Board of Directors – Public Session
Meeting to be held on Thursday 28th August 2014 at 09:30
in the Elisabeth Room, Endeavour House, 8 Russell
Road, Ipswich, IP1 2BX
(Please note that there is no parking at Endeavour House, but there is ample parking in
Portman Road)
AGENDA
Time
Item No
09:30
14.105
Chair’s welcome, apologies for absence and
notification of any urgent business.
Apologies:
14.106
Standing Item: Declarations of Interest
Verbal
09:35
14.107
To note the minutes of the previous meeting in
public, held on 26th June 2014
Attachment A
09:40
14.108
Chair’s report (Gary Page)
Attachment B
09:55
14.109
CEO’s report (Michael Scott)
Attachment C
14.110
Items For Approval
10:10
i.
Risk Register (Jane Sayer)
Attachment D
10:20
ii.
Board Assurance Framework (Robert Nesbitt)
Attachment E
10:30
iii.
Patient Safety and Quality Report - (Jane Sayer)
Attachment F
10:45
iv.
Finance Report Month 04 (Andrew Hopkins)
Attachment G
11:00
v.
Business Performance Report Month 04 (Andrew
Hopkins)
Attachment H
11:15
BREAK
14.111
11:25
i.
14.112
11:25
i.
Items for Debate
None
Items for Information
Lorenzo update (Leigh Howlett) Dave Huggins in
attendance
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Time
Item No
11:55
ii.
Volunteer service update (Jane Sayer)
Attachment I
12:10
iii.
Audit & Risk Committee – Chair’s Report 13th Aug
2014 (John Brierley)
Attachment J
12:20
iv.
OD and Workforce Committee 26th Aug 2014
(Brian Parrott)
12:25
v.
Charitable Funds Committee - Chair’s Report 11th
August 2014 (Graham Creelman)
12:30
14.113
Any other urgent business, previously notified
to the Chair
12:35
14.114
Date, time and location of next meeting
Verbal
Attachment K
The next meeting in public of the Board of
Directors will be held on:
Thursday 23rd October 2014 at 09.30 am at the
Kirkley Centre, 154 London Road South,
Lowestoft, Suffolk, NR33 0AZ
Note - The AGM will be held on 19th September
2014 at Trinity Park, Ipswich, c. 17.30 (see
www.nsft.nhs.uk for details).
12:40
14.115
13:00
Motion to pass resolution to hold board meeting in
private in order to discuss confidential matters.
(Gary Page).
CLOSE
Robert Nesbitt
Trust Secretary
th
19 Aug 2014
I:\Trust Secretariat\Board of Directors - Public\Public BoD 2014\05. 28 Aug 2014\Agenda PUBLIC BoD 28Aug2014 Final.doc
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Date:
28 August 2014
Item:
14.107
A
Confirmed
Minutes of the Board of Directors – Public Session
held on 26th June 2014 at 09:30
in the Captain Paul Watson Room,
Green Britain Centre (formerly Echotech),
Turbine Way, Swaffham PE37 7HT
Present:
Barry Capon (Chair)
Michael Scott: CEO
Leigh Howlett: Commercial Director
Andrew Hopkins: Director of Finance & Performance
Jane Sayer: Director of Nursing, Quality and Patient Safety
Kathy Chapman: Director of Operations – Norfolk & Waveney
Debbie White: Director of Operations – Suffolk
Jane Marshall-Robb: Director of Workforce & OD
John Brierley: Non-Executive Director
Brian Parrott: Non-Executive Director
Stuart Smith: Non-Executive Director
Adrian Stott: Non-Executive Director
In attendance:
Robert Nesbitt: Trust Secretary
Alex Petty: Acting Asst. Trust Secretary (minutes)
Sara Fletcher: DIPC: Physical Health Team Leader (present for Item 14.81iii)
Julian Beezhold: Consultant Psychiatrist (present for item 14.82i)
Chris Hardwell: Deputy Services Manager (present for item 14.82i)
Clive Hudson: Consultant Counselling Psychologist (present for item 14.82i)
Alison Simpkin: Deputy Community Service Manager – Adult (present for item
14.82i)
Imogen Kirk: Team Leader in Adult Social Care (present for item 14.82i)
Jonathan Wilson: Consultant Psychiatrist (present for Item 14.82ii)
Bonnie Teague: Research Manager (present for Item 14.82ii)
Fraser McKay: Communications Officer
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There were eight governors, 10 members of staff and public, two
representatives of Advantage Healthcare, three members of Norfolk County
Council and one representative from the EDP in attendance.
Meeting commenced at: 09:30
There was a break at 11:10 until 11:25
Certain items were taken out of order, but for clarity the minutes reflect the agenda
14.75
Chair’s welcome, notification of any urgent business and apologies for
absence
Barry Capon welcomed those present including the attending Governors and
members of the Campaign. The structure of the meeting, and how questions
would be taken from the public was then explained.
There were no notifications of urgent business.
Apologies for absence were received from Gary Page, Graham Creelman,
Hadrian Ball and Peter Jefferys.
14.76
Standing Item: Declarations of Interest
There were no declarations of interest.
14.77
To note the minutes of the previous meeting held in public on 24th April
2014
The minutes had been previously approved but the following additional
change was requested: Min 14.47: change to read “Brian Parrott asked for
clarification about the medical vacancy in the Learning Disability (CAMHS Child and Adolescent Mental Health) service and asked how much this was a
cause for concern.”
The minutes were re-approved for release in accordance with the Freedom of
Information Act subject to the above change being made.
14.78
i.
To address any Matters Arising from the minutes of the previous meeting,
not covered by the Agenda
Min 14.16iii: The report on the flu vaccination plan will come back to the June
2014 public Board meeting. (Jane Sayer)
Although an update was provided at the May 2014 Board of Directors meeting,
Jane Sayer re-confirmed that this year NSFT would not be offering staff a day’s
leave as part of the flu vaccination plan. Jane Sayer informed the board that
the NSFT target was 75%, and that they would be working hard to achieve that.
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14.79
Chair’s report
In Gary Page’s absence, Barry Capon introduced the Chair’s report and invited
questions from the board.
Brian Parrott requested that under item 4.2, Key Observations, a discussion
was had regarding Woodlands and acute beds. Michael Scott confirmed that
these issues would be covered in later reports.
14.80
Chief Executive’s report
Michael Scott introduced his report and said he wanted to highlight three areas:
As part of his recent appointment as Chief Executive, he informed the board
that he had visited several services over the past month, especially those in
Suffolk namely: Ipswich, Bury St. Edmunds and Newmarket. During these visits
Michael Scott reported that he was grateful to have been well received by staff
and found them to be proud of the services they worked for.
Michael Scott said he recognised that numbers of out of area beds had been
unacceptably high and that it was an area of concern for the Trust, but assured
those present that it was being addressed.
Questions and comments were then invited from the public, and received as
follows:
It was reported by a member of the Campaign that the services were not
safe, that the staff were not proud, that morale was low, and that there
was concern over the continued use of agency staff. Michael Scott
provided assurance that the Trust was aware of these issues, and
recognised that it had the responsibility to put it right.
Concerns were raised about use out of area non-specialist beds,
especially for under 18’s and Kathy Chapman agreed to clarify the
numbers of under 18s affected.
The question of how the Trust ensured that service users were heard
was raised. Michael Scott said that he had spoken with two service
users that day, and had had regular dialogue with service users over the
past month. The proposal was to engage with service users and obtain
their views by both direct personal contact, and via forums and user
councils.
Brian Parrott stressed the importance of the Health and Wellbeing boards, and
asked about their progress in Norfolk. Michael Scott responded saying that the
Suffolk Health & Wellbeing board was functioning well, but that he had yet to
attend a board in Norfolk where the Clinical Commissioning Groups (CCGs)
were leading on integration items with the support of Norfolk County Council.
14.81
i.
Items for Approval
Trust 5 year strategic plan (Leigh Howlett)
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Leigh Howlett presented the 5 year strategic plan, and explained that an early
draft version of the working document had been previously circulated and that
today’s presentation was in order to gain approval for the final version of the 5
year strategic plan which would be submitted to Monitor on Monday 30 th June
2014.
Leigh Howlett described the engagement process that had taken place across
the two counties and presented five strategic options explaining that the
preferred option would set the Trust’s strategic intention and direction. See
slides.
Barry Capon added that the strategic plan was an overview, and whilst
comments on the key themes could be made, the plan could not at this point be
re-designed. Barry Capon then invited questions from the board:
Stuart Smith said that the Finance & Performance Committee had reviewed the
financial envelope and were satisfied with the financial assumptions had been
included in the strategic plan. Stuart Smith added that the power of the
document was that it put the information, including increased demands and
constrained resources, into the public domain.
Brian Parrott said that the plan formed a good strategic basis and requested the
following minor amendments:
-
‘Integration of health’ to read, and be referred to as: ‘integration of health
and social care’.
-
Health & social care to read, and be referred to as: ‘Health and social care
economy’.
-
Care to be taken over the use of the word ‘rural’ since most people in
Suffolk and Norfolk live in small towns.
The above comments were noted by the board.
Brian Parrott added that as a responsible public body, the Trust must
acknowledge the reality of the financial situation and reflect it honestly.
Referring to the 4% efficiency figure, John Brierley said that in the absence of
payment by results (where income reflects activity) the Trust could be facing a
factor of at least 7.5%. Andrew Hopkins said that a key debate had been parity
of esteem and whether the Trust could expect a 2% uplift of funding. Andrew
Hopkins said that a serious position was being presented: the plan reflected a
4% reduction of cost reduction, and was conservative about assumptions of
some funding coming back the other way reflecting parity of esteem. At some
point the Trust would go into deficit unless these factors were addressed.
Michael Scott said that it was important to note that the plan was a strategic
framework, and the dialogue for its implementation started today. The board did
not want to see funding reduce, and that the Trust was reflecting a national
situation. Michael Scott said that the board must lobby and work hard to ensure
the Trust saw as much resource as possible.
In response to a question asking whether there was anything in the strategic
plan about the S75 agreement, and the reduction of social workers in teams
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Michael Scott said that the Trust was already in discussion with Harold Bodmer
(Norfolk County Council) about how to integrate services.
Option two (with amendments on the wording and inclusion of social care) was
approved by the board. It was confirmed that comments on the draft 5 year
Strategic Plan could be emailed to [email protected] and that
the plan would be submitted to Monitor by 30th June 2014.
ii.
Patient Safety and Quality Report (inc. Safe Staffing update) (Jane Sayer)
Jane Sayer updated the board on the complaints process which had been
changed as a result of feedback from governors and Non-Executive Directors.
Jane Sayer reported that there had been fewer complaints received in May
2014, but that there were a number of repeat complaints. This was being
analysed and results would become available in July 2014. In the future, figures
presented would include a denominator so that the relative levels could be
judged. Jane Sayer stressed the importance of reserving judgement at this
stage saying that variations could also be due to certain teams encouraging
feedback more than others. It was confirmed that future analysis would include
break down by specific areas.
In response to a question relating to the number of unallocated cases and the
implications on patient safety & quality of care, Jane Sayer guided those
present through the data presented in the report, including Serious Incidents
and Harm-free Care.
Jane Sayer referred to the data in Chart 2: Trust-wide Serious Incidents
Reported and said that a final version of the Root Cause Analysis paper would
be available soon. Barry Capon added that where there were inpatient deaths
and very serious incidents, two Non-Executive Directors were involved in setting
the terms of reference for the reviews.
Jane Sayer said of medication errors that there were no harms reported as a
result of those recorded, and in response to a question about the increase of
medication errors in Suffolk explained that am audit had identified one particular
unit where medication had not been recorded to the required standards on the
chart. The Trust had provided further training on accuracy and medication
recording for the staff concerned, and the service would be re-audited to ensure
that there was no recurrence.
Responding to a request to see more information on equality and diversity and
a breakdown of complaints data into categories by protected characteristics,
Jane Sayer said that this type of detail was sometimes difficult to measure as it
had to be offered by the complainant, and wasn’t always provided. Robert
Nesbitt added that the under the Equality Delivery System these characteristics
would be monitored, but that it was difficult to interpret data when absolute
numbers were so small. It was therefore important to draw on qualitative data
from people who use the Trusts’ services as well as quantitative and this is one
of the Trust’s equality objectives.
Jane Sayer provided an update on the number of assaults in Norfolk, and noted
that the incidents reported on Blickling Ward related to an area where patients
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with dementia could at times be distressed. In response to Stuart Smith’s
question on levels of challenging behaviour in learning disability services, Brian
Parrott noted the skills with which staff support people who present with these
needs in our services.
Jane Sayer reported that level 3 safeguarding training was now up to 92% but
that they were continuing to promote it and that the NFST Safeguarding
strategy was being in launched in July 2014.
Jane Sayer updated the board on the independent management reviews into
the deaths of two patients with learning disabilities who had physical health
problems explaining that the reports were expected to be published in late
summer 2014.
Jane Sayer said that in preparation for the full Care Quality Commission (CQC)
inspections in October 2014, mock inspections were on-going with Governors
and Non-Executive Directors’ help.
Regarding safe staffing, Jane Sayer said that this was the first report following
on from Hard Truths and set out staffing numbers against establishment. The
lack of e-rostering made this difficult but Jane Sayer said she was confident that
the reports contained as accurate figures as possible. Jane Sayer explained
that NHSP reported a national increase in the need for registered nurses
therefore it was sometimes difficult to provide back-fill. The development plan
for healthcare assistants was in place and the Trust was actively encouraging
staff to report concerns through Datix.
Jane Sayer said that they had agreed to look at how NHSP are encouraged to
modify the recruitment process in order to make it more flexible and Brian
Parrott added that staff needed to provide NHSP with more warning when
registered nurses were needed and that local teams should be as anticipating
as possible. Michael Scott said that staffing levels should be decided according
to the needs of the patients who were on the ward.
In response to a question requesting clarity on staff establishment at
Sandringham Ward, Jane Sayer said that there had been a health and safety
review of the unit and staffing requirements had been discussed with the team
leader. Jane Sayer confirmed that permanent staff on their establishment had
been for 22 patients, although there were now 15 and the permanent
establishment was for 12 beds.
Referring to Table 6: mean staffing, actual against establishment, Jane Sayer
explained that staff were involved in creating action plans and monitoring them.
Under service user & carer experience, Jane Sayer acknowledged that further
work was needed to improve involvement and provided an update on the work
currently being undertaken and the upcoming engagement events.
In response to a comment from the public that parents and carers in the youth
service had felt in limbo since the merger, and that the Trust needed to go
beyond the Youth Council to address service users more widely, Debbie White
said she recognised that there was a gap for carers, and that the Trust were
working on improving the focus on under 18s. Debbie White continued by
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saying that she would arrange a meeting with CYP Participation Lead, Emma
Corlett and the public member concerned.
John Brierley said that the Triangle of Care was designed to improve
engagement and support although it was also noted that the Triangle of Care
was concerned with the needs of the service user more than those of the carer.
Barry Capon requested that Jane Sayer consider this issue as part of the review
of the user and carer strategy and for this to return to the Board.
In response to a question on the current travel policy for carers visiting patients
placed out of area, Debbie White said that the Trust reimbursed travel costs and
that she would send the individual a copy of the policy.
In conclusion Jane Sayer updated the board on the Quality Dashboard and said
that she was working with Informatics to develop denominators. Jane Sayer
confirmed that the finalised Quality Dashboard would be brought to the August
2014 board.
Action 14.81ii
a. The topic of care for carers, with a focus on Norfolk Carers, to be considered
by the board (Jane Sayer to propose date and to lead).
b. Debbie White to initiate contact between Emma Corlett and the member of
the public who raised a query about the profile of the Youth Council before next
board meeting.
c. Carer Travel Policy to be emailed to the member of the public who raised this
query (Debbie White) before next board meeting.
d. Finalised Quality Dashboard to be taken to August 2014 board (Jane Sayer)
iii
Infection prevention and control report, and physical health report (Jane Sayer,
Sara Fletcher in attendance)
Sara Fletcher presented the third bi-annual report and quarterly update on
infection control.
Work was in progress to develop a physical health strategy; Stuart Smith would
be the Non-Executive Director of this group, which would report to the Service
Governance Committee.
Sara Fletcher said that the CQUIN goals regarding inpatient areas were
welcomed, and highlighted that the Trust had achieved its 2013 goal on
schizophrenia. Sara Fletcher spoke of the importance of embedding work in the
community, and in community teams saying that it was a big part of the work
being done. Sara Fletcher further added that her deputy had recently secured a
two day a week secondment post to Suffolk CCG.
Sara Fletcher provided an update on education and training, and emphasised
that the Trust needed a skilled workforce with staff that recognised when they
needed training, and attended accordingly. Sara Fletcher confirmed that the
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Physical Health Strategy Group would be responsible for assessing training
needs.
Brian Parrott asked whether, in relation to resuscitation, clinical leads were
more engaged and Sara Fletcher confirmed that this was the case.
Sara Fletcher assured the board that repeat incidents such as pressure ulcers
were acted on and underwent Root Cause Analysis, a process she was
involved in.
John Brierley asked whether GPs should be carrying out physical health checks
in the community rather than the Trust. Sara Fletcher said that she was
working with CCGs to address this question, including the use of GP SMI
registers. It was important to address the poor health outcomes for people with
mental health problems and there was a 3 stage approach to primary care
involvement but that ultimately the individual patients’ needs needed to be
paramount.
In response to a question from the public regarding efforts to prioritise the
Trust’s most vulnerable patients Kathy Chapman responded by saying they
were looking carefully at the work of Assertive Outreach Teams and national
research on the best models. The aim was to ensure that the needs of the most
vulnerable service users were addressed. Debbie White added that the FACT
(Flexible Assertive Community Treatment) model was in place in Newmarket
and whilst not fully implemented was showing encouraging results.
Sara Fletcher provided an update on infection control, confirming that there
were no major outbreaks to report. Regarding the 75% flu vaccination target,
Sara Fletcher said that support would be needed from across the Trust
including Occupational Health & HR to achieve this.
iv.
Financial Performance Report for 2014-15 Month 02 (Andrew Hopkins)
Andrew Hopkins introduced the report for Month 02 and said that overall the
Trust was on plan, but asked the board to note three main issues:
The first was secondary commissioning and out of area/specialist placements.
Andrew Hopkins reported a reduction in figures due to discharges in services,
but reported that costs for external acute placements were significantly higher
than in the same period last year (April-May).
Regarding pay and temporary staffing Andrew Hopkins said that he had written
to Executive Directors requesting a review of the figures in order to reduce the
rising costs. Andrew Hopkins added that the high numbers of temporary staff
recruited to implement Lorenzo were nationally funded.
Andrew Hopkins said that CIP programme was slightly behind plan, but That the
Trust was maintaining a COSRR rating of 3. Andrew Hopkins advised that there
was a £4.4m gap (i.e. there was no firm plan in place as yet) and that this had
been discussed at the Executives meeting, and proposals would be taken to the
Finance & Performance Committee (F&PC).
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Brian Parrott noted that the work of the Suffolk CRHT teams in avoiding
admissions and asked whether there was a similar focus in Norfolk. Kathy
Chapman said staff were working hard and were under considerable pressure
but that the number of adult 18-65 admissions had decreased slightly.
Questions and comments were then received from the public.
Regarding patients travel costs, Michael Scott and Andrew Hopkins
confirmed that ambulance costs were covered under the terms of the
Patient Transport Contract and paid by the Trust.
Concern was raised regarding the Trusts’ spending rate: current figures
totalling £4.5m on out of area placements and £10m on salaries were
confirmed by Andrew Hopkins who went on to say that whilst the figures
quoted were accurate, the issue of acute placements was not a new one,
and had been on-going for the past 12 months. Despite these pressures,
the Trust was on plan financially.
Concern was raised regarding the impact of the Trusts’ use of temporary
and agency staffing, an example being given of a temporary member of
staff who had been in post for two years, but not recruited permanently.
Jane Marshall-Robb said that she would be reviewing this.
v.
Monitor governance compliance statements (Robert Nesbitt)
Robert Nesbitt explained that Monitor required all Trust boards to confirm their
compliance statements, and that he was seeking the board’s review and
approval of the statements and mitigations within the report in order to submit
them to Monitor by 30th June 2014.
Following a review of the statements, the board approved them for submission
to Monitor.
vi.
Communication Committee Terms of Reference (Leigh Howlett & Graham
Creelman)
Approved.
14.82
i.
Items for Information
Care Pathways (including discharge planning) (Kathy Chapman)
Kathy Chapman gave a presentation on care pathways and began by
explaining that a year ago there had been no acute mental health out of area
placements. Today, there were fourteen.
Referring to admissions, discharges, and length of stay slide data for 18-65 year
olds, Kathy Chapman said that there were no more admissions than the year
before, and that although the median length of stay looked high, it was actually
steady. Kathy Chapman explained that when individual wards were looked at in
detail, it became clear that there was a group of patients occupying beds for
longer periods of up to 100-200 days, the impact of which was that the beds
were not available for new admissions.
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Kathy Chapman said that how to improve this was a question that both the
Trust and Commissioners were working on.
It was clear that the Crisis
Resolution Home Treatment (CRHT) had been under pressure and changes to
the ways of working were needed to address this. Kathy Chapman informed
the board that as part of the system-wide action plan, Commissioners had
provided funding for specific posts to enable the CRHT to focus on their areas.
It was recognised that the Trust needed to increase alternatives to admission
enabling service users, including those that were homeless, to step down from
acute services to more appropriately supported arrangements.
Julian Beezhold presented an example of the sorts of needs which service
users had said that this had been chosen as it illustrated themes common to
many people.
A further case was presented by Clive Hudson demonstrating the week by week
progression, and overall timescales involved in care pathways and discharge
planning. Kathy Chapman said that along with Clinical Commissioning Groups
and Commissioners, the Trust was learning from these cases and focussing on
increasing the flow of patients through wards.
Questions and comments followed:
Brian Parrott said that the presentation showed a slow, progressive ‘one
step at a time’ sequence that under the Continuing Healthcare Checklist
(CHC) took too long to get from one stage to another. Brian Parrott
thought that progress could be more active. Whilst acknowledging this it
was also noted that some of the ‘delays’ were actually appropriate and
part of the clinical process.
Governor Dr Duncan Double said that the graph data displayed showed
the median length of stay as static and queried whether, if this was the
case, the problem was due to planning, and so the beds in Norfolk might
need to be increased. It was noted that this year had seen investment by
the Clinical Commissioning Group, and that there were also plans to
increase community services. Michael Scott said that it was also
possible to provide appropriate support to some people without admitting
them.
Following comment from a member of staff that accessing Central
Norfolk beds had been a problem since 2012, Julian Beezhold
responded saying that demand for acute beds had actually gone down in
Central Norfolk, and that the median length of stay over the past six
months had been 23 days per admission in comparison to 25 days per
admission ten years ago. Four years ago, the median length of stay was
12 days per admission. Julian Beezhold said that in Central Norfolk,
particular factors such as rising numbers of Crisis Team caseloads were
a large factor, but that these had reduced from 70 to 40 which was more
appropriate.
Concluding the item, Barry Capon summarised the discussion and said that the
Board would continue to be kept informed on this important matter.
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ii.
Update on Trust research activity (Jon Wilson & Bonnie Teague)
Jon Wilson and Bonnie Teague supported their Research Update Report with a
PowerPoint presentation (see slides) and briefly highlighted their proposal to
invest in and develop three areas of mental health research, namely: Child &
Youth, Adult and Dementia and complexity in later life. Jon Wilson informed the
board that a strategy had been developed over the past six months, and that
they were seeking board approval and support to implement the plan. Jon
Wilson stressed the importance of the Trusts’ participation in national research
and emphasised that the sooner the proposal itself was approved, the sooner
research grant applications could be made.
Bonnie Teague drew the board’s attention to the research training programme
and the launch of Inspire at the end of May 2014: a strategy that involved
service users, public and carers in mental health research.
Barry Capon reminded those present that that the presentation came as a result
of the board’s request for focus on research, and that the proposal should be
fully reviewed by Finance Department before coming back to board for
approval.
