Board of Directors Meeting - merseycare.nhs.uk · The Public Meeting of the Board of Directors is a...

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AGENDA FOR

Board of Directors Meeting Date: Wednesday 29 November 2017 Time: 10.00 a.m. – 12.30 p.m.

Venue: Rooms 1, 2 & 3 V7 Building, Kings Business Park, Prescot, Merseyside, L34 1PJ

No. Item Lead Details Timing

A A1 Welcome & Employee of the Month B Fraenkel Verbal to note 10.00 a.m.

A2 Just and Learning Culture Ambassadors S Eales Verbal 10.02 a.m.

B Board of Directors Business B1 Member’s Apologies: M Birch;

Attendee’s Apologies: B Fraenkel Verbal to note 10.30 a.m.

B2 Declarations of Interest B Fraenkel Verbal to note B3 Minutes of the Meeting held on 25 October 2017

(including action log) B Fraenkel Paper for decision

[ref TB/17/18/146]

B4 Matters Arising --- ---B5 Chief Executive Report J Rafferty Paper to note

[ref TB/17/18/147] 10.35 a.m.

C Our Services C1 Governance of Quality Report R Walker Paper for assurance

[ref TB/17/18/148] 10.50 a.m.

C2 Care at a Glance (including SLD Retraction Plan position)

R Walker Paper for assurance [ref TB/17/18/149]

11.05 a.m.

D Our Future D1 Estates Strategy Principals L Edwards/

N Smith Paper for decision [ref TB/17/18/152]

11.30 a.m.

E Our GovernanceE1 Board Assurance Framework R Walker Paper for decision

[ref TB/17/18/153] 11.45 p.m.

E2 Board Governance A Meadows Paper for decision [ref TB/17/18/154]

11.55 p.m.

F Other Business F1 Board Committee Minutes (including Chairs Reports)

a) Audit Committee (Oct-17)b) Executive Committee (Sep-17, Oct-17)c) Quality Assurance Committee (Sep-17)d) Performance, Investment and Finance Committee

(Oct-17)e) Remuneration and Terms of Service Committee

(Sept-17, Oct-17)f) Council of Governors (Oct-17)

P Williams J Rafferty R Beardall M Birch

B Fraenkel

B Fraenkel

Paper for assurance [ref TB/17/18/155]

12.05 p.m.

F2 Chairman’s Report B Fraenkel Verbal to note 12.15 p.m.

G Consent Items Note – these items are provided for consideration by the Committee. Members are asked to read the papers prior to the meeting and, unless the Chair / Trust Secretary receives notification before the meeting that a member

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wishes to debate the item or seek clarification on an issue, the items and recommendations will be approved without debate at the meeting in line with the process for Consent Items. The recommendations will then be recorded in the minutes of the meeting.

G1 Reporting, Mangement & Review of Adverse Incidents Policy

S Morgan Paper for assurance [ref TB/17/18/156]

12.20 p.m

I Any Other Business

Opportunity for Questions from the Public The Public Meeting of the Board of Directors is a meeting held in public, rather than a public meeting in which the public may participate. Once the Public Meeting closes the Chairman will ask if anybody would like to ask a question or raise any issues with the Board of Directors.

The Board of Directors is invited to adopt the following resolution: ‘That the Board hereby resolves that the remainder of the meeting to be held in private, because publicity would be prejudicial to the public interest, by reason of the confidential nature of the business to be transacted’. [Section (2) of the Public Bodies (Admission to Meetings) Act 1960]

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Dates of Future Meetings: • 31 January 2018

• 28 March 2018

• 30 May 2018

Mersey Care’s Strategy:

Throughout the discussions at / and reports to our Board of Directors, reference will be made to our strategy which is summarised below.

Agenda Item No: B3

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Status of these minutes (check one box): Paper No: TB/17/18/146

Draft for Approval: ☒ Report to: Board of Directors

Formally Approved: ☐ Meeting Date: 29 November 2017

MINUTES OF THE MEETING OF THE

Public Board of Directors’ Date: Wednesday, 25 October 2017 Time: 10.30am

Venue: Princess Royal Stand, Princess Royal Suite, Aintree Racecourse.

Name Job Title (Division/ Organisation*) *if not Mersey Care

Present: Beatrice Fraenkel Gerry O’Keeffe Rob Beardall Gaynor Hales Pam Williams Cath Green Neil Smith Elaine Darbyshire David Fearnley Mark Hindle Amanda Oates Trish Bennett Louise Edwards

Chairman Non Executive Director Non Executive Director Non Executive Director Non Executive Director Non Executive Director Executive Director of Finance / Deputy Chief Executive Executive Director of Communications & Corporate Governance Medical Director Executive Director of Operations Executive Director of Workforce Director of Integration Director of Strategy

In Attendance: Mandy Gregory Andy Meadows Sarah Jennings Hilary Tetlow

Staff Side Chair Trust Secretary Deputy Trust Secretary (Minutes Secretary) Governor

Apologies Received: Matt Birch Nick Williams Joe Rafferty Ray Walker

Non Executive Director Non Executive Director Executive Director of Nursing Chief Executive

ISSUES CONSIDERED 2017 A1 WELCOME

1. Mrs Fraenkel welcomed all Board members to the public Board of Directors meeting including those in the public gallery.

B1 APOLOGIES

2. The apologies for absence received were noted, as detailed on page one of these minutes.

Agenda Item No: B3

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B2 DECLARATIONS OF INTEREST

3. There were no declarations of interest.

B3 MINUTES OF THE PREVIOUS MEETING HELD ON 27 SEPTEMBER 2017

4. The minutes of the previous meeting held on 27 September 2017 were accepted as an accurate record. No amendments were required.

5.

Action Lead Timescale Status

Recommendations approved by the Board, namely: • Approve the minutes of the previous meeting

Further actions required: • None identified.

B4 MATTERS ARISING

6. There were no matters arising.

C1 LIVERPOOL COMMUNITY HEALTH UPDATE [INCLUDING NEXT STEPS, MANAGEMENT CONTRACT, SELF-CERTIFICATIONS]

7. Mr Meadows outlined to members of the Board of Directors the consequences of Mersey Care being identified as the ‘Preferred Acquirer’ by NHS Improvement to acquire Liverpool Community Health NHS Trust (LCH) from 1 April 2018.

8. Mr Meadows referred to the announcement by NHS Improvement on 4 October 2017 that the Trust had been identified as the preferred acquirer following its bid for Liverpool Community Health Services and advised that the transaction was due to be completed on 1 April 2018. Mr Meadows informed Board members that discussion was on-going with NHS Improvement regarding the transaction process given the expected imminent publication of a revised Transaction Manual.

9. Mr Meadows advised that on submitting bids for the service, both Mersey Care and Alder Hey NHS FT had been asked by NHS Improvement that the successful bidder take on a management agreement from 1 November 2017 - 1 April 2018. Whilst this was an atypical arrangement, this would allow the provision of management support and as such, members of Mersey Care's Board of Directors would be appointed to the Liverpool Community Health Board for this period. Mr Meadows added that as an NHS Trust, LCH were unable to appoint Non Executive Directors to their Board and therefore the regulators were leading on this process.

10. Mr Meadows informed Board members that during this interim period (November 17 -

April 18), LCH would remain a statutory body, overseen by its regulators and Mersey Care would not be responsible for the services they provided. In addition, whilst the management agreement would result in a series of conflicts of interests, NHS Improvement were aware of this and had issued Directions to mitigate this issue. As such, LCH Board would not be asked to take a view as to the appropriateness of Mersey Care as the preferred acquirer.

Agenda Item No: B3

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11. Mrs Darbyshire referred to the Management Agreement and queried the accountability

arrangements for LCH in this context. Mr Meadows confirmed that Mersey Care would continue to meet with NHS Improvement to discuss the Trusts performance and discussion would incorporate how Mersey Care were managing LCH in this period.

12. Mr O'Keeffe noted the support that would be provided to LCH by Mersey Care and queried how this was defined. In response, Mr Meadows advised that given the increased turnover of staff at LCH, a number of staff within Mersey Care would be seconded to LCH to provide management support. Mrs Bennett added that Mersey Care would be held to account for the success of the support provided through the Management Agreement.

13. Mrs Fraenkel highlighted that accountability for the quality of care provided at LCH would remain with the Board at LCH in line with the accountability for any NHS Trust. Members of the Board at LCH were required to separate this responsibility from their responsibilities at Mersey Care. Mrs Fraenkel added that Mr Meadows, as Trust Secretary in Mersey Care was unable to support LCH so as to retain independence. Mr Meadows concurred and advised that arrangements for the appointment of a Trust Secretary at LCH were in discussion so as to ensure continued compliance with the Provider License.

14. Mr O'Keeffe raised concerns regarding the accountability arrangements and queried

the appropriateness of NHS Improvement holding Mersey Care to account for the support provided to LCH. Mrs Hales concurred and queried the process for measuring delivery of the Management Agreement. Mr Smith referred to section 9c within the report which set out clearly the accountability arrangements and advised that the Management Agreement provided the opportunity, together with the due diligence exercise, to assess the issues and challenges that Mersey Care would face when the transaction was completed. Mr Smith added that Mersey Care was not liable for the performance of LCH but the Executive Directors seconded to LCH for the duration of the Agreement would be accountable.

15. Mrs Darbyshire emphasised the need to ensure Mersey Care remained stable through

the period within which the Management Agreement was in place to ensure there was no negative impact on reputation.

16. In response to clarification sought by Dr Beardall regarding the seconding of staff to

LCH, Mr Meadows confirmed that Mersey Care could re-charge for these appointments.

17. Mr Meadows referred Board members to section 4.6 of the Management Agreements

regarding the day-to-day operation of LCH in which the Agreement provided clarification that the two Trusts remained separate bodies with separate Boards and accountabilities. Mrs Hales welcomed this assurance and noted that through the Agreement, the seconded Board members would be held to account for delivery of services in LCH.

Agenda Item No: B3

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18. Ms Green highlighted the importance that a risk assessment was undertaken to determine both the conflicts of interest and the capacity of Mersey Care to deliver its Operational Plan over the next 5 month period in light of the Management Agreement. Mr Smith concurred and proposed that this was documented and presented to the Board of Directors in November 2017.

19. Mr Smith highlighted the need to acknowledge the significant achievement of the Trust

in being identified as preferred acquirer and the opportunity that this provided and gave thanks to Mrs Bennett and colleagues. Mrs Fraenkel concurred and added that this also reflected the level of scrutiny applied by the Board in ensuring that quality of care within Mersey Care would not be compromised through bidding for LCH services.

20.


Recommendations approved by the Board, namely: • note the contents of this paper; • approve the Interim Management Agreement and

provide delegated authority for the Chief Executive / Deputy Chief Executive to sign the document; and

• note that in approving the Interim Management Agreement, the Board recognises and authorises the conflict of interest that will occur for those members of Mersey Care’s Board joining LCH’s Board as listed in Table 1 of this paper

Further actions required: • Risk Assessment to be undertaken and presented to

the Board regarding seconded staff and associated conflicts of interest and capacity to deliver the Mersey Care Operational Plan

A Oates / A Meadows

Nov 17

On Agenda

D ANY OTHER BUSINESS

21. There were no items of other business raised.

22. The meeting closed.

1

Date of Meeting Agenda Item Action Lead

Proposed Date of

Completion

Item Status Comments

24 May 2017 - Public Board Meeting

A2-SUC Story Mr Mulhaney to be invited to share his experience with the Board. A Meadows Mar-18 On Mar-18 Board agenda

26 July 2017 - Public Board Meeting

B4-Matters Arising a) Alignment of Resources to Quality Priorities

Corporate cost improvement plans to be reported to the Board of Directors N Smith Sep-17 Deferred to Nov-17

30 August 2017 - Public Board Meeting

C2-Service User and Carer Consultation

Mr Whelan to be engaged in the audit of consultation and co-production M Crilly Dec-17 By Dec-17



Outcomes of service user and carer engagement review to be considered at a Board Development Session

M Crilly Dec-17 on Board Dev agenda for Dec-17



Proposed Service User and Carer Engagement Model to be presented to QAC M Crilly Jan-18 on QAC agenda for Jan-18



Proposed Service User and Carer Engagement Model to be presented to Board of Directors

M Crilly Jan-18 on Board agenda for Jan-18

Public - Board of Directors - Action Log

27 September 2017 - Public Board Meeting


26 July 2017 - Public Board Meeting

24 May 2017 - Public Board Meeting

2


C1-Quality Report Audit Committee to request an audit of Physical Health Data Quality by MIAA

A Meadows/ P Williams 2017/18 To be confirmed


F2-Learning from Deaths Policy

SoRD to be updated to reflect the Learning from Deaths Policy A Meadows Nov-17 Due Nov-17

25 October 2017 - Public Board Meeting

C1-Liverpool Community Health Update (including next steps, management contract, self-certifications)

Risk Assessment to be undertaken and presented to the board regarding seconded staff and associated conflicts of interest and capacity to deliver the Mersey Care Operational Plan

A Oates / A Meadows Nov-17 On Board Private Agenda for Nov-17

KEY

COMPLETEDONGOINGTO ACTION

25 October 2017 - Public Board Meeting

Agenda Item No: B5

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Report provided (check necessary boxes): Paper No: TB17/18/147

To Note: ☒ For Assurance: ☐ Report to: Board of Directors

For Decision: ☐ For Consent: ☐ Meeting Date: 29 November 2017

Chief Executives Report

Accountable Director(s): Joe Rafferty, Chief Executive Report Author(s): Sarah Jennings, Deputy Trust Secretary

Alignment to the Trust’s Strategic Objectives: (listed by the 4 Strategic Aims)

Our Services ☒ Save time and money ☒ Improve quality

(STEEP)

Our People ☒ Great managers and teams ☒ A productive, skilled

workforce ☒ Side by side with service users and carers

Our Resources ☒ Technology that helps

us provide better care ☒ Buildings that work for us

Our Future ☒ Effective Partnerships ☒ Research and innovation ☒ Grow our services

Purpose of Report:

• This paper provides an update on key issues of interest / information arising since the last Board of Directors that are not already covered in other papers to this meeting.

Summary of Key Issues:

• The Chief Executive’s paper provides the Board of Directors with updates on national announcements /documents in respect of:

o Appointment of a senior local government leader as National Learning Disability Director;

o Publication of the updated NHS Improvement Single Oversight Framework;

o Review of Services Provided by Liverpool Women’s NHS Foundation;

o Census 2017: workforce figures for consultants and specialty doctor psychiatrists;

o Speak Up - Healthwatch Annual Report 2016/17 o Liverpool Community Health Update o 2017 Mersey Care Awards o recent issues discussed by Service User and Carer

Assembly / Standing Committee o CQC National Community Mental Health Survey 2017

Recommendation:

The Board of Directors is asked to: 1) note the Chief Executive’s report

Next Steps: (Subject to recommendation being accepted)

None identified.

Agenda Item No: B5

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Previously Presented to:

Committee Name Date (Ref) Title of Report Outcome / Action

Do the action(s) outlined in this paper impact on any of the following issues? Area Yes None If ‘Yes’, outline the consequence(s) (providing further detail in the report)

Patient Safety ☐ ☒

Clinical Effectiveness ☐ ☒

Patient Experience ☐ ☒

Operational Performance ☐ ☒

CQC Compliance ☐ ☒

NHS Provider Licence Compliance ☐ ☒

Legal / Requirements ☐ ☒

Resource Implications (financial or staffing) ☐ ☒

Equality and Human Rights Analysis Yes No N/A

Do the issue(s) identified in this document affect one of the protected group(s) less or more favourably than any other? ☐ ☒ ☐

Are there any valid legal / regulatory reason(s) for discriminatory practice? ☐ ☐ ☒ If answered ‘YES’ to either question, please include a section in the report explaining why

Does this paper provide assurance in respect of delivery of our Equality Delivery System goals and objectives (if it does please click the appropriate ones below)

EDS 1.2 - Individual people’s health needs are assessed and met in appropriate ways ☐

EDS 1.4 – When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse

☐

EDS 2.2 – People are informed and supported to be as involved as they wish to be in decisions about their care

☐ EDS 2.3 – People report positive experiences of the NHS ☐

Does this paper provide assurance in respect of a new / existing risk (if appropriate) Area New Existing N/A If new or existing, please indicate where the risk is described

Type of Risk ☐ ☐ ☒ Board Assurance Framework ☐ Risk Register ☐

Risk Reference / Description: (only include reference to the highest level framework / register)

Agenda Item No: B5

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MERSEY CARE NHS FOUNDATION TRUST

Chief Executives Report

PURPOSE

1. This paper provides an update on key issues of interest / information arising since the last Board of Directors that are not already covered in other papers to this meeting.

NHS England appoints senior local government leader as National Learning Disability Director 2. On 5 October 2017 NHS England announced the appointment of Ray James as its first

National Learning Disability Director, to drive improvement across the country on services to people with a learning disability, their families and carers.

3. Ray is the former national president of the Association of Directors of Adult Social Services and the long-standing executive director of health, housing and adult social care at the London Borough of Enfield.

4. Ray has led on significant programmes of work nationally and at Enfield he has led teams who have achieved multiple award-winning services in respect of safeguarding, community involvement and independent living for disabled adults.

NHS Improvement Single Oversight Framework

5. On 13 November 2017 NHS Improvement (NHSI) published the updated Single Oversight Framework (SOF).

6. The first iteration of the Single Oversight Framework was published in September 2016. In light of recent developments and in order to reflect the learning from the framework’s first year of operation, NHSI conducted a feedback exercise on making a series of changes to the framework including:

a) Changes to improve the structure and presentation of the document, updating the

introductory sections and summarising key information more succinctly; b) Introducing a separate section to outline the five key themes of the SOF and

summarising under each theme what would trigger consideration of a support need;

c) Changes to some of the metrics that NHS utilises to assess providers’ performance under the SOF themes and the indicators that trigger consideration of a potential support need (including removing some metrics and adding new ones). Of note is the addition of new standards on the reduction of inappropriate adult mental health out-of-area placements as a standards for mental health providers;

d) Making clear under all themes that in addition to specific triggers, other material concerns arising from intelligence gathered by or provided to NHSI could trigger consideration of a support need;

e) Making explicit that providers are expected to notify NHSI of significant actual or prospective changes in performance or risk outside of routine monitoring;

7. There were no changes to the underlying framework itself i.e. there will be no changes to the five themes, NHSI’s approach to monitoring, how support needs are identified, and how providers are segmented.

Agenda Item No: B5

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8. The updated Single Oversight Framework (Nov 2017) is available here: https://improvement.nhs.uk/resources/single-oversight-framework/

Review of Services Provided by Liverpool Women’s NHS Foundation 9. Liverpool CCG have published their review of services at Liverpool Women’s NHS

Foundation Trust. The review, part of Healthy Liverpool, has been led by NHS Liverpool Clinical Commissioning Group (CCG) in partnership with Liverpool Women’s NHS Foundation Trust, and CCGs in Knowsley and South Sefton, whose residents also use these services.

10. In January 2017 Liverpool CCG set out four potential options for the future of services

for women and newborn babies, including a ‘preferred option’ for relocating services to a new hospital next to the new Royal Liverpool Hospital. On 26 September 2017 the CCG published an independent clinical report produced by a group of midwives and doctors who work outside of the North West. They were asked to provide their view on the work that has taken place so far.

11. Their report agrees that there is a strong clinical argument for change, emphasising

the risks with delivering care for women and newborns on a stand-alone site away from other related services, as is currently the case at Liverpool Women’s. Among the range of issues they highlight are the problems that the Trust faces recruiting anaesthetics specialists, due to its isolated position; the fact that Liverpool Women’s does not have CT or MRI scanning facilities, a blood bank or an adult intensive care unit; and the lack of space in the neonatal unit.

12. The report also recognises that because services for adults and children currently take

place on different hospital sites in Liverpool, there is no solution which could meet all of the issues which have been identified. It is judged that on balance the option to relocate services to a new hospital next to the new Royal was the most appropriate and sustainable of the four potential options for the future which were published in January 2017.

13. The independent report was requested by NHS England as part of its process to make

sure that proposals are fit for purpose and ready to be presented to the public. Assuming this process is successful, local authorities in Knowsley, Liverpool and Sefton will be presented with plans for a public consultation on our proposal for a new Liverpool Women’s Hospital to be built next to the new Royal Liverpool Hospital. This could start as soon as late 2017 or early 2018.

14. The public consultation would present more detail on how this proposed solution aims

to improve services. It would also describe the three other potential solutions that were set out in January 2017, and explain why they are no longer considered to be options for the future of women’s and neonatal services in the city. No final decision about the future would be taken without first considering the views gathered during this consultation.

https://improvement.nhs.uk/resources/single-oversight-framework/

Agenda Item No: B5

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15. The full report can be accessed here: http://www.liverpoolccg.nhs.uk/media/2677/lwh-report-finaldocx.pdf

Census 2017: workforce figures for consultants and specialty doctor psychiatrists

16. In November 2017 the Royal College of Psychiatrists published a report outlining the findings of this year's census of psychiatric workforce across England, Scotland, Northern Ireland and Wales. The collection of the data took place between April and September 2017, and Mersey Care participated in this process.

17. Compared to the 2015 census the number of filled consultant posts reported by

employers (excluding Scotland to get a direct comparison) has decreased by 101, though it should be noted that the 2017 census had a lower return rate. This is despite the well-recognised increased demand for mental health services and the reported workforce provision is unlikely to be sufficient to meet the mental health needs of the patient population requiring psychiatric input. The growth rate in the consultant psychiatry workforce has been significantly lower than the growth rate in the wider consultant medical workforce. Improving recruitment and retention is a key focus for the College, Health Education England (HEE), NHS England and NHS Employers, as documented in Stepping Forward to 2020/21: Mental Health Workforce Plan for England.

18. There was another significant increase in the reported number of vacant and unfilled

consultant posts across the UK to the current level of 537. The overall reported vacancy rate at consultant level is 9%, up from 7% in 2015 and 5% in 2013. The number of vacant consultant posts across England more than doubled from 220 in 2013 to 452 in 2017, which has resulted in 10% of all consultant psychiatrist roles being unfilled. This increase in vacant consultant posts is indicative of the on-going recruitment challenges in mental health and is likely to put a strain on staff currently in post.

19. Challenges around the recruitment of permanent staff are also underlined by the

increasing reliance upon locum consultants. The number of full time locums working in psychiatry reported by NHS organisations across England has risen by 60% in just four years (an increase from 217 to 348 between 2013 and 2017).

20. The number of reported specialty doctor vacancies has risen since 2015 (10%) to 12%

in 2017 and a marked increase in the percentage of reported locum specialty doctor posts from 8.8% of the specialty doctor workforce (2013) to 15.9% (2015) and 17.9% in 2017, has also been observed. These changes are likely to reflect the particularly challenging recruitment difficulties within the specialty doctor workforce. NHS employers are struggling to fill the posts and it may be that funding is being used to employ non-medical staff to undertake these roles. The mental health workforce plan for England highlights that specialty doctors are a vital and valued part of the specialist medical workforce. The College intends to work with key stakeholders to improve recruitment and retention of this group of doctors.

http://www.liverpoolccg.nhs.uk/media/2677/lwh-report-finaldocx.pdf

http://www.liverpoolccg.nhs.uk/media/2677/lwh-report-finaldocx.pdf

Agenda Item No: B5

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21. The full report is available here: http://www.rcpsych.ac.uk/pdf/RCPsych_workforce_census_report_2017.pdf

Speak Up: Healthwatch England Annual Report 2016/17

22. Healthwatch, the independent national champion for people who use health and social care services, have published their 2016/17 Annual Report which reflects the views of 341,000 people, carers and staff during the last year about what they think of health and social care services.

23. With regard mental health services, two thirds of the Healthwatch network have found that their communities want to see a greater focus on improving mental health support. People want to see mental health concerns treated with equal importance as their physical wellbeing.

24. Although Healthwatch identified positive examples of good practice, the following were

key themes for improvement in mental health service provision:

a) Lack of mental health awareness and early intervention; b) Difficulties in accessing effective and appropriate support; c) Not receiving continuous or consistent care; d) Accessing care in a crisis can be a challenge;

25. The report also outlined the key area for improvement in respect of primary care,

hospital care and social care.

26. As outlined in the report, throughout 2017/18 Healthwatch will focus upon: a) Empowering people and communities; b) Strengthening the Healthwatch network; c) Ensuring people’s views help improve care;

27. The full report, including the progress made by Healthwatch in 2016/17, is available

here: http://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20171101_-_healthwatch_england_annual_report_2016-17_-_speak_up.pdf

LOCAL ISSUES

Zero Suicide Alliance

28. Mersey Care has a strong reputation as a Trust leading on mental health. As we’ve been joined by new services and valuable staff in the community and in learning disability, and as we work to bring together a fully person-centred approach to care, I make no apology for returning us today to a central issue of mental health.

29. Because, quite simply it is possible that 17 people in this country may take their own life today. We can do something about this. If 20 British long haul aeroplanes crashed every year, there would be a national outcry, demands for change, a long hard look at systems and processes and funds diverted to things that would quickly make the most

http://www.rcpsych.ac.uk/pdf/RCPsych_workforce_census_report_2017.pdf

http://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20171101_-_healthwatch_england_annual_report_2016-17_-_speak_up.pdf

http://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20171101_-_healthwatch_england_annual_report_2016-17_-_speak_up.pdf

Agenda Item No: B5

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difference to the problem. This week, we have started that public outcry for people thinking of, or affected by, suicide.

30. The Zero Suicide Alliance came together on 16 November 2017 for the first time. I was

at Westminster with the Secretary of State for Health, representatives of charities, major employers, CCGs and with politicians from several political parties, as we united to address the challenge of suicide prevention.

31. The Zero Suicide Alliance believes that no death by suicide should ever be regarded

as either acceptable or inevitable. Each and every single death has an incalculable impact on those who knew the deceased and each instance has huge impact on society, the local community and its resources. The Secretary of State, the Lib Dem’s Norman Lamb and also one of our local MPs, the former shadow mental health minister, Luciana Berger, spoke at the Westminster event. That level of backing is welcome. Luciana told guests that the Zero Suicide Alliance is about giving each of us a role in raising public awareness: “We leave today with a resolve that simply reducing suicide rates is not enough; we all need to collectively and individually use our influence to create that burning sense of urgency to engage the top of the system down so that funding and support is given to the people and organisations who can have the biggest influence on suicide rates now.”

32. My challenge to our partners in Westminster was, if zero isn’t the right number, then

what is the right number? Talking about zero means we reset our views to eradicating suicide, as we want to eradicate death from HIV or cancer, or in our Trust, aim for zero restraint.

33. Once we as an organisation said that we didn’t want to see anyone die in our services,

we realised that the access to training was long and expensive – those costs would challenge most organisations. But we want to do this. So we worked hard to co-produce something with those who can bring personal experience to get across the message not just for health professionals, but to everyone.

34. Already, nearly 4,000 members of staff at all levels across Mersey Care have had level

1 suicide prevention training. We want more people to have that training, and with it needing just 20 minutes of your time it’s not a big ask. Please share the link with your family and friends. You could help us towards that million. More importantly, you could save someone’s life.

35. I want to see a million people across the country complete the suicide prevention

training offered by the Zero Suicide Alliance, giving people the skills they need to approach situations where they may encounter someone with suicidal thoughts. And if they encourage their friends, their colleagues or family members to take the training, we can spread the message and move up through the hundreds of people, the thousands of people – and towards our target which will mean that finally we are equipping people to have a real conversation and help to prevent the heartbreak of suicide for the people of this country. It can be done and it should be done.

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Tate Liverpool Draws World Mental Health Day Crowds

36. A stigma-challenging arts event that demonstrates the power of creativity and social inclusion in recovery was held at Tate Liverpool on World Mental Health Day. Mersey Care works with Tate Liverpool and other cultural partners to support service users in a variety of inpatient and community settings.

37. Months of planning by the Communications and People Participation teams went into ‘Art, Mental Health and Me’ as a public demonstration of the work we undertake as a Trust, attracting hundreds of visitors.

38. A collection of themed artwork from the ‘Make It’ programme for young service users

at Tate Liverpool (with Liverpool City College) earlier this year was displayed. In tandem were the ‘I’ve Walked in Many Shoes’ arts project from Sudley House museum with The Artists Group and poet in residence Pauline Rowe. Pauline ran two creative writing workshops during the day attracting members of the public and service user groups from the Kindfulness Coffee Club in Bootle and Park Unit at the Hesketh Centre.

39. Participants from both art projects, supported by communications staff and volunteers,

were on hand to talk to visitors throughout World Mental Health Day and a leisurely sofa enabled deeper ‘Conversations on the Couch’ to take place.

40. Lindsey Fryer, Head of Learning at Tate Liverpool said: “Tate Liverpool has worked

with Mersey Care for many years placing creative thinking, teaching and learning at the heart of recovery. We are delighted to welcome Mersey Care as a Tate Exchange Associate which means that future proposals are possible using this space. Tate Exchange is a space for conversation and debate with the public on the value of art to society and to individuals. This year’s Tate Exchange theme is ‘Production’. The term Production not only refers to things or objects in the world but also the production of knowledge, skills and more importantly in this case with Mersey Care to the production or creation of understanding.”

41. Chairman Beatrice Fraenkel welcomed guests and officially opened the event, which proved so popular on one day with 220 visitors attending that Tate Liverpool asked for the artworks to remain in place a further two days.

Liverpool Community Health Update

42. Mersey Care has been successfully chosen as the preferred acquirer (subject to the completion of the approvals process) to deliver the Liverpool Community Health (LCH) Liverpool Core Services. If approved, all the staff and services will transfer to the Trust on 1 April 2018.

43. Following a request from NHS Improvement, Mersey Care has been asked to enter into an interim management agreement to provide management and other support to LCH from 1 November 2017. This means from 1 November members of Mersey Care’s Board joined LCH’s Board. LCH remains an independent statutory body which itself will be responsible for the management and delivery of LCH services to its

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commissioners and regulators. Mersey Care will not be responsible for managing LCH during the Interim Management Agreement, which is expected to stay in place until such time as Mersey Care is approved as LCH’s acquirer.

