A MEETING OF THE BOARD OF DIRECTORS OF THE SOUTH LONDON AND
MAUDSLEY NHS FOUNDATION TRUST
WILL BE HELD ON TUESDAY 28TH APRIL 2015 AT
3:00PM, BOARDROOM MAUDSLEY HOSPITAL
AGENDA
1
APOLOGIES for absence:
2
Declarations of Interest
3
Minutes of the Board Meeting held on 24th March 2015
3.00pm
4
MATTERS ARISING/ACTION POINTS REVIEW
3.05pm
Page 10
Attached
QUALITY
5
Approve the Lewisham MHOA Consultation
3.10pm
Page 13
App A
6
PERFORMANCE AND ACTIVITY
Approve the Finance Report – Month 12
3.25pm
Page 79
App B
App C
7
Approve the Performance Report – Month 11
GOVERNANCE
3.40pm
Page 95
8
For Information Report from the Chief Executive
3.55pm
Page 107 App D
9
For Information an Update from the Council of Governors
4.00pm
Page 114 App E
10
Approve the Social Care Strategy
4.10pm
Page 118 App F
11
For Information Key issues and Minutes from the Quality Committee Meeting
4.30pm
Page 127 App G
12
4.35pm
Page 129 App H
13
For Information Key issues and Minutes from the Audit Committee Meeting
INFORMATION
Director’s Reports
4.40pm
Verbal
14
Approve 2016 Board and CoG dates
4.45pm
15
Actions summary from today’s meeting
Verbal
16
Reflections on today’s meeting
Verbal
17
Forward Planner
4.50pm
18
To agree future disciplines for Board meetings
4.55pm
19
Annual Report publication schedule
Page 147 App K
20
Report from previous Month’s Part II
Page 154 App L
21
Any other business
Page 142 App I
Page 144 App J
Verbal
To consider a motion that representatives of the press and other members of the public be excluded from
the remainder of the meeting having regard to the confidential nature of the business to be transacted,
publicity on which would be prejudicial to the public interest (Section 1(2) Public bodies (Admission to
Meetings) Act 1960
Date of Next Meeting: Tuesday 28th April 2015 – 3:00pm, Boardroom, Maudsley Hospital,
Denmark Hill, London, SE5 8AZ. Please send apologies to Alison Baker 0203 228 4763
[email protected]
Please note that minutes from this meeting are a public document and will be published on the Internet and may
be requested under the Freedom of Information Act (2000). Any attendee that would like their name omitted from
the minutes should discuss this with the minute taker. Note that it may not always be possible to oblige as this is
dependent on the persons role and the business being discussed.
web site: www.slam.nhs.uk
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MINUTES OF THE EIGHTY FOURTH MEETING OF THE BOARD OF DIRECTORS OF
THE SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST
HELD ON 24TH MARCH 2015
PRESENT
Roger Paffard
Dr Martin Baggaley
Dr Neil Brimblecombe
Robert Coomber
Alan Downey
Gus Heafield
Dr Julie Hollyman
Prof Shitij Kapur
June Mulroy
Dr Matthew Patrick
Chair
Medical Director
Director of Nursing
Non Executive Director
Non Executive Director
Chief Financial Officer
Non Executive Director
Non Executive Director
Non Executive Director
Chief Executive
IN ATTENDANCE
Mark Allen
Chris Anderson
Alison Baker
Ellie Bateman
Dr Alison Beck
Lucy Canning
Dr Bruce Clark
Stephen Docherty
Jo Fletcher
Louise Hall
Roy Jaggon
Matthew McKenzie
Paul Mitchell
Zoë Reed
Steven Thomas
Interim Director of Estates (item 9 onwards)
Council of Governors
PA to Chair & Non Executive Directors
Service Director, B&D CAG
Head of Psychology & Psychotherapy
Service Director, Psychosis CAG
Clinical Director, CAMHS CAG
Chief Information Officer
Service Director, CAMHS CAG
Director of Human Resources
Head of Performance Management
Council of Governors
Trust Board Secretary
Director of Organisation and Community
Audit Committee Secretary
APOLOGIES
Emily Buttrum
Lesley Calladine
Steve Davidson
Dr Emily Finch
Angela Flood
John Muldoon
Commercial Director
Non Executive Director
Service Director, MAP & Psychological Medicine CAGs
Clinical Director, Addictions CAG
Council of Governors
Lead Governor
DECLARATIONS OF INTEREST
Routine declarations were made:
x
x
Dr Martin Baggaley declared that he occasionally provided consultancy support
via Deloitte.
Prof Shitij Kapur declared an interest as a member of the CNS Scientific Advisory
Board of Lundbeck Co and Roche Co. Prof Kapur advised and consulted with
pharmaceutical companies periodically.
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x
x
Dr Matthew Patrick declared that he was London Mental Health Clinical Director
for NHS England London Region and Chair of the London Mental Health
Strategic Clinical Network, and Non Executive Director/Clinical Advisor to
BigWhiteWall International Board.
Stephen Docherty declared that he was a Non Executive Director of Maudsley
Learning.
MINUTES
The minutes of the meeting held on the 24th February 2015, were agreed as an accurate
record of the meeting with the following clarification:
BOD 28/15 - Update from the Council of Governors – the last paragraph
should read as follows: “Chris Anderson reported as governor observer on the
Board’s quality sub-committee that he had raised concerns over a recent PEDIC
report and also a recent review of the Trust’s response to the Francis report one
year on where there had been limited achievement. He was pleased that
processes were in train to address these issues.”
BOD 35/15 MATTERS ARISING/ACTION POINTS REVIEW
BOD 24/15 – Finance Report – Month 10 - Gus Heafield reported that he was
currently undertaking a scoping process across the organisation, documenting the
systems including the overall dashboard and working with CAGs and the
infrastructure teams for a new mechanism for tracking CIPs. Further information
would be brought back to the April Board meeting: Action: Gus Heafield – April.
BOD 25/15 – Performance Report – Roy Jaggon explained that a supplementary
action log was contained within the current report.
BOD 32/15 – Forward Planner – Paul Mitchell explained there was further work to
be carried out, he would be taking this up with the Senior Management Team and
would report back to the April meeting. Action: Paul Mitchell – April.
BOD 33/15 – AOB – Paul Mitchell explained that he had received responses back
regarding the iPad survey he had sent out, the main requirement had been
regarding training.
BOD 36/15 FRANCIS INQUIRY REPORT
Neil Brimblecombe introduced the Francis update report. He emphasised that
many of the recommendations around staffing and governance were now standard
practice for the Trust.
Alison Beck stressed the need to ensure the Trust had the correct processes and
strategy for the delivery of safe care. Throughout the reviews the emphasis had
been on the move from regulatory compliance and financial management to safe
and compassionate care, with this change starting with the Board. Leaders needed
to be kind, available, empathetic, fair and respective. Listening to patients was the
most important source of feedback on organisational performance, leading to an
open, honest and transparent culture. Staff engagement was the key indicator of
patient satisfaction, with staff being more engaged when they were clear about
their roles.
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The appointment of a Speak up Guardian to champion staff concerns was being
piloted. Alan Downey suggested that this could help tackle the bullying and
harassment targets which had been highlighted via the staff survey. Louise Hall
explained that progress had been made on the target this year. It was agreed to
take forward the work on the role of Speak up Guardians. Action: Neil
Brimblecombe – May.
Roger Paffard asked that this be an item for discussion at the next CoG meeting.
Action: Forward planner for CoG – Paul Mitchell – June.
It was also agreed to review best practice of how the Board involved patients.
Action: Zoe Reed – June.
The Board of Directors noted the report.
BOD 37/15 NATIONAL STAFF SURVEY RESULTS 2014
Louise Hall explained that this report presented the main findings from the National
Staff Survey 2014 and the initial next steps.
This year 1,805 employees completed the survey which was a 42% improvement
on the 2013 response rate. Themes from the previous year’s report had been
addressed. The theme around equal opportunities was concerning, this was being
investigated. Louise Hall confirmed that further analysis around the high levels of
violence and aggression was being carried out as this had now been a theme for
five years.
The Trust was now developing a plan to address areas of concern. CAGs were
working with HR business partners, with each CAG required to develop their own
action plan. There would be a communications plan to inform staff about the Trust
commitment to the action plan. Neil Brimblecombe emphasised the importance of
visible leadership in this area. Julie Hollyman suggested that this was not easy in
such a large organisation but it could help if Board meetings were not always held
in the same place. Matthew Patrick agreed and suggested we experiment by
holding board meeting in different places, with maybe a one hour open session
beforehand for staff and service users to come and raise issues.
Feedback from CAGs and the CQC would be brought back to the Board in May, on
BME staff and POVA. Action: Neil Brimblecombe & Louise Hall. May
The Board of Directors agreed the recommended next steps, and would
receive an update in May.
BOD 38/15 IT STRATEGY
Stephen Docherty introduced his presentation on the IT strategy. It was noted that
the Board had reviewed this earlier in a Board development session as part of a
deep dive process. Stephen Docherty explained it was clear that the Trust’s
infrastructure and the associated IT Services needed a radical transformation, with
many areas not fit for purpose, resulting in degradation of services such as email.
The IT Support Service had a poor service delivery reputation, with not enough
support staff to cover the number of sites.
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The IT service desk had recently seen improvements with phones being answered
more quickly and the backlog of tickets being cleared. A service management
culture was being developed.
The utilisation of cloud storage was being taken forward. Underpinning the IT
Strategy was the necessity to optimise the operational performance of IT
infrastructure and reduce the number of outages.
Gus Heafield confirmed that changes requiring investment would be subject to the
submission and approval of relevant business cases.
It had been agreed that PCs over 5 years old would be replaced throughout the
Trust. The Executive had also been asked to develop a replacement programme.
The roll out programme would be tracked on delivery through the Audit Committee.
They would also review the development of the service culture and demonstration
of benefits. Matthew Patrick explained that the investment required was within the
financial envelope agreed as part of the plan for next year.
It was agreed that immediate priorities around email platform would be delegated
to the Executive Team, particularly around the move to cloud storage. Action:
Stephen Docherty – May.
Progress check on delivery via Audit Committee would be brought back in
September. Action: Stephen Docherty – September.
An IT replacement programme would be developed. Action: Stephen Docherty –
May.
The Board of Directors approved the IT Strategy and the investment
required.
BOD 39/15 STRENGTHENING LEADERSHIP AND MANAGEMENT
Louise Hall explained that this report informed the Board on progress regarding the
programme of work being taken forward to strengthen management within the
organisation. The Trust had undertaken a significant amount of analysis and
consulted with key stakeholders that had reinforced the need for a programme that
built on what we had already delivered but which could be applied consistently
across our current and emerging people manager population. Much of the SLaM
content was already available within the Trust’s existing learning and development
catalogue, however analysis had shown that employees did not always select or
were directed to the most relevant learning for their role or their personal
development needs as a manager. It was aimed to take two/three years, however
not everyone would need this and an assessment process would highlight what
was needed via individual PDP’s.
Louise Hall confirmed that funding had been received from HESL and the next
step was to finalise the details.
The Board of Directors approved SLaM Squared and supported the next
steps.
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BOD 40/15 FINANCE REPORT – MONTH 11
Gus Heafield reported that discussions were taking place with local CCGs and
NHSE to reach agreement regarding funding for 2015/16. Negotiations with NHS
England were the furthest behind. Matthew Patrick confirmed that this was the
experience across the country. He would be taking this up with the group of ten
London Mental Health Trusts. The Board endorsed the necessary action to raise
this publically.
Gus Heafield confirmed that the Trust was reporting a net surplus of £6.2m and
EBITDA of £15.5m at the end of February. This included an operational deficit of
£7.8m caused by overspends particularly in the Psychosis CAG and Estates. The
operational deficit was being offset by the Trust contingency reserves at month 11
but these would not be sufficient to negate the current run rate over the remainder
of the year.
The Board of Directors noted the report.
BOD 41/15 PERFORMANCE REPORT
Neil Brimblecombe introduced the performance report which had been considered
by the QSC and had been well received. Roy Jaggon explained that this was the
new style report with the dashboard now consisting of an issue tracker indicating
when an issue was first identified, when it would be resolved and the lead owner
with responsibility for delivery. A description of the issue and actions being taken
was also included, which provided improved oversight and assurance in the
resolution of items raised in previous months. Matthew Patrick suggested that as
the report was constantly evolving it would be necessary to regularly review
whether the dashboard was measuring the right items. Dr Martin Baggaley gave
the example that our crisis services were currently under severe pressure,
however this was not reflected in the dashboard.
It was noted that there was a timetable for CAGs to bring patient stories to the
Board as part of the report.
Roy Jaggon explained that the balanced scorecard consisted of a range of
indicators across four perspectives which were linked to the delivery of the
Strategic Plan and the Trusts Operational Plan. This new approach offered the
Board the opportunity to track progress against delivery. Shitij Kapur suggested
that there was an opportunity to integrate this information with other reports
received by the Board. Roger Paffard agreed and suggested that Deloitte be
commissioned to undertake this work as part of their review in the summer.
Action: Neil Brimblecombe/Roy Jaggon.
The Board of Directors noted the report.
BOD 42/15 ASSOCIATE HOSPITAL MANAGERS – ANNUAL REVIEWS
Julie Hollyman reported that the Associate Hospital Mangers had now been
interviewed as part of their annual reviews. Out of the 33 annual reviews carried
out, 32 were recommended for approval, one AHM had not been reviewed due to
health issues.
The Board of Directors approved the Associate Hospital Mangers.
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BOD 43/15 REPORT FROM THE CHIEF EXECUTIVE
Matthew Patrick explained that The Secretary of State for Health, Jeremy Hunt
would now be unable to be a guest at the Trust Conference which would be taking
place the following day.
The official launch of the Bethlem Gallery and Museum had been an outstanding
event. The renovation of the building was a tremendous achievement and would
now be a real asset for staff and people that use our services.
Matthew Patrick reported that unfortunately the Trust had not been successful with
the recent Vanguard bids, although the work involved would be beneficial in the
longer term.
The Board of Directors noted report.
BOD 44/15 UPDATE FROM THE COUNCIL OF GOVERNORS
Chris Anderson reported that an induction session for new governors had been
held on 2 March. Following a report at the COG meeting it had been agreed
feedback should be gathered from the induction session, with further consideration
for training for governors which would assist the planning of future training and
induction for governors.
At the joint Governors/Board meeting it had been agreed the key issues for
clarification and understanding were:
x
x
x
The governor role
Holding to account
Development of the role and provision of support to governors
A report from the meeting was considered at the Council of Governors meeting
held on 12 March 2015. The key decisions agreed were:
x
The Council of Governors ratified the governance group as an authorised
committee to examine governance issues. The status to be reviewed by the
end of the year.
x
The Trust Secretary, in consultation with the group, to conduct an audit of
governors to better understand skill sets, preferences and availability.
x
Agreement to the finalisation of descriptions of the roles and responsibilities
of the Chair and the Senior Independent Director/Deputy Chair. Examples
were given in the presentation made at the joint meeting.
x
The responsibilities of the Lead and Deputy Lead Governor were
confirmed. Self-nominations to be made for the post of Deputy Lead
Governor and, if necessary, an election process to be initiated by the Trust
Secretary.
After attending a recent Involvement Register Management Steering Group
meeting, Chris Anderson had some concerns. These concerns would be
addressed by the Chair of the Governors Involvement and Social Responsibility
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working group, who would be writing to the Director of Organisation and
Communities.
Chris Anderson reported that the Council of Governors were also seeking
assurance that In-patient and Community staff would be receiving appropriate
training in view of the Carers Act coming into force on 1st April 2015.
Matthew Patrick explained that the Social Care Strategy would be brought to the
Board of Directors next meeting.
The Board of Directors noted the report.
BOD 45/15 QUALITY COMMITTEE MEETING KEY ISSUES
Julie Hollyman explained that the CQC did an unannounced inspection at the
National Psychosis Service between the February and March meetings of the QC,
the report is yet to be received.
The Trust was not meeting the target on mandatory training, the fees for DNA/late
withdrawal would be re-introduced as these had a beneficial effect previously.
Efforts were also being made to streamline training to reduce the time
commitment. Louise Hall explained that there were 10 areas of training staff
needed to attend.
Several clinical audits were reviewed. There was concern over the patchy
recording of risk assessments and crisis planning and hence the Committee was
pleased that a working group had been set up to focus on this.
Not all CAGs had provided updates on the Francis action plans but as discussion
was deferred pending the outcome of discussions on Francis at the Board these
would be taken at the next meeting.
The H&S policy and the Smoking policy were ratified. A Ligature Reduction policy
was also endorsed.
The Board of Directors noted the report.
BOD 46/15 DIRECTOR’S REPORTS
No Directors reports were received.
BOD 47/15 ACTIONS SUMMARY FROM TODAY’S MEETING
Paul Mitchell summarised the actions agreed during the meeting. (See attachment
for the updated actions list).
The Board of Directors noted the actions agreed.
BOD 48/15 REFLECTIONS ON TODAY’S MEETING
Comments included:
x
x
x
x
Could some updates be considered through sub committees?
Could some information items be taken as read?
Test presentations/videos beforehand.
Ensure the right balance to focus on key items.
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x
Good to have development time beforehand for the deep dive.
The Board of Directors noted the comments made.
BOD 49/15 FORWARD PLANNERS
The Forward planner was noted. Further work was taking place to streamline the
planner. Action: Paul Mitchell – April.
BOD 50/15 AGREE FUTURE DISCIPLINES FOR BOARD MEETINGS
Roger Paffard explained that a couple of Board reports did not meet the
requirements regarding page numbers. Paul Mitchell reported that this was work
in progress, he would be looking at this again as well as TORs for Board
Committees, as it was timely to review. An update would be brought back to the
next meeting. Action: Paul Mitchell.
The Board of Directors noted the report.
BOD 51/15 ANY OTHER BUSINESS
No other business was discussed.
BOD 52/15 MOTION TO EXCLUDE THE PRESS AND PUBLIC
The Board of Directors agreed that representatives of the press and other
members of the public be excluded from the remainder of the meeting having
regard to the confidential nature of the business to be transacted, publicity on
which would be prejudicial to the public interest (Section 1(2) Public bodies
(Admission to Meetings) Act 1960.
The date of the next meeting will be: Tuesday 28th April 2015 – 3:00pm Boardroom,
Maudsley Hospital, Denmark Hill, London, SE5 8AZ
Chair
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Bring back to Board monthly.
Develop a supplementary
action log.
Strategy update
Lessons learned from CQC inspections
Workforce update
Poly pharmacy paper
Community pharmacy development
Quality strategy
Details of assurance process for managing
CIPs
Performance report – track items for future
reports
Smoking cessation
3
4
5
6
7
8
9
10
11
Update for future meeting.
Bring back annually.
Take forward cost
implications in conjunction
with MB and Psychosis CAG.
Circulate to Board
Bring to Board.
Bring to Board
Update next meeting.
Update report.
Equality update
2
Circulate workforce
information report and report
back.
Action
Bank and agency costs
February meeting
Issue
1
Ref
Board meeting 24 March 2015 – action points
NB
RJ
GH
NB
GH
SM
LH
NB
MP
ZR
LH
By
June
March
March
Feb 16
Apr
Feb
July
June
Mar
Apr
Sept
When
On schedule
Complete
Review meeting
requirement
On schedule
Update at April
Board.
Done
On schedule
On schedule
Taken to seminar
On agenda
Done, on
schedule
Status
RAG
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Staff survey
Agenda planner
iPads for Board papers
March meeting
Involve the CoG in discussion on Francis
Review of best practice of how Boards
involves patients
Take forward work on role of Speak up
Guardians and bring back to Board
Experiment on format of Board meetings
Co-ordinate feedback from staff survey on
BME staff and POVA issues and produce
action plan
Action immediate priorities around email
platform delegated to Executive,
particularly around move to cloud storage
PC time expired kit to be eliminated this
financial year in conjunction with CAGs
Check progress on delivery via Audit Cttee
12
13
14
15
16
17
18
19
20
21
22
23
Bring back to Board in
September
Action in line with appropriate
business processes
Programme with risks and
mitigation brought back to
Board
Bring back in two months
Review after Board
development programme
Bring back to future Board
Bring back to future Board
Forward planner for CoG
Finalise training.
Bring back to next meeting.
Report to next meeting.
SD
SD
SD
NB/LH
RP/PM
NB
ZR
PM
PM
PM
LH
Sept
May
May
May
Dec
May
June
June
March
April
March
On schedule
On schedule
On schedule
On schedule
On schedule
On schedule
On schedule
On schedule
In progress
On agenda
Complete
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Approval of leadership and management
programme and next steps
Endorse action to raise funding for MH
services at the highest level
Performance report review to ensure the
Board is measuring the right issues and
reflecting quality priorities.
Brief Board on social care strategy in light
of Health Care Act
BAF development
Take disciplines forward for Board
committees
Revise scheme of delegation
Review agenda structure
25
26
27
28
29
30
31
32
PNJM/April 2015
Develop an IT replacement programme
24
Items for decision first
Bring to June meeting
Bring to next meeting
Bring to next meeting
Bring to next meeting
Comments to NB
In discussions via Cavendish
Group and NHSE
Take forward
Bring to May meeting
RP/PM
GH
PM
GH
CG
NB
MP
LH
SD
On schedule
Complete
Apr
June
Apr
Apr
Apr
Reflected on
agenda
On schedule
Being actioned
Now may meeting
On agenda
Apr and Review
ongoing
Apr
ongoing Complete
May
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A
TRUST BOARD OF DIRECTORS – SUMMARY REPORT
Date of Board meeting:
28th April 2015
Name of Report:
Proposed Change in the Lewisham Mental
Health of Older Adults Service
Heading: - (Strategy, Quality,
Performance & Activity,
Governance)
Quality
Author:
David Norman, Service Director, Mental
Health of Older Adults & Dementia
Approved by:
(name of Exec Member)
Matthew Patrick
Presented by:
David Norman
Purpose of the report:
This reports advises the Board of Directors of the outcome of the public consultation led by
the MHOA CAG on a proposal to reduce capacity of Specialist Care beds in Lewisham and
transfer activity to MHOA services in neighbouring boroughs.
Action required:
The Board of Directors is asked to note the consultation process and agree the proposed
recommendation
Recommendations to the Board:
That the proposal contained in the consultation to close Inglemere Specialist Care Unit is
agreed
Relationship with the Assurance Framework (Risks, Controls and Assurance) and
level of assurance provided by the report - none, low, moderate, high:
Moderate
Summary of Financial and Legal Implications:
The proposal will release funding to support elements of the Lewisham Quality, Innovation,
Productivity and Prevention Programme (QIPP).
Equality & Diversity and Public & Patient Involvement Implications:
This proposal will have an impact on a small number of older people in receipt of the existing
service and the impact on these individuals will be reviewed as part of implementation of the
closure.
Service Quality Implications:
The impact on quality is minimal.
1
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Mental Health of Older Adults and Dementia
Clinical Academic Group (CAG)
Outcome of the Public Consultation of the proposed closure of Inglemere Specialist Care Unit.
1. Introduction
1.1 The Mental Health of Older Adults and Dementia CAG has carried out a Public Consultation
between 14th January and 15th April 2015 on a proposal to close the Inglemere Specialist
Care Unit. This paper outlines the consultation process and recommends to the Board of
Directors that the proposed closure of this facility should take place.
1.2 The Consultation process was undertaken over a period of 90 days. It allowed for
consultation with all stakeholders, including relatives of patients affected by the proposal,
the wider health and social care community in Lewisham as well as partner organisations.
1.3 The feedback from the consultation was collated and themed and informed the
recommendations.
2. Inglemere Specialist care Unit
2.1 Inglemere Specialist Care Unit is a 16 Bed unit that provides mental health nursing care for
patients’ with a diagnosis of Dementia who are experiencing severe Behavioural and
Psychological Symptoms of Dementia (BPSD). The focus of the nursing care is to devise care
plans that will alleviate, reduce and manage the symptoms of BPSD.
3. Proposed Reasons for closure
3.1 The reasons for this proposed change in NHS service provision are:
x
x
x
x
The numbers of specialist care mental health places available in the borough are
running at a surplus.
The demand for these beds in Lewisham and Nationally in specialist mental health units
has consistently declined over the last five years.
The current service level in the borough is disproportionately focused on inpatient care.
A recent evidence based needs assessment indicate there are many people in Lewisham
with low to moderate mental health needs and a high number of people in care homes
with unmet mental health needs.
There are more cost effective ways to deliver care needed. This can be delivered via
community services providing early intervention to patients’. Front loading the service
reduces the need for multiple interventions and multiple reviews of patients’ living
situation.
2
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4. Summary of the consultation process
4.1 The consultation process ran from January the 14th 2015 to April 15th. The consultation
process was delivered over a period of 90 days following approval by Lewisham Healthier
Communities Select Committee and the SLaM Trust board. The process was based on a
model of engagement with the stakeholders this took the form of:
4.2 Written information
This consisted of a consultation paper, covering letter, and schedule of public meetings. This
was sent via email, post and hand delivered to stakeholders. In addition the public
consultation document was published on the Trust Internet site. The full consultation paper
is attached as an appendix to this report (appendix 1). This included a Equality Impact
Assessment, which was reviewed within SLaM (appendix 2)
4.3 Open public meetings
At the launch of the consultation process the schedule of open public meetings was widely
distributed via email, post and prominently displayed in the unit .The meetings were
scheduled in such a way to maximise the opportunity for attendance and participation from
the widest possible audience. The schedule was designed to cross a wide variety of time
frames to enable access for patients’, relatives, staff and stake holders to attend. Carers
and relatives with individual needs to access the meeting were accommodated e.g. taxi,
Skype provision.
The integrity of the flow of information from the meetings was maintained by the use of a
number of key staff acting as chair.
The participants were as follows:
x
x
x
x
x
x
x
x
Service Director, MHOAD CAG
Associate Clinical Director, MHOAD CAG
Joint Commissioner, Lewisham Clinical Commissioning Group.
MHOA&D Involvement lead
MHOA&D Clinical Service Manger
Continuing Health Care Manager, Lewisham CCG.
Unit Manager, Inglemere SCU.
Lewisham Health Watch.
4.4 Attendance at external stakeholder meetings
Two members of the consultation team the Clinical Service Manager MHOA&D and the
SLaM Public Involvement lead attended Meetings hosted by Health Watch to present the
proposal to their members and receive feedback.
3
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4.5 Carers’ and relatives
The focus of the consultation team was to provide maximum input to carers and relatives.
This was to enable as much feedback to be obtained from individuals who would have
experience high impact from the closure. This was conducted face to face, by telephone and
via email.
4.6 Follow up to written information
Telephone calls were made to stakeholders at appropriate intervals to ensure consultation
paperwork have been received and also obtain comments.
4.7 Feedback
This was built into the process via a system of face to face contact, email or post to the
Clinical Service Manager who was leading the process.
4.8 Contact with staff
Staff were involved in the process they were invited to meeting s and had access to the
written information pertaining to the process. They also had the opportunity to meet with
the Clinical Service Manager at regular intervals during the process.
4.9 Equality
Equalities impact assessments were completed as part of the consultation process.
5 Summary of the consultation responses and comments
During the consultation the following themes arose via feedback these themes have been
grouped as some overlap occurs:
5.1 Patient Care
x
x
x
x
x
There were a number of expressions of overriding concern for the continuance of good
quality care received in Inglemere to be delivered to patients. To achieve this, relatives
expressed a preference for Inglemere to remain open.
There was concerns about the availability of other suitable providers in the local and
regional, National areas. Relatives had previous experience of needing to transfer
patients’ care to Inglemere to enable the patients’ needs to be met.
Feedback relating to unsatisfactory care previously received under private sector
provision.
There was concerns about timeline for moving their relatives if the consultation
recommend closure.
There we concerns regarding increased risk of mortality as a result of a move.
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x
x
It should be noted that some feedback reflected that they did always feel care was of a
high standard at Inglemere.
It was observed the condition of the building required significant investment to upgrade
the building to improve the environment to provide excellent patient experience and to
meet CQC standards.
5.6 Impact on relatives
x
x
x
x
Relatives expressed concerns about financial implications for families. Patients’ are
currently fully funded by the NHS. Families were concerned they would now be required
to fund the care needed.
Relatives were concerned that the ongoing annual review of funding for NHS continuing
care would be undertaken by less skilled staff leading to incorrect assessments of
patients’’ needs.
Concerns were raised regarding by relatives and carers’ about how easy it would be to
visit patients’ once moved had moved to a new residence. This was related to the
distance people would need to travel and how accessible new residences might be to
public transport.
Relatives raised the question of trust in relation to the consultation process. Expressing
concerns decisions had already been made and it was an inevitable that Inglemere
would close.
5.7 Future provision
x
x
x
Removal of beds from the borough of Lewisham meaning patients’ and relatives would
need to travel.
Expressed concerns about the long term plan for the National Health Service. A service
they valued and want to see maintained. This was also related to the information
received via the media and government regarding an explosion in Dementia diagnosis
and indicating a higher level of provision needed to provide care to patients’ diagnosed
with Dementia.
Concerns were raised about the provision in Lewisham for community mental health
care provision being inadequate.
6.0 Response to consultees
A summary of the responses received by stakeholders involved in the consultation and the
issues that were raised appears as appendix 3 of this report. We have reviewed the themes
and have summarised our responses below.
6.1 Patient care
We recognised there is variation in the provision of private sector mental health patient care
locally, regionally and nationally. In Lewisham borough we are currently delivering a
specialist service dedicated to supporting private sector providers in the management of
patient s’ who have a diagnosis of Dementia and are experiencing BPSD as a symptom. This
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team demonstrates good outcomes. Staff have been supported to manage SlaM patients’
symptoms enabling them to be cared for in the same environment by the same home/
provider. This means fewer moves for people with a diagnosis of Dementia. This is beneficial
as change can be distressing for patients’ with a diagnosis of Dementia. The long terms
vision is increasing work with the private sector to support Patients’ and providers deliver
evidence based care.
SLaM will continue to provide specialist residential mental health care for patients’ who
have severe BPSD and require a highly specialist intervention in Units in Lambeth and
Southwark. We recognise that these are not located in Lewisham borough but they are
accessible to Lewisham residents (distances/ transport links).We have offered travel support
to families whose relatives will need to be placed in our out of borough Specialist care Units
as a result of this closure.
We recognise that moving can be distressing for both patent and family and in some cases
patient have died following a move. We have expertise in the movement of mental health
patients to minimise the risks. We will work in conjunction with Lewisham Clinical
Commissioning group brokerage team to identify suitable alternative placements for our
current patients’. Discharges will be managed through rigorous discharge planning with the
clinical team.
6.2 Impact on Relatives
We acknowledge that the impact of a Dementia diagnosis on families is significant. We
acknowledge that any additional pressure needs to be kept to a minimum. Communication is
essential during any process of change to ensure concerns are promptly addressed.
The financial impact on families will be negligible because all current patients at Inglemere
meet the criteria for either ongoing NHS Continuing Health Care or social services funding.
A number of relative live away from the Lewisham Borough we are committed to support
them to identify placements that are near to them to reduce travelling time and support
ease of visiting.
6.3 Future Provision
A concern about the increasing numbers of patients’ are being diagnosed with Dementia
was raised. Patient s’ have been living with an undiagnosed Dementia with our
communities. The commitment to increase diagnosis rates will increase recorded numbers
of Dementia sufferers in the UK. However this will enable patients’ to access early
intervention services and enable them to live well with Dementia for longer.
Lewisham Borough has no significant projections for increased Dementia rates due to the
age demographic indicates a minimal increase in older adults additionally a low rise in
Dementia. In the last two years Lewisham CCG has invested in memory services and
specialist mental health team to support private sector providers. This model has now been
adopted by neighbouring CCG’s.
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7.0 Lewisham Healthier Select Committee
The consultation process and outcome was reviewed by the Lewisham Healthier Select
Committee at its meeting on 21st April 2014.
8.0 Recommendation to be made to Trust Board
Following a review of the consultation, SLaM considers that the majority of concerns raised
can be addressed through clinical support by the services to those patients who will be
transferred to alternative provision, and through continued engagement with Lewisham CCG
in providing clinical service to older people with mental health needs in Lewisham.
The recommendation to the Board of Directors will be to proceed with the planned closure
of Inglemere Specialist Care Unit as outlined in the Consultation proposal.
If the Board of Directors approve the recommendation, the CAG will plan for the relocation
of current service users into alternative placement with the support of Lewisham Clinical
Commissioning Group. It is planned for these moves to take place over the summer months
following best practice in the relocation of frail vulnerable older people.