Action 14.82ii
The research paper costings set out in Jon Wilson and Bonnie Teague’s report
to be reviewed by Finance with report and recommendation coming back to
August 2014 board (Andrew Hopkins).
14.83
Standing Item: Have the most pertinent items of the agenda have been
reviewed adequately and at the beginning of the agenda? (All)
Barry Capon recognised that whilst all important items had been covered, time
constraints mean that some items received less than optimal time.
14.84
Any other urgent business, previously notified to the Chair=
There were no other items of urgent business.
14.85
Date, time and location of the next meeting
The next meeting in public of the Board of Directors will be held on:
28th August 2014 at Endeavour House, Russell Road, Ipswich, IP1 2BX
from 09:30
Meeting closed at: 13:40
Chair: ……...…..…………………………
Date: ……....…………………………….
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th
28 August 2014
14.108
Report To:
Board of Directors - Public
Meeting Date:
28th August 2014
Title of Report:
Chairs Report
Action Sought:
For Information
Estimated time:
15 minutes
Author:
Gary Page, Chair
Director:
Gary Page, Chair
B
Executive Summary:
The report details my most significant meetings and my key observations over the last
month.
1.0
Interaction with External Organisations
1.1
I met with Ken Applegate Chair of Norfolk Community Health and Care Trust .
They have recruited a new CEO on an interim basis Roisin Fallon-Williams.
1.2
I met with Chris Lawrence the new Chair of Hertfordshire Partnership Mental
Health Trust. Interestingly they operate with far fewer Board Meetings all of which
are in public, they are likely to increase the number of Board meetings but are still
likely to operate with substantially less than the 12 we have at NSFT.
1.3
I attended the Independent Advisory Group meeting run by the Norfolk Police
and Crime Commissioner as Mental Health was on the agenda. The Norfolk
Constabulary gave a very positive report on improving working relationship with
the Trust and especially the impact on having our staff in the control room.
Concerns were expressed by the IAG around out of area placements and I
provided an update on the progress that we have made.
1.4
I held a further meeting with Suzy Clifford and Dan Pennock from Survivors of
Bereavement of Suicide, we continue to work with them to plan the opening of a
third branch in Suffolk. I will also be joining a meeting with David Skevington
Assistant Chief Constable Suffolk and SOBS to discuss how the police can be
better trained to deal with survivors of suicide.
Board of Directors – Public
28 August 2014
Chair’s Report
Page 1 of 3
Version 1.0
Author: Gary Page
Department: Corporate
Date produced: 20 August 2014
Retention period: 30 years
1.5
I met with Andrea Stribling the Manager of Richmond Fellowship in Suffolk
and discussed how we could potentially improve our working relationship which I
will take up with Pete Devlin.
1.6
I met with Anna Hughes Chief Executive of Suffolk Mind who is undertaking a
strategic review of were Suffolk Mind should focus its attentions and how it could
work more closely with the Trust.
2.0
Interaction with Services and Staff
2.1
I spent the morning with the Crisis Resolution Home Treatment Team based at
Hellesdon including visiting service users in the community. I saw first-hand the
excellent work that we are doing with some very vulnerable people and the stressful
environment that the team continue to work under. The sense I got from talking to
people was that things were improving although caseloads remain high.
2.2
I attended the BME Networking meeting where considerable interest was shown in
the Trusts Equality objectives and the introduction of Equality leads.
2.3
I met with the new Maeve Heaney NSFT new Legal Counsel. Maeve has been
recruited from private practise and will bring a greater commercial edge to our legal
function which will enable us to perform more legal services in house.
2.4
I visited the Learning Disability service at Walker Close with Sue Bridges.
Speaking to service users I was very impressed by their very positive comments on
the service we provide. However the protracted discussions with commissioners
around the service continue to cause considerable uncertainty for the staff and the
visit served to remind me of the need to have greater learning disability expertise in
the Trust which I have discussed with Roz Brooks.
2.5
I visited the Coastal IDT in Suffolk. The Team appreciates the much improved
working environment, but it seems to me that there are on-going pressures
particularly around the Enhanced Community Pathway which I have raised with Roz
Brooks, together with some issues raised by the admin team.
2.6
I chaired a Private Board of Governors meeting at which we approved the
appointment of two new Non-Executive Directors. Tim Newcomb was formerly
the Assistant Chief Constable at Suffolk Police with specific responsibilities around
Mental health and Marion Saunders from North Norfolk is a trained social worker
with wide spread experience around safeguarding and the CQC.
3.0
Service User and Carers Interaction
3.1
Together with Ravi Seenan Equality Manager I met with Ashok Bhatt to discuss
how we can improve access to our services for Ethnic Minority Communities in
Ipswich.
Board of Directors – Public
28 August 2014
Chair’s Report
Page 2 of 3
Version 1.0
Author: Gary Page
Department: Corporate
Date produced: 20 August 2014
Retention period: 30 years
3.2
I met with the father of a service user who was unhappy about the level of
communication with the Trust which I have followed up on with the relevant
Service Manager.
4.0
Key Observations
4.1
The recent management changes involving the Directors of Operations appear to
have been well received in Norfolk and Suffolk.
4.2
The Board will be discussing Learning Disabilities in the coming few months which
is long overdue and I believe that it is very important that we make some clear
decisions in order to ensure that we can properly support this important part of our
service
Gary Page
Chair
20 August 2014
Board of Directors – Public
28 August 2014
Chair’s Report
Page 3 of 3
Version 1.0
Author: Gary Page
Department: Corporate
Date produced: 20 August 2014
Retention period: 30 years
Report To:
Board of Directors – Public
Meeting Date:
28th August 2014
Title of Report:
CEO Update
Action Sought:
For Information
Estimated time:
15 minutes
Author:
Michael Scott, Chief Executive
Director:
Michael Scott, Chief Executive
th
Date:
28 August 2014
Item:
14.109
C
Executive Summary:
This report provides an update on the main issues and activities undertaken by the Chief
Executive for the month.
1.0
Corporate Plan:
1.1
2.0
Medical Director appointment:
2.1
3.0
I am pleased to confirm that after robust interview an appointment has
been made. Dr Solomka has been invited to join the Board from the 1
January 2015. He has already commenced discussions on hand over with
our current Medical Director and the identification of any development
needs to equip him for the role.
Julian Housing
3.1
4.0
A review of the Directors portfolio has been initiated, draft corporate plans,
and a review of financial modelling with consultation will commence on the
1 September 2014
I met with Pip Coker, who has expressed interest in working more closely
with our Trust, a proposal which was discussed at the Executive Team
meeting. We are continuing to meet to consider this proposal
Great Yarmouth and Waveney Consultation
4.1
I attended, together with other team members, the option appraisal
workshop after the consultation process was completed. Finer details
continue to be discussed with Andy Evans, Chief Executive. Their Board
meeting due to take place today was stood down and it is anticipated that
they will discuss the mental health consultation and commissioning
Board of Directors – Public
28August2014
Chief Executive Report
Page 1 of 3
Version 1.0
Author: Michael Scott
Department: Corporate
Date produced: 20 Aug2014
Retention period: 30 years
intentions during a joint governing body and clinical executive team
meeting to be held next month.
5.0
6.0
Suffolk User Forum:
5.1
I was invited as guest speaker to the Suffolk User Forum where I met with a
number of stakeholders and services users alike.
5.2
I was also invited to meet with Sue Gray, Suffolk MIND Chief Executive at
their head office in Hintlesham.
Introduction into Recovery
6.1
7.0
LNC
7.1
8.0
Having been involved in a CRHT meeting I decided to attend a further
meeting and visit some service users in their home environment with one of
the team members which gave me an interesting insight to their every-day
work and the service user’s expectations.
Section 75
11.1
12.0
We held the second SMF this month where we held an interactive exercise
on the 5-year strategic plan, confirmed the trust objectives, future staff
engagement plans, learning from RCA and update plans for the future Care
Quality commission visit in October.
CRHT Visit:
10.1
11.0
I had a very interesting meeting with representatives of Norfolk Constabulary
regarding Safeguarding and Harm Reduction. I will be meeting with our
representative Terri Cooper-Barnes who works alongside the police at their
Wymondham Headquarters next month.
Senior Management Forum:
9.1
10.0
I attended the local negotiating committee where they discussed the
committee terms of reference, medical staffing 5-year strategy and general
issues.
Norfolk Police
8.1
9.0
I attended one of the Recovery College training session held all over Norfolk
and Suffolk which I would recommend to others in the team to participate if
they have not already engaged.
We are continuing dialogue with Harold Bodmer regarding Section 75 issues.
General Medical Council
12.1
I met with Dr Stephen Jones the Core Programme Director for the GMC to
discuss NSFT action plans.
Board of Directors – Public
28August2014
Chief Executive Report
Page 2 of 3
Version 1.0
Author: Michael Scott
Department: Corporate
Date produced: 20 Aug2014
Retention period: 30 years
12.2
13.0
Members of Parliament
13.1
14.0
I also met with the local General Practitioners leads for mental health at their
monthly meeting.
I met with Chloe Smith who continues to show interest in local mental health.
NHS BME Network Pilot Study
14.1
15.0
Ministerial visit to Addictions Services:
15.1
16.0
17.0
We have been invited to participate in a study for the Joint Commissioning
Panel for Mental Health. 5 mental health providers will join the pilot in a
study in using this tool and help address the inequalities issues among
BME service users. We have agreed to participate and the first
introductory meeting has been held.
I meet with Norman Lamb and members from the Royal College of
Psychiatrists who visited the addictions facility and Unthank Road.
Induction:
16.1
I have also continued my induction, meeting with Kevin James, Chair of
the Service User and Carer Council, Nick Hulme, Chief Executive Ipswich
Hospital, Anna McCreadie, Director of Adult and Community Services,
Suffolk County Council, Mark Easton, Interim Chief Executive of NCHC,
Councillor Michael Carttiss, Chair of Norfolk HOSC.
16.2
I also met with the Specialist Commissioning Team, Carol Theobald and
Karen Lockett.
16.3
I made visits to Sandringham and Blickling Wards with our Director of
Operations for Norfolk and Waveney.
Recommendation:
17.1
The Board is asked to note the content of this report
Michael Scott
Chief Executive
Board of Directors – Public
28August2014
Chief Executive Report
Page 3 of 3
Version 1.0
Author: Michael Scott
Department: Corporate
Date produced: 20 Aug2014
Retention period: 30 years
th
Date:
28 August 2014
Item:
14.110i
Report To:
Board of Directors - Public
Meeting Date:
28th August 2014
Title of Report:
Risk Register Progress Report
Action Sought:
For Information
Estimated time:
10 minutes
Author:
Neil Paull: Risk Management and Security Lead
Director:
Jane Sayer: Director of Nursing, Quality and Patient Safety
D
Executive Summary:
The attached table (appendix 1) highlights the current Trust Risk Register.
This paper identifies Risk Management action, reviews, new risks rated at 12 or above and
closures which have been approved since June 2014.
The Executive team are advised of these risks upon scoring by the Head of Risk &
Security Management and should consider at this meeting whether the action plan is
sufficient given the impact on the overall business of the Trust, whether they are accepted
risks or concerns and if any further risks may have been highlighted.
Risks have been grouped into categories. Whilst some overarching risks are shown
corporately i.e. Staffing, there are also operational risks that arise and these are shown to
ensure appropriate focus is given to the risk at each level.
Each recorded risk is reviewed within the Risk Management team weekly and assurance is
gathered from the Service Manager of progress. Outcomes of significant risk are
discussed with the Trust Board Secretary and recorded on the Board Assurance
Framework.
1.0
Risk Movement
1.1
There have been two new risks identified since the last report;
1.1.1
ID 1133 highlights concerns of staffing cover at West Suffolk services,
where NHSP staff have been unable to fill the shifts
1.1.2
ID 1136 has been drawn to the attention of the Chief Executive on his
visits to some of the Trust wards. The environmental assessments of
Board of Directors - Public
28 August 2014
Risk Register Progress Report
Page 1 of 3
Version 0.1
Author: Neill Paull
Department: Risk Management
Date produced: 18August2014
Retention period: 30 years
ligature risks have been reviewed in line with Trust policy Q46. Differences
in standards are now being addressed following a programme review by
Risk, Estates, Maintenance and Nursing leads.
1.2
In addition, two risks (ID 938 and ID 1070) have reached the target scores and can
be removed from the register.
1.3
Patient safety systems risk (ID 863) has been reduced from 12 to 10 and will be
monitored as the progress of Lorenzo impacts with the engagement of other
services within the Trust.
2.0
Risk Development
2.1
The most recorded risk is still around staffing and indeed there are still high levels
of staffing concern recorded on the Datix incident system. This is currently being
reviewed with the staff level returns reported to ensure risks are focused on
appropriately.
2.2
The Health, Safety and Environmental Lead raises with managers any risk
assessments on their operational register at inspection
2.3
Performance review group documents highlight the current risks recorded, the
most recent incident reporting trends and current complaints compliance.
2.4
Head of Risk Management and Security and Patient Safety and Complaints Lead
have set up some training in September, October and November to deliver
learning from claims, complaints and incident events. This will help teams to focus
on their current and potential risks.
2.5
Training in identifying and recording risk has taken place with 20 NRP staff and
this will be followed up at Health & Safety inspections.
2.6
An overview of the risk register and the dashboard used within the Datix system
was presented to the Chief Executive
2.7
The Deputy Director of Finance received training and reviewed the financial risks
within the system. Discussions were held with the Risk Management Analyst about
progressing risks from local day-to-day risks and overreaching risks affecting a
number of areas.
3.0
Risks / Mitigation in relation to the Trust Objectives
3.1
The ligature programme will need to be addressed and presented to the Audit and
Risk Committee to ensure there is an understanding by all staff as to which risks
can be managed and which need to be removed and pre merger, where there are
different solutions in the building and/or design of an environment, the controls that
need to be in place for future assessments.
4.0
Recommendations
Board of Directors - Public
28 August 2014
Risk Register Progress Report
Page 2 of 3
Version 0.1
Author: Neill Paull
Department: Risk Management
Date produced: 18August2014
Retention period: 30 years
4.1
The Board of Directors accept the updated report as progress.
Neil Paull
Head of Risk Management and Security.
Background Papers / Information
Risk Register, current register attached August 2014. The following feed into to the Risk
Register:
Datix Risk Register Dashboard,
Lorenzo Risk Register
ICT Risk Register
Board of Directors - Public
28 August 2014
Risk Register Progress Report
Page 3 of 3
Version 0.1
Author: Neill Paull
Department: Risk Management
Date produced: 18August2014
Retention period: 30 years
Risk Register August 2014
record
Name of risk
ID
ICT RISKS
1100 Disaster
Recovery
Capability
Risk description
Locality (Team)
Svs / Dept Lead
The existing infrastructure
design does not include
effective disaster recovery
measures.
ICT Services (Risk Commercial
Register)
Director
1101 Data Backup
Capability
The existing infrastructure
design is not effective
enough to ensure that all
business critical clinical and
corporate data is reliably
backed up
ICT Services (Risk Commercial
Register)
Director
1095 ICT
Infrastructure
Failings in aspects of our
ICT Services (Risk Commercial
core ICT Infrastructure may Register)
Director
result in network, application
or service failures that could
result in a breach in the
availability or integrity of all
clinical or corporate data.
Controls in place
Opened
ICT are developing a plan to
procure an interim Disaster
Recovery solution that will give the
Trust time to formulate and
procure a solution that will meet its
long term needs.
A project mandate has been
produced to audit and develop the
backup stabilisation plan that
meets recognised industry
standards and methodologies.
Work on backups, including
successful recoveries, have given
ICT staff the assurance that the
likelihood of the risk occurring has
reduced
Fortnightly working group
meetings including operational
management representation.
07/02/2014
reviewed
4/8/2014
In proactive monitoring tool to be
installed to help ICT monitor
problems. This is not a fix but will
minimise likelihood of disruption.
The monitoring tool has
demonstrated a period of recent
stability
10/04/2012
reviewed
4/8/2014
07/02/2014
reviewed
13/06/2014
Date:
28th August 2014
Item:
14.110i App 1
Risk
Action Plan /Lead
Current
D
Gaps in assurance
This work will be
completed by 31
July 2014.
Reviewed at ICT
Programme Board
15 RG
This work will be
If key backups fail,
completed by 31
systems are not
July 2014.
recoverable.
Reviewed at ICT
Programme Board
RG
15
27/01/2014
reviewed
13/06/2014
Linked with
Infrastructure
Rectification
Programme PID.
Risk reviewed at
ICT Programme
Board
RG
12
885 Stability of
ePEX
The historical level of stability ICT Services (Risk ICT Security
of ePEX gives ICT sufficient Register)
Manager
concern that it is prone to
prolonged disruptions that
would result in the nonavailability of clincial records
to its users.
Linked with
Infrastructure
Rectification
Programme PID.
Following ICT
Programme Board,
the title and
desription rewritten
to reflect currnet
situation.
12 RG
1
record
Name of risk
ID
938 Clinical &
Patient Admin
Notes
Risk description
Locality (Team)
Svs / Dept Lead
Controls in place
Opened
No contemporaneous clinical Suffolk Wellbeing
notes available due to limited (Risk Register)
IT equipment for SWS
Partners to access PC-MIS
Deputy Director Some equipment has been
26/02/2013
of Operation
delivered onto sites, plan for
reviewed
Suffolk
outstanding kit to be placed
14/7/2014
agreed for next few weeks,
updates requested from partners.
A lack of involvement from
Corporate (Risk
key stakeholders within the
Register)
programme (esp. future state
design activities) may cause
new processes to be rejected
leading to an inability to fully
realise benefits.
Commercial
Director
Risk
Action Plan /Lead
Gaps in assurance
Current
Monthly monitoring remaining IT issues
seem resolved case
closed
4
863 Patient
Administration
systems
(Formerly
Lorenzo
Programme)
Business Change Agent network 13/02/2012
established and engaged in
reviewed
process design work. Workshops 22/6/2014
planned 30/5, 2/6 to encourage
further engagement.
Wider comms efforts have begun
now approval has been received.
Execs (esp Ops
Director) to be kept
appraised of levels
of engagement
from staff.
Recruitment to
clinical
engagement leads
roles will provide
more clinical input.
The Lorenzo
programme may be
adversely affected as a
result of the risks
identified within the
programme and
therefore may not
deliver as expected in
terms of cost, quality or
time.
Regular update
reports are
10 provided
HR RISKS
1116 Inability to
deliver clinical
services safely
due to high
number of
vacancies
The Trust currently has 530
vacancies, 413 of which are
being actively recruited to.
Current plan 19 post
appointed to for June 2014
and 113 in July 2014
Human Resources Director of HR
(Risk Register)
Flexible Workforce Strategy which
incorporates the recruitment
strategy (joint strategy with NHS
Professionals) with detailed
implementation plan.
24/04/2014
updated
13/8/2014
from Exec.
meeting
comment
Staffing Strategy Reported via
Workforce
Development
Splitting clinical and
non-clinical risks
20
2
record
Name of risk
ID
1065 Post TSS
impact of
increasing
locality
boundary on
level of patient
demand and
available
service
capacity
Risk description
Locality (Team)
Svs / Dept Lead
Controls in place
Opened
Excess service demand
West Norfolk (Risk Service
poses risk of; breach of
Register)
Manager
external waiting time target,
waiting lists (internal and
external), waiting list risks,
reduced capacity to handle
high risk patients, reduced
work quality, lower priority
work deferred (GP meetings,
group work), reduced morale,
increased patient incidents
and patients / GP / carer /
commissioner complaints,
and long working hours an
staff stress, sickness and
turnover
Regular tracking of patient referral 20/11/2013
numbers, status and plans by
reviewed
senior service team. Develop case 6/8/14
for appropriate staff level and plan
to implement. Fill vacancies with
agency staff in interim, explore
creating interim supernumerary
staff .
NHSP are unable to fill the West Suffolk
shifts required when put on (Risk Register)
the system resulting in
unsafe staffing levels on
occasion across west
inpatient areas.
Centralised recruitment
process has impacted on
ability to be able to recruit
to vacancies.
Agencies being contacted
directly to block book staff.
Recruitment to be managed at
local level
Risk
Action Plan /Lead
Current
Monthly update
received 6/8/2014
Gaps in assurance
12
1133 Staffing
Levels - West
Suffolk
Service
Manager
14/07/2014
monthly updates
12
3
record
Name of risk
Risk description
ID
1060 Sandringham Sandringham Ward has
Staffing levels. moved to it's new staffing
establishment with effect
from 16th September 2013.
The new establishment is
designed to cover 10 inpatient CLL beds. At present,
22 beds remain open on
Sandringham Ward, with a
mix of CLL and non-CLL
patients. Bed occupancy is
consistently near 100%. The
new staff
establishment designed to
cover 10 beds is insufficient
to provide adequate cover for
the current 22 open beds.
This raises risk issues with
regard to patient and staff
safety, care quality, and
reduced staff resource to
facilitate effective timely
discharge.
COMMUNICATION
1112 Trust
Current negative media
Reputation/
coverage; Request from
Public
CCG in response to media
Relations
coverage and campaign.
Locality (Team)
Central Locality
(Risk Register)
Svs / Dept Lead
Service
Manager
Controls in place
Opened
Under the management of the
26/09/2013
DCLL service line Sandringham
reviewed
Wd has been subject to a weekly 16/06/14
action plan meeting which has
looked primarily at addressing the
bed status/staffing/gate-keeping
/daily clinical
meetings/engagement with East &
West Localities around Dist
interventions. Progress against
these actions are on track and the
ward is reducing bed capacity
from 22 to 15 by the end of June
'14. Staff recruitment has been
completed.
Risk
Action Plan /Lead
Gaps in assurance
Current
monthly updates of Expected reduction
the action plan
30/06/2014
12
Commercial
Commercial
Development (Risk Director
Register)
Appointed outside agency on
reputation recovery through the
Comms team.
10/04/2014
updated
13/8/2014
Committee of the
Board set up .
The proactive approach
is proving effective but
it is not possible to
predict the campaign’s
future activities.
16
4
record
Name of risk
ID
FINANCIAL RISKS
1090
Overall CIP
delivery.
1093
Risk description
Financial risk review
Norfolk
Failure to win:
IAPT/Wellbeing - Significant loss of revenue
tender
to the Trust (circa £10-12m)
- Loss of credibility and
reputation
- significantly hinders the
ability of the Trust to grow
business as a specialist in a
growth area
- Allows a competitor to
establish significant business
on our doorstep
- Unknown impact on future
service line tenders being
split from the block contract
- Potential staff liability
- Weakens Trust position for
the future Suffolk
IAPT/Wellbeing tender.
1070 TSS - Suffolk
Shortfall in the Suffolk
IDT financial
finances:
gaps
a) Lack of mitigation plans in
relation to financial gap for
2013/14 14/15 and 15/16
b) Unbudgeted cost of
change i.e. notice periods,
pay protection not covered by
the Transitional fund which
was principally set-up to
safeguard patient safety.
c) Delivery of unbudgeted
services.
PATIENT SAFETY
Locality (Team)
Svs / Dept Lead
Controls in place
Corporate (Risk
Register)
Director of
Finance
CIP plan for 2014/15
Corporate (Risk
Register)
Commercial
Director
Project team in place reviewing
risk. Pull on lessons learnt from
previous IAPT/Wellbeing tenders
such as Suffolk and Mid-Essex.
Merger/Integration Director of
Programme (Risk Operations
Register)
Suffolk
Opened
24/12/2014
reviewed
11/7/2014
21/01/2014
meeting set
for 12/8/2014
CIP plans for 14/15 are being
02/12/2013
finalised and a number of
reviewed
mitigations have been identified. 14/7/2014
Suffolk will be imposing a turnover
rate of 2% on community
vacancies in order to achieve
savings for 14/15
Risk
Action Plan /Lead
Current
Gaps in assurance
DoF updating CIP
targets
16
The April 2014
Investment
Committee
requested that the
executive team
consider a
proposal to
increase bid
capability so as to
reach a 50%
confidence level in
relation to the
Suffolk community
services tender.
