity and capability.
13. GOVERNANCE
Yes
30/09/2015
RESPONSE:
N/A
BOARD STATEMENTS:
Page 210 of 230
14. The board is satisfied that: the management team has the capacity, capability and experience necessary to
deliver the annual operating plan; and the management structure in place is adequate to deliver the annual
operating plan.
14. GOVERNANCE
Yes
30/09/2015
RESPONSE:
N/A
Submit
Page 211 of 230
Board meeting date :
7th October 2015
Report Title:
Agenda Item number:
13.1
Enclosure:
13
Wendy Pugh
Neil Tong (Risk and Assurance Facilitator)
• The purpose of this report is to provide the Trust Board
with the Red Risks held on the Trusts Risk Registers for
the period 29th September 2015. The report also details
the following key information:
o Any new red risks being escalated to the Trust Wide
Risk Register
o Any red risks being downgraded from the Trust Wide
Risk Register
o Any updates to red risks currently held on the Trust
Wide Risk Register.
Action required from the Committee
Decision / Approval
Gain assurance
Discussion
Information




Committee: Quality and Safety Committee and Finance
Key points or
Committee:
• The Quality and Safety Committee Reviewed the
Operational/ Governance/ Quality related risks red risks
on 9th September 2015 and approved following risks for
inclusion on the Trust Wide Risk Register:
o 202
o 225
o 253
o FINAN 1
o HR 002
o PERF 09
• The Trusts Finance and Performance Committee also
reviewed the red risks which had links to the Trusts to
finances and to Trust performance on 28th September
These were Risks:
o 202
o 253
and Performance Committee
Date reviewed: 09/09/2015 (Q&S) and 28/09/2015 (F&P)
Page 212 of 230
o FINAN 1
o PERF 09
High quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources






relates to are:
Caring
Some of the risks held on the register have the
ability to directly or indirectly impact upon the
care/services offered
The Trust Wide Risk Register Provides a
representation of the Trusts “Red Risks” and the
responses to managing/action planning these
risks; some (due to the nature of the risk) provide
a response to a short term or long term issue
Some of the risks held on the Trust Wide Risk
Register impact upon the future viability /
effectiveness of the Trusts operations.
Responsive
Effective
Well-led
Safe
Risk FINAN 1 specifically relates to the long term
outlook in relation to CIP
Some risks held on operational risk registers
pertain
to issues around service redesign and may have
impacts upon leadership and staffing issues
The appropriate management of risk is central to
the provision of a quality, safe service. In
particular CQC Outcome 16 – Assessing and
monitoring the quality of service provision
Page 213 of 230
Title
Introduction
It is the purpose of this report is to provide the Trust Board with the Red Risks
Operational risks held across the Trusts Risk Registers (for the period 29th September
2015) and in doing so provides the committee with information on:
• Any new red risks being escalated to the Trust Wide Risk Register.
• Any red risks being downgraded from the Trust Wide Risk Register
• Any updates to red risks currently held on the Trust Wide Risk Register.
There are currently 6 risks included within this report and as such these 8 risks
represent the Trusts Red Operational Risks.
Of the 8 risks held on the Trust Wide Risk Register, the 6 risks with links to
operational issues were reviewed by the Trusts Quality and Safety Committee,
these were risks:
• 202
• 225
• 253
• FINAN 1
• HR 002
• PERF 09
In addition, the Trusts 4 red risks with links to Finance and Performance Issues
were also reviewed by the Trusts Finance and Performance Committee these
were risks:
• 202
• 253
• FINAN 1
• PERF 09
It was noted that in relation to risk PERF 09, Audit committee has signed off the
report on Data Quality, it was noted that there was now "significant assurance" in
relation to this area. It was therefore recommended to the Finance and
Performance Committee that this risk is downgraded to an amber risk due to the
outcomes of the internal audit
Further detail (if required)
The risks are outlined further in table 1.1, 1.2 and Appendix 1.
Page 214 of 230
Table 1.1 – Summary of risks
Risk ID
202
Risk Description
The Better Care Fund (BCF) involves circa £1.9bn of NHS
funding being allocated to a pooled budget to provide
integrated health and social care services. This presents
several elements of risk as follows:
225
The risk of insufficient resilience and skills in leadership,
which may result in poorly engaged, demotivated staff and
poor service quality.
