4th February 2015 - Dudley and Walsall Mental Health Partnership

Transcription

Dudley and Walsall Mental Health
Partnership NHS Trust
Papers for the Trust Board Meeting
Wednesday 4th February 2015
1:00 pm – 3:00 pm
Board Room, 1st Floor, Canalside House,
Abbotts Street,
Bloxwich, Walsall, WS3 3BW
PUBLIC MEETING OF THE TRUST BOARD
1pm, Wednesday 4th February 2015
Boardroom, Canalside House
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
1pm
Minutes of the Previous Meeting
2.
To approve the minutes of the Board meeting held on
Wednesday 7th January 2015
Approval
Mrs Cooper
3.
Summary Report of Confidential session of Trust
Board held on Wednesday 7th January 2015
Information
Mrs Cooper
4.
Matters Arising
Continuity
Mrs Cooper
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.
Chair’s Comments
Information
(Acting Chair)
9.
Chief Executive Officer’s Overview (including written
summary of strategic publications and headlines)
Information
Mr Graham
10.
QUALITY, SAFETY, EFFICIENCY &
EFFECTIVENESS
Assurance
Mr Axcell
/Ms
Pugh/Ms
Ingram
10.1
Trust Integrated Performance Dashboard (Month 9)
x Performance Report
x Quality Governance Report
x Finance Report
x Workforce Report
Enc 1
(Acting Chair)
Enc 2
(Acting Chair)
Enc 3
(Acting Chair)
Oral
All
Enc 4
Oral
Mrs Cooper
Enc 5
1.10pm
Enc 6
1.15pm
Enc 7
1.20pm
ITEM
Purpose
Board Lead
Format
Timings
Mr Axcell
Enc 8
1.35pm
Approval
10.2
Board Statements for Monitor and TDA - Month 9
(following
Chair’s
action)
10.3
Governance and Quality Committee Chair’s Report
Assurance
Dr
Gutteridge
Enc 9
1.40pm
10.4
Finance and Performance Committee Chair’s Report
Assurance
Mr Higgs
Enc 10
1.45pm
10.5
Audit Committee Chair’s Report
Assurance
Mr
Matthews
Enc 11
1.50pm
10.6
Management Executive Team Chair’s Report
Assurance
Mr Graham
Oral
1.55pm
10.7
NHS England EPRR Core Standards: Compliance
Update
Information
(Mr Martin
Perkins in
attendance)
Enc 12
10.8
Data Quality Risk Assessment Report
Assurance
Mr Axcell
Enc 13
2.10pm
11.
LEADERSHIP, CULTURE & WORKFORCE
11.1
Medical Directors’ Update
Assurance
Dr
Weaver/Dr
Gingell
Oral
2.20pm
11.2
Nurse Director Update
Assurance
Ms Pugh
Oral
2.25pm
11.3
Monthly Ward Staffing Report
Assurance
Rosie Musson
in attendance)
Enc 14
2.30pm
12.
STRATEGIC DEVELOPMENT & DIRECTION
12.1
Foundation Trust Progress Update
Information
/Assurance
Mr Graham
Enc 15
2.40pm
12.2
Quarter 3 Board Assurance Framework and Annual
Plan Update
Assurance
Ms Edwards
Enc 16
2.50pm
13.
ANY OTHER BUSINESS
14.
DATE AND TIME OF THE NEXT MEETING
Mr Graham
2pm
Ms Pugh (Ms
Wednesday 4th March 2015, 1pm, Conference Room
1, Trafalgar House, Dudley
3pm
MINUTES OF THE TRUST BOARD MEETING OF
DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUST
Held on Wednesday 7th January 2015
Conference Room 1, Trafalgar House
PUBLIC SESSION
Present
Ms D Oum
Mr G Graham
Ms M Ingram
Ms W Pugh
Mr M Axcell
Dr M Weaver
Dr K Gingell
Mr D Matthews
Dr R Gutteridge
Chair
Chief Executive Officer
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
Non Executive Director
In Attendance
Ms M Edwards
Mrs P Roberts
Mrs Bytheway
334.
FT Project/Company Secretary Consultant
Minute Taker
Strategic Planning Manager (item 343.7 only)
APOLOGIES
ACTION
Apologies were received from Mr M Higgs, Non Executive Director,
Mrs G Cooper, Non Executive Director and Dr R Gutteridge, Non
Executive Director. Dr Gutteridge’s apologies were for the beginning of
the meeting and she joined the meeting at 13:40.
335.
MINUTES OF THE PREVIOUS MEETING
The minutes of the meeting held on 3rd December 2014 were agreed as
an accurate record, with the following exceptions:
Under item 328, the second to last point should read ‘in the loop’ and not
‘First in the loop’.
The minutes were approved and would be signed by the Chair
following the completion of the above amendments.
336.
SUMMARY REPORT OF CONFIDENTIAL SESSION OF TRUST
BOARD
The Board noted a summary of the business transacted in the
confidential session of the Trust Board held on 3rd December 2014.
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337.
MATTERS ARISING
The schedule of matters outstanding was discussed and an update was
provided on those actions, where appropriate:
Item 329.7 – Should be amended to read Trust Board development.
Mr Axcell commented that he would like to raise, under any other
business, the Data Quality Risk Assessment which had been previously
taken to MExT.
The Chair highlighted that it had previously been agreed that the matters
arising would be taken to MExT following the Board meeting in order to
set the due dates. However this was not occurring, therefore, moving
forward, the Board would agree matters arising due dates in the actual
Board meeting and not at MExT.
338.
NOTIFICATIONS OF ITEMS OF ANY OTHER BUSINESS
Mr Axcell’s item of any other business as stated above under matters
arising.
339
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.
340.
QUESTIONS FROM MEMBERS OF THE PUBLIC
No members of the public were present.
341.
CHAIR’S COMMENTS
The Chair advised the Board verbally that her main focus throughout the
month had been:
-
-
-
Capturing the work, which was undertaken in the Board risk
session and planning the Board development for the coming year.
The draft Board development programme would be brought to the
next board.
There is a planned Board development session on the morning of
the next Board meeting on 4th February, subject to Board
members diary commitments. The subject matter will be Duty of
Candour and finance and performance.
Some stakeholder engagement in the form of a Chair session with
Dudley CCG.
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The Board received the Chair’s update for information and
assurance.
342.
CHIEF EXECUTIVE OFFICER’S OVERVIEW
Mr Graham took the Board through the key points of the strategic
overview and horizon scan report, which summarized recent important
publications and information items with actions. The following was
highlighted:
-
-
-
Monitor assessment update.
Planning for 2015/16 and the first year for non block contracts in
mental health. Mr Axcell is leading on a risk share agreement
with commissioners and Mr Graham highlighted that a block
contract would not be acceptable.
Planning for how to deliver ‘the forward view into action. The
Trust has planned a strategy meeting with Dudley CCG in
January to share progress.
There are two more strikes planned, one being 12 hours and one
being 24 hours with a potential of more strikes to come
afterwards.
Ms Ingram mentioned the Health Education England Leadership Awards
and that the Trust’s EBE’s were shortlisted for equality. The Trust won
both awards which they were shortlisted for.
Mr Matthews stated that the Audit Committee had raised the concern of
how are Board members assured that the actions in the CEO horizon
scan are being completed, and should there be a formal record of
completed/non completed actions?
Mr Graham answered the question by stating that the Lead Director
should take responsibility for their action and ensure it is followed
through.
The Chair stated that the paper is a horizon scan and should have
actions, however these actions should be recorded in the Board minutes
and therefore assurance is taken from the minutes.
Mr Graham commented that the last two columns of the report should be
joined together and if there is an action, it is that person’s responsibility
to take forward and complete.
Action: The Board agreed for the last two columns of the horizon
scanning report to be joined together.
Ms Edwards
The Board received the CEO’s overview for information and
assurance.
343.
QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS
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343.1
Trust Integrated Performance Dashboard – Month 8
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:
-
-
-
Copies of Care Plans have improved to 92.2% for November and
early indication for December’s position is at 95%.
New cases access to early intervention, the year to date suggests
the Trust will hit target and have just seen a dip in November.
Early indication for December shows the Trust is back on track.
ALoS remains good.
Activity against contract is at 99.5%, which is a rise, and gives the
opportunity for the Trust to go to contract negotiations for next
year showing that levels of activity are being maintained.
CIP against plan is showing as amber for the month but green
over year.
The Governance risk rating should be 0 for the Trust not 1. This
is a mistake, which unfortunately was not noticed for the report
which has been presented to the Board.
The Chair questioned the Copies of Care Plan’s and asked what was
done to turn this around, how much of the planning and implementation
of improvement activity was being owned by the team and how much
was managers taking up the issue?
Ms Pugh responded by stating that the performance framework, which
was used with managers, was different, and certain areas were
addressed with a slightly different approach of looking at the individual
input. Staff are now clear of what is required going forward.
Mr Matthews commented that there seemed to be more ambers and
reds on this month’s performance report and do the Executives feel
everything is okay? He referenced the ‘Iceberg under the water’
acronym.
Ms Pugh explained reasons behind the ambers and reds and did feel
that the Trust could look at the friends and family test, however the
others were under control.
Mr Axcell was confident that all the red and ambers were being looked at
and monitored at Sub Committees.
Mr Graham commented that he understood that the position might seem
worse than it actually is.
Ms Edwards stated that the sickness absence does link to the sickness
review paper later on the agenda.
Quality Governance Report
Ms Pugh took the Board through the key messages from the Quality
Governance report and the following was highlighted:
-
-
There were 5 serious in November. 3 related to failure to return
from leave or absconding, one to homicide, and one to an
observed fall, which resulted in a fracture.
There shows a slight increase around patient accident.
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The Chair highlighted that this is concerning. Ms Pugh stated that it can
be quite difficult to try and maintain the level of harm as low for
individuals, as the nature of the patient’s means that it is difficult to stop
some accidents. The Trust is looking at different types of flooring to help
with preventing falls.
The Chair questioned how the Trust compares with other Trusts data
with regard to serious incidents and falls?
Ms Pugh commented that she has asked the TDA for this comparative
data and continues to ask at the monthly TDM meetings.
Ms Pugh will ask the TDA to give the benchmarking information as part
of the Trust quality priorities.
Finance Report
Mr Axcell took the Board through the finance report and the following
was highlighted:
-
Strong financial position for month 8 with a surplus if £728k, which
is £255k ahead of plan.
Monitor metric rating of 3.9 for the year end position.
Slight shortfall in income.
On plan to hit the planned annual surplus of 880k by the end of
year.
The Chair asked if Mr Axcell would say that the Trust has an overly
ambitious capital plan and whether future planning will look any
different?
Mr Axcell commented that it is not an overly ambitious plan and
processes have improved over the last 12 months. The Trust is currently
setting the capital plan for the next financial year which will be linked to
the priorities and discussed further in the next Board session. The Trust
is brining planning and implementation closer through closer working
between Estates and Operational teams.
Mr Graham commented that the difference between the planning and the
reality is the challenge and coming up with the correct plan.
Mr Matthews stated that the Trust’s use of locums had reduced, however
the report shows a high cost of locums?
Dr Gingell commented that there are some occasions when the Trust
has to use locums which are at a very high cost. The Trust does try to
keep locum costs down by using use Trust locums.
Mr Axcell suggested that this might be resolved by the wording in the
report.
Dr Gutteridge entered the meeting.
Workforce Report
Ms Ingram took the Board through the workforce report, highlighting the
key messages. The following was noted:
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-
Turnover is being reported on a 12 months rolling basis and
following the departure of the MARS scheme and SMS services
the previous red position has now returned to normal.
- Position on vacancy management; There are 220 funded
vacancies with just over 100 already being recruited to with plans
to transform services, therefore there are 116 vacancies to be
actively recruited to. Heads of service have been working with
HR to develop workforce plans for their service which
demonstrate new ways of working. These plans area currently
being collated and the plans will be turned into a programme for
recruitment.
The Chair asked for this to go to the Finance and Performance
Committee and then to the Board.
Action: Bring final report to the March Board
-
-
Ms Ingram/
Ms Pugh
Sickness has deteriorated in November to 5.9% with an increase
in both long and short term sickness with seasonal issues such as
cold and flu. The Trust has seen an increase across all service
lines and there is a significant piece of work being completed on
sickness to help the Trust understand, which will be picked up
later on the agenda.
The Trust has not seen any improvement in appraisal compliance
and HR are meeting with managers to agree timescales and to
understand what the issues are facing this.
Mr Matthews questioned whether the Board should be driving
compliance with appraisals harder, put the resource in and state that
they simply have to be done.
Ms Ingram stated that HR have been trying to explain to managers the
importance of appraisals, however they have not strongly stated that this
is a must do.
The Chair commented that the Board is very close to the point of taking
a more hard-line approach, and that we should be looking at why the
managers are not insisting that these areas are happening.
Mr Graham suggested that before the next quarterly performance
meetings, the Board could ask for an agreed percentage of appraisals by
the end of the year. If a mutually agreement was not reached a target
will be set for service lines and managers.
Board agreed this way forward
Ms Ingram commented that the Associate Director of Workforce post has
now been recruited to.
The Board noted the performance of the Trust as at month 8.
343.2
Board Statements for Monitor and TDA – Month 8
The Board noted the content of the submissions, which set out the
Boards statements and declarations regarding the Trust’s performance
as at the end of month 8 2014/15. The Board declarations had already
been signed off for submission to the TDA on the 30th November as a
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Chair’s action. The Finance and Performance Committee had also
endorsed the returns.
The Chair asked Mr Axcell if the Board could see some of the
information behind the Board statements at least quarterly for assurance.
Mr Axcell agreed to this and will provide more information on a quarterly
basis.
The Board endorsed and ratified the submission as at month 8.
343.3
Governance and Quality Committee Chair’s Report
Dr Gutteridge took the Board through the Governance and Quality
Committee Chair’s report, highlighting the following:
-
There were no new risks to add to the Governance and Quality
risk register.
- The Governance and Quality Committee had agreed to a deep
dive in research and development and Dr Gutteridge asked if the
Board would like a future agenda item to debate priorities and
investment into research and development?
It was agreed that the Board would have a development session on
Research and development the morning of the July Board meeting
with Dr Gingell to lead on.
Ms Edwards/
Dr Gingell
The Board were asked to approve the QGAF score at 2.5.
The Board endorsed and approved the QGAF and its contents.
The Board were asked to consider an external review to pressure test
systems around the QGAF as it may be a valuable thing to undertake
and external audit would be the best option.
Discussions arose around the value of an external QGAF audit with the
imminent Monitor assessment and it was concluded that an external
audit would be useful as a benchmarking exercise.
Action: Ms Pugh to source and arrange an external assessment of
the QGAF process.
Ms Pugh
The Board accepted the report for assurance and endorsed the
decisions and recommendations made by the Committee.
343.4
Finance and Performance Committee Chair’s Report
Mr Axcell updated the Board on the business of the Finance and
Performance Committee, which included the following:
-
Activity continues to improve.
PBR update and progress in clustering activity.
Mr Matthews commented that there was no mention in the report of the
Committee reviewing Finance and Performance risks and were these
looked at?
Mr Axcell stated that the risks were not reviewed at this meeting and he
will ensure they are discussed at the next meeting.
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343.5
MHA Scrutiny Committee Chair’s Report
Ms Pugh briefed the Board on the business transacted within the MHA
Scrutiny Committee, which included:
-
Serious Incident regarding illegal detention.
Challenges with systems of recording, however there is a piece of
work going on around this.
De Facto Seclusion/DoLS.
The Chair mentioned diary pressures and attendance at this Committee.
Ms Pugh and Ms Ingram plan to work with Mrs Cooper to make sure
there is good attendance at this Committee going forward.
The Chair commented on the street triage pilot and if this is recognised
as a valuable service and what is being done to keep this going after the
pilot?
Ms Pugh stated that the Trust is working with commissioners and
collating a whole suit of evidence to use going forward with lots of
discussions happening across the patch.
343.6
Management Executive Team (MExT) Chair’s Report
Mr Graham informed the Board that the main topic of discussion at
MExT meetings had been:
-
CIP’s over the next 2 years.
PBR and the way forward.
New service developments and new business opportunities.
Data quality risk assessment.
The Board accepted the update for assurance.
343.7
Annual Community, and Inpatients, Patient Survey
Mrs Bytheway presented the report to the Board and gave an update on
the survey action plans, highlighting the following:
To focus on 3 or 4 key areas, triangulate with the Quality Account and
objectives and link to local or Trust wide issues.
The Inpatient survey will be a similar exercise with a presentation to the
Board.
The Chair questioned if the presentation would give value as the quality
of the last presentation did not add much value.
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The draft action plan is to address 17 recommendations received in the
highlight report.
The big theme from this survey is continuity of care and people seeing a
different person each time they attend the Trust. The Trust may not be
able to do anything about this but it can communicate the reasons for the
inconsistency.
Mrs Bytheway commented that there were no surprises from the survey
and the Trust did know about most issues and a lot had been done
already as the survey was last year. This will feed into the Quality
Priorities and Quality Accounts
The Chair questioned feedback from the survey on crisis care and the
actions put in place. Can the Trust work better with the commissioners
in changing what is commissioned and is the Trust providing the service
required?
Ms Pugh commented that there is a need to discuss with the
commissioners of how the Trusts services are relinked. There is a need
for an urgent care hub, which will have all the different elements of crisis
care.
The Chair asked if this was being worked on for the contract this year?
Ms Pugh responded by stating that this is part of the evaluation of the
pilot working being undertaken.
The Board accepted the report for approval
344.
Procurement Strategy
Mr Axcell informed the Board of the main details of the strategy, which
included:
-
This strategy is more closely aligned to the Trust’s strategic vision
and to strategic and clinical procurement.
There is a more clearer action plan about implementation.
Looking at how to manage supplier portfolio.
Dr Gutteridge commented that the whole document could be grounded
more to procurement guidelines.
Mr Axcell stated that he would ensure this is brought through in the
document.
The Chair commented that the document was incredibly wordy and when
next refreshing strategy could there be an Executive summary for the
reader so that the main points were clear.
The Board accepted the report for approval
345.
LEADERSHIP, CULTURE, AND WORKFORCE
345.1
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Dr Gingell informed the Board that a paper had been presented to the
Finance & Performance Committee on waiting times in EAS, which
showed that waiting times had reduced.
The Trust continues to meet with CCG Mental Health leads to look at
quality and ways to improve clinical productivity. The Trust is thinking
about how to meet new waiting time standards and good progress is
being made.
Mr Matthews questioned if the Trust sets targets for EAS waiting times?
Dr Gingell responded by stating there are no specific KPI’s, however the
scrutiny the Trust is giving at the moment will suffice.
Ms Pugh stated that EAS is a new service model, which is subject to
regular review, and the Trust is now confortable that it can start to think
about setting specific metrics which will form part of the 2015/16
contracts.
Dr Weaver had nothing further to add.
The Board received the update for information and assurance.
345.2
Ms Pugh informed the Board of three CQC unannounced inspections, of
which verbal reports had been positive on all three.
The three visited were Cedar, Wrekin and Grasmere. Grasmere’s report
has been received and reflected the verbal report given. Once all three
reports have been received and actions plans are in place they will be
taken to the Governance & Quality Committee.
The Board received the update for information and assurance.
345.3
Monthly Ward Staffing Report
Ms Pugh informed the Board that there was no electronic staff rostering,
however there is a template for the report now in place which will be
piloted in March.
Dr Gutteridge commented that there was no impact on Holywood ward
and staffing levels were maintained when an exception report was given.
She questioned, if monitor asked her how staffing levels were
maintained what should she say as there is no explanation in the report?
Ms Pugh responded by stating that Managers and Senior Nurses have
spare capacity and can step in and keep safe staffing levels when
necessary.
The Board noted the data, and were assured of safe staffing levels
for September 2014.
345.4
Sickness Absence Review Scope
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Ms Ingram took the Board through the sickness absence report and gave
context on report.
The Board had started to talk about this a few months ago when they
noticed that sickness absence was on a downward trend.
This is a wide range piece of work, which involved pulling information
together from various departments. There has been an update meeting
which has looked at patterns of sickness absence and has helped to give
a better understanding. For example, the issue of absence related to
stress, anxiety and depression, is only around a third due to work related
stress.
The absence levels may be linked to local demographics as an average
Trust has a third of its staff with no absence. The Trust has 2% to 2 ½ %
of staff with no absence and this may be a correlation in the Trust
drawing its staff from communities which are deprived.
The review is a work in progress, which will be brought back to the
Board.
The Chair stated that the review would need to answer the question: “Is
the Trust making staff sick?”
Ms Ingram responded that on the basis that a third of absence is work
related with half of this being a HR process then at this moment in the
review, no we are not.
Mr Matthews commented that he has undertaken some work previously
around this topic and quite a lot of London Trusts had very low sickness
levels and it maybe an idea to investigate how they manages their
sickness absence.
The Chair asked if the Trust was doing as much as possible to help
people return to work and make use of their skills, maybe in a different
role.
Ms Ingram stated that yes, this is being looked at and will be included in
the scope.
The Board received the update for information and assurance
346.
STRATEGIC DEVELOPMENT AND DIRECTION
346.1
Foundation Trust Update
Mr Graham had nothing further to add as he had given an FT update in
his CEO update.
The Board received the update for information and assurance
347.
ANY OTHER BUSINESS
Mr Axcell gave an update on the Data Quality Risk Assessment and
informed the Board that Internal audit have undertaken an assessment
of data quality and have assessed against 5 criteria.
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The findings of internal audit were that all indicated green apart from 3
areas which were:
- Compliments
- Activity – multiple systems but adequate processes in place to
cross reference
- IAPT
This has been presented to MExT and it was accepted that this
represented a true picture.
This information is to update the Board and Mr Axcell will circulate the
report.
Action: This item to be added to the agenda for the February Board
meeting
348.
Ms Edwards
DATE AND TIME OF NEXT MEETING
Wednesday 4th February 2015, 1pm, Canalside House, Walsall
Signature……………………………………………………….. Date…………….
Ms D Oum, on behalf of the Dudley and Walsall Mental Health Partnership NHS Trust Board
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Board meeting date:
4th February 2015
Title
Agenda Item number: 3
Enclosure: 2
Summary of Confidential session of Trust Board held on 7th January
2015
Accountable Director:
Ms Oum, Chair
Author:
Mandy Edwards, Interim Company Secretary
CONTEXT AND BACKGROUND FOR 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 7th January 2015.
KEY ISSUES FOR BOARD OF DIRECTORS CONSIDERATION AND
DECISION
Chair’s Update
The Chair had nothing further to update the Board on than the business that had
already been covered in the preceding public Board meeting.
The Chief Executive Officer’s (CEO’s) overview
The Board received an update on:
x The outcome of the partnership working programme involving Providers,
Commissioners and Social Care in Walsall.
x The Dudley Health Economy sustainability review.
x Discussions with Monitor regarding FT assessment reactivation.
CIP PMO and Service Transformation Report
A report was presented which highlighted:
x The Early Intervention scheme had delivered and it slightly over achieved.
x Two schemes for closure.
x Three schemes which were predicting a shortfall.
x The schemes that have been agreed for the next two years.
An update on progress against current service development projects was given which
included rehabilitation services, CAMHS and Agile Working.
Trust Wide Risk Register
The Board were informed of a meeting scheduled in January to review and refine the
Trust Wide risk register following a Board Development session held on the 17th
December. It was reported that at the present time there were no key changes in
risks to bring to the Board’s attention.
The Chair reminded the Board that the outcome of the Board Development session
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on strategic risk would also inform the refreshing of the Risk Strategy and supporting
policies and feed through to revised Committee ToRs.
Stakeholder Engagement Plan
Mrs Bytheway presented an update to the draft plan already received and outlined
the next steps for developing the stakeholder engagement plan.
The plan had moved on significantly although it remained a working draft that had
two strands:
x Capturing the stakeholder engagement the Trust currently undertakes.
x Identifying what further engagement the Trust might undertake in the future.
The aim was to develop this plan into a firm communication and engagement plan,
that would be brought to the Board in April.
Options and proposals for a potential future property purchase
Mr Axcell updated the Board on progress and reported that the Trust was still
awaiting the valuation report from the District Valuer. As soon as the report was
received then a formal business case would be prepared.
Ms Pugh had nothing further to add than that covered in the preceding public Board
meeting.
Dr Gingell had nothing further to add than that covered in the preceding public Board
meeting. Dr Weaver updated the Board on a previously reported referral to the GMC.
Service and Business Development PMO Report
A briefing regarding a forthcoming tender was presented to the Board. The Board
discussed and confirmed contribution levels, cost pressures and financial risks.
For Assurance
The Board noted the minutes of the MHA Scrutiny Committee held on 4th December
2014, the Finance and Performance Committee meeting held on 24th November
2014, the Audit Committee held on 8th December 2014 and the Governance and
Quality Committee held 12th November 2014.
Any Other Business
The Board received a presentation on the Estates Rationalisation strategy. The
strategy considered how the Trust would move forward with a modern approach to
service provision including activity and space occupation per area. The Board would
agree principles, direction of travel and strategic aspirations prior to sharing with
Commissioners.
RECOMMENDATIONS
The Board is invited to note the business transacted in the private session held on 7th
January 2015.
14 of 182
MATTERS ARISING FROM PUBLIC MEETINGS
Item
No.
Date
Added
Action
187
5th Feb
2014
A Board to Board to be
organised with the 2 CCG’s
to take place within the next
6 months.
244.1
4th
June
2014
Integrated Dashboard
Mr Axcell to look into
benchmarking of reference
costs against estates costs.
Responsibility
Due
Date
Ms Edwards
March
2015
Mr Axcell
5th Nov
2014
March
2015
Update
Walsall CCG Board to
Board (B2B) complete. A
B2B to be scheduled with
Dudley CCG in early 2015.
A 4 way conversation
between Trust, Dudley
CCG Chair & CEOs to
agree format of B2B to be
arranged.
Duty of Candour
th
316.4
328
5 Nov
2014
3rd Dec
2014
Give consideration to Non
Executive lead for candour.
Ms Oum
7th Jan
2015
4th Feb
2015
Undertake an audit in to
serious incident and
complaint handling
processes to provide
assurance on application of
duty of candour. Audit
outcome and any areas
identified for improvement to
be reported to Board
through Governance and
Quality Committee.
Ms Pugh/
Dr Gutteridge
4th Feb
2015
Ms Edwards
Feb
2015
To liaise with the Chair to
include session on Fit &
Proper Persons Test and
Duty of Candour on future
Board Development agenda.
Under consideration. To
be confirmed when the
new Non Executive
Director is appointed.
Draft Board Development
programme on Private
Board Agenda.
Performance Report
329.1
3rd Dec
2014
Deep dive on quality impact
of under-performance on
CPA and activity targets to
be discussed at Board in 3
months time.
Ms Pugh
April
2015
Governance Report
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Item
No.
Date
Added
Responsibility
Due
Date
Summary of lessons learned
from the 3 serious incidents,
as discussed at December’s
Trust Board to be brought
back to Board, subject to
completion of full
investigations.
Ms Pugh
4th Feb
2015
Report outlining topics being
discussed nationally
regarding Safety
Thermometer Metrics more
relevant to Mental Health, to
be presented at a future
G&Q Committee
Ms Pugh
Feb
2015
Ms Pugh
Feb
2015
Ms Edwards
4th Feb
2015
Dr
Gingell
March
2015
Ms Pugh
4th Feb
2015
Ms Ingram
March
2015
Action
329.5
3rd Dec
2014
Concerns regarding Walsall
IMHA service to be raised at
monthly Quality Review
Meeting.
329.7
3rd Dec
2014
To include Therapeutic
Interventions on a future
Trust Board Development
agenda in the New Year.
rd
330.2
3 Dec
2014
330.3
3rd Dec
2014
330.4
3rd Dec
2014
Business case regarding
further investment in
Research & Development to
be presented at a future
Trust Board meeting.
Information on temporary
staffing to be included in
future reports in line with
national template.
Detailed staff engagement
delivery plan and progress
update to be presented to
Trust Board in March 2015.
Update
On Agenda.
Draft Board Development
programme on Private
Board Agenda.
It has been agreed at the
Governance and Quality
Committee that a spotlight
session would be done on
this prior to bringing it to
Trust Board.
CEO Horizon scan
342
7th Jan
2015
The last two columns of the
table in the report to be
joined together.
Ms Edwards
4th Feb
2015
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Item
No.
Date
Added
Responsibility
Due
Date
Ms Ingram / Ms
Pugh
4th
March
2015
Board to have a
development session on
Research and development
the morning of the July
Board meeting with Dr
Gingell to lead on.
Ms Edwards / Dr
Gingell
1st July
2015
External assessment of the
QGAF process to be
arranged.
Ms Pugh
4th
March
2015
Action
Update
Workforce Report
343.1
7th Jan
2015
Report on programme for
recruitment to be taken to
March Trust Board.
Governance and Quality
Committee Chair’s Report
7th Jan
2015
343.3
7th Jan
2015
347
7th Jan
2015
Data Quality Risk
Assessment Report to be
added as an agenda item to
February Board
Ms Edwards
4th Feb
2015
On Agenda.
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18 of 182
4th February 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, Walsall Healthcare
NHS Trust
Non-Executive Director, Optima Community
Trust
West Midlands Committee Member, National
Housing Federation
Non-Executive Director of Extra Care Trust

Nothing to declare

Michael Higgs
01.10.08
David Matthews
20.09.10
Dr Robin Gutteridge
01.12.11
Gill Cooper
01.06.13
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
Chief Executive
Joint
Medical
Director
Director of
People and
Corporate
Development
Director of
Operations &
Nursing
Joint Medical
Director
Director of
Finance and
Performance
Consultant in Health and Wellbeing, Faculty of
Education, Health and Wellbeing, University of
Wolverhampton
Chartered Psychologist: Full member Division
of Teachers and Researchers
Accredited Member of the British Association
for Counselling and Psychotherapy (BACP)
Member of the College of Sexual and
Relationship Therapists (CoSRT)
HCPC Registered Counselling Psychologist:
Number PYL27928.
Trustee – Frederick Pearson Fisher Charity
Serving Justice of the Peace – Dudley Bench
Nothing to declare

Nothing to declare

Trustee – A Child of Mine Charity
19 of 182
20 of 182
Agenda Item number:
8
Board meeting date:
4th February 2015
Report Title:
Enclosure: 5
Chair’s Comments
Danielle Oum, Chair
Author (name & title):
Purpose of the report:
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.
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
8
9
9
9
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
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources
8
9
9
8
9
8
The CQC domains that this report
relates to are:
Please give brief details:
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
21 of 182
Title
Chair’s Comments
Introduction
This paper forms the Chair’s monthly report to the Board regarding Chair and Board activities
undertaken during the previous month, together with a forward look at programmed work.
Summary of key points, issues and risks
During January, together with board colleagues, I have been focusing in on the Trust’s vision,
strategy and staff engagement.
In summary, the things I have been involved in and my key learning points are:
1. Board development programme development
I have been identifying areas to cover within the Board development programme for the
coming year and briefing facilitators on their topics and the level of detail required. The draft
Board development programme will be discussed and agreed in this month’s private session
of the Board.
2. Risk strategy, policy and Committee ToR refresh
I have been working with the Executive team to translate the outcomes of the December
Board development session into the Trust’s risk and governance framework.
3. Stakeholder Meetings
This month I have undertaken meetings with some key stakeholders including; the Chair of
Birmingham and Solihull Mental Health NHS FT, the new Chair of Black Country
Partnership NHS FT and the Chair of Healthwatch Walsall. The key themes arising from
these meetings were a common interest in more partnership working, collaboration,
communication, involvement and a greater profile for the Trust.
4. NED Recruitment
The Non-Executive Director recruitment process has completed and we have successfully
appointed a new NED, Simon Murphy, and also a new associate NED, Pawiter Rana to add
capacity to the non- executives and facilitate succession planning.
5. NED appraisal/objective setting
I am partway through the annual NED appraisals. As part of this process we will also be
reviewing and setting objectives for the coming year.
6. Next Month
Over the next month my plan is to focus on the upcoming Monitor assessment that is about
to recommence in February.
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Recommendation
It is recommended that: the board notes the Chair’s induction activities.
Board action required
The Board is asked to receive this report for information and assurance.
23 of 182
24 of 182
Agenda Item number: 9
Board meeting date:
4th February 2015
Report Title:
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 in
each publication and identifies the officer accountable for any action
required and appraising the Board where appropriate.
Decision / Approval
Gain assurance
Discussion
Information
9
9
9
9
Committee: N/A
Date reviewed:
Key points or
Committee:
High quality
services
Inclusive
partnerships
Leadership
culture
Accountable
workforce
Supporting
strategies
Effective/efficient
resources
9
9
9
9
9
9
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
25 of 182
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:
Monitor - guidance to help patients receive more joined-up
care
Monitor - NHS foundation trusts: financial accounting
guidance - updated
Department of Health - New Mental Health Act code of
practice
NHS England - New resource launched to improve Child
and Adolescent Mental Health Services
NHS England - Friends and Family test rolled out to mental
health and community health
NHS Employers - Pay Review Body propose changes to
national pay and conditions
NHS Providers - NICE has updated the guidance on mental
health after stopping smoking
British Geratrics Society - Fit for Frailty Part 2 guidance
published
HSJ - NHS England to examine the cost implications of
expanding NHS services across seven days.
Accountable Officer
Director of Operations, Nursing and
Estates
Director of Finance, Performance &
IM&T
Estates
Clinical Development Director
Director of People and Corporate
Development
Director of People and Corporate
Development
Estates
Joint Medical Directors
Estates
Recommendation
It is recommended that the Board note and discuss the information contained within this report.
The Board is asked to:
x Note the information contained within the report.
x Agree the Accountable Officer identified within the report and any specific action required.
26 of 182
Strategic Overview and Horizon Scan Report
February 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
Monitor Assessment Update
The Trust has received a letter from Monitor which confirmed their current
intention to recommence the Trust’s FT assessment at the beginning of February.
Accountable Officer
Chief Executive
Monitor
Website link: https://www.gov.uk/government/organisations/monitor
Monitor guidance to help patients receive more jointed-up care
Monitor believes that greater integration of health and care services can bring
many benefits to patients. The regulator is consulting on draft guidance that
makes it clear that Monitor can take action if providers block efforts to deliver
joined-up care for patients.