Resources to
support improved
bidding capability
have been set
12 aside for 2014/15
CIP plans for 14/15
and a number of
mitigations have
been identified.
The two year
operational plan and 5
year strategic planning
will identify a resource
plan to support delivery
of the Trust’s agreed
strategic direction
closed 14/7/2014
12
5
record
Name of risk
ID
1062 Bed Pressure
Risk description
Locality (Team)
Use of 'red leave' bed's to
Central Locality
manage patients locally,
(Risk Register)
meaning using beds deemed
to be held for patients
considered to be potentially
at risk by inpatient teams.
Increased demands on
staffing to manage high turn
over of service users as well
as protracted time periods
required to manage
applications for OOA
placements as well as
transport issues.
OOA placement usage, this
provides financial pressures
and risk as well as quality
risk.
Extended time periods spent
in S136 suite.
Staff absence impacting
including maternity leave,
staff suspended for
investigation purposes, and
longer term sickness
absence.
Svs / Dept Lead
Controls in place
Opened
Deputy Director Recruitment is underway to
15/10/2013
of Operations
additonal posts in BMDFT to
reviewed
Norfolk
provide 24/7 cover and
24/7/2014
Leadership position. Evidence
from weekly reporting is that OOA
placements and lengths of stay is
improving. Use of red leave beds
is under review to ensure
consistent safe use of beds, led by
ASF.
Risk
Action Plan /Lead
Current
A report is being
developed to
include all metrics
suggested by
Board members
and there is ongoing negotiation
with CCG
regarding
commissioned bed
numbers including
placement of
people delayed in
wards. Executive
team recieves
report weekly from
Deputy Director of
Operations
Gaps in assurance
Further analysis on
admissions by CCG
area is required to
understand whether
there is a pattern
emerging over time and
whether this reflects
demand in previous
years
16
6
record
Name of risk
ID
1118 NRP Contract
Notice
Risk description
Locality (Team)
NRP has been given a final TADS /NRP (Risk
notice by NCC Public Health. Register)
The areas of concern are
around patient safety (case
loads and learning from
RCAs) and the governance
framework - ensuring that
senior managers are aware
of and actively supporting
NRP.
Svs / Dept Lead
Director of
Operations
Norfolk
Controls in place
1. Senior Management to be
present at NRP Quality, Safety
and performance contract meeting
(Directors)
2. An action plan to be planned
and actions commenced in
agreement with commissioners.
3.Immediate targets- to ensure all
staff have received mandatory
training in Suicide prevention and
care planning.
4. To send a workforce report for
NRP to commissioners.
5. To amend and update the RCA
review template and ensure
documentation re staff aware of
content.
6.staff survey on engagement.
7. Restructure of meetings.
1040 Delivery of
Increased sickness is
West Norfolk (Risk Service
New Band 5 staff have joined the
Acute services, evident, therefore putting
Register)
Manager
acute team in the last 4 weeks.
Norfolk West
pressures on existing staff.
One more due to start August and
Shifts are not safely covered
2 newly qualified due to start Sept.
without using NHSP or
Band 5 x 4 WTE still to be
equivalent
recruited in to. Band 3 x 2.6 WTE
vacancys. Interview date to be
arranged.
928 Ligature Risks - Work on Northgate was not Suffolk West
Deputy Director Programme of was due to start
Wedgwood
fully completed to the same Assessment &
of Operations
4/8/14
standards as Southgate ward Treatment (Risk
Suffolk
Register)
Opened
07/05/2014
reviewed
24/6/2014
Risk
Action Plan /Lead
Current
Monthly monitoring
Gaps in assurance
16
19/06/2013
reviewed
23/7/2014
Staffing vacancies Awaiting interview dates
being filled/ SP
16
22/11/2012
reviewed
5/6/2014
Awaiting progress
lead is on annual
leave
16
Environmental risks in
Northgate reliant on
staffing and
observations
7
record
Name of risk
ID
1033 Inability to
provide an
individual
practitioner to
every Service
User in Central
Adult
Community
Risk description
Locality (Team)
Svs / Dept Lead
Controls in place
Opened
There are a growing number Central Locality
of unallocated clinical cases (Risk Register)
in the Central Locality who
require Care Coordination or
Lead Care Professional
alignment which could result
in a lack of timely intervention
if required.
Locality
Operations
Manager
Monthly Caseload Management by 24/05/2013
CTL's with each practitioner, focus reviewed
on safe discharge to free up
28/7/2014
capacity. Exploration of more
efficient ways of delivering
treatment eg clinics, use of a Lead
Care Professional. Transitional
Plan commenced. Regular review
of all unallocated cases by
members of the team and duty
worker in place to take any calls
related to this group. Request to
recruit Agency workers to fill gaps
until recruitment completed
agreed. CCR being completed to
request temporary staffing cover
for teams to enable the
transformational work to be
completed
Following 2011 ligature
plans and 2013 Ligature
and Suicide Environment
Policy, June 2014 local
assessments identified
gaps and differences in
systems.
Risk
Management
and Security
Lead
Programme of review
25/07/2014
completed by the Risk
Management and Security Lead
with assistance of Estates and
Maintenance Managers;
Directors of Operations and
Deputy Director of Nursing.
Action plan to be agreed
Risk
Action Plan /Lead
Current
Weekly reporting
and monitoring
continues with
actions in place to
increase discharge
to enable capacity
to be built into the
teams. Recruitment
to vacanct post
ongoing, a number
of posts in pre
employment stage.
Long Term
Treatment Team,
implementation
phase 1
commenced,
impact should be
noted in next 2
Months.
Gaps in assurance
last recorded
unallocated numbers
awaiting caseload
allocation is 381.
15
1136 Ligature
Programme
Corporate (Risk
Register)
weekly
monitoring of
progress and staff
awareness
Some significant cost
and timeframe risks
need to be agreed at
Executive level. i.e
window controls
12
8
record
Name of risk
ID
QUALITY and AUDIT
1099 Meeting Key
Performance
Indicators
1125 System
confidence
Risk description
Failure of team to meet 24hour, 4-hours 72-hours and
28-day targets have resulted
in CCG issuing performance
notice. Financial service and
operational risks.
A loss of system confidence
affecting sustainability of trust
Locality (Team)
Svs / Dept Lead
Controls in place
Opened
Risk
Action Plan /Lead
Current
Suffolk Access & Locality Service Performance management of
28/01/2014
Assessment Team Manager team, regular review of targets,
reviewed
(Risk Register)
Primary Care
reporting to executive team. CCG 12/5/2014
report satisfactory progress.
Gaps in assurance
Monthly updates
reported - target
date 25th October
2014
12
Corporate (Risk
Register)
Chief Executive This risk is mitigated by:
30/05/2014
a. A more structured approach by discussed
the executive team to ensuring
13/8/2014
that information that leaves the
organisation is accurate, complete
and contextualised.
b. Executive director time has
been focussed on engaging
proactively with commissioners so
as to understand their concerns
and to address them.
c. Significantly improved
performance on Access and
Assessment targets.
15
a)rules for
meetings
introduced, follow
up of actions and
minutes in a timely
manner, b) more
regular contact with
commissioners
established
including clinical
leads, c) Access
and Assessment
service being
reviewed, d)
Constructive
approach to
dialogue with the
Campaign.
9
record
Name of risk
Risk description
ID
914 Compliance
Low compliance with
with mandatory mandatory training resulting
training
in non-compliance with legal
obligations, NHSLA & CQC,
& poorer quality of care
REGULATION
1109 DOLS
Supreme court judgement in
Regulation
March 2014 widened the
Change
definition of deprivation of
liberty meaning that some
patients may be detained
without correct legal
safeguards.
Locality (Team)
Svs / Dept Lead
Controls in place
Opened
Human Resources Director of
Project work to review and
(Risk Register)
Workforce and improve relevance and access to
OD
stat/mand training.
29/08/2012
reviewed
12/8/2014
Governance (Risk Trust Board
Register)
Secretary
28/03/2014
reviewed
20/6/2014
Review group set up with
Safeguard and Legal Service
leads leading to scope issue and
put in place arrangements for
referrals for DOLS assessments
where needed.
Risk
Action Plan /Lead
Current
A comprehensive
report to the Board
of Directors was
provided in May.
12
Review scope of
those affected/
DR & SB
Supported by
clinical leads
Gaps in assurance
We continue to
experience a low takeup of stat/mand training
places.
Working group will be
bringing forward
proposals for improved
tracking system.
12
Removed from current
register
Key
Bold writting
Newly recorded risk
10
Report To:
Board of Directors – Public
Meeting Date:
28th August 2014
Title of Report:
Board Assurance Framework
Action Sought:
For Approval
Estimated time:
10 minutes
Author:
Robert Nesbitt: Trust Secretary
Executive:
Robert Nesbitt: Trust Secretary
th
Date:
28 August 2014
Item:
14.110ii
E
Executive Summary:
The BAF has been updated since the July 2014 Board and now includes cross-referencing
of the risks to the Trust objectives and, where feasible, timed plans to move the mitigation
confidence to green.
The risks to our maintaining a CoSRR of 3, evident in the M04 finance report, means that
the mitigation confidence level has moved to ‘red’.
The ‘Performance’ theme is now focussed on ‘Quality’ (patient safety, experience and
clinical effectiveness) and so has been re-named to reflect this. Lorenzo as a strategic risk
has been added, as has weaknesses in learning from Root Cause Analysis reports, and
the risks that would arise from a critical CQC report (following the planned inspection in
October 2014). The annual ligature audit will be considered at the executive team meeting
on 20th August 2014.
NB: The mitigation RAAG rating is based on Monitor’s Governance Risk Rating system:
‘Red’ (the mitigation is so weak that there is likely risk of a breach to the provider license),
‘Red / Amber’ (the mitigation is such that there are material concerns of a breach to the
provider license),
‘Amber Green’ (the mitigation leaves limited concerns of a breach).
‘Green’ (the mitigation is so strong as to mean that there are no material concerns of a
breach).
Scores shown are ‘Consequence x Likelihood’ as recorded on Datix. The executive owner
is not always the risk owner on Datix (this is intentional).
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28Aug2014
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Department: Corporate
Date produced: 21Aug2014
Retention period: 30 years
1.0
Staffing (OD and WF Committee)
Relevant Trust objectives:
Implementation of Hard Truths recommendations so agreed inpatient
staffing levels are achieved, maintained and published weekly from June
2014.
To agree recording and monitoring process for safe caseloads levels by
October 2014.
Delivery of a Workforce and OD strategy.
1.1
Risk. The risk is that shortages of staff impact on safety. Staff sickness
exacerbates this problem and remains at c.5.55%.
1.2
Mitigation. Confidence level = red/amber as there are plans in place.
a. Risks associated with cases requiring allocation are being monitored to
prioritise resources.
b. The Flexible Working Strategy includes specific measures to improve staffing
levels. As it is rolled out the mitigation confidence level should increase.
1.3
Additional actions required. No additional action is required at present.
1.4
Datix ID 1116 (Risk of inability to delivery clinical services due to vacancies) /
Owner – 5 x 4 = 20 Jane Marshall-Robb. Datix ID 1133 (NHSP difficulty in
covering shifts in W. Suffolk) 4 x 3 = 12. Jane Marshall-Robb.
1.5
Timeline to reach confidence level of ‘Green’
Recording and monitoring of safe caseloads is due by October 2014.
Safe staffing in now published on NHS Choices. Delivery of the Workforce and OD
strategy is part of the two year operational plan and five year strategic plan.
Subject to business case approval e-rostering will be rolled out by year end with a
full implementation date of March 2016.
2.0
System confidence (Finance and Performance Committee)
Relevant Trust objectives:
For the 2014/15 financial year: delivery of all operational targets including
receiving 100% CQUIN and the avoidance of any operational and financial
penalties from commissioners in the final quarter of the year.
Engage with the wider health economy, third and voluntary sector to ensure
the Trust is a known and trusted partner evidenced by a 10% increase in
new business with external parties by March 2015, evidenced by financial
turnover.
2.1
Risk. A loss of system confidence in the management of the Trust could impact on
the ability of the Trust to retain and win contracts, lead to escalated regulatory
actions that would impact on management capacity, and could also weaken the
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Department: Corporate
Date produced: 21Aug2014
Retention period: 30 years
public’s confidence in the quality of the service. A critical CQC report in October
2014 could weaken patient (and wider) confidence in the Trust.
2.2
Mitigation. Confidence level = Red / Amber as the issues are multi-factorial.
This risk is mitigated by:
a. Prioritisation of meeting performance standards and addressing problems
quickly.
b. Positive attempts to reach out to the Campaign so as to find common ground
in our joint desire to protect and improve services.
c. Preparation for October 2014 CQC visit to ensure that an accurate picture of
Trust services can be evidenced.
2.3
Additional actions required.
None at present.
2.4
Datix ID 1145 (risk of not learning from RCAs leading to repeat incidents) = 3 x 4
= 12. Owner Jane Sayer. Datix ID 1112(Risk of damage to Trust reputation) 5 x 3
= 15 Owner Michael Scott. Datix ID 1144 (Risk of poor CQC report affecting
confidence in Trust) 4 x 3 = 12 Owner Jane Sayer.
2.5
Timeline to reach confidence level of ‘Green’
A greater degree of confidence in the Trust should be established by the financial
year end. However, this could be seriously impacted by the CQC inspection and
financial performance.
3.0
Quality (a – d Finance and Performance Committee, f Service Governance
Committee)
Relevant Trust objectives:
Achieve zero out of area non specialist bed placements by March 2015.
Achieve a positive CQC review in 2014 and effectively addressing any
issues that arise as part of this.
Agree recording and monitoring process for safe caseloads levels by
October 2014.
3.1
Risk. The risk is that quality is compromised by service performance problems.
These include:
a. Out of area capacity placements indicating bed / care pathway pressures in
Norfolk and Waveney.
b. The under 18s incorrect referral entry problem (this relates to 28 day referrals)
and the Norfolk CAMHS 8 week target breaches. This was reviewed at F&PC and is
now resolved.
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Department: Corporate
Date produced: 21Aug2014
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c. IAPT access activity in Norfolk, Suffolk and GY&W is below the 2.5% per month
trajectory. In Suffolk this is the subject of a contract query notice. This was reviewed
at F&PC and is now resolved.
d. The Suffolk Access and Assessment 28 days target (95%) has been missed for
April (65%) and May (75%) 2014 and the recovery plan is impeded by high levels of
sickness (15%). This was reviewed at F&PC and is now resolved.
e. The strategic risk that Lorenzo does not deliver the quality benefits that the Trust
needs to provide safe and effective services.
f. In addition, there are is a risk that learning from Root Cause Analysis reports is
not applied adequately across the Trust leading to repeated safety issues.
3.2
Mitigation. Confidence levels a. Bed availability = Red / Amber, e. Lorenzo =
Amber/Green, f. RCA learning = Red/Amber
a. In relation to Norfolk and Waveney bed availability, The current level of capacity
out of Trust placements has come down from a high of 31 in June 2014 and is 10
(on 31.07.14) down from 14 (on 23.07.14). The approach is to consider the whole
of the care pathway and this work has started with a review of Access and
Assessment. The impact of S.75 and the Cluster 1 – 4 tender and remaining
community services is being scoped.
e. Lorenzo has a clear programme management structure and is adequately
resourced to deliver benefits and to provide early warning of risks.
f. RCA reports are improving in quality and in the formulation of recommendations.
The DoN and MD now scrutinise every report monthly, identifying key themes and
assign appropriate follow up actions with monthly reporting to the Senior
Management Forum on learning points. There will be learning events to be held
locally for practitioners to attend. There are a range of communication
mechanisms lessons learned where necessary changing policy and training,
monitoring completion of action plan. Clinical audit reviews how well embedded
lessons are.
3.3
Additional actions required.
None at present.
3.4
Datix ID 1062 (Bed management) 4 x 4 = 16 and owner. Debbie White. Datix ID
(Lorenzo) 1146 4 x 3 = 12 Leigh Howlett
3.5
Timeline to reach confidence level of ‘Green’
a) Bed availability – Whilst the process has been effective in reducing out of
county beds. The review of A&A will be complete by the end of September 2014.
When the scoping work is completed it will be possible to develop a timeline.
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f) RCA learning – the expectation is that the measures above will increase
confidence in mitigation to green, with the proviso that human unpredictable
behaviour means that a perfectly safe system may never be reached and there
has to be a balance of respecting human rights and securing safety. SIs can never
be eliminated completely but the measures above should mean that mistakes are
not repeated. In order to provide a timeline further debate will be needed to agree
what counts as ‘green’ mitigation confidence.
4.0
Public relations (Communications Committee)
Relevant Trust objectives:
We will look for, and exploit, opportunities to work on prevention and antistigma by development and delivery of a robust communication plan,
evidenced by monthly positive media messages from launch in September
2014.
4.1
Risk. Negative media messages including those related to the MH ‘crisis’
campaign may damage the reputation of the Trust to the extent that service users
are put off from seeking support. This could affect patient safety and also feeds
into system confidence.
4.2
Mitigation. Confidence = Amber / Red, as the proactive approach is proving
effective but it is not possible to predict the campaign’s future activities.
The new public internet site is now live. The staff cascade communications system
will be rolled out in September 2014. There is now a more proactive approach to
working with local media and engaging with the ‘crisis’ campaign.
A communications plan was reviewed by the Board at its March 2014 meeting and
investment in an increased team has been agreed. This investment will also
provide mitigation against the risk of poor staff morale (see below) since it includes
resources for internal communications.
Additional staff have been employed to remedy short term issues such as the
website redevelopment and establish new communication channels. As the new
structure comes into place this will strengthen the capacity of the Trust to ensure
balanced coverage.
The newly formed Communication Committee is receiving regular reports on the
impact of the communication activity. In July 2014 the Trust generated /
responded to 93 stories in the media. Of these 52 (56%) were positive as
opposed to 17 positive stories in June, an increase of 306%.
Ultimately the key to improved stakeholder perception lies in performance.
4.3
Additional actions required. Development (and funding) of training on social
media to improve engagement (service user and staff) and updating intranet
information for staff.
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Department: Corporate
Date produced: 21Aug2014
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4.4
Datix ID 1112 (Trust reputation 4 x 4 = 16) and owner Leigh Howlett
4.5
Timeline to reach confidence level of ‘Green’
Communication activity will always require concerted effort given health is a
dynamic environment which attracts negative media coverage due to the nature of
the issues dealt with.
Regular review of communication activity and impact by the Communication
Committee will be used to ensure that progress is maintained and meets the
Trust’s objectives.
5.0
Staff morale (OD and Workforce Committee)
Relevant Trust objectives:
1. Delivery of a Workforce and OD strategy which enables:
•
improvement in the staff survey so the Trust is not in the bottom 20% of
Trusts in any category by the 2016 results.
•
Staff friends and family tests show quarterly improvements throughout the
year 2014/15 (measured quarterly on a rolling year)
•
stable staff turnover levels of 10% by March 2016
•
90% of staff participating have an appraisal and wellbeing review in the last
12 months
•
a 50% increase (from the 2013 staff survey baseline) in staff reporting they
have had a meaningful appraisal by March 2016
•
sickness rates of no more than 4.5% in any area by March 2016.
•
all staff undertake key areas of mandatory training with a target of 90%
attainment by March 2016.
2. All vacancies recruited to the point of offer within 8 weeks by March 2015.
3. Develop plans to meet seven day services by end of 2014/15 financial year.
4. Roll out of e-rostering across all clinical areas to support delivery of staff staffing by
March 2016.
5.1
Risk. Low staff morale impacts on quality of care as well as our reputation as an
employer.
From April 2014 the ‘Friends and Family’ test, including three core staff
engagement questions, was introduced to monitor progress with staff engagement
on a quarterly rather than annual basis. This will report via the OD and WF
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Department: Corporate
Date produced: 21Aug2014
Retention period: 30 years
committee. The initial results for Q1 had a response rate of 4.5% which may lead
to sample bias but were disappointing with low scores for both recommending the
Trust for care and treatment and recommending the Trust as a place to work.
These echoed the 2013 staff survey results which were published on 25.02.14.
The Q2 survey is has been widely promoted and staff no longer need to enter their
assignment number which may increase the return rate.
Workforce Development and Effectiveness measures as shown in the July 2014
Board Performance Report remain at Red other than for episodes of sickness
absence and voluntary resignations.
5.2
Mitigation. Confidence = Red. The range of scores between different localities in
the staff survey indicates that low engagement and staff morale is not systemic
across the Trust, but the underlying factors are complex.
The Trust has developed a staff engagement plan, alongside a joint working group
(with staff side) as part of the OD strategy. Major organisational change can be
expected to impact on staff morale in the short term, and executive team members
have set up staff engagement sessions to provide an opportunity for staff to raise
concerns and to understand the rationale for the changes in more detail. Although
the TSS changes have been intense this will mean that teams will reach a steadystate more quickly and will be able to build relationships and job satisfaction more
quickly.
The staff appraisal and performance management changes that come into effect
later this year will assist in ensuring that all staff are clear as to how their
objectives contribute to the Trust’s work and receive feedback on their
performance.
5.3
Additional actions required. None at present.
5.4
Datix ID 1065 (Post TSS Impact) 3 x 4 = 12 and 1102 and owner Michael Scott.
5.5
Timeline to reach confidence level of ‘Green’
The Friends and Family Test is quarterly. The early signs are the current F&FT
which closes towards the end of August 2014 will have a significantly higher return
rate than the first sample. Results will be available one month later. However, the
executive team recognise that the challenges in this area are medium to long term
issues and so the expectation is that it will take 12 – 18 months for changes now
being implemented to feed through into some measurable improvement.
Following the trial of a new central lean recruitment process for three months this
is now being rolled out and delivery of the recruitment KPIs is anticipated by March
2016.
Enhanced management of sickness absence will be introduced over the next
quarter and the results should be seen by March 2016.
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Author: Robert Nesbitt
Department: Corporate
Date produced: 21Aug2014
Retention period: 30 years
The review of the first quarter of the appraisal results as part of the Talent
Framework is complete and will be reported at OD&WF committee on 26.08.14
The target for a stable turnover rate of 10% is March 2016.
6.0
Maintaining and growing business (Investment Committee)
Relevant Trust objectives:
By October 2014, delivery of a Commercial Strategy to protect current
services and develop new business.
Engage with the wider health economy, third and voluntary sector to ensure
the Trust is a known and trusted partner evidenced by a 10% increase in
new business with external parties by March 2015, evidenced by financial
turnover.
6.1
Risk. Loss of income will destabilise the organisation. Loss of key contracts
where we are the incumbent, such as IAPT, could also damage our reputation
since they could be interpreted as a loss of commissioner confidence.
Developing bids and winning contracts requires an increasingly specialised skill
set where demand is variable and where competitors such as Serco are
continually raising the bar. Successful bids require evidence of a track record of
delivery which has been variable in recent months.
For an organisation of our size it is a challenge to be able to maintain a strong bid
capability with the right skills on tap that is also cost-effective during quieter
periods.
Bid development teams need access to specialist service knowledge in the context
of clinical managers who are already short of capacity.
6.2
Mitigation. Confidence = Red/Amber.
Resources to support improved bidding capability have been set aside for
2014/15. The two year operational plan and 5 year strategic planning will identify a
resource plan to support delivery of the Trust’s agreed strategic direction.
6.3
Additional actions required.
The executive team will restructure support to contract and bidding functions in
order to provide greater clarity and focus. An update on this work will be provided
to the Board by Leigh Howlett at the Board meeting on 28th August 2014.
6.4
Datix ID1093 (Norfolk IAPT / Wellbeing tender) 4 x 3 = 12 and owner. Leigh
Howlett.
6.5
Timeline to reach confidence level of ‘Green’
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Author: Robert Nesbitt
Department: Corporate
Date produced: 21Aug2014
Retention period: 30 years
The corporate restructure is planned for September / October 2014. In the interim
project support and plans are in place for reviewing and securing current / new
business in accordance with their own time frames.