David Norman
Service Director
Mental Health of Older Adults and Dementia
April 2015
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Appendix 1
Public consultation for closure of Inglemere Specialist NHS Continuing Healthcare
Care Home
1.0 Introduction
1.1 The South London & Maudsley NHS Foundation Trust wish to bring a proposal for public
consultation for the reduction of specialist care inpatient beds in Lewisham Borough .The
proposed service change is to close the Specialist Care Unit in Lewisham and transfer
activity to SLaM provision in neighboring boroughs. The unit in question is Inglemere
Specialist Care unit in Forest Hill. This proposal is supported by the Lewisham NHS
Clinical Commissioning Group.
1.2 This paper outlines the reasons for the public consultation. It also provides background
information on the current services, mental health needs of older adults in the borough
and information on how the change in service can be managed.
1.3 The reasons for this proposed change in NHS service provision are that the numbers of
places available in the borough continue to be more than is needed. The demand for
places in these specialist units has consistently declined over the last five years. The
decline in demand is due to changes in the provision of service by SLaM, national policy
changes and improved developments in community mental health treatment.
1.4 In the past twelve months t there have been two new admissions to the unit. There are
currently eight empty beds.
1.5 Another factor in proposing a closure the specialist units is that the current service levels
in the borough are disproportionately focused on inpatient care. Recent evidence based
needs assessments indicate there are many people in Lewisham with low to moderate
mental health needs and a high number of people in care homes with unmet mental
health needs.
1.6 Following completion of the public consultation on the proposed closure of Inglemere
Specialist Care Unit, all remaining patients who require ongoing inpatient treatment by
SLaM will be transferred to alternative SLaM provision. Patients and their relatives will be
fully involved if patients are assessed as requiring (and being suitable) for alternative
placements. Based on this information, each patient’s individual need will be taken into
account before planned moves are made.
1.7 If the proposal is agreed it is anticipated that there will be minimal staff redundancies as
SLaM will be able to transfer staff affected to alternative services.
1.8 It is acknowledged that it is complex piece of work to close a specialist care unit, as
vulnerable, physically frail patients are involved. However SLaM and Lewisham Clinical
Commissioning Group (CCG) are experienced in delivering this type of service change
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1.9 Lewisham CCG agrees with SLaM that there is no longer the demand for a unit in the
borough and that the needs of patients who require specialist care placements can be
met within SLaM provision in other boroughs with a new emphasis on shorter stays and
care plans that will enable patients to be transferred to other facilities within the borough.
2.0 Specialist Mental Health Services for Older People in Lewisham
2.1 The Mental Health of Older Adults service in the South London & Maudsley NHS
Foundation Trust (SLaM) provides specialist mental health services for people aged 65
and over who suffer from a serious mental health condition. Almost three quarters of the
people the service looks after suffer from an organic mental health problem such as
dementia. The remainder has a disorder such as depression, schizophrenia or bi-polar
disorder. Some service users will suffer from two or more conditions. , for example a
common mental illness such as depression as well as dementia. All service users in the
SLaM NHS Specialist Care Units will display challenging complex behavior that requires
a period of skilled mental health intervention to stabilise their condition.
2.2 SLaM mental health older adults services in Lewisham Borough currently provides acute
inpatient care for 18 patients in a ward located in the Ladywell Unit at University Hospital
Lewisham.
2.3 Two Community Mental Health Teams operate in the community to support at around
400 older adults with mental health difficulties in the community.
2.4 Since early 2014, Lewisham CCG has commissioned SLaM to provide a seven day
Home Treatment Team for older people, with a remit to provide intensive community
based support to older people in crisis situations in order to avert unnecessary admission
to an acute psychiatric bed. This team also provides intensive post-discharge support for
patients who no longer require an inpatient stay.
2.5 In addition, there is a Mental Health Liaison Service which works within University
Hospital Lewisham to assess older adults who may have mental health difficulties.
2.6 In addition SLaM has a Specialist Mental Health Care Home Intervention Team that
works specifically with the private care sector supporting patients in care homes with
mental disorders associated with severe behavioural disorders.
2.7 These services work closely with primary care, Social Care & Health Services as part of
a whole system approach to support the needs of Older Adults with Mental health
difficulties. The focus of all these services is to support older people to live at home as
independently as possible. This is in line with national policy such as ‘delivering care
closer to home’.
2.8 There is good evidence that timely diagnosis of dementia makes sense economically,
improves life of carers’. New specific treatments (medication, psychology (CBT, reality
orientation, skills training), and psychosocial (day care, CST) if targeted correctly, can
improve symptoms for the person with dementia. These approaches, which SLaM are
starting to offer in our Memory Services, Community teams and care home intervention
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teams can reduce the need for admission into care homes or hospitals. See evidence
below with links to sites.
Summary of non-pharmacological interventions to reduce functional decline- provides clinical
trial evidence that non-pharmacologic interventions can delay progression of functional
impairment or disability among community-dwelling dementia patients.
http://www.ncbi.nlm.nih.gov/m/pubmed/23611141/?i=55&from=dementia%20early%20interv
ention%20review
Cognitive psychosocial intervention in dementia stimulates cognitive functions, especially by
means of reality orientation, improves overall cognitive function in patients suffering from
dementia.
http://www.ncbi.nlm.nih.gov/m/pubmed/24022505/?i=38&from=dementia%20early%20interv
ention%20review
A Systematic review of adjustment depression and anxiety in dementia and Mild Cognitive
Impairment (MCI). It shows positive findings in the treatment of depression in older adults
with early dementia using problem solving and modified cognitive behaviour therapy (CBT)
approaches. Amongst the large range of approaches trialled to improve adjustment and
quality of life for patients with MCI and early dementia, some approaches, such as modified
CBT, have shown promise.
http://www.ncbi.nlm.nih.gov/m/pubmed/24125507/?i=34&from=dementia%20early%20interv
ention%20review
Review of economic case for early diagnosis. Although early assessment has significant upfront costs, identifying AD patients at an early stage results in cost savings and health
benefits compared with no treatment or treatment in the absence of early assessment.
http://www.ncbi.nlm.nih.gov/m/pubmed/21420366/?i=60&from=benefits%20of%20early%20d
iagnosis%20dementia
Early diagnosis of Dementia on care givers with early interventions may help caregivers in
anticipating and accepting the future care role and transitions, with the increased possibility
that caregivers can still involve the patient in the decision making process. As levels of
stress and burden are still low in the pre dementia stage it provides excellent opportunities to
empower the resources of caregivers.
http://www.ncbi.nlm.nih.gov/m/pubmed/23689068/?i=28&from=benefits%20of%20early%20d
iagnosis%20dementia
2.9 SLaM provides the Lewisham Memory Service which aims to provide a specialist
dementia assessment service for the population of Lewisham. NHS Lewisham has also
commissioned a support service for people with dementia provided by Lewisham Mind
care. The referral rates are stable and will enable early support identified above to be
provided at diagnosis.
2.10
Graph below Shows referrals and discharge To Lewisham memory service
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2.11 SLaM provide the Specialist Mental Health Intervention Team set up in early 2014
with a remit to work with patient’s and care providers in residential and day settings. The
aim of the team is to undertake assessment and treatment and work with organizations
to manage behaviour that challenges, thus reducing the need for unnecessary patient
moves providing a better quality of life for patients’ living with a diagnosis of dementia.
This team has increased the level of support to Care Homes in the borough and is one of
the reasons why the activity into Inglemere has reduced. The team is currently
supporting approximately 70 service users
Graph below shows referrals and discharges to Lewisham Specialist Care Home
intervention Team since start of service.
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Table to show which care homes have been working with Specialist Mental Health service
since started in 2013.
Care Home
Count
Patients
Adelaide House Care Home
1
Alexander Care Centre
7
Barchester Health Care
6
Becket House Unit
1
Beechcroft Nursing Home
4
Benedict House Nursing Home
1
Brownhill Lodge
2
Brymore House Nursing & Residential Home
6
Castlebar Nursing Home
9
Fieldside Residential Home
7
Gibsons Lodge
2
of
Kirkdale Care Centre, Old Cedars Nursing 1
Home
Manley Court Nursing Home
6
Oakcroft Nursing Home
1
Pear Tree Care Centre
4
Penerley Lodge Residential Home
2
Ranyard, Mulberry House
1
St Magnus Hospital
1
The Glebe
2
The Hill House
1
The Ranyard, Dowe House
3
The Swallows
3
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Welcome Care Home
2
Westwood House
1
Other
55
Total
129
2.12 The remaining element of the mental health services provided by SLaM in Lewisham
is the inpatient specialist care service. The SLaM Specialist Care Service is a very small,
highly specialized part of mental health of older adults’ provision in the borough. The
service is only available for NHS patients.
2.13 Reviews of the current mental health services provided by SLaM have concluded the
Community Mental Health Teams, Home Treatment Team and Specialist Mental Health
Intervention Team are busy and responding to increased demand has been challenging.
The same statement cannot be applied to the specialist continuing care services
provided by SLaM. In fact referrals to this service have been reducing over time.
3.0 SLaM Specialist Continuing Care Services for older people with mental health
needs in Lewisham
3.1 Patients admitted to the Inglemere Specialist Care Unit are usually well known to
mental health services, as they will have been under the care of the specialist services
for some time. Admission to this unit will only take place if there are no alternative care
options left, mainly due to the patient exhibiting challenging behaviour. The unit does
not admit patients under “home for life” principles, instead the expectation is that once
the patient’s mental health condition, either a challenging dementia or ongoing
psychiatric condition is stabilised that the patient can be discharged to a more suitable
long term placement. SlaM uses a variety of approaches to assess the patients and
develop care plans that will enable the patient to be transferred back to a care home.
3.2 There are currently three Specialist Care Units operated by SLaM across the whole
SLaM catchment area. The sister units to Inglemere are Ann Moss Specialist Care Unit
in Rotherhithe and Greenvale Specialist Care Unit in Streatham. These services have
higher rates of occupancy than Inglemere. Ann Moss has an occupancy level of 95%
and Greenvale is 75%. One possible reason for this difference is that Lambeth and
Southwark CCGs have only recently commissioned Care Home Intervention Teams,
although these are currently being developed in both boroughs.
3.3 The quality of care in the SLaM Specialist Care Units is regarded as high. The units
comply fully with Care Standards and have been registered as Independent Hospitals
under the Care Standards Act. They therefore have the capacity to take and detain
patients under the Mental Health Act.
3.4 Residents who have stabilised or recovered from serious mental illnesses in specialist
care units may find challenging behaviour from other residents disturbing, and such
behviours can place patients at risk. So a move to a more appropriate unit is good
practice.
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3.5 The key success of the SLaM Specialist Care Units is the specialist mental health
knowledge that supports the planning and implementation of discharge patients into
care homes. We have a comprehensive discharge planning process see attached
(Appendix 1). We have looked critically at previous discharges to ensure we can
develop our systems to improve discharge of patients.
3.6 The benefits to patients moving from the SLaM Specialist Care Units to a standard
nursing home are as follows. Care Homes may be better able to manage a patient’s
physical health needs. This may possibly be due to a patient requiring more general
nursing component due to their primary need being frailty rather than a serious mental
health conduction.
3.7 SLaM Specialist Care Units are not registered to provide primary physical healthcare
interventions.
3.8 It is not uncommon for a person’s primary need to change over time from a primary
mental health condition to a physical health condition. Hence a different type of service
will be required for the individual person over time.
4.0 NHS Continuing Healthcare for older people with mental health needs
4.1 Access to the SLaM Specialist Care Units is commissioned to meet the needs of clients
who meet fully funded NHS Continuing Healthcare eligibility criteria for mental health
conditions (also known locally as ‘Category One ‘Continuing Healthcare ). This is an
important distinction as it differentiates patients with the highest level of NHS
healthcare need.
4.2 Criteria for eligibility for fully funded NHS Continuing Healthcare are set out at national
level, very specific and would not apply to the majority of older adults unless they meet
clearly defined eligibility criteria. To establish eligibility, in line with the Department of
Health’s National Framework for Continuing Healthcare, the healthcare needs of each
patient have to be individually assessed by a multi-disciplinary team (MDT) of social
workers, nurses and doctors. This is evidenced in a 60 page national assessment form
for each patient. The recommendation of the MDT is then ratified by the Lewisham
Continuing Healthcare Panel. This process has to occur before a person enters any
form of NHS Continuing Healthcare care home to ensure that each person receives the
right level of care based on their individual assessed need.
4.3 Following placement, a patient will have a review after 3 months and then an annual
Continuing Healthcare review to assess if any alterations are needed to their level of
care.
4.4 Older adults who meet the eligibility criteria for fully funded NHS Continuing Healthcare
mental health placements are placed in private/ standard nursing homes which have
been registered as providing mental health care for older adults. However, the older
adults placed in the SLaM Specialist Care Units are assessed as requiring a higher
level of mental health care. This specialist mental health nursing component is above
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and beyond the level of mental health care that could be provided in a standard care
home with nursing.
4.5 Other types of fully funded NHS Continuing Healthcare placements are for those
patients assessed as meeting ‘elderly frail’ criteria. Older adults however, will require
placements either in care homes, (which are funded following a means test by Social
Services) or in care homes with nursing where a contribution from the NHS is made
towards registered nursing care (i.e. NHS Funded Nursing Care or funded Nursing
Care).
5.0 Changes to National Policies and the resulting local impact
5.1 The previous clinical model operated by SLaM was the “Domus” model of care which
was developed in the early nineties to provide NHS specialist continuing care services
for older people with severe mental health problems. The philosophy of the service was
to provide a “home for life” funded by the NHS, and located in small residential units
(the smallest was 12 beds and the largest 16 beds). This service grew out of the major
closure program of the large mental health institutions and the need for long term
residents to be placed in a safe environment after years of institutionalised living. In the
early 1990s it was seen as an innovative service model, which was underpinned by
home for life principles. However, this principle was discarded after 1996 because of
changes in National Continuing Care policy and an understanding that there were no
clinical benefits to supporting long term institutionalisation for patients whose mental
health needs was changing and who required more personalised care that could be
provided in different residential settings.
5.2 Historically, Lewisham had 56 NHS Continuing Healthcare beds due to a high demand
for the units in the early 1990s. This was reduced to 44 beds with the closure of
Churchdown in 2007, and further reduced to 32 beds with the closure of Dillwyn in
November 2010 and then to 16 beds with the closure of Granville Park in 2013. The
reason for this decreasing demand is because of changes to national policy, which has
influenced local demand (see 5.3 below).
5.3 In 1996, a significant national policy change occurred to the original model of care and
then again in 2006 with the revision of NHS Continuing Healthcare Guidance. This
essentially removed the home for life policy for new entrants to Continuing Care
Homes. A subsequent revision of NHS National Continuing Healthcare guidance in
September 2009 again changed the policy context, and clarified the eligibility criteria for
patients entering this level of NHS nursing care.
5.4 Other significant national policy drivers that have influenced changes to how care is
delivered to older adults are as follows. In 2005, ‘Everybody’s Business’ (2005) aimed
to ensure older adults with mental health conditions had access to appropriate physical
healthcare needs and to mainstream services based on their need. ‘Delivering care
closer to home’ (2008), placed the focus on health and social care agencies deliver
care to older adults in a community setting, ideally at home. ‘Personalisation’ (2008)
which requires service users and carers’ are given more choice to self-select from a
range of service providers for their care needs. Historically, this decision was made by
health and social care services on the patient’s behalf. A more recent policy driver is
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the ‘National Dementia Strategy’ (2009) which highlights a need for earlier intervention
services in the community for older people with dementia.
5.5 Other policy drivers have been the creation of the London Procurement Project (LPP) in
2009. This project standardized NHS Care Home contracts across London and
introduced quality standards across NHS funded Continuing Healthcare Homes.
Consequently this has resulted in care homes allocating beds specifically for patients
with Category 1 Continuing Healthcare needs for mental health of older adults. This has
facilitated more choice and availability of Care Homes for the Older Adults client group
that have mental health conditions. In Lewisham, in addition to SLaM services, there
are four other NHS Continuing Healthcare Care Home Providers which are specifically
registered to cater for the Category 1 Mental Health Older Adult clients. These four
providers have a combined capacity to provide 64 additional beds within Lewisham for
NHS fully funded Continuing Healthcare for older adults with mental health problems.
This may also explain why demand for the SLaM Care Homes has continued to
decrease.
5.6 Following all the policy changes, the demand has altered. The reasons are summarised
as follows.
x
x
x
x
Impact of national policy changes. The revised model of NHS Continuing Healthcare
is now more responsive to patients changing needs to ensure they are placed in a
suitable environment that clinically meets all their individual healthcare requirements.
The old psychiatric institutions have been replaced by a new model of care, and the
number of patients has dried up, this has made the Domus model redundant.
Since 2000 more mental health intervention has been completed in the community.
South London & Maudsley NHS Trust has worked with the NHS Lewisham NHS
provider services and the London Borough of Lewisham Social Care services to
develop enhanced community service to support people with complex mental health
problems in the community for longer.
More recently, other NHS Care Home providers have entered the local market place
due to the London Procurement Project. This has increased availability of Category
One NHS Continuing Healthcare Care Homes for older adults with mental health
conditions.
5.7 As a result of these changes, the need for the SLaM service has changed. The net
impact of these changes has seen a general reduction in the need for the type of
provision that the SLaM specialist care units has provided. Consequently, since 2000
the Domus specialist care homes service has never been fully utilised, with a proportion
of beds left empty. This pattern has continued despite reducing beds. This is the main
reason for the public consultation to close the Inglemere Specialist care home.
6.0 A Case for Change : Reasons for the closure proposal
6.1 The main reasons for the proposed closure of Inglemere Specialist Care Unit is due to;
x Decreasing demand for specialist care units.
x An increase of other Continuing Healthcare Care home providers into the local
market, which has increased availability of Category 1 NHS Continuing Healthcare
beds for Older Adults with Mental Health difficulties via the London Procurement
Program (an increase of approximately 64 additional beds).
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x
x
x
Responding to a range of changes in national policies relating to delivering care to
Older Adults.
Responding to evidenced demographic need in the Borough for more community
provision at low to moderate levels for those older adults with mental health
difficulties.
Improved provision at early stages of illness through Specialist Mental Health Care
Home intervention Team.
Each one of these points will be addressed in detail for clarity.
6.2 Decreasing demand for specialist continuing care units. There is no longer an inflow of
patients from the closure of the old psychiatric units. Many patients placed from the old
institutions in the SLaM Specialist Care units have since died, due to old age. For
patients who have not lived in institutional care, advancements in clinical interventions
such as medication, therapy and outreach have enabled them live in the community
with the support of the SLaM community mental health team. This shift to older adults
remaining in the community rather than a residential setting has occurred in Lewisham.
These are the main factors which have seen a reduction in demand for patients to be
placed in the SLaM specialist care units.
6.3 Since 2002/3 to the present there has been a decline in occupancy in the SLaM mental
health of older adults’ specialist care units funded by Lewisham CCG. Only 9 places
are now occupied.
6.4 The decline in usage of these beds over the last 12 years is illustrated in the
Graph below:
6.5 In the past twelve months Inglemere has operated under capacity and there have been
empty beds with only 2 new admissions to the Unit.
6.6 In January 2015, SLaM is required to reassess existing patients who have been in the
unit over 12 months against National NHS Continuing Healthcare Guidance. It is
anticipated that only a small proportion of the remaining 9 patients in Inglemere will
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continue to require SLaM treatment and support and therefore the unit will cease to be
viable clinically or economically.
6.7 This evidence suggests that that there is insufficient demand for this
service, particularly when combined with low admission rates, a high number of empty
beds due to low demand, plus a high proportion of existing residents who did not meet
the NHS Continuing Healthcare eligibility criteria (at the point in time they were
assessed). It is envisaged that due to natural mortality rates over the winter months,
there is the possibility that by spring/summer 2015 the units may be approaching unsafe
vacancy levels.
6.8 These are the reasons that there is no longer the need for Lewisham CCG to continue to
commission 16 specialist care beds. Therefore SLaM is considering the option of closing
this unit and transferring activity to the remaining units in Rotherhithe and Streatham.
This will directly affect the patients who are currently in the Inglemere Specialist Care
Unit (currently nine).
6.9 Part of the public consultation will ensure existing inpatients in the specialist care units
and their relatives are fully informed about options available to them. Nevertheless it is
important to note that once the public consultation process is completed all the existing
patients will need to be re-assessed to determine their level of need. No decisions will be
made about moving residents into care homes from specialist care unless there is
clinical evidence that this would be beneficial to them. Every effort will be made to avoid
undue distress to service users and fully involve relatives. SLaM and NHS are
experienced at delivering this type of service change sensitively and smoothly.
6.10 There has been a range of additional national policies which has changed the
landscape for providing care for mental health older adults. The focus over the past 20
years has moved from reliance on delivering interventions in an institutional setting to
delivering care closer to home, in order to enable people to be more independent and
offer them choice and control over which services to choose.
6.11 SLaM, Lewisham CCG and Social Services have responded locally by ensuring that
older adults with mental health conditions can safely remain at home. This has been
achieved primarily by positive joint working between Social Services and SLaM
Community Mental Health Teams, Home Treatment Team and Care Home Intervention
Team.
6.12 Evidence based demographic needs assessments for Lewisham indicate that there is
a greater need for services for people with low to moderate mental health conditions
such as dementia.
6.13 The currently Lewisham CCG service investment in mental health services is
disproportionately invested for those with severe mental health conditions. The evidence
appears to suggest that re-configuration of NHS investment should be shifted to earlier
intervention services.
6.14 The population profile for Lewisham consists of a total of 24,656 older adults over 65
years old. The borough has a relatively younger population compared to the UK average
and outer London boroughs. In relation to other London boroughs, Lewisham is relatively
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young and has smaller numbers of people with dementia than are seen in other parts of
the city. The population aged 60 years and over represents one in eight people in the
borough. This contrast with England as a whole, where more between one in four and
one in five people is over 60.Males comprise 49% of Lewisham’s population, females
51%. These proportions are not expected to change in the next few years.
Age Group
2001
2011
Age 0 to 4
17772
22004
Age 5 to 7
9732
10580
Age 8 to 9
6772
6085
Age 10 to 14
15312
15268
Age 15
3001
3199
Age 16 to 17
5934
6371
Age 18 to 19
5431
6557
Age 20 to 24
18739
20883
Age 25 to 29
23730
26465
Age 30 to 44
70309
74795
Age 45 to 59
36020
47754
Age 60 to 64
8809
9789
Age 65 to 74
14163
13641
Age 75 to 84
9655
9013
Age 85 to 89
2369
2271
Age 90 and over
1174
1210
248922
275885
Total
*All demographic data relates to 2001 & 2011 census
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6.15 Recent evidence needs assessments conducted by Healthcare for London have
helped to give a better profile of older adults mental health needs in Lewisham. This
data focuses on dementia, not the whole range of mental health conditions found in older
adults. Nevertheless, it does indicate that local NHS services need to be re-configured in
order to address the mental health care needs that would not be defined as having a
serious mental illness.
6.16 Lewisham is estimated to have a total of 1,781 people with Dementia in 2007.
x 55% (952) are estimated to have mild dementia.
x 32% (559) are estimated to have moderate dementia.
x 13% (222) are estimated to have severe dementia.
x 1.2% (48) are estimated to have early onset dementia (early onset are those aged
30+ to 64) Source: Derived from ‘Dementia UK’ prevalence rates and 2007 GLA
populations.
Table below show prevalence of dementia diagnosis across London in 2012
2012
Barking
Dagenham
and 0.68%
Barnet
1.16%
Bexley
1.16%
Brent
0.70%
Bromley
1.33%
Camden
0.60%
Hackney
0.44%
Croydon
0.98%
Ealing
0.71%
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Enfield
0.99%
Greenwich
0.70%
Hammersmith
Fulham
and 0.61%
Haringey
0.59%
Harrow
1.03%
Havering
1.32%
Hillingdon
1.00%
Hounslow
0.76%
Islington
0.61%
Kensington
Chelsea
and 0.74%
Kingston
Thames
upon 0.95%
Lambeth
0.56%
Lewisham
0.69%
Merton
0.87%
Newham
0.44%
Redbridge
0.91%
Richmond
Thames
upon 0.98%
Southwark
0.51%
Sutton
1.11%
Tower Hamlets
0.41%
Waltham Forest
0.71%
Wandsworth
0.56%
Westminster
0.71%
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Data source: Dementia map. http://dementiachallenge.dh.gov.uk/map/?map=1v Contains
Ordnance Survey data, Crown copyright and database right 2014 Dementia Prevalence
Calculator (v3), adjusted to reflect GP patient list and estimates from care homes.
6.17 The table below illustrates projected figures for Lewisham from 2005 to 2021 which
show that the older adult population with dementia is predicted to remain stable. The
NHS Healthcare for London Dementia Needs Assessment has forecast that there will be
a 0% change in the numbers of people with dementia in Lewisham in 2021, when
compared with the numbers in 2005.
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6.18 This suggests that the current and future service provision and investment in
Lewisham for the dementia client group should be targeted at those with low and
moderate dementia. This means that shifting of existing NHS mental health investment
away from residential provisions to earlier intervention community provisions may be
required to benefit those in need of such services.
6.19 National Projected growth
If current trends continue and no action is taken, the number of people with dementia in
the UK is forecast to increase to 1,142,677 by 2025 and 2,092,945 by 2051, an increase
of 40% over the next 12 years and of 156% over the next 38 years. Many people talk
about a 'dementia time bomb' that the state cannot cope with. This is misleading. A
steady, rather than dramatic, growth is expected over the next 25 years. (Source
Dementia UK 2014).
6.20 NHS Lewisham hosted a dementia planning event in July 2009 which focused on the
need to develop strategies to meet the challenges of the National Dementia Strategy.
This event comprised of members of the public, voluntary agencies and the statutory
services.
6.21 The conclusion from this event and the feedback was that although there are good
quality NHS services for older people in Lewisham there needs to be further
modernisation of services to ensure that the wider needs of older people with mental
health needs in Lewisham are met. It was also apparent that such modernisation cannot
rely on new investment and will need to be funded from existing resources.
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6.22 Demand for placements in the continuing care units has continued to decline since
2000. This is due to national policy changes. In addition, there are no longer any
admissions from the old mental health institutions following their closure in the 1990s.
6.23 Evidence on decreasing beds in the units since 2002 was presented. This was
supported by a joint piece of work between SLaM and NHS commissioners which
assessed current residents against national eligibility criteria and found that only 52%
(23) of patients have a healthcare need requiring them to be placed in the SLaM
specialist units. Low admission rates combined with high empty placements and natural
mortality rates could tip the balance and result in the specialist care units operating at
unsafe levels.
6.24 Locally, the NHS Continuing Healthcare Home market providing the same category
of residential care has expanded due to the London procurement Project. This has a
twofold impact of increasing opportunities for the specialist unit to move suitable clients
to local care homes once they have stabilised. Additionally, it increases local competition
and choice for service users to choose continuing care homes from a variety of
providers.
6.25 Finally, demographic needs assessments for the borough suggest that investment for
mental health services is required to be invested in earlier intervention services. This
would require shifting resources/investment from residential mental health services to
community services.
7.0 Proposal
7.1 Based on reasons listed above it is proposed to close Inglemere Specialist Care unit. If
implemented, this would result in access to specialist care placements for Lewisham
residents moving to facilities in neighboring London boroughs (Southwark and
Lambeth). If this proposal is agreed, this will have a direct impact on around eight
patients in the Inglemere Specialist Care Unit who will need to be found alternative
placement.
7.2 Relatives and advocates will be fully involved in these NHS Continuing Healthcare
assessments and consulted at every stage of the process. In all aspects of this
assessment, where there is a potential change of service for individuals, SLaM will
follow NHS best practice guidance on the transfer of frail older patients from long-stay
settings. Those residents who lack capacity and/or do not have relatives to support
them will be supported by independent mental capacity advocates.
7.3 If the decision is made to close Inglemere Specialist Care Unit, any resident qualifying
under “home for life” principles that is assessed and agreed for alternative placement in
a non-NHS home will not be charged for their care. This is because these individuals
will continue to qualify under arrangements for home for life principles, because of the
length of time they have been living there. In these instances, future care costs will be
fully met by the NHS.
7.4 SLaM has significant experience in clinically managing this level of service change for
individuals, having managed similar processes from 2000 onwards.
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7.5 Transfer of residents will be managed by a specific team of professionals who will
assess the needs of residents and take into account factors such as their specific
health and social needs and will include discussion with family members where
appropriate. They will be supported by the Specialist Care Home Intervention Team
who currently works closely with local care providers.
8.0 Financial Issues
8.1 The change in the level of continuing care places funded by Lewisham CCG will
release approximately £1.3 million into the commissioning budgets. This will provide an
opportunity for Lewisham CCG to fund alternative placement for the patients affected
by the proposal and to re-invest the remainder in new services in line with their
commissioning intentions.
9.0 Consultation Timetable
9.1 The timetable for the public consultation will be as follows
Process
Date
Notify Care Home staff, service users, relatives of proposal for January 2015
public consultation prior to public publishing of reports by
Healthier Communities Select Committee (HCSC)
Healthier Communities Select Committee (HCSC) paper for
meeting publically published
January 2015
Healthier Communities Select Committee (HCSC) meeting to January 2015
bring proposal for consideration
Feedback from (HCSC) – to incorporate into public consultation January 2015
before it starts
Public Consultation Begins (90 days)
20th January
2015
Formal 1 to 1 meetings with service users, relatives and
February –
March 2015
Advocates.
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Adult Joint Strategic Commissioning Group
February/March
2015
Lewisham Clinical Commissioning Group Executive
February 2015
Formal meetings with Staff and Trade Unions – SLaM to conduct
February –
March 2015
Ward Councillors consultation
February/March
2015
SLaM Board Consultation
February 2015
End of Public consultation
19th April 2015
Preliminary data analysis of public consultation results
April 2015
Feedback to SLaM Board
28th April 2015
Confirm to Healthier Communities Select Committee outcome of
formal Consultation
April 2015
10.0 Implications of the Proposal
10.1 If the proposal is agreed and implemented there will be obvious implications for staff.
However it is envisaged that minimal redundancies will occur for clinical healthcare
staff as there are a number of vacancies within other parts of SLaM.
10.2 There are approximately 24 whole time equivalent staff working in the specialist
continuing care unit and if a decision to close this service is made then these posts will
be at risk. However, SLaM anticipates that the majority of staff will be offered suitable
alternative employment. The breakdown of grades is provided below:
Nursing grade
Whole
Time
Equivalent (WTE)
7 (acting)
1
6
1
5
6
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4
1
3
0
2 HCA
9.82
support staff
3.23
10.3 As part of the consultation, staff and their unions will have the opportunity to discuss
the proposals. Subject to the outcome of the consultation there will also be a separate
staff consultation process to address the employment issues for those affected by the
change.
10.4 It is anticipated that there will be continued employment opportunities for the staff
affected by this proposal.
10.5 If the decision is made to close the service, the facility will be deemed by SLaM to be
surplus to requirement and offered to partner organisations for use. If it is subsequently
not required for public sector use it will be placed on the market for sale under current
rules on disposal of public assets.
11.0 Conclusion
11.1 SLaM is consulting on a proposal to close the Inglemere Specialist Care Unit and to
transfer the activity to alternative provision in Lambeth and Southwark. This proposal is
supported by Lewisham CCG.
11.2 The justification for this proposal is the reduced usage of this service which has been
a result of changes in service delivery to older people with mental health needs,
changes in the eligibility criteria for these placements created by the national continuing
care criteria, and commissioning of other care homes by NHS Lewisham and Adult and
Social Care Services. The impact of these changes has resulted in under utilisation of
the SLaM service which has led to resources not being deployed to their best effect. The
proposed changes will only affect a very small number of patients. SLaM and Lewisham
CCG are very experienced in delivering this type of service change.
How to Respond
Please send your responses no later than the 15th of April 2015 to:
By post: C/O Helen Kelsall, Mental Health of Older Adults Clinical Academic Group, 115
Demark Hill, Camberwell, SE5 8AZ
By email: [email protected]
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Works Cited
Lewisham's Population. (2012). Retrieved January 24, 2014, from Lewisham's Joint
Strategic Needs Assessment: http://www.lewishamjsna.org.uk/a-profile-oflewisham/demography/population
(n.d.). Dementia Needs Assessment. Healthcare for London, NHS Commissioning Support
for London.
Lewisham CCG. (October 2012). RESULTS OF CONSULTATION: Proposal to reconfigure
specialist Mental Health of Older Adults NHS Continuing Healthcare services in
Lewisham; 10 April 2012 – 8 July 2012 and 20 July – 17 October 2012. FINAL
REPORT. Lewisham CCG.
Circulation and consultation
Consultative Bodies
Healthier Communities Select Committee
Adult Strategic Partnership Board
Ward Councilors
Health Watch
Statutory Sector Organizations
Lewisham Adult and Social Care Services
NHS Lewisham
University Hospital, Lewisham
Internal Stakeholders
Relatives of current residents
Trades Unions
GMB
Unison
RCN
Voluntary Sector Groups
Alzheimer’s Society
Lewisham Age Concern
Mind Care
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Lewisham Carers’
Lewisham Pensioners Forum
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Appendix 2
PART 1: Equality relevance checklist
The following questions can help you to determine whether the policy, function or service development is
relevant to equality, discrimination or good relations:
x
x
x
x
x
x
Does it affect service users, employees or the wider community? Note: relevance depends not
just on the number of those affected but on the significance of the impact on them.