44. A single Transaction Team with colleagues from across LCH and Mersey Care will be

formed to ensure there is a safe and smooth transition.

Mersey Care Awards

45. Congratulations to the Primary Care Mental Health Liaison team that have won the Best Nursing Technology award at the EHI Awards 2017 – Recognising Innovation and Excellence in Digital Health and Wellbeing. The award was won for developing and implementing the GATE assessment tool in primary care, which is used by the Community Care teams across Liverpool to screen for health needs and is playing an important part in the transformation of community services across the city.

46. Importantly, this is a tool that has been developed in partnership between Mersey Care, Liverpool Community Health NHS Trust, Liverpool Community Commissioning Group, Liverpool City Council and Informatics Merseyside. This partnership approach is going to become more and more important given this period of austerity and is just one of the ways we can make the public pound stretch further.

47. The GATE is a perfect example of that, which was developed as an holistic

assessment, where information is shared and we work more collaboratively with providers across Liverpool to enhance patient care and reduce hospital admissions.

48. This was the start of an impressive week for Mersey Care with the ‘No Force First’

team winning the Improving Patient Safety Award at the Nursing Times Awards while Neil Smith won the Finance Director of the Year for the Liverpool City Region at the FD Awards 2017.

49. A final mention must also go to the Everton in the Community programme, which also

won silver for Best Football Community Scheme at the Footiebiz awards.

Update on the Service User and Carer Assembly / Standing Committee

50. The Full Service User & Carer Assembly met on 3rd October 2017 and received a presentation from the Director of Integration regarding her role and in particular the acquisition of community health services. The Chief Operating Officer for the Local Division also led a question and answer session regarding the work of the Local Division.

51. The Standing Committee of the Assembly met on both the 2nd and 16th October in order to explore more fully the Trust’s definition and understanding of the term ‘co-production’. It was highlighted that there were differing understandings of co-production across the organisation as well as in different contexts, e.g. co-production in a decision-making context may be quite different from a research or service development context. The Committee has acknowledged that it will take time to effectively work through a strategy around co-production for the organisation. In

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particular, the Committee has highlighted that if this is to be done properly it must also factor in what co-production might mean for our physical health community services.

52. The Full Service User & Carer Assembly will meet again 5th December 2017 to

receive a presentation from service users from the Specialist Learning Disability Division for an overview of services delivered in Whalley. The Chief Operating Officer for the Specialist Learning Disability Division will also lead a question and answer session regarding the work of the Division.

CQC National Community Mental Health Survey 2017

53. The 2017 Community Mental Health survey received feedback from more than 12,000 people and had a response rate of 26%. The results will be published in December; a full analysis of the report will be presented to Quality Assurance Committee (Jan-18) and the Executive Committee (Dec-17).

54. The key findings of this national report are that

• around two-thirds of respondents reported a positive experience of overall care; • the vast majority of respondents said that they knew how to contact the person in

charge of their care if they had concerns; • Higher proportion of respondents this year also knew who to contact out of hours if

they were experiencing a crisis.

55. However,

• Substantial concerns remain about the quality of care some people experience when using community mental health services;

• There has been little notable improvement in survey results in the last year in the majority of areas;

• The survey results suggest scope for further improvements in a number of areas including: crisis care, access and coordination of care, involvement in care, monitoring the effects of medication and receiving additional support.

56. Three trusts were classed as ‘better than expected’ across the entire survey (details below)

• 2gether NHS Foundation Trust • Humber NHS Foundation Trust • Mersey Care NHS Foundation Trust

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RECOMMENDATION

57. The Board of Directors are asked to:

a) note the Chief Executive’s report;

JOE RAFFERTY

CHIEF EXECUTIVE

November 2017

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END OF DOCUMENT

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Report provided (check necessary boxes): Paper No: TB/17/18/148

To Note: ☒ For Assurance: ☒ Report to: Board of Directors


Quality Report

Accountable Director(s): Ray Walker, Executive Director of Nursing 0151 473 2965

Report Author(s): Steve Morgan, Director of Patient Safety 0151 473 2873


Our Services ☒ Save time and

money ☒ Improve quality (STEEP)

Our People ☒ Great managers

and teams ☒ A productive, skilled workforce ☒

Side by side with service users and carers

Our Resources ☒

Technology that helps us provide better care

☒ Buildings that work for us

Our Future ☒ Effective

Partnerships ☒ Research and innovation ☐ Grow our services

Purpose of Report:

• The Quality Assurance Committee is established and constituted by the Board of Directors to provide assurance that quality in the Trust is of the highest standard; this report contains a summary of the key issues discussed at the last Quality Assurance Committee and a copy of the new high level Quality Dashboard, Appendix A.


The Key issues from the Quality Assurance Committee are identified on page 3 & 4 of the report. • The Local and Secure Division’s confirmed that they have clear

trajectories to achieve the MCA/DoLs training requirements, which are a key priority for the Trust. It is recognised that it is essential for staff to have a clear understanding of this legislation to prevent the possibility of illegal detentions occurring.

• Concerns about the ability of the Trust to achieve training targets were considered, it was recognised that there are many conflicting priorities for staff. It was confirmed that the Executive Director of Workforce is going to facilitate a review of mandatory training programmes with the aim of ensuring that the training that staff undertake is valid and appropriate.

• It was confirmed that the Trust had undertaken a project to understand its data related to the number of service users from a BME background who are detained under sections of the Mental Health Act (1983). An initial review of the data has been undertaken by the University of Central Lancashire (UCLAN). They found that service users within the Trust were three times more likely to be placed on a Community Treatment Order

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(CTO) if they were from a BME background than if they were not. The project team have identified anecdotally that service users from a BME background tend to come into services via a crisis pathway and therefore the initial stages of their illness have, for a variety of reasons, either not been recognised or treated. This hypothesis will be explored via the work of the project team and contributory factors and remedial actions identified.

• The ability of the environment at the Park Lodge Community Hub to provide safe accommodation for staff and service users has been highlighted as a risk and has attracted a score of 16. Whilst it was accepted that remedial estates work, which has included making the fire escape safe, has improved the situation, it was recognised that this was not a situation that could carry on for an extended period. It was confirmed that the implementation of the improvement plan will be overseen by the Executive Committee.

• The reduction in the number of Quality Review Visits that had been completed during the last six months particularly in the Specialist Learning Disability Division was raised as a concern. Non Executive Directors challenged the fact that only fourteen out of sixty five teams assessed had achieved the green rating, this underpinned the view that further QRV’s should be undertaken to monitor that standards do not fall.

• It was highlighted that there have been three incidents since May 2017 where service users have died after allegedly putting themselves in the path of oncoming traffic. Two of these deaths related to people who were on leave. The Perfect Care Team is completing a review of the current systems in place to agree and manage leave arrangements across the Trust. Initial enhanced safety measures have been put in place by the Local Division.

• The High Secure Division has received an increased number of allegations against staff during this reporting period. It was recognised that a significant number of these incidents were carried out by one service user who has also made complaints to the Nursing and Midwifery Council (NMC). All issues raised are reviewed, specific care plans are in place to support and manage the individual. The Committee recognised that staff facing the constant flow of complaints are finding the situation very stressful and are being supported by the division’s management team.

Recommendation:

The Board of Directors is asked to: 1) Discuss the report. 2) Identify any Changes required to the high level Quality

Dashboard. 3) Identify any further assurances it requires.


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Patient Safety ☒ ☐

The Board needs to have robust assurances for patient safety otherwise increased numbers of adverse incidents will be reported and it will come under scrutiny from the CCG and CQC.



Operational Performance ☒ ☐

CQC Compliance ☒ ☐

NHS Provider Licence Compliance ☒ ☐

Legal / Requirements ☒ ☐




Are there any valid legal / regulatory reason(s) for discriminatory practice? ☐ ☒ ☐ If answered ‘YES’ to either question, please include a section in the report explaining why




☒


☐ EDS 2.3 – People report positive experiences of the NHS ☒


Type of Risk ☐ ☒ ☐ Board Assurance Framework ☐ Risk Register ☐


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Quality Report

PURPOSE

1. The Quality Assurance Committee is established and constituted by the Board of Directors to provide assurance that quality in the Trust is of the highest standard; this report contains a summary of the key issues discussed at the last Quality Assurance Committee in relation to the presentation of the Quality Report.

2. This report also contains some information from the new high level Quality Dashboard which is presented at Appendix A. The dashboard contains high level measures that reflect the Trust model of Quality (STEEEP).

ISSUES (raised at the last QAC meeting)

3. The Quality Assurance Committee discussed the following issues -: 4. South Sefton Community Division shared the work that they are undertaking to reduce

the number of Community Acquired Pressure Ulcers ((i.e. those ulcers that develop whilst the service user is receiving care from the division) The division has developed and embedded a pressure ulcer reduction programme (PURP) the project focuses on six key areas -;

a) The high risk patient. b) Staff training and skill mix. c) Education of carers and the third sector. d) Mental capacity and non- adherence to care packages. e) Use of equipment. f) Risk Assessment and management.

5. The South Sefton Community Division has recognised that there are teams that are

struggling to reduce and manage pressure ulcers and is working with them on their specific issues. The focus is on preventing pressure ulcers initially occurring and deteriorating by focussing on the above key areas.

6. The Local and Secure Division’s confirmed that they have clear trajectories to achieve

the MCA/DoLs training requirements, which are a key priority for the trust. It is recognised that it is essential for staff to have a clear understanding of this legislation to prevent the possibility of illegal detentions occurring.

7. Concerns about the ability of the Trust to achieve training targets, was considered, it was recognised that there are many conflicting priorities for staff. It was confirmed that the Executive Director of Workforce is going to facilitate a review of mandatory training programmes with the aim of ensuring that the training that staff undertake is valid and appropriate.

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8. The Trust has undertaken a project to understand its data related to the number of service users from a BME background, who are detained under sections of the Mental Health Act (1983). An initial review of the data has been undertaken by the University of Central Lancashire (UCLAN). They found that services users within the Trust were three times more likely to be placed on a Community Treatment Order (CTO) if they were from a BME background than if they were not. The project team have identified anecdotally that service user’s from a BME background tend to come into services via a crisis pathway and therefore the initial stages of their illness have for a variety of reasons not either been recognised or treated. This hypothesis will be explored via the work of the project group and contributory factors and remedial actions identified.

9. The reduction in the number of Quality Review Visits that had been completed during

the last six months particularly in the Specialist Learning Disability Division was raised as a concern. Non Executive Directors challenged the fact that only fourteen out of sixty five teams assessed had achieved the green rating, this underpinned the view that further QRV’s should be undertaken to monitor standards and enable actions to be put in place to prevent them falling and or improve them. It was confirmed that a paper would be presented to the QAC at their next meeting to share the trust’s strategic approach to undertaking audits of clinical teams.

10. The ability of the environment at the Park Lodge Community Hub to provide safe accommodation for staff and service users has been highlighted as a risk and has attracted a score of 16. Whilst it was accepted that remedial estates work, which has included making the fire escape safe, has improved the situation, it was recognised that this was not a situation that could carry on for an extended period. It was confirmed that the implementation of the improvement plan will be overseen by the Executive Committee.

11. The reduction in the number of Quality Review Visits that had been completed during

the last six months particularly in the Specialist Learning Disability Division was raised as a concern. Non Executive Directors challenged the fact that only fourteen out of sixty five teams assessed had achieved the green rating, this underpinned the view that further QRV’s should be undertaken to monitor that standards do not fall. It was agreed that a paper would be shared at the next meeting of the QAC outlining the Trust’s strategic approach to monitoring the quality of care provided by clinical teams.

12. The Committee recognised that the changes that will take place from December 11th 2017 to the way Section 136 (MHA 1983) can be implemented (as part of the Policing and Crime Act 2017 amendments to the Mental Health Act and Deprivation of Liberty Safeguards) will potentially put pressure on clinical teams. The impact will be experienced primarily at the A and E services in acute trusts and the Prenton Suite in Clock View. The time period for detaining service users in a Place of Safety will be reduced from the current seventy two hours to 24 hours with the possibility of an extension for a further twelve hours. As service users can currently wait extended periods both to be assessed and to obtain an inpatient bed this could create difficulties for staff in ensuring that service users wait safely in the departments for services to be provided. Whilst the Committee accepted that plans are currently being put in place to enable the Trust and it’s partner agencies to adapt to the changes and keep service

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users and staff safe, they have requested a formal update on the effect of the changes at their next meeting.

13. The committee received an update on the Trust’s progress with implementing the

Green Light Toolkit which provides a framework for auditing and improving services to ensure that they are effective in supporting people with Autism and a Learning Disability. The tool kit guidance suggests that audits should be completed at least annually. The toolkit provides three levels of audit –basic, better and best. The Local and Secure divisions have carried out the basic audit and the Specialist Learning Disability Division has completed an assessment against the basic, better and best standards. Action plans are being put in place in each division where this is required and implementation will be overseen by the Quality Assurance Committee. Each division will be asked to complete a re-audit by the end of September 2018

14. The Trust has undertaken a Trust wide review of Allied Health Professions it has been

undertaken in the context of guidance published by NHSi to support the development of safe and sustainable staffing in learning disability and mental health services. The original review reported to the Q.A.C. in May 2107. It was confirmed that the Trust has started to implement the findings of the review; the actions to describe what good should look like will be completed by November 2017. This work will include guidance on how to undertake safer staffing reviews and enable the Local Division to identify a solution to its service line Occupational Therapy (OT) leadership and divisional senior AHP gaps. Some interim arrangements have been put in place to fill OT roles via the additional staffing system.

15. The committee were informed that the new system of centrally managing the NICE guidance review process has been working effectively for the mental health divisions. Nine audits have been completed including ones related to oral health, drug misuse, anti-social behaviour and dementia. All these baseline assessments were 100% compliant; they will inform the audit programme for 2018/19. In addition the micro audit programme has been operational and is based on the health needs of secure /SpLDD patients. The eight audits conducted have included ones on Epilepsy, Irritable Bowel Syndrome (I.B.S.), Low back pain and menopause. SpLDD have used the audits to develop and implement pathways for I.B.S. and the menopause.

16. There are currently risks on the risk register which relate to the implementation of the findings of NICE guidance but do not directly reference NICE. These relate to the implementation of care for the prevention and management of obesity, access to services and provision of high intensity psychological therapy for people with depression. Mitigation plans are in place and reviewed regularly.

17. Mortality reviews continue to be undertaken using the Trust’s agreed policy and procedure. Currently the lead Non Executive Director is working with the team to monitor adherence to the agreed review process with the aim of identifying any areas of non compliance which require remedial action. It was confirmed that the Trust is working with local acute trust’s to develop procedures to recognise where service users have died and have been receiving care from both mental health and acute providers. This will enable full clinical pathway reviews to take place and increase the likelihood of effective changes to practice being put in place. Mazars have suggested that that the Trust considers analysing the seasonal variation in the number of deaths

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for older people, to identify if remedial actions are required. See Appendix B for mortality data.

18. The Committee were informed that there have been three incidents since May 2017 where service users have died after allegedly putting themselves in the path of oncoming traffic. Two of these deaths related to people who were on leave. The Perfect Care Team are completing a review of the current arrangements in place to agree and manage leave arrangements across the Trust. Initial enhanced safety measures have been put in place by the Local Division.

19. The High Secure Division has received an increased number of allegations against staff. It was recognised that a significant number of these incidents were carried out by one service user who has also made complaints to the Nursing and Midwifery Council (N.M.C.). All issues raised are reviewed, specific care plans are in place to support and manage the individual service user involved. The Committee recognised that staff facing the constant flow of complaints are finding the situation very stressful and are being supported by the division’s management team.

RECOMMENDATION 20. The Board of Directors is asked to:

a) Discuss the report.

b) Identify any Changes required to the high level Quality Dashboard.

c) Identify any further assurances it requires.

STEVE MORGAN DIRECTOR OF PATIENT SAFETY November 2017

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Appendix A Level 2 - Our Services - Key Performance Indicators

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Appendix B Mortality Review Information

Within Scope - patients who have had contact with MCT within the last 6 months and subject to mortality review process.

Not in Scope - patients who have had contact with MCT over a six month period. Not subject to formal mortality review process.

Investigated by Steis – incidents that are potential suicide incidents and are subject to a full RCA review.

100 % of all reported deaths that are within scope are now being subject to at least the 1st stage screening review as per policy.

The 18 to 59 age range comprises of patients who have died from drug and alcohol related issues, those with a learning disability and as a result of suicide. Mazars have suggested that the Trust considers analysing the seasonal variation in the number of deaths for older patients to identify potential causes and outline if remedial actions are required. This work will be undertaken as a thematic review.

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Following the 1st stage screening process 13 cases of Excellent Care were recorded, 254 cases of Good Care, 27 cases of Adequate Care and 8 cases of Poor Care. There were no incidents of very poor care. Adequate care was recorded primarily for those cases where an up to date care plan or risk assessment was not evident within the clinical notes. Poor Care was recorded for 8 cases. Of these 8 cases 4 where deemed to be avoidable following 1st and 2nd Structured Judgement reviews and 4 cases were re-graded to adequate care. The 4 avoidable deaths either went to a SARs or a Level 2 RCA Review.

All deaths occurring within Specialist Services are reported to the combined Public Health England and JMU study for further review.

All Learning Disability incidents are reported to LeDeR – the Learning Disability Mortality Review programme.

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Expected Natural (EN1) – deaths that were expected to occur in an expected timeframe e.g. terminal illness. Unlikely to be preventable – no further investigation needed.

Expected Natural (EN2) – deaths that were expected but not expected to happen within timeframe e.g. cancer or liver cirrhosis but dies earlier than anticipated - may be preventable – some would benefit from investigation.

Expected Unnatural (EU) – deaths that are expected but not from the cause expected or timescale e.g. misuse of drugs, alcohol dependant, eating disorder – likely to be preventable should consider further investigation.

Unexpected Natural (UN1) – death from a natural cause e.g. sudden cardiac condition, stroke – may have been preventable – may need further investigation.

Unexpected Natural (UN2) – death from natural cause but didn’t need to be e.g. Alcohol, and drug dependency, care concerns – likely to be preventable – consider further investigation.

Unexpected Unnatural (UU) – suicide, homicide, abuse/neglect – preventable - needs investigating.

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To Note: ☐ For Assurance: ☐ Report to: Board of Directors Meeting

For Decision: ☒ For Consent: ☐ Meeting Date: 29 November 2017

Care at a Glance – Month 7 2017/18

Accountable Director(s): Ray Walker, Executive Director of Nursing 0151 473 2965

Report Author(s): Jennifer Billingsley, Performance & Business Intelligence Analyst


Our Services ☒ Save time and money ☐

Improve quality (STEEEP)

Our People ☒Great managers and teams ☒

A productive, skilled workforce ☒


Our Resources ☒

Technology that helps us provide better care ☒

Buildings that work for us

Our Future ☒ Effective Partnerships ☒Research and innovation ☒ Grow our services

Purpose of Report: • To provide a summary of the trust performance to 31 October2017.

Summary of Key Issues: South Sefton Community Division (SSCD) data has been incorporated into the following KPIs at trust level:

• Safe staffing• Delayed transfers of care• Board assurance framework (Risks)• Vacancy Rate• Turnover• Sickness• Core statutory training• Work is ongoing to integrate SSCD data at trust level where

applicable.

The below key issues have been discussed with the individual directors and work is in train to action these.

REGULATORY POSITION

• The trust continues to be allocated by NHS Improvement tosegment 2 in the single oversight framework and the NHSiFinance and Use of Resources has reduced to a score of 2,which is in line with the annual plan. The capital service coverrating has reduced to 2 from 1 in October. This is driven by theprofiling of the operating surplus, compared to capital servicewhich has accrued evenly throughout the year.

• The trust has been assessed as “Good” following the CareQuality Commission inspection between 20 March 2017 and 23

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March 2017. • The services that received a rating of “good” were effective,

caring, responsive and well led. A “requires improvement’rating was given for safe.

• Agency Spend continues to be a key underperforming metric forthe trust. The position for October 2017 is 44.00%.

SINGLE OVERSIGHT FRAMEWORK 2017

• The consultation for the Single Oversight Framework (SOF) hasnow finished and the updated version has been published on 13November 2017. The updated version has been updated to:- reflect changes in national policy priorities and standards- clarify certain process and definitions- improve the structure and presentation of the document

• No timescales have been released from NHS Improvement(NHSI) to indicate when the new iteration will be implemented.

• Currently the Trust uses data published from the Model Hospitaldata tool to monitor the SOF however due to the release of thenew SOF the Model Hospital is no longer due to be updateduntil the new calendar year. The trust has decided to revertback to local reporting of the SOF until the changes have beenimplemented and the Model Hospital data tool is updated. Nobenchmarking data will be available until the Model Hospitaldata tool is updated.

• An update will be provided in next months report in relation toany timescales which are published.

CONTROL CHARTS

The trust displays the strategy measures in the visualisation of control charts which are used to display whether processes are stable or not as per the “Western Electric Rules”. If there are 8 consecutive points above or below the mean average or 8 consecutive data points increasing or decreasing, special cause variation has been identified and a step change has been applied to the control chart. The narrative below will identify measures where special cause variation has been identified or where measures are performing below the expected target. If there is no narrative, this is because the measure is within normal variance.

STRATEGIC PRIORITIES

Our Services

• Physical Health screening (new admissions) remains belowtarget at 10% in October 2017. The Quality AssuranceCommittee (QAC) has requested a deep dive into theunderperformance. An update will be provided to the QAC inJanuary 2018.

• The detention of people from a BME background remains highbut relatively stable at 36.36% in October 2017. The data nowincludes the Specialist Learning Disability Division and this hasbeen backdated to April 2017.

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• The % likely to recommend the trust to friends and family(patient experience) in October 2017 position is 88.77%. This isa minimal improvement when compared with September 2017of 88.47%.

• The year to date surplus at month 6 is £3.463m.

Our People

• Core statutory training remains below the 95% target at 83.78%in October 2017. This is a slight improvement when comparedwith September 2017 at 83.50%.Significant work is on-going to improve and sustain statutoryand mandatory training compliance across the divisions. Alldivisions have produced an action plan which shows how theyaim to reach trajectories determined by the Strategic WorkforceGroup as follows:-Core Statutory – 95% by the end of OctoberCore Mandatory – 85% by the end of NovemberRole Specific Statutory and Mandatory – 50% by the end ofDecember.All subjects – 65% by end of December and 95% compliance byend of March 2018.Access to training on the Oracle Learning Managemente-learning platform can be problematic locally andnationally. The Trust is currently implementing the ReliasLearning Management System (LMS) to address current issueswhich affect e-learning,Role specific mandatory subjects, divisions are raising someconcerns that positions agreed by subject matter expertsagainst staff roles are incorrect. For example staff withincorporate division most roles do not include front line clinicalpractice therefore to understand the rationale for therequirement to complete, a full review with Subject MatterExperts will be undertaken in December with representativesfrom all divisions. The outcome will be reported back to theStrategic Workforce Group for sign off in December.Statutory training taught classroom sessions will continue to bedelivered to also support divisions.Training compliance will be discussed at surveillance and alloperational management groups Staff road shows will alsoreiterate importance of statutory and mandatory training tostaff.

• The trust’s in-month sickness rate for October 2017 is 7.22%.This is a deterioration when compared with 6.54% in September2017. The figures for SSCD are reflective of the revisedreporting i.e. we have referenced under reporting of sicknessabsence for the division in previous CAAG reports however thesickness absence reporting process has been reviewed withinthe division and it has become apparent that sickness has notbeen accurately reported via e-svl. The division is now assuredthat the current position is a more accurate reflection ofsickness absence.For this report the corporate management/support staff whichhad historically been reported on via SSCD have been

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realigned into the MC corporate functions and typically this has had low sickness absence rates which has disguised SSCD’s true position.

• The vacancies vs budgeted establishment continues to remainhigher than planned. In October 2017 the position reported is10.84%. An increase has been observed in SpLD and SSCD.The increase in SSCD is due to various posts being createdand are currently vacant. The posts created were as a result ofposts previously provided by Aintree and new posts createdfollowing a restructure.

• The turnover rate for the trust is at 13.53% in October 2017. Animprovement in turnover can be observed from September2016 (19.18%). The target is between 8% and 12%. FromMarch 2017 a positive special cause variation has beenobserved and a step change has been applied to the controlchart.

Our Future

• In October 2017 the count of actual and potential suicides was34 (rolling 12 month figure). This has remained the same whencompared with September 2017 (34). The target is 25.There appears no real trends or hotspots within the suicides atpresent, although we have had an increase in the numbers ofpensioners (over 65) in the past year. Similarly there has beena number of deaths by collisions with vehicles recently. Butnone of these occurrences can be linked as have occurred indifferent parts of the trust across different age ranges.

• There is one risk associated with contracts from the BoardAssurance Framework.

TRANSFORMATION PLANS

Local Division

• The number of new referrals from GP continues to be aboveplan at 1137 for October 2017 against a plan of 1036.

• Adult Mental Health bed occupancy has deteriorated in October2017 at 95.53%. The deterioration is due to an increase indelayed discharges. The reasons for these are: placementunavailability i.e. LSU, Huntington, patient choice; LocalAuthority assessments completed with no bids, thusassessments having to be redone and failed asylum seekerswho have been admitted but cannot be discharged until homeoffice arrangements are in place.

• The number of Out of Area Placements for October 2017 isfour. This equated to 23 OAP bed days.

• An improvement has been observed in October 2017 for in-month staff sickness (6.69% to 6.60%).

• The % on caseload on clusters 1, 2 and 3 continues to beabove plan (3.83%) at 6.92% in October 2017. An upwardtrend can be observed from March 2017.

• The % of vacancies against budgeted plan in October 2017 is

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reported as 10.73%. This remains above target. • Patient Experience Friends and Family has remained stable in

October 2017 to 93.82% against a plan of 95%.• The Local Division is on target to meet its key financial targets

for budget as at 31 October 2017 (YTD). The Local Division in-month position was overspent by £156.

• The Local Division is not meeting their CIP as at the 31 October2017.

Secure Division

• The reduction in time spent in long-term segregation has beenreported on in line with Reducing Long-Term Segregation: AZero Approach. The plan is by March 2018 for long-termsegregation to be reduced by 20% from the baseline (April2017). A reduction in the number of days spent in segregationcan be observed from April 2017.

• A deterioration has been observed in October 2017 for in-monthstaff sickness (7.47% to 8.55%).

• The % likely to recommend the trust to friends and family(patient experience) in October 2017 is 75.25%. This is adeterioration when compared with September 2017 at 78.43%.This is due to a deterioration within HSS.

• The % of vacancies against budgeted plan in October 2017 isreported as 6.34%. This remains above plan (5.00%).

Specialist Learning Disabilities Transformation Plan

• The number of service users discharged remains significantlybelow plan (4) at two discharges in October 2017. Since April2017, altogether there have been 16 discharges against a planof 54.

• A deterioration has been observed in October 2017 for in-monthstaff sickness (8.36% to 10.31%).

• The % of vacancies against budgeted plan in October 2017 isreported as 20.83%. This remains above target.

• The SpLD is not on target to meet its key financial targets forbudget as at 31 October 2017.

South Sefton Community Division

• There have been one Grade 3 CAA Pressure Ulcers reported inOctober 2017 against a plan of one. In total there has been 13reported Grade 3 CAA Pressure Ulcers since April 2017. Thetarget for the 2017/18 Quality Account is 13 and therefore it islikely that this will not be met.

• The completion of the falls risk assessment tool in October2017 is reported as 94.40%. This is an improvement whencompared with September 2017. This is below the target of95%.

• The completion of the malnutrition universal screening tool inOctober 2017 is reported at 93.79%. This is a deteriorationwhen compared with September 2017. This is below the target

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of 95%. • Delayed transfers of care has been added as metric to replace

the % of rejected referrals urgent care as this has beenremoved by the division. Delayed transfers of care for October2017 was 9.97% (N=8).

• Staff sickness in October 2017 was 9.43%. This was adeterioration when compared with September 2017 at 7.94%.Narrative as above.

• The % of vacancies against budgeted plan in October 2017 isreported as 10.76%. This is a deterioration when comparedwith September 2017 at 7.94%. This is above the target of 5%.Narrative as above.

Recommendation: The Committee is asked to note: • The assessment of performance• The Internal Reporting of SOF• The new metric Delayed Transfers of Care for SSCD which

has replaced the metric for % of rejected referrals urgentcare.

• The Specialist Learning Disabilities Retraction Plan as perthe action from the Performance, Investment and FinanceCommittee held in October 2017.