7.0
Maintaining CoSRR of 3 from 2014/15 onwards (Finance and Performance
Committee)
Relevant Trust objectives:
Delivery of the 2014/15 financial plan so the Trust achieves a COSRR of 3
as a foundation for 2015/16
Delivery of the 2014/15 CIP and capital programmes
Develop a new strategy for procurement by end of 2014/15 financial year
For the 2014/15 financial year: delivery of all operational targets including
receiving 100% CQUIN and the avoidance of any operational and financial
penalties from commissioners in the final quarter of the year.
7.1
Risk. Trust finances have worsened in M04 with £0.44m deficit for the month and
£0.77m YTD. Temporary pay expenditure levels have risen, this month to £2.39m
with total YTD expenditure already at £8.46m (this compares to £4.70m YTD for
the previous year). There is a discrepancy between those CIP schemes showing
at Gateway 5 and actual reductions in expenditure. The risk is that the Trust fails
to meet its financial targets and its future stability is jeopardised which impacts on
our ability to provide services.
For the period ending June 2014 the Trust had a deficit of £340k (almost £200k
worse than plan) including an overspend on locum doctors of £500k.
7.2
Mitigation. Confidence = Red.
Achievement of CIPS is to be managed outside the executive team meeting to
allow greater executive director input into identification of and delivery of plans.
CIP schemes at Gateway 1 are to be progressed to Gateway 2 by 15.09.14.
An increased focus on reducing temporary staffing with a revised control total.
Acute out of area (OOA) placements expenditure has significantly decreased this
month to £0.18m.
CoSRR remains at 3 for M04.
7.3
Additional actions required. By 31.07.14 additional schemes were to have been
brought forward to address the CIPS 2014/15 shortfall. Although there has been
some reduction in this pressure through one-off reserve releases, at M04 there
remain £2.6m where plans need to be identified (Gateway 0).
7.4
Datix ID 1084 (TSS finances 4 x 4) / 1090 (Overall CIPs delivery 4 x 4) owner
Andrew Hopkins.
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Department: Corporate
Date produced: 21Aug2014
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7.5
Timeline to reach confidence level of ‘Green’
The Finance Report for M04 presented at this meeting sets out the actions
underway to address these issues and a timed plan will be available to reach
green for the September 2014 board.
8.0
ICT weaknesses (Investment Committee)
Relevant Trust objectives:
Delivery of an ICT strategy which supports engagement with service users
and carers in a convenient and timely way and makes best use of clinicians
time (e.g. reduce travel) by October 2014
8.1
Risk. The risk is that patient safety and business continuity may compromised by
weaknesses in ICT components. In February 2014 the investment committee
referred a set of ICT risks to the Audit and Risk Committee. These risks centre on
i. Core Infrastructure weaknesses, ii. Disaster Recovery Capability, and iii. Data
Backup Capability. Since May 2014’s report there has been significant progress on
managing this risk with Datix scores falling.
8.2
Mitigation. Confidence = amber/green moving to green as the investment is rolled
out.
The Investment Committee on 5th June 2014 received a detailed verbal report from
Lloyd Bye (Head of ICT) who said that the Disaster Recovery Risk has been
brought down to an acceptable level. For core functionality the updating of
software patches is underway and will take approximately six months to complete.
For data back-up plans are underway to find an outsourcing solution that is
scalable to the Trust’s needs. There will be an independent audit of ICT
weaknesses at the end of the calendar year to confirm that these risks have been
appropriately mitigated. There is also a rolling programme to replace MS XP with
W7 and a warranty is in place to protect XP security over the transition.
Datix shows an end date for the data backup capability risk of 31.10.14. For
Disaster Recovery the procurement process has a risk end date of 31.10.14.
8.3
Additional actions required. None at present.
8.4
Datix ID 1101 (Data backup capability) 5 x 3 = 15, 1100 (Disaster Recovery
Capability) 5 x 3 = 15, 1095 (ICT infrastructure 4 x 3 = 12) and owner is Leigh
Howlett.
9.0
Conclusion
9.1
Board members are to review the above themes and consider whether any
additional actions are required to provide assurance on management of the risks.
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Date produced: 21Aug2014
Retention period: 30 years
9.2
The board is also asked to consider whether there are additional significant risks
that have come to light but which are not represented in the BAF at present.
Robert Nesbitt
Trust Secretary
Board of Directors – Public
28Aug2014
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Page 11 of 11
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Author: Robert Nesbitt
Department: Corporate
Date produced: 21Aug2014
Retention period: 30 years
th
Date:
28 August 2014
Item:
14.110iii
Report To:
Board of Directors – Public
Meeting Date:
28th August 2014
Title of Report:
Patient Safety and Quality Report July 2014
Action Sought:
For Approval
Estimated time:
15 minutes
Author:
Jane Sayer, Director of Nursing, Quality and Patient Safety
Director:
Jane Sayer, Director of Nursing, Quality and Patient Safety
F
Executive Summary:
This is a report on current quality and patient safety issues. Information is reported on key
areas of concern or activity since the last report to the Board in July 2014. The main
messages for the Board to note in this report relate to:
Variation in the numbers of SIs reported continues. Improvements in the process
for SIs are summarised.
The Trust has signed up to two national initiatives designed to improve patient
safety.
Draft reports on unexpected deaths in West Norfolk and NRP services have been
received.
Safe staffing report, and key issues in provision of Registered Nurses in some
settings.
Implementation of the Friends and Family Test is under way.
1.0
Report contents
2.0
Patient safety indicators, including complaints and compliments, serious incidents,
medication incidents, harm free care, absconsions and assaults.
3.0
Safety and quality reports.
4.0
Benchmarking, including CQC visits.
5.0
Safe staffing.
6.0
Service user and carer experience.
7.0
Quality dashboard.
Board of Directors – Public
28 August 2014
Patient Safety & Quality Report
Page 1 of 26
Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
2.0
Patient Safety Indicators
2.1
Complaints and Compliments
In July 2014, 66 complaints were received. Following amendments to the
Complaints process in June 2014, with a central acknowledgement function
introduced, this high figure has sustained. With a second month of data the Patient
Safety & Complaints Team can commence analysis of this trend.
Chart 1: Number of Complaints received monthly from April 2013
Chart to show Complaints received from April 2013
No of complaints
80
71
70
66
60
50
45
13-14
40
26
30
14-15
20
13-14ave
10
0
April
2.1.1
May
June
July
Aug
Sept
Oct
Period
Nov
Dec
Jan
Feb
Mar
Indicators of Potential Emerging Themes and Systemic Issues
Analysis of the complaints received in July do not indicate a new emerging theme
or systemic issue. Whilst there are some concentrations of complaints with
particular teams, the individual complaints demonstrate differing concerns.
The Chief Executive Office now signs all complaint responses, and the Director of
Nursing and Quality looks at random samples of responses. The quality has been
found to be generally high, and much more personalised than previously. Review
by Governors and NEDs in the future is welcomed.
2.1.2
Compliments
Norfolk: 1 compliment
Suffolk : 5 compliments
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28 August 2014
Patient Safety & Quality Report
Page 2 of 26
Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
2.2
Serious Incidents
During July there were 13 SIs reported.
Alleged patient abuse
Other
Patient accident
Serious Incident by inpatient
Serious Incident by outpatient
Under 18 admission
Unexpected death - community
2
1
2
1
1
1
5
This represents a decrease of 12 since the previous month.
Chart 2: Trustwide serious incidents reported, January 2012 – June 2014
Comparison of SIs reported from April 2012
Number of SIs reported
30
25
20
12 13
13 14
14 15
15
10
5
0
2.2.1
12 13
April
14
May
18
June
10
July
14
Aug
17
Sept
15
Oct
17
Nov
12
Dec
9
Jan
11
Feb
13
March
11
13 14
14 15
15
7
21
25
8
18
17
9
15
15
8
14
20
10
25
13
Improvements to the Process of Serious Incident Reporting
The Serious Incident team has been collating feedback on the SI process from a
range of sources, including NEDs, clinicians, service users and carers, and
commissioners. A presentation to the Strategic Management Forum (SMF) in
August collated the Trust’s response to this, and included all the developments
since January 2014, including the Board overview process for Level 2 incidents,
the appointment of dedicated RCA facilitators, and a new system for monthly
feedback of themes to SMF. A summary is included in Appendix 1, and will be
discussed in more detail at the September Service Governance Committee.
Board of Directors – Public
28 August 2014
Patient Safety & Quality Report
Page 3 of 26
Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
2.2.2
Inquests
Inquests since the last report are detailed in Table 1.
Table 1: Summary of Inquests, July 2014
DOD
Inquest
date
389 Suffolk East
326 Suffolk West
30.3.14
9.11.13
16.7.14
9.7.14
349 Central
4.1.14
15.7.14
396 Central
4.4.14
15.7.14
Gt Yar and
375 Wav
367 NRP
7.3.14
8.2.14
16.7.14
17.7.14
6.3.14
17.7.14
16.3.14
6.8.14
RCA Locality
377 Central
Gt Yar and
381 Wav
2.3
Inquest Verdict
Documentary basis: “died from bronchopneumonia
occurring against a background of drug use”.
Took his own life
He died as a result of dependence on drugs
against a background of physical and mental ill
health
On 1.4.14 she jumped into the River Wensum. She
was pulled out, despite attempts at resuscitation
she died in hospital on 4.4.14. Her intention at the
time was not known.
Committed suicide while the balance of his mind
was disturbed and whilst under the care of the
mental health services.
Drug related
Voluntarily toppled from railings to his death. At the
time of his death he was suffering from a mental
illness of long duration and under the care of
mental health services.
He hung himself. His intention at the time is not
known.
Medication Administration Errors
Whilst there has been an increase in Suffolk site reporting, 20 events of nonrecording on Avocet were picked up following a two week audit in May/June. Lack of
signature does not mean medication was not given, but there is no recording, which
is not acceptable practice. The staff will be putting into place a plan that the clinic
door should be closed during medication round to prevent disruption, and the
following was made aware to staff;
Patients not to be in the clinic during medication round unless directly
supervised by a member of staff – this may relate to times when, to promote
concordance the individual wishes to watch medication being dispensed or
the need for observation that relates to the taking of medication.
Staff to inform patients (via community meeting) of steps to be taken to
minimise risk of error.
Medication competencies to be reviewed with all RMNs.
Prescription card audit to be used as means of on-going audit / quality
checking. Band 6 / and pharmacy link to complete monthly.
Board of Directors – Public
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Patient Safety & Quality Report
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Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
Other occurrences have been one or two events over several sites. Moderate
harm occurred on two occasions (repeated dose and bloods indicating a red
result) and resulted in increased observations of those patients as they recovered.
In Norfolk the recorded errors reduced from 12 (May) to 10 (June) to 6 (July),
again in most cases it involved one or two incidents each month, with six events
occurring on Churchill Ward (two wrong dose, two given after stop date, one given
late and one omission). Of these, three separate events occurred within 12 hours.
No harm or adverse outcome was caused in these cases. One event resulted in
Moderate harm, following a repeated dose, patient became drowsy and
paramedics attended, the patient was kept on four hourly observations and
recovered.
Chart 3: Trust wide medication administration errors, August 2013 - July 2014
30
25
20
15
Suffolk
Norfolk
10
5
0
Aug Sept Oct Nov Dec Jan Feb Mar April May Jun
13 13 13 13 13 14 14 14 14 14 14
2.4
Jul
14
Prescribing Errors
There were no events reported in Suffolk for this period.
Norfolk reported seven events, of which five were near misses as they were noted
before an error occurred, no harm resulted in any of these events.
Chart 4: Trust wide medication prescribing errors, August 2013 – July 2014
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Patient Safety & Quality Report
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Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
10
9
8
7
6
5
Suffolk
4
Norfolk
3
2
1
0
Aug Sept Oct Nov Dec Jan Feb Mar April May Jun
13 13 13 13 13 14 14 14 14 14 14
2.5
Jul
14
Absconsions
A number of absconsions from Glaven ward are now occurring when patients are
attending the laundry or OT, as there are a number of doors that are fire doors and
observation cannot be maintained. Assessment of the fire door has been
undertaken by the Fire Officer and Head of Risk Management & Security. Action:
costing need to link the door into an alarm system and or operation on the release.
Chart 6: Trustwide absconsions, August 2013 – July 2014
25
20
15
Suffolk
10
Norfolk
5
0
Aug Sept Oct Nov Dec Jan Feb Mar April May Jun
13 13 13 13 13 14 14 14 14 14 14
2.6
Jul
14
Assaults
Suffolk recording increased from 4 (May) 11(June) 8(July) with seven events
occurring on Lark ward, five of which were between two patients.
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Patient Safety & Quality Report
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Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
Norfolk reporting remains consistent.
Having reviewed the figures for assaults in June, the number of service user to
service user assaults in continuing care services accounted for 45% of the total
number. Over the last year, assaults in continuing care facilities accounted for
34% of the total number of assaults, with Blickling Ward accounting for a further
18% of all assaults. The Matrons in these services have been asked to work with
the Head of Prevention and Management of Aggression to look into the issue
further, and develop an action plan.
Chart 7: Trust-wide service user to service user assaults, August 2013 – July 2014
70
60
50
40
Secure
30
Suffolk
20
Norfolk
10
0
Aug Sept Oct Nov Dec Jan Feb Mar April May Jun
13 13 13 13 13 14 14 14 14 14 14
2.7
Harm-Free Care
2.7.1
Pressure Ulcers
Jul
14
There have been a total of seven developed pressure ulcers across the Trust
between April and July 2014 inclusive. Of these, three patients developed four
pressure ulcers in July, one of which is a grade 3 pressure ulcer and therefore a
serious incident.
Root Cause Analysis is conducted on all pressure ulcers with action plans
identified to address any deficits. The root cause analysis process is very robust
with any lapse in documentation leading to a decision that the wound was
avoidable. Focus on education and training will continue and the trend will be
monitored. The action for Abbeygate includes refresher training on completing risk
assessments.
Carlton Court has identified some issues in the timeliness of risk assessments but
also comments on the low numbers of staff on the wards and the use of NHSP
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Author: Jane Sayer
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Date produced: 11 August 2014
Retention period: 30 years
staff: actions include the handover sheets to include skin checks as a reminder to
NHSP staff.
It should be noted that there had been no pressure ulcers on Carlton Court wards
since September 2013. These recent pressure ulcers affect achievement of the
CQUIN goal set by Great Yarmouth and Waveney commissioners which requires
five consecutive months with no reported pressure ulcers using the Safety
Thermometer tool.
2.7.2
Slips, trips and falls
The physical health team are currently focussing on analysing all aspects of the
falls data for the Trust as recorded on Datix. A member of the team is also liaising
with the falls lead for Norfolk Community Healthcare services to benefit from her
expertise and experience. The team has weekly access to a volunteer who has
proved invaluable in developing databases and presenting data in a reportable
format.
The initiatives include:
Applying CCG agreed definitions of falls to those reported on Datix,
removing those that do not meet the definition. In reality, these are low
numbers but allow comparison of NSFT data with other services.
Reviewing the patient data for each report and identifying those who are
falling more than twice, ensuring these have had an MDT review
Following up on individual falls where the Datix information has not
provided a considered root cause
Updating the Trustwide action plan to include actions to address common
themes emerging from the analysis of the falls
Reporting numbers of falls by bed days
The Datix RCA tool has been in use for approximately one year and will be
reviewed to ensure it is providing the most useful information. The policy will be
reviewed to ensure it supports best practice and provides simple flowcharts and
other supporting material. The training opportunities and resources will be
reviewed.
In addition, a potential route to access physiotherapy services for specialist work
related to falls for East Suffolk where currently no service exists is being followed
up with the contracts team.
It is hoped that this work will address the apparent rising trend in reported falls
(Chart 8), although the great majority of these are with no reported harm.
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Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
Chart 8 - NSFT Trustwide Slips trips and fall data (STF) – falls per bed days, 2014
0.0080
0.0069
0.0070
0.0062
0.0060
0.0050
0.0054
0.0048
0.0040
0.0030
0.0020
0.0010
0.0000
Apr
May
Apr
Jun
May
Jun
Jul
Jul
The physical health team lead is an active member of both the Norfolk and Suffolk
systemwide falls groups which each focus on initiatives to reduce the number of
falls across all services and ensure pathways of care are developed to improve
continuity of care.
2.7.3
Safety Thermometer (ST)
The national Safety Thermometer tool provides monthly point prevalence data on
harm-free care in the later life wards which participate in data submission. As it is
a point prevalence survey, it does not correlate with information reported on the
incidence of harms, such as pressure ulcers.
In July 2014, the results demonstrated that three patients had harms, within the ST
definitions. These were 2 admitted pressure ulcers and 1 deep-vein thrombosis
(that is, VTE) on Sandringham ward. This is followed up with the ward and
emphasises the importance of carrying out the VTE risk assessments. The Trust
had an overall VTE risk assessment compliance of 91% with many wards
consistently achieving 100%. Sandringham ward reported 60% compliance.
The Safety Thermometer data on pressure ulcers for the Trust shows an average
of approximately 0.7 patients per month (or 0.53%) developing a pressure ulcer
across the surveyed wards: a small number of these will have been assessed to
be unavoidable. This should be viewed in context of the previously mentioned
provisos.
2.8
Alerts Received From Central Alert System, July 2014
Thirteen alerts were received from the central alert system in July 2014, ten of
which required no further action, one for which action has been completed, and
two with action pending. These are detailed below in Table 2.
Table 2: Actions ongoing, July 2014
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Patient Safety & Quality Report
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Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
Action Ongoing
Additional information for Mental Health Units with regards to
EFA/2014/002: E-cigarettes, batteries and chargers – action points to be taken
forward by the Physical lead for example e-cigarettes to be included on the
smoke free strategy. Alert will be discussed at the Health & Safety Committee
meeting 14.08.2014
Completion date of alert 29.09.2014
NHS/NPSA/005 Improving medication error incident reporting and learning
Completion date 19 September 2014.
Action to date: Reminder email sent 24.07.2014 requesting evidence that action
points have been considered.
Safety, availability and suitability of equipmentAt recent Medical Devices Standards group it was raised by representative from
EME (electrical biomedical engineering) at NNUH, Ipswich, Queen Elizabeth,
Hospital that currently no contract is in place for routine maintenance of medical
devices. That maintenance checks are carried out on good will and because of
historical practice. Action to date: no reply received from initial and subsequent
emails sent to Procurement lead.
3.0
Quality Reports
3.1
Safeguarding
Training compliance; the Trust is compliant at Level 1 and 2 training, Level 3
training remains on the risk register and the action plan to address this continues.
Compliance is expected by December 2014.
The new RCPCH Intercollegiate document which is the document the Trust is
measured against in terms of training competencies for safeguarding training has
been revised. This will have implications for the Trust and how training is
delivered, at what level and to whom. One aspect for the Board to consider is that
the Board, including Non-executive Directors, should receive safeguarding training
and updates annually.
3.2
Whistleblowing
The Trust has been asked to report to Monitor the number of Bullying and
Harassment cases brought through the Public Interest Disclosure route related to
bullying by Senior Managers between April 2011 and March 2014.
There have been three such cases;
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Date produced: 11 August 2014
Retention period: 30 years
1. The Trust could not investigate as none of the witnesses would make a
formal statement, anonymous or otherwise, and therefore natural justice
could not be applied.
2. Investigated; no case to answer.
3. Investigated; informal sanction given.
As a result of these cases the relevant policies are under review by the
Governance and Human Resources teams to reflect lessons learnt, and to inform
both those who raise concerns and those who deal with them of the correct
process for individual cases, support available for all parties and outcome
management frameworks.
3.3
Sign up to Safety
Sign up to Safety is a national patient safety campaign that was announced in
March by the Secretary of State for Health. The campaign was launched on 24
June 2014 with the mission to strengthen patient safety in the NHS and make it
the safest healthcare system in the world.
The Sign up to Safety campaign supports the principles that organisations listen to
patients, carers and staff, learn from what they say when things go wrong and take
action to improve patient’s safety. Sign up to Safety aims to deliver harm free care
for every patient, every time, everywhere. It champions openness and honesty
and supports everyone to improve the safety of patients.
Organisations who Sign up to Safety commit to strengthen patient safety by:
Setting out the actions they will undertake in response to the five Sign up to
Safety pledges and agree to publish this on their website for staff, patients
and the public to see.
Committing to turn their actions into a safety improvement plan which
will show how organisations intend to save lives and reduce harm for
patients over the next 3 years.
The campaign is based on 5 key safety pledges:
Put safety first. Commit to reduce avoidable harm in the NHS by half and
make public the goals and plans developed locally.
Continually learn. Make their organisations more resilient to risks, by
acting on the feedback from patients and by constantly measuring and
monitoring how safe their services are.
Honesty. Be transparent with people about their progress to tackle patient
safety issues and support staff to be candid with patients and their families
if something goes wrong.
Collaborate. Taking a leading role in supporting local collaborative
learning, so that improvements are made across all of the local services
that patients use.
Support. Help people understand why things go wrong and how to put
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Date produced: 11 August 2014
Retention period: 30 years
them right. Give staff the time and support to improve and celebrate the
progress.
To sign up to the campaign the Trust needs to set out what actions it will take to
strengthen patient safety by:
Describing the actions the Trust will undertake in response to the five Sign
up to Safety pledges and publish these on the Trusts website for staff,
patients and the public to see.
Commit to turning proposed actions into a safety improvement plan which
will show how the Trust intends to save lives and reduce harm for patients
over the next 3 years.
Identify the patient safety improvement areas the Trust will focus on for
which the Trust will be supported to identify two or more areas from a
national menu of high priority issues and two or more from our own local
priorities.
The Trust will announce its intention to Sign up to Safety in August 2014.
3.4
Speak out Safely
The Speak out Safely (SOS) campaign led by the Nursing Times aims to
encourage NHS organisations and independent healthcare providers to develop
cultures that are honest and transparent, and to encourage staff to raise the alarm
when they see poor practice, and to protect them when they do so.
The Trust is signing up to this campaign to demonstrate to staff a clear message
that it is committed to safe patient care and to empowering staff to raise concerns
in the knowledge that they will not suffer as a consequence.
The Trust’s involvement and support of the Speak out Safely campaign will be
acknowledged in the SOS section of the Nursing Times website as well as
displayed on NSFT Website.
There is no cost to signing up to the campaign and the process to signing up is a
straightforward process and is achieved by taking the following steps:
The Trust will display the SOS logo and pledge prominently on the Trust
website,
Ensuring that the Trust whistleblowing policy makes explicit that staff will be
supported if they raise concerns; that all staff know where they can find the
policy; and that it is publicly available rather solely via the Trust intranet.
Once these actions are completed the Trust will email the evidence to the SOS
campaign who then acknowledge the Trust’s support and commitment to the
campaign.
3.5
Learning Disability Strategy
In preparing for the Monitor declaration on access to services for people with a
learning disability, it was identified that the Trust has inconsistent approaches to
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Date produced: 11 August 2014
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the provision of mental health care for this group. Further work was agreed to
address these inconsistencies. Previous audits demonstrated that some excellent
work had been undertaken, but that this had not been followed through the Trust
merger and TSS process. As a result, the Trust needs to pull together these
previous strands of work, and develop much better relationships with service users
and carers in developing a meaningful strategy. The Trust is working with the
National Delivery Team for inclusion (NDTi) to provide some short-term solutions
and then support the development of a strategy within the next six months.
Updates will be provided to the Board on this vital piece of work.
3.6
External Review of Unexpected Deaths in West Norfolk
West Norfolk CCG commissioned an external review of ten unexpected deaths
from April 2013 in West Norfolk. The draft report on nine of these incidents has
been sent to the Trust for data checking, and a final report is expected in
September. The locality is developing an action plan in response to the report,
with Trustwide learning being carried through by the Patient Safety Team, and this
will be discussed at the Service Governance Committee.
