SUSSEX PARTNERSHIP NHS
FOUNDATION TRUST
MEETING OF THE BOARD OF
DIRECTORS HELD IN PUBLIC
28 January 2015
10.00 – 13.00
Board Room, Trust Headquarters, Swandean,
Arundel Road, Worthing, West Sussex, BN13 3EP
Contact: Rebecca Huth, Diary Manager to Chief Executive,
[email protected], 01903 843033
BOARD OF DIRECTORS MEETING IN PUBLIC
To be held on 28 January 2015 at 10.00
In the Board Room, Swandean, Arundel Road, Worthing,
West Sussex, BN13 3EP
AGENDA
TBP01 /15
INTRODUCTION
1000
TBP01. 1/15
Chair’s Welcome and Introduction
1001
TBP01 .2/15
Apologies for Absence
1002
TBP01 .3/15
Declaration of Interests
1003
TBP01 .4/15
Minutes of the Board of Directors meeting held 26 November 2014
1004
TBP01 .5/15
1005
TBP01 .6/15
TBP02 .15
1015
TBP02 .1/15
1025
TBP02 .2/15
1035
TBP02 .3/15
1045
TBP02 .4/15
TBP03 .15
1055
1125
TBP03 .1/15
TBP03 .2/15
1130
TBP03 .3/15
1135
TBP03 .4/15
1145
TBP03 .5/15
1200
TBP04 .15
TBP04. 1/15
Action Points and Matters Arising from the previous meeting held
on 26 November 2014
To receive a report from the Chief Executive which sets the
context for the meeting
UPDATE
To receive an update report on Specialist Services
(Simone Button, Interim Managing Director of Specialist Services)
To receive an update report on Adult Mental Health Services
(Lorraine Reid, Managing Director of Adult Services)
To receive an update on Langley Green Hospital
(Lorraine Reid, Managing Director of Adult Services)
To receive an update on North West Sussex
(Lorraine Reid, Managing Director of Adult Services)
PERFORMANCE AND QUALITY
To receive a report on the Performance of the Trust to the end of
December 2014
(Helen Greatorex, Executive Director of Nursing and Quality, Sue
Morris, Executive Director of Corporate Services, and Sally Flint,
Executive Director of Finance & Performance)
To agree the Q3 In-Year Governance Statement to Monitor (for
decision)
(Peter Lee, Head of Corporate Governance)
To receive an update on Board of Director’s Site Visits
(John Bacon, Chair)
To receive the Patient Experience Report
(Vincent Badu, Strategic Director of Social Care and Partnerships &
Helen Greatorex, Executive Director of Nursing and Quality)
To receive a report on Safe Staffing
(Helen Greatorex, Executive Director of Nursing and Quality)
GOVERNANCE
To receive a report on the last meeting of the People Committee
(Mike Geerts, Non Executive Director)
22/01/2015 15:04:52
1
A
B
C
D
E
Verbal
Verbal
F
G
H
I
J
Verbal
1205
1210
1215
TBP04. 3/15
TBP04. 4/15
TBP04 .5/15
1220
TBP04. 6/15
1225
TBP04. 7/15
1230
TBP04 .8/15
TBP05 .15
1235
1245
1255
TBP05. 1/15
TBP05 .2/15
TBP06. 1/15
To receive a report on the last meeting of the Finance and
Investment Committee
(Richard Bayley, Non-Executive Director)
To receive a report on the last meeting of the Charitable Funds
Committee
(Diana Marsland, Non-Executive Director)
To receive a report back from the Council of Governors meeting
held on 19 January 2015
(John Bacon, Chair)
To receive a Quarterly Notification of Sealed Documents
(Peter Lee, Head of Corporate Governance)
To receive the Fit and Proper Person’s Test (for decision)
(Peter Lee, Head of Corporate Governance)
Fundamental Standards – Duty of Candour
(Peter Lee, Head of Corporate Governance)
M
N
Verbal
O
P
Q
STRATEGY
Board Development Programme
(Colm Donaghy, Chief Executive)
Living Wage
(Sue Morris, Executive Director of Corporate Services)
R
S
Any Other Business
Date and Venue for Next Meeting:
25 February 2015
0900– 1300
Board Room, Swandean, Arundel Road, Worthing,
West Sussex, BN13 3EP
To adopt the motion:
“That representatives of the press and other members of the public be
excluded from the remainder of this meeting, having regard to the
confidential nature of the business to be transacted, publicity on which
would be prejudicial to the public interest ” (Section 1(2) Public Bodies
(Admission to Meetings) Act 1960)
NB
Those present at the meeting should be aware that their name will be issued in the notes of this
meeting which may be released to members of the public on request
22/01/2015 15:04:52
2
Sussex Partnership NHS Foundation Trust
Board of Directors: 28 January 2015 - Public
Agenda Item: TPB01.4/15
Attachment: A
For: Decision
By: Hellen Ward, Executive Assistant to Executive Director of Corporate Services
SUSSEX PARTNERSHIP NHS FOUNDATION TRUST
Minutes of the Board of Directors Meeting held in Public on 26 November
2014 at 10.00 in the Boardroom, Swandean, Arundel Road, Worthing, West
Sussex, BN13 3EP
Present:
John Bacon, Chair
Colm Donaghy, Chief Executive
Melloney Poole, Non-Executive Director
Helen Greatorex, Executive Director of Nursing and Quality
Diana Marsland, Non-Executive Director
Tim Ojo, Executive Medical Director
Simone Button, Interim Managing Director of Specialist Services
Tim Masters, Non-Executive Director
Sally Flint, Executive Director of Finance and Performance
Richard Bayley, Non-Executive Director
Sue Morris, Executive Director of Corporate Services
In attendance:
Peter Lee, Head of Corporate Governance
Kay Macdonald, Clinical Academic Director
Vincent Badu, Strategic Director of Social Care and Partnerships
Sam Allen, Commercial Director
Hellen Ward, Executive Assistant to the Executive Director of Corporate Services
(Minutes)
Observers:
Sue Esser, People Director
Dan Charlton, Director of Communications
Rebecca Huth, Diary Manager to Chief Executive
TBP72/14
INTRODUCTION
Page 1 of 14
TBP72.1/14
Chair’s Welcome and Introduction
John Bacon welcomed the members, governors and observers to the public
meeting
TBP72.2/14
Apologies for absence
Mike Geerts, Non-Executive Director
Professor Gordon Ferns, Non-Executive Director
TBP72.3/14
Declaration of Interests
None
TBP72.4/14
Minutes of the Meeting of the Board of Directors held on 29 October
2014
TBP68.1, Page 4 - Peter Lee advised that the action for Sam Allen to include
some details on the recruitment strategy in Kent should be for Sue Morris.
TBP69.1, Page 8 - Sue Morris highlighted that “assumed audit” should read
“audit”.
TBP70.1, Page 9 - Melloney Poole advised that the lead governor’s name is
Mick Burtenshaw rather than Mike Burtenshaw.
TBP70.5 Richard Bayley advised there is a typing error – this should read “be
on” instead of “e on”.
TBP71.1 - Tim Masters suggested that the wording on page 11, fourth
paragraph from the bottom of the page should be reworded as it doesn’t
reflect John Bacon’s view on the vision. John Bacon will suggest some
alternative wording.
With the exception of the above amendments the Board agreed to approve
these Minutes as an accurate record of the public Board meeting of 29
October 2014.
TBP72.5/14
Action Points from previous meeting held on 29 October 2014
TBP69.2 – Melloney Poole advised that this action is not yet complete. Peter
Lee and Melloney Poole agreed to follow this up after today’s meeting.
All other outstanding actions are either complete or on the agenda.
TBP72.6/14
To receive a report from the Chief Executive which sets the context of
the meeting
Colm Donaghy advised that he had kept his report short, but wanted to reflect
on some of the conversations taking place between the executives and some
of the Trust’s commissioners and the move toward building a different kind of
relationship with the CCGs.
In a couple of areas, including North West Sussex, a team of people have
been identified to act as a conduit for the CCGs to input into the organisation.
These conversations will help the Trust to interact with the CCGs, help the
Trust to respond to commissioners’ intent and offer a care pathway as
Page 2 of 14
opposed to an individual service. Of particular concern is the need to
appropriately signpost people to ensure they receive the help they need and
avoid them being passed from service to service. East Sussex services are
very keen to form a similar team to hold conversations with their local
commissioners and the executive team are supporting them in this. An
executive to executive meeting is being arranged with the CCGs in East
Sussex in order to highlight the strategic issues.
The Strategic review is gathering pace. A number of road shows have been
held internally with staff, as well as discussions at the Leadership Forum,
Council of Governors and Trust Board. In January and February it is planned
to have wider discussions with the public, patients and commissioners.
Colm Donaghy also highlighted the preparation taking place for the Care
Quality Commission inspection taking place in January 2015. A mock
inspection is taking place on 3 December and the executive team are keen to
involve the Non-Executive Directors.
Colm Donaghy also wanted to note that this month showed a slight worsening
of the financial situation, although the executive team believe that a break
even position is still possible by the end of the financial year.
Melloney Poole asked how many teams there are having these conversations
with the CCGs and how many different types of meetings are taking place.
Colm Donaghy advised that the CCGs are clustered. East Sussex has three
CCGs, for example. Colm Donaghy assured the Board that he believes the
Trust has capacity to move this work forward at both a local and an
organisation-wide level.
TBP73/14
UPDATE
TBP73.1/14
To receive a themed report on Specialist Services
Simone Button advised that her report has focussed on quality issues and has
tried to highlight that there is a lot of good quality work taking place that could
be used in other areas of the Trust. Her report highlights the progress that is
being made in care group services plans and sets out the five year strategy. A
new specialist services governance board has been set up to help keep track
of the important strategic work taking place, focus on preparing for the
forthcoming CQC inspection and assist in reaching a positive financial
position by the end of the year. The outcome of the Lewes Prison and
Healthcare tender has been delayed, but Simone Button hopes to hear the
outcome next week. The shortlist for the Hampshire CAMHS tender is due to
be announced today.
Diana Marsland asked how good practice is shared (for example work in
Chichester on reducing the use of physical restraint) and whether suggestion
boxes are used and monitored. Simone Button advised that some ideas are
already being used in a lot of areas. One of the purposes of the specialist
services governance support group is to help share good practice.
Diana Marsland asked whether opportunities for using teleconferences for
prisoner hospital appointments were being investigated. Simone Button
advised that they are continuing to look at these opportunities and are having
discussions with IT. Vincent Badu advised that there is a video linking pilot
site in the corporate service within the prison services to enable people to
give court evidence via video link. Kay Macdonald advised that three new
Page 3 of 14
learning centres with video links are being established with the help of IT.
Tim Ojo suggested that the Selden Centre is an example of exemplary
practice. Simone Button advised that the clinical director for Learning
Disability is taking part in a radio interview. Simone Button agreed to send a
link to this interview to the Board members. John Bacon suggested that the
Clinical Director of Learning Disability be invited to the next Board meeting in
order to give her view on the impact of the review by Sir Stephen Bubb. Sally
Flint advised that the Mayfield Court Development is working very closely with
East Sussex commissioners who have taken someone on board to look at
Winterbourne.
ACTION: Clinical Director of Learning Disability Services to be invited to
the next Board meeting in order to give her view on the impact of the
review by Sir Stephen Bubb.
Sam Allen advised that having recently visited both Promenade Ward and
Dove Ward, she was struck by the level of complexity that is being managed
in the substance misuse services. In practice the Trust is running a dual
diagnosis service and in future this should be considered in light of the
strategic work being undertaken and what the CCGs are commissioning the
Trust to do. It will be possible to demonstrate to the CCGs that the services
have moved on in terms of the level of expertise.
Tim Masters asked whether there were any particular areas of focus in terms
of quality. Simone Button advised that the specialist services governance
support group will be looking at identifying elements of risk and think about
how to triangulate and provide more robust assurance.
The Board agreed to note the content of this report.
TBP73.2/14
To receive an update report on Adult Mental Health Services
Lorraine Reid advised that her report sets out the priorities for the next six
months in adult services and explains the actions for North West Sussex.
Lorraine Reid and Sally Flint are undertaking line by line service review
budgets for all four localities. Her report also sets out what’s emerging from
the work that has been done on vision and service design.
John Bacon suggested that questions around North West Sussex and
Langley Green be addressed later in the agenda and invited comments or
questions on the remainder of the report.
Melloney Poole highlighted that adult services appears to have a separate
vision from the Trust’s overarching vision currently in development. Lorraine
Reid advised that the aim is to summarise the work that has been undertaken
without putting in too much detail, but not to capture it as a vision or model.
Colm Donaghy assured Melloney Poole that this work will link in to the overall
organisational vision. Sam Allen advised that the adult services statement is
currently a work in progress and reflects the key themes coming out of the
work being undertaken in adult services and the conversations taking place
with the CCGs as well as the strategic review.
Kay Macdonald advised that she attended the partnership day while Lorraine
Reid was on leave and wanted to reflect her impression that a very strong
clinical and managerial leadership is emerging and that a lot of leadership and
partnership working was evidenced.
Page 4 of 14
Tim Masters asked what the likely impact of the new Clinical Information
System would be on the work streams identified. Lorraine Reid advised that
she is anticipating this will have a huge impact both by reducing duplication
and making it easier for clinicians to access information. Some clinical leads
are being identified to work with Kay Macdonald and her team. Colm Donaghy
advised that in addition the new system will help the Trust to provide
information against outcomes, both those that are internally set and KPIs.
The Board agreed to note the content of this report.
TBP73.3/14
To receive an update on Langley Green Hospital
Helen Greatorex advised that the report of the CQC’s return inspection visit to
Langley Green in October has now been received. They confirmed the
compliance action the Trust needs to take in relation to recording care details.
Action is being taken in this regard.
CQC also undertook a detailed review of the seclusion and restraint records
and found them to be in order. They confirmed that whilst there remained
work to do at the hospital they could draw no straight line between the areas
highlighted and a risk to safety. The executive team remain very focussed on
Langley Green. Sustainability of improvements has proved to be a challenge
and a lot of support and attention from the executive team and the support
teams has been provided to help bring Langley Green up to the required
standard. It was decided not to focus on Langley Green for the mock CQC
inspection on 3 December 2014 in order to allow the leadership team there to
get on with making the improvements required.
Helen Greatorex advised that Dr Jason Read has taken up the role as service
improvement lead at Langley Green Hospital. Emma Wadey is also there, as
is Mihaela Bucur, Justine Rosser and Jonathan Beder. Jonathan Beder has
now been with the Trust for a number of months and has confirmed that he
does feel well supported in his new role.
Helen Greatorex advised that there is an on-going recruitment challenge in
Langley Green. There are currently 11 nurse vacancies. Sue Esser and the
recruitment team are putting a lot of resource into recruiting and retaining staff
at Langley Green. Sue Morris clarified that the reason the number of
vacancies has risen from 7 to 11 is because of the new safer staffing
guidelines necessitating an increase. Sue Morris advised that two of these
vacancies have been recruited to already and that a further round of
interviews is taking place on Friday.
Melloney Poole asked how long it would take to get to ensure that sustainable
change takes place in Langley Green. Tim Ojo advised that constant
vigilance is being applied and that ensuring all patients receive the best care
remains the focus. Tim Ojo advised that he would expect to see some of
these improvements by the time the CQC inspection takes place, but that this
is a milestone in a longer journey.
John Bacon asked that a regular report on Langley Green be provided to the
Board.
ACTION: Helen Greatorex to provide a monthly report on Langley Green
to the Board.
Page 5 of 14
TBP73.4/14
To receive an update on North West Sussex Action Plan
Lorraine Reid advised that the North West Sussex action plan encompasses
Langley Green. A basic diagnostic has been undertaken and a plan has been
created. Lorraine Reid’s team are looking at what plans need to be put in
place for people who are staying in hospital for longer than they need to.
Some of these plans are necessarily complex. Lorraine Reid advised that she
has also been working with Sally Flint in order to undertake a systems review
at Langley Green. The focus is on ensuring the leadership team in North
West Sussex feel supported and in control. A decision has been made
around staffing number and Sue Esser and her team have been assisting with
consultations. There is a rolling recruitment programme and a specific
meeting with the CCG about community care pathways and service redesign.
John Bacon asked if a regular update on North West Sussex could be
provided to the Board.
ACTION: Lorraine Reid to provide a monthly report to the Board
regarding North West Sussex.
TBP74/14
PERFORMANCE AND QUALITY
TBP74.1/14
To receive a report on the Performance of the Trust to the end of
October 2014
Quality and Experience of Patients
Helen Greatorex advised that the complaints department are meeting the 25
working day deadline for closure of complaints. The on-going focus will now
be on the quality of responses being sent out to complainants. Helen
presented a paper which set out three recent complaints, their outcomes and
examples of what changed as a result of the complaints being investigated.
This new report was welcomed by the Board and it was agreed that a regular
report including similar examples would be useful.
People
Sue Morris advised that a second survey has been undertaken to capture the
satisfaction of new starters with the recruitment process. This has shown an
improvement from 34% satisfaction to 84% satisfaction.
Sue Morris also highlighted to work being undertaken to improve agencies.
Although the long term goal is to eliminate the use of agency, there will need
to be a transition period where the level of agency being used is reduced
slowly. It was originally hoped to be able to reduce the number of agencies
being used by the Trust to 5, but the 5 agencies identified were unable to
provide assurance around capacity. The original figure of 5 agencies has
been increased to 20, all of which will be on the new national framework.
Richard Bayley asked what the timescale was on this. Sue Morris advised
that this is going to be reviewed this week with the operational directors.
Within the next two weeks it is hoped to communicate the new list of agencies
to staff.
Helen Greatorex suggested that as well as asking new starters what their
Page 6 of 14
experience is, it would be useful to capture the views of people who are
successful at interview but then chose not to join the Trust. Sue Morris
suggested that caution needs to be exercised when it comes to the
investment of time, however it would be useful to explore with candidates their
reasons for coming for an interview.
Performance
Sally Flint wished to highlight the good work being undertaken in children’s
services in Kent. Attempts are now being made to take the learning from this
and apply it to Hampshire. Sally Flint also highlighted that patients are not
being clustered as before. A performance board review was recently held
with commissioners and they are keen to move this work forward, even if it is
just in shadow form. In addition Sally Flint wished to highlight that the
indicators in the performance report are high level only. The in depth reports
are received at the sub committees. More importantly, it’s about getting the
teams to use information and this month adult services took the performance
data and worked that into their report for the first time which is encouraging.
John Bacon suggested that it is not always obvious who is setting the targets
in the report – some are Monitor, some are internal. When presenting to the
Council of Governors this can cause some confusion. S Flint advised that this
is reflected in the dashboard but she could work to make this more explicit.
ACTION: Sally Flint to provide clarification in performance report on
who is setting the Trust’s targets.
Tim Masters commented that he would be interested to know what the
demand pattern is across the services as this would help to develop the
Trust’s strategy.
Melloney Poole advised that she is concerned about the readmissions within
28 days in Crawley. Sally Flint advised that Dave West and Dr Shakil Malik
met with consultants in Adult Services recently in order to examine this.
There are three factors; delayed transfer of care, length of stay and
readmissions. It was also noted that in the case of personality disorder, short
periods of readmission within 28 days is not unexpected. Colm Donaghy is
undertaking work with the commissioners about risk sharing around length of
stay. Tim Ojo advised that there are a number of factors that can influence
length of stay and that this would need to be inspected at team and ward
level, however he would caution against taking standards in acute care and
attempting to apply these to mental health.
John Bacon observed that there seems to be a systemic element in that
where an area is struggling they are struggling in various performance factors.
Lorraine Reid advised that this is one of the issues Justine Rosser is
examining in her new role. Sam Allen highlighted that a contributing factor in
North West Sussex is that there is currently no comprehensive liaison service
in the emergency care department at PRH. Colm Donaghy advised that he is
in discussions with the CCGs about looking at the care pathways.
Lorraine Reid advised that she has some concerns around the provision of
social care data in Sussex from the local authorities. Two service directors are
working directly with the local authority and will be presenting a report at the
next performance review meeting which sets out what the issues are.
Richard Bayley asked if some more analysis can be provided in the narrative
Page 7 of 14
of the performance report, particularly by way of comparing the current month
to previous months. He also asked if there some more information could be
given in the narrative about the trajectory of where the Trust is going.
Richard Bayley highlighted that the length of stay in East Sussex seems high.
Sally Flint advised that there is one particular patient which complex needs
and that NHS England are involved.
Richard Bayley asked for Simone Button’s thoughts on the 4 week waiting list
target in Hampshire and Kent as demand seems to have increased. Simone
Button advised that the new business continuity plan in Hampshire is
beginning to take effect which includes good demand and capacity planning.
Currently there is an average of a 4 week wait in Hampshrie and Kent
although some areas are higher. It is worth noting that in some areas of Kent
the target is 4-6 weeks. By the end of December she anticipates all areas will
be 4-6 weeks.
Finance
Sally Flint advised that in month 7 the financial status of the Trust plateaued
and is in a much more stable position. There is currently a £2.4m deficit. The
focus is now on recovering this in the remainder of the financial year. The
issues which remain a challenge are agency use, external placements and
slippage on CIP on adult services redesign. The Monitor call for Quarter 2
took place this week. They challenged over these issues but reflected that
there are a number of Trusts facing significant financial challenge and Monitor
are not particularly concerned about us in comparison.
TBP74.2/14
To receive an update on Safe Staffing
Helen Greatorex presented this paper which had been received by both the
Executive Management Board and Transformation Programme Board. It set
out the current position in relation to staffing numbers and bands, placing the
issues in both national and local context.
The decision was taken by the Executive Management Board in October to
return to the three shift system in adult services. This decision is driven by
concerns about the quality of care provided in the 2-shift system.
With regard to nurse to patient ratio, acute hospitals have been advised that
they need to have a 1:8 ratio. There is no guide for mental health trusts yet,
but the expectation is that recommended level will be no lower.
Finally, Helen Greatorex advised that transparency around the cost of
returning to the three shift system is a priority. John Bacon suggested that the
cost of moving back to three shift could be easily absorbed by avoiding the
premium currently being paid for agency staff.
Richard Bayley noted that in the report, some wards are shown as having no
comments on their staffing level, and asked why. Helen Greatorex confirmed
this was unacceptable and would be addressed through the Matrons.
Richard Bayley asked if column headers could be included on section 3.1.
John Bacon asked whether Helen Greatorex was confident that there is a
consistent approach to managing the different levels of observation. Helen
Page 8 of 14
Greatorex advised that there is a very clear policy based on national best
practice which advises that a nurse doesn’t need to wait for a doctor to give
permission to reduce the level of observation on a patient. Part of the
problem is that some wards are larger and make observation of patients more
difficult. There is an audit taking place in December which should look into
the different reasons around this in more detail.
Diana Marsland asked how the impact of the return to the three shift system
on agency use will be measured. S Morris advised she would look at how this
would be monitored. Sue Morris also suggested that the return to the three
shift system might have a positive impact on the bank as staff may be more
willing to consider extra bank work if they are only doing 8 hour shifts rather
than 12.5 hours.
John Bacon asked whether there was already any correlation between high
agency use and areas that are on the 12.5 hour shift system compared to
those who did not move to 12.5 hour shift system. Sue Morris advised that
Mill View did not go to 12.5 hour shift, but that there are various other factors
in that area which would make a correlation difficult. John Bacon suggested
that if the data and the ability to compare is available, correlations should be
looked for in order to prevent pursuing the wrong objectives.
Melloney Poole highlighted that the number of occupational therapists is quite
low and this might explain some of the feedback being received about not
enough activities on the wards. Kay Macdonald advised that some
benchmarking work is being done around this.
TBP74.3/14
To receive an update on the CQC Inspection Project
Helen Greatorex advised that a project office has been created and is being
led by Adam Churcher. There is also a weekly CQC project meeting taking
place and staff are receiving regular briefings in order to prepare them for the
inspection. There will be a mock CQC inspection on 3 December 2014 which
will focus on Brighton and Hove. Colin Dale will be assisting as an external
chair. Various areas will be inspected, members of the Board will be
interviewed during the day and feedback will be provided.
The preparation for the real inspection in January continues. There is a
certain level of anxiety amongst staff, although the CQC project office is
working with comms in order to update and reassure people.
In addition the CQC published an intelligent monitoring report on all NHS
Trusts and Sussex Partnership’s report was published last week. This
highlights the areas the CQC believes may be at risk for the Trust. There is
some push back from GPs saying that this is a blunt instrument, although it is
also a helpful prompt for questions.
TBP74.4/14
To receive a report on Lessons Learnt from Complaints
Helen Greatorex presented the Lessons Learnt from Complaints paper to the
Board, which includes examples of complaints received recently together with
lessons learned and changes and improvements which have been made as a
result. Helen Greatorex advised that the Board may need to decide later in
the year about whether a standalone complaints report should come to every
meeting, or whether this should be subsumed into a quarterly report that
addresses different kinds of patient experience.
Page 9 of 14
Sam Allen highlighted that the narrative around the complaint from “Mrs Z”
seems to highlight a gap in commissioning in specialist services, and that this
could indicate some learning about how the Trust relays these gaps in service
back to the commissioners in terms of the unmet need, managing
expectations and also clarity with individuals and when and where a service
can be provided.
John Bacon suggested that sometimes the difficulties the Trust experiences in
delivering a service is often visited up on the complainant; if someone is on
leave, this is not the complainant’s problem. If the Trust does not provide a
service at the very least they should be signposting the patient to the
appropriate local service.
Vincent Badu advised that a new customer services training programme is
about to be rolled out to staff across the organisation which picks up how to
respond to feedback.
Colm Donaghy cautioned about cherry picking where improvements have
been made. If the most recently closed complaints are given to the Board,
then it will provide a more realistic picture about responses to complaints.
TBP74.5/14
To receive an update on the Board of Directors’ Site Visits
John Bacon observed that a lot of directors visited Chichester as there was a
meeting that day.
Helen Greatorex advised that she worked a shift in the A&E Liaison at the
Royal Sussex County Hospital. This really demonstrated how admissions can
be avoided or expedited where appropriate by having mental health
professionals in A&E. John Bacon agreed and suggested that where liaison
services are not so good because of resourcing we need to highlight this to
the relevant commissioners.
Colm Donaghy advised that he visited Cavendish House in Hastings and was
very impressed with the team culture.
Colm Donaghy advised that he had also visited Winchester and had the same
feel from the CAMHS service there. Although they are currently awaiting the
outcome of the tender, the staff are still working on improving care and
working closely with GPs.
TBP75/14
GOVERNANCE
TBP75.1/14
To receive a report on the last meeting of the People Committee
Diana Marsland advised that she had chaired the last meeting of the People
Committee. The Committee reviewed its terms of reference which currently
contain a lot about driving performance but not much about enabling staff.
The Committee also discussed some of the innovation approaches being
taken around recruitment, time to hire and retention. It was noted that
statutory and mandatory training is an issue at the moment, and the
Committee received a paper on how to improve this. Finally, an update was
provided on electronic forms which will help improve the processes around
leavers and starters.
TBP75.2/14
To receive a report on the last meeting of the Audit Committee
Page 10 of 14
Tim Masters advised that prior to the last Audit Committee he met with the
governor observers for a meeting in order to clarify what the Audit Committee
is about. There has been a change in emphasis in the internal audit
programme in order to look at concerning issues such as agency staffing.
When the auditors visit services they will look at processes in place to sign off
invoices. The review of the capital programme and IT security will be carried
out in the next financial year.
Internal audits have demonstrated that there was a limited understanding
among some managers and budget holders about their own responsibilities.
This has been referred back to the People Committee in order to take on
board performance management. The Audit Committee has also suggested
that this may be a good time to have a leadership communication about
budget responsibility.
TBP75.3/14
To receive a report on the last meeting of the Mental Health Act
Committee
Melloney Poole advised that one of the Associate Hospital Managers has
written to the CQC to suggest that they talk to Associate Hospital Managers
during their inspection in January. This is not a practice for mental health
trusts yet, but Sussex Partnership may prove to be the first. Vincent Badu
and Helen Greatorex are ensuring Associate Hospital Managers are being
kept fully briefed on the possibility of contact.
John Bacon advised that he is involved in protracted correspondence around
data protection issues around how papers are obtained for hearings.
Melloney Poole advised that this was raised at the last Committee meeting
and that members were happy that the Trust is following procedure. Some
other trusts haven’t been sending out paper copies of a number of years and
this has not had an impact upon the quality of hearings. A good half of
Associate Hospital Managers have also advised that this is not an issue for
them. While there is one person who is very concerned and took her own
legal advice on whether she could discharge her duty of care appropriately in
the changed system, Vincent Badu has responded to her to let her know that
if she feels she cannot meet her duty of care she should perhaps not
participate.
TBP75.4/14
To receive a report on the last meeting of the Finance and Investment
Committee
Richard Bayley advised that the F&I Committee continue to scrutinise
financial performance, adult services and agency/ECRs. Richard Bayley also
noted that in relation to the financial recovery plan, the aim is to break even.
Richard Bayley raised the concern that there has been some poor
management around salary overpayments.
TBP75.5/14
To receive a report on the last meeting of the Quality Committee
Melloney Pool advised that the Quality Committee has invited the clinical
directors to comment on the matters raised in the quality and safety report
which has sparked some lively discussion. It has been very helpful to see the
responsibility taken for the outstanding serious incident reports; the
information here surprised them to a certain extent and they have taken this
on board and moved quickly to make improvements.
The audit on the use of seclusion is referred to in this report. There are some
areas of good practice, but the need to improve training, awareness and
Page 11 of 14
monitoring has been highlighted. There has been a slight decrease in the last
quarter. Helen Greatorex advised that some of the variance was to do with
documentation. This is a key issue for the Trust currently. Seclusion should
be the very last resort, to be used only when all other options have failed and
seclusion is the only way to keep the patient and everyone else safe. The
Trust has its own example of best practice in Fir Ward at the Chichester
Centre, where there is almost no seclusion due to the way they engage with
patients. This model is being built on.
TBP75.6/14
To receive the Q2 Board Assurance Framework 2013/14 report
Helen Greatorex advised that a slightly different process of review has been
used which involved individual meetings with the leads identified for each
area in the framework. None of the risks have increased. A risk radar is
provided at the end of the paper which shows the movement of risk.
TBP75.7/14
To receive the Trust Scheme of Delegation Standing Financial
Instructions and Delegated Financial Limits
Sally Flint advised that this is an overview only. This is an important
mandatory document and shows changes to the organisation in terms of
structures and key posts. There is a separate section added in around the
joint venture with Care UK and will talk about the Horder Centre joint venture
later. The SFIs need to be increased to cover these areas.
Sally Flint advised that she wished to pick up on the training and clarification
of roles and responsibilities for staff. With regard to Oracle and procurement,
the responsibility of the Service Directors has been increased as the current
level is very low and results in the majority of requisitions being sent to the top
of the organisation.
Sally Flint asked that the Board note the part in the paper about joint ventures
and sign this off in order to roll out across the Trust and focus on the
compliance agenda.
Tim Masters raised the concern that if ward managers can approve up to
£5,000 they could book weekly agency staff.
Diana Marsland asked how compliance on training is going to be monitored.
Sally Flint advised that the executive team are looking at this. A new
performance framework is going to be brought to the Board prior to the new
financial year.
Richard Bayley asked what opportunity there is as a shareholder to
understand the future budgets. Sally Flint advised that this has not been
brought back to F&I yet due to the large agenda at that meeting. John Bacon
asked if each of the two joint venture companies have an equivalent of this
paper. Sally Flint advised that they have and that they mirror Sussex
Partnership’s SFI.
The Board agreed to adopt these standing financial instructions.
TBP76/14
STRATEGY
TBP76.1/14
To receive the Safeguarding Adults Annual Report
Vincent Badu advised there are four key points he wished to highlight to the
Page 12 of 14
Board.
The first point is that there is a lot of partnership working around safeguarding
adults which includes alerts raised around the care and treatment and where
Trust staff members may be responsible for abuse. Outcomes are shared
with local services.
Secondly, Vincent Badu highlighted that safeguarding adults at risk is going to
be a statutory requirement from April 2015. A huge amount of work is being
undertaken to ensure compliance with the Care Act. This will lead to a large
scale review of all policies and procedures around safeguarding and a large
scale training programme for all staff and partners. The Local Authority will
have a duty to carry out enquiries around issues related to safeguarding and
neglect, and where are reported issues about quality of care this will be
referred to the CQC.
Vincent Badu advised the Board that Sussex Partnership is one of two mental
health trusts selected to be part of a national programme about improving the
response to domestic violence. There is a funding for a domestic violence
coordinator. Yesterday began 16 days of action in relation to stamping out
domestic violence and Vincent encouraged Board members to join him in
supporting this by pledging as a Board never to condone or remain silent
about men’s violence towards women.
Finally Vincent Badu highlighted that there has been an internal audit towards
governance around safeguarding. This has been RAG rated amber and
green.
John Bacon asked why Sussex Partnership was selected. Vincent Badu
advised that his department put the Trust forward. The Trust is also involved
in a research study engaged in the response around domestic violence,
improving policies and training to our staff.
Simone Button asked whether there was a need to strengthen governance
arrangements where the Trust is linked into local groups. Vincent Badu
advised that this would be picked up in the review around safeguarding
adults.
John Bacon asked why this endorsement is not gender neutral. Vincent Badu
advised that the 16 days of action is a national pledge, however the work
being undertaken by the Trust is more broadly around all forms of domestic
and sexual violence.
The Board agreed to endorse the 16 days of action in relation to stamping out
domestic violence.
Page 13 of 14
TBP76/14
Any Other Business
None.
Date and Venue for Next Meeting:
28 January 2015
10.00 – 1300
Board Room, Trust Headquarters,
Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP
Signed ………………………………………… Date: ………………………………………..
John Bacon, Chair, Sussex Partnership NHS Foundation Trust
Page 14 of 14
Sussex Partnership NHS Foundation Trust
Board of Directors: 28 January 2015 - Public
Agenda Item: TBP01.5/15
Attachment: B
For: Information
By: Hellen Ward, Executive Assistant
MATTERS ARISING: ACTION POINTS FROM THE BOARD OF DIRECTORS MEETING HELD IN PUBLIC ON
26 NOVEMBER 2014
Date of
Action
Action or
Agenda Item
Min. No.
Action Points from previous meeting
Lead
Action Taken
26.11.2014
Action
TBP73.1/14
Clinical Director of Learning Disability to be invited to the next
Board meeting in order to give her view on the impact of the
review by Sir Stephen Bubb.
Simone
Button
Complete – Vicki Baker
attending January Board
meeting
26.11.2014
Action
TBP73.3/14
To provide a monthly report on Langley Green to the Board.
Helen
Greatorex/
Lorraine Reid
Complete – added to the
Board agenda forward plan
26.11.2014
Action
TBP73.4/14
To provide a monthly report to the Board regarding North West
Sussex.
Lorraine Reid
Complete – added to the
Board agenda forward plan
26.11.2014
Action
TBP74.1/14
Performance reports to state which targets are externally by the
Trust.
Sally Flint
Complete – future
performance reports will
include this
Page 1 of 1
Board Meeting 28 January 2015 – Public
Agenda Item: TBP01.6/15
Attachment C
For information and discussion
By: Colm Donaghy, Chief Executive
CHIEF EXECUTIVE REPORT
1. Introduction
In my report this month I will focus on the recent CQC wave inspection which took place between 12th
and 16th January. I also wish to mention our on-going strategic review and touch on our financial
position.
2. Context
The CQC arrived on 12th January with approximately 100 inspectors. Prior to their arrival the Trust had
prepared by establishing a project led by Helen Greatorex, Executive Director of Nursing & Quality,
and managed by Adam Churcher. As part of our preparation we completed a mock inspection,
provided guidance to staff delivering services and worked closely with the CQC on their data pack for
inspectors.
On 12th January I presented on behalf of the Trust to the CQC inspectors. The inspections had started
the previous week in Hampshire and Kent. The inspections in Sussex began on 13th January.
Over the course of the week feedback from our services and informally from CQC was mostly positive.
On Friday 16th January John Bacon, Chairman, Simone Button, Interim Manager Director Specialist
Services, Tim Ojo, Executive Medical Director, and myself attended a feedback session with Paul
Lelliott, Chairman for the Inspection and Natasha Sloman, Head of Hospital Inspection (SE).
CQC emphasised that they were still collecting evidence and triangulating data and therefore could
only provide headline feedback, some of which still had to be finalised in relation to evidence.
They were very positive about the open and welcoming environment their inspectors experienced from
our staff in all areas. They were impressed with the caring commitment and compassion of our staff
and most inspectors reported that it was a pleasure to inspect our services.
They highlighted concerns regarding training, reporting of incidents, mixed gender wards, a gap in our
assurance framework and compliance with the Fit & Proper Persons Test.
The next steps are that CQC will complete collection of data and evidence, including carrying out
some unannounced inspections over the next two weeks. They will then draft their report and share it
with us, in approximately six weeks, for factual accuracy checking. At this stage we will have two
weeks to respond, including challenging any areas that we believe they have got wrong or providing
new evidence.
Following this the CQC will present the final report including the rating for our organisation at a Quality
Summit in April.
Finally CQC commented that the logistics provided by our Trust were fantastic and complimented
those involved. Special mention in this regards needs to be made of Adam Churcher, Project Manager
and his staff who worked tirelessly during the preparation phase and the week of the inspection.
1 of 1
Finance
It is disappointing that the Trust reported a deficit for the month of December. Discussions with our
CCGs have been positive and we are optimistic that they will provide financial support to recognise the
additional costs the Trust has incurred dealing with service pressures.
Strategic Review
The process for reviewing our strategic direction continues at pace. During January I am holding a
series of leadership forums to outline learning to date and highlight how staff can get engaged. In
February we are holding a number of public events and on 27th February we have our leadership
conference. We have invited our commissioners to the conference on 27th February and to date most
have accepted the invitation.
3.
Recommendations
Board members are invited to note the contents of this report, comment and ask questions.
2 of 1
MANAGING DIRECTOR SPECIALIST SERVICES REPORT
Board Meeting
By: Simone Button
Agenda Item:
1. Introduction
This is my third report as Interim Managing Director for Specialist Services. At the November
Board meeting there was a request to provide the Board with an update on the Bubb report.
This was a report published in November 2014 commissioned by DH post the abuse of
people with a learning disability at Winterbourne View Hospital. Therefore this month I am
primarily focusing my report on that report, and its implications for our Learning Disability
Services. Viki Baker, Director of Learning Disability Service has written the update included.
2. Context and Operational Overview this month
Over the last 8 weeks all care groups have been primarily focused on their preparation for the
CQC visit. All services were generally well prepared and those inspected used the
opportunity to share the good practice and what they are proud of in their service as well as
being open and honest in their conversations with inspectors. A number of services, indeed,
were disappointed that they were not visited and able to showcase their good work.
Within substance misuse services, there has been a strategic separation from CRI was
completed on the 31st December 2014. As of the 1st January Sussex Partnership NHS
Foundation Trust is no longer in a contractual relationship to provide services in partnership
with CRI (except for Lewes Prison: MOU regarding use of our pharmacy). The service will
focus over Q4 to deliver the exit from the Brighton & Hove community Substance Misuse
Services. A project plan is in place and we are working in conjunction with the new providers.
The Trust is now focussed on our remaining two wards, Dove and Promenade. Both achieved
a contract extension to March 31st 2016. The strategy is to place these two wards under the
leadership of Adult Services and develop the Dual Diagnosis pathways.
Our
prison healthcare services are on track with the Service re-design at HMP Lewes. The
Implementation model has already been drafted and shared with NHS England. The
consultation document for staff is due to go out at the beginning of February and the start of
the Prisoner consultation is this week. Staff have been positive about the changes we have
already discussed with them, including their hours being made more sociable and an
opportunity to use their specialist skills and develop new ones. One of the nurses has gained
a place on the prescribing course. They are all pleased to note there are no redundancies.
The Hampshire tender has been suspended as commissioners believe they may have some
additional funding to add to the new contract. As yet we are unclear what the implications that
will make to the tender process. Discussions are underway with commissioners regarding
their request for a further extension to the existing contract.
1
Learning Disability Service and Bubb Report
The Bubb Report and its implications for the Trust’s Learning Disability Service Plan
Introduction
The following paper briefly describes the findings from the most recent DH commissioned
report, post the abuse at Winterbourne View Hospital .It summarises how the
recommendations from the Bubb report impact on Sussex Partnership NHS Foundation
Trust’s (SPfT) provision for people with a learning disability.
The report ‘Winterbourne View – Time for Change’ (Bubb, 2014), together with the draft
commissioning guidance for community teams ‘Delivering Effective Specialist Community
Learning Disabilities Health Team Support to People with Learning Disabilities and their
Families or Carers’ (Draft, Professional Senate, December 2014), are both welcome
documents and very timely given the current service planning process being undertaken by
specialist services. These are also in keeping with the NHS Five year forward view and the
Forward View into Action Planning 2015/16.
The Bubb Report highlighted issues which those of us working directly with people with a
learning disability are very familiar with. There were no surprises and the content of the report
resonates with the current state of play in Sussex.
The Report
Sir Stephen Bubb is the CEO of the Charity Leaders Network. The report was requested by
NHS England when the original government pledge of moving people who were
inappropriately placed in inpatient care out of hospital by June 2014, was missed. In fact
more people were admitted than discharged in this time period.
The report takes a two-pronged approach to its recommendations – from the ‘bottom up’ i.e.
the current disempowerment of people with a learning disability and their families and what
can be done to shift this, and ‘top down’ in terms of the need for a national commissioning
framework for securing community based support for people with a learning disability .
The reports top line recommendations are as follows:
To urgently close inappropriate (unsuitable) in-patient care institutions ;
A Charter of Rights for people with learning disabilities and/or autism and their families;
To give people with learning disabilities and their families a ‘right to challenge’
decisions and the right to request a personal budget;
A requirement for local decision-makers to follow a mandatory framework that sets out
who is responsible, for which services and how they will be held to account, including
improved data collection and publication;
Improved training and education for NHS, local government and provider staff;
To start a social investment fund to build capacity in community-based services, to
enable them to provide alternative support and empowering people with learning
disabilities by giving them the rights they deserve in determining their care.
Impact for Sussex Partnership Learning Disability services and proposed service plan
Inpatient - “To urgently close inappropriate in-patient care institutions”
The Selden Centre is clinically excellent and provides safe and effective care. We do not
believe it provides any inappropriate care. The recent CQC visit has highlighted an area of
concern regarding the use of a room for seclusion in the building however the service is
2
providing additional evidence to reassure CQC of its compliance with policy and good
practice.
We will need to consider our business model regarding the provision of inpatient beds in the
light of expectations to reduce admissions, and whether this could include becoming one of a
small number of key quality providers of inpatient beds for people with a learning disability
nationally.
It is of note that there do remain some delayed discharges at the Selden Centre due to an
absence of quality community provision to provide ‘capable’ (Mansell 2007) environments for
some highly complex and risky clients.
We are keen to address this situation and are working with commissioners and providers to
improve pathways in and out of the Selden Centre. A new pan-Sussex commissioning
meeting will be focussing on the challenging behaviour pathway and admissions. Numbers of
beds needed in Sussex and other ways to fund the service will be on this agenda in coming
months. This will also be included in the financial and business component of the LD service
plan.
Support in the community - “ build capacity in community-based services, to enable
them to provide alternative support and empowering people with learning disabilities by
giving them the rights they deserve in determining their care “
To address the current gap in service provision for the most complex and high risk clients,
Mayfield Court (8 supported living flats) was developed by the Learning Disability Service
together with Southdown Housing as landlords as a way of providing high quality care in the
community. These are clients, who, in the past could have received services from
assessment treatment centres in the long term, and who are now receiving a service in their
own flats in the community. These services are however high cost in comparison with purely
third sector providers and are viewed by commissioners as potentially unsustainable in the
long-term. Our current position is that costs are justifiable given the clinical risks of the
clients and the NHS governance and expertise required managing these risks.
There is new business potential which is clinically needed to develop more accommodation
services geared to this client cohort and commissioners are keen to work with SPfT as future
providers. However, we need to work with them to develop the model and reduce costs in
new and innovative ways. New business models for learning disabilities need to be
developed jointly with commissioners, clients and their families. Our service plan, developed
with our colleagues in commercial, HR and finance, which will involve strategic commissioning
partners, will help describe how we do business in future.
A new nurse consultant post, employed by SPFT, funded by East Sussex CCGs and
managed through social care has been recruited to. Their role will be to care manage all
people with a learning disability falling into the Winterbourne cohort for East Sussex and to
chair a programme board between CCGs, SPFT and LA to look at what their needs are and
therefore how we can plan for their futures locally.
Community teams
The biggest impact from all the current post Winterbourne documents, The Bubb Report being
no exception, is the need for expansion in commissioning provision across accommodation
and clinical services.
3
The Bubb Report calls for increased financial investment in services and describes a ‘Life in
the Community Social Investment Fund’.
What is clear, however from the service planning days is our need, regardless of potential
increased resources, to remodel our teams to be better organised to prevent and respond to
crises. This will mean reducing work elsewhere and increased flexibility of roles. Reasons
why people with a learning disability go into crisis are complex, and therefore a multiple
systems approach between SPFT and social care is required. It will also mean greater joint
working with Adult Mental Health Service crisis response services, A&E liaison and primary
care services. There are numerous models of crisis support and prevention which are being
discussed with social care partners and commissioners across Sussex in a very positive way.
In our draft tiered model we have included a tier ‘3.5’ to focus on this element of service
delivery, which will be the focus with commissioners over the next year:
In Summary
SPFT is a quality provider of inpatient LD services with a track record of providing safe, high
quality inpatient care. Any potential expanded role as a learning disability inpatient provider
will need to be considered as part of the service business planning. It will be important
however that the Selden centre is commissioned as part of a localised challenging behaviour/
mental health pathway.
In addition to inpatient care, SPFT should continue extending its provider role to develop
Supported Living and outreach Services for the most complex and high risk people. The
service will be looking at a range of cost effective models to achieve this jointly with
commissioners and third sector partners, with SPFT holding the expertise in clinical risk
management and professional governance. Growth in this area very much fits the national
direction of travel and would be highly valued by families as well as commissioners locally and
nationally.
4
Community Learning Disability Teams (CLDTs) need to (as part of newly developing
challenging behaviour pathways) develop proactive and reactive crisis management solutions
together with commissioners and third sector service partners. This too could involve
extended and new business opportunities for community services as through the Bubb report
recommendations, new monies from ring fenced budgets are a real possibility for growth in
community models.
Viki Baker
Care Group Director, Learning Disability Service
January 2015
4.
Recommendation
Board members are invited to note the contents of the report and ask any questions and offer any
suggestions for future themed reports.
5
MANAGING DIRECTOR ADULT MENTAL HEALTH SERVICES REPORT
Board Meeting
By: Lorraine Reid
Agenda Item: TBP02 .2/15
Attachment: E
1. Introduction
Since the last meeting teams have been preparing for the CQC Wave Inspection. I have been working
with my team to create a simpler structure with clear roles around clinical leadership to provide the
level of engagement we need to face the challenges ahead. I have also been working closely with the
CCG and the leadership team in North West Sussex to ensure a robust and timely operational
response to the review at Langley Green Hospital (LGH).
Building on the learning from LGH, a trust-wide process for ensuring that care plans, risk assessments
and progress notes are linked and comprehensive, has been introduced. Templates for patient files
are available on all wards and audits are in place ensure that change is embedded in practice. This
system will ensure that patient records reflect the care that they are receiving. It is not a tick box
exercise and is concerned with the spirit within which care is formulated and delivered. This should
ensure that record keeping is responsive to change and minimises risk as we move to a more
integrated electronic system clinical information system later this year.
2. Context
Service system reviews have been held in three of the four geographical divisions. The purpose of the
review is to identify system pressures and areas for improvement and to promote the launch process
for guiding each division towards functioning as care delivery units. Within this model each division will
have clearly defined clinical leadership roles to support the delivery of strategic priorities and
developments that are identified and agreed at the local level; between providers, commissioners,
partners and service users. Discussions have included system pressures, care pathway development,
urgent care and integrated working with community partners, as outlined in the operational section of
this report. These themes will be carried through in our strategic planning and also in the contract
negotiation process.
3. Strategy
The outcomes of the service design workshops in adult services have been distilled into key strategic
priorities for the next five years. These priorities have been outlined and the proposed framework for
services has been communicated across the trust. Discussions with commissioners are underway and
proving productive in light of the work that has been done over the last year to co-design our future
service model. The Adult Services Transformation Group will drive the development and
implementation of the strategy, which will also oversee the journey towards a more devolved structure.
Local development plans will be produced during the current quarter. These plans will not only capture
the clinical and operational imperatives but will also identify the core/corporate (estates, human
resources, finance, performance, commercial and communications) requirements to deliver
meaningful services within a rebased budget and in line with our proposed performance framework.
This work will build on the specialist services development programme and will include support and
input from colleagues who have been through a similar process.
The Brighton & Hove division has been identified as the early implementer in defining their delivery
unit plans and, as such, will be a pilot for the initiative. Facilitated development sessions will be
1
provided to populate and nurture a full and detailed development plan.
The headline plans for each division will be presented at the forthcoming Leadership Conference in
February. The full plans will describe the division’s response to the strategic priorities as interpreted
and agreed with stakeholder partners responsible for services. These will include commissioners, third
sector and other statutory partners, carers and central to all; service users.
4. Update from Divisions
North West Sussex
A robust operational improvement plan is in place for this division and agreed with commissioners.
There is also a project structure for Langley Green Hospital (LGH) development plan with a project
board for which I am the executive sponsor. The enhanced clinical leadership that was recently put in
place is working well and successful driving change while engaging staff in the process. Their focus
ostensibly has been improving patient records to ensure that care plan, risk assessment and progress
notes are properly aligned. Significant progress has been made, this was recognised in the external
review process and as a result the restrictions on admissions were lifted.
Good progress is being made in completing the leadership team; however, recruitment remains a
challenge at the hospital and within the division. A monthly recruitment plan is in place and the trust is
working with an agency to recruit nursing staff from overseas. We are also looking at using further
sustainable incentives to address pay issues as well as undertaking work on staff development and
wellbeing.
A Street Triage service for Crawley will be introduced later this month; this is a pilot which will operate
until the end of March using winter resilience funding. Initially it will be a weekend service and will be
expanded to cover the rest of the week. Winter resilience funding is also being used to increase A&E
liaison provision and work with people who are frequent attenders.
Coastal West Sussex
Through the system resilience group, teams are working to provide a more joined up response to older
adults with dementia this involves developing closer links with the rapid assessment and intervention
team provided by Sussex Community Trust and our dementia crisis service. Access to care home
accommodation for people with dementia is having an impact on our inpatient services which have
been operating with higher bed occupancy. Unlike adult services, it is very difficult to find provision
within the private sector when our wards are full. Winter pressures have been particularly challenging
to the local health and social care economy this year which is exacerbating this situation in both West
Sussex and Brighton and Hove.
Work is progressing with CCG lead GP commissioners to develop a care pathway for people with
emotionally unstable personality disorder in Coastal West Sussex, they are keen to develop a crisis
café alongside a remodelled service with improved accessibility.
East Sussex
Additional investment in urgent care is funding a street triage team in Hastings. Further investment
form acute commissioners will also enhance out of hours urgent response to mental health crisis
within the communities across East Sussex: recruitment is underway. This will bring improvements to
response rates across the whole system. This work falls within the 'Better Together' programme which
aims to support the whole system and has a particular focus on urgent care.
The team is currently developing a business case for enhancing management of long term conditions.
They hope to build on the learning from Brighton and Hove to provide a care pathway for people with
emotionally unstable personality disorder.
Brighton and Hove
Crisis Care Concordat declaration and action plan has been signed off at the Brighton & Hove Health
2
& Well Being Board. This includes an expectation to consider the principles of street triage within the
new mental health rapid response service alongside developments around the Lighthouse, Children's
Liaison Service and potential amendments to the hospital place of safety. We are aiming to launch the
new mental health rapid response service in February 2015 as recruitment allows. There is a plan to
work jointly with Children and Young People’s Services around urgent care pathway developments,
Section 136 and crisis care concordat action plan due to overlap in need.
Resilience funding has been used to fund two nurses in dementia services with a specific remit to
prevent admissions from care homes and for additional social work input into both adult and later life
wards at Mill View Hospital.
Two streams of Better Care activity: the frailty pathway and homelessness pathway are particularly
relevant to our services. We are attending planning meetings regarding the frailty pathway pilot sites.
There is an aspiration that the Mental Health Homeless Team will be co-located in a new 'homeless
service' hub and provide the expert mental health advice working closely with the voluntary sector and
physical health care.
5.
Recommendation
Board members are invited to note the contents of the report and ask any questions and offer any
suggestions for future themed reports.
3
Board of Directors: 28 January 2015 – Public
Agenda Item: TBP03.1/15
Attachment: F
For Information
By: Sally Flint, Executive Director of Finance & Performance
Trust Performance Report - December
SUMMARY & PURPOSE
The Trust Performance report provides a summary of Trust performance against an agreed
set of performance indicators related to Quality, People, Finance, and those set by Monitor
and CCG Commissioners.
The Trust Board is asked to:

Review the performance of the organisation as reported.
LINK TO ANNUAL PLAN
The Annual Plan areas this paper relates to –
1. Quality and Experience of patients
2. Finance Information and Performance
3. People
ACTION REQUIRED BY BOARD MEMBERS
The Trust Board is asked to:

Review the performance of the organisation as reported.
Trust Performance Report - November
1.0 Executive Summary
The Trust Performance report provides a summary of Trust performance against an
agreed set of performance indicators related to Quality, People, Finance, and those set by
Monitor and CCG Commissioners. The key issues to note in the month are as follows:







The Trust is focusing on avoiding patients being re-admitted back into acute wards
within 30 days of being discharged. A significant proportion of these readmissions are
patients with personality disorders, specifically in East Sussex and Coastal West
Sussex. A personality disorder pathway is being designed in East Sussex as part of the
Trusts Commissioning of Quality and Innovation scheme (CQUIN). Options for a
personality disorder pathway are also being considered in the Coastal West Sussex
area.
Teams in Hampshire Children and Adolescent services are developing a demand and
capacity plan and a trajectory towards achieving the waiting times targets by the end of
March 2015.
Monitor is carrying out a consultation regarding new proposed governance indicators
for Early Intervention services, for Access to Psychological Therapies, and new
standards for Medium Secure services. Feedback will be provided to the Board once
the review has taken place.
The Trust has not incurred any penalties in relation to contractual indicators in 2014/15.
An agreed action plan is in place in Brighton & Hove in relation to the 4 week waiting
time target. The Trust is working closely with Commissioners towards achieving the
agreed actions in this plan. Further detail of actions is provided in the report.
The Friends & Family test has been successfully introduced in the Trust. In December,
a positive response was received by 84% of respondents. 57% of respondents would
be extremely likely to recommend the service to friends and family.
The time to hire has been reduced significantly from 18 to 15.8 weeks over this
financial year through the streamlining of processes.
At the end of month 9, the Trust is reporting an in month operating deficit of £392K
increasing the year to date deficit to £2.7m. However after taking account of a technical
adjustment for depreciation, this reduces the year to date deficit to £1.6m.
A data quality dashboard is now in place, accessible through Susie (The Trust Intranet)
for all staff. Actions are being reviewed, through the Managing Directors performance
contract meetings in relation to data quality, including the capture of all clinical activity.
2.0 Introduction
The Trust Performance dashboards are attached to this paper. They are presented as
follows:1. A Trust wide performance dashboard covering Quality, Finance, and People
indicators that are appropriate to report for the Trust as a whole.
2. An Adult Services performance dashboard covering the performance of the Adult
Services directorate.
3. A Specialist Services performance dashboard covering the performance of the
Specialist Services Directorate. This includes Child and Adolescent Mental Health
Services, Secure & Forensic Services, Learning Disabilities, Substance Misuse
Services, Prison Services and Intermediate Care Services.
3.0 Report
3.1 MONITOR INDICATORS
3.1.1 The Trust has achieved the following indicators at the end of Q3: 7 day followups, Delayed Transfers of Care, Early Intervention new cases of psychosis,
Gate-keeping of Inpatient Admissions, Access to Healthcare for people with a
Learning Disability, Mental Health Minimum Dataset (completeness),
Mental Health Minimum Dataset (Outcomes) and Patients on CPA having had
a Formal Review within the last 12 months.
3.2 TRUST WIDE PERFORMANCE DASHBOARD
3.2.1
Patient Experience, Friends & Family test: Patient experience is now being
reported through the Friends and Family Test. This is a nationally mandated
patient experience survey which the Trust has been required to implement in all
services by 1st January 2015. It asks patients and their carers to rate whether
they would recommend the service received to friends and family in similar
circumstances. The survey asks for a rating on the scale from extremely likely to
extremely unlikely and asks for a reason for the rating. Team leads and service
managers will receive a summary of their feedback on a weekly basis.
In December a positive response was received by 84% of respondents. 57%
of respondents would be extremely likely to recommend the service to friends
and family.
3.2.3 Patient Experience, Complaints: 86% of complaints were responded to within
25 days or the agreed timeframe. 58 new complaints were received in
December. Complaints took an average of 28 days to resolve. This is the 5th
consecutive month that the complaints service has achieved the agreed service
response times. Work is now focused on improving the quality of our responses
and ensuring that the new Duty of Candour is consistently met. The board will
receive today, the first of a new monthly report on Patient Experience. Details
about the theme of complaints and examples of practice changes as a direct
result of feedback are included in the report.
3.2.4 People, Time to Hire: The average time to hire in the Trust was 15.8 weeks in
December against a previously agreed target of 17.4 weeks.
3.2.5 People, Sickness Absence: The sickness absence rate for November 2014
was 4.4%, which compares to 4.3% for the same month in the prior year.
There was a significant increase in the number of WTE days lost due to ’cold,
cough, flu,’ from 707.5 days in October to 880.9 days in November.
Detailed action plans are reviewed routinely at all management meetings and
individual case monitoring takes place between HR Business Managers and
appropriate Operational Managers. Detailed reports are available for all
managers to support improvements required.
3.2.6 People, Agency Spend: Total agency spend in December is 4.0% of the total
month's pay bill compared to 3.5% in the previous month. All areas of
agency spend are reviewed in detail at monthly performance meetings. The
key three areas are Child and Adolescent services in Kent, Langley Green
Hospital and Dementia wards
3.2.7 People, Appraisals: The target for the completion of appraisals by the end of
Q2 is 95%. Monthly surveys of staff have run since June 2014. The year-todate figure for the completion of appraisals, based on these surveys, is 90%.
Teams are now required to report on appraisals in the monthly performance
meetings. Additionally, individual teams are being followed up to confirm
completion of appraisals and for the reasons behind any non-completions.
3.2.8 Data Quality: The Trust has achieved the Monitor data quality indicators
relating to the completeness of key fields and the completeness of information
relating to key outcome measures. A data quality lead is in place as part of
the Clinical Information Systems programme and is developing action plans for
each area to improve data quality. The data quality dashboard, available over
the intranet, has led to improvements in data quality over the past few
months, see table below.
Item
NHS Number
GP Practise
Postcode
Inactive
Referrals on
systems
Target
98.5%
98.5%
98.5%
0
2nd July
93.2%
95.5%
98.3%
38.2%
26th November
99.7%
99.8%
100%
18.6%
3.2.9 Finance, Financial performance: At the end of month 9 the Trust is reporting
an in month surplus of £733k. The surplus was achieved through a £1,125k
backdated depreciation adjustment. The underlying position in the month was
a deficit of £392k. The year to date position is a deficit of £1,585k, against a
surplus plan of £600k. The year to date deficit has meant that the Trust’s
Continuity of Services Risk Rating remains at 3, against a planned rating of 4.
The areas of concern contributing to the financial position continue to be those
that challenged the Trust throughout last year. The main issues are expenditure
on agency staff, the pressure on adult inpatient services, and delivery of cost
improvement plans, which are all contributing to significant overspending
particularly across the adult service divisions.
The Trust is still aiming to achieve a break even financial position by the end
of the financial year, although achievement of this plan is dependent on
achievement of all key dependencies as described in the finance paper.
3.2.10 Finance, Cost Improvement Plan (CIP): The year to date savings at the end of
December (Month 9) was £6,327k against a plan of £8,460k.
3.3 SPECIALIST SERVICES PERFORMANCE DASHBOARD
3.3.1 Safety, Serious Incidents: 2 Serious incidents (SIs) were reported in
Specialist Services in December. There were no grade 2 Serious Incidents
(Grade 2 is the most serious category) in the month
3.3.2 Effectiveness, Urgent Referrals: 100% of urgent referrals were seen within the
required contractual timeframe in Sussex, Hampshire and Kent & Medway in
November.
3.3.3 Waiting times to assessment, Sussex: 98% of patients in CAMHS and
Learning Disability services were assessed within 4 weeks in Sussex. The
average waiting time for assessment was 28 days.
3.3.4 Waiting times to assessment, Hampshire: In month assessment
appointments continue within 12 weeks of referral with 88% of referrals seen
within 12 weeks, 77% being seen within 8 weeks and 44% in 4 weeks.
.
The team in Hampshire have produced a trajectory for meeting the waiting
times targets.
3.3.5 Waiting times to assessment, Kent & Medway: The service has progressed
as planned and achieved the business continuity plan targets that were agreed
with Commissioners in January 2014. Commissioners have agreed to lift the
special measures put in place following the Health Overview Scrutiny
Committee in January 2014.
A key outcome of the continuity plan is improved waiting times for children and
adolescents in this area. The number of children and adolescents waiting for
an assessment at the end of December was 590, which is an increase of 60
since the end of November. This is in the context of the service receiving
significantly more referrals than planned from February to December 2014.
The service received 975 referrals in the month.
3.3.6 Average Length of stay: The dashboard graph descry`ibes the average length
of stay of patients on discharge from Chalkhill, the Trust CAMHS inpatient unit
based on the Princess Royal Acute Hospital site in Haywards Heath. The
average length of stay was 95 days on discharge in the last quarter ending
December 2014 compared to 65 days in 2014-15 overall. The service expects
that the average length of stay will vary on a month by month basis depending
on the patient diagnosis. Patients with Eating Disorders, for example, generally
have a longer stay.
3.3.7 Effectiveness Prison Transfer: Access to Mental Health Services for adult
patients – transfer times from prison: Transfer times from prison to the
mental health bed for individuals under section 7/48 of the Mental Health Act
should be no more than 14 days from the date that the transfer warrant was
issued by the Ministry of Justice (MOJ). 2 prisoners were transferred in
December, both within the required timeframe.
3.3.8 Patient Experience – Long Term Service Users, Sussex CAMHS: The Trust
offers rapid re-assessments to patients who have received services from the
Trust within the last two years. In December all 38 patients referred for
reassessment were assessed within the target of 7 days.
3.4 ADULT SERVICES PERFORMANCE DASHBOARD
3.4.1 Safety, Serious Incidents: 8 Serious Incident (SI) were reported during
December in Adult Services, of which 2 were Grade 2 (Grade 2 is the most
serious category).
3.4.2 Effectiveness, Gatekeeping of Admissions: In December there were 189
admissions to Trust psychiatric acute inpatient services. 100% of these
admissions were gate-kept by the Crisis & Home Treatment teams prior to
admission. In gatekeeping patients, these teams look to provide home
treatment whenever possible to avoid unnecessary acute admissions.
3.4.3 Effectiveness, 4 hour response to urgent referrals: 100% of urgent
referrals meeting the required definition were responded to within 4 hours in
December.
o Following a review of the referral routes in West Sussex last year, referrals
are now received as Urgent (to be responded to in 4 hours), Priority (to be
responded to in 5 days and routine (to be responded to in 4 weeks). The
services are working closely with GPs and GP leads to ensure that referrals
are made to the most appropriate route to ensure the best outcome for the
patients. This service has received good feedback from GPs.
3.4.4 Effectiveness, 4 weeks waiting time to assessment: In Sussex Adult
Services, 98% of referrals received were assessed within 4 weeks during
December. In the month, 1,138 assessments were carried out. The average
waiting time for assessment was 14 days. The target was met in all CCG area
apart from Brighton & Hove.
o In Brighton and Hove, 92% of assessments that were carried out occurred
within 4 weeks of referral. The current action plan was reviewed with
Commissioners in December. Actions include:


Using appointment text reminders to reduce wasted appointment
slots in patients who do not attend
Data quality and use of predictive system information to monitor
potential waiting times breaches
Re-launching communication to GPs regarding the use of the 5 day
priority gateway.
3.4.5 Effectiveness, Liaison services response rates: Sussex Partnership provides
Mental Health Psychiatric Liaison services in Acute Hospitals across Sussex.
The Trust plans to respond within 2 hours to emergency referrals, these could
come from A&E wards, A&E linked wards or general wards. Urgent referral
response times vary depending upon the ward, for A&E Linked this must be
within 24 hours, and 48 hours for General Wards. All services were on target in
December.
3.4.6 Effectiveness, Readmissions within 28 days: This report shows that 13.7% of
working age adult and 6.9% of adults older than 65 were re-admitted to acute
wards within 65 days in this financial year. A clinical audit was carried out in
East Sussex which highlighted that a large proportion of readmissions were
unplanned readmissions for patients with a diagnosis of personality disorder. To
address this, a personality disorder pathway is being designed as part of the
Trusts CQUIN (Commissioning for quality and innovation) scheme this year. The
pathway is planned to go live in April 2015 and is expected to impact positively
on services for patients with this diagnosis.
Coastal West Sussex is the other CCG area where a proportion of readmissions
have been experienced from patients with a personality disorder. The services
are considering options for a personality disorder pathway in this area.
3.4.7 Effectiveness, Length of stay. The average length of stay for adult 18-65
patients was 31 days, and for adults older than 65 it was 50 days in Q3 2014/15.
An increased length of stay is one of the key factors that impacts on the demand
for psychiatric inpatient beds in Sussex. An acute dashboard is produced
weekly for all wards that provide details of lengths of stays for patients’
admission, discharges and trends.
3.4.8 Patient Experience, Delayed Transfers of Care: 4.4% of applicable adult
bed days and 4.6% of applicable beds days Trust wide were delayed in
December. 22 patients were delayed in adult services. Details of patients who
have a delayed transfer of care are being shared with Trust Commissioners to
ensure any blockages are resolved in a timely manner.
3.4.9 Rapid Reassessment of long term service users: The Trust offers rapid reassessments to patients who have received services from the Trust within the
last two years. 96% of the assessments carried out in December happened
within 7 days. (There were 133 people who met the criteria in the month). Of
the 3 patients who were not seen in 7 days in Brighton & Hove, 2 patients were
allocated to the 4 week routine pathway as they did not clinically need to be
seen in 7 days. This practice has been agreed with the lead GP.
3.4.10 Payment By Results (PbR) Reassessments: The Trust is preparing for the
introduction of Payment by Results for Mental Health. The Trust is working
towards an internal target of 95% of patients having their needs reassessed
according to the cluster specific timeframes by the end of the financial year. At
the end of December 80% of adult patients had received a PbR reassessment
within the required timeframe.
An internal governance group, “The Outcomes Assurance Group” is being
launched in January to focus on Payment By Results and Clinical outcomes.
4.0 Recommendation/Action Required
The Trust Board is asked to:

Review the performance of the organisation as reported.
5.0 Next Steps
The performance of the organisation is reviewed each month in Adult and Specialist
Services performance contact meetings, which review key areas of Finance, Performance,
quality and people issues.
Performance
Dashboard
December 2014
Sussex Partnership
NHS Foundation Trust
December 2014
Trust Dashboard
Page
SAFETY
Serious Incidents - Reporting on and demonstrating learning No Target
1
PATIENT EXPERIENCE
Reporting patient experience feedback - Friends and Family Test No Target
2
Complaints resolved within 25 working days - target 85% CONTRACTUAL TARGET
3
PEOPLE
Time to Hire - Trust-wide 17.6 weeks or less TRUST-ONLY TARGET
4
Sickness absence - 3.5% or less TRUST-ONLY TARGET
4
Agency spend - maintain spend at less than 1% of pay bill TRUST-ONLY TARGET
4
Appraisals (85% by the end of Q1 and 100% by end of Q2) TRUST-ONLY TARGET
4
DATA QUALITY
MHMDS Data Completeness Identifiers - target 97% MONITOR TARGET
5
MHMDS Data Completeness Outcomes - target 50% MONITOR TARGET
5
FINANCE
Financial Risk Ratings (3 or above) MONITOR TARGET
6
Achievement of Cost Improvement Plan TRUST-ONLY TARGET
6
Income and Expenditure Account (£2.5m surplus by year end) TRUST-ONLY TARGET
6
December 2014
2
Index
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Safety
Serious Incidents
24
TRUST-WIDE (Local indicator)
20
Month: December 2014
16
All Serious Incidents
Month
YTD
12
Sussex (Adult & Specialist)
9
124
8
Hampshire (Specialist)
0
0
4
Kent (Specialist)
1
9
0
Corporate
0
1
TRUST
10
134
2
15
Jan-14
Feb-14
Mar-14
Apr-14
May-14
All Serious Incidents
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Grade 2 incidents only
Dec‐13
Jan‐14
Sis
16
23
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
23
14
13
13
15
Jul‐14
19
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
17
19
16
12
10
GRADE 2
2
1
1
0
0
1
0
2
3
4
1
2
2
Performance by CCG - December 2014
Adult
Specialist
Grade 2
Coastal W Sussex
1
0
0
Crawley
0
0
0
Horsham & Mid Sx
0
0
0
Brighton & Hove
5
1
2
Eastbourne
0
0
0
High Weald
2
0
0
Hastings & Rother
0
0
0
S-E Hampshire
0
0
0
December 2014
1
Trust-wide Performance
Safety
Grade 2 incidents only
Dec-13
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Patient Experience
Patient Experience Feedback
100%
Trust-wide (Local indicator)
80%
60%
Month
Quarter
YTD
262
567
676
% Positive
84%
84%
84%
% Extremely Likely
57%
55%
53%
% Negative
5%
7%
7%
% Extremely Unlikely
3%
3%
3%
Friends & Family Test
Figures reported from September 2014 onwards
Resolving Complaints
40%
20%
0%
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
% Positive Feedback
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
TRUST
84.0%
84.0%
80.0%
82.0%
86.0%
91.0%
80.0%
81.5%
81.5%
78.9%
86.4%
83.4%
84.0%
TARGET
80.0%
80.0%
80.0%
80.0%
80.0%
80.0%
80.0%
80.0%
80.0%
80.0%
80.0%
80.0%
80.0%
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Patient Experience
Month: December 2014
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
100%
(Local indicator)
80%
Month: December 2014
Target: 85%
60%
Resolved within 25 working days or agreed timeframe
Complaints resolved this month
58
Resolved within the agreed timeframe
50
% resolved within agreed timeframe
86%
Average number of days to resolution
27.8
Number of complaints received
78
Performance by CCG - December 2014
SUSSEX
40%
20%
0%
Dec-13
Jan-14
Feb-14
TRUST - responded to within timeframe
Dec-14
Target
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
TRUST
69.8%
80.9%
66.7%
55.6%
66.7%
75.0%
75.0%
71.6%
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
88.2%
85.4%
90.0%
96.1%
90.0%
TARGET
85.0%
85.0%
85.0%
85.0%
85.0%
85.0%
85.0%
85.0%
85.0%
85.0%
85.0%
85.0%
85.0%
Performance by CCG - December 2014
Resolved
Ave Days
Coastal W Sussex
11
100%
19.0
Crawley
4
100%
Horsham & Mid Sx
6
Brighton & Hove
HAMPSHIRE
Complaints
Resolved
Ave Days
Fareham
1
100%
10.0
18.8
North Hampshire
1
100%
55.0
100%
34.2
N E Hampshire
2
100%
14.5
10
60%
38.5
S E Hampshire
0
100%
Eastbourne
5
80%
23.6
West Hampshire
2
100%
High Weald
4
50%
37.3
Hastings & Rother
5
100%
22.6
S-E Hampshire
0
100%
0.0
25.5
Performance by CCG - December 2014
KENT
Complaints
Resolved
Ave Days
Ashford
0
100%
0.0
Canterbury
0
100%
Dartford
0
100%
0.0
Medway
1
100%
11.0
South Kent Coast
0
100%
0.0
Swale
0
100%
Thanet
1
100%
24.0
West Kent
1
0%
46.0
December 2014
2
Trust-wide Performance
Patient Experience
Complaints
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - People
Time to Hire
28
TRUST-WIDE (Local indicator)
24
Month: December 2014
Target: <=17.4 weeks
20
16
Month
2014-5
Time to Hire - TRUST (weeks)
15.8
15.4
Time to Hire - Adult Services
14.9
4
Time to Hire - Specialist Services
15.0
0
People
12
8
Dec-13
The average time to hire was 25.6 weeks in 2013.
The 2014-5 figure is the average for the year-to-date
since April 2014.
Sickness Absence
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Time to Hire - TRUST
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Target
Dec‐13
Jan‐14
TRUST
0.0
18.0
18.6
16.8
16.8
13.6
14.8
Jul‐14
16.7
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
16.5
14.5
14.5
15.0
15.8
TARGET
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
4.8%
4.6%
TRUST-WIDE (Local indicator)
Month: November 2014
Weeks
4.4%
Target: <=3.5%
Year
2014-15 absence rate
4.39%
3.81%
2013-14 absence rate
4.33%
4.14%
Reported one month in arrears. The 2013-14 year figure
is for the whole 12 month period.
4.0%
3.8%
People
Month
4.2%
3.6%
3.4%
3.2%
3.0%
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Trust Absence rate
Absence rate (previous 12 months)
Target
Nov‐13
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
TRUST
4.33%
4.10%
4.17%
4.14%
3.93%
3.89%
3.74%
3.41%
3.62%
3.38%
3.97%
4.10%
4.39%
TARGET
3.50%
3.50%
3.50%
3.50%
3.50%
3.50%
3.50%
3.50%
3.50%
3.50%
3.50%
3.50%
3.50%
Jul-14
Aug-14
Agency Spend
8%
TRUST-WIDE (Local indicator)
7%
Aug‐14 Sep‐14 Oct‐14 Nov‐14
6%
Month: December 2014
Target: 1%
YTD
Agency Spend (2014-15)
4.01%
4.45%
Agency Spend (2013-14)
4.01%
4.40%
Agency spend as a proportion of the total pay bill. Target
is to maintain this below 1%.
Last year's YTD figure is for the whole year (2013-14).
Appraisals
3%
2%
1%
0%
Apr-14
May-14
Jun-14
Sep-14
% Agency spend (Current Year)
Oct-14
Nov-14
Dec-14
Jan-15
% Agency spend (Last Year)
Feb-15
Mar-15
Target
Apr‐14 May‐14 Jun‐14
Jul‐14
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
Jan‐15
Feb‐15 Mar‐15
Current Year
5.08%
5.08%
5.69%
4.58%
3.79%
3.89%
4.55%
3.50%
4.01%
0.00%
0.00%
0.00%
Last Year
3.45%
4.29%
3.52%
4.88%
4.33%
4.09%
4.32%
3.80%
4.01%
4.21%
5.09%
6.81%
Jun-14
Jul-14
Feb-15
Mar-15
100%
TRUST-WIDE (Local indicator)
Month: December 2014
4%
People
Month
5%
80%
Target: 95% by end of Q2
60%
100% by end of Q3
Appraisals completed
90%
People
40%
20%
0%
Apr-14
Appraisals not yet booked to
take place before end of Q3
December 2014
May-14
Aug-14
Sep-14
Oct-14
Appraisals completed
7%
Apr‐14 May‐14 Jun‐14
Jul‐14
Nov-14
Dec-14
Jan-15
Target
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
Jan‐15
Feb‐15 Mar‐15
Completed
0%
62%
68%
81%
86%
87%
90%
90%
90%
0%
0%
0%
Target
85%
85%
85%
88%
92%
95%
100%
100%
100%
100%
100%
100%
3
Trust-wide Performance
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Data Quality
Data Completeness Identifiers
100%
TRUST-WIDE (MONITOR indicator)
100.0%
99.6%
100.0%
99.8%
99.8%
99.7%
99.2%
98%
Month: December 2014
Month
Quarter
YTD
Commissioner Code
99.6%
99.6%
99.7%
Date of Birth
100.0%
100.0%
100.0%
Gender
100.0%
100.0%
100.0%
GP Code
99.8%
99.9%
99.9%
NHS Number
99.8%
99.0%
98.6%
Postcode
99.2%
99.2%
98.8%
TOTAL
99.7%
99.6%
99.5%
Data Completeness Outcomes
92%
Commissioner
Code
Date of Birth
Gender
GP Code
% valid
NHS Number
Postcode
TOTAL
Target
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
TRUST
99.2%
99.2%
99.2%
99.2%
99.2%
99.3%
99.3%
99.5%
99.7%
99.7%
99.7%
99.4%
99.7%
TARGET
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
87.9%
87.7%
Accommodation
Employment
80%
Month: December 2014
Target: 50%
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
Quarter
YTD
Accommodation
87.9%
88.2%
88.4%
Employment
87.7%
88.1%
88.5%
HoNOS
89.3%
89.8%
92.7%
TOTAL
88.3%
88.7%
90.0%
89.3%
88.3%
HoNOS
TOTAL
60%
Data Quality
Month
December 2014
94%
100%
TRUST-WIDE (MONITOR indicator)
MHMDS Outcome
96%
Data Quality
MHMDS Identifier
Target: 97%
40%
20%
0%
% valid
Target
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
TRUST
92.3%
92.3%
92.2%
89.9%
90.3%
89.7%
90.7%
91.7%
90.5%
90.3%
89.4%
88.5%
88.3%
TARGET
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
4
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
Trust-wide Performance
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Finance
Financial Risk Rating
A
Continuity of Service Risk Ratings
Year to Date
Dec-14
Plan
2014/15
6.2
13.2
-4.8
-6.5
Capital Service Cover Metric
1.3
2.0
Capital Service Cover Rating
2
3
14.8
24.9
-169.1
-218.8
Liquidity Metric
7.9
41.0
Liquidity Rating
4
4
Continuity of Service Risk Rating
3
4
Revenue A vailable for Capital
Service
Capital Service
Cash for CoS Liquidity Purposes
Operating Expenses within
EBITDA , Total
Cost Improvement Plans
December has resulted in a continuity of service risk rating of 3,
due to the large year to date deficit, which is being countered by
the strong liquidity position.
R
The year-to-date savings amounted to £6,237K against a target of
£8,460K.
Total Savings 2014-15
14,000
12,000
£000
10,000
CIP
8,000
Savings Achieved year to date
6,000
4,000
Savings Achieved 2013-14
2,000
1
2
3
4
5
6
7
Month
8
9
10
11
12
Income and Expenditure Account
Income and Expenditure Account
ANNUAL
BUDGET
R
In Month - Dec-14
£000's
Budget
£000's
Actual
£000's
(233,911)
(20,859)
(20,597)
Year to Date - Dec-14
Variance
£000's
Budget
£000's
Actual
£000's
Variance
£000's
Revenue from Activities
Total operating Revenue
262
(175,978)
(175,180)
798
Operating Expenses
Total Pay Costs
Total Non Pay Costs
Total Operating Costs
Reserves
182,925
16,390
16,589
200
138,253
140,064
1,811
38,556
3,408
3,686
277
28,734
31,106
2,371
221,481
19,798
20,275
477
166,988
171,170
4,182
(300)
(300)
(2,100)
(2,100)
EBITDA
(12,430)
0
(1,061)
(622)
439
(8,991)
(6,111)
2,880
Retained Surplus For the Year
(1,200)
(133)
(733)
(600)
(600)
1,586
2,185
(880)
(129)
129
(494)
(390)
104
(2,080)
(261)
Non Trading (Gains)/Losses
Retained Surplus For the Year
December 2014
0
0
(733)
(471)
5
0
(1,094)
1,196
December has resulted in a surplus of £733K, against a £133K
surplus target.
The main in month issues relate
to the shortfall of cost improvement targets within pay and nonpay, overspending inpatient
wards, and high agency usage.
This has been off set by savings
on depreciation due to an asset
life review. However, the year-to
-date figure continues to remain
in deficit.
2,290
Trust-wide Performance
Sussex Partnership
NHS Foundation Trust
Sussex CCG Map
© Graham Ainsworth - Sussex HIS - December 2012
Population
(2013-14)
Number of
GP Practices
Coastal West Sussex CCG
492,515
55
Crawley CCG
127,372
13
Horsham & Mid Sussex CCG
228,231
23
Brighton & Hove CCG
300,900
46
Eastbourne, Hailsham & Seaford CCG
186,798
22
High Weald, Lewes, Havens CCG
166,464
27
Hastings & Rother CCG
183,178
33
South Eastern Hampshire CCG
209,845
26
CCG
December 2014
6
Trust-wide Performance
Adult Services
Dashboard
December 2014
Sussex Partnership
NHS Foundation Trust
December 2014
Adult Services Dashboard
Page
SAFETY
Serious Incidents - Reporting on and demonstrating learning No Target
1
7 Day Follow-up - Acute inpatient discharges followed up <7 Days - 95% threshold MONITOR TARGET
1
EFFECTIVENESS
Crisis team gate-keeping - Avoiding unnecessary admissions - 95% threshold MONITOR TARGET
2
Emergency referrals responded to in 4 hours - target 95% CONTRACTUAL TARGET
2
Routine assessments within 4 weeks of referral - target 95% CONTRACTUAL TARGET
3
Liaison Services reponse times - target 95% (emergency & urgent referrals) CONTRACTUAL TARGET
3
Readmissions within 28 days No Target
4
Length of Stay No Target
4
PATIENT EXPERIENCE
Delayed Transfers of Care - Timely discharge of patients - less than 7.5% MONITOR TARGET
5
Long term service users reassessed in 7 days - 95% threshold CONTRACTUAL TARGET
5
Care Programme Approach reviews (at least every 12 months) - target 95% MONITOR TARGET
6
PbR - Reassessment frequency in accordance with patient needs TRUST-ONLY TARGET
6
Complaints resolved within 25 working days - target 85% CONTRACTUAL TARGET
7
PEOPLE
Time to Hire - Trust-wide 17.6 weeks or less TRUST-ONLY TARGET
8
Sickness absence - 3.5% or less TRUST-ONLY TARGET
8
Agency spend - maintain spend at less than 1% of pay bill TRUST-ONLY TARGET
8
Appraisals (85% by the end of Q1 and 100% by end of Q2) TRUST-ONLY TARGET
8
ACTIVITY & DATA QUALITY
External Referrals No Target
9
MHMDS Data Completeness Identifiers - target 97% MONITOR TARGET
9
MHMDS Data Completeness Outcomes - target 50% MONITOR TARGET
9
GOVERNANCE
MONITOR Governance Risk Rating MONITOR TARGET
December 2014
2
Index
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Safety
Serious Incidents
24
Adult Services (Local indicator)
20
Month: December 2014
16
All Serious Incidents
Month
YTD
12
8
89
8
West Sussex
1
45
East Sussex
2
26
Brighton & Hove
5
18
SUSSEX
8
89
2
11
Adult Services
0
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
All Serious Incidents - Adult
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Grade 2 incidents only - Adult
Dec‐13
Jan‐14
ADULT
10
17
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
14
9
10
7
10
Jul‐14
11
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
13
12
13
5
8
GRADE 2
1
1
1
0
0
1
0
1
2
3
0
2
2
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Performance by CCG - December 2014
Month
YTD
Coastal W Sussex
1
18
Crawley
0
13
Horsham & Mid Sx
0
14
Brighton & Hove
5
18
Eastbourne
0
5
High Weald
2
8
Hastings & Rother
0
13
S-E Hampshire
0
0
7 Day Follow-up
Safety
Grade 2 incidents only
4
100%
Adult Services (MONITOR Indicator)
Month: December 2014
Target: 95%
Month
Quarter
YTD
Discharged
262
776
2,383
Followed-up
257
764
2,316
% Followed-up
98%
98%
97%
95%
90%
85%
80%
% followed-up
Performance by CCG - December 2014
Discharged
Dec-14
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
TRUST
97.2%
95.1%
95.6%
97.1%
94.7%
96.5%
95.7%
97.7%
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
97.4%
97.6%
98.2%
99.2%
97.3%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
100%
Followed-up % follow-up
Coastal W Sussex
63
62
98%
Crawley
7
7
100%
Horsham & Mid Sx
21
20
95%
Brighton & Hove
59
58
98%
Eastbourne
53
52
98%
High Weald
21
21
100%
Hastings & Rother
34
33
97%
S-E Hampshire
1
1
100%
December 2014
Nov-14
90%
80%
70%
60%
50%
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
% followed-up
1
Hastings &
Rother CCG
South-East
Hants CCG
Target
Adult Services
TRUST
Safety
All adults aged over 18 discharged from Adult Mental
Health inpatient units
Oct-14
Target
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Effectiveness
Gate-keeping of Admissions
100%
Adult Services (MONITOR Indicator)
Month: December 2014
Target: 95%
Month
Quarter
YTD
No. of Admissions
189
566
1,743
No. Gate-kept
189
564
1,740
% Gate-kept
100%
100%
100%
95%
90%
85%
80%
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
% gatekept
Dec‐13
Performance by CCG - December 2014
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jul‐14
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
TRUST
100.0% 100.0% 100.0%
99.5%
100.0% 100.0%
99.5%
100.0% 100.0% 100.0% 100.0%
98.9%
100.0%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
100%
Admissions
Gate-kept
% gate-kept
Coastal W Sussex
45
45
100%
Crawley
12
12
100%
Horsham & Mid Sx
12
12
100%
Brighton & Hove
42
42
100%
Eastbourne
33
33
100%
High Weald
10
10
100%
Hastings & Rother
28
28
100%
S-E Hampshire
0
0
100%
4 hour response to urgent referrals
Effectiveness
AMHS patients under 65
Jul-14
Target
95%
90%
85%
80%
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
% gatekept
Hastings &
Rother CCG
South-East
Hants CCG
TRUST
Target
100%
Adult Services (Local indicator)
Month: December 2014
Target: 95%
Month
YTD
Urgent GP referrals received
142
1,527
Referrals meeting definition
65
589
% response under 4 hours
100%
100%
Performance by CCG - December 2014
90%
85%
80%
Dec-13
Jan-14
Mar-14
Apr-14
May-14
Jun-14
% response <4 hours
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Target
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
ADULT
100.0%
99.0%
100.0%
97.2%
99.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
Jul‐14
95.0%
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
95.0%
95.0%
95.0%
95.0%
95.0%
100%
GP Referrals
Definition
% <4 hours
Coastal W Sussex
37
12
100%
Crawley
24
7
100%
Horsham & Mid Sx
29
10
100%
Eastbourne
18
17
100%
High Weald
12
11
100%
Hastings & Rother
22
8
100%
S-E Hampshire
0
0
100%
80%
60%
40%
20%
0%
Coastal West
Sussex CCG
Brighton & Hove CCG is covered by the BURS service
December 2014
Feb-14
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Lewes,
Hailsham &
Seaford CCG Havens CCG
% response <4 hours
2
Hastings &
Rother CCG
South-East
Hants CCG
Target
Adult Services
TRUST
Effectiveness
Urgent GP referrals presenting an immediate risk either to
the patient or others require an immediate response and
meet the "4 hour response" definition.
95%
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Effectiveness
4 week waiting time to assessment
100%
Adult Services (Local indicator)
95%
Month: December 2014
Target: 95%
Month
YTD
Number of Assessments
1,138
10,075
% assessments <4 Weeks
98%
96%
Average Wait Days
13.6
13.7
90%
85%
80%
75%
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
Indicator covers AMHS (inc Dementia)
Performance by CCG - December 2014
<4 weeks
Wait Days
383
99%
12.8
92
97%
17.6
Horsham & Mid Sx
173
99%
12.2
Brighton & Hove
126
92%
14.4
Eastbourne
114
99%
15.9
High Weald
115
100%
12.2
Hastings & Rother
135
96%
13.4
1
100%
3.0
S-E Hampshire
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Target
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
ADULT
96.3%
97.1%
97.1%
97.8%
96.1%
95.0%
95.3%
96.3%
96.8%
97.3%
96.6%
96.8%
97.7%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
100%
Assessments
Crawley
Jun-14
Liaison Services response times
90%
Effectiveness
Average Wait Days = average wait time from receipt of
referral to assessment.
Coastal W Sussex
May-14
% assessments <4 weeks
80%
70%
60%
50%
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
% assessments <4 weeks
Hastings &
Rother CCG
South-East
Hants CCG
TRUST
Target
100%
100%
Adult Services (Local indicator)
Month: December 2014
95%
95%
90%
90%
85%
85%
Target: 95%
Month
YTD
Emergency referrals
307
3,098
% responded to within target
95%
97%
80%
80%
Dec-13
Urgent referrals
2,125
100%
100%
Performance by Locality - December 2014
Referrals
Urgent
Response
West Sussex
69
54
98%
East Sussex
177
63
95%
61
116
100%
West Sussex Acute
Hospitals
St Richards Hospital
The Princess Royal Hospital
Worthing District General Hospital
East Sussex Acute
Hospitals
Eastbourne District General Hospital
The Conquest Hospital
Brighton Acute Hospital
The Royal Sussex County Hospital
December 2014
Mar-14
Apr-14
May-14
Jun-14
Emergency Referrals
Dec‐13
Jan‐14
Emerg.
98.5%
98.2%
99.3%
98.8%
97.8%
99.4%
Urgent
100.0%
99.3%
100.0%
99.6%
99.6%
100.0%
Jul-14
Aug-14
Urgent Referrals
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Sep-14
Oct-14
Nov-14
Dec-14
Target
Jul‐14
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
96.7%
97.1%
97.8%
96.7%
98.6%
97.7%
98.6%
98.8%
100.0% 100.0%
99.6%
99.6%
100.0%
99.6%
100%
Emergency
Brighton & Hove
Feb-14
95%
90%
85%
80%
West Sussex
East Sussex
Emergency Referrals
3
Brighton & Hove
Urgent Referrals
TRUST
Target
Adult Services
Performance
% responded to within target
233
Jan-14
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Effectiveness
Readmissions within 28 days
25%
Adult Services (local indicator)
20%
Month: December 2014
15%
YTD
219
2,103
12.3%
13.7%
70
608
7.1%
6.9%
289
2,711
AMHS <65 Patients Discharged
% AMHS <65 Readmitted
AMHS 65+ Patients Discharged
% AMHS 65+ Readmitted
All AMHS Patients Discharged
% all AMHS Readmitted
11.1%
12.2%
AMHS <65 AMHS 65+
14.3%
9.7%
18.2%
0.0%
18.2%
0.0%
0.0%
0.0%
Brighton & Hove
10.2%
7.7%
9.7%
Eastbourne
16.7%
8.3%
14.6%
High Weald
21.4%
0.0%
17.6%
Hastings & Rother
20.0%
0.0%
13.5%
0.0%
0.0%
0.0%
Horsham & Mid Sx
S-E Hampshire
0%
Dec-13
Jan-14
Feb-14
Average Length of Stay
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
AMHS 65+ % Readmitted
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
<65
14.0%
13.2%
13.9%
18.1%
16.4%
13.7%
11.6%
13.4%
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
10.6%
14.8%
16.0%
13.7%
12.3%
65+
1.9%
3.1%
5.3%
3.8%
4.1%
6.3%
3.1%
2.9%
13.6%
11.8%
5.6%
7.9%
7.1%
15%
10%
5%
0%
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
Hastings &
Rother CCG
South-East
Hants CCG
TRUST
% AMHS Patients Readmitted
100
Adult Services (Local indicator)
80
Current Quarter: Quarter 3 (Oct - Dec)
60
Benchmark
Quarter
2014-15
Adult - 18 - 65
28
31.4
32.9
Adult - 65+ Functional
50
50.3
51.2
Adult - Organic
60
85.7
78.3
40
20
0
Q2 - 13/14
Performance by CCG - Quarter 3 (Oct - Dec)
18-65
65+ Functional
Coastal W Sussex
30.9
58.5
Crawley
38.1
87.0
Horsham & Mid Sx
36.7
50.3
Brighton & Hove
31.1
43.7
Eastbourne
30.2
34.8
High Weald
26.3
79.8
Hastings & Rother
29.5
41.8
S-E Hampshire
33.5
Q3 - 13/14
Q4 - 13/14
AMHS <65
Q1 - 14/15
AMHS 65+ Functional
Q2 - 14/15
Q3 - 14/15
AMHS 65+ Organic
Q2 ‐ 2013‐4
Q3 ‐ 2013‐4
Q4 ‐ 2013‐4
Q1 ‐ 2014‐5
Q2 ‐ 2014‐5
Q3 ‐ 2014‐5
AMHS <65
28.9
34.2
40.3
31.4
36.0
31.4
AMHS 65+ Func
58.8
52.6
59.3
53.8
49.4
50.3
100
80
60
40
20
0
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
AMHS <65
4
Eastbourne, High Weald,
Lewes,
Hailsham &
Seaford CCG Havens CCG
Hastings &
Rother CCG
South-East
Hants CCG
AMHS 65+ Functional
Adult Services
TRUST
Effectiveness
Length of Stay is measured in days for patients discharged
during last quarter.
December 2014
Mar-14
AMHS <65 % Readmitted
AMHS
7.8%
Crawley
5%
20%
Performance by CCG - December 2014
Coastal W Sussex
10%
Effectiveness
Month
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Patient Experience
Delayed Transfers of Care (DTC)
15%
Adult Services (MONITOR Indicator)
Month: December 2014
Target: <7.5%
Month
Quarter
YTD
% Delayed (Adult)
4.4%
4.7%
5.5%
% Delayed (TRUST)
4.6%
4.3%
4.9%
10%
5%
0%
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
% delays
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Target
Dec‐13
Jan‐14
ADULT
4.3%
3.8%
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
3.6%
3.3%
4.0%
5.6%
7.5%
Jul‐14
6.6%
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
5.6%
6.0%
5.3%
4.4%
4.4%
TARGET
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
7.5%
25%
Performance by CCG - December 2014
Month end patient delays
Dec-13
% delayed
Coastal W Sussex
4
4.1%
Crawley
1
4.4%
Horsham & Mid Sx
4
7.1%
Brighton & Hove
10
9.6%
Eastbourne
0
1.0%
High Weald
0
0.0%
Hastings & Rother
1
1.3%
S-E Hampshire
0
0.0%
Long Term Service Users Referrals
20%
Patient Experience
Non-acute adult patients aged 18 and over from AMHS
(inc Dementia). Reported to MONITOR quarterly. TRUST
figure (for MONITOR) includes numbers from LDS and
S&F.
15%
10%
5%
0%
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
% delays
Hastings &
Rother CCG
South-East
Hants CCG
TRUST
Target
100%
Adult Services (Local indicator)
Month: December 2014
Target: 95%
Month
YTD
LTSU Referrals
133
1,323
Seen within 7 days
128
1,218
% seen within 7 days
96%
92%
Performance by CCG - December 2014
85%
80%
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
% seen <7 days
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Target
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
ADULT
92.2%
93.1%
87.8%
86.2%
89.6%
88.6%
89.9%
93.0%
93.4%
92.3%
94.2%
92.4%
96.2%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
100%
Referrals
<7 days
% <7 days
Coastal W Sussex
40
40
100%
Crawley
13
12
92%
Horsham & Mid Sx
24
24
100%
Brighton & Hove
13
10
77%
Eastbourne
15
15
100%
High Weald, Lewes
11
11
100%
Hastings & Rother
17
16
94%
S-E Hampshire
0
0
100%
December 2014
90%
80%
60%
40%
20%
0%
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
% seen <7 days
5
Hastings &
Rother CCG
South-East
Hants CCG
Target
Adult Services
TRUST
Patient Experience
Patients referred back to AMHS within 2 years of their last
episode (at least 6 months or more). Some referrals may
be downgraded if clinically appropriate.
95%
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Patient Experience
CPA 12 month Formal Review
100%
Adult Services (MONITOR indicator)
98%
Current Quarter: Quarter 2 (Jul - Sep)
Target: 95%
96%
Quarter
YTD
Adults on CPA at end of quarter
2,691
2,706
94%
Last Review within 12 months
2,602
2,624
92%
% adults with review <12 months
96.7%
97.0%
90%
Q1 - 2013/4
Q3 - 2013/4
Q4 - 2013/4
Q1 - 2014/5
Q2 - 2014/5
Target
Q2 ‐ 2013‐4
Q3 ‐ 2013‐4
Q4 ‐ 2013‐4
Q1 ‐ 2014‐5
Q2 ‐ 2014‐5
TRUST
97.2%
97.4%
94.6%
95.1%
97.6%
Q3 ‐ 2014‐5
96.7%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
100%
Performance by CCG - Quarter 2 (Jul - Sep)
Patients
Vaild Review
% Valid
Coastal W Sussex
865
852
98%
Crawley
142
119
84%
Horsham & Mid Sx
311
306
98%
Brighton & Hove
678
633
93%
Eastbourne
316
316
100%
High Weald
124
124
100%
Hastings & Rother
228
227
100%
10
10
100%
Payment by Results (PbR)
95%
Patient Experience
% <12 month Review
This MONITOR indicator is currently reported quarterly. A
manual audit is completed at the end of the quarter.
S-E Hampshire
Q2 - 2013/4
90%
85%
80%
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
% <12 month Review
Hastings &
Rother CCG
South-East
Hants CCG
TRUST
Target
100%
Adult Services (Local indicator)
90%
Month: December 2014
Target: 95%
Under 65
65 & over
TOTAL
11,375
11,522
22,897
With a valid Cluster
8,116
10,251
18,367
% valid Cluster
71%
89%
80%
With a Cluster
Performance by CCG - December 2014
70%
60%
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
% valid cluster
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
TRUST
82.1%
83.5%
83.2%
85.8%
84.7%
83.9%
84.1%
84.1%
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
83.1%
83.1%
81.0%
81.1%
80.2%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
100%
Patients
+ valid Cluster
% valid Cluster
Coastal W Sussex
8,063
6,614
82%
Crawley
1,694
1,347
80%
Horsham & Mid Sx
3,329
2,666
80%
Brighton & Hove
3,127
2,188
70%
Eastbourne
2,642
2,196
83%
High Weald
1,794
1,497
83%
Hastings & Rother
2,248
1,859
83%
80%
60%
40%
20%
0%
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
% valid cluster
December 2014
Jul-14
Target
6
Hastings &
Rother CCG
South-East
Hants CCG
Target
Adult Services
TRUST
Patient Experience
Each cluster has a review period and the cluster is valid if
the patient's needs are reassessed before the end of the
respective review period and the patient is re-clustered.
80%
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Patient Experience
Resolving Complaints
100%
Adult Services (Local indicator)
80%
Month: December 2014
Target: 85%
60%
Resolved within 25 working days or agreed timeframe
Complaints resolved this month
34
Resolved within the agreed timeframe
31
91%
Average number of days to resolution
29.9
Total number of complaints received
53
Performance by CCG - December 2014
0%
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
TRUST - responded to within timeframe
TRUST
May-14
Jun-14
Jul-14
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
69.8%
80.9%
66.7%
55.6%
ADULT
Aug-14
Sep-14
Oct-14
Nov-14
Adult Services - responded to within timeframe
Dec-14
Target
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
66.7%
75.0%
75.0%
71.6%
88.2%
85.4%
90.0%
96.1%
90.0%
60.0%
74.2%
63.0%
65.9%
90.9%
90.0%
92.0%
93.8%
92.0%
100%
Complaints
Resolved
Ave Days
Coastal W Sussex
7
100%
18.4
Crawley
2
100%
14.0
Horsham & Mid Sx
5
100%
35.6
Brighton & Hove
9
67%
40.7
Eastbourne
4
100%
23.0
High Weald
2
100%
33.0
Hastings & Rother
3
100%
22.7
S-E Hampshire
0
100%
0.0
December 2014
20%
80%
60%
40%
20%
0%
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
% complaints responded to within timeframe
7
Hastings &
Rother CCG
South-East
Hants CCG
Target
Adult Services
TRUST
Patient Experience
% resolved within agreed timeframe
40%
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - People
Time to Hire
28
Adult Services (Local indicator)
24
Month: December 2014
Target: <=17.4 weeks
2014-5
Time to Hire - TRUST (weeks)
15.8
15.4
Time to Hire - Adult Services
14.9
16
Weeks
12
People
Month
20
8
4
The average time to hire was 25.6 weeks in 2013.
The 2014-5 figure is the average for the year-to-date
since April 2014.
Sickness Absence
0
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Time to Hire - TRUST
Jun-14
Jul-14
Aug-14
Sep-14
Time to Hire - Adult Services
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
Oct-14
Nov-14
Dec-14
Target
Dec‐13
Jan‐14
ADULT
0.0
0.0
0.0
0.0
0.0
9.5
10.7
0.0
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
15.7
15.7
15.0
16.5
14.9
TARGET
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
4.8%
4.6%
Adult Services (Local indicator)
4.4%
Month: November 2014
Target: <=3.5%
Year
Trust absence rate
4.39%
3.81%
Adult Services absence rate
4.26%
3.82%
4.0%
3.8%
People
Month
4.2%
3.6%
3.4%
3.2%
3.0%
Reported one month in arrears
Nov-13
Dec-13
Jan-14
Trust Absence rate
Adult Services Absence rate
Absence rate (previous 12 months)
Target
Nov‐13 Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
TRUST
4.33%
4.10%
4.17%
4.14%
3.93%
3.89%
3.74%
3.41%
3.62%
3.38%
3.97%
4.10%
4.39%
ADULT
0.00%
0.00%
0.00%
0.00%
4.33%
4.38%
3.99%
3.39%
3.26%
3.24%
3.95%
4.08%
4.26%
May-14
Jun-14
Jul-14
Agency Spend
8%
Adult Services (Local indicator)
7%
Aug‐14 Sep‐14 Oct‐14 Nov‐14
6%
Month: December 2014
5%
Month
YTD
4%
Agency Spend (2014-15)
4.81%
4.80%
3%
Agency Spend (2013-14)
3.95%
4.25%
Agency spend as a proportion of the total pay bill. Target
is to maintain this below 1%.
Last year's YTD figure is for the whole year (2013-14).
Appraisals
People
Target: 1%
2%
1%
0%
Apr-14
Aug-14
Sep-14
% Agency spend (Current Year)
Oct-14
Nov-14
Dec-14
Jan-15
% Agency spend (Last Year)
Feb-15
Mar-15
Target
Apr‐14 May‐14 Jun‐14
Jul‐14
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
Jan‐15
Feb‐15 Mar‐15
Current Year
5.53%
5.82%
6.28%
4.71%
3.97%
4.25%
4.50%
3.27%
4.81%
0.00%
0.00%
0.00%
Last Year
3.39%
4.17%
3.43%
4.66%
3.99%
4.00%
3.29%
4.04%
3.95%
3.80%
5.21%
7.17%
May-14
Jun-14
100%
TRUST-WIDE (Local indicator)
Month: December 2014
80%
Target: 95% by end of Q2
60%
100% by end of Q3
Appraisals completed
90%
People
40%
20%
0%
Apr-14
Appraisals not yet booked to
take place before end of Q3
December 2014
Jul-14
Aug-14
Sep-14
Oct-14
Appraisals completed
7%
Apr‐14 May‐14 Jun‐14
Jul‐14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Target
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
Jan‐15
Feb‐15 Mar‐15
Completed
0%
62%
68%
81%
86%
87%
90%
90%
90%
0%
0%
0%
Target
85%
85%
85%
88%
92%
95%
100%
100%
100%
100%
100%
100%
8
Adult Services
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Activity & Data Quality
External Referrals
4,500
Adult Services (Local indicator)
4,000
3,500
Month: December 2014
3,000
Month
YTD
3,306
31,754
Brighton & Hove Locality
647
6,428
East Sussex Locality
975
8,933
West Sussex Locality
1,611
15,540
Number of External Referrals
2,500
2,000
1,500
1,000
500
0
Apr-14
May-14
Jun-14
Jul-14
Apr‐14 May‐14 Jun‐14
AMHS only
Jul‐14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
AMHS Referrals (last year)
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
Jan‐15
Feb‐15 Mar‐15
Current Year
3,460
3,342
3,553
3,615
3,354
3,675
3,859
3,590
3,306
0
0
0
Last Year
3,745
3,755
3,810
4,201
3,840
3,437
3,929
4,279
3,440
4,066
3,663
3,384
YTD
1,072
10,033
Crawley
192
2,044
Horsham & Mid Sx
347
3,463
Brighton & Hove
647
6,428
Eastbourne
395
3,780
High Weald
228
2,001
Hastings & Rother
352
3,152
11
71
Data Completeness Identifiers
Activity
Month
S-E Hampshire
Sep-14
1,200
Performance by CCG - December 2014
Coastal W Sussex
Aug-14
AMHS Referrals
1,000
800
600
400
200
0
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
Hastings &
Rother CCG
South-East
Hants CCG
Sussex referrals
100%
TRUST-W IDE (MONITOR indicator)
100.0%
99.6%
100.0%
99.8%
99.8%
99.7%
99.2%
98%
Month: December 2014
Month
Quarter
YTD
Commissioner Code
99.6%
99.6%
99.7%
Date of Birth
100.0%
100.0%
100.0%
Gender
100.0%
100.0%
100.0%
GP Code
99.8%
99.9%
99.9%
NHS Number
99.8%
99.0%
98.6%
Postcode
99.2%
99.2%
98.8%
TOTAL
99.7%
99.6%
99.5%
Data Completeness Outcomes
92%
Commissioner
Code
Date of Birth
Gender
GP Code
% valid
NHS Number
Postcode
TOTAL
Target
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
TRUST
99.2%
99.2%
99.2%
99.2%
99.2%
99.3%
99.3%
99.5%
99.7%
99.7%
99.7%
99.4%
99.7%
TARGET
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
87.9%
87.7%
Accommodation
Employment
80%
Month: December 2014
Target: 50%
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
Quarter
YTD
Accommodation
87.9%
88.2%
88.4%
Employment
87.7%
88.1%
88.5%
HoNOS
89.3%
89.8%
92.7%
TOTAL
88.3%
88.7%
90.0%
89.3%
88.3%
HoNOS
TOTAL
60%
Data Quality
Month
December 2014
94%
100%
TRUST-W IDE (MONITOR indicator)
MHMDS Outcome
96%
Data Quality
MHMDS Identifier
Target: 97%
40%
20%
0%
% valid
Target
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
TRUST
92.3%
92.3%
92.2%
89.9%
90.3%
89.7%
90.7%
91.7%
90.5%
90.3%
89.4%
88.5%
88.3%
TARGET
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
50.0%
9
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
Adult Services
Sussex Partnership
NHS Foundation Trust
Performance Indicators 2014 - 2015
7 Day Follow-up
(page 1)
Patients are at their most vulnerable and most at risk of suicide within the first seven days after being discharged from an inpatient unit. The 7
day follow-up process attempts to reduce the number of suicides and serious incidents within this time frame.
Every adult patient, including those on the Care Programme Approach (CPA) receiving secondary mental health services should be followed up,
either in person, or by phone, within 7 days of discharge.
The MONITOR and Contractual target is 95%. A schedule of working principles has been agreed to define expected practice.
RAG status: Green - 95% and above; Amber - 85-95%; Red - below 85%.
Gate-keeping of Admissions
(page 2)
A key role of the Crisis Resolution Home Treatment Team is to gate-keep admissions to inpatient services to reduce inappropriate inpatient admission and provide crisis care in the home or in the community where this is more appropriate.
They should provide a mobile 24 hour, seven days a week response to requests for assessment and be actively involved in all requests for admission. For the avoidance of doubt, this should involve face-to-face contact unless it can be deemed that this was not appropriate, or possible. For
each case where face-to-face is deemed to be inappropriate, a self-declaration is required. In relation to Mental Health Act assessments the team
should be notified of assessment; be assessing all these cases before admission happens; and be central to the decision making process in conjunction with the rest of the multi disciplinary team.
The MONITOR and Contractual target is 95%. RAG status: Green - 95% and above; Amber - 85-95%; Red - below 85%.
4 hour response to urgent GP referrals
(page 2)
All Urgent GP referrals are carefully screened by clinicians, to ensure they are responded to in the most appropriate way. Where, in the view of
the clinician, the patient is presenting an immediate risk to themselves or others; an immediate response is required. The response that the Trust
makes must be adequate to address the level of risk described above. This could be either assessment, or other actions, to ensure the safety of
the patient and others appropriate to the particular circumstances. This may not necessarily mean meeting the patient face-to-face. This could
be achieved through discussion with the GP or patient. The clinical responsibility is to ensure that the GP’s request has been responded to and
the patient is safe.
100% of all urgent GP referrals that meet the definition must be responded to within 4 hours. RAG status: Green - 95% and above; Amber - 8595%; Red - below 85%.
Urgent GP referrals for adult patients in Brighton & Hove are managed by the Enhanced Brighton Urgent Response Service.
4 weeks waiting time to assessment
(page 3)
This indicator addresses the patient pathway from referral (from external source) to first assessment. It describes the numbers of external referrals achieving the 4 week target across the Trust.
The indicator is expressed as the number of patients waiting less than 4 weeks between referral and first assessment. It takes the first contact
following referral to represent assessment.
The Contractual target is that at least 95% wait under 4 weeks to first assessment following referral. RAG status: Green - 95% and above; Amber
- 85-95%; Red - below 85%.
Liaison Services response times
(page 3)
Psychiatric liaison services provide mental health care to people being treated for physical health conditions in general acute hospitals. The cooccurrence of physical and mental health problems is very common and often leads to poorer health outcomes for these patients. It also has a
detrimental effect on health care costs. The Centre for Mental Health issued a report in 2011 (Economic Evaluation of a Liaison Psychiatry Service) which estimated that an acute hospital could save £3.5m a year in shorter lengths of stay and lower readmission rates through the use of
high-quality psychiatric liaison services. This represented a cost-benefit ratio of 4:1.
The targets for patients to be seen are:

2 hours for emergency referrals (A&E wards, A&E linked wards, general wards)

24 hours for urgent referrals (A&E linked wards)

48 hours for urgent referrals (general wards)

For non-urgent referrals (general wards) the aspirational target is 72 hours
95% of patients should wait no more than indicated. RAG status: Green - 95% and above; Amber - 85-95%; Red - below 85%.
Delayed Transfers of Care (DTC)
(page 5)
A delayed discharge occurs when a patient is assessed as medically ready to be discharged from an inpatient bed but remains due to non medical
delays. These include, awaiting public funding, awaiting a housing placement or a package of care in their own home. A patient is ready for
transfer when:

A clinical decision has been made that patient is ready for transfer and

A multi-disciplinary team decision has been made that patient is ready for transfer and

The patient is safe to discharge/transfer.
A multi-disciplinary team in this context includes nursing and other health and social care professionals, caring for that patient in an acute setting.
For patients of no fixed abode, the council responsible for the patient is the council whose area they reside. This is irrespective of whether the
patient lives on the street or in a hostel. Asylum seekers and others from overseas are listed under the council in which they currently reside. It
is the responsibility of the local authority to decide whether they are eligible for social services.
The MONITOR and Contractual target is that DTCs should be no more than 7.5% (expressed as the number of bed days delayed divided by the
total number of occupied bed days). RAG status: Green - 7.5% and below; Amber - 7.5-12.5%; Red - above 12.5%.
December 2014
10
Adult Services
Sussex Partnership
NHS Foundation Trust
Performance Indicators 2014 - 2015
Long Term Service Users (LTSU)
(page 5)
People discharged to primary care after a long period of being supported by secondary services, May feel insecure about what will happen if their
mental health should deteriorate. A rapid re-assessment will increase their confidence to live more independently.
95% of patients meeting the criteria below should be offered an assessment within 1 week.
Patients in receipt of services for six months or more in their last episode.
Patients were discharged no more than two years before the referral.


The Contractual threshold is 95%. The Trust’s aim is a target of 100%. RAG status: Green - 95% and above; Amber - 85-95%; Red - below
85%.
CPA 12 month Formal Review
(page 6)
“The Care Programme Approach (CPA) is at the centre of the personalisation focus, supporting individuals with severe mental illness to ensure
that their needs and choices remain central in what are often complex systems of care.” - from the Foreword to ‘Refocusing the Care Programme
Approach—Policy and Positive Practice Guidance’ Dept of Health (2008).
In identifying what a service user, who has the support of a CPA, should expect, the need for a comprehensive formal written care plan features
prominently. This care plan should include a risk and safety/contingency/
crisis aspect. An on-going, formal multi-disciplinary, multi-agency review is required at least once a year (but likely to be needed more regularly).
The 12 month review is a key MONITOR performance indicator. It is expressed as a percentage of adult patients having had a formal review in
the past 12 months from the total number of adults on the Care Programme Approach at any time in the past 12 months.
The MONITOR target is that 95%of all patients on CPA should have had at least one formal review in the past 12 months. RAG status: Green 95% and above; Amber - 85-95%; Red - below 85%.
Payment by Results (PbR) cluster reassessment
(page 6)
Under the Department of Health Guidance for Payment By Results, there is a requirement that patients, whose needs are defined in terms of
Payment By Results clusters, are re-assessed in accordance with defined review periods. The defined review periods vary in length according to
the cluster concerned. Clusters are considered as “valid” if the patients’ needs have been re-assessed in the review period and the patient has
been re-clustered.
There are a number of possible reasons as to why a patient may have an EXPIRED cluster including:

Patients with no current activity that have not been discharged from the system.
(these patients need to be discharged).

Patients whose clusters have not been reviewed within the defined review periods.
(all patients need to be clustered in accordance with the review periods guidance).
RAG status: Green - 95% and above; Amber - 85-95%; Red - below 85%.
Responding to Complaints
(page 7)
All complaints are taken extremely seriously. They must be fully investigated with care and consideration and the findings reported to the complainant.
There is a clear correlation between satisfaction and responsiveness and the Trust has taken the decision that complaints must be responded to
within 25 working days, or within a different agreed timeframe.
The target is 85% of all complaints are responded to within 25 working days or different agreed timeframe. RAG status: Green - 85% and above;
Amber - 75-85%; Red - below 75%.
MHMDS Data Completeness Identifiers and Outcomes
(page 9)
The Mental Health Minimum Data Set (MHMDS) is a nationally defined framework of data held locally by Trusts around the country. Each record
in the data set looks at the whole period an individual is cared for by the provider from the initial referral to the final discharge. The MHMDS is
central in providing information for clinical audit and for the assessment of patient outcomes. At a local level the MHMDS data completeness enables monitoring of outcomes for individuals in terms of morbidity, quality of life and user satisfaction with services. The latest version (4.1) of
MHMDS is used.
The indicator measures the completeness of the mental health minimum data set in two parts:
1.
Identifier - 6 selected data items






Date of birth
Patient’s current gender
Patient’s NHS number
Postcode of patient’s normal residence
Organisational code of patient’s registered General Medical Practice
Organisational code of Commissioner
The MONITOR target for is set at 97% overall. RAG status: Green - 97% and above; Amber - 95-97%; Red - below 95%.
2.
Outcomes - 3 selected data fields
(using the most recent entered for adult patients aged 18-69 on CPA in the last 12 months)



Settled accommodation
Employment
HoNOS
The MONITOR target for is set at 50% overall. RAG status: Green - 50% and above; Amber - 45-50%; Red - below 45%.
December 2014
11
Adult Services
Sussex Partnership
NHS Foundation Trust
Sussex CCG Map
© Graham Ainsworth - Sussex HIS - December 2012
Population
(2013-14)
Number of
GP Practices
Coastal West Sussex CCG
492,515
55
Crawley CCG
127,372
13
Horsham & Mid Sussex CCG
228,231
23
Brighton & Hove CCG
300,900
46
Eastbourne, Hailsham & Seaford CCG
186,798
22
High Weald, Lewes, Havens CCG
166,464
27
Hastings & Rother CCG
183,178
33
South Eastern Hampshire CCG
209,845
26
CCG
December 2014
12
Adult Services
Specialist Services
Dashboard
December 2014
Sussex Partnership
NHS Foundation Trust
December 2014
Specialist Services Dashboard
Page
SAFETY
Serious Incidents - Reporting on and demonstrating learning No Target
1
EFFECTIVENESS
Emergency referrals responded to in 4 hours (Sussex) - target 95% CONTRACTUAL TARGET
2
Emergency referrals responded to in 4 hours (CAMHS Hants) - target 95% CONTRACTUAL TARGET
2
Emergency referrals responded to in 24 hours (ChYPS Kent) - target 95% CONTRACTUAL TARGET
3
New cases of psychosis - Effective treatment - 48 new cases each quarter MONITOR TARGET
3
Routine assessments within 4 weeks of referral (Sussex) - target 95% CONTRACTUAL TARGET
4
Routine assessments within 4 weeks of referral (CAMHS Hants) - target 95% CONTRACTUAL TARGET
4
Routine assessments within 4 weeks of referral (ChYPS Kent) - target 95% CONTRACTUAL TARGET
5
Length of Stay (CAMHS Sussex) No Target
5
Appropriate Placement of Prisoners - prisoner transfer times - target <2 weeks TRUST-ONLY TARGET
5
PATIENT EXPERIENCE
Long term service users reassessed in 7 days (CAMHS Sussex) 95% target CONTRACTUAL TARGET
6
Complaints resolved within 25 working days (Sussex) - target 85% CONTRACTUAL TARGET
7
Complaints ressolved within 25 working days (CAMHS Hants) - target 85% CONTRACTUAL TARGET
7
Complaints resolved within 25 working days (ChYPS Kent) - target 85% CONTRACTUAL TARGET
7
PEOPLE
Time to Hire - Trust-wide 17.6 weeks or less TRUST-ONLY TARGET
8
Sickness absence - 3.5% or less TRUST-ONLY TARGET
8
Agency spend - maintain spend at less than 1% of pay bill TRUST-ONLY TARGET
8
Appraisals (85% by the end of Q1 and 100% by end of Q2) TRUST-ONLY TARGET
8
ACTIVITY & DATA QUALITY
External Referrals (CAMHS Sussex) No Target
9
MHMDS Data Completeness Identifiers - target 97% MONITOR TARGET
9
GOVERNANCE
MONITOR Governance Risk Rating MONITOR TARGET
December 2014
2
Index
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Safety
Serious Incidents
10
Specialist Services (Local indicator)
8
Month: December 2014
All Serious Incidents
6
Month
YTD
2
44
Sussex
1
35
Hampshire
0
0
Kent
1
9
Specialist Services
0
4
2
0
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
SIs - Specialist - Sussex
May-14
Jun-14
Jul-14
Aug-14
SIs - Specialist - Hants
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
Sep-14
Oct-14
Nov-14
Dec-14
SIs - Specialist - Kent
Dec‐13
Jan‐14
SPECIAL
6
6
9
5
3
6
5
8
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
4
7
3
6
2
GRADE 2
1
0
0
0
0
0
0
1
1
1
1
0
0
Performance by CCG - December 2014
Month
YTD
Coastal W Sussex
0
4
Crawley
0
0
Horsham & Mid Sx
0
8
Brighton & Hove
1
5
Eastbourne
0
9
High Weald
0
6
Hastings & Rother
0
3
S-E Hampshire
0
0
December 2014
1
Specialist Services
Safety
Grade 2 incidents only
4
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Effectiveness
4 hour response to urgent referrals
100%
Specialist Services - CAMHS Sussex (Local Ind)
Month: December 2014
Target: 95%
Month
YTD
Urgent GP referrals received
50
349
Referrals meeting definition
4
103
% response under 4 hours
100%
100%
95%
90%
85%
80%
Dec-13
Performance by CCG - December 2014
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
% response <4 hours
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Target
Dec‐13
Jan‐14
SUSSEX
95.2%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
Jul‐14
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
100%
GP Referrals
Definition
% <4 hours
Coastal W Sussex
20
0
100%
Crawley
2
0
100%
Horsham & Mid Sx
17
4
100%
Brighton
7
0
100%
Eastbourne
0
0
100%
High Weald
0
0
100%
Hastings & Rother
4
0
100%
S-E Hampshire
0
0
100%
4 hour response to urgent referrals
80%
Effectiveness
Urgent GP referrals presenting an immediate risk either to
the patient or others require an immediate response and
meet the "4 hour response" definition.
60%
40%
20%
0%
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
% response <4 hours
Hastings &
Rother CCG
South-East
Hants CCG
TRUST
Target
100%
Specialist Services - CAMHS Hants (Local Ind)
Month: December 2014
Target: 95%
Month
YTD
Urgent GP referrals received
47
416
Referrals meeting definition
10
86
% response under 4 hours
100%
100%
95%
90%
85%
80%
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
CAMHS Hants % response <4 hours
Performance by CCG - December 2014
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Sep-14
Oct-14
Nov-14
Dec-14
Target
Jul‐14
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
HANTS
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
100%
GP Referrals
Definition
% <4 hours
Fareham
11
0
100%
North Hampshire
8
2
100%
N E Hampshire
12
5
100%
S E Hampshire
7
0
100%
West Hampshire
9
3
100%
80%
60%
40%
20%
0%
Fareham &
Gosport CCG
North Hampshire
CCG
NE Hampshire
& Farnham
CCG
South East
Hampshire
CCG
CAMHS Hants % response <4 hours
December 2014
2
West Hampshire
CCG
Other CCGs
HAMPSHIRE
Target
Specialist Services
Effectiveness
Urgent GP referrals presenting an immediate risk either to
the patient or others require an immediate response and
meet the "4 hour response" definition. CAMHS Hampshire.
Aug-14
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Effectiveness
24 hour urgent referrals
100%
Specialist Services - ChYPS Kent (Local Ind)
Month: December 2014
Target: 95%
Month
YTD
Emergency referrals received
108
745
Emergency referrals seen
108
745
100%
100%
% seen under 24 hours
Performance by CCG - December 2014
90%
85%
80%
Dec-13
Definition
% <24 hours
Ashford
11
11
100%
Canterbury
7
7
100%
Dartford
12
12
100%
Medway
18
18
100%
South Kent Coast
13
13
100%
Swale
6
6
100%
Thanet
12
12
100%
West Kent
20
20
100%
EIS - New Psychosis Cases
Mar-14
Apr-14
May-14
Jun-14
Jul-14
ChYPS Kent % seen <24 hours
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Target
Jul‐14
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
KENT
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
80%
60%
40%
20%
0%
Ashford
CCG
200
Month: December 2014
150
Month
Quarter
YTD
West Sussex
15
23
70
East Sussex
8
13
44
Brighton & Hove
5
12
35
TRUST
28
49
156
Medway
CCG
Dartford,
Gravesham
& Swanley
CCG
South Kent
Coast CCG
Swale
CCG
Thanet
CCG
West
Kent
CCG
Other
CCGs
KENT
Target
100
50
0
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
EIS New Cases - TRUST - YTD
Apr‐14 May‐14 Jun‐14
Jul‐14
Dec-14
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
NEW CASES
18
36
48
71
82
101
108
121
149
TARGET
16
32
48
64
80
96
112
128
144
3
Jan-15
Feb-15
Mar-15
Target
Jan‐15
160
Feb‐15 Mar‐15
176
192
Specialist Services
Effectiveness
National Target: 48 cases/quarter
Canterbury
& Coastal
CCG
ChYPS Kent % seen <24 hours
Specialist Services (MONITOR indicator)
December 2014
Feb-14
100%
Referrals
Reported to MONITOR quarterly.
Jan-14
Effectiveness
Emergency referrals presenting an immediate risk either
to the patient or others must be seen within 24 hours,
irrespective of whether within normal or out-of-hours.
95%
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Effectiveness
4 week waiting time to assessment
100%
Specialist Services - CAMHS Sussex (Local Ind)
95%
Month: December 2014
Target: 95%
Number of Assessments
% assessments <4 Weeks
Average Wait Days
Month
YTD
490
4,012
100%
99%
24.3
26.7
90%
85%
80%
75%
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
Indicator covers CAMHS Sussex and LDS.
Performance by CCG - December 2014
<4 weeks
Wait Days
118
99%
24.4
Crawley
35
100%
24.1
Horsham & Mid Sx
63
98%
14.0
Brighton & Hove
57
100%
17.0
Eastbourne
59
100%
31.6
High Weald
64
100%
24.8
Hastings & Rother
91
100%
19.6
S-E Hampshire
0
100%
0.0
4 week waiting time to assessment
Target: 95%
YTD
Number of Assessments
311
2,110
% assessments <4 Weeks
41%
44%
Average Wait Days
41.0
41.9
Oct-14
Nov-14
Dec-14
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
SUSSEX
99.2%
99.1%
99.5%
98.9%
98.6%
97.6%
99.8%
99.8%
97.9%
99.2%
98.5%
99.4%
99.6%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
90%
80%
70%
60%
50%
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
% assessments <4 weeks
Hastings &
Rother CCG
South-East
Hants CCG
TRUST
Target
60%
40%
20%
0%
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
Indicator covers CAMHS Hampshire
May-14
Jun-14
Jul-14
% assessments <4 weeks
Performance by CCG - December 2014
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Target
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
HANTS
51.8%
33.2%
41.6%
50.0%
45.9%
41.7%
34.3%
45.6%
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
42.2%
55.7%
46.0%
45.2%
40.5%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
100%
Assessments
<4 weeks
Wait Days
Fareham
54
28%
37.1
North Hampshire
34
50%
39.6
N E Hampshire
40
53%
32.0
S E Hampshire
57
42%
31.7
119
36%
52.8
80%
60%
40%
20%
0%
Fareham &
Gosport CCG
North
Hampshire
CCG
NE Hampshire
& Farnham
CCG
South East
Hampshire
CCG
% assessments <4 weeks
December 2014
4
West Hampshire
CCG
Other CCGs
HAMPSHIRE
Target
Specialist Services
Effectiveness
Average Wait Days = average wait time from receipt of
referral to assessment.
West Hampshire
Sep-14
80%
Month
HAMPSHIRE
Aug-14
Target
100%
Specialist Services - CAMHS Hants (Local Ind)
Month: December 2014
Jul-14
100%
Assessments
Coastal W Sussex
Jun-14
Effectiveness
Average Wait Days = average wait time from receipt of
referral to assessment.
SUSSEX
May-14
% assessments <4 weeks
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Effectiveness
4 week waiting time to assessment
100%
Specialist Services - ChYPS Kent (Local
Indicator)
80%
Month: December 2014
Target: 95%
Month
YTD
Number of Assessments
540
3,847
% assessments <4 Weeks
56%
46%
Average Wait Days
48.1
59.0
60%
40%
20%
0%
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
Indicator covers ChYPS Kent
Jun-14
Jul-14
Performance by CCG - December 2014
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Target
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
KENT
46.0%
54.7%
47.4%
42.5%
38.3%
45.5%
46.9%
45.0%
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
38.4%
42.5%
47.7%
52.5%
55.6%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
100%
Assessments
<4 weeks
Wait Days
Ashford
46
57%
82.8
Canterbury
53
55%
45.4
Dartford
75
61%
61.5
Medway
97
47%
53.6
South Kent Coast
56
45%
37.8
Swale
39
51%
34.7
Thanet
60
43%
59.5
108
70%
26.3
Average Length of Stay
80%
60%
40%
20%
0%
Ashford
CCG
Canterbury
& Coastal
CCG
Medway
CCG
Dartford,
Gravesham
& Swanley
CCG
South Kent
Coast CCG
Swale
CCG
Thanet
CCG
% assessments <4 weeks
West
Kent
CCG
Other
CCGs
KENT
Target
100
Specialist Services - CAMHS Sussex (Local ind)
80
Current Quarter: Quarter 3 (Oct - Dec)
60
2014-15
94.4
65.1
40
20
Length of Stay is measured in days for patients discharged
during last quarter.
0
Q2 - 13/14
Q4 - 13/14
Q1 - 14/15
Q2 - 14/15
Q3 - 14/15
Length of Stays (days)
Q2 ‐ 2013‐4
Q3 ‐ 2013‐4
Q4 ‐ 2013‐4
Q1 ‐ 2014‐5
Q2 ‐ 2014‐5
Q3 ‐ 2014‐5
64.2
92.3
68.0
53.2
47.6
94.4
CAMHS
Appropriate Placement for Prisoners
Q3 - 13/14
100%
Specialist Services - S&F (Local indicator)
Effectiveness
Quarter
CAMHS
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
80%
Month: December 2014
Target: 100%
YTD
Under 2 weeks
2
14
TOTAL
2
14
1
60%
40%
20%
0%
Prisoner transfer time from receipt of Ministry of Justice
warrant to hospital bed. Target is under 2 weeks.
% transferred in under 2 weeks
<2 wks
Dec‐13
Jan‐14
2
2
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
3
2
2
0
1
Jul‐14
4
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
1
0
1
3
2
%<2 wks 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
5
Specialist Services
Effectiveness
Month
December 2014
Effectiveness
Average Wait Days = average wait time from receipt of
referral to assessment.
West Kent
May-14
% assessments <4 weeks
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Patient Experience
Long Term Service Users Referrals
100%
Specialist Services (Local indicator)
Month: December 2014
Target: 95%
Month
YTD
LTSU Referrals
38
311
Seen within 7 days
38
305
100%
98%
% seen within 7 days
95%
90%
85%
80%
Dec-13
Performance by CCG - December 2014
Feb-14
Mar-14
Apr-14
May-14
Jun-14
% seen <7 days
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Target
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
SPECIAL 96.9%
98.1%
100.0% 100.0% 100.0% 100.0%
97.1%
96.8%
100.0%
96.2%
95.5%
97.6%
100.0%
TARGET
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
95.0%
100%
Referrals
<7 days
% <7 days
Coastal W Sussex
4
4
100%
Crawley
5
5
100%
Horsham & Mid Sx
9
9
100%
Brighton & Hove
4
4
100%
Eastbourne
6
6
100%
High Weald, Lewes
4
4
100%
Hastings & Rother
6
6
100%
S-E Hampshire
0
0
100%
December 2014
Jan-14
80%
60%
40%
20%
0%
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
% seen <7 days
6
Hastings &
Rother CCG
South-East
Hants CCG
TRUST
Target
Specialist Services
Patient Experience
Patients referred back to CAMHS within 2 years of their last
episode (which must have lasted at least 6 months.
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Patient Experience
Resolving Complaints
100%
Specialist Services (Local indicator)
80%
Month: December 2014
Target: 85%
60%
Resolved within 25 working days or agreed timeframe
Complaints resolved this month
20
Resolved within the agreed timeframe
16
% resolved within agreed timeframe
80%
Average number of days to resolution
25.6
Total number of complaints received
24
Performance by CCG - December 2014
SUSSEX
20%
0%
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
TRUST - responded to within timeframe
TRUST
Jun-14
Jul-14
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
69.8%
80.9%
66.7%
55.6%
SPECIAL
Aug-14
Sep-14
Oct-14
Nov-14
Specialist Services responded to within timeframe
Dec-14
Target
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
66.7%
75.0%
75.0%
71.6%
88.2%
85.4%
90.0%
96.1%
90.0%
68.8%
76.9%
65.0%
84.6%
82.4%
78.3%
86.7%
100.0%
84.0%
100%
Resolved
Ave Days
Coastal W Sussex
1
100%
11.0
Crawley
2
100%
23.5
Horsham & Mid Sx
1
100%
27.0
Brighton & Hove
0
100%
0.0
Eastbourne
1
0%
26.0
High Weald
2
0%
41.5
Hastings & Rother
2
100%
22.5
S-E Hampshire
0
100%
0.0
Performance by CCG - December 2014
80%
60%
40%
20%
0%
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
Hastings &
Rother CCG
Sussex - complaints completed within timeframe
South-East
Hants CCG
TRUST
Target
100%
Complaints
Resolved
Ave Days
Fareham
1
100%
10.0
North Hampshire
1
100%
55.0
N E Hampshire
2
100%
14.5
S E Hampshire
0
100%
West Hampshire
2
100%
25.5
80%
60%
40%
20%
0%
Fareham &
Gosport CCG
North Hampshire
CCG
NE Hampshire
& Farnham
CCG
South East
Hampshire
CCG
West Hampshire
CCG
Hampshire - complaints completed within timeframe
Performance by CCG - December 2014
KENT
HAMPSHIRE
Target
100%
Complaints
Resolved
Ave Days
Ashford
0
100%
0.0
Canterbury
0
100%
Dartford
0
100%
0.0
Medway
1
100%
11.0
South Kent Coast
0
100%
0.0
Swale
0
100%
Thanet
1
100%
24.0
West Kent
1
0%
46.0
December 2014
Other CCGs
80%
60%
40%
20%
0%
Ashford
CCG
Canterbury
& Coastal
CCG
Dartford,
Gravesham
& Swanley
CCG
Medway
CCG
South Kent
Coast CCG
Swale
CCG
Thanet
CCG
Kent - complaints completed within timeframe
7
West
Kent
CCG
Other
CCGs
KENT
Target
Specialist Services
Patient Experience
Complaints
HAMPSHIRE
40%
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - People
Time to Hire
28
Specialist Services (Local indicator)
24
Month: December 2014
Target: <=17.4 weeks
2014
Time to Hire - TRUST (weeks)
15.8
15.4
Time to Hire - Specialist Services
15.0
16
Weeks
12
People
Month
20
8
4
The average time to hire was 25.6 weeks in 2013.
The 2014-5 figure is the average for the year-to-date
since April 2014.
Sickness Absence
0
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Time to Hire - TRUST
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Time to Hire - Specialist Services
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
Nov-14
Dec-14
Target
Dec‐13
Jan‐14
SPECIAL
0.0
0.0
0.0
0.0
0.0
11.7
12.0
0.0
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
19.4
19.4
14.2
14.5
15.0
TARGET
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
17.4
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
5.2%
5.0%
Specialist Services (Local indicator)
4.8%
4.6%
Month: November 2014
Target: <=3.5%
4.4%
4.2%
Month
Year
4.0%
Trust absence rate
4.39%
3.81%
3.6%
Specialist Services absence rate
4.90%
3.75%
3.2%
3.8%
People
3.4%
3.0%
2.8%
2.6%
Reported one month in arrears
Nov-13
Dec-13
Jan-14
Trust Absence rate
Absence rate (previous 12 months)
Target
Nov‐13 Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
4.33%
4.10%
4.17%
4.14%
3.93%
3.89%
3.74%
3.41%
3.62%
3.38%
3.97%
4.10%
4.39%
SPECIAL 0.00%
0.00%
0.00%
0.00%
3.67%
3.84%
3.77%
3.08%
2.91%
3.52%
3.75%
4.23%
4.90%
May-14
Jun-14
Jul-14
TRUST
Agency Spend
Specialist Services Absence rate
Aug‐14 Sep‐14 Oct‐14 Nov‐14
10%
9%
Specialist Services (Local indicator)
8%
Month: December 2014
Target: 1%
YTD
Agency Spend (2014-15)
5.08%
5.27%
Agency Spend (2013-14)
5.05%
5.70%
6%
5%
4%
People
Month
7%
3%
2%
1%
Agency spend as a proportion of the total pay bill. Target
is to maintain this below 1%.
Last year's YTD figure is for the whole year (2013-14).
Appraisals
Apr-14
Aug-14
Sep-14
% Agency spend (Current Year)
Oct-14
Nov-14
Dec-14
Jan-15
% Agency spend (Last Year)
Feb-15
Mar-15
Target
Apr‐14 May‐14 Jun‐14
Jul‐14
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
Jan‐15
Feb‐15 Mar‐15
Current Year
4.72%
5.03%
5.95%
5.63%
4.83%
5.18%
6.04%
4.93%
5.08%
0.00%
0.00%
0.00%
Last Year
3.70%
4.56%
3.95%
6.50%
9.00%
5.38%
7.35%
4.52%
5.05%
5.46%
6.58%
7.68%
May-14
Jun-14
100%
TRUST-WIDE (Local indicator)
Month: December 2014
0%
80%
Target: 95% by end of Q2
60%
100% by end of Q3
Appraisals completed
90%
People
40%
20%
0%
Apr-14
Appraisals not yet booked to
take place before end of Q3
December 2014
Jul-14
Aug-14
Sep-14
Oct-14
Appraisals completed
7%
Apr‐14 May‐14 Jun‐14
Jul‐14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Target
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
Jan‐15
Feb‐15 Mar‐15
Completed
0%
62%
68%
81%
86%
87%
90%
90%
90%
0%
0%
0%
Target
85%
85%
85%
88%
92%
95%
100%
100%
100%
100%
100%
100%
8
Specialist Services
Sussex Partnership
NHS Foundation Trust
December 2014
Key Indicators - Activity & Data Quality
External Referrals
1,400
Specialist Services - CAMHS Sussex (Local ind)
1,200
1,000
Month: December 2014
800
Month
YTD
Number of External Referrals
910
7,381
Brighton & Hove Locality
165
1,397
200
East Sussex Locality
331
2,611
0
West Sussex Locality
408
3,258
600
400
Apr-14
May-14
Jun-14
Jul-14
Apr‐14 May‐14 Jun‐14
CAMHS Sussex & EIS only
YTD
233
1,906
64
479
Horsham & Mid Sx
111
873
Brighton & Hove
165
1,397
Eastbourne
125
901
High Weald
95
707
111
1,003
0
3
Hastings & Rother
S-E Hampshire
Jul‐14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
CAMHS & EIS Referrals (last year)
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
Jan‐15
Feb‐15 Mar‐15
Current Year
725
776
852
862
578
731
1,029
898
930
0
0
0
Last Year
808
893
758
965
638
818
974
1,014
778
973
938
1,206
Data Completeness Identifiers
Activity
Month
Crawley
Sep-14
300
Performance by CCG - December 2014
Coastal W Sussex
Aug-14
CAMHS & EIS Referrals
250
200
150
100
50
0
Coastal West
Sussex CCG
Crawley
CCG
Horsham &
Mid Sussex
CCG
Brighton &
Hove CCG
Eastbourne, High Weald,
Hailsham &
Lewes,
Seaford CCG Havens CCG
Hastings &
Rother CCG
South-East
Hants CCG
Sussex referrals
100%
TRUST-W IDE (MONITOR indicator)
100.0%
99.6%
100.0%
99.8%
99.8%
99.7%
99.2%
98%
Month: December 2014
Month
Quarter
YTD
Commissioner Code
99.6%
99.6%
99.7%
Date of Birth
100.0%
100.0%
100.0%
Gender
100.0%
100.0%
100.0%
GP Code
99.8%
99.9%
99.9%
NHS Number
99.8%
99.0%
98.6%
Postcode
99.2%
99.2%
98.8%
TOTAL
99.7%
December 2014
99.6%
99.5%
96%
94%
92%
Commissioner
Code
Date of Birth
Gender
GP Code
% valid
NHS Number
Postcode
TOTAL
Target
Dec‐13
Jan‐14
Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14
Jul‐14
TRUST
99.2%
99.2%
99.2%
99.2%
99.2%
99.3%
99.3%
99.5%
99.7%
99.7%
99.7%
99.4%
99.7%
TARGET
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
97.0%
9
Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14
Specialist Services
Data Quality
MHMDS Identifier
Target: 97%
Sussex Partnership
NHS Foundation Trust
Performance Indicators 2014 - 2015
4 hour response to urgent GP referrals
(pages 2)
All Urgent GP referrals are carefully screened by clinicians, to ensure they are responded to in the most appropriate way. Where, in the view of
the clinician, the patient is presenting an immediate risk to themselves or others; an immediate response is required. The response that the Trust
makes must be adequate to address the level of risk described above. This could be either assessment, or other actions, to ensure the safety of
the patient and others appropriate to the particular circumstances. This may not necessarily mean meeting the patient face-to-face. This could
be achieved through discussion with the GP or patient. The clinical responsibility is to ensure that the GP’s request has been responded to and
the patient is safe.
100% of all urgent GP referrals that meet the definition must be responded to within 4 hours. RAG status: Green - 95% and above; Amber - 8595%; Red - below 85%.
Early Intervention Services - New Psychosis Cases
(page 3)
Early Intervention services work with young people aged between 14 and 35. Patients referred to the Service are usually either at risk or are
experiencing a first episode of psychosis. Research has shown that the longer an episode of psychosis goes untreated, the poorer the outlook.
Research has also indicated that early intervention services may reduce hospital stays, reduce relapses and lower suicide rates.
MONITOR requires that the agreed Commissioner contract figures for new cases, either those on extended assessment or those added to the
three-year caseload, are met on a quarterly basis. The Contractual target is 48 new cases per quarter. RAG status: Green - on or above target;
Amber - within two cases of target; Red - more than two cases off target.
4 weeks waiting time to assessment
(pages 4 & 5)
This indicator addresses the patient pathway from referral (from external source) to first assessment. It describes the numbers of external referrals achieving the 4 week target across the Trust.
The indicator is expressed as the number of patients waiting less than 4 weeks between referral and first assessment. It takes the first contact
following referral to represent assessment.
The Contractual target is that at least 95% wait under 4 weeks to first assessment following referral. RAG status: Green - 95% and above; Amber
- 85-95%; Red - below 85%.
Long Term Service Users (LTSU)
(page 6)
People discharged to primary care after a long period of being supported by secondary services, may feel insecure about what will happen if their
mental health should deteriorate. A rapid re-assessment will increase their confidence to live more independently.
95% of patients meeting the criteria below should be offered an assessment within 1 week.