This is the first time the regulator has produced guidance to help providers comply
with the integrated care condition of the NHS provider license. The license is
Monitor’s main tool for regulating NHS providers and contains a specific condition
requiring providers not to block the delivery of integrated care when it can benefit
patients.
Accountable Officer
Director of Operations,
Nursing and Estates
The full guidance can be found at:
https://www.gov.uk/government/news/monitor-guidance-to-help-patients-receivemore-joined-up-care
NHS foundation trusts: financial accounting guidance - updated
NHS foundation trust finance staff should use this guidance, which is updated
regularly, to do their work.
Director of Finance,
Performance & IM&T
The full guidance can be found at:
https://www.gov.uk/government/publications/nhs-foundation-trusts-financialaccounting-guidance#history
NHS foundation trust bulletin January 2014
The FT Bulletin has information for foundation trust chairs, chief executives,
finance, medical and nursing directors and board secretaries
For Information
The January bulletin can be found at:
https://www.gov.uk/government/organisations/monitor
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Department of Health (DoH)
Website link: https://www.gov.uk/government/organisations/department-of-health
Nick Clegg at Mental Health Conference
At the Mental Health Conference on 19th January, held at the King’s Trust, Nick
Clegg called for a new ambition for zero suicides across the NHS. The Deputy
Prime Minister spoke about removing mental health stigma and the need to adopt
a 'zero suicide' ambition across the NHS.
Accountable Officer
For information
The full news story can be found at:
https://www.gov.uk/government/speeches/nick-clegg-at-mental-health-conference
New Mental Health Act code of practice
A revised code of practice for the Mental Health Act 1983 provides guidance for
professionals.
Nursing and Estates
The revised code aims to provide stronger protection for patients and clarify roles,
rights and responsibilities. This includes:
x involving the patient and, where appropriate, their families and carers in
discussions about the patient’s care at every stage
x providing personalised care
x minimising the use of inappropriate blanket restrictions, restrictive interventions
and the use of police cells as places of safety.
The new code will come into force on 1 April 2015, subject to Parliamentary
approval.
More information and the revised code can be found at:
https://www.gov.uk/government/news/new-mental-health-act-code-of-practice
The Dementia Challenge is an ambitious programme of work designed to make
a real difference to the lives of people with dementia and their families and carers
including a website with up to date news regarding Dementia.
For Information
More information can be found at:
http://dementiachallenge.dh.gov.uk
NHS England
Website link: http://www.england.nhs.uk
Dementia ‘ambassador’ meets CCGs to explore barriers
An NHS ambassador aiming to help increase the diagnosis rate of people with
dementia and provide the post diagnostic support is to meet 21 CCGs to help
explore challenges to diagnosis.
Accountable Officer
For Information
By the end of January Dr Dan Harwood, Consultant Psychiatrist at South London
and Maudsley NHS Foundation Trust and a Dementia Ambassador for the
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London area for NHS England, will have met with 21 CCGs and advised them on
how to overcome obstacles to diagnosis and how to improve care pathways.
The full article can be found at:
http://www.england.nhs.uk/2015/01/19/dementia-ambassador/
New resource launched to improve Child and Adolescent Mental Health
Services
A new resource with tools for commissioning effective mental health services for
children and young people has been published.
NHS England has published the new model specification for Children and
Adolescent Mental Health Services (CAMHS) targeted and specialist services
(tiers 2 and 3) which treat patients with a range of emotional and behavioural
difficulties such as behavioural problems, depression and eating disorders, to help
improve the standards of care being given to vulnerable youngsters.
Clinical Development
Director
http://www.england.nhs.uk/2015/01/09/camhs/
Friends and Family test rolled out to mental health and community health
Patients using mental health and community health services are now able to
feedback on their experiences through the latest expansion of the Friends and
Family Test. Patients receiving therapy for dementia, depression or addiction,
those receiving care at home and people on mental health wards are amongst
those who can now feedback.
Director of People and
Corporate Development
http://www.england.nhs.uk/2015/01/01/mh-patients-test-services/
NHS Employers - Workforce Bulletin
Website link: http://www.nhsemployers.org/about-us/our-communications/nhs-workforce-bulletin
Pay Review Body propose changes to national pay and conditions
In its recent submission to the NHS Pay Review Body NHS Employers said that
wider changes to national pay and conditions, including changes to unsocial hours
provisions, must be negotiated with health unions to develop a new employment
package that is fair to staff and could support wider services at all hours.
Accountable Officer
Director of People and
Corporate Development
Possibilities including paying more hours in the week as ‘plain time’, adjusting
enhanced unsocial hours payments and various flexibilities to enable adequate
staffing at all times. Such changes would return greater efficiency to the NHS and
support future growth of services, for example by making better use of expensive
diagnostic equipment and facilities.
In parallel, NHS Employers will continue urging significant changes to the doctors’
contracts which currently include significant barriers to improving seven-day care.
http://www.nhsemployers.org/pay2015
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Better Training Better Care evaluation reports published
Health Education England published the evaluation report to the Better Training
Better Care (BTBC) pilot projects and the evaluation report to the national
elements on 16 January 2015. Both reports set out what was achieved, the
benefits that were realised and opportunities that have arisen, as well as the
challenges and lessons learnt.
For Information
http://www.nhsemployers.org/news/2015/01/better-training-better-care-reportspublished
NHS Providers – (Formally known as Foundation Trust Network)
Full newsletters can be obtained from mandy.edwards@dwmh.nhs.uk
Provider Focus – January Issue Main highlights:
x NICE has updated the guidance on mental health after stopping smoking,
after a systematic review and meta-analysis showed that smoking cessation
may improve psychological quality of life, and that continued smoking may
exacerbate some symptoms of mental illness.
Accountable Officer
Nursing and Estates
The publication can be found at:
http://nhsproviders.cmail1.com/t/ViewEmail/t/D30402F50790159B/EE8BCAE1400
216E6C9C291422E3DE149
This week next week – 23rd January 2015 Main highlights:
x NHS England recognises need to respond to an ageing society. Sir Bruce
Keogh says the 5YFV will need to respond to demographic change. Simon
Stevens acknowledges potential risks of vertical integration
For Information
http://nhsproviders.cmail2.com/t/ViewEmail/t/4B6B42447AAE8A20/C0F7EC2267
CC19B5C5EC08CADFFC107B
This week next week – 16th January 2015 Main highlights:
x Tariff decision delayed. Monitor is reviewing hundreds of responses to
determine whether it has received enough formal objections to require more
consultation or referral to CMA. Its board is expected to make a decision on 28
January.
x Pressure on child and adolescent mental health services grows, but
spending has fallen since 2010. In addition, more than half of English
headteachers feel the referrals system to access these services is failing.
For Information
http://nhsproviders.cmail2.com/t/ViewEmail/t/4F378CC6134A555B/F5F7C1CD4B
8D4CD86A4D01E12DB8921D
This week next week – 9th January 2015 Main highlights:
x Nick Clegg promises NHS extra £8bn by 2020. The pledge depends on
For Information
30 of 182
economic growth and the elimination of the budget deficit by 2017/18. The
Conservatives and Labour focused on A&E pressures.
x Warning about proposed marginal specialised services tariff. NHS
Providers tells NHS England and Monitor the tariff will force its members to
take decisions with "profound implications on patient services".
http://nhsproviders.cmail1.com/t/ViewEmail/t/337E6A456EC9049F/008306ECE1B
FF79AC5EC08CADFFC107B
Mental Health Foundation
Website link: http://www.mentalhealth.org.uk
What Does A Mindful Nation Look Like?
Over the last eight months the Mindfulness All Party Parliamentary Group
(MAPPG) have held eight hearings in parliament on the potential of mindfulness in
key areas of public services and the workplace.
Accountable Officer
For Information
Mindfulness is a mind-body based approach that helps people change the way
they think and feel about their experiences, especially stressful
experiences. Mindfulness exercises or mindfulness-based cognitive therapy
(MBCT) are ways of paying attention to the present moment, using techniques like
meditation, breathing and yoga. Mindfulness training helps people become more
aware of their thoughts and feelings so that instead of being overwhelmed by
them, they're better able to manage them.
Full article can be found at:
http://www.mentalhealth.org.uk/our-news/news-archive/2015/15-01-14-mindfulnation/
British Geriatrics Society
Website link: http://www.bgs.org.uk
Fit for Frailty Part 2 guidance published
Frailty is increasingly common with older age. Despite this, it isn’t really discussed
as a “long term condition” even though it often accompanies such illnesses, as
well as dementia.
Accountable Officer
The Fit for Frailty guidance was born out of work between the British Geriatrics
Society and AGE UK. The Part 2 guidance follows on from Fit for Frailty Part 1
and provides advice and guidance on the development, commissioning and
management of services for people living with frailty in community settings. It is
aimed at GPs, geriatricians, Health Service managers, Social Service managers
and Commissioners of Services.
http://www.bgs.org.uk/campaigns/fff/fff2_full.pdf
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NHS Benchmarking Network
Website link: http://www.nhsbenchmarking.nhs.uk/index.php
NHS Benchmarking Network - Urgent Care Report
The Network has released the Urgent Care Benchmarking report for the 2014
cycle of the project. Urgent and Emergency care provision has been the subject of
much discussion recently, and the Urgent Care project aims to test the
effectiveness of the urgent care system.
The report compares capacity and demand across primary care out of hours,
community services, and secondary care. A wide number of areas are explored
including service models, access and waiting, infrastructure, activity, workforce,
finance, quality and outcomes. The report also contains detailed information on
the 4-hour wait target, as well as other key performance metrics.
Accountable Officer
Nursing and Estates
The report is available to download on their members area:
http://members.nhsbenchmarking.nhs.uk
http://www.nhsbenchmarking.nhs.uk/news/view-article.php?id=71
NHS Confederation
Website link: http://www.nhsconfed.org
MHN opens nominations process for new board members
The Mental Health Network (MHN) is currently seeking nominations to three
positions on its board:
x 2 x service user representatives
x 1 x healthcare practitioner in active substantive clinical practice
representative
Accountable Officer
Representing a constituent group on the Mental Health Network board is an
opportunity to shape the work of the Network and become involved in shaping
mental health policy and practice on a national level.
http://www.nhsconfed.org/news/2015/01/mhn-opens-nominations-process-fornew-board-members
Care Quality Commission (CQC)
Website link: http://www.cqc.org.uk
Information on The CQC website includes the following:
x Chief Inspector of Hospitals welcomes new Mental Health Act code of
practice
x Special measures to help GP practices improve - Under proposals
announced by the CQC, all GP practices rated Inadequate by their inspectors
Accountable Officer
For Information
32 of 182
will be placed in special measures and offered support to help them improve.
More Information can be found at:
http://www.cqc.org.uk/search/site/news
Health Service Journal (HSJ)
Website link: http://www.hsj.co.uk/
NHS England to examine the cost implications of expanding NHS services
across seven days.
Accountable Officer
Nursing and Estates
Financial consultancy firm Deloitte has been commissioned to examine three
health economies and look at the potential cost of bringing in seven day services
at acute providers, as well as community and mental health services and social
care. It will also look at the configuration of services, the clinical case for seven
day services and the workforce implications.
NHS England published 10 clinical standards for seven day services in December
2013 that largely focused on acute and emergency care. Similar standards are
being worked on to cover community and mental health services but in the past
12 months there has been mounting concern over the cost of implementing the
proposals. Under planning guidance for 2015-16, published last month, providers
will need to meet at least five of the 10 clinical standards.
http://www.hsj.co.uk/5078336.article?WT.tsrc=email&WT.mc_id=Newsletter23#.V
MT-F1oswVQ
Midlands trust chief executive to retire
The chief executive of Coventry and Warwickshire Partnership Trust has
announced she will retire later this year.
For Information
http://www.hsj.co.uk/hsj-local/mental-health-trusts/coventry-and-warwickshirepartnership-nhs-trust/midlands-trust-chief-executive-to-retire/5078318.article
'Perfect storm' tips Walsall trust into the red
Walsall Healthcare Trust has instigated an action plan to clear its ‘significant’
waiting list after being hit by a ‘perfect storm’ of IT problems and heightened
demand that threatens to push it £9m into the red.
For Information
http://www.hsj.co.uk/5077657.article?WT.tsrc=email&WT.mc_id=Newsletter83
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Board meeting date:
Agenda Item number:10.1
Enclosure:7
4th February 2015
Trust Integrated Performance Dashboard Month 9 (December
2014/15)
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 9 of 2014/15
x
x
x
x
x
Quality and Safety
Service User Experience
Efficiency
Resources
Monitor and Trust Development Authority
Decision / Approval
Gain assurance
Discussion
Information
8
9
9
9
Committee:
x
x
Governance and Quality 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
x
Finance and Performance Committee – 26th January 2015
Key points or
Committee:
High quality
Inclusive
Leadership
Responsible
Supporting
Effective/efficient
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services
partnerships
culture
workforce
strategies
resources
9
8
9
9
8
9
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
36 of 182
Trust Integrated Performance Dashboard Month 9 (December)
2014/15
Title
Introduction
x
This paper presents the Trust’s performance at the end of month nine 2014/15 financial year.
x
The 2014/15 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.
x
The 2014/15 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.
x
Sickness - Trust Sickness for December 2014 is 6.15%. This is an increase of 0.25% compared
to November 2014.
x
Copies of Care Plan – month nine has seen an improvement and the Trust is now performing
above the agreed 95% target.
x
The 12 month rolling sickness percentage has increased from 5.42% in November 2014 to
5.46% in December 2014. Long Term Sickness accounts for 72.8% of sickness in the 12 month
rolling period.
x
The overall finance risk rating for the month remains green with a score of 3.9.
x
Our overall governance risk rating for the month is green with a score of 0.
Further detail (if required)
Recommendation
x
It is recommended that the Board note the performance of the Trust as at month nine and
debate accordingly.
x
Debate the content of the reports accordingly.
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Presented at Trust Board 4th February 2015
Trust Integrated Performance Dashboard
Month 9 (December)
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• Appraisal Data Capture still remains below target at to 53.7% as at 31st December 2014, the Trust is reviewing the current policy and procedure in order to
improve appraisal compliance.
• Sickness - The in month Trust sickness absence rate for month nine has increased to 6.15%. The 12 month rolling sickness percentage has increased from 5.42% in
month eight to 5.46% in month nine. Long Term Sickness accounts for 72.8% of sickness in the 12 month rolling period. The Human Resources team are working
closely with Operational teams to focus on the absence issues within the Trust and an action plan to reduce sickness absence is currently being developed.
Regular case review meetings are on-going with Occupational Health service.
• Turnover for all areas of the Trust has increased following the implementation of MARS. Turnover for Recovery services is high due to the TUPE transfer of Dudley
SMS Services on 1st April 2014.
Resources Domain
• Cost Improvement Programme (CIP) - The Trust’s CIP target for the year is £2,087k. The in year achievement of CIP is forecast at £1,799k which leaves £288k to
be managed centrally through uncommitted reserves. The full year recurrent effect of these schemes is £2,098k, representing a recurrent £11k planned overachievement. The indicator is rated amber as a reflection of the work on-going to deliver the full year effect of the £2,087k plan.
• All IAPT Indicators – month nine has seen a decrease in performance (47.1%) for people who have successfully completed treatment in Walsall so therefore the
Walsall team is below the agreed target of 50.5%. Head of Service and Team Manager confirm this is primarily due to seasonal variation.
Efficiency Domain
• Activity against contract (NHS Activity) – As at month nine, the Trust has reported 237,298 units of activity against a target of 239,366 year to date. Certain
services have been identified for additional investment, and action plans are in place to address the shortfall. The underperformance is being closely monitored by
the Trust Finance and Performance Committee.
• Copies of Care Plan – month nine has seen an improvement and the Trust is now reporting performance above the agreed 95% target (95.4%).
• CPA Formal Review – month nine has seen an improvement and continues to perform above the agreed 95% target.
Quality and Safety Domain
• During month nine there were six serious incidents logged – 1 relates to Abscond/Failure to return from agreed leave and 2 are in relation to patients who have
fallen, resulting in bone fractures. Number of incidents reports in month nine remains the same as month eight (296).
Trust Level Integrated Dashboard – Exception Commentary
Activity against contract remains above the target as at month nine which is due
to the high bed occupancy levels and increase in activity recorded by CRHT and
Psychiatric Liaison.
•
42 of 182
Acute Services sickness is 8.11% in month nine and the 12 month sickness is
7.33%, of which 69.0% is due to Long Term Sickness.
• This service line is underspent against budget by £418k as at December 2014,
mainly due to uncovered vacancies in CRHT, the separately funded Urgent Care
Centre pilot and sustained reduction in Ward costs.
•
Service Line Summary
Copies of Care Plan – has seen an increase in performance and is now above
target (96.8%).
Activity against contract remains below the target as at month nine (this includes
all three teams in community services). This is closely monitored by Operational
colleagues and the services are confident that this will improve.
•
•
Complaints Upheld/Partially Upheld is rated as Amber for month nine, however it
is only in relation to one complaint which distorts the percentage figure.
•
43 of 182
Community Services sickness is 7.49% in month nine and the 12 month sickness is
5.40%, of which 70.3% is due to Long Term sickness.
•
• Community Services are forecast to over spend by £37k due to extended Agency
usage.
CPA Formal Review – indicator remains compliant in month nine (97%).
•
•
Complaints Upheld/Partially Upheld is rated as Amber for month nine, however it
44 of 182
is only in relation to one complaint which distorts the percentage
figure.
• Early Intervention sickness is 7.51% in month nine and the 12 month sickness is
6.03%, of which 74.3% is due to Long Term sickness.
• This service line has a full year CIP delivery of £80K for 2014/15 which has been
met within the CAMHS service. Additional investment of £63K has been added to
support the Primary Care to support the recent Older Adult Primary Care pilot
scheme in Dudley.
• Activity against contract remains below the target as at month nine. The Head of
Service has plans in place which will see an increase in Activity levels.
•
Older Adults sickness is 7.61% in month nine and the 12 month sickness is 7.81%,
of which 78.3% is due to Long Term sickness.
45 of 182
• This service line has an £8k overspend in Month 9 and is forecast to over spend
by £58k. This is due to a combination of agency usage and vacancies on wards
and community teams.
• CPA Formal Review and Copies of Care Plan – Both indicators still remain below
target in month nine. The underperformance is being closely monitored by the
Trust Contract Activity Review Meeting, with action plans in place to address the
underperformance.
46 of 182
• Recovery Services sickness is 8.16% in month nine and the 12 month sickness
is 5.54%, of which 77.5% is due to Long Term sickness.
• Recovery is under spent for April-December 2015 by £37k. Cost pressures
remain from last year within EAS where there are 1.00 WTE agency workers
unfunded to manage assessments, for which a solution is being scoped. The
service now has a run-rate consistent with budget, due to vacancies within
Walsall SMS and additional Criminal Justice growth funding.
• Recovery services continue to report over-performance in activity levels
against the NHS contracted target.
Month 9
2014/15
Trust Performance Report
47 of 182
1
Dudley
95%
95%
(99/104)
(89/92)
95%
95%
100%
96%
100%
100%
(76/76)
(67/67)
100%
100%
100%
May
Jun
98%
(82/84)
97%
100%
100%
(65/65)
100%
7
8
9
6
16
13
May
July
96%
(102/106)
96%
100%
100%
(90/90)
100%
15
12
13
8
28
20
Jun
Aug
96%
(92/94)
97%
100%
100%
(71/71)
100%
21
14
17
11
38
25
July
100%
Sept
97%
100%
100%
(92/92)
34
27
27
21
61
48
Oct
100%
95%
(100/100) (113/116)
100%
100%
100%
Oct
100%
26
24
23
16
49
40
Sept
(81/81)
23
21
20
14
43
35
Aug
95%
(71/73)
97%
100%
100%
(63/63)
100%
Nov
36
32
30
27
66
59
Nov
97%
(115/119)
96%
100%
100%
(84/84)
100%
Dec
42
36
39
32
81
68
Dec
95%
95%
95%
Dudley
Walsall
95%
95%
41
<64 days Walsall
Trust
39
<64 days Dudley
95%
40
5. Average length of <64 days Trust
stay *
6. Users with a copy
of their care plans *
1.5%
Walsall
<7.5%
0.0%
Dudley
<7.5%
95.4%
95.4%
95.4%
58
37
45
0.04%
0.0%
96.2%
96.2%
96.2%
71
39
52
1.3%
0.6%
95.4%
95.4%
95.8%
95.8%
95.4%
76
52
62
1.5%
1.8%
95.8%
35
37
36
1.0%
2.9%
95.1%
95.1%
95.1%
48
32
39
2.2%
1.8%
92.1%
92.1%
92.1%
61
40
50
0.4%
3.2%
92.2%
92.2%
92.2%
42
42
42
0.2%
4.7%
95.4%
95.4%
95.4%
47
64
57
0.7%
2.3%
95% Walsall 100%
95%
97%
97%
100%
100%
100%
100%
98%
0.7%
0.0%
0.9%
2.0%
1.7%
2.0%
1.9%
2.7%
1.6%
4. DToCs (All reasons) <7.5%
Trust (30/4510) (1/4701) (42/4447) (101/4937) (79/4709) (90/4563) (94/4983) (136/5047) (82/5050)
Trust
Walsall
95%
95%
Dudley
95%
3. 7 day follow up on
Inpatient discharge *
Trust
Actual
Walsall
95%
2
Target
2. Gate-keeping of
inpatient admission *
5
4
Actual
46
Apr
4
Target
43
Dudley
Loc
7
Actual
Target
7
Target
Apr
89
Loc
Trust
Target
KPI
1. New cases
accepted to EI Cumulative
KPI
Contractual and Quality KPIs, month 9
RAG
95.4%
95.4%
95.4%
53
43
47
1.0%
2.0%
1.5%
98%
96%
97%
100%
100%
100%
YTD RAG
Actual
42
36
39
32
81
68
YTD
48 of 182
2
Trust
Dudley
Walsall
0
0
Walsall
Dudley
0
(51/mth)
608
(49/mth)
579
Trust
Loc
12. Completion of
ethnicity code on
MHMDS
11. Completion of NHS
number on MHMDS
10. Physical health
checks for inpatients
more than 12 months
96%
99%
99.5%
81.9%
Walsall
Trust
Dudley
Walsall
Trust
Dudley
Walsall
100%
99%
99%
99%
90%
90%
90%
81.9%
81.9%
(6959/8502)
99.5%
(8463/8502)
99.5%
100%
100%
Dudley
100%
100%
Trust
90.1%
90.1%
91.3%
91.3%
91.3%
99.6%
99.6%
92%
92%
92%
99.7%
99.7%
99.7%
100%
100%
100%
95%
100%
89%
100%
93%
100%
1
0
0
0
55
73
128
July
92.7%
92.7%
92.7%
99.7%
99.7%
99.7%
100%
100%
100%
95%
100%
97%
100%
96%
100%
0
0
0
0
62
70
132
Aug
91.9%
91.9%
91.9%
99.4%
99.4%
99.4%
100%
100%
100%
92%
100%
94%
100%
93%
100%
0
0
0
0
65
73
138
Sep
90.7%
90.7%
90.7%
99.4%
99.4%
99.4%
100%
100%
100%
93%
100%
95%
98%
94%
98%
1
0
0
0
75
89
164
Oct
92.3%
92.3%
92.3%
99.6%
99.6%
99.6%
100%
100%
100%
100%
100%
97%
96%
97%
97%
0
0
0
0
82
79
161
Nov
92.2%
92.2%
92.2%
99.5%
99.5%
99.5%
100%
100%
100%
92%
100%
97%
100%
95%
100%
0
0
0
0
71
77
148
Dec
(8078/8880) (8321/9108) (8370/9094) (8335/8993) (8416/9153) (8510/9386 (8346/9041) (8345/9050)
)
90.1%
99.6%
99.6%
99.6%
100%
100%
100%
97%
100%
94%
96%
95%
97%
1
0
0
0
59
64
123
Jun
(8848/8880) (9072/9108) (9065/9094) (8963/8993) (9098/9153) (9328/9386 (9009/9041) (9011/9050)
)
99.6%
100%
100%
100%
98%
100%
98%
100%
97%
98%
97%
100%
98%
100%
0
0
0
0
61
70
131
May
0
0
0
0
54
78
132
Apr
100%
95%/ 92% Walsall
8a. Appropriate
No target Trust
admissions of Under
18s to Adult Ward
9. % of patients seen 95%/ 92% Trust
in 18 weeks Complete
/ incomplete
95% /92% Dudley
8. Inappropriate
admissions of under
18s to an adult ward*
1187
7. CRHT HT episodes *
(100/mth)
Target
KPI
92.2%
92.2%
92.2%
99.5%
99.5%
99.5%
100%
100%
100%
95%
100%
95%
99%
95%
99%
3
0
0
0
584
673
1257
YTD
Actual
RAG
49 of 182
3
Target
Loc
15. IAPT - completion
of outcome data PHQ9
and GAD7
14. IAPT - People
who have
successfully
completed
treatment
Dudley
Walsall
90%
90%
99.1%
59.2%
34.6%
507
99.1%
61.0%
50.8%
567
488
1055
Jun
98.0%
53.3%
53.6%
423
424
847
July
98.6%
52.0%
43.3%
418
379
797
Aug
96.0%
51.9%
37.5%
620
474
1094
Sept
94.8%
51.0%
52.5%
556
501
1057
Oct
93.0%
52.6%
56.3%
543
577
1120
Nov
97.5%
47.1%
60.3%
481
457
938
Dec
98.3%
100%
98.9%
99%
98.9%
99%
98.9%
97.0%
99.3%
97.7%
97.7%
93.8%
96.0%
93.3%
96.2%
90.0%
96.3%
98.1%
98.4%
97.3%
54.6%
49.7%
4693
4143
8836
YTD
Actual
96.4%
(334/337) (341/344) (328/331) (343/350) (276/280) (291/303) (343/362) (334/359) (318/326)
99.1%
Trust
90%
62.8%
Walsall
50.5%
50.8%
578
418
425
Dudley
Walsall
925
May
1003
Apr
50.5%
(480/mth)
5760
13. IAPT - number of 10585
Trust
people who receive
(882/mth)
psychological
4825
therapies - attending
Dudley
(402/mth)
one session only
KPI
RAG
50 of 182
4
Section 5
51 of 182
During December there were 21 alerts received from the Central Alert System.
Trust Summary of all Safeguarding and Vulnerable
Adults activityy
•
Section 4
Position on Previous Month
• Overall the total number of incidents has decreased by 1.3%
• Acute Service, has seen a decrease in the overall numer of incidents compared
to the previous month. Disruptive / Aggressive Behaviour remains the highest
reported incident category for this service.
• The Older Adults service line has seen a significant increase in the number of
Incidents reported compared to last month and compared to the last 12 months.
• Within this increase, there is a significant number of incidents relating the
Category of Disruptive / Aggressive Behaviour.
• There are also high levels of incidents relating to one specific ward area.
Individual Operational Service line Reports
dŚŝƐĚĂƐŚďŽĂƌĚŝƐŝŶƚĞŶĚĞĚƚŽŐŝǀĞĂŶŽǀĞƌǀŝĞǁŽĨƚŚĞĐĂƐĞƐƌĂŝƐĞĚŝŶƌĞƉĞĐƚƚŽ^ĂĨĞŐƵĂƌĚŝŶŐ
ĂŶĚsƵůŶĞƌĂďůĞĂĚƵůƚƐĂĐƚŝǀŝƚǇ͘ This shows the number raised and which service is considered
responsible. It also shows the nature of the alleged abuse and whether this has subsequently
been referred on to be reviewed further or passed for investigation.
• There has been 6 Serious incidents reported during December, the
figures have shown a slight increase on the previous month.
• 1 relates to Abscond / Failure to return from agreed leave.
• 2 are in relation to patients who have fallen, resulting in bone fractures.
• 2 relate to incidents of Serious Harming Behaviour
• 1 incident was in relation to an outbreak of Sickness & Diarrhoea
Serious Incidents & Embedding Lessons
Section 3
There have been 6 Serious incidents during December, this number has
Slightly increased when compared to the previous month
• Overall the total number of Incidents have decreased by 1.3% on the
previous month.
Key messages
Summary of Trust Incidents and Serious
Section 2
Governance Quality Report
Section 1
Summary of Trust Incidents and
Serious Incidents
Section 1
52 of 182
16
11
10
6
5
Acute
Recovery
E.I.
Community
Other
No.
Incidents
Older
Service Line
0 Never
Events
55 SIRS**
47.16% of incidents were Patient Safety
Incidents (141 of 29 incidents)
* SI: Serious Incidents
** SIRS: Security Incidents Reporting System
SIs*
29 INCIDENTS
REPORTED
to
Summary of Trust Incidents and Serious Incidents
Section 1
21
19
11
Serious Harming Behaviour
Access, Admission, Transfer
Medication
Ser
Ac
2
2
1
1
Infection Control Incident
Fire Incident
Skin Integrity
29 Total Incidents
Reported
3
Equipment
7
8
Documentation
Security
Consent, Communication And
10
22
Clinical Care, Assessment And MHA
Clin
Health & Safety
50
Patient Accident
Pat
142
No.
Incidents
DisDisruptive / Aggressive Behaviour
Cause Group
Governance Exception Report
:ĂŶƵĂƌǇ201ϱ
Incidents by Cause
Service Lines
Patient - Faint/ Fit / Unwell
3
Self Harm - Asphyxiation
Self Harm - Medication Overdose
3
28 Day Re-Admission
2
53 of 182
Failure To Return From Leave
1
3
3 incidents
3 incidents
6 incidents
2 incidents
4 incidents
5 incidents
10 incidents
Access, Admission, Transfer Discharge: Top Causes
Attempted Suicide - Medication Overdose
2
Serious Harming Behaviour: Top Causes
Clinical - Delay / None Referral
Death - Natural Causes/Expected
1
3
2
7 incidents
9 incidents
Clinical Care, Assessment And MHA: Top Causes
Clinical - Treatment / Care Related
9 incidents
Fall - Observed Fall Chair/Toilet
2
1
Fall - Unobserved Fall Mobilising Alone
1
11 incidents
13 incidents
Behavioural - Disruptive
Patient Accident: Top Causes
38 incidents
Physical Assault - Pt On Staff
2
3
59 incidents
Behavioural - Aggressive
Disruptive / Aggressive Behaviour: Top Causes
1
Section 2
Individual Operational Service line Reports
54 of 182
Chart 2.1 shows that Acute services incidents have fallen when compared to the
previous month. The total number of incidents for the month has fallen below the
12 monthly average figure.
The number of Disruptive /Aggressive Behaviour type incidents has fallen since the
previous month.
The figures show an increase in the number of Serious Harming Behaviour.
There has also been an increase the number of Access, Admission, Transfer
Discharge incidents from the previous month.
All other reporting categories remain at low levels.
1
1
2
Equipment
Skin Integrity
110
4
2
1
1
Consent, Communication And Confidentiality
Health & Safety
Documentation
Fire Incident
Grand Total
40
18
17
9
6
4
4
Current Month
Disruptive / Aggressive Behaviour
Access, Admission, Transfer Discharge
Medication
Patient Accident
Security
Incident Cause Group
129
0
1
0
2
3
3
1
Ð
Ï
Î
Ï
Ï
Ð
Ð
Î
Position on previous month
51
Ð
11
Ï
10
Ï
18
Ð
7
Ð
11
Ð
11
Ð
TTrend
d analysis
l i
Table 2.1
Total Acute incidents by Cause Group and showing a position on the previous months figures
•
•
•
•
•
Exceptions/Trends
The monthly (mean) average for incidents relating to Acute services (calculated using
data from the last 12 months) is 124.25
0
50
100
150
200
Apr-14
Mar-14
Feb-14
Jan-14
Last 12 months
12 Monthly Average
Mean - 2S.D.
Sep-14
Aug-14
Jul-14
Jun-14
May-14
110
162
10
6
5
3
Older
Recovery
E.I.
Community
Other
Incident
Numbers
Acute
Operational
Service Lines
3
10
5
20
133
129
Î
Ð
Ï
Ð
Ï
Ð
Position on
previous month
Table 1.1
All Operational Service Lines - showing a
position of total incidents against the
previous month
55 of 182
Patient B - This patient was briefly transferred onto one of the wards, and was involved in
several incidents of Disruptive / Aggressive Behaviour. This patient had severe underlying
health problems, and was subsequently transferred back to the Acute hospital. 2 weeks
post transfer staff were advised that this patient had sadly passed away.
Patient A - This patient has been involved in 18 incidents since admission in October 2014.
4 incidents of self harm during the last month. Following a recent case conferenc this
patient is now well enough to be discharged to an appropriate placement.
It is noted that of the 110 incidents for Acute Services there were 62 patients involved,
with no individual involved in high numbers or repeat types of incidents.
Acute Services - Incident comments
During the month there has been a decrease in the number of Disruptive /Aggressive
Behaviour type incidents this category has remained the most frequently reported type
of Incident.
The category of Serious Harming Behaviour has shown a slight increase, however apart
from one patient (A) who has been involved in 4 incidents of self harm, there are no other
trends in this area.
Acute
Mean + 2S.D.
Oct-14
Chart 2.1
Total Acute incident numbers received by the Trust during the last 12
Nov-14
2.1 - Acute Service Line
Dec-14
0
Older
Current
Month
98
42
10
5
2
1
0
2
0
1
0
1
0
0
162
Disruptive / Aggressive Behaviour
Patient Accident
Health & Safety
Security
Medication
Skin Integrity
Consent, Communication And Confidentiality
Equipment
Documentation
Fire Incident
Grand Total
12 Monthly Average
Mean + 2S.D.
20
Mean - 2S.D.
Trend analysis
Position on previous
month
67
Ï
41
Ï
10
Î
3
Ï
4
Ð
3
Ð
1
Ð
0
Ï
1
Ð
0
Ï
0
Î
1
Î
1
Ð
1
Ð
133
Ï
Last 12 months
0
10
30
40
50
60
70
80
Chart 2.3
Total Older Adults incident numbers
by ward / department, for the month
of December 2014
3
Other
89
90
3
10
5
20
133
129
100
Î
Ð
Ï
Ð
Ï
Ð
Position on previous
month
56 of 182
In a separate piece of work additional MAPA / Holding Skils training is being carried out in February to All
Older Adults Staff .
The ward currently has high numbers of patient, presenting with challenging behaviours. The Head of Older
Adults has agreed a meeting with medics and Senior Nursing staff at Bloxwich Hospital to look at the
increase in incident numbers and will look to identify some of the reasons behind this increase.