3.7
Internal Review of Serious Incidents in Norfolk Recovery Partnership
A review of the unexpected deaths in NRP was commissioned by the Director of
Nursing and Quality on behalf of the Board in March 2014, commencing in late
April 2014. This was in response to an apparent increase in the number of deaths
being reported by the newly-commissioned service, although there was no
comparison for this trend, as the service had not been operational for sufficient
time to provide any baseline data. Despite this, the Board was keen to establish if
the number of deaths being reported was within the range expected, and whether
there were any operational issues that may have contributed. Being able to
implement lessons learned from previous incidents was also an area of concern.
Terms of Reference were drawn up and agreed with the NRP management and
commissioners, and an external expert appointed to undertake the review.
Although the report was initially due back in July 2014, delays in securing access
to incident reports, and then leave by the report author has meant that a draft
report was produced in July, and the final report is due by the end of August 2014.
NRP managers have seen the draft report, and been informed of findings as the
investigation was underway, in order to make any immediate changes required,
and to link to the service’s quality improvement action plan. The
recommendations in the final report will augment the service’s improvement plan,
and form part of quality monitoring by commissioners. This will also be discussed
at the Trust’s Service Governance Committee.
4.0
Benchmarking – Evaluation Against National Standards And Reports
4.1
Mental Health Act Commission (MHAC) CQC visits
Since the last report the CQC have visited Rollesby ward and the reports for
Rollesby and Glaven wards have been received. The issues continue to be the
same: recording patients’ rights (Sec 132), and T2 and 3 forms being correct and
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also attached to medicine cards. Reminders have been issued to relevant staff to
ensure that this is rectified, and additional checks are being put in place.
Glaven ward was felt to breach standards of privacy and dignity due to the poor
environment and possible breaches of single sex regulations. A decision was
made on the 8th August to re-designate the wards as single gender. Although the
gender distribution has largely been equal, this will result in less flexibility in bed
availability, so conversion of a room on each ward to an additional bedroom has
been commissioned to give greater capacity to manage admissions. It is intended
to complete the work needed and change the wards in September 2014.
4.2
CQC Full Trust Inspection
Preparation for the visit is under way and awareness sessions for all staff are
taking place as well as benchmarking sessions with team leaders. In addition, the
15 steps framework is being used to assess patient environments and clinical
leads are supporting governance to assess their areas.
The Fortnightly Focus on one of the five key questions that the CQC will ask is
designed to ensure that the awareness and benchmarking is undertaken in
manageable sections and an overview has been produced which compares the
old Essential Standards with the new Fundamental Standards so that the work
undertaken by teams in the past is not lost.
A newsletter is being produced and a FAQ list is available on the intranet in a
dedicated link.
Areas of risk are being collated and reported to the executive team
4.3
Mock CQC Inspections.
The mock inspections will continue until September. Inspections undertaken in
July are detailed in Appendix 2, and include visits to:
Rose Ward
Reed Ward
HTT, West Suffolk
Bury South IDT
Churchill Ward
4.4
Non-Executive Director Visits
One visit was recorded in July 2014 to the Norvic Clinic, and the findings are
detailed in Appendix 3.
5.0
Safe Staffing
5.1.
In line with the Government’s requirements as set out in Hard Truths, the Trust
continues to submitted data via the National reporting system Unify 2 with the 3rd
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Author: Jane Sayer
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Date produced: 11 August 2014
Retention period: 30 years
submission entered on 15th August. The data submitted in August reporting on
July’s figures demonstrates a 109% fill rate of planned level. The data reported
continues to demonstrate actual staffing levels compared against the ward
established figures. This data is reported in Appendix 4. The mean staffing levels
against establishment are shown in Table 3 below. A clear example of how the
needs of the services can vary against established figures is demonstrated by
Rose ward which has shown higher than expected fill rates due to the high number
of service users currently on 1:1 observations and a variation in unexpected
activities on the ward.
Table 3: Mean staffing, actual against establishment, July 2014
Day shifts
Night shifts
RN % fill against
establishment
99.8%
92.5%
HCA % fill against
establishment
122.4%
134.2%
The headline fill rate shows a decrease from 102.70% of RN’s by day compared to
June but an increase from 88.8% to 92.5% by night.
This shortfall continues to be mitigated by increase fill rates of HCA’s which have
increase from 117.4% by day and 132% by night in comparison to June.
Identified hotspots via safe staffing reporting include:
Foxhall House average fill rate of RN’s 63.71% in July by day and 54.8% by
night
Poppy Ward average fill rate of 75.81% of RN’s by day but achieving 95.2%
by night.
Rose Ward average fill rate 75.81% of RN’s by day but achieving 100% at
night
A number of areas also report RN’s average fill rates of 80% or under on one or
other shift. These include:
Night shifts
Glaven Ward 79%
Acle Ward 74.2%
Whitlingham Ward 50%
Sandringham 80.6%
Blickling Ward 62.9%
Day Shifts
6 Airey Close 80.65%
Reed Ward 80.65%
All of the above areas demonstrate over-establishment of support workers in July
to mitigate against the lack of RN’s. Monitoring is in place at monthly patient
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Date produced: 11 August 2014
Retention period: 30 years
safety meeting to monitor for any emerging clinical and safety concerns that could
be attributed to lack of staff.
Of note, only 6 Airey Close and Glaven are represented in the staffing concerns
Datix reports below. Foxhall, Poppy or Rose Wards have not submitted reports to
Datix that would reflect the concerns reported by their average fill rates.
5.2
Reporting of Staffing Concerns via Datix
A total of 148 concerns regarding staffing have been reported in July 2014
compared with 160 reports in June. Of these, the highest reporting category is low
staffing levels with 67 reported incidents in this category, a decrease from 94
reports in June. The wards which contributed the highest level of reporting in this
category are:
6 Airey Close - 12
Glaven Ward - 7
Lark Ward - 5
Yare Ward - 5
Of the reports received related to staffing concerns, low staffing continued to
present the highest trend. A breakdown of categories of the highest reported
incidents shown in Table 4:
Table 4: Staffing concerns reported in July 2014
Highest Number of
Categories Reported
Low staffing levels
67
Highest Reporting Areas – Number of Reports
No or lack of trained
supervisory staff - 28
Central Norfolk Acute Services – 11
East Suffolk Acute service - 6
Insufficient regular
nursing staff 10
Central Acute Services - 7
East Suffolk Acute Services -2
Abbeygate - 1
Central Acute Services - 12
East Suffolk Acute services - 10
6 Airey Close - 12
Of the 67 low staffing incidents reported within Suffolk Specialist Services, twelve
can be attributed to Number 6 Airey Close. Within East Suffolk Acute Services
Lark Ward accounts for a total of five of the ten low staffing concerns reported
during July. Glaven Ward accounts for seven of the twelve reports within Central
Acute Services.
July has seen an increase from 23 to 28 reports of no or lack of trained staff,
eleven of these are within central Norfolk Acute services, with six attributed to
Board of Directors – Public
28 August 2014
Patient Safety & Quality Report
Page 16 of 26
Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
Glaven Ward. Lark Ward accounts for four of the six reports within East Suffolk
Acute Services.
Reports received regarding insufficient regular nursing staff has also increased
from seven in June to ten in July. Seven reports are attributed to Central Acute
Services with five reported from Glaven and two from Rollesby.
Vacancies and short-term staffing issues will continue to be addressed within
meetings with NHSP, and when possible, those wards with the most acute staffing
issues have been prioritised within recent central recruitment events.
6.0
Service User and Carer Experience
6.1
Service User and Carer Payment Policy
The payment policy and guidelines will be submitted to the Service User and Carer
Trust Partnership meeting on 22nd August. The new guidelines will ensure that
payments are made promptly and staff, service users and cares are able to
complete return reimbursement forms, following the set procedure. The Service
User and Carer Trust Partnership will set a review date for the guidance.
6.2
Service User and Care Involvement Strategy
Work is on-going to produce the combined service user and Carer involvement
strategy. There is a working group of service users, carers, staff and members of
our third sector partners to ensure that all work is coproduced. The working group
is facilitated by the NSFT Involvement Team, who will put wider consultation
processes in place once the draft is complete.
6.3
Interview Process for Service Users and Cares
It has been agreed by HR Business Partners and Involvement Team there will be
a rota system in place for all rolling recruitment events in central Norfolk and
Suffolk. This process will ensure that service user and carer involvement in the
interview process is fair and equitable when interviews are rolled out over a
number of days. Discussions are on-going with regard to the service user and
care input in to a revised recruitment training module and delivery of the module.
6.4
Friends and Family Test
As from the 1st January 2015 the FFT will be introduced in all mental health
services. The recently published Friends and Family Test Guidance published on
27th July 2014 sets out the guidance for implantation within services. The
implementation of the FFT is aligned to a National CQUIN. The FFT data must be
submitted to NHS England monthly. The implementation of the FFT is part of a
National CQUIN and has a value to the Trust of £214,063 for full implementation
before the end of December 2014. Funding of 20% of the patient FFT is to be
awarded for partial implementation in services, as per FFT guidance, from 1
October 2014.
Board of Directors – Public
28 August 2014
Patient Safety & Quality Report
Page 17 of 26
Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
Although the use of digital pens has been welcomed in various parts of the Trust, it
is unlikely that the digital pens will provide a long-term solution to the collection
and submission for FFT as the FFT has to be available for service users to access
24 hours a day, 7 days a week. Collating the information would also be labour
intensive and resource heavy. As a result, the Executive Team have decided to
contract an external company to provide the support required to collect the data
and provide meaningful information, and the data collection is hoped to start in
October 2014.
7.0
Quality Dashboard (Appendix 5)
The Quality Dashboard is still in development; on-going improvements planned in
conjunction with the Informatics Team continue. Work has been delayed this
month due to leave, so improvements discussed at the Board in July 2014 are now
anticipated in September.
8.0
Risks / Mitigation in Relation to the Trust Objectives (Implications for Board
Assurance Framework)
8.1
Quality and patient safety issues are fundamental to the delivery of Trust
objectives, and the Board’s ability to manage the performance of the Trust.
Relevant mitigating action is included above, and residual risks are noted.
9.0
Recommendations
9.1
The Board of Directors is asked to note and approve the contents of this report.
Jane Sayer
Director of Nursing and Quality
14th August 2014
Background Papers / Information
Appendix 1:
Improvements to Process of Investigating Serious Incidents
Appendix 2:
Mock CQC Visits, July 2014
Appendix 3:
NED Visits, July 2014
Appendix 4:
In-Patient Staffing, Actual Vs. Budget, July 2014
Appendix 5:
Quality Dashboard, Q2, 2014
Board of Directors – Public
28 August 2014
Patient Safety & Quality Report
Page 18 of 26
Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
th
Date:
28 August 2014
Item:
14.110iii Appendix 1
F
Appendix 1: Improvements to Process of Investigating Serious Incidents
Since January 2014, a number of actions have been taken in relation to the Trust’s
processes of responding to serious incidents. Improvements have been informed by NE
D scrutiny of the RCA process, feedback from clinical staff, service users and carers, and
feedback from commissioners and Coroners.
Reporting and Investigation
Since January 2014, all Level 2 and 3 incidents (In-patient deaths and other high
impact incidents) have Director level scrutiny from the outset of the investigation.
An Executive and a Non-Executive Director, one of whom must be from a clinical
background, meet with the investigation team at the outset of the investigation to
agree Terms of Reference. When the draft report is produced, a meeting is chaired
by the two Directors, with the investigation team, clinical team, commissioners and
other stakeholders to review the process of investigation and agree the final report,
including recommendations and an action plan.
Funding for two Band 7 clinicians has been identified to join the Patient Safety
team. Seconded from clinical services, these two posts will lead on investigation of
Level 1 incidents, and it is anticipated that they will focus on all suicide and
suspected suicide incidents. This dedicated resource means that there will be a
consistency to these investigations, and clinical services, although still supporting
the investigations, will not have to lead these investigations. The facilitator for
Norfolk will start in September, and we are recruiting to the Suffolk post currently.
The two initiatives above means that there will be clear identification of timelines at
the outset of investigations, ensuring that all incidents are investigated in a timely
manner, and that clinical teams will know when to expect feedback and requests for
checking of reports prior to finalisation. Since the CCGs started requiring a
response within 45 days (April 2014), the Trust has not incurred any fines for late
reports.
RCA Facilitators are now asked to consider when to engage family members and
carers sensitively, so any questions that may want to ask can be included in the
RCA process. Sometimes, the timing may mean that this is too early for the family
to think about what they would like to know, so the Trust continues to allocate a
family liaison member who can raise issues and questions at any stage.
The Trust now uses a consistent approach for falls and pressure ulcers, which
addresses the issues that commonly arise in such incidents.
Reports and Recommendations
From recommendations made, the Trust is considering how to include a more
personalised description of the service user in the RCA report, as they may be
considered rather cold and clinical.
Facilitators are being asked to consider fewer and SMARTer recommendations that
address the root cause of the incident, in order to increase the likelihood of actions
that will prevent incidents recurring.
There will be feedback to managers at an early stage regarding professional issues
that should be followed up separate to the RCA process. Although the Trust
supports a No Blame culture, there are sometimes situations that occur where
professional concerns need to be explored, and this is picked up concurrently.
Board of Directors – Public
28 August 2014
Patient Safety & Quality Report
Page 19 of 26
Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
All actions identified as part of an RCA process are followed up until completed,
including embedding of lessons.
Learning Lessons
There is a monthly review of RCAs by the Medical Director and Director of Nursing,
with themes fed back to the Lead Clinicians and operational managers at the
Strategic Management Forum.
Learning events are held locally to inform clinical staff of findings from RCAs
Dissemination of learning is done through management and professional routes,
and the embedding of learning is assessed through audit processes.
Themes from SIs are fed into the Trust’s Risk Register and Board Assurance
Framework, so there is Board level assurance on embedding of learning through
the Service Governance Committee.
Board of Directors – Public
28 August 2014
Patient Safety & Quality Report
Page 20 of 26
Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
Appendix 2: Mock CQC Visits
DATE
Location
ISSUES RAISED
02/07/14
Rose Ward,
Information for service users and carers not visible.
Hammerton
Activity timetable needs review as it appears over ambitious and staff shortages means it
Court
is not being delivered.
VTE assessments not completed/documented.
Additional observations training and register was not identifiable and not known about.
Bedrooms are locked so there is no free access.
Action plan update requested 08.08.14
03/07/14
Reed Ward,
Hammerton
court.
10/7/14
HTT West
Suffolk
10/7/14
Bury South
IDT
Staffing issues?
Compliance with single sex requirements is difficult due to the availability of assisted
toilets.
Information for service users and carers is not visible.
Activity timetable needs review as it appears over ambitious and staff shortages means it
is not being delivered.
Action plan update requested 08.08.14
Very positive visit
Staff on occasion will bring drugs back from patients houses either because they have
too many and it poses a risk in which cases they will deliver the dose as required or
because they have stockpiled drugs which are no longer required and they are brought
back for disposal. There needs to be a documented, safe process for recording,
transport, storage and disposal; also dispensing if then taking back to patient’s house.
The drug fridge temperature must be recorded according to policy.
Staffing levels were mentioned by several staff – it was felt that there was still an impact from
TSS affecting vacancy levels; also on sickness levels.
One staff member felt that moving teams had left her feeling out of her depth – however this
was counteracted by another staff member who had sourced additional training to support
herself in her new role.
Board of Directors – Public
28 August 2014
Patient Safety & Quality Report
Page 21 of 26
Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
Appendix 2: Mock CQC Visits
Some care plans were not reviewed regularly (standard stated as 6-monthly if nothing has
changed), some exceed this – this was stated to be because of high caseload.
There was a view that service users are frightened of discharge (and staff members may be
reluctant to discharge service users) because of difficulties getting back onto caseload.
There was little evidence of discharge planning with CPA review prior to this (although there
was evidence of MDT handover from one service to another with a transitional care plan).
There was an impression that the service was not recovery focussed.
Data protection was brought up as a reason for not involving a carer in care planning.
The process for transporting patient medication needs reviewing and standardising with
documentation to support risk management.
The distance to travel for training was felt to be a barrier – a suggestion that there is a training
day when the relevant sessions are brought to the teams (as with safeguarding training on the
day of the visit).
There are some inexpensive improvements to the environment which could be made which
would create a better impression for service users eg rationalising furniture, filling holes and
adding art work.
Action plan update requested 08.08.14
31/07/14
Churchill Ward
Fermoy Unit.
Kings Lynn.
Pt 4580282213 – T3 needs to be attached to medicine card.
Please check all section patients’ paperwork is in order.
Female lounge needs a sign.
Inconsistent picture.
Board of Directors – Public
28 August 2014
Patient Safety & Quality Report
Page 22 of 26
Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
Appendix 2: Mock CQC Visits
Paperwork:
o Not correctly filed
o Some documents undated, unsigned – crucial
o Risk assessments with no plan
o Risk assessments not completed
o Care plan and risk assessment file – difficult to find – not consistently filed –
duplicates.
o Care plans completed with review date but then review not evident
o T2 / 3 forms not on medication
o 132 rights recording
o Care plans not shared / signed
15 Steps – good.
Leaflets:
o Check only the current version is available
o Posters still with N&W on
No social engagement at lunch, otherwise good.
Action plan update requested 08.08.14
Board of Directors – Public
28 August 2014
Patient Safety & Quality Report
Page 23 of 26
Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
Appendix 3: NED Clinical Visits
Board Member
Ward visited
Date
Personnel seen
Graham Creelman
Catton Ward, Norvic
Clinic
17 July 2014
Secure Services
Manager, Acting Ward
Manager, Mental Health
Nurse, Service Users
and Staff
Board of Directors – Public
28 August 2014
Patient Safety & Quality Report
Page 24 of 26
Comments
The ward was calm, with observed good engagement
between service users and staff, although the staff were
largely agency on this day
There was strong support for the MDT approach which
appears to be working well
Praise for the Secure Services Manager as an
approachable and engaged leader
Service Users felt the staff were overall helpful,
supportive and accessible
The Acting Ward Manager stated the absence of a
psychological therapies strategy was becoming a
serious issue
Lorenzo needed to take on board that the
documentation for secure services is quite different from
other areas
It was said that delayed transfers to other areas of the
Trust are often caused by “the rest of the Trust” having
too little knowledge and understanding of secure
services
A perceived lack of activities for service users. The
access to music appears to be a general issue.. The
Trust might investigate creating a library of varied music
on MP3 sticks.
Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
Appendix 4: In-Patient Staffing Actual versus Budget, July 2014
Day
Reg
5 Airey Close
6 Airey Close
7 Airey Close
Abbeygate
Acle
Avocet
Blickling
Catton
Churchill
Drayton
Eaton
Fernwood
Foxglove
Foxhall
Glaven
GYAS
Lark
Northgate
Poppy
Reed
Rollesby
Rose
Sandringham
Southgate
Sweetbriar
Thorpe
Walker Close
WAS
Waveney Ward
Whitlingham
Willows
Yare
Total
monthly
planned
staff
hours
930
930
465
930
930
1395
930
930
930
930
697.5
465
465
930
930
930
930
1117.5
1395
930
930
930
930
1395
465
697.5
930
930
930
930
1162.5
930
Total
monthly
actual
staff
hours
885
750
570
937.5
877.5
1282.5
960
997.5
1050
1102.5
862.5
457.5
465
592.5
952.5
937.5
1087.5
1290
1057.5
750
1102.5
705
1027.5
1537.5
487.5
570
915
900
937.5
1027.5
1245
885
Night
Unreg
Total
monthly
planned
staff
hours
1162.5
1395
1395
1860
1395
1162.5
1860
1395
1395
1395
1162.5
1860
1860
1162.5
1395
930
1395
1057.5
1162.5
1395
1395
1395
1860
1395
1860
1162.5
1860
930
1395
1395
1860
1395
Total
monthly
actual
staff
hours
1215
1522.5
1380
2227.5
2212.5
1635
2340
1350
1417.5
1507.5
1762.5
2107.5
1875
1875
1350
1147.5
2032.5
1162.5
1845
2572.5
1995
2917.5
2520
922.5
1860
1395
1905
1042.5
1372.5
1155
2805
1530
Reg
Total
monthly
planned
staff
hours
232.5
232.5
232.5
465
465
465
465
232.5
465
232.5
232.5
232.5
232.5
465
465
232.5
465
217.5
465
232.5
232.5
232.5
465
465
232.5
232.5
465
465
465
465
465
232.5
Total
monthly
actual
staff
hours
225
232.5
247.5
450
345
420
292.5
232.5
472.5
277.5
232.5
202.5
225
255
367.5
442.5
390
232.5
442.5
232.5
270
232.5
375
420
232.5
247.5
465
450
457.5
232.5
465
240
Day
Night
Unreg
Total
monthly
planned
staff
hours
465
465
232.5
465
465
465
697.5
697.5
465
465
465
697.5
930
465
697.5
465
697.5
435
465
465
697.5
465
697.5
465
465
465
697.5
465
465
465
697.5
697.5
Total
monthly
actual
staff
hours
442.5
697.5
315
660
855
877.5
1072.5
697.5
465
517.5
690
930
765
990
750
585
1230
465
772.5
885
1057.5
900
1185
480
570
465
757.5
472.5
502.5
697.5
892.5
712.5
Average fill
rate as %
of
established
hours registered
nurses (%)
Average fill
rate as a %
of
established
hours care staff
(%)
Average fill
rate as a %
of
established
hours registered
nurses (%)
Average fill
rate as a %
of
established
hours - care
staff (%)
95.2
80.6
122.6
100.8
94.4
91.9
103.2
107.3
112.9
118.5
123.7
98.4
100.0
63.7
102.4
100.8
116.9
115.4
75.8
80.6
118.5
75.8
110.5
110.2
104.8
81.7
98.4
96.8
100.8
110.5
107.1
95.2
104.5
109.1
98.9
119.8
158.6
140.6
125.8
96.8
101.6
108.1
151.6
113.3
100.8
161.3
96.8
123.4
145.7
109.9
158.7
184.4
143.0
209.1
135.5
66.1
100.0
120.0
102.4
112.1
98.4
82.8
150.8
109.7
96.8
100.0
106.5
96.8
74.2
90.3
62.9
100.0
101.6
119.4
100.0
87.1
96.8
54.8
79.0
190.3
83.9
106.9
95.2
100.0
116.1
100.0
80.6
90.3
100.0
106.5
100.0
96.8
98.4
50.0
100.0
103.2
95.2
150.0
135.5
141.9
183.9
188.7
153.8
100.0
100.0
111.3
148.4
133.3
82.3
212.9
107.5
125.8
176.3
106.9
166.1
190.3
151.6
193.5
169.9
103.2
122.6
100.0
108.6
101.6
108.1
150.0
128.0
102.2
Board of Directors – Public
28 August 2014
Patient Safety & Quality Report
Page 26 of 26
Version 1.0
Author: Jane Sayer
Department: Trust Management
Date produced: 11 August 2014
Retention period: 30 years
Report Published 14/08/2014
Quality and Safety Dashboard
By Location and Specialty
Q2 (Jul) 2014-2015 version 3.0
Page 1 of 6
Report Published 14/08/2014
Risk Management by Locality
Deliberate Self
Physical Assault
Harm
Q2 (Jul) 2014-2015
Norfolk Central (Adult)
16
4
Restraint
Slips Trips &
Falls
27
Absconsions
Complaints
1
23
Norfolk Central (Child Family & Young People)
2
West Norfolk (Adult) (Under 65 / Non Pt related)
5
19
23
45
6
4
2
1
2
7
1
West Norfolk (Older Persons 65+)
Great Yarmouth & Waveney (Adult)
10
Great Yarmouth & Waveney (CAMHS)
1
8
1
4
5
7
12
2
34
28
71
62
13
4
16
10
Great Yarmouth & Waveney (Older Persons)
Suffolk East Assessment/Treatment
2
1
2
Norfolk Central (Older Persons)
Norfolk & Waveney Total
Serious
Medication
Serious
Incidents
Administration Pressure Ulcers Incidents (ward
(community &
and Prescribing
based patients)
office)
3
Suffolk East Coastal IDT
1
Suffolk Specialist Services
13
1
34
5
1
7
1
7
16
1
1
5
1
1
1
4
Suffolk East Central IDT
Suffolk East Ipswich IDT
1
7
4
2
1
39
Suffolk Countywide
2
3
2
1
5
4
4
1
1
6
1
1
4
1
2
7
2
Suffolk West
Suffolk West Assessment/Treatment
Suffolk West Bury North IDT
Suffolk West Bury South IDT
2
Suffolk Total
Norfolk Recovery Partnership
34
6
3
1
Other (Non Trust Incident)
57
31
2
22
1
2
2
1
1
Secure Services
18
7
28
3
1
2
4
1
1
Other Total
21
8
29
3
1
4
4
1
2
Trust Total
89
42
157
96
6
65
18
7
8
Corporate & Support Services
Data Collated and Published by: Informatics
Source of Data: Datix
7
Page 2 of 6
Report Published 14/08/2014
Risk Management by Service Line
Deliberate Self
Physical Assault
Harm
Q2 (Jul) 2014-2015
Restraint
Slips Trips &
Falls
Absconsions
Complaints
Serious
Medication
Serious
Incidents
Administration Pressure Ulcers Incidents (ward
(community &
and Prescribing
based patients)
office)
(N & S) Access & Assessment
(N & S) Adult
1
(N & S) Adult Acute
43
(N & S) Adult Community
1
(N & S) CAMHS/Youth
1
1
6
50
6
8
1
1
2
(N & S) Criminal Justice Liason
(N & S) Dementia & Complexity in Later Life (DCLL)
2
24
30
(N & S) Low Secure Services
7
5
4
(N & S) Older People Acute Service
1
57
3
5
2
4
2
1
3
24
2
2
7
(N & S) Other
(N & S) Youth
Norfolk & Suffolk Total
(N only) Medium Secure Services
Norfolk Total
56
35
87
88
15
6
5
11
2
24
3
2
1
11
2
24
3
2
1
(S only) Complexity in Later Life (CLL)
(S only) Enhanced Community
(S only) Neurodevelopmental
1
(S only) Neurodevelopmental Acute
Suffolk Total
Data Collated and Published by: Informatics
1
Other Total
22
5
46
5
Trust Total
89
42
157
96
Source of Data: Datix
6
65
18
7
1
2
7
8
Page 3 of 6
Report Published 14/08/2014
Workforce by Locality
Q2 (Jul) 2014-2015
% of
% of Staff
Annualised
Sickness
with an
Sickness
Absence Appraisal in
Absence
Episodes >= the Last 12
Rate
21 Days
Months
Turnover
Rates
Vacancy
Rate
Central Norfolk
12.3%
11.0%
5.8%
14.6%
10.0%
Great Yarmouth & Waveney
11.5%
7.5%
5.0%
17.2%
8.4%
West Norfolk Locality
11.3%
14.4%
6.7%
17.8%
9.3%
9.5%
19.4%
5.8%
12.6%
7.9%
11.8%
11.7%
4.8%
19.3%
21.0%
16.9%
17.2%
8.0%
8.3%
9.0%
12.1%
16.4%
5.6%
14.3%
12.4%
Number of Statutory /
Mandatory Training
Elements which are 40%
below compliance
Norfolk & Waveney Total
Suffolk East Assessment
/Treatment
Suffolk Wellbeing
Suffolk West
Assessment/Treatment
Suffolk Access & Assessment
Suffolk Total
Secure Services
Corporate
Trust Total
13/33
Total Spend on Temporary Staffing - the total spend on temporary staffing is a
consolidated figure for the whole of the Trust and includes total temporary pay and
overtime pay.