Patients in receipt of services for six months or more in their last episode.

Patients were discharged no more than two years before the referral.
The Contractual threshold is 95%. The Trust’s aim is a target of 100%. RAG status: Green - 95% and above; Amber - 85-95%; Red - below
85%.
Responding to Complaints
(page 7)
All complaints are taken extremely seriously. They must be fully investigated with care and consideration and the findings reported to the complainant.
There is a clear correlation between satisfaction and responsiveness and the Trust has taken the decision that complaints must be responded to
within 25 working days, or within a different agreed timeframe.
The target is 85% of all complaints are responded to within 25 working days or different agreed timeframe. RAG status: Green - 85% and above;
Amber - 75-85%; Red - below 75%.
MHMDS Data Completeness Identifiers and Outcomes
(page 9)
The Mental Health Minimum Data Set (MHMDS) is a nationally defined framework of data held locally by Trusts around the country. Each record
in the data set looks at the whole period an individual is cared for by the provider from the initial referral to the final discharge. The MHMDS is
central in providing information for clinical audit and for the assessment of patient outcomes. At a local level the MHMDS data completeness enables monitoring of outcomes for individuals in terms of morbidity, quality of life and user satisfaction with services. The latest version (4.1) of
MHMDS is used.

Identifier - 6 selected data items






Date of birth
Patient’s current gender
Patient’s NHS number
Postcode of patient’s normal residence
Organisational code of patient’s registered General Medical Practice
Organisational code of Commissioner
The MONITOR target for is set at 97% overall. RAG status: Green - 97% and above; Amber - 95-97%; Red - below 95%.
December 2014
10
Specialist Services
Sussex Partnership
NHS Foundation Trust
Sussex CCG Map
© Graham Ainsworth - Sussex HIS - December 2012
Population
(2013-14)
Number of
GP Practices
Coastal West Sussex CCG
492,515
55
Crawley CCG
127,372
13
Horsham & Mid Sussex CCG
228,231
23
Brighton & Hove CCG
300,900
46
Eastbourne, Hailsham & Seaford CCG
186,798
22
High Weald, Lewes, Havens CCG
166,464
27
Hastings & Rother CCG
183,178
33
South Eastern Hampshire CCG
209,845
26
CCG
December 2014
11
Specialist Services
Board of Directors: 28 January 2015 – Public
Agenda Item: TBP03.2/15
Attachment: G
For Decision
By: Peter Lee, Head of Corporate Governance
Q3 IN-YEAR GOVERNANCE STATEMENT TO MONITOR
SUMMARY & PURPOSE
As part of the quarterly return, Monitor requires the Board of Directors to confirm the InYear Governance Statement, found at appendix 1. This asks whether, in-year, the Trust
anticipates maintaining a continuity of service risk rating of at least 3 and complying with
existing performance targets.
In light of the liquidity of the Trust, it is certain to maintain a risk rating of at least 3. It will
achieve a rating of 4 (the highest) if the planned breakeven position is achieved.
As Board members will see from the Performance Reports, the Trust continues to achieve
the eight performance targets set out by Monitor in the Risk Assessment Framework –
CPA 7 day follow up/12 month review; access to crisis resolution and home treatment
teams; access to early intervention teams; delayed transfers of care; data completeness
(identifiers & outcomes & community services) and; access for people with a LD.
Sussex Partnership currently has a continuity of services rating – 3, and governance rating
- green.
LINK TO ANNUAL PLAN
4.1 Maintain sound financial performance to deliver financial governance and stability
4.3 To meet contracted levels of performance
ACTION REQUIRED BY BOARD MEMBERS
The Board is asked to confirm the In-Year Governance Statement at Appendix 1, which will
then be signed on behalf of the Board by the Chair and Executive Director of Finance and
Performance, and sent to Monitor.
Page 1 of 2
Appendix 1
Page 2 of 2
Sussex Partnership NHS Foundation Trust
Board of Directors: 28 January 2015 – Public
Agenda Item: TBP03.3/15
Attachment: H
For Information
By: John Bacon, Chair
BOARD OF DIRECTORS’ SITE VISITS
This paper gives an overview of the sites and services visits by Board members since the last public
Board of Directors meeting held on 26 November 2014.
Date
Site
Service
Board Member
01.10.2014
All wards, Langley Green
Hospital, Crawley, West
Sussex
Grove Ward, Harold Kidd
Unit, Chichester, West
Sussex
Royal Sussex County
Hospital, Brighton, East
Sussex
Adult Mental Health
Services
Helen Greatorex
Dementia and Later
Life Services
Helen Greatorex
A&E Liaison Team
Helen Greatorex
George Turle House,
Canterbury, Kent
Amberstone Hospital,
Hellingly, East Sussex
Caburn Ward, Mill View
Hospital, Hove, East Sussex
Orchard Ward, Harold Kidd
Unit, Chichester, West
Sussex
All Wards, Langley Green
Hospital, Crawley, West
Sussex
Roadshow/Staff
Engagement.
Knightrider House,
Maidstone, Kent
Worthing Hospital, Worthing,
West Sussex
Linwood CMHT Day Hospital,
Haywards Heath, West
Sussex
Nelson House, Gosport,
Hampshire
East Brighton Mental Health
Homeless Team, Brighton
General Hospital, Brighton,
East Sussex
Georges Turle House,
Canterbury, Kent
CAMHS
Helen Greatorex
Adult Mental Health
Services
Adult Mental Health
Services
Adult Acute Services
Helen Greatorex
02.10.2014
Early
Saturday
Shift
18.10.2014
27.10.2014
30.10.2014
10.11.2014
19.11.2014
21.11.2014
27.11.2014
Shift
01.12.2014
25.11.2014
01.12.2014
04.12.2014
05.12.2014
Helen Greatorex
Helen Greatorex
Adult Mental Health
Services
Helen Greatorex
CAMHS
Colm Donaghy
Mental Health Liaison
Service
Dementia and Later
Life Services
Helen Greatorex
Recovery and
Rehabilitation Services
Adult Community
Mental Health Services
Kay Macdonald
CAMHS
Sam Allen
Diana Marsland
Colm Donaghy
Page 1 of 1
05.12.2014
08.12.2014
10.12.2014
12.12.2014
18.12.2014
18.12.2014
19.12.2014
19.12.2014
19.12.2014
02.01.2015
07.01.2015
08.01.2015
14.01.2015
14.01.2015
Knightrider House,
Maidstone, Kent
Lighthouse Centre, Hove,
East Sussex
Chalkhill
Langley Green Hospital,
Crawley, West Sussex
Roadshow/Staff
Engagement.
Langley Green Hospital,
Crawley, West Sussex
Lindridge Centre, Hove, East
Sussex
East Brighton Community
Mental Health Team,
Brighton General Hospital,
Brighton, East Sussex
78 Crawley Road, Crawley,
West Sussex
East Brighton Community
Mental Health Team,
Brighton General Hospital,
Brighton, East Sussex
Shepherd House, Worthing,
West Sussex
Woodlands & the St Anne’s
Centre
Chichester Centre
Langley Green Hospital,
Crawley, West Sussex
Langley Green Hospital,
Crawley, West Sussex
CAMHS
Sam Allen
Recovery and Support
Services
CAMHS
Kay Macdonald
Helen Greatorex
Adult Mental Health
Services
Adult Mental Health
Services
Helen Greatorex
Care Home
Vincent Badu
Assertive Outreach
Team
Tim Ojo
Residential
Rehabilitation
Assertive Outreach
Team
Sam Allen
Community
Rehabilitation
Department of
Psychiatry
Wards
Sue Morris
Adult Mental Health
Services
Adult Mental Health
Services
John Bacon
Colm Donaghy
Richard Bayley
Helen Greatorex
Helen Greatorex
Melloney Poole
22/01/2015
Page 2 of 2
BOARD OF DIRECTORS SITE VISITS NAME: Sue Morris Date of visit: 2 January 2015 Service visited Shepherd House Overall comments: Met a team well prepared for the CQC visit and staff up to date with mandatory training. Very positive and enthusiastic staff team who described a positive transition over the past year to a strong recovery orientated approach. Positive feedback:  Positive staff team engaged with discussions about the recovery services clinical model for the future.  Easy to recruit to the service and a stable workforce  High demand for the service Issues of concern:  Although areas had been refurbished the condition of the bathrooms remains very poor as well as the decorative state and furniture in some of the bedrooms.  Challenging place to keep clean and look welcoming given condition of the parts of the environment. Action taken: Discussed current progress with defining the clinical model with operational and executive colleagues. Given continued minimum life span of 18 months Exec Team approved investment of up to £150k through the OCP to improve bathrooms, redecoration etc to a better safe standard. Follow up (if required):  Estates team organising deep clean pending full works programme.  Awaiting project plan for capital scheme.  Fed back to Shepherd House staff.  Anticipating recovery services clinical model to EMB in February. Please return to: Ailee Baxter Business Manager on email [email protected] Board of Directors: 28 January 2015 - Public
Agenda Item: TBP03.4/15
Attachment: I
For Discussion
By: Vincent Badu, Strategic Director Social Care & Partnerships
and Helen Greatorex, Executive Director of Nursing
IN CONFIDENCE
Patient Experience and Complaints Paper for December 2014.
SUMMARY & PURPOSE
This report brings together an update to the Board on Patient Experience feedback from
the Friends and Family Test (FFT) for the month of December 2014, with a complaint
report that identifies themes from quarter 2, with the intention of considering of how better
these two sources of feedback can be triangulated going forward. The Board wants to
ensure that it is truly listening and responding to feedback, both from the FFT and
complaints.
Part 1 reviews FFT feedback and suggests next steps and likewise, Part 2 looks at
complaints feedback and sets out examples of how improvements or changes have been
made as a result. Part 3 looks at the differing information provided by Parts 1 & 2 and
suggests how future reports might pull these two areas of reporting closer together.
LINK TO ANNUAL PLAN
1.2 A positive patient experience
2.1 Improve services for people who use adult mental health services
2.2 Improve services for people who use specialist services
ACTION REQUIRED BY BOARD MEMBERS
The Board is asked to review and discuss the report. and ask any questions of the
Executive Director of Nursing & Quality and the Strategic Director, Social Care and
Partnerships.
Part 1: Patient Experience Monthly Report December 2014
1.0 Executive Summary
Whilst the FFT was fully implemented by the end of December, many teams are still
embedding the survey within their practice. Over the coming months we hope to see take
up increasing across teams that are newer to this approach and that by the end of the
financial year we will have consistent usage across call care groups.
1.1 Introduction
As a Trust we need to ensure that we obtain and act upon feedback from our
patients/service users and their carers. The following is the first time we have produced a
monthly report about patient experience for the Board and it intends to give a snapshot of
the feedback received via the FFT for the previous month.
In addition we will be producing a quarterly report, which will go to the Quality Committee
and then to the Board. In the quarterly report we will explore in more detail themes, trends
over time and will be developing how we triangulate with other metrics (i.e.
complaints/S.I.’s). We will also give an overview of patient experience work planned or
taking place across the Trust.
1.2 Report
1: National Reporting Requirements: NHS England each month requires us to provide:
The following table gives the data required above for December:
Total number
of responses
Rating
Extremely likely
Likely
Neither likely
nor unlikely
Unlikely
Extremely
unlikely
Don’t know
Recommended
Primary
care
Secondary
care
community
services
Acute
services
Specialist
services
Secure
and
forensic
services
17
66
106
38
25
Child and
Adolescent
mental
health
services
10
13
4
0
37
19
2
59
32
11
28
9
1
6
6
6
6
1
1
0
0
2
2
1
2
0
0
2
4
0
1
0
100
1
85
1
86
0
97
1
48
0
70
2
%
Not
Recommended
%
Method of
response
Text
Online
Tablet
0
6
3
0
24
10
13
4
0
10
16
40
2
0
104
1
13
24
0
0
25
1
4
5
Additionally, organisations must submit the number of ‘unique patients’ accessing services
in the last month. These figures do not need to be submitted for the separate subcategories, just an overall number. Our number for December was: 17,919
2: Overview of rating responses:
The following graphs are broken down into groups that we feel ‘make sense’ to us as a
Trust:
3
Graphs 1 & 2: Responses by Division and CCG:
NB: Future reports will specify sample size for each area, as the above can be misleading (i.e. 50% ‘don’t know’ in North West Sussex is actually only 2 people).
5
It should be noted that there is a difference in sample sizes between the two sets of data
above. This is due to the data being collated on two different date, with further
submissions being uploaded in the meantime. Future reports will need to allow for this ‘lag’
and have an agreed day after the end of the reporting period, where all data is collated.
We will also work with teams to help them upload data in a timely manner.
Please also note that some graphs suggest ‘unusual’ levels.
3: Overview of free text responses:
Given that of over 200 responses for December only 9 people gave a satisfaction
response of ‘extremely unlikely’. Given the small number we will be focusing upon
triangulating against these ‘outliers’ in future quarterly reports.
‘Extremely Unlikely:
Lack of activities (Fir Ward, Chichester Centre)
It should be noted that Fir Ward also received the highest number of extremely likely to
recommend ratings demonstrating a positive commitment to implementing FFT in their
service
‘Extremely Likely’
The following section features comments taken from those made about teams which had
the highest number of ‘extremely likely to recommend’ ratings.
Questions answered- problems are solved with the help of nurses (Bodiam)
Chalk hill and its staff is such a special place. The facilities and professionalism of the staff
completely exceeded my expectation. There is such a negative perception in the media
about the NHS and mental health. I feel so blessed that my daughter was treated at chalk
hill. (Chalk Hill)
Excellent therapist (Hastings and Rother Primary Care MH Practitioners)
The care that I have received is second to none. The staff are helpful, caring and
unjudgemental. (Fir Ward Chichester Centre)
The staff are so supportive and show great empathy. I would highly recommend
the service to others (The Lighthouse, Brighton and Hove)
7
Because the staff were really friendly when I arrived and having one person who stays with
you for the first couple of hours. It defied my expectations. (Promenade Ward)
5: Summary/Conclusion:
As described in the introduction, this report is intended to provide a snapshot of the
feedback we are receiving whilst the fuller quarterly report will give much greater
consideration for emergent themes, triangulation with other metrics and will highlight
patient experience initiatives across the Trust.
That said the data identified here has some interesting points to note, including:




CAMHS and Secure & Forensic services received the lowest ratings from the FFT
with a score of 70% and 40% respectively. However it should be noted that for
CAMHS the relatively small sample of 10 meant that 1 negative response had a
disproportionate effect. The score for Secure & Forensic is more reflective of overall
feedback and therefore warrants further investigation. Though it should be
remembered that this is the first time the FFT has been used in such settings and
we will be monitoring the feedback nationally to see whether negative responses
are found in these settings.
Overall the vast majority of people are rating our services positively
The number of respondents is increasing as expected but there are areas where
take up still needs to improve
The numbers of carers responding remains consistent at 15% - there is scope for
this to be improved -increasing our knowledge about carers views as well as our
overall response rate.
1.3 Recommendation/Action Required
The Board is asked to discuss the report.
1.4 Next Steps
Monthly and Quarterly reports shall be produced from herein incorporating the
recommendations from the Board.
Looking ahead between January and March 2015 we will focus on:




Introducing an easy to use tool which will allow frontline staff to categorise
comments against the 5 CQC domains of safe, caring, responsive, effective and
well led
Developing the Staff FFT survey, bringing it in line with the approach taken in the
patient FFT survey
Exploring the potential for adding division and team specific questions to the
standard FFT survey
Additional support on areas finding introduction of FFT challenging
8

Considering the first national publication of the FFT results which are expected in
February 2015. This will enable us to review learning from other areas and use this
to inform quality improvement work across our services.
Part 2: Complaint Service Update
2.0 Introduction
Performance against basic targets in relation to complaints are currently reported to
Monthly to the Board through the Performance Report Quarterly to the Quality Committee
through the Quality Report
Below are graphs of Quarter 2(July - September) of complaints by Care Group and
Division.
Figure 1 shows the number of complaints received by Division
Figure 1
9
Breakdown of complaints received by Care Group.
Figure 2
During this period Q2 (1st July – 30 Sept) 153 complaints were received. 166 complaints
were responded to in Q2, 134 were within the agreed timescale. Some closures of
complaints were delayed due to the complexity of the complaint and level of investigation
required. Where this is the case, the complainant is contacted to agree a revised date for
closure.
2.1 Sharing Feedback
Each complaint is given a unique reference number and all information relating to that
complaint is stored securely using the electronic Safeguard system. In November 2014 a
Lessons Learnt function was added to the electronic system. This enables information on
lessons learnt and changes made to practice or process as a direct result of that complaint
to be recorded. This information is fed back directly to the complainant and service
involved and forms the basis of the quarterly Learning from Experience Board paper. A
recent addition to this is the monthly Report and Learn Bulletin which provides an
opportunity for learning from complaints to be summarised and circulated to all staff.
Making Changes and Improvements
Learning from experience
The complaints service is committed to ensuring that we maximise the opportunities to
learn from complaints and that this intelligence is collated and shared across the trust.
During Q2 the following changes and improvements have been made
10







Robust re-stocking systems implemented on Pavilion Ward to ensure that
diagnostic interventions do not incur any future delays as a result of inadequate
stock levels to undertake Electrocardiograms.
Written management plan developed in Older People’s Mental Health Liaison to be
used on discharge from A&E to ensure that all patients are provided with up to date
copies of their care plans and contact details for emergency crisis teams.
Referral Nurse Practitioner recruited to coordinate and follow up daily referrals
made to the Older People’s Mental Health Liaison Service in order to ensure that
seamless referral pathways are in place.
Chichester CAMHS ADHD Care Pathway reviewed and streamlined as a specialist
care pathway.
Commissioners allocated additional resources to address the ASD waiting list in
Kent
Brighton Later Life Services offering families meetings with the Doctor to explain the
findings from brain scans and their significance to ensure that patients and their
families are kept fully informed and have the opportunity to talk to the medical
teams directly.
North West Sussex Memory Assessment Service have implemented a system to
acknowledge referrals as soon as they are received in order to avoid delays in
referrals which led to patients complaining.
Key Themes in Q2
Changes and improvements to services are recorded and we are developing a catalogue
of lessons learnt. The top three themes from complaints in Q2 were:



Aspects of clinical care
Correspondence/lack of communication
Procurement
2.2 Work in progress
Vision and Strategy
Following the publication of “Hard Truths” the government’s response to the Francis
Inquiry into the failings at Mid Staffordshire NHS Foundation Trust, the Parliamentary and
Health Service Ombudsman (PHSO), the Local Government Ombudsman (LGO) and
Healthwatch England committed to developing a user-led ‘vision’ of the complaints system.
This report, “My Expectations for raising concerns and complaints” published in November
2014 discusses the vision and key principles of good complaint handling. The Trust’s
strategy and vision will be underpinned by national and best practice recommendations
and will be ratified in February.
Working more closely with operational services
A rolling programme of visits by Complaints Caseworkers to Teams across the
organisation is planned to commence in February 2015 to provide direct feedback
regarding themes and lessons learnt at a local level. Also to encourage discussion on how
best the complaints service and operational teams can work together to ensure that
complaints are resolved in a timely manner and opportunities for learning are optimised.
11
Complaints involving Doctors
An empirical research report funded by the General Medical Council’s “Understanding the
rise in fitness to practice complaints from members of the public”, was published in July
2014 and discusses this national issue in detail. This report provides an in-depth and
independent evaluation of the social, political and cultural factors which have driven the
increase in complaints from the public, focused particularly on the period 2007-2012.
Closer liaison with Medical Leads across the Trust will support a meaningful analysis as to
why this is the case and identify any future actions as our current position echoes this
national trend.
Training for staff on how to resolve complaints?
Complaint training is included in the Trust’s revised core induction programme
commencing in January 2015. One of the main priorities for visiting teams locally is to
strengthen relationships between Complaints Caseworkers and Teams. These visits will
also include
Best practice for resolving complaints. A rolling programme of drop in sessions for Team
Leaders with the Complaints and PALS Manager across the organisation is being
developed.
Triangulation
Jayne Bruce, Deputy Director of Nursing Standards and Safety and Bryan Lynch, Deputy
Director of Patient Experience have introduced from January 2015 regular meetings to
collate and triangulate feedback. The new web complaints module on Safeguard will be
rolled out across the organisation in March 2015 and will be a positive addition to
improving data collection for analysis and triangulation.
2.3 Next Steps
Commitment to continuous improvements in how we respond to complaints
Feedback questionnaires are currently being designed and will be sent out to all
complainants following the resolution of their complaint. This intelligence will enable us to
better understand the complainant’s experience of our complaints process and contribute
to our on-going service improvements. We know what matters most to people who make a
complaint is the outcome from that and seeking their views is pivotal to achieving this.
References:
GMC funded report “Understanding the rise in fitness to practice complaints from members
of the public” Dr Julian Archer et al July 2014
Healthwatch Report 20th November 2014
http://www..co.uk/resource/my-expectations-raising-concerns-and-complaints-report
healthwatch
Authors:
Jayne Bruce Deputy Director of Nursing Standards and Safety in conjunction with
Simon Street Complaints and PALS Manager
January 2015
12
Part 3: Triangulating Patient Experience and Complaints Data
3.0 Summary of Patient Experience and Complaints feedback
Parts 1 & 2 give a snap shot of the types of data we are currently collating in relation to
patient experience and complaints. The data in Part 1 breaks down the numbers of
responses by CCG and division, whilst Part 2 looks at geographical areas and care
groups. Additionally Part 1 looks at who is responding and numbers over time whilst
similarly Part 2 looks at numbers of respondents. Whilst Part 2 states the top 3 reasons for
complaints, neither Part 1 nor 2 has a detailed themed analysis of the feedback they have
received. Most importantly, although both parts present similar types of information,
because they refer to different groupings and time periods, meaningful triangulation is not
possible.
3.1 Next Steps
The above paper demonstrates that there is significant data being collated from both the
FFT and from complaints. However it also highlights that currently the 2 areas are not
aligned, but that work is under way to rectify this situation. Key to this will be ensuring that
the data received is themed using a shared process, with the 5 CQC domains currently
being proposed as the best approach. Over the coming months the Board will continue to
receive monthly reports and these will seek to increasingly pull together the information
from both complaints and patient experience, to provide a richer picture of how our
patients and their carers’ are experiencing our services.
13
Board of Directors: 28 January 2015 – Public
Agenda Item: TBP03 .5/15
Attachment: J
For Information
By: Helen Greatorex, Executive Director of Nursing & Quality
Safe Staffing
SUMMARY & PURPOSE
From June 2014 all NHS trust boards have been required to receive in public, a report
setting out the expected and actual number of nurses on duty by ward.
The attached summary report (Appendix 1) provides that information and is published
monthly on the Trust’s website.
In November 2014, the Board received a detailed paper on improving the quality of nursing
care, in addition to the Safe Staffing report. The paper was provided to the Board for
information having been considered in detail by both the Executive Management and
Transformation Programme Board. It confirmed that in order to address concerns about the
negative impact of the two shift system on the quality of nursing care, all wards in Adult
Mental Health Services would return to a three shift system.
The affected wards are now agreeing the timescale for returning to the three shift system
by March.
LINK TO ANNUAL PLAN
The provision of high quality care is central to each of the Trust’s objectives.
ACTION REQUIRED BY BOARD MEMBERS
The Board is asked to formally note the content of the summary report and the information
provided by matrons regarding wards where concerns are identified and action taken to
resolve variance.
SAFE STAFFING
Set out below are the 17 wards whose returns for December 2014 prompted questions. Since
June, each hospital has been paired with a member of the Chief Executive’s team ensuring that
where an issue arises, it can be resolved by the local team using where needed, support from a
member of the Board.
Ward
5. Woodlands
Issue
Overall fill rate (136%).

Low day fill rate for qualified.
High day and night fill rate for
unqualified.

High level of 1:1 and
eyesight observation.
6. Amberley
Overall fill rate (141%).

Very High fill rate for day and
night for unqualified due to
2:1 for a specific patient.

Some 1:1 for other patients.
Staffing Training

7. Coral
Overall fill rate (180%).

High fill rate for day and night
unqualified due to 2 specific
patients.
a) 2:1 for a specific
patient due to high
risk and presentation.
b) 1:1 for a specific
patient daily as well
as increased
observation for other
patients


Action
Daily Monitoring and
review of 1:1 and
eyesight observation
by staff.
Support and
monitoring at Matron
Level.
Specific patient’s
funding has been
approved and now
discharged to Home
County.
Daily reviews of 1:1
and any other
eyesight observation
by ward staff.
Monitoring by Matron
Appropriate placement
identified and funding
approved for (b)
specific patient. Still
waiting for bed
vacancy at identified
placement.
Daily monitoring and
review of all 1:1 and
eyesight observations.
Support and
monitoring at Matron
level.
Other patients requiring
eyesight observations.
8. Jade
9. Opal
Overall fill rate (130%).

High numbers of
observations for December.

Overall fill rate (123%).

Daily monitoring and
review of eyesight
observations.
Support and
monitoring by Matron
level.
Daily monitoring and
review of 2:1. This
intervention lasted for
a week.
One female patient requiring
2:1 intervention.
Staff Training
10. Meridian
Overall fill rate (113%).

High number of patients
requiring escorts to attend
physical health hospital
appointments.

11 Caburn
1 extra unqualified for the
early shift to support the
ward with personal care
intervention for the patients.

Overall fill rate (111%).

Daily monitoring and
review of eyesight
observations

Daily monitoring and
review of eyesight
observations
Overall fill rate (140%).

Low day fill rate for qualified.
High day and night fill rate for
unqualified.

Daily monitoring and
review of 1:1 and
observation level.
Support and
monitoring at Matron
level.
Numerous Patients requiring
eyesight observations.
12. Regency
Overall fill rate (110%).
Numerous Patients requiring
escort and eyesight
observations.
14. Beechwood
Daily Monitoring and
reviewing of roster
allocations to ensure
safe staffing and
optimal use of
resources.
Support and
monitoring at Matron
and General Manager
Level.
Proposal to review
staffing establishment
for unqualified day
shift.
High level of 1:1 observation
for December.
Average two patients
required 1:1.
15. St Gabriel
Overall fill rate (113%).

Daily monitoring and
review of the 1:1 and
eyesight observations.

Daily Monitoring at
At least 2patients requiring
2:1 and eyesight
observations.
There were 4 patients
requiring 3:1 for personal
care interventions on various
shifts.
Staff training
16. St Raphael
Overall fill rate (124%).
High day and night fill rate for
unqualified due to numerous
close observations.


17. Burrowes
18. Grove
Overall fill rate (126%).

Two patients requiring 1:1
and extra cover required for
night shifts.

Overall fill rate (141%).

One female patient on 2:1
and at times required 3 staff
intervention.

Matron Level.
Support at Matron and
General Manager
level.
Proposal to review
establishment for day
unqualified staff.
Daily Monitoring and
review of patients on
1:1.
Monitoring by Matron /
General Manager
level
Daily monitoring and
reviewing 1:1 and
intermittent
observation levels.
Support and Monitor
at Matron Level.
One male patient required
3:1 for personal care
intervention.
Frequently having patients
requiring 15 to 30 mins
intermittent observation
levels.
20. Iris
Overall fill rate (150%).