Is it likely to affect people with any of the protected characteristics (see below) differently?
Is it a major change significantly affecting how functions are delivered?
Will it have a significant impact on how the organisation operates in terms of equality,
discrimination or good relations?
Does it relate to functions that are important to people with particular protected characteristics or
to an area with known inequalities, discrimination or prejudice?
Does it relate to any of the following 2013-16 equality objectives that SLaM has set?
1. All SLaM service users have a say in the care they get
2. SLaM staff treat all service users and carers well and help service users to achieve the
goals they set for their recovery
3. All service users feel safe in SLaM services
4. Roll-out and embed the Trust’s Five Commitments for all staff
5. Show leadership on equality though our communication and behaviour
Name of the policy or service development: Re-organisation of SLaM-MHOA Specialist
Continuing Care provision on the basis of reduced demand
Is the policy or service development relevant to equality, discrimination or good relations for
people with protected characteristics below?
Please select yes or no for each protected characteristic below
Age
Disability
Gender reassignment
Pregnancy
&
Maternity
Race
Religion
and
Belief
Sex
Y
Y
N
N
Y
Y
N
If yes to any, please complete Part 2: Equality Impact Assessment
Sexual
Orientation
N
Marriage &
Civil
Partnership
(Only if
considering
employment
issues)
N
If not relevant to any please state why:
TH
Date completed: 6 January 2015
Name of person completing: Helen Kelsall
CAG: MHOA&D
Service / Department:
Please send an electronic copy of the completed EIA relevance checklist to:
1. [email protected]
2. Your CAG Equality Lead
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PART 2: Equality Impact Assessment
1. Name of policy or service development being assessed? Re-organisation of SLaM-MHOA&D
Specialist Care provision in Lewisham on the basis of reduced demand.
2. Inglemere Specialist care Unit
3. Name of lead person responsible for the policy or service development?
Lead:
David Norman, Service Director, Mental Health of Older Adults & Dementia
Others involved: Daniel Harwood, Helen Kelsall.
- Clinical staff working in the Inglemere Specialist Care unit
- Colleagues in Lewisham Commissioning and Continuing Care Panels
- Service users and their representatives including relatives and advocates where appropriate
4. Describe the policy or service development
What is its main aim? SLAM and Lewisham CCG are seeking to redesign the current Specialist Care services so
that they can meet the current need for the small number of older people with mental health needs who
require specialist care because their continuing care needs are so complex that no other providers locally have
the capacity to provide this level of care.
This will also entail SLaM to fully implement the NHS Continuing Care Framework 2009 and assess current
residents in SLaM units Inglemere Specialist Care Unit and support the discharge of those service users who no
longer meet the criteria for these beds because their needs have changed.
The impact of this change will be that NHS Lambeth will not need to commission the current level of
continuing care provision that it is and SLaM will therefore wish to re-organise current services accordingly.
The net impact of this will be a reduction of continuing care beds provided by SLaM and this will result in
savings in staffing and resources being re-invested by Lewisham CCG through its QIPP programme.
What are its objectives and intended outcomes?
1.4 Service Objectives
What are the main changes being made?
x
Reduction in specialist care beds and a no longer any provision of specialist care beds
in Lewisham. Beds will be available out of borough.
x
What is the timetable for its development and implementation? 6 months aiming for
closure June 2015.
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5. What evidence have you considered to understand the impact of the policy or service
development on people with different protected characteristics?
(Evidence can include demographic, ePJS or PEDIC data, clinical audits, national or local research or
surveys, focus groups or consultation with service users, carers, staff or other relevant parties).
x
The Lewisham Joint needs assessment has identified that Lewisham has a population of
approximately 285 thousand of this population only 8.8. % of patients’ is over 65 in
comparison with the national figures of 15.9%.
x
In Lewisham they consider more women over 65 receive service and higher number of white
men in Inglemere specialist care unit we have a higher number of men receiving services but
they meet the demographic of white.
x
Evidence suggests that SLAM currently provides a greater number of continuing care beds
per head of the local population(s) as compared with the national average and including other
London boroughs (see main assessment). This is mainly as a result of history with SLaM
Continuing Care provision mainly being established as long ago as the 1990s as a result of
the closure of Tooting Bec and Cane Hill Hospitals and the need to establish facilities to
support a large number of institutionalised older people being discharged from that hospital.
Since then the clinical and commissioning processes for access to a continuing care
placement have changed radically, most recently through the introduction of the NHS
Continuing Framework in 2009, which requires all residents in continuing care facilities to be
reviewed using national assessment criteria in order to assess for eligibility under the
framework.
x
This process has effectively removed the home for life entitlement for residents in these units.
Coupled to this, the application of the criteria in the current care pathways from acute mental
health services to continuing care placement has resulted in less referral to SLaM provision
with higher numbers of patients being correctly referred to care homes in Lambeth and
beyond. There is no evidence therefore that demand for SLaM beds will increase.
x
We have used data relating to local population, service use and service evaluations from both
the Trust and other MH units. This data covers a number of the equality protected grounds,
however there are gaps in terms of current data collection (for example in relation to disability)
and these are addressed in the action plan which accompanies this EIA.
6. Have you explained, consulted or involved people who might be affected by the policy or
service development?
(Please let us know who you have spoken to and what developments or action has come out of this)
Staff consultation – staff working within the SLaM units have been made conversant with the NHS
Continuing Care Framework and the changes that this will have on future provision. This has involved
discussions with individual staff in regular supervision and in groups in wider fora such as team
briefings and management team meetings.
- User consultation – when the Decision Support Tool and Health Need Assessment processes take
place, those service users who have capacity and their relatives have the process explained to them
and are expected to participate and contribute in the reviews.
- Carers consultation – As above. The SLaM units have carers groups and any changes to the way
these units operate are discussed in these meetings.
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-We also intend to carry out a public consultation and Staff consultation as part of this process.
7. Does the evidence you have considered suggest that the policy or service development
could have a potentially positive or negative impact on equality, discrimination or good
relations for people with protected characteristics?
(Please select yes or no for each relevant protected characteristic below)
Age
Positive impact: Yes
Negative impact:
Please summarise potential impacts: The service provides specialist support for people aged 65
and over. A breakdown of the current age range of service users in the SLaM MHOA facilities is given
below:
Ages of patients’ at Inglemere
SCU
GENDER
68
Male
71
male
74
male
78
female
79
male
82
male
86
female
97
male
100
female
Disability
Positive impact:
Please summarise potential impacts:
Negative impact:
We are aware that most service users accessing our services have long term mental health
conditions and therefore meet the definition of disability. In addition this group presents a high risk of
vulnerability and therefore effective Safeguarding arrangements are paramount. We believe that the
number of service users with additional identified disabilities is higher than recorded as the disability
will be detailed in the case notes narrative.
In relation to mobility, all the services whether managed directly by SLAM MHOA or commissioned by
the NHS and Local Authority are required to be registered by the CQC and must therefore meet
current requirements in respect of disabled access and facilities, in particular bathroom and WC
facilities. Therefore it is the norm for these services to be able to provide necessary adjustments to
enable facilities to be accessible for service users.
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The majority of service users impacted by this change will suffer from a primary diagnosis of
dementia, which is a progressive condition that affects the memory functions in the brain leading to
confusion, disorientation, loss of personality and sometimes aggressive and dis-inhibited behaviour.
Diagnosis
All patients’ at Inglemere have a diagnosis of dementia one has a secondary diagnosis of depression.
All patients’ and their carers’ have access to independent mental capacity advocates.
Gender re-assignment
Positive impact:
Negative impact: NO
Please summarise potential impacts: We have no patients’ who have undergone gender
reassignment and we have no data from Lewisham borough.
Race
Positive impact:
Please summarise potential impacts:
Negative impact:
Our ethnicity mix is aligned to the Lewisham needs assessment of higher percentage of patients’
being white .
Ethnicity Break down of patients’ at Inglemere
Asian Other -0
Black African-0
Black Caribbean - 1
Other Ethnic Groups-0
Pakistani/British Pakistani-0
White British
-6
White Irish-0
White Other - 1
Pregnancy & Maternity
Positive impact:
Please summarise potential impacts: Not applicable
Negative impact:
Religion and Belief
Positive impact:
Please summarise potential impacts:
Negative impact:
All services outlined above will focus on developing care plans for individual service users and these
will record religious preference and where a service user or their family expects to be supported in
religious observance, this will be accommodated in the care plan with an expectation that care staff
will support this. We would not expect any patient move to have a negative impact for a patient
wishing to meet their spiritual needs.
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Sex
Positive impact:
Please summarise potential impacts:
Negative impact:
We have higher proportion of men to women. This is not in line with the joint needs assessment that t
women represent a higher percentage of receiving services in Lewisham. No group would be
disadvantaged by closure as alternative options for care can be offered to both men and women the
distance to Lewisham would be dependent on the individuals different mental health needs. As
ongoing nhs specialist care services are out of borough
Sexual Orientation
Positive impact:
Negative impact:
Please summarise potential impacts: We record sexual orientation at patient agreement. No
patient at Inglemere has identified as Gay lesbian or transgender.
No impact
Marriage & Civil Partnership
Positive impact: Yes or No
(Only if considering employment
issues)
Please summarise potential impacts: N/a
Negative impact: Yes or No
Other (e.g. Carers)
Positive impact: Yes
Please summarise potential impacts:
Negative impact: No
Impact for carers is they may be required to travel greater distances to visit their relatives. This will be
mitigated by involvement in choosing suitable alternative care homes.
8. Are there changes or practical measures that you can take to mitigate negative impacts or
maximise positive impacts you have identified?
YES: Please detail actions in PART 3: EIA Action Plan
9. What process has been established to review the effects of the policy or service
development on equality, discrimination and good relations once it is implemented?
(This may should include agreeing a review date and process as well as identifying the evidence
sources that can allow you to understand the impacts after implementation)
All patients’ will be followed up by slam services for review of placement and suitability via care home
support team.
Date completed: January 2015
Name of person completing:
CAG: MHOA-D
Service / Department: Inglemere speciliast care unit
Please send an electronic copy of the completed EIA relevance checklist to:
1. [email protected]
2. Your CAG Equality Lead
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Ensure all benefits and allowances are offered
to meet this need.
Full carers assessments for all relevant parties
Identify clear transport options for individuals
who may be affected.
Proposed actions
36
1. [email protected]
2. Your CAG Equality Lead
Please send an electronic copy of your completed action plan to:
Date completed: January 2015
Name of person completing:
CAG:
Service / Department:
Carers needing to travel greater distances to
see their relatives/ next of /kin /significant other
Potential impact
Helen Kelsall
lead person
Responsible/
PART 3: Equality Impact Assessment Action plan
ongoing
Timescale
Progress
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Aileen Buckton Executive Director, Community Services
Fourth Floor
Laurence House
1 Catford Road
SE6 4RU
Chief Executive
University Hospital Lewisham
Lewisham High Street
London
SE13 6LH
All personal details withheld ( retained email and postal evidence)
Lewisham Adult
and Social Care
Services
NHS Lewisham
University
Hospital
Lewisham
37
All staff
employed to
Sent via work email and paper copies made available
Miriam Long / Jade Fairfax
Health Watch
Relatives of
current residents
Timothy Andrews
Name
Healthier
Communities
Select Committee
Statutory Sector
Stake holder
Appendix 3
Inglemere Stakeholder Information circulation list
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Sent via email evidence retained by Helen kelsall
RCN
38
Lewisham Carers’
Mind Care
Lewisham Age
Concern
Alzheimer’s
Society
Devon House
58 St Katharine’s Way
London
E1W 1LB
[email protected]
Stones End Centre
11 Scovell Road
Southwark
London
SE1 1QQ
[email protected]
Lewisham Mind Care,
10 Catford Broadway (c/o Age UK Shop),
Catford
SE6 4SP
Lewisham Carers Centre
Waldram Place
Forest Hill
Sent via email evidence retained by Helen kelsall
Unison
Voluntary Sector
Sent via email evidence retained by Helen kelsall
GMB
Trade Unions
work in the unit
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39
ISIS
1 Aislibie Road
Se12 8qh
Tel: 020 8695 1955
Fax: 020 8695 5600
Email: [email protected]
http://www.familyhealthisis.org/
Members of parliament
MP Lewisham
Jim Dowd
Constituency Office
West and Penge
43 Sunderland Road
Forest Hill
LONDON SE23 2PS
[email protected]
MP Lewisham
Heidi Alexander
Heidi Alexander MP
East
House of Commons
London SW1A 0AA
[email protected]
MP Lewisham,
Joan Ruddock
Rt Hon Dame Joan Ruddock MP,
Deptford
House of Commons,
London SW1A 0AA
[email protected]
Sydenham
Gardens project
Lewisham
Pensioners Forum
London
SE23 2LB
[email protected]
The Saville Centre
436 Lewisham High St
Lewisham
SE13 6LJ
Sydenham Garden
[email protected]
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40
Helen Kelsall
Service
Manager
Nula Conlan
Patient and
public
Involvement
Lead.
Dr Daniel
Harwood
Consultant
Psychiatrist and
Associate
Clinical Director
Tuesday 13th
January 2015
Helen Kelsall
Clinical Service
Manager
Public Consultation
meeting held at
Inglemere Specialist
Care Unit Monday
2nd February 2015
Time – 6pm-8pm
Date of Meeting
Consultation
Team
No attendance at
group Meetings
Individual
conversations as
below.
Relative/Carer/
Stakeholder
attendance
All patients’ had
representation and
staff were also
present
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Explained that there will be no minutes circulated from this meeting due to meetings were help
privately with individual relatives.
Several patients had moved several times in recent years putting them and their carers under
stress
At the time of the Granville closure the refurbishment of Inglemere was promised but this has
not been delivered.
Concerns were expressed about the risks of moving, physically frail older people with complex
needs.
There was praise for the quality of care provided at Inglemere and concerns that staff in a new
home may not know the patients as well and may not be able to provide the intensity of care
that Inglemere provides. There were concerns that Inglemere currently has unused beds and
some relatives felt these beds should be used for alternate service provision.
Concerns were expressed that the threshold for admission had increased.
Some relatives made the point that the Inglemere building could be used for another purpose as
well as Inpatient care to make it economically viable.
There were concerns that the consultation would be a bureaucratic exercise and will not make
any difference to a decision which has already been made.
Some relatives expressed a wish that the cost of the consultation could be saved if the
consultation was scrapped and the money saved in doing this could be put forward towards
funding placements for patients.
Relatives wanted assurance as far as possible that the next move for their loved one would be
the last move.
Relatives were grateful that they had been involved at an early stage of the consultation
process.
Email sent to relatives and carers regarding public consultation meeting held on the 2nd
February 2015.
Themes from meeting
41
Helen Kelsall
Service
Manager
Helen Kelsall
Service
Manager
2nd February 2015
Face to face
meeting
Time 2-4pm
2nd February 2015
3a
3b
2a
53 of 155
Discussed that the family are very distressed about the closure. They do not want 3 to leave the
borough and are not happy for 3 to go to another one of our SCU. 3a is very concerned about
the reliability of the information being given to 3a does not trust us or the process. 3a feels we
should not have moved 3 to IM if we were considering closure due to the impact of any further
moves on his health as the family feel that every move has a negative impact.
Hard copy of Relative Letter and Public Consultation letter given to 3b and 3a at Inglemere by
Helen kelsall.
Disappointment about closure wanted assurance that funding would be provided to meet
relative’s needs.
42
Helen Kelsall
Service
Manager
meeting Nula
Conlan
Involvement
lead present
Helen Kelsall
Clinical Service
Manager
Helen Kelsall
Service
Manager
Time 2-4pm
January 22nd 2015
Time – 11am -1pm
Public Consultation
meeting held at
Inglemere Specialist
Care Unit
2nd February 2015
Face to face
meeting
Tuesday 10th
February 2015
3b
4a
No attendance
6a
54 of 155
Several patients had moved several times in recent years putting them and their carers under
stress
Concerns were expressed about the risks of moving, physically frail older people with complex
needs.
There was praise for the quality of care provided at Inglemere and concerns that staff in a new
home may not know the patients as well and may not be able to provide the intensity of care
that Inglemere provides.
Relatives are anxious that this will be a rushed process. commented that it is important to
include members of the ‘hands-on’ ground staff to future meetings to gain their input on the
situation as they have come to know the patients well.
It is important that the new nursing homes are in a reachable distance for the relatives as travel
through different boroughs can be difficult for some.
Relatives wanted assurance as far as possible that the next move for their loved one would be
the last move.
Upset and worried about where will meet 4 needs. Discussed that the first step was to
undertake the assessment of the case
Cross that we moved 3 here when it might have been closing. We explained this was not agreed
at the time of 3 moves. Worried that 3 might have to go and live in Lambeth or Rotherhithe.
Wants him to stay in Lewisham.
6a expressed that although he would rather IM did not close 6a primary concern is 6a 6 and
establishing 6 need for ongoing CHC and finding a home that can meet 6 needs 6a
43
Helen Kelsall
Service
Manager
4a
4b
4c
Nula Conlan
Service User
Involvement
and
Participation
Lead
Kenneth
Gregory
Lewisham Joint
Commissioner
Helen Kelsall
Service
Manager
Public meeting
Time 11am -12pm
Public Consultation
meeting held at
Inglemere Specialist
Care Unit
Tuesday 17th
February 2015
Time 2-4pm
Public Consultation
meeting held at
Inglemere Specialist
Care Unit
Saturday 14th Feb
2015.
Miriam Long health watch
55 of 155
It was agreed that Nuala would attend the Health watch meeting on 17th February and Helen
will present the consultation at the HW committee meeting on 25th February. Both meetings
are at the Civic Suite in Catford.
.
Only 1 family attended Don’t feel able to engage in a public consultation process because last
one was so challenging and felt they had been previously lied too. They Want to concentrate on
making this moves the last one for their loved one if possible.
New services have been introduced such as the Care Home Support Team which will support
Nursing and Care Homes to provide care in the future. Lewisham is also at the forefront of
having a Home Treatment Team that assesses people at home and can prevent hospital
admissions.
Miriam expressed concern at the loss of services for older people with challenging needs who
Inglemere currently supports. It was agreed that the meeting on 3rd March would outline the
plans for provision of support for people with end stage dementia in the borough. It was agreed
that it is important to provide for the holistic needs of current patients in Inglemere and provide
an improved carer pathway
Relatives were grateful that they had been involved at an early stage of the consultation process
Other relatives had been in touch and said they too would prefer to come to the evening session
on 3rd March.
Helen outlined that she is in constant contact with relatives and knows their views and wants to
maintain contact so that all avenues are available to relatives for comment.
It was suggested that the consultation document could go to:
Sydenham Gardens, Age Exchange, Ladywell Centre, and other day services, including the
Diamond Club for Older active people in the borough.
44
No attendance
Public Consultation
meeting held at
Inglemere Specialist
Care Unit.
Helen Kelsall
Clinical service
Manager
Friday February
20th 2015
2pm -4pm
Attended on behalf
of consultation
team
Lewisham
Pensioner’s forum.
Voluntary action
Lewisham
Health Watch
stakeholder
Meeting
Nula Conlan
Service User
Involvement and
Participation Lead
Helen Kelsall
Service Manager
25th February 2015
Health Watch
Community
Meeting
Nula Conlan
attended on behalf
of consultation
team
17th February
Nula Conlan
Service User
Involvement
and
Participation
Lead
Nula Conlan
Service User
Involvement
and
Participation
Lead
Helen Kelsall
Service
Manager
People out in the community may benefit from this type of services
Concerns re sending patients’ out of borough for SLaM care
Does not want to lose a facility to Lewisham
Can you ensure patients they will get the care they need
Costs £1.2 m to run (funding allocated) Will it be returned to CCG.
Property, how much is it worth are we making money
Deeply sceptical about our data.
Short Presentation given to group comments and questions were :
Presented outline of Plans to the committee and their visitors
56 of 155
45
Continuing
Care manager
Lewisham CCG.
Nula Conlan
Service User
Involvement
and
Participation
Lead
Kenneth
Gregory
Lewisham Joint
Commissioner
Dr Daniel
Harwood
Consultant
Psychiatrist and
Associate
Clinical Director
Helen Kelsall
Service
Manager
6pm -8pm
Public Consultation
meeting held at
Inglemere Specialist
Care Unit
3rd March 2015
No attendance
57 of 155
46
Dr Daniel
Harwood
Consultant
Psychiatrist and
Associate
Clinical Director
Helen Kelsall
Service
Manager
Kenneth
Gregory
Lewisham Joint
Commissioner
Tina Emefieh
Discharge
Coordinator
Helen Kelsall
Service
Manager
Helen Kelsall
Service
Manager
Lesley Broom
continuing
health care
manger
Time 6:30pm-8pm
No Attendance
No attendance
17th March 2015
Public Consultation
meeting held at
Inglemere Specialist
Care Unit
Time- 11am-1pm
19th March 2015
Public Consultation
meeting held at
Inglemere Specialist
Care Unit.
review the panel
process for the
residents and
ensure that the
system runs
smoothly and will
not cause any
added distress and
the is an issue the
relatives are
concerns about
10th March 2015
58 of 155
47
Helen Kelsall
Clinical Service
Manager
Helen Kelsall
Clinical Service
Manager
All day.
13th of April 2015
Public Consultation
meeting held at
Inglemere Specialist
Care Unit
11am -1pm
Public Consultation
meeting held at
Inglemere Specialist
Care Unit
Thursday 9th April
2015
No attendance
6a relatives via
telephone
conference
Lewisham
Pensioners
representative.
Need to retain a core number of beds for Lewisham residents
Concerned decisions were financially driven.
Negative experience of private sector providers.
Need to ensure we look after current patients’
Concerns that dementia rates are increasing is now a good time to cut services.
Themes raised :
Struggle to understand reasons for closure
59 of 155
6th January relative
consultation letter sent via
email
5b
Disappointed but understands there are reasons for closure and just wants best place for his dad and
to ensure end of life plans are clearly addressed prior to any move
Disappointed very concerned re impact on 5. Mentioned press. Did briefly discuss if 5 could be
moved closer will be on holiday for 2 week from 14th Jan
7th January in person was
visiting unit when HK was
present. Letter sent via post
8th January telephone
1a
5a
48
3a
8th January am and pm
telephone message left on
Letter sent via post and
email
Disappointed about the closure of Unit
7TH January telephone call
and Letter sent
4a
2a
6th January relative
consultation letter sent out
via post
Overview of feedback or summary of conversation
5a
7a
Contact date & type
Relative / Carer
Contact with family members during consultation process.
60 of 155
49
8a
Very concerned about his relative due to high levels of behaviour.
Discussed other SCU units as possible options.
8th January via telephone
Letter sent by post
Letter sent by email
8th January via telephone
Letter sent by post 7th
January.
Very concerned lives in Hithe. Wants best for relative.
Initial message left on landline and mobile. Provide with an alternate mobile number was able to
speak with her. Very upset worried about where 7 will go. But was requesting list of home 7 could
visit and explore a possible move to be nearer to her
8th January via telephone
7a
2a
Disappointed wants a service in Lewisham for Lewisham people. Plans to fight any potential closure
8th January in person at
carers meeting
4a
And Letter sent by email
Very shocked and worried about relative
Very upset very concerned for her uncle welfare and who can meet his needs.
8th January in person at
carers meeting
Letter sent by post 7th
January.
8th January via telephone
3b
9a
Letter given by hand no
address on system
answer phone
61 of 155
9th January 2015
consultation letter sent out
via email
Telephone message left for
HK on Friday 9th Jan 2015 at
19:35 in response to the
message left on her mobile.
Said 3a would try again.
6a
3a
50
9th January sent us an email
6a
Letter sent by post 7th
January and Letter sent by
email on 8th
Mobile telephone initially
left message left then rang
back phone answered.
Sent email expressing concerns about any proposed closure HK emailed back apologising for short
notice of meeting on 13th of January. Explained early start of the process and will be lots of
opportunity to engage. MP coped in.
Very unhappy felt closure made no sense. Initially thought the decision had been made. Tried to
explain we were at very early stage in process
8th January via mobile
6a
Landline unavailable
Extremely upset and stating will not let this happen Also raised concerns about care delivered at
Inglemere.
8th January via telephone
and letter via email
5b
Cant praise staff and services enough
62 of 155
Very concerned why unit is closing. Doesn’t make sense dementia is increasing. Concerned about
staff maturity in other homes not having enough experience to manage pts with dementia. Worry
about other homes and the ability to provide same level of care. Also worried about location to
family.HK offered a taxi to the meeting today as 3a expressed a desire to attend but due to the bus
strike this would be difficult
Taxi’s arranged as needed
Telephone call message left
called back. Tuesday 13th
2015.
Tuesday 13th January 2015
Due to bus strike Joyce
Healey contacted relative to
ask if they needed a taxi to
enable them to attend the
meeting today
3a
All Relatives in
London area
51
Concerned would not be able to fund placement
1-2-1 with Dr Harwood 12th
January pm ,about possible
future plans for relative
4a
Concerns nowhere would be able to meet care needs
Meeting arranged
Received email Sunday 11th
January f on 5b behalf
requesting 1-2-1 meeting
with DH and HK
5b
Contact on Saturday or on
Tuesday. hk returned call on
Tuesday 13th January 2015 at
10:35 left voicemail
message
63 of 155
Tuesday 13TH HK spoke to
twice in response to her
phoning HK to speak with
her. Once briefly to
explained I would call her
back when a meeting had
finished and secondly after
the meeting approx. 8pm
Hard copy of Relative Letter and Public Consultation letter given at Inglemere by Sonia Small.
30th January 2015
30th January 2015
4a
5b
52
Concerned about possible options for relative
Emails correspondence
between HK and 6a
6a
Ensure she had received hard copy of Relative Letter and Public Consultation Document. As was due
Concerned about who would meet relative needs
Did understand that services are not always sustainable
Monday 26th January 2015
Face to face one to one
appointment with HK and
DH
5b
Expressed concerns about closure
Copy of minutes from 13th
sent by Joyce Healy
See Minutes
Objecting to closure
Need to make sensible decisions for placement
Felt would increase risk of mortality
Felt cruel to put patients through a move at their age.
All families
Family Members Tuesday 13th January 18:30( see minutes
20:00 hrs. Face to face Dr
Harwood , Helen kelsall,
for full list )
Nula Conlan
5b
64 of 155
53
3b
3a
2a
1a
5a
6a
7a
1a
5b
2a
30th January 2015
30th January 2015
Phone conversation with HK
sent letter via post with Relative Cover Letter and Public Consultation Document enclosed
HK sent email with Relative Cover Letter and Public Consultation Document enclosed
to leave the country.
65 of 155
2nd February 2015
3a3b
54
2nd February 2015
2a
.
Email received
5a
8a
7a
6a
5a
4c
4b
4a
Hard copy of Relative Letter and Public Consultation letter given to 3b and 3aat Inglemere by Helen
kelsall
Discussed that the family are very distressed about the closure. They do not want 3 to leave the
borough and are not happy for him to go to another one of our SCU. 3b is very concerned about the
reliability of the information being given to her she does not trust us or the process. She feels we
should not have moved 3 to IM if we were considering closure due to the impact of any further
moves on 3 healths as the family feel that every move has a negative impact.
Unhappy with closure believes that we are not trust worthy regarding the information we provide
Face to face meeting regarding possible options for relative
Hk replied she would do so.
Requesting to be kept up to date with aspects of consultation as could not get to meeting until April.
66 of 155
55
4a
All
6a
Explained that there will be no minutes circulated from this meeting due to meetings were help
privately with individual relatives.
2rd February 2015 date set
for public meeting no
relatives attended however
there were relatives in the
building they were met with
on 1-2-1 basis as noted
above
Secure email sharing information regarding relatives assessment of clinical need
Gave next of kin a copy of health watch leaflet advised should contact them re her concerns about
the closure of IM.
Email 4th February 2015
Feb 9th 2015
Meeting minutes re circulated
Email sent regarding public
consultation meeting held
on the 2nd February 2015.
Face to face meeting regarding HNA and DST. For his relative asked for private conversation with Dr
Harwood and Helen Kelsall. 6a expressed that although he would rather IM did not close his primary
concern is his 6 and establishing 6 need for ongoing CHC and finding a home that can meet 6 needs
he was satisfied with the outcome of the meeting and the decisions made on DST. 6a will read the
final version and sign and return for submission to panel.
2nd February 2015
67 of 155
Text received from 6a to Hk stating had received his 6 final papers 6a will read and returned. Hk Text
back and said 6a must feel free to make comments 6a felt necessary and where to sign.
update of the public consultation meeting minutes sent to all informing them that CHC manager will
be attending meeting on 3rd March and Health watch
Email received stating cannot attend meeting today due to health. Hk emailed back on 14th offering
a further telephone conversation and asking when would be a good time to call. Email replied
received but not seen until Monday 16th
Email informing
Thursday 12th
Friday 13th February
Saturday 14th Feb
1a
6a
All
7a
56
1a’s 1 case had been to panel and that brokerage team would be getting in touch soon regarding a
placement.
Monday 9thFebrary.
8a
Discussed the importance of environment pf 8 acknowledged that although would prefer Rotherhithe
unit as close 8b who find it difficult to visit due to finance and children. Can understand how
Greenvale may be a better environment for 8. Agreed to talk to his8b and I will call him to discuss
next steps such as a visit. I also discussed that we could explore a regular taxi to facilitate his 8b
visiting their 8.
Said that 7a understands that some people want IM to stay open however 7a is not as attached to
the place 7a has had some problems historically with the care given. As a result 7a primary concerns
if finding somewhere that can meet her 7 needs.
APPROX 19:15 FOR APPROX 30 MINUTES. Discussed 7a concerns about finding somewhere that can
meet her7 needs. Discussed the importance of waiting for panel and also using resources available to
identify places such as CQC website. 7a looking to move 7mother closer to 7abecause then7a
can7her daily.
Telephone conversation
7a
Sad Inglemere is closing but acknowledged relative is most important for her now. closure to her if
possible
February 9th 2015
7a
68 of 155
Email from her and replied agreed to talk wed eve
Tuesday 17th February 2015
7a
57
5a
5c
5a
8a
5a
No answer unable to leave message
Monday 16th February via
telephone
8a
emails JH and confirms that 5a cannot attend any meetings in Feb or March
JH email’s5a and 5c the CPA review document
February 20th 2015
February 21st 2015
8 can go to Inglemere has declined a visit wants to be there on day of transfer. Hk has emails dress
agreed she will liaise with drs and get back to 8a with a plan.
Telephoned call Tuesday
17th February
Email clarify attendance at
meeting on 23rd
Individual Discussion about DST and HNA agreed that we will sit down together and review first draft.
4a very worried about 4 banding as 4a is uncertain if they will be able to afford the care. 4a was very
distressed.
14th February
4a
69 of 155
Letter
February 23rd 2015
1a
6a
Telephone consultation
Face to face meeting
Email 19th March 2015
6a
6a
7a
58
Email 16th March 2015
7a
6a responds
February 25th 2015
February 23rd 2015
7a
.
Discussing placement options and how to identify suitable placement and the opportunity for
involvement in this
Unable to attend due to family emergency agreed to discuss issues on the telephone
Discussion about relative needs for future placement
Providing assurance relative was ok and discussing possible future placement options
HK emails 6a regarding signing the assessment paper work 6a has few points 6a needs to have
amended HK agreed.
Concerns closure is cost driven.
Concerns for relative needing to move and impact on them
Suitability of private providers
Letter re consultation response concerns re
JH emails 7her 7statement account.
70 of 155
to discuss next steps and confirm meeting on 13th at 2pm
31st March telephone call
Email
Face to face
Email
Letter in response to
consultation to close
Inglemere
5a
7a
4a
5a
6a
59
to establish if she had reviewed our paper work
31st March telephone call
3a
the estimated future prevalence of dementia in the older population and patterns of demand for
specialist continuing care facilities, and secondly the capacity within the health and social care system
to support individuals, and their families and carers, with the most complex of needs. We have found
We strongly object to the proposed closure of Inglemere. In our opinion Inglemere should remain
open to continue its excellent work in providing services for the mentally ill. The reasoning behind
such a closure is flawed in our opinion for the reasons stated below as it will only bring great stress,
anxiety and unhappiness to our mother and our family when she should be allowed to spend her
remaining time around familiar surroundings and staff who know her.
Rationale for closure is cost cutting
Thanking us for care and understanding regarding care of relative and discussion re this process.