253
Mental Health Currencies - Implementation of Clustering as
the Currency for MH payment will impact upon data
recording within the Trust and impact upon how the Trust is
reimbursed going forward.
FINAN 1
Inability to meet CIP targets and the impact on the viability
of the Trust. Issues Include:
• Costed service plans not yet developed.
• Lack of clarity around commissioner investment plans
and resulting CIP requirement.
• Reduction in investment by Local Authorities.
HR 002
Reduction in Local Authority Funding for Mental Health
Social Care Workforce, which may impact on service
delivery
Impacts and updates
Comments
There is now a national template for creation of the BCF
and plans are in development.
The value of the respective BCFs within each locality are
now known
Update
Risk reviewed by Director of Finance and Performance,
no updates or changes to risk.
Update
Risk reviewed and updated by Director of People and
Corporate Development. The Trusts friends and family
test has indicated positive results for the organisation and
the staff engagement actions on the Trusts CQC action
plan have now been completed and the staff engagement
workplan has been fully signed up to by the Trust board
and is being implemented
Comments
There is a plan to reduce the level of unclustered activity.
The Trust is currently negotiating with commissioners at a
local price for un-clustered work and an action plan has
been developed
Update
Risk reviewed by Director of Finance and Performance,
no changes to this risk at this time
Comments
Thorough quality impact assessments are undertaken
against each CIP.
Any high risk quality issues highlighted will be escalated
to the Executive Team for discussion via the Trusts CIP /
PMO processes
Update
Risk reviewed by Director of Finance and Performance.
QIAs are being reviewed by Trust Board on a Quarterly
basis for both in year schemes and future schemes to
review progress against the CIP project and any impacts
upon quality.
Comments
Risk reviewed by Director of Operations and Nursing No
changes to risk aside from slight update to further actions
which now reads “Discussions ongoing at POG (Monthly)
+ Partnership Board Quarterly
Status
of risk
=
=
=
=
=
Page 215 of 230
Risk ID
PERF09
Risk Description
Maintaining Data Quality Issues:
* Lack of external assurance on data quality since the
implementation of OASIS
* Clinical and system processes not aligned
* Capacity and cultural changes within operational teams
regarding the prioritisations of data quality
* Cultural challenges within the Performance and
Informatics Teams
* Lack of Effective interface between Informatics and
Operational Teams
* Increasing focus on the completeness and accuracy of
the MHMDS by external bodies to form a view of the
organisation in the context of an imminent CQC inspection.
Impacts and updates
Comments
Following internal audit report into data quality, it is felt
that the report provides enough assurance to allow this
risk to be downgraded.
Update
Following discussion with the Director of Finance &
Performance it was felt that the internal audit report in
respect to risk PERF09 provides the Trust “significant
Assurance” in respect to this particular area and as such
it was felt that this risk could be downgraded.
Status
of risk
▼
Table 1.2 below outlines the source of the risks held on the Trust Wide Risk
Register
Table 1.2
Source of risk (How the risk has been identified)
National Guidance / Initiative / Reforms
Feedback from stakeholders/partners
Finance projections/data
Workforce Statistics / Information
Departmental Priorities / Pressures
Number of risks
on the Risk
Register
2
1
1
1
1
Recommendation
It is recommended that the Trust Board approve the enclosed copy of the Trust
Wide Risk Register and the details included within this report, which outlines the
“Red Risks” to the organisation
Action required
The board is asked to approve the Trust Wide Risk Register, approve the
contents of this report and agree/approve the decision to downgrade risk
PERF09.
Page 216 of 230
Appendix 1
O th e r
C o n tr i b u to r s
M a rk A xc e ll Trust Board
S
4
R ed
L
4
S
C o n tr o ls
16
4
D ud ley and W a ls a ll M en ta l H ea lth
P a rtne rs h ip N H S T rus t C E O is a
m e m be r o f W a ls a ll's in teg ra tion
R ed
boa rd , a k ey fo ru m to m ov e fo rw a rd
w ith p lans .
F ina l p lans hav e been rec iev ed fro m
bo th hea lth ec ono m ies .