Agenda Item No: C2



Executive Committee

EC17/18/1052 Care at a Glance Report


Patient Safety ☒ ☐

The impact is anticipated to be positive and to provide assurance of compliance with quality standards

Clinical Effectiveness ☒ ☐


Patient Experience ☒ ☐




CQC Compliance ☒ ☐


NHS Provider Licence Compliance ☒ ☐


Legal / Requirements ☒ ☐






Are there any valid legal / regulatory reason(s) for discriminatory practice? ☐ ☒ ☐

If answered ‘YES’ to either question, please include a section in the report explaining why Does this paper provide assurance in respect of delivery of our Equality Delivery System goals

and objectives (if it does please click the appropriate ones below) EDS 1.2 - Individual people’s health needs are assessed and met in appropriate ways ☒


☒


☒EDS 2.3 – People report positive experiences of the NHS ☒


Type of Risk ☐ ☒ ☐ Board Assurance Framework ☒ Risk Register ☐


SRR.60 Strategic Risk that the focus on the drivers for financial sustainability and quality improvement become out of balance

Agenda Item No: C2

Mersey Care NHS Foundation Trust Care at a Glance Report

Report Area

Regulatory Position (Internal Reporting)

Regulation – Overview

Regulation – Quality of Care

Regulation – Finance and Use of Resources

Regulation – Leadership and Improvement

Regulation – Operational Performance

Strategy

Strategic Wheel – Overview

Our Services Top Lines reviewed at QACOur People Top Lines reviewed at PIFCOur Resources Top Lines reviewed at PIFCOur Future Top Lines reviewed at PIFC

Operational Transformation

Transformation - OverviewTransformation - LocalTransformation - SecureTransformation - Specialist LDTransformation - Community

Appendices

Safe Staffing Report - TrustOur Services KPIs - LocalOur People KPIs - LocalOur Future KPIs - LocalOur Services KPIs - SecureOur People KPIs - SecureOur Future KPIs - SecureOur Services KPIs - SpLDOur People KPIs - SpLDOur Future KPIs - SpLDFinance ReportSpLD Retraction Plan Update

Contents

EC: B2

TB: C2 1

Agenda Item No: C2

Regulation - Single Oversight Framework / CQC

CQC Rating

3 3 3 3

1 1

2

0

1

2

3

4

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

NHSi Finance & Use of Resources Score

2 2 2 2 2 2 2

0

1

2

3

4

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-17

Sep

-17

Oct

-17

NHSi Segment Score

EC: B2

TB: C2 2

Agenda Item No: C2

Regulation - Quality of Care

(Internal Reporting)

Measure Type Data Frequency

Threshold Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

Written Complaints -

rateCaring Quarterly TBC 34.4 29.1 *

Staff FFT % recommended

- careCaring Quarterly TBC 68.63% 67.41% 71.13%

* Local data not available.

Trend Source

NHS Digitial

NHS England National Data

Measure Type Data Frequency

Threshold Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Source

Occurrence of Never Event

SafeMonthly (six

monthly rolling)

Green - 0, Red - 1 or

more 0 0 0 0 0 0 0 MCFT Internal

Reporting

Patient Safety Alerts not

completed by deadline

Safe Monthly Green - 0, Red - 1 or

more 0 0 0 0 0 0 0

NHS Improvement

(publicly available)

Admissions to adult facilities of

patients under 16 years old

Safe MonthlyGreen - 0, Red - 1 or

more 0 0 0 0 0 0 0 MCFT Internal

Reporting

Mental health scores from FFT -

% positiveCaring Monthly 86.67% 86.91% 88.26% 89.99% 85.53% 93.32% 88.51%

MCFT Internal Reporting

Community scores from Friends and

Family Test - % positive

Caring Monthly TBC 100% 100% * NHS England

Mixed Sex Accommodation

BreachesCaring Monthly

National Median 3 0 0 0 0 0 0 0


CQC Community Mental Health

Survey

Organisational Health Annual 8.91 *** Care Quality

Commission

Aggressive Cost Reduction Plans

Organisational Health Monthly

National Median 4.1%

2.83% 2.83% 2.83% 2.83% 2.83% 2.83% 2.83%MCFT Internal

Reporting

Care Programme approach follow up within 7 days

Effective Monthly 95% 92.00% 93.72% 94.67% 94.07% 95.56% 95.05% 92.73%MCFT Internal

Reporting

% clients in settled

accomodation Effective Monthly

National Median

64%63.00% 62.00% 62.00% 61.00% *** *** *** NHS Digital

via MHSDS

% clients in employment Effective Monthly

National Median

9%3.00% 4.00% 4.00% 4.00% *** *** *** NHS Digital

via MHSDS

** CQC Community Mental Health Survey results published in November 2017. The trust has been reported as better than expected. Details to follow.*** Data not reported on locally, data is reported on via NHS Digital.

* October 2017 data not available

Trend

EC: B2

TB: C2 3

Agenda Item No: C2

Regulation - Finance & Use of Resources


Financial Risk Measure Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18Days 28 22 21 24 22 21 20

Risk Score 1 1 1 1 1 1 1RAG Green Green Green Green Green Green Green

Rating 3 3 3 3 3 3 2Risk Score 1 1 1 1 1 1 2

RAG Green Green Green Green Green Green Yellow

Rating 3.03% 2.71% 2.80% 3.00% 2.80% 2.22%Risk Score 1 1 1 1 1 1 1

RAG Green Green Green Green Green Green Green

Rating 0.12% 0.10% (0.10%) 0.00% 0.04% 0.02%Risk Score 1 1 2 1 1 1 1

RAG Green Green Yellow Green Green Green Green

Rating 56.0% 52.3% 50.9% 57.3% 42.8% 42.7% 44.00%Risk Score 4 4 4 4 3 3 3

RAG Red Red Red Red Amber Amber Amber

3 3 3 3 1 1 2

Amber Amber Amber Amber Green Green YellowOverall Financial Sustainability RAG

Liquidity days

Capital services capacity

I&E Margin

I&E Margin Variance (based on original plan)

Agency Spend

Finance Score

EC: B2

TB: C2 4

Agenda Item No: C2

Regulation - Operational Performance (Internal Reporting)

Measure Data Frequency

Threshold Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Source

People with a first episode of psychosis begin treatment with a NICE recommended

care package within 2 weeks of referral.

Quarterly (three month rolling)

50% 62.79% 66.67% 72.97% 82.05% 75.47% 70.77% 63.83% Unify Return

Accommodation Status Monthly 85% 80.50% 80.20% 81.07% 80.06% 79.67% 78.80% 81.73% MCFT Internal Reporting

Commissioner Org Code Monthly 95% 99.98% 99.99% 99.99% 99.99% 99.99% 99.99% * MCFT Internal Reporting

Date of Birth Monthly 95% 100% 100% 100% 100% 100% 100% * MCFT Internal Reporting

Employment Status (adults) Monthly 85% 83.62% 82.45% 78.04% 82.45% 82.06% 81.20% 83.97% MCFT Internal Reporting

Ethnicity Monthly 85% 82.00% 82.26% 82.17% 83.31% 82.88% 82.88% 82.85% MCFT Internal Reporting

Current gender Monthly 95% 100% 100% 100% 100% 100% 100% * MCFT Internal Reporting

Registered GP Org Code Monthly 95% 98.41% 98.12% 98.08% 98.36% 98.32% 98.05% * MCFT Internal Reporting

NHS Number Monthly 95% 98.82% 98.50% 98.74% 99.08% 99.09% 98.70% * MCFT Internal Reporting

Postcode Monthly 95% 99.73% 99.72% 99.73% 99.72% 99.72% 99.71% * MCFT Internal Reporting

Patients requiring acute care who received best practice gatekeeping assessment

Monthly 95% 97.62% 88.78% 88.16% 98.21% 95.85% 92.86% 93.98%MCFT Internal

Reporting

IAPT - proportion of people completing treatment who move to recovery (from IAPT minimum dataset)

3-month rolling

>=50% green;

<50% red85.10% 89.48% 94.64% 96.06% 96.21% 95.50% 95.62%


IAPT – waiting time to begin

treatment (from IAPT minimum data set) within six weeks

3-month rolling

>=75% green;

<75% red98.27% 98.78% 99.41% 99.91% 100% 100% 100%


Trend

* Local data not available due to submission due on Wednesday 22.11.2017.


Threshold Q4 16/17 Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18

IAPT - proportion of people completing treatment who move to recovery (from

IAPT minimum dataset) Quarterly

>=50% green; <50% red 30.50% 31.59% 33.78%

Ensure that cardio-metabolic assessment and treatment for people with psychosis is delivered routinely in

inpatient wards

Annual >=90% green; <90% red

66.00%

Ensure that cardio-metabolic assessment and treatment for people with psychosis is delivered routinely in early intervention in psychosis services


Not Applicable

Ensure that cardio-metabolic assessment and treatment for people with psychosis is delivered routinely in early intervention in community mental

health services (people on CPA)


8.00%CQUIN - to be reported on in Q4 2017/18

Trend Source


CQUIN - to be reported on in Q4 2017/18

CQUIN - to be reported on in Q4 2017/18

EC: B2

TB: C2 5

Agenda Item No: C2

Regulation - Leadership & Improvement



Threshold Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Source

NHS Staff Survey Annual 3.68 3.63 NHS England

Proportion of Temporary Staff MonthlyNational Median 4.60%

5.57% 5.57% 5.13% 5.01% 5.13% 4.66% 4.91% 4.93%MCFT Internal

Reporting

Staff sickness Monthly National Median 4.46%

6.93% 6.36% 6.47% 6.76% 6.70% 6.54% 7.22%MCFT Internal

Reporting

Turnover Monthly

Internal - Between 8% and

12%

15.66% 15.75% 15.22% 14.49% 14.13% 13.73% 13.53%MCFT Internal

Reporting

Trend

EC: B2

TB: C2 6

Agenda Item No: C2

RAG Kitemark RAG Kitemark

RAG Kitemark RAG Kitemark

Globlar Digital Exemplar - Delivery against milestone plan to

attract the external funding

Substantive leader in place for 3 months or

more (Self Assessment)

Completion of Core Statutory Training

Involved in the development of your care

plan

Turnover Rate

No of Actual and Potential Suicides

Metric

Sickness Absence

Vacancies Vs Budgeted Establishment

Strategic Priorities 2017/18 - Summary

Metric Trend line Metric

No of STEIS Incidents

Trend line

Trend lineMetric

Delayed Discharges

Detention of BME under MHA

Safe Staffing Levels

Physical Health for new admissions (local

division only)

Plan Surplus v Actual

Patient Experience Friends and Family

Plan Cashflow v Actual

Estate Category B (Metric under review)

Risks associated with Contracts from Board

Assurance Framework

No of Restrictive Practice Incidents

Win Rate

Self-harm incidents (Project wards Arnold,

Dee, Harrington and Poplar)

Assaults on staff

Trend line

EC: B2

TB: C2 7

Agenda Item No: C2

Trust Level Strategic Priorities - Our Services - Key Performance Indicators

% BME Detained within last 12 months under the Mental

Health Act

% of shifts filled by nurses against planned establishment

(NHS England Fill rate measure) / CHPPD

Equitable - Detention Under MHA by BME

Service Users

Effective - Physical Health Screening for New

Admissions

Safe - STEIS Incidents

No of STEIS Incidents

Patient Centred - Friends & Family

% likely to recommend our service to friends and family

% of new admissions who have had physical health screening

completed (NAS Standard) (Local Division Only)

Timely - Delayed Discharge

Deyaled Transfers of Care (Step Change Nov 2016)

Efficient - Safe Staffing Levels

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

110.00%

Mean Average Upper control limit Lower control limit Target

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%


0

5

10

15

20

25

30

35

Mean Average Upper control limit Lower control limit

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%


90.00%

95.00%

100.00%

105.00%

110.00%

115.00%

120.00%


EC: B2

TB: C2 8

Agenda Item No: C2

Trust Level Strategic Priorities - Our People - Key Performance Indicators

A productive, skilled workforce

Sickness Absence

Vacancy Rate % Involved in the development of your care plan


Substantive leader in place for 3 months or more (Self

Assessment)

Great managers and teams A productive, skilled workforce


Great managers and teams A productive, skilled workforce

Turnover % (Step Change March 2017)

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%


0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%


0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%


89.00%

90.00%

91.00%

92.00%

93.00%

94.00%

95.00%

96.00%

97.00%

98.00%


30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%


EC: B2

TB: C2 9

Agenda Item No: C2

Current Rating

Delivery against milestone plan to attract the

external funding

Trust Level Strategic Priorities - Our Resources - Key Performance Indicators

Estate category B Global Digital Exemplar

Buildings that work for us Technology that helps us provide better care

Finance

Plan Surplus v Actual

Finance

Plan Cashflow v Actual

-619

-290

-715

-1,011

-445

-160-223

-£1,200

-£1,000

-£800

-£600

-£400

-£200

£0

Apr

-17

May

-17

Jun-

17

Jul-1

7

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18

Feb-

18

Mar

-18

Surplus (£000) Excluding I&E impairments

Actual surplus Planned surplus

20,711 21,15722,749

26,594 27,41729,055

27,595

£0

£5,000

£10,000

£15,000

£20,000

£25,000

£30,000

£35,000

Apr

-17

May

-17

Jun-

17

Jul-1

7

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18

Feb-

18

Mar

-18

Cash Balance (£000)

Actual cash balance Planned cash balance

A1.02%

B69.39%

C29.59%

as at April 2015

New metric in development

EC: B2

TB: C2 10

Agenda Item No: C2

Trust Level Strategic Priorities - Our Future - Key Performance Indicators

Research and innovation Research and innovation Grow our service

Actual & Potential Suicide count - Community Team Caseload

(rolling 12 months) Physical restraint reduction Win Rate

Research and innovation Research and innovation Effective partnerships

Self-harm incidents (Project wards only Arnold, Dee,

Harrington and Poplar)Assaults on Staff (Step Change Nov 2016) Risks associated with Contracts from Board Assurance Framework

If the Trust continues to fail to achieve the appropriate levels of

compliance with Safeguarding training, then a performance

notice may be issued from CCG resulting in

financial and reputational damage

for the Trust.

16 316

Initial Risk

RatingTarget Score

Current Risk

RatingTitle

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

1

2

3

4

5

6

7

8

9

No

of

Bid

s Y

TD

Bids YTD Win Rate % Target

50

100

150

200

250

300

350


commencement of intervention

10

15

20

25

30

35

40


EC: B2

TB: C2 11

Agenda Item No: C2

MetricApr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Plan 925 965 956 993 926 963 1036 991 868 1029 1014 1038Actual 935 1163 1092 1112 1068 1020 1137

Plan 30.00 30.00 30.00 30.00 30.00 30.00 30.00 30.00 30.00 30.00 30.00 30.00

Actual 26.66 27.04 26.89 26.96 25.92 19.61

Plan 16.70% 16.70% 16.70% 16.70% 16.70% 16.70% 16.70% 16.70% 16.70% 16.70% 16.70% 16.70%Actual 25.59% 23.63% 25.53% 25.59% 25.00% 20.97% 21.23%Plan 3.83% 3.83% 3.83% 3.83% 3.83% 3.83% 3.83% 3.83% 3.83% 3.83% 3.83% 3.83%

Actual 5.73% 5.81% 5.83% 5.83% 6.00% 5.95% 6.92%Plan 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%

Actual 94.57% 95.54% 94.59% 95.50% 94.87% 93.72% 95.53%Plan 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4

Actual 32.0 42.0 31.0 33.0 46.0 34.0 39.0

Plan 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50%Actual 7.26% 6.55% 5.93% 6.69% 6.92% 6.67% 8.15%Plan 0 0 0 0 0 0 0 0 0 0 0 0

Actual 11 8 3 4 9 3 4

Plan 17.26% 17.26% 17.26% 17.26% 17.26% 17.26% 17.26% 17.26% 17.26% 17.26% 17.26% 17.26%Actual 8.86% 7.73% 15.42% 14.66% 15.13% 13.61% 12.02%Plan 4.80% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00%

Actual 7.09% 6.42% 6.60% 7.56% 7.12% 6.69% 6.60%Plan 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%

Actual 96.39% 92.52% 95.49% 94.47% 96.74% 93.81% 93.82%Plan 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%

Actual 9.24% 10.62% 10.39% 11.39% 11.59% 12.06% 10.73%Plan £6,875 £5,357 £6,150 £6,467 £6,235 £6,255 £5,997

Actual £7,004 £5,247 £6,050 £5,997 £6,072 £6,170 £6,153Plan £1,062 £170 £170 £170 £170 £170 £199 £199 £199 £199 £199 £199

Actual £913 £42 £87 £22 £4 £62 £86149 128 83 148 166 108 113

GOVERNANCE

The operational lead is Donna RobinsonThe Accountable Director is Mark HindleAssurance is provided to the Performance Investment and Finance Committee

Local Transformation Plan

12 Month Trend Line

COMMUNITY - New referrals from GP practice

Local Division

2017/18

COMMUNITY/INPATIENTS - % Caseload on Clusters 1, 2 and 3

COMMUNITY - Average Days between Referral date to the First Seen in Assessment Service's*

COMMUNITY - AMH DNA Rate for 1st appointments only

INPATIENTS - AMH Delayed Discharges

INPATIENTS - AMH Bed Occupancy (excluding leave)


* Reported with a month timelag to allow service users to be assessed who were referrered at the end of September 2017. ** In October 2017, out of the eight wards within Adult Mental Health, six wards are achieving better than the NHS Benchmark 2015-16 Discharged Patients LOS.

INPATIENTS - Number of unplanned Adult Acute Out of Area Placements (Count of Service Users)

INPATIENTS - AMH Discharged Patients LOS (in-month) achieving better than the NHS benchmark 2015-16 Discharged Patients LOS (mean average).

% Incidents that result in harm

% Vacancies against budget

CIP's £000

Budget £000

Absence rate

EC: B2

TB: C2 12

Agenda Item No: C2


Plan 16521 16521 16521 16521 16521 16521 16521 16521 16521 16521 16521 16521Actual 20652 18387 18576 18732 18960 18057 18340Plan 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50%Actual 3.30% 3.17% 3.18% 3.63% 3.64% 3.51% 2.89%PlanActual N/A 46.69 27.56 18.97 21.62 46.53 10.44Plan 7.42% 7.42% 7.42% 7.42% 7.42% 7.42% 7.42% 7.42% 7.42% 7.42% 7.42% 7.42%Actual 6.77% 4.22% 6.49% 4.83% 3.70% 4.55% 5.79%Plan 4.80% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00%Actual 6.95% 6.79% 6.82% 7.39% 7.04% 7.47% 8.55%Plan 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Actual 73.45% 81.44% 77.57% 69.64% 84.62% 78.43% 75.25%Plan 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%Actual 5.66% 5.35% 5.76% 5.80% 6.36% 6.07% 6.34%Plan £4,536 £3,881 £4,087 £4,016 £4,070 £4,044 £4,027Actual £4,526 £3,935 £4,057 £3,996 £4,065 £4,019 £3,993Plan £166 £166 £166 £166 £166 £166 £166 £166 £166 £166 £166 £166Actual £166 £166 £166 £166 £166 £166 £166

£0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00

GOVERNANCE

The operational lead is Des JohnsonThe Accountable Director is Mark HindleAssurance is provided to the Performance Investment and Finance Committee


Absence rate

* Data has been reported for this indicator, however, this is still in the 'sense check' stage. The figures reported show the total cumulative segregation in days. In line with the Reducing Long-term Segregation: A Zero Approach, the plan has been aligned to the outcome: To Reduce Long-term Segregation by 20%. The baseline used is April 2017. **Based on discharged patients in the period. Where it states N/A this represents that there were no discharges within that month. Plan to be confirmed by the division.


Budget £000

CIP's £000

Secure Transformation Plan

Secure Division

12 Month Trend Line

2017/18

Reduction in time spent in long term segregation (days)*

Delayed discharges


Reduction in LOS in Low Secure based on discharged patients (months)**

Plan to be confirmed

EC: B2

TB: C2 13

Agenda Item No: C2


Plan 5 4 10 8 7 12 8 9 9 12 1 24Actual 3 2 1 1 2 5 2Plan 143 143 143 143 143 143 143 143 143 143 143 143Actual 134 133 133 132 130 129 128PlanActualPlan 19.93% 19.93% 19.93% 19.93% 19.93% 19.93% 19.93% 19.93% 19.93% 19.93% 19.93% 19.93%Actual 4.48% 4.95% 1.65% 9.66% 9.73% 6.89% 2.85%Plan 4.80% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00%Actual 10.74% 9.40% 9.48% 8.40% 8.92% 8.36% 10.31%Plan 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Actual 81.44% 76.47%Plan 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%Actual 4.48% 19.56% 20.76% 19.19% 19.41% 17.31% 20.83%Plan £2,224 £1,818 £1,882 £1,908 £1,891 £2,007 £2,129Actual £2,239 £2,017 £1,850 £1,978 £2,006 £2,001 £2,033PlanActual

GOVERNANCE

The operational lead is Lee TaylorThe Accountable Director is Mark HindleAssurance is provided to the Performance Investment and Finance Committee

% of workforce in posts within the new clinical model

Patient Experience Friends and Family *

No CIP's for SpLD

Metric in development

Budget £000


*The Friends and Family Test in the Specialist LD Division is asked as part of the quarterly patient experience survey. The Division’s survey is different to the Trust-wide patient

experience survey and is completed quarterly until the data systems can be aligned in an easy-read format.

SpLD Transformation Plan

Specialist Learning Disabilities Division

12 Month Trend Line

No of service users discharged

No of service users

Absence rate


2017/18

CIP's £000

EC: B2

TB: C2 14

Agenda Item No: C2


Plan 1 1 1 1 1 1 1 1 1 1Actual 1 1 3 2 1Plan 0 0 0 0 0 0 0 0 0 0Actual 0 0 0 0 0Plan 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Actual 89.40% 89.30% 92.80% 92.87% 94.40%Plan 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Actual 91.30% 92.10% 93.20% 94.45% 93.79%Plan 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50%Actual 15.80% 20.86% 18.77% 11.85% 9.97%Plan 36.65% 36.65% 36.65% 36.65% 36.65% 36.65% 36.65% 36.65% 36.65% 36.65%Actual 37.50% 28.96% 34.46% 29.60% 36.67%Plan 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00%Actual 6.81% 6.98% 8.29% 7.62% 9.43%Plan 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Actual 98.18% 100.00% 100.00% 100.00% 100.00%Plan 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%Actual 6.07% 6.35% 8.01% 7.94% 10.76%Plan £1,986 £2,001 £1,999 £2,003 £2,000Actual £1,986 £2,001 £2,008 £2,006 £1,985PlanActual

GOVERNANCE

The operational lead is Judith Malkin

The Accountable Director is Trish Bennett

Assurance is provided to the Performance Investment and Finance Committee

2017/18

South Sefton Community Transformation Plan


3 Month Trend Line

Pressure Ulcers: Number of Grade 3 CAA

Pressure Ulcers: Number of Grade 4 CAA

Ward 35: Delayed Discharges

• Delayed transfers of care has been added as metric to replace the % of urgent care referrals

District Nurse Falls Risk Assessment Tool completionDistrict Nurse Malnutrition Universal Screening Tool completion


Budget £000

CIP's £000


Absence rate

No CIP's for SSCD


EC: B2

TB: C2 15

Agenda Item No: C2

Please note the following appendices are provided for information

Safe Sustainable Staffing Trust Level

Our Services

The operational lead for Our Services is Steve Morgan , The Accountable Director is Ray Walker, Performance is reviewed by the Executive CommitteeAssurance is through the Quality Assurance Committee

Our People

The operational lead for Our People is Claire Almond, The Accountable Director is Amanda Oates, Performance is reviewed by the Executive CommitteeAssurance is through the Performance and Investment Committee

Our Future

The Accountable Director is Louise Edwards, Performance is reviewed by the Executive CommitteeAssurance is through the Performance and Investment Committee

Finance Dashboard

SpLD Retraction Plan Update

Appendices

EC: B2

TB: C2 16

Agenda Item No: C2

Safe Sustainable Staffing Dashboard

Fill rate reported as over 100% mainly due to the need to support observation levels. Recruitment to vacancies continues to be challenging across the divisions. Local division report ongoing delay for staff awaiting start dates and have escalated to head of HR to address. Secure division have recruited to posts but also awaiting start dates. SLDD vacancy at 17% due to site retraction.Mandatory training rates are being monitored with an aim for 100%. A significant decrease in incidents is reported with a corresponding increase in patient experience .

EC: B2

TB: C2 17

Agenda Item No: C2

Local Division Strategic Priorities - Our Services - KPI's

Safe - STEIS Incidents Timely - Delayed Discharge


Admissions

No of STEIS Incidents Delayed Transfers of Care - April 2016 to October 2017% of new admissions who have had physical health screening

completed (NAS Standard) (Local Division only)


Service Users

Efficient - Safe Staffing Levels Patient Centred - Friends & Family


Health Act



Step Change Sept 2016


0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%


75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

105.00%


0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%


0

5

10

15

20

25

Mean Average Upper control limit

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%


EC: B2

TB: C2 18

Agenda Item No: C2

Local Division Strategic Priorities - Our People - KPIs


Turnover

Great managers and teams A productive, skilled workforce A productive, skilled workforce


Assessment)


(Step Change Feb 2017)Sickness Absence



Great managers and teams

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%


4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%


0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%


50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

110.00%


0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%


EC: B2

TB: C2 19

Agenda Item No: C2

Local Division Strategic Priorities - Our Future - KPI's

Research and innovation Research and innovation


(rolling 12 months)Physical restraint reduction

TitleInitial

Risk

Current Risk

RatingTarget Score


compliance with Safeguarding

training, then a performance notice may be issued from

CCG resulting in financial and

reputational damage for the Trust.

16 16 3


Self-harm incidents (Project wards Dee & Harrington)

Assaults on staff rolling 12 months (assaults on staff resulting

in harm for inpatient wards only per 1000 staff headcount)

Step Change Jan 2017

Risks associated with Contracts from Board Assurance Framework

0

20

40

60

80

100

120

140


0

5

10

15

20

25

30

35

40


0

10

20

30

40

50

60

70

80

90

100

Self Harm Mean Average Upper Natural Process Limit Lower Natural Process Limit

EC: B2

TB: C2 20

Agenda Item No: C2

Secure Division Strategic Priorities - Our Services - KPI's



Admissions

No of STEIS Incidents Deyaled Transfers of Care (Step Change Oct 2016)% of new admissions who have had physical health screening

completed (NAS Standard)

Data not yet available


Service Users



Health Act




(Step Change Feb 2017)

94.00%

96.00%

98.00%

100.00%

102.00%

104.00%

106.00%

108.00%

110.00%

112.00%

Upper control limit Lower control limit Target

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%


0

5

10

15

20

25


EC: B2

TB: C2 21

Agenda Item No: C2

Secure Division Strategic Priorities - Our People - KPI's


Turnover



Assessment)


(Step Change Feb 2017)Sickness Absence




0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%


4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%


0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%


50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

110.00%


0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%


EC: B2

TB: C2 22

Agenda Item No: C2

Secure Division Strategic Priorities - Our Future - KPI's


Self-harm incidents (Project wards Arnold & Poplar)Assaults on staff rolling 12 months (assaults on staff resulting


Risks associated with Contracts from Board Assurance

Framework




TitleInitial

Risk

Current Risk

RatingTarget Score


compliance with Safeguarding

training, then a performance notice may be issued from

CCG resulting in financial and

reputational damage for the Trust.

16 16 3

0

10

20

30

40

50

60

70

80


0

1

2

3

4

5

Mean Average Target

0

10

20

30

40

50

60

70

Self Harm Secure Mean Average Upper Natural Process Limit

EC: B2

TB: C2 23

Agenda Item No: C2

SpLD Division Strategic Priorities - Our Services - KPI's



Admissions

No of STEIS IncidentsDelayed Transfers of Care - April 2016 to October 2017 (Step

Change Feb 2017)

% of new admissions who have had physical health screening

completed (NAS Standard)

Data not currently available at Divisional level


Service Users



Health Act



Data unavailable until alignment of systems for

SpLDD

60.00%

70.00%

80.00%

90.00%

100.00%

110.00%

120.00%

130.00%

140.00%


0

1

2

3

4

5

6

7


0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

20.00%

Mean Average Upper control limit Target

EC: B2

TB: C2 24

Agenda Item No: C2

SpLD Division Strategic Priorities - Our People - KPI's

Data unavailable until alignment of systems

for SpLDD


Turnover (Step Change Jan 2017)



Assessment)Completion of Core Statutory Training Sickness Absence




0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%


0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%


0.00%

5.00%

10.00%

15.00%

20.00%

25.00%


0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

140.00%


EC: B2

TB: C2 25

Agenda Item No: C2

SpLD Divisions Strategic Priorities - Our Future - KPI's

No Risks to report associated with Contracts

from Board Assurance Framework

Effective partnerships

Self-harm incidents (Project wards only Arnold, Dee,

Harrington and Poplar)

Assaults on staff rolling 12 months (assaults on staff resulting


Risks associated with Contracts from Board Assurance

Framework




Data not currently available at Divisional level

No Suicides to report within last 12 months

rolling period


0

20

40

60

80

100

120

140

160

180


0

100

200

300

400

500

600

700

800

900

Mean Average Upper control limit Lower control limit

EC: B2

TB: C2 26

Agenda Item No: C2

Finance Dashboard 2017/18 - Month 7

Finance and Use of Resources Metrics Weight M7 Plan M7 ActualYear End

Plan

Year End

Forecast

Capital Service Capacity 20% 2 2 2 2

Liquidity 20% 1 1 1 1

I&E Margin 20% 1 1 1 1

Distance from financial plan 20% 1 1

Agency Spend 20% 2 3 2 3

Overall Score (after overrides) 100% 2 2 2 2

Agenda Item No: C2

Agenda Item No: B2


Month 7 Financial Performance

OVERALL FINANICAL PERFORMANCE 1. The trust is reporting a surplus of £3.463m at Month 7. It is forecast to achieve the

control total of £5.162m at the year end. A summary of the financial position is provided in Table 1.0 and detailed in Appendix A. Table 1.0 – Summary Financial Position – Month 7

2. From Table 1.0 it can be seen divisional pressures, in month 7, are being supported by the local, secure and corporate divisions. A more detailed analysis is provided in Appendix B. Key areas to note:

a) The local division underspend at month 7 of £0.837m is due to non recurrent funding in the division. This will reduce in future months as vacant posts are recruited to. Currently overspends within out of Area Treatments (OATs), Talk Liverpool, radiology and nuclear medicine alongside CIP underachievement of £1.2m. The forecast outturn for 2017/18 is breakeven and includes additional growth funding of £0.385m and £0.428m CQUIN. The forecast is assumes: non-delivery of £1.2m CIP; a high level of OATs activity; overspends in Talk Liverpool, agency spend for Supported Living Services (SLS) and an increase in costs as newly funded posts are recruited to. It is also anticipated back pay will be paid to SLS staff amounting to £0.463m. The STAR Unit transferred to the Specialised LD division in month 7, however the year to date overspend of £0.327m has been retained within the Local Division.

b) The secure division is underspent by £0.100m as a consequence of vacancies, offset in part by non pay cost pressures. The division is forecast to breakeven. CIP savings of £1.256m have been delivered to month 7 and the plan of £2.200m is forecast to be delivered. However £0.263m is being delivered non-recurrently, therefore recurrent plans need to be developed for 2018/19.

c) The Specialist LD division is £0.449m overspent at month 7. The overspend is related to the operational requirement for additional staffing required to deliver

YTD

BudgetYTD Actual

YTD

Variance

Annual

Budget

Forecast

OutturnVariance

£000 £000 £000 £000 £000 £000

Income 153,415 153,318 (97) 265,200 265,138 (62)Total Income 153,415 153,318 (97) 265,200 265,138 (62)

Expenditure

Local Division (41,810) (40,973) 837 (72,586) (72,586) 0Secure Division (28,662) (28,562) 100 (49,519) (49,519) 0Specialist Learning Disabilities (15,394) (15,844) (449) (26,333) (27,077) (744)Sefton Community Division (9,989) (9,985) 4 (20,203) (20,360) (156)Corporate Division (Excl. Medical Services & LCH) (26,333) (25,844) 490 (46,148) (45,698) 450LCH (182) (346) (163) (230) (1,230) (1,000)Medical Services (12,316) (13,088) (773) (20,971) (21,821) (850)Informatics Merseyside (IM) (6,008) (6,008) (0) (10,461) (10,461) 0Sub Total - Divisional Expenditure (140,693) (140,649) 44 (246,450) (248,750) (2,300)

Reserves & Other Budgets (5,659) (9,206) (3,547) (9,988) (10,376) (388)Revaluation Reserve (3,600) 3,600 (3,600) (850) 2,750Other Budgets & Reserves (9,259) (9,206) 53 (13,588) (11,226) 2,362

I&E Surplus/(Deficit) 3,463 3,463 0 5,162 5,162 0

Division

Agenda Item No: C2

Agenda Item No: B2

increased levels of clinical observations, especially in low secure services. The transfer of the STAR unit from the local division has generated an in month overspend of £0.034m due to agency usage associated with patient acuity. The division has spent £0.928m on agency and £2.108m on bank staff to month 7. Additional staffing costs linked to unplanned care continue to be closely monitored by the management team. The forecast position has been amended to reflect delays in patient discharges from a breakeven position to £0.500m overspent In addition, the transfer of the STAR unit has increased the forecast by £0.244m to £0.744m overspent.

d) Sefton community services division is breakeven at month 7, mainly due to vacancies in clinical areas, which are non-recurrently supporting the CIP position. The forecast outturn for 2017/18 is £0.150m overspent due to additional posts of £0.282m, which have been approved to stabilise the Division’s services and meet winter pressures. The division is currently undertaking a number of clinical service reviews, there is a risk this may identify further cost pressures. The impact of service reviews will be monitored regularly and the forecast outturn position will be updated accordingly.

e) The corporate division is under-spending across executive nursing, finance, estates, corporate governance and workforce, offsetting overspends within IPI, perfect care and costs associated with the LCH bid.

f) Medical services are overspending as a result of senior medical staffing costs within the local division. These are currently being offset by underspends within the specialist learning disabilities medical staff and vacancies across junior medical staff areas. A plan has been developed by the Medical Director, to reduce spend by £1.5m in 2018/19. This is currently being verified by the finance.