Saturday 11th April 2015 from relative issues raised
To ascertain if 4a had reviewed paperwork. Due to health issues 4a said 4a would review with 4b on
Wednesday and then bring in Thursday. We would then confirm everything and 4a could sign.
To inform paperwork would be sent out via recorded delivery for 7a to review.
Sating had received message to discuss what type of placement would meet relatives needs
Email sent 31st March
1a
71 of 155
60
13th April
Text message
HK confirms recite of consultation feedback to relative
The staff of Inglemere do a fantastic job. They are true professionals in the care needed for the
patients in this type of care home. If this type of home is closed and staff are redeployed or take
redundancy, you are breaking up a great ‘team’ This team have known my mother for many years
(including her time at Granville) and they have managed to ‘stabilise’ my mother and know how to
handle her. If, as seems likely with the reduction in public homes available, my mother ends up in a
private home, then we fear for her. Staff from public service rarely move to private service.
We do not know how you can cost the disturbance, stress and anxiety that a closure and subsequent
re-location for a mentally ill patient and their family. Not to mention NHS staff. Where is this shown
and incorporated into any cost benefit analysis
a few statistics of our own to support our view.
72 of 155
61
Mr A Timothy
Ms Buckton
MP Mr Dowd
MP Ms J Ruddock
30th January 2015
MP Ms H Alexander
email with Stakeholder Cover Letter and Public Consultation Document enclosed
30th January 2015
email with Stakeholder Cover Letter and Public Consultation Document enclosed
30th January 2015
HK sent email with Stakeholder Cover Letter and Public Consultation Letter
enclosed
30th January 2015
email with Stakeholder Cover Letter and Public Consultation Letter enclosed
30th January 2015
email with Stakeholder Cover Letter and Public Consultation Letter enclosed
Contact date & type
Stakeholder
Contact with stakeholders during public consultation for proposed closure of Ingelemere
73 of 155
62
Lewisham Pensioners Forum
Lewisham Carers’
Mind Care
Lewisham Age Concern
Alzheimer’s Society
Alzheimer’s Society
30th January 2015
Lewisham Age Concern
30th January 2015
sent letter via post with Stakeholder Cover Letter and Public Consultation
Document enclosed
30th January 2015
sent letter via post with Stakeholder Cover Letter and Public Consultation
Document enclosed
30th January 2015
sent letter via post with Stakeholder Cover Letter and Public Consultation
Document enclosed
30th January 2015
sent letter via post with Stakeholder Cover Letter and Public Consultation
Document enclosed
30th January 2015
email with Stakeholder Cover Letter and Public Consultation Document enclosed
30th January 2015
email with Stakeholder Cover Letter and Public Consultation Document enclosed
30th January 2015 email with Stakeholder Cover Letter and Public Consultation
Document enclosed
Carers’ Lewisham
74 of 155
February 19th 2015
Sydenham Gardens
63
Ladywell Centre
Age Exchange
met with Lb to review the panel process for the residents and ensure that the
system runs smoothly and will not cause any added distress and the is an issue the
relatives are concerns about
Lesley Broom continuing health
care manger
sent letter via post and an Email with Stakeholder Cover Letter and Public
Consultation Document enclosed
February 19th 2015
sent letter via post and an Email with Stakeholder Cover Letter and Public
Consultation Document enclosed
February 19th 2015
sent letter via post and an Email with Stakeholder Cover Letter and Public
Consultation Document enclosed
Met with health watch for another purposed but discussed the potential closure
invited them to come to the unit to meet relatives. Health watch have agreed to
attend some of the public meeting s. Took leaflets for circulation at the unit.
Health watch
sent letter via post with Stakeholder Cover Letter and Public Consultation
Document enclosed
75 of 155
5th March 2015 sent out Public Consultation letter by mail and email
5th March 2015 called to see if they received our Public Consultation letter sent
30th Jan 2015. They were unsure so a new one was sent out via email.
11TH of March 2015 Letter received regarding public consultation informing us
agreement with the closure as it is consistent with commissioning intentions for
Adult Mental Health services
30th March 2015 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 05.03.2015.
30th March 2015 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 05.03.2015.
30th March 2015 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 05.03.2015.
30th March 2015 Telephoned to inquire about any comment regarding the public
Age UK
Lewisham Pensioners Forum
Lewisham Clinical
Commissioning Group
Family Health ISIS
Lewisham Pensioners Forum
Alzheimer’s Society
Lewisham Age Concern
64
5th March 2015 sent out Public Consultation letter by mail and email
Family Health ISIS
76 of 155
30th March 2015 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 05.03.2015.
30th March 201 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 05.03.2015.
30th March 2015 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 05.03.2015.
30th March 2015 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 05.03.2015.
Lewisham Pensioners forum
Email feedback regarding consultation
Email Feedback re consultation Informing us they had no objections to closure
14th April 2015 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 05.03.2015.
14th April 2015 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 05.03.2015 and the 30.03.2015
Mind care Lewisham
Sydenham Garden
Age Exchange Lewisham
Ladywell Centre Lewisham
Consultation Meeting Thursday
9th April
Enquiry from Lewisham
Pensioners forum
Sydenham Garden project
Family Health ISIS
Age UK Lewisham
65
Age Concern Lewisham
30th March 2015 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 05.03.2015.
Lewisham Carers
consultation document sent out on the 05.03.2015.
77 of 155
14th April 2015 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 05.03.2015.
14th April 2015 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 05.03.2015.
14th April 2015 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 05.03.2015.
Email feedback regarding consultation see attached
Mind Care
Age Exchange
Lady Well Centre
Lewisham Pensioner forum
66
14th April 2015 Telephoned to inquire about any comment regarding the public
consultation document sent out on the 30.03.2015.
Lewisham Carers’
78 of 155
TRUST BOARD OF DIRECTORS – SUMMARY REPORT
Date of Board meeting:
28th April 2015
Name of Report:
Finance Report
Heading:
Performance & Activity
Author:
Tim Greenwood, Mark Nelson
Finance Directorate, BRH
Approved by:
(name of Exec Member)
Gus Heafield
Presented by:
Gus Heafield
Purpose of the report:
The Finance Report provides an update on the financial position of the Trust as at
28th April 2015 (month 12).
Action required:
To note the contents of the Report and the financial pressures and for the members
of the Board of Directors to satisfy themselves that the 2015/16 plan addresses these
issues appropriately.
Recommendations to the Board:
That the Trust Board of Directors approves the report on the financial position for
March 2015
Relationship with the Assurance Framework (Risks, Controls and Assurance):
The report is a key component of risk item 6 of the Board Assurance Framework
(maintaining financial balance) in terms of the effective and efficient management of
resources.
Summary of Financial and Legal Implications:
The Trust must make the best possible use of public money and meet regulatory
requirements and deliver to plan.
Equality & Diversity and Public & Patient Involvement Implications:
The report identifies activity and financial pressures that if not resolved may have
implications on the Trust’s ability to deliver its equality, diversity and patient
involvement commitments as set out in the Annual Plan
Service Quality Implications:
The report identifies activity and financial pressures that if not resolved may have
implications on the Trust’s ability to deliver its quality commitments as set out in the
Annual Plan
79 of 155
80 of 155
-
2
4
6
8
10
12
14
16
£m's
4
8
12
16
20
24
-
£m's
3
M1
£m's
(3)
(2)
(1)
1
-
2
3
4
5
6
7
8
-
6
9
12
15
Pay forecast against plan including agency
agency and bank
agency plan
plan
forecast
actual
Cumulative EBITDA
Cumulative Net Retained Surplus (deficit)
employed plan
employed
plan
forecast
total
plan
forecast
actual
plan
forecast
actual
M3
18
M2
EBITDA
I&E surplus (deficit)
EBITDA margin
Debt service cover
FY Plan
£16m
£0.9m
4.7%
2.14
z
z
z
z
Cost Improvement Programme
Rating 2
Rating 3
Rating 4
plan
forecast
actual
Rating 2
Rating 3
Rating 4
plan
forecast
actual
CoSRR - Debt service cover
£m's
£m's
-
10
20
30
40
50
60
70
80
-
2
4
6
8
10
12
14
16
18
20
Net assets
cash
plan cash
payables
receivables
revised plan
Monitor lower risk indicator <85%
original plan
forecast
actual
Cash at bank and in hand
Debt service cover (from 4)
CoSRR - Liquidity rating
M5
Other metrics
Capital spend against plan
Better payment practice code (non-NHS by value)
Debtor Days
Capital expenditure < 85% or > 115% revised plan
Forecast CoSRR less than 3 in next 12 months
(15)
(10)
(5)
-
5
10
15
20
25
30
35
Days
40
0.0
0.5
1.0
1.5
2.0
2.5
cover x
Continuity of Service Risk Rating (from 4)
Financial Position
M6
3.0
M12
£m's
M1
M1
M1
M4
M4
M4
M4
M2
M2
M2
M8
M8
M8
M8
M3
M5
M5
M5
M5
M3
M3
M6
M6
M6
M6
M9
M9
M9
M9
M7
M7
M7
M7
M10
M10
M10
M10
M1
M1
M2
Actual
£13.9m
£2.9m
3.9%
1.91
M4
M11
M11
M11
M3
M3
M3
YTD Plan
£16m
£0.9m
4.7%
2.14
M5
M12
M11
M12
M1
M12
Working Capital
M6
M2
M1
M12
M12
M12
M4
M4
M7
M7
M7
YTD
£13.9m
£2.9m
3.9%
1.91
12 days
79%
£69.6m
Possible
Possible
Liquidity rating (from 4)
M8
M5
M5
M8
M8
M8
M4
[
Z
z
z
z
z
z
[
Commentary
z
z
z
z
z
‚ Psychosis Drugs - £0.7m overspent
‚ Ward Nursing - £0.5m overspent
‚ Acute Overspill - £0.4m overspent including impact of risk share
‚ Cost per Case/Cost & Volume - £1.1m ytd > target
z
‚ Complex/Non Secure Placements - £2.5m overspent
‚ Performance v CIP - £4.6m - 29% < target
Key Financial Drivers
overspends in some CAGs and infrastructure departments will require new savings measures
and improved contractual positions to be realised.
Whilst the year end position represents an improvement from that forecast 6 months ago and is a
considerable improvement from the £10m adverse variance from EBITDA in 2013/14, further work
is required if we are to deliver a balanced position in 2015/16. On-going national efficiency
targets, new local QIPP targets, use of non recurring solutions in 2014/15 and continuing
- C&V income – an increase in activity, particularly in forensic services, clinical neurosciences
perinatal
- CCG & other income – recognition of acute overperformance in Lambeth but offset by an
increase in various other provisions and changes made to commissione
outturn positions
- Nurse bank/agency – an increase in the final month partly due to staff being able to take
outstanding annual leave before the 31st March deadline
- Post EBITDA – an increase in the provision for redundancies associated with a number of
closures and restructures due to take place early in the new financial year
- B&D – a review of placement accruals resulted in a reduction in the provision previously being
made
- R&D – an improvement in the commercial R&D income position and approval given to retain
funding that had previously been deferred
- ICT – investment in March not as high as expected
The overall EBITDA position at month 12 was in line with the forecast position. The main changes
from forecast occurred in -
Net surplus of £2.9m and EBITDA of £13.9m at the end of March. This included an operational
deficit of £9.5m caused by overspends particularly in Psychosis and Estates. The operational
deficit was offset by the Trust contingency reserve at month 12 but these reserves were not
sufficient to keep the Trust within its planned EBITDA of £16m (£2.1m adverse from EBITDA plan)
SLaM - Financial Overview as at 31st March 2015 (Qtr 4, Month 12)
M9
M6
M6
M9
M9
M9
M2
M3
M2
M7
M10
Income and Expenditure
M10
M11
M11
M11
M11
M10
M10
M12
M12
M12
M12
South London and Maudsley NHS Foundation Trust
Finance Report 2014/15 – March 2015 (month 12)
The Finance Report is split into 2 sections –
A) Headlines and Key Issues
B) Finance Analysis
Section A – Headlines & Key Issues
1)
Headlines
•
£2.9m net surplus (£2.0m favourable variance from plan) – see Table 1
•
£13.9m EBITDA (£2.1m adverse variance from plan) – see Table 1
•
The Operational Plan performance shows a Continuity of Service Rating (CoSRR) of
4 with a liquidity rating of 4 and a debt service ratio of 3 based on our EBITDA at
month 12
2)
Key Issues
The overall EBITDA position was in line with the forecast. The main changes from forecast
occurred in –
•
B&D – a review of placement accruals resulted in a reduction in the provision
previously being made
•
R&D – an improvement in the commercial R&D income position and approval given
to retain funding that had previously been deferred
•
ICT – investment in March not as high as expected
•
C&V income – an increase in activity, particularly in
neurosciences and perinatal
forensic services, clinical
81 of 155
•
CCG & other income – recognition of acute overperformance in Lambeth but offset
by an increase in various other provisions and changes made to commissioner
outturn positions
•
Nurse bank/agency – an increase in the final month partly due to staff being able to
take outstanding annual leave before the 31st March deadline
•
Post EBITDA – an increase in the provision for redundancies associated with a
number of closures and restructures due to take place early in the new financial year
Whilst the year end position represents an improvement from that forecast 6 months ago
and is a considerable improvement from the £10m adverse variance from EBITDA in
2013/14, further work is required if we are to deliver a balanced position in 2015/16. Ongoing national efficiency targets, new local QIPP targets, use of non recurring solutions in
2014/15 and continuing overspends in some CAGs and infrastructure departments will
require new savings measures and improved contractual positions to be realised. Progress
has been made with all 4 of our local CCGs such that funding positions have been agreed
although the Croydon position is still subject to business case approval. The Trust has yet to
finalise its overall contract with NHS England. Negotiations are expected to be concluded
this month. A gap in the savings plans remains at this stage and the Board will need to
weigh up the status of these plans together with the ability to invest when determining the
Financial Plan targets for 2015/16.
Gus Heafield
Chief Financial Officer
April 2015
82 of 155
Section B - Finance Analysis
1) Financial Summary
Monthly Figures
Full Year Live
Budgets (£)
Service Analysis
01. Psychosis
Year to Date Figures
Variance
From Live
Budgets (£)
Current
Month
Actual(£)
Year To Date
Actual (£)
Variance From
Live Budgets
(£)
101,218,400
9,122,700
644,900
106,371,200
5,152,800
0
(275,000)
(275,000)
114,400
114,400
919,300
50,900
(45,800)
1,136,500
217,200
04. Psychological Medicine
(741,000)
160,100
(12,500)
(1,308,700)
(567,700)
05. Child & Adolescent Service
06. MHOA And Dementia
2,530,200
0
254,800
174,900
64,700
174,700
2,206,100
(171,000)
(324,100)
(171,000)
0
(123,500)
(123,500)
(124,400)
(124,400)
02. Behavioural And Dev. Psych
03. Mood, Anxiety, Personality
07. Addictions
08. Clinical Support Services
1,862,900
123,200
(32,000)
2,077,600
214,700
09. Infrastructure Directorates
49,105,700
5,451,200
228,100
51,599,200
2,493,000
(100,636,000)
54,259,500
(7,231,700)
1,056,000
1,679,600
(98,116,100)
2,519,800
9,524,700
(77,501,600)
(6,060,800)
226,600
(77,683,200)
(181,600)
1,796,000
0
(149,667)
0
(1,796,000)
17,800
17,800
17,800
17,800
0
10. Corporate Income
Operational Deficit
11. Corporate Other
12. Contingency - planned
7,707,600
63,784,800
13. Contingency - committed
14. Other reserves/provisions
released
Corporate Other
5,409,000
0
(458,333)
0
(5,409,000)
(70,278,800)
(6,043,000)
(363,600)
(77,665,400)
(7,386,600)
EBITDA
(16,019,300)
1,664,600
1,316,000
(13,880,600)
2,138,100
15,085,000
1,556,500
35,500
10,939,300
(4,145,700)
(934,300)
3,221,100
1,351,500
(2,941,300)
(2,007,600)
15. Post EBITDA Items
Trust Financial Position
Area
2014/15
Mth 7
Variance
2014/15
Mth 8
Variance
2014/15
Mth 9
Variance
2014/15
Mth 10
Variance
2014/15
Mth 11
Variance
2014/15
Mth 12
Variance
£000
£000
£000
£000
£000
£000
2014/15
Total
Variance
£000
CAGs
(353)
(342)
(335)
318
(307)
(428)
(4,297)
Infrastructure Directorates
(342)
66
(121)
(213)
(382)
(196)
(2,708)
176
(251)
486
(118)
(731)
(1,056)
(2,520)
Other reserves/provisions
released or Unidentified CIPs
Use of Contingency prior to
finalising budget allocations
(419)
(209)
1,070
(204)
(447)
(226)
(182)
418
(144)
(964)
109
2,326
590
7,205
Total EBITDA
(520)
(880)
137
(108)
459
(1,316)
(2,138)
Corp Income
83 of 155
2)
Key Cost Drivers
Surplus/Deficit £000's
Psychosis & B&D - 12 Month Rolling Run Rates
0
1
2
3
4
5
6
7
8
9
10
11
12
B&D
-500
Psychosis
-1,000
-1,500
Month
Note – for B&D £3.5m of transitional funding has been provided in 14/15, overspending forensic placements transferred to NHS E
from 1/4/14 and NDS closed in Q4 13/14. Psychosis includes funding for safe staffing from month 6
Area
Ward Nursing*
Acute Overspill**
Unmet CIPs***
Psychosis Drugs
CPC/C&V Income
Placements ****
Total
2014/15
Mth 7
Variance
2014/15
Mth 8
Variance
2014/15
Mth 9
Variance
2014/15
Mth 10
Variance
2014/15
Mth 11
Variance
2014/15
Mth 12
Variance
2014/15
Total
Variance
£000
£000
£000
£000
£000
£000
£000
156
(130)
(380)
(50)
172
(283)
72
369
(350)
(70)
71
(248)
38
(13)
(694)
(41)
116
(225)
44
(12)
(682)
(54)
301
(235)
(98)
6
(770)
(41)
76
(165)
(192)
(113)
(848)
(55)
263
58
(511)
(450)
(4,577)
(726)
1,131
(2,490)
(515)
(156)
(819)
(638)
(962)
(887)
(7,623)
* includes safer staffing funding for MHOA, Psych Med, Psychosis and Place of Safety at month 6
** includes impact of Lambeth and Southwark risk shares following year end agreements in month 8
*** excludes the acute overspill CIP as this is reflected explicitly in the row above
**** excludes risk share income of £576k ytd
Performance against the main cost drivers is detailed below –
•
Acute/PICU Overspill
Overall, 21 beds were used outside the Trust in March, an increase of 10 compared to the
previous month. This put the Trust about 5.3 beds above Plan over the course of the year
resulting in a net £450k overspend. There has been a noticeable increase in the activity in
the final month with March recording the third highest use of overspill beds during the year.
The recent increases in activity have, in part, been reflected in contract discussions with
local commissioners where new contract baselines have been agreed with Lambeth and
Southwark. Discussions continue with Lewisham and Croydon to agree realistic baselines
for 2015/16.
84 of 155
SLaM Adult Acute/PICU Bed Overspill (per month) excl Bridge
Hse
Bed Days
1,200
800
Actual Overspill
Bed Days
400
0
1
2
3
4
5
6
7
8
9
10
11
12
Planned
Overspill Bed
Days
-400
Month
•
Ward/Unit Nursing Costs (Table 2)
At month 12 ward nursing costs were overspent by £192k with the year to date position now
showing a £511k overspend. At the end of 2013/14 the Trust had overspent on ward nursing
by £2.2m. However since then nursing budgets have been uplifted by £3.1m for safer
staffing. The last 2 months have seen a rise in nursing costs (mirroring increases in previous
years) which are partly due to staff utilising annual leave before the 31st March deadline.
SLaM Ward Nurse Overspend (per month)
Overspend/£000s
400
300
200
2014/15
100
2013/14
0
-100
-200
Month
•
Complex Placements
Forensic placements transferred to NHS E at the start of the year having overspent by
£2.3m in 2013/14. The Trust remains the secondary commissioner for other placements in
Lambeth, Southwark and Lewisham. At month 12 these placements had overspent by
£2.49m excluding risk share income. Risk share agreements with Lambeth and Southwark
CCGs resulted in £630k of funding to help offset the forecast year end over-performance. In
addition Southwark CCG covered the £450k reduction in funding that the Council had
signalled at the start of the year and which had remained a risk. In Lewisham however the
overspend has continued to deteriorate and although there is no risk share in place, the
Trust has invoiced the CCG for £750k given the level of activity overperformance this year.
Taking account of the Lambeth and Southwark risk share income, the Trust overspent by
£1.9m. The on-going issue of placement activity risk has formed a significant part of
2015/16 contract discussions.
85 of 155
•
Cost per Case/Cost and Volume
Variable Income (Cumulative) Variance From Plan (By CAG)
V a rian c e (n e g ativ e =
ad verse)
1,200,000
Psychosis
950,000
B&D
700,000
Psych Med
450,000
MAP
200,000
CAMHS
Addictions
-50,000
-300,000
M1
M2
M3
M4
M5
M6
M7
M8
M9
M10
M11
TOTAL
M12
Month
CAG
Psychosis
At Month 12
Actual
Invoiced
At Month 12
Surplus/
Deficit(-)
At Month 12
Surplus/
Deficit(-)
Last Month
£'000
£'000
£’000
£’000
3,988
4,052
64
61
Income Target
1,048
893
Behavioural & Dev
19,669
20,716
Psychological Med
17,978
17,832
(145)
(218)
Mood and Anxiety
10,536
10,488
(49)
(60)
CAMHS
21,848
22,279
431
371
1,983
1,765
(218)
(180)
77,133
1,131
868
Addictions
TOTAL
76,002
The general improvement continued with good occupancy levels in the National Autism Unit,
River House and CAMHS inpatient services and improvements this month across a number
of previously underperforming Psychological Medicine and MAP services.
3)
Cost Improvement Programme (CIP) & CCG QIPP
a) Trust CIP (Table 3)
The Trust reported an overall adverse variance of £4.6m (29%) against its original
Monitor plan of £15.9m. The main areas of current variance had been highlighted in
previous reports and in Table 3. This included both a delay in closing Gresham PICU
and requirement to utilise the savings to fund external placements and continuing
pay overspends in MAP A&T teams which were planned to be addressed by month
1. These adverse variances were partly offset by savings that had been delivered
ahead of plan in MHOA and in excess of Plan in Addictions.
Specific schemes were being identified to try and mitigate those CIPs which were
unidentified and those which were Trustwide projects at the time that the Operational
86 of 155
Plan was being finalised. However these schemes did not begin delivering in
2014/15 and ended up accounting for 70% of the final variance.
b) CCG QIPP (disinvestment) - Table 4
There was a shortfall of £1.1m against the CCG QIPP target attributable to SLaM at
month 12. This included the impact of agreements with Lambeth, Southwark and
Lewisham CCGs to partially re-fund QIPP where there was no viable QIPP scheme
in place. The shortfall of £1.1m largely related to the placements and acute obd
position in Lambeth where activity was above plan (after a reduction for QIPP).
4)
Local CCG/NHSE Contract Positions
Discussions have concluded with Lambeth, Southwark, Lewisham CCGs and
agreement reached about funding and risk shares for 2015/16. Agreement has also
been reached with Croydon CCG subject to business case approval for a number of
investment schemes. Negotiations continue with NHS England. The current
CCG/NHSE agreement/proposals (at 20/4/15), excluding CQUIN, are –
CCG
Lambeth CCG
Lambeth
Alliance
Starting
AMH
Transfer
to
Baseline
Invest
Alliance
£0
£0
£0
54,937
1,356
-6,723
0
Southwark CCG
52,742
Lewisham CCG
Croydon CCG
QIPP
Inflation
£0
£0
-1,306
-781
EI
Other
Invest
Invest
£0
£0
461
2,248
5,172
1,089
0
55,496
918
36,615
1,200
NHSE
45,136
Total
244,926
Total
£0
Overall
CCG
Change
Growth
£0
%
50,192
-4,745
5,172
5,172
1,389
3.55%
-1,225
-766
376
1,915
54,131
3.61%
0
-979
-858
383
1,479
56,439
943
3.87%
0
-2,169
-707
236
690
35,865
-750*
6.89%
0
0
-1,135
-597
0
-40
43,364
-1,772
4,563
-1,551
-6,814
-3,709
1,456
7,593
245,163
237
* pending the approval of investment business cases
Additional funding was secured this month for Lambeth acute overperformance .
5) Capital Expenditure
Capital expenditure at month 12 is £14.6m against the revised plan of £17.5m
(original plan £17.3m). This represents a 17% variance against the revised plan. A
new capital plan will be submitted to Monitor as part of the 2015/16 Forward Plan.
The main variances from the revised plan were due to • £4.6m slippage on Douglas Bennett refurbishment
• £1.8m slippage on Eating Disorders Unit relocation to Aubrey Lewis
• £1.2m slippage on ICT projects
87 of 155
• £0.6m slippage on Ladywell ward refurbishment programme
• £0.5m slippage on Marina House refurbishment
• £0.3m slippage on Luther King and Nelson refurbishment
• £0.3m slippage on anti-ligature work
• £0.2m slippage on River House key management system
Less;
• £0.9m over plan on staff attack alarms due to additional ward refurbishments
• £0.5m Granville Park refurbishment – not in Plan
• £0.3m purchase of legacy staff attack alarm installation – not in Plan
• £0.3m overspend on Westways reprovision (Alex and Queens)
• £0.3m St Pauls (ICT relocation) – not in Plan
• £0.3m overspend on Bethlem museum project
• £4.0m release of slippage contingency
Disposals were also resubmitted to Monitor along with capital expenditure. The
revised plan and the original plan are both £4.7m although the buildings, valuations,
and timings vary.
Disposals have slipped £1m behind revised plan. Oaks completed in M05 at £1.2m,
and Westways and Crystal Centre in M09 at £2.5m. Sale of Morland Rd and David
Pitt House have slipped.
6)
2014/15 Draft Accounts
The draft accounts were submitted to Monitor and the External Auditors on 23rd April. A
meeting of the Audit Committee has been arranged for 26th May to agree and sign off the
Final Audited Accounts. The main headlines to note from the draft accounts that confirms
the position shown in this report are •
Total income of £364m
•
EBITDA of £13.9m (£2.1m below Plan)
•
Net surplus of £2.9m (£2.0m above Plan)
•
Forecast Monitor Risk Rating of 4 (in line with Plan) subject to ratification by Monitor
•
Cash at bank & in hand at 31st March 2015 - £70m
•
Capital expenditure - £14.6m (£2.7m below original Plan)
•
Dividend Payment - £7.4m
Tim Greenwood & Mark Nelson
Finance Department
April 2015
88 of 155
Table 1
March 2015
The South London and Maudsley NHS Foundation Trust - Operating Budgets
Monthly Figures
Service Analysis
01. Psychosis
Full Year Live
Budgets (£)
Year To Date
Actual (£)
Variance From
Live Budgets (£)
Variance Last
Month (£)
101,218,400
9,122,700
644,900
106,371,200
5,152,800
0
(275,000)
(275,000)
114,400
114,400
389,400
919,300
50,900
(45,800)
1,136,500
217,200
263,800
02. Behavioural And Dev. Psych
03. Mood, Anxiety, Personality
Year to Date Figures
Current Month Variance From
Actual(£)
Live Budgets (£)
4,507,900
04. Psychological Medicine
(741,000)
160,100
(12,500)
(1,308,700)
(567,700)
(556,000)
05. Child & Adolescent Service
06. MHOA And Dementia
2,530,200
0
254,800
174,900
64,700
174,700
2,206,100
(171,000)
(324,100)
(171,000)
(388,800)
(345,700)
0
(123,500)
(123,500)
(124,400)
(124,400)
(800)
1,862,900
123,200
(32,000)
2,077,600
214,700
246,700
07. Addictions
08. Clinical Support Services
09. Infrastructure Directorates
49,105,700
5,451,200
228,100
51,599,200
2,493,000
2,265,200
(100,636,000)
54,259,500
(7,231,700)
7,707,600
1,056,000
1,679,600
(98,116,100)
63,784,800
2,519,800
9,524,700
1,463,900
7,845,600
(77,501,600)
(6,060,800)
226,600
(77,683,200)
(181,600)
(408,200)
1,796,000
0
(149,667)
0
(1,796,000)
(1,765,592)
13. Contingency - committed
14. Other reserves/provisions released
Corporate Other
17,800
5,409,000
(70,278,800)
17,800
0
(6,043,000)
17,800
(458,333)
(363,600)
17,800
0
(77,665,400)
0
(5,409,000)
(7,386,600)
0
(4,849,108)
(7,022,900)
EBITDA
(16,019,300)
1,664,600
1,316,000
(13,880,600)
2,138,100
822,700
15,085,000
1,556,500
35,500
10,939,300
(4,145,700)
(4,181,200)
(934,300)
3,221,100
1,351,500
(2,941,300)
(2,007,600)
(3,358,500)
10. Corporate Income
Operational Deficit
11. Corporate Other
12. Contingency - planned
15. Post EBITDA Items
Trust Financial Position
Monthly Figures
Corporate Analysis
A1) Estates & Facilities
A2) Hotel Services
B) Education & Nursing
C) Information & I.T.
D) Finance And Corp Governance
E) Human Resources
F) Organisation & Community
G) Chief Executive
H) Medical & Clinical Govern.