This month has seen and significant increase in the overall number of incidents within Older Adult Services,
with the service seeing an increase in the number of Disruptive aggressive behaviour type incidents.
Chart -2.3 provides a breakdown of the Older Adults total month incident figures , shown by ward /
department. This highlights that 89 out of the total 162 incidents for this service line, have been reported by
Linden ward. This is a significant increase for the ward and is one of the contributing factors for the increase
in the overall numbers for the Service.
Older Adults Services - Incident comments
Linden Ward
Malvern Ward
Holyrood
Cedars Ward
Birch Day Hospital
CMHTOP East
CMHTOP Central
Woodside (CMHTOP)
5
Community
Recovery
6
10
Older
E.I.
162
Acute
100
50
110
Operational
Service Lines
Incident
Numbers
Table 1.1
All Operational Service Lines - showing a position of
total incidents against the previous month
150
200
Chart 2.2
Total Older Adults incident numbers during the last 12 months
Table 2.2
Total Older Adults incidents by Cause Group and showing a position on the previous months figures
Exceptions/Trends
• Chart 2.2 shows that the Older Adult Services incident
numbers have significantly increased since the previous
month, and are above the 12 monthly average.
• The monthly figure has also risen above the standard deviation
line (+2) based on the average of the last 12 months.
• Disruptive /Aggressive Behaviour related incidents have shown
a significant increase since the last month and remains the
most reported incident category.
• The Number of patient accidents has remained at a similar
level to the previous month.
• All other reporting categories remain at low levels.
The monthly (mean) average for incidents relating to Older Adults
Services (calculated using data from the last 12 months) is 100.1
2.2 - Older Adults Service Line
Community Services -comments
ůůŝŶĐŝĚĞŶƚƐƌĞůĂƚĞƚŽŝŶĚŝǀŝĚƵĂůƐĞƌǀŝĐĞƐĂŶĚƚŚĞ
ŝŶĐŝĚĞŶƚƐŚĂǀĞŶŽƐƉĞĐŝĨŝĐƚƌĞŶĚ͘
Early Intervention Services -comments
ůůŝŶĐŝĚĞŶƚƐƌĞůĂƚĞƚŽŝŶĚŝǀŝĚƵĂůƐĞƌǀŝĐĞƐĂŶĚƚŚĞ
ŝŶĐŝĚĞŶƚƐŚĂǀĞŶŽƐƉĞĐŝĨŝĐƚƌĞŶĚ͘
ůůŽĨƚŚĞ other ŝŶĐŝĚĞŶƚƐƌĞůĂƚĞƚŽŝŶĚŝǀŝĚƵĂůƐĞƌǀŝĐĞƐ
ĂŶĚƚŚĞŝŶĐŝĚĞŶƚƐŚĂǀĞŶŽƐƉĞĐŝĨŝĐƚƌĞŶĚ͘
Recovery Services -comments
dŚĞϯDĞĚŝĐĂƚŝŽŶŝŶĐŝĚĞŶƚƐƌĞůĂƚĞƚŽƉƌĞƐĐƌŝƉƚŝŽŶ
ŝŶĐŝĚĞŶƚƐ͕ŽƵƚŽĨƚŚĞĐŽŶƚƌŽůŽĨdƌƵƐƚƐƚĂĨĨ͘
Recovery
• dŚĞŵŽŶƚŚůǇ;ŵĞĂŶͿĂǀĞƌĂŐĞĨŽƌŝŶĐŝĚĞŶƚƐƌĞůĂƚŝŶŐƚŽ
ZĞĐŽǀĞƌǇ^ĞƌǀŝĐĞƐ;ĐĂůĐƵůĂƚĞĚƵƐŝŶŐĚĂƚĂĨƌŽŵƚŚĞ
ůĂƐƚϭϮŵŽŶƚŚƐͿŝƐϮϰ͘
• ZĞĐŽǀĞƌǇ^ĞƌǀŝĐĞŝŶĐŝĚĞŶƚƐŚĂǀĞƐŚŽǁŶĂĚĞĐƌĞĂƐĞ
ĂŐĂŝŶƐƚƚŚĞƉƌĞǀŝŽƵƐŵŽŶƚŚ͘
Early Intervention
ĂƌůǇ/ŶƚĞƌǀĞŶƚŝŽŶ^ĞƌǀŝĐĞƐ;ĐĂůĐƵůĂƚĞĚƵƐŝŶŐĚĂƚĂ
ĨƌŽŵƚŚĞůĂƐƚϭϮŵŽŶƚŚƐͿŝƐϮϱ͘ϲϳ
• ĂƌůǇ/ŶƚĞƌǀĞŶƚŝŽŶ^ĞƌǀŝĐĞƐƐĂǁĂƐůŝŐŚƚŝŶĐƌĞĂƐĞ
ƐŝŶĐĞƚŚĞƉƌĞǀŝŽƵƐŵŽŶƚŚĂŶĚƐŝƚƐďĞůŽǁƚŚĞ
^ƚĂŶĚĂƌĚĚĞǀŝĂƚŝŽŶ
Community
ŽŵŵƵŶŝƚǇ^ĞƌǀŝĐĞƐ;ĐĂůĐƵůĂƚĞĚƵƐŝŶŐĚĂƚĂĨƌŽŵƚŚĞ
ůĂƐƚϭϮŵŽŶƚŚƐͿŝƐϭϮ͘ϴϯ
• ŽŵŵƵŶŝƚǇ^ĞƌǀŝĐĞƐƌĞƉŽƌƚĞĚϱŝŶĐŝĚĞŶƚƐĚƵƌŝŶŐƚŚĞ
ŵŽŶƚŚĂŶĚƐĂǁĂĚĞĐƌĞĂƐĞƐŝŶĐĞƚŚĞƉƌĞǀŝŽƵƐ
ŵŽŶƚŚ͘
0
10
20
ϯϬ
40
50
ϲϬ
Early Intervention
0
5
1
10
15
1
2
20
2
25
Mar-14
Feb-14
Jan-14
Aug-14
Jun-14
:ƵůͲϭϰ
DĂǇͲϭϰ
Mar-14
ƉƌͲϭϰ
KĐƚͲϭϰ
^ĞƉͲϭϰ
Feb-14
Jan-14
ŝƐƌƵƉƚŝǀĞͬŐŐƌĞƐƐŝǀĞĞŚĂǀŝŽƵƌ
ůŝŶŝĐĂůĂƌĞ͕ƐƐĞƐƐŵĞŶƚŶĚD,
DĞĚŝĐĂƚŝŽŶ
^ĞƌŝŽƵƐ,ĂƌŵŝŶŐĞŚĂǀŝŽƵƌ
,ĞĂůƚŚΘ^ĂĨĞƚǇ
ŽŶƐĞŶƚ͕ŽŵŵƵŶŝĐĂƚŝŽŶŶĚŽŶĨŝĚĞŶƚŝĂůŝƚǇ
WĂƚŝĞŶƚĐĐŝĚĞŶƚ
ĐĐĞƐƐ͕ĚŵŝƐƐŝŽŶ͕dƌĂŶƐĨĞƌŝƐĐŚĂƌŐĞ
^ĞĐƵƌŝƚǇ
Documentation
ƋƵŝƉŵĞŶƚ
&ŝƌĞ/ŶĐŝĚĞŶƚ
^ŬŝŶ/ŶƚĞŐƌŝƚǇ
/ŶĨĞĐƚŝŽŶŽŶƚƌŽů/ŶĐŝĚĞŶƚ
Grand Total
DĂǇͲϭϰ
Jun-14
ƉƌͲϭϰ
Dec-14
>ĂƐƚϭϮ
Current
Month WƌĞǀŝŽƵƐŵŽŶƚŚ ŵŽŶƚŚƐ
1
ϵ
Ð
2
4
Ð
ϯ
ϯ
Î
0
0
Î
2
1
Ï
0
2
Ð
2
0
Ï
0
1
Ð
0
0
Î
0
0
Î
0
0
Î
0
0
Î
0
0
Î
0
0
Î
10
20
Ð
ZĞĐŽǀĞƌǇ
dƌĞŶĚĂŶĂůǇƐŝƐ
Jan-14
Dec-14
EŽǀͲϭϰ
^ĞƉͲϭϰ
KĐƚͲϭϰ
Aug-14
:ƵůͲϭϰ
ĂƌůǇ/ŶƚĞƌǀĞŶƚŝŽŶ
ĂƌůǇ
/ŶƚĞƌǀĞŶƚŝŽŶ
Current WƌĞǀŝŽƵƐŵŽŶƚŚ >ĂƐƚϭϮ
Month
ŵŽŶƚŚƐ
ϯ
2
Ï
0
1
Ð
0
0
Î
0
1
Ð
2
0
Ï
0
0
Î
0
0
Î
0
0
Î
1
0
Ï
0
1
Ð
0
0
Î
0
0
Î
0
0
Î
0
0
Î
6
5
Ï
Community
^ĞƉͲϭϰ
KĐƚͲϭϰ
ƉƌͲϭϰ
Feb-14
57 of 182
ŽŵŵƵŶŝƚǇ
Žŵŵ
Current WƌĞǀŝŽƵƐŵŽŶƚŚ >ĂƐƚϭϮ
Month
ŵŽŶƚŚƐ
0
2
Ð
0
2
Ð
0
0
Î
1
1
Î
0
0
Î
1
0
Ï
1
2
Ð
2
1
Ï
0
0
Î
0
1
Ð
0
0
Î
0
0
Î
0
0
Î
0
0
Î
5
9
Ð
Jun-14
ϯ
ϯϬ
DĂǇͲϭϰ
70
Mar-14
EŽǀͲϭϰ
Table 2.3
dŽƚĂůZĞĐŽǀĞƌǇ͕ĂƌůǇ/ŶƚĞƌǀĞŶƚŝŽŶΘŽŵŵƵŶŝƚǇŝŶĐŝĚĞŶƚƐďǇĂƵƐĞ'ƌŽƵƉĂŶĚƐŚŽǁŝŶŐĂƉŽƐŝƚŝŽŶŽŶƚŚĞƉƌĞǀŝŽƵƐŵŽŶƚŚƐĨŝŐƵƌĞƐ
0
5
10
15
20
25
ϯϬ
ϯϱ
40
Recovery
:ƵůͲϭϰ
45
Aug-14
2.3 - ŽŵďŝŶĞĚ^ĞƌǀŝĐĞ>ŝŶĞƌĞƉŽƌƚ͗
ZĞĐŽǀĞƌǇ͕ĂƌůǇ/ŶƚĞƌǀĞŶƚŝŽŶΘŽŵŵƵŶŝƚǇ
EŽǀͲϭϰ
Dec-14
Section 3
Serious Incidents
58 of 182
13/12/2014
15/12/2014
19/12/2014
20/12/2014
2014/40935
2014/41025
2014/41645
2014/41717
Ops - Older Adults
Ops - Acute Services
Ops - Older Adults
Service Line
Linden Ward
Ambleside
Kinver ward
Linden Ward
Psychiatric Liaison Team - Dudley
Langdale Ward
Service Area
Fall and Fracture
Sickness & Diarrhoea (Untested)
Fall and Fracture
Failure To Return From Leave
Incident Description
•
•
•
•
•
•
2014/39623 - This patient was on leave and failed to return within the agreed time, patient considered low risk
2014/40922 - A patient known to our service was admitted onto the ward following an overdose, this has also been raised as a
Safeguarding case with concerns of Domestic Abuse.
2014/40935 - A patient fell whilst mobilising alone, resulting in a fractured hip. All appropriate risk assessments.
2014/41025 - This incident was in relation to an outbreak of Sickness & Diarrhoea - affecting 17 people ; 10 patients, 7 staff. 2
samples were taken and tested negative for suspected Norovirus. The ward was closed to admissions and transfers between
18th - 26th Dec.
2014/41645 - A patient had returned from home leave and reported to staff that they had taken an Overdose.
2014/41717 - This patient had a history of falls and agitated behaviours. The patient fell whilst wearing hip protectors and
substainial a hip fracture.
Commentary
Exceptions/Trends/Actions Taken
The monthly (mean) average for serious incidents across the Trust (calculated using data from the last 12 months) is 5.1
• The number of Serious Incidents has slightly increased since the previous month.
• During this month there were 6 Serious Incidents, all of which are being investigated as level 1 clinical reviews.
• Of the 4 Serious incidents relating to the Acute Service; 2 of the incidents were incidents of Harming Behaviour 1 was in
relation to a patient who failed to return from agreed leave, the other incident was in relation to Sickness and Diarrhoea on a
ward.
• Both Older Adults Incidents relate to patients who had falls resulting in bone fractures. Both reported from Linden Ward.
02/12/2014
12/12/2014
2014/39623
Date of Incident
2014/40922
SI Number
Table 3.1
List of Serious Incident raised during the month of January 2015
Level 1 Clinical Review
Level of response
13%
24%
%
2%
56%
Clinical Care And Assessment
Patient Accident
serious Harming Behaviour
0
2
4
6
8
10
Serious Incidents
Mean + 2S.D.
59 of 182
Trust Average
Mean - 2S.D.
Chart 3.2
Total number of Serious Incidents during the last 12 months
5%
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Current status
Chart 3.1
Summary of the Serious Incident types during the last 12 months
Moderate Risk
Moderate Risk
Moderate Risk
Moderate Risk
Moderate Risk
Moderate Risk
Level of Risk
Section 4
National Guidance:
Safety Alert Broadcasts (SAB's)
60 of 182
x
x
Action not
Required
5
2
1
0
10
0
0
18
Assessing
Relevance
0
0
0
0
0
0
0
0
Action
Required
0
0
0
0
0
0
2
2
Circulated for
Information
0
0
1
0
0
0
0
1
61 of 182
NHS/PSA/W/2014/016R – The alert was issued in relation to “Risk of death and serious harm from accidental ingestion of
potassium permanganate preparations”. Identify if potassium permanganate preparations are used in our organisation and if
accidental ingestion has or could occur”. The alert has been circulated to team managers for sharing with staff and the Trusts
Pharmacy department are also fully aware of this.
The table below (4.2) outlines a summary of the alerts issues and any action taken.
During December 2014 there were 21 alerts issued via the Central Alerting System, of these 21 alerts:
o 18 alerts required no formal action taking by the organisation
o 1 alert required circulating for information. This alert was in relation to Whe most recent surveillance data which indicated that there is
now a substantial likelihood that people presenting with an influenza-like illness are infected with an influenza virus and that GPs can
now prescribe at NHS expense, antiviral medicines for the prophylaxis and treatment of influenza, in accordance with NICE guidance
and Schedule 2 to the National Health Service
o 2 alerts required action taking. This was alerts:
NHS/PSA/W/2014/017 – The alert was issued in relation to “Risk of death and serious harm from delays in recognising and treating
ingestion of button batteries”. The alert required the Trust to Ldentify if delay in recognising and treating ingested button batterieshas
occurred, or could occur, in our organisation and to Consider if immediate action needs to be taken locally and develop anaction
plan. Upon reviewing evidence available, the Trust has no history of patients ingesting button batteries as no incidents inrelation to
this have ever been reported via the Trusts incident reporting system. However the alert has been circulated to staff viaHeads of
Service and Team Managers and has requested that managers remain mindful of this issue and report any potential risksthey may
identify to the Clinical Governance Department. Furthermore team managers have been requested to share this alert withstaff.
Type of Alert
MDA
MHRA
CMO
DDL
EFN
DH – EFA
NHS – PSA
Total
Number of
Alerts in
December
5
2
2
0
10
0
2
21
Table 4.1 – Summary of Alerts received during December 2014
CAS Alerts
January 2015
Alert
Date
01-Dec2014
02-Dec2014
03-Dec2014
03-Dec2014
05-Dec2014
08-Dec2014
17-Dec2014
17-Dec2014
17-Dec2014
17-Dec2014
Alert
Number
EFN/2014/49
EFN/2014/50
EL (14)A/18
MDA/2014/045
MDA/2014/045
R
MDA/2014/046
CEM/CMO/20
14/008
EFN/2014/51
CEM/CMO/20
14/008R
EFN/2014/52
High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - GEC Alsthom - Saturn RT Ring Main Unit
Influenza Season 2014/15 - Use of antiviral medicines
High Voltage Hazard Alert -DANGEROUS INCIDENT NOTIFICATION (DIN) - CG Power Systems - Pole
Mounted 11 kV Transformers
Drug alert class 4, caution in use, Fannin (UK) limited, heparin sodium 100iu/ml I.V. flush solution
There is an error on carton labels. The text on all faces of the carton states that the product is preservative
free whereas the product actually contains three preservative excipients, including benzyl alcohol.
Central venous catheters: Multicath Expert 5 lumen (9.5FG/16cm) Manufactured by Vygon. Product code:
8159.167 Lot/batch number: 020414GE
Risk of incorrect placement of catheter and delay to treatment.
This is due to a manufacturing problem resulting in:
x Decreased length of the catheter. The catheter tip may not reach the desired position during placement
x Catheters with four lumens (instead of five). This may then require additional catheter or extension sets
after placement
Central venous catheters: Multicath Expert 5 lumen (9.5FG/16cm) Manufactured by Vygon. Product code:
8159.167 Lot/batch number: 020414GE
Risk of incorrect placement of catheter and delay to treatment.
This is due to a manufacturing problem resulting in:
x Decreased length of the catheter. The catheter tip may not reach the desired position during placement
x Catheters with four lumens (instead of five). This may then require additional catheter or extension sets
after placement
Toshiba ultrasound transducers All models
Counterfeit ultrasound transducers have been supplied to 2 hospitals.
These devices may not meet the performance specified by Toshiba. There have been no reports of patient
harm.
Influenza season 2014/15 - use of antiviral medicines
High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - CG Power Systems 11kV/0.433 kV Transformer
High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - English Electric - E7 - Circuit
Breaker
Description of Alert
Table 4.2 –Alerts issued during October via the Central Alerting System
January 2015
Circulated
for
information
Action Not
Required
Action Not
Required
Action not
required
Action Not
Required
Action Not
Required
Action Not
Required
Action not
required
Action Not
Required
Action Not
Required
Status
62 of 182
The Trusts authorising officer acknowledged
receipt of the alert and that no action was required
by the Trust
No action was required in relation to this particular
alert as this alert was superseded by alert
CEM/CMO/2014/008R
by the Trust
The alert was circulated for information in line
with the requirements of the alert
The Trust does not have any of these particular
devices
The Trust had no history of having purchased any
of these particular items.
No action was required in relation to this particular
alert. Superseded by Alert MDA/2014/045R
by the Trust
by the Trust
No action was required in respect to this particular
alert
Notes / action taken / assurance
Alert
Date
17-Dec2014
18-Dec2014
18-Dec2014
18-Dec2014
19-Dec2014
22-Dec2014
22-Dec2014
23-Dec2014
23-Dec2014
23-Dec2014
23-Dec2014
Alert
Number
MDA/2014/047
EL (14)A/19
MDA/2014/048
EFN/2014/53
NHS/PSA/W/2
014/017
EFN/2014/54
NHS/PSA/W/2
014/18
EFN/2014/55
EFN/2014/56
EFN/2014/57
EFN/2014/58
Low Voltage Hazard Alert - SUSPENSION OF OPERATIONAL PRACTICE (SOP) - Landis & Gyr - ZMB 127
- Three Phase whole current meter
High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - Schneider
Electric/Merlin Gerin - CE2 - Ring Main Unit
High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - Groupe
Schneider/Merlin Gerin - RN2 - Ring Main Unit
High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - Ferranti - 11/0.433 kV 1000
kVA Transformer
Risk of death and serious harm from accidental ingestion of potassium permanganate preparations
High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - Merlin Gerin - CE2 Circuit Breaker
Risk of death and serious harm from delays in recognising and treating ingestion of button batteries
Autopen insulin pen injection devices. Manufacturer: Owen Mumford.
Risk of hyperglycaemia, which could lead to immediate and long-term deterioration of health.
Affected devices may have a mechanical fault which could cause the dose selector to revert to zero resulting
in the devices not delivering the correct dose of insulin
Drug alert, class 2, action within 48 hours, Lundbeck limited, Ebixa 5mg/pump actuation 50ml and 100ml
bottles.
Recall of specific batches because of a fault with some of the pump devices which may result in suboptimal
dosage of the product.
IW900-series infant warmers. Manufactured by Fisher and Paykel Healthcare. Specific model and lot
numbers are affected.
Risk of serious injury to the infant in the warmer
The heater head may partially detach due to a manufacturing fault where the nut securing the heater head
may break.
High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - Schneider Electric - RE2c Ring Main Unit
Description of Alert
January 2015
Action Not
Required
Action Not
Required
Action Not
Required
Action Not
Required
Action
Complete
Action
Complete
Action Not
Required
Action Not
Required
Action Not
Required
Action Not
Required
Action Not
Required
Status
63 of 182
by the Trust
by the Trust
by the Trust
by the Trust
by the Trust
The alert was reviewed and action has been
taken accordingly
by the Trust
The alert was reviewed and action has been
taken accordingly
The Trust does not have any of these particular
devices
Neither pharmacy at Russells Hall and Walsall
Manor were affected by this particular alert
The Trust had no history of having purchased any
of these particular items.
Notes / action taken / assurance
dŚŝƐĚĂƐŚďŽĂƌĚŝƐŝŶƚĞŶĚĞĚƚŽŐŝǀĞĂŶŽǀĞƌǀŝĞǁŽĨƚŚĞĐĂƐĞƐƌĂŝƐĞĚŝŶƌĞƉĞĐƚƚŽ^ĂĨĞŐƵĂƌĚŝŶŐĂŶĚsƵůŶĞƌĂďůĞĂĚƵůƚƐ
ĂĐƚŝǀŝƚǇ͘dŚŝƐƐŚŽǁƐƚŚĞŶƵŵďĞƌƌĂŝƐĞĚĂŶĚǁŚŝĐŚƐĞƌǀŝĐĞŝƐĐŽŶƐŝĚĞƌĞĚƌĞƐƉŽŶƐŝďůĞ͘/ƚĂůƐŽƐŚŽǁƐƚŚĞŶĂƚƵƌĞŽĨƚŚĞ
ĂůůĞĚŐĞĚĂďƵƐĞĂŶĚǁŚĞƚŚĞƌƚŚŝƐŚĂƐƐƵďƐĞƋƵĞŶƚůǇďĞĞŶƌĞĨĞƌĞĚŽŶƚŽďĞƌĞǀŝĞǁĞĚĨƵƌƚŚĞƌŽƌƉĂƐƐĞĚĨŽƌŝŶǀĞƐƚŝŐƚŝŽŶ͘
Section ϱ
Trust Summary of all Safeguarding and
Vulnerable adults activity
64 of 182
Grand Total
1
1
Child
Parental Mental Health Concerns (Child)
Alert only
Case Type
Referred
7
5
2
Alert only
1
1
1
1
Referred
Community
Alert only
1
1
E.I.
2
1
1
Older
0
Alert only
Acute
Referred
0
Recovery
Table 5.1.3 This shows the total number of Safeguarding Children cases broken down by
service line, showing Case type and number of incidents and status.
Table 5.1.3
This shows information as in table 1.2 but shows this information broken down by Service line
• 16 cases in total were raised across the trust during December
Table 5.1.1
This shows that the number of Safeguarding 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. 1 case has been referred within Dudley ; 11 within Walsall.
There are no noted trends to the child safeguarding alert figures.
Graph 5.1.1
This graph provides information relating to the last 12 months and shows a breakdown of Safeguarding
cases which are just for alert and those which have been progressed to the continue under Safeguarding
Commentary
Section 5.1 - Safeguarding Children activity
Referred
1
1
3
2
4
11
0
5
10
15
20
25
30
35
Jul
2014
Jan Feb Mar Apr May Jun
65 of 182
Aug Sep Oct Nov Dec
Graph 5.1.1 - Total number of Safeguarding Children incidents reported during
the last 12 months
1
Referral
Alert
16
0
Grand Total
0
8
8
Under 18 Death
6
5
Grand
Total
Under 18 Admission
1
Parental Mental Health
Concerns (Child)
1
3
0
Walsall
Dudley
Child
Table 5.1.1 Total number of Safeguarding
Children cases for the current month,
showing case type and broken down by
locality , and showing current status
Referral
January 2015
Alert only
Alert Only
Referral
Section 5 - Trust Summary of all Safeguarding Activity
Referred
Alert Only
January 2015
0
10
20
30
40
50
60
70
80
Jan
Feb
Mar
Apr
May
Jul
2014
Jun
Aug
Sep
Oct
Nov
Dec
Referral
Alert
Adult
Patient Considered High Risk
Position Of Trust (Adult)
Domestic Homicide Review
Grand Total
14
1
20
19
14
13
11
1
1
65
2
1
1
69
Grand
Total
66 of 182
22
21
1
Walsall
Dudley
Referral
Table 5.2.2
Total number of Vulnerable Adults incidents for the current month,
showing case type, number of incidents and status.
Alert Only
Referral
Graph 5.2.1 Total number of Vulnerable Adults incidents reported during the Last 12 Months
Commentary
Graph 5.2.1
This graph provides information relating to the last 12 months and shows a breakdown of Vulnerable Adults Cases which are just for alert and those which have been progressed to be continue under
Safeguarding
• There has been a slight reduction in the number of cases reported since the previous month.
Table 5.2.2
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 .
• There has bee a slight reduction in the number of cases reported, this is in contrast to an increase in the number of Older Adults Incidents; however these incidents appear to be Aggression aimed towards
staff and therefore no significant Safeguarding concerns in relation to patient Vulnerability or aggression toward other patients.
Section 5.2 - Vulnerable Adults activity
Alert Only
January 2015
0
0
2
0
7
7
1
1
7
7
0
1
1
2
2
Jun
2
1
1
3
2
5
Jul
0
Aug
2
2
2
1
1
Sep
2
1
1
2
2
4
Oct
Table 5.2.3
Domestic abuse cases are now being 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.
• The second table provides information on Domestic Abuse cases which have been
reported internally into our Trust
Table 5.2.1
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 9 active Cases of DoL's.
• 5 In Dudley and
• 4 In Walsall
Commentary
1
0
Total Active Case
1
DOL's Closed
DOL's Active
Walsall
4
3
2
2
1
May
DOL's Closed
2
Apr
1
4
2
Mar
DOL's Active
Dudley
Feb
Jan
2014
0
1
1
Nov
9
21
4
25
19
5
24
Grand Total
80
N/A
10
December 2014 - Safeguarding Cases Internally
reported as Domestic Abuse
Alert Only
Referral
DART
MARAC
Dudley
Open To Mental
Cases Checked
Health
10
4
Dec
1125
121
67 of 182
56
12
Walsall
Open To Mental
Cases Checked
Health
Table 5.2.3
Total number of cases of Domestic Abuse for the current month, these include cases
reported within the Trust and Externally notified by MARAC (Multi-Agency Risk Assessment
Conference)
2
2
2
4
Dec
Table 5.2.1
Deprivation Of Liberties (DOL's) - This shows the total number of active cases of DOL's, broken down by Locality
Section 5.2 - Vulnerable Adults activity
68 of 182
2014/15 DWMHPT Finance Report Month 9
69 of 182
Key Messages
Overall Summary and RAG Assessment
Trust Income Statement: Functional Analysis
Capital Programme
Financial Performance Metrics
TDA Key Financial data: Month 9
Cash Flow Statement
Debtor and Creditor Performance
Cost Improvement Target Achievement
Statement of Financial Position (Balance Sheet)
•
•
•
•
•
•
•
•
•
•
2014/15 DWMHPT Finance Report Month 9
70 of 182
16
15
14
13
12
11
10
6-9
4-5
3
Page
Bank, Agency and Locum spend
continues to receive close
management
Income – 2014/15 outturn
CIP plans delivered for 2014/15
Financial Position
Key Messages
In Medical Services there are 12.50 wte high cost agency locums.
•
71 of 182
The level of expenditure on temporary Nursing pay in both Acute and Older Adults services saw a small
reduction in December with the exception of one Older Adult ward where a number of issues combined to
result in a significant increase in expenditure.
•
The activity in the Detox beds at Bushey Fields now have a regular stream of patients, but it is not expected to
achieve the planned levels of activity to deliver the income target and there is forecast to be an under recovery
against budget of £100k in 2014/15.
•
The full year effect of the schemes being implemented is £2,098k.
•
The Trust has continued to under perform against the NCA income and it is likely that there will be an under
recovery of £60k against plan
As at Month 09 approximately £1.9 million of savings have been identified.
•
•
The Trust’s Cost Improvement Target for the year is £2,087k.
This is £251k ahead of the planned surplus for the year to date.
•
•
The Trust has delivered a year to date surplus in Month 09 of £795k.
•
64,486
Total Revenue
67
(4)
0
71
67
(0)
0
0
(4)
0
0
(4)
19
292
(46)
192
(19)
(4)
808
71
0
4
(108)
172
(21)
(137)
330
(5,032)
(630)
0
200
(158)
(401)
(23)
(13)
5
(6)
(15)
4
(10)
(10)
0
Technical Surplus
808
0
3
(108)
176
(21)
(137)
334
(5,050)
9
(4,443)
5,361
226
48
28
125
26
5,135
203
4,932
£000
Variance
Technical Adjustment
Net Surplus /(Deficit)
0
P/L Disposal
2,069
(1,301)
Net Operating Surplus
PDC
40
(246)
Interest Receivable
(1,311)
(60,860)
Depreciation
(11,047)
Other Costs
Total Operating Expenditure
Amortisation
741
CIP Target
3,626
(923)
(261)
EBITDA
46
(1,930)
Clinical Supplies and Services
Expenditure Reserves
(140)
(48,363)
(4,043)
5,385
239
43
34
140
22
Pay
Expenditure
522
2,740
246
Revenue NHS Non-Clinical
Total Other Operating Revenue
1,671
Revenue-Education & Training
Other Revenue
301
Revenue-Employee Benefits
Other Operating Revenue
214
2,564
61,746
Revenue-Non NHS Clinical
Total Revenue From Activities
5,146
4,932
£000
Actual
Plan
£000
Plan
£000
59,182
Revenue-NHS Clinical
Revenue From Activities
Income
In Month
Annual
Plan
544
544
0
30
(976)
1,490
(183)
(989)
2,662
(45,715)
(8,270)
603
(488)
(1,421)
(36,138)
48,377
2,067
394
170
1,269
234
46,310
1,923
44,387
£000
795
0
795
67
33
(976)
1,671
(183)
(989)
2,843
(45,470)
(8,044)
0
(308)
(1,357)
(35,761)
48,314
2,196
418
165
1,313
300
46,118
1,755
44,363
£000
Actual
Year To Date
Statement of Comprehensive Income - Financial Position to 31th December 2014
Overall Summary and RAG Assessment
251
0
251
67
3
0
181
0
0
181
246
226
(603)
180
64
378
(63)
129
24
(5)
44
66
(192)
(168)
(24)
£000
Variance
This achieves a Monitor metric of 3.90 for the year end
position, against a plan for the year of 3.70.
Key message – The Trust is ahead of plan to achieve its
planned annual surplus of £808k.
•
•
Most CIP targets been devolved to the appropriate
management levels and slippage is covered by reserves.
The Trust’s cash balance has seen a small reduction from
£14,798k at the end of Month 08 to £14,705k at the end of
Month 09.
•
72 of 182
Total capital expenditure to the end of month 09 was £751k.
Capital
•
Cash
•
CIP 2014/15 Delivery
The Trust is reporting a Month 09 surplus £795k, which is
£251k ahead of plan.
•
Revenue Position
Commentary
£'000
CIP Target
Transacted
part year
effect
Transacted
full year value
900
800
700
600
500
400
300
200
100
0
0
1,000
2,087
1,799
2,098
£'000
2,000
CIP 2014/15
Run Rate 2014/15
3,000
Actual Run
Rate
Cumulative
Budgeted
Planned Run
Rate
Overall Summary and RAG Assessment Continued
£'000
0
500
1,000
1,500
2,000
2,500
3,000
73 of 182
Capital Programme 2014/15
Cumulative
Actual Spend
Cumulative
Planned Spend
61,746
Total Revenue from Activies
Corporate Departments
(12,746)
(47,175)
(59,677)
Medical Services
Total Operational Services
Total Expenditure
40
808
0
Technical Surplus
808
Technical Adjustment
(1,301)
Net Surplus/(deficit)
PDC Dividend
Interest Receivable
2,069
(15,727)
Total Community Services
Sub Total
(18,702)
(12,502)
(261)
Total Acute & Older Adults
Operational Services
Total Corporate Functions
Central Reserves
(12,241)
2,564
Revenue from LAs
Corporate Functions
59,182
71
0
71
(108)
3
176
(4,969)
(3,923)
(1,047)
(1,314)
(1,563)
(1,046)
9
(1,055)
5,145
214
4,932
£'000
£'000
NHS Revenue-Activities
Actual
2014/15
4
67
67
(108)
(4)
(4)
0
0
(4)
6
(4,963)
172
4
(4)
2
6
2
192
(190)
(10)
(10)
0
£'000
Variance
(3,919)
(1,051)
(1,311)
(1,557)
(1,044)
200
(1,244)
5,135
203
4,932
£'000
In Month
Plan
Annual Plan
543
0
543
(976)
30
1,489
(44,821)
(35,170)
(9,420)
(11,787)
(13,963)
(9,651)
(488)
(9,163)
46,310
1,923
44,387
£'000
Plan
795
795
(976)
33
1,738
(44,373)
(34,554)
(9,342)
(11,810)
(13,401)
(9,819)
(308)
(9,512)
46,111
1,755
44,356
£'000
Actual
Year to Date
251
0
251
0
3
249
448
616
78
(23)
562
(169)
180
(349)
(198)
(168)
(31)
£'000
Variance
0
0
0
0
(0)
0
255
862
154
43
665
(607)
(259)
(348)
(255)
(218)
(37)
£'000
Var
FOT M09
•
•
•
•
•
•
•
74 of 182
The forecast outturn is in line with plan.
Expenditure on in-patient services has
reduced in recent months.
Additional expenditure may be incurred as
services take action to address the under
performance on some activity lines.
MARs payments of over £840k have been
incurred and are being managed in the
position at present.
There continues to be cost pressures in
corporate areas in Estates and
Performance and IT.
There are risks around relating to non NHS
income: slippage on detox beds, non
recovery of out of areas SMS activity and
under performance against NCAs.