COST IMPROVEMENT PLANS (CIP) 3. The target CIP for 2017/18 is £6.210m. At month 7, the target is £3.801m of which

£2.740m has been delivered. The areas of underachievement are within the local and corporate divisions.

a) The local division have a month 7 CIP target of £2.109m and have achieved £1.217m. Schemes that are under achieving include the community services redesign and income generation. The forecast for the division indicates a recurrent underachievement against the CIP of £1.2m in 2017/18. Delivery of the recurrent CIP target is critical to the trusts ability to meet its control total for 2018/19. The division is currently developing alternative schemes.

b) The corporate division have a year to date CIP target of £0.533m of which

£0.365m has been achieved. The underachieving schemes relate to the pharmacy drugs review and executive nurse patient safety review. Alternative schemes have been requested from the relevant executive directors.

4. It is essential recurrent replacement schemes for the above are required to be presented

to the Quality Assurance Committee in during quarter four by the respective director.

FINANICAL RISKS 5. The Trust is currently planning to meet the control total of £5.162m. However there are

financial risks of circa £2.750m for 2017/18. The key areas are summarised below:

Agenda Item No: C2

Agenda Item No: B2

a) Medical services - The medical services budget is forecast to overspend by

£0.850m. b) Specialist LD division - The division has a £0.744m overspend. Delays in

discharges are becoming more likely as availability of client placements outside the trust becomes more difficult. This could result in an over spend of up to £0.500m, in addition to £0.244m relating to the transfer of Local services in month 7.

c) Sefton community services division – The division is forecasting a £0.156m overspend position. This reflects the need to stabilise the new service.

d) New business developments – The trust will incur additional costs associated with being selected as the preferred provider for the Liverpool Community Health Service. These are currently estimated at £1.000m.

6. Remedial action plans for the areas identified above should be presented and monitored

through the Performance, Investment and Finance Committee in December by the relevant Chief Operating Officer or Executive Lead.

7. As part of the financial planning for 2018/19 work has been undertaken to assess the

financial risks. In total these amount to £4.970m and include:

a) Medical Services (£1.0m) – Overspend to continue into 2018/19 whilst case load review is undertaken and recruitment takes place.

b) Local Division (1.470m) – This includes cost pressures for SLS (£0.100m), OATS (£0.500m), YMCA (£0.250m) and IAPT services (£0.620m)

c) Specialist LD division (£0.500m) – A similar financial position to 2017/18 is anticipated resulting in an overspend.

d) Corporate CIP Under achievement (£1.0m) – At present there are insufficient plans to meet the £4.0m corporate CIP target.

e) LCH Support (£1.0m) – The financial envelope associated with LCH services included the requirement to achieve £1.0m in efficiencies. There are currently no robust plans to meet this target.

8. Unless these issues are resolved there will be long term financial implications for the trust.

9. A paper will be presented to the Executive Committee and the Performance, Investment and Finance Committee detailing the proposed financial plan and associated risks for 2018/19 in December 2017.

NHS IMPROVEMENT RISK RATING 10. The overall ‘use of resources’ risk rating is currently at level 2, which is on plan.

11. Capital services capacity measures how well the Trust can meet fixed payments

associated with capital financing (e.g. lease interest payments, public dividend capital). The trust is able to cover the payments 2.39 times.

12. Liquidity measures the availability of liquid (cash) resources to be able to meet liabilities

as they fall due. The Trust is currently at 20 days, which is rated as 1.

13. The I&E margin metric measures the percentage of financial performance surplus compared to operating income. This is currently at 2.22% and is rated at 1.

Agenda Item No: C2

Agenda Item No: B2

14. The I&E margin distance from plan, compares the planned I&E metric to actual

performance. The trust is on plan and is rated at 1.

15. The agency rating measures agency spend against the ceiling applied by NHS Improvement. At month 7, agency spend totals £5.734m, which is 44% above national target levels and this metric is rated at 3, compared to a plan of 2. An analysis of agency costs is provided in Appendix C. Divisions have developed remedial action plans from all divisions to identify areas where agency spends will reduce.

CAPITAL EXPENDITURE 16. At the end of October capital costs of £9.162m have been incurred. This is £6.056m

below plan as a result of slippage against the following schemes: Liverpool & Southport inpatient facilities, pharmacy relocation, Kevin White Unit redevelopment and the Trust decant facility.

17. A review of the 2017/18 capital programme has been undertaken and submitted to NHSi. The forecast outturn has reduced by £8.888m to £28.930m due to slippage in the Medium Secure Unit (MSU), Local Secure Unit (LSU) and Southport Inpatient Facility.

18. Southport Inpatient Facility is underspent by £1.668m due to delays with planning

permission. The trust is forecasting £2.250m will be spent in 2017/18.

19. The business case for the MSU (£60.700m) is currently with the Department of Health (DH) awaiting Ministerial, then Treasury, approval.

CASH POSITION 20. At the end of October the cash balance is £27.595m, which is £7.791m above plan. This

is driven by a combination of slippage on capital investment and favourable working capital movements. A detailed analysis is provided in Appendix D.

21. The statutory duty to pay 95% of suppliers within 30 days has been achieved in September at 97.7%. (NHS suppliers are 98.5% and Non NHS suppliers are 97.7%).

22. The trust has requested a loan of £60.700m to finance the MSU. Once Treasury approval for the scheme has been received, the trust will develop an accurate draw down profile for the funds. It is anticipated that the first receipt will be in January 2018 (£6.370m) and will continue until 2019/20. This can be seen in the cash flow statement in Appendix D.

23. Treasury approval for the MSU was expected in November but is subject to DH and

ministerial approval which is yet to be granted. Delays at this stage may impact on the draw down profile.

24. During 2018/19, planned expenditure on the Southport Inpatient Facility will reduce the

trust’s cash balance to £5.000m which equates to 10 days working capital. FORWARD LOOK 25. The revaluation reserve of £3.600m is currently being held to support forecast

overspends of £2.399m in 2017/18. It is proposed the remaining balance of £0.850m is

Agenda Item No: C2

Agenda Item No: B2

utilised non-recurrently to support transformation schemes within the trust. Options will be evaluated by the executive team and will be included in the December finance paper.

RECOMMENDATIONS 26. The Board is asked to:

a) Note the current financial position and planned achievement of the control total.

b) Agree and monitor the recommendation for replacement CIP schemes to be presented to the Quality Assurance Committee in January by the Chief Operating Officer of the local division, the Medical Director and Executive Nurse Director.

c) Note the risks associated with the 2017/18 financial position and require the following to be presented at the December Performance, Investment and Finance Committee:

o Chief Operating Officer to provide assurance of the financial position for Local and specialist learning disabilities division

o Medical Director to provide a recovery plan for the local medical staffing budget.

d) Note the financial risk of £4.970m associated with 2018/19. e) Proposed plans for the remaining revaluation reserves funding of £0.850m to

be agreed by the executive team and included in the December finance paper.

Neil Smith Executive Director of Finance November 2017

Agenda Item No: C2

Plan Actual Variance Plan Actual Variance

Contract Income 144,641 144,120 (521) 252,503 249,982 (2,521)Sustainability & Transformation Funding (STF) 582 582 (0) 1,294 1,294 0Informatics Merseyside Income 4,688 4,698 10 7,966 7,966 0Operational Income 6,052 6,563 510 10,354 9,334 (1,020)Total Income 155,964 155,963 (1) 272,116 268,576 (3,540)

Employee Expenses (119,511) (115,461) 4,050 (210,250) (200,667) 9,583Non Pay Expenses (25,527) (29,312) (3,785) (43,798) (49,421) (5,623)EBITDA (Earnings before interest, tax, depreciation and amortisation) 10,926 11,190 264 18,069 18,488 419

EBITDA Margin % 7.01% 7.17% 0.17% 7% 7% 0%

Capital Charges (3,201) (3,305) (104) (5,491) (5,734) (243)Public Dividend Capital (2,830) (2,830) 0 (4,930) (4,930) (0)Provisions unwinding of discount (53) (53) 0 (53) (53) 0Interest Payable (1,345) (1,410) (65) (2,375) (2,491) (116)Interest Receivable 63 32 (31) 108 43 (65)Carbon Credits (97) (161) (64) (166) (161) 5I&E Surplus 3,463 3,463 (0) 5,162 5,162 0

I&E Surplus Margin % 2% 2% 0% 2% 2% 0%

Capital Impairment 0 0 0 (8,435) (2,755) 5,680Net I&E Surplus 3,463 3,463 (0) (3,273) 2,407 5,680

FoTYTDStatement of Comprehensive Income (SoCI)

Appendix A

Statement of Comprehensive Income (SOCI)

Agenda Item No: C2

Budget

£000

Actual

£000

Variance

£000

265,680 Income 153,415 153,318 (98)265,680 Total Income 153,415 153,318 (98)

EXPENDITURE

Local Division

(42,025) Liverpool (24,475) (22,776) 1,699(8,911) Management (4,719) (4,899) (179)

(21,650) Sefton & Kirby (12,615) (13,298) (683)(72,586) Sub-Total Local Division (41,810) (40,973) 837

Secure Division

(36,301) High Secure (21,053) (20,720) 333(13,126) Medium & Low Secure (7,609) (7,842) (233)(49,427) Sub-Total Secure Division (28,662) (28,562) 100

Specialist LD Division

(399) Divisional Services (388) (1,064) (676)(926) Management (535) (477) 58

(21,380) Forensic & High Support (12,497) (12,315) 182(497) Forensic Support Service (290) (269) 21

(2,890) Local LD Services (1,684) (1,718) (34)(26,093) Sub-Total Specialist LD Division (15,394) (15,844) (449)

Corporate Division

(3,020) Board (1,783) (1,795) (12)(3,893) Executive Nurse (2,202) (1,981) 222(2,939) Finance (1,662) (1,626) 37

(14,937) Estates & Facilities (8,802) (8,392) 410(3,189) Corporate Govn & Business Dev (1,775) (1,667) 108(7,403) Informatics & Performance Impr (3,663) (3,693) (30)

(182) LCH Bid (182) (347) (164)(23,514) Medical Services (13,781) (14,544) (764)(2,242) Perfect Care (1,526) (1,782) (255)

0 Calderstones Transition (86) (86) (0)(5,782) Workforce (3,368) (3,365) 3

(67,102) Sub-Total Specialist LD Division (38,831) (39,278) (447)

Sefton Division

(2,521) Sefton Corporate Services (1,216) (1,202) 14(17,683) Sefton Cross Divisional Services (8,773) (8,783) (10)(20,203) Sub-Total Sefton Division (9,989) (9,985) 4

(10,311) Informatics Merseyside (IM) (6,008) (6,008) (0)

(14,797) Other Budgets & Earmarked Reserves (9,259) (9,206) 53

(260,518) Total Expenditure (149,952) (149,855) 98

5,162 Net Surplus/(Deficit) before technical adjustments 3,463 3,463 (0)

Divisions

Month 7 2017/18Annual

Budget

£000Year to Date

Appendix B

Financial Position by Division

Agenda Item No: C2

01,0002,0003,0004,0005,0006,0007,0008,000

Apr

May Jun Jul

Aug

Sept

Oct

Nov Dec Jan

Feb

Mar

£'0

00

Agency Spend - Trust WideActual Agency Spend Agency Cap

0100200300400500600700800900

Apr

May Jun Jul

Aug

Sept

Oct

Nov Dec Jan

Feb

Mar

£'0

00

Agency Spend - Corporate DivisionActual Agency Spend Agency Cap

0

50

100

150

200

250

Apr

May Jun Jul

Aug

Sept

Oct

Nov Dec Jan

Feb

Mar

£'0

00

Agency Spend - Secure DivisionActual Agency Spend Agency Cap

0200400600800

1,0001,2001,4001,6001,800

Apr

May Jun Jul

Aug

Sept

Oct

Nov Dec Jan

Feb

Mar

£'0

00

Agency Spend - Local DivisionActual Agency Spend Agency Cap

0100200300400500600700800900

Apr

May Jun Jul

Aug

Sept

Oct

Nov Dec Jan

Feb

Mar

£'0

00

Agency Spend - iMerseyside (IM)Actual Agency Spend Agency Cap

0200400600800

1,0001,2001,4001,6001,800

Apr

May Jun Jul

Aug

Sept

Oct

Nov Dec Jan

Feb

Mar

£'0

00

Agency Spend - Specialist LD DivisionActual Agency Spend Agency Cap

Agency spend within the corporate division to month 7 is £0.513m, compared to a ceiling of £0.455m. An option being considered by the Executive team as part of the recovery plan is to cease all corporate agency spend.

At £5.734m, the Trust is 44.0% above its agency ceiling as at October 2017. This equates to a risk score of 3. The main areas of high agency usage continue to be the local division and medical staff. Action plans have been requested from all areas operating above the ceiling to reduce the forecast outturn.

The local division agency spend as at month 7 is £1.529m, which is £0.909m above the ceiling of £0.621m. The overspend relates largely to agency nursing costs covering vacancies and sickness. The division has started to address agency use as part of a key action in the divisions recovery plan.

Agency usage within the secure division remains at a minimum

Specialist learning disability division's agency spend at month 7 is £1.073m which is above the ceiling by £0.098m. Remedial action plans continue in place and further reductions are expected as the service retracts.

As at end of October, IM's agency spend is £0.676m compared with its agency ceiling of £0.457m. Temporary staff are used to resource change notices on SLA's and to fill vacancies that require specialist skill sets. However the main driver of agency spending has been resourcing the Liverpool Community Health SLA due to the uncertainty of the future direction of the organisation. Plans to recruit to posts have been developed and the level of spend should reduce to within the ceiling by March 2018.

Appendix C

Cumulative Agency Spend by Division

Agenda Item No: C2

0

100

200

300

400

500

600

700

Ap

r

May Jun Jul

Au

g

Sep

t

Oct

No

v

Dec Jan

Feb

Mar

£'0

00

Agency Spend - LCH South Sefton DivisionActual Agency Spend Agency Cap

The south sefton division transferred to Mersey Care on 1st June. The agency spend to October is £0.328m, which is slightly above the ceiling of £0.292m. The spend is mainly within district nursing, discharge planning and intermediate care.

0200400600800

1,0001,2001,4001,6001,8002,000

Ap

r

May Jun Jul

Au

g

Sep

t

Oct

No

v

Dec Jan

Feb

Mar

£'0

00

Agency Spend - MedicsActual Agency Spend Agency Cap

As at end of October, medical agency/locum spend is £1.595m, compared to a ceiling of £1.064m. This is mainly due to senior medical staffing costs within the local division, offset in part by vacancies across junior medical staff and senior medical staff within Specialist LD. A recovery plan has been developed by the Medical Director and the level of spend will reduce slightly in 2017/18, but the full year effect of the saving is £1.5m.

Cumulative Agency Expenditure by Division - October 2017

Agenda Item No: C2

Statement of Cash Flows (CF)

April May June July August September October November December January February March

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

CASH FLOWS FROM OPERATING ACTIVITIESOperating Surplus/(Deficit) 1,262 997 1,325 1,402 1,043 868 989 851 527 694 1,208 (996)Depreciation and Amortisation 446 447 461 490 490 490 480 463 493 494 490 490Impairments and Reversals 0 0 0 0 0 0 0 0 400 0 0 2,355Interest Paid (160) (196) (198) (198) (197) (254) (207) (209) (212) (211) (208) (255)Dividend Paid 0 0 0 0 0 (1,609) 0 0 0 0 0 (3,291)Losses 0 0 0 0 0 0 0 0 0 0 0 0(Increase)/Decrease in Inventories 18 (22) (12) 15 (41) 18 42 (6) (6) (6) 0 0(Increase)/Decrease in Trade and Other Receivables (1,106) 3,712 (2,629) 2,706 1,084 (290) 267 (1,267) (1,267) (1,265) 0 0Increase/(Decrease) in Trade and Other Payables 637 (937) 3,266 264 (269) 3,153 (902) 881 882 881 (137) (5,104)Increase/(Decrease) in Other Current Liabilities 0 0 0 0 0 0 0 0 0 0 0 0Increase/(Decrease) in Provisions (526) (19) 383 (274) (331) 317 (839) 334 333 (16) (6) 252Net Cash Inflow/(Outflow) from Operating Activities 571 3,982 2,596 4,405 1,779 2,693 (170) 1,047 1,150 571 1,347 (6,549)

CASH FLOWS FROM INVESTING ACTIVITIESInterest received 4 4 7 3 4 6 4 0 0 1 5 5(Payments) for Property, Plant and Equipment (1,383) (3,507) (979) (530) (884) (1,030) (1,130) (1,985) (3,033) (3,608) (4,873) (5,417)(Payments) for Intangible Assets 0 0 0 0 0 0 0 0 0 0 0 0Proceeds of disposal of assets held for sale (PPE) 0 0 0 0 0 0 0 0 0 0 0 0Net Cash Inflow/(Outflow)from Investing Activities (1,379) (3,503) (972) (527) (880) (1,024) (1,126) (1,985) (3,033) (3,607) (4,868) (5,412)

NET CASH INFLOW/(OUTFLOW) BEFORE FINANCING (808) 479 1,624 3,878 899 1,669 (1,296) (938) (1,883) (3,036) (3,521) (11,961)

CASH FLOWS FROM FINANCING ACTIVITIESNew Public Dividend Capital 0 0 0 0 0 0 0 1,250 0 0 0 500Loans received from DH - New Capital Investment Loans 0 0 0 0 0 0 0 0 0 6,370 0 0Public Dividend Capital repaid in year 0 0 0 0 0 0 0 0 0 0 0 0Other Capital Receipts 0 0 0 0 0 0 0 0 0 0 0 0Loans repaid to DH - Capital Investment Loans Repayment of Principal 0 0 0 0 0 0 0 0 0 0 0 (64)Capital Element of Finance Leases and PFI (33) (34) (32) (33) (74) (33) (164) (50) (55) (54) (60) (63)Net Cash Inflow/(Outflow)from Financing (33) (34) (32) (33) (74) (33) (164) 1,200 (55) 6,316 (60) 373

Net Increase/(Decrease) in Cash (841) 445 1,592 3,845 825 1,636 (1,460) 262 (1,938) 3,280 (3,581) (11,588)

Cash at the Beginning of the Period 21,553 20,712 21,157 22,749 26,594 27,419 29,055 27,595 27,857 25,919 29,199 25,618

Cash at the End of the Financial Period 20,712 21,157 22,749 26,594 27,419 29,055 27,595 27,857 25,919 29,199 25,618 14,030

ForecastActual

Appendix D

Statement of Cash Flow

Agenda Item No: C2

Agenda Item No: A5a

Page 1 of 10

Report provided (check necessary boxes): Paper No: EC17/18/1047

To Note: ☒ For Assurance: ☐ Report to: Executive Committee


Specialist Learning Disabilities Division Retraction Plan Update

Accountable Director(s): Mark Hindle, Executive Director of Operations

Report Author(s): Lee Taylor, Chief Operating Officer, Specialist LD Division


Our Services

☒ Save time and money ☐ Improve quality (STEEEP)

Our People ☐ Great managers and teams

☒ A productive, skilled workforce

☒ Side by side with service users and carers

Our Resources

☐ Technology that helps us provide better care

☒ Buildings that work for us

Our Future ☒ Effective Partnerships ☐ Research and innovation

☐ Grow our services

Purpose of Report:

To update the Executive Committee on the progress on the retraction of services within the Specialist Learning Disability Division.


Discharge dates given by commissioners continue to slip. The interdependencies on workforce, estate and finance are tracked weekly.

Scott House and Lancaster services have an increased workforce risk due to organisational change.

The workforce plan dependent on discharge dates continues to be under pressure due to discharge dates slipping.

The Division is forecasting a break even position but this is heavily dependent on commissioners discharge dates.

The new Specialist Support Teams are being actively recruited to with a ramp up plan to April 2018 full establishment.

Recommendation:

The Executive Committee is asked to note the progress regarding:

1) Note the progress to date regarding the retraction plan and the reasons for any delay

2) Note the next steps around the planned work with commissioners to progress timely and safe discharges


Next steps include: Weekly discharge calls with commissioners Agreement, design and provision of the new service offer Plans that monitor interdependencies the across discharges,

workforce, estate and finance.

Agenda Item No: C2

Agenda Item No: A5a

Page 2 of 10



Do the action(s) outlined in this paper impact on any of the following issues?

Area Yes None If ‘Yes’, outline the consequence(s) (providing further detail in the report)

Patient Safety ☒ ☐ Contraction needs to be undertaken in planned way to ensure

patient safety is not compromised


Patient Experience ☒ ☐ We need to work with service users to ensure the least

disruption during contraction

Operational Performance ☒ ☐ Contraction will need to be managed to ensure operational

performance is not adversely affected

CQC Compliance ☒ ☐ CQC need to be informed of closures (ideally with 5 weeks

notice)



Resource Implications (financial or staffing)

☒ ☐ Contraction needs to be undertaken in planned way to ensure patient safety is not compromised





EDS 1.2 - Individual people’s health needs are

assessed and met in appropriate ways ☐ EDS 1.4 – When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse

☐



Does this paper provide assurance in respect of a new / existing risk (if appropriate)

Area New Existing N/A If new or existing, please indicate where the risk is described

Type of Risk ☐ ☒ ☐ Board Assurance Framework ☐ Risk Register ☒


Risk that not all current ESS patients will be transferred to alternative placements due to insufficient community resources and capacity issues in other establishments. Thereby affecting the bed closure programme. Target number of transfers of secure users on the Whalley site into community care programmes is not possible to achieve within the 3 year implementation period.

Agenda Item No: C2

Agenda Item No: A5a

Page 3 of 10


Specialist Learning Disabilities Retraction Plan

PURPOSE

1. The purpose of this paper is to update and assure the Executive Committee on the progress on the retraction of services within the Specialist Learning Disability Division.

BACKGROUND

2. The national transformation plan ‘Building the Right Support’ (NHSE 2015), outlines

the requirement to move people with learning disabilities (LD) into ‘more appropriate

community settings’ with less reliance on in-patient beds. The report also signalled a 50% reduction in low secure learning disability beds and 25% reduction in MSU beds. In addition, NHS England advised following the consultation (28th March 2017) that all hospital beds on the Whalley site will close and be re-provided over the next three years on a case by case basis for each patient, in the community or in new state of the art units elsewhere in the North West.

3. A contraction plan had been agreed with commissioners (NHS England and CCGs) in November 2016, which set out the planned closure of wards/houses based on a number of assumptions including the continuation of admissions into MSU and LSU and the discharge of service users in line with the commissioners’ plans.

PERFORMANCE

4. Discharges

Actual Total Forecast Total Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Year

Actual 3 2 1 1 2 5 2 16 9 9 12 1 24 71 Plan 5 4 10 8 7 12 8 54 9 9 12 1 24 109

Variance -2 -2 -9 -7 -5 -7 -6 -38 0 0 0 0 0 -38

5. In October there were 2 people discharged from LSU to the community.

6. There were 54 discharges planned between April and October 2017. Only 16 people were successfully discharged in this period. This equates to a 29.62% success rate and a 70.38% failure rate against the plan.

7. The main reasons for discharges not going ahead are as follows:

Funding Issues Community RC Issues Building work/renovation delay No provider engaged MOJ or legal issues Awaiting LSU bed

Agenda Item No: C2

Agenda Item No: A5a

Page 4 of 10

8. Weekly accelerated calls, chaired by NHS England, continue to be held to help solve any issues immediately and are proving to be very useful.

9. Discharge Planning Information is monitored by face to face meetings and countersigned and any issues are raised to the Divisional Operational Support Manager to discuss with NHS England and CCG commissioners.

10. A weekly meeting “Active Discharge Planning” with Senior Managers meets with

different service line each week to look at barriers and solutions and provide assurance that everything possible is done to support the discharge process.

Discharge Risk Register

Risks Actual Forecast

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

SPLDOP04 16 16 16 16 16 16 16 12 9 9 9 9

Plan 16 16 16 16 16 12 12 12 9 9 9 9 SPLD OP02 9 9 9 9 9 9 9 9 6 6 6 6

Plan 9 9 9 9 9 9 9 9 6 6 6 6

SPLD OP 04: There is a Risk that the target number of transfers of secure Service Users on the Whalley site into community care programmes is not possible to achieve, within the 3 year implementation period. Discharge trajectories are heavily reliant on future placements being available that can provide safe transition for service users with forensic histories. Current risk remains rated at 16 as establishment of SST is still in initial development phase and therefore the impact is not yet being realised. The weekly discharge planning meetings outlined above are one of the control measures in place to mitigate this risk.

SPLD OP 02: Risk of deterioration in health and well-being and potential for exacerbation of challenging behaviour for patients currently in situ due to delays in discharging service users ready to move on and uncertainty around the implementation of the clinical model. Regular Easy Read communications and face to face discussions about the future for individuals and the future of the services take place to mitigate this risk as well as ensuring all parties are fully involved in the CTR process.

Agenda Item No: C2

Agenda Item No: A5a

Page 5 of 10

Workforce

11. There is currently an increased workforce risk at Lancaster and Scott House due to staff attrition and an inability to recruit staff. The two services are undergoing organisational change due to pending service user discharges. The Division is meeting responsible CCG’s fortnightly to ensure discharges happen to enable the workforce

risk identified in January 2018 to be mitigated.

12. Release of staff that have been recruited to the new Specialist Support Teams from the Inpatient Service has become an issue due to the delays in service contraction. The teams are currently actively working to plan a phased transition.

Actual

Total Forecast Total

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Year

Actual 755.48 751.98 741.98 739.11 737.61 701.53 701.53 -53.95 699.78 671.97 668.87 643.87 631.82 -123.66

Plan 736.46 732.06 724.06 722.06 722.06 693.87 688.32 -48.14 679.47 671.97 668.87 643.87 631.82 -104.64

Variance -19.02 -19.92 -17.92 -23.43 -15.55 -7.66 -14.77 -5.81 -20.31 0 0 0 0 -19.02

13. Summary of workforce performance against the plan this financial year: a. April – 5 discharges planned, actual discharges were 3. Unable to release the

planned 19.02 staff.

b. May – 4 planned discharges, 2 actual discharges. Projected to release 19.92 wte. Due to clinical association, staff could not be released.

c. June – 10 planned discharges. 1 actual discharge. Release of staff not possible due to the overall clinical need being the same for the population. Would have released 17.92 wte if projected discharges went ahead.

d. July – 8 planned discharges. 1 discharged but again the release of staff not possible due to the overall clinical need being the same for the population. There was a projected release of 23.43 WTE that couldn’t be facilitated.

e. August - 7 planned discharges. 2 people discharged but again the release of staff not possible due to the overall clinical need being the same for the population. There was a projected release of 15.55 WTE that couldn’t be facilitated.

f. September – 12 planned discharges. 5 people were discharged – but again the release of staff not possible due to the overall clinical need being the same for the population. There was a projected release of 7.66 WTE that couldn’t be

facilitated.

g. October - 8 planned discharges 2 people discharged but again the release of staff not possible due to the overall clinical need being the same for the population. There was a projected release of and additional 14.47 WTE that couldn’t be facilitated.