£k
Bank (incl Locum)
Agency
Overtime
TRUST TOTAL
Data Collated and Published by: Informatics
Jul
731.8
1,672.0
104.1
2,507.9
Aug
-
Sep
-
Source of Data: ESR
Totals
731.8
1,672.0
104.1
2,507.9
Page 4 of 6
Report Published 14/08/2014
Workforce by Service Area
Workforce Planned
Establishment (Budgeted
FTE)
Vacancy Rate
Turnover Rates
Absence Rate
Sickness Absence
Episodes >= 21 Days
Appraisals
Wellbeing
769.5
20.8%
15.5%
3.8%
11.4%
19.7%
3.8%
Adult Acute
344.1
13.9%
14.8%
6.6%
13.5%
2.7%
0.3%
Adult Community
227.2
17.7%
23.3%
8.6%
17.3%
5.0%
1.4%
Children & Youth
255.2
6.1%
6.3%
3.5%
7.7%
14.8%
1.5%
Continuing Care
129.2
5.4%
19.5%
4.7%
6.9%
6.9%
1.5%
Iapt/Wellbeing
173.8
9.3%
19.3%
4.7%
11.7%
19.2%
0.6%
Management & Admin
169.4
2.2%
11.4%
4.2%
8.5%
2.7%
0.5%
Older People
264.1
6.0%
20.6%
6.2%
14.9%
22.7%
6.3%
1,562.9
9.4%
15.9%
5.6%
11.9%
10.4%
1.8%
Low Secure
175.2
10.3%
9.0%
7.3%
16.5%
12.8%
0.6%
Management & Admin
63.6
11.5%
3.3%
3.4%
15.4%
26.2%
0.0%
Medium Secure
169.9
6.6%
9.5%
9.9%
17.6%
18.7%
1.8%
408.7
9.0%
8.3%
7.9%
16.9%
17.1%
1.0%
107.0
7.6%
13.8%
7.8%
14.5%
9.8%
0.0%
107.0
7.6%
13.8%
7.8%
14.5%
9.8%
0.0%
Adult Acute
264.8
18.5%
9.5%
5.9%
10.1%
15.8%
1.1%
Adult Community
63.8
9.1%
25.6%
5.1%
11.6%
16.5%
1.2%
Children & Youth
85.9
9.4%
26.6%
4.6%
11.4%
9.6%
1.0%
Enhanced Wellbeing
42.3
7.1%
12.5%
3.9%
5.1%
9.2%
0.0%
Management & Admin
123.4
9.3%
14.6%
6.1%
9.5%
24.0%
3.0%
Neuro-developmental
130.6
4.0%
10.9%
5.0%
7.2%
12.4%
3.1%
Older People
186.3
17.6%
15.5%
5.8%
12.7%
23.8%
0.9%
Suffolk Access & Assessment
67.3
18.2%
6.5%
5.3%
10.2%
80.7%
6.4%
Suffolk Wellbeing Service
102.4
5.9%
3.3%
7.0%
9.8%
16.4%
1.6%
1,066.7
3,914.9
12.5%
12.4%
13.3%
14.2%
5.7%
5.6%
10.2%
12.1%
23.0%
16.4%
1.9%
2.1%
Q2 (Jul) 2014-2015
Corporate Total
Norfolk Total
Secure Services Total
Substance Misuse
Substance Misuse Total
Suffolk Total
Grand Total
Data Collated and Published by: Informatics
Source of Data: ESR
Page 5 of 6
Report Published 14/08/2014
Risk Management Definitions
Risk Management
Deliberate Self Harm
Physical Assault
Restraint
Where a service users harms themselves in any way. i.e. scratching, cutting, overdose, attempted
hanging, strangulation, set light to self etc.
Where one service user makes contact with another
Where a service user needs to be restrained
Slips Trips and Falls
Slip, trip or a fall.
General Comment
The data is selected from a pick list on the Datix database, users do not need to type in the
information. The information is updated on the system by the Datix administrator.
Workforce
% of sickness absence episodes
> = 21 days
% of Staff with a Wellbeing
interview
% of Staff with an Appraisal in
the Last 12 Months
Annualised sickness absence
rate
Number of statutory/mandatory
training elements which are
below 40% compliance.
Total Spend on Temporary
Staffing
Turnover Rates
The total number of staff expressed as a percentage of sickness absence who have a sickness episode
of more than 21 days.
We have no information on how this is calculated as yet.
The number of staff appraisals in rolling 12 months.
The number of full time equivalent (FTE) calendar days lost to sickness absence in a rolling 12 month
period expressed as a percentage of available FTE calendar days in a rolling year.
Number of statutory/mandatory training elements which are below 40% compliance.
This includes the total staff payments for temporary staff for the month with an additional figure for
overtime.
Number of leavers (HC) divided by average staff in post over the previous 12 months. Permanent staff
only.
Vacancy Rate (WTE)
The vacancy rate calculation is the percentage of unfilled posts against the budgeted WTE's for the
Trust, in the given month. Finance take the actual WTE's being reported from ESR, so this would include
any WTE's reported for staff who left part month, who also received a payment, and include those who
started part way through the month (assuming that they had been set up on ESR and paid in the
month), and those still employed but on maternity leave or in a nil pay situation.
Workforce Planned
Establishment (WTE)
Funded establishment at the end of the month.
Data Collated and Published by: Informatics
Source of Data: Datix
Page 6 of 6
th
Date:
28 August 2014
Item:
14.110iv
Report To:
Board of Directors - Public
Meeting Date:
28th August 2014
Title of Report:
2014/15 Financial Performance Report (for the four month period
ending 31st July 2014)
Action Sought:
For Information
Estimated time:
20 minutes
Author:
Adrian Brooke – Business Accounting & Reporting Manager
Director:
Andrew Hopkins, Finance Director
G
Executive Summary:
The purpose of this report is to inform the Board of Directors of the Trust’s financial
performance for the period 1 April 2014 to 31 July 2014. Key headlines for the month
include:
A deficit in the month of £0.43m, increasing the year to date deficit at month four to
£0.77m.
A reported Continuity of Service Risk Rating (COSRR) of 3 for July.
Temporary staffing expenditure levels rising to a record high of £2.39m in the month
bringing the year to date expenditure up to £8.46m.
Overall reduction in the costs for out of area placements, particularly acute out of
area (OOA) placements. Specialist placements expenditure (for which the funding
from East of England specifically relates) continues to remain within the funded
levels.
A turnaround in the cash position during July with the cash held by the Trust now
£5.4m higher than planned at this point in the year. Come year end however, the
cash position is forecast to be significantly below plan.
Year to date capital expenditure of £1.39m against an original plan of £4.11m.
Board of Directors – Public
28August2014
2014/15 Financial Performance
Report M04
Page 1 of 4
Version 1.0
Author: Adrian Brooke
Department: Finance
th
Date produced: 20 August 2014
Retention period: 1 year
1.0 Financial Position
The attached power-point document details the overall Trust Financial
Performance as at the end of July 2014. A summarised position is also attached
to this paper in Appendix 1.
The Trust report is reporting a year to date deficit of £0.77m which is £0.62m
behind plan, although because of improved debtor collection a COSRR rating of
3 has been maintained.
The Board of Directors is asked to note that a number of actions are required to
drive improvements in the financial position and maintain a COSRR of 3. The
three most significant areas to address are the overspend on pay and in
particular reducing temporary pay costs, reductions in Out of Area Placements
(both acute and specialist) and improving CIP performance.
The Trust also needs to manage its cash position. Improvements in the above
three areas will drive up cash balances, but the shortfall in cash in the year from
the pushing back of asset sales will also mean a reduction in capital
expenditure in the year, in order that the Trust can continue to maintain a
COSRR of 3.
For budget managers across the Trust this will mean additional controls on
vacancy management and enhanced controls on the authorisation of temporary
staffing and additional controls over the authorisation of non-pay expenditure.
In the longer term the introduction of e-rostering is essential to improve the
management of temporary pay resources.
There is a detailed review of all CIP schemes currently taking place, which will
include the identification of those CIPs that have been agreed and removed
from budgets, bit where expenditure is still being incurred. The nonachievement of CIP in 2014/15 will have an impact on 2015/16 and detailed
planning, scheme identification and delivery timescales are required in this year
in order to facilitate delivery in 2015/16. The Trust is therefore considering how
that work can be best supported to enable managers to deliver against both
quality and financial targets.
In analysing the Trust’s performance it is interesting to note that the Health
Service Journal (HSJ) recently identified that mental health funding had fallen
nationally for the third year running. Mental health providers have been dealing
with increased demand whilst receiving less and less money each year. This
Board of Directors – Public
28August2014
2014/15 Financial Performance
Report M04
Page 2 of 4
Version 1.0
Author: Adrian Brooke
Department: Finance
th
Date produced: 20 August 2014
Retention period: 1 year
has driven up CIP requirements and these have not always been met 100%
year on year, thus leading to a build-up of CIP each year. The reasons behind
that is the need to maintain quality of care and the rising demand and acuity
(level of illness) in our service users, which has increased during the economic
recession. The parity of esteem commitment for mental health needs to be
reflected in resourcing.
The Trust is not the only mental health Trust dealing with such issues – many
Trusts are dealing with increases in acute workload and out of area placements,
recruitment and temporary staffing issues and maintaining quality whilst looking
to reduce costs.
2.0 Recommendation
The Board of Directors is asked to review the report and provide comment on
the suggested actions.
Andrew Hopkins
Director of Finance
th
20 August 2014
Board of Directors – Public
28August2014
2014/15 Financial Performance
Report M04
Page 3 of 4
Version 1.0
Author: Adrian Brooke
Department: Finance
th
Date produced: 20 August 2014
Retention period: 1 year
Appendix 1
£m unless otherwise stated
Board of Directors – Public
28August2014
2014/15 Financial Performance
Report M04
Page 4 of 4
Version 1.0
Author: Adrian Brooke
Department: Finance
th
Date produced: 20 August 2014
Retention period: 1 year
Date:
28th August 2014
Item:
14.110iv Appendix 1
G
Financial Performance for
the Period ending July 2014
Meeting Date: 28th August 2014
Index
Slides 1-2 - Executive Summary
Slide 3 - Key Highlights
Slide 4 - Finance Dashboard
Slides 5-6 - Income
Slides 7-10 - Expenditure – Pay & Non Pay
Slide 11 - CIP
Slide 12 - Capital
Slide 13 - Balance Sheet
Slide 14 - Cashflow
Executive Summary
The Trust is reporting a deficit of £0.44m for the month and £0.77m YTD (year to date). This
is similar to the monthly deficit position reported last month. This YTD variance is now
adverse against the Annual Plan by £0.62m.
Despite the continued adverse position, the COSRR (Continuity of Service Risk Rating) remains
at 3, which is above the 2 that was originally planned for in July.
This is driven by increased cash collection so that Cash held by the Trust this month is
£5.4m higher than planned. This is more of a timing issue rather than a long tern benefit to
the cash position.
The key Income and Expenditure variances are shown overleaf in the waterfall diagram
and discussed in further detail on the following pages.
Given the current run rate of expenditure reflected in the YTD position, there is a
significant risk that the Trust will not achieve the plan for this year and not achieve a
COSRR of 3, unless action is taken to address this position over the remainder of the year.
1
Executive Summary
2
Key Highlights – YTD Position
Specialist placement expenditure for the month (i.e. cost of placements to specialist
providers) in Norfolk has remained at £0.15m. YTD expenditure totals £0.64m bringing
overall levels close to the original plan (see expenditure non pay detail)
Acute out of area (OOA) placements expenditure has reduced by £0.10m this month to
£0.18m as a result of reduced bed-days. YTD costs now total £0.94m. There is no
additional funding for this type of expenditure so these placements are continually being
reviewed with the expectation that these placements cease by end September (see
expenditure non pay detail).
Temporary Pay expenditure levels have risen again, this month to £2.39m with total YTD
expenditure already at £8.46m (this compares to £4.70m YTD for the previous year).
Total YTD activity income is slightly behind plan due to under occupancy provisions and
under achievement of CQUIN targets (see income summary).
CIP (Cost Improvement Plan) continue to remain behind original target, with only £10.8m of
the original £14.7m target progressed through to gateway 5. £3m of this has been met nonrecurrently.
Capital spend is behind plan, which is reflected by the favourable position on depreciation
in the I&E. Current forecast spend is that the Trust will achieve original plans.
Cash held by the Trust YTD is £5.4m higher than planned, however the year end forecast
position is expected to be significantly below plan.
3
Finance Dashboard
Monthly Surplus/Deficit £000's
FY CIP £m
600
2.6
400
200
Gateway zero
0.9
0.4
10.8
Gateway one
Gateway four
-
Gateway five
(200)
(400)
(600)
Apr
May
Jun
Jul
Aug
Plan
Sept
Oct
Nov
Forecast (Actual)
Dec
Jan
Feb
Mar
Capex £m
12.0
10.0
8.0
6.0
4.0
2.0
Apr
May
Jun
Plan
Jul
Aug
Sept
Oct
Forecast (Actual)
Nov
Min
Dec
Jan
Feb
Mar
Max
COSRR
Actual Plan
Variance
YTD
3
2
1
Forecast
3
3
-
4
Income – Summary
Year to date Income position
Block contracts
Clinical Partnerships
Clinical income-Secondary Commissioning
Other clinical income
NHS Mental Health activity Income, Total
Research and Development
Education and Training
Misc. Other Operating
Other Operating income, Total
Operating Income, Total
Annual
Plan
£'000
58,289
4,715
741
1,346
65,091
297
1,118
2,338
3,753
68,844
Actual
£'000
58,049
4,556
746
1,651
65,001
980
1,136
3,599
5,715
70,716
Variance to
Annual Plan
£'000
(240)
(159)
5
305
(89)
682
19
1,261
1,961
1,872
Full Year Income position
Annual
Plan
£'000
174,868
11,863
2,222
4,038
192,991
892
3,353
7,015
11,260
204,251
Forecast
Variance
£'000
174,736
11,697
2,238
5,086
193,756
1,816
3,398
10,037
15,251
209,008
£'000
(132)
(166)
16
1,048
766
923
45
3,022
3,991
4,757
5
Income – Summary
Health Care Block Contracts – (£240k) lower than plan due to:
•
•
•
•
(£182k) under-occupancy provision for CAMHS Tier 4 and Secure Services,.
(£320k) CQUIN underachievement provision
£142k increase in Additional Observations for Suffolk CCG’s
£120k of other contract variations including West Norfolk CCG Psychiatric Liaison
contract.
Clinical Partnerships – (£159k) lower than plan of which:
• (£61k) is the 1.5% reduction in the Section 75 contract and lower than estimated
travel recharges.
• (£25k) reduction in NRP Contract for Section 75 staff transfers
• (£73k) re-phasing of Norfolk Recovery Partnership innovation monies, which will be
recovered by the end of the year.
Other Clinical Income - £305k increase to plan is due to:
• New contracts of £74k (£317k full year effect).
• An additional £242k increase on existing contracts (£886k full year effect).
• an increase in system wide CQUIN £90k (from Suffolk Acute hospitals) less the 40%
underachievement provision (£54k).
• Non contracted activity is down (£59k).
6
Expenditure – Summary
Vacancy levels continue to increase across the Trust, with a total of 485 vacant WTE’s
being reported in July, hence the favourable permanent pay position being reported. The
rise is attributed to additional WTE budget as a result of new services starting as opposed
to reduction in staff numbers, as actual headcount rose in July.
Both bank and agency staff are utilised through NHSP in order to close this staffing gap,
as well as a number of external agencies, including medical locum agencies. The levels of
temporary pay expenditure, however, exceeds the funding available from the vacant roles.
Overall temporary staffing levels increased again this month to £2.39m and YTD now
totals £8.46m.
The return of the social care contract (S75) to NCC from October will present the Trust
with a significant potential cost pressure in the region of £0.9m. This is due to the loss of
income not being met by a reduction in costs.
Significant spend continues on Out of Area Placements, with just under £1m spent YTD
on acute OOA placements. There was a reduction in the month on acute OOA
placements of around £0.1m, reflecting the actions being undertaken by the Trust to
reduce the numbers.
7
Expenditure – Pay 1
Pay costs report an adverse variance YTD
against original plan of £1.38m, and £1.69m
against revised budgets.
The chart shows total spend by pay type. A full
forecast position is currently being refined.
There is £0.29m of ICT agency costs, funded
by the trading accounts income.
Temporary pay is driven by the vacancy level
of 485 WTE’s.
The bank and agency ratio (excluding medical
locum agency) has worsened each month this year,
with bank expenditure now accounting for only 37%
of the total bank and agency staffing expenditure
levels, meaning that more expensive agency staff
continue to be utilised instead. This is reflected in
the significant rise once again in agency staff
during July, some of which however is funded
through by trading income and additional CCG
funding.
8
Expenditure – OOA Placements
Total spend on placements YTD is £2.10m
Specialist placement expenditure in Norfolk accounts for £0.64m of this, however as can
been seen in the graph below, expenditure levels are becoming more stabilised at 0.15m
per month. This expenditure reflects the cost of 10 patients that remain as at the end of
July.
Acute out of area (OOA) placements expenditure has significantly decreased this month to
£0.18m reflecting reduced bed days during July of 351 (June - 511). As at end of July, 8
patients remained. The target is to cease these placements by end September as no
specific funding for these exists. YTD costs now total £0.94m.
To help alleviate the demand on OOA placements the Trust has contracted a number of
community decant beds (currently 4) costing £0.01m during July, funded by the CCG.
OOA Placements (PICU) – Expenditure levels have also dropped this month, from £0.09m
to £0.03m and relate to five patients totalling 41 bed days, against 107 bed days during
June. One patient remained at the end of July. The reduction in costs is partly due to the
utilisation of Suffolk PICU who in turn increased their temporary staffing levels to
accommodate these patients.
NHS Funded care costs for July were in line with expectation and relates to the care of 7
patients. YTD expenditure now totals £0.14m.
9
Expenditure – Non Pay 2
(Placements)
10
CIP
The pie chart below shows that at present there is a shortfall in the expected CIP delivery
at year end compared to original plan, however an improvement is being reported in the
expected overall delivery. It should be noted that this reported improvement is as a result of
the utilisation of reserves and balance sheet provisions, and not true savings schemes
being implemented.
The utilisation of reserves together with a number of other schemes only achieve the
savings target non recurrently. Recurrent schemes will therefore need to be identified to
avoid further shortfalls in future years.
The remaining shortfall is across all areas however direct care services is the main driver.
The pie chart below shows in value terms how much of the CIP is at each gateway. It is
worth noting that Gateway 5 represents removal of budget but current performance shows
that these plans are not being met.
Gateway description
Gateway zero No ideas generated
Gateway one Idea generated and being investigated
Gateway two Quality impact assessment (QIA)
completed and signed off.
Gateway three Detailed Plan signed off in principle
and adoption started. Full delivery is
likely but details not 100% clear.
Gateway four Detailed Plan completed in full. Full
delivery of plan is highly likely.
Gateway five
Finance validated and signed off on
delivery plan. Budget is fully allocated
or 100% delivery is certain.
11
Capital
The capital programme is currently forecast to remain more than 15% below
plan until November 2014 due to a large amount of slippage on projects in
the first half of the year. The cash position described on slide 14 will also
have an impact on the capital programme and will see a reduced spend in
2014/15.
12
Balance Sheet
At the end of month 4, the Trust held cash of
£17.2m, £5.4m higher than planned. The
variance is predominantly due to a number of
long outstanding debtors being paid in the
month, as reflected in the aged debtor
information, and a low level of capital spend. .
Statement Of Position
Variance
(adverse)
Jul-14
YTD
Annual Plan
Actual
Jul-14
YTD
Jul-14
YTD
Non-Currrent Assets
142.8
146.9
4.1
Current Assets
27.8
20.6
(7.3)
Current Liabilities
(29.9)
(27.5)
2.4
Receivables are now £0.5m behind plan.
Although this is set off against a higher than
anticipated level of accrued income, as a result
of delayed billing.
Non-Current Liabilities
(22.7)
(21.8)
0.9
TOTAL ASSETS EMPLOYED
118.2
118.2
0.0
Public dividend capital
81.3
80.6
(0.7)
Retained Earnings (Accumulated Losses)
11.2
11.8
0.6
Revaluation reserve
25.5
Net current liabilities are £2.4m higher than
planned, as the Trust is holding higher than
planned level of provisions, for example
against possible HMRC liabilities.
Donated asset reserve
Non current assets are £4.1m behind plan due
to slippage on projects. See capital expenditure
slide for further details.