The Trust is reporting a surplus to Month 09
of £795k, which is £251k ahead of plan.
Commentary
Trust Summary Income & Expenditure Statement Including Functional Analysis
9
10
24
34
9
10
1
4
2,078
288
403
32
105
123
3
232
17
Sandwell & West Birmingham CCG
Wolverhampton CCG
Birmingham Cross City CCG
Birmingham South Central CCG
South East Staffs & Seisdon CCG
Cannock Chase CCG
Stafford & Surrounds & E Staffs CCGs
Total Staffs CCGs
Redditch & Bromsgrove CCG
115
303
1,384
59,182
NCAs
CAMHs Deaf
Total NHS Revenue-Activities
20
12
205
0
0
2,564
61,746
Stafford MBC
Detox Beds
Dudley CRI
NCA - Other HC
Total Revenue from LAs
Total Revenue from Activies
87
Wolverhampton MBC
10
120
Dudley MBC
Sandwell MBC
5,145
214
0
0
17
1
2
7
177
4,932
(3)
2,118
Walsall MBC
Revenue - Local Authorities
25
(30)
Budget for Under Recovery
6
51
68
Wyre Forrest CCG
Total Worcester CCGs
19
0
3
173
0
5,135
203
0
0
17
0
0
0
10
177
4,932
115
22
0
6
4
1
19
0
3
34
24
173
0
2,282
0
NHS Walsall
2,282
27,378
Walsall CCG
2,254
27,048
2,254
£'000
£'000
Dudley CCG
Revenue From NHS Activities
Actual
2014/15
£'000
In Month
Plan
Annual Plan
Trust Income Statement – Income
(10)
(10)
0
0
(0)
(1)
(2)
(7)
0
0
0
0
(3)
3
0
0
0
0
(0)
0
0
0
0
(0)
(0)
0
(0)
(0)
£'000
Variance
46,310
1,923
0
0
154
9
15
66
90
1,589
44,387
1,038
228
(23)
51
38
13
174
3
92
79
24
302
216
1,558
0
20,534
20,286
£'000
Plan
46,111
1,755
1
0
64
0
0
10
90
1,589
44,356
1,038
181
(7)
51
38
13
174
3
92
79
24
302
216
1,558
0
20,534
20,286
£'000
Actual
Year to Date
(199)
(168)
1
0
(89)
(9)
(15)
(55)
(0)
0
(31)
0
(47)
16
0
0
0
0
(0)
0
0
0
0
(0)
(0)
0
(0)
0
£'000
Variance
(255)
(218)
1
0
(100)
(12)
(20)
(87)
0
0
(37)
0
(60)
23
0
0
0
(0)
(0)
0
0
(0)
(0)
(0)
0
0
0
0
£'000
Var
FOT M09
•
•
•
75 of 182
The level of NCA activity has not achieved
that seen in 2013/14 and it is forecast that
there will be a £60k under recovery against
the target in 2014/15.
Month 09 total activity has fallen compared
to that seen in months 07 and 08. It is
forecast that this will recover in Months 10
to 12.
The Trust has negotiated block contract
agreements with its host and neighbouring
CCGs, which reduces the risk of in year
loss of income, but equally this limits the
scope for over performance.
Commentary
(842)
(951)
(1,465)
(1,152)
(2,603)
(1,816)
(1,223)
(2,190)
(12,241)
Corporate Affairs
Corporate Human Resources & Dev.
& People
Corporate Medical
Corporate Estates
Corporate Operations
Corporate Finance
Corporate Performance & IT
Total Corporate Functions
(240)
(96)
(167)
(264)
(125)
(130)
(117)
(104)
£'000
(190)
(32)
3
(16)
(47)
(28)
(4)
(33)
(33)
£'000
Actual Variance
In Month
(1,055) (1,244)
(209)
(100)
(151)
(217)
(97)
(127)
(84)
(70)
£'000
£'000
Chief Executive
Corporate Functions
Plan
2014/15
Annual Plan
(9,163)
(1,646)
(924)
(1,362)
(1,952)
(864)
(1,085)
(699)
(630)
£'000
Plan
(9,512)
(1,778)
(854)
(1,339)
(2,222)
(910)
(1,059)
(708)
(642)
£'000
Actual
(349)
(132)
70
24
(270)
(46)
26
(9)
(11)
£'000
Variance
Year to Date
Trust Income & Expenditure Statement- Corporate Functions
(348)
(189)
94
33
(268)
(63)
23
27
(5)
£'000
Var
FOT M09
•
•
76 of 182
Corporate Estates – The
delayed delivery of CIP Plans
is creating financial risk for
the Estates budgets.
Proposals are in place for
savings through external
contracts across the Trust but
continue to slip further into
the financial year.
OASIS Server dual-running
has had a negative impact on
the IT and Performance
outturn for the year. The
server has to run in parallel
to the existing server for a
period due to testing.
Commentary
(1,563)
(2,689)
(6,558)
(18,702)
Acute Estates
Older Adults
Total Acute & Older
Adults
(15)
(262)
(1,314)
(217)
(4,242)
(7,362)
(3,149)
(15,727)
(12,746)
(47,175)
Community Services
Early Intervention
Recovery Services
Total Community
Services
Medical Services
Total Operating Services
(3,923)
(1,047)
(621)
(352)
(63)
(756)
(228)
Community Estates
Management and
Administration
Community Services
(543)
(8,411)
Acute Services
(703)
(1,044)
(89)
£'000
£'000
Acute and Older Adults
Management and
Administration
Operational Services
Plan
2014/15
Annual Plan
(3,919)
(1,051)
(1,311)
(245)
(636)
(349)
(14)
(67)
(1,557)
(551)
(220)
(693)
(92)
£'000
4
(4)
2
17
(15)
2
1
(4)
6
(8)
8
10
(3)
£'000
Actual Variance
In Month
(9,342)
(35,170) (34,554)
(9,420)
616
78
(23)
(11,787) (11,810)
(38)
(15)
9
(17)
37
(5,538)
(3,201)
(161)
(585)
(2,325)
(2,362)
(5,500)
(3,187)
(171)
(567)
562
(13,963) (13,401)
10
418
160
£'000
Variance
(25)
(2,003)
(5,831)
(617)
£'000
Actual
(4,951)
(4,925)
(2,013)
(6,248)
(776)
£'000
Plan
Year to Date
862
154
43
12
17
22
13
(21)
665
(58)
3
509
211
£'000
Var
FOT
M09
Trust Income & Expenditure Statement-Operational Services
•
•
•
•
•
77 of 182
Acute & Older Adult services underspent by £31k in
December, which was less than forecast, but the current
month’s figures include £25k of November agency
nurses costs (mainly DPH wards) which had been
omitted from AVA booking reports when Month 8
accounts were prepared, reducing the reported inmonth underspend to £6k. The £31k underspend mainly
relates to a vacancy underspend on the Acute wards,
and acute psychologist posts. Vacancy savings in CRHT
are now relatively small, due to the use of agency nurse
cover. There was a large overspend on Linden ward inmonth (£32k), which was offset to some extent by
vacancies savings across various other OA wards and OA
community teams.
There is a year to date and forecast underspend against
budget for medical services, generated from the drugs
budget and from growth funds for a PLS pilot which has
not proceeded. As well as a forecast underspend of
£154k, there is £56k budget set aside in contingency for
any staffing emergencies which may arise in February
and March.
Community - Recruitment to posts and removal of
agency costs is still expected by December, post
management of change process. Any further slippage is
likely to result in moving from break-even outturn to an
over spend.
CAMHS Restructure for £80k CIP target has been
delivered in full for the year. Recruitment to posts is
expected and Agency costs to reduce.
SMS have additional costs due to the replacement of
staff with temporary arrangements until the outcome of
the current tender is known. This is off-set by not
recruiting to posts that will not be required within the
new model.
Commentary
Capital Programme
The balance of expenditure year to
date relates in the main to the Agile
Working Pilot (to include Wi-Fi
Provision) that was rolled out at the
beginning of this financial year and
the second Phase in the BFH
Heating Controls scheme
A number of other schemes are in
the process of being scoped for
approval by ECPG and/or Board
Accruals have been made in Mth 9
for works completed at the end of
December that had not been
invoiced or GRNd in the system.
•
•
•
78 of 182
A small amount of expenditure has
been incurred in respect of old year
schemes £47k
•
Commentary
810
Liquidity Ratio Days
Liquidity Ratio Metric
840
850
860
Annual Debt Service
Capital Servicing Capacity (times)
Capital Servicing Capacity metric
Continuity of Services Rating for Trust
+/-
+/-
+/-
+/-
+/-
+/-
+/-
+/-
+/-
3.70
1.25
0.60
0.60
0.75
0.50
Weighted
FRR - Plan
83.0
1.6%
2.0%
5.9%
106.8%
Actual Month 9
4.00
4.00
2.7
880
2,351
4.00
56
39,867
9,347
4.00
4.00
2.9
867
2,543
4.00
54
40,438
9,146
(mc 02)
£000s
(mc 01)
£000s
1
<1.25
1
<-14
0.00
0.00
0.3
(13)
192
0.00
(2)
571
(201)
£000s
(mc 03)
Current Month Metrics
Actual /
Plan
Forecast
Variance
5
3
3
3
5
Score Plan
Continuity of Service Parameters
Liquidity ratio (days)
4
3
2
0
-7
-14
Capital servicing capacity
4
3
2
2.5
1.75
1.25
820
830
Revenue Available for Debt Service
Capital Servicing Capacity (times)
790
800
Annual Operating Expenses
780
Working Capital Balance
Liquidity Ratio (days)
Continuity of Services Risk Ratings
Memorandum
Sub
Code
67.0
Liquidity ratio
SIGN
1.3%
I&E surplus margin
Weighted Average
1.5%
6.0%
100.0%
Plan
Net Return after Financing
EBITDA margin
EBITDA, % achieved
Amended Monitor Financial Risk
Rating Metric
Financial Performance Metrics
3.90
1.25
0.60
0.80
0.75
0.50
(mc 05)
4.00
4.00
2.8
1,247
3,510
4.00
47
60,959
7,982
£000s
50% Weighting
50% Weighting
4.00
4.00
2.7
1,320
3,623
4.00
53
59,802
8,844
£000s
(mc 04)
0.00
0.00
0.1
(73)
(113)
0.00
(6)
1,157
(862)
£000s
(mc 06)
Forecast Outturn Metrics
Actual /
Plan
Forecast
Variance
5
3
4
3
5
Weighted FRR
Score - Actual
- Actual Month
Month 9
9
•
79 of 182
The Capital Servicing score is 2.9
when a score of 2.5 or more is
sufficient to give a score of 4.
The liquidity score is 54 days
when 0 would give a 4.
•
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).
•
The financial performance to
month 09 gives an overall score
of 4, which is the highest possible
score.
The underspending in Month 08
has resulted in an actual FRR of
3.90.
•
•
The reduced planned surplus for
2014/15 of £808k means that the
planned FRR will reduce to 3.7
As detailed below Monitor have
issued new Financial metrics, but
the FRR will continue to be
reported in order to provide a
degree of consistency during the
transition
•
•
Commentary
150
1b) Year to Date, Actual compared to Plan
215
220
225
230
2b) Actual Efficiency recurring/non-recurring compared
to plan - Forecast compared to plan
- Total Efficiencies for Forecast Outturn compared to
Plan
- Recurrent Efficiencies for Forecast Outturn compared
to Plan
400
455
5) Permanent PDC accessed for liquidity purposes
Trust Overall RAG Rating
460
465
470
Year to Date Rating
Forecast Outturn Rating
(C) Number of unresolved Validation Errors (Level
1 only)
(B) Continuity of Service Risk Ratings
350
4) Forecast Year End Charge to Capital Resource
Limit
Cash and Capital
3) Forecast Underlying surplus / (deficit) compared to
Plan
250
210
- Total Efficiencies for Year to Date compared to Plan
- Recurrent Efficiencies for Year to Date compared to
Plan
Underlying Revenue Position
200
2a) Actual Efficiency recurring/non-recurring compared
to plan - Year to date actual compared to plan
Financial Efficiency
100
1a) Forecast Outturn, Compared to Plan
NHS Financial Performance
Code
+/-
+/-
+/-
+/-
+/-
+/-
+/-
+/-
+/-
+/-
+/-
+/-
+/-
4.00
4.00
2,180
1,088
2,616
2,616
1,918
1,918
536
4.00
4.00
0
1,795
1,971
2,616
2,616
1,938
1,938
795
808
£000s
£000s
808
(mc 02)
(mc 01)
Plan
0
0.00
0.00
385
883
0
0
20
20
259
£000s
(mc 03)
Variance
Actual /
Forecast
Sign
(A) Accountability Framework
Sub
Current Month Metrics
Key Metrics
TDA Key Financial Data: Month 9
10
GREEN
GREEN
GREEN
GREEN
AMBER
GREEN
GREEN
GREEN
GREEN
GREEN
(mc 04)
RAG
Rating
0
0
0
68
883
0
0
0
0
180
£000s
(mc 09)
Sep
0
0
0
68
0
0
0
1
1
290
£000s
(mc 10)
Oct
Varianc
e By
Month
0
0
0
68
0
0
0
1
1
252
£000s
(mc 11)
Nov
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
0
(mc 20)
Sep
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
0
(mc 21)
Oct
RAG by
Month
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
GREEN
0
(mc 22)
Nov
•
80 of 182
Continuity of Service
scores are at a maximum
of 4.
Capital Expenditure has
moved to amber as a
result of the level of
underspend against the
Capital plan.
The underlying position
reflects the Trust
reserves, approximately
£500k in year, and the
fact that £500k has been
used to support nonrecurring cost pressures
in 2014/15.
•
•
The TDA return for Month
09 is shown in the table
to the left.
•
Commentary
Cash Flow Statement
Trade and Other Receivables decreased over the
period (a positive impact on cash)
Trade and Other Payables increased over the period (a
positive impact on cash)
The Trust has received £33k of interest, and spent
£1,043k on capital (£399k on reducing capital payables
from the year end and £644k on 2014/15 capital
expenditure). Total capital expenditure in cash terms
was less than the cash received for depreciation and
amortisation (a positive impact on cash)
The impact of all these movements was to increase the
Trust’s cash balance YTD by £1,957k
•
•
•
•
It assumes no working capital movements other
than those specifically listed
•
81 of 182
This is a useful figure to compare actual cash
against as the year progresses
•
Cash Benchmark for March 2015
The Trust made an operating surplus of £1,737k for the
first three quarters of 2014/15, and received cash of
£1,173k in respect of depreciation and amortisation
•
Cash Flow
Commentary
Payables Performance
The Trust does not meet any of the
95% targets for NHS or Non-NHS
YTD.
Non-compliance continues to be as
a result of IAS transactions not
being approved on a timely basis
by Managers and delays caused
by requisitioners raising orders
retrospectively.
In response to a recent internal
audit review Managers responsible
for the late authorisation of
invoices will be contacted going
forwards
•
•
•
13% of debt was aged 90 days or older
at the end of December. This figure was
34% at the end of November.
There are continuing disputes with Local
Authorities relating to Drug and Alcohol
Charges. These invoices are all now
greater than 90 days old and are fully
provided for in the Bad Debt Provision.
However, one council paid these
invoices in November and it is hoped
that this may set a precedent for others.
•
•
82 of 182
79% of outstanding invoices were aged
60 days or less at the month end (this
figure was 64% at the end of November.
•
Aged Debt Profile by Value
The Trust meets the 95% target
across only the NHS transaction by
value indicator in the month.
•
Better Payment Practice Code
Commentary
Current FYE value of those schemes transacted in Month 09 = £2,098k.
TDA CIP target is £2,616k, but the Trust has reviewed its commitments for 2014/15, and agreed a internal target of £2,087k.
•
•
Budgets for the 2014/15 target have been devolved to the appropriate budget areas.
Work is ongoing to ensure that the FYE of all the 2014/15 schemes is realised and deliverable from 1st April 2015.
Work is ongoing to ensure 2015/16 schemes begin to deliver cash reduction from 1st April 2015.
•
•
•
83 of 182
2014/15 Month 09 year to date = £1,867k and £220k is being managed centrally in reserves.
•
Commentary
Target for 2014/15 = £2,087k.
•
Headlines
Cost Improvement Target Achievement
Statement of Financial Position
Progress against capital schemes is reviewed elsewhere in
this report
•
Cash is £1,957k higher than the balance at 31 March 2014
An analysis of cash flows can be seen elsewhere in this
report
•
•
NHSLA Provisions have reduced by £28k, provisions in
relation to medical pay arrears and staff of fixed term
contracts have remained constant.
•
This provision is in respect of VAT over-recovered from
HMRC. This has reduced by £430k in the year as most
outstanding issues are now thought to be resolved.
•
84 of 182
The Current Year I&E figure reflects the surplus YTD of
£795k
Tax Payers’ Equity
•
Provisions
Payables have decreased by £33k
•
Current Liabilities
Receivables are £1,027k less than at 31 March 2014
•
Current Assets
Depreciation and amortisation exceed capital expenditure
in 2014/15.
•
Non Current Assets
Commentary
Workforce Report
2014/15 Month 9
Trust Board
Meeting Date – 4th February 2015
85 of 182
Workforce Report - Contents
4
5
6
7
8
9
10
Workforce Dashboard
FTE v Workforce Plan
Vacancies
Turnover
Sickness Absence
Appraisal
Mandatory Training
86 of 182
3
Key Messages
Page
2
Industrial Action – Planned for 29th January 2015. A verbal update will be provided to the Board.
87 of 182
Mandatory Training compliance is reported using competency based reporting functionality within ESR. This approach (in conjunction
with manager self service) will provide more accurate, real time information with potential to incorporate compliance with all areas of
essential training in addition to mandatory areas. The Trust has achieved an overall compliance rate of 77% for Month 9, which exceeds
the Trust’s target of 70% overall. A focussed programme of work is underway relating to Information Governance training compliance.
Appraisal – compliance is still below the Trust’s target of 85%. HR and L&D continue to implement a targeted support programme with
managers to improve both compliance and data recording. In January, the L&D Manager and the Staff Engagement Facilitator have been
meeting with managers across the Trust who have responsibility for appraising staff, focussing initially on the ‘hotspot areas’, to agree
plans to improve appraisal quality and compliance. Appraisal trajectories for 2015/16 are to be agreed for each Service in the February
QPRs.
Sickness Absence – Sickness has increased from 5.90% in Month 8 to 6.15 % in Month 9. 58% of this absence is due to Long Term
Sickness, and there are currently 40 Long Term sickness cases. As part of the work programme to improve staff wellbeing, the Trust is in
the process of organising Trust Stress Resilience Training courses. The HR Team are continue to roll-out a programme of training on
Sickness Management. Additionally, a staff Health & Wellbeing Survey is to be undertaken to help understand what the Trust could do
additionally to support staff wellbeing.
Turnover – The turnover for Month 9 is back at normal levels for the second month in a row, with only 8 employees people having left
during the month. However, the rolling 12-month turnover rate remains higher due to changes earlier in the year, attributable mainly to
the departure of individuals under the MARS scheme. A further analysis of this area is shown on slide 9.
Vacancy Management – Each service line has completed a Workforce/Recruitment Plan for their areas to include vacancies that require
immediate recruitment. The individual plans have been collated into a Trust-wide Recruitment Requirements document which was sent
to Finance for approval. A total of 104 FTE posts were submitted, of which 89 FTE have been approved. An Interim Recruitment Project
Manager has been appointed to lead on the implementation of the plan, and will start with the Trust on the 2nd February.
Key Messages
3
Total Cases (Open at Month End)
Total Cases (New)
Total Cases (Closed)
Average Time to Close (Days)
Employee Relations
Appriasals Completed
Appraisals Outstanding
Appraisal %
Mandatory Training
Development
Sickness % (Month)
Sickness Days Lost FTE (Month)
No of Sickness Episodes (Month)
Long Term Sickness % (Month)
Cost of Sickness (Month)
Maternity % (Month)
Sickness % (12 Months)
Long Term Sickness % (12 Months)
Cost of Sickness (12 Months)
Absence
Headcount
Funded Establishment
Staff in Post FTE (Contracted)
No of Vacancies
Vacancy %
No of Starters (Headcount)
No of Leavers (Headcount)
Turnover % (12 Months)
Staff in Post
Target
85%
70%
Target
4.68%
Target
4.68%
8-14%
Target
£1,455K
£1,424K
Jan-14
-
Feb-14
-
Feb-14
728
334
68.55%
-
£126K
1.71%
4.89%
71.04%
£147K
2.02%
4.80%
69.90%
Jan-14
700
367
65.60%
-
Feb-14
5.81%
1,581
187
53.07%
Feb-14
1080
1,179.7
972.7
207.0
17.5%
12
16
10.46%
Jan-14
6.13%
1,854
207
52.65%
Jan-14
1086
1,178.7
976.3
202.4
17.2%
13
15
10.13%
Mar-14
-
Mar-14
758
297
71.85%
-
£1,460K
£130K
1.84%
4.92%
71.77%
Mar-14
5.30%
1,592
182
50.03%
Mar-14
1074
1,144.4
960.9
183.5
16.0%
8
35
11.30%
445 Dudley and Walsall Mental Health Partnership NHS Trust
Workforce Dashboard
Apr-14
15
1
6
108
Apr-14
732
316
69.85%
-
£1,479K
£146K
1.65%
4.97%
72.34%
Apr-14
5.84%
1,674
180
55.31%
Apr-14
1063
1,122.4
957.3
165.1
14.7%
11
11
11.58%
May-14
19
5
1
169
May-14
684
365
65.20%
80.18%
£1,495K
£127K
1.59%
5.02%
73.02%
May-14
4.90%
1,456
149
58.71%
May-14
1063
1,124.4
959.0
165.4
14.7%
19
9
11.33%
Jun-14
15
3
7
94
Jun-14
661
386
63.13%
80.47%
£1,512K
£123K
1.61%
5.11%
73.47%
Jun-14
5.03%
1,450
153
62.55%
Jun-14
1069
1,111.5
961.5
150.1
13.5%
15
11
11.73%
Jul-14
12
1
4
103
Jul-14
637
405
61.13%
80.82%
£1,530K
£134K
1.97%
5.18%
72.52%
Jul-14
5.40%
1,611
171
59.94%
Jul-14
1064
1,111.0
959.9
151.1
13.6%
8
16
11.94%
Aug-14
3
0
9
121
Aug-14
635
392
61.83%
80.69%
£1,553K
£137K
1.98%
5.28%
73.59%
Aug-14
5.76%
1,694
154
63.25%
Aug-14
1048
1,111.0
946.0
165.0
14.8%
16
33
12.57%
Sep-14
5
2
0
-
Sep-14
611
419
59.32%
79.38%
£1,564K
£116K
1.98%
5.39%
74.18%
Sep-14
5.18%
1,471
166
51.67%
Sep-14
1047
1,125.4
945.7
179.7
16.0%
18
54
16.20%
Oct-14
5
0
0
-
Oct-14
572
419
57.72%
78.24%
£1,551K
£107K
1.93%
5.40%
73.31%
Oct-14
4.92%
1,390
174
50.02%
Oct-14
1008
1,125.4
911.7
213.7
19.0%
14
18
17.27%
Dec-14
6
0
0
-
Dec-14
503
434
53.68%
76.61%
£1,551K
£147K
2.13%
5.46%
72.75%
Dec-14
6.15%
1,741
204
58.01%
Dec-14
1010
1,124.3
907.4
216.8
19.3%
9
8
17.12%
88 of 182
Nov-14
6
2
1
256
Nov-14
522
458
53.27%
78.42%
£1,533K
£127K
2.10%
5.42%
73.10%
Nov-14
5.90%
1,611
185
53.93%
Nov-14
1007
1,124.3
907.5
216.8
19.3%
12
7
17.44%
Dec-14
4
976
Actual FTE
973
1151
961
1151
957
1113
959
1113
961
1113
Feb-14 Mar-14 Apr-14 May-14 Jun-14
960
1113
Jul-14
Actual FTE v Workforce Plan
946
1113
946
1113
912
1113
908
1113
907
1113
Aug-14 Sep-14 Oct-14 Nov-14 Dec-14
89 of 182
Staff in Post FTE has remained static in Month 9. Trust Wide Actual FTE has reduced by 69 FTE since Jan-2014.
1151
Jan-14
WP Target
800
850
900
950
1000
1050
1100
1150
1200
FTE v Workforce Plan
5
224.04
35.00
13.99
4.50
11.73
3.00
106.53
172.78
31.12
22.65
134.65
183.88
96.25
84.14
1,124.26
Funded FTE
163.79
28.55
11.12
3.00
10.92
2.00
88.54
149.18
28.66
19.88
106.84
140.79
85.96
68.22
907.44
Contracted
FTE
60.25
6.45
2.87
1.50
0.81
1.00
17.99
23.60
2.46
2.77
27.81
43.09
10.29
15.92
216.82
Vacancies
26.9%
18.4%
20.5%
33.3%
6.9%
33.3%
16.9%
13.7%
7.9%
12.2%
20.7%
23.4%
10.7%
18.9%
19.3%
Vacancy %
17.00
0.00
0.00
1.00
0.00
0.00
2.80
1.00
4.00
4.00
5.00
9.00
2.00
0.00
45.80
Live
Recruitment
Vacancies not
being Recruited
to
43.25
6.45
2.87
0.50
0.81
1.00
15.19
22.60
-1.54
-1.23
22.81
34.09
8.29
15.92
171.02
2.21
3.17
0.00
0.00
0.00
1.00
6.55
0.00
1.81
3.15
3.50
18.73
6.55
4.59
51.26
CIP / Service
Transformation
Vacancies
available for
Recruitment
41.04
3.28
2.87
0.50
0.81
0.00
8.64
22.60
-3.35
-4.38
19.31
15.36
1.74
11.33
119.76
90 of 182
Of the 217 vacancies 44 FTE are currently being recruited to, of which 37 are at offer stage. There are 51 FTE vacancies that have been identified for CIP or Service
Transformation.
The table above details the number of contracted vacancies, how many are currently being recruited to and the number of posts that are currently identified for CIP
or Service Transformation. There are 217 FTE contracted vacancies in the Trust at a vacancy rate of 19.3% as at the end of Month 9.
445 ACU Acute Services Level 4
445 AMGT Management Level 4
445 CAF Corporate Affairs Level 4
445 CDP Corporate Development and People Level 4
445 CHX Chief Executive Level 4
445 CMGT Community Management Level 4
445 COM Community Services Level 4
445 EIN Early Intervention Level 4
445 FIN Finance Level 4
445 HR Human Resources Level 4
445 MED Medical Level 4
445 OAS Older Adults Level 4
445 OPS Operations Level 4
445 RCS Recovery Services Level 4
DWMH Total
Service
Vacancies
6
10.13%
14.00%
Turnover %
Upper Target
14.00%
10.46%
8.00%
Feb-14
14.00%
11.30%
8.00%
Mar-14
14.00%
11.58%
8.00%
Apr-14
14.00%
11.33%
8.00%
May-14
14.00%
11.73%
8.00%
Jun-14
14.00%
12.57%
8.00%
Aug-14
14.00%
16.20%
8.00%
Sep-14
14.00%
17.27%
8.00%
Oct-14
14.00%
17.44%
8.00%
Nov-14
14.00%
17.12%
8.00%
Dec-14
No of Starters
No of Leavers
13
15
Jan-14
12
16
Feb-14
8
35
Mar-14
11
11
Apr-14
19
9
May-14
15
11
Jun-14
8
16
Jul-14
The turnover rate excludes Junior Doctors, due to the nature of their rotational contracts.
16
33
Aug-14
18
54
Sep-14
14
18
Oct-14
12
7
Nov-14
9
8
Dec-14
91 of 182
Total
155
233
The reason for the significant increase in the financial year is the implementation of MARS, in which 34.89 FTE left the Trust. Additional the TUPE transfer of
Dudley SMS Services in April 2014 increased the position.
14.00%
11.94%
8.00%
Jul-14
DWMH Turnover % by Month
The 12 Month turnover rate reduced from 17.44% in Month 8 to to 17.12% in Month 9.
8.00%
Jan-14
Lower Target
19.00%
17.00%
15.00%
13.00%
11.00%
9.00%
7.00%
5.00%
3.00%
Turnover (12 Months)
7
4.00%
3.50%
3.00%
0.04
0.035
0.03
cute
al Lev
0
0
No of Episodes
(Month)
13
23
37
3
22
0
40
35
21
10
204
98.07
106.00
412.86
30.55
206.53
0.00
353.62
330.97
174.63
27.28
1,740.51
5.84%5.03%
4.68%4.68%
4.29%
3.19%
8.11%
3.45%
7.49%
0.00%
7.51%
7.61%
8.16%
1.01%
6.15%
Sickness % (Month)
5.30% 4.90%
4.68% 4.68%
FTE Days Lost
5.81% 6.13% 5.30% 5.81% 5.84%
4.68% 4.68% 4.68% 4.68% 4.68%
Apr-14Jun-14
5.03%
5.76%
4.68%
4.68%
Jun-14
Aug-14
Sickness %
(12 Months)
4.06%
3.13%
7.33%
3.08%
5.40%
0.72%
6.03%
7.81%
5.54%
2.17%
5.46%
4.90%5.40%
4.68%4.68%
May-14
Jul-14
Sickness Absence % v Trust Target
Jan-14Month Feb-14 Jan-14 Mar-14 Feb-14 Apr-14 Mar-14May-14
Medical Directorate
Acute Services
Mana Acute Management
CommuCommunity Services
CommCommunity Management
rly InteEarly Intervention
Older AOlder Adults
ecoveRecovery Services
perat Ops Management
DWMH Total
ate L Corporate
Service
4.50%
6.13%
5.00%
0.05
0.045
Sickness %
5.50%
4.68%
6.00%
0.06
0.055
Target
6.50%
0.065
Sickness
Jul-14
Sep-14
5.76%
4.92%
4.68%
4.68%
Aug-14
Oct-14
5.18%
5.90%
4.68%
4.68%
Sep-14
Nov-14
4.92%
6.15%
4.68%
4.68%
Oct-14
Dec-14
92 of 182
In Month 9 1740 FTE days were due to
sickness absence. This is a increase of 129
FTE days compared to Month 8.
The rolling 12 month comparison has
increased slightly from 5.42% to 5.46% in
Month 9.
Sickness has increased from 5.90% in Month
8 to 6.15% in Month 9.
5.40%
5.18%
4.68%
4.68%
8
Feb-14
45%
72%
44%
48%
57%
50%
70%
53%
49%
36%
53%
ate L Corporate
al Lev Medical Directorate
cute Acute Services
Mana Acute Management
CommuCommunity Services
CommCommunity Management
rly InteEarly Intervention
Older AOlder Adults
ecoveRecovery Services
perat Ops Management
and DWMH Total
Nov-14
68.55%
85.00%
Service
65.60%
Appraisal %
Jan-14
85.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Target
Appraisal
71.85%
85.00%
Mar-14
Apr-14
50%
68%
40%
60%
52%
50%
70%
51%
67%
34%
54%
Dec-14
69.85%
85.00%
65.20%
85.00%
May-14
Dec-14
63.13%
85.00%
Jun-14
61.13%
85.00%
Jul-14
Appraisal % v Trust Target
Aug-14
Sep-14
59.32%
85.00%
Oct-14
57.72%
85.00%
Nov-14
53.27%
85.00%
Dec-14
53.68%
85.00%
93 of 182
The Learning & Development Team are meeting with
managers across the Trust to support the improvment of both
quality of appraisals and compliance levels.
There are 434 employees in the Trust that havent had an
appriasal in the last 12 months.
Appraisal compliance has increased slightly to 54%, but is still
tracking significantly below the Trust target of 85%.
61.83%
85.00%
9
70%
70%
70%
70%
70%
95%
70%
70%
70%
70%
Equa l i ty & Di vers i ty
Fi re Sa fety
Hea l th & Sa fety
Infecti on Control - Cl i ni ca l
Infecti on Control - Non Cl i ni ca l
Informa ti on Governa nce
Movi ng & Ha ndl i ng
Sa fegua rdi ng Adul ts
Sa fegua rdi ng Chi l dren
Aggregated Total
80.2%
82.5%
83.8%
77.5%
83.1%
70.1%
72.9%
83.2%
73.9%
85.2%
Apr-14
80.5%
83.1%
82.4%
79.6%
83.7%
71.5%
71.1%
84.1%
73.9%
85.8%
May-14
80.8%
82.2%
80.1%
81.6%
85.1%
70.1%
75.0%
83.1%
75.6%
85.3%
Jun-14
80.7%
81.1%
79.3%
82.1%
84.9%
69.3%
77.7%
82.7%
76.1%
84.3%
Jul-14
79.4%
79.0%
77.8%
80.5%
85.5%
70.2%
76.6%
80.1%
75.7%
81.9%
Aug-14
78.2%
77.6%
76.7%
82.0%
83.8%
71.4%
71.1%
80.6%
72.1%
81.9%
Sep-14
78.4%
77.2%
76.4%
83.6%
84.3%
73.8%
71.5%
80.6%
71.3%
81.7%
Oct-14
76.6%
76.2%
76.7%
83.2%
78.2%
72.2%
66.2%
83.1%
66.8%
80.5%
77.1%
75.5%
78.7%
82.8%
78.3%
74.9%
68.7%
82.9%
67.7%
80.5%
Nov-14 Dec-14
Jan-15
Feb-15
Mar-15
94 of 182
The data identifies that Information Governance below the required target – a focussed programme of work is underway to ensure that the
required 95% compliance is achieved by year end.
The core mandatory training is giving an aggregated total of 77% for actual – above target.
Staff on Maternity Leave and Long Term Sickness, Secondments, Junior Doctors and trainees are excluded from the report
Mandatory Training compliance is set at 70% for all areas with the exception of Information Governance ( IG) which is set at 95%
Target
Competency
Mandatory Training Dashboard
Mandatory Training
10
Board meeting
February 2015
date:
4th Agenda Item number: 10.2
Enclosure: 8
Trust Development Authority Self Certification Documents
Monthly report (Month 9)
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:
x
x
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
8
9
9
9
Committee: Finance and Performance Committee
Date reviewed: 26th January 2015
Key points or
Committee:
High quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources
9
8
9
9
8
9
95 of 182
following:
Caring
Responsive
Effective
Well-led
Safe
96 of 182
Trust Development Authority Self Certification Documents
Monthly report (Month 9)
Title
Introduction
x
This paper presents the Trust’s compliance with Monitor Licensing Requirements at the end of
month nine, 2014/15 financial year, together with Board statements on compliance with
fundamental standards of:
o Clinical quality
o Finance
o Governance
x
Governance Risk Rating (GRR) remains 0 with 0 being the best rating possible.
x
Monitor Financial Risk Rating (FRR) is 3.9 with 5 being the best rating possible. The overall
FRR is rating is therefore Green.
x
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 31st January 2015.
x
Late submissions will be over-ridden to a red governance risk rating.