D oF P has es tab lis hed c o m m un ic a tio n
c hanne ls w ith bo th C C G s / M B C s
rega rd ing the B C F in o rde r to be tte r
unde rs tand p lans and the po ten tia l
im pac t on the hea lth ec ono m y ,
pa th w ay s and the T rus t
R egu la r E x ec lev e l m ee ting
es tab lis hed w ith D ud ley C C G w ho w il
be ho ld ing the poo led budge t in
D u d le y
L
4
F u rth e r A c tio n s R e q u ire d
16
D oF P to C on tinue to m ee t w ith C F O
a t bo th D ud ley and W a ls a ll C C G s to
fu rthe r unde rs tand p lans (O ngo ing
b a s is )
E s tab lis h M en ta l H ea lth o f the
p lann ing fra m e w o rk fo r bo th hea lth
ec ono m ies and c on tinue a ttendanc e
a t m ee tings , bec o m ing fu lly a w a re o f
p lans and s tages o f dev e lop m en t
and risk s inhe ren t w ith in (O ngo ing
b a s is )
S
4
S o u rces o f
A s su ran ce
L
3
A m be r
12
F u rth e r C o m m e n ts
R epo rts to e M E x T
M ins and A c tions
fro m in teg ra tion
b o a rd s
M ins and A c tions
fro m B C F s tee ring
g roups
17 /09 /20 15
* T h e re is no w a
na tiona l te m p la te fo r
c rea tion o f the B C F
and p lans a re in
* T h e T rus ts ex is ting
b lock c on trac t
a rrange m en t c ou ld pu t
the T rus t a t ris k if
p lans do no t c o m e to
fru ition and C C G s look
to reduc ing the b loc k
c on trac t to fund any
gaps
* T h e ex ten t o f
ac tiv ity c hange
requ ired to fund the
B C F is la rge enough
to c aus e c ons ide rab le
financ ia l s tress if B C F
s e rv ices and p lans do
no t c o m e to fu ll
fr u iti o n .
* T h e V a lues o f the
B C F s a re k no w n to be
8 m w ith in the D ud ley
loc a lity and 300k
w ith in W a ls a ll.
P r in c ip le
O w ne r o f
R is k
R e s id u a l
S c ore
D a te o
f R ev ie
T h e B e tte r C a re F und
N a tio n a l
(B C F ) inv o lv es c irc a
In itia tiv e /
£1 .9bn o f N H S
G u idanc e
fund ing be ing
a lloc a ted to a poo led
budge t to p rov ide
in teg ra ted hea lth and
s oc ia l c a re se rv ic es .
T h is p res en ts s ev e ra l
e le m en ts o f risk as
fo llo w s :
* C C G c o m m iss ione rs
a re lik e ly to hav e les s
fund ing to inv est in
hea lth s e rv ic es fro m
A p ril 2014 (av e ra ge
pe r C C G £10 -£15 m ) th is c ou ld im pac t
d irec tly on T rus t
in c o m e .
* P a th w ay redes ign to
c rea te the B C F
s e rv ices c ou ld im pac t
on D W M H P T
pa th w ay s and s e rv ic es
05 /03 /20 14
202
D a te
Iden tifie d
R isk N o . R isk D esc rip tio n
S o u rce o f
R is k
Curre nt
S c ore
In itia l S co re
R isk rev ie w ed by D irec to r
o f F inanc e and
P e r fo rm a n c e
N o c hanges to risk sc o re .
R isk to re m a in on the F & P
R isk R eg is te r.
F u rthe r upda tes a re requ ired to
e M E X T on p rog ress w ith p lann ing
and risk s to s e rv ic es (J une 2015 )
T h e re is regu la r ex ec a ttendanc e a t
B C F in teg ra tion m ee tings
T h e T rus t hav e been inv o lv ed in the
dev e lop m en ts o f the B C F s w ith in
e ithe r loc a lity des p ite no t be ing a
s igna to ry o f e ithe r ag ree m en t.
T h e C lin ic a l D ev e lop m en t D irec to r is
a rep res en ta tiv e on bo th s tee ring
g ro u p s .
T h e v a lue o f bo th the D ud ley (8 m )
and W a ls a ll (300k ) B C F s a re no w
k no w n .