Agenda Item No: C2

Agenda Item No: A5a

Page 6 of 10

14. The future workforce for the Specialist Support Teams is detailed in the table below:

15. Recruitment is actively underway for the Specialist Support Teams in Lancashire and

Greater Manchester. A number of posts have now been actively recruited to but are currently undergoing pre-employment check. Three external candidates appointed in August have start dates for January.

16. There is a staggered recruitment process to enable staff to be released from the current service provision as the inpatient service contracts, however delays to the planned discharges are impacting on this process.

Workforce Risk Register


Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar SPLD OP05 9 9 9 3 3 3 3 3

Plan 9 9 3 3 3 3 3 3 SPLD CP009 9 9 9 9 6 6 6 6 6

Plan 9 9 9 6 6 6 6 6 6

SLDD 38 12 12 12 12 12 12 9 9 6 6 6 6

Plan 12 12 12 12 12 12 9 9 6 6 6 6

SLDD 49 12 12 12 12 12 12 12 9 9 9 9 9

Plan 12 12 12 12 12 12 12 9 9 9 9 9

SPLD OP 05: If baseline staffing and process for changes is not agreed there will be a delay to implementing organisational change for the contraction. This may lead to a delay to the contraction of the workforce in line with decreasing service user numbers, leading to additional costs for the trust. As well as the consideration that a delay to consultation and engagement with the staff will potentially lead to heightened anxiety and increased sickness. Due to the changing discharge trajectories, the planning for the contracting workforce requirements has been difficult to accurately plan. A process is being put in place to agree how changes are agreed to ensure future delays are avoided SPLD CP 009: If a significant number of the positions for the SST’s are filled by staff currently working in the inpatient setting at Whalley, there is potential to either destabilise services in the inpatient setting or delay the operationalisation of the SST This is being carefully monitored by the operational management team to ensure any agreed start dates are considered I line with the contraction plan, thereby reducing the impact to wards however this is impacting on the staffing of the new teams.

SLDD 38: Shortage of Registered Learning Disability Nurses which will impact on the trusts ability to staff wards safely. If Services are unable to recruit Registered Nurses into vacant posts there will be an impact on the safety and quality of care provided. The cause of this is due to a shortage of registered learning disability nurses, leading to competition within the register nurse market place. Uncertainty in the division’s longevity means that competing for these staff is an added difficulty. If the wards are not staffed safely it could reduce quality of service delivery and impact on staff wellbeing and health. This is managed through weekly staffing meetings and daily staffing assurance checks as well as being discussed at weekly surveillance.

Future Actual Forecast

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

SS

T

Actual 10 10 10 10 10 10 10 10 10 24 46 70

Plan 10 10 10 10 10 24 24 24 24 46 46 70

Total; Variance 0 0 0 0 0 -5 0 0 0 0 0 0

Agenda Item No: C2

Agenda Item No: A5a

Page 7 of 10

SLDD 49: If the levels of sickness are high, then this may affect the continuity of care and consistency in approach. There is use of bank and agency staffing to cover absences. Increased costs are associated with extra bank payments and costs associated with the use of agency staff.

Estate

Actual Forecast Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Actual Gisburn Lodge

4 Daisy Bank

Lancaster

West Drive LSU Flat B

Trentville close to

Male and Reopen to

Female

2 West Drive,

Ravenswood reopen as male

ESS

North Lodge

Lancaster, Scott

House

Plan

Gisburn Lodge,

West Drive LSU Flat B

4 Daisy Bank

Lancaster

1Flat 3 west Drive

Ravenswoo

d Close

Trentville close to

Male and Reopen to

Female

2 West Drive,

Ravenswood reopen as male

ESS

North Lodge

Lancaster, Scott

House

17. The estate contraction plan is delayed due to the discharge performance rate.

18. West Drive LSU had planned to close one area in September. However, this has been delayed further until 7th November, due to service user association issues and discharges not going ahead as planned.

Estate Risk Register

SPLD CM 03: Risk that key programme dates for the clinical model implementation will be delayed due to commissioners / NHS England not being able to meet critical deadlines. If commissioners/ NHS England are not able to meet critical deadlines regarding decisions on the requirements for Low Secure Services, then key programme dates for the clinical model implementation may be delayed, resulting in further delays in the MSU and LSU builds and financial deficit for the Trust. A considerable amount of work has taken place with NHSE to resolve any issues regarding the future requirements of the commissioners for both LSU and non secure CCG commissioned beds. It is expected that some of the required clarification will be available in September and further specifications for the CCG commissioned beds will be available late in the year leading to the future forecast of a lower risk rating.


Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar SPLD CM

03 20 20 20 20 20 20 20 12 12 4 4 4

Plan 20 20 20 20 20 12 12 12 12 4 4 4

Agenda Item No: C2

Agenda Item No: A5a

Page 8 of 10

Finance

19. The Specialist Learning Disabilities Division is overspending by £0.415m cumulatively against budget up to month 7 and the forecast spend for the remaining months can be seen in the table below. These figures do not include the LD services transferred in this month from Local Services. The Star Unit & Community LD teams transferred in from Local Division report a £0.034, resulting in a total year to date combined position of £0.449 overspent.

20. The reported overspend during October, is the result of reduced budgets due to ESS income being removed following 2 discharges, the associated staffing costs can not yet be removed in line with this reduced income.

21. The year to date over spend continues to be associated with the requirement of temporary staffing (agency and bank) to cover vacancies and support observations linked to unplanned care.

22. The forecast has been revised at month 7, there was £0.500m risk reported previously relating to delayed discharges, due to these materialising the forecast has moved to a planned £0.500m overspend. This forecast still assumes a level of discharges taking place before the end of the financial year to enable areas within the Division to close. This will allow permanent staff to be relocated, reducing the reliance on temporary staff as the patient numbers lessen. Any further delays in discharged still pose a financial risk for the division and its ability to meet the year end forecast. The Star Unit & Community LD teams transferred in from Local Division have a forecast year end position of £0.244m overspent the specialist LD team are actively managing the reduction of spend in these areas. The combined FOT is £0.744m overspent.

23. The trust has incurred redundancy costs of £0.380m year to date and is anticipating further costs to be incurred throughout the year, as areas away from the main trust site are closed. These are not included in the above financial position.

24. Options are being explored to mitigate the risks around discharges not occurring as currently planned:

a. Funding arrangements of the stepdown service post 31st March 2017 have begun. NHSE have serviced notice on this area however the result of delayed discharges means at least 7 patients will still remain with Mersey Care on 1st April 2017. Initial indications are that those patients remaining post 31st March 2017 will be funded with continued service by Mersey Care.

b. An initial meeting has taken place with the lead commissioner with regards to a review of individual packages of care. These discussions will continue through November.

TOTAL

April May June July August September October November December January February March Full Year

Actual 2,118,556£ 2,135,285£ 1,849,966£ 1,970,564£ 2,006,028£ 2,000,874£ 2,035,550£ 1,906,241£ 1,844,031£ 2,243,070£ 1,648,169£ 1,943,619£ 23,701,953£

Budget 2,050,100£ 1,997,821£ 1,884,979£ 1,907,601£ 1,890,634£ 2,007,370£ 1,971,756£ 1,898,398£ 1,898,398£ 1,898,398£ 1,898,398£ 1,898,398£ 23,202,251£

Variance 68,456-£ 137,464-£ 35,012£ 62,963-£ 123,394-£ 6,496£ 63,794-£ 7,843-£ 54,367£ 344,672-£ 250,229£ 45,221-£ 499,701-£

ACTUAL FORECAST

Agenda Item No: C2

Agenda Item No: A5a

Page 9 of 10

c. The cohorting of patients as permanent staffing levels decrease to ensure safe patient care is maintained.

d. In addition the trust is evaluating the options regarding the use of estate.

e. Weekly retraction meetings at various levels are ongoing to ensure the most efficient use of resources as patients are discharged.

Finance Risk Register


Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar SPLD CP

04 12 12 12 12 12 12 12 12 9 9 9 9

Plan 12 12 12 12 12 9 9 9 9 9 9 9 SPLD CM

04 20 20 16 16 16

Plan 20 20 16 16 16

SPLD CP 04: There is a risk that redundancy costs are anticipated to be higher than expected. This will put additional pressure on Mersey Care’s funding base in 2018/2019 financial year to ensure adequate funding is identified and allocated appropriately. The cause of this risk is due to full closure of the Whalley site and consultations with existing staff, there is an understanding that the majority of the existing Whalley staff will not travel to Maghull or relocate. Also, there has been minimal take up of recruitment opportunities presented at recruitment roadshows.

SPLD CM 04: If capital funding is unavailable to re-provide LSU services off Whalley, this will conflict with NHS England commissioning intentions and could result in the loss of the LSU contract for Specialist LD services. An appraisal is being carried out to understand the full impact of this risk to the trust

NEXT STEPS

25. Accelerated discharge calls with NHS England continue. In November 2017 the Chief Operating Officer for the Division has set up fortnightly discharge monitoring meetings directly with the responsible CCG’s to ensure workforce risks are mitigated at Scott

House and Lancaster with timely discharges.

26. Mersey Care will continue to work closely with commissioners, through the Strategic Partnership Board to deliver:

a) Medium Secure - NHS England have confirmed that they will commission 40

learning disability beds in the proposed new medium secure unit at Maghull. This means that we already have reached the reduction required and are working within the future commissioned limit. We will now maintain this level of activity and keep within the future commissioned requirement.

b) Low Secure - Following the outcome of the consultation, NHS England have confirmed that they will commission 40 Low Secure learning disability beds in the future from Mersey Care. The configuration of these beds remains yet to be agreed.

Agenda Item No: C2

Agenda Item No: A5a

Page 10 of 10

c) Step Down and Enhanced Support Service - The close management of these individuals’ discharge pathways will be a priority for the Strategic Partnership

Board, and the Trust, with commissioners, has been asked to revise discharge trajectories for each individual, and escalate any barriers to discharge as quickly as possible, involving all relevant partners and the resettlement hubs where appropriate

d) Specialist Support Teams (Community Provision) Recruitment is actively underway for these posts for Lancashire and Greater Manchester. The plan is detailed in section 5 under ‘future workforce’.

RECOMMENDATION

27. The Executive Committee is asked to:

a) Note the progress to date regarding the retraction plan and the reasons for any delay

b) Note the next steps around the planned work with commissioners to progress timely and safe discharges

Mark Hindle

Executive Director of Operations

November 2017

Agenda Item No: C2

Agenda Item No: D1

Page 1 of 8


To Note: ☐ For Assurance: ☐ Report to: Board of Directors


Estates Strategy Principles

Accountable Director(s): Neil Smith, Director of Finance, Deputy Chief Executive Tel No. 0151 473 2794 Louise Edwards, Director of Strategy and Planning Tel No. 0151 473 2767

Report Author(s): Louise Edwards, Director of Strategy and Planning Tel No. 0151 473 2767


Our Services ☐ Save time and money ☒ Improve quality

(STEEP)

Our People ☐ Great managers and teams ☐ A productive, skilled


Our Resources ☐ Technology that helps


Our Future ☒ Effective Partnerships ☐ Research and innovation ☐ Grow our services

Purpose of Report: • To propose ‘strategy principles’ for our estate


• As our Trust moves forward with its commitment to strive for perfect care across the communities and people we serve, we have identified two key infrastructure enablers to help achieve this goal –IM&T and our estates.

• With recent acquisitions the number and size of our estate has grown, and it is felt we need an updated estates strategy to help the Trust navigate how best to utilise this key resource.

Recommendation:

The Board of Directors is asked to: • Approve the proposed estates ‘strategy principles’


The strategy principles will be base document for the Strategic Estates lead to interpret into a location by location review, resulting in turn in our 3 and 5 year estates implementation strategy by the end of March 2018.

Agenda Item No: D1

Page 2 of 8



Do the action(s) outlined in this paper impact on any of the following issues?

Area Yes None If ‘Yes’, outline the consequence(s) (providing further detail in the report)

Patient Safety ☐ ☐ Estates are a key enabler of patient safety

Clinical Effectiveness ☒ ☐ Estates are a key enabler of clinical effectiveness

Patient Experience ☒ ☐ Estates are a key enabler of better patient experience

Operational Performance ☒ ☐ Estates are a key enabler of operational performance

CQC Compliance ☒ ☐ Estates are a key enabler of CQC compliance




Equality and Human Rights Analysis Yes No N/A Do the issue(s) identified in this document affect one of the protected group(s) less or more favourably than any other? ☐ ☒ ☐





☒





Type of Risk ☒ ☐ ☒ Board Assurance Framework ☐ Risk Register ☐ Risk Reference / Description: (only include reference to the highest level framework / register)

Agenda Item No: D1

Page 3 of 8


Estates Strategy Principles

PURPOSE

1. To propose ‘strategy principles’ for the development of our estate

BACKGROUND

2. As our Trust moves forward with its commitment to strive for perfect care across the communities and people we serve, we have identified two key infrastructure enablers to help achieve this goal –IM&T and our estates

3. With recent acquisitions the number and size of our estate has grown and it is felt we need a more strategic approach to estates to help the Trust navigate how best to utilise this key resource.

RECOMMENDATION

4. The Board of Directors is asked to:

• Approve the proposed estates ‘strategy principles’ Louise Edwards Director of Strategy and Planning

November 2017

Agenda Item No: D1

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BACKGROUND 5. As our Trust moves forward with its commitment to strive for perfect care across the

communities and people we serve, we have identified two key infrastructure enablers to help achieve this goal –IM&T and our estates. Our vision is to use planned major change in our estate as the opportunity to not only meet 21st century standards in facilities but to reshape the services themselves delivering high class, integrated care and world-class research. Significant investment is required in our estate to achieve required standards. Our proposed transformation will meet the physical shortcomings but more importantly deliver the clinical vision of accessible and integrated services locally alongside world class innovation and research. People in our services deserve the very best healthcare in the most effective local settings, and our estates strategy will enable us to meet those ambitions for our patients, staff and partners.

6. In the past, our estate strategy has focused on two main themes - the updating of our

existing estate where the accommodation we have falls short of our perfect care ambition, and new developments, be they to support new models of care or to reach out to new or wider communities or services. With recent acquisitions the number and size of our estate has grown and it is felt we need a new approach to estates to help the Trust navigate how best to utilise this key resource.

7. As with our overall strategy, improving quality and efficiency in our estate are two

sides of the same coin. Better buildings and more effective utilization and consolidation of our estate, based on improvements to quality and more productive working, will generate savings to reinvest in improving the quality of care we provide.

8. A recent visit to Camden and Islington provided a useful framework for the

development of the strategy, whereby a series of “estates Principles” have been developed that have their origin directly in the clinical strategy for the trust. We have taken this idea into the following document which is draft, and is proposed as the framework principles around which a site by site strategy could be built.

9. These principles should also be capable of being applied in retrospect to

developments and buildings we already have, to assess their effectiveness, and looking forward to new developments to avoid some of the mistakes that we have made in the past.

KEY THEMES FROM OUR SERVICE TRANSFORMATION STRATEGY 10. The following are the central themes that run through our service transformation

strategy that are relevant to the organisation of our estate:

- Perfect care - getting the basics right and making sure the environments in which we deliver care are Safe, Timely, Efficient, Effective and Person Centred (STEEP) - Working side by side with services users and careers in all we do - Working side by side with our staff to improve quality - Delivering care pathways that are recovery oriented, reducing length of stay and preventing admission and re-admission where possible - Working in partnership across the health economy to meet people’s needs sooner - Clearer crisis path ways developed in partnership with the wider

public sector to find alternatives to hospital admission

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- Using technology to enable faster, more personalised care and greater productivity

11. We have attempted to capture these service transformation principles in the following framework, to relate to our estate. KEY STRATEGY PRINCIPLES FOR OUR ESTATE

a) Our buildings will support the Trusts ambition to deliver Perfect Care (STEEP) b) Our buildings will reflect the clinical needs of service users c) Our buildings will provide and environment in which colleagues want to work d) Our buildings will support agreed partnership pathways across the health economy and wider community

a) Our buildings will support the Trusts ambition to deliver Perfect Care (STEEP)

12. In order to test our existing and future buildings against this ambition it is proposed to

use the STEEP approach in our overall strategy. Our estates will therefore be tested against:

o SAFE: Our buildings will support our Zero suicide work and our no force first

approach, as tested by our clinicians and colleagues who will deliver care within them. They will be designed with the safety of care in mind.

o TIMELY: Our locations and buildings will enable the delivery of care where

and when our service users need it. Where possible this will be in one location, and as close to home as it can be. It will enable care to be clearly signposted and be planned so that there is availability when needed.

o EFFECTIVE: Our buildings will be centred around the most effective care

pathways we can design, enabling those pathways to promote early intervention, recovery, avoidance of admission and reduced length of stay.

o EFFICIENT: In order to promote the focus of perfect care on early

intervention and recovery, we will test all existing and future buildings on a needs basis, building or investing only where care cannot be provided in an existing setting where associated care is already provided, or through a path way not requiring admission. We will focus on technology to transform existing buildings, maximise the efficiency of new developments and refurbishment and prevent admission where possible.

o PERSON CENTRED: Our buildings will be designed around the people for

who they support care and those who work in them to deliver the care. This extends to all aspects including the choice of macro and micro location, transport links, local amenity as well as external and internal design. Sites will be tested and reviewed by service users, careers and colleagues before during and after development.

b) Our buildings will reflect the needs and experience of our service users

13. Our buildings will be regularly assessed and reviewed by our service users and

carers, with their experiences and feedback helping to formulate our design briefs

Agenda Item No: D1

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and capital prioritisation. Through our Design Council a community of services users and careers input will be sought through the development process.

c) our buildings will provide and environment in which colleagues want to work

14. Our buildings will meet the needs of our workforce and provide them with high quality

facilities and ensure their specialist skills can be used productively. Our buildings will be assessed and reviewed by our colleagues with their experiences and feedback helping to formulate our design briefs and capital prioritisation.

d) Our buildings will support agreed partnership pathways across the health economy and wider community

15. Our buildings will be supported by agreed and signed up partnership pathways

across the health economy including commissioning, and other providers, with a clear understanding between all relevant organisations on the pathway itself and most importantly the type of care/admission the building is designed to deliver and what it is NOT designed for, to ensure objectives on length of stay and recovery can be delivered according to plan and financial sustainability is ensured.

ESTATES OBJECTIVES 2017-22

16. Following on from the strategy principles for our estate, we have developed a series

of long and short-term objectives. 17. Long term estates objectives 2017-22

• Complete the redevelopment of our inpatient services as the centre- piece of Mersey Care’s transformation of its core services

• • Consolidate our community estate to provide services more efficiently and in

partnership with partners in the NHS, local government and the voluntary/housing sector.

18. Short term estates objectives 2017-18

• Build a () bed Medium Secure Unit for mental health and learning disabilities at Maghull

• Build a () bed acute mental health inpatient unit in Southport • Build Life Rooms Bootle in partnership with Hugh Baird College • Decide utilization of Whalley site • Consolidate and improve utilization of community estate where possible • Improve or find alternative facilities for our inpatient services at Mossley Hill, Broad

Oak and the STAR Unit NEXT STEPS 19. These principles and objectives are high level and require development by the

Estates and Strategy teams in wide consultation with the Trust. This will be base document for the Strategic Estates lead to interpret into a location by location review,

Agenda Item No: D1

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resulting in turn in our 3 and 5 year estates implementation strategy by the end of March 2018.

20. To deliver this strategy some review of governance may be required. For example,

the above framework could imply a 4-stage test for any building investment going forward, or indeed 4 stage review of any inherited estate:

- Full STEEP review of proposal - Service user and carer approval - Involved partners sign off - Clinical approval

21. All four could be required prior to any proposal going to the PIFC for financial

approval and then on to the board. There may also be sense in reviewing the role of the Design Council, which could take accountability for the administration and delivery of the Service user and care input and approval, but also potentially the colleague review. It should also perhaps have a role in reviewing care environments more widely seeking innovation and progress and introducing it into the design and thinking of our estate.

Agenda Item No: D1

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SUMMARY TABLE

Service transformation themes

Estates strategy principles

Long term estates objectives 2017-22

Short term estates objectives 2017-18

Perfect Care (STEEP principles)

Our buildings will support the Trust ambition to deliver Perfect Care

Complete the redevelopment of our inpatient services as the centre-piece of Mersey Care’s transformation of its core services

Build Medium Secure Unit at Maghull Build acute mental health inpatient unit at Southport Improve or find alternative facilities for our inpatient services at Mossley Hill, Broad Oak and the STAR Unit

Working side by side with service users and carers

Our buildings will reflect the needs and experiences of our service users

Working side by side with our clinical staff to improve quality

Our buildings will provide an environment in which colleagues want to work

Using technology to provide safe, more personalised care and more productive working

Recovery-oriented care pathways

Our buildings will support agreed partnership pathways across the whole health economy

Consolidate our community estate to provide services more efficiently and in partnership with partners in the NHS, local government and the voluntary/housing sector

Decide future use or sale of Whalley site Build Life Rooms Bootle, in partnership with Hugh Baird college. Consolidate and improve utilization of community estate

Working in partnership across the health economy Clearer crisis pathways developed in partnership

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Board Assurance Framework Accountable Director(s): Ray Walker, Executive Director of Nursing

Nursing Directorate Report Author(s): Steve Morgan, Director of Patient Safety



(STEEP)






Purpose of Report:

• To present the Board Assurance Framework for the Board’s consideration and approval.

• To provide assurance that the strategically significant risks are being actively managed.


• Ten 2017/8 Board Assurance Framework (BAF) risks were approved by the Board on the 26th July 2017 based on the 2017/19 Operational Plan and in line with the organisations’ strategic framework.

• The 2017/18 BAF consists of 18 strategic risks identified on the Board Assurance Framework.

1. Ten strategic risks identified and approved by the Board.

2. Three escalated risks from Local Division.

i. If there are long term Consultant Psychiatrist vacancies

within the Local Division then there is a risk that the quality and safety of care is being compromised. Score 16

ii. If improvements are not made to Park Lodge environment then there is a risk of breaches in Safety Regulations, increases in health related, security and safety incidents, reduction in staff morale, service users experience and damage to reputation. Score 16

iii. If clinic letters and discharge summaries are delayed then

there is a risk of inadequate communication leading to clinical care being negatively affected. Score 16


To Note: ☐ For Assurance: ☐ Report to: Board of Directors


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Agenda Item No: E1

3. One escalated risk from South Sefton.

i. Pressure ulcer hotspots are not identified early enough

leading to a lack of intervention and an increase in avoidable Grade 3 and Grade 4 pressure ulcers across the Division. Risk Score 16

4. Four project/ programme risks were scrutinised at the Risk

Management Group and were deemed strategically significant to be escalated to the Committees and Board.

i. Relias Learing System (New Risk): If Relias are

unsuccessful in the tendering process this would mean moving the Trust back to OLM by 1st June 2018 causing major disruption to training reporting. Score 20

ii. MSU New Build: If the Full Business Case for the Secure Health Park is not approved by the 1 December 2017an increase in the Guaranteed Maximum Price, resulting in financial implications for the Trust. Score 16

iii. Specialist LD Contraction: Risk that the TCPs and Mersey Care are unable to agree an appropriate model for CCG-commissioned inpatient beds Score 16

iv. Specialist LD Contraction: There is a risk that the

target number of transfers of service users from inpatient into community care programmes is not possible to achieve, in time required, leading to an inability to close the site resulting in additional costs for the Trust. Score 16

Recommendation:

The Board is asked to:

1. Note the escalated Local Divisional risks (paragraph 7). 2. Note the escalated South Sefton Community Services

Division risk (paragraph 8). 3. Note the escalated programme risks (paragraph 10).


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Agenda Item No: E1




Patient Safety ☒ ☐ The Board will have robust assurances for patient safety




The Board will have significant assurance for operational performances.

CQC Compliance

☒ ☐

Good governance standards require that the trust has robust risk management and assurance process which provide significant assurance to the Trust Board, and through them to our regulators.

NHS TDA Ratings

☒ ☐


Legal / Requirements

☒ ☐





Are there any valid legal / financial reason(s) for discriminatory practice? ☐ ☒ ☐ If answered ‘YES’ to either question, please include a section in the report explaining why




☒





Type of Risk ☐ ☒ ☐ Board Assurance Framework ☐ Risk Register ☐


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Agenda Item No: E1


Board Assurance Framework

PURPOSE

1. To present the Board Assurance Framework for the Board’s consideration and approval.

2. To provide assurance that the strategically significant risks are being actively managed.

BOARD ASSURANCE FRAMEWORK - November 2017 3. In the Operational Plan 2017/19, the Trust has identified that the 4 overarching risk areas

which are aligned to the current Board Assurance Framework remain the same:

a) Can we deliver Cost Improvement Plans financially? b) Can we maintain quality whilst delivering the Cost Improvement Plans (CIPs)

against a background of increasing demands. c) Can we afford capital investment without financially destabilising the Trust? d) Do we have the organisational capacity to deliver our transformational agenda?

4. The November 2017/18 BAF consists of 10 Board approved strategic risks and 8

divisional and programme risks of 15 and above. Should these risks materialise they will have adverse financial, qualitative, reputational and or regulatory implications for the strategic objectives of the organisation.

5. The risks are articulated in a way that encourages cooperation amongst directorates. 6. Since the Board last met the Quality Assurance Committee, the Performance and

Investment Committee and the Executive Committee have reviewed the risks for which they are responsible.

7. There are three strategically significant risks identified by the Local Division on the Board Assurance Framework:

a) If clinic letters and discharge summaries are delayed then there is a risk of

inadequate communication leading to clinical care being negatively affected (LOC.118). Risk Score 16

• Risk score reduced from a 20 to 16 following review in the QAC meeting in September.

Controls and Mitigations

• Recruitment underway; use of bank and agency staff to cover gaps. • Outsourcing of backlog started week commencing the 6th November

following approval by IG. • Safety Sub Committee reviewed the risk on the 2nd November and agreed

keeping the current risk score at 16. • Use of Dragon voice dictation software to be considered to reduce future

backlogs.

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Agenda Item No: E1

b) If there are long term Consultant Psychiatrist vacancies within the Local Division

then there is a risk that the quality and safety of care is being compromised (LOC,113). Risk Score 16

Controls and Mitigations • Recruitment plan developed in line with Local Division workforce action

plan. • Medical Director to lead on the recruitment plan • Cost plan information provided to the PIC in August. • Caseloads to be reviewed to make post more attractive. • Use of medical bank to cover vacancies. • Target date reviewed by Andrew Sedgwick and the Medical Director and

increased from 31st December 2017 to 1st April 2018 to allow for feedback from David Fearnley from PIC discussion and advice regarding progressing of Action Plan.

• Review of Corporate’s Workforce recruitment and retention of staff risks in relation to Local’s risk.

c) If improvements are not made to Park Lodge environment then there is a risk of breaches in Safety Regulations, increases in health related, security and safety incidents, reduction in staff morale, service users experience and damage to reputation (LOC.116). Risk Score 16

Controls and Mitigations • A security risk assessment, a safety QRV and an Infection Control QRV

completed. • Joint action plan in place to address actions and recommendations. • Fire escape structural survey carried out. • Remedial works currently being carried out at Park Lodge. • Plan for Park Lodge to be developed by the Chief Operating Officer Donna

Robinson and Executive Director of Operations Mark Hindle.

8. There is one strategically significant risks escalated by the South Sefton Community

Services Divisions onto the Board Assurance Framework:

a) If pressure ulcer hotspots are not identified early enough leading to a lack of intervention and an increase in avoidable Grade 3 and Grade 4 pressure ulcers across the Division. (SSCD.16). Risk Score 16

Controls and Mitigations • Pressure Ulcer Improvement Plan with identified leads in place; • Pressure Ulcer Harm Free Group established to implement and monitor

plan. • Hot spots identified following data analysis - local plans to be implemented. • Work with South Sefton Commissioning Group (SSCG) commenced to

enable collaborative approach to reduction. • “Being Open” meeting moved to twice weekly to ensure 72 hour reviews

are taking place.

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9. There are currently no strategically significant risks with a risk score of 15+ from the Corporate, Secure and Specilaist LD Divisions.

10. There are four strategically significant risks escalated from projects/programmes on to the Board Assurance Framework:

a) Relias Learing System (New Risk): If Relias are unsuccessful in the tendering

process this would mean moving the Trust back to OLM by 1st June 2018 causing major disruption to training reporting(RLPO5). Score 20

• The current contract for Relias is only for 1 year until June 2018. The contract cannot be extended without going through a tendering process as the supplier is not on the NHS Framework. Controls and Mitigations

• Relias are identifying a partner in the NHS Procurment Framework to work with.

• Tender document being developed by Finance and HR • In talks with Relias regarding supporting the system beyond 1st June

2018 if the tendering process is not complete. .

b) Specialist LD Contraction:Risk that the Greater Manchester and Lancashire Transforming Care Partnerships (TCPs) and Mersey Care are unable to agree an appropriate model for CCG-commissioned inpatient beds (SPLD CP 006). Risk Score 16

Controls and Mitigations • Weekly meetings with Lancashire Transforming Care to Pick up issues with

CCG Beds • A meeting with NHS England’s Assistant Director of Nursing, was attended

by the Trust to discuss the option for locating the CCG beds on the Whalley site.

• High level discussions between the Trust and the Commissioners still ongoing. Target date to be reviewed and reported to the Risk Management Group, due to third consecutive change to target date.