£m
25.7
-
TOTAL FUNDS EMPLOYED
Aged Debtors
< 30 Days
30-60 Days
60-90 Days
90+ Days
Total
118.2
Q1
1,780
329
1,914
2,466
6,489
0.2
-
118.2
0.0
Q2
819
488
32
1,620
2,959
13
Cash flow
The cash balance of £17.25m is £5.42m ahead of the annual plan. This reflects the
payment of several long outstanding receivables and slippage in capital expenditure.
The forecast cash position at year end has been reduced (compared with plan) as the
Trust may have to push back the sale of assets into 2015/16, in order that we achieve
maximum value from those sales. This impacts on cash flow by nearly £4m and will
reduce what the Trust can spend on its capital programme this year.
The forecast is also based on current run rate and so the COSRR is at risk by year end if
actions are not taken to reduce expenditure and improve the liquidity (cash) position of the
Trust
14
th
Date:
28 August 2014
Item:
14.110v
Report To:
Board of Directors – Public
Meeting Date:
28th August 2014
Title of Report:
Business Performance Report – M04 2014/15
Action Sought:
For Approval
Estimated time:
15 Minutes
Author:
Tim Walsh: Business Intelligence Manager
Director:
Andrew Hopkins: Director of Finance
H
Executive Summary:
The Business Performance report shows that the Trust is compliant across all seven of the
key performance standards under the Monitor Risk Assessment Framework. This is
shown in the Monitor targets section.
The Trust is maintaining a Continuity of Service Risk Rating (CoSRR) score of 3.
1.0
Report contents
1.1
The Business Performance Report is submitted to the Board for month 04 2014/15
and contains details of performance against key Monitor Compliance Framework
targets and KPIs for Finance, Organisational Delivery, Quality, Safety &
Experience and Workforce Development & Effectiveness.
1.2
The Trust is maintaining a Continuity of Service Risk Rating (CoSRR) score of 3.
Board of Directors – Public
th
28 August 2014
Business Performance Report
Page 1 of 11
Version 1 0
Author: Tim Walsh
Department: Informatics
th
Date produced: 08 August 2014
Retention period: 30 years
2.0
Monitor Targets
2.1
Monitor Performance Summary
Ref
M01
M02
M03
M04
M05
M06
M07
3.0
Measure
CPA patients receiving follow up
within 7 days of discharge
CPA patients having formal
review within 12 months
Minimising Delayed Transfers of
Care
Admissions to inpatient services
had access to Crisis Resolution
and Home Treatment (CRHT)
teams
Meeting commitment to serve
new psychosis cases by Early
Intervention teams
Data completeness: Identifiers
Target
95%
95%
7.5%
Data completeness: Outcomes
Quarter 2 to Date (M04)
100 out of 100
100%
discharges
2,002 out of 2,047
98%
reviews
489 delayed days out of
3.58%
13,644 bed days
95%
97.9%
141 out of 144
admissions gate-kept
95%
140%
80 new cases against
target of 57
97%
99.6%
50%
83%
215,840 valid entries
out of 216,708 possible
data fields
8,601 valid records out
of 10,398 records
Performance
Director of Operations
Norfolk Summary – Performance against the 72 hour metric is improving. Bed
use is slowly decreasing. All 3 CRHTs are functioning well, length of stay is
decreasing as well. CAMHS referrals are now going directly to the CAMHS
service. The locality should start seeing the impact on the data in the next month.
A&E liaison is at capacity and are still recruiting to posts although out of area
placements is still not coming down to the level that the locality would like although
there has been an improvement in the position for out of area placements
compared to last month.
Suffolk Summary – Performance is holding steady and the locality is focussing on
key issues. The work that is taking place in the access and assessment team is
being reflected in the improvement in the 28 day referral performance. The priority
for the locality will continue to be on meeting the A&A targets and on addressing
the IAPT access rates. The teams will also be working to identify where the data
completeness metric is not being met and managing the teams accordingly.
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28 August 2014
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Date produced: 08 August 2014
Retention period: 30 years
Minimising delayed transfers of care (DTOC)
In July the DTOC position for the trust was reported at 3.58%, well below the 7.5%
threshold. Suffolk East were reporting above the threshold at 11.87%in June
however in July this had dropped to 8.73%. The number of DTOCs in Suffolk
attributable to LD service users also dropped in July from over 4% to 2.6%
The LD service have put actions from the DTOC meeting in place to address this
and they are employing an additional person in Suffolk for this purpose.
A significant amount of work is being undertaken in conjunction with social
services to look at those delayed because they are awaiting placements in
residential care. Of the ten delays reported in the last week of June, three were
attributable to the LD service.
The discharge coordinator in West Suffolk has proved to be very effective in
facilitating engagement with the county council to help find accommodation for
patients being discharged and this post will be mirrored by a new post in East
Suffolk with a view to achieving the same benefits.
Meeting commitment to new psychosis cases by Early Intervention (EI)
Performance against the EI target has improved further to 140% in July. This is
based on a commitment to identify new EI cases.
All AAT and IDT staff are continuing to use the new process designed to record
and identify EI patients and in East Suffolk the service are now confident that this
metric will remain on target.
Percentage of qualifying patients with a MHCT cluster (OD07)
In Suffolk the position is improving – the service is identifying areas where
outstanding clusters need to be added, targeting Coastal and Central Suffolk
where there are issues that need to be worked through. This work is being
completed by the Business Support Manager in Suffolk in July and August. At the
performance meetings with localities the importance of this metric has been
stressed due to the move to cluster based contract for 2014/15.
The service are continuing to target the un-clustered CLL (Care in Later Life)
patients because they have the highest percentage of patients without a MHCT
cluster. In Suffolk East reports are being sent out to identify invalid clusters and the
service is also monitoring referrals coming in from AAT into the IDT to ensure that
they have had a cluster added.
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Department: Informatics
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Retention period: 30 years
Data quality including timely entry
Each locality has an action plan in place. In the Central locality Smart phones in
Adult Community teams are facilitating quicker data entry and a report of
performance by team is now available to all localities. The provision of
performance by team now means that specific teams who are not meeting the
criteria can be identified and managed accordingly by each locality.
Included in the action plan for Central locality are:
Daily reminders to clinicians to complete contact sheets
Facility for clinicians to call in contacts for the day
Facility for clinicians to email contacts
Folders for unsigned contacts for CTLs to capture
Admin staff being reviewed to ensure capacity to input contacts
daily
In the West locality exception reporting is being generated to identify late contact
submissions and these are being addressed with individual practitioners in 1 to 1
management supervision which ensures there are plans in place to address any
issues. The locality is also reviewing remote working options including mobile
communications devices.
All localities are working to a target for 100% completion by the end of October
2014.
Percentage of inpatient finished consultant episodes during the period with
an ICD10 code and % of patients on CPA at the end of the period with ICD10
code
This metric needs to be discussed with the Medical director and backing is sought
to ensure that there is support from the medical colleagues to meet a 100% target
in this area. This will be followed up by the locality manager in Norfolk.
Percentage of IAPT patients who have depression and or anxiety disorders
who receive psychological therapy
Access continued to be below the 15% trajectory in Norfolk, Great Yarmouth and
Suffolk IAPT services.
This is a tough target with a clear action plan to achieve this. The action plan is
being reported to CCGs on a monthly basis.
In Norfolk the service was falling below the IAPT access target. Work is taking
place in Norfolk looking at clusters 1 to 4 and the activity taking place in these
clusters to assess whether the individuals would be appropriate for an IAPT
service. The service is seeing an increase in referrals but these numbers are not
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Date produced: 08 August 2014
Retention period: 30 years
being converted in to accessing the service that is there. A weekly action plan is
sent to the CCGs.
As part of the action plan the service is working with large employers, acute
hospital sites, working with hard to reach service user groups, creating pop up
clinics, partnership working with MIND and identifying low referring practices.
The focus for the service in Norfolk and Great Yarmouth and Waveney is also to
work on referrals which have not converted to access.
Average Length of stay
The average length of stay indicator has been updated to report on the length of
stay of those in the ward in month rather than looking at those discharged in month
alone. This has meant that the figure more accurately reflects the full average
length of stay in the wards.
All localities are reporting below the 28 day target on this metric. It may be
necessary to review the target based on the revised metric.
Medium Secure Bed Occupancy Rate
Bed occupancy for the medium secure unit has been below target for more than
three months. It was reported at 83% against a 90% target. This has been raised
with commissioners in terms of whether this lower occupancy would impact on the
contract value.
NSFT are not getting the volume of referrals through and it is out of the trusts
control as to whether there are service users to admit to the medium secure unit.
The service has confirmed that they are not refusing any admissions.
Commissioners have been alerted to the low occupancy and they have agreed to
work with the trust to address the issue.
Waiting times in completed pathways breaching standard and Number of
incomplete pathways waiting over 18 weeks
The 18 week breaches are being investigated on a case by case basis in Norfolk
and Suffolk localities. The service is still looking at the remit of the CAMHS teams
in terms of how they operate with the Access and assessment service in Norfolk.
From the 1st July referrals were being triaged straight through to the AAT for
assessment with the aim of adding capacity to the AAT and ensuring that there is
no delay in the CAMHS referrals receiving specialist assessments.
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Department: Informatics
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Retention period: 30 years
Carers Assessments and Reviews (Norfolk County Council Section 75)
Carers assessments were below target in Central Norfolk in July and continued to
be low in West Norfolk and Great Yarmouth and Waveney.
Training on Care First is being picked up under the Section 75 Transition Project
which is currently scheduled to complete on 1st October 2014.
Patient Safety Thermometer(QU14)
All localities were reporting at 100% for the patient safety thermometer in July.
Bed occupancy, out of locality and out of area acute placements
As of the 17th July there were 12 out of area placements for Central locality. There
was also one Norfolk service user placed in a Suffolk ward. The out of area
placements remain high in Central Norfolk and this is monitored daily by the
locality manager. Patients from the central locality are also being placed in beds in
West and GY&W.
The high levels of bed occupancy in the adult acute areas in Norfolk is reflective of
demand.
In East Suffolk the lower bed occupancy in the PICU unit can be attributed to a
bed that was unavailable due to the use of the low stimulus area which takes up
an additional bed.
Access and Assessment
Norfolk
In July the service achieved 100% against the 4 hour referrals. There were 6 72
hour breaches. The AAT have continued to meet the target and exceeded the 95%
target for 4 and 72 hours.
From 1st July all under 14 CFYP (Children, Family and Young People) central
referrals went straight to the service which means that they have a basic screening
to assess their urgency and then they go through to service line. This will allow the
service to identify whether there is any imminent risk.
For under 18s including the backlog, the service has the support from the CFYP
service line and the benefits of this should be proven in the coming months. The
move to service line has released appointment slots which can be used for the
over 18s referrals. For over 18s the service were at 91% in June so were still
below the target. The service are continuing with the recruitment of experienced
practitioners to the team. In addition to this more medics are also scheduled to join
the AAT in August.
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Suffolk
In July the service achieved 100% for 4 hour referrals and 100% for 72 hour
referrals against a 98% target. For the 28 day routine referrals the team saw
94.7% of their referrals within standard against a target of 95%.
The service will continue to identify areas for improvement in order to meet the 28
day target. There is high sickness absence within the team which is being worked
on by the service managers. There is also work taking place to review how
resource is deployed within the team particularly focussing on the role of social
workers.
Norfolk Recovery Partnership (NRP) and Suffolk Alcohol Service
All NRP partners continue to work on a remedial action plan to address
commissioners concerns regarding the NRP service.
The caseload numbers are reducing in NRP and the service are focussing on
improving performance in three areas:
1. TOPS reviews
2. Positive discharges
3. Reducing the number of long term clients
In terms of TOPS reviews the service had seen a marginal improvement from last
month from 64% to 67% against a 90% target.
The Community Team Leaders within the service have been asked to provide
action plans at the start of August to address these areas of performance.
4.0
Research Performance Indicators
The Key Performance Indicators as set by the National Institute of Health
Research (NIHR – DH) are going to be changed for 2014/15 but have not yet been
announced nationally. The KPIs are designed to give a reflection of overall
research activity and performance for the Trust compared to other Trusts
nationally. The Research Manager does not have the new KPIs to report at
present.
5.0
Section 75 Partnership
Norfolk
Norfolk County Council's and the Trust's Project Teams are continuing to work on
producing a project timescale that will include key milestones for the design of a
new integrated health and social care model, staff engagement events, workforce
changes and transition plans.
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Department: Informatics
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During July, Norfolk practitioners who hold care coordination or lead care
professional caseloads worked with Clinical Team Leads to apply a simple
caseload scoping tool to identify whether cases are social care, health care or
joint. The project has largely been able to gather this information and now Admin
teams are populating a work sheet that will enable the Trust to work with Norfolk
County Council (NCC) to create CareFirst records for all social care and joint
cases for the 1 October 2014.
Three joint workshops were held during July led by NCC to develop working
protocols and processes between the two organisations. Further joint workshops
are planned for September around NCC internal processes to understand and
shape how they link with NSFT systems and processes.
Suffolk
The targeted training to support the implementation of personal budgets for mental
health service users across Suffolk (including Waveney) is nearing completion.
New procedures are in the process of being phased into to existing operational
processes. These new arrangements will be monitored and subject to evaluation
and review at agreed periods.
With the Care Act 2014 becoming law there are further considerations required on
the duties that this new legislation will impose on Suffolk County Council and
consequently the impact that this will have on the delegated legal duties conferred
upon NSFT through the S75 Partnership Agreement. As well as the service
delivery / operational implications of these changes, it will require scrutiny of the
existing care documentation that is used to ensure that it is compliant with the
changes in law. The timing of this will also need to correspond with the
development work going on within the Trust to support the migration to Lorenzo.
Lorenzo will need to be configured to take into account the new statutory duties
and contract reporting requirements. Work is underway with informatics leads in
NSFT & SCC and the Lorenzo Project Lead to support this IT work.
Suffolk County Council, Adult Community Services are in the process of
operational transformation as it phases in the new operating model ‘Supporting
Lives Connecting Communities’ and continues work on the wider health and social
care integration agenda. We, in mental health, are continuously comparing our
structures to ensure that the philosophy and underpinning principles of this model
is embedded and integrated through our services. It is anticipated that we will
continue to an active role in influencing the development of system-wide health
and social care integration in Suffolk through representation on the various work
programmes.
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6.0
Workforce Development and Effectiveness
Headlines
Vacancies
The Trust’s vacancy rate (WD08) is 12.38% to the end of month 4. This
represents 484.72 whole time (wte) equivalent vacancies against an
establishment of 3,914.19 wte (3,421.55wte in post). This breaks down into
a rate of 10.32% in clinical services and 20.82% in corporate and support
services (where vacancies are being held and/or temporarily filled pending
restructure). Within clinical services, the rate is 12.5% in Suffolk (70.76 wte
vacancies) with particular pressure in West Suffolk across Acute, Child and
Youth and Older Peoples Services. The rate is 9.37% (146.45%) in Norfolk
and Waveney clinical services with particular pressure within the
Community teams across the county (running at between 15% to 24%
vacancies, West Norfolk being worst affected)
It should be noted that the establishment has increased within the month by
24.34 wte. 5.3 wte of this increase was due to previously under-stated
accounting in the budget for Central Norfolk which has been rectified in
month 4. 11.2 wte reflects an increase in establishment within Secure
Services through conversion of a temporary staffing budget created at the
last budget setting. The cause(s) of the remaining 5.56 wte is being
explored with Locality Service Managers and Management Accountants but
is thought to relate to skill mix changes
Despite 275.79 wte posts being recruited to since January 2014 which is a
significant achievement, in light of the increase in establishment and taking
account of turnover (see below), the net increase of staff in post in the
month is 8.64 wte. It should be noted, however, that the figures are
distorted by the negative position of posts appointed versus leavers within
corporate and support services (-39.33 wte posts filled since January 2014
within these services)
90% of vacancies (432 wte) are currently being actively recruited to
Turnover
Turnover (WD09) within the Trust is 14.25% to the end of month 4. With
the exception of Corporate, this is on a positive downward trend with
turnover decreasing in all localities within the month in respect of both
voluntary and controlled leavers
Temporary Resourcing
For month 4, the Trust’s total temporary staffing costs equate to 17.95% of
all staffing costs
NHSP demand has increased by 12% within the last quarter. This is in line
with similar trends reported by NHSP in other mental health Trusts
Fill rates remain fairly stable although an increased agency rate fill reflects
the higher demand despite positive recruitment activity (for example, 59
extra workers engaged in June 2014 alone)
Demand related to vacancies is decreasing in line with recruitment activity.
Demand related to specialising and sickness remain fairly high but stable.
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Demand for planned leave has increased (doubled between April and June
(1,212 shifts in June) which suggests poor operational workforce resource
planning
Absence
Overall, the Trusts sickness absence rate (WD01) has marginally increased
in the month from 5.55% in June 2014 to 5.59% in July 2014.
The highest absence rate continues to be within Secure Services, however,
this has had a positive reducing trend for the last 3 consecutive months
(8.20% to 8.01%)
Absence attributable to anxiety/stress/depression accounts for 25.04% of all
sickness absence in the Trust and increased in the month by 0.52%.
Although the Trust’s Substance Misuse Services continue to have the
highest instance of anxiety/stress/depression (35.19% of all sickness
absence time lost), the Service also recorded the largest reduction in this
performance indicator (-3.45%) for the third consecutive month
Workforce development
Following the change in approach to appraisals from April 2014 with
appraisals now linked to incremental dates, of the cohort of 793 staff who
should have had an appraisal in quarter 1, only 297 staff are recorded as
actually having had one (37.4%). Plans for the current and future cohorts
have been discussed by the Executive Team
7.0
7.1
Finance
The Continuity of Service Risk Rating (CoSRR) comprises the trust liquidity ratio
and the debt service cover rating. Overall, the Trust maintained a COSRR of 3 in
the month, above the planned rating of 2 at this stage in the year. The capital
service cover has now dipped below plan to a 2, which has been caused by the fact
the Trust is currently operating at a deficit.
The adverse performance for debtors (FM04) has jumped significantly this month to
29.52%, way above the 5% target. This has been due to the vast improvement in
the overall debtor’s total, now down from £10.9m to £5.4m. This improvement
however is almost all against the more recent debtors (less than 90 days). The
creditors performance (FM05) improved in the month with over 90 days outstanding
balance more than halving, bringing the performance back within the 5% target, at
2.55%. The remaining creditors over 90 days relate largely to NCC, and these
invoices have subsequently been approved for payment, so a further improvement
in this performance is expected again next month.
Expenditure on capital projects (FM09) remains significantly behind plan, with only
14.74% of Capital budget being spent to date, compared to the planned level of
46.25%, representing an adverse variance of £2.8m. This slippage is forecast to
remain more than 15% below plan until November. Although all capital categories
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Page 10 of 11
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Department: Informatics
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Date produced: 08 August 2014
Retention period: 30 years
contribute to this position, ICT and Estates related projects continue to be the main
driver.
An improvement in the overall CIP achievement is reported this month, with a jump
in the total percentage to 70.48% of plan. It should be noted that this improvement
is as a result of the utilisation of reserves and balance sheet provisions, and not true
savings schemes being implemented. The utilisation of reserves only achieve the
savings target non recurrently, which is reflected in the limited improvement of the
recurrent CIP performance indicator up from 63.20% to 65.88%. Recurrent
schemes will therefore need to be identified to avoid further shortfalls in future
years.
The continued reliance on temporary staffing has pushed up the adverse
performance being reported this month for FM09. The expenditure levels need to be
significantly reduced in order to bring the Trust back to a surplus run rate, which in
turn will help to improve the capital service cover rating, in order to maintain the
COSRR of 3 going forward
8.0
Recommendations
8.1
The Board is requested to consider the Trust’s performance as described within
the Business Performance Report.