High numbers of 1:1
throughout December at
least up to 5 patients on
intermittent 15 mins
observation.

Daily monitoring and
reviewing 1:1 and
intermittent
observation levels.
Support and Monitor
at Matron and General
Manager Level.
Minimum of 2 patients on 1:1
eyesight observation.
25. Hazel
Overall fill rate (122%).
During December, had one
female patient regularly in
seclusion and requiring
consistent line of sight
observation.


4 hourly Nurses’
reviews and twice a
day Medical reviews
of the individual in
seclusion.
Daily monitoring and
reviewing of the
eyesight observation.
Another 2 patients requiring
intermittent eyesight
observation.
31. Amber
Overall fill rate (117%).
High fill rate for day and night

Daily monitoring and
review of observation.
unqualified due to increased
observation.
Staff Training.
32. Pavilion
Overall fill rate (126%).
Additional unqualified
required for day and night
due to two eyesight
observations plus additional
eyesight observations for
patients managed in the
seclusion room and Calm
Room at times.



Extremely high acuity levels
on the ward including up to
six patients on intermittent
observations four times an
hour (minimum).

Daily Monitoring and
reviewing of patients
on 1:1 and intermittent
observations.
Daily Monitoring and
reviewing of roster
allocations to ensure
safe staffing and
optimal use of
resources.
Daily/weekly reporting
to Matron on staffing
fill rate, clinical
demands and
observations.
Daily/weekly roster
management to
minimise the use of
bank and agency
staffing whilst
maintaining clinical
safety.
Safer Staffing Summary Report - September 2014
Day Duty
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
Ward name
Bodiam
Maple Ward
Oaklands Ward
Rowan Ward
Woodlands Centre
Amberley Ward
Coral Ward
Jade Ward
Opal Ward
Meridian Ward
Caburn Ward
Regency Ward
Chalkhill
Beechwood
St Gabriel Ward
St Raphael Ward
Burrowes Ward
Grove Ward
Brunswick Ward
Iris Ward
Heathfield Ward
Larch Ward
Orchard Ward
Selden Centre
Fir Ward
Hazel Ward
Pine Ward
Southview
Ash
Oak Ward
Willow Ward
Amber Ward
Pavillion Ward
Amberstone
Bramble Lodge
Connolly House
Hanover Crescent
Rutland Gardens
Shepherd House
Dove Ward
Promenade Ward
Type of ward
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
CAMHS
Dementia
Dementia
Dementia
Dementia
Dementia
Dementia
Dementia
Integrated
Integrated
Integrated
LD
Low Secure
Low Secure
Low Secure
Low Secure
Medium Secure
Medium Secure
Medium Secure
PICU
PICU
Rehab
Rehab
Rehab
Rehab
Rehab
Rehab
Substance Misuse
Substance Misuse
TRUST TOTAL
Rutland Gardens
Selden Centre
Shepherd House
Night Duty
Day Duty
Night Duty
TOTAL
Qualified Nurses
Healthcare Assistants
Qualified Nurses
Healthcare Assistants
Total monthly
Total monthly
Total monthly
Total monthly
planned staff
Total monthly
planned staff
Total monthly
planned staff
Total monthly
planned staff
Total monthly
Average Fill Rate Average Fill Rate Average Fill Rate Average Fill Rate
hours
actual staff hours hours
actual staff hours hours
actual staff hours hours
actual staff hours % - Qualified
% - Unqualified
% - Qualified
% - Unqualified
Overall Fill Rate %
713
713
713
713
713
713
713
713
100%
100%
100%
100%
100%
775
763
1,163
1,028
388
388
1,163
1,163
98%
88%
100%
100%
96%
750
750
750
763
750
750
750
808
100%
102%
100%
108%
102%
775
732
775
709
388
388
775
775
94%
91%
100%
100%
96%
1,070
754
713
1,660
713
690
748
1,300
70%
233%
97%
174%
136%
713
685
713
1,405
713
698
713
1,231
96%
197%
98%
173%
141%
775
921
775
1,757
775
838
388
1,375
119%
227%
108%
355%
180%
713
766
713
1,267
713
649
702
1,019
107%
178%
91%
145%
130%
775
1,000
775
1,138
775
400
388
788
129%
147%
52%
203%
123%
900
1,043
1,163
1,256
310
300
630
792
116%
108%
97%
126%
113%
870
1,099
900
1,187
620
620
310
100
126%
132%
100%
32%
111%
900
1,146
930
854
620
660
310
382
127%
92%
106%
123%
110%
1,395
1,058
930
930
620
460
310
430
76%
100%
74%
139%
88%
930
757
930
1,906
310
340
930
1,330
81%
205%
110%
143%
140%
253
366
1,070
1,199
357
360
713
786
144%
112%
101%
110%
113%
713
681
368
752
357
380
713
863
96%
204%
106%
121%
124%
496
849
1,488
1,554
310
310
620
950
171%
104%
100%
153%
126%
465
661
1,395
1,806
324
403
648
1,134
142%
129%
124%
175%
141%
900
489
1,163
1,345
310
150
620
860
54%
116%
48%
139%
95%
388
743
1,163
1,556
388
413
775
1,363
192%
134%
106%
176%
150%
713
618
713
773
357
414
713
656
87%
108%
116%
92%
99%
775
750
775
825
775
650
388
388
97%
106%
84%
100%
96%
465
599
930
780
333
376
333
387
129%
84%
113%
116%
104%
372
372
1,860
2,092
372
372
744
732
100%
112%
100%
98%
107%
713
599
713
1,063
713
506
713
886
84%
149%
71%
124%
107%
713
951
1,070
1,302
713
391
713
1,277
133%
122%
55%
179%
122%
713
743
713
723
357
357
713
713
104%
101%
100%
100%
102%
713
638
1,426
1,234
713
387
725
932
89%
87%
54%
129%
89%
713
587
1,070
1,284
357
393
1,070
949
82%
120%
110%
89%
100%
1,070
1,011
1,426
1,362
713
495
1,070
1,283
95%
96%
69%
120%
97%
771
806
1,760
1,576
713
536
1,070
1,265
105%
90%
75%
118%
97%
1,070
852
1,426
1,955
713
667
1,426
1,967
80%
137%
94%
138%
117%
900
1,204
1,395
1,802
620
680
620
764
134%
129%
110%
123%
126%
930
930
930
916
310
310
572
593
100%
98%
100%
104%
100%
357
372
713
614
357
357
357
357
104%
86%
100%
100%
95%
759
729
515
452
333
333
333
333
96%
88%
100%
100%
95%
0
837
844
0
434
434
0%
101%
0%
100%
101%
465
606
458
365
310
310
310
310
130%
80%
100%
100%
103%
465
600
930
840
310
310
310
310
129%
90%
100%
100%
102%
713
665
357
375
357
357
357
357
93%
105%
100%
100%
98%
1,048
1,051
459
444
310
310
310
310
100%
97%
100%
100%
99%
29,704
1
1
1
30,649
39,061
46,399
20,185
18,415
26,195
33,356
103%
119%
91%
127%
112%
Comments
x
high volume of 1:1 observations
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Board of Directors: 28th January 2015
Agenda Item: TBP04.3/15
Attachment: O
For Information
By: Richard Bayley, Non-Executive Director & Chair, Finance and Investment
FINANCE AND INVESTMENT COMMITTEE SUMMARY REPORT
SUMMARY & PURPOSE
This report provides a summary of the papers and discussions held at the Finance and Investment
Committee meeting held on the 21st November 2014.
The purpose of this Committee is to drive excellent financial performance and ensure that the Trust
has an investment strategy that supports the business and is financially deliverable. The
Committee is responsible for ensuring that robust scrutiny is in place, taking action to commission
further work as required in the achievement of this objective.
It should be noted that a summary of the Finance and Investment Committee is reported to the
Board on a monthly basis and the paper is public part of the Board and therefore the paper is
available on the Trust’s website. It should also be noted that the full minutes of the meeting are
circulated to all members of the Board for information.
LINK TO ANNUAL PLAN
The Annual Plan objectives this paper relates to include:2. Our Services & Creating New Opportunities
2.3 Review Business Develop Strategy
4. Finance, Information & Performance
4.1 Maintain sound financial performance to deliver financial governance and stability
4.2 Fully deliver the agreed quality, efficiency and productivity programme
4.3 To meet contracted levels of performance
4.4 Review our performance and information reports and implement improvements
5. Estates & Capital
5.1 To improve asset productivity
5.4 To deliver the agreed capital programme
5.5 To improve procurement activity to deliver efficiency
ACTION REQUIRED BY BOARD MEMBERS
The Trust Board is asked to note the contents of this report and ask any questions of the Chair of
the Finance and Investment Committee.
FINANCE AND INVESTMENT COMMITTEE SUMMARY REPORT
1.0 Executive Summary
This report provides a summary of the papers and discussions held at the Finance and Investment
Committee meeting held on the 21st November 2014.
The Committee Received papers on a number of current topics including: Month 7 Financial position
 The Trust’s Agency Reduction Programme and Progress on Recruitment & Retention Plans
 Cost Improvement Programme and Themed Review on Drug Expenditure & Prescribing
 Forecast and Financial Recovery Plan for 2014/15
 Operational Performance
 Contract Update
 Capital Expenditure Report
 Update on Short Term Plans in Adult Services
 Commercial Report
 Estates Strategy
2.0 Introduction
The purpose of this Committee is to drive excellent financial performance and ensure that the Trust
has an investment strategy that supports the business and is financially deliverable. The
Committee is responsible for ensuring that robust scrutiny is in place, taking action to commission
further work as required in the achievement of this objective.
The Finance and Investment Committee meet in the week before the Board meeting. The next
Committee meeting is due to be held on the 23rd January 2015. This report provides a summary of
the meeting held on the 21st November 2014, the main areas of discussion are set out in the body
of the report below.
3.0 Report
Month 7 Financial Report and Cost Improvement Plan for 2014/15
The Committee received a report on the Trust’s financial performance for month 7 noting that
following an improvement in the monthly financial position in September, the monthly position
deteriorated again in October, with a deficit in the month of £322k, before release of reserves.
However, the Trust is now starting to see an improvement in the Trust’s underlying position. After
release of £300k reserves in the month, the Trust is reporting a monthly deficit of £22k and a year
to date deficit of £2,326k. The year to date deficit means that the Trust continues to report a
Continuity of Services Risk Rating of 3, against a planned rating of 4.
The Committee discussed the position for month 7 and acknowledged that whilst the overall
financial position appeared to have stabilised, the challenge was to recover the £2.3m deficit over
the remaining 5 months of the financial year. The Committee noted that the Executive
Management Board (EMB) had considered the month 7 position at its meeting earlier in the week
and were focussed on delivering a position of break even or better by the end of the financial year.
The Committee held a lengthy discussion on the issues and actions that were being taken to
address the areas impacting on financial performance, and asked a number of questions of the
executive directors to gain assurance that the issues contributing to the financial position were
being addressed. A summary of these discussions is set out below:-



Use of Agency Staff & Progress on Recruitment & Retention Plans – the Committee
received an update on the work being undertaken to reduce the use of agency staff, noting
that an Agency Reduction Group had been established to oversee this work. There was
also a discussion regarding the challenges in reducing the use of agency staffing in the
Children and Young people’s Service in Kent and in Adult Services in North West Sussex.
The Committee were also updated on the work being undertaken to procure a number of
key agency supplies to ensure value for money from the agencies that are used.
The Committee also received a report on the work that was being undertaken on
recruitment and retention plans. It was noted that the Human Resources Team have robust
plans in place to support recruitment to the Secure and Forensic Service at Hellingly,
Langley Green Hospital and Kent Children and Young People’s Service.
Cost Improvement Plan – progress on the delivery of the Cost Improvement Programme
(CIP) at month 7 was discussed noting that year to date £4,503k had been saved against a
target of £6,162k, £1,658k less than planned. Concerns over the underperformance, of the
CIP were discussed, with the Committee noting that one of the main risks to the CIP was
the slow progress being made on the Adult Services re-design programme, which was
discussed under a separate agenda item.
Financial Recovery Plan - the Committee were updated on the progress being made to
deliver the Financial Recovery Plan. The Committee noted the new regulatory requirement
for all foundation trusts, requiring trusts to submit a year end forecast on a monthly basis.
The Committee discussed the best, worst and most likely forecast for the year-end financial
position and agreed on the position statement to be submitted to Monitor.
Cost Improvement Programme Themed Review – Drug Expenditure and Prescribing
As part of its on-going themed reviews of the cost improvement plan the Committee received a
presentation from the Trust’s Medical Director and Chief Pharmacist on the work that is being
undertaken to reduce expenditure on drugs and improve prescribing practice.
Operational Performance Report
The Committee received the Performance Reports for Adult and Specialist Services for Month 7,
as well as the Trust wide performance report. The areas that were highlighted for discussion were:


Data Quality – the Committee discussed the work being undertaken to improve data
quality in preparation for the introduction of the new clinical information system and noted
that a paper had been presented to the Audit Committee on the emerging risks around data
quality.
Length of Stay, Delayed Transfers of Care and Readmission Rates – the Committee
were also updated on the work being undertaken to review delayed transfers of care and
readmission rates to better understand the reasons and impact these were having on the
Trust’s bed pressures and use of external placements.
Triangulation of Performance Reporting – it was reported that work was being
undertaken to triangulate the performance reports being reviewed across the Trust to
ensure that there was focus on risks and emerging issues.
Adult Services
The Committee received an update on the work being undertaken in Adult Services, noting the
work was being undertaken in three phases; an immediate detailed budget review, a strategic
review of each local area and the introduction of service improvement plans and new models of
care. The paper to the Committee focused on the outcome of the budget reviews, noting the
findings in each area which will help address the current pressures in the service, as well as
informing the processes and pathways for redesign.
Contract Update
The contract report provided the Committee with details of progress being made on the contract
negotiations for 2015/16. The Committee also received an update on the good progress that was
being made towards delivering the CQUIN schemes for 2014/15.
Capital Expenditure Report & Estates Strategy
The Committee received a report on the progress being made in delivering the capital programme
for 2014/15, providing an update on a number of the schemes. The Committee also received a
paper which provided an update on the development of the Trust’s 5 year estates strategy, noting
that further work to clarify the Trust’s commercial and clinical strategies and business plans was
required before the estates strategy can be finalised.
Commercial Report
The Committee received and discussed the Commercial Report noting the current bids, an update
on current tenders and new developments being considered by the Trust.
4.0 Recommendation/Action Required
The Trust Board is asked to note the contents of this report and ask any questions of the Chair of
the Finance and Investment Committee.
5.0 Next Steps
This report is for discussion. The next Finance & Investment Committee is on 23rd January 2015
and the Chair of the Committee will be able to provide a verbal update on the discussions held at
this meeting, highlighting any matters for action or ratification by the Trust Board.
Sussex Partnership NHS Foundation Trust
Board of Directors: 28 January 2015 – Public
Agenda Item: TBP04.4/15
Attachment: N
For Information
By: Diana Marsland, Non-Executive Director & Chair, Charitable Funds Committee
CHARITABLE FUNDS COMMITTEE SUMMARY REPORT
1.0
EXECUTIVE SUMMARY
1.1
The last meeting of the Charitable Funds Committee was held on the 8th December
2014, this report provides a summary of the meeting.
1.2
Grant making: The Committee agreed an amendment to the grant making
process from the General Fund. All applications to the General Fund will now be
submitted to the Committee to allow for a more strategic approach to grant making
and a closer management of available funds.
Service Managers will no longer be able to approve applications from the General
Fund but will continue to be able to authorise those made to their restricted funds in
line with the agreed approval thresholds. Training for service managers will begin in
the New Year to outline the new funding priorities and application process.
1.3
Terms of Reference: Revised Terms of Reference were agreed by the Committee
to bring them up to date in line with the Association of NHS Charities’
recommendations and the revised grant making process. The Board of Directors is
asked to review and approve the revised Terms of Reference.
1.4
Financial Reports: The Financial Report, Income Analysis and Investment
Update were noted by the Committee.
2.0
MATTERS FOR ACTION OR RATIFICATION BY THE BOARD
The Board are asked to review and approve the amended Terms of Reference for
the Charitable Funds Committee.
3.0
MATTERS FOR ACTION OR RATIFICATION BY OTHER COMMITEES OF THE
TRUST BOARD
There were no matters arising.
4.0
RECOMMENDATION
The Trust Board is asked to review and approve the Terms of Reference and ask
any questions of the Clinical Academic Director.
CHARITABLE FUNDS COMMITTEE
TERMS OF REFERENCE – DECEMBER 2014
1. Background
The Charitable Funds Committee (Committee) exercises the Trust’s function as
sole corporate trustee of Heads On, formerly known as Sussex Partnership NHS
Trust Charity (registered charity number 1051736).
The Trust Board has responsibility for exercising the functions of the Trustee. The
Trust Board delegates these functions to the Committee, within any limits set out
in these Terms of Reference and the charitable funds section of Standing
Financial Instructions.
In relation to Funds Held on Trust, powers exercised by the Trust as corporate
trustee shall be exercised separately and distinctly from those powers exercised
as a Trust.
2. Objectives of the Charitable Funds Committee






To develop the strategy and objectives for the Charity for consideration by
the Board
To oversee the implementation of an infrastructure appropriate to the
efficient and effective running of the Charity
To oversee the development and delivery of the Fundraising Strategy
To oversee the expenditure of the Charity
To oversee the Charity’s investment plans
Monitor the performance of all aspects of the Charity’s activities and
ensure that it adheres to the principles of good governance and complies
with all relevant legal requirements
3. Membership
3.1 The Trustees of Heads On are all members of the Trust Board.
3.2 Members of the Trust Board automatically become Trustees of Heads On
upon appointment to the Board, and will no longer be Trustees when they
leave the Board.
3.3 All Trustees are entitled to be members of the Committee.
3.4 The core Committee membership comprises:

One non-executive Director (Chair & Trustee) - voting

Clinical Academic Director (Deputy Chair) - voting

Two Governors - voting

Executive Director of Finance & Performance (Trustee) - voting

Executive Medical Director (Trustee) - voting

Head of Corporate Finance – non-voting

Head of Fundraising – non-voting

Director of Communications – non-voting

Fundraising Officer (Committee Administrator) – non-voting
3.5 When a member is unable to attend a meeting they may appoint a deputy to
attend on their behalf. The nominated deputy of a Board member will have the
same voting rights as the member; any other deputies will have no vote.
3.6 Other Charity and/or Trust officers may be asked to attend when the
Committee is discussing areas that are the responsibility of that individual.
The Committee may also invite external advisors to attend for appropriate
items.
3.7 The Committee is accountable to the Board of Trustees.
3.8 The Committee will produce a report for the Trust Board following each
Committee meeting.
4. Committee Meetings
4.1 The Committee shall meet at least four times a year.
4.2 It is expected that all members will attend every meeting. Members must
attend at least half of all meetings and may send a deputy on no more than two
occasions during the year.
4.3 The quorum for the meeting shall be: Chair or Deputy Chair, Two Trustees
and One Governor.
4.4 The Charity Committee is authorised by the Board of Trustees to take any
decisions which fall within its terms of reference and are in accordance with the
Scheme of Delegation.
5. “Feeder” Committees to the Committee
5.1 The Committee may establish a sub-committee for a specific purpose. For
example, an Investment sub-committee or a Fundraising/ Appeal Committee for a
particular project.
6. Administration
6.1 It is the duty of the Deputy Chair to ensure that:
 the administration of the Committee is managed efficiently and effectively
 the Committee undertakes the duties assigned to it
 reports to the Committee and actions arising from meetings are completed
in a timely manner
 the chair, operational lead and Committee administrator meet as required
to set agendas and follow-up action points
 meeting papers are circulated at least five days in advance of the meeting
by the administrator and minutes circulated within ten days.
6.2 The Committee administrator’s duties include:
 agreement of the agenda with the Chair and Head of Fundraising
 collation of all meeting papers
 the taking of minutes and keeping a record of action points and issues to
be carried forward
 forward planning of agenda items
 ensuring records of Committee business, terms of reference etc. are
stored appropriately and are retained in line with the corporate record
retention requirements
 reminding contributors of report deadlines
 distributing papers at least five days in advance of meetings
 keeping mailing lists up to date
 recording attendance and drawing the chair’s attention when this needs
follow up action.
 Maintaining a risk register
7. Duties
7.1 The Committee will:
 Act as the committee which discharges the Trust Board’s responsibilities
(as Sole Corporate Trustee) as they relate to Charitable Funds under the
Trust’s custodianship.
 Ensure that the charitable funds held by the Trust are managed in a
manner consistent with the requirements of the relevant regulatory and
statutory frameworks and in accordance with the guidance on NHS
Charities set out by the Charity Commission.
 When in this role act solely in the best interests of Heads On and in a
manner consistent with the Charity Commission’s requirements and
expectations of Charity Trustees.
 Oversee the Charity’s strategy, governance, major plans and key risks on
behalf of the corporate Trustee.









Establish, prioritise and approve major fundraising projects over
(£100,000), and approve major expenditure items over (£100,000). See
Financial standing investments for the full list of authority levels.
Monitor the performance of the fundraising and marketing activity,
ensuring that the return on investment is satisfactory and that income
targets are met
Devise and implement (through a sub-committee where appropriate) an
investment strategy for the Charity, including the appointment and
monitoring of any investment managers.
Receive and review the Annual accounts, incorporating the Statutory
Returns, Reserves Policy, and Trustees’ report in accordance with the
Charity Commission’s Statement of Recommended Practice before
recommendation to the Board for approval.
Promote and encourage charitable giving to the Charity, acting as
ambassadors to raise its profile and fundraising capabilities.
Review and approve the management accounts, annual budgets and
audit arrangements for the Charity.
Note approval of expenditure between £3,001 and £10,000 authorised by
Executive Director of Finance or Chief Executive.
Review grant applications, including full supporting financial information,
and where appropriate approve expenditure, in accordance with the
Delegated Limits for Grant Approval outlined in Section 9.
Approve the recharge of costs from the Trust for services supplied in
relation to managing Funds held on Trust.
8. Authority
8.1 The Committee has delegated authority from the Trust Board and is
authorised to pursue any activity within its Terms of Reference.
8.2 The Committee can seek external advice from any source if necessary, taking
into consideration issues of confidentiality and Standing Financial Instructions.
9. Delegated limits for grants approval
9.1 Service specific restricted funds (open application rounds):
 Approval by Fund Manager (up to £499 per request).
 Approval by Head of Corporate Finance or relevant Service Director (£500 £3,000 per request).
 Approval by Executive Director of Finance & Performance (£3,001 £10,000 per request).
 Approval by Charity Committee (£10,001 - £30,000 per request).
 Approval by Trust Board (greater than £30,000 per request).
9.2 General charitable fund (4 application deadlines per year):
 Approval by Charity Committee (£1 - £30,000 per request).
 Approval by Board of Trustees (greater than £30,000 per request).
10. Monitoring compliance and effectiveness
10.1 In order to support the continual improvement of governance standards, subcommittees of the Trust Board are required to annually:
 review the terms of reference for the Committee, reaffirming the purpose
and objectives
 review an annual work plan, where appropriate
 maintain an up to date Risk Register
 present a written report to the Trust Board
11. Review
11.1 These terms of reference will be reviewed in the summer of 2015, and
annually thereafter.
11.2 These terms of reference can be made available in alternative formats if
required.
Date agreed by group/committee: December 2014
Sussex Partnership NHS Foundation Trust
Board of Directors: 28 January 2015 – Public
Agenda Item: TBP04 .6/15
Attachment: O
For: Information
By: Peter Lee, Head of Corporate Governance
NOTIFICATION OF SEALED DOCUMENTS
Q3 REPORT
1.0
PURPOSE AND RECOMMENDATION
Standing Order 8.3 requires the Board of Directors to receive a report each quarter, on all sealed
documents. This is the Q3 summary report of sealed documents (01 October 2014 to 31
December 2014).
2.0
SEALED DOCUMENTS
No.
276
Date
07.11.2014
277
22.12.2014
278
22.12.2014
279
22.12.2014
280
22.12.2014
281
22.12.2014
282
22.12.2014
283
22.12.2014
284
30.12.2014
Document
Transfer of whole of registered title Land Adjoining New Acute
Unit, Graylingwell Hospital, Graylingwell Drive, Chichester.
Deed of variation in respect of a contract for the sale of freehold
land at Graylingwell Hospital, College Lane, Chichester. SPFT &
Homes and Communities Agency.
Deed of variation to the Project Agreement relating to Midhurst
and Eastbourne District Cottage Hospital, Midhurst. NU Local Care
Centres (Chichester no. 5) Limited & SPFT.
Deed of variation to the Project Agreement relating to Chichester
Health Clinic, Chapel Street, Chichester. NU Local Care Centres
(Chichester no.4) Limited & SPFT.
Deed of variation to the Project Agreement relating to Summerdale
Block, Graylingwell Hospital Site, Chichester. NU Local Care
Centres (Chichester no.3) Limited and SPFT.
Deed of variation to the Project Agreement relating to Havenstoke
House, Graylingwell Hospital, Chichester. NU Local Care Centres
(Chichester no.2) Limited & SPFT.
Deed of variation to the Project Agreement relating to Bognor War
Memorial Hospital, Bognor Regis. NU Local Care Centres
(Chichester no.6) Limited & SPFT.
Deed of variation to the Project Agreement relating to Centurion
Mental Health Unit, former Graylingwell Hospital Site, Chichester.
NU Local Care Centres (Chichester no.1) Limited & SPFT.
Deed of Release & Re-grant of Leasehold Rights relating to
Centurion Mental Health Unit, former Graylingwell Hospital Site,
Chichester between (1) NU Local Care Centres (Chichester no.1)
Limited (2) SPFT (3) Homes and Communities Agency and (4)
Linden Downland Graylingwell LLP.
Board of Directors: 28 January 2015 – Public
Agenda Item: TBP04. 7/15
Attachment: P
For Information
By: Peter Lee, Head of Corporate Governance
FIT & PROPER PERSON TEST
SUMMARY & PURPOSE
To brief the Board of Directors on the implications to them and to the organisation, of
Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations
2014.
LINK TO ANNUAL PLAN
1.1 Provision of Safe Services
ACTION REQUIRED BY BOARD MEMBERS
1) To note the requirements of Regulation 5 of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2014, and
2) To discuss and agree the recommendations listed in section 6.0.
FIT AND PROPER PERSON TEST
1.0 Executive Summary
Regulation 5 (The Fit and Proper Persons: Directors) of the Health and Social Care Act
2008 (Regulated Activities) Regulations 2014 came in to force on 27 November 2014. It is
commonly referred to as the Fit and Proper Persons Test and the current guidance
suggests that broadly speaking a ‘director’ is defined as a member of the Board of
Directors.
Prior to this regulation, providers had a general obligation to ensure that, at appointment,
staff were fit for the role. Now, in addition to these being set in statute, the requirement
extends to existing directors; includes a specific unfit person test (where no discretion is
permitted), and a requirement to test whether a director has been part of any serious
misconduct or mismanagement.
There is some guidance about how these requirements might be most properly applied,
but there are some uncertainties, for example; the precise role the CQC will have in
assessing the fitness of a director; and the specific expectation relating to self-declaration
and communication to the CQC. These are expected to be resolved as the CQC publish
the learning from the early implementation.
In the meantime, Sussex Partnership is taking steps to ensure that it satisfies the
requirements; this includes asking directors to complete an annual self-declaration and
reviewing HR processes to ensure the additional checks needed are made.
2.0 Introduction
The Fit and Proper Person Test was made a statutory requirement as a direct response to
the failings at Winterbourne View Hospital and Mid Staffordshire NHS Foundation Trust.
Prior to this, providers had only a general obligation to ensure that, at appointment, staff
were fit for the role.
The new regulation has a wider impact, in both the scope of its application and the nature
of the test. It now includes the requirement to ensure directors continue to meet the test
and makes it clear that individuals who have authority in organisations that deliver care are
responsible for the overall quality and safety of that care and, as such, can be held
accountable if standards of care do not meet legal requirements.
3.0 The Law
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 prescribe
the kinds of activities that are regulated activities for the purposes of Part 1 of the Health
and Social Care Act 2008 and the requirements that must be met in order to be registered
with the Care Quality Commission (CQC). They replace the 2010 Regulations.
Regulation 5 (Fit and Proper Persons: Directors – (Appendix 1) came in to force from 27
November 2014 and this introduces a new requirement on NHS providers to take proper
steps to ensure directors are fit and proper for their role.
The current guidance suggests that a ‘director’ is defined as:



A member of the board of directors;
Associate positions and/or;
Individuals “performing the functions of or equivalent or similar to the functions of a
director”
Until such time as further guidance is published, the proposal is that we interpret this to
include voting executive and non-executive members of the board, and non-voting board
members.
Paragraph 3 of Regulation 5 sets out the requirement each director must satisfy in order
for the Trust to be able to appoint or allow them to continue in post;
a. … is of good character,
b. …has the qualifications, competence, skills and experience which are necessary for
the relevant office or position or the work for which they are employed
c. …is able by reason of their health, after reasonable adjustments are made, of properly
performing tasks which are intrinsic to the office or position for which they are
appointed or to the work for which they are employed,
d. …has not been responsible for, been privy to, contributed to or facilitated any serious
misconduct1 or mismanagement2 (whether lawful or not) in the course of carrying on a
regulated activity or providing a service elsewhere which, if provided in England, would
be a regulated activity, and
e. None of the grounds of unfitness specified in Part 1 of Schedule 4 (Appendix 2) apply
to the individual.
It is the responsibility of the Chair to ensure that all directors meet these requirements and
do not meet any of the “unfit” criteria. The Chair is required to confirm to the CQC that the
fitness of all new directors has been assessed in line with the regulations, and to declare
to the CQC in writing that they are satisfied that they are fit and proper individuals for that
role. Although the process of this communication to the CQC is currently not very clear.
The significant difference to the previous general obligation is that the regulation sets out
when individuals are prevented from holding office (e.g. under a directors disqualification
order) and, perhaps most significantly, where it excludes from office people who are
judged to fit the criteria in 5(3)(d)
To meet the requirement of Regulation 5 the Trust has to:

1
Provide evidence that appropriate systems are in place to ensure all new directors
and existing directors are, and continue to be, fit and that no appointments meet the
unfitness criteria set out in Schedule 4.
For example; assault; fraud; theft; breach of H&S regulation; intoxication while on duty; breach of confidentiality;
disobedience of lawful and reasonable instruction
2
For example; dealt with responsibilities badly or carelessly; mismanaging funds; not adhering to recognised practice
or guidance.