I) Professional Heads
J) Chief Operating Officer
K) R&D
Infrastructure Directorates
Full Year Live
Budgets (£)
Current Month Variance From
Actual(£)
Live Budgets (£)
Year to Date Figures
Year To Date
Actual (£)
Variance From
Live Budgets (£)
Variance Last
Month (£)
17,469,100
10,580,600
2,510,000
5,664,800
4,671,800
3,491,700
1,753,600
3,744,000
2,946,500
1,787,300
1,593,100
(7,106,800)
49,105,700
1,769,300
871,400
383,000
714,200
551,400
253,900
172,300
476,300
1,045,800
231,300
152,300
(1,170,000)
5,451,200
113,200
(18,000)
171,700
204,900
(37,700)
(40,400)
(19,700)
158,800
180,300
74,300
19,500
(578,800)
228,100
18,626,400
10,546,800
2,468,100
6,528,700
4,634,200
3,057,200
1,859,600
5,111,300
3,039,900
1,738,500
1,739,900
(7,751,400)
51,599,200
1,157,200
(33,800)
(42,000)
863,900
(37,600)
(434,500)
105,900
1,367,200
93,400
(48,900)
146,800
(644,600)
2,493,000
1,044,100
(15,800)
(213,700)
659,000
200
(394,200)
125,700
1,208,500
(86,900)
(123,200)
127,300
(65,800)
2,265,200
L) Corporate Service
M) Trust Reserves
(77,501,600)
7,222,800
(6,060,800)
17,800
226,600
(590,200)
(77,683,200)
17,800
(181,600)
(7,205,000)
(408,200)
(6,614,700)
Corporate Other
(70,278,800)
(6,043,000)
(363,600)
(77,665,400)
(7,386,600)
(7,022,900)
89 of 155
Table 2 - 2014/15 Nursing Overspend - Monthly Data by Borough (£000's)
CAMHS
Over/Underspend/(£1000)
12
23
57
53
-1
44
62
16
46
23
38
43
416
CAMHS
190
Overspend / £000's
Month
1
2
3
4
5
6
7
8
9
10
11
12
Total
150
110
70
30
-10
-50
1
2
3
4
5
6
7
8
Month
9
10
11
12
11
12
MHOA & DEMENTIA
MHOA
Over/Underspend/(£1000)
Month
1
-8
2
11
3
-28
4
-24
5
83
6
42
7
65
8
6
9
-4
10
9
11
49
12
49
Total
250
Note - now includes backdated safer staffing
Overspend / £000's
250
190
130
70
10
-50
1
2
3
4
5
6
7
8
9
10
Month
ADDICTIONS
ADDICTIONS
Over/Underspend/(£1000)
-10
-4
-10
-8
-3
-8
-13
-2
-8
-5
-11
-4
-86
200
Overspend / £000's
Month
1
2
3
4
5
6
7
8
9
10
11
12
Total
150
100
50
0
-50
1
2
3
4
5
6
7
8
9
10
11
12
Month
PSYCHOSIS
Over/Underspend/(£1000)
20
52
-24
41
77
8
-218
29
-47
-35
29
29
-39
PSYCHOSIS
Overspend / £000's
Month
1
2
3
4
5
6
7
8
9
10
11
12
Total
150
70
-10
-90
-170
-250
1
2
3
4
5
6
7
8
9
10
11
12
Month
Note - now includes safer staffing
90 of 155
Table 2 - 2014/15 Nursing Overspend - Monthly Data by Borough (£000's)
BEHAVIOURAL & DEVELOPMENTAL PSYCHIATRY
BEHAVIOURAL & DEVELOPMENTAL PSYCHIATRY
Over/Underspend/(£1000)
-13
21
-35
4
20
-6
-22
-38
8
38
51
83
111
Overspend / £000's
Month
1
2
3
4
5
6
7
8
9
10
11
12
Total
170
120
70
20
-30
-80
1
2
3
4
5
6 Month7
8
9
10
11
12
MOOD ANXIETY PERSONALITY
MOOD ANXIETY PERSONALITY
Over/Underspend/(£1000)
2
-3
-3
0
0
0
0
0
-1
0
0
0
-5
Overspend / £000's
Month
1
2
3
4
5
6
7
8
9
10
11
12
Total
200
150
100
50
0
-50
1
2
3
4
5
6
7
8
9
10
11
12
Month
PSYCHOLOGICAL MEDICINE
PSYCHOLOGICAL MEDICINE
180
Overspend / £000's
Over/Underspend/(£1000)
Month
1
7
2
61
3
60
4
54
5
85
6
-118
7
-30
8
-83
9
-32
10
-74
11
-58
12
-8
Total
-136
Note - now includes safer staffing
130
80
30
-20
-70
-120
1
2
3
SLaM
5
6
Month7
8
9
10
11
12
SLaM WARD NURSE OVERSPEND (per month)
Over/Underspend/(£1000)
10
161
17
120
261
-38
-156
-72
-38
-44
98
192
511
500
Overspend / £000's
Month
1
2
3
4
5
6
7
8
9
10
11
12
Total
4
300
2013-14
100
2014-15
-100
-300
1
2
3
4
5
6
7
8
9
10
11
12
Month
91 of 155
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92 of 155
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ϲϲй
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/WƐǁŝƚŚŝŶ &ƵƌƚŚĞƌ dŽƚĂů
й
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sĂƌŝĂŶĐĞ
WůĂŶ
/WƐ
/WƐ
DŽŶƚŚ
/ŶĐŽŵĞ/WƐ
džƉĞŶĚŝƚƵƌĞ/WƐ
/ŶĐŽŵĞ/WƐ
,ŽƚĞů^ĞƌǀŝĐĞƐŝŶĐŽŵĞ
,Z
,ZŝŶĐŽŵĞ
ĐŚĞĐŬ
dŽƚĂůŝƌĞĐƚŽƌĂƚĞ/W^
ϮϬϭϰͬϭϱ/WƐƉůĂŶ
Dϭ
DϮ
Dϯ
Dϰ
Dϱ
Dϲ
Dϳ
Dϴ
Dϵ
DϭϬ
Dϭϭ
DϭϮ
Ͳ
Ϯ͕ϬϬϬ
zĞĂƌƚŽĚĂƚĞ/WƐ
Ͳ ϭϭ ϭϭ ϭϭ
ͲͲ
Ͳ Ͳ
ͲͲ
Ͳ Ͳ
ͲͲ
Ͳ Ͳ
Ͳ ϱϵ ϱϵ ϱϵ
ͲͲ
Ͳ Ͳ
Ͳ ϱϬ ϱϬ ϱϬ
ͲͲ
Ͳ Ͳ
ϰ͕ϬϬϬ
ϲ͕ϬϬϬ
ϰ͕ϰϭϰ
ϭϲϯ
ϰ͕ϱϳϳ
Ϭ
Ϭ
Ϭ
;ϬͿ
Ϭ
Ϭ
Ϭ
ϱϬ
;ϬͿ
Ϭ
Ϭ
Ϭ
;ϬͿ
Ϭ
;ϬͿ
Ϭ
Ϯϭ
Ϭ
;ϰͿ
^ƚĂƚƵƐŽĨƐĂǀŝŶŐƐƉůĂŶƐ;ǀĂƌŝĂŶĐĞĂŶĂůLJƐŝƐͿ
ϲ͕ϬϬϬ
'ƌĞĞŶ
Ͳ
Ϯ͕ϬϬϬ
ϰ͕ϬϬϬ
ϴ͕ϬϬϬ
ϭϬ͕ϬϬϬ
ϭϮ͕ϬϬϬ
ϭϰ͕ϬϬϬ
ϭϲ͕ϬϬϬ
ϭϴ͕ϬϬϬ
ϱϬй džƉĞŶĚŝƚƵƌĞsĂƌŝĂŶĐĞ
Ϯй /ŶĐŽŵĞsĂƌŝĂŶĐĞ
Ϯϵй
ĐƚƵĂů
WůĂŶ
Ϭй
;ϰйͿ ŚĞĂĚŽĨƚĂƌŐĞƚ
dŚĞƌĞŝƐĂƐŝŐŶŝĨŝĐĂŶƚƐŚŽƌƚĨĂůůďĞŝŶŐŽĨĨƐĞƚďLJƉĂLJƐĂǀŝŶŐƐ͘dŚĞďƵĚŐĞƚƐĂƌĞŶŽƚ
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ĞdžƉĞŶĚŝƚƵƌĞŝŶůŝŶĞǁŝƚŚĚĞŵĂŶĚ͘
;ϬйͿ KŶdĂƌŐĞƚ
Ϭй
Ϭй
Ϭй
;ϬйͿ KŶdĂƌŐĞƚ
Ϭй
;ϬйͿ KŶdĂƌŐĞƚ
Ϭй
EŽƐĂǀŝŶŐƐĂĐŚŝĞǀĞĚƚŽĚĂƚĞ͘WƌŽŐƌĞƐƐŽŶƚŚĞĂĐŚŝĞǀĞŵĞŶƚŽĨƚŚŝƐ/WŝƐĚĞƉĞŶĚĞŶƚ
ϭϬϬй
ƵƉŽŶƌĞͲŶĞŐŽƚŝĂƚŝŽŶŽƌƌĞͲƚĞŶĚĞƌŽĨĞdžƚĞƌŶĂůĐŽŶƚƌĂĐƚƐ
Ϭй
Ϭй
Ϭй
;ϬйͿ džƉĞĐƚĞĚĨƵůůĂĐŚŝĞǀĞŵĞŶƚ
Ϭй
Ϭй
Ϭй
ŵďĞƌ
ZĞĚ
ϭϱ͕ϵϰϭ ϭϱ͕ϵϰϬ ϭϭ͕ϯϲϯ ϰ͕ϱϳϳ
Ͳ
Ͳ
Ͳ
Ͳ
ϴ͕ϴϱϵ ϴ͕ϴϱϵ ϰ͕ϰϰϲ
ϳ͕Ϭϴϭ ϳ͕Ϭϴϭ ϲ͕ϵϭϳ
ϭϬ͕ϬϬϬ ϭϮ͕ϬϬϬ ϭϰ͕ϬϬϬ ϭϲ͕ϬϬϬ ϭϴ͕ϬϬϬ
ΖάϬϬϬ
ϴ͕ϬϬϬ
ϭϱ͕ϵϰϭ Ͳ
Ͳ
Ͳ
ϴ͕ϴϱϵ Ͳ
ϳ͕Ϭϴϭ Ͳ
ϭϱ͕ϵϰϭ ϭϱ͕ϵϰϬ ϭϭ͕ϯϲϯ
ͲͲ
Ͳ Ͳ
ͲͲ
Ͳ Ͳ
ͲͲ
Ͳ Ͳ
Ͳ ϭϳ ϭϳ ϭϳ
ͲͲ
Ͳ Ͳ
ͲͲ
Ͳ Ͳ
ͲͲ
Ͳ Ͳ
ϭϱ͕ϵϰϭ Ͳ
Ͳ
Ͳ
Ͳ
ϭϳ
Ͳ
Ͳ
Ͳ
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ϭϭ
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Ͳ
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Ͳ
ϱϬ
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ϭϱ Ͳ ϭϱ ϭϱ Ͳϲ
Ͳ ͲͲ
Ͳ Ͳ
ϴϮ Ͳ ϴϮ ϴϮ ϴϲ
/WƐǁŝƚŚŝŶ &ƵƌƚŚĞƌ dŽƚĂů
й
DŽŶŝƚŽƌ ƉůĂŶŶĞĚ ƉůĂŶŶĞĚ WůĂŶŶĞĚ ĐƚƵĂů sĂƌŝĂŶĐĞ
sĂƌŝĂŶĐĞ
WůĂŶ
/WƐ
/WƐ
DŽŶŝƚŽƌWůĂŶďLJZ'ƉĞƌŵŽŶƚŚ
ĐŚĞĐŬ
ŝĨĨĞƌĞŶĐĞ
džƉĞŶĚŝƚƵƌĞ/WƐ
/ŶĐŽŵĞ/WƐ
džƉĞŶĚŝƚƵƌĞ/WƐ
/ŶĐŽŵĞ/WƐ
džƉĞŶĚŝƚƵƌĞ/WƐ
/ŶĐŽŵĞ/WƐ
džƉĞŶĚŝƚƵƌĞ/WƐ
/ŶĐŽŵĞ/WƐ
džƉĞŶĚŝƚƵƌĞ/WƐ
/ŶĐŽŵĞ/WƐ
WĂƚŚŽůŽŐLJ
WĂƚŚŽůŽŐLJŝŶĐŽŵĞ
WŚĂƌŵĂĐLJ
WŚĂƌŵĂĐLJŝŶĐŽŵĞ
WƌŽĨ,ĞĂĚƐ
WƌŽĨ,ĞĂĚƐŝŶĐŽŵĞ
^ƚƌĂƚĞŐLJĞdžĐůKΘ
^ƚƌĂƚĞŐLJĞdžĐůKΘŝŶĐŽŵĞ
/d
džƉĞŶĚŝƚƵƌĞ/WƐ
/dŝŶĐŽŵĞ
/ŶĐŽŵĞ/WƐ
DĞĚŝĐĂů
džƉĞŶĚŝƚƵƌĞ/WƐ
DĞĚŝĐĂůŝŶĐŽŵĞ
/ŶĐŽŵĞ/WƐ
EƵƌƐŝŶŐ
džƉĞŶĚŝƚƵƌĞ/WƐ
EƵƌƐŝŶŐŝŶĐŽŵĞ
/ŶĐŽŵĞ/WƐ
KƌŐĂŶŝƐĂƚŝŽŶΘŽŵŵƵŶŝƚLJ
džƉĞŶĚŝƚƵƌĞ/WƐ
KƌŐĂŶŝƐĂƚŝŽŶΘŽŵŵƵŶŝƚLJŝŶĐŽŵĞ /ŶĐŽŵĞ/WƐ
/WdzW
'ͬŝƌĞĐƚŽƌĂƚĞ
93 of 155
94 of 155
2
Total
1
545
5,474
Other
815
Lewisham
0
1,000
2,000
3,000
4,000
5,000
6,000
3
5,474
1,952
Southwark
Total
2,706
Lambeth
Annual
Target
£000
1,483
MHOA
2) By PCT
3,446
Annual
Target
£000
Psychosis
1) By CAG
4,396
745
1,780
1,872
Lambeth acute obds and complex placements are above plan whilst other schemes (e.g pharmacy) have not been
agreed. Both Lambeth and Swk CCGs have now partially re-instated QIPP on a non recurrent basis in recognition of
4
5
6
Month
7
8
9
10
11
1,077 Excludes QIPP attached to reductions in specialist C&V activity (CCG risk)
70 arrangements
12
Forecast
Actual
Target
Acute bed reductions in MHOA that can't be offset by additional income as other CCGs operate under block
173 offset by funding from CCG. Male PICU bed reduction not achieved
Reduction in local authority placements funding not agreed (placements budget is already overspending) but now
835 contract. Placement and acute budgets are overspending and not meeting QIPP activity targets
A number of schemes were not agreed. The CCG have agreed to partially re-instate the QIPP taken from the baseline
1,077 Excludes QIPP currently earmarked for specialist C&V activity (CCG risk)
(0) Use of CQUIN to bridge shortfall in QIPP plans (non rec) - dependent upon achieving 100% CQUIN
215 contract under a block arrangement.
Acute bed reductions but either savings already taken or not capable of selling beds to overperforming CCGs who
863 schemes lack of deliverability
YTD
YTD
Achieved Variance
£000
£000
4,396
545
1,268
2,583
YTD
YTD
Achieved Variance
£000
£000
Notes
PCT QIPP (Target Versus Actually Achieved)
5,474
815
1,952
2,706
YTD
Target
£000
5,474
545
1,483
3,446
YTD
Target
£000
2014/15 CCG QIPP Plan - Actual Versus Target (at month 12)
Table 4
£000
TRUST BOARD OF DIRECTORS – SUMMARY REPORT
Date of Board meeting:
28th April 2015
Name of Report:
Performance Report, Month 11, 2014/15
Heading: - (Strategy, Quality,
Performance & Activity,
Governance)
Performance
Author:
Roy Jaggon, Head of Performance
Management
Approved by:
(name of Exec Member)
Neil Brimblecombe, Director of Nursing
Presented by:
Roy Jaggon, Head of Performance
Management
Purpose of the report:
To report the Trusts’ performance against a range of key indicators for
2014/15, identify any major areas of learning and success, identify and
analyse underperformance and provide action plans to address such
underperformance, taking due account of benchmarking information as
appropriate and available.
Action required:
To review the approach being taken for the reporting of performance and
quality information moving forward and to note the actions being taken for
those areas of underperformance
Recommendations to the Board:
To approve the report noting the ongoing development of the Trust
performance reporting.
Relationship with the Assurance Framework (Risks, Controls and Assurance)
and level of assurance provided by the report - none, low, moderate, high:
The Performance Framework is an operational control with an assurance level
of moderate.
Summary of Financial and Legal Implications:
Specified where relevant in the report.
Equality & Diversity and Public & Patient Involvement Implications:
The report identifies performance and activity issues that if not resolved may have
implications on the Trust’s ability to deliver its equality, diversity and patient
involvement commitments as set out in the Annual Plan
Service Quality Implications:
The report identifies performance and activity and issues that if not resolved may
have implications on the Trust’s ability to deliver its quality commitments as set out in
the Annual Plan
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TRUST BOARD OF DIRECTORS
PERFORMANCE REPORT: APRIL 2015
INTRODUCTION
This report consists of the following elements:
1. Quality and Performance Dashboard
2. Monitor Q4 Return
3. Safer Staffing
4. Patient Stories
1.
Quality and Performance Dashboard - Updates April 2015
I.
SPC charts have been included. This provides an illustration of the variation for the
particular dataset and provides a better definition of trends and outliers.
II.
There are no specific areas of concern for the month other than those already listed
in the ‘issue tracker’. There are a number of CQUIN items that have Q4 targets that
are awaiting audit. These are planned to take place mid April 2015.
III.
Issue tracker
2.
•
Mandatory training - the data cleansing exercise has now begun with information
sent to all teams on 15th April 2015. Teams need to respond by 11th May 2015 and
we would anticipate the impact of the exercise to be 4-6 weeks later. We have
therefore adjusted the tracker to reflect an improvement in performance for the end of
June 2015.
•
Safer staffing – this is regular report that is included within the performance report to
the Board every month. It is proposed to remove this item from the tracker.
•
Care delivery system – investment has been received and an implementation plan is
being developed. It is planned to report to this committee in September 2015. Under
the circumstances it is proposed to remove this item from the tracker.
•
Child need risk screen (CNRS) – the target for completing this risk screen is 96%.
Overall the Trust has consistently failed to meet this target. At a CAG level the
Psychosis CAG and Addictions CAG have consistently met this target. Initially the
intention is to review the guidance relating to CNRS i.e. which clinical teams does it
apply to and how frequently should risk screens be completed for individual cases.
Monitor Q4 Return
The Trust has met all of the eight indicators for Q4 as outlined in Monitor’s Risk
Assessment Framework. These are:
•
•
•
•
•
•
Care Programme Approach (CPA) follow up within 7 days of discharge
Care Programme Approach (CPA) formal review within 12 months
Admissions had access to crisis resolution / home treatment teams
Meeting commitment to serve new psychosis cases by early intervention teams
Minimising MH delayed transfers of care
Data completeness, MH: identifiers and outcomes
96 of 155
•
3.
Compliance with requirements regarding access to healthcare for people with a learning
disability
Safer Staffing
The safer staffing report for February 2015 is enclosed.
The majority of the 14 breaches for February are due to support workers covering for
qualified nurses. The Trust has reviewed the recruitment processes, is working with NHSP
with regards to the recruitment of qualified nurses and reviewing e-roster use/management.
Some services adjust staffing based on level of service user dependency, acuity or bed
occupancy which account for some of the breaches particularly at night & weekends. The
Safer Staffing Lead is meeting with the Heads of Nursing for these particular areas to review
the minimum safe staffing levels and where changes can address the breaches.
4.
Patient Stories
BDP CAG has kindly agreed to present two patient stories in the form of two short video
clips. These are of forensic patients talking about their recovery journey and one patient has
created his own short film which has won a Koestler award http://www.koestlertrust.org.uk/
Roy Jaggon
Head of Performance Management
April 2015
97 of 155
Quality and Performance Dashboard
Status:
Developmental
Reporting Period:
Circulation Date:
Circulation List:
April - Feb 2015
14/04/2015
Quality Sub-Committee
Theme Links:
Items of Focus
Safety
Effectiveness
Caring
Responsiveness
Well Led
This dashboard provides a monthly summary of performance grouped by the CQC Key Lines of Enquiries
98 of 155
99 of 155
No new issues
Indicator Issue
Description
Current Items of Focus: February 2015
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SPC
Future versions of the dashboard will address how this can best be
incorporated.
Statistical Process Control Charts introduced for a range of
measures.
Pending
feedback
Feb 2015
QSC
Feb 2015
QSC
Guidance under review
Child Need Risk
Performance is consistently below target - existing guidance will be reviewed
Screening
13
Feb 2015
QSC
12 wards reported that over 20% of shifts were breached in January compared
to 14 wards in December 2014. The vast majority of breaches were the result of
support workers covering for qualified nurses. The post of Lead for Safer
Staffing has been recruited too and is now in post.
Funding of £0.5 million has been secured from the Health
Foundation. The 1st cohort is due to start in September. Recruitment
is now underway for the staffing to support this and work on
communication and sustainability will occur throughout the summer.
Feb 2015
QSC
Feb 2015
QSC
Date issue
first
reported
Care Delivery
System
Additional funding has been secured to support the delivery of this work.
(Reduction in
violent incidents)
6
Note
Status
Feb 2015
QSC
Mandatory training data in WIRED continues to fall below target in a number of
areas. Particularly in Adult Safeguarding Alerters Plus and Life Support (Basic
and Immediate). CAGS have supplied trajectories for meeting the target for
these items through OPM, data cleansing of WIRED staffing data and
assurance through the supply of training logs to E&T.
PEDIC report and information was presented to February subcommittee.
Data for January and February is available for a number of indicators
and has been included within the dashboard.
PEDIC QUESTIONS:
Do you feel safe
Can you access mental health services quickly and easily if you
need to?
Do you know what to do in an Emergency Mental Health Crisis?
The PEDIC surveys have changed from April 2014/15 due to:
• The implementation of the Friends and Family test. The majority of SLaM
services started FFT in December 2014. SLaM combined our FFT and PEDIC
into one complete patient experience survey; providing over 140 electronic
devices for teams across the Trust, survey web links for patients to use at any
time and a continuation of paper survey.
• The advantage of combining FFT and PEDIC enables us to provide greater
granularity to respond more appropriately to our FFT scores and the electronic
devices and the online link enable real time data for immediate intelligence and
effective response.
Mandatory training results (based on WIRED) continue to fall below
target in a number of areas. CAGS have undertaken a range of
measures to improve compliance including protected time, team
training, and agenda items at performance meetings with Team
Leaders. A number of CAGs have provided trajectories outlining how
the targets will be met. Compliance with targets is being addressed
at Part 1 and 2 Performance meetings in addition to the Trust wide
Education and Training committee.
WIRED staffing data (job roles) is being reviewed at CAG level re:
applicability of specific training to staff members - currently delayed.
This has the potential to impact upon reported compliance.
Triangulation to ensure data capture of training delivered externally
is captured.
Actions / Trajectories
Description
To address safer staffing breaches in the main the priority is
improved recruitment. There has been recent appointment of an
individual to co-ordinate recruitment campaigns and to ensure that
recruitment processes are continuous rather than sporadic.
Safer Staffing
7
45-55
Mandatory
Training
Patient
Experience
3, 14 & Reporting
(PEDIC and
34
Family and
Friends) issues
Indicator Issue
Issue Tracker:
Apr-15
TBC
Jun-15
Apr-15
Resolution
Date
Performance &
Nursing Teams
Roy Jaggon
Proposal to
remove from
tracker
CAG Leads
Anne Watts
Responsible
Owner
101 of 155
Safety
MHA
Ϭ
ϱ
ϭϬ
ϭϱ
ϮϬ
Ϯϱ
ϯϬ
ϯϱ
ϰϬ
Ϯϵ
ϮϬ
ϯϰ
Ϯϯ
Ϯϯ
ϭϴ
ϭϲ
ϭϴ
sŝŽůĞŶĐĞ;WŚLJƐŝĐĂůƐƐĂƵůƚƐͿĂŐĂŝŶƐƚ^ƚĂĨĨ
Patients with a Child Risk Screen completed
Patients with a Brief/Full Risk Screen completed
12
13
Number of AWOLs (Datix)
11
ϭϱ
ϭϳ
NRLS
WŚLJƐŝĐĂůƐƐĂƵůƚƐŽŶ^ƚĂĨĨ;LJWĂƚŝĞŶƚͿ
DĞĚŝĂŶ
нϮʍ
нϯʍ
Ͳ Ϯʍ
Ͳ ϯʍ
Ϭ
ϱ
ϭϬ
ϭϱ
ϮϬ
Ϯϱ
ϯϬ
CCG/NHSE
Monitor Target
Trust Quality
Strategy
Trust Quality
Strategy,
Trust Quality
Priority 1
National
Requirement
Trust Quality
Priority 7
Trust Quality
Priority 7
Trust Quality
Strategy
Governance
Driver
ƉƌͲϭϰ DĂLJͲϭϰ :ƵŶͲϭϰ :ƵůͲϭϰ ƵŐͲϭϰ ^ĞƉͲϭϰ KĐƚͲϭϰ EŽǀͲϭϰ ĞĐͲϭϰ :ĂŶͲϭϱ &ĞďͲϭϱ
Ϯϱ
Safeguarding
New SIs Notified to STEIS
Reported incidents % harm
9
10
8
SI's and
Follow Up
7 Day Follow up post discharge from hospital
7
Care delivery system, violence reduction (roll-out)
(Target - add 4 wards each quarter)
No of wards which breached >20% total shifts for safe
staffing levels (SLaM Targets)
SUIs Violence and aggression - patient victims
SUIs Violence and aggression - staff victims
Can you access mental health services quickly and
easily if you need to?
Do you know what to do in an Emergency Mental Health
Crisis?
Do you feel safe?' [on the ward] target =>90 %
Safer Staffing
6
5
4
3
Number of Adult Acute Patients in Private Beds
Number of Adult Patients in PICU Private Beds
1
Indicator
2
No.
Follow up
SI's Violence
and
Aggression
Patient
experience
Use of private
beds
Indicator
Area
ϭϴ
ϮϬ
:ƵůͲϭϰ
ϭϴ
-
93.4%
93.98%
50
32.4%
8
94.7%
-
17
54
32.0%
3
98.6%
-
20
20
-
-
-
5.7
4.2
Jun-14
ϭϵ
ϭϳ
ϭϵ
161
32.6%
13
98.6%
9.5
11
55
74
-
-
77.9%
8.1
14.6
Q1
14/15
DĞĚŝĂŶ
80
34.9%
6
98.2%
8
11
18
34
-
-
84.8%
8.7
5.6
Jul-14
54
34.3%
6
95.9%
6
13
19
23
-
-
81.8%
4.6
10.7
55
39.4%
7
97.2%
10
13
17
23
-
-
-
0.5
0.4
Aug-14 Sep-14
189
36.1%
19
97.0%
8.0
13
55
77
-
-
-
4.6
5.6
Q2
14/15
61
34.2%
2
100%
11
13
19
18
-
-
-
3.6
2.0
Oct-14
37
41.8%
12
98.4%
8
13
12
16
-
-
-
4.8
2.0
52
35.0%
6
98.5%
14
13
12
18
-
-
-
7.7
4.5
Nov-14 Dec-14
150
36.7%
20
99.2%
11.0
13
43
52
-
-
-
5.4
2.8
Q3
14/15
93.2%
93.0%
ϭϮ
ϭϮ
ϭϮ
93.2%
нϮʍ
нϯʍ
Ͳ Ϯʍ
Ͳ ϯʍ
&ĞďͲϭϱ
ϭϭ
ϵϮ͘ϵй
ϮϮϵ
92.6%
92.3%
92.5%
92.4%
Ϯϰϭ
ϭϰϲ
Ͳ Ϯʍ
ϭϭϬ
Ϭ
Ͳ ϯʍ
ϭϭϬ
ϰϬ
ϲϬ
ϱϬ
ϳϬ
ϴϬ
ϵϬ
ϭϬϬ
Ϭ
ϭϬ
ϮϬ
нϯʍ
ϭϳϵ
92.5%
Direction of
Travel
ϱϬ
нϮʍ
ϮϬϮ
90.5%
93.41%
40
29.6%
5
96.0%
14
13
11
17
73.4%
81.2%
81.5%
8.0
3.9
Feb-15
ϯϬ
DĞĚŝĂŶ
ϭϴϵ
ϮϮϳ
/ŶĐŝĚĞŶƚƐ;ĂƚĞŐŽƌŝĞƐͲͿ
ϮϮϬ
92.9%
/ŶĐŝĚĞŶƚƐ;ĂƚĞŐŽƌŝĞƐͲͿ
ϭϴϴ
92.8%
93.47%
37
29.3%
8
96.8%
12
13
12
15
-
-
80.6%
5.9
3.7
Jan-15
Commentary / Exception Reporting
ϱϬ
tK>^
ϱϳ
ϱϰ
DĞĚŝĂŶ
ϴϬ
ϱϰ
нϮʍ
ϱϱ
tK>^
нϯʍ
ϲϭ
ϯϳ
Guidance to be reviewed - refer to issue tracker
Ͳ Ϯʍ
ϱϮ
Ͳ ϯʍ
ϯϳ
ϰϬ
SLAM has successfully bid for additional resources to support this
work. Refer to issue tracker.
The majority of breaches were due to support workers covering for
qualified nurses. Refer to issue tracker.
Change in PEDIC questioning commenced October 14 - a review and
full year analysis will be available in April.
Average number of placements per day over the month
Average number of placements per day over the month
Deterioration
Stable
Improvement
Direction of travel key
ϭϬϬ
ϭϱϬ
ϮϬϬ
ϮϱϬ
ϯϬϬ
ϯϱϬ
92.9%
93.74% 93.74% 93.82% 93.72% 93.78% 93.79% 93.76% 93.58% 93.39% 93.40% 93.46%
57
33.3%
2
96.6%
-
18
29
25
-
-
7.7
15.0
May-14
-
-
11.0
24.4
Apr-14
ƵŐͲϭϰ ^ĞƉͲϭϰ KĐƚͲϭϰ EŽǀͲϭϰ ĞĐͲϭϰ :ĂŶͲϭϱ
WŚLJƐŝĐĂůƐƐĂƵůƚƐŽŶWĂƚŝĞŶƚƐ;LJWĂƚŝĞŶƚͿ
ƉƌͲϭϰ DĂLJͲϭϰ :ƵŶͲϭϰ
ϭϳ
Monthly
Monthly
Monthly
Monthly
Monthly
Quarterly
Monthly
Monthly
Monthly
Monthly
On-going
On-going
Target
Type
sŝŽůĞŶĐĞ;WŚLJƐŝĐĂůƐƐĂƵůƚƐͿĂŐĂŝŶƐƚWĂƚŝĞŶƚƐ
96%
G > 80
A 75-79
G > 96
A 90-95
-
TBC
TBC
Take Up
G<3
A 3-6
R >6
G > 95%
A 90-95%
R < 89
SPC Trend
SPC Trend
RAG
Thresholds
80%
SPC Trend
SPC Trend
95% Per
Quarter
4 New Ward
Per Qtr
SPC Trend
SPC Trend
90% by Q4
<6
<2
Target
Summary:
Usage of private overspill beds is above target for PICU and Acute in February with an upward trend in March.
102 of 155
Effectiveness
QUeSTT
Tool
Social Care
Clinical
Outcomes
Flow
Smoking
Cessation
Discharges
28
QUeSTT Indicator
Total of wards with total QUeSTT score at level 2
and 3, where level 1 is good. N=15 wards
26
Contracts
Contracts
Settled Accommodation Assessment Completed
(CPA patients)
Employment Assessment Completed (CPA
patients)
CCG Sanction
25
27
CCG Sanction
Inpatient annual Physical Health Screen.
Percentage of New Patients with the Ability to
Consent that are Admitted to AMH Inpatient
Services Offered a HIV Test (500K Penalty)
24
Paired HoNOS score in an episode for patients on Trust Outcomes
CPA
Target
23
TBC
95%
95%
30.00%
90%
70%
95%
Monthly
HTT Gatekeeping
Monitor (and CCG
Sanction
Delayed Discharges
21
22
Monitor
Trust Quality Priority 5 50% by Q4
Achievement against smoking cessation training
target
20
7.5%
Monthly
Trust Quality Priority 5 50% by Q4
Trust Quality Priority 5 80% by Q4
80% Q4
(AMH) 50%
Q4 (OA,
CAMHS,
CF)
No of smokers offered NRT or counselling to quit
No of patients with smoking status recorded
18
CQUIN
Trust Quality Priority 4
90% by Q4
and CQUIN
19
Discharge communications to GP
Part 2: Communication with GP CQUIN
17
16
Trust Quality Priority 4
90% by Q4
and CQUIN
Part 1: No of eligible patients having six key
metabolic c-v tests CQUIN
15
Physical
Health
National requirement
Friends & Family (Patients)
Target
14
Governance Driver
Friends &
Family
Indicator
No.
Indicator
Area
-
TBC
30%
85-90%
60-70%
90-95%
7.5-10%
40-50%
25-50%
50-80%
70-90%
70-90%
RAG
Thresholds
Highlights & Concerns:
Completion of accommodation and employment assessments is being addressed through OPM meetings.
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly /
Quarterly
Quarterly
Quarter 4
Quarter 4
Quarter 4
Quarter 4
Quarter 4
Quarter 4
Target
Type
-
93.3%
91.8%
31.5%
56.1%
82.3%
86.6%
3.0%
-
-
-
-
-
-
-
Apr-14
-
93.3%
91.8%
38.6%
63.0%
93.0%
80.6%
2.6%
-
-
-
-
-
-
-
May-14
-
92.6%
91.0%
26.2%
72.2%
75.0%
77.8%
2.3%
-
-
-
-
-
-
Jun-14
7
92.6%
91.0%
32.10%
63.7%
85.6%
81.8%
2.7%
61.5%
56.0%
59.0%
-
-
-
-
Q1 14/15
8
92.1%
90.6%
31.7%
69.9%
85.7%
91.3%
2.9%
-
-
-
-
-
-
-
Jul-14
7
92.0%
90.3%
18.2%
71.9%
78.4%
97.8%
3.6%
-
-
-
-
-
-
-
Aug-14
6
92.2%
90.6%
32.0%
79.1%
92.3%
97.4%
4.1%
-
-
-
-
8.0%
-
-
Sep-14
7
92.2%
90.6%
27.30%
73.6%
86.2%
95.0%
3.5%
63.6%
86.0%
86.7%
-
-
-
-
Q2 14/15
6
92.7%
91.2%
48.1%
84.6%
90.2%
92.8%
2.9%
-
-
-
-
-
-
-
Oct-14
5
93.18%
91.7%
45.8%
90.5%
88.9%
96.6%
2.2%
-
-
-
-
-
-
-
Nov-14
5
93.42%
91.8%
53.8%
87.6%
92.1%
96.1%
2.7%
-
-
-
-
-
-
-
Dec-14
5
93.4%
91.8%
49.20%
87.6%
87.3%
95.1%
2.6%
60.6%
-
-
-
-
-
-
Q3 14/15
5
93.3%
92.9%
40.00%
96.9%
90.6%
96.64%
2.8%
-
-
-
-
-
-
79%
Jan-15
5
93.2%
92.6%
60.60%
95.7%
89.5%
95.93%
2.7%
-
61.0%
89.0%
-
-
-
-
Feb-15
-
-
-
Direction of
Travel
Cohort 15 wards. QUeSTT scores are calculated from
15 weighted factors of team healthiness
CCG Monthly contract reporting.
Target met
CCG Monthly contract reporting.
Quarterly reporting
Audit undertaken mid February - sample of all active
patients
Audit undertaken mid February - sample of all active
patients
Quarter 4 audit underway.
Jan - Mar audit found 24% had all the relevant
information requirements.
Audit completed - results submitted to RCP/NHSE for
validation. Audit results now available.
In the majority of services F&F started in December.