Tim Walsh
Business Intelligence Manager
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08 August 2014
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Page 11 of 11
Version 1 0
Author: Tim Walsh
Department: Informatics
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Date produced: 08 August 2014
Retention period: 30 years
Business Performance Report
July 2014 version 2.0
NSFT Informatics
1
BPR July 2014 v2.0.xlsx/Front
Monitor
Ref
M01
Metric
Period
CPA patients receiving follow up within
7 days of discharge
Month
YTD
Value
Apr-14
May-14
Jun-14
Jul-14
Actual
100%
98%
98%
100%
Target
95%
95%
95%
95%
Actual
98%
97%
97%
98%
Target
95%
95%
95%
95%
Actual
4.05%
4.87%
4.55%
3.58%
Target
7.50%
7.50%
7.50%
7.50%
Actual
100%
100%
100%
98%
Target
95%
95%
95%
95%
Actual
79%
89%
133%
140%
Target
95%
95%
95%
95%
Actual
100%
100%
100%
100%
Target
97%
97%
97%
97%
Actual
83%
83%
83%
83%
Target
50%
50%
50%
50%
Actual
6
6
6
6
Target
6
6
6
6
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
7.50%
7.50%
7.50%
7.50%
7.50%
7.50%
7.50%
7.50%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
97%
97%
97%
97%
97%
97%
97%
97%
50%
50%
50%
50%
50%
50%
50%
50%
6
6
6
6
6
6
6
6
Trend
M02
CPA patients having formal review
within 12 months
Month
YTD
Trend
M03
Minimising delayed transfers of care
Month
YTD
Trend
M04
Admissions to inpatient services had
access to CRHT teams
Month
YTD
Trend
M05
Meeting commitment to serve new
psychosis cases by early intervention
teams
Month
YTD
Trend
M06
Data Completeness: Identifiers
Month
YTD
Trend
M07
Data Completeness : Outcomes
Month
YTD
Trend
M08
Self-certification against compliance
regarding access to healthcare for
people with LD
Month
YTD
Trend
Trend is calculated using Actual at Month 3 2014/2015 as compared to
the Actual in the current month
Performance is neither improving or worsening
Performance is worsening
Performance is improving
2
BPR July 2014 v2.0.xlsx/Monitor
Organisational Delivery
Ref
Metric
CPA patients having formal review
OD01
within 12 months
Period
Month
YTD
Value
Apr-14
May-14
Jun-14
Jul-14
Actual
98%
97%
97%
98%
Target
95%
95%
95%
95%
Actual
4.05%
4.87%
4.55%
3.58%
Target
7.50%
7.50%
7.50%
7.50%
Actual
100%
100%
100%
98%
Target
95%
95%
95%
95%
Actual
79%
89%
133%
140%
Target
95%
95%
95%
95%
Actual
100%
100%
100%
100%
Target
97%
97%
97%
97%
Actual
83%
83%
83%
83%
Target
50%
50%
50%
50%
Actual
97%
97%
98%
98%
Target
99%
99%
99%
99%
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
95%
95%
95%
95%
95%
95%
95%
95%
7.50%
7.50%
7.50%
7.50%
7.50%
7.50%
7.50%
7.50%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
97%
97%
97%
97%
97%
97%
97%
97%
50%
50%
50%
50%
50%
50%
50%
50%
99%
99%
99%
99%
99%
99%
99%
100%
Trend
OD02 Minimising delayed transfers of care
Month
YTD
Trend
Admissions to inpatient services had
OD03
access to CRHT teams
Month
YTD
Trend
Meeting commitment to new psychosis
OD04
cases by EI
Month
YTD
Trend
OD05 Data Completeness: Identifiers
Month
YTD
Trend
OD06 Data Completeness: Outcomes
Month
YTD
Trend
% of qualifying patients with a MHCT
OD07
cluster
Month
YTD
Trend
3
BPR July 2014 v2.0.xlsx/Organisational Delivery
Organisational Delivery
Ref
Metric
Number of contacts recorded on Trust
OD09 systems within 3 working days of event
(Last 30 days)
Period
Month
YTD
Value
Apr-14
May-14
Jun-14
Jul-14
Actual
91%
91%
89%
92%
Target
100%
100%
100%
100%
Actual
98%
98%
99%
100%
Target
100%
100%
100%
100%
Actual
0.73%
1.60%
2.63%
3.69%
Target
1.25%
2.50%
3.75%
5.00%
Actual
51%
50%
53%
50%
Target
40%
40%
40%
40%
Actual
81%
82%
83%
79%
Target
90%
90%
90%
90%
Actual
85%
80%
79%
81%
Target
90%
90%
90%
90%
Actual
15
16
14
15
Target
28
28
28
28
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
6.25%
7.50%
8.75%
10.00%
11.25%
12.50%
13.75%
15.00%
40%
40%
40%
40%
40%
40%
40%
40%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
28
28
28
28
28
28
28
28
Trend
% of inpatient Finished Consultant
OD10 episodes during the period with an
ICD10 code
Month
YTD
Trend
% of IAPT patients who have
OD12 depression and/or anxiety disorders
who receive psy therapy
Month
YTD
Trend
% of IAPT patients who complete
OD13 treatment and 'move to recovery during
the month
Month
YTD
Trend
Medium Secure Bed Occupancy Rate
OD14
(including leave)
Month
YTD
Trend
Low Secure Bed Occupancy Rate
OD15
(including leave)
Month
YTD
Trend
Average Length of Stay - Adult Acute
OD16
Service
Month
YTD
Trend
Trend is calculated using Actual at Month 3 2014/2015 as
compared to the Actual in the current month
4
BPR July 2014 v2.0.xlsx/Organisational Delivery
Quality, Safety and Experience
Ref
Metric
CPA patients receiving follow up within
QU01
7 days of discharge
Period
Month
YTD
Value
Apr-14
May-14
Jun-14
Jul-14
Actual
100%
98%
98%
100%
Target
95%
95%
95%
95%
Actual
88%
88%
92%
86%
Target
90%
90%
90%
90%
Actual
67
54
46
64
Target
0
0
0
0
Actual
92%
75%
91%
77%
Target
80%
80%
80%
80%
Actual
97%
100%
97%
100%
Target
100%
100%
100%
100%
Actual
100%
100%
100%
100%
Target
100%
100%
100%
100%
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
95%
95%
95%
95%
95%
95%
95%
95%
90%
90%
90%
90%
90%
90%
90%
90%
0
0
0
0
0
0
0
0
80%
80%
80%
80%
80%
80%
80%
80%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Trend
Waiting Times - % of completed
QU02
pathways within standard
Month
YTD
Trend
Waiting Times - Number of incomplete
QU04
pathways waiting > 18 weeks
Month
YTD
Trend
Waiting Times - % of CAMHS patients
QU05
seen within standard
Month
YTD
Trend
Patient Safety Thermometer
QU14
(Development KPI)
Month
YTD
Trend
% of long-term (over 12 months)
QU17 inpatients that have received an annual
health check
Month
YTD
Trend
5
BPR July 2014 v2.0.xlsx/Quality, Safety & Experience
Workforce Development and Effectiveness
Ref
Metric
WD01 Annualised sickness absence rate
Period
Month
YTD
Value
Apr-14
May-14
Jun-14
Jul-14
Actual
5.59%
5.62%
5.55%
5.59%
Target
4.76%
4.76%
4.76%
4.76%
Actual
12.17%
11.38%
11.37%
11.36%
Target
20.00%
20.00%
20.00%
20.00%
Actual
11.84%
15.51%
11.96%
12.06%
Target
6.52%
6.52%
6.52%
6.52%
Actual
24.31%
24.13%
24.52%
25.04%
Target
16.17%
16.17%
16.17%
16.17%
Actual
61.60%
49.30%
46.20%
16.44%
Target
100.00%
100.00%
100.00%
100.00%
Actual
N/A
N/A
N/A
N/A
Target
100.00%
100.00%
100.00%
100.00%
Actual
14.00%
11.00%
13.00%
12.00%
Target
33.00%
33.00%
33.00%
33.00%
Actual
11.84%
11.59%
12.06%
12.38%
Target
10.00%
10.00%
10.00%
10.00%
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
4.76%
4.76%
4.76%
4.76%
4.76%
4.76%
4.76%
4.76%
20.00%
20.00%
20.00%
20.00%
20.00%
20.00%
20.00%
20.00%
6.52%
6.52%
6.52%
6.52%
6.52%
6.52%
6.52%
6.52%
16.17%
16.17%
16.17%
16.17%
16.17%
16.17%
16.17%
16.17%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
33.00%
33.00%
33.00%
33.00%
33.00%
33.00%
33.00%
33.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
Trend
% of staff with 4 or more absence
WD02
episodes (WD2)
Month
YTD
Trend
% of sickness absence episodes > = 21
WD03
days
Month
YTD
Trend
% of sickness absence days attributed
WD04
to Anxiety/stress/depression/etc.
Month
YTD
Trend
% of staff with an appraisal since April
WD05 2013
Month
YTD
Trend
% of medical staff compliance with
WD06 planned 2012/13 appraisal timetable
(Cohort 1)
Month
YTD
Trend
Number of statutory/mandatory training
elements which are below 40%
WD07
compliance.
Month
YTD
Trend
WD08 Vacancy Rate
Month
YTD
Trend
6
BPR July 2014 v2.0.xlsx/Workforce Development & Eff
Workforce Development and Effectiveness
Ref
Metric
Period
WD09 Turnover Rate
Month
YTD
Value
Apr-14
May-14
Jun-14
Jul-14
Actual
15.65%
17.54%
15.69%
14.25%
Target
10.00%
10.00%
10.00%
10.00%
Actual
51.34%
49.91%
51.17%
52.27%
Target
45.00%
45.00%
45.00%
45.00%
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
10.00%
45.00%
45.00%
45.00%
45.00%
45.00%
45.00%
45.00%
45.00%
Trend
WD10 % of resignations which are voluntary
Month
YTD
Trend
Actual
Staff engagement - mini survey
WD11
(Development KPI)
Month
YTD
Target
Trend
Actual
Staff in post to caseload ratio
WD12
(Development KPI)
Month
YTD
Target
Trend
Trend is calculated using Actual at Month 3 2014/2015 as
compared to the Actual in the current month
7
BPR July 2014 v2.0.xlsx/Workforce Development & Eff
Financial Management
Ref
Metric
FM01 Continuity of Service Risk Rating
Period
Month
YTD
Value
Apr-14
May-14
Jun-14
Jul-14
Actual
3
3
3
3
Target
3
3
3
2
Actual
3
3
3
2
Target
3
3
3
3
Actual
3
3
3
3
Target
2
2
2
1
Actual
10.30%
10.12%
21.08%
29.52%
Target
5.00%
5.00%
5.00%
5.00%
Actual
5.10%
4.48%
5.18%
2.55%
Target
5.00%
5.00%
5.00%
5.00%
Actual
2.02%
7.19%
11.32%
14.74%
Target
10.96%
22.30%
35.55%
46.25%
Actual
51.91%
55.11%
55.11%
70.48%
Target
79.91%
81.65%
83.40%
85.15%
Actual
62.66%
63.20%
63.20%
65.88%
Target
100.00%
100.00%
100.00%
100.00%
Actual
102.84%
105.14%
107.69%
110.34%
Target
90.00%
90.00%
90.00%
90.00%
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Full Year
Outturn
2
3
3
3
3
3
3
3
3
3
3
4
4
3
4
4
3
3
1
2
2
2
2
2
2
3
3
5.00%
5.00%
5.00%
5.00%
5.00%
5.00%
5.00%
5.00%
5.00%
5.00%
5.00%
5.00%
5.00%
5.00%
5.00%
5.00%
5.00%
5.00%
56.50%
64.97%
69.86%
75.34%
81.83%
87.21%
92.62%
100.00%
100.00%
86.90%
88.65%
90.54%
92.43%
94.33%
96.22%
98.11%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
90.00%
90.00%
90.00%
90.00%
90.00%
90.00%
90.00%
90.00%
90.00%
Trend
FM02 Capital Service Cover rating
Month
YTD
Trend
FM03 Liquidity rating
Month
YTD
Trend
Debtors > 90 days past due account for
FM04
more than 5% of the total debtor base
Month
YTD
Trend
Creditors > 90 days past due account
FM05 for more than 5% of the total creditor
balances
Month
YTD
Trend
FM06 CAPEX % of plan spent
Month
YTD
Trend
FM07
CIPs % of planned CYE (R&NR)
savings achieved
Month
YTD
Trend
CIPs % of planned FYE (recurring only)
FM08
savings achieved
Month
YTD
Trend
Temporary staffing cost/ notional
FM09
budget
Month
YTD
Trend
BPR July 2014 v2.0.xlsx/FRR_Financial 14_15
th
Date:
28 August 2014
Item:
14.112ii
Report To:
Board of Directors – Public
Meeting Date:
28th August 2014
Title of Report:
Voluntary Services update
Action Sought:
For Information
Estimated time:
15 Minutes
Author:
Adam Chilvers – Voluntary Services Officer
Director:
Dr Jane Sayer Director of Nursing, Quality and Patient Safety
I
Executive Summary:
This report provides an update to the board on the current status, delivery model and
projected developments of voluntary services. The main points for the Board to note in
this report relate to:
The model in which voluntary services is delivered to the Trust has
changed from central voluntary service recruitment to locality and service
lead recruitment of volunteers.
An update of current voluntary projects and roles
The establishment of a volunteer award, volunteer forum and interactive
volunteer page for volunteers and staff.
Establishment of partnership working with local voluntary agencies and
educational institutions.
Investing In Volunteers Charter
1.0
Report contents
2.0
Model of voluntary services
3.0
Status of volunteering
4.0
Volunteer projects
5.0
Partnership working
6.0
Investing in Volunteers Charter
7.0
Other development
Board of Directors – Public
Voluntary Services Report
Page 1 of 6
Version 1.0
th
Date produced: 11 August 2014
Author: Adam Chilvers
Department: Governance
Retention period: 30 years
2.0
Model of voluntary services
2.1
In consideration of the safe and efficient recruitment of volunteers, a new model
of volunteer recruitment with appropriate governing procedures has been
established.
2.2
Current status of volunteer recruitment has evolved from central volunteer
recruitment to locality and service lead volunteer recruitment. The change of
process recognises the need for localities to promptly recruit local volunteers
and support localities and services in taking ownership for recruiting of
volunteers to their service.
2.3
A clear and robust procedure for the recruitment of volunteers is applied by
each locality and service. Services have been trained on the safe recruitment
and management of volunteers. Training and support will continue within
localities and services through direct training to teams, a safe recruitment guide
and check-list.
2.4
Teams and services are briefed on the restrictions placed upon volunteer
recruitment based upon legislative and national policy guidance. This is to
ensure that volunteers are engaging in roles that are appropriately risk
assessed and do not detract from roles that are otherwise undertaken by paid
members of staff. For this reason, volunteer roles are created to provide support
to services which compliments service delivery.
2.5
The voluntary service officer will provide direct assistance and assurance to
each locality and service to ensure procedures are followed, as set out within
the volunteer policy (Q27), which has also been reviewed as part of the change
in process.
2.6
A summary of the new procedure for the recruitment of volunteers is provided
(Appendix A).
2.7
Norfolk Recovery Partnership (NRP)
NRP shall continue to remain responsible for the recruitment of volunteers in to
this service. NRP currently have their own team of voluntary co-ordinators and
associated processes for the recruitment of volunteers.
3.0
Status of volunteering
3.1
As at the end of July 2014, there are 105 active volunteers registered with the
Trust who are engaging with voluntary roles. There has been a decrease in the
number of registered volunteers due to volunteers moving on to external
volunteering roles, students graduating, or volunteers that no longer wish to
engage in volunteering. Of note one volunteer has taken up a substantive role
within the Trust
3.2
There are currently 28 volunteer applications being processed.
Board of Directors – Public
Voluntary Services Report
Page 2 of 6
Version 1.0
th
Date produced: 11 August 2014
Author: Adam Chilvers
Department: Governance
Retention period: 30 years
3.3
Volunteers continue to provide support to staff and contribute to enhancing the
quality of service delivery within a wide range of roles, and areas including:
Inpatient services
Forensic services
Carlton Court
Norfolk Recovery Partnership
Governance
Community services
Wellbeing teams
4.0
Volunteer projects
4.1
Volunteer drivers
It is recognised that there is a continuing need to support care givers and
immediate family members whose relative(s) currently receive inpatient
dementia services from the Trust. Family members and carers play a pivotal
role in the promotion and maintenance of wellbeing for those with dementia.
There is an identified need for direct family members and/or carers to be
provided with support to visit their relative whilst receiving inpatient care from
the Trust. For this reason, we are currently setting-up a volunteer service that
will aim to support family visits for those who require assistance to visit loved
ones adding to the quality of experience and care that the Trust delivers to its
patients and carers. It is anticipated that voluntary services will recruit a bank of
volunteer drivers to provide transport to family and carers, facilitating a return
journey.
4.2
Music Library
Following an inspection from one of the Trust’s non- executive directors to a
forensic inpatient service, a need for safe access to music as part of their
recovery and wellbeing has been identified from feedback. Voluntary services
are currently exploring the establishment of an accessible music library,
supported by a bank of Trust volunteers. It is anticipated that volunteers will
help with setting-up and maintaining a music library for the forensic service, with
the possibility of replicating this within other services in the future
4.3
Volunteer gardening project
Following voluntary services attendance at a local service user and carer forum,
feedback from attendees mooted the establishment of recruiting volunteers in to
a gardening project. The aim of the project is to engage local partners,
organisations, staff and service users in helping to rejuvenate and maintain
areas based at the Hellesdon Hospital site, supported by volunteers. One
Board of Directors – Public
Voluntary Services Report
Page 3 of 6
Version 1.0
th
Date produced: 11 August 2014
Author: Adam Chilvers
Department: Governance
Retention period: 30 years
participant at the forum discussed the relevance of engaging the wider
community in engaging with volunteering with the joint aim of tackling stigma
surrounding mental health. It was felt that volunteering could play a central role,
with a focus on gardening. Voluntary services are currently engaging with
participants from the service user and carer forum to scope this project.
4.0
Partnership working
The voluntary services officer is actively engaging with local volunteer
organisations to promote volunteer roles available through the Trust. Local
connections have also been made with educational establishments, including
City College Norwich and the University of East Anglia to promote volunteering
within the Trust, which not only offering valuable skills to the Trust services
through volunteering, but offering unique volunteering opportunities to student’s
who wish to gain valuable experience engaging with mental health services. It is
the aim of voluntary services to engage students with volunteer projects that are
currently planned, such as the music library and collecting service user
feedback.
5.0
Investing In Volunteers Charter
6.1
Investing in Volunteers is the UK quality standard for good practice in volunteer
recruitment and management. This is a benchmark for quality of practice in the
management of volunteering within an organisation. Following the initial project
meeting held last year, the Trust completed a self-assessment project which
identified current practices for the recruitment and management of volunteers
and identified areas for improvement. This was completed and approved by the
assessor.
6.2
In order to obtain certification, the final stage is for volunteers and Trust staff to
continue to engage in a formal inspection by the assessor in September. An
outcome of this shall be provided to the Board of Directors next public meeting.
6.0
Other developments Volunteer award
In recognition for the dedication and time that our volunteers give the Trust, its
staff, patients and carers, voluntary services has established a quarterly
volunteer award. It is the aim of voluntary services to increase the awareness
and value that volunteering serves within the Trust. Volunteers within the Trust
can be nominated for the volunteer award which will be presented quarterly. All
members of staff across the Trust will be able to nominate a volunteer for the
award by providing an outline as to why this should be awarded. The volunteer
that receives the award shall be published using Trust media, including Insight
Magazine, Trust updates and seek approval for the volunteer to be highlighted
at the Board of Directors Public Meeting.
Board of Directors – Public
Voluntary Services Report
Page 4 of 6
Version 1.0
th
Date produced: 11 August 2014
Author: Adam Chilvers
Department: Governance
Retention period: 30 years
7.1
Volunteer forum
Voluntary services shall establish a volunteer forum for the Trust. The aim of the
volunteer forum shall be a formal opportunity for volunteers and volunteer
supporters to attend a local forum to discuss opportunities and issues with
volunteering within the Trust. We wish to provide our volunteers and volunteer
supporters with an opportunity to help develop and improve voluntary services
for the Trust and contribute to innovative ways that volunteers can help add to
the quality of service delivery. This will also provide a necessary forum for any
volunteers or staff who wish to voice any concerns about any aspect of
volunteering, to which they seek improvement.
7.2
Supporting volunteer engagement through Information Technology
Voluntary services are currently working on an interactive way of Trust
volunteers and services to discuss volunteer issues using the Trust Intranet.
This will provide an opportunity to services to share ideas about volunteering,
including projects and roles. This will also act as a central resource for
volunteers and services to access necessary documentation, advice and
guidance, in addition to the support of the voluntary services officer.
8.0
Recommendations
8.1
The Board of Directors to receive this receive and note this report.
Adam Chilvers
Voluntary Services Officer
12th August 2014
Background Papers / Information
Appendix A
Board of Directors – Public
Voluntary Services Report
Page 5 of 6
Version 1.0
th
Date produced: 11 August 2014
Author: Adam Chilvers
Department: Governance
Retention period: 30 years
Appendix A
Board of Directors – Public
Voluntary Services Report
Page 6 of 6
Version 1.0
th
Date produced: 11 August 2014
Author: Adam Chilvers
Department: Governance
Retention period: 30 years
th
Date:
28 August 2014
Item:
14.112iii
Report To:
Board of Directors - Public
Meeting Date:
28th August 2014
Title of Report:
Chair of Audit & Risk Committee’s report – 13th August 2014
Action Sought:
For Information
Estimated time:
10 minutes
Author:
John Brierley, Chair
Director:
John Brierley, Non-Executive Director
J
Executive Summary:
The Audit & Risk Committee met on 13th August 2014. A summary of work done is
provided.
1.0
Work done:
1.1
The Committee meeting covered matters relating to: IT Infrastructure, Danwood
procurement and performance, and a number of confidential reports relating to
Declarations of Interest, Conflicts of Interest and the Working Time Directive.
1.2
The meeting was also attended in part by Interim Resilience Manager Ryan Hills
to discuss the Emergency Preparedness, Resilience and Response (EPRR)
update and approval.
2.0
Matters to be reported to the Board of Directors
2.1
The following issues are reported for consideration by the Board of Directors:
i.
The Internal Audit Interim Report was received and considered. The
Committee noted the weak assurance on CQC Essential Standards,
an issue also raised by the Service Governance Committee.
ii.
The Committee received and approved the Internal Audit Terms of
Reference and Charter.
iii.
The Committee received a report on contracting with Danwood and
resolved that the contract would not be extended to accommodate any
renegotiations. It was agreed that for recompense, renegotiations
would be requested on the remainder of the contract.
Board of Directors - Public
13August2014
Audit & Risk Committee Chair’s
Report
Page 1 of 2
Version 1.0
Author: John Brierley
Department: Corporate
Date produced: 13Aug2014
Retention period: 30 years
iv.
The Committee received and noted the Report on Losses and Special
Payments and expressed concern on the number of single tenders
under SFI’s and lack planning and appropriate arrangements.
v.
The Committee noted Monitor’s Consultation on amendments to the
‘NHS foundation trust annual reporting manual 2014/15’ and amended
the Committee’s plan to accommodate the received actions.
vi.
The Committee received the EPRR report and approved: the
establishment of the Trust Resilience Planning Group, the EPRR
policy, and the arrangements for the identification of risks associated
with this issue. The Committee also asked that an action plan for
immediate use is prepared for the Executive Director’s approval.
vii.
The Committee received a confidential report on the Register of
Declaration of Interests.
Internal Audit requested a revised
management response, which would be submitted to the Chair for
response under delegated authority.
viii.
The Committee received the Chair’s Report of the Service
Governance Committee and supported the recommendation to review
the quality of information provided to the Service Governance
Committee and if necessary, the Board of Directors.
ix.
The Committee received the confidential Counter Fraud Interim
Report and expressed concerns over continued misunderstandings
and or non-compliance with SFI’s and procurement, particularly in
relation to ICT.
.
John Brierley
Chair
th
13 August 2014
Background Papers / Information
None
Board of Directors - Public
13August2014
Audit & Risk Committee Chair’s
Report
Page 2 of 2
Version 1.0
Author: John Brierley
Department: Corporate
Date produced: 13Aug2014
Retention period: 30 years
th
Date:
28 August 2014
Item:
14.112v
Report To:
Board of Directors – Public
Meeting Date:
28th August 2014
Title of Report:
Charitable Funds Committee Chair’s Report
Action Sought:
For information
Estimated time:
5 minutes
Author:
Graham Creelman: Non-Executive Director
Director:
Graham Creelman: Non-Executive Director
K
Executive Summary:
Report of Committee meeting on 11 August 2014 at St Clements Hospital, Ipswich
The Committee approved a proposal to begin charging NHS Ipswich and East Suffolk
CCGs; NHS West Suffolk CCGs and Great Yarmouth and Waveney CCG (trading as East
Coast Community Healthcare) a proportionate share for the administration of their
Charitable Funds which are now lodged with NSFT. These costs used to be defrayed by
the interest on the funds, which is now negligible. The Committee also agreed to continue
discussions with East Coast Community Healthcare (ECCH) for the return to them of
responsibility for the Beccles Hospital Fund which, at £1,250,000 is the overwhelming bulk
of the funds administered by NSFT.
Committee resolutions
The Committee heard that there had been no movement on the £1.25 million Beccles
Hospital Fund. All previous proposals for this fund, which can only be spent on
improvements at Beccles Hospital, have fallen down on the issue of who would pay for any
continuing revenue costs of any development at the hospital. This could clearly not be the
responsibility of the NSFT Charitable Funds. Kate Gill, representing ECCH agreed that it
might be sensible for them to take the funds back, as perhaps a more flexible way of using
them could be found. It is not clear whether, under NHS Charity rules, this will be
possible. This will be investigated, and conversations will continue. As ECCH are a
registered Social Enterprise, rather than directly an NHS body, this may be difficult.
The Committee approved a proposal that the various “owners” of the constituent parts of
the Charitable Funds should in future be charged a proportion of the costs of administering
the funds.
This would break down as follows:
Board of Directors – Public
th
Date 28 August 2014
Chair of the Charitable Funds
Committee Report
Page 1 of 2
Version 1.0
Author: Graham Creelman
Department: Corporate
Date produced: 19/8/14
Retention period: 30 years
NSFT
NHS Ipswich and East Suffolk CCGs
NHS West Suffolk CCG
ECCH
£9,436.26
£6,710.29
£3,039.07
£3,694.38
These fees are calculated based on the level of expenditure incurred in the previous
financial year by each fund, and not the totality of each fund.
Welcome Packs
Kathy Walsh agreed to investigate whether welcome packs of toiletries and other
essentials for patients who arrive in wards with nothing, and with no-one to bring any,
could be paid for out of existing NSFT revenue. The Committee had previously agreed
that such things were needed, and Hadrian Ball reported to the Committee that Clinical
Cabinet had also agreed that this was desirable. The Committee, however, was reluctant
to enter into an open-ended commitment to provide money for this if alternative sources of
funding could be found.
Income and Expenditure
The Committee noted the current income and expenditure for the Funds.
Total income for the period April 2014 to June 2014 is £26,877. This is £18,000 more than
the last quarter. This is due in part to a donation of £10,000 to Newmarket Hospital and
donations of £7,600 from the League of Friends.
Expenditure in the First Quarter was £19,055.06-slightly more than the previous quarter.
The total balance of all funds at the bank is £1,699,515.78 on 30 June 2014. The
Committee reviewed the performance of the assets lodged with banks, and agreed that,
although returns were pitifully small, there was no obvious alternative.
Financial implications
If the administration re-charge is approved by all parties, then there will be a financial
benefit to NSFT.
Quality Implications
Properly badged, the use of NSFT Charitable Funds on good causes is an example of our
commitment to and engagement with the community.
Recommendations
The Board is invited to approve the contents of the report, particularly the
recommendations relating to the Beccles Hospital Fund and the re-charge of
administration costs.
Board of Directors – Public
th
Date 28 August 2014
Chair of the Charitable Funds
Committee Report
Page 2 of 2
Version 1.0
Author: Graham Creelman
Department: Corporate
Date produced: 19/8/14
Retention period: 30 years