• Discussions with Specalist Commissioners and NHSE regarding LSU service requirments. Agreed an option for a 40 bed unit in the business case along side the dispurse model.

c) MSU New Build: If the Full Business Case for the Secure Health Park is not approved in time leading to an increase in the Guaranteed Maximum Price, resulting in financial implications for the Trust (SHP.040). Score 16

• The underlining cause of the risk has now become an issue as final external approval for the business case by the Treasury is only expected in December 2017. Business case is currently with the Minister for Health.

Controls and Mitigations • The Trust has set a tolerance indicating a set limit of what is considered an

affordable increase

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Agenda Item No: E1

• The developer Kier have provided indicative costs in terms of the potential inflation and re-tendering process. The indicative costs provided are within the Trust’s tolerance levels.

• Kier are currently working on a final cost which the Trust will be closely monitoring.

• Finance are discussing with NHSI a proposal to advance order the build to secure the GMP, while the Business Case goes through final external approval.

• If final costs are outside the tolerable level, the Trust will review were savings can be made.

d) Specialist LD Contraction: There is a risk that the target number of transfers of

service users from inpatient into community care programmes is not possible to achieve, in time required, leading to an inability to close the site resulting in additional costs for the Trust(SPLD OP 04). Score 16

• The underlining cause of the risk as now become an issue as currently running at a 30% (16 service users )success rate against a planned discharge from April to October 2017 of 54 service users.

Controls and Mitigations

• Fortnightly meeting in place with Specialised Commissioners with an agenda item that reviews the Strategic Contraction Plan. This plan has all discharge trajectories for all service users over the next three years.

• Ensure recruitment to Specialist Support Teams (SST's) to work towards new clinical model. Staff for phase one recruitment in post, and caseload review with current team undertaken to reallocate cases according to location of new teams.

• Plan to close the satellite sites at Rochdale in January 2018 and Lancaster in March 2018 and transfer service users and staff onto the Whalley site.

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NUMBER OF RISKS INCLUDED IN BAF AGAINST THE TRUST STRATEGIC WHEEL

SUMMARY 14. The 2017/18 BAF consists of:

a) 10 Board identified strategic risks. b) 4 Divisional risks scoring 15 or above. c) 4 Programme / Project risks scoring 15 or above.

RECOMMENDATIONS

15. The Board is asked to: The Board is asked to:

a) Note the escalated Local Divisional risks (paragraph 7).

b) Note the escalated South Sefton Community Services Division risk (paragraph 8).

c) Note the escalated programme risks (paragraph 10). Ray Walker Executive Director of Nursing

November 2017 Chris

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Agenda Item No: E1

Appendix A BAF 2017/18

Our Future

Reference Risk Type Title Executive

Owner Impact Date Identified

Initial Risk Rating

Current Risk

Rating

Target Score

Spark Chart (Last 6 Assessments)

Current Trend

Target Date

Initial Target Date

Next Review

Date

Tolerable Risk

LOC.118 Quality/ Reputational

If clinic letters and discharge summaries are delayed then there is a risk of inadequate communication leading to clinical care being negatively affected

Mark Hindle 4 09-Aug-2017 16 16 4 31-Mar-

2018 31-Mar-

2018 06-Dec-

2017

SHP.040 Finance

If the Full Business Case for the Secure Health Park is not approved by the 1 December 2017an increase in the Guaranteed Maximum Price, resulting in financial implications for the Trust

Elaine Darbyshire 4 27-Jun-2017 16 16 8

01-Dec-2017

01-Oct-2017

01-Dec-2017

SPLD CP 006 Quality

Risk that the TCPs and Mersey Care are unable to agree an appropriate model for CCG-commissioned inpatient beds Mark Hindle 4 02-Aug-2017 16 16 8

31-Oct-2017

30-Jun-2017

30-Nov-2017

SRR 2017/18 - 09 Reputational

If the organisations’ strategic options are not progressed in partnership with appropriate other organisations, then opportunities for improvement and future growth may be lost.

Louise Edwards 3 02-Aug-2017 12 9 3

30-Oct-2019

30-Oct-2019

31-Dec-2017

SRR 2017/18 - 04 Quality

If the organisation does not successfully operationalise South Sefton Community Services, then mental health and primary care may fail to integrate, resulting in the Trust not meeting its deliverables for the improvement of quality of care and performance

Mark Hindle 4 01-Jun-2017 8 8 4 01-Apr-2018

01-Apr-2018

31-Dec-2017

SRR 2017/18 - 08 Finance

If the organisation’s financial activity and workforce plans are not consistent with Sustainability and Transformation Plans, then partnerships may be compromised, resulting in negative financial implications for the Trust and uncertain future growth.

Louise Edwards 4 01-Apr-2017 8 8 4

01-Apr-2018

01-Apr-2018

11-Dec-2017

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Agenda Item No: E1

Our People



Initial Risk Rating

Current Risk

Rating

Target Score


Current Trend

Target Date

Initial Target Date

Next Review

Date

Tolerable Risk

RLP05 Quality/ Regulatory

If Relias are unsuccessful in the tendering process this would mean moving the Trust back to OLM by 1st June 2018 causing major disruption to training reporting

Amanda Oates 5 18-Oct-2017 10 20 6

01-March-2018

29-Dec-2017

29-Dec-2017


If there are long term Consultant Psychiatrist vacancies within the Local Division then there is a risk that the quality and safety of care is being compromised

Mark Hindle 4 20-Mar-2017 12 16 9

30-Apr-2018

31-Dec-2017

06-Dec-2017

SRR 2017/18 - 01 Finance

If the new corporate services strategy and operational model are not produced based on the Carter Review recommendations, then corporate services may not be fit for purpose and corporate CIPs may not be delivered.

Amanda Oates 4 02-Aug-2017 12 12 8

31-Mar-2018

31-Mar-2018

11-Dec-2017


If the Trust fails to develop a workforce model that is aligned to the clinical delivery model, which takes into account the available workforce supply and existing gaps, then the safety, responsiveness and quality of the care provided may be compromised.

Amanda Oates 4 01-Apr-2017 12 12 8

31-Mar-2018

31-Mar-2018

31-Dec-2017


If the measures used to provide assurance for performance are not valid and reliable, then [...]

Ray Walker 3 02-Aug-2017 9 9 4

31-Mar-

2018 31-Mar-

2018 29-Dec-

2017

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Agenda Item No: E1

Our Resources



Initial Risk Rating

Current Risk

Rating

Target Score


Current Trend

Target Date

Initial Target Date

Next Review

Date

Tolerable Risk


If improvements are not made to Park Lodge environment then there is a risk of breaches in Safety Regulations, increases in health related, security and safety incidents, reduction in staff morale, service users experience and damage to reputation

Mark Hindle 4 26-Jul-2017 16 16 4

31-Mar-

2018 31-Mar-

2018 06-Dec-

2017

SRR 2017/18 - 10 Reputational

If the Global Digital Exemplar programme is not implemented effectively, then the Trust may face financial and reputational consequences and opportunities to improve care and treatment may be lost.

David Fearnley 3 01-Aug-

2017 9 9 6 31-Mar-

2018 31-Mar-

2018 30-Nov-

2017

SRR 2017/18 - 03

Quality/ Finance

If the organisations’ estates strategy is not implemented appropriately, then the delivery of perfect care and transformation programmes may not be effectively supported, resulting in quality of care not improving and financial implications for the Trust.

Neil Smith 4 02-Aug-2017 8 8 4

31-Mar-2018

31-Mar-2018

31-Dec-2017

Our Services



Initial Risk

Rating

Current Risk

Rating

Target Score


Current Trend

Target Date

Initial Target Date

Next Review

Date

Tolerable Risk

SPLD OP 04 Regulatory

There is a Risk that the target number of transfers of Service Users on the Whalley site into community care programmes is not possible to achieve, in time required, leading to an inability to close the site resulting in additional costs for the Trust.

Mark Hindle 4 14-Mar-2016 16 16 4

31-Mar-2018

26-Dec-2017

31-Dec-2017

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Agenda Item No: E1



Initial Risk

Rating

Current Risk

Rating

Target Score


Current Trend

Target Date

Initial Target Date

Next Review

Date

Tolerable Risk

SSCD.16 Quality

There is an increasing trend in the reporting of Community Acquired, Avoidable pressure ulcers across the Division due to identified hot spots within community services where further training, awareness and timely intervention is required.

Trish Bennett 4 29-Sep-

2017 16 16 8 01-Dec-2017

SRR 2017/18 - 02 Quality/ Finance

If the Trust does not implement the transformation programmes for clinical services timely and effectively, then the quality of services may be negatively affected including a potential increased use of Out of Area Treatments.

Mark Hindle 4 05-Nov-2015 12 8 4

31-Mar-2018

31-Mar-2016

31-Dec-2017

SRR 2017/18 - 05 Quality/

Reputational

If the Life Rooms model is not implemented fully, then increased pressures may be put on services in the form of bed occupancy, increased community attendance with lower recovery, employment and patient satisfaction rates.

Elaine Darbyshire 3 02-Aug-

2017 12 6 3

30-Apr-2018

01-Apr-2018

31-Dec-2017

Agenda Item No: E2

Page 1




Board Governance

Accountable Director(s): Andy Meadows, Trust Secretary Report Author(s): Andy Meadows, Trust Secretary


Our Services ☐ Save time and money ☐ Improve quality

(STEEP)

Our People ☐ Great managers and teams ☐ A productive, skilled

workforce ☐ Side by side with service users and carers

Our Resources ☐ Technology that helps

us provide better care ☐ Buildings that work for us

Our Future ☐ Effective Partnerships ☐ Research and innovation ☐ Grow our services

Purpose of Report:

To propose some amendments to the trust’s Standing Financial Instructions (SFIs) and Scheme of Reservation & Delegation of Powers (SoRD)


1) Amending the SFIs to take account of latest national guidance on managing conflicts of interest.

2) Amending the SoRD to take account that: o only the Board of Directors can approval of the trust’s

Learning from Deaths policy, o the terms of reference for both the Executive Committee

and the Performance, Investment and Finance Committee (PIC) require amendment as the PIC takes over accountability for the Digital Board (a sub-committee).

Recommendation:

The Boards of Directors is asked to: 1) consider and approve the changes to the trust’s Standing

Financial Instructions and Scheme of Reservation and Delegation of Powers as outlined in this paper.


Agenda Item No: E2

Page 2




Patient Safety ☐ ☒



Operational Performance ☐ ☒

CQC Compliance ☐ ☒






Are there any valid legal / regulatory reason(s) for discriminatory practice? ☐ ☐ ☒ If answered ‘YES’ to either question, please include a section in the report explaining why




☐






Agenda Item No: E2

Page 3


Board Governance PURPOSE

1. The purpose of this paper is to propose some amendments to the trust’s Standing Financial Instructions and Scheme of Reservation & Delegation of Powers.

STANDING FINANCIAL INSTRUCTIONS (SFIs)

2. Members are asked to consider the following amendments to the SFIs to reflect the latest national guidance in respect of managing conflicts of interest, namely amending

a) paragraph 10.2.6(a)(iv) (Duties of Managers and Officers), and

b) paragraph 19.1 (Acceptance of Gifts by Staff)

by replacing references to ‘HSG(93)5, Standards of Business Conduct for NHS Staff’ with references to ‘NHS England’s Managing Conflicts of Interest in the NHS: Guidance for staff and organisations’.

SCHEME OF RESERVATION AND DELEGATION OF POWERS (SoRD)

Learning from Deaths Policy

3. In September 2017 the Board approved the Learning from Deaths policy, agreeing that its approval was a matter that would be reserved by the Board of Directors and not delegated to a Board Committee or an Executive Directors. It is therefore proposed to include an additional sub-paragraph to section 3.3 (Regulation and Control) of the SoRD which details those policies which are reserved for approval by the Board. The following text is proposed:

“3.3.1(x) approval of the Trust’s Learning from Deaths policy.”

Changes to Board Committee Terms of Reference

4. At the Performance, Investment & Finance Committee (PIC) meeting on 20 October 2017 it was agreed that the Digital Board, a sub-committee accountable to the Executive Committee, would now be accountable to the PIC. Previously the Digital Board oversaw the trust’s Digital Strategy; however with the trust being successful in its Global Digital Exemplar (GDE) bid the role Digital Board has been re-worked to oversee the implementation of the GDE and the investment this will require. This is the reason for the change of accountability and the Digital Board now being a sub-committee of the PIC

Agenda Item No: E2

Page 4

5. As a result of this change the Board is asked to approve the following changes to terms of reference:

a) Executive Committee – remove the reference to the Digital Board in paragraph 10.4(h) of this committee’s terms of reference;

b) PIC - make the following changes to the PIC’s terms of reference:

• insert the following new sub-paragraph into section 9 (Duties):

“9.14 Be assured that the trust effectively implements the Global Digital Exemplar Programme together with receiving and considering business cases / requests for investment from the Digital Board, either approving such requests or recommending their consideration by the Board of Directors (in line with the Scheme of Reservation and Delegation of Powers)”

• add the following text to section 10 (Reporting):

“10.4 The following sub-committees and working groups report to the PIC: a. Digital Board”

RECOMMENDATION

6. Members of the Board of Directors are asked to:

a) consider and approve the changes to the trust’s Standing Financial Instructions and Scheme of Reservation and Delegation of Powers as outlined in this paper.

ANDY MEADOWS TRUST SECRETARY

November 2017

Agenda Item No: F1

Page 1 of 94

Report provided (check necessary boxes): Paper No: TB16/17/155


Meeting Date: 29 November 2017

Minutes of Board of Directors Committees and of the Council of Governors (including Chairs’ Reports)

Page Name of Board Committee (Chair) Date of the Board Committee Meeting

Approved

Yes No

2 Audit Committee (Mrs P Williams) 11 October 2017 ☐ ☒

16 Executive Committee (Mr Smith) 21 September 2017 ☒ ☐

32 Executive Committee (Mr Smith) 19 October 2017 ☐ ☒

46 Quality Assurance Committee (Dr Beardall) 13 September 2017 ☐ ☒

63 Performance, Investment and Finance Committee (Mr N Williams)

20 October 2017

☐ ☒

81 Remuneration and Terms of Service Committee (Mrs Fraenkel) 27 September 2017 ☒ ☐

81 Remuneration and Terms of Service Committee (Mrs Fraenkel) 25 October 2017 ☐ ☒

82 Council of Governors (Mrs Fraenkel) 25 October 2017 ☐ ☒

Recommendation: The Board is asked to note the contents of these Committee minutes and the accompanying reports from the respective Chairs.

This report was compiled by

Paula Murphy Corporate Governance Compliance Manager Tel: 0151 472 4042

November 2017

Agenda Item No: F1

Page 2 of 94

CHAIR’S REPORT AND MINUTES FOR THE

Audit Committee

Date of Meeting: Wednesday 11 October 2017 Chair: Mrs P Williams

Summary of key issues from this meeting:

The Audit Committee received an update in respect of: • The Executive Committee being updated on MIAA reviews in which limited assurance

had been identified, via the regular Care at a Glance report going forward. • The Trust’s risk management system, noting that the term ‘accepted risk’ had been

reviewed and amended to ‘tolerable risk’. There were 8 tolerable risks which were not in line with the organisation’s appetite for risk and as all related to patient safety being compromised, mitigations and controls must be reviewed on a monthly basis and the ‘tolerable’ status was removed. Following a risk maturity review by MIAA, the overall rating concluded that the Trust was ‘Risk Defined’ and an action plan had been put in place to address areas for improvement identified.

• The Quality Improvement and Clinical Audit programme along with feedback received from MIAA following the review of the clinical audit arrangements. The Committee noted that all clinical audit posts were filled; plans were in place to address deviations from plan timescales within year; MIAA had provided significant assurance of clinical audit arrangements and there were plans to improve reporting to the Committee with greater emphasis on outcomes.

• The New Care Models (NCM) noting that although work was on-going in developing the model, the Trust would not look to assume delegated financial responsibility until 1 Jan-18.

• An update regarding progression of work against the agreed 2017/18 Anti-Fraud Work Plan in addition to progress made in addressing fraud referrals received by the Trust’s Anti-Fraud Specialist.

• The External Audit Update which provided information to ensure that in their role as those charged with governance, the Committee had access to information and reports to support their work in this role.

The Audit Committee noted the following: • An update on compliance in relation to the MIAA review of consultant job planning, noting

that all areas reflected in the review action plan had now been implemented. Work would be undertaken with I.T. to move to electronic job planning and this was currently under consideration. A further update/assurance would be provided in April 2018.

• Following the MIAA Review of the Quality Spot Check Process in August 2017, work was on-going to develop a robust action plan to address the areas for improvement identified and a report would be presented to the Dec-17 Audit Committee.

• An update in respect of the assurances, key issues and progress against the Internal Audit Plan for 2017/18 for Mersey Care, specifically finalised reports in relation to Woodview Cash Misappropriation; Clinical Information Systems; Risk Maturity; Medical Staff Absence Management.

• An update in respect of assurance, key issues and progress against the Internal Audit Plan for 2017/18 for Informatics Merseyside, noting that a number of reviews had been completed as part of IM’s Internal Audit plan, namely those relating to Service management and Cyber Security Essentials.

• An update on the outstanding high risk internal audit recommendations and actions, noting that outstanding actions had been discussed with the relevant Executive Director and Operational Lead and evidence requested by 30 Nov-17.

Agenda Item No: F1

Page 3 of 94

• An update on the Trust’s consideration of recent developments and publications as identified by Grant Thornton, noting that the emerging issues and developments outlined in the Grant Thornton report ‘External Audit Update’ reported to the Committee in Aug-17 had been issued to the relevant staff across the Trust charged with governance.

• Five Tender Waiver applications approved since the last meeting in line with the Trust’s Standing Financial Instructions.

• Under Any Other Business, the Committee were informed of: a) The Liverpool Community Health transaction process – noting the Committee would

receive a report in Dec-17 on the robustness of the due diligence process; b) National Audit Office – A review would be undertaken by the National Audit Office of

Value for Money management with regard to Liverpool Community Health and South Sefton transactions;

c) Ashworth Hospital Security Audit – High Secure Services at Ashworth would shortly undertake a new process of audit concerning security systems, the outcomes of which would be presented to the Audit Committee in due course.

Agenda Item No: F1

Page 4 of 94

Status of these minutes (check one box): Paper No: AC17/18/

Draft for Approval: ☒ Report to: Audit Committee

Formally Approved: ☐ Meeting Date: 13 December 2017


Audit Committee Date: Wednesday, 11 October 2017. Time: 2.00pm

Venue: Room 3, V7 Building, Kings Business Park, Prescot, L34 1PJ.


Present:

Pam Williams Gerry O’Keeffe

Non-Executive Director (Chair) Non-Executive Director

In Attendance:

Ray Walker Gary Baines Steve Parker Mina Patel Ian Lythgoe Steve Morgan Mark Hindle Noir Thomas Neil Krajewski Clare Smallman Paula Murphy

Executive Director of Nursing Mersey Internal Audit Agency Associate Director of IT Deputy Director of Finance Senior Assistant Director of Finance Director of Patient Safety Executive Director of Operations Consultant Forensic Psychiatrist Grant Thornton Mersey Internal Audit Agency Corporate Governance Compliance Manager (Minute Secretary)

Apologies Received:

Nick Williams Darrel Davies Kevin Knowleson Neil Smith Mike Thomas

Non-Executive Director Mersey Internal Audit Agency Service User / Carer Representative Executive Director of Finance / Deputy Chief Executive Mersey Internal Audit Agency

ISSUES CONSIDERED 2017 A1 APOLOGIES FOR ABSENCE

1. The apologies for absence are as detailed above.

A2 DECLARATIONS OF INTEREST


Agenda Item No: F1

Page 5 of 94

A3 MINUTES OF THE PREVIOUS MEETING – 16 AUGUST 2017

3. The minutes were accepted as an accurate record, no amendments required.

4. Mr Meadows referred to paragraph 35 of the previous minutes (Aug-17) in which it was requested that the Executive Committee were notified of Mersey Internal Audit Agency Reviews in which limited assurance had been identified. Mr Meadows confirmed that reports produced by Internal Audit were considered by the relevant executive lead, but not considered corporately. In light of this the Executive Committee had agreed that such reports would be reported to the Executive Committee via the regular Care at a Glance report.

5.


Recommendations approved by the Committee, namely: • Approve the minutes of the previous meeting, held on

16 August 2017.

• None Identified.

A4 MATTERS ARISING

a. UPDATE ON MIAA REVIEWS OF PATIENT PROPERTY

6. With regard the MIAA review of patient property, Mr Baines stated that further work would be undertaken to address the issues identified and a full report would be provided to the December 2017 Committee.

7.


Recommendations approved by the Committee, namely: • Note the verbal update.

• Report on MIAA Reviews of Patient Property Security Processes to the next Audit Committee.

G Baines Dec-17 On Dec-17 Audit Agenda

b. UPDATE ON MIAA REVIEW OF CYBER SECURITY

8. Mr Baines stated that this item would be covered within today’s C1b agenda item, Internal Audit Progress Report – IM.

9.



• None identified.

Agenda Item No: F1

Page 6 of 94

B1 RISK REGISTER UPDATES

10. Mr Morgan stated that following an issue raised at the Committee meeting in August 2017 by Mr O’Keeffe in relation to a series of risks with extended target dates, work had been undertaken to create a standard operating procedure to govern such extensions and ensure appropriateness of these. The Executive Committee would have oversight of this via the monthly risk report. Mrs Williams and Mr O’Keeffe welcomed the improvements to the system and the actions taken to address the concerns raised.

11. Mr Morgan provided an update in relation to the 8 tolerable risks which were not in line with the organisation’s risk appetite in addition to an update regarding the MIAA Risk Maturity Review and risks which had their target dates extended.

12. Mr Morgan summarised key issues as follows:

• the term ‘accepted risk’ had been reviewed by the Risk Management Group and had been amended to ‘tolerable risk’;

• the 8 tolerable risks which were not in line with the organisation’s appetite for risk had been reviewed and it was concluded that as all 8 risks were related to patient safety being compromised, mitigations and controls must be reviewed on a monthly basis and the ‘tolerable’ status was removed;

• a risk maturity review had been conducted by MIAA. The overall rating concluded that the Trust was ‘Risk Defined’ and an action plan had been put in place to address the areas for improvement identified;

• arrangements were in place for risks that required their target dates to be extended; • no risk target dates had been extended since the Committee last met.

13. In response to Mrs Williams, Mr Morgan confirmed that delivery of the action plan

would support the Trust in attaining the next level of managed risk.

14. Mr Meadows referred to the diagram on page 12 of the report [Programme / Project Risk Management Process] and proposed that project risks should be shown as part of the divisional governance processes. Mr Hindle disagreed, stating that an Executive Lead was responsible for each project; therefore such risks were governed via the Executive Committee. Mr Morgan agreed consider this feedback and provide an updated process for the management of programme/ project risks to the next meeting of the Committee.

15.


Recommendations approved by the Committee, namely: • Discuss the report; • Identify any further assurance required;

Further actions required: • Update/feedback in relation to Programme / Project

Risk Management Process to be provided to the next Audit Committee

S Morgan

Dec-17

On Dec-17 Audit Agenda

Agenda Item No: F1

Page 7 of 94

B2 MIAA REVIEW OF CONSULTANT JOB PLANNING: UPDATE ON COMPLIANCE

16. Dr Thomas provided an update of the management response and action plan provided to the Committee in August 2017 following the MIAA review of Job Planning undertaken in February 2017.

17. Dr Thomas confirmed that all areas reflected in the review action plan had now been implemented and a sampling of job plans (20%) had been undertaken for internal consistency. Following discussions with I.T. it has been confirmed that work could be undertaken to move to electronic job planning and this would be further explored going forward. Dr Thomas agreed to provide further assurance to the Committee in April 2018.

18. In response to Mr Walker’s query in relation to IT use in the Specialist Learning Disability Division, Mr Hindle confirmed that the intention was to adopt PACIS at Whalley.

19. Mr Meadows highlighted risk No6 (page 6) which referred to the involvement of the Remuneration and Terms of Service Committee in the appeal process, noting that this was not appropriate. Dr Thomas concurred and agreed to consider an alternative body to consider appeals.

20. Mrs Williams welcomed the report, noting the progress made and requested an update in relation to the monitoring system be scheduled for a future meeting.

21. Dr Thomas left the meeting.

22.


Recommendations approved by the Committee, namely: • Acknowledge 6 specific risks raised by MIAA and the

proposed remediation plans; • Note the report and its content; • Seek further assurance as required;

Further actions required: • In relation to Risk No6 (page 6), Remuneration and

Terms of Service Committee to be replaced with a more appropriate body for the appeals process;

• Update in relation to the job planning monitoring system to be scheduled for a future Audit Committee;

N Thomas N Thomas

Nov-17 Feb-18

Due Nov-17 On Feb-18 Audit Agenda

B3 MIAA QUALITY SPOT CHECK REVIEW – MANAGEMENT RESPONSE AND

ACTION PLAN

23. Mr Walker provided a brief verbal update stating that following the Committee’s receipt of the MIAA Review of the Quality Spot Check Process in August 2017, work was on-going to develop a robust action plan to address the areas for improvement identified and this would be reported to the Committee in December 2017.

Agenda Item No: F1

Page 8 of 94

24.


Recommendations approved by the Committee, namely: • Note the verbal update;

Further actions required: • Update report in relation to MIAA Quality Spot Check

Review – Management Response and Action Plan, to be provided to the next Committee.

R Walker

Dec-17

On Dec-17 Audit Agenda

B4 QUALITY IMPROVEMENT AND CLINICAL AUDIT PROGRESS UPDATE

25. Mr Walker updated the Committee on the Quality Improvement and Clinical Audit programme as of 30 September 2017 and feedback received from MIAA following the recent review of the clinical audit arrangements, specifically:

• All clinical audit posts were now filled; • All clinical audits were being completed in line with the Clinical Audit Programme

and where there had deviations from the timescales within the programme, there were plans to address this in-year;

• MIAA had undertaken a review of the clinical audit arrangements which had provided significant assurance;

• There were plans in place to improve reporting to the Committee with greater emphasis on outcomes;

26. Mr Walker stated that delivery of the Clinical Audit Programme was on track and acknowledged the excellent leadership of Joanne Bull in driving this. Mrs Williams congratulated Ms Bull and the team on progress made and proposed that the Quality Assurance Committee monitor Clinical Audit going forward, bringing any issues to the Audit Committee as necessary.

27.


Recommendations approved by the Committee, namely: • Note the findings/actions and areas for improvement

from the 17/18 Clinical Audit Programme; • Note feedback from MIAA and recommendations;

Further actions required: • None identified

B5 NEW CARE MODELS – GOVERNANCE UPDATE

28. Mr Meadows provided a verbal update in relation to New Care Models (NCM), stating that although work was on-going redeveloping the clinical model, the Trust would not be looking to assume delegated financial responsibility until 1 January 2018, adding that this date may change. There were 2 significant pieces of governance work, specifically the Management Agreement between Mersey Care and NHS England and a Collaborative Agreement between Mersey Care and the other PROSPECT partners, which Hempsons were assisting with.

29. A key component of the development of the Collaborative Agreement was a risk / gain-share agreement with partners and also whether all partners would have the same

Agenda Item No: F1

Page 9 of 94

status, subject to further discussions in respect of partners investing in the development of community services (which all may not wish to do), Mr Meadows stated that it may be necessary for the Trust to provide additional money in order to kick start the community element of the Model and discussions were on-going with NHS England regarding the potential for funds to be provided for this. If the request for funds were to be unsuccessful, a business case would be submitted to the Performance, Investment and Finance Committee seeking additional investment. There was a process in place for either outcome. Mr Meadows stated that another meeting with NHS England would take place w/c 16 October 2017 to discuss the development of the Management Agreement.

30. Mrs Williams referred to the risk / gain-share agreement and queried if the intention was to accrue savings in a ‘pot’. Mr Meadows confirmed that the Trust would have contractual amendment, therefore savings would come to the Trust and the Trust would have risk gain-share agreement with the other partners. The intention is that monies will be reinvested. In response to Mrs Williams, Mr Meadows confirmed that non-investing partners would not be in the same financial savings position as investing partners.

31. Mr Hindle stated that the NCM was completely consistent with work undertaken at Whalley and therefore there was experience of this process within the organisation. In response to Mrs Williams, Mr Hindle confirmed that co-operative working with partners was a very different way of working, which was difficult to implement but provided a solution.

32. Mrs Williams noted the importance of being very clear about where savings are accrued and re-invested.

33.


Recommendations approved by the Committee, namely: • Note the verbal update;


C1 INTERNAL AUDIT PROGRESS REPORTS

a. Mersey Care NHS Foundation Trust

34. Mr Baines provided an update in respect of the assurances, key issues and progress against the Internal Audit Plan for 2017/2018 as previously agreed by the Committee.

35. Mr Baines confirmed that since the previous meeting of the Audit Committee, the following reports had been finalised:

• Woodview Cash Misappropriation – Assurance level N/A; • Clinical Information Systems – Limited Assurance; • Risk Maturity – Risk Defined;

Agenda Item No: F1

Page 10 of 94

• Medical Staff Absence Management - Significant Assurance;

36. In reference to the incident at Whalley regarding cash misappropriation, Mr Baines confirmed that this issue had involved 11 service users’ petty cash not being evidenced correctly, which was a lapse in basic control. Key actions had been outlined to address this issue and avoid reoccurrence. Mr Baines confirmed that spot checks had been undertaken on 3 other wards at in the Specialist Learning Disabilities Division which had provided assurance that this was an isolated incident.

37. In response to Mr O’Keeffe, Mr Baines confirmed that the three wards were selected at random at the Whalley site for spot checks and this had been deemed to be a sufficient independent check. Mrs Williams queried if random, unannounced spot checks could be carried out on a regular basis to ensure the safety of patient property/cash. Mr Baines and Mr Hindle agreed to discuss this further outside of the meeting and provide a formal update to the Committee.