Page 217 of 230
Iden tifie d
Executive
Executive
g
a s s u ra n ce
Page 218 of 230
P r in c ip le
O w ne r o f
R is k
O th e r
S
L
C o n tr o ls
S
L
R e s id u a l
S c ore
S
D a te
of R
i
Da
te Iden
tifi d
S o u rce o f
R is k
Curre nt
S c ore
In itia l S co re
S o u rces o f
A s su ran ce
L
R e m ode lled e ffic ienc y p lan due to
c hanges in M on ito rs requ ire m en ts ,
ag reed by T rus t boa rd , F inanc e and
P e rfo rm anc e c o m m ittee and M E x T
S trong financ ia l pe rfo rm anc e to da te
in y ea r
R epo rting a rrange m en ts to boa rd
enha nc ed s inc e A ugus t 2013 to
p rov ide m o re de ta il on sc he m es as
w e ll as qua lity im pac t as s es sm en ts
M on ito ring o f bank , agenc y and
loc u m s no w fo rm s pa rt o f financ e
repo rt and d isc us s ion a t bo th F and
and M E X T .
P lans in p lac e fo r 2014 /15 and
m a jo rity in p lac e fo r 2015 /16
W endy
P ugh
4
R ed
4
16
S ec tion 75 ag ree m en ts p rov ide
4
4
fo rm a l p la tfo rm as the bas is fo r any
fu rthe r nego tia tions in fund ing and
R ed
res ou rc e c hanges
J o in t app roac h ag reed w ith W a ls a ll
M B C rega rd ing im p le m en ta tion o f
fund ing reduc tions .
R isk A ss ess m en ts on loss o f pos ts
has been c o m p le ted
16
D isc us s ions ongo ing a t P O G
(M o n th ly )
4
2
A m be r
8
R epo rts to M E X T
U pda tes to B oa rd
10 /06 /20 15
R educ tion in Loc a l
F e e db ack F ro
m S tak eho lde rs
A u tho rity F un ding fo r
M en ta l H ea lth S oc ia l
/P
C a re W o rk fo rc e , w h ic h
m ay im pac t on s e rv ic e
de liv e ry and on the
v iab ility o f the S 75
a g re e m e n ts
30 /05 /20 12
H R 002
R isk rev ie w ed by
G ov e rnanc e and Q ua lity
C o m m ittee . R isk to
re m a in on the T rus t w ide
risk reg is te r, no c hanges to
ris k .
R egu la r d is c uss ions be ing he ld a t
P a rtne rs h ip O pe ra tions G roup .
A dd itiona l s ho rt te rm c apac ity has
been c o m m iss ioned
Page 219 of 230
P r in c ip le
O w ne r o f
R is k
O th e r
2
L
2
G reen
S
C o n tr o ls
4
L iv e da ta qua lity im p rv e m en t p lan in 4
p lac e
In te rna l aud its p rog ra m m ed fo r Q 4
on D a ta Q ua lity Im p rov e m en t
P rog ra m
L
3
A m be r
D Q c u rren tly s c ru tin iz ed a t C A R M
A dd itiona l res ou rc e in p lac e w ith in
In fo rm a tics to im p rov e D a ta Q ua lity
R egu la r c o m m un ic a tion be tw een
P e rfo rm anc e and In fo rm a tic s tea m s
and O pe ra tiona l T e a m s
T ra in ing p rog ra m o f O as is and
C lin ic a l P roc es s es is c u rren tly in p la c e
A liv e ac tion p lan dea ling w ith the
c o m p le tenes s o f the M H M D S
s u b m is s io n
12
S
E ns u re ro ling p rog ra m o f da ta qua lity
im p rov e m en t (O ngo ing bas is )
4
R o ll ou t O A S IS to inpa tien ts to
im p rov e c o m p le tenes s o f da ta and
reduc e risk o f dup lic a tion o r e rro r (on
ho ld )
A m be r
E ns u re regu la r in te rna l aud it/rev ie w
(ongo ing bas is )
E ns u re regu la r jo in t in fo rm a tic s and
ope ra tions m ee ting to d isc us s k no w n
iss ues (ongo ing bas is )
S o u rces o f
A s su ran ce
L
2
8
In te rna l A ud its
D a ta qua lity
repo rts to C A R M
16 /06 /20 15
M a rk A xc e ll Dan Howard
S
R e s id u a l
S c ore
D a te o
f R ev ie
13 /07 /20 12
P E R F 0 9 M a in ta in ing D a ta
D e p a rtm e n ta l
Q ua lity Iss ues ;
P rio rities / P res
* Lac k o f ex te rna l
as s uranc e on da ta
qua lity s inc e the
im p le m en ta tion o f
O A S IS
* C lin ic a l and s ys te m
p roc es s es no t a ligned
* C apac ity and c u ltu ra l
c hanges w ith in
ope ra tiona l tea m s
rega rd ing the
p rio ritis a tions o f da ta
q u a lity
* C u ltu ra l c ha llenges
w ith in the
P e rfo rm anc e and
In fo rm a tics T e a m s
* Lac k o f E ffec tiv e
in te rfac e be tw een
In fo rm a tics and
O pe ra tiona l T e a m s
* Inc reas ing foc us on
the c o m p le tenes s and
ac c urac y o f the
M H M D S by ex te rna l
bod ies to fo rm a v ie w
o f the o rgan is a tion in
the c on tex t o f an
im m inen t C Q C
in s p e c tio n .