Refer to issues tracker.
Commentary / Exception Reporting
Deterioration
Stable
Improvement
Direction of travel key
103 of 155
Caring
Patients
receiving an
individualised
service
Care Planning,
Recovery &
Support
Indicator Area
Monitor
CQC, CCG
Sanction
Trust Quality
Priorities
Trust Quality
Priority 3
Trust Quality
Priority 2
CPA Formal Review within 12 months
Copies of Care Plan given % (% of
patients given a copy of their CPA care
plan) - AMH only
Have you been offered a crisis plan for
emergency mental health situations?
Wards where patients are expected to
queue for medication. Target = 0
Wards where patients are expected to
queue for meals. Target = 0
33
34
35
36
Trust Quality
Priority 9 & CQUIN
32
No of R&S plans meeting acceptable
standards
10% by
Q4
10% by
Q4
70% by
Q4
95% by
Q4
95%
-
50% by
Q4
30
31
80% by
Q4
Target
No of Patients with completed R&S plan Trust Quality
MHOA, Community Forensics &
Priority 9 & CQUIN
CAMHS
Governance
Driver
No of Patients with completed R&S plan - Trust Quality
AMH
Priority 9 & CQUIN
Indicator
29
No.
10-25%
10-25%
>95%
-
40-50%
70-80%
RAG
Thresholds
Quarter 4
Quarter 4
Q4
Quarter 4
Quarterly
Quarterly
Update
Quarter 4
Quarter 4
Target
Type
-
95.0%
-
-
-
-
Apr-14
-
95.0%
-
-
-
-
May-14
-
95.0%
-
49.2%
-
-
Jun-14
-
-
68.0%
94.9%
95.90%
49.2%
-
-
Q1 14/15
-
-
65.6%
95.0%
-
-
-
58.6%
Jul-14
-
-
56.3%
94.9%
-
-
-
60.4%
Aug-14
Highlights & Concerns:
The Recovery and Support plans (AMH) target of 80% by quarter 4 has been met.
CPA reviews in 12 months performance for February has achieved target and continues to be managed through pre-emptive reports at CAG level and reviewed at OPM
meetings.
-
-
-
94.8%
-
-
-
61.7%
Sep-14
53.8%
23.1%
-
94.8%
95.20%
-
-
60.3%
Q2 14/15
-
-
-
94.8%
-
-
56.0%
63.8%
Oct-14
-
-
-
94.7%
-
-
59.3%
65.5%
Nov-14
-
-
-
94.7%
-
-
65.2%
68.3%
Dec-14
-
-
-
94.8%
96.00%
-
60.2%
65.9%
Q3 14/15
-
-
84.1%
94.7%
92.29%
-
67.0%
68.5%
Jan-15
-
94.9%
95.67%
-
69.8%
87.1%
Feb-15
Direction of
Travel
43% February and March sample
23% February and March sample
Action plan undertaken in response to Q1
audit. Improvement audit including individual
team feedback being established through new
facilitator posts. Audit underway.
Commentary / Exception Reporting
Deterioration
Stable
Improvement
Direction of travel key
104 of 155
Ϭ
ϭϬ
ϮϬ
ϯϬ
ϰϬ
ϱϬ
ϲϬ
ϳϬ
Complaints
Learning
Disabilities
Waiting
Times
Indicator
Area
ƉƌͲϭϰ
ϱϰ
42
DĂLJͲϭϰ
ϰϳ
:ƵůͲϭϰ
ϱϳ
EĞǁŽŵƉůĂŝŶƚƐ
:ƵŶͲϭϰ
ϰϲ
Reopened Complaints
DĞĚŝĂŶ
ƵŐͲϭϰ
ϯϵ
нϮʍ
^ĞƉͲϭϰ
ϰϬ
нϯʍ
KĐƚͲϭϰ
ϱϱ
EĞǁŽŵƉůĂŝŶƚƐ
Ͳ Ϯʍ
EŽǀͲϭϰ
ϰϰ
13/14
Baseline
514
SPC
Trend
Ͳ ϯʍ
ĞĐͲϭϰ
ϯϯ
TBC
SPC Trend
:ĂŶͲϭϱ
ϯϴ
Monthly
Monthly
Number of complaints
41
Francis
Quarterly
Compliance with requirements
regarding access to healthcare for Monitor
people with a learning disability
40
Achieved
Quarterly
Quarterly
Monthly
39
100%
TBC
Target
Type
National waiting
<18 week wait time IAPT services time targets for
IAPT
TBC
National waiting
time targets for MH
RAG
Thresholds
Meeting commitment to serve new
psychosis cases by early
Monitor
intervention teams
<18 week wait time AMH services
37
Target
Governance
Driver
38
Indicator
No.
Responsiveness
&ĞďͲϭϱ
ϰϰ
3
54
-
-
-
95.8%
Apr-14
0
47
-
-
-
97.1%
May-14
0
46
-
-
-
96.4%
Jun-14
3
147
100%
93.2%
100%
96.5%
Q1 14/15
1
57
-
-
-
95.9%
Jul-14
3
39
-
-
-
96.6%
Aug-14
6
40
-
-
-
96.9%
Sep-14
10
136
100%
92.1%
100%
96.5%
Q2 14/15
3
55
-
-
-
94.9%
Oct-14
5
44
-
-
-
95.6%
Nov-14
0
33
-
-
-
95.7%
Dec-14
8
132
100%
-
100%
95.4%
Q3 14/15
3
38
-
-
-
90.4%
Jan-15
0
44
-
-
-
91.3%
Feb-15
-
-
Direction of
Travel
HSCIC experimental statistical release:
waiting time from date of referral received
to First Assessment. Q3 pending
publication.
The Trust is collating responses from the
Green Light Toolkit audit to reassess
progress and developments required
Waiting Time from date of referral
received to first FTF contact. Waiting
times measures will be developed to
reflect emerging national standards for
2015/16
Commentary / Exception Reporting
Deterioration
Stable
Improvement
Direction of travel key
105 of 155
Well Led
Workforce
Mandatory Training
In-patient
Community
Services
85%
Trust Mandatory
Training
Board
Board
Adult Safeguarding Alerters Plus (All Clinical Staff)
Basic Life Support Level 1 (All Non Clinical Staff)
Fire Training
Admission (All, Monthly)
Discharges (All, Monthly)
AMH Programme Avg LOS (Acute Closed Spells in Month Excl.
Leave)
Patient Seen
Appointment Attended
50
51
52
53
54
55
56
57
59
Ϭ
ϱϬϬ
ϭϬϬϬ
ϭϱϬϬ
ϮϬϬϬ
ϮϱϬϬ
ϯϬϬϬ
ϯϱϬϬ
ƉƌͲϭϰ
Caseload
63
62
Accepted Referrals (Initial Referrals Only)
Discharges (YTD)
61
60
58
85%
Trust Mandatory
Training
Adult Safeguarding Alerters (All Non Clinical Staff)
49
DĂLJͲϭϰ
:ƵŶͲϭϰ
Performance
:ƵůͲϭϰ
ƵŐͲϭϰ
^ĞƉͲϭϰ
KĐƚͲϭϰ
EŽǀͲϭϰ
ĞĐͲϭϰ
ŽŵŵƵŶŝƚLJͲ ZĞĨĞƌƌĂůƐΘŝƐĐŚĂƌŐĞƐ
Board
Board
Performance
Performance
Performance
Performance
Performance
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Performance
Performance
G: >85%
A: 61-84%
R: < 60
G: >85%
A: 61-84%
R: < 60
G: >85%
A: 61-84%
R: < 60
G: >85%
A: 61-84%
R: < 60
G: >85%
A: 61-84%
R: < 60
G: >85%
A: 61-84%
R: < 60
G: >85%
A: 61-84%
R: < 60
G: >85%
A: 61-84%
R: < 60
G: >85%
A: 61-84%
R: < 60
G: >85%
A: 61-84%
R: < 60
G: >85%
A: 61-84%
R: < 60
TBC
Yes
Current in QSC
Dashboard
Board
Board
Board
Board
85%
85%
Trust Mandatory
Training
Child Safeguarding Level 3 (Refresher for 1&2, All Trust Inpatient
Clinical Teams)
Trust Mandatory
Training
85%
Trust Mandatory
Training
Child Safeguarding Level 1 and 2 (All Clinical Staff)
48
85%
85%
Trust Mandatory
Training
Child Safeguarding Level 1 (All Non Clinical Staff)
47
85%
85%
Trust Mandatory
Training
Infection Control
46
Trust Mandatory
Training
85%
Trust Mandatory
Training
Immediate Life Support (Medical staff (excluding Consultants)
Inpatient Band 5 nurses & above Senior community nurses if they
form part of the Emergency Team Leader Roster)
85%
Trust Mandatory
Training
PSTS 5day/refresher for inpatient staff
45
Basic Life Support Level 2 (All Inpatient Clinical staff up to band 4, Trust Mandatory
Community Nurses and Consultants, AHP's)
Training
TBC
Workforce
Vacancy Rate (WTE)
<5%
<5%
Monthly
Workforce
44
RAG
Thresholds
Target
Governance
Driver
Staff Sickness rate % (rolling year %)
Indicator
43
No.
džŝƐdŝƚůĞ
Indicator
Area
Highlights & Concerns:
There continues to be incremental improvement in staff sickness rates (measured on a 12 month rolling year).
Mandatory training performance - refer to issue tracker.
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Quarterly
Quarterly
Quarterly
Quarterly
Quarterly
Quarterly
Quarterly
Quarterly
Quarterly
Quarterly
Quarterly
Monthly
Monthly
Target
Type
36752
2435
2547
29442
13971
43.1
312
303
-
-
-
-
-
-
-
-
-
-
-
16.5%
5.50%
May-14
ŝƐĐŚĂƌŐĞƐ;zdͿ
ĐĐĞƉƚĞĚZĞĨĞƌƌĂůƐ
;/ŶŝƚŝĂůZĞĨĞƌƌĂůƐKŶůLJͿ
36826
2526
2568
28239
13927
33.39
305
331
-
-
-
-
-
-
-
-
-
-
-
13.6%
5.63%
Apr-14
36830
2442
2630
29711
14352
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299
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-
-
-
-
-
-
-
-
-
-
-
17.9%
5.62%
Jun-14
-
-
-
-
-
-
79.0%
76.0%
69.0%
53.0%
79.0%
86.0%
73.0%
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85.0%
81.0%
82.0%
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31923
14857
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327
324
-
-
-
-
-
-
-
-
-
-
-
18.8%
5.58%
Jul-14
35993
2575
2345
25981
13056
35.87
299
289
-
-
-
-
-
-
-
-
-
-
-
18.2%
5.33%
Aug-14
35367
3228
2745
29167
14102
34.83
281
287
-
-
-
-
-
-
-
-
-
-
-
18.3%
5.35%
Sep-14
-
-
-
-
-
-
90.0%
84.0%
64.0%
88.0%
79.0%
56.0%
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-
-
-
-
-
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13499
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-
-
-
-
-
-
-
-
-
-
-
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-
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-
-
-
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Notes
D
TRUST BOARD - SUMMARY REPORT
Date of Board meeting:
28 April 2015
Name of Report:
Chief Executive’s report
Heading: - (Strategy, Quality,
Performance & Activity,
Governance, Information)
Governance
Author(s):
Paul Mitchell, Trust Secretary
Approved by (name of Executive
member):
Dr Matthew Patrick, Chief Executive
Presented by:
Dr Matthew Patrick, Chief Executive
Purpose of the report:
To inform the Board of significant issues arising from the local health economy and
nationally in the NHS and Social Care.
Action required:
To discuss items of concern and, where necessary, initiate additional assurance action.
Recommendations to the Board:
To note the report.
Relationship with the Assurance Framework (Risks, Controls, and Assurance):
The report highlights issues relating to the Assurance Framework arising from the local
health economy and nationally in the NHS and Social Care.
Summary of Financial and Legal Implications:
The report highlights any financial and legal Implications arising from the local health
economy and nationally in the NHS and Social Care.
Equality & Diversity and Public & Patient Involvement Implications:
The report highlights equality & diversity issues arising from the local health economy and
nationally in the NHS and Social Care.
Service Quality Implications:
A number of the national issues listed in the report will have an impact on the quality of
services provided by the Trust.
Page 1 of 4
107 of 155
Chief Executive’s Report
April 2015
1. Trust issues
Introduction
This is always a busy time of year for the Trust. We are working on closing our accounts for
the preceding year, finalising our contract negotiations for the year to come, and writing our
forward plan to submit to our regulator, Monitor. Over the past year people have worked
tremendously hard across the organisation, for which I am very grateful. Much has
happened. We have a new Chair and four relatively new Non Executive Directors; our
Monitor Investigation has been closed and I believe we are in a good place in terms of
governance; our Council of Governors are getting to grips with their newly specified roles
and responsibilities; and across the Trust staff have continued their dedicated work to
ensure we continue to deliver high quality services, even when under tremendous pressure
in terms of activity. We are lucky to have such a dedicated staff group and it is essential that
as an organisation we create a context, both culturally and materially (e.g. in terms of
estates and IT) that enables people to give of their best. I am personally committed to
ensuring that we do this, and know that in this I am fully supported by the Board of Directors
and Council of Governors.
Trust Conference
I was delighted to take part in my first Trust Conference on 25 March at the Maudsley
Learning Centre. The event was very well attended and I hope set a tone of openness and
inclusiveness that we can use as a benchmark as we move forward. I welcomed everyone
attending and spoke about the Trust’s forward view and then introduced Roger Paffard who
talked about his first two months at the Trust and emphasised how impressed he was by the
motivation of SLaM staff, despite often working in challenging environments and in difficult
circumstances.
This conference was different to previous ones in that we made a point of inviting outside
speakers with the aim of emphasizing our interdependency. Dr Jonty Heaversedge, Chair of
NHS Southwark Clinical Commissioning Group, gave his views on commissioning and
primary care, while Rob Blackstone, London Borough of Hackney and MH Social Care
Leads Network Chair spoke about the Social Care agenda, so critical for mental health. Zoe
Reed, Director of Organisation and Community, introduced the interactive parallel
sessions that were taking place on a variety of topics. These included service user and carer
involvement, HR relations, mental wellbeing, learning and development in SLaM,
mindfulness, day treatment service for bipolar disorder, reducing health
inequalities, partnership working and SLaM IT and digital services.
The afternoon plenary session started with Dr Neil Brimblecombe speaking about quality and
the preparations taking place for the upcoming CQC visit. Dr Fiona Gaughran, Consultant
Psychiatrist for the Psychosis CAG, gave an overview on physical health care, followed by
Dr Martin Baggaley, Medical Director, talking about value-based healthcare.
The feedback gave a strong sense that staff enjoyed the day and found the parallel session
informative. We will take all feedback into account when planning for next year.
KHP Conference
Page 2 of 4
108 of 155
On Wednesday 15th April we held the KHP annual conference. This was also an excellent
event, showcasing many of the exciting developments taking place across KHP. Matthew
Hotopf, Director of our Biomedical Research Centre, spoke excellently about the tremendous
work they are leading on informatics. This highlighted how important the relationship
between SLaM, the BRC and the IoPPN is going to be over the next three years. I spoke in a
session of integrated care, in my role as KHP Senior Responsible Officer for integrated care,
and was joined by Dr Tarek Radwan, a Lambeth GP. The session was chaired by Roger
Paffard, highlighting our role in this area.
Monitor update
Work has continued to ensure that the commitments made to Monitor following the closure
of their investigation are actioned at pace. Attached, as usual, is an update on the action
tracker.
Initial discussions are taking place with Deloitte regarding their planned visit to the Trust in
June. This will comprise a mixture of interviews with senior staff, observation of Board and
CAG meetings plus work with selected focus groups. The intention is that they will help the
Trust self-assess against the Monitor Well Led Framework, review the developing data
quality strategy and Board reporting arrangements as well as confirming that outstanding
actions from the earlier review have been completed.
Bromley LA Public Protection Committee
I attended the meeting on 8 April with Roger Paffard, Martin Baggaley and members of the B
and D CAG. Relationships with Bromley have got much closer over the past two years and
we are keen to ensure that this remains the case.
Chief Operating Officer
Shortlisting for the position has been completed and candidates will attend an assessment
day on 23 April. Final interviews will be held on 29 April.
2. National issues
We are in a purdah period as the general election is only two weeks away so there are no
national developments relating to health care to report. All national parties are emphasising
the importance of health in their manifestos. Attached is a summary produced by NHS
Providers of the commitments of the major political parties.
3. Information governance
The Trust completed the annual self-assessment of compliance with national information
governance requirements and submitted the HSCIC Information Governance Toolkit for
2014-15 (version 15) on 27 March 2015.
The Trust overall score represented 90% compliance with the requirements of the Toolkit by
demonstrating Level 3 (highest) compliance with 73% of the standards and Level 2
(satisfactory) compliance with the remainder. The assessment was independently audited.
An action plan has been agreed to outline the work required to further improve Trust
compliance next year. The key objectives of the Information Governance Action Plan for
2015-16 include:
-
To implement the new operating model for information and IT governance,
Page 3 of 4
109 of 155
-
To cement the process to ensure all new developments and changes consider
patient privacy and data security from the outset (privacy-by-design),
To support health records management taking the integrated nature of new service
models,
To review all internal and external data flows to ensure secure, lawful and effective
flow of data without duplication,
To review disaster recovery plans for all key systems to ensure these plans integrate
with service business continuity plans,
To continue to improve staff awareness of information governance utilising resources
that are suitable for each role,
4. And Finally…
I was lucky enough on Friday the 17th of April to speak at the opening of two separate
events. The first, the European Outreach Conference, was focused on work that ensures
accessibility of the creative arts and museum to disadvantaged groups. Our own Museum
and Gallery are tremendous examples of this, and Helen Shearn was also speaking about
the Journey of appreciation programme (JOAP) programme. The second event was the
annual Trust IT conference for all IT staff, who will now be focused on delivering the Trust
new IMT strategy.
Dr Matthew Patrick
Chief Executive
April 2015
U / Board / Chief Exec report Apr 15
Page 4 of 4
110 of 155
We are committing to finalising our work on CAG leadership and to clarify lines of reporting and
accountability.
We are committing to deliver the first version of the data quality dashboard by the end of
September 2014 and the working data quality dashboard to be embedded by the end of October
2014.
We are committing to appoint a new Chief Information officer from a very strong field by the end of
September 2014.
We are committing to have a revised and updated Information and Technology Strategy to be
agreed by the Board in December 2014.
2
3
4
We are committing to bring forward the next stage Ward Renovation Programme covering the year
2015/16 also to the November 2014 Board of Directors (having committed to improve over 20 ward
and clinical areas during 2014/15).
8
1
Nov 14/Jan 15
We are committing to bring forward the revised Estates Service Level Standards together with an
external qualitative view of the estates service to the November 2014 Board of Directors, and to
implementing all improvements by the end of January 2015.
7
Nov-14
Oct 14/Mar 15
Dec-14
Sep-14
Sept 14/Oct 14
Dec-14
Dec-14
When
Estates
We are committing to bring forward the Stage 2 Statutory Maintenance Improvement Plan to the
6
October 2014 Board of Directors (having delivered the Stage 1 Plan 6 months early). Stage 2
improvements will be delivered by the end of March 2015.
5
We are committing to assess the effectiveness of changes to quality governance through an audit
that will be completed by December 2014.
1
SLaM Monitor Commitments - SMT Tracker
ND
ND
ND
GH
MP
GH
ND
GH
Status On track
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GH155
PM
Lewisham Ladywell Unit - 7 Wards refreshed. Lambeth - 2 Wards
refreshed in Bridge House, Reay House - Leo Ward Refresh &
ASCOM completed. Bethlem - Alexandra House, Fitzmary - Grnd
& 1st (Mother & Baby), Dower House, Dennis Hill, Monks
Orchard, Tyson Triage,
Qualatative Report received. SLA & Benchmark information and
metrics have been assembled. Comparison with collaborative
members of National Performance Advisory Group Facilities
Benchmarking Forum to be formalised.
Years 1 & 2 Complete. Board support required to commit to Year
3 proposal for the 2015/16. Compliance Programme being
assembled for submission to Board as part of the Compliance
Programme 2015-16
CIO presented to the Board 16 December 2014 on process and
key issues and risks identified to date. Board supported
direction and recognised immediate need for stabilisation and
ongoing engagement process. Strategy presented as a deep dive
to Board development seminar and approved at Board meeting
in March 2015.
SD started Dec 14.
The DQ Dashboard is now part of the Operations Performance
Management monthly process. CAG leads have been identified development sessions are scheduled for CAGs. Usage and
profile of use of dashboard is being monitored to date we have
had 140 unique visitors to the DQ Dashboard, which has
included senior leaders in the organisation
The Head of Nursing role in the CAG leadership teams has been
established with clear lines of accountability; noted as
completed at Board 22October 2014.
The final audit report was presented to the Audit Committee on
16 December 2014. Reasonable Assurance. 3 important and 4
routine recommendations none of which were urgent.
Recognised this is an ongoing piece of work to continuously
review and improve quality governance. All important actions
completed by the end of Jan. Remainder by 31 March 2015.
Lead Position/action reviewed 17/12/14
We are committing to bring forward the OBCs for the four key estates strategy projects to the
November 2014 Board of Directors for approval, alongside an external accreditation of our Estates
Strategy, with the FBCs being brought forward to the March 2015 Board of Directors for approval.
We are committing to embedding our Board Development Programme on an ongoing basis to
ensure that the Board is always functioning to the top of its skill set. This programme will include a
regular focus on succession planning.
13
We are also committing to monthly updates on the public agenda of the Board meetings on
progress and pace of delivery.
We committing to invite Deloitte, our most recent external consultants, to revisit the Trust in
January/February 2015, with a view to working with the new Chair and Board to ensure that all
necessary changes are in place; but also with a developmental remit to see if there is more that we
can do to ensure that the quality of our governance properly matches our ambition to deliver the
highest quality and safest mental health services anywhere within the NHS.
We are also committing to invite Deloitte to conduct a review against the new Monitor Well-Led
Governance Framework to validate changes made.
15
16
17
2
New Year
Jan/Feb 15
monthly
14/15
Nov-14
The Board is also committing to appoint a Senior Independent Director and a Deputy Chair in
November 2014, once the Board is back up to full strength.
12
Assurance
14 We are committing to create a resource within the 14/15 internal audit programme to provide
additional assurance on pace and progress which will be reported to the Audit Committee as part of
their regular reporting.
Nov-14
We are committing to complete the appointment of a further two new NEDs by November 2014.
Monitor to appoint external assessor to be involved.
Dec-14
Nov 14/Mar 15
When
11
Board Governance
10 the Nominations Committee is committing to work towards appointing a new Chair by early
December 2014 (this process having already commenced).
9
SLaM Monitor Commitments - SMT Tracker
MP
MP
MP
GH
PM
PM
PM
PM
ND
Status On track
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GH155
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Deloittes secured - briefing in New Year. Initial discussions taken
place regarding production of initial self-assessment for further
consideration.
Deloittes secured - briefing in December. Initial discussions
taking place regarding visits in June 15.
In place.
Audit Committee quarterly item on QSC escalation report, and
assurance framework. 14/15 Plan discussed at Dec AC includes
aspects of quality governance, and site visits.
Board development programme: 2 awaydays late January and
Summer with external faciliation. Full annual timetable including
seminars and a series of deep dives has been issued.
Appointment made.
Appointment made and approved by Council of Governors on 11
December.
Appointment made and approved by Council of Governors on 11
December.
Progressed work on the Maudsley development and Lewisham
community cluster. Plan to produce a Strategic Outline
Programme (SOP) outlining the 5 key enabling programmes that
need to take place to facilitate the 4 major schemes. SOP to be
submitted to the May 2015 Trust Board and subsequent
business cases following from June 2015.
Lead Position/action reviewed 17/12/14
Funding
Conservatives
Labour
Lib Dem
Additional £8bn in real terms by 2020 to
implement the Five Year Forward View
combined with efficiencies, in full.
£2.5bn time to care fund for 36,000
more frontline staff “to transform
services in communities and at home so
our NHS can meet the challenges of the
21st century”
Additional £8bn in real terms by 2020 to
improve the NHS, guarantee equal care
for mental health and increase focus on
prevention and delivering care closer to
home.
Review of health and care “to ensure the
NHS is safeguarded for the long term”
Reform NHS funding systems to tariffs
encouraging joined-up services and
prevention care.
Primary
care and
access to
services
GP access from 8am-8pm 7 days a week
by 2020.
Guaranteed same-day consultation with
a doctor or nurse, right to a GP
appointment within 48 hours and to
book advance with GP of choice.
Expansion of GP evening and weekend
opening, phone and Skype
appointments, GP federations
encouraged.
£100m for GP surgeries to improve
access to appointments.
Patient premium to encourage work in
disadvantaged areas.
“Properly staffed” hospitals to ensure
consistency of care quality seven days a
week.
Maximum one week wait for cancer test
and results by 2020.
Community pharmacist to become first
point of contact for minor illness.
End of life care – commissioners to be
supported to combine better health and
social care services for those with terminal
illness to allow more people to die in a
place of their choice.
Budgets, commissioners and providers
brought together at a local level with
local areas supported to develop NHS
integrated care organisations and
network.
Full responsibility for care policy and
funding shifted to the Department of
Health.
Continued integration of the health and
social care systems. “Joining - services
between homes, clinics and hospitals”
including piloting approaches such as the
pooling of health and social care funding
in Greater Manchester and the Better
Care Fund.
Health and wellbeing boards to become
“a vehicle for system leadership”.
A guarantee against having to sell your
home for social care.
A single point of contact and a
personalised care plan for people with
complex physical and mental health
conditions.
Guaranteed same-day GP appointments
for all over 75 who need them.
Right to access a named GP.
Integration/
Social care
Year- of-care budgets.
Monitor’s role to focus on viability of
health economies.
Local agreement on pooling of NHS and
care budgets to be secured by 2018.
Local commissioning of services.
Health and wellbeing Boards to “take a
broad view of how services can improve
wellbeing ” .
“Joined- up health providers” covering
hospital and community
NHS commissioners and providers
permitted to form single integrated health
organisations
End of role of the MA in health.
Mental
Health
Increased funding for mental health care.
Enforcement of access and waiting time
standards for adults and children.
Ensure access to perinatal and postnatal
mental health support.
Proportion of mental health spending on
CAMHS to increase
£500m a year over next parliament to
improve mental health services.
New right to access talking therapies.
Continued rollout of access and waiting
time standards.
All NHS staff training to include mental
health, with a core perinatal mental
health module in midwifery training.
£250m over five years for ante and post
natal mental health.
£1.25bn investment in CAMHS.
£50M mental health research fund.
Comprehensive collection of data and
funding reform.
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E
TRUST BOARD OF DIRECTORS – SUMMARY REPORT
Date of Board meeting:
28 April 2015
Name of Report:
Report from the Council of Governors
Heading: - (Strategy, Quality,
Performance & Activity,
Governance, Information)
Governance
Author:
Paul Mitchell, Trust Secretary
and working group chairs
Approved by:
(name of Exec Member)
Dr Matthew Patrick, Chief Executive
Presented by:
Chris Anderson, Deputy Lead Governor
Purpose of the report:
To update the Board on the current areas of Council of Governors’ activity.
Action required:
To note the report.
Recommendations to the Board:
To note the report.
Relationship with the Assurance Framework (Risks, Controls and Assurance):
The Council of Governors is an integral component of the Trust’s Constitution as a
Foundation Trust.
Summary of Financial and Legal Implications:
Budgetary provision has been made to support the activities of the Council of Governors.
Equality & Diversity and Public & Patient Involvement Implications:
The Council of Governors has a responsibility to ensure that the Trust’s membership is
representative of the local populations in terms of diversity and that all members,
including those from the patient & public constituencies, are fully involved.
Service Quality Implications:
The Council of Governors’ bids programme specifically welcomes bids which “improve
the patient experience”.
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Council of Governors update report
April 2015
Working Group and Board committee observer reports
Planning and Strategy Group
The Planning and Strategy Working Group has met twice in 2015 – February and
April. Agenda items continue to reflect priorities, changes and activities across the
Trust including:
1. 5-year Strategic Plan
- Integrated, partnership approach: highlighting the increasing importance
of an integrated, alliance-based approach and funding acquisition to
support delivery of the plan whilst minimising potential risk to
implementation from complex models of delivery
- Monitor requirements: move from a 2-year Operational Plan to a one-year
plan to include high level financial information, quality priorities, key risks,
workforce implications and corporate areas
- Flexibility and systems management: Building resilience and sustainability
in the face of significant pressures and risks at financial, social and
external environmental levels.
2. Cross-borough public meetings:
- Attendance: this was down on previous years prompting questions around
membership, purpose of meetings, timing, venues, changing health and
social environment
- Report: produced from participant feedback, includes key thematic areas
and proposed recommendations for further action
- Future events: development will be informed by the report and a specific
sub-group, including involvement of the Membership and Communications
Working Group, is being convened to look at the planning of future events.
3. Governor observers:
- Audit Committee: ensuring PSWG (and CoG) understanding of financial
issues and the relationship and alignment between strategic areas to
support delivery of the Strategic Plan. Key potential issues include: use of
agency staff; compliance with mandatory training; ICT; challenges of
working with strategic partners; quality governance
- Business Development and Investment Committee: ensuring PSWG (and
CoG) understanding of the development and implementation of the Trust’s
commercial strategy, the role of scrutiny and governance to support
robust decision making to enable delivery of the Trust’s strategic and
operational objectives.
4. PSWG:
- Monitoring and self-assessment: feedback was obtained from members
on current state, ensuring the effectiveness and value of the group and
informing future planning
-
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-
Feedback report: highlighted the value of the group’s individual and
collective knowledge, skills and experience; regular attendance of senior
management; development of collaborative strategic partnerships;
importance of effective governance (improving how we do things;
adopting a system-wide view; developing positive relationships with
directors and NEDs; establishing specific goals); importance of clear
understanding of the Trust internally and externally and risks to delivery of
the Strategic Plan; importance of collaborative, partnership working with
key stakeholders; need for high quality, timely information to support
effective review and decision making; robust information and
communication systems in place to support an open, transparent and
quality-focused approach as part of effective governance; more effective
use of networks; establishing relevant partnerships that add value.
Quality Group
The draft Quality Account has now been received and the Working Group is currently
formulating a response on behalf of the Council.
Quality Committee observer’s report
Chris Anderson will give a verbal update from the meeting of the Quality SubCommittee.
Membership and Communications Group
The next meeting will be taking place on 23 April. Agenda items include
consideration of membership targets for 2015/16, progress on the introduction of
electronic voting plus the development of governors’ leaflets.
Involvement and Social responsibility group
Over the last month, members of the group have attended meetings of the PPI
Strategy working group, the Engagement Participation & Involvement committee
(EPIC) and the Involvement Register Management steering group (IRMSG).
PPI Strategy
The schedule had slipped but was back on track. Strategy action headings were
discussed and agreed in advance of the next EPIC meeting. Some tension over
terminology was evident (e.g. patient/ service user/survivor;
involvement/participation/co-production; representation/democracy). The deployment
of the National Involvement Standards was again confirmed.
EPIC
The PPI Strategy headings were considered by the representatives who are drawn
from across the four boroughs and from both SLaM and external groups. The
presentation by the Addictions PPI lead highlighted special problems (fixed-term
commissioning by varying local authorities) faced by this directorate which remains
the sole CAG without a Service User Advisory Group (SUAG).
IRMSG
ISR continues to maintain a presence in this steering group (IRMSG) and will report
back in greater detail for the May Board.
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Working arrangements
Work is continuing to ensure that recommendations are in place at the June meeting
of the Council of Governors regarding clarification of roles, confirmation of
governance arrangements and further development of training programmes for
governors. This is building on the work commenced at the joint meeting between the
Board and Council of Governors to ensure that working practices are in line with
national guidance and best practice elsewhere.
Paul Mitchell
Trust Secretary
April 2015
U: / board / cog update report Apr 15
Page 4 of 4
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F
TRUST BOARD OF DIRECTORS – SUMMARY REPORT
Date of Board meeting:
28th April 2015
Name of Report:
Social Care Strategy (draft)
Heading: - (Strategy, Quality,
Performance & Activity,
Governance)
Governance
Author:
Cath Gormally, Director of Social Care
Approved by:
(name of Exec Member)
Dr Matthew Patrick
Presented by:
Cath Gormally, Director of Social Care
Purpose of the report:
The purpose of this draft social care strategy is to provide a basis upon which to
have further external discussion and consultation with external local authority
partners and to agree a focussed programme of work.
The draft strategy will provide vision and direction for social care and professional
social work within SLaM to maximise the benefits of the integrated health and social
care approach to service users, carers and local communities.
Action required:
Trust Board is asked to approve the draft strategy for further external consultation
and discussion with local authority partners.