38. Mr Lythgoe proposed that awareness-raising was undertaken to provide wards / staff members with a reminder of the formal process. Mr Hindle confirmed that an email had been sent to ward managers regarding the process to follow. Following a comment from Mrs Williams, it was agreed that the learning from the MIAA review would be shared across the organisation. Mr Walker added that it had been agreed previously to share good news stories and ensure lessons learnt through MIAA reviews were shared and this was an ideal opportunity to do so. Mr Lythgoe also agreed to circulate information to all cashiers to remind them of the process.

39. Mr Baines referred to page 4 of the report in relation to the review of the PACIS clinical information system, stating that all information had not been transferred across from the legacy server to the live server which could expose a high risk. Mr Baines confirmed that outstanding actions were due to be completed in November 2017 and an update would be provided to the December 2017 Committee.

40. Mr Parker stated that Informatics Merseyside (IM) provided the servers, however PACIS was an in-house service. Mr Hindle noted the vulnerability this posed.

41. Mr Meadows stated given that the PACIS system (and other in-house systems) were not subject to regular audit processes; this may need to be incorporated into the annual audit plan. Following discussion, it was agreed that a review of systems managed in-house and through contracts was required. Training to the Board of Directors on the new data protection legislation had indicated that the Trust should assess compliance with new regulations. Mrs Williams proposed that a piece of work was commissioned, specifically to determine compliance with new data protection regulations and to determine the internal control arrangements in place. Mr Hindle concurred and proposed that a report outlined the key systems and controls be developed to inform whether a formal review was required. Mr Walker added that the Due Diligence exercise to be undertaken as part of the Liverpool Community Health transaction may inform how this was progressed.

42. In light of discussions, Mr Meadows proposed that Dr Asim Patel, Steve Parker and Gary Baines scope a piece of work in relation to a review of robustness and deliver an update to the Committee in December 2017 which would provide timescales n relation

Agenda Item No: F1

Page 11 of 94

to completion of the work. Mr Meadows also requested a report to the next Performance, Investment and Finance Committee in relation to IT systems across the Trust.

43. Mr Baines confirmed that MIAA were developing a review in relation to the Trust’s readiness for compliance with new data protection regulations.

44. In relation to the review of Risk Maturity (page 7), Mr Baines confirmed that the full report had been provided to the Risk Management Group in September 2017 and work was on-going in relation to the action plan which was being managed by the Risk Management Group. Mr Baines confirmed that the review had identified an open culture across the organisation.

45. Mr Walker left the meeting.

46.


Recommendations approved by the Committee, namely: • The Committee is asked to note the assurances

provided within the document and issues raised within completed audits and seek assurance that corrective actions are being taken by management to address recommendations made;

Further actions required: • Update in relation to implementation of random spot

checks across the Trust regarding petty cash/patient property;

• Share learning from internal audit work with the whole organisation;

• Further update in relation to PACIS/Actions to be provided to the next Committee;

• Update report to the next Committee in relation to timescales for completion of piece of work to review robustness all IT systems (including in-house/via contract etc)

• Report to PIFC in relation to mapping of IT systems;

G Baines / M Hindle M Hindle G Baines A Patel / S Parker / G Baines A Patel

Feb-18 Dec-17 Dec-17 Dec-17 Dec-17

On Feb-18 Audit Agenda Due Dec-17 On Dec-17 Audit Agenda On Dec-17 Audit Agenda On Dec-17 PIFC Agenda

b. Informatics Merseyside

47. Mr Baines provided an update in respect of the assurances, key issues and progress

against the Internal Audit Plan for 2017/2018 for Informatics Merseyside as agreed previously by the Committee.

48. Mr Baines confirmed that since the last meeting of the Audit Committee a number of reviews had been completed as part of IM’s Internal Audit plan, namely those relating to Service Management and Cyber Security Essentials, adding that improvements in cyber control impacting Mersey Care arising from the previous review and other related initiatives had been implemented across the wider infrastructure.

49. Mrs Williams welcomed the report, noting the excellent outcome and congratulated all teams involved. Mr O’Keeffe concurred noting the significant improvements evidenced.

Agenda Item No: F1

Page 12 of 94

50.


Recommendations approved by the Committee, namely: • Note the assurances provided within the document

and issues raised within completed audits and seek assurance that corrective actions are being taken by management to address recommendations made;


C2 OUTSTANDING HIGH RISK MIAA RECOMMENDATIONS – MANAGEMENT

RESPONSE AND ACTION PLAN

51. Ms Patel provided an update on the outstanding high risk internal audit recommendations and actions which were agreed as a result of work undertaken since April 2014/2015. Ms Patel confirmed that outstanding actions had been discussed with the relevant Executive Director and Operational Lead and a request made that evidence was provided by 30 November 2017. A further update would be provided to the Audit Committee in December 2017.

52. Ms Patel noted that policy compliance in relation to Deprivation of Liberty Safeguards (page 7) had been superseded by another system.

53. Mrs Williams stated it was important to monitor recommendations and ensure these were actioned adding that responsible officers would be asked to attend the Audit Committee to respond to any questions arising in relation to any actions that remained outstanding.

54.


Recommendations approved by the Committee, namely: • Note the contents of the report;

Further actions required: • Update on outstanding high risk MIAA

recommendations to be provided to the Committee

M Patel

Dec 17

On agenda

C3 ANTI-FRAUD WORK PLAN UPDATE

55. Ms Smallman provided an update regarding progression of work against the agreed 2017/18 Anti-Fraud Work Plan in addition to progress made in addressing fraud referrals which had been received by the Trust’s Anti-Fraud Specialist (AFS). Ms Smallman highlighted key issues as follows:

• Delivery of the 2017-18 Work Plan was on track; • The AFS had delivered a number of awareness sessions across Trust sites; • The AFS was liaising with learning and development to develop a new eLearning

module; • The summer edition of the Anti-Fraud newsletter had been circulated across the

Trust; • One referral had been received since the last Committee and the AFS had

commenced enquiries; • The AFS had responded to a number of fraud queries on behalf of the Trust;

Agenda Item No: F1

Page 13 of 94

56. Mrs Williams thanked Ms Smallman for the comprehensive report.

57.


Recommendations approved by the Committee, namely: • Receive the report and note its contents;


D1 EXTERNAL AUDIT UPDATE

58. Mr Krajewski provided an update on audit progress including an information section, the purpose of which was to ensure that Audit Committee members, in their role as those charged with governance, had access to information and reports that support their work in this role.

59. Mr Krajewski noted key issues as follows:

o The report provided a summary of audit progress to date, setting out the status of work on the opinion audit, the value for money conclusion and the Quality Account;

o The report reflected relevant publications by Grant Thornton, the King’s Fund and the Department of Health which may be of interest to members of the Committee.

o Grant Thornton representatives had attended the July 2017 Council of Governors meeting to discuss 2016/17 the annual audit of the accounts and review of the Quality Account;

o Lessons learnt in drafting Annual Reports following the acquisition of Calderstones had been noted;

60. Mr Krajewski confirmed that all work was on track and the interim audit would commence in November 2017.

61. In response to clarification sought by Mrs Williams in relation to the Foundation Trust KPI benchmarking report, Mr Krajewski agreed that comparison against 11 months performance (1 May 16 – 31 March 17) distorted outcomes therefore context had been provided. Mr Krajewski confirmed that this benchmarking was undertaken against fellow Foundation Trusts.

62.


Recommendations approved by the Committee, namely: • The Committee is asked to note the content of the

External Audit Update;


Agenda Item No: F1

Page 14 of 94

D2 EXTERNAL AUDIT ISSUES AND DEVELOPMENT LOG

63. Ms Patel provided an update on the Trust’s consideration of recent developments and publications as identified by Grant Thornton in their recent update report. Ms Patel stated that the emerging issues and developments outlined in the Grant Thornton report ‘External Audit Update’ which had been reported to the Committee in August 2017, had been issued to the relevant staff across the Trust who were charged with governance and the actions taken to date were detailed in the report.

64. Ms Patel highlighted the emerging issue number 2, ‘Local support for people with a learning disability’, stating that the issues raised by the National Audit Office were consistent with those identified in the organisational.

65.




E1 TENDER WAIVER REPORT

66. Ms Patel presented the Tender Waiver Report to the Committee in accordance with the Trust’s Standing Financial Instructions, confirming that 5 waiver applications had been approved in the reporting period. Ms Patel noted that a number of these were extensions to previous tender waivers and all had been checked against the rules in place with two nearing the waiver limit of £100k and the relevant Executive Directors had been notified accordingly.

67. Mr O’Keeffe referred to the waiver PUR044/214 in respect of preparation of the Trust magazine and website, stating that the daily rate was substantial. Mr O’Keefe queried whether this fee this could be justified and noted that it would be more economical to employ staff members to undertake this role. Mr Lythgoe advised that the waiver value had increased following attainment of FT status and assured Mr O’Keeffe that due process had been followed regarding this waiver. In response to Mr O’Keeffe, Mr Lythgoe advised that this waiver would not be further extended.

68.




F1 ANY OTHER BUSINESS

69. Liverpool Community Health – Mr Meadows confirmed that work was on-going to clarify the transaction process and the Committee would receive, in December 2017, an update report in relation to the robustness of the Due Diligence process, as previously requested.

Agenda Item No: F1

Page 15 of 94

70. National Audit Office – Mr Meadows stated that the Trust had been contacted by the National Audit Office regarding a review of the Value for Money management with regard to the Liverpool Community Health and South Sefton transactions.

71. Whistle-Blowing Incident – Mr Meadows sought the Committee’s permission to share an MIAA audit report following investigation of a whistle-blowing incident into aspects of Estates/ Facilities management. This would be outside of the normal process in which a MIAA report would be presented to the Audit Committee following sign-off by the Executive Lead prior to being shared.

72. Mr O’Keeffe stated that within the remit of his role as a Senior Independent Director, he was already aware of this incident.

73. Mr Baines confirmed that the incident had raised concerns in respect of systems and processes and therefore MIAA had been commissioned to review these. Mr Lythgoe advised that the report should be discussed by the Committee prior to being shared. Mr O’Keeffe concurred, stating that there were a number of issues the Committee would likely wish to discuss.

74. The Committee agreed that the report must be presented to the Audit Committee in December 2017prior to being shared.

75. Ashworth Hospital Security Audit – Mr Hindle stated that High Secure Services at Ashworth were shortly to undertake a new process of audit concerning security systems and proposed that the outcomes of the audit/mechanism were presented to the Audit Committee. Mrs Williams agreed.

76.


Further actions required: • Update report in relation to robustness of Due

Diligence process for LCH to the next Committee;

• MIAA review into estates/ facilities to be presented to the next Committee before being shared;

• Outcomes of review of High Secure Services

inspection of security systems to be presented to the Committee;

A Meadows/ T Bennett G Baines M Hindle

Dec-17 Dec-17 Dec-17/ Feb-18

On Dec-17 Audit Agenda On Dec-17 Audit Agenda On Dec-17/Feb-18 Audit Agenda

F2 RISK REFLECTION

77. The Committee proposed that, if not already reflected, issues in relation to I.T. Systems were to be included on the Risk Register (see agenda item C1a). Mr Meadows agreed to speak with Mr Walker to confirm.

78.


Further actions required: • Mr Meadows to discuss IT issues/Risk Register with

Mr Walker and if appropriate, add this issue to the register;

A Meadows

Nov-17

Due Nov-17


Agenda Item No: F1

Page 16 of 94


Executive Committee Date of Meeting: Thursday 21 September 2017 Chair: R Walker

Summary of key issues from this meeting: The Executive Committee received assurance in respect of: • An update on delivery of the SLD Retraction Plan in which it was noted that a

Consultant Psychiatrist with extensive knowledge in complex case management had concluded that 75% of the remaining discharges were very likely not to take place. This information would be utilised to revise the retraction plan. It was noted that the plan currently in place had been set by Commissioners and this had been deemed unachievable, therefore a new retraction proposal would be developed and presented to Commissioners. A review of the national position in relation to transformation would be undertaken regarding whether other providers were facing comparable challenges.

• An update in relation to the RIO Implementation Plan Update in order to provide progress on the deployment of the RiO solution to the Local Division. A clinician with good knowledge of the Local Services Division had been seconded onto the RiO Implementation Team for 3 days a week in order to increase the clinical lead presence. Assurance was provided of the deliverability of the system change.

• The key quality issues identified in the reporting period, including: o The cancellation of 8 quality review visits (QRVs) during the last reporting period,

largely due to lack of availability of managers in Local Division. This would be reviewed further by Mr Hindle and Mrs Robinson.

o Mr Walker agreed to develop a risk-based approach to the completion of QRVs which would be presented to the Committee in Oct-17;

• Trust performance in the reporting period in which the following issues were discussed: o The 25% DNA rate for first appointments (Local Division, Community Services)

reported in August 2017, noting that some improvement had been achieved since the introduction of a text and telephone reminder service; however clinics were overbooked to compensate for this. A further meeting would be held on 25 Sep-17 in order to address the current issues in delivery of the transformational programme;

o Issues relating to continuity of care in light of the increase in vacancies within the Local Division;

o Discussion in relation the activities around recruitment and concerns raised at a lack of a proactive approach and the delay between an offer of employment and commencement to post;

o Cost Improvement Plans within the Local Division and the significant challenges faced/mitigations in place to address issues;

o In relation to South Sefton Community Services, following discussion in relation to pressure ulcers, it was proposed that a presentation be delivered to the next Committee in order to improve general understanding in this area;

• An update in relation to the Estates Portfolio including plans for the Trust’s buildings and information of the latest position around capital investment. Any decision relating to use of capital would be put before the Performance, Investment and Finance Committee and the Board of Directors for consideration and approval. It was noted Park Lodge was considered not fit for purpose and an approved refurbishment programme was in place, however this was currently paused whilst investigatory work took place relating to development of the whole site. Details of immediate work required for Park Lodge had been put to the Executive Director of Finance for a decision to be made;

• The Reference Cost Submission noting a significant reduction in the 2016/17 reference

Agenda Item No: F1

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costs index scores in comparison to the 2015/16 figures; • The Business Development Pipeline was received and noted.

The Executive Committee discussed and noted: • An Agency Expenditure update, noting the current position in relation to agency

expenditure and progress made by the divisions regarding reducing agency usage and how an invoicing delay impacted on the figures presented.

• An update in relation to Medical Staffing in Local Division which demonstrated the benefits of creating a single medical staffing budget, highlighted the mitigations in place to manage the risk of an undersupply of doctors of all grades and sought assurance for plans to remunerate medical staff in the optimal way to increase recruitment and retention.

• The Six Monthly Inpatient Staffing Review which provided findings of the multi-professional strategic staffing review across the inpatient wards.

• The Regulatory Risk Report outlining those strategically significant risks that could result in a failure to safeguard assets or impact adversely on the Trust’s regulatory or reputational viability and capability to provide services; or which may impact on the ability of the trust to deliver high quality care in accordance with the requirements of regulators and national standards. Key issues discussed included:

o There were currently 39 reputational/regulatory risks with an impact score of 3 or more from across Corporate, Local, Secure and Specialist Learning Disability Divisions, however there were none reported for the South Sefton Community Services Division. Four were scored at 15 or above;

• The Divisional update report, providing an overview of current issues within Secure, SLD and Local Services Divisions, including performance, key challenges, patient experience and operational management. Specifically, this included:

o Local Division - £0.214m underspend at 30 Aug-17; proposal for introduction of Discharge co-ordinators and a nurse led discharge now developed; Walton FT’s intention to bring the trauma and rehab psychology and neuropsychiatry service (currently sub contracted to MCT) back in house;

o Secure Division - £41k underspent at end of month 5; Transformation agenda progressing well; CIP plans of £3.3m achieved in full of which £92k achieved non-recurrently; the Kiosks pilot concluded and facility well received by patients and appreciated by staff;

o SLD Division – Financial position was a cumulative £0.357m overspend due to additional staffing requirements associated with unplanned care. An update in relation to eRostering would be provided to the Committee in Nov-17;

• The minutes and chairs reports of its sub-committees; The Executive Committee approved: • The EPRR Core Standards Statement of Compliance; • The introduction of eCigarettes to support the implementation of smoke-free

environments and the ‘go-live’ date of 2nd October 2017 for the Smoke-Free Trust; • 7 Trust-wide policy documents for implementation; • The Equality and Human Rights Annual Report 2016/17; • The Health and safety Annual Report 2016/17;

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Status of these minutes (check one box): Paper No: EC17/18/1013

Draft for Approval: ☐ Report to: Executive Committee

Formally Approved: ☒ Meeting Date: 19 October 2017


Executive Committee Date: Thursday, 21 September 2017 Time: 10.00am

Venue: The Boardroom, V7 Building, Kings Business Park, Prescot, L34 1PJ.


Present: Ray Walker Elaine Darbyshire Louise Edwards Mark Hindle

Executive Director of Nursing (Chair) Executive Director of Communications & Corporate Governance Director of Strategy Executive Director of Operations

In Attendance: Clare Almond Arun Chidambaram Melanie Higgins Des Johnson Sarah Jennings Helena McCourt Mina Patel Donna Robinson Andrew Sedgwick Lee Taylor Ashley Crossland

Deputy Director of Workforce Consultant Forensic Psychiatrist Associate Medical Director – Secure and SLD Divisions Chief Operating Officer – Secure Division Deputy Trust Secretary Deputy Director of Nursing Senior Assistant Director of Finance Chief Operating Officer – Local Services Division Associate Medical Director Chief Operating Officer – Specialist Learning Disabilities Division Corporate Governance Assistant (Minutes secretary)

Apologies Received: Trish Bennett David Fearnley Steve Morgan Amanda Oates Asim Patel Joe Rafferty Neil Smith

Director of Integration Medical Director Director of Patient Safety Executive Director of Workforce Chief Information Officer Chief Executive Executive Director of Finance (Deputy Chief Executive)

ISSUES CONSIDERED 2017

A1 APOLOGIES

1. The apologies for absence received for this meeting were recorded, as detailed above.



Agenda Item No: F1

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A3 MINUTES OF THE MEETING HELD ON 24 AUGUST 2017

3. The minutes of the previous meeting, held on 24 August 2017, were accepted as an accurate record with no amendments necessary.

4.


Recommendations approved by the Committee, namely: • Approve the minutes of the previous meeting.


A4 MATTERS ARISING

a. RENAMING OF THE KEVIN WHITE UNIT 5. Mrs Darbyshire confirmed that the family of Kevin White had been contacted and

informed of the planned change of name to the Kevin White Unit and had been invited to attend the re-naming ceremony, where a plaque commemorating Kevin White would also be unveiled.

b. AGENCY EXPENDITURE UPDATE 6. Ms Almond referred to page 4 of the previous minutes of the Executive Committee

regarding the process for reducing agency spend and confirmed that this would be shared with Mrs Robinson by the end of September 2017.

7.


Recommendations approved by the Committee, namely: • Note the verbal updates provided.

Further actions required: • Process for the reduction in nursing agency spend to

be shared with Mrs Robinson.

C Almond

Sep-17

Due Sep-17

A5 STANDING ITEMS:

a. SLDD RETRACTION PLAN UPDATE

8. Mr Taylor delivered the SLDD Retraction Plan Update to the Committee, in order to provide information of the progress on the retraction of services within the Specialist Learning Disabilities Division.

9. Mr Hindle referred to a recent meeting in which a Consultant Psychiatrist with extensive knowledge in complex case management delivered a patient-focussed review of discharges and concluded that 75% of the remaining discharges from learning disability services would were very likely to not take place due to a number of individual factors. Mr Hindle confirmed that this information would be utilised to revise the retraction plan in place.

Agenda Item No: F1

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10. In response to concerns raised by Mrs Edwards regarding amending the retraction plan, Mr Hindle advised that the plan currently in place had been set by the commissioners and had been deemed unachievable. In consideration of this, Mr Walker suggested that this information was fed back to the commissioners, with a new retraction proposal being developed by the Trust and also presented to commissioners. Mr Hindle informed the Committee that whilst the current plan was unachievable, a failure to deliver against this would have negative implications for the Trust, as well as significant financial ramifications for commissioners.

11. Mrs Edwards suggested that due to the seriousness of this issue, a gap analysis should be undertaken and presented to the Committee, prior to delivery to the Board of Directors’ (in private) in order for a decision to be made in relation to informing the commissioners that the discharge target would not be met. Mr Walker requested that a paper, detailing the financial and workforce implications of non-delivery of the existing retraction plan, be brought to the next meeting of the Committee.

12. Dr Chidambaram advised Committee members that he had discussed alternative options for the LD service users concerned with Dr Sedgwick and commissioners were aware of this.

13. In response to Mr Walker, Mr Taylor agreed to examine the national position in relation to implementation of the national transformation plan ‘Building the Right Support’ (NHSE 2015) and whether other providers were facing challenges comparable to those being currently faced by the SLD Division.

14. Following further discussions, Mr Walker confirmed that the risks relating to the current retraction plan would be picked up at the next meeting of the Public Board of Directors’ under the listed Board Assessment Framework item. Mr Hindle affirmed this, expressing his opinion that the current risk rating score of 20 given to this was adequate.

15.


Recommendations approved by the Committee, namely: • Note the progress to date regarding the retraction

plan and the reasons for any delay • Note the next steps around the planned work with

commissioners to progress timely and safe discharges

Further actions required: • Gap analysis to be undertaken and presented to the

Committee and the Private Board of Directors’ • A paper detailing the financial and workforce

implications of non-delivery of the existing retraction plan to be brought to the next meeting of the Committee.

L Taylor L Taylor/ M Hindle

Nov 2017 Oct 2017

Due Nov-17 On agenda

b. AGENCY EXPENDITURE UPDATE

16. Ms Almond presented the Agency Expenditure Update in order to provide the

Committee with the current positions on agency price and wage caps and clarity on

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new requirements in relation to agency expenditure ceilings, in addition to an update on the progress made by the divisions in regards to reducing agency usage.

17. Mr Walker referred to page 5 of the report, and queried the disparity between the decreased number of shifts filled and reduction in agency costs. Dr Sedgwick explained that this could be attributed to the period of time taken by agencies to invoice the Trust, adding that the average amount of time for this process was around 6 weeks. Mr Walker acknowledged this but enquired as to whether further data could be provided in relation to nursing and medical staff. Mrs Robinson explained the difficulties in obtaining such information, but added that the October 2017 agency update should reflect the August 2017 agency spend for these staff groups. With this in mind, Mr Walker requested that a footnote was added to the table to explain the contradictory information.

18. Mrs Robinson explained that obtaining a true recruitment pipeline was currently a manual process, adding that this would be the case until the implementation of the new system in approximately 3 to 4 months. Ms Almond added that this would be a Trust-wide pipeline and the preparation for this would begin on Tuesday, 26 September 2017.

19.


Recommendations approved by the Committee, namely: • The divisions and departments continue to review all

agency usage over 6 months and request approval from the executive team if these are to continue.

• Action is still required by the Local, Corporate and to reduce forecast spend.

• Mersey Internal Audit Agency are currently undertaking a review of the systems and processes for agency staff and engagement of personal service companies. Recommendations from the review will be included in a future report.

• That divisional leads complete the work requested for a recovery plan and revised forecast outturn within the required timeframe to support the trusts ability to meet the NHS Improvement agency ceiling.

Further actions required: • A footnote to be added to table 2 of the report to

explain the impact of the invoicing delay on the figures presented.

C Almond

Sep-17

Due Sep-17

c. RIO IMPLEMENTATION PLAN UPDATE

20. In the absence of Dr Patel, Mr Walker delivered the RiO Implementation Plan Update

in order to provide the Committee with the progress on the deployment of the RiO solution to the Local Services Division.

21. Mrs Robinson notified the Committee of the current issues being experienced in relation to the completion of data cleansing, explaining that this was due to the capacity of administration staff within the Cohort One teams. Mrs Robinson confirmed that in order to provide a pragmatic solution to this, a decision had been made for the task to be shared by all the Local and Addiction Services involved. Mrs Robinson

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continued, adding that a clinician with good knowledge of the Local Services Division had been seconded onto the RiO Implementation Team for three days a week in order to increase the clinical lead presence.

22. In response to concerns raised by Mr Hindle, Dr Sedgwick assured Committee members of the deliverability of the system change, explaining that approximately 98% of the staff within the first cohort had received smart cards and had booked onto the relevant training sessions, with preparatory information having been cascaded to staff who were in the latter cohorts of the implementation. Dr Sedgwick also advised that the Trust had managed the transfer from paper notes to the current EPEX system effectively, confirming that the RiO system also contained clinically designed forms for ease of use. Mrs Robinson assured the Committee that the project had a high level of focus within the Local Division, adding that staff were aware of the pressures of achieving the implementation plan targets, as well as the risks currently associated.

23. Mr Walker requested that Mr Smith and Dr Patel consider and agree the information to be included in future reports to the Committee regarding the current position of the implementation plan.

24.


Recommendations approved by the Committee, namely: • Note the contents of the report. • Continue to support the prioritisation of RiO within

both the Local Services and Corporate Divisions’ work plans, specifically the Business Intelligence team and the existing EPEX system support team

• Support the joint programme with appropriate clinical and managerial support within the relevant governance structures.

• Acknowledge the size, complexity, costs and risks associated with a programme of this type.

Further actions required: • N Smith and A Patel to consider the information being

presented to the Committee in relation to the current position of the implementation plan.

N Smith / A Patel

Sep-17

Due Sep-17

d. MEDICAL STAFFING IN LOCAL DIVISION

25. Dr Chidambaram presented the Medical Staffing in Local Division paper to the

Committee in order to demonstrate the benefits of creating a single medical staffing budget, highlight the mitigations in place to manage the risk of an undersupply of doctors of all grades and seek assurance for plans to remunerate medical staff in the optimal way to increase recruitment and retention.

26. Dr Chidambaram summarised the key issues of the report, including details of a number of factors which were contributing to current overspend against the medical budget.

27. Dr Sedgwick advised that changes in practice needed to be considered given the challenges of medical staffing, including the cease of outpatient clinics in favour of consultant-led clinics. Dr Sedgwick added that the current shortage of psychiatrists

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had forced the Trust to consider service design should no further recruitment be possible. In response to Mr Walker, Dr Sedgwick confirmed that 25% of outpatient appointments were reported as not attended by the service user, with Mrs Robinson adding that clinics were regularly overbooked in order to compensate for this.

28. Mrs Edwards referred to the action plan included within the appendix of the report and proposed that trajectories were included.

29.


Recommendations approved by the Committee, namely: • note action taken already and progress made • seek further assurance

Further actions required: • Trajectories to be added to the action plan.

D Fearnley / A Chidambaram

Oct-17

Due Oct-17

B1 GOVERNANCE OF QUALITY REPORT

30. Mr Walker delivered the Governance of Quality Report to the Committee in order to provide a monthly update on the on-going issues that are raised via the weekly concerns log and weekly concerns process.

31. Mr Walker highlighted the key issues of the report, including the cancellation of eight quality review visits (QRVs), during the last reporting period, largely due to the lack of availability of managers in the Local Division. Mr Hindle and Mrs Robinson agreed that they would meet to discuss this issue outside of the meeting. Mr Walker agreed to develop a risk-based approach to the completion of QRVs’ which would be presented to the Executive Committee in October 2017.

32. Mrs Edwards referred to the CQC self assessment process within the Divisions, questioning how these were utilised and reported on, to which the Chief Operating Officers confirmed that this information was scrutinised and addressed through divisional governance groups.

33.


Recommendations approved by the Committee, namely: • Discuss the report • Identify any new risks • Identify any further assurances it requires

Further actions required: • Paper to be produced for the next meeting of the

Committee outlining a risk based approach to QRVs.

R Walker

Oct-17

Due Oct-17

B2 CARE AT A GLANCE REPORT

34. Mr Walker presented the Care at a Glance Report in order to provide the Committee with a summary of Trust performance to 31 August 2017 and outlined the key issues.

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35. Mr Walker sought further clarification with regard the DNA rate for first appointments (Local Division, community services) outlined on page 13 of the report, which reported at 25% for August 2017. Mrs Robinson advised that this was an aggregated position, adding that there had been some improvement since the introduction of a text and telephone reminder service. Mrs Robinson confirmed however that clinics were over-booked in order to compensate for this. Mrs Edwards and Mr Walker expressed concern that the figures depicted a degree of programme failure. Mrs Edwards added that further assurances were required that the programme was viable prior to any further investment. Mrs Robinson and Dr Sedgwick stated that a meeting would be held on Monday, 25 September 2017 in order to address the current issues in delivery of the transformational programme.

36. Mr Walker referred to the increase in vacancies within the Local Services Division, noting his concern at the challenges this was presenting in terms of continuity of care and adding that this had been a recurring theme which required assurance of being proactively managed. Mrs Robinson concurred and advised that whilst new staff appointments were being made, there were significant delays to their subsequent commencement in post. This, in turn, was impacting upon agency spend and was skewing the vacancy figures presented month-on-month. Mr Walker emphasised the need for a deep-dive into performance in respect of vacancy and recruitment in order to further understand the current position, which Ms Almond agreed to provide to the next meeting of the Committee.

37. Mrs Robinson referred to a recent recruitment event, at which the Trust had been represented, explaining that a number of Trusts had been actively offering positions to interested applicants on the day of the event. Dr Higgins raised concerns regarding this, noting that the Trust could potentially be losing out on recruiting quality staff into vacancies through lack of a proactive approach.

38. In response to Mr Walker, Ms Almond advised that it currently took an estimated average of 43 days from offer of employment to post commencement. Mr Hindle and Mrs Robinson noted that this time period was often significant longer which placed additional pressure on services. Ms Almond acknowledged this point and confirmed that the recruitment pipeline, once produced, would provide a definite figure.