Recommendation
x
It is recommended that the Board note the performance of the Trust as at month nine, and the
fact that these documents have been approved for submission by the Finance and Performance
Committee and the Chairperson and Chief Executive.
x
The Board is asked to ratify the submitted Board statements and Monitor licensing requirements
declarations.
97 of 182
98 of 182
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:
31/01/2015
Select the Month
Reporting Year:
2014/15
April
May
June
July
August
September
October
November
December
January
February
March
COMPLIANCE WITH MONITOR LICENCE REQUIREMENTS FOR
NHS TRUSTS:
99 of 182
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
31/01/2015
31/01/2015
N/A
31/01/2015
4. Condition G8
Patient eligibility and
selection criteria.
Yes
N/A
31/01/2015
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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
31/01/2015
N/A
8. Condition P4
Compliance with the
National Tariff.
31/01/2015
31/01/2015
N/A
31/01/2015
9. Condition P5
Constructive engagement
concerning local tariff
modifications.
Yes
N/A
31/01/2015
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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
31/01/2015
31/01/2015
N/A
31/01/2015
102 of 182
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:
31/01/2015
Select the Month
Reporting Year:
2014/15
April
May
June
July
August
September
October
November
December
January
February
March
BOARD STATEMENTS:
103 of 182
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
31/01/2015
RESPONSE:
N/A
Comment where noncompliant or at risk of noncompliance
BOARD STATEMENTS:
104 of 182
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
31/01/2015
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
31/01/2015
RESPONSE:
N/A
BOARD STATEMENTS:
105 of 182
For FINANCE, that
. 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
31/01/2015
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
31/01/2015
RESPONSE:
N/A
BOARD STATEMENTS:
106 of 182
. 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
31/01/2015
RESPONSE:
N/A
BOARD STATEMENTS:
. 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
31/01/2015
RESPONSE:
N/A
BOARD STATEMENTS:
107 of 182
. 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
31/01/2015
RESPONSE:
N/A
BOARD STATEMENTS:
. 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
31/01/2015
RESPONSE:
N/A
BOARD STATEMENTS:
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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
31/01/2015
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
31/01/2015
RESPONSE:
N/A
BOARD STATEMENTS:
109 of 182
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
31/01/2015
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
31/01/2015
RESPONSE:
N/A
BOARD STATEMENTS:
110 of 182
1 . 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
31/01/2015
RESPONSE:
N/A
111 of 182
112 of 182
Board meeting date:
4th Feb 2015
Report Title:
Agenda Item number: 10.3
Enclosure 9
Governance and Quality Committee Chair Report
Committee:
Governance & Quality Committee
Tom Jinks – Governance Manager
Wendy Pugh – Director of Operations and Nursing
Dr Robin Gutteridge – NED and Chair of Governance and Quality
Committee
Decision / Approval
Gain assurance
9
9
Discussion
Information
Key issues and Risks
At the Governance and Quality Committee meeting held on the 14 January 2015, key issues were
discussed around the dimensions of Risk. Quality, and Safety, Experience and Effectiveness and
Regulation and Compliance. Time was allocated to more detailed consideration of the following:
In relation to Quality and Safety:
The Governance and Quality Committee discussed key issues relating to Quality and Safety including a
spotlight session held to review the Trust’s National Audit of Schizophrenia report and Physical Health
Checks, the monthly Quality Report, the Trust Wide Risk Register, the Trust results of the CQC Place
of Safety Survey and a NHS Benchmarking Report regarding the Use of Restraint.
In relation to Experience and Effectiveness:
An update on the planned revision to the Experts by Experience (EBE) recruitment process, induction
and work plan was provided to the Committee.
In relation to Regulation and Compliance:
The Committee received an update on the latest version of the Trust Performance Report
113 of 182
1. Quality and Safety
1.1 The Quality Report for December
The report was scrutinised for assurance and the Committee discussed the contents of the report.
One trend was noted for Board consideration: there is an increase in reported incidents in the Older
Adults Service Line. The Committee discussed the trend at length and it was noted that a high
proportion of the incidents were in relation to 5 service users, 3 of whom had DOLS in place. The Head
of Older Adults Services has commissioned a full review of the reported incidents with a focus on
medication and medication prescribing for these patients. The review will also focus on de-facto
seclusion and least restrictive practice. G&Q will update the Board following scrutiny of this report
The Committee also noted that any environmental factors will be addressed by the overall Older Adults
Review.
In relation to section 5 of the report (Safeguarding) it was brought to the Committee’s attention that the
Trust’s Commissioners are asking for more information. The Committee agreed that there is a clear
need to assist the commissioners and Safeguarding Boards in ensuring that their requests are aligned,
effective and that the appropriate Trust information can be provided to them in a timely and meaningful
format.
The Quality Report is recommended to the Board for approval
1.2 The Quality and Governance Risk Register
The Quality and Governance Risk Register was considered. No new Quality and Safety Risks are
recommended to the Board for addition to the register this month.
Two new risks that are not directly related to Quality and Safety that are proposed to be added to the
Trust Wide Risk Register.
Following the recent Board Development session, work is underway to review the Trusts risk strategy
and strategic risks, and a schedule of planned meetings between the Governance Team and Executive
Directors is currently being established where the Executive directors will have an opportunity to review
and update their risk registers with the Trust’s Risk and Assurance Lead.
1.3 Director of Operations and Nursing Update:
The following points were raised to the Committee:
x
Work with commissioners - In respect to the Quality agenda, Key Performance Indicators
(KPI’s) are currently being developed in partnership with the Trust Commissioners. There has
been a noted change in approach, with the commissioners clearly focusing on quality outcomes
in the new KPI’s. There is still however a clear need to continue to develop and monitor the
previously agreed KPI’s. The Committee agreed that a framework with the proposed KPI’s will
be brought back to the March G&Q.
114 of 182
x
Therapeutic activities –A query has been received from the Commissioners regarding the new
Psychological Therapies Hub – it was reported that is work progressing well particularly within
the Community Service Line.
x
Safer Staffing –The Trust is fully participating in the regional Safer Staffing Levels Groups
x
Nurse Revalidation –The Trust continues to make substantial progress and it was agreed that
an update would be provided to the Committee in March 2015.
1.4 CQC Place of Safety Survey Results
The results of the CQC Place of Safety Survey and the resultant Trust action plan were presented to
the Committee. The overall results were positive for the Trust and the Committee endorsed the
proposed action plan. It was agreed that there was also a need to draw together the results of the
survey, the initial outcome of the Street Triage project alongside the recent National Benchmarking
report into Restraint and the work that has been undertaken by the Least Restrictive Practice Working
Group. The Committee agreed that a fixed term Task and Finish Group would be established to
undertake this task.
1.5 National Health Service Benchmarking Report - Use of Restraint
The results of the recent National Audit on the Use of Restraint had been received. Results for the
Trust were very positive; the Trust is shown as a low reporter for incidences of restraint and the use of
prone restraint. A regionally led working group is focusing on this area. The Trust are fully engaged with
and participating in this group.
2. Experience and Effectiveness
2.1 Experts by Experience Recruitment, Induction and Work Plan
The EBE Induction and Work Plan will be presented to the Committee in April 15
3. Regulation and Compliance
3.1 The Performance Report was received for information and assurance. It was noted that:
x
x
x
There was a strong overall performance by the Trust with 14 out of 15 KPIs being achieved for
December 2014.
IAPT 14 – People who have successfully completed treatment – The KPI showed an amber rating
for Dudley locality The Committee were informed that this was a current month issue and the
results have improved with the Trust on course to achieve its target.
There was an underperformance in Copies of Care Plans KPI in October and November. Work has
been undertaken by the Operational Teams to address these issues. Assurance had previously
been given to the Committee that the Trust would improve in Month 9 and it was stated that
current data showed the Trust as currently being above 96%. compliant.
115 of 182
4. Spotlight Session – National Audit of Schizophrenia Results and Physical Health Checks
The Committee was presented with the results of the National Audit of Schizophrenia and the proposed
action plan. The presentation gave an overview of some of the outcomes and findings from the Audit in
relation to the physical health and medicines management priorities.
The committee held in depth discussions and was informed that the top action plan priorities would be:
a more integrated coherent approach to prescribing and recording; improved I.T support to prompt
better recording and monitoring; more effective physical health monitoring and improved access to
Psychological Therapies. The Committee asked for discussion at CQR about better liaison with Primary
care, to explore the possibility of enabling GP health checks records to be made available to the Trust.
This could reduce duplication of activity
The Committee requested that an update report is presented in March 2015.
5. Committee Business, Reporting and Planning
5.1 Exception reports were received from the following Sub-groups:
x
Infection Prevention Control Committee - The Committee were informed about a recent
confirmed Norovirus outbreak on Grasmere Ward and the actions that had been undertaken to
contain the outbreak and to support the patients and staff.
x
Policy and Procedures Group –No meeting was held in December. A virtual meeting had
therefore been established with members requested to submit their comments to the Chair on
policies that had been circulated, by the 14th January.
x
Triangulation Group – The Triangulation Group Terms of Reference were presented and
approved by the Committee. The need for the Group was also re-endorsed and it was agreed
that the Group should report by exception only to the Committee rather than through the
submission of formal minutes.
Key action points and work in progress
x
Increase in Older Adults Service Line reported Incidents – The Committee has requested
that the increase is investigated by the Head of Service and that feedback is proved in next
month’s Quality Report.
x
National Audit of Schizophrenia - The Committee reviewed the results of the audit and the
proposed action plan. It was agreed that an update would be proved to the committee on
progress made in relation to the action plan in May 15.
x
Duty of Candour – It was agreed that a Framework for the audit of Duty of Candour practices
in operation in the Trust will be developed. The plan will involve an externally led audit of current
116 of 182
processes (it will be added to Trust Audit Committees Audit Forward Plan) An action plan will
then be developed and presented back to the Governance and Quality Committee.
x
Restraint Task and Finish Group – A task and finish group is being established to review the
outcomes of the recent 136 Place of Safety Audit, the Trust’s Street Triage project, and the
results of the NHS Benchmarking Use of Restraint Survey
x
Triangulation Group: the committee approved the ToR and purpose of this group which
will be a sub group of G&Q
Interfaces with other Committees
The business that was discussed by the Committee interfaces with the following Committees / Groups:
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
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
x Accept this report for assurance about the exercise of delegated authority by the Governance
and Quality Committee
x Endorse the decisions and recommendations made by the Governance and Quality Committee.
117 of 182
In particular, the Board is asked to:
x Approve the Quality Report for September 2014 (period ending 31st October 2014)
x Agree the proposed management of the Quality risks detailed on the Trust Wide Risk Register
as recommended by the Governance and Quality Committee.
x Note and endorse the formation of the Triangulation Group as a Sub Group of the Governance
and Quality Committee.
x Note the proposed development of an audit framework in relation to Duty of Candour
x Endorse the proposed management of the National Audit of Schizophrenia Action Plan.
x Note that the Francis Action Plan Update Report has been added onto the Governance and
Quality Committee Reporting Schedule 2015/16
N.B.
During December the Trusts Policies and Procedures Focus Group did not occur in line with the normal
committee reporting timescales. It was therefore not possible to for the Policies and Procedures Focus
Group to provide an exception report to the Governance and Quality Committee. It was agreed by
Governance and Quality Committee that that the report should be circulated to members outside the
meeting.
A copy of the Policies and Procedures Focus Group exception report is included with this report.
118 of 182
Subject:
Policies and Procedures Focus Group Exception Report
Sub
Committee:
Chair of Sub
Committee:
Presented by:
Policies and Procedures Focus Group
Aim of the report:
x To advise the Governance and Quality Committee on Exceptions / items of
importance from the Policies and Procedures Focus Group for the period of
December 2014
Key points:
The Policies and Procedures Focus Group did not meet in December 2014, however
due to the number of policies a virtual meeting was received. Policies and
Procedures Focus Group would therefore like to inform the Governance and Quality
Committee of the following:
x The Environmental Policy – This has been developed by the Trusts Estates
and Facilities Department and is designed to ensure that the Trust complies with
all statute, NHS and industry guidance and good practice relevant to NHS aims
to assist the UK o reduce the Carbon Footprint in the UK. The document has
been consulted on by key individuals with specialist interests within the estates
and facilities department as well as those involved in Service Transformation. I
can confirm that an equality impact assessment has been completed in respect
to this particular policy. This represents a new policy for the Trust. Policies and
Procedures Focus Group has therefore agreed that this document can be taken
forward for ratification
x
The Policy for the Control of Asbestos – This has been developed by the
Trusts Estates and Facilities Department defines responsibilities for the duty to
manage Asbestos Containing Material and sets out arrangements for minimising
risk of exposure, and describes operational procedures for working in areas
containing asbestos all in accordance with The Control of Asbestos at Work
Regulations 2012. The document has been consulted on by the Estates
Manager, Estates Project Officer and Service Transformation Lead, Facilities
Support Manager and the Estates and Facilities Help Desk team. The document
also has a completed equality impact assessment. It should be noted that is a
new policy for the Trust. Policies and Procedures Focus Group has therefore
agreed that this document can be taken forward for ratification
x
Claims Management Policy and Procedures – This particular document
outlines the Trust’s processes and procedures for managing claims and is
designed to ensure that all employees have clear guidance on what to do if they
receive a letter of claim. The document also aims give assurance that robust
governance arrangements are in place for the management of claims in line with
legislation. The changes to the document are minor and are in respect to the
inclusion of the new “Portal System” for managing claims and in respect to the
losses and special payments compensation claim form. The document has been
widely consulted on by key stakeholders and managers and as a result Policies
and Procedures Focus Group agreed to ratify the changes.
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x
Associate specialists’ discretionary points policy and procedure – The
discretionary points scheme for associate specialists is a mechanism for
recognizing professional excellence and contribution of individual clinicians, and
providing a financial incentive for the same. This represents a new policy for the
Trust and as a result Policies and Procedures Focus Group has therefore agreed
that this document can be taken forward for ratification, subject to amendments
to the format of the document.
x
Health and Safety policy – The Health and Safety Policy has been revised by
the Trusts Health and Safety Officer the policy has been revised in light of
changes to HSG65 Management of Health and Safety. The changes to HSG65
is designed to be make the processes managing Health and Safety less
bureaucratic and is based around the Plan, Do, Check, Act approach to
managing health and safety. These changes to the policy are however minor
and have been consulted on widely with key stakeholders, reviewed by Health
and Safety Committee and the key changes to the principles explained at service
line quality meetings and as a result Policies and Procedures Focus Group
agreed to ratify the changes.
x
The Health and Safety Strategy – This is a new document for the organisation
as it represents the vision for Health and Safety within the Trust for the next for
the period through to 2017/18. The purpose of this Strategy is to illustrate that
successful Health and Safety management is an integral part of effective
business management and should be considered as an enabler rather than a
hindrance to the workplace. The document covers key topics such as
management arrangements, Organisational Safety Aims and Objectives as well
as links to risk registers. The document has been consulted on by the Trusts
Health and Safety Committee. As this represents a new strategy for the Trust,
the Policies and Procedures Focus Group has therefore agreed that this
document can be taken forward for ratification.
x
Recruitment and Selection Policy & Procedure – An extension to the current
review date is requested in respect to this particular policy. There are no
changes required as the extension is required until 2015 when a wider review of
this document is required to incorporate a values based recruitment model. As a
result Policies and Procedures Focus Group agreed to ratify the extension
x
Seclusion and De Facto seclusion Policy (Including resource for best
practice / guidance) – This document has been developed by the Trusts Least
Restrictive Practice Working Group in response to the Trusts CQC visit, the
document has taken on an unusual format with a small working document (which
meets the Trusts “policy minimum requirements) with a supporting best practice
guide as an appendix. This has been done on the advice of the Trusts solicitors
and the agreement of the director of Operations and Nursing. Policies and
Procedures Focus Group has therefore agreed that this document can be taken
forward for ratification
x
Advance Decision to Refuse Treatment and Advance Statement – This
document represents a new document for the Trust; the document has been
developed by the Trusts Clinical Processes Manager in cooperation with the
Trusts Least Restrictive Practice Working Group in response to the Trusts CQC
visit. The document has been widely consulted on and has been reviewed by
the Trusts solicitors from a legal perspective. Any comments have been
incorporated into the document. Policies and Procedures Focus Group has
therefore agreed that this document can be taken forward for ratification, subject
to amendments to the format of the document.
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x
Information Governance Policy – This document represents a re-ratification to
the pre-existing document. The document has been reviewed by the Trusts IG
manager. The document has been reviewed in line with the IG toolkit and there
are no changes. It is the aim of this document to support protection, control and
management of Trust information assets. The document provides a framework
to which the elements of Information Governance will be met. As a result
Policies and Procedures Focus Group agreed to ratify the extension to the
review date
x
Confidentiality and Data Protection Policy – This document represents a reratification to the pre-existing document. The document has been reviewed by
the Trusts IG manager. The document has been reviewed in line with the IG
toolkit and there are no changes. It is the aim of this document to provide staff
guidance to staff to find a balance between the need to use information within
the Trust and the confidentiality considerations. The policy provides an
appropriate level for staff to aid them to abide by their legal obligations. As a
result Policies and Procedures Focus Group agreed to ratify the extension to the
review date
x
Privacy Officer Policy – This document represents a re-ratification to the preexisting document. The document has been reviewed by the Trusts IG
are no changes. This policy provides the framework which the Trust’s Privacy
Officers must follow in the case of alerts relating to access to Patient Identifiable
Data (PID). As a result Policies and Procedures Focus Group agreed to ratify
the extension to the review date.
x
Freedom of information policy – The Policy will provide a framework within
which the Trust will ensure compliance with the requirements of the Act. The
Policy will underpin any operational procedures and activities connected with the
implementation of the FOIA. This document represents a re-ratification to the
pre-existing document. The document has been reviewed by the Trusts IG
are no changes. As a result Policies and Procedures Focus Group agreed to
ratify the extension to the review date
x
Bring Your Own Device Policy – This document is intended to define the
responsibilities of staff and the Trust when using personal devices to access
corporate information. The policy establishes a framework within which staff can
apply self-regulation to their own activities as well as understand the basic
principles of using personal devices to access corporate information. The
document has been widely consulted on by the Trusts Senior Management as
well as the Trusts information Governance department and the Trusts IT
providers. This document represents a new policy and new way of working for
the Trust. The Policies and Procedures Focus Group has therefore agreed that
this document can be taken forward for ratification.
Recommendation(s)
x
The Committee are asked to note the current position in relation to the exception
points raised above and to agree those new policies agreed by the Policies and
Procedures Focus Group for ratification.
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Board meeting date:4th February
2015
Report Title:
Enclosure: 10
Finance and Performance Committee Chair Report
Committee:
Finance and Performance Committee (F&P)
David Matthews – Non Executive Director
Decision / Approval
Gain assurance
Discussion
Information
9
9
9
9
Key issues & risks
The Finance and Performance committee met on the 26th January and considered the Finance,
Performance information and HR position for December.
The committee reviewed the following items of business
Performance
The trust is currently green rated across 14 out of 15 KPIs . The committee received an update on all
KPIs. It was noted that copies of care plans had returned to achieving the 95% target in December –
this was in line with the improvement plan shared with commissioners. The trust is currently under the
target for people who have successfully completed treatment in Dudley. This had been reviewed with
line managers and the trust is projected to hit the target for the year.
Activity levels continue to improve with the Trust. The trust saw a slight drop in activity levels in
December by 0.4% against plan however when this is seasonally adjusted for bank holidays and fewer
working days in December there was 1.2% increase in activity. The committee discussed the forecast
for the remaining months of the year. Excellent progress has been made to date on improving our
activity levels but January would be a key month for delivery. The committee agreed to keep this as a
standing item for review.
Finance
The committee received an update on the financial position for the Trust . The trust remains ahead of
plan for the year. The year to date surplus had slowed in month in line with forecast and the trust
remained on course to achieve its £808k surplus. The committee received an update on some the
underperformance of the Sandwell contract and the performance on detox beds.
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Workforce Report
Sickness has continued to rise in December. This was reviewed by the committee and an update on
the detailed work to understand underlying issues was received. The committee was also updated on
the regional sickness performance.
PBR Update.
The PBR lead for the Trust presented an update on progress with clustering. The level of unclustered
activity in the Trust continues to improve. A trajectory for reducing this further between now and 1st
April 2015 was received by the committee as well as a supporting action plan. Progress and
mitigations to deliver the trajectory would continue to be reviewed by the committee.
Reference Costs 2013/14
The committee reviewed the reference costs for the Trust for 2013/14 – this has reduced from 109 to
92. The underlying reasons for this were discussed including changes in expenditure between the
years and activity recording. The areas for review based on the reference cost schedules were agreed
with a report to come back to committee in April
Review of Risk Register
The committee reviewed the red risks currently on the Trust wide risk register and agreed the following
x Risk to be added for unclustered activity
x Review of the narrative for the Better Care Fund risk (risk 202) to reflect the latest position
x Risk Strat 18 to be updated to include reference to the newly formed GP company that has
been set up in Dudley
The business that was discussed by the committee interfaces with the following Committees/Groups:
x
x
x
x
x
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.
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Board meeting date:
4th February 2015
Report Title:
Enclosure:11
Board Sub Committee Chair Report
Committee:
Audit Committee
David Matthews, Non-Executive Director
Annalee Russell, Finance Manager – Audit & Assurance
Decision / Approval
Gain assurance
Discussion
Information
9
Key issues and Risks
Internal Audit
Internal Audit presented the following documents to the Committee –
x
Progress Report – Internal Audit advised that good progress was being made against plan and
that all 2014/15 audit work should be completed by the end of March 2015 with the possible
exception of the Data Quality Audit. In keeping with previous reports, this report included a ‘key
developments’ section highlighting issues that may affect the Trust or the wider Health Economy
in future months and years. It was decided that this information would be distributed to the
Committee members on a monthly basis by email and that only issues specifically affecting the
Audit Committee of the Trust would be included in future reports.
x
Outstanding Recommendations – There were no overdue recommendations and the Committee
was pleased to note the improvements since the last meeting. However, discussion was had
around the continual delay of the ratification and implementation of the Trust’s Locum Policy.
The Committee agreed that Dr Weaver would be invited to attend Audit Committee if the policy
has not been ratified before the 28th March 2015.
x
Internal Audit Management Letter – Data Quality Risk Assessment – This report focused on the
relative risk of data quality. Whilst no red rated assessments were made, there were three
amber rated assessments in respect of Compliments, Activity against Contract and IAPT. Once
these assessments have been reviewed by MexT and the Board they will be used to form the
basis of the Data Quality Audit. The Committee emphasized the need to complete this work in
March 2015 as its outcome will feed into the next review of the QGAF.
In addition, the following Internal Audit Reports were presented to the Committee –
x
Payroll – Significant Assurance
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x
x
x
x
Follow Up of CQC Action Plan – Significant Assurance
As is normal this audit had reviewed the systems and processes in place. However, because of
the importance of this area the Committee considered it would be appropriate for it to be able to
provide assurance to the Board that the actions themselves necessary to comply with the CQC
Compliance Notices have been completed. Therefore the Committee deferred acceptance of
this report and requested Internal Audit to undertake this additional work and report back to the
next meeting.
Costing / SLR System – Significant Assurance
It was agreed the Mr Axcell would report to the F&P Committee on the progress on the
implementation of the Costing/SLR system.
Management of Change – Significant Assurance
The Audit Committee considered that the audit work undertaken had not fully addressed one
aspect of the original scope of the work, as Internal Audit had not liaised directly with those staff
affected by the change to take into account their experience of the change. Internal Audit
agreed to undertake this additional work and report back to the next Committee meeting.
Procurement and Tendering – Moderate Assurance
It was agreed that a follow up audit should take place next year to provide assurance that the
issues identified in this audit have been fully addressed. As moderate assurance had been
given, the Committee discussed whether further assurance was required regarding the
individual tenders awarded over the last 12 months and it decided that a piece of follow-up work
would be undertaken looking in detail at two procurements over the last 12 months (one being
subject to a full Tender process and another subject to the Waiver process).
The Committee agreed that the extra work identified must be undertaken in addition to the Audit Plan
agreed at the outset of 2014/15.
External Audit
External Audit presented the following reports to the Committee –
x
x
Draft Audit Plan – External Audit advised that the Trust was in a robust financial position and
highlighted the main risks as those which apply to any organization as being the revenue cycle
and management over-ride of control.
Emerging Issues – This report included details of emerging issues and developments that may
affect the Trust and the wider health economy. Again, the Committee requested that this
information would be distributed to the Committee members on a monthly basis by email and
that only issues specifically affecting the Audit Committee of the Trust would be included in
future reports.
External Audit also confirmed that the findings of the Interim Audit would be presented to the meeting in
March 2015 and the findings of the Final Accounts Audit to the meeting in May 2015.
Counter Fraud
Counter Fraud presented the usual Progress Report to the Committee.
Trust Business
The following issues were discussed under Trust Business –
x
Board Assurance Framework (BAF) – The BAF was presented to the Committee in its new
layout. The Committee were advised that they should consider the following –
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o
o
o
Whether the sources of assurances identified in the BAF provide the Committee with
sufficient and appropriate assurance
Whether there are any additional assurances that the Committee are aware of that are
not reflected in the BAF
The BAF should be used to inform its future internal audit plans
Significant discussions were held around the possible introduction and use of a Board
Assurance Map (BAM) within the Trust. This was agreed in principle, Mr Matthews agreed to
discuss with the Chair how best to move the BAM forward and report back to the next
Committee.
x
Annual Audit Committee Self-Assessment Checklist – The checklist was reviewed and
amendments noted to be added to a final version of the document. Review of the document also
resulted in a number of actions being agreed.
x
Effectiveness of the Audit Committee Survey – The results of the recent survey were reviewed
and as a result a number of actions were agreed.
x
Annual Review of the Effectiveness of Local Counter Fraud Specialist, Internal Audit and
External Audit – The Committee confirmed that it was satisfied with the effectiveness of the
services received.
x
Management Papers – the regular updates on the number and value of waivers, purchase
invoices with no orders and losses and special compensations were provided.
Any Other Business
The Committee had originally decided to undertake a “mini-tender” in respect of the Internal Audit and
Local Counter Fraud Services contract. The Committee was advised that as the current Health Trust
Europe Framework ended in April 2016 that if the Trust went out to tender now it would have to do it
again in 2016 when the new Framework is put in place. Therefore the Committee agreed that the most
appropriate way forward would be to extend the current contract for a year, and then undertake a
procurement exercise at the expiry of the extended contract.
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Key action points and work in progress
Ms Ingram to review which staff had received counter fraud training and email the results to the
Committee.
Ms Ingram to ensure that the relevant details around completion of actions identified in the Chief
Executives Overview and Horizon Scanning report are to be added to future Board Reports by Mrs
Edwards.
Ms Barnard-Ghaut to send monthly Key Development Report to Audit Committee and MexT members
and include in future Internal Audit Progress reports those items to be considered by the Audit
Committee.
Mr Axcell to advise Dr Weaver on the position relating to the Locum Policy.
Mr Axcell to circulate the Internal Audit Letter on the Risk Assessment of Data Quality to Executive
Team members for comments prior to inclusion on Board Agenda for January 2015.
Mr Capener to undertake additional verification work and provide a revised updated report to the next
meeting (CQC Action plan).
In respect of Management of Change, Mr Capener is to speak to those staff involved regarding the type
and timeliness of the communication and report back to the next Committee.
Mr Capener to undertake a complete review of the tender process for contracts for work to Holyrood
and anti- ligature windows and report back to the next meeting.
Mr Axcell to report to F&P on the Costing/SLR system.
Mr Matthews to discuss with the Chair how best to move the Board Assurance Map forward and report
back to the next Committee.
Self-Assessment Checklist
Dr Gutteridge to request G&Q Committee to include a summary of its Security Management work in its
annual report to this Committee on Clinical Audit.
Mr Axcell to draft policy on the use of external audit for non-audit work.
Effectiveness of Audit Committee Survey
Mr Axcell to produce a report around outsourced services for the next Committee.
Mr Axcell to restructure the Committee agenda with effect from 01/04/2015 to include sections on
quality, data quality, performance and financial matters.
Mr Axcell/Ms Russell to include item on future agendas, so that Committee can discuss the attendance
of relevant staff at the next meeting..
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Mr Matthews to discuss with Chair and other NEDs and report back to the next meeting regarding the
suggestion that Chairs of other Committees attend and update the Audit Committee on an annual
basis.
Key developments as identified by Internal and External Audit to be reported to MExT and the
Committee and those requiring Board attention to be included in the Chief Executives Report to Board.
Results of Data Quality Risk Assessment to be taken straight to Board in January 2015 following review
by MExT.
Progress in respect of implementation of Costing and SLR System to be reported to Finance and
Performance Committee.
G&Q Committee to include a summary of its Security Management work in its Annual Report to Audit
Committee.
The Board is asked to receive and note this report from Audit Committee.
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Board meeting date:
Agenda Item number:
Enclosure:
4 February 2015
10.7
12 (i)
Report Title:
NHS England EPRR Core Standards: Compliance
Update
Martin Perkins, BounceBack Solutions
Following submission of the Trust's 2014 NHS England EPRR
Core Standards Self-Assessment in line with NHS England
guidelines and attached as Enclosure 12 (ii) for information to:
x Update the Trust Board on key milestones in achieving
current majority compliance.
x Indicate proposed next steps in maintaining ongoing
compliance.
Decision / Approval
Gain assurance
Discussion
Information
8
8
8
9
Key points or
Committee:
Committee: MExT
Date reviewed: 20 January 2015
EPRR Report and Core Standards Self-Assessment to be
submitted to full Trust Board for information as part of its
4 February 2015 agenda.
High quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources
9
8
9
9
9
9
relates to are:
Caring
Compliance with the detailed requirements of the NHS
EPRR Core Standards will ensure that staff can maintain
a high level of client care in the event of an incident or
disruption to normal service provision.
Maintenance of compliance will ensure that staff can
Responsive
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Effective
Well-led
Safe
appropriately and proportionately respond to ensure that
clients are not subject to avoidable delays in service
provision as a result of an incident or emergency.
Managerial and clinical leadership and accountability in
delivering and maintaining compliance will ensure that
continuity of critical and essential services remains
central to the Trust.
Managerial and clinical leadership and accountability in
achieving and maintaining EPRR Core Standards
compliance will ensure that the Trust maintains its critical
and essential services and continues to meet other
standards and performance targets in the event of an
incident or business disruption.
Compliance provides assurance that arrangements are
in place which meet the requirements of the Civil
Contingencies Act 2004 to respond to and manage major
incidents and emergency situations. This will ensure that
services users are safe and risks to care and treatment
are minimised should these situations occur.
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Title
NHS England EPRR Core Standards: Compliance Update
Introduction
All NHS Trusts must comply with the NHS England Core Standards for Emergency Preparedness,
Resilience and Response (EPRR) under the Health and Social Care Act 2012. The Core Standards
provide a consistent and detailed suite of requirements and a platform for assurance.
As part of the assurance process NHS Trusts are required to provide their NHS England Area Team
with an annual update on their progress against the Standards. In submitting its initial return in October
2013, the Trust assessed itself as future compliant for a significant number of the standards, due
principally to the impending ratification and rollout of its new Major Incident and Business Continuity
Plan and associated staff training programme.
In line with this year's requirement, the 2014 self-assessment was endorsed and submitted to the NHS
Area Team on 24th October 2014 by the Trust's Chief Executive, who acts as its Accountable
Emergency Officer (AEO) under the Health and Social Care Act 2012. A copy of the return is included
at Enclosure 12 (ii).
The 2014 return demonstrates significant progress on the part of the Trust, resulting in
substantial compliance against the Standards. This is as a direct consequence of successful
implementation by the Trust of the Major Incident and Business Continuity Plan and associated detailed
training programme as well as a refreshed Business Continuity Policy. Further detail can be found in
Section 1 of the Summary of Key Points, Issues and Risks Section of this paper.
Having achieved substantial compliance, the key focus necessarily moves to ensuring that compliance
is maintained. In the coming months it is anticipated that this work will centre principally on reviewing,
testing and exercising. Further detail is included at Section 2 of the Key Points, Issues and Risks
Section below.
1
Key milestones in achieving current EPRR Core Standards substantial compliance
1.1
Major Incident and Business Continuity Plan
Ratification by the Trust Board in January 2014 and rollout of a fully Core Standards compliant
combined Major Incident and Business Continuity Plan with a comprehensive supporting suite
of materials has been a key contributor to ensuring that the Trust in has achieved almost
complete compliance with the Core Standards in 2014. In the context of the Standards,
successful rollout of this plan across the Trust has been key to providing assurance that the
organisation has:
a. Identified those critical and essential services which, if interrupted for any reason, would
have the greatest impact upon the community, the health economy and the organisation.
b. Identified and reduced the risks and threats to the continuation of these critical and
essential services.
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c. Developed plans, which enable the organisation to maintain and/or recover critical and
essential services in the shortest possible time.
d. Clear command and control and reporting frameworks to support decision making during
the management of incidents.
e. The required infrastructure in place to support the management of Major incidents. This
includes access to Incident Control Rooms and Loggists.
f. Appropriately trained staff at all levels in their roles during the management of incidents
g. Routinely tests its resilience in maintaining key patient care during the management of
incidents.
In addition to exercising at the draft stage through Exercise Valentine 2 in September 2013, the
new Plan has already been successfully used by key staff to respond to the need to decant
inpatients from Dorothy Pattison Hospital, Walsall to Bushey Fields Hospital, Dudley (January
2014).
1.2
EPRR Staff Training Database
Alongside an all-staff EPRR awareness training record on the Trust's ESR system, a detailed
training needs analysis and training record for all staff with an identified role in the new Major
Incident and Business Continuity Plan forms a key annex to the Plan. This database:
x Ensures effective matching of staff against anticipated roles within the Plan;
x Identifies the training needed by each individual to fulfill their role(s) in line with current NHS
England best practice and the relevant training provider;
x Records all training received, including historic training in which Trust personnel have in the
past been willing participants; and
x Identifies future dates for any refresher training required.