D a te
Iden tifie d
S o u rce o f
R is k
Curre nt
S c ore
In itia l S co re
Risk reviewed by Director of
Finance and Performance.
Audit committee has signed off
the report on Data Quality, it was
noted that there was now
"significant assurance" in relation
to this area.
It is therefore reccomended that i
light of the content of the report
that this risk is downgraded to an
amber risk
E ns u re sy s te m a tic p rog ra m o f oas is
tra in ing and s uppo rt to ens u re c lin ic a l
p roc es s es ag reed a re then re flec ted
in oas is (O ngo ing B as is ).
S igned o ff m e tric s pec ific a tion
doc u m en t in p lac e fo r a ll K ey
P e rfo rm anc e Ind ic a to rs
R o ll ou t o f E O A S IS to c o m m un ity
s e rv ices c o m p le ted .
C lin ic a l P roc es s es G roup has been
re -es tab lis hed as sis ting w ith the
a llign m en t o f c lin ic a l sys te m and
p ro c e s s e s.
A pe riod o f c los e m anage m en t o f th e
T rus ts in fo rm a tics depa rtm en t has
been c o m p le ted , ens u ring tha t ro les
and res p onsib ilities a re no w re flec tiv e
o f the needs o f the o rgan is a tion
A c tion p lan in re la iton to M H M D S
c o m p le te
O as is dev e lop m en t boa rd has
bec o m e the T rus ts C lin ic a l S ys te m s
G roup
Page 220 of 230
Committee meeting date:
7th October 2015
Report Title:
Agenda Item number:
14.1
Enclosure:
14
Quality and Safety Committee Summary Report
Committee:
Quality and Safety Committee (Q&S)
Tom Jinks – Governance Manager
Decision / Approval
Gain assurance


Discussion
Information
Summary of Key Issues & Risks
The Quality and Safety Committee was inquorate when it met on the 9th September 2015. It therefore
considered and discussed the Trust’s key Quality and Safety issues as a management committee.
The management committee wishes to highlight the following key points, issues and risks to the Board:
The Quality Report for the period ending the 31st August 2015 was reviewed and discussed. This report
is considered in detail as a separate Board agenda item, forming a key part of the Integrated
Performance Dashboard Report. Areas of specific consideration by the management committee were:
•
It was reported that there had been an overall decrease in incidents reported for the period. The
Committee was informed that there had been 1 case where Duty of Candour had been applied
since the last committee, but owing to the fact the incident had occurred after the reporting
period this case would be detailed in the next Quality Report.
•
Within the Acute Service Line it was reported that there had been an increase in reported
disruptive and aggressive behavior incidents which were attributable to a small number of
complex needs patients. Assurance was given that appropriate management and care plans
were in place. A breakdown of these incidents was requested for the next meeting for further
assurance.
•
There was a reported decrease in incidents within Older Adults Services, and the number of
incidents within Community and Recovery Services also remained at a low level.