Make every reasonable effort to assure itself about an individual by all means
available.
Make specified information about directors available to the CQC
Implement procedures based on guidance and best practice
Where a director no longer meets the requirement, take action to ensure the
position is held by a person meeting the requirements.
Breaches can incur fixed financial penalties and the CQC has the statutory power (s.12(5)
of the Act) to place a condition on the Trust’s registration requiring removal of a person,
when that person is deemed to not meet the test.
4.0 The CQC
The CQC will not undertake their own fit and proper person’s test; as this is the
responsibility of the provider. However, they can cross-check notifications about new
directors against other information that they hold or have access to, to decide whether they
wish to look further into the individual’s fitness. In this event they will also have regard to
any other information that they hold or obtain about directors in line with current legislation
on when convictions, bankruptcies or similar matters are to be considered ‘spent’.
Where a director is associated with serious misconduct or responsibility for failure in a
previous role, the CQC will have regard to the seriousness of the failure, how it was
managed, and the individual’s role within that. There is no time limit for considering such
misconduct or responsibility. Where any concerns about an existing director come to the
attention of the CQC, they may also ask the Trust to provide the same assurances.
The CQC does recognise that a provider may not have access to all relevant information
about a person, and that false or misleading information may be supplied to them.
However, they expect providers to demonstrate due diligence in carrying out checks and
that every reasonable effort is made to assure themselves about an individual.
As part of its inspection regime the CQC will ask how the leadership and culture reflects
the vision and values, encourages openness and transparency and promotes quality care.
In doing so it will be seeking to understand whether leaders have the relevant skills,
knowledge and experience, and the capacity and capability to lead effectively.
Value-based recruitment will, therefore, go some way to helping the Trust meet the
requirements of this regulation.
5.0 Requirements and Potential Issues
In meeting the requirements of Regulation 5, the Trust needs to keep under review its HR
processes to ensure that proper measures continue to be taken at appointment and on a
regular basis (at least annually) to ensure on-going compliance. The annual declaration
(Appendix 3) and the table of assurance3 in Appendix 4, which list the checks required, will
assist with this.
Robust and well documented decision-making by the appointment committees will be
required, especially when judging good character and whether paragraph 3 (d) applies.
3
The table of assurance is a working document and will be kept under regular review to ensure it is up-to-date with
guidance and best practice
This might require checking serious case reviews/Ombudsmen reports and, where this
part of the regulation is relevant to an individual, careful assessment is needed. For
example, if a person has been responsible for serious misconduct and/or mismanagement
in carrying out a regulated activity then the regulation is clear that this person must not be
appointed and/or removed from office. If however there has been a conviction on the basis
of the way their entire management team managed the activity of the organisation then
judgement is needed as to the person’s specific role. If the breach/conviction is found to be
directly attributable then the conclusion must be that they are ‘unfit’.
Regulation 5(3)(d) also refers to a person being “privy to…”. This could potentially catch
any director who knew things were wrong. However, the guidance points to a second
factor; failing to take appropriate action to ensure it was addressed. The regulation
underlines that NHS Boards are unitary boards and, as board members regularly receive
papers describing problems, it is unlikely an individual will be criticised if they seek
appropriate assurance; so the test is likely to relate to when issues recur and how well
these are challenged and monitored by board members.
A beneficial consequence of this might be that there is even greater challenge at board
level.
It is noteworthy that while it is not directly referenced in the regulations, the CQC have
recognised that individuals may be fit for their roles while, collectively, the board
demonstrates a lack of fitness. There is no guidance as to how Trusts might assess this
and, in its guidance, the CQC simply state that they will address this on a case by case
basis.
Where a director is deemed to be unfit (by the CQC), the guidance describes the provider
being able to challenge that decision by way of appeal to the First-tier Health and Social
Care Tribunal. It is unclear why the guidance does not include the right of the individual as
one reading of the Care Act 2014 is that this provides a statutory right to both.
Another area needing to be clarified relates to 5(3)(d) – this section refers to a director
being declared unfit if judged to have been “…responsible for, been privy to, contributed to
or facilitated any serious misconduct or mismanagement whether lawful or not…”
However, the guidance from the CQC refers to this relating only to unlawful acts.
Finally, in the event that a director is deemed to no longer meet the Fit and Proper
Persons Test, the Trust will be required by statute to either dismiss the individual or move
to another post. This points to a need to carefully review the contracts of employment of
directors, to give effect to this requirement.
6.0 Recommendation/Action Required
It recommended that:
1) We determine the scope of this regulation to cover;
i. voting executive and non-executive members of the board, and
ii. non-voting board members
2) We introduce with immediate effect;
i) the additional checks as set out in Appendix 4, which identifies the specific
requirements of the fit and proper persons test and sets alongside those
requirements and how the Trust intends to assure itself about the suitability of
individuals.
ii) The annual declaration at Appendix 3
7.0 Next Steps
1) The Head of Corporate Governance will work closely with the People Director and the
Chair, to ensure all the requirements of Regulation 5 are met.
2) Directors will be sent the annual declaration to be completed and returned to the Head
of Corporate Governance within 2 weeks of receipt.
3) The Head of Corporate Governance will maintain a register of these declarations and
ensure they are updated annually and more frequently, as required.
4) The Head of Corporate Governance will ensure the Board is updated following any
newly published guidance affecting how we might best manage our obligations under
this regulation.
Status: This is the original version (as it was originally made). This
item of legislation is currently only available in its original format.
S TAT U T O R Y I N S T R U M E N T S
2014 No. 2936
The Health and Social Care Act 2008
(Regulated Activities) Regulations 2014
PART 3
SECTION 1
Requirements in relation to Regulated Activities
Requirements relating to persons carrying on or managing a regulated activity
Fit and proper persons: directors
Fit and proper persons: directors
5. (1) This regulation applies where a service provider is a health service body.
(2) Unless the individual satisfies all the requirements set out in paragraph (3), the service
provider must not appoint or have in place an individual—
(a) as a director of the service provider, or
(b) performing the functions of, or functions equivalent or similar to the functions of, such
a director.
(3) The requirements referred to in paragraph (2) are that—
(a) the individual is of good character,
(b) the individual has the qualifications, competence, skills and experience which are
necessary for the relevant office or position or the work for which they are employed,
(c) the individual is able by reason of their health, after reasonable adjustments are made, of
properly performing tasks which are intrinsic to the office or position for which they are
appointed or to the work for which they are employed,
(d) the individual has not been responsible for, been privy to, contributed to or facilitated any
serious misconduct or mismanagement (whether unlawful or not) in the course of carrying
on a regulated activity or providing a service elsewhere which, if provided in England,
would be a regulated activity, and
(e) none of the grounds of unfitness specified in Part 1 of Schedule 4 apply to the individual.
(4) In assessing an individual’s character for the purposes of paragraph (3)(a), the matters
considered must include those listed in Part 2 of Schedule 4.
(5) The following information must be available to be supplied to the Commission in relation to
each individual who holds an office or position referred to in paragraph (2)(a) or (b)—
(a) the information specified in Schedule 3, and
(b) such other information as is required to be kept by the service provider under any
enactment which is relevant to that individual.
Document Generated: 2014-11-19
Status: This is the original version (as it was originally made). This
item of legislation is currently only available in its original format.
(6) Where an individual who holds an office or position referred to in paragraph (2)(a) or (b) no
longer meets the requirements in paragraph (3), the service provider must—
(a) take such action as is necessary and proportionate to ensure that the office or position in
question is held by an individual who meets such requirements, and
(b) if the individual is a health care professional, social worker or other professional registered
with a health care or social care regulator, inform the regulator in question.
2
Document Generated: 2014-12-14
Status: This is the original version (as it was originally made). This
item of legislation is currently only available in its original format.
SCHEDULE 4
Regulation 5
Good character and unfit person tests
PART 1
Unfit person test
1. The person is an undischarged bankrupt or a person whose estate has had sequestration
awarded in respect of it and who has not been discharged.
2. The person is the subject of a bankruptcy restrictions order or an interim bankruptcy
restrictions order or an order to like effect made in Scotland or Northern Ireland.
3. The person is a person to whom a moratorium period under a debt relief order applies under
Part VIIA (debt relief orders) of the Insolvency Act 1986(1).
4. The person has made a composition or arrangement with, or granted a trust deed for, creditors
and not been discharged in respect of it.
5. The person is included in the children’s barred list or the adults’ barred list maintained under
section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained
under an equivalent enactment in force in Scotland or Northern Ireland.
6. The person is prohibited from holding the relevant office or position, or in the case of an
individual from carrying on the regulated activity, by or under any enactment.
PART 2
Good character
7. Whether the person has been convicted in the United Kingdom of any offence or been
convicted elsewhere of any offence which, if committed in any part of the United Kingdom, would
constitute an offence.
8. Whether the person has been erased, removed or struck-off a register of professionals
maintained by a regulator of health care or social work professionals.
(1)
1986 c. 45. Part VIIA was inserted by section 108 of, and Schedule 17 to, the Tribunals, Courts and Enforcement Act 2007
(c. 15).
1
Appendix 3
Fit and Proper Persons Test
Annual Declaration
For
Director and Director-equivalent Posts
DECLARATION:
1.
It is a condition of employment that those holding director and director-equivalent posts
provide on appointment and thereafter on demand, confirmation in writing of their fitness to
hold such posts. Your post has been designated as being such a post. Fitness to hold such a
post is determined in a number of ways, including (but not exclusively) by the Trust’s Provider
Licence, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and the
Trust’s Constitution.
2.
By signing this declaration you are confirming that;
i.
you do not fall within the definition of an “unfit person” or any other criteria set out
below, and that you are not aware of any pending proceedings or matter which may
call such a declaration into question.
ii.
you understand and, will comply with your obligation to disclose any matters that may
arise from the date you sign this declaration and which may affect your fitness to hold
your post thereafter.
Provider licence
3.
Condition G4(2) of Sussex Partnership NHS Foundation Trust’s Provider Licence (“the
Licence”) provides that the Licensee shall not appoint as a director any person who is an unfit
person, except with the approval in writing of Monitor.
4.
Licence Condition G4(3) requires the Licensee to ensure that its contracts of service with its
directors contain a provision permitting summary termination in the event of a director being or
becoming an unfit person. The Licence also requires the Licensee to enforce that provision
promptly upon discovering any director to be an unfit person, except with the approval in
writing of Monitor.
2
5.
An “unfit person” is defined at condition G4(5) of the Licence as:
(a) an individual;
i.
who has been adjudged bankrupt or whose estate has been sequestrated and (in either
case) has not been discharged; or
ii.
who has made a composition or arrangement with, or granted a trust deed for, his
creditors and has not been discharged in respect of it; or
iii.
who within the preceding five years has been convicted in the British Islands of any
offence and a sentence of imprisonment (whether suspended or not) for a period of not
less than three months (without the option of a fine) was imposed on him; or
iv.
who is subject to an unexpired disqualification order made under the Company
Directors’ Disqualification Act 1986; or
(b) a body corporate, or a body corporate with a parent body corporate:
i.
where one or more of the Directors of the body corporate or of its parent body corporate
is an unfit person under the provisions of sub-paragraph (a) of this paragraph, or
ii.
in relation to which a voluntary arrangement is proposed under section 1 of the
Insolvency Act 1986, or
iii.
which has a receiver (including an administrative receiver within the meaning of section
29(2) of the 1986 Act) appointed for the whole or any material part of its assets or
undertaking, or
iv.
which has an administrator appointed to manage its affairs, business and property in
accordance with Schedule B1 to the 1986 Act, or
v.
which passes any resolution for winding up, or
vi.
which becomes subject to an order of a Court for winding up.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
6.
Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
states that the Trust must not appoint or have in place an individual as a director, or
performing the functions of or equivalent or similar to the functions of, such a director, if they
do not satisfy all the requirements set out in paragraph 3 of that Regulation.
7.
The requirements of paragraph 3 are that:
(a) the individual is of good character;
(b) the individual has the qualifications, competence, skills and experience which are
necessary for the relevant office or position or the work for which they are employed;
Fit and Proper Persons Test - Annual Declaration
January 2015
3
(c) the individual is able by reason of their health, after reasonable adjustments are made, of
properly performing tasks which are intrinsic to the office or position for which they are
appointed or to the work for which they are employed;
(d) the individual has not been responsible for, privy to, contributed to or facilitated any serious
misconduct or mismanagement (whether unlawful or not) in the course of carrying on a
regulated activity or providing a service elsewhere which, if provided in England, would be
a regulated activity; and
(e) none of the grounds of unfitness specified in Part 1 of Schedule 4 apply to the individual.
8.
The grounds of unfitness specified in Part 1 of Schedule 4 are:
(a) the person is an un-discharged bankrupt or a person whose estate has had sequestration
awarded in respect of it and who has not been discharged;
(b) the person is the subject of a bankruptcy restrictions order or an interim bankruptcy
restrictions order or an order to like effect made in Scotland or Northern Ireland;
(c) the person is a person to whom a moratorium period under a debt relief order applies under
Part VIIA (debt relief orders) of the Insolvency Act 1986;
(d) the person has made a composition or arrangement with, or granted a trust deed for,
creditors and not been discharged in respect of it;
(e) the person is included in the children’s barred list or the adults’ barred list maintained under
section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list
maintained under an equivalent enactment in force in Scotland or Northern Ireland;
(f) the person is prohibited from holding the relevant office or position, or in the case of an
individual for carrying on the regulated activity, by or under any enactment.
Trust’s Constitution
9.
The Trust’s constitution places a number of restrictions on an individual’s ability to become or
continue as a director. Paragraph 26 states that a person may not become or continue as a
member of the Board of Directors if:
i.
ii.
iii.
iv.
v.
vi.
a person who has been adjudged bankrupt or whose estate has been sequestrated and
(in either case) has not been discharged.
a person who has made a composition or arrangement with, or granted a trust deed for,
his creditors and has not been discharged in respect of it.
a person who within the preceding five years has been convicted in the British Isles of
any offence if a sentence of imprisonment (whether suspended or not) for a period of
not less than three months (without the option of a fine) was imposed on him.
They are the spouse, partner, parent or child of a member of the board of directors
They are subject to a disqualification order made under the Company Directors’
Disqualification Act 1986
He has had his name removed from a list maintained under regulations pursuant to
sections 91, 106, 123 or 146 of the 2006 Act, or the equivalent lists maintained by Local
Fit and Proper Persons Test - Annual Declaration
January 2015
4
vii.
viii.
ix.
x.
xi.
xii.
Health Boards in Wales under the National Health Service (Wales) Act 2006, and he
has not subsequently had his name included in such a list.
In the case of a non-executive director they are no longer a member of one of the public
or service user constituencies.
In the case of the non-executive director nominated by the Medical School, that they no
longer exercise these functions on behalf of the Medical School.
They have within the preceding two years been dismissed, otherwise than by reason of
redundancy from any paid employment with a health service body.
They have a tenure of office as a chair or as a member or as a director of a health
service body terminated on the grounds that their appointment is not in the interests of
the health service, for non-attendance at meetings or for non-disclosure of a pecuniary
interest.
In case of a non-executive director if they have failed without reasonable cause to fulfil
any training requirement established by the council governors.
They have refused to sign and deliver to the Secretary a statement in the prescribed
format confirming acceptance of a Code of Conduct for Directors.
I acknowledge the extracts from the Provider Licence, Health and Social Care Act 2008
(Regulated Activities) Regulations 2014, and the Trust’s Constitution above, and I confirm that
I do not fit within the definition of an “unfit person” as listed above and that there are no other
grounds under which I would be ineligible to continue in post. I undertake to notify the Trust
immediately if I no longer satisfy the criteria to be a “fit and proper person” or other grounds under
which I would be ineligible to continue in post come to my attention.
Name: ____________________________
Signed: ______________________________
Position: ___________________________ Date: _______________________
Fit and Proper Persons Test - Annual Declaration
January 2015
Appendix 4
Regulation 5: Fit and Proper Person Requirement for Directors
STANDARD
ASSURANCE
Providers should make every effort to ensure that all
available information is sought to assess whether the
individual is of good character, taking account of the
two matters that must be considered pursuant to Part
2 of Schedule 4 of the regulations;
Employment checks are undertaken in accordance with
NHS Employers pre-employment check standards and
include:
 Two references, one of which must be most recent
employer and cover a period of 3-years
 qualification and professional registration checks
 right to work checks
 proof of identity checks
 occupational health clearance
 DBS checks (where appropriate)
 Search of insolvency and bankruptcy register
 Search of disqualified directors register
References
Fit and Proper Person Annual Declaration
Annual self-declaration forms
1. Whether the person has been convicted in the
United Kingdom of any offence or been
convicted elsewhere of any offence which, if
committed in any part of the United Kingdom,
would constitute an offence.
2. Whether the person has been erased,
removed or struck-off a register of
professionals maintained by a regulator of
health care or social work professionals.
EVIDENCE
Other pre-employment checks
DBS checks where appropriate
Signed declarations from
applicants
Register search results
References
Employment Checks policy
Recruitment policy and procedure
If information is discovered that suggests an individual
is not of good character after they have been
appointed to a role, the provider must take
appropriate and timely action to investigate and rectify
the matter.
Disciplinary policy and procedure provides for such
investigations.
Medical revalidation process applies for some Directors
inclusive of probity disclosures.
1
Contracts of employment
Statement of terms and conditions
Terms and conditions of service
agreements (for NEDs)
Disciplinary policy and procedure
Medical Revalidation legislation
(License to Practice and
Revalidation Regulations 2012)
Where a provider deems the individual suitable
despite not meeting the characteristics outlined in
Part 2 of Schedule 4, the reasons should be recorded
and information about the decision should be made
available to those that need to be aware.
Discussion and debate at the Appointment and
Remuneration and Nomination and Remuneration
Committees.
Where specific qualifications are deemed by the
provider as necessary for a role, the provider must
make this clear and should only employ those
individuals that meet the required specification,
including any requirements to be registered with a
professional regulator.
This requirement is included within the job description and
person specification for relevant posts and is checked as
part of the pre-employment checks.
The provider should have appropriate processes for
assessing and checking that the individual holds the
required qualifications and has the competence, skills
and experience required, (which may include
appropriate communication and leaderships skills and
a caring and compassionate nature), to undertake the
role; these should be followed in all cases and
relevant records kept.
Employment checks include a candidate’s qualifications
and employment references.
The recruitment process also includes values-based
questions.
Minutes of meetings and records
from the recruitment process.
Decision-making process recorded.
The Chair would take advice from internal and external
advisors as appropriate.
Person specification
Employment Checks policy
Recruitment policy and procedure
Recruitment policy and procedure
Employment Checks policy
Values-based questions
Professional Register Checks
2
Record of interview
The provider may consider that an individual can be
appointed to a role based on their qualifications, skills
and experience with the expectation that they will
develop specific competence to undertake the role
within a specified timeframe.
Any such decision would be discussed by the Appointment
and Remuneration Committee or Nomination and
Remuneration Committee and would be minuted.
When appointing relevant individuals the provider has
processes for considering a person’s physical and
mental health in line with the requirements of the role,
all subject to equalities and employment legislations
and to due process.
All post-holders are subject to clearance by occupational
health as part of the pre-employment process.
Wherever possible, reasonable adjustments are made
in order that an individual can carry out the role.
This is included in Trust Policy
The provider has processes in place to assure itself
that the individual has not been at any time
responsible for, privy to, contributed to, or facilitated,
any serious misconduct or mismanagement in the
carrying on of a regulated activity; this includes
investigating any allegation of such potential
behaviour. Where the individual is professionally
qualified, it may include fitness to practise
proceedings and professional disciplinary cases.
This has been incorporated as a specific declaration to
cover the pre-employment process, through the references
validation process and as part of the annual declaration
process.
Actions would be subject to follow-up as part of on-going
review and appraisal.
Director appraisal framework
NED competence framework
Record of interview
Employment Checks policy
Occupational health clearance
process including self-declaration
from individual
Equality and Diversity Policy
Pre-employment declaration
References covering the last 3
years
Annual Declaration returns
“Responsible for, contributed to or facilitated” means
that there is evidence that a person has intentionally
3
or through neglect behaved in a manner which would
be considered to be or would have led to serious
misconduct or mismanagement.
“Privy to” means that there is evidence that a person
was aware of serious misconduct or mismanagement
but did not take the appropriate action to ensure it
was addressed.
“Serious misconduct or mismanagement” means
behaviour that would constitute a breach of any
legislation/enactment CQC deems relevant to meeting
these regulations or their component parts.”
The provider must not appoint any individual who has
been responsible for, privy to, contributed to, or
facilitated, any serious misconduct or
mismanagement (whether lawful or not) in the
carrying on of a regulated activity; this includes
investigating any allegation of such potential
behaviour. Where the individual is professionally
qualified, it may include fitness to practise
proceedings and professional disciplinary cases.
This has been incorporated as a specific declaration as
part of the pre-employment process and through the
references validation process.
Recruitment Interview pack
HR Policies
Annual Self-Declaration
Only individuals who will be acting in a role that falls
within the definition of a “regulated activity” as defined
by the Safeguarding Vulnerable Groups Act 2006 will
be eligible for a check by the Disclosure and Barring
Service (DBS).
NB – The CQC recognises that it may not always be
possible for providers to access a DBS check as an
individual may not be eligible.
DBS checks are undertaken only for those posts which fall
within the definition of a “regulated activity” or which are
otherwise eligible for such a check to be undertaken.
Employment Checks policy
DBS checks for eligible postholders only in line with the Act.
As part of the recruitment/appointment process,
DBS checks are undertaken only for those posts which fall
Employment Checks policy
4
Reference Returns
providers should establish whether the individual is on
a relevant DBS barring list.
within the definition of a “regulated activity” or which are
otherwise eligible for such a check to be undertaken.
DBS checks for eligible postholders
DBS periodic checks for eligible
post-holders (every 3 years)
The fitness of directors is regularly reviewed by the
provider to ensure that they remain fit for the role they
are in; the provider should determine how often
fitness must be reviewed based on the assessed risk
to business delivery and/or the service users posed
by the individual and/or role.
The provider has arrangements in place to respond to
concerns about a person’s fitness after they are
appointed to a role, identified by itself or others, and
these are adhered to.
Post-holders undertake annual declarations of fitness to
continue in post.
Annual declaration returns
Appraisal process
Statement of Terms and
Conditions
Revised contracts
Capability policy
Disciplinary policy
Maintaining High Professional
Standards (Disciplinary Process
for Medical Staff)
Raising Concerns
(Whistleblowing) policy
Grievance policy
5
Contracts of employment
The provider investigates, in a timely manner, any
concerns about a person’s fitness or ability to carry
out their duties, and where concerns are
substantiated, proportionate, timely action is taken;
the provider must demonstrate due diligence
This will be undertaken if concerns are identified and
revised contracts provide for termination if individuals fail
to meet necessary standards
Statement of Terms and
Conditions
Capability policy
Disciplinary policy
Maintaining High Professional
Standards (Disciplinary Process
for Medical Staff)
Raising Concerns
(Whistleblowing) policy
Grievance policy
Where a person’s fitness to carry out their role is
being investigated, appropriate interim measures may
be required to minimise any risk to service users.
This would be reviewed when concerns are identified
Revised employment contracts for
relevant directors
Disciplinary policy
Maintaining High Professional
Standards (Disciplinary Process
for Medical Staff)
Capability Policy
Raising Concerns
(Whistleblowing) policy
The provider informs others as appropriate about
concerns/findings relating to a person’s fitness; for
example, professional regulators, CQC and other
This would be completed if any concerns were identified.
Maintaining High Professional
Standards (Disciplinary Process
6
relevant bodies, and supports any related
enquiries/investigations carried out by others.
for Medical Staff)
Disciplinary policy
Internal safeguarding referral
process
External safeguarding referral
process
7
Board of Directors: 28 January 2015 – Public
Agenda Item: TBP04.8/15
Attachment: Q
For Information
By: Peter Lee, Head of Corporate Governance
FUNDEMENTAL STANDARDS - DUTY OF CANDOUR
SUMMARY & PURPOSE
This paper is to brief the Board of Directors on the steps being taken to ensure compliance
with the new Fundamental Standards as contained within the Health and Social Care Act
2008 (Regulated Activities) Regulations 2014, and to update it as to the steps already
taken in relation to the one standard which has already come in to force; Duty of Candour.
LINK TO ANNUAL PLAN
Impacts in varying degrees on each objective
ACTION REQUIRED BY BOARD MEMBERS
1) To note the changes to the regulations and the requirement of the Board
2) To discuss and agree the recommendations listed in section 5.0.
FUNDEMENTAL STANDARDS – DUTY OF CANDOUR
1.0 Executive Summary
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 introduce
twelve Fundamental Standards which replace the previous Essential Standards. Save for
the Duty of Candour (Regulation 20) which came in to force on 27 November 2014 these
standards take effect from 1 April 2015.
The Duty of Candour builds on the existing contractual requirement of NHS Trusts to be
candid. The well-established Being Open Policy evidences Sussex Partnership’s
commitment to this; for example, our long-standing procedure of involving patients and
families in Serious Incident investigations. Regulation 20 makes this now a statutory
requirement and extends what we already had in place with regard to serious incidents, by
including incidents of moderate harm and prescribing a duty to notify the ‘relevant person’
and providing them with reasonable support.
The Trust has taken steps to help ensure this new requirement is well understood by staff
and that it forms part of the procedure for reporting and managing incidents. This has
included reviewing the Being Open Policy.
As the duty to meet each of the Fundamental Standards rests with the organisation, the
Board of Directors will receive a report in March which will set out the steps taken to
ensure compliance, and will then receive periodic updates so it is kept informed about the
duty and how it is being discharged.
2.0 Introduction
The new Fundamental Standards set in law a clear baseline below which care must not
fall. In preparation for this, the Trust has been developing existing and creating new
systems to ensure compliance.
One of the standards, the Duty of Candour, came in to force on 27 November 2014. This is
perhaps the most high profile of the standards and is primarily the means to ensure that
patients are told when something goes wrong. In this sense, it essentially enshrines best
practice in to statute.
While the statutory obligation is on providers, not individuals, work has been undertaken to
make sure staff are reminded of their own professional and ethical duties of candour, so
that we always act in an open and transparent way with relevant persons in relation to care
and treatment provided to service users.
3.0 Fundamental Standards - The Law
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 prescribe
the kinds of activities that are regulated activities for the purposes of Part 1 of the Health
and Social Care Act 2008 and the requirements that must be met in order to be registered
with the Care Quality Commission (CQC). They replace the 2010 Regulations and make
important changes to health and social care standards which are regulated by the CQC –
Fundamental Standards.
They arise at least in part from the failings identified at Mid Staffordshire NHS Foundation
Trust, and one of the subsequent recommendations that enforcement of fundamental
standards were needed.
There are 12 Fundamental Standards (Appendix 1) and they replace the previous
Essential Standards, which were contained within the 2010 regulations. They are:
9. Person Centred Care
10. Dignity and Respect
11. Need for Consent
12. Safe Care and Treatment
13. Safeguarding services users from abuse
14. Meeting nutritional and hydration needs
15. Premises and Equipment
16. Receiving and Acting on Complaints
17. Good Governance
18. Staffing
19. Fit and Proper Persons Employed
20. Duty of Candour
Save for the Duty of Candour which came in to force from 27 November 2014, these
standards apply from 1 April 2015 and come with the force of criminal law1 behind them.
The Essential Standards they replace were relatively less onerous; the CQC needed for
example to give prior notice of any breaches before initiating criminal prosecution. In
practice, these warning notices were effectively a means to an end. The risk of prosecution
and conviction is therefore now significantly increased and, while the penalties (fines) are
quite modest, the greatest impact will be reputational.
4.0 Meeting the Requirements
Supported by the Governance Support Team, the Trust is taking steps to ensure robust
systems and processes are in place which ensures each Fundamental Standard is met.
For example, a handbook has been drafted and is currently being consulted on, aimed at
guiding staff in how to best monitor compliance. Work is also being undertaken to develop
a new performance/quality dashboard which will be based on the five CQC domains,
incorporating the fundamental standards.
The Board needs to continue to assure itself that the systems in place deliver compliance.
This will require receiving periodic reports about how the duties are being met and the
1
Fundamental Standards in BOLD carry risk of criminal prosecution without notice
Board can test this against other related data it receives, such as incidents and
complaints.
With regard to the Duty of Candour and the scope now extending to incidents of moderate
harm, the Governance Support Team has introduced new systems of ensuring compliance
against the requirement to keep ‘relevant persons’ informed. This is part of the incident
reporting and management procedure and the Being Open Policy.
The Board should be aware however that, as part of the evidence gathering for the recent
CQC inspection, some gaps in compliance was identified. Immediate corrective action was
taken as a result and, in addition, closer monitoring introduced.
5.0 Recommendation/Action Required
It is recommended that:
1. The Board receives a report in March 2015, setting out the progress towards
meeting the fundamental standards which come in to force from 1 April 2015.
2. The Board receives periodic reports – perhaps bi-annually – giving assurance on
how the Trust is discharging its duty in relation to the fundamental standards.
3. On behalf of the Board, the Quality Committee ensures and monitors that systems
and processes continue to be in place and, by exception, reports to the Board when
gaps are identified.
6.0 Next Steps
Led by the Governance Support Team, work will continue to ensure systems are in place
in time for 1 April 2015 and, taking account of any further guidance, that training and
advice is provided to ensure compliance.
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S TAT U T O R Y I N S T R U M E N T S
2014 No. 2936
The Health and Social Care Act 2008
(Regulated Activities) Regulations 2014
PART 3
Requirements in relation to Regulated Activities
SECTION 2
Fundamental Standards
General
8. (1) A registered person must comply with regulations 9 to 19 in carrying on a regulated activity.
(2) But paragraph (1) does not require a person to do something to the extent that what is required
to be done to comply with regulations 9 to 19 has already been done by another person who is a
registered person in relation to the regulated activity concerned.
(3) For the purposes of determining under regulations 9 to 19 whether a service user who is 16
or over lacks capacity, sections 2 and 3 of the 2005 Act (people who lack capacity) apply as they
apply for the purposes of that Act.
Person-centred care
9. (1) The care and treatment of service users must—
(a) be appropriate,
(b) meet their needs, and
(c) reflect their preferences.
(2) But paragraph (1) does not apply to the extent that the provision of care or treatment would
result in a breach of regulation 11.
(3) Without limiting paragraph (1), the things which a registered person must do to comply with
that paragraph include—
(a) carrying out, collaboratively with the relevant person, an assessment of the needs and
preferences for care and treatment of the service user;
(b) designing care or treatment with a view to achieving service users’ preferences and
ensuring their needs are met;
(c) enabling and supporting relevant persons to understand the care or treatment choices
available to the service user and to discuss, with a competent health care professional or
other competent person, the balance of risks and benefits involved in any particular course
of treatment;
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(d) enabling and supporting relevant persons to make, or participate in making, decisions
relating to the service user’s care or treatment to the maximum extent possible;
(e) providing opportunities for relevant persons to manage the service user’s care or treatment;
(f) involving relevant persons in decisions relating to the way in which the regulated activity
is carried on in so far as it relates to the service user’s care or treatment;
(g) providing relevant persons with the information they would reasonably need for the
purposes of sub-paragraphs (c) to (f);
(h) making reasonable adjustments to enable the service user to receive their care or treatment;
(i) where meeting a service user’s nutritional and hydration needs, having regard to the service
user’s well-being.
(4) Paragraphs (1) and (3) apply subject to paragraphs (5) and (6).
(5) If the service user is 16 or over and lacks capacity in relation to a matter to which this
regulation applies, paragraphs (1) to (3) are subject to any duty on the registered person under the
2005 Act in relation to that matter.
(6) But if Part 4 or 4A of the 1983 Act applies to a service user, care and treatment must be
provided in accordance with the provisions of that Act.
Dignity and respect
10. (1) Service users must be treated with dignity and respect.
(2) Without limiting paragraph (1), the things which a registered person is required to do to
comply with paragraph (1) include in particular—
(a) ensuring the privacy of the service user;
(b) supporting the autonomy, independence and involvement in the community of the service
user;
(c) having due regard to any relevant protected characteristics (as defined in section 149(7)
of the Equality Act 2010) of the service user.
Need for consent
11. (1) Care and treatment of service users must only be provided with the consent of the relevant
person.
(2) Paragraph (1) is subject to paragraphs (3) and (4).
(3) If the service user is 16 or over and is unable to give such consent because they lack capacity
to do so, the registered person must act in accordance with the 2005 Act.
(4) But if Part 4 or 4A of the 1983 Act applies to a service user, the registered person must act
in accordance with the provisions of that Act.
(5) Nothing in this regulation affects the operation of section 5 of the 2005 Act, as read with
section 6 of that Act (acts in connection with care or treatment).
Safe care and treatment
12. (1) Care and treatment must be provided in a safe way for service users.
(2) Without limiting paragraph (1), the things which a registered person must do to comply with
that paragraph include—
(a) assessing the risks to the health and safety of service users of receiving the care or
treatment;
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(b) doing all that is reasonably practicable to mitigate any such risks;
(c) ensuring that persons providing care or treatment to service users have the qualifications,
competence, skills and experience to do so safely;
(d) ensuring that the premises used by the service provider are safe to use for their intended
purpose and are used in a safe way;
(e) ensuring that the equipment used by the service provider for providing care or treatment
to a service user is safe for such use and is used in a safe way;
(f) where equipment or medicines are supplied by the service provider, ensuring that there are
sufficient quantities of these to ensure the safety of service users and to meet their needs;
(g) the proper and safe management of medicines;
(h) assessing the risk of, and preventing, detecting and controlling the spread of, infections,
including those that are health care associated;
(i) where responsibility for the care and treatment of service users is shared with, or
transferred to, other persons, working with such other persons, service users and other
appropriate persons to ensure that timely care planning takes place to ensure the health,
safety and welfare of the service users.
Safeguarding service users from abuse and improper treatment
13. (1) Service users must be protected from abuse and improper treatment in accordance with
this regulation.
(2) Systems and processes must be established and operated effectively to prevent abuse of
service users.
(3) Systems and processes must be established and operated effectively to investigate,
immediately upon becoming aware of, any allegation or evidence of such abuse.
(4) Care or treatment for service users must not be provided in a way that—
(a) includes discrimination against a service user on grounds of any protected characteristic
(as defined in section 4 of the Equality Act 2010) of the service user,
(b) includes acts intended to control or restrain a service user that are not necessary to prevent,
or not a proportionate response to, a risk of harm posed to the service user or another
individual if the service user was not subject to control or restraint,
(c) is degrading for the service user, or
(d) significantly disregards the needs of the service user for care or treatment.
(5) A service user must not be deprived of their liberty for the purpose of receiving care or
treatment without lawful authority.
(6) For the purposes of this regulation—
“abuse” means—
(a)
any behaviour towards a service user that is an offence under the Sexual Offences Act
2003(1),
(b)
ill-treatment (whether of a physical or psychological nature) of a service user,
(c)
theft, misuse or misappropriation of money or property belonging to a service user, or
(d)
neglect of a service user.
(7) For the purposes of this regulation, a person controls or restrains a service user if that person—
(1)
2003 c. 42.
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(a) uses, or threatens to use, force to secure the doing of an act which the service user resists, or
(b) restricts the service user’s liberty of movement, whether or not the service user resists,
including by use of physical, mechanical or chemical means.
Meeting nutritional and hydration needs
14. (1) The nutritional and hydration needs of service users must be met.
(2) Paragraph (1) applies where—
(a) care or treatment involves—
(i) the provision of accommodation by the service provider, or
(ii) an overnight stay for the service user on premises used by the service for the purposes
of carrying on a regulated activity, or
(b) the meeting of the nutritional or hydration needs of service users is part of the arrangements
made for the provision of care or treatment by the service provider.
(3) But paragraph (1) does not apply to the extent that the meeting of such nutritional or hydration
needs would—
(a) result in a breach of regulation 11, or
(b) not be in the service user’s best interests.
(4) For the purposes of paragraph (1), “nutritional and hydration needs” means—
(a) receipt by a service user of suitable and nutritious food and hydration which is adequate
to sustain life and good health,
(b) receipt by a service user of parenteral nutrition and dietary supplements when prescribed
by a health care professional,
(c) the meeting of any reasonable requirements of a service user for food and hydration arising
from the service user’s preferences or their religious or cultural background, and
(d) if necessary, support for a service user to eat or drink.
(5) Section 4 of the 2005 Act (best interests) applies for the purposes of determining the best
interests of a service user who is 16 or over under this regulation as it applies for the purposes of
that Act.
Premises and equipment
15. (1) All premises and equipment used by the service provider must be—
(a) clean,
(b) secure,
(c) suitable for the purpose for which they are being used,
(d) properly used
(e) properly maintained, and
(f) appropriately located for the purpose for which they are being used.
(2) The registered person must, in relation to such premises and equipment, maintain standards
of hygiene appropriate for the purposes for which they are being used.
(3) For the purposes of paragraph (1)(b), (c), (e) and (f), “equipment” does not include equipment
at the service user’s accommodation if—
(a) such accommodation is not provided as part of the service user’s care or treatment, and
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(b) such equipment is not supplied by the service provider.
Receiving and acting on complaints
16. (1) Any complaint received must be investigated and necessary and proportionate action
must be taken in response to any failure identified by the complaint or investigation.
(2) The registered person must establish and operate effectively an accessible system for
identifying, receiving, recording, handling and responding to complaints by service users and other
persons in relation to the carrying on of the regulated activity.
(3) The registered person must provide to the Commission, when requested to do so and by no
later than 28 days beginning on the day after receipt of the request, a summary of—
(a) complaints made under such complaints system,
(b) responses made by the registered person to such complaints and any further
correspondence with the complainants in relation to such complaints, and
(c) any other relevant information in relation to such complaints as the Commission may
request.
Good governance
17. (1) Systems or processes must be established and operated effectively to ensure compliance
with the requirements in this Part.
(2) Without limiting paragraph (1), such systems or processes must enable the registered person,
in particular, to—
(a) assess, monitor and improve the quality and safety of the services provided in the carrying
on of the regulated activity (including the quality of the experience of service users in
receiving those services);
(b) assess, monitor and mitigate the risks relating to the health, safety and welfare of service
users and others who may be at risk which arise from the carrying on of the regulated
activity;
(c) maintain securely an accurate, complete and contemporaneous record in respect of each
service user, including a record of the care and treatment provided to the service user and
of decisions taken in relation to the care and treatment provided;
(d) maintain securely such other records as are necessary to be kept in relation to—
(i) persons employed in the carrying on of the regulated activity, and
(ii) the management of the regulated activity;
(e) seek and act on feedback from relevant persons and other persons on the services provided
in the carrying on of the regulated activity, for the purposes of continually evaluating and
improving such services;
(f) evaluate and improve their practice in respect of the processing of the information referred
to in sub-paragraphs (a) to (e).
(3) The registered person must send to the Commission, when requested to do so and by no later
than 28 days beginning on the day after receipt of the request—
(a) a written report setting out how, and the extent to which, in the opinion of the registered
person, the requirements of paragraph (2)(a) and (b) are being complied with, and
(b) any plans that the registered person has for improving the standard of the services provided
to service users with a view to ensuring their health and welfare.
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Staffing
18. (1) Sufficient numbers of suitably qualified, competent, skilled and experienced persons
must be deployed in order to meet the requirements of this Part.
(2) Persons employed by the service provider in the provision of a regulated activity must—
(a) receive such appropriate support, training, professional development, supervision and
appraisal as is necessary to enable them to carry out the duties they are employed to
perform,
(b) be enabled where appropriate to obtain further qualifications appropriate to the work they
perform, and
(c) where such persons are health care professionals, social workers or other professionals
registered with a health care or social care regulator, be enabled to provide evidence to
the regulator in question demonstrating, where it is possible to do so, that they continue
to meet the professional standards which are a condition of their ability to practise or a
requirement of their role.
Fit and proper persons employed
19. (1) Persons employed for the purposes of carrying on a regulated activity must—
(a) be of good character,
(b) have the qualifications, competence, skills and experience which are necessary for the
work to be performed by them, and
(c) be able by reason of their health, after reasonable adjustments are made, of properly
performing tasks which are intrinsic to the work for which they are employed.
(2) Recruitment procedures must be established and operated effectively to ensure that persons
employed meet the conditions in—
(a) paragraph (1), or
(b) in a case to which regulation 5 applies, paragraph (3) of that regulation.
(3) The following information must be available in relation to each such person employed—
(a) the information specified in Schedule 3, and
(b) such other information as is required under any enactment to be kept by the registered
person in relation to such persons employed.
(4) Persons employed must be registered with the relevant professional body where such
registration is required by, or under, any enactment in relation to—
(a) the work that the person is to perform, or
(b) the title that the person takes or uses.
(5) Where a person employed by the registered person no longer meets the criteria in
paragraph (1), the registered person must—
(a) take such action as is necessary and proportionate to ensure that the requirement in that
paragraph is complied with, and
(b) if the person is a health care professional, social worker or other professional registered
with a health care or social care regulator, inform the regulator in question.
(6) Paragraphs (1) and (3) of this regulation do not apply in a case to which regulation 5 applies.
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Duty of candour
20. (1) A health service body must act in an open and transparent way with relevant persons in
relation to care and treatment provided to service users in carrying on a regulated activity.
(2) As soon as reasonably practicable after becoming aware that a notifiable safety incident has
occurred a health service body must—
(a) notify the relevant person that the incident has occurred in accordance with paragraph (3),
and
(b) provide reasonable support to the relevant person in relation to the incident, including
when giving such notification.
(3) The notification to be given under paragraph (2)(a) must—
(a) be given in person by one or more representatives of the health service body,
(b) provide an account, which to the best of the health service body’s knowledge is true, of all
the facts the health service body knows about the incident as at the date of the notification,
(c) advise the relevant person what further enquiries into the incident the health service body
believes are appropriate,
(d) include an apology, and
(e) be recorded in a written record which is kept securely by the health service body.
(4) The notification given under paragraph (2)(a) must be followed by a written notification given
or sent to the relevant person containing—
(a) the information provided under paragraph (3)(b),
(b) details of any enquiries to be undertaken in accordance with paragraph (3)(c),
(c) the results of any further enquiries into the incident, and
(d) an apology.
(5) But if the relevant person cannot be contacted in person or declines to speak to the
representative of the health service body—
(a) paragraphs (2) to (4) are not to apply, and
(b) a written record is to be kept of attempts to contact or to speak to the relevant person.
(6) The health service body must keep a copy of all correspondence with the relevant person
under paragraph (4).
(7) In this regulation—
“apology” means an expression of sorrow or regret in respect of a notifiable safety incident;
“moderate harm” means—
(a)
harm that requires a moderate increase in treatment, and
(b)
significant, but not permanent, harm;
“moderate increase in treatment” means an unplanned return to surgery, an unplanned readmission, a prolonged episode of care, extra time in hospital or as an outpatient, cancelling
of treatment, or transfer to another treatment area (such as intensive care);
“notifiable safety incident” means any unintended or unexpected incident that occurred in
respect of a service user during the provision of a regulated activity that, in the reasonable
opinion of a health care professional, could result in, or appears to have resulted in—
(a)
the death of the service user, where the death relates directly to the incident rather than
to the natural course of the service user’s illness or underlying condition, or
(b)
severe harm, moderate harm or prolonged psychological harm to the service user;
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“prolonged psychological harm” means psychological harm which a service user has
experienced, or is likely to experience, for a continuous period of at least 28 days;
“relevant person” means the service user or, in the following circumstances, a person lawfully
acting on their behalf—
(a)
on the death of the service user,
(b)
where the service user is under 16 and not competent to make a decision in relation to
their care or treatment, or
(c)
where the service user is 16 or over and lacks capacity (as determined in accordance with
sections 2 and 3 of the 2005 Act) in relation to the matter;
“severe harm” means a permanent lessening of bodily, sensory, motor, physiologic or
intellectual functions, including removal of the wrong limb or organ or brain damage, that is
related directly to the incident and not related to the natural course of the service user’s illness
or underlying condition.
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Board of Directors: 28 January 2015 – Public
Agenda Item: TBP05.1/15
Attachment: R
For Decision
By: Colm Donaghy, Chief Executive
Board Development/External Board Governance Review
SUMMARY & PURPOSE
The Trust Board has requested that a specification for a Board Development Programme
be drawn up to enable commissioning of the programme through appropriate open
procurement processes.
The paper attached sets out a draft specification for the Board’s consideration, with an
indication of possible costs and time commitment. It also outlines the aims of the
programme; its phases of implementation; procurement process an estimated timescales
to commission a provider to deliver the programme.
At the same time, we will procure an external review of board governance, in accordance
with Monitor's expectations as set out in the Risk Assessment Framework. The output from
this review will also help to inform the board development programme.
ACTION REQUIRED BY EXECUTIVE MANAGEMENT BOARD
The Trust Board is asked to discuss and agree the specification for a Trust Board
Development Programme and external Board Governance Review, and support the
recommendation being made by the Chief Executive to the Board of Directors to proceed
with the procurement process
SPECIFICATION FOR THE TRUST BOARD
DEVELOPMENT PROGRAMME
1. Executive Summary
The Trust Board has requested that a specification for a Board Development Programme
be drawn up to enable commissioning of the programme through appropriate open
procurement processes.
This Programme will apply to all Trust Board members and should take place over two
years starting in April 2015. The Board wishes to provide flexibility for potential providers
in terms of the organisation and provision of the Programme over that period; it is
anticipated that there will be a commitment to approximately 6 days per year over two
years, in addition to an initial diagnostic phase.
The financial envelope available for this Programme is £75-100k. This is to include all
phases of the two year Programme outlined in the proposal attached including any
individual 1-1 coaching and the cost of buying tests or psychometrics.
In addition, the proposal is that we take this opportunity to also commission an external
Board Governance Review. This will help to inform the development programme while
gaining assurance that the organisation is well-led. Such external review is also a
requirement of Monitor and will broadly follow the four domains of the board governance
framework.
2. Introduction
The Trust Board has requested that a specification for a Board Development Programme
be drawn up to enable commissioning of a programme through an appropriate open
procurement process.
At the same time, we will procure an external review of board governance, in accordance
with Monitor's expectations as set out in the Risk Assessment Framework. The output from
this review will also help to inform the board development programme.
This paper sets out a draft specification for the Board’s consideration, with an indication of
possible costs and time commitment.
3. Scope
This Programme will apply to all Trust Board members. Other programmes are either
currently in place or are being developed for other senior leaders in the organisation.
The Programme will take place over two years starting in April 2015. The Board wishes to
provide flexibility for potential providers in terms of the organisation and provision of the
programme over that period; it is anticipated that there will be a commitment to
approximately 6 days per year, in addition to an initial diagnostic phase.
The financial envelope available for this Programme is £75-100k. This is to include all
phases of the two year Programme outlined below including any individual 1-1 coaching
and the cost of buying tests or psychometrics as well as the governance review.
4. Aims
The aims of the Board Development Programme are to:

Assist the Board in setting and maintaining a clear mission, vision and values for
the Trust in the light of the internal and external environment – particularly national,
political, policy and financial considerations – over the next five years.

Assist the Board in ensuring that a clear strategic plan is developed and delivered
for the Trust and monitoring its implementation throughout the organisation via the
Executive Team.

Assist the Board in enabling a cultural shift across the Trust towards the delivery
of high quality patient care by staff who are fully engaged, trust their leaders and
understand their contribution in the delivery of Trust objectives.

Improve the leadership of the Trust and ensure that the leadership behaviours for
Board members are implemented and role-modelled.

Improve the effectiveness of the Trust Board as a team and as individual
members to ensure high quality performance, assisting Board members to reach a
high level of self-awareness.

Ensure clarity of role for the Trust Board.

Ensure highly effective working relationships, particularly between the Trust
Board and the Executive Team, the Trust Board and Governors and with external
partners.
The external Board Governance Review will cover the four domains of the board
governance framework:
Strategy and Planning:
 How well is the Board setting direction for the Trust?
 Is it sufficiently aware of potential risks to the quality and delivery of current and
future services?
Capability and Culture
 Does the Board have the appropriate experience and ability?
 Does it communicate this to the Trust and shape an open, transparent and quality
focussed culture?
Process and Structure
 Do reporting lines and accountabilities support the effective oversight of the Trust?


Are there clearly defined, well understood processes for escalating and resolving
issues?
Does the Board actively engage patients, staff and other stakeholders on quality
and operational performance?
Measurement
 Does the Board receive appropriate, robust and timely information and does this
support the leadership of the Trust?
 Is this information being analysed and challenged and used to drive improvement?
These aims may be amended at the outset of the Programme in agreement with the
provider and Board.
5. Specification
Diagnostic phase
The provider will carry out an initial diagnostic of the current situation in relation to the key
criteria for the Programme as set out in Aims (e.g. current team relationships, culture of
the organisation, clarity and understanding of vision.) This will be achieved through a
number of means which could include:








interviews with all members of the Board
Team observation or facilitated team meeting
Peer observation
Self-assessment
Assessment of a range of Trust documents (staff and patient surveys, CQC and
Monitor reports etc.).
Possible discussion with managers reporting to Board members
The use of individual and/or team leadership diagnostic tools such as 360 degree
assessments, emotional intelligence indicators, psychometrics, MBTI etc.
Governance review
It is anticipated that this will take in the region of 5 days.
Programme delivery phase
A report will be produced which will be presented to and discussed with the Board.
Following this, the Aims may be amended as necessary and a Board Development Needs
Analysis produced, outlining individual and team development needs. This will be
accompanied by a number of options for the Development Programme to meet the
identified needs. This is likely to include:







An agreed ‘contract’ with the Board for their participation in the Programme and
their ownership of the final Programme according to the diagnostic and the Board’s
understanding of their own, and the Trust’s, needs
Facilitated Strategic Board Away days on a range of identified issues (e.g. vision
and values)
Team effectiveness workshops
Coaching
Individual development activities
Action learning sets
‘Master classes’ or taught classes on specific issues

Appraisals.
The themes and issues likely to be addressed in the Programme include:



















Vision, values and culture
Transformation, creativity and innovation
What Board leadership means at Sussex Partnership
The modern leader
The role of the Trust Board at Sussex Partnership
Understanding the opportunities and threats in the external environment; horizon
scanning
Leading in partnership, entrepreneurship and business development
Improving patient care and performance
Improving team performance
Communication and information
Financial leadership
People leadership
Board structures for high performance
Decision making and accountability
Impact of national papers and reports (e.g. Francis).
Strategic thinking
Safety Culture
Effective behaviour in Boardroom
New Care models
The preparation and discussion of the initial options and the preparation, delivery and
write-up of the agreed sessions is difficult to assess until the Programme is finalised, but
assuming a maximum of 6 Board away-days per year, consultancy days are likely to be in
the region of 15-20 days a year.
Programme Assessment Phase
The Programme must have an integrated assessment process to enable the Board to gain
an understanding of their starting position as individuals and as a team on the key areas of
activity concerned with leadership. A report will be produced at the end of the first and
second years to assess progress. The Board is looking for a number of key improvements
from the Programme, which will be agreed at the outset, and which must be measurable;
for example:




Achievement of or year-on-year improvement of organisational KPI’s or other
agreed measures of improvement.
Year-on-year improvement against, say, 6 key leadership/management
competences/behaviours from the Board leadership values and behaviours
framework.
Percentage improvement, year-on-year, on key elements of stakeholder, patient or
staff surveys on Board leadership.
Specific improvements for individuals based on development needs identified as
part of the leadership assessment process.
This is likely to need a further 3-5 consultancy days depending on the complexity of the
process and the involvement level of the provider.
6. Process and Timescale
It is proposed that the Procurement Team will be involved in the tendering process for this
Programme, to help ensure we encourage applications from a broad range of providers
with different approaches.
Once agreed in principle, this specification will be finalised and a pack of background
information on the Trust’s key metrics, current performance and other relevant details will
be added.
It is suggested that the Chair, together with the Chief Executive, People Director, one other
NED, the Company Secretary and another Executive Director act as the selection panel
for the Programme. An initial long-listing through a paper assessment will be carried out
by the Chief Executive, People Director and the other Executive Director. The long-list will
then be reduced to a short-list by the full panel and no more than five organisations will be
asked to attend an interview for the final selection process. The People Director will lead
on the provision of criteria for selection and assessment at different stages of the process.
Procurement Process
As this is a one-off programme and the costs are less than £111K a formal OJEU process
is not required in this instance.
Timetable:
 Issue ITT
 Selection and Assessment stage
 Interview suppliers (1 day)
 Recommend preferred supplier to Board for approval
 Award contract
It is anticipated that the tendering process will start by mid February 2015 with a closing
date of 25th March 2015, allowing six weeks for tenders to be prepared.
7. Recommendation
The Trust Board is asked to discuss and agree the specification for a Trust Board
Development Programme and external Board Governance Review, and support the
recommendation being made by the Chief Executive to the Board of Directors to proceed
with the procurement process
8. Next Steps
Finalise the specification following discussion at Trust Board and commence the
procurement process.
Bo
oard of Directors: 28 Ja
anuary 2015
5 - Public
Agend
da Item: TBP
P05.2/15
Attach
hment: S
For Decision
D
By: Sue Morris
s, Executive Director of Corporate Services
S
LIV
VING WA
AGE
SUMM
MARY & PU
URPOSE
The pu
urpose of th
his paper is to inform
m the Board
d of the Livving Wage accreditattion and
to set o
out the reccommendattions and benefits
b
to becoming
g an accred
dited Living
g Wage
Employyer.
The Livving Wage
e is an hourrly wage ra
ate that ensures work
king people
e on the lo
owest
income
es achieve an improvved standa
ard of living
g, for them and their families.
f
ACTION
N REQUIRE
ED BY BOA
ARD MEMB
BERS
oard of Dire
ectors is assked to co
onsider the introductio
on of the Living
L
Wage for
The Bo
staff att Sussex Partnership
P
NHS Foundation Trust.
LIVING WAGE
1. Executive Summary
The Living Wage is an hourly wage rate that ensures working people on the lowest
incomes achieve an improved standard of living for them and their families.
Based on the November staff profile the total cost for implementation in the Trust
would be £154k for 167 substantive staff and a further £100k for bank staff giving a
total cost of £254k.
The Executive Management Board considered this paper on 20 January 2015 and,
acknowledging the cost pressure, supported this proposal in principle.
2. Introduction
In October 2013 Citizens UK launched a Social Care Campaign; a new movement of
care recipients, their families, care workers, and communities, calling for better
quality social care and a better deal for care workers.
Representatives from Citizens UK member churches, synagogues, mosques,
schools, and universities gathered to launch the Citizens UK Care Charter, which
calls on civil society, Government, care providers and commissioners to come
together and play their part to implement better standards. The charter calls for:




Proper Training - Ensure that care workers are trained in dealing with
dementia
Better Relationships - Ensure that 90% of care is provided by a small team of
named care workers
Enough Time – An end of 15 minute care visits
Dignity In Work - Care workers to be paid a Living Wage and paid for
travel time
The Living Wage Foundation is an initiative of Citizens UK and will play an active
role in supporting and developing the Social Care Campaign. This will include
working with all accredited councils that provide social care to involve them in the
movement.
Accredited Living Wage Employers in Social Care provide the Living Wage to all staff
members for every hour worked, including travel time.
Sussex Community NHS Trust, amongst other NHS Trusts, including some mental
health trusts have been accredited as Living Wage employers and this paper
explores the costs and benefits associated with introducing the living wage for our
people.
3. Benefits and Cost Pressure
The Living Wage Foundation reports that an independent study examining the
business benefits of implementing a Living Wage policy in London found that more
than 80% of employers believe that the Living Wage had enhanced the quality of the
work of their staff, while absenteeism had fallen by approximately 25%.
Two thirds of employers reported a significant impact on recruitment and retention
within their organisation, and 70% of employers felt that the Living Wage had
increased consumer awareness of their organisation’s commitment to be an ethical
employer.
By achieving accreditation as a ‘Living Wage Employer’ the Trust will ensure all
employees whose pay was below £7.45 per hour receive a pay rise to ‘top up’ their
pay. The Living Wage will also apply to all new employees who join the Trust. Whilst
it is important to note that NHS terms and conditions in relation to sickness and
annual leave pay are more generous than most companies, pay remains the most
important factor for the majority of people paid below the living wage.
The total cost for implementation in the Trust would be £154k for 167 substantive
staff and a further £100k for bank staff giving a total cost of £254k. The staff working
at the Trust’s Nursing Home in Hove have not been included in this report as a new
pay structure has recently been agreed for those employees.
Due to the financial commitment required, this would need to be reviewed annually
to ensure it remains affordable for the Trust.
4. Recommendation
The Board of Directors is asked to consider the introduction of the Living Wage for
staff at Sussex Partnership NHS Foundation Trust.
5. Next steps
The Living Wage Foundation offer accreditation to employers that pay the Living
Wage or those committed to an agreed timetable of implementation, by awarding the
Living Wage Employer Mark. They provide advice and support to employers
including best practice guides; case studies from leading employers; model
procurement frameworks and access to specialist legal and HR advice.
If approved the Trust will need to submit an application to the Living Wage
Foundation for accreditation and start a consultation exercise with affected staff.
Safer Staffing Summary Report - September 2014
Day Duty
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
Ward name
Bodiam
Maple Ward
Oaklands Ward
Rowan Ward
Woodlands Centre
Amberley Ward
Coral Ward
Jade Ward
Opal Ward
Meridian Ward
Caburn Ward
Regency Ward
Chalkhill
Beechwood
St Gabriel Ward
St Raphael Ward
Burrowes Ward
Grove Ward
Brunswick Ward
Iris Ward
Heathfield Ward
Larch Ward
Orchard Ward
Selden Centre
Fir Ward
Hazel Ward
Pine Ward
Southview
Ash
Oak Ward
Willow Ward
Amber Ward
Pavillion Ward
Amberstone
Bramble Lodge
Connolly House
Hanover Crescent
Rutland Gardens
Shepherd House
Dove Ward
Promenade Ward
Type of ward
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
CAMHS
Dementia
Dementia
Dementia
Dementia
Dementia
Dementia
Dementia
Integrated
Integrated
Integrated
LD
Low Secure
Low Secure
Low Secure
Low Secure
Medium Secure
Medium Secure
Medium Secure
PICU
PICU
Rehab
Rehab
Rehab
Rehab
Rehab
Rehab
Substance Misuse
Substance Misuse
TRUST TOTAL
Rutland Gardens
Selden Centre
Shepherd House
Night Duty
Day Duty
Night Duty
TOTAL
Qualified Nurses
Healthcare Assistants
Qualified Nurses
Healthcare Assistants
Total monthly
Total monthly
Total monthly
Total monthly
planned staff
Total monthly
planned staff
Total monthly
planned staff
Total monthly
planned staff
Total monthly
Average Fill Rate Average Fill Rate Average Fill Rate Average Fill Rate
hours
actual staff hours hours
actual staff hours hours
actual staff hours hours
actual staff hours % - Qualified
% - Unqualified
% - Qualified
% - Unqualified
Overall Fill Rate %
713
713
713
713
713
713
713
713
100%
100%
100%
100%
100%
775
763
1,163
1,028
388
388
1,163
1,163
98%
88%
100%
100%
96%
750
750
750
763
750
750
750
808
100%
102%
100%
108%
102%
775
732
775
709
388
388
775
775
94%
91%
100%
100%
96%
1,070
754
713
1,660
713
690
748
1,300
70%
233%
97%
174%
136%
713
685
713
1,405
713
698
713
1,231
96%
197%
98%
173%
141%
775
921
775
1,757
775
838
388
1,375
119%
227%
108%
355%
180%
713
766
713
1,267
713
649
702
1,019
107%
178%
91%
145%
130%
775
1,000
775
1,138
775
400
388
788
129%
147%
52%
203%
123%
900
1,043
1,163
1,256
310
300
630
792
116%
108%
97%
126%
113%
870
1,099
900
1,187
620
620
310
100
126%
132%
100%
32%
111%
900
1,146
930
854
620
660
310
382
127%
92%
106%
123%
110%
1,395
1,058
930
930
620
460
310
430
76%
100%
74%
139%
88%
930
757
930
1,906
310
340
930
1,330
81%
205%
110%
143%
140%
253
366
1,070
1,199
357
360
713
786
144%
112%
101%
110%
113%
713
681
368
752
357
380
713
863
96%
204%
106%
121%
124%
496
849
1,488
1,554
310
310
620
950
171%
104%
100%
153%
126%
465
661
1,395
1,806
324
403
648
1,134
142%
129%
124%
175%
141%
900
489
1,163
1,345
310
150
620
860
54%
116%
48%
139%
95%
388
743
1,163
1,556
388
413
775
1,363
192%
134%
106%
176%
150%
713
618
713
773
357
414
713
656
87%
108%
116%
92%
99%
775
750
775
825
775
650
388
388
97%
106%
84%
100%
96%
465
599
930
780
333
376
333
387
129%
84%
113%
116%
104%
372
372
1,860
2,092
372
372
744
732
100%
112%
100%
98%
107%
713
599
713
1,063
713
506
713
886
84%
149%
71%
124%
107%
713
951
1,070
1,302
713
391
713
1,277
133%
122%
55%
179%
122%
713
743
713
723
357
357
713
713
104%
101%
100%
100%
102%
713
638
1,426
1,234
713
387
725
932
89%
87%
54%
129%
89%
713
587
1,070
1,284
357
393
1,070
949
82%
120%
110%
89%
100%
1,070
1,011
1,426
1,362
713
495
1,070
1,283
95%
96%
69%
120%
97%
771
806
1,760
1,576
713
536
1,070
1,265
105%
90%
75%
118%
97%
1,070
852
1,426
1,955
713
667
1,426
1,967
80%
137%
94%
138%
117%
900
1,204
1,395
1,802
620
680
620
764
134%
129%
110%
123%
126%
930
930
930
916
310
310
572
593
100%
98%
100%
104%
100%
357
372
713
614
357
357
357
357
104%
86%
100%
100%
95%
759
729
515
452
333
333
333
333
96%
88%
100%
100%
95%
0
837
844
0
434
434
0%
101%
0%
100%
101%
465
606
458
365
310
310
310
310
130%
80%
100%
100%
103%
465
600
930
840
310
310
310
310
129%
90%
100%
100%
102%
713
665
357
375
357
357
357
357
93%
105%
100%
100%
98%
1,048
1,051
459
444
310
310
310
310
100%
97%
100%
100%
99%
29,704
1
1
1
30,649
39,061
46,399
20,185
18,415
26,195
33,356
103%
119%
91%
127%
112%
Comments
x
high volume of 1:1 observations
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Appendix 4
Regulation 5: Fit and Proper Person Requirement for Directors
STANDARD
ASSURANCE
Providers should make every effort to ensure that all
available information is sought to assess whether the
individual is of good character, taking account of the
two matters that must be considered pursuant to Part
2 of Schedule 4 of the regulations;
Employment checks are undertaken in accordance with
NHS Employers pre-employment check standards and
include:
 Two references, one of which must be most recent
employer and cover a period of 3-years
 qualification and professional registration checks
 right to work checks
 proof of identity checks
 occupational health clearance
 DBS checks (where appropriate)
 Search of insolvency and bankruptcy register
 Search of disqualified directors register
References
Fit and Proper Person Annual Declaration
Annual self-declaration forms
1. Whether the person has been convicted in the
United Kingdom of any offence or been
convicted elsewhere of any offence which, if
committed in any part of the United Kingdom,
would constitute an offence.
2. Whether the person has been erased,
removed or struck-off a register of
professionals maintained by a regulator of
health care or social work professionals.
EVIDENCE
Other pre-employment checks
DBS checks where appropriate
Signed declarations from
applicants
Register search results
References
Employment Checks policy
Recruitment policy and procedure
If information is discovered that suggests an individual
is not of good character after they have been
appointed to a role, the provider must take
appropriate and timely action to investigate and rectify
the matter.
Disciplinary policy and procedure provides for such
investigations.
Medical revalidation process applies for some Directors
inclusive of probity disclosures.
1
Contracts of employment
Statement of terms and conditions
Terms and conditions of service
agreements (for NEDs)
Disciplinary policy and procedure
Medical Revalidation legislation
(License to Practice and
Revalidation Regulations 2012)
Where a provider deems the individual suitable
despite not meeting the characteristics outlined in
Part 2 of Schedule 4, the reasons should be recorded
and information about the decision should be made
available to those that need to be aware.
Discussion and debate at the Appointment and
Remuneration and Nomination and Remuneration
Committees.
Where specific qualifications are deemed by the
provider as necessary for a role, the provider must
make this clear and should only employ those
individuals that meet the required specification,
including any requirements to be registered with a
professional regulator.
This requirement is included within the job description and
person specification for relevant posts and is checked as
part of the pre-employment checks.
The provider should have appropriate processes for
assessing and checking that the individual holds the
required qualifications and has the competence, skills
and experience required, (which may include
appropriate communication and leaderships skills and
a caring and compassionate nature), to undertake the
role; these should be followed in all cases and
relevant records kept.
Employment checks include a candidate’s qualifications
and employment references.
The recruitment process also includes values-based
questions.
Minutes of meetings and records
from the recruitment process.
Decision-making process recorded.
The Chair would take advice from internal and external
advisors as appropriate.
Person specification
Employment Checks policy
Recruitment policy and procedure
Recruitment policy and procedure
Employment Checks policy
Values-based questions
Professional Register Checks
2
Record of interview
The provider may consider that an individual can be
appointed to a role based on their qualifications, skills
and experience with the expectation that they will
develop specific competence to undertake the role
within a specified timeframe.
Any such decision would be discussed by the Appointment
and Remuneration Committee or Nomination and
Remuneration Committee and would be minuted.
When appointing relevant individuals the provider has
processes for considering a person’s physical and
mental health in line with the requirements of the role,
all subject to equalities and employment legislations
and to due process.
All post-holders are subject to clearance by occupational
health as part of the pre-employment process.
Wherever possible, reasonable adjustments are made
in order that an individual can carry out the role.
This is included in Trust Policy
The provider has processes in place to assure itself
that the individual has not been at any time
responsible for, privy to, contributed to, or facilitated,
any serious misconduct or mismanagement in the
carrying on of a regulated activity; this includes
investigating any allegation of such potential
behaviour. Where the individual is professionally
qualified, it may include fitness to practise
proceedings and professional disciplinary cases.
This has been incorporated as a specific declaration to
cover the pre-employment process, through the references
validation process and as part of the annual declaration
process.
Actions would be subject to follow-up as part of on-going
review and appraisal.
Director appraisal framework
NED competence framework
Record of interview
Employment Checks policy
Occupational health clearance
process including self-declaration
from individual
Equality and Diversity Policy
Pre-employment declaration
References covering the last 3
years
Annual Declaration returns
“Responsible for, contributed to or facilitated” means
that there is evidence that a person has intentionally
3
or through neglect behaved in a manner which would
be considered to be or would have led to serious
misconduct or mismanagement.
“Privy to” means that there is evidence that a person
was aware of serious misconduct or mismanagement
but did not take the appropriate action to ensure it
was addressed.
“Serious misconduct or mismanagement” means
behaviour that would constitute a breach of any
legislation/enactment CQC deems relevant to meeting
these regulations or their component parts.”
The provider must not appoint any individual who has
been responsible for, privy to, contributed to, or
facilitated, any serious misconduct or
mismanagement (whether lawful or not) in the
carrying on of a regulated activity; this includes
investigating any allegation of such potential
behaviour. Where the individual is professionally
qualified, it may include fitness to practise
proceedings and professional disciplinary cases.
This has been incorporated as a specific declaration as
part of the pre-employment process and through the
references validation process.
Recruitment Interview pack
HR Policies
Annual Self-Declaration
Only individuals who will be acting in a role that falls
within the definition of a “regulated activity” as defined
by the Safeguarding Vulnerable Groups Act 2006 will
be eligible for a check by the Disclosure and Barring
Service (DBS).
NB – The CQC recognises that it may not always be
possible for providers to access a DBS check as an
individual may not be eligible.
DBS checks are undertaken only for those posts which fall
within the definition of a “regulated activity” or which are
otherwise eligible for such a check to be undertaken.
Employment Checks policy
DBS checks for eligible postholders only in line with the Act.
As part of the recruitment/appointment process,
DBS checks are undertaken only for those posts which fall
Employment Checks policy
4
Reference Returns
providers should establish whether the individual is on
a relevant DBS barring list.
within the definition of a “regulated activity” or which are
otherwise eligible for such a check to be undertaken.
DBS checks for eligible postholders
DBS periodic checks for eligible
post-holders (every 3 years)
The fitness of directors is regularly reviewed by the
provider to ensure that they remain fit for the role they
are in; the provider should determine how often
fitness must be reviewed based on the assessed risk
to business delivery and/or the service users posed
by the individual and/or role.
The provider has arrangements in place to respond to
concerns about a person’s fitness after they are
appointed to a role, identified by itself or others, and
these are adhered to.
Post-holders undertake annual declarations of fitness to
continue in post.
Annual declaration returns
Appraisal process
Statement of Terms and
Conditions
Revised contracts
Capability policy
Disciplinary policy
Maintaining High Professional
Standards (Disciplinary Process
for Medical Staff)
Raising Concerns
(Whistleblowing) policy
Grievance policy
5
Contracts of employment
The provider investigates, in a timely manner, any
concerns about a person’s fitness or ability to carry
out their duties, and where concerns are
substantiated, proportionate, timely action is taken;
the provider must demonstrate due diligence
This will be undertaken if concerns are identified and
revised contracts provide for termination if individuals fail
to meet necessary standards
Statement of Terms and
Conditions
Capability policy
Disciplinary policy
Maintaining High Professional
Standards (Disciplinary Process
for Medical Staff)
Raising Concerns
(Whistleblowing) policy
Grievance policy
Where a person’s fitness to carry out their role is
being investigated, appropriate interim measures may
be required to minimise any risk to service users.
This would be reviewed when concerns are identified
Revised employment contracts for
relevant directors
Disciplinary policy
Maintaining High Professional
Standards (Disciplinary Process
for Medical Staff)
Capability Policy
Raising Concerns
(Whistleblowing) policy
The provider informs others as appropriate about
concerns/findings relating to a person’s fitness; for
example, professional regulators, CQC and other
This would be completed if any concerns were identified.
Maintaining High Professional
Standards (Disciplinary Process
6
relevant bodies, and supports any related
enquiries/investigations carried out by others.
for Medical Staff)
Disciplinary policy
Internal safeguarding referral
process
External safeguarding referral
process
7