1.3
Business Continuity Management Policy (BCM) Policy
The Core Standards require that NHS organisations undertake their business continuity
planning in accordance with the new International Standard for Business Continuity
Management ISO 22301 as well as the NHS's own Publicly Available Standard PAS 2015:
2010. These standards have already been explicitly followed in the new Major Incident and
Business Continuity Plan and the Directorate planning which underpins it. The Trust's existing
Business Continuity Management (BCM) Policy, which set the strategic framework for the
Trust's overall approach to BCM, was however developed to meet the previous NHS standard
(British Standard 25999). A revised BCM Policy to fully align with ISO 22301 and PAS 2015
was ratified by the Trust in May 2014.
1.4
Update of Trust Business Impact Analysis (BIA)
The Core Standards expect all NHS Trusts to maintain and update a comprehensive suite of
information detailing their services, the resources needed to maintain these and their priority for
recovery in the event of a business disruption. This is referred to as a Business Impact Analysis
(BIA) and forms an annex to the Trust's Major Incident and Business Continuity Plan as well as
informing Business Continuity Planning at Directorate level.
The Trust has for some time maintained its BIA through a single, highly flexible database which
can be interrogated at many different levels. This has already significantly improved the Trust’s
ability to dynamically and proportionately respond in the event of a disruptive challenge to the
routine provision of its services.
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Following internal audit in May 2014, it has however been recognised that it would be helpful in
the longer term to refine and expand the existing Trust Business Impact Analysis and through
this further strengthen the relationship between the Trust's Major Incident and Business
Continuity Plan and it's IT provider's Disaster Recovery (DR) Plan. The work to update the BIA
element has now been completed by BounceBack Solutions (who act as the Trust's Emergency
Planning and Business Continuity Officer) working with the Trust's Interim Head of ICT and in
line with agreed audit report timescales. Details were approved by MExT at its meeting of 20
January 2015 and will form the start point for further discussion and negotiation between the
Trust's Head of IT and Dudley IT Services as the Trust's provider.
2
Next steps in ensuring ongoing compliance
The Core Standards recognise that continued compliance is an iterative process and that
therefore plans and policies must be subject to regular review and testing. Following the
successful rollout of the Major Incident and Business Continuity Plan, refresh of key supporting
elements and further testing and exercising is already in hand to ensure their continued fitness
for purpose:
2.1
Exercising and Testing
To comply fully with the Core Standards, NHS organisations and providers of NHS funded care
must demonstrate as a minimum that they test plans through:
a. A communications exercise every six months
The Trust regularly and routinely tests its communications and resilience in maintaining key
patient care during the management of incidents. This is demonstrated through its robust inhouse on-call arrangements (via the Dorothy Pattison Hospital switchboard) to ensure contact
details are resilient and key resilience documentation fit for purpose and is effective for the
accurate recording and assessing situations. A further exercise is being planned with
BounceBack Solutions to execute a full Major Incident call-out communications test before the
end of the current calendar year. Progress will be reported to meetings of MExT and the Trust
Board as appropriate
b. An Incident Control Room test every six months
The Trust has equipped and regularly tests its three established Incident Control Rooms (ICRs)
at Trust Headquarters, Trafalgar House and at Dorothy Pattison and Bloxwich Hospitals.
BounceBack Solutions will oversee the planning and execution of an additional 6 monthly
Incident Control Room test before the end of the current financial year.
c. A desktop exercise once a year
The Trust successfully delivered Exercise Valentine 2 in September 2013 to test key elements
of its new Major Incident and Business Continuity Plan. A further table-top exercise will be
executed by the end of the current financial year with progress and outcomes reported to both
MExT and the Trust Board, including provision of a full Exercise Report.
d. A major live or simulated exercise every three years
Action is currently in hand to convert the incident in January 2014 at the Dorothy Pattison
Hospital site which required the decanting of inpatients to Bushey Fields to allow it to qualify as
a major live or simulated exercise for the purposes of the Core Standards. This is being
achieved thorough a debrief and lessons learned process, including a report, overseen by the
Trust's Chief Executive and Deputy Chief Executive and facilitated where requested to do so by
BounceBack Solutions.
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Lessons learned from all of these activities will be used to inform and refine the Trust's
established plans, policies and procedures as appropriate.
Background and Context
The NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR)
are the minimum standards which NHS organisations and providers of NHS funded care must meet as
part of the Health and Social Care Act 2012. They are intended to provide a consistent framework for
self- assessment, peer review and more formal control processes carried out by NHS England and
regulatory organisations.
To comply fully with the Core Standards, NHS organisations and providers of NHS funded care must
demonstrate as a minimum that they:
x
x
x
x
x
x
Have nominated a suitable accountable emergency officer (AEO) who will be responsible for EPRR.
Contribute to area planning for EPRR through Local Health Resilience Partnerships (LHRPs) and
other relevant groups.
Have suitable, up to date plans which set out in detail how they:
o Plan for, respond to and recover from major incidents and emergencies as identified in local
and community risk registers.
o Maintain continuous service when faced with disruption from identified local risks.
o Resume key services that have been disrupted by, for example, severe weather, IT failure,
an infectious disease, a fuel shortage or industrial action. This planning should follow the
principles of ISO 22301 and PAS 2015.
Test these plans through:
o A communications exercise every six months.
o An Incident Control Room (ICR) exercise every six months.
o A desktop exercise once a year.
o A major live or simulated exercise every three years.
Have suitably trained, competent staff and the right facilities available around the clock to effectively
manage a major incident or emergency.
Share their resources as required to respond to a major incident or emergency.
As part of the assurance process NHS Trusts are required to provide to their NHS England Area Team
with an annual update on their progress against the Standards. In October 2013 a detailed
Red/Amber/Green-rated self-assessment against each of approximately 120 individual Standards and
an associated action plan to address any shortfall in compliance was submitted to the NHS England
Birmingham, Solihull and Black Country Area Team.
In submitting its return at this time, the Trust assessed itself as future compliant (Amber) for a
significant number of the standards, due primarily to the impending ratification and rollout of its new
Major Incident and Business Continuity Plan and associated staff training programme.
Following a mid-year review in May, for October 2014 EPRR Core Standards progress reporting took
the form of a straightforward update against areas of non-compliance in the Trust's initial 2013 return,
including where appropriate revised compliance ratings.
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In line with this year's requirement, this update was endorsed and submitted to the NHS Area Team on
24th October 2014 by the Trust's Chief Executive, who acts as its Accountable Emergency Officer
(AEO) under the Health and Social Care Act 2012. A copy of the return is included for information at
Enclosure 12 (ii).
Recommendation
It is recommended that the Trust Board notes the content of this Report and the associated 2014 EPRR
Core Standards self-assessment attached at Enclosure 12 (ii).
The Trust Board is asked to note the content of this Report and the associated EPRR Core Standards
self-assessment attached at Enclosure 12 (ii).
137 of 182
138 of 182
Assessment of EPRR Core Standards - NHS Trusts, CCGs, NHS England : Phase 1, Autumn 2013
On the following page, please insert Organisation Name, Organisation Type (eg mental health trust), name of
completing officer (usually a EPO), name of authorising officer (Accountable Emergency Officer) and date of
submission
Select dropdown menu for relevant organisation type
Select your organisation
Filters have been provided to select only those questions relevant to each organisation type.
type using Autofilter
dropdown arrow(s)
Mental
health
CCGs
If your organisation provides two types of service (eg: acute and community services, or mental health and community
services) then you will need to select the appropriate columns sequentially, ensuring you have deselected the intial
colum first.
Uncategorised
Community
providers
NHS
England
NHS
England
Ambulance
trusts
Acute trusts
For example, if you represent an Acute Trust, click the down arrow for Acute trusts and check the X, this will hide the
Cat 1
Cat 2
questions that are not relevant to acute trusts
For example, if you represent an Acute Trust, click the down arrow for Acute trusts and check the X and complete the
relevant questions. Once completed, re-click the down arrow for acute trusts, ensure all boxes are checked, select the
Community Trust down arrow, and check the X box under that field and complete any unanswered fields.
Specialist Trusts should use Acute Trust dropdown, however some areas may not be applicable to them and the
option of N/A is available where this occurs.
Please note that some standards have been blanked out and will not be assessed in this round of assurance.
Suggested Evidence
Column U contains a list of suggested evidence that you may be asked to provide to demonstrate your selfassessment. You are not required to submit evidence in this submission, but be prepared to provide it upon request
later.
Self-Assess Progress
In Column V, provide a commentary to support your self-assessment including reference to the evidence you are
using to support your self-assessment. This may include evidence not listed in Column U. DO NOT SUBMIT
EVIDENCE AT THIS STAGE.
Work through each core standard and self-assess your progress using the following RAG-rating:
GREEN - arrangements in place now, compliant with core standards
AMBER - draft or scheduled for completion by Dec 2013
RED - arrangements not in place or scheduled for completion after Jan 2014
N/A - Not applicable to organisation
N/R - Not rated in 2013
Actions
Column X has been provided for those trusts that wish to use it. An improvement/rectification plan is required for all
NHS organisations.
Approval(s) & Submission
The completed self-assessment and accompanying action/rectification plan must be approved by the Accountable
Emergency Officer (executive-level) for the organisation prior to submission by 25th October 2013.
All NHS organisations will be required to provide evidence that their assessment of their progress against Core
Standards and the development of an action/rectification plan has been endorsed by their Trust Boards. This
endorsement by the Trust Board must be completed before mid-December.
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140 of 182
All NHS organisations and providers of NHS funded care must have plans setting out how they contribute to coordinated planning for emergency preparedness and resilience (for example surge, winter & service continuity) across
the area through LHRPs and relevant sub-groups. These plans must include details of:
Planning in
Partnership 'Preparedness'
be approved by the relevant board;
be signed off by the appropriate Senior Responsible Officer;
5 . 14
Governance
define how the organisation will meet the Prevent strategy’s objectives for health (1. prevent people from being drawn into
terrorism and ensure that they are given appropriate advice and support and 2. work with sectors and institutions where there
are risks of radicalisation which we need to address, and the wider CONTEST strategy).
Incident response plans must follow NHS governance arrangements. They must:
have been written in collaboration with PHE;
have been written in collaboration with all relevant partner organisations;
refer to all other associated plans identified by local, regional and national risk registers;
Incident response plans must be in line with published guidance, threat-specific plans and the plans of other
responding partners. They must:
refer to all relevant national guidance, other supporting and threat-specific plans (eg pandemic flu, CBRN, mass casualties,
burns, fuel shortages, industrial action, evacuation, lockdown, severe weather etc) and policies, and all other supporting
documents that enhance the organisation’s incident response plan;
include plans to maintain the resilience of the organisation as a whole, so that the Estates Department and Facilities
Department are not planning in isolation.
5 . 13
5 . 12
5 . 10
5.8
5.7
5.6
5.5
Interoperability
make sure that the funding and resources are available to cover the EPRR arrangements;
5.3
5.4
make sure that all arrangements are trialled and validated through testing or exercises;
5.2
plan for the potential effects of a significant incident or emergency or for providing healthcare services to prisons, the military
and iconic sites; and
be based on risk-assessed worst-case scenarios;
Incident Response All NHS organisations and providers of NHS funded care must have plans which set out how they plan for, respond to
Plan and recover from disruptions, significant incidents and emergencies. Incident response plans must:
'Preparedness'
Organisations must maintain a risk register which links back to the National Risk Assessment (NRA) and Community Risk
Register (CRR).
Organisations must have an annual work programme to reduce risks and learn the lessons identified relating to EPRR
(including details of training and exercises). This work programme must link back to the National Risk Assessment (NRA) and
Community Risk Register (CRR).
System Assurance All NHS organisations and providers of NHS funded care must contribute to an annual NHS England report on the
for Emergency
health sector’s EPRR capability and capacity in responding to national, regional and LRF incidents. Reports must
Preparedness
include control and assurance processes, information-sharing, training and exercise programmes and national
capabilities surveys. They must be made through the organisations’ formal reporting structures.
director-level representation at the LHRP; and
All NHS organisations and providers of NHS funded care must share their resources as necessary when they are
required to respond to a significant incident or emergency.
Resource
contribution 'Response'
5.1
5
4 .2
4 .1
4
3.1
3
2
1
Accountable
All NHS organisations and providers of NHS funded care must nominate an accountable emergency officer who will be
Emergency Officer responsible for EPRR and business continuity management.
NHS Core Standards for Emergency Preparedness, Resilience & Response (EPRR)
Cat 1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Ambulance
trusts
X
Acute trusts
dropdown arrow(s)
type using Autofilter
Select your organisation
X
X
X
X
X
X
X
X
X
-
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
-
X
X
NHS
England
NHS
England
Organisation name: DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP TRUST
Organisation type(s): Mental Health Trust
Name of completing officer: Wayne Deakin, Interim Emergency Planning and Business
Continuity Officer
Name of authorising officer: Gary Graham, Chief Executive Officer
Submission date: 24th October 2014
Cat 2
X
X
X
X
X
X
X
X
X
-
-
X
X
X
x
X
X
X
X
X
X
X
X
X
X
X
CCGs
- NHS England EPRR Core Standards Self-Assessment 2014
Uncategorised
X
X
X
X
-
X
X
X
X
X
X
X
X
X
x
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
x
X
X
X
X
X
X
X
X
X
X
X
Mental
health
Enclosure 12 (ii)
Community
providers
Gary Graham, Trust Chief Executive Office
Full suite of ERMA Commander training completed over last 3 years
Media training (with all Trust Executive Directors and Trust Chair) Feb 2011
Bond Solon Witness Training 9 Sept 2012
Acute Commander Training for NHS England IRP May 2013
AEO role not currently explicitly referenced in CEO Job Description
Commentary
References to Suggested Evidence
Trust is a specialist Trust; nature of business therefore means focus should be
on effective business continuity. Current Trust BCM Policy (v1.0 ratified 14
March 2012) includes a fully compliant risk assessment methodology but not
yet completed across the Trust
Annual Board Reports which include work programme underpinned from Trust
Risk Assessment methodology which includes consideration of Community Risk
Register ; latest Board Report outstanding
Not rated in 2013
Trust draft Major Incident and Business Continuity Plan is a generic, flexible plan
appropriate to the range of services delivered and the varying scales and
complexities of situations which may be faced by the Trust at Team, Directorate
and at Trust-wide level. The draft Plan compliments the existing suite of Trust
policies and Plans already developed which take account of relevant national
guidance including the national Heatwave Plan and Flu Pandemic Planning
arrangements (the local update of which requires issue of outstanding national
DH guidance)
See Incident Assessment Guidelines within the Plan which appear in Sections 2,
3, 4, 5, 6 and 7.
See also the risk assessment methodology outlined in the Trust's ratified
Business Continuity Policy (see Section 8.2 of policy).
Trust draft Major Incident and Business Continuity Plan refers explicitly at
Sections 3, 4, ,5, 6 and in Action Cards at Section 7 to use of existing Policies
and Strategies as appropriate. Ratified Trust Business Continuity Policy at
Section 8.2 refers to use of risk registers.
Draft Major Incident and Business Continuity Plan is a generic plan which
supports existing policies and procedures which have been written in
collaboration with all appropriate internal and external agencies e.g. Infectious
disease outbreak Infection Prevention & Control Policy.
Draft Major Incident and Business Continuity Plan is a generic plan which
supports existing policies and procedures which have been written in
collaboration with all appropriate internal and external agencies e.g. Infection
Prevention & Control Policy.
Planning and response complements existing policies and strategies across the
Trust (see statements throughout draft Major Incident and Business Continuity
Plan, including Action Cards at Section 7).
See ratified Trust Business Continuity Policy which outlines roles and
responsibilities across the Trust
Draft Major Incident Plan has specific action card for estates and facilities
working in liaison with other roles
Application of preferred risk assessment methodology as outlined in Policy, all
departments are asked to identify and assess risks affecting estates and
possible mitigations.
Trust contributes to 'Resilience of 'Estates and Facilities Service' survey
organised by the Health and Social Care Information Service.
● Page/ section references in IRP, annexes to plans or
Section 1.4.1 of draft Major Incident and Business Continuity Plan
standalone plans
See Section 1 of draft Major Incident and Business Continuity Plan (v0.1 June
standalone plans
2013)
● Notes from relevant approving Board meeting
Not rated in 2013
standalone plans
standalone plans
standalone plans
standalone plans
● Business Continuity planning arrangements
demonstrate joint working between EP and estates/
facilities staff (ToR for related meetings, task and
finish groups)
● Action card for E&F in IRP/ BCP
which takes account of the range of services delivered and the varying scales
and complexities of situations which may be faced by the Trust at Team,
Directorate and at Trust-wide level. See Incident Assessment Guidelines within
the Plan which appear in Sections 2, 3, 4, 5, 6 and 7. This is underpinned by the
risk assessment methodology outlined in the Trust's ratified Business Continuity
Policy (see Section 8.2 of policy)
Ongoing contract with external EPRR consultancy plus roles and responsibilities
as outlined in Section 7.1 of current Business Continuity Policy
● Details of agreed budget
● EPRR business cases/ papers for funding,
● EPLO job description showing WTE
● Demonstrate representation on relevant planning
groups, ToR/ minutes (eg: Security Liaison Groups for
COMAH sites etc)
● Associated risk reflected on local risk register
● IRPs recognise specific local challenges
See Section 1.7 and 1.8 of draft Major Incident and Business Continuity Plan
(draft v0.1 June 2013)
● Testing and Exercising programme / log that
complies with national exercising standards
● Post exercise/ incident reports, showing lessons
identified, with an action plan to address gaps
and complexities of situations which may arise within the Trust at Team,
Directorate and at Trust-wide level. This is underpinned by the risk assessment
methodology outlined in the Trust's ratified Business Continuity Policy (see
Section 8.2 of policy)
● Page/ section reference in arrangements
demonstrating how the organisation plans for incidents and complexities of situations which may arise within the Trust at Team,
Directorate and at Trust-wide level. This is underpinned by the risk assessment
● Demonstration of risk assessments
methodology outlined in the Trust's ratified Business Continuity Policy (see
● ToR of MI/BC Planning Groups
Section 8.2 of policy)
NHS organisation's Incident Response Plan and
supporting plans, appendices and other documents
(eg Standard Operating Procedures)
● Risk register
● Details on the process/ schedule of review
● Work plan for EPRR
● Risk Register reflects community risk register
● EPRR Board report, issues/ lessons log
Contributing through NHS England Core Standards Self Assessment process
Annual Board Reports which include work programme underpinned from Trust
Risk Assessment methodology which includes consideration of Community Risk
Register ; latest Board Report outstanding
Gary Graham, Trust Chief Executive Officer, deputy is Marsha Ingram, Trust
Deputy CEO
● LHRP Terms of Reference (ToR), membership list
● most recent LHRP minutes
● Participation in annual process (eg NHS Safe
System process)
● EPRR Board report/ formal reporting structure
outlined
● Training and exercise programmes
● Post exercise reports, showing lessons identified,
with an action plan to address gaps
Membership of LHRP, CEO (and Deputy CEO as nominated CEO alternative)
invited to attend
Membership of West Midlands Health Emergency Planning Group through
Interim Emergency Planning and Business Continuity Officer who regularly
attends meetings
Representation to the LRF through NHS England Area Team
● Local Health Resilience Partnership (LHRP) and
Local Resilience Forum (LRF) where applicable
● LA-boundary Resilience Forum / subgroup
participation
● Articulated in Incident Response Plans (IRP)
See Section 3 draft Major Incident and Business Continuity Plan, also NHS
● MoU/ mutual aid arrangements, evidence of
England Area Team IRP for coordination of resources
participation in multiagency planning groups/ LHRP as
Trust also participates in West Midlands Health Emergency Planners Group
appropriate
● Accountable Emergency Officer (AEO) details
(name, role)
● AEO job description
●Evidence that AEO completed relevant training (SLC,
witness familiarisation etc - dates completed)
● Competency assessed against National
Occupational Standards
Suggested Evidence
N/R - Not rated in 2013
N/A - Not applicable to organisation
GREEN - arrangements in place now, compliant with core standards
AMBER - draft or scheduled for completion by Dec 2013
RED - arrangements not in place or scheduled for completion after Jan 2014
N/R
Self
Assessment
(Red, Amber,
Green, N/A, N/R)
Mid-year 2014 update
Explicit recording to be included as part of ESR
record by end June 2014
Progress to Date
Not Applicable
BounceBack Solutions with executive oversight from Gary
Major Incident Plan ratified by full Trust Board 8
Graham to complete development, ratification and rollout of draft January 2014 and already used to respond to
Major Incident and Business Continuity Plan by end December
incident at Dorothy Pattison Hospital 7/8
2013
January 2014
2013
January 2014
Not rated in 2013
2013
January 2014
2013
January 2014
2013
January 2014
2013
January 2014
2013
January 2014
2013
January 2014
Not Applicable
January 2014 and already used to respond to
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
Not Applicable
January 2014
Directorate BDRAs and Trust-wide aggregated
BDRA now in place to underpin ratified Major
Incident and Business Continuity Plan
Directorate BCM Leads and BounceBack Solutions to complete
Business Disruption Risk Assessment process in line with Policy
across all Directorates to underpin new Major Incident and
Business Continuity Plan by end December 2013
Major Incident and Business Continuity Plan and associated
training and exercising programme by end December 2013
January 2014
Specific functional submissions and updates to
MExT (Operational Board) 17 December 2013
and full Trust Board 8 January 2014.
BouceBack Solutions to complete and Trust Board to ratify EPRR
Board Report by end December 2013
BouceBack Solutions to complete and Trust Board to ratify EPRR
Board Report by end December 2013
Attendance delegated to Emergency Planning
and Business Continuity Officer in line with
latest NHS Area Team guidance
Issue ongoing. Identified in original Core
CEO and Deputy CEO to consider direct participation in LHRP by
Standards return October 2013. Consideration
end December 2013 for full compliance
of possible options ongoing
January 2014
Included as part of ESR record.
Not Applicable
Current Position
October 2014 Self Asssessment
Progress to Date
Attendance delegated to Emergency Planning
and Business Continuity Officer in line with
latest NHS Area Team guidance
Not Applicable
Current Position
Issue ongoing. Identified in original Core
CEO and Deputy CEO to consider direct participation in LHRP by
Standards return October 2013. Consideration
end December 2013 for full compliance
of possible options ongoing
Major Incident and Business Continuity Plan to provide current
statement of position by end December 2013
January 2014
Updated CEO Job Description including AEO role specific
references to be considered and agreed by end December 2013
Areas Requiring Improvement
Actions to be Taken (including timescales)
2013 Self Assessment Return
1 of 5
141 of 182
X
X
5 . 48
5 . 47
5 . 46
Explain the process of recovery and returning to normal processes.
Explain how VIPs will be managed, whether they are casualties or visiting others who are casualties.
Explain how specific casualties will be managed – for example, burns, paediatrics and those from certain faiths.
X
X
X
X
Describe how stores and supplies will be maintained.
5 . 45
X
X
Consider using helplines in an emergency. Set up procedures in advance which explain the arrangements. Make sure foreign
language lines are part of these arrangements.
Explain how to communicate with partners, the public and internal staff based on a formal communications strategy. This must
take into account the FOI Act 2000, the Data Protection Act 1998 and the CCA 2004 ‘duty to communicate with the public’.
Social networking tools may be of use here.
X
5 . 44
5 . 42
5 . 41
X
5 . 40
Explain how extended working hours will apply and how they can be sustained. Explain how handovers are completed.
X
Explain the process for completing, authorising and submitting NHS England standard threat-specific situation reports and
how other relevant information will be shared with other organisations.
X
X
X
X
Refer to specific action cards relating to using the incident response plan.
Define the role of the loggist to record decisions made and meetings held during and after the incident, and how an incident
report will be produced.
Identify where the incident or emergency will be managed from (the ICC).
Explain how mutual aid arrangements will be activated and maintained.
Set out the responsibilities of the appropriate Senior Responsible Officer or nominated Executive Director.
5 . 39
5 . 36
5 . 35
5 . 34
5 . 33
X
Set out the responsibilities of key staff and departments.
5 . 32
X
X
X
Include 24-hour arrangements for alerting managers and other key staff, and explain how contact lists will be kept up to date.
Set out responsibilities for carrying out the plan and how the plan works, including command and control
arrangements and stand-down protocols.
Describe the alerting arrangements for external and self-declared incidents (including trigger points, decision trees and
escalation/de-escalation procedures)
5 . 31
5 . 28
X
It must be clear how key staff can achieve and maintain suitable knowledge and skills.
X
X
5 . 27
It must be clear how awareness of the plan will be maintained amongst all staff (for example, through ongoing education and
information programmes or e-learning).
Key knowledge and skills for staff must be based on the National Occupation Standards for Civil Contingencies. Directors on
NHS on-call rotas must meet NHS published competencies.
There must be an annual work programme setting out training and exercises relating to EPRR and how lessons will be learnt.
Key staff must know where to find the plan on the intranet or shared drive.
Staff must be aware of the Incident Response Plan, competent in their roles and suitably trained.
X
X
X
X
X
X
X
X
X
Incident 'Response'
Staff Competence
& Training
demonstrate a systematic risk assessment process in identifying risks relating to any part of the plan or the identified
emergency.
explain how predicted and unexpected spending will be covered and how a unique cost centre and budget code can be made
available to track costs; and
include an audit trail to record changes and updates;
set out how the plan will be published – for example, on a website;
include version controls to be sure the user has the latest version;
explain how internal and external consultation will be carried out to validate the plan;
identify who is responsible for making sure the plan is updated, distributed and regularly tested;
Acute trusts
5 . 26
5 . 25
5 . 24
5 . 23
5 . 22
5 . 21
5 . 20
5 . 19
5 . 18
5 . 17
5 . 16
5 . 15
set out how legal advice can be obtained in relation to the CCA;
Ambulance
trusts
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
-
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
-
X
X
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
NHS
England
NHS
England
X
CCGs
X
-
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
Community
providers
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Mental
health
Commentary
To be considered as part of training plan for ALL staff with a role at Annex 4 of
draft Major Incident and Business Continuity Plan (v0.1 June 2013)
● Training Needs Analysis
● Training schedule
● Training materials
● Training records
See Section 3 of draft Major Incident and Business Continuity Plan (v0.1 June
2013) and Notification and Escalation Diagram extensively throughout Plan
On-call rotas for OC1, OC2 and OC3 maintained and updated, stored on Trust
'j' drive
Progress to Date
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
Progress to Date
Not Applicable
Section 6.11 of draft Major Incident and Business Continuity Plan (v0.1 June
2013) refers, to stand down and return to normality to be overseen by MIMG,
standalone plans
informed by escalatory and de-escalatory Trust incident assessment guidelines
● Action Cards
which appear at Sections 3, 4, 5, 6 and 7 of the draft Plan.
● Page/ section references in IRP, annexes to plans or Due to the referral process into the Trust services we do not anticipate receiving
standalone plans
a VIP as a patient. Trust Senior Management and Communications Team
● Action Cards
personnel are fully competent to deal as necessary with visits by VIP
Management of burns and paediatrics with Plans inappropriate to the activities of
● Page/ section references in IRP, annexes to plans or this Trust. The draft Major Incident and Business Continuity Plan includes
standalone plans
management of incidents of services routinely provided to service users of
● Action Cards
different faiths. All Plans and Policies within the Trust are Equality Impact
Assessed as a matter of policy.
Not Applicable
2013
January 2014
Not applicable
2013
January 2014
January 2014
Not Applicable
January 2014
January 2014
2013 to codify role of Estates and Facilities Adviser
January 2014
● Page/ section references in IRP, annexes to plans or Estates and Facilities Adviser Action Card within Section 7 of draft Major
standalone plans
Incident and Business Continuity Plan (v0.1 June 2013). Standard procurement
● Action Cards
procedures also include emergency procurement.
Not Applicable
Not Applicable
January 2014
January 2014
January 2014
2013
January 2014
2013
January 2014
Not Applicable
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
Graham to complete development, ratification and rollout of draft
2013
2013
2013
2013
2013
2013
January 2014
January 2014. Detailed staff training matrix and
role based individual training needs Annex
endorsed by MExT (Operational Board) 29 April
2014
2014
Progress has been made and work is
anticipated to be completed by the West
Midlands Health Emergency Planning Network
by end November 2014
January 2014
2014
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
January 2014
Not Applicable
Current Position
2013
January 2014
2013
January 2014
Major Incident and Business Continuity Plan including training
plan by end December 2013
January 2014
Major Incident and Business Continuity Plan by end December January 2014. Detailed staff training matrix and
2013 , work programme to be overseen by proposed EPRR
Working Group
2014
West Midlands Health Emergency Planning
Network has developed a work programme to
adapt the principles of the NOS to provider
Major Incident and Business Continuity Plan including training
Trusts. This is not anticipated to be competed
plan by end December 2013
by end June 2014
2013
2014
2013
2014
2013
January 2014
2013
2013
2013
2013
2013
2013
2013
2013
January 2014
Self
Assessment
(Red, Amber,
Green, N/A, N/R)
Action Cards for Communications & Media Adviser at Section 7 of draft Major
Incident and Business Continuity Plan (v0.1 June 2013) refers, IT an
standalone plans
Telecommunications Adviser and IT & Telecoms Technical Support Action
● Action Cards
Cards also at Section 7. ICCs include in-situ set-up instructions as appropriate
● Page/ section references in IRP, annexes to plans or Action Cards for Communications & Media Adviser at Section 7 of draft Major
standalone plans
Incident and Business Continuity Plan (v0.1 June 2013) refers, in particular to
● Action Cards
develop appropriate and proportionate communications strategy
Action Cards at Section 7 of draft Major Incident and Business Continuity Plan
standalone plans
(v0.1 June 2013) refer
● Action Cards
Threat specific plans include standard reporting procedures e.g. Pandemic Flu
standalone plans
and Heatwave Plan in line with current national guidance
● Action Cards
Section 7 of draft Major Incident and Business Continuity Plan (v0.1 June 2013)
standalone plans
refers
● Action Cards
● Page/ section references in IRP, annexes to plans or See Decision Loggist Action Card at Section 7 of draft Major Incident and
standalone plans
Business Continuity Plan (v0.1 June 2013)
● Action Cards
Cadre of Trust PAs completed Loggist training 13 Dec 2011
Section 1.4.1 of draft Major Incident and Business Continuity Plan (v0.1 June
standalone plans
2013) refers
● Action Cards
● Page/ section references in IRP, annexes to plans or Sections 3 and 6 of draft Major Incident and Business Continuity Plan (v0.1
standalone plans
June 2013) refers plus escalation hierarchy in Notification and Escalation
● Action Cards
Diagram used throughout Plan
standalone plans
2013) refers
● Action Cards
See entirety of draft Major Incident and Business Continuity Plan (v0.1 June
standalone plans
2013)
● Action Cards
● On-call arrangements/ processes, On-call pack, Oncall staff lists
● Responsibility assigned to an Action Card
● Admin / support role assigned to maintain systems
● Reports from COMMEX/ regular cascades using
contact lists
● Page/ section references in IRP, annexes to plans or See Section 3 of draft Major Incident and Business Continuity Plan (v0.1 June
standalone plans
2013) and Notification and Escalation Diagram extensively throughout Plan
Training plan for ALL staff with a role at Annex 4 of draft Major Incident and
Not a standard of which the Trust was aware, to be considered as part of
training plan for ALL staff with a role at Annex 4 of draft Major Incident and
See ratified Business Continuity Policy for commitment to appropriate staff
training and exercising - see Section 11.2
Training programme for all staff in development to be added as Annex 4 to draft
Major Incident and Business Continuity Plan (also see Sections 1.7 and 1.8 of
Plan)
2013), also Annex 4 draft Training Plan
● Testing and Exercising schedule
● Details on process for reviewing plans in light of
lessons learnt
● Training plan for staff with a specific role
● Training Needs Analysis for those staff
Trust draft Major Incident and Business Continuity Plan refers explicitly at
Sections 3, 4, ,5, 6 and in Action Cards at Section 7 to use of existing Policies
and Strategies as appropriate. Ratified Trust Business Continuity Policy at
standalone plans
Section 8.2 refers to use of risk registers.
Risk Assessment methodology at Annex 3 of draft Plan
Finance Adviser Action Card at Section 7 of draft Major Incident and Business
Continuity Plan includes development and implementation of appropriate
standalone plans
financial management and strategy
Section Amendment Sheet of draft Major Incident and Business Continuity Plan
standalone plans
Section 1.4.1 of draft Major Incident and Business Continuity Plan
standalone plans
Section Amendment Sheet of draft Major Incident and Business Continuity Plan
standalone plans
● Page/ section references in IRP, annexes to plans or Draft Major Incident and Business Continuity Plan is owned by the Trust Board,
standalone plans
will follow standard Trust ratification procedures (see Trust Policies on Policies)
● Page/ section references in IRP, annexes to plans or Section 1.4.1 of draft Major Incident and Business Continuity Plan, consider
standalone plans
expansion to e.g. include explicit role of EP and BCM officer prior to finalisation.
Legal adviser Action Card at Section 7 of draft Major Incident and Business
Continuity Plan.
standalone plans
Links with existing external EPRR groups provide established conduit for advice.
Suggested Evidence
Not Applicable
Not Applicable
Current Position
2 of 5
142 of 182
patients with burns requiring critical care; and
severe weather.
5 . 56
5 . 57
7 . 12
7 . 11
7 . 10
7.9
7.8
7.7
7.6
7.5
7.4
7.3
7.2
7.1
7
6.4
6.3
6.2
6.1
Organisational
Knowledge
PLANNING
CONTEXT OF THE
ORGANISATION
LEADERSHIP
Plans must be maintained based on risk-assessed worst-case scenarios.
Business continuity plans must take into account the organisation’s critical activities, the analysis of the effects of
disruption and the actual risks of disruption.
Organisations must identify and manage internal and external risks and opportunities relating to the continuity of their
operations.
The planning process must take into account nationally available toolkits that are seen as good practice.
There must be an audit trail to record changes and updates such as changes to policy and staffing.
The BCMS policy and business continuity plan must be approved by the relevant board and signed off by the appropriate
Senior Responsible Officer.
Business continuity plans must include governance and management arrangements linked to relevant risks and in line
with international standards.