•
There was a total of three serious incidents that occurred within the calendar month, one related
to failure to return from leave, one related to an attempted suicide and one related to a
homicide. It was agreed that due to the unusual circumstances of the homicide incident that an
outline of the case would be presented at the next Quality and Safety Committee. ( Please note
that further details in relation to this incident is provided within the separate DON’s Update
report)
Page 221 of 230
•
The management committee was informed that from 1st October 2015 all Acute and Mental
Health Trusts will be required to collate and submit data regarding Female Genital Mutilation
and this information will be included in future Quality Reports
The meeting also reviewed risks relating to Quality and Safety matters. The following key points were
highlighted:
•
All the risks pertaining to Quality and Safety had been fully reviewed and updated by the risk
owners
•
All risk assessment relating to the ongoing Water Management issues had been reviewed and
had been added onto the risk register. ( Please note that further details in relation to this issue is
provided within the separate DON’s Update report)
The management committee was updated on key Nursing, Operations and Medical Director matters,
the main highlights of which were:
•
The Trust is currently working in partnership, exploring different options / models of care for
Mental Health and reviewing various proposals from a Dudley and Walsall perspective.
Discussions are also focused in relation to the Trust inpatient bed capacity and ensuring a
quality service is continued to be provided. It was reported that a presentation will be made to
the Finance and Performance Committee at the end of September and it is proposed that the
Quality and Safety Committee will review the quality aspect of that report in the October
meeting.
•
The management committee were also informed that the outcome of the Vanguard bid is
currently being awaited. Partnership work with Dudley Vanguard continues and a meeting has
recently been held that was in relation to the bid for CAMHS services in Dudley.
The meeting reviewed and endorsed the Draft Annual Safeguarding Report. 2014/15. The extensive
progress that had been made by the Trust in the last year was commended, and it was acknowledged
that there are challenges and significant amounts of work that will be required in 2015/16. There were a
number of minor amendments suggested and the subsequent revised draft annual report is presented
to the Board as a separate agenda item.
The draft results of the Annual Community Health Survey were presented. The management committee
was informed that an action plan will be developed to address any areas of concern and will be
presented to the Committee once the report has been Nationally published. In addition, it was agreed
that a deep dive into crisis care would be conducted and presented to the Committee in October.
The Trust Integrated Performance Dashboard report was considered and key focus areas included
copies of care plans, sickness and PDR rates. The management committee was informed that there is
a major drive in Acute Services to achieve target by the end of the month.
The meeting was informed that the Trust Development Authority (TDA) had carried out an audit on two
Wards and the Trust was compliant with 5 out of 7 areas which were reviewed. Action Plans have
been put in place and the two areas highlighted have been fully rectified. The TDA will return in 4-6
Page 222 of 230
weeks to check that the issues have been addressed and undertake a visit of all the Trust’s hospital
sites.
It was also highlighted that the TDA had been very complimentary about Trust practices in relation to
Infection Control and Water Management.
It was reported t that a number of policies with minor amendments had been reviewed and ratified by
the Policy and Procedures Group, The newly developed “Being Open/Duty of Candour Policy” was
also reviewed by the Group and it is recommend by the management committee that the Policy is
ratified by the Board.
It was reported that the Birmingham Safeguarding Adult Board had recently published its Executive
Summary of the Serious Case Review on a patient who had minimal contact with the Trust.. The
Serious Case Review had made two recommendations which have subsequently been included in the
Trust Safeguarding Work Plan and that this is being monitored through the Safeguarding Strategic
Group
Interfaces with other Committees
The business that was discussed by the management committee interfaces with the following
Committees/Groups:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Audit Committee
Finance and Performance Committee
MExT
CARM/ CQR
Clinical Audit and Effectiveness Committee
Embedding Lessons Group
Regulation and Risk Working Group
Safeguarding Strategic Group
Suicide Prevention Group
Equality and Diversity Steering Group
R&D Committee
Health & Safety Committee
Infection Prevention Control Committee
Medicines Management Committee
Mental Health Forum
Policy & Procedures Group
Resuscitation Committee
Recommendations and requests for direction
The Trust Board is asked to:•
Review and consider for ratification the newly developed Being Open / Duty of Candour Policy
•
Accept the management committee’s endorsement of and recommendation to approve the
2014/15 Annual Safeguarding Report
Page 223 of 230
•
Note the remedial actions that have been undertaken by the Trust in response to the recent
Trust Development Authority (TDA) Infection and Prevention Control visit / findings and also
receive assurance from the positive comments made by the TDA in relation to the Trusts
infection control and water management processes,
•
Accept this report for assurance about the exercise of delegated authority by the Quality and
Safety Committee whilst accepting that on this occasion it was inquorate
Page 224 of 230
Board meeting date:
7th October 2015
Report Title:
Agenda Item number:
14.2
Enclosure:
15
Finance and Performance Committee Chair Report
Committee:
Finance and Performance Committee (F&P)
Mike Higgs – Non Executive Director
Decision / Approval
Gain assurance
Discussion
Information




Key issues & risks
The Finance and Performance committee met on the 28th September and considered the Finance,
Performance information and HR position for August.