39. In relation to Cost Improvement Plans (CIPs) within the Local Division, Mrs Robinson advised Committee members of the significant challenges being faced and detailed the mitigations that were currently in place to try and address this. Mrs Robinson added that support had been commissioned from KPMG to assist in the identification of areas where further savings could be made, however it was unlikely that a figure nearing the current shortfall could be recouped.

40. Mr Walker noted that there was no representation at the Executive Committee meeting from the South Sefton Community Services (SSCS) Division and requested that this was escalated following the meeting.

41. In terms of the data presented for SSCS Division, Mr Walker referred to the pressure ulcers metric and proposed that a presentation on this be delivered to the next meeting of the Committee in order to improve general understanding of this area. Mr Walker

Agenda Item No: F1

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noted that there remained some discrepancies reflected in the information reported for SSCS Division, but added that this could be due to the transfer of the data.

42.


Recommendations approved by the Committee, namely: • Note the assessment of performance.

Further actions required: • Vacancy and recruitment deep-dive to be performed

and report to the next meeting of the Committee • Divisional representation on the Committee to be

ensured • Pressure Ulcer Presentation to be produced and

delivered at the next meeting.

A Oates S Jennings TBC

Oct-17 Sep-17 Oct-17

On agenda Completed Due Oct-17

B3 SIX MONTHLY STAFFING REVIEW (INPATIENT)

43. Mrs McCourt delivered the Six Monthly Inpatient Staffing Review in order to present the findings of the multi-professional strategic staffing review across the inpatient wards, with an approach reflecting the draft guidance published by the National Programme for Safe Sustainable and Productive Staffing.

44. Mrs McCourt confirmed that the Lead Nurse from each Division had collated and submitted the information being presented, before summarising the key issues of the report as follows:

o Requirement of 5.26 WTE nursing/allied health professionals reported within the Local Division. The division have secured internal funding to meet this variance;

o A reduction of 23 WTE unregistered staff reported in the Secure Division as agreed at the quality review of the cost improvement approval process;

o Requirement of 19.74 WTE nursing staff reported in the Specialist Learning Disability Division. A reduction of 4.20 WTE from the wards is associated with the retraction plan for the Whalley site. The requirement for an additional 23.94 WTE to support individual packages of care (IPC) has been highlighted to commissioners and additional funding streams are being discussed.

45.


Recommendations approved by the Committee, namely: • Note the contents of the paper. • Note the proposed actions identified by divisions

which will be scrutinised by the Operational Management Board and overseen by Executive Committee.

• Identify any further assurances that may be required.


Agenda Item No: F1

Page 26 of 94

C1 REPUTATIONAL / REGULATORY RISK REPORT

46. Mr Walker presented the Reputational / Regulatory Risk Report to the Committee in order provide information to allow the Executive Committee, on behalf of the Board of Directors to undertake detailed scrutiny of those strategically significant risks that could result in a failure to safeguard assets or impact adversely on the Trust’s regulatory or reputational viability and capability to provide services; or which may impact on the ability of the Trust to deliver high quality care in accordance with the requirements of regulators and national standards.

47. Mr Walker highlighted the key issues of the report, stating that there were currently 39 reputational / regulatory risks with an impact score of 3 or above reported from within Local, Secure and SLD Division; however there were none reported for the SSCS Division. Mr Walker added that of these risks, four were scored at 15 or above and went on to give details of these.

48. In response to clarification sought by Mr Walker regarding LOC.118 (If clinic letters and discharge summaries are delayed then there is a risk of inadequate communication leading to clinical care being negatively affected) Dr Sedgwick confirmed that any faxes sent out were generated by EPEX and added that although some clinicians still made paper notes from which they would then dictate, staff dealing with those presenting with an acute mental health problem or in crisis should always make contemporaneous notes directly onto EPEX. Mrs Robinson added that a visit to North West Boroughs had been arranged in order to observe their practice and procedure where clinicians inputted their notes directly into the RiO system at the point of consultation. Dr Sedgwick informed Committee members of the intention to reduce the score of this risk to 12 by December 2017.

49.


Recommendations approved by the Committee, namely: • Confirm that the risks are being identified and

managed appropriately. • Identify any risks that need to be escalated to the

Board as part of the Board Assurance Framework.


C2 EPRR CORE STANDARDS – COMPLIANCE STATEMENT

50. Mr Walker presented the EPRR Core Standards Compliance Statement to the Committee in order to provide information on the organisation’s EPRR Core Standards self-assessment, as well as information on the element of assurance for NHS Strategic Assets; an additional element which will include a site visit by NHS England to High Secure facilities (Ashworth Hospital) to review the systems and processes in place regarding business continuity and EPRR.

51. Mr Walker drew attention to recommendation 2 of the report pertaining to the accountability arrangements and confirmed that following circulation of the report,

Agenda Item No: F1

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advice had been received that this change in accountability could not take place. This recommendation was therefore disregarded.

52.


Recommendations approved by the Committee, namely: • Note the contents of the report; • Sign off the Statement of Compliance


C3 DIVISIONAL UPDATE REPORT

53. Mr Hindle presented the Divisional Update Report to the Committee in order to provide an overview of current issues within the Secure, SLD and Local Services Divisions, including performance, key challenges, patient experience and operational management.

54. Mr Hindle summarised the key issues within each of the Divisions:

Local Division

• The Financial position was at £0.214m underspent at the 30 of August 2017; • A proposal for the introduction of Discharge Co-ordinators and a Nurse Led

Discharge had now been developed; • Walton FT intended to bring the Trauma and Rehab Psychology and

Neuropsychiatry Service, currently sub contracted to Mersey Care, back in house.

Secure Division

a) The Financial position was £41k underspent at the end of month 5; b) Transformation agenda is progressing well with key programmes in place; a) CIP plans for 2017/18 of £2.2m had been achieved in full of which £92k had been

achieved non-recurrently; b) The Kiosks pilot had now concluded and the facility had been well received by

patients and appreciated by staff. A full review of this would be submitted to CSPF in November 2017;

Specialist LD Division

a) The Financial position was a cumulative £0.357m overspend due to additional staffing requirements associated with unplanned care;

55. Mr Johnson informed the Committee of the intention of the Secure Division to bring the responsibility of staff allocation back to the unit managers. In order to discover whether eRostering was an effective approach to staff allocation, Mr Walker requested that Ms Almond provide an update on the implementation of eRostering to the Executive Committee in November 2017.

56. Mr Walker referred to the financial information contained within the Care at a Glance Report, which reported the Specialist Learning Disabilities Division as underspent and

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noted that this was not reflected in the Divisional Update Report. Ms Patel confirmed that this was a reporting error and would be corrected accordingly.

57.


Recommendations approved by the Committee, namely: • Note the contents of the report

Further actions required: • A report relating to the implementation and impact of

eRostering to be presented to the November meeting of the Committee.

• Error in relation to the current financial position of the Specialist Learning Disability Division, as reported in Care at a Glance, to be addressed.

C Almond M Patel

Nov-17 Sep-17

Due Nov-17 Due Sep-17

C4 NICOTINE MANAGEMENT UPDATE

58. Mrs McCourt presented the Nicotine Management Update in order to update the Committee on the work that has been completed to introduce the use of e cigarettes and support the implementation of smoke-free environments in Local Division and Specialist LD Division, the implementation of which has been deferred until 2 October 2017. The report also served to provide information on the changes made to the Nicotine Management Policy and the actions that had been coordinated through the Centre for Perfect Care task and finish group led by Dr Jennifer Kilcoyne.

59. Dr Higgins and Mr Johnson expressed their concerns in relation to the parity between the medium secure services in Whalley and Liverpool, which was noted. Mrs Robinson added that legal advice had been sought in relation to applying the policy to SLS & DISH Services, explaining that this had confirmed the Trust would be unable to enforce the policy within these properties. In this context, Mr Walker requested that the wording of the policy be updated in order to exclude High Secure Services and SLS Housing Services.

60. The Committee confirmed their agreement with the go-live date of 2 October 2017 for the Smoke-Free Trust.

61.


Recommendations approved by the Committee, namely: • Note the contents of the paper • Note the changes recommended for to the Nicotine

Management Policy • Agree the introduction of e cigarettes

Further actions required: • A change of wording to be made to the policy in order

to exclude High Secure Services and SLS / DSH Housing Services.

H McCourt

Sep-17

Due Sep-17

Agenda Item No: F1

Page 29 of 94

D1 ESTATES PORTFOLIO

62. Mr Atkinson presented the Estates Portfolio to the Committee in order to provide an update on plans for the Trust’s buildings, including information of the latest position around capital investment.

63. Mr Walker confirmed that the report was for information only, and any decision regarding use of capital would be submitted to the Performance, Investment and Finance Committee and Board of Directors for consideration and approval.

64. Mrs Robinson and Mr Atkinson referred to Park Lodge, which was considered as not being fit for purpose and added that there had been an approved refurbishment programme in place; however this had been paused whilst investigatory work took place in relation to fully redeveloping the whole site. In response to Mr Walker, Mr Atkinson explained that the estimated cost of making the unit fit for purpose would be in the region of £30 to £40k. Mrs Robinson emphasised that without the remedial work being carried out, the unit should be closed. Mr Atkinson explained that an assessment and action plan had been produced and details of the immediate work required had been brought to the attention of Mr Smith and Ms McGee in order for a decision to be made.

65. Mrs Robinson and Mr Hindle agreed that they would discuss this further outside of the meeting.

66.


Recommendations approved by the Committee, namely: • Note the progress • Make decisions where required

Further actions required: • Further discussions and an urgent solution to be

sought in relation to Park Lodge

D Robinson / M Hindle / S Atkinson

Oct -17

Due Oct-17

E1 BUSINESS DEVELOPMENT PIPELINE & SERVICE REVIEWS UPDATE

67. Mr Walker referred to the governance arrangements surrounding the nine current STP work streams and requested that an update report be produced for the next meeting of the Committee.

68. Mrs Robinson confirmed that the Out of Area Placements (OAPs) meetings had been taking place and details of the new standards that were to be released in relation to Crisis Resolution and Home Treatment would shortly be available.

69.


Recommendations approved by the Committee, namely: • review the report and note and/or approve the

opportunities as detailed in the body of the report (as applicable)

• note requirements from their area of responsibility • share any intelligence that may affect the Trust’s

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decision to engage in a competitive procurement process

• note the timescales associated with each business opportunity and agree to progress/reject

• keep contents confidential Further actions required:

• Paper to be delivered to the next meeting in relation to the governance proposals around the nine STP workstreams.

L Edwards

Oct-17

Due Oct-17

E2 REFERENCE COST SUBMISSION

70. Mr Walker made reference to table one of the report (draft 16/17 reference costs index scores v 2015/16) and noted that reference cost had significant reduced in comparison to those of last year. Ms Patel explained that the methodology for producing reference costs had been revised which provided more sophistication regarding allocation of costs and recording of activity.

71.


Recommendations approved by the Committee, namely: • Note the content of the paper


F1 POLICY UPDATE

72.


Recommendations approved by the Committee, namely: In respect of the Policy Update: • note the update on the status of the trust-wide policy

set, • approve the 7 policy documents listed in paragraph 5

which have been approved by the relevant executive lead and recommended by the Policy Group;


F2 EQUALITY AND HUMAN RIGHTS ANNUAL REPORT 2016/17

73.


Recommendations approved by the Committee, namely: • Approve the Equality and Human Rights sub

committee annual report • To agree the proposal for the Equality Objectives as

required by the Equality Act 2010 (Appendix a page 13)

• To agree to implement greater quality assurance for the Equality and Human Rights Analysis of the CIP’s.

• Agree the formal development of equality and human rights analysis as a fundamental part of the Executive Committee receiving of annual reports to support the

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delivery of the Equality Act 2010 general duty and EDS2 particularly noting: 4.2: Papers that come before the Board and other major Committees identify equality-related impacts including risks, and say how these risks are to be managed.


F3 HEALTH AND SAFETY ANNUAL REPORT 2016/17

74.


Recommendations approved by the Committee, namely: • Note the content of the report • Identify any further assurances it requires with regard

to the quality of the arrangements in place relating to the management of Health and Safety


G1 EQUALITY AND HUMAN RIGHTS SUB-COMMITTEE MINUTES AND

CHAIR’S REPORT

75. The minutes and chair’s report of the Equality and Human Rights Sub-Committee were received and noted.

G2 DIGITAL BOARD MINUTES AND CHAIR’S REPORT

76. The minutes and chair’s report of the Digital Board were received and noted.

G3 PATIENT SAFETY COMMITTEE MINUTES AND CHAIR’S REPORT

77. The minutes and chair’s report of the Patient Safety Committee were received and noted.

H1 ANY OTHER BUSINESS

78. Miss Jennings advised the Committee of a request by Mrs Williams, Audit Committee Chair that the Executive Committee received details of those reviews undertaken by Mersey Internal Audit Agency, which received a limited assurance opinion. Miss Jennings confirmed that discussion had commenced with Mr Walker to determine the most appropriate approach to the reporting of this information to the Executive Committee.

H2 ISSUES FOR CONSIDERATION BY AUDIT AND / OR OTHER

COMMITTEES

79. There were no items raised.

80. The meeting closed

Agenda Item No: F1

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Executive Committee Date of Meeting: Thursday 19 October 2017 Chair: Mr Smith

Summary of key issues from this meeting:

The Executive Committee received assurance in respect of: • An update in relation to Park Lodge, noting that an urgent programme of work was being

agreed for completion and the Performance, Investment and Finance Committee would receive full details.

• An update in relation to the Specialist Learning Disabilities Division (SLD) retraction plan, noting that during Apr-Sep 2017 there had been 14 discharges made against the plan projection of 46. As a result, the estate would not be able to close within the timescales set by commissioners. Work continued to review alternative measures.

• An update informing the Committee of progress made in relation to medical staffing within the Local Services Division, noting that a number of improvement programmes had been created and implemented.

• The key quality issues identified in the reporting period through the surveillance systems and processes, noting that there had been a decrease in the number of concerns raised that met the criteria for the log. There had been 9 possible suicides, 7 self-harm incidents and 5 allegations against staff, which were all being investigated accordingly.

• Trust performance in respect of finance; workforce; quality and external indicators to 30 September 2017. Key areas discussed related to: o a concern raised in relation to staff retention; o significant efforts within clinical divisions to improve training uptake and noted that

issues in respect of non-completion of training were largely attributed to the Corporate Division;

o alternative CIP plans within the Local Services Division would be provided to the Nov-17 Board;

o further discussions would be undertaken outside of the meeting in relation to urgent care referral rejections within the South Sefton Community Services Division;

• In relation to Vacancy and Recruitment Deep Dive, work was on-going to address the current resourcing issues which were hampering recruitment in certain areas of the Trust.

• A Pressure Ulcer Reduction presentation, which provided information in relation to the grading of pressure ulcers, including information on incident reporting criteria and work being undertaken to reduce the occurrence of pressure ulcers within community-based services.

• Governance processes for the transition of the STAR Unit and the Community Learning Disability Teams in Liverpool and Sefton were in place with a programme of work to enable the performance reporting systems to align to the Specialist Learning Disability (SLD) Division. The Committee noted the Wavertree Bungalow would transfer to the SLD Division from Jan-18.

• An update on the development of the Digital Strategy noting a further update would be provided to the next Performance, Investment and Finance Committee.

• A Cheshire and Merseyside Sustainability and Transformation Programme (STP) update, providing details on the leadership, workstreams and governance.

• An update in relation to the management of the North West Boroughs Health Care sub-contract, noting that quarterly meetings were now being held to manage this.

• An update on commercial development activity, including active and prospective tenders.

The Executive Committee discussed and noted: • An update in relation to Agency Expenditure, noting that the agency ceiling now included

a part year effective increase in respect of South Sefton Community Services and there had been a further slight improvement with the Trust sitting at 42.7% above its agency

Agenda Item No: F1

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ceiling. It was noted a number of areas still required improvement and as such recovery plans had been requested.

• The Regulatory Risk Report outlining those strategically significant risks that could result in a failure to safeguard assets or impact adversely on the Trust’s regulatory or reputational viability and capability to provide services; or which may impact on the ability of the trust to deliver high quality care in accordance with the requirements of regulators and national standards. The Committee noted there had been no further risks raised since the Sep-17 report; however it had not been possible to obtain mitigation information requested at the last Committee. Work was in progress to identify risk themes and underpinning root causes.

• A Divisional Update to provide an overview of current issues across all Divisions including performance, key challenges, patient experience and operational management.

• The minutes and chairs reports of its sub-committees;

The Executive Committee approved: • The proposed amendment in the Performance Assurance Framework 2017-18 (as per the

Care at a Glance Report Update). • The process for the refresh of the Operational Plan 2018/19. • Actions taken by the Divisions and complaints department to manage complaints, and

noted the Complaints Report 2015-17

Agenda Item No: F1

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Status of these minutes (check one box): Paper No: EC17/18/1046

Draft for Approval: ☒ Report to: Executive Committee



Executive Committee Date: Thursday, 19 October 2017 Time: 10.00am

Venue: The Boardroom, V7 Building, Kings Business Park, Prescot, L34 1PJ.


Present: Neil Smith Trish Bennett Elaine Darbyshire Louise Edwards David Fearnley Mark Hindle Amanda Oates Ray Walker

Executive Director of Finance / Deputy Chief Executive (Chair) Director of Integration Executive Director of Communications & Corporate Governance Director of Strategy Medical Director Executive Director of Operations Executive Director of Workforce Executive Director of Nursing

In Attendance: Melanie Higgins Jenny Hurst Des Johnson Sarah Jennings Steve Morgan Nicky Ore Asim Patel Donna Robinson Lee Taylor Ashley Crossland

Associate Medical Director – Secure and SLD Divisions Deputy Director of Nursing Chief Operating Officer – Secure Division Deputy Trust Secretary Director of Patient Safety Clinical Lead – South Sefton Community Services Division Chief Information Officer Chief Operating Officer – Local Services Division Chief Operating Officer – Specialist Learning Disabilities Division Corporate Governance Assistant (Minutes Secretary)

Apologies Received: Joe Rafferty Helena McCourt

Chief Executive Deputy Director of Nursing

ISSUES CONSIDERED 2017 A1 APOLOGIES

1. The apologies for absence received for this meeting were recorded, as detailed above.



A3 MINUTES OF THE MEETING HELD ON 21 SEPTEMBER 2017

3. The minutes of the previous meeting, held on 21 September 2017, were accepted as an accurate record with no amendments necessary.

Agenda Item No: F1

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4.


Recommendations approved by the Committee, namely: • Approve the minutes of the previous meeting.


A4 MATTERS ARISING

c. PARK LODGE UPDATE 5. Mrs Robinson provided a verbal update relating to the the Park Lodge site following

discussion at the previous meeting of the Committee.

6. Mrs Robinson confirmed that she had met with Stuart Atkinson and Michele McGee, resulting in a programme of urgent work being agreed for completion. Mrs Robinson affirmed that the Performance, Investment & Finance Committee would be updated with full details of this.

7.


Recommendations approved by the Board, namely: • Note the verbal update provided.


A5 STANDING ITEMS:

d. SLDD RETRACTION PLAN UPDATE

8. Mr Taylor delivered the SLDD Retraction Plan Update to the Committee, in order to provide information of the progress on the retraction of services within the Specialist Learning Disabilities Division.

9. Mr Taylor highlighted the key issues of the report, confirming that during the period of April to September 2018 there had been 14 actual discharges made against the plan projection of 46, which was interpreted as a 69.57% failure rate and as a result the estate would not be able to close within the timescales set by the commissioners. Mrs Darbyshire added that it had become apparent that the closure would not be completed by 2019 and therefore work to explore alternative measures had commenced.

10. Mr Taylor confirmed that a gap analysis paper would be presented to the next meeting of the Committee, and would be reported to the Private Board of Directors’ meeting in November 2017.

11.




Agenda Item No: F1

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e. AGENCY EXPENDITURE UPDATE

12. Mrs Oates presented the Agency Expenditure Update in order to provide the

Committee with the current positions on agency price and wage caps and clarity on new requirements in relation to agency expenditure ceilings, in addition to an update on the progress made by the divisions in regards to reducing agency usage.

13. Mrs Oates explained that the agency ceiling now included a part year effective increase in respect of South Sefton Community Services, adding that there had been some further improvement with the Trust currently sitting at 42.7% above its agency ceiling.

14. Mrs Oates informed the Committee that there were still a number of areas that required improvement and as such recovery plans had been requested accordingly. Mrs Oates emphasised the importance of the timely submission of these plans.

15.


Recommendations approved by the Committee, namely: • The divisions and departments continue to review all

agency usage over 6 months and request approval from the executive team if these are to continue.

• Action is still required by the Local, Corporate and to reduce forecast spend.

• Mersey Internal Audit Agency are currently undertaking a review of the systems and processes for agency staff and engagement of personal service companies. Recommendations from the review will be included in a future report.

• That divisional leads complete the work requested for a recovery plan and revised forecast outturn within the required timeframe to support the trusts ability to meet the NHS Improvement agency ceiling.

Further actions required: • Recovery plans to be submitted, as per Mrs Oates

individual requests.

All relevant members

End of Oct-17

Due Oct-17

f. RIO IMPLEMENTATION PLAN UPDATE

16. Dr Patel delivered the RiO Implementation Plan Update in order to provide the

Committee with the progress on the deployment of the RiO solution to the Local Services Division.

17. Dr Patel confirmed that, with less than seven days until the intended system go-live date, the EPEX activity data cleansing and demographic data migration had been completed on target, as had the super user training within Cohort 1, with 81% of other staff contained within the Cohort having received or booked onto their system training.

Agenda Item No: F1

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18. Dr Patel advised that there were still some remaining risks; however discussions were underway to mitigate against these accordingly, confirming that the definitive decision to go live would take these into consideration and be made at the next meeting of the Joint RiO Oversight Group.

19. Dr Patel confirmed that a joint lessons learnt session had been planned in preparation for Cohort 2 which consisted of a further 1,500 staff.

20.


Recommendations approved by the Committee, namely: • Note the contents of the report. • Continue to support the prioritisation of RiO within

both the Local and Corporate Divisions’ workplans, specifically the Business Intelligence team and the existing EPEX system support team

• Support the joint programme with appropriate clinical and managerial support within the relevant governance structures.


g. MEDICAL STAFFING IN LOCAL DIVISION

21. Dr Fearnley presented an update on Medical Staffing in the Local Division to the

Committee in order to demonstrate the benefits of creating a single medical staffing budget, highlight the mitigations in place to manage the risk of an undersupply of doctors of all grades and seek assurance for plans to remunerate medical staff in the optimal way to increase recruitment and retention.

22. Dr Fearnley explained that the establishment of the single medical budget had enabled a thorough review of the existing medical workforce throughout the Trust, with a number of areas identified where potential efficiencies could be made. Dr Fearnley added that as a result of this a number of improvement programmes had been developed and implemented, with a combined estimated efficiency to be generated of circa £1.6million.

23. Mrs Edwards requested that a trajectory of estimated delivery and completion was included within future reports to the committee.

24. In response to Mr Walker, Dr Fearnley advised that the Trust did not currently utilise a medical staffing bank, adding that this was something that needed to be addressed. Dr Fearnley confirmed that the Trust had however, been involved in plans to create a regional medical staffing bank for the Cheshire and Merseyside footprint and this remained an on-going piece of work.

25.


Recommendations approved by the Committee, namely: • note action taken already and progress made • seek further assurance

Agenda Item No: F1

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Further actions required: • A trajectory of estimated delivery / completion to be

included within future updates to the Committee.

D Fearnley

Nov-17 and on-going

Nov-17 onwards


26. Mr Morgan delivered the Governance of Quality Report to the Committee in order to provide a monthly update on the on-going issues that are raised via the weekly concerns log and weekly concerns process.

27. Mr Morgan summarised that overall, throughout August and September 2017, there had been a decrease in the number of concerns raised that would meet the criteria for the log, adding that there had been 9 possible suicides, 7 self-harm incidents and 5 allegations against staff which were all being investigated accordingly.

28.


Recommendations approved by the Committee, namely: • Discuss the content of the report • Identify any further assurances that may be required



29. Mr Walker presented the Care at a Glance Report in order to provide the Committee with a summary of Trust performance to 30 September 2017 and outlined the key issues.

30. Mr Walker drew attention to staff retention, confirming his intention to raise this as a concern.

31. In relation to Mr Walker’s comments in respect of statutory and mandatory training compliance, Mrs Oates explained that there had been some national system issues, which had exacerbated the lack of movement in certain areas. Mrs Oates acknowledged the significant efforts within the clinical divisions in improving training uptake and advised that issues in respect of non-completion of training were largely attributed to the Corporate Division. It was suggested that Mrs Oates provide details of those areas proving to be particularly problematic to the next meeting of the Committee in order for appropriate management direction and support to be provided in order to achieve compliance.

32. Mr Hindle informed Committee members that a paper relating to alternative CIP plans within the Local Services Division was to be presented to the next meeting of the Private Board.

33. Following clarification sought by Mr Walker in relation to urgent care referral rejections within the South Sefton Community Services Division, it was agreed that this would be discussed with Mrs T Bennett outside of the meeting.

Agenda Item No: F1

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34.


Recommendations approved by the Committee, namely: • The assessment of performance; • To approve the amendment in the Performance

Assurance Framework 2017-18;

Further actions required: • Staff retention to be raised as a concern. • Non-compliant areas of mandatory / statutory training

to be detailed in order for management direction & support to be provided

• Discussion to be held in relation to urgent care referral rejections within SSCS Division

A Oates A Oates R Walker / T Bennett

Nov-17 Oct-17 Oct-17

Due Nov-17 Due Oct-17 Due Oct-17

B3 VACANCY AND RECRUITMENT DEEP DIVE

35. Mrs Oates advised that following discussions at the last meeting of the Strategic Workforce Committee, work would be completed to address the current resourcing issues, which were hampering recruitment in certain areas of the Trust. Mrs Oates explained that the forthcoming implementation of the TRACK system would highlight barriers within the current processes, which would then allow these to be investigated and addressed. Mrs Oates added that a trajectory for expected improvement would then also be produced.

36. Mrs Robinson noted that there were currently a number of new services with whole-time equivalent posts attached to them and this could skew the vacancy figures being reported at the present time.

37.


Recommendations approved by the Committee, namely: • Note the verbal update provided.


B4 PRESSURE ULCER REDUCTION

38. Mrs Hurst and Mrs Ore delivered a presentation to the Committee in order to provide information in relation to the grading of pressure ulcers, including information on incident reporting criteria and work currently being undertaken to reduce the occurrence of pressure ulcers within community-based services.

39. Mrs Hurst confirmed that in order to lessen the instances of pressure ulcers within the community, patients and carers were being provided with preventative information, as well as pictures to help identify the early onset of ulcerations. Mrs Hurst added that work was underway with the Information Governance Department, which would hopefully allow for pictures of service user ulcerations to be used as part of training and diagnosis.

Agenda Item No: F1

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40. Mrs Hurst advised that 16 November 2017 was World Pressure Ulcer Reduction Day, explaining that liaison with the Communications Department was taking place in order to plan a Trust-wide awareness event.

41.


Recommendations approved by the Committee, namely: • Note the content of the presentation.


C1 REPUTATIONAL / REGULATORY RISK REPORT

42. Mr Morgan presented the Reputational / Regulatory Risk Report to the Committee in order provide information to allow the Executive Committee, on behalf of the Board of Directors to undertake detailed scrutiny of those strategically significant risks that could result in a failure to safeguard assets or impact adversely on the Trust’s regulatory or reputational viability and capability to provide services; or which may impact on the ability of the Trust to deliver high quality care in accordance with the requirements of regulators and national standards.

43. Mr Morgan explained that there had been no further risks raised since the production of the September 2017 report; however he had been unable to obtain mitigation information requested at the last meeting of the Committee. Mr Morgan detailed the current piece of work that was in progress in order to identify risk themes and under-pinning root causes.

44. Mrs T Bennett confirmed that a meeting was to take place at Aintree Hospital within

the next week in relation to 24/7 medical cover on Ward 35. Mrs T Bennett explained that there was currently no 24/7 medical cover for the ward; however Aintree had been providing support. In response to Mr Smith, Mrs T Bennett stated that this would be best sub-contracted to an acute care provider, rather than covered as an on-call by a Mersey Care medic. Mrs T Bennett agreed to provide a further update on this to the next meeting of the Committee.

45.





Further actions required: • Update in relation to 24/7 medical cover of Ward 35

to be provided for the next meeting of the Committee.

T Bennett

Nov-17

On Nov-17 agenda

C2 DIVISIONAL UPDATE REPORT

46. Mr Hindle delivered the Divisional Update Report in order to provide the Committee with an overview of current issues in the Secure, Specialist LD and Local Divisions

Agenda Item No: F1

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including performance, key challenges, patient experience and operational management.

47. Mr Hindle summarised the key issues within each of the Divisions, as the following:

Local

• As at 30th September 2017 the Local Division was £0.799m underspent; • Review of the Transformation plan and re-structure of programme was underway; • Collaborative work with commissioners regarding the decommissioning of the SLS

service was underway for completion by the end of March 2018. Secure

• At the 30th September 2017 the Secure Division was £0.064m underspent; • There had been iimprovement in delayed discharges in the Low Secure Unit; • Development was underway of a medium and long term estates strategy; • There had been a further reduction in the use of long term segregation;

Specialist LD

• As at 30th September 2017 Specialist LD division was £0.351m overspent. Additional staffing requirements associated with unplanned care were creating the overspend and the Division was forecast to break even by the end of the financial year 2017/18.

• The Specialist LD Division had amalgamated the STAR Unit and the Community LD Teams into the structure from 1st October 2017;

• Recruitment was underway for the new Specialist Support Teams.

48. Mr Hindle acknowledged the positive work and progress made across the Divisions, stating that staff were working hard during what had been some challenging times due to the number of changes within practice and structure.

49. Mr Hindle referred to the Local Services Division and highlighted that although there were still a number of financial difficulties that needed to