Each organisation’s BCMS must be based on its legal responsibilities, internal and external issues that could affect service
delivery and the needs and expectations of interested parties.
Organisations must establish a business continuity policy which is agreed by top management, built into business processes
and shared with internal and external interested parties.
Organisations must make clear how their plan will be published, for example on a website.
develop, use and maintain business continuity plans to manage disruptions and significant incidents based on recovery time
objectives and timescales identified in the business impact analysis
BC Plans
Governance
develop business continuity strategies for continuing and recovering critical activities within agreed timescales, including the
resources required such as people, premises, ICT, information, utilities, equipment, suppliers and stakeholders; and
set out how finances and unexpected spending will be covered, and how unique cost centres and budget codes can be made
available to track costs;
make sure that there are suitable financial resources for their BCMS and that those delivering the BCMS understand and are
competent in their roles;
BC Strategy
SUPPORT
Service 'Resilience' All NHS organisations and providers of NHS funded care must develop, maintain and continually improve their
business continuity management systems. This means having suitable plans which set out how each organisation will
maintain continuity in its services during a disruption from identified local risks and how they will recover delivery of
key services in line with ISO22301. Organisations must:
Facilities and equipment must meet the requirements of the NHS England Corporate Incident Response Plan.
There must be a plan setting out how the Incident Coordination Team will be called in and managed over any length of time
There must be detailed operating procedures to help manage the ICC (for example, contact lists and reporting templates).
There must be a plan setting out how the ICC will operate.
Incident CoAll NHS organisations must provide a suitable environment for managing a significant incident or emergency (an ICC).
ordination Centre - This must include a suitable space for making decisions and collecting and sharing information quickly and efficiently.
'Response'
pandemic flu;
5 . 55
6
mass casualty incidents;
5 . 54
Link the Incident Response Plan to threat-specific incidents
Describe local escalation arrangements and trigger points in line with regional escalation plans and working alongside acute,
ambulance and community providers.
Set out how surges in demand will be managed.
Explain who will be responsible for managing escalation and surges.
CBRN incidents;
Threat Specific
Surge
Explain how to support patients, staff and relatives before, during and after an incident (including counselling and mental health
services).
5 . 53
5 . 52
5 . 51
5 . 50
5 . 49
Explain the de-briefing process (hot, local and multi-agency)at the end of an incident.
Acute trusts
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
-
X
X
X
X
X
X
X
X
Ambulance
trusts
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
-
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
-
-
-
-
X
X
X
X
X
NHS
England
NHS
England
X
CCGs
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
-
-
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Community
providers
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Mental
health
Commentary
See Section 1.4.1 of v0.1 June 2013 draft Major Incident and Business
Continuity Plan, locations to be finalised
● Page/ section references in BC arrangements
See Section 8.2 of ratified v1.0 March 2012 Business Continuity Policy and
v0.1 June 2013 draft Major Incident and Business Continuity Plan Annex 3
Trust-wide BDRA
Trust-wide BDRA
● Risk assessments/ methodology
Not rated in 2013
See Amendment Record Sheet v0.1 June 2013 draft Major Incident and
Business Continuity Plan,
Will be reviewed when National Toolkit available
See Section 1.4.1 of v0.1 June 2013 draft Major Incident and Business
Continuity Plan
See ratified Trust Business Continuity Policy v1 .0 March 2012
See ratified Trust Business Continuity Policy v1.0 March 2012
Draft Major Incident and Business Continuity Plan underpinned by Trust-wide
BIAs with RTOs which form Annex 2 of draft v0.1 of the Plan
Draft Major Incident and Business Continuity Plan underpinned by Trust-wide
BIAs containing details of resources required such as people, premises, ICT,
information, utilities, equipment, suppliers and stakeholders and which form
Annex 2 of draft v0.1 of the Plan
Finance Adviser Action Card in Major Incident and Business Continuity Plan
(draft v0.1 June 2013) includes a role empowered to address unexpected
spending including the creation of unique cost centres and budget codes
Roles and responsibilities included at Section 7.1 of current ratified Business
Continuity Policy (v1.0 March 2012)
Draft training plan included as Annex 4 to Major Incident and Business
Continuity Plan (draft v0.1 June 2013)
Draft Major Incident and Business Continuity Plan (v0.1 June 2013) is written to
comply with ISO 22301
Current ratified BCM Policy (v0.1 March 2012) currently aligned with BS25999.
Policy update to include ISO22301 compliance
● Page/ section references in Business Continuity
Management System arrangements/ Business
Continuity Policy/ Business Continuity Plan, annexes
to plans or standalone plans
● BUSINESS CONTINUITY POLICY, BUSINESS
CONTINUITY PLAN AND APPENDICES
● Arrangements dealing with site/organisation specific
risks (eg: flooding)
● Action plan for transition to/ alignment with
ISO22301
standalone ICC plans
4 x ICCs established proportionately and appropriately equipped to the role and
● Action Cards
size of the Trust
● Provide detail on equipment available within ICC
● Provide detail on the programme for exercising ICC
arrangements
refers
● Action Cards
refers
● Action Cards
● Page/ section references in IRP, annexes to plans or All Trust ICCs have specific set up instructions, The Trust has a cadre of
internal officers at all relevant sites routinely trained in set up. Section 7 of draft
● Action Cards
Major Incident and Business Continuity Plan (v0.1 June 2013) also refers
● Page/ section references in IRP, annexes to plans or The Trust has 4 facilities already equipped for use as ICCs. See Section 1.4.1
and 6.7 of draft Major Incident and Business Continuity Plan for specific
● Action Cards
locations (v0.1 June 2013)
Draft Major Incident and Business Continuity Plan (v0.1 June 2013) is a generic
plan which compliments existing threat specific plans such as the national
● Page/ section references in IRP/ Surge Management Heatwave Plan in use by the Trust. The Major Incident and Business Continuity
arrangements, annexes to plans or standalone plans
Plan makes clear that response to threat specific incidents will be achieved
● Specific Severe Weather plans
through the relevant threat-specific policy or plan. Trust-wide Directorate Risk
Assessments provide details of severe weather risks, current controls and
potential additional mitigations
● Page/ section references in IRP/ Surge Management
Not applicable to the nature of services provided by this Trust
● Specific Burns plans
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Directorate BCM Leads and BounceBack Solutions to ensure
Trust-wide completion of Directorate BDRAs which underpin the
January 2014 includes Trust-wide aggregated
new Major Incident and Business Continuity Plan by end
BDRA derived from Directorate BDRAs
December 2013
Trust-wide completion of BIAs and BDRAs which underpin the
December 2013
Not rated in 2013
2013
January 2014
2013
January 2014
2013
January 2014
Not Applicable
Not Applicable
January 2014. Policy compliant with ISO22301
2013., also redrafted BCM Policy aligned with ISO 22301 by
ratified by MExT (Operational Board) 29 April
same date
2014
January 2014 including detailed training plan at
2013
Annex 4
2013
January 2014
January 2014 includes Trust wide aggregated
BIAs for all Directorates
2013
Trust-wide completion and programmed review of BIAs to
underpin draft Major Incident and Business Continuity Plan. Initial
completion to be by end December 2013
Not Applicable
2013
January 2014
2013
January 2014
2013
January 2014
Not Applicable
Graham to complete development, ratification and rollout of draft Major Incident Plan ratified by full Trust Board 8
Major Incident and Business Continuity Plan to codify
relationships by end December 2013,
Ensure all Directorates complete Business Disruption Risk
January 2014
Assessments by end December 2013
Not applicable
2013 to codify relationship
January 2014. BounceBack Solutions to
Timescales for update of Flu Pandemic planning not possible to complete Trust Flu Pandemic Plan by end June
establish until publication date for updated DH guidance is known
2014
Not applicable
Not applicable
Not applicable
2013
January 2014
Not applicable
Draft Major Incident and Business Continuity Plan (v0.1 June 2013) is a generic
plan which compliments existing threat specific plans.
Pandemic Flu Plan is a multi-agency one which requires updating but which
cannot be revised until issue of outstanding DH guidance which reflects new
NHS arrangements
The Major Incident and Business Continuity Plan makes clear that response to
● Specific Pandemic Flu plans
threat specific incidents will be achieved through the relevant threat-specific
policy or plan
(RAG rating assumes that availability of updated DH Pandemic Guidance will
not allow refreshed Pandemic Flu Plan to be delivered by Jan 2014)
Progress to Date
2013
January 2014
● Specific Mass Casualties plans
N/R
Self
Assessment
(Red, Amber,
Green, N/A, N/R)
● Specific CBRN plans
● Escalation framework including trigger points for
ambulance, acute and community
● Action Cards
● Action Cards
Staff dealt with through normal Trust Occupational Health procedures
Draft Major Incident and Business Continuity Plan includes references in Action
● Page/ section references in IRP, annexes to plans or Cards at Section 7 for managers to maintaining Health and Safety as
standalone plans
appropriate
● Action Cards
Approach to patients would be built in as appropriate to individual care plans
Access to mental health services and counselling would be made available
through existing referral pathways (e.g. via GP when considered appropriate)
Section 6.12 of draft Major Incident and Business Continuity Plan (v0.1 June
standalone plans
2013) refers
● Action Cards
Suggested Evidence
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Current Position
Progress to Date
January 2014
January 2014
January 2014
Not Applicable
Not Applicable
January 2014. Policy compliant with ISO22301
2014
January 2014 including detailed training plan at
Annex 4
January 2014
Not Applicable
January 2014
January 2014
January 2014
Not Applicable
January 2014
Not applicable
Mid-year update in May 2014 assumed
availability of updated national Flu Pandemic
guidance in time to revise and update Trust
arrangements. National guidance still in fact
awaited as of October 2014
Not applicable
Not applicable
Not applicable
Not applicable
January 2014
January 2014
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Current Position
3 of 5
143 of 182
details of a surge plan to maintain critical services.
X
Embedded in the
Organisation
Business continuity plans must specify how they will be communicated to and accessed by staff. Plans must include:
X
X
X
Organisations must identify and take action to correct any irregularities identified through the BCMS and must take steps to
prevent them from happening again. They must continually improve the suitability and effectiveness of their BCMS.
IMPROVEMENT
7 . 39
X
X
X
Organisations must monitor, measure, analyse and assess the effectiveness of their BCMS against their own requirements,
those of relevant interested parties and any legal responsibilities.
Plans must identify who is responsible for making sure the plan is updated, distributed and regularly tested.
Organisations must use, exercise and test their plans to show that they meet the needs of the organisation and of other
interested parties. If possible, these exercises and tests should involve relevant interested parties. Lessons learnt must be
acted on as part of continuous improvement.
Business continuity plans must specify how they will be used, maintained and reviewed.
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Ambulance
trusts
X
X
X
X
X
X
PERFORMANCE
7 . 38 EVALUATION
Exercising,
Maintaining &
T&E
how stores and supplies will be managed and maintained; and
how staff will be accommodated overnight if necessary;
how the organisation will respond to the media following a significant incident, in line with the formal communications strategy;
how decisions and meetings will be recorded during and after an incident, and how the incident report will be compiled;
recovery and restoration processes and how they will be set up following an incident;
a scalable plan setting out how incidents will be managed and by whom;
alternative locations for the business;
Business continuity plans must describe the effects of any disruption and how they can be managed.
Plans must include:
contact details for all key stakeholders;
the insurance arrangement that are in place and how they may apply.
how the independent healthcare sector may help if required; and
where the incident or emergency will be managed from (the ICC);
how mutual aid arrangements will be called into use and maintained;
the responsibilities of the appropriate Senior Responsible Officer or Executive Director;
7 . 37
7 . 36
7 . 35
7 . 34
7 . 33
7 . 32
7 . 31
7 . 30
7 . 29
7 . 28
7 . 27
7 . 26
7 . 25
7 . 24
7 . 23
7 . 22
X
the responsibilities of key staff and departments;
X
X
X
X
X
X
7 . 21
24-hour arrangements for alerting managers and other key staff, including how up-to-date contact lists will be maintained;
the procedures for escalating emergencies to CCGs and the NHS England area, regional and national teams;
Plans must set out: the alerting arrangements for external and self-declared incidents, including trigger points and escalation
procedures;
Business continuity plans must set out how the plans will be called into use, escalated and operated.
Organisations must develop, use, maintain and test procedures for receiving and cascading warnings and other
communications before, during and after a disruption or significant incident. If appropriate, business continuity plans must be
published on external websites and through other information-sharing media.
Organisations must highlight which of their critical activities have been put on the corporate risk register and how these risks
are being addressed.
They must identify all critical activities using a business impact analysis. This must set out the effect business disruption may
have on the organisation and how this will be overcome, including the maximum period of tolerable disruption.
X
X
X
Implementation
Strategy
Warning &
Communications
OPERATION
Risk assessments must take into account community risk registers and at very least include worst-case scenarios for:
• severe weather (including snow, heatwave, prolonged periods of cold weather and flooding);
• staff absence (including industrial action);
• the working environment, buildings and equipment;
• fuel shortages;
• surges in activity;
• IT and communications;
• supply chain failure; and
• associated risks in the surrounding area (e.g. COMAH and iconic sites).
Organisations must develop, use and maintain a formal and documented process for business impact analysis and risk
assessment.
Acute trusts
7 . 20
7 . 19
7 . 18
7 . 17
7 . 16
7 . 15
7 . 14
7 . 13
Risk Assessments
X
X
X
X
X
X
X
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
NHS
England
NHS
England
X
CCGs
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Community
providers
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Mental
health
See Section 3 v0.1 June 2013 draft Major Incident and Business Continuity Plan
● Page/ section references in BC plans, annexes to
plans or standalone plans
● Responsibility assigned to Action Card
● Page/ section references in BC plan, annexes to
● Reports to Board or Management Teams
● Business Continuity strategies developed in
response to problems identified
● Reports to Board or Management Teams
● Post incident / exercise debrief reports
● Details of expenditure/ investment
● Testing and Exercising programme / log that
complies with national exercising standards
Not applicable to the services delivered by this Trust
See Section 11 of ratified v1.0 March 2012 Business Continuity Policy, also Ex
Valentine 2 ^ September 2013 testing proposed notification and escalation
procedures in v0.1 June 2013 draft Major Incident and Business Continuity
Plan
See Section 11 of ratified v1.0 March 2012 Business Continuity Policy
See Section 7.1 of ratified v1.0 March 2012 Business Continuity Policy, also 1.4
of v0.1 June 2013 draft Major Incident and Business Continuity Plan
Exercise Valentine 14 February 2011 testing existing notification, escalation and
incident management procedures, Final Report and Recommendations
Exercise Valentine 2, 6 September 2013 testing proposed notification and
escalation procedures in v0.1 June 2013 draft Major Incident and Business
Continuity Plan, Final Report and Recommendations (currently in progress) to
inform draft 0.2 and subsequent versions of the Plan
Estates and Facilities Adviser Action Card within Section 7 of draft Major
Incident and Business Continuity Plan (v0.1 June 2013). Standard procurement
procedures also include emergency procurement.
Not applicable to the activities and services of this Trust
See Section 6.10 and Communications and Media Adviser Action Card at
Section 7 of v0.1 June 2013 draft Major Incident and Business Continuity Plan
See Sections 6.9 and 7 (Decision Loggist) of v0.1 June 2013 draft Major
Cadre of Trust PAs completed Loggist training 13 Dec 2011
See Incident Assessment Guidelines in Sections 3, 4, 5,6 and 7 of v0.1 June
2013 draft Major Incident and Business Continuity Plan which set framework for
management of incidents at Departmental, Directorate and Trust-wide levels
both escalating and deescalating. Also see Directorate Business Continuity
Plans for details of how incidents are to be managed at Departmental and
Directorate levels
See specifically Sections 3, 4, 5 and 6 of v0.1 June 2013 draft Major Incident
and Business Continuity Plan
See Section 9.8 of ratified v1.0 March 2012 Business Continuity Policy, next
update to ISO 22301 to fully include new NHS structures
● Action Cards
● Sample incident log
● Spokespersons identified and assigned to an Action
Card
● Action Cards
● Link to IRP (Standard 5.48) if using these
arrangements
● Action Cards
Draft Directorate Business Continuity Plans will include at Annex B database of
key external contacts as identified by Directorates
● Action Cards
NHSLA Liabilities to Third Party Scheme (membership number T671)
● Action Cards
See Sections 1.4.1 and Section 6.7 of v0.1 June 2013 draft Major Incident and
Business Continuity Plan
See Section 9.8 of ratified v1.0 March 2012 Business Continuity Policy, next
update to fully include new NHS structures, see also Section 1.6 of v0.1 June
2013 draft Major Incident and Business Continuity Plan.
Also NHS England AT IRP embedded in escalation procedures at Sections, 3,
4, 5, 6 and 7 of draft Major Incident and Business Continuity Plan
Sections 1, 2, 6 and 7 of v0.1 June 2013 draft Major Incident and Business
Continuity Plan
Sections 3, 4, 5 6 and 7 of v0.1 June 2013 draft Major Incident and Business
Continuity Plan
Business Disruption Risk Assessments underpinning draft Major Incident and
Business Continuity Plan as completed by estates and facilities do not anticipate
staff accommodation capacity issues
Arrangements with independent sector for patient support is routinely maintained
to ensure ongoing service provision
● Action Cards
● Action Cards
● Action Cards
● Action Cards
● On-call arrangements/ processes, On-call pack, Oncall staff lists
● Responsibility assigned to an Action Card
On-call rotas for OC1, OC2 and OC3 maintained and updated, stored on Trust
● Admin / support role assigned to maintain systems 'j' drive
● Reports from COMMEX/ regular cascades using
contact lists
Robust communication tree in place for e.g. weather alerts, heatwave and
miscellaneous useful notifications from the NHS England Area Team which is
well rehearsed and tested
Trust BCM Policy publication follows standard Trust publication following
ratification. Detailed decisions regarding publication of draft Major Incident and
Business Continuity Plan to be taken in line with established Trust procedures
Trust-wide BIAs
Trust-wide BIAs
Trust-wide BDRAs
Trust-wide BDRA
Commentary
● Action Cards
● Action Cards
● Appropriate risk register
● Prioritised list of critical activities/ services
● Business Impact Analysis methodology
● Risk registers and arrangements for review
Suggested Evidence
Self
Assessment
(Red, Amber,
Green, N/A, N/R)
Progress to Date
Revised ISO 22301 compliant BCM Policy
2014
Information already held requires transfer to
Directorate Plan Annex templates; to be
completed by end June 2014
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
2013
January 2014
Not Applicable
Not applicable
2013
January 2014
Not applicable
2013
January 2014
2013
January 2014
2013
January 2014
2013
January 2014
BounceBack Solutions to Include new arrangements as part of
complete update and ratification of existing BS25999-compliant
Business Continuity Policy to align with new ISO 22301 standard
Directorate BCM Leads and BounceBack Solutions Complete
development, ratification and rollout of draft Directorate Business
Continuity Plans including key staff details, key external contacts
and Directorate action plans by end December 2013
Not Applicable
completion and ratification of Trust-wide BDRAs to ensure fully
informed risk based underpinning of draft Major Incident and
2013
January 2014
2013
January 2014
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
January 2014
Not Applicable
Not Applicable
January 2014
Not Applicable
January 2014
January 2014
January 2014
January 2014
Revised ISO 22301 compliant BCM Policy
2014
Transfer of Information already held to
Directorate Plan Annex templates ongoing; to
be completed by end January 2015
Not Applicable
January 2014
January 2014
January 2014
January 2014
2013
January 2014
2013
January 2014
January 2014
January 2014
January 2014
BIA derived from Directorate BIAs
Progress to Date
January 2014
Not Applicable
Current Position
2013
January 2014
2013
January 2014
2013
January 2014
Major Incident and Business Continuity Plan including publication
in line with established Trust approach by end December 2013
January 2014
Trust-wide completion of BIAs across all Directorates which
underpin the new Major Incident and Business Continuity Plan by
end December 2013
Trust-wide completion of BIAs across all Directorates which
underpin the new Major Incident and Business Continuity Plan by
December 2013
December 2013
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Current Position
4 of 5
144 of 182
19 . 1
outline how they can support NHS organisations affected by service disruption, especially by treating minor injuries to reduce
the pressure on emergency departments. They will need to develop procedures for this in partnership with local acute trusts
and ambulance and patient care transport providers.
X
X
X
-
Urgent care centres must also:
make sure the needs of mental health patients involved in a significant incident or emergency are met and that they are
discharged home with suitable support.
19
18 . 5
-
-
-
-
-
support local acute trusts by managing physically unwell inpatients if there is an infectious disease outbreak; and
-
18 . 4
-
-
identify locations which patients can be transferred to if there is an incident;
-
outline how, when required, Ministry of Justice approval will be gained for an evacuation;
18 . 3
-
-
18 . 2
-
-
co-ordinate and provide mental health support to staff, patients and relatives in collaboration with Social Services;
Mental healthcare providers must also:
18 . 1
18
X
X
X
explain how the Mobile Privileged Access Scheme (MTPAS) and Fixed Telecommunications Privileged Access Scheme
(FTPAS) will be provided across the organisation; and
9 . 42
X
X
X
details of how suitable knowledge and skills will be achieved and maintained.
X
X
X
7 . 43
X
X
Acute trusts
X
details of the tools that will be used to make sure staff remain aware through ongoing education and information programmes
(for example, e-learning and induction training); and
reference to the National Occupation standards for Civil Contingencies and NHS England competencies when identifying key
knowledge and skills for staff; (directors of NHS England on-call rotas to meet NHS England published competencies);
details of the training provided to staff and how the training record is maintained;
Ambulance
trusts
7 . 42
7 . 41
7 . 40
Training
-
-
-
-
-
-
-
-
-
X
X
X
-
-
-
-
-
-
-
-
-
X
X
X
X
NHS
England
NHS
England
X
CCGs
-
-
-
-
-
-
-
-
X
X
X
X
X
X
X
X
X
-
-
-
-
-
-
X
X
X
X
X
X
Community
providers
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Mental
health
Annex 4 of v0.1 June 2013 draft Major Incident and Business Continuity Plan
refers (Staff Training Plan)
● Training attendance records
Flu Pandemic Plan, Outbreak Control Plan, Infection Prevention and Control
Policy plus principles of the draft Major Incident and Business Continuity Plan
(draft v0.1 June 2013) would be applied
Prior to discharge normal procedure involves Risk Assessment to ensure
appropriate care within the community
● Page/ section references in IRP, annexes or
standalone plans
standalone plans
Trust would be unlikely to set up Urgent Care centre for general public to utilise.
Where appropriate Trust would aim to reduce impact of MI by providing non
emergency (Minor injury - cuts and bruises etc) to S/U and staff. Staff may
provide emergency first aid only within their level of competency. Where injuries
Not appropriate to the patient services provided by the Trust which does not
provide PICUs
Evacuation plans in place for Trust sites and facilities
2 x internal Trust hospital sites routinely buddy up to address issue
standalone plans
standalone plans
standalone plans
● Commissioning specifications should include
provisions for appropriate support
Staff dealt with through normal Trust Occupational Health procedures
Draft Major Incident and Business Continuity Plan includes references in Action
Cards at Section 7 for managers to maintaining Health and Safety as
appropriate
Approach to patients would be built in as appropriate to individual care plans
Access to mental health services and counselling would be made available
through existing referral pathways (e.g. via GP when considered appropriate)
standalone plans
12 identified MTPAS users within the Trust. FTPAS is however not an
● Detail arrangements for MTPAS enabled telecoms in
appropriate solution for the Trust due to the nature of its on-site telephone
the service/ invocation arrangements
provision (voice over IP)
Annex 4 of v0.1 June 2013 draft Major Incident and Business Continuity Plan
refers (Staff Training Plan)
Not a standard of which the Trust was aware. However, to be considered as
part Annex 4 of v0.1 June 2013 draft Major Incident and Business Continuity
Plan refers (Staff Training Plan)
To be included in Annex 4 of v0.1 June 2013 draft Major Incident and Business
Continuity Plan refers (Staff Training Plan)
Commentary
Suggested Evidence
Self
Assessment
(Red, Amber,
Green, N/A, N/R)
Progress to Date
Not Applicable
2014
West Midlands Health Emergency Planning
Network has developed a work programme to
adapt the principles of the NOS to provider
Trusts. This is not anticipated to be competed
by end June 2014
2014
2014
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
January 2014
2013
Not applicable
January 2014
2013
Not Applicable
2013
2013
2013
2013 , including Training Plan and record
Not applicable
Not applicable
Not applicable
Not Applicable
Current Position
Progress to Date
Not applicable
Not applicable
January 2014
Not applicable
January 2014
Not Applicable
2014
2014
Progress has been made and work is
anticipated to be completed by the West
Midlands Health Emergency Planning Network
by end November 2014
2014
Not applicable
Not applicable
Not applicable
Not Applicable
Current Position
5 of 5
145 of 182
146 of 182
Board meeting date:
Enclosure:13
4th Feb 2015
Data Quality Risk Assessment
Report Title:
Mark Axcell, Director of Finance and Performance
Chris Reynolds, Interim Head of Information, Performance and IMT
To provide assurance regarding the relative risk to data quality
underpinning the reported KPIs contained within the Integrated
Performance Dashboard Scorecard
Decision / Approval
Gain assurance
Discussion
Information
8
9
8
9
Key points or
Committee:
Committee: MeXT
Date reviewed: 6th Jan 2015
The report was noted and approved
High quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources
9
8
9
8
9
9
following:
Caring
Not directly Applicable
Responsive
Being able to reliably demonstrate the quality of
service provision via performance metrics is critical
to the assessment of the collective performance of
the Trust. Poor performance will impact on
assessment of the organization
Poor data quality could impact on the Trust’s ability
to proceed smoothly through the FT assessment
Effective
147 of 182
Well-led
Safe
process
Good data quality allows the DWMH to hold
individuals to account for their performance
Accurate, valid, reliable, timely, relevant and
complete data is critical to being able to assess
delivery of high quality services
148 of 182
Title
Introduction
This Data Quality Risk Assessment is intended to inform the Trust Board and senior managers with
respect to the relative risk to data quality underpinning the reported KPIs.
The auditors assessed all data items within the Integrated Performance Dashboard. Each item was
scored on a RAG status based on a series of five questions shown below:
A
Is performance reported from a single data source and/or through a single
Yes or no
reporting system?
B
Are there well established systems in place for data capture, supported by a Yes or no
robust operational policy and procedure?
C
Are there well established systems in place for data processing, supported by a
Yes or no
robust operational policy and procedure?
D
Are there defined responsible individuals for validating / signing off the reporting
Yes or no
stage?
E
Is
the
data
quality
of
an
indicator
independently
verified
and/or
Yes or no
scrutinised/challenged by an external body?
A score of no equaled 0 points, and yes = 1 point, and the following RAG rating scheme was used: 0/1
Red, 2-3 Amber, 4-5 green.
There are fifty two indicators included within the Integrated Performance Dashboard. Forty eight of the
indicators were assessed as having a green rating. No red rated assessments were made. The
following indicators were risk assessed as amber rated:
x Compliments (month) – it is difficult to ensure completeness, accuracy or timeliness in relation to
this KPI, with data drawn from wide range of sources, but there is no material impact to the Trust if
this KPI is misreported
x
Activity against contract – different sources are used to record activity and there is potential for
incompleteness of collection and recording of patient activity, or incorrectly recorded activity.
x
IAPT – people who have successfully completed treatment (Dudley) and IAPT – people who have
successfully completed treatment (Walsall) – there are known issues regarding inconsistencies in
reporting and this is being managed through the Data Quality Improvement Plan for 2014-15.
The risk assessment was “sense-checked” by MeXT.,
149 of 182
MeXT considered what actions to take to improve the data quality associated with these
indicators. MeXT agreed the actions outlined above were sufficient.
None required
Recommendation
Information/assurance only
Board to note the report
150 of 182
cw audit services
Audit and Assurance Services
Kingston House
438-450 High Street
West Bromwich
B70 9LD
Tel: 0121 612 3871
Date:
2nd October 2014
To:
Mark Axcell
Director of Finance
From:
Paul Capener
Head of Internal Audit
Re:
Cc:
Dear Mark,
As part of the 2014/15 Internal Audit Plan, it was agreed that CW Audit would facilitate
a data quality risk assessment of the Key Performance Indicators (KPIs) within the
Trust-level Integrated Performance Dashboard (as at August 2014).
Background
The Data Quality Risk Assessment is intended to inform the Trust Board and senior
managers with respect to the relative risk to data quality underpinning the reported
KPIs. Consequent to this, the Trust needs to consider any remedial action to improve
data quality, and the risk assessment will also be used to direct future internal audit
work in the area of data quality.
Approach and results
We facilitated a workshop on 11th September designed to risk assess the relative data
quality of KPIs reported within the Trust-level Integrated Performance Dashboard
Scorecard. Those staff that attended the workshop were:
x
Chris Reynolds
x
Dimitrinka Manassieva
x
Tom Jinks
x
Paul Chamberlain
x
Craig Tunstall
x
James Parker
x
Jackie Heath
x
Justin Wright
x
Graeme Welsh
x
Sandra McShane
151 of 182
The following approach was adopted to risk assess the data quality of KPIs:
x
A set of criteria was agreed by the Group that was used to risk assess data quality
against each measure, using a numeric scoring system, having arrived at a
consensus view.
x
This was used to derive a "RAG" rating for each measure
The following criteria were used to assess data quality:
Data quality criteria
A
Is performance reported from a single data source and/or Yes or no
through a single reporting system?
B
Are there well established systems in place for data capture, Yes or no
supported by a robust operational policy and procedure?
C
Are there well established systems in place for data Yes or no
processing, supported by a robust operational policy and
procedure?
D
Are there defined responsible individuals for validating / signing Yes or no
off the reporting stage?
E
Is the data quality of an indicator independently verified and/or Yes or no
scrutinised/challenged by an external body?
A score of no equalled 0 points, and yes = 1 point, and the following RAG rating
scheme was used:
Score
RAG
rating
0/1 = highest risk
2
3 = medium risk
4
5 = lowest risk
The results of this assessment are attached as Appendix 1. We recommend that this
initial assessment is now taken to MExT for review, comment, and any amendments,
before then being shared with the Trust Board for their comment and adoption. After
this, the assessment should be periodically refreshed.
152 of 182
No red rated assessments were made, but the following indicators were risk assessed
as amber rated:
x
Compliments (month) – it is difficult to ensure completeness, accuracy or
timeliness in relation to this KPI, with data drawn from wide range of sources, but
there is no material impact to the Trust if this KPI is misreported
x
Activity against contract – different sources are used to record activity and there is
potential for incompleteness of collection and recording of patient activity, or
incorrectly recorded activity.
x
IAPT – people who have successfully completed treatment (Dudley) and IAPT –
people who have successfully completed treatment (Walsall) – these are known
data quality issues regarding inconsistencies in data collection.
Once this initial risk assessment is “sense-checked” by MeXT, they should consider
what actions should/can be taken to improve the data quality associated with these
indicators (where this does not already feature in the Data Quality Improvement Plan).
The risk assessment should then be formally shared with the Trust Board.
If you would like to discuss further please do not hesitate to contact me.
Yours sincerely
Paul Capener
Head of Internal Audit
153 of 182
Mixed gender breaches (wards)
Inappropriate admissions of U18's to an adult ward
QUALITY & SAFETY
CQC conditions or warning notices
7 day follow up on inpatient discharges
CPA - review in 12 months
CPA - copies of care plans
Home treatment episodes by CRHT
Delayed transfers of care (all reasons)
Physical health checks (inpatients over 12 months)
Never events
Incidents
Falls resulting in severe injury/death
Grade 3 or 4 pressure ulcers whilst in our care
MRSA bacteraemia
C-Diff
New cases accepted to early intervention
CRHT gate keeping of inpatient admissions (YTD)
Domain and measure
11-Sep-14
DQ risk assessment
Appendix 1
Dudley & Walsall Mental Health Partnership Trust
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
A
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
B
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
C
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
D
CRITERIA ASSESSMENT
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
E
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
TOTAL & RAG
RATING
154 of 182
previously flagged by CQC - now
resolved
COMMENTS
Activity against contract (NHS activity)
IAPT - people receiving psychological therapies
IAPT - people who have successfully completed treatment
(Dudley)
IAPT - people who have successfully completed treatment
(Walsall)
IAPT - completion of outcome data (PHQ9 & GAD 7)
0
0
0
0
1
1
1
1
1
1
1
1
1
0
1
1
1
1
1
1
0
B
1
1
1
1
1
1
1
1
1
0
1
1
1
1
1
1
0
SERVICE USER EXPERIENCE
RTT in 18 weeks - complete (YTD)
RTT in 18 weeks - incomplete (YTD)
Friends & Family Test - % of promoters (CQUIN)
New complaints
% complaints/concerns regarding care/treatment
Complaints upheld/partially upheld
Compliments (month)
EFFICIENCY
Average length of stay (admission to discharge)
Bed occupancy (inc Leave & exc Grasmere)
Bed occupancy (exc Leave & Grasmere)
Data completeness: identifiers
Data completeness: outcomes
Completion of NHS number on MHMDS
Completion of ethnicity on MHMDS
A
Domain and measure
1
0
1
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
C
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
D
CRITERIA ASSESSMENT
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
0
0
0
0
E
4
3
4
3
5
5
5
5
5
5
5
3
5
5
5
4
4
4
2
TOTAL & RAG
RATING
155 of 182
two teams assess differently known issue
two teams assess differently known issue
3 systems, potential for activity
being missed
No material impact upon Trust of
poor DQ
COMMENTS
RESOURCES
FRR EBITDA margin
FRR EBITDA % achieved
FRR net return after financing
FRR - I & E surplus margin
FRR - liquidity ratio (days)
CIP against plan (FYE of delivery)
Income against plan
Performance against budget (variance)
Turnover - rolling 12 months
Sickness in month
Sickness - rolling 12 months
Mandatory training (aggregate)
PDRs % in date (data in ESR)
Agency as % of employee benefit expenditure
MONITOR/TDA
Finance Risk Rating
Governance Risk Rating
Domain and measure
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
B
1
1
1
1
1
1
1
1
1
1
1
1
1
1
A
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
C
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
D
CRITERIA ASSESSMENT
0
0
1
1
1
1
1
1
1
1
0
0
0
0
0
0
E
4
4
5
5
5
5
5
5
5
5
4
4
4
4
4
4
TOTAL & RAG
RATING
156 of 182
doesn’t include social care staff
COMMENTS
Board meeting date:
Enclosure: 14
4th February 2015
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 work in progress to provide more detailed analysis
including bank and agency usage.