The committee reviewed the following items of business
Performance
Of the agreed 27 and 28 KPIs for Dudley and Walsall respectively the Trust is currently green rated
across all but four KPIs – these are 1) IAPT – people moving to recovery; 2) ICD10 valid code; 3) Initial
Cluster adhering to red rules and 4) Patients within a Cluster period.
For both the Cluster KPI’s the Trust needs to show steady improvement against these targets for the
remainder of the year in order to achieve these KPI’s.
The trust continues to maintain appropriate activity levels with the trust outturning at 105.8% of
contracted activity; however, this is not showing such a favorable position in terms of the finances
associated with activity due to reductions in In-Patient activity primarily within Older Adults.
Finance Report 15/16
The committee received the financial position for the period ended 31st August 2015. The trust has
achieved a surplus of £192k against a plan of £410k, and is therefore £218k behind plan. The plan has
now been revised to take account of the additional ‘stretch’ target imposed by the TDA.
Page 225 of 230
The main area of discussion focused around the current level of activity performance against contract
and the current under-performance of £536k (based on £340k under-performance coupled with £196k
of activity CIP not met).
The balance of CIP schemes still not devolved to service lines along with the requirement to slow down
spend on Capital Expenditure to support the ‘stretch’ target was also discussed.
CIPs are to be discussed further at a meeting on the 9th October and Jacky O’Sullivan will be invited
back to F&P in October to update the committee.
Activity was further reviewed alongside financials to assess how the trust was performing against its
commissioned activity. Admitted activity continues to be an issue within Acute and Older Adults,
although Acute occupancy is showing signs of significant improvement. Part of this under-performance
is being supported by increased activity within CAMHs and Primary Care. The under-performance on
Admitted beds also means the respective element of the Activity CIP is also not currently being met.
With the Trust currently running behind its plan to achieve the required £1.2m ‘stretch’ target a paper
was presented on additional savings of £600k that could be initiated in order to meet the forecast
financial outturn. The committee received the paper and agreed the actions indicated.
In addition the committee requested that particular focus and control needed to be made over particular
areas, namely:
• Review of Older Adults wards in relation to staffing against occupied beds/demand in order to
reduce excessive pay costs and temporary staffing spend.
• Review of Bank and Agency spending across the Trust and within areas such as EI CAMHs in
order to meet the TDA target of 8% for the remainder of the financial year and to reduce the
forecast overspend where possible.
• Review Corporate budgets areas to eliminate forecast overspend position.
The review of temporary staffing in both community and In-Patients will be taken to the meeting on the
9th October and will be reviewed through F&P at the end of October.
Workforce
The committee received a detailed review of workforce.
Sickness has reduced from 4.89% to 4.74%.
Mandatory Training had exceeded the target of 70% with an achievement of 83% to date%, with
Information Governance running below the planned 95% at 90% and Appraisals have remained static
at 76%
The level of vacancies and associated recruitment position was presented and reviewed by the
committee, currently reported at 16.5% (an improved position on the 18.0% reported last month but
marginally behind the expected plan of 14.2% to date) – a trajectory has been set to bring vacancy
rates down to below 10% by the end of the financial year. This will continue to be reviewed on an ongoing basis by the committee.
PBR Update.
The PBR lead for the Trust presented an update on progress with clustering. The level of un-clustered
activity in the Trust has reduced from the beginning of the financial year from £2.4m in April to £1.7m in
Page 226 of 230
August (although the position hasn’t reduced overall compared to July). A trajectory has now been put
in place to bring the level of un-clustered activity down to a level of around £1m by the end of the
financial year and current performance is ahead of that plan (£1.9m plan v £1.7m actual).