Recommendations to the Board:
The Trust Board is recommended to note the contents of the report and support the
strategic intentions
Relationship with the Assurance Framework (Risks, Controls and Assurance)
and level of assurance provided by the report - none, low, moderate, high:
If implemented, the strategy will provide a higher level of assurance that social care outcomes
are being delivered and the delegated duties of the local authorities exercised appropriately.
Summary of Financial and Legal Implications:
There are no financial or legal implications to the implementation of this strategy
Equality & Diversity and Public & Patient Involvement Implications:
No adverse implications identified
Service Quality Implications:
If accepted and implemented, a strategic approach to enhancing and improving
social care outcomes within SLaM will improve quality of care and service delivery.
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Social Care Strategy
2015 - 2019
Author:
Cath Gormally
Director of Social Care
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Introduction
This social care strategy will provide vision and direction for social care and professional social work
within South London and Maudsley NHS Foundation Trust (SLaM).
A meaningful strategy has to be based on the intended benefits it will bring to the people it serves
and, as such, this is aligned to the existing strategic plans within SLaM and those of local borough
partners, to ensure there is a clear focus and collaborative approach to delivering the best possible
outcomes for people with mental health problems, their carers and our local diverse communities.
The strategy will lay the foundations to work collaboratively with staff, partners, commissioners and
service users and carers on a programme of work focussed on social care and social work outcomes
within SLaM.
As the largest mental health trust in the United Kingdom SLaM is a unique and historic organisation.
It has a long-established, international reputation as a centre of excellence in healthcare delivery
and clinical academia based on its partnership with the King’s Health Partners Academic Health
Sciences Centre as a founding member and its special relationship with the Institute of Psychiatry.
SLaM is also the main provider of local community mental health services across the London
boroughs of Lambeth, Lewisham, Croydon and Southwark. As the local provider of choice, its
purpose and ambition is to make a real and felt contribution to integrated and preventative health
and social care that improves the lives of local people and communities, and to promote mental
health and well-being in those communities. The social determinants of mental health such as
poverty, housing and employment are well documented and similarly, people with mental health
problems are far more likely to be disadvantaged in these areas. A social perspective and model of
working to empower people, carers and our diverse communities to achieve the social and economic
outcomes that are important to them to lead fulfilled lives, is strongly dependent upon robust
relationships and partnerships to integrate care and support holistically around individuals, families
and social networks.
SLaM’s existing social care partnerships with local authority social care partners, commissioners, the
local community and voluntary sector and the wider systems of education, employment and housing
are critical to achieving this ambition.
1.0
National legislative and policy context
Health and social care legislation dating back to the 1940’s and the inception of the welfare
state, assumed an artificial distinction between ‘health’ needs, on the basis of ‘illness’; and
‘social care’ needs, on the basis of ‘disability’ or ‘vulnerability’ Glasby, J (2014). This led to
the development of the two separate agencies of the NHS and local authorities, with very
different structures, systems and governance arrangements, having responsibilities to meet
the health and social care needs of the same population. Arguably, over recent decades,
national legislation and policy has been addressing this divide, resulting in mental health
policy which has an increasingly strong focus on prevention, early intervention and a holistic,
recovery and outcomes-based approach to helping individuals to manage their own mental
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health with support from services. This has resulted in a strong emphasis on partnership
working and integration between health and social care to bridge divides to deliver
personalised, holistic care and move the focus of care from hospitals into local communities
and people’s homes. There is also a growing expectation from people who use services to
have much greater choice and control over their own care and lives and this is reflected in
the most recent Care Act legislation.
2.0
The Care Act 2014
The main provisions of the Care Act 2014 came into force on the 1st April 2015 and heralded
the most radical reform of social care legislation in over 60 years. The Act repealed a raft of
community care legislation including: the Community Care Act 1990, Carer’s Acts (several)
and the National Assistance Act 1948. The Act places a range of new duties and
responsibilities on local authorities and, where these statutory duties are delegated through
Section 75 agreements, these are now the responsibility of SLaM. Therefore, these wideranging reforms and changes have implications for the professional practice of all care coordinators and other staff within multi-disciplinary, integrated teams within SLaM, as they
exercise the delegated statutory duties and responsibilities on behalf of the local authority.
The underlying ethos and principles of the Act aims to put people and their carers in control
of their own care and change the focus of care by putting ‘well-being’ and ‘personalisation’
at the heart of interventions and work with the whole person and their strengths and assets
and those of their family and social networks.
The Act introduces wide-ranging statutory duties but some of the key new duties on local
authorities which are delegated to SLaM include:
x
Well-being and prevention principles: the duty to promote well-being in undertaking
care and support functions and to prevent or delay the need for care and support.
x
Personalisation: providing care and support which is person-centred and provides
personal budgets and support plans for people with assessed, eligible needs.
x
Carers: carers have a right to have an assessment of need and for eligible need to be met
by a personal budget where appropriate
x
Safeguarding adults: the Act places Safeguarding Adults Partnership Boards on a
statutory footing for the first time. SLaM is a key partner on the multi-agency boards and
has a duty to co-operate with multi-agency partners
Since the publication of the statutory guidance to the Act in October 2014, a Care Act
Implementation group has been working internally within SLaM, in partnership with social
care colleagues. The focus has been to ensure compliance with the legislation and that
service user and carer’s new rights and eligibility to care and support and personal budgets,
where applicable, are upheld. The next stage of work will focus on embedding the principles
and ethos of the Act and the statutory changes into professional practice.
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3.0
Partnerships
3.1
Section 75 partnership agreements
The duties of the local authorities as described above are delegated to SLaM under
Section 75 of the National Health Service Act 2006. SLaM has long-standing
partnership arrangements with the London boroughs of Lambeth, Lewisham,
Croydon and Southwark. These legally binding arrangements support the integration
of health and social care in multi-disciplinary community mental health teams in
which local authority employed social workers are based, and managed by, SLaM.
Over recent years, a lot of negotiation and work has taken place with partners to put
governance structures in place to oversee the Section 75 agreements and monitor
and give assurance on performance on social care outcomes. This work also resulted
in the post of Director of Social Care being established, jointly funded by SLaM and
the four boroughs to strengthen social care and social work leadership and
performance. Over the last year, with the inception of the Care Act and the changes
in senior leadership posts in some of the boroughs, it is timely to review the
governance and performance structures to ensure robust arrangements are in place
to support the partnerships. This is a key priority for the coming year.
4.0
Social Care Performance
By accepting the delegated duties as articulated in the Section 75 agreements, it is essential
that we are able to demonstrate that they are exercised appropriately and effectively on
behalf of our local authority partners and the Directors of Adult Social Care who ultimately
remain the accountable officers in their respective boroughs.
Since May 2014, the Director of Social Care in SLaM has co-ordinated a project group with
the SLaM and borough performance teams to produce a comprehensive data set to enable
the local authorities to submit a return to the Health and Social Care Information Centre to
meet the reporting requirements of the Short and Long term Return (SALT).
This has been a positive piece of work but, in order to give assurance on the delivery of
social care outcomes across all domains of the Care Act and Adult Social Care Outcomes
Frameworks, robust quality and performance management arrangements must be
evidenced. Social care performance monitoring should be embedded in SLaM’s existing
arrangements to ensure social care outcomes have parity of esteem with health outcomes
and quality improvements are made as a result.
5.0
Professional Social Work
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The social workers who work in mental health are, in the main, employed by the local
boroughs and made available by them to work in the integrated, multi-disciplinary
community mental health teams. SLaM also directly employs a minority of social workers
who work as care co-ordinators in some of the community services.
In recent years, following national reviews of children’s and adult social work, professional
social work has undergone significant change, resulting in some key reforms including: the
establishment of the College of Social Work and the appointment of Chief Social Workers for
Adults and Children and Families. This is raising the profile of social work nationally and
giving it an expert voice in relation to national policy and legislation.
Social workers in mental health have a long history of working in partnership with service
users, carers and families to promote recovery and independence in communities. Effective
social work interventions can be powerful enablers for people to live as independently as
possible and should be at the heart of interactions with individuals and service
transformations.
The College of Social Work recommends that the role of the social worker in adult mental
health services should focus on five key areas:
1. Enabling citizens to access the statutory social care and social work services and advice
to which they are entitled, discharging the legal duties and promoting the personalised
social care ethos of the local authority.
2. Promoting recovery and social inclusion with individuals and families
3. Intervening and showing professional leadership and skill in situations characterised by
high levels of social, family and interpersonal complexity, risk and ambiguity.
4. Working co-productively and innovatively with communities to support community
capacity, personal and family resilience, early intervention and active citizenship.
5. Leading the Approved Mental health Professional workforce.
5.1 Think Ahead
The ‘Think Ahead’ programme is an innovative ‘fast-track’ mental health social work
training programme which aims to recruit exceptional graduates to become mental
health social workers. The programme will support the adoption of innovative practice
focussed on prevention and building resilience which will help to crystallise a distinct
role for social work within multi-disciplinary teams. SLaM has agreed to partner with
Lambeth, Lewisham and Croydon boroughs to submit an application to participate in the
programme. If successful, the programme will support social work leadership and values
within the integrated services. In order to get the best value from our social work
professionals in integrated teams, we need to make sure they are actively focussed and
deployed in the right areas and pieces of work.
6.0
Recovery and Social Inclusion
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The effectiveness of recovery and social inclusion approaches in assisting people with
mental health problems to recover and lead fulfilled lives are well-evidenced and
documented. The work within SLaM on recovery and social inclusion through the Recovery
College is outlined in the strategic plans of the Social Inclusion and Recovery (SIR) Board
which this strategy needs to be aligned with. Evidenced based, social approaches which
promote recovery and social inclusion should be core interventions, central to the work of
integrated teams. As recommended by the College of Social Work, social workers in mental
health teams should have a key role in promoting recovery and social inclusion with
individuals and families and should be taking a key leadership role in this respect. Further
work with the SIR Board is recommended to mainstream social care and recovery
approaches in team interventions and to align social care and recovery strategies.
7.0
Future opportunities
x
8.0
Further integration: The Care Act gives a duty to local authorities to carry out their
functions with the aim of integrating services with the NHS where appropriate and a
power to delegate core functions and duties. This may present SLaM and local
authorities with future opportunities to further integrate services between health and
social care or for SLaM to respond to potential tender opportunities which may not have
traditionally considered.
Potential risks
x
The current Section 75 partnership agreements are dependent on the delivery of the
outcomes contained within them. If SLaM does not deliver the required outcomes, there
is a risk that local authority partners may wish to dissolve existing partnerships. Lack of
integrated care delivery would lead to poorer outcomes for service users and carers and
potential reputational damage to the organisation.
x
Continued funding reductions to local authority budgets may put additional pressure on
partnerships and the wider health and social care economy.
x
There may be a risk of higher demand for services associated with the implementation
of the Care Act, which may have an adverse impact on capacity of teams.
x
Currently, we have problems in providing robust performance data in relation to
Safeguarding Adults due to a variety of technical reporting issues. These include:
difficulty in reporting to Safeguarding Adults Boards on a borough basis as SLaM
reporting systems are set up by Clinical Academic Groups (CAGs) and the lack of
safeguarding fields on ePJS. Work is on-going to address this as it leads to a lack of
assurance in safeguarding practice and is a key priority to resolve.
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9.0
Key priorities for 2015
A focussed programme of work is recommended to address the issues, opportunities and
risks raised in this document, centred around three core stream of work:
1. Section 75 Partnership Agreement
x Engage and consult with partners and joint commissioners to agree the SLaM social
care strategy
x Full implementation and completion of the Care Act 2014 Implementation Plan to
ensure professional practice is focused on personalisation, prevention and recovery
x Engage in work with the London Social Care Partnerships
x Agree and sign off Section 75 agreements and embed governance arrangements
x Embed a Social Care Performance Framework in existing SLaM quality and
performance management arrangements and monitor improvement plans
x Align social care with existing programmes of work on recovery, social inclusion and
the Recovery College to ensure it is core practice.
2. Safeguarding Adults
x Embed and consolidate safeguarding practice as a key partner of the statutory
boards by strengthening and maturing the work of the SLaM Safeguarding Adults’
Committee to ensure learning from local Safeguarding Adults’ Boards, serious case
reviews and local reviews is disseminated and embedded in practice.
x Embed the regular and active attendance of the Service Directors at the
Safeguarding Adults Partnership Boards.
x Strengthen systems and processes to enable the provision of robust quality
performance data.
3. Professional Social Work
x Raise the status and profile of professional social work within SLaM and ensure the
social work contribution is recognised and valued within the integrated services
x Promote and support future social work innovation and research. Support the
adoption of pioneering models, for example: Open Dialogue.
x Think Ahead: submit the joint application to the Think Ahead programme with
Lambeth, Lewisham and Croydon and, if successful, support the programme across
the partnership.
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x In collaboration with Heads of Social Care and boroughs ensure professional social
work practice is focused on the key areas of practice in which social work add most
value
x Engage social work in the recovery and social inclusion agenda and the Recovery
College already established with the Trust.
Finally, the Trust Board is asked to support a change to the current governance
arrangements in relation to social care: the Section 75 Delivery Board, the Care Act
Implementation group, performance management and core contract meetings. It is
recommended that the Director of Social Care consults with external partners and
commissioners and internal colleagues to agree a new governance structure for social care
which will focus on the effective delivery of all the recommendations proposed above.
10.0 References
‘No Health without Mental Health’, (February 2011)
‘No Health without Mental Health: Implementation Framework’ (July 2012)
‘Closing the Gap: Priorities for essential change in mental health” (February 2014)
‘Mental Health Crisis Concordat’ (February 2014)
Glasby, J and Dickinson, H (2014) Partnership Working in health and social care. “What is
integrated care and how can we deliver it?” Policy Press
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TRUST BOARD OF DIRECTORS – SUMMARY REPORT
G
Date of Board meeting:
28th April 2015
Name of Report:
Briefing from the Quality Sub Committee
Heading:
Authors:
Governance
Neil Brimblecombe
Approved by:
Neil Brimblecombe, Director of Nursing
Presented by:
Neil Brimblecombe
Purpose of the report:
To present a brief summary of key points discussed at the meeting of the Quality Sub
Committee of the Board held on 17th March 2015, drawing the Board’s attention to key points
for consideration.
Action required:
The Board of Directors is asked to note this report and decide whether any further action or
briefing is required in relation to the key issues raised.
Recommendations to the Board:
Issues for attention are highlighted within the report.
Trust-wide risk(s) affected by this report and the level of assurance provided (none,
low, moderate, high):
The Quality Sub Committee provides assurance to the Board that the principal risks to
service quality, recorded within the Assurance Framework and Corporate Risk Log, are
being correctly identified, correctly judged and classified and, most importantly, are being
actively managed and mitigated by named staff.
Service Quality Implications:
The primary objective of the Quality Sub Committee is to ensure that there are processes in
place to monitor service quality effectively.
Summary of Financial and Legal Implications:
The Audit Committee carries out an annual review of the Annual Governance Statement; the
work of the Quality Sub Committee informs this review.
Equality & Diversity and Public & Patient Involvement Implications:
Equality & Diversity and Public & Patient Involvement are reviewed by the Quality Sub
Committee on a regular basis.
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Key points
The Quality Sub Committee draws the following items to the attention of the Board for noting
and for consideration as to whether further briefing is required.
1. Policies agreed
x Health and Safety
x Smoke Free
x Physical Health
2. Trust audit of clinical risk assessment
Findings from the Trust audit of clinical risk assessments were presented and discussed.
The aim of the audit was to assess the level of compliance with Trust policy standards
regarding completion of risk screening tools and subsequent management plans.
The audit highlighted the need for improvement in the following areas:
x
x
x
Risk planning
Crisis planning
Ensuring plans were recorded in the correct place on ePJS
Agreed actions
x
x
A working party will be formed to review the current risk assessment policy and the
Trust risk assessment and planning documentation
The audit results to be discussed in relevant CAG forums for action
3. Trust mandatory training
A report on Trust compliance with mandatory training was provided by the Education and
Training department. Areas of non compliance were highlighted and contributing factors
were discussed. These factors include increased numbers of DNA’s and late cancellations.
Agreed Action
x
x
x
Education and Training to review all mandatory training in order to ensure training is
efficient, easily accessible and effective.
Education and Training have reinstated charges for late cancellations and DNA’s
from 1st April 2015.
To continue to monitor CAG compliance with mandatory training at Performance
Management.
4. CQC compliance inspection
An unannounced compliance visit was made to National Psychosis Unit on 24th March 2015.
Initial feedback highlighted that inspectors observed positive interactions between staff and
service users and staff were knowledgeable about patients individualised needs.
Issues of note include:
x Quality of documented care plans
x Staff awareness of safeguarding processes
x Ligature risks.
A draft report has been received from the CQC and is currently being reviewed by the CAG
for any factual inaccuracies.
Next meeting: 21st April 2015
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H
TRUST BOARD OF DIRECTORS (‘THE BOARD’) – SUMMARY REPORT
Date of Board meeting:
Tuesday 28th April 2015
Name of Report:
(a) Key issues summary (overpage)
(b) Draft minutes of Audit Committee meeting held 24 March 2015
(c) Signed and sealed report
Purpose of report:
For information
Heading:
Governance
Author:
Steven Thomas (Audit Committee Secretary)
Approved by:
(name of Exec Member)
June Mulroy (Audit Committee Chair and Non Executive Director – ‘NED’)
Presented by:
June Mulroy (Audit Committee Chair and NED)
Purpose of the reports:
The following reports are presented for the Board’s information
Item (a): key issues summary. To inform the Board about key issues noted at the Audit Committee
meeting held on Tuesday 24th March 2015
Item (b): Audit Committee draft minutes. To inform the Board about proceedings at the Audit Committee
meeting held on Tuesday 24th March 2015
Item (c): signed and sealed report. To inform the Board about documents signed and sealed on behalf of
the Trust
Action required:
All items: review the documentation presented
Recommendations to the Board:
Note the documents
Relationship with the Assurance Framework (Risks, Controls and Assurance):
The Audit Committee’s role includes consideration of the Assurance Framework
Summary of Financial and Legal Implications:
No specific significant implications identified.
Equality & Diversity and Public & Patient Involvement Implications:
No specific significant implications identified.
Service Quality Implications:
Each of the key issues identified overpage may affect service quality, but no specific significant implications
have been identified
129 of 155
th
KEY ISSUES SUMMARY (references are to the 24 March 2015 Audit Committee (‘AC’) minutes attached)
Note: the AC Chair may wish to expand or amend the following at the Board meeting
th
At its meeting on 24 March 2015 the AC concluded that no matters required escalation for the attention of the
Board (14.1 refers). However the AC considers that the Board should be made aware of the AC’s concerns about
the following key potential issues/proposed resolutions noted at the meeting.
Key potential issues
th
(as at 24 March 2015)
(1). The AC discussed ‘synchronising’ issues dealt
with at meetings of the AC, Quality Committee
(‘QC’), Business Development and Investment
Committee (‘BDIC’) and the Board. The AC also
discussed rationalising the terms of
reference/schemes of delegation relating to the AC,
QC, BDIC and Board so that issues are dealt with
efficiently and effectively.
(2). Maudsley Charity. The AC discussed the
Maudsley Charity, its constitution and governance,
and issues around the relationships of SLaM and of
the Charity with the ORTUS learning centre.
(3). Qatar performance bonds. The AC Chair and
the CFO advised that they had concerns about the
request, in the terms of a document requesting bids
for large consultancy opportunity in Qatar, for SLaM
to provide a performance bond.
(4). Monitoring Monitor. The AC was advised that
Monitor was issuing an increasing number of
reporting requests, despite an initial commitment to
a ‘light touch’ reporting regime.
(5). Assurance framework. The AC discussed the
assurance framework presented, including
improvements required.
(6). Benchmarking report. The AC discussed a
progress report from external audit (Deloitte)
including reports benchmarking SLaM against other
NHS bodies.
(7). Bribery Act. The meeting discussed the
implications of the Bribery Act 2010.
AC
mins
ref
1.1
1.2
Actions proposed to address key issues (as at
th
24 March 2015)
1.1
1.3
9.4
External audit and internal audit will report to the
AC Chair with views on governance at the
Maudsley Charity, in particular giving an opinion on
whether it needs an audit committee.
The CFO will discuss with the Commercial Director
(and LCFS) the legality and risks around SLaM
providing a performance bond regarding the
potential Qatar contract, and will report back to the
AC Chair.
Points to cover in future AC agendas will include a
standing item as to Monitor’s requirements
(including a summary of reports required by
Monitor, with timings).
The CFO will discuss matters with external audit
and internal audit outside the AC meeting, with a
view to improving the assurance framework and
related systems.
The CFO will circulate Deloitte’s report to Board
members and the QC Chair with a brief introductory
note flagging the key issues of waiting times and
CIP performance.
A Trust policy has been drafted and will be ratified
and publicised as soon as possible.
7.2
7.4
8.1
10.2
11.1
12.1
All those attending will contact the AC Chair with
any views on how best to ‘synchronise’ issues dealt
with at meetings of the AC, QC, BDIC and Board,
so that a ‘running routine’ is created between the
various meetings to deal with issues efficiently and
effectively.
130 of 155
Draft for comment
MINUTES OF THE
AUDIT COMMITTEE (‘AC’)
HELD ON: Tuesday 24 March 2015
AT: Boardroom, Maudsley Hospital, Denmark Hill from 08:45 to 11:00
Present:
June Mulroy
Robert Coomber
Prof. Shitij Kapur
Steven Thomas
Title
AC Chair. Non Executive Director (‘NED’)
AC Member, NED
AC member. NED
AC Secretary
Initials (presence for items)
JM (All items)
RC (All items)
SK (All items)
ST (All items)
In attendance:
Gus Heafield
Dr. Neil Brimblecombe
Stephen Docherty
Anthony Schnaar
Deborah Heron
Helen Bell
Matthew Hall
Angus Fish
Kevin Limn
Thanzil Khan
David Kenealy
Ian Creagh
Chief Financial Officer (‘CFO’)
Director of Nursing
Chief Information Officer (‘CIO’)
Head of Health Intelligence
Finance and Development Manager, CAMHS*
Directorate Accountant for CAMHS*
External Audit (Partner – Deloitte)
External Audit (Senior Manager – Deloitte)
Internal Audit (Chief Internal Auditor – TIAA)
Internal Audit (Internal Audit Manager – TIAA)
Local Counter Fraud Specialist (‘LCFS’ – TIAA)
Governor Observer
GH (All items)
NB (Items 2 to 7)
SD (Items 7, and 9.1 to 9.3)
AS (Items 1 to 7, and 9.1 to 9.3)
DH (Items 7 and 9.1)
HB (Items 7 and 9.1)
MH (All items)
AF (All items)
KL (All items)
TK (All items)
DK (All items)
IC (All items)
Apologies for absence:
Jo Fletcher
Service Director, CAMHS*
JF
* CAMHS denotes Child and Adolescent Mental Health Service
NOTES
The AC Chair decides on the appropriate order in which to take agenda items at AC meetings, and this is not
necessarily the order shown below. The minutes focus on recording the information and assurances provided
in the meeting, in response to questions and otherwise, rather than on the questions themselves.
Item no.
1.
Business Item
Action
by
Date
Non-minuted session
1.1 JM opened the meeting, summarising her background, her initial
view of key issues faced by SLaM, and her views on key changes in
approach needed to deal with these. Subsequent subjects discussed
included:
(a) the Quality Committee (‘QC’) and its remit;
Minutes of AC meeting 24.Mar.2015 (draft for approval)
Page 1 of 9
131 of 155
Item no.
Action
by
Date
1.2 Action. All those attending will contact the AC Chair with any
views on how best to ‘synchronise’ issues dealt with at meetings
of the AC, QC, BDIC and Board, so that a ‘running routine’ is
created between the various meetings to deal with issues
efficiently and effectively.
ALL
Apr.15
1.3 Action. External audit and internal audit will report to the AC
Chair with views on governance at the Maudsley Charity, in
particular giving an opinion on whether it needs an audit
committee.
Apologies for absence and introductions
2.1 Received as above. All present introduced themselves as
appropriate. After due discussion the AC noted this agenda item, and
noted that the AC meeting was quorate.
Declarations of interest
3.1 JM asked all present to declare any relevant interest at the
appropriate point during the meeting. Routine declarations were made.
SK declared an interest as a member of the CNS Scientific Advisory
Board of Lundbeck Co and Roche Co. SK advises and consults with
pharmaceutical companies periodically. SD declared an interest as a
NED of The Maudsley Learning Company. After due discussion the AC
noted this agenda item.
Minutes of previous AC meeting(s)
4.1 All present considered, page by page, the final draft minutes of the
AC meeting held on Tuesday 16th December 2014 together with the
schedule showing comments received on the prior draft of those
minutes and resolutions of those comments in the final draft. After due
discussion the AC approved the minutes and ratified matters flagged
therein as covered when the December AC meeting was inquorate.
Action points from previous AC meetings
5.1 All present considered the list of action points, and gave updates as
appropriate. After due discussion the AC noted the list of action points
and the AC Chair approved deletion of action points agreed as
resolved.
Matters arising
6.1 ST advised, and after due discussion the AC noted, that there were
no matters arising that would not be appropriately dealt with in the
agenda.
Quality Committee (‘QC’) and Business Development and
Investment Committee (‘BDIC’)
MH, KL
Apr.15
-
-
-
-
-
-
-
-
-
-
Business Item
(b) ‘synchronising’ issues dealt with at meetings of the AC, QC,
Business Development and Investment Committee (‘BDIC’) and
the Board;
(c) rationalising the terms of reference/schemes of delegation relating
to the AC, QC, BDIC and Board so that issues are dealt with
efficiently and effectively;
(d) rationalisation of SLaM’s policy and procedure documents, and
ways to ensure that all staff have appropriate knowledge of these
documents and how to access them; and
(e) the Maudsley Charity, its constitution and governance.
2.
3.
4.
5.
6.
7.
Minutes of AC meeting 24.Mar.2015 (draft for approval)
Page 2 of 9
132 of 155
Item no.
Business Item
Action
by
Date
GH
Apr.15
-
-
7.1 NB spoke to, and the meeting considered, minutes of the QC’s
meeting of 17.Feb.2015 and the summary of key points from the QC’s
20.Jan.2015 meeting. In particular:
(a) NB noted the breadth of the QC’s remit, and advised that QC
meetings to date were covering all agenda items appropriately
within the planned duration of the meetings;
(b) NB advised improvements: to the QC’s ‘dashboard’; to dealing with
matters from ‘ward to Board’ and vice versa; and in monthly
highlight reporting by CAGs to the QC about key risks and
exceptional good practice;
(c) NB advised that each QC meeting was structured around a central
theme;
(d) NB advised that, in general, clinicians at QC meetings appeared to
involve themselves less in discussion of the structure and
organisation of the QC;
(e) JM noted that a key potential risk is lack of accountability within
CAGs as regards resolving agreed actions. NB confirmed that
action trackers assigned actions to named individuals with set
deadlines, and NB advised that preparation for the coming Care
Quality Commission (‘CQC’) review would help CAGs improve their
arrangements, and provided an incentive for them to do so; and
(f) JM noted her concern that the QC and AC may both fail to consider
a key risk unless their working practices are defined and aligned
clearly. NB advised that the QC would escalate key financial and
organisational risks to the AC. RC noted that review of QC and
BDIC minutes by the AC was insufficient, and the AC needed to be
advised of key unusual issues, changes therein and longstanding
unresolved issues. GH considered that the AC’s role includes
forming an overview judgment about SLaM’s systems around risk
(for example the QC’s capacity and remit).
7.2 The meeting considered the minutes of the BDIC’s 16.Feb.2015
meeting and the summary of key points from that meeting. In particular:
JM and GH advised that they had concerns about the request, in the
terms of a document requesting bids for large consultancy opportunity
in Qatar, for SLaM to provide a performance bond.
7.3 After due consideration the AC noted the agenda item.
8
8.1
7.4 Action. The CFO will discuss with the Commercial Director
(and LCFS) the legality and risks around SLaM providing a
performance bond regarding the potential Qatar contract, and will
report back to the AC Chair.
AC-RELATED MATTERS
Forward planner (AC workplan for the year ahead)
8.1.1. ST presented the workplan. GH noted that Monitor was issuing
an increasing number of reporting requests, despite an initial
commitment to a ‘light touch’ reporting regime. After due discussion the
AC approved the workplan, subject to any updating required to reflect
points raised in the meeting. (Post meeting note 30.Mar.2015: following
enquiry of SLaM management and external audit, ST was advised that
an appropriate date for the May 2015 AC meeting to review the draft
Minutes of AC meeting 24.Mar.2015 (draft for approval)
Page 3 of 9
133 of 155
Item no.
Action
by
Date
8.1.2 Action. The AC Chair and the AC Secretary will liaise in
advance of producing the AC agenda for the next AC meeting.
Points to cover in future agendas include: a standing item as to
Monitor’s requirements (including a summary of reports required
by Monitor, with timings); coordination of Annual Reports from the
AC, QC and BDIC; and review of governance documentation.
REPORTS FROM/DISCUSSIONS WITH SLAM MANAGEMENT
(OTHER THAN FINANCE)
CAMHS: success factors re compliance with Cost Improvement
Programmes (‘CIPs’) targets
9.1.1 ST tabled the 1 page report produced by DH previously emailed to
attendees, and DH spoke to this. The meeting discussed the report and
in particular:
(a) DH (and subsequently GH) noted key factors contributing to
CAMHS’s success in achieving CIPs targets, including that: (1) the
service management culture is strongly cost-grounded and
integrates the finance function. CIPs is a standing item on the
CAMHS agenda, and the need for teams to play their part in
complying with CIPs is an absolute requirement; (2) HB is the
current management accountant for CAMHS (DH previously held
that role and is ‘embedded’ in the CAG – this is less the case with
other CAGs; and (3) there is considerable input from senior
members of the finance function to the CAMHS service plan;
(b) DH confirmed that CAMHS’s internal financial monitoring covered
income and all costs, both direct costs and indirect costs;
(c) HB confirmed that if teams did not perform financially they were put
into ‘turnaround’ to focus attention on cost efficiency, and
continued loss-making would, and had in practice, lead to closure
of teams;
(d) DH confirmed that CAMHS continued to grow organically (not just
through acquisition of services such as the Kent contract), and this
made it easier to retain and re-assign staff. There had been few
redundancies in past years;
(e) GH confirmed that SLaM still worked under some block contracts,
and moving on from these was proving challenging, although
trading accounts were prepared and rebasing exercises were
underway;
(f) SK noted that no NHS bodies were reporting financial results
based on outcomes; payment is not truly ‘by results’ but is based
on processes; and
(g) after due discussion the AC noted the agenda item.
JM, ST
May.15
-
-
9.1.2 Action. The AC Chair will discuss CIPs matters further with
CAMHS management on a separate occasion.
IT: key risks and delivery of new strategy
9.2.1 SD gave a verbal report, based on the IT strategy document in the
agenda papers for the 24.Mar.2015 Board meeting which AC members
received separately, and in particular:
(a) SD advised that the potential risk around SLaM’s email system
(flagged at the previous AC meeting) had materialised, and SLaM
JM
May.15
-
-
Business Item
audited accounts has not yet been set.)
9
9.1
9.2
Minutes of AC meeting 24.Mar.2015 (draft for approval)
Page 4 of 9
134 of 155
Item no.
9.3
9.4
10
10.1
10.2
Business Item
had implemented an 18 month interim solution (this was the cause
of single tender action STA 133 on page 52 of the AC agenda);
(b) SD advised that SLaM was looking for the electronic patient
journey system (‘ePJS’) to be hosted in a data centre in Slough
used by a number of other Trusts, and advised that this would
enable useful comparisons of data sets between Trusts, where
agreed appropriate;
(c) SD advised that work was progressing to ensure that the IT system
ensured a single reliable source of information which teams would
not need to adjust in order to produce appropriate reports as
required each month. GH advised the difficulties resulting from
differing definition specifications used by SLaM, by commissioners
and by other bodies nationally;
(d) JM and RC noted that an email failure on the scale experienced by
SLaM was highly unusual and highly concerning and, in the wake
of previous major issues, SLaM might well not be able to cope with
yet another major issue. RC noted that the IT strategy needed to
include: (i) an overview assessment of IT capacity; and (ii) a
summary of risk management and ownership of risks;
(e) SD advised that work was in hand to address the issue of shared
drives, which he considered was the next most likely risk to
materialise;
(f) JM offered the AC’s support should SD consider this helpful. KL
advised that internal audit could support the IT department’s review
of COBIT 4/COBIT 5 (‘COBIT’ denotes Control Objectives for
Information and Related Technology); and
(g) after due discussion the AC noted the agenda item.
Data warehousing: updated action plan summary
9.3.1 AS presented this report and:
(a) AS advised that: a new governance structure was in place chaired
by SD: a new data quality policy is in place; and each CAG has a
data quality board and there is good attendance at meetings;
(b) as an incentive, JM offered an appropriate modest prize to the
CAG showing the best data quality improvement; and
(c) after due discussion the AC noted the agenda item.