Decision / Approval
Gain assurance
Discussion
Information
9
9
Committee:
Date reviewed:
Key points or
Committee:
High quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources
9
8
8
9
8
9
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
157 of 182
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.
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.
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 to be published by NICE later in
2015. 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 report aims to provide the Trust Board with:
x
x
x
x
the summary report of planned and actual staffing for December 2014 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
update on work in progress to provide more detailed analysis including bank and agency usage.
This set of data indicates an 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 99.3%, with 95.3%for registered staff and 102.1%
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.
There are two wards to note as exceptions, whereby the staff fill in part is within the lowest category
(Langdale and Holyrood). An impact assessment has been completed that provides assurance safe
staffing levels have not been compromised, and during December there were no reported incidents of
unsafe staffing levels related to these areas.
Trend analysis included in report, which are regularly monitored nursing teams. Variance predominately
attributed to initial data quality. Trends will continue to be monitored.
The Board are asked to note that work is currently underway to enable more detailed analysis of
staffing data, this will include data related to bank and agency usage and bed occupancy, however as
the Trust is currently reliant on manual systems to gather this data, this information will have to be
gathered manually at ward level. A data collection tool has been developed and piloted the last two
158 of 182
weeks of January with the aim of a full months data being gathered in February. Care is being taken to
minimalise additional work for ward managers. 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. This work will be commencing in January 2014, starting with a benefits analysis which will be
completed early February 2015.
The Trust also continues to be involved in the Regional development and refinements of safer staffing
tools for both Inpatients and Community. It is anticipated that this project will be completed by April
2015.
Furthermore the Trust Board are asked to note that the national guidance for safe staffing in mental
health services is still under development and includes consideration for metrics. The scope of NICE
guidance regarding safe staffing levels in mental health has now been out for consultation and will
inform the development of NICE guidance later in 2015. The Trust will need to consider this guidance
once published.
Recommendation
To note and discuss the monthly data return submitted providing details of planned and actual staffing
at ward level. Data represents December 2014 and a monthly trend analysis for 2014/15.
To note
x the work underway to enable more detailed analysis of staffing data and the current
complexities.
x the Trust is engaged in the regional projects relating to the development of safe staffing tools
x national work continues to define best practice standards within NICE Guidance.
The Board of Directors are asked to:
x
To note and discuss the monthly data return submitted, providing details of planned and actual
staffing at ward level. Data represents December 2014 and a monthly trend analysis for
2014/15.
159 of 182
Care Staff
RMN
Night
Care Staff
104.7%
91.9%
99.5%
112.6%
109.0%
102.9%
97.6%
80.9%
90.7%
94.3%
98.8%
99.8%
96.0%
100.0%
100.0%
97.7%
99.2%
100.3%
99.2%
91.3%
102.1%
98.4%
Greater than 90% but less than 120%
High range – greater than 120% but less than 150%
Average fill rate care staff (%)
Day
Average fill rate registered
nurses/midwives
(%)
Highest range – greater than 150%
Low range – greater than 80% but less than 90%
Lowest range – less than 80%
Planned Actual Planned Actual Planned Actual Planned Actual
930
915
1047.5
1070
612.75
612.75
397.75
397.75
930
922.5
2396
2403.5
666.5
666.5 1066.75
1077.5
964.15
941.65
1132.5
1132.5
666.5
636.25
750
764.75
1038
996
1025
1023
666.5
591.25
677.25
721.5
964.25
886.25
261
273.25
333.25
333.25
387
387
1125
1027.5
1222.5
1207.5
333.25
333.25
999.75
989
967.5
960
930
930
337.75
337.75
677.25
677.25
744.5
727
999.5
994.5
333.25
333.25
795.5
795.5
903.5
731
1672.5
1882.5
344
344 1322.25 1322.25
885
802.5
1335
1455
342.9
333.25
1118 1128.75
9451.9
8909.4 12021.5 12371.75 4636.65
4521.5
8191.5 8261.25
Day
97.5%
97.2%
100.0%
100.0%
100.0%
100.0%
100.0%
88.7%
95.5%
100.0%
100.0%
100.9%
101.0%
100.0%
100.0%
100.0%
98.9%
100.0%
106.5%
102.0%
101.0%
100.0%
Average fill rate care staff (%)
Night
Average fill rate registered
nurses/midwives
(%)
160 of 182
Across the inpatient areas the overall fill rates are 99.3%, with 95.3%for registered staff and 102.1% 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.
Cedars
Linden
Ambleside
Langdale
Grasmere
Clent
Kinver
Wrekin
Holyrood
Malvern
Grand Total
RMN
The following table provides a summary of the planned verses actual staffing levels on the inpatient wards.
The data submission was made on 14th January 2015 of December data
1. Nursing and healthcare staffing fill rates December 2014
Exception Report on Variance – December 2014
80.9% Day – Average fill rate –
Registered Nursing (low range)
Holyrood Ward – Bushey
Fields Hospital
88.7% Night – Average fill rate
– Registered Nursing (low
range)
Exceptions
Langdale Ward – Dorothy
Pattison Hospital
Average fill rate for registered
nurse differed from planned
staffing during December due
to the following reasons:
x Annual leave/sick leave of
registered nurses
x Additional care staff
required to meet service
needs (112.6%)
Rationale
Average fill rate for registered
nurse differed from planned
staffing during December due
to the following reasons:
x Annual leave/sick leave of
registered nurses
x Additional care staff
required to meet service
needs (106.5%)
Safe staffing levels maintained,
no reported incidents
Impact
Safe staffing levels maintained,
no reported incidents
For December, the Trust has two exceptions to report to the Trust Board.
2.
161 of 182
Ensure effective management
of sickness and annual leave.
Remedial Actions
Ensure effective management
of sickness and annual leave.
Trend Analysis average fill rate (2014/15)
162 of 182
The following table shows a 2014/15 month 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 planned hours of working.
3.
Agenda Item number:
12.1
Board meeting date:
4th February 2015
Report Title:
Enclosure:
15
This report provides an update on progress with the Trust’s
application to Monitor to become a NHS Foundation Trust.
Decision / Approval
Gain assurance
Discussion
Information
8
9
9
9
Committee: N/A
Date reviewed: N/A
Key points or
Committee:
High quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources
8
8
8
8
9
8
relates to are:
Caring
The FT application relates to all of the CQC
domains and the Trust’s performance and
capabilities against each of these will be rigorously
tested as part of the assessment process.
Responsive
Effective
Well-led
Safe
163 of 182
Title
Introduction
This report provides an update on the Trust’s progress towards becoming a NHS Foundation
Trust and the latest position with regard to reactivating its assessment by Monitor, the sector
Regulator.
The Trust commenced its original assessment by Monitor in October 2012 at the end of which in
March 2013, Monitor recommended that its decision to authorise the Trust would be deferred for
a brief period, to enable some proposed changes to be completed and have time to become
embedded.
Reactivation with Monitor was planned for October 2013, but unfortunately in the intervening
period the new CQC Chief Inspector of Hospitals regime was announced and Monitor decided
that they would no longer authorise NHS Trusts until they had ungone a CQC assessment and
achieved a rating of either ‘good’ or ‘outstanding’. This meant a longer deferral period for the
Trust than had been planned, as the CQC assessment process for Mental Health Trusts was
not established by CQC until early 2014.
The Trust was identified as one of the first pilot sites for the new CQC assessment and was
inspected in February 2014, the outcome of which was formally reported in May that year.
Although as a pilot site, the Trust could not be awarded a formal rating, the CQC informed
Monitor that The Trust was providing care of a level equivalent to ‘good’. This meant that the
Trust was therefore able to reactivate its FT assessment.
The Trust agreed with Monitor and the NHS Trust Development Authority (TDA) that the FT
assessment process would recommence after the end of August 2014, recognising that this
would be dependent on Monitor’s capacity.
Towards the end of September 2014 Dudley CCG announced that they were about to
commence a sustainability review of the whole local health economy. Given that the Trust would
be a key part of the review and that a key focus point for Monitor assessments is whole health
economy sustainability not just that of individual organisations, Monitor agreed that a further
short deferral period was a sensible approach to take.
Following a series of monthly calls between the Chief Executive and Monitor, in early January it
was agreed that, given the health economy review was confirming congruence between the
Trust’s and CCG’s financial plans, this was not an issue with regard to the reactivation of the FT
assessment process. Monitor therefore confirmed that it would have sufficient capacity to
recommence the Trust’s FT assessment process from the beginning of February 2015.
A letter from Monitor confirming their “current intention” to re-start the assessment process on
the 2nd February was received by the Trust on 20th January 2015. The letter anticipates a Board
to Board with Monitor taking place around the end of April 2015.
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x Note the progress to date.
165 of 182
168 of 182
Board meeting date:
4th February 2015
Report Title:
Enclosure: 16
2014/15 Annual Plan and Board Assurance Framework
Review
Marsha Ingram, Director of People and Corporate
Development
To update the Board on a review of the format and
presentation of the quarterly Annual Plan and BAF reports.
Decision / Approval
Gain assurance
Discussion
Information
9
8
9
8
Committee:
Date reviewed:
Key points or
Committee:
High quality
services
Inclusive
partnerships
Leadership
culture
Responsible
workforce
Supporting
strategies
Effective/efficient
resources
9
9
9
9
9
9
relates to are:
Caring
Responsive
Effective
Well-led
Safe
Some of the objectives on the annual plan directly or
indirectly impact upon the quality of care and the
service experience.
The BAF and annual plan reviews ensure that good
progress is being made against key objectives and
that slippage and risks are known and managed.
The BAF provides the Board with insight and
assurance that allows them to effectively manage
performance against key objectives and supports
decision making that can impact upon longer term
strategic aims.
The BAF provides assurances that the Trust’s
strategic/red risks and the responses to
managing/mitigating these risks are within the Trust’s
statement of risk appetite.
169 of 182
Title
2014/15 Annual Plan and Board Assurance Framework Q3
Review
Introduction
This report links together the Q3 review of performance against annual objectives with the
corresponding Trust Wide Risk Register (January TWRR). This enables the Trust to present the Board
Assurance Framework position at Q3.
The 2014/15 objectives and supporting priority activities have been collated following discussions with
Executive Directors and their direct reports during the quarterly Annual Plan/BAF reviews. The 2014/15
Annual Plan was approved by the Trust Board in May 2014.
The priority activities generally reflect what the Trust needs to do to achieve its objectives for 2014/15
and are aligned to the Trust’s six overarching strategic themes that then enables establishment of the
Board Assurance Framework.
The combined Annual Plan and BAF report comprises:
x Performance against objectives (annual plan performance review) demonstrating progress
made against each of the 14 high-level objectives. It includes a RAG rating of the current status.
x Assurances on the management of risks related to achieving the 2014/15 objectives (Board
Assurance Framework BAF).
UPDATE
There are 14 strategic objectives identified for 2014/15 and of these, there are now:
1) 13 with full / significant assurance
x Financial and CIP performance remains strong
x TDA escalation rating of Level 5 (Green)
x CQC inspection shadow rating of ‘good’
x Some risks around Better Care Fund and Local Authority funding
x Staff resilience and leadership skills is an area with continued strong focus
x Strengthened commissioner relationships and Trust playing an active role in local health
economy sustainability reviews, partnership development, service development and raising
profile of Mental Health
x Good progress made to grow Research and Development portfolio with investment
business case scheduled for a forthcoming Trust Board meeting
x Significant staff and patient/carer engagement activity
Areas with significant rather than full assurance are as a result of the following:
x Participation in the ‘Care Makers’ programme commenced as planned in Q3 but the most
significant progress is anticipated in Q4 therefore progress remains rated amber at the
current time.
x The refresh of the L&D portfolio has not commenced as planned in Q3 although general
refreshes and reviews have occurred on an ongoing basis throughout the year. Further
170 of 182
reviews will take place as part of the new Associate Director of HR’s scope during Q1
2015/16 but will be ‘business as usual’ rather than forming a specific annual Corporate
objective.
x Engagement with the shadow Council of Governors is being reviewed by the new Chair and
reactivation of the FT assessment which is anticipated for February 2015, will be used as
the platform to launch a new and improved strategy and programme.
x Exploration of e-health, e-prescribing and auto-dispensing have not progressed since Q2
and are currently amber rated for delivery
2) 1 with moderate assurance
x Objective 11 has been amended to moderate assurance as a result of:
o The development of Service Line Business Planning and Services Marketing has not
commenced and has been deferred to Q1 2015/16. This has been however been a
deliberate decision to ensure the work aligns with the launch of the new Clinical and
Social Care Vision.
o Commercial skills training has seen progress via the development of intranet resources,
however the need to establish commercial skills training as part of the L&D portfolio is
currently being re-considered.
3) 0 with limited / negative assurance
x There are no areas of Trust business, which at Quarter 3 have been identified as having
significant areas of residual risk or limited/negative assurance.
Further detail
The Q3 BAF and objectives framework is presented for consideration and discussion at Appendix 1.
Recommendation
It is recommended that the Board consider the Quarter 3 BAF report together with progress against the
annual objectives and debate accordingly highlighting any further action required.
The Board is asked to approve the Quarter 3 Annual Plan progress review and Board Assurance
Framework.
171 of 182
Objective 2
Objective 1
DoON&E
DoFP&IT
DoON&E
Participate in the “Care
Makers” programme
Support service
developments with
investment and/or funding
applications
Lead on development of a
local formulary across the
LHE
GREEN
GREEN
Work has started on a unified policy for the
use of psychotropic medicines in
conjunction with the BCPT . At present
psychotropic medicines are approved for
use across the Dudley and Walsall health
economies.
AMBER
Reporting to the Board is continues via the
PMO structure. Bids are fully supported by
the finance lead.
Work has commenced during Q3 as part of
the programme development. This work will
be progressed significantly in Q4.
Exec Lead Progress at Q3 / RAG
Priority Activities
GREEN
This is ongoing due to a number of
developments in this area. The Mental
Health Urgent Care Centre is being piloted
in Dudley which has resulted in changes to
the urgent care pathway for GP referrals
out of hours. This will be evaluated for
potential recurrent funding. The Trust has
also started to accept 111 referrals to EAS
and the crisis team. In December the Trust
signed up to the Mental Health Crisis Care
Concordat in both boroughs along with a
number of other agencies. Next steps will
include development of an action plan to
review and improve the crisis pathway.
DoON&E
GREEN
The KPIs in relation to the acute ward
changes have been evaluated and do not
show any negative impact to the acute
pathway. The Trust has successfully
recruited to a number of vacancies in
CR/HT. Street Triage is now up and
running and having a positive impact in
reducing the use of Place of Safety and
A&E attendance.
Urgent care pathway review
DoON&E
GREEN
Mental Health Strategies work is now
complete with 3 scenarios for the Trust to
consider. Discussions have taken place
with commissioners to finalise the OA
Model and a workshop is planned for
February.
Older Adult Services pathway
DoON&E
review and redesign
Priority Activities
Acute services provision
Implement 2014/15 service review
transformation plans,
including workforce, finance
CIP and activity plans and
develop the framework for
future plans
Appendix 1
Principal Risks
Regular reports to MExT
Quarterly Quality Priority progress report
to G&Q and Board.
Quarterly QGAF review and update by
G&Q and Board.
Monthly CQR meeting with both LHEs.
Trust rated Level 4 (Amber/Green) on TDA
Risk
Current Assurances and link to Trust
Owner Performance Framework
HR002 - Reduction in Local
WP
Authority Funding for
Mental Health Social Care
Workforce.
Regular Service Transformation and CIP
PMO reports to MExT and Trust Board.
Service Transformation KPIs reported to
CARM, F&P, G&Q and Trust Board.
Regular reports to MExT, G&Q & Board.
Mental Health Programme Board.
Strategic partners.
FT assessment process.
Risk
226 - The Trust's ability to
respond to rising demands
MI
in relation to current
healthcare reforms
including the Trust's FT
application
Principal Risks on TWRR
4
Residual
Level of
Risk
Assurance
Score
Risk
HR002
4x2=8
AMBER
Risk 226
4x2=8
AMBER
Residual Overall
Level of
Risk
Assurance
Score
172 of 182
High Quality Services
Objective 2
DoST
Joint MD
DoPCD
Establish Mortality Review
Group
"Your Experience Matters"
campaign
DoON&E
Work with commissioners to
address identified service
gaps and inconsistencies
Utilise national, regional
and, most importantly, local
priorities, to drive continuous Deliver Quality Account key
improvement in service
priorities
quality and safety
This activity is now complete
This activity is now complete
The Trust has worked with commissioners
to identify gaps in relation to ASD, ADHD
and Tier 3+ services. Business cases have
been developed and remain in discussion
with the CCGs about their intentions, with
the exception of Tier 3+ in Walsall that has
been commissioned on a pilot basis until
September 2015.
Quality improvement priorities continue to
make progress. Q2 update report provided
to the Board in November 2014 . Q3 report
scheduled for Governance and Quality
Committee in February 2015. The Trust is
in the process of developing 2015/16
priorities.
GREEN
Complete
GREEN
Complete
GREEN
GREEN
202 - Better Care Fund
MA
Escalation framework. Monthly TDA IDM
meetings.
CEO is a member of Walsall's integration Risk 202
board, a key forum to move forward with
4x3=12
plans. Draft plans received from both
AMBER
health economies.
DoFP&IT has established communication
channels with both CCGs/MBCs regarding
the BCF in order to better understand
plans and the potential impact on the
health economy, pathways, and the Trust.
Regular Exec level meetings with both
CCGs established and B2Bs taking place.
3
173 of 182
Objective 3
Support a culture of
innovation and new ways of
working to enable staff to
contribute to all aspects of
the QIPP agenda
Skills training for frontline
staff
Enhance Nurse Prescribing
Priority Activities
DoON&E
DoON&E
Nurse development initiatives have been
progressed and include:
• Band 5 development
• Portfolio of nurse development
opportunities including national, regional
and local priorities
• Focus groups for nurses to assist with
developing new nursing strategies
• Trust Board to receive overview of
nursing initiatives in March 2015
Nominations to train 3 further nurses from
CAMHS and Early Intervention teams have
been approved in line with the NMP
operational policy. 2 will commence
training January 2015 and the 3rd later in
the year. An existing NMP in EI Walsall is
being supported to gain approval to
prescribe. The number of patients being
prescribed for by NMPs in SMS and
Memory Service is gradually increasing.
Areas of training referred to in quarter 2 are
on-going. Further current initiatives
include: DBT essentials programme
commissioned for Dudley based staff
taking place March 2015. ECG training is
being rolled out across CRS teams and for
senior nurses in in-patients. Training to
underpin implementation of policies within
the least restrictive practice suite are taking
place e.g. DOLs for clinical leads &
managers, advanced decisions is being
planned. Level 3 safeguarding training has
been commissioned for staff in EI and
CAMHS taking place in February 2015. A
dementia work book has been developed
by psychology for registered professionals
& is being piloted across OA wards in
March 2015.
GREEN
GREEN
225 -The risk of insufficient
resilience and skills in
leadership, which may
result in poorly engaged,
demotivated staff
and poor service quality.
Principal Risks
MI
Staff survey results and quality monitoring
metrics.
Staff surveys undertaken on a regular
basis.
Trust has a robust leadership programme
in place.
The Trust has developed a number of
quality metrics to measure service quality.
'Good' CQC shadow rating, report and
subsequent action plan in place for "must,
could & should do's".
Staff engagement workplan in place.
Staff leadership development plan in
place.
Risk
Risk 225
4x2=8
AMBER
4
Residual
Level of
Risk
Assurance
Score
174 of 182
Enhance the Trust's
embedding lessons
processes
Objective 4
This work is on-going and this needs to be
embedded in the structure and working of
the two teams rather than definite actions.
Think Family
Joint MD
Focus on triangulation across
safeguarding, incidents and DoPCD
complaints
A new Triangulation Group has been
established as a sub-group to the
Governance & Quality Committee. Terms
of Reference are being developed and will
be approved by G&Q. The Board will be
kept appraised via the regular G&Q Chair's
report to Board.
Priority Activities
GREEN
GREEN
225 -The risk of insufficient
demotivated staff and poor
service quality.
Principal Risks
MI
Monthly triangulation meeting between
service Experience Desk, Head of
Governance and service line leads.
Risk
Risk 225
4x2=8
AMBER
4
Residual
Level of
Risk
Assurance
Score
175 of 182
Inclusive Partnerships
Provider collaboration /
partnership management
approach
Build better commissioner
Work within the local health
liaison
economy to explore
partnership working that
improves patient pathways
and service experience
Objective 6
DoPCD
DoST
GREEN
GREEN
Partnership work is being explored or
developed in relation to a number of
services including an integrated
rehabilitation pathway in Walsall, a 12
month pilot in Liaison and Diversion in
partnership with the Black Country MH FT
for delivery from April 15, Street Triage
being piloted with the police and
paramedics from November 14, and sign
up with a number of agencies to the Mental
Health Crisis Care Concordat.
The Trust is working closely across the
Local Health Economy to implement local
plans for the 5 year forward view. The
Trust is also Working collaboratively on
Street Triage and Liaison and Diversion
pilots.
Exec Lead Progress at Q3/ RAG
GREEN
LETC Community Volunteering Project is
still live and is due to complete in March
2015. Additional admin apprentices have
been recruited. A support package for
apprentices is being implemented. Comms
plan to promote further apprenticeships.
Priority Activities
GREEN
DoPCD
DoPCD
Significant progress made but remains a
working draft. Two strands include
capturing existing stakeholder engagement
and considering future opportunities. Full
update and next steps for development of
the plan were presented to the January
Trust Board and approved principle. The
communication strategy and action plan are
to be finalised at April Board.
Volunteering / apprentice
schemes
Objective 5
Stakeholder communication
strategy and plan
Take a lead on mental
health across the local
health economy, raising
awareness, knowledge and
skills of our partners
Priority Activities
Monthly GP Leads meetings
Dudley Service Improvement meeting
Commissioner Strategy Group
MA
Regular reports to MExT
Monthly GP Leads meetings
Dudley Service Improvement meeting
Commissioner Strategy Group
Risk
GG
Risk
HR002 - Reduction in Local
WP
Authority Funding for
Mental Health
Social Care Workforce.
202 - Better Care Fund
Principal Risks
STRAT 18 - Increasingly
competitive environment for
Healthcare providers,
potentially threatening
existing and future
business.
Principal Risks
4
Risk
HR002
4x2=8
AMBER
Risk 202
4x3=12
AMBER
4
Residual
Level of
Risk
Assurance
Score
Risk
STRAT18
4x3=12
AMBER
Residual
Level of
Risk
Assurance
Score
176 of 182
Leadership Culture
Objective 7
DoST
Develop the clinical strategy
for 2015-2020
Further develop the research
Joint MD
and development portfolio
Empower leaders to develop
a culture that will enable us
to achieve the high
Develop and implement a
standards of quality and programme of work to nurture
DoPCD
innovation that we aspire to and embed a culture of
business development
DoPCD
GREEN
GREEN
Presentation made to Non Executive
Directors meeting. Governance and Quality
spotlight session on R&D planned prior to
presentation of Investment Business Case
to March 2015 Trust Board for approval.
Involvement in large scale multicentre
studies have allowed the Trust to reach and
exceed it's accrual target for engaging
participants in studies.
GREEN
Following stakeholder engagement events
in September 14, a first draft has now been
developed and is being consulted on before
a further draft is produced for wider
circulation.
There is no change from Q2. The Growth
PMO is now fully established and working
closely with all Trust departments to
respond to active tenders. In Q4 the Trust
will begin work on establishing income
generation plans by service. An intranet is
being developed to provide greater
awareness amongst staff.
GREEN
Discussions with the Chair have taken
place and links established with the
regional HEWM leadership team. 360
feedback process is being planned.
Regular promotion of regional leadership
development opportunities is taking place.
Leadership strategy to
include talent management
and succession planning
Priority Activities
4
Residual
Level of
Risk
Assurance
Score
metrics.
basis.
in place.
quality metrics to measure service quality. Risk 225
'Good' CQC shadow rating - report and
4x2=8
subsequent action plan in place for "must, AMBER
could & should do's".
place.
Regular BDPMO report to MExT, F&P and
Board.
R&D presentation to NEDs meeting
Risk
225 - The risk of insufficient
MI
demotivated staff and poor
service quality
Principal Risks
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Responsible Workforce
DoPCD
DoPCD
DoPCD
DoPCD
Staff Engagement Strategy
linked to innovative Health
and Well Being Initiatives
Staff focus groups to give
staff additional opportunities
to have a ‘voice’
GREEN
Complete
GREEN
Staff Engagement plan is now agreed by
the Board and being implanted with a
progress report due to the Board in March.
Health and Wellbeing initiatives are now
being taken forward under the new
outsourced Occupational Health service
banner.
This activity is complete
GREEN
Joint MD
Principal Risks
metrics.
basis.
in place.
quality metrics to measure service quality.
Good CQC report and subsequent action
plan in place for "must, could & should
do's".
place.
Annual staff awards ceremony.
Regular updates to Board on revalidation.
suspensions, exclusions and referrals.
Risk
225 - The risk of insufficient
MI
GREEN demotivated staff and poor
Complete service quality
GREEN
GREEN
Complete
BLUE
The appraisal policy is being refreshed to
include nurse revalidation. Awareness
sessions are being delivered to nurses to
understand revalidation. Revalidation will
be included in update of nursing initiatives
report to Trust Board in March.
The Trust won two awards at the HEWM
event and both recipients will also be
entered in to the national awards.
DoPCD
Nurse revalidation
Celebrate success by
Objective 8
supporting staff to apply for
Motivating, developing and
awards
empowering staff to meet
the challenges we face
Competency framework for
Doctors
This was originally happening in Q3. In
practice, this has been happening on an
ongoing basis throughout the year which
includes general refreshes and reviews of
both the portfolio or training offered, and
amends to responsibilities and functions
etc. Any further reviews will be done as
part of the new Associate Director of HR's
scope who joins the Trust the end of
February, so in practice this will not be
completed until at least Q1 next year. This
would be part of the new Associate
Directors ‘business as usual’ rather than a
notable specific objective for the BAF.
Recognise success with new
“going the extra mile”
DoPCD
initiative
Refresh of our Learning and
Development portfolio
Priority Activities
Risk 225
4x2=8
AMBER
3
Residual
Level of
Risk
Assurance
Score
178 of 182
Supporting Strategies
Priority Activities
Objective 11
Effective marketing of the
Trust and its services
DoPCD
DoPCD
Commercial skills training
Service Line Business
planning and Services
Marketing
This has been deferred until Q1 2015/16 in
line with the launch of the new Clinical
&Social Care Vision,
Intranet resources are being developed and
the Trust is reviewing the need for a set of
commercial skills training as part of the L
and D portfolio.
There is no change in Q3. The Trust has
collated a number of patient stories to
support bids but will also be producing a
Trust wide resource for staff to use as
testimonials etc.
Development of a suite of
case studies and testimonials DoPCD
to support bids / marketing
Priority Activities
Principal Risks
BLUE
AMBER
GREEN
IBP
Mental Health Programme Board
Business development PMO reports to
MExT and Board
Feedback from tender processes.
Risk
STRAT18 - Increasingly
competitive environment for GG
Health Care providers
Principal Risks
IBP
Mental Health Programme Board
Business development PMO reports to
MExT and Board
Risk
4
Risk
STRAT18
4x3=12
AMBER
2.5
Residual
Level of
Risk
Assurance
Score
Risk
STRAT18
4x3=12
AMBER
Residual
Level of
Risk
Assurance
Score
3
Residual
Level of
Risk
Assurance
Score
FTPB reports & minutes.
Regular reports to MExT, G&Q & Board.
Mental Health Programme Board.
SED quarterly report.
Strategic partners.
FT assessment process.
Risk 226
Council of Governors meetings and
4x2=8
monthly briefings.
AMBER
CQC assessment outcome 'good'
Escalation framework.
Monitor reassessment commences
February 2015.
Risk
226 - The Trust's ability to
respond to rising demands
in relation to current
MI
healthcare reforms
including the Trust's FT
application
Principal Risks
STRAT18 - Increasingly
GREEN
competitive environment for
GG
Complete
Health Care providers
GREEN
GREEN
An open house event is planned for Q4.
Work to develop a youth forum has been
delayed due to other engagement activities
but will recommence in Q4.
The EBE workplan is now well developed
and almost all are actively involved in
projects across the Trust and within the
community.
AMBER
The way in which the Trust engages with
the Council of Governors is currently being
reviewed by the new Chair. Re-activation of
the Trust's FT assessment by Monitor will
provide a key platform from which to launch
a new and improved engagement strategy
and programme.
Increased focus on growth
and service portfolio
Resourcing of a Service /
DoPCD
development
Business Development PMO
Objective 10
DoPCD
DoPCD
EBE Model development and
DoPCD
recruitment
Young Members’ Forum
Objective 9
Council of Governors
Continue to maximise
engagement programme
progress towards becoming
authorised as a Foundation
Trust
GREEN
Complete
DoPCD
New Mental Health Forum
Priority Activities
179 of 182
fficient Resources
Meet and where possible
exceed national, regional
and local performance
targets
Objective 12
Implementation of the Agile
working strategy
Sustainability campaign and
action plan
DoST
DoON&E
Following a positive evaluation of the agile
working pilot, MExT have approved the roll
out of agile working across the Trust. The
Trust is waiting for the outcome of the bid
to the nursing technology fund and
following the outcome of this in January
2015 a business case and implementation
plan will be developed.
CIP 14/15 remains on track to deliver full
year effect. CIP planning 15/16 and 16/17
plans have been approved by the Board
The Trust are currently investigating the
use of solar energy with a scheme at the
Elms. The Sustainable Development Group
is set to meet in February to review the
action plan and develop year 3 phase of
the plan. The focus in Q4 being to develop
proposals for analysing the wider
introduction of sola systems across the
estate.
A number of wards have had windows
replaced with more energy efficient
variants, these being appropriate to the
service needs. Other sites have had solar
gain/glare film fitted.
A new energy management system have
been installed across Bushey Fields
Hospital. Upgrades are currently underway
on the Dorothy Pattison site. These
contribute to the net reduction of
consuming fossil fuels by improving the
efficiency of controls and boilers.
HEAL is still in place and is refreshed
monthly as agreed.
Cycle to work scheme is being investigated
to identify the “appetite” of staff to take part
and possible locations to roll out too, this
includes identifying what other
infrastructure is required to support any
proposed scheme.
CIP, CQUIN and QIPP plans
DoFP&IT
into action
Priority Activities
GREEN
GREEN
GREEN
4
Residual
Level of
Risk
Assurance
Score
Robust CIP framework in place with
regular reporting to MExT and Trust Board.
QIA in place for all 14/15 schemes.
Risk
Strong financial performance year to date.
FINAN 1
2014/15 Slippage covered through
reserves and non-recurrent CIP. Workshop 5x1=5
in August to refine 15/16 plans, to be
GREEN
finalised in September.
Regular CARM and CQR meetings.
TDA IDM meeting and level 4 escalation
Risk
FINAN 1 - Inability to meet
CIP targets and the impact MA
on the viability of the Trust.
Principal Risks
180 of 182
Effective and E
Objective 13
Progress PbR and SLR
against agreed milestones
Objective 14
Utilise technology to
improve productivity and
efficiency
DoPCD
Mobile App launch
Priority Activities
Prepare for implementation of
DoFP&IT
PbR
DoFP&IT
Joint MD
Roll out of digital dictation
Embed new costing system
This activity is complete.
DoON&E
Implement interactive ward
screens
F&P Committee continue to receive regular
updates. Confirmed Cluster will be
currency for 15/16. Action plan and
trajectory for reducing unclustered activity
by 31/3/15 will be presented to January
Finance and Performance Committee.
Testing of SLR information is now
complete. End user training is to be rolled
out to ensure wider use of the system in
financial decision making.
Principal Risks
GREEN
GREEN
PERF09 - Maintaining Data
Quality issues
Principal Risks
OPS 013 - A current lack of
GREEN strategic direction in
Complete relation to records
management leading to
unacceptable practice in
relation to record keeping
within the organisation.
GREEN
AMBER
Continues to develop and will now be
subsumed into the Technology Working
Group, to be expanded to other clinical
groups and involving the agile working
programme.
This activity is complete. The Trust is
looking into analytics to evaluate its impact. GREEN
Feedback would indicate that is very well
Complete
received.
No further progress from Q2 which was a
visit to Leicester Partnership Trust planned
for January 2015 as part of a fact finding
initiative.
Explore e-health and
telehealth, e-prescribing and Joint MD
auto-dispensing
Priority Activities
MA
3
4
Residual
Level of
Risk
Assurance
Score
Risk
OPS 013
4x1=4
GREEN
Residual
Level of
Risk
Assurance
Score
Live data quality improvement plan in
place
Internal audits in Q4 on Data Quality
Improvement Programme
DQ currently scrutinised at CARM
Additional resource in place within
Risk
Informatics to improve Data Quality
PERF09
Regular communication between
4x2=8
Performance and Informatics teams and
AMBER
Operational Teams
A live action plan dealing with the
completeness o f the MHMDS submission
in place
Metric specification document in place for
all Key Performance Indicators
Risk
Training sessions provided for staff re
requesting records held offsite
Exploration of scanning solutions and the
restrictions of note movement.
Internal audit to conduct audit of Systems
and controls.
Development of strategic direction with
particular focus on: Integration of medical
and nursing notes; Records Tracking
Processes; Standardised formats; and
Archiving practices
Risk
181 of 182
BLUE
Negative assurance
Limited assurance
Moderate assurance
Significant assurance
Full assurance
Classification
Gaps in the application of controls put the achievement of objectives at risk
2
Blue in the progress /RAG box means that the
commencement of progress is planned in a forthcoming
quarter.
Gaps in the application of controls have opened up the risk of significant failure to achieve its objectives
A sound system of controls has, for the most part, been consistently applied, minor inconsistencies have occurred that
may cause some objectives to be put at risk
2.5
1
A sound system of controls has, for the most part, been consistently applied, minor inconsistencies have occurred but
there is no evidence to suggest that the system's objectives have been put at risk
A sound system of controls has been effectively applied and manages the risks to the achievement of the objectives
4
3
Description
Score
The proposed levels of assurance above are based on the following scoring framework:
182 of 182