Review of Risk Register
The committee reviewed the risk register and noted the downgrading of the risk in relation to Data
Quality following assurance from Internal Audit. The committee agreed that no further changes were
required at this stage to the remaining risks.
The business that was discussed by the committee interfaces with the following Committees/Groups:
•
•
•
•
•
MEXT
Audit Committee
Governance & Quality Committee
CARM
CQR
The Trust Board are asked to:Accept this report for assurance about the exercise of delegated authority by the Finance and
Performance Committee
Endorse the decisions and recommendations made by the Finance and Performance Committee.
Page 227 of 230
Board meeting date:
7th October 2015
Report Title:
Agenda Item number:
14.3
Enclosure:
16
Board Sub Committee Chair Report
Committee:
MExT
Gary Graham, Chief Executive
Mandy Edwards, Interim Co Secretary
Decision / Approval
Gain assurance

Discussion
Information

Key issues and Risks
Enhanced Management Executive Team (MExT) met on 15th September and the key items
considered were:
Water management issues were discussed and an update on the current position given. It
was noted that the Health & Safety Executive checks were carried out, no breaches were
noted and areas of good practice were identified.
The 2015/16 CIP projects were discussed, and it was noted that the acute bed position had
begun to improve. Particular focus was given to red rated PODs which were reviewed in
detail. Discussions included:
− The revaluation of Perseverance House
− Timelines required for the catering review survey
− Changes to the IT helpdesk link on the intranet to ensure it is more visible and contact
information to be added to desktops.
− A need to focus on avoiding missed patient appointments and maximising attendance
Concerns were raised with regard to the agile working roll out with some Trust buildings
causing difficulty with Wifi connections. Addressing this could result in an extra cost pressure.
The 2016/17 CIP schemes were presented and discussed and it was agreed that a review of
all CIP schemes would take place by 9th October, to include the outputs of the Meridian work.
MExT were presented with the Health and Wellbeing Clinics proposal, which highlighted that
additional funding was required from Walsall CCG. The proposal was agreed on the basis that
CCG funding was provided.
Page 228 of 230
MExT were provided with an update with regard to the recent MERIT Vanguard bid and
informed that an outcome was anticipated within the following week.
Information regarding temporary labour and the recent new rules on agency spend and cap on
spending being introduced were discussed. Budgets and expenditure were highlighted and
points to consider with agency staffing were discussed.
An update with regard to the staff engagement action plan was presented together with a
summary of the current position. This included an update on the forthcoming launch of the
national staff survey with a mix of postal and on-line surveys.
The research and development business case was presented for approval. After discussion, it
was suggested that in light of the TDA stretch target and water management issues, the
financial climate had moved since finances were discussed at Trust Board. MExT supported
the proposal with the condition that the financial impact over the next 3 years was re-evaluated
before the business case returned to Trust Board.
The MSS e-rostering proposal was presented and following discussion was supported by
MExT.
Key action points and work in progress
•
•
•
•
•
•
•
•
It was agreed that a paper would be presented to a future Enhanced MExT relating to a
sustainable water management plan and lessons learnt.
Diagnostic work, with regard to water management, would be undertaken. This would
be submitted to the Health & Safety Executive and presented to a future MExT
Revaluation of Perseverance House
Changes to the IT helpdesk link on the intranet to ensure it is more visible and contact
information to be added to desktops.
Review of all CIP schemes with a plan of what is achievable/undeliverable by 9th
October
Flu vaccination campaign plan to be presented to the next Enhanced MExT meeting.
Canvass staff views on how they would like to prepare for the CQC inspection due in
February 2015 - by team or on an individual basis via the engagement champions.
Financial impact of the research and development business case over the next 3 years
to be re-evaluated.
The business that was discussed by MExT interfaces with the following Committees/Groups:
•
•
•
Audit Committee
Quality & Safety Committee
Finance & Performance Committee
Page 229 of 230
The Board is asked to receive this report from MExT for information and assurance.
Page 230 of 230

7th October 2015 - Dudley and Walsall Mental Health Partnership

Transcription

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