SLaM and ORTUS learning company: implications of relationship
9.4.1. GH gave a verbal report, outlining the relationship and the
potential issues arising and:
(a) GH advised that the Maudsley Charity required certain
improvements in governance, including reporting issues to its
parent (SLaM);
(b) JM and SK noted issues around the interests of the different
parties involved and factors affecting the viability of the learning
centre;
(c) RC noted that some changes were in progress and needed to be
fully implemented to effect a resolution; and
(d) after due discussion the AC noted the agenda item.
RISK MANAGEMENT AND FINANCE
CFO’s report on ‘GH’ items in this agenda
10.1.1 GH reported as appropriate within agenda items 10.2 and 10.3
below. After due discussion the AC noted this.
Assurance framework (covering report to flag key changes)
Minutes of AC meeting 24.Mar.2015 (draft for approval)
Action
by
Date
-
-
-
-
-
-
Page 5 of 9
135 of 155
Item no.
Business Item
Action
by
Date
GH
Apr.15
-
-
-
-
10.2.1. GH presented this agenda item and in particular:
(a) GH reported that in the next few months the Board would challenge
risks recorded in the assurance framework;
(b) RC noted that the assurance framework should also summarise
key changes in risks and key actions taken since the prior report;
(c) JM noted that the assurance framework lacked a timeline indicating
when planned actions/changes to risks would occur;
(d) KL advised that a number of tools were available to Trusts to help
them to improve their assurance frameworks and related systems;
and
(e) after due discussion the AC noted this agenda item.
10.3
11
11.1
12
12.1
10.2.2. Action. The CFO will discuss matters with external audit
and internal audit outside the AC meeting, with a view to
improving the assurance framework and related systems.
Signed and sealed documents, SFI breaches and STAs
10.3.1 GH presented the agenda item. The AC noted SD’s explanation
about STA 133 (AC minutes para 9.2.1(a) refers) and after due
discussion the AC noted the agenda item and approved the proposal
that the signed and sealed report be appended to the draft minutes of
the AC meeting when these are taken to the Board of Directors for
information.
EXTERNAL AUDIT
Progress report: plan for 2014/15 audit
11.1.1 MH and AF presented this agenda item, and in particular:
(a) JM noted that the report was highly informative and should be
circulated to the Board;
(b) the meeting discussed the key new requirement to disclose waiting
time information in the Annual Governance Statement, and
concurred with Deloitte’s view on the importance of early
consideration of assurance about the quality of waiting time data;
(c) the meeting discussed the report benchmarking SLaM’s CIP
performance against that of other Trusts, noting that all Trusts are
underperforming but SLaM is below average;
(d) JM noted her intention to gain an understanding, through
shadowing, of the various groups involved in contracting; and
(e) after due discussion the AC noted the agenda item.
11.1.2. Action. The CFO will circulate Deloitte’s report to Board
GH
members and the QC Chair with a brief introductory note flagging
the key issues of waiting times and CIP performance.
LOCAL COUNTER FRAUD SPECIALIST (‘LCFS’)
Progress report with summary cover sheet including full report on
declaration and monitoring of interests and definition thereof
12.1.1 DK presented this agenda item, and in particular:
(a) the meeting discussed the implications of the Bribery Act 2010, and
the need for a Trust policy to be ratified and publicised as soon as
possible. JM noted that the vast majority of items on the action plan
in the LCFS report on the Bribery Act (agenda pages 103 and 104)
were ‘red rated. DK confirmed that all actions were actually
complete or nearly so;
(b) the meeting discussed Trust mobile phones: loss and damage;
Minutes of AC meeting 24.Mar.2015 (draft for approval)
Apr.15
-
Page 6 of 9
136 of 155
Item no.
Action
by
Date
12.1.2 Action. The AC Secretary will include a session on the
Bribery Act, lead by LCFS, in the AC’s workplan.
ST
Apr.15
12.1.3 Action. All those presenting reports to the AC will, when
assigning target action completion dates, wherever possible take
account of deadlines for lodging agenda papers with the AC, so as
to allow reporting of completed actions to the AC.
INTERNAL AUDIT
Progress report
13.1.1 KL presented the agenda item, and:
(a) the meeting discussed the briefings on developments in
governance, risk and control. In particular, SK noted that many
people with mental health issues are not being presented or not
presenting themselves to the mental health system – there is a
large ‘hidden’ need;
(b) GH commented that there was a lack of GP representation in
commissioning meetings; and
(c) after due discussion the AC noted the agenda item.
Draft internal audit plan 2015/16
13.2.1 KL presented the agenda item. After due discussion the AC
noted the agenda item and agreed the plan for quarter 1 of 2015/16.
ALL
Ongoing
-
-
13.2.2 Action. The AC Secretary will ensure that the coming
special ‘short’ AC meeting (AC minutes para 15(c) refer) will
include consideration and, if thought fit, approval of internal
audit’s plans for the remainder of 2015/16.
‘CPD’ needs, escalation of matters (feedback) to the Board and
any other business
14.1 After due discussion the AC concluded that all agenda items and
supporting agenda papers had received due consideration, that no
significant training (Continued Professional Development – ‘CPD’)
needs had been identified for AC members, and that (except where
otherwise noted in these minutes) no matters required escalation for the
attention of the Board. There being no further AC business, JM closed
the meeting.
Dates of next meetings
(a) The next quarterly meeting is set for Tuesday 23rd June 2015 at
10:30 to 12:30, Boardroom, Maudsley Hospital.
(b) A date/time/venue needs to be set for the special AC meeting to
consider the draft 2014/15 accounts and related items. It will be
held towards the end of May 2015 – AC members should
please hold time available in their diaries.
(c) A date/time/venue needs to be set for a special (short) AC meeting
to consider: risk and financial planning for 2015/16 onwards; how
ST
Apr.15
-
-
-
-
Business Item
ways to check the current holders of mobile phones; and ways to
reinforce with holders their responsibilities for looking after Trust
mobile phones;
(c) the meeting briefly discussed LCRNs (Local Clinical Research
Networks) and SK outlined the complicated funding related thereto;
and
(d) after due discussion the AC noted the agenda item.
13
13.1
13.2
14
15
Minutes of AC meeting 24.Mar.2015 (draft for approval)
Page 7 of 9
137 of 155
Item no.
Action
by
Business Item
Date
dealings with commissioners might be managed most effectively;
and internal audit’s plans for 2015/16.
ACTION POINT (‘AP’) LIST
Excluded from the AP list below are actions previously agreed by the AC as completed and actions
agreed by the AC Chair as completed.
Date
arising
AC action point
Notes/evidence that
AC
completed (or ref to relevant Chair
agenda item)
sign off
Note. The table seeks to help AC members monitor and control key actions arising at AC meetings, and so does not necessarily list all
points of detail such as drafting points. Attendees are expected also to make their own notes of action points affecting their areas of
responsibility.
25.03.14
9.1.2 Internal audit (KL, NM) will add into their
KL, NM,
386
2014/15 workplan a review of contracts/income from TK
commissioners and will report to the AC regarding:
Sep.14
(i) Done. Considered at
(i) (report in Sep.2014) the appropriateness of
contracts in place; and (ii) (report in Mar.2015)
Mar.15
23.Oct.14 AC meeting
payments from commissioners and recoverability of
(ii) was on the agenda for the
Mar.15 AC meeting, but
related debtors
appears not to have been
included in the internal audit
report provided
23.10.14
1.2.4. ND and GH will feedback the AC’s
GH will check with the Senior
ND, GH
Nov.14
404
comments from this session to SLaM management
Management Team (‘SMT’)
and confirm whether this was
as appropriate.
done
23.10.14
1.2.5. ND and GH will obtain internal audit’s
ND, GH
Jun.15
405
independent assessment of the Estates
Department, including benchmarking it with other
departments, and will report back to the AC and
Board.
23.10.14
11.1.3. LCFS will report to the next AC meeting with
Dec.14
The Dec.14 AC meeting
DK, MW
412
recommendations as to: (i) an appropriate
received a short verbal
Mar.15
framework for declaration and monitoring of
update. A full report was on
the agenda for the Mar.15 AC
interests; and (ii) the interests that should be
meeting but appears not to
covered by such a system (which should include
any externally paid employment in respect of full
have been included in the
LCFS report provided
time senior staff and other paid employment for
consultants).
16.12.14
8.4.2. GH and TM will update the AC about
GH, TM
Jun.15
420
Procurement’s contribution to CIPs, including
appropriate background/context.
16.12.14
10.1.3. RC will flag to the Chief Executive the AC’s
RC confirmed he had flagged
RC
Jan.15
423
recommendations: (1) that the Chief Executive
these matters, and awaits an
should coordinate production of a strategy or other
appropriate response.
means of prioritising competing demands on time
and resources when dealing with strategic partners;
and (2) that the Board should consider the internal
audit report on quality governance arrangements as
a means of improving the efficiency and
effectiveness of Board and committee operations
generally.
16.12.14
12.3.2. ST will agree with the AC and GH
Agreed to be held in April
ST
Jan.15
2015 before the April 2015
424
whether/when to hold a short (1 hour) AC meeting
Board meeting. ST to liaise to
before March 2015, focused on: risk and financial
planning for 2015/16 onwards; and how dealings
set a date/time/venueg
with commissioners might be managed most
effectively.
24.03.15
1.2 All those attending will contact the AC Chair with ALL
Apr.15
426
any views on how best to ‘synchronise’ issues dealt
with at meetings of the AC, QC, BDIC and Board, so
that a ‘running routine’ is created between the
various meetings to deal with issues efficiently and
effectively.
Minutes of AC meeting 24.Mar.2015 (draft for approval)
Action
lead
Date to
complete
Page 8 of 9
138 of 155
Date
arising
24.03.15
427
24.03.15
428
24.03.15
429
24.03.15
430
24.03.15
431
24.03.15
432
24.03.15
433
24.03.15
434
24.03.15
435
AC action point
1.3 External audit and internal audit will report to the
AC Chair with views on governance at the Maudsley
Charity, in particular giving an opinion on whether it
needs an audit committee.
7.4 The CFO will discuss with the Commercial
Director (and LCFS) the legality and risks around
SLaM providing a performance bond regarding the
potential Qatar contract, and will report back to the
AC Chair.
8.1.2 The AC Chair and the AC Secretary will liaise
in advance of producing the AC agenda for the next
AC meeting. Points to cover in future agendas
include: a standing item as to Monitor’s
requirements (including a summary of reports
required by Monitor, with timings); coordination of
Annual Reports from the AC, QC and BDIC; and
review of governance documentation.
9.1.2 The AC Chair will discuss CIPs matters further
with CAMHS management on a separate occasion.
10.2.2. The CFO will discuss matters with external
audit and internal audit outside the AC meeting, with
a view to improving the assurance framework and
related systems.
11.1.2. The CFO will circulate Deloitte’s report to
Board members and the QC Chair with a brief
introductory note flagging the key issues of waiting
times and CIP performance.
12.1.2 The AC Secretary will include a session on
the Bribery Act, lead by LCFS, in the AC’s workplan.
12.1.3 All those presenting reports to the AC will,
when assigning target action completion dates,
wherever possible take account of deadlines for
lodging agenda papers with the AC, so as to allow
reporting of completed actions to the AC.
13.2.2 The AC Secretary will ensure that the coming
special ‘short’ AC meeting (AC minutes para 15(c)
refer) will include consideration and, if thought fit,
approval of internal audit’s plans for the remainder
of 2015/16.
Minutes of AC meeting 24.Mar.2015 (draft for approval)
Action
lead
Date to
complete
MH, KL
Apr.15
GH
Apr.15
JM, ST
May.15
JM
May.15
GH
Apr.15
GH
Apr.15
ST
Apr.15
ALL
Ongoing
ST
Apr.15
Notes/evidence that
completed (or ref to relevant
agenda item)
AC
Chair
sign off
Page 9 of 9
139 of 155
10/12/2014-25/02/2015
18/12/2014
18/12/2014
27/01/2015
25/02/2015
122
123
124
125
SLaM
SLaM
Amadeus Properties Ltd
King's College Hospital
Kier Construction Ltd
SLaM
Deed of settlement in respect of part of second and third floors Leonard
House, 7 Newman Road, Bromley BR1 1RJ (2 copies)
The Fetal Medicine Foundation and
London Power Networks PLC
And
SLaM
Between
Underlease agreement in respect of flats at North House (2-8) and Middle
House (16-10) at Monks Orchard Road, Beckenham, Kent
(1 copy)
Lease in respect of a Transformer Chamber forming part of 16-20 Windsor
Walk (1 copy)
Memorandum of Agreement and Project order form in respect of the
refurbishment and alterations to Granville Park ( 1 copy each of the
Memorandum of Agreement and the Project Order Form
Description
DoF Report to Audit Committee Meeting 24th March 2015
Date
Number
Summary of Documents signed on behalf of the South London & Maudsley NHSFT where sealing is required
South London and Maudsley NHS Foundation Trust
Gus Heafield
Gus Heafield
Nick Dawe
Nick Dawe
Signature
Martin Baggaley
Matthew Patrick
Gus Heafield
Martin Baggaley
Signature
140 of 155
Appendix 1
10/12/2014-25/02/2015
18/12/2014
18/12/2014
29/01/2015
09/02/2015
25/02/2015
25/02/2015
25/02/2015
26/02/2015
02/03/2015
435
436
437
438
439
440
441
442
443
Variation to Contract in respect of the NIHR/BRC/BRU payment schedule
for 2015/2016 ( 2 copies)
Agreement of Providing Services from (1st April 2015-31st March 2016) ( 2
copies)
Agreement in respect of the Nursing Technology Fund (1 copy)
Clinical Trials Agreement Ref: 2013 - 002584-25 (3 copies)
Agreement in respect of the Cycle to Work Scheme (2 copies)
SLaM
SLaM
SLaM
SLaM
SLaM
SLaM
SLaM
Non-Disclosure Agreement Project Nash - confidential opportunity
comprising two mental health hospitals in the South and South East (1copy)
Engagement of Deloitte LLP as Auditors to SLaM 2014-2015 (2 copies)
SLaM
SLaM
Framework Agreement in respect of a Call-off contract under reference
RM1498 (2 copies)
Framework Agreement in respect of a Call-off contract under reference
RM1498 (2 copies) (Duplicate of entry 435 which was lost in transit)
Between
Description
DoF Report to Audit Committee Meeting 24th March 2015
Date
Number
Secretary of State for Health
Cygnet Health Care
NIHR/BRC/BRU
AFM Solutions
King's College London
Piramal healthcare UK Ltd
Deloitte LLP
Telefonica UK Ltd
Telefonica UK Ltd
And
Summary of Documents signed on behalf of the South London & Maudsley NHSFT where sealinsigning is required
South London and Maudsley NHS Foundation Trust
Zoe Reed
Zoe Reed
Gus Heafield
Gus Heafield
Martin Baggaley
Martin Baggaley
Gus Heafield
Paul Mitchell
Matthew Patrick
Gus Heafield
Signature
Gus Heafield
Martin Baggaley
Gus Heafield
Gus Heafield
Matthew Patrick
Gus Heafield
Gus Heafield
Nick Dawe
Signature
141 of 155
Appendix 1
I
TRUST BOARD OF DIRECTORS – SUMMARY REPORT
Date of Board meeting:
Name of Report:
28 April 2015
Board dates 2016
Heading: - (Strategy, Quality,
Performance & Activity,
Governance, Information)
Governance
Author:
Paul Mitchell, Trust Board Secretary
Approved by:
(name of Exec Member)
Matthew Patrick, Chief Executive
Presented by:
Roger Paffard, Chair
Purpose of the report:
To produce a full schedule of Board, Council of Governors, Board seminars and away days
for 2016.
Action required:
To agree.
Recommendations to the Board:
To agree and publicise in advance.
Relationship with the Assurance Framework (Risks, Controls and Assurance):
No direct link but earlier publication of key dates is good practice.
Summary of Financial and Legal Implications:
N/A
Equality & Diversity and Public & Patient Involvement Implications:
N/A
Patient quality implications
N/A
142 of 155
Board and Council of Governors dates 2016
Date
Meeting
26 January
Board
23 February
Board
10 March
Board seminar (2.00 – 4.00)
Council of Governors (5.00 – 6.30)
30 March
Board – this is a Wed as the Tue would follow the Easter
break
28 April
Board – this is a Thu
23 May
Board overnight
24 May
Board
16 June
Board seminar (2.00 – 4.00)
Council of Governors (5.00 – 6.30)
28 June
Board
26 July
Board
August
No Board
12 September
Board overnight
13 September
Board seminar (9.00 – 12.00)
Board (1.00 – 3.00)
Council of Governors (3.30 – 5.00)
Annual Public Meeting (5.30 – 7.00)
1 November
Board – (previous week is half term)
29 November
Board
15 December
Board seminar (2.00 – 4.00)
Council of Governors (5.00 – 6.30)
20 December
Board
143 of 155
May
Month
April
King’s College London as an academic partners within KHP
Public Sector Equality Duty – Local equality information
(action from Jan)
Public Sector Equality Duty – Workforce equality
recommendation (action from Jan)
Finance Report
Performance Report
Council of Governors Update
Chief Executive Report
Key issues and Minutes from Quality Committee Meeting
Assurance Framework Report
National Staff Survey – Action plan on Feedback from BME
Staff & POVA issues (action from March meeting)
IT Replacement Programme (action from March Meeting)
Strategy
Performance & Activity
Performance & Activity
Governance
Governance
Governance
Governance
Performance & Activity
Performance & Activity Discussion
Louise Hall/Radhika Nair
Gus Heafield
Roy Jaggon
Paul Mitchell
Paul Mitchell/ Matthew Patrick
Neil Brimblecombe/Lesley Calladine
Gus Heafield/Roy Jaggon
Neil Brimblecombe/Louise Hall
Stephen Docherty
144 of 155
Discussion
Discussion
Information
Information
Information
Discussion
Discussion
Discussion
Presentation
Strategy
Discussion
Discussion
Approval
Approval
Discussion
Decision
Discussion
Discussion
Information
Information
Information
Information
Information
Decision
Decision
Decision
Reason
Ed Byrne
Zoe Reed/Kay Harwood
P2
P2
P2
Quality
Performance & Activity
Performance & Activity
Governance
Governance
Governance
Governance
Governance
Quality
Cath Gormally/Matthew Patrick
Gus Heafield
Roy Jaggon
Paul Mitchell
Paul Mitchell/ Matthew Patrick
Matthew Patrick
Neil Brimblecombe/Lesley Calladine
Steven Thomas
Gus Heafield/Martin Baggaley/Psych
CAG
Gus Heafield
Louise Hall/Matthew Patrick
Gus Heafield
Monitor Return – Q4
HR IT System
Plan
Quality
Quality
David Norman/Matthew Patrick
David Norman/Matthew Patrick
Lewisham Mental Health Older Adults (action from Jan)
Approve outcome & recommendation consultation Inglemere
Unit
Social Care Strategy
Finance Report
Performance Report
Council of Governors Update
Chief Executive Report
KHP Update
Key issues and Minutes from Quality Committee meeting
Minutes from Audit Committee Meeting
Community Pharmacy Development (action from Feb)
Section
Lead
Item
SOUTH LONDON & MAUDSLEY NHS FOUNDATION TRUST
Forward Planner for Reports to the Board of Directors Meeting – 2015
Sept
July
June
Finance Report
Performance Report
Council of Governors Update
Chief Executive Report
Key issues and Minutes from Quality Committee Meeting
Eliminating Mixed Sex Accommodation
Safer Staffing update report (action from Jan)
Finance Report
Performance Report
Council of Governors Update
Chief Executive Report
KHP Update
Key issues and Minutes from Quality Committee Meeting
Assurance Framework Report
Minutes from Audit Committee Meeting
Workforce Update (action from Feb and deep dive follow up)
Commercial strategy (deep dive follow up)
Monitor return – Q1
Finance Report
Performance Report
Council of Governors Update
Chief Executive Report
Key issues and Minutes from Quality Committee Meeting
Lessons learned from CQC inspections (action from Feb)
Smoking Cessation (action from Feb)
Francis Report – Review best practice of how Board involves
patients (action from March Meeting)
Family and Carers Strategy
Value based healthcare (deep dive follow up)
Annual report and Accounts
Estates strategy
BDIC update
Gus Heafield
Roy Jaggon/
Paul Mitchell
Paul Mitchell/ Matthew Patrick
Neil Brimblecombe/Lesley Calladine
Neil Brimblecombe/Matthew Patrick
Performance & Activity
Performance & Activity
Governance
Governance
Governance
Quality
Quality
Performance & Activity
Performance & Activity
Governance
Governance
Governance
Governance
Governance
Governance
Governance/Strategy
Strategy
P2
Strategy
Strategy
Zoe Reed
Neil Brimblecombe/Martin Baggaley
Neil Brimblecombe
Gus Heafield
Roy Jaggon
Paul Mitchell
Paul Mitchell/ Matthew Patrick
Matthew Patrick
Neil Brimblecombe/Lesley Calladine
Gus Heafield/Roy Jaggon
Steven Thomas
Louise Hall/Matthew Patrick
Emily Buttrum/Matthew Patrick
Gus Heafield
Performance & Activity
Performance & Activity
Governance
Governance
Governance
Quality
Quality
Quality
145 of 155
Discussion
Discussion
Information
Information
Information
Discussion
Discussion
Discussion
Discussion
Information
Information
Information
Information
Discussion
Information
Information
Discussion
Approval
Approval
Discussion
Discussion
Discussion
Information
Information
Information
Discussion
Discussion
Discussion
Performance & Activity Approval
P2
Approval
P2
Discussion
Gus Heafield
Roy Jaggon/
Paul Mitchell
Paul Mitchell/ Matthew Patrick
Neil Brimblecombe/Lesley Calladine
Neil Brimblecombe
Neil Brimblecombe
Zoe Reed
Gus Heafield/Sarah Crack
Mark Allen
Alan Downey/Emily Buttrum
Feb
Jan
2016
Dec
Nov
Oct
Trust Quality Strategy (action from Feb 15)
HR Annual Plan
Monitor return – Q3
Finance Report
Performance Report
Council of Governors Update
Chief Executive Report
Key issues and Minutes from Quality Committee Meeting
Contracting update
R&D Annual Report
Finance Report
Performance Report
Council of Governors Update
Chief Executive Report
Key issues and Minutes from Quality Committee Meeting
Finance Report
Performance Report
Council of Governors Update
Chief Executive Report
KHP Update – Robert Lechler
Key issues and Minutes from Quality Committee Meeting
Assurance Framework Report
Minutes from Audit Committee Meeting
Risk Management Assurance Strategy (update)
Monitor return – Q2
Healthcare strategy (deep dive follow up)
Arts Strategy
EPIC Annual Report
Neil Brimblecombe/Matthew Patrick
Louise Hall/Matthew Patrick
Gus Heafield
Gus Heafield
Roy Jaggon
Paul Mitchell
Paul Mitchell/Matthew Patrick
Neil Brimblecombe/Lesley Calladine
COO
Gill Dale/Tom Craig
Gus Heafield
Roy Jaggon
Paul Mitchell
Paul Mitchell/Matthew Patrick
Neil Brimblecombe/Lesley Calladine
Gus Heafield
Roy Jaggon
Paul Mitchell
Paul Mitchell/Matthew Patrick
Matthew Patrick
Neil Brimblecombe/Lesley Calladine
Gus Heafield/Roy Jaggon
Steven Thomas
Gus Heafield/Roy Jaggon
Gus Heafield
Matthew Patrick
Matthew Patrick
Zoe Reed/Matthew Patrick
Strategy
P2
Performance & Activity
Performance & Activity
Governance
Governance
Governance
Performance & Activity
Presentation
Performance & Activity
Performance & Activity
Governance
Governance
Governance
Performance & Activity
Performance & Activity
Governance
Governance
Governance
Governance
Governance
Governance
Governance
P2
Strategy
Strategy
Strategy
Decision
Discussion
Approval
146 of 155
Discussion
Discussion
Information
Information
Information
Discussion
Discussion
Discussion
Discussion
Information
Information
Information
Discussion
Discussion
Information
Information
Information
Information
Discussion
Information
Decision
Approval
Discussion
Discussion
Discussion
K
TRUST BOARD OF DIRECTORS – SUMMARY REPORT
Date of Board meeting:
Tuesday 28 April 2015
Name of Report:
Annual Report publication schedule
Heading:
Governance
Author:
Sarah Crack
Approved by:
Matthew Patrick
(name of Exec Member)
Presented by:
Matthew Patrick
Purpose of the report:
To present to the Board the publication schedule for the 2014/15 Trust Annual Report.
The Trust is required to report to Monitor and publish this report annually which includes the
Trust’s financial accounts and quality report.
The Annual Report is a vital tool that allows the Trust to communicate important information
to its key stakeholders: parliament, patients and the public.
The purpose of the report is to: make the Trust more transparent and accountable for our
performance, to engage both our stakeholders and staff in the improving quality, and
demonstrate real improvements in care.
Action required:
The Board are asked to note the timeline for the production of the report.
Recommendations to the Board:
The Board are asked to endorse the suggested structure and contents for the Report and
note that a near final draft of the Report will be presented at the May 2015 Board meeting.
Relationship with the Assurance Framework (Risks, Controls and Assurance):
Service quality is one of the three domains of the assurance framework.
Summary of Financial and Legal Implications:
The Trust is required by law to report annually on quality and publish its financial accounts.
Equality & Diversity and Public & Patient Involvement Implications:
There are no immediate and direct implications to equality & diversity and public & patient
involvement
147 of 155
SLaM Annual Report production 2014/15
Production schedule
Thursday 23 April
Monitor deadline: draft text and accounts to
auditors
Tuesday 28 April
Trust Board meeting: receive production
schedule with cover note
Tuesday 19 May
Near final version of Annual Report included in
May Board papers for sign off.
Tuesday 26 May
Special Audit Committee meeting: to receive
auditor’s update
Tuesday 26 May
Trust Board meeting: review near final Annual
Report and agree that MP / GH will have final
sign off on behalf of the Board on Thursday 28
Wednesday 27 May
Final amends by close of play
Thursday 28 May
Sign off by MP/GH close of play
Friday 29 May
FINAL Monitor deadline 12:00 noon
No amendments on this day
Annual report contents
1. Message from the Chair
2. Strategic report
3. Directors’ report
4. Remuneration report
5. Our people: patients, staff and partners
6. Research, teaching and training
7. Quality report
8. Annual accounts
148 of 155
The strategic report must be
approved by the directors and signed
and dated by the Accounting Officer.
About our Trust
2. Strategic report
a brief history of the foundation trust and its
statutory background;
Developing commercial partners
employees.
o
Our performance
x
other senior managers; and
o
a breakdown at year end of the number of
male and female:
x
directors;
a description of the foundation trust’s
business model;
x
o
a description of the foundation trust’s
strategy;
x
must also include:
Our strategic direction
x
Must include:
(including KHP, our purpose and values)
Review of year
Section
1. Message from the Chair
Chapter
Paul Mitchell
Sarah Crack
Responsibility
for coordinating
chapter
content
Adam Pryce
Louise Hall
Zoe Reed/Kay
Harwood 81665
Sarah Crack
Contribution
from
Sign off /
signature
required
Received
1 April.
Received
149 of 155
Use business
model from last
yr’s AR
Deadline 1st
draft received /
notes
the position of the business at the end of the
financial year;
a description of the principal risks and
uncertainties facing the foundation trust.
x
x
a note explaining that the accounts have
been prepared under a direction issue by
Monitor under the National Health Service Act
2006;
an analysis using financial and other key
performance indicators, including information
relating to employee matters and
environmental matters;
the main trends and factors likely to affect
the foundation trust’s future development,
performance and position;
the financing implications of any significant
changes in the foundation trust’s objectives
and activities, its investment strategy or its
long-term liabilities (including significant
provisions and PFI and other leasing
contracts);
x
x
x
x
Must include
including income and expenditure; charitable funding
Financial performance
a fair review of the foundation trust’s
business ( the development and performance
of the NHS foundation trust during the
financial year)
x
Must include:
84717
Dep.Dir Finance
Barry Ashworth
Mark Nelson /
Dep Dir. Finance
84718
Head.Perf.Mgme
nt. 81683
Roy Jaggon
84986
Dep.Dir.Finance
Tim Greenwood
Rec’d
150 of 155
Received – with
sections to
confirm
4. Remuneration report
3. Directors’ report
an explanation of the adoption of the going
concern basis where this might be called into
doubt
Trust Management Executive, CAGs and CAG
Leadership
Our membership
x
x
Disclosures in the public interest
Roy Jaggon
Board remuneration report
x
Carol Stevenson
Regulatory rating report
Board Committees – attendance, membership
and purpose.
x
Pam Russell
Paul Mitchell
Mark Nelson
Board of Directors’ biographies
x
Paul Mitchell
Mark Nelson /
Barry Ashworth
Board remuneration report
Statement of disclosure to the auditors
(Directors’ fair, balanced and understandable
statement)
x
Board of Directors
Board, Council of Governors and subcommittees - composition, attendance, role
and responsibilities, elections
x
An explanation of:
Our organisational structure
x
Going concern
Yes
Matthew
Patrick
Yes
Matthew
Patrick
Rec’d
151 of 155
Paul M providing
narrative on
Board subcommittees.
Use statement
from pg 21 last
yr’s AR
Paul Mitchell to
supply content
(from MP Monitor
letter) for
narrative
Yes
5. Our people: patients,
staff and partners
Info on occupational health
Better payment practice code
Details of consultations
Consultations with local groups eg. O&S
Countering fraud and corruption
PPI involvement
x
x
x
x
x
x
environmental matters (including the impact
of the foundation trust’s business on the
environment);
the trust’s employees; and
social, community and human rights issues;
including information about any trust policies
in relation to these matters and the
effectiveness of those policies.
Listening to patients; Learning from
complaints; patient involvement; patient
information; our staff; communicating with
staff; staff survey; equality and diversity;
training and development; Get Involved;
EPIC; Partnerships (KHP, SLIC, Maudsley
Charity)
x
x
x
x
x
information about:
Our people: patients, staff and partners
The role of internal audit
Info on H&S performance
x
Sarah Crack
Zoe Reed / Kay
Harwood
Louise Hall
Graham Richards
Mark Nelson
Kay
Harwood/Ray JC
Dave Kenealy
Zoe Reed
Mark Nelson
Michael Kelly
Cherry Cornelius
84623
Geoff Wake
providing info.
152 of 155
Foreword to the accounts
8. Annual Accounts
Notes to the accounts and full accounts
Independent Auditor’s report to the Council of
Governors and Board of Directors
Annual Governance Statement
Statement of the Chief Executive’s responsibilities as
the Accounting Officer
Including Auditor’s report to the Council of Governors
on the Quality Report and the Chief Executive’s
statement
Teaching and training; Maudsley SIM; BRC; Clinical
Research Facilities; involving patients;
Research and teaching and training
7. Quality report
6. Research , teaching and
training
Staff survey
Mark Nelson
Mary O’Donovan
Gill Dale
Sarah Crack
Michael Kelly
Yes,
Matthew
Patrick
153 of 155
Received - Mary
will have as much
as possible ready
to send to
auditors on 23
April and will
send to Comms
before this date
excl. stakeholders
comments
Rec’d 5 March
Rec’d
Rec’d 2/04/15
L
TRUST BOARD OF DIRECTORS – SUMMARY REPORT
Date of Board meeting:
Name of Report:
28 April 2015
Report from previous month’s Part 2 meeting
Heading: - (Strategy, Quality,
Performance & Activity,
Governance, Information)
Governance
Author:
Paul Mitchell, Trust Board Secretary
Approved by:
(name of Exec Member)
Matthew Patrick, Chief Executive
Presented by:
Roger Paffard, Chair
Purpose of the report:
To produce a summary report for consideration in the part of the Board meeting held in
public which lists the items which were discussed in the P2 (private) meeting the previous
month.
Action required:
To note.
Recommendations to the Board:
To agree whether this report should be produced for future Board meetings.
Relationship with the Assurance Framework (Risks, Controls and Assurance):
No direct link but the report increases the transparency of the Board’s governance
arrangements.
Summary of Financial and Legal Implications:
N/A.
Equality & Diversity and Public & Patient Involvement Implications:
N/A
154 of 155
Ref
BOD PTII 16/15
BOD PTII 17/15
Date of
meeting
24 March
24 March
Part 2 report to Board
Plan update
Forensic update 2015/16
Item discussed
Discussion on
negotiations with NHSE.
Update for the Board on
the production of the
2015/16 Plan
Summary of discussion
Gus Heafield
Gus Heafield
Lead Director
Commercial in confidence
Commercial in confidence
Reason for taking in P2
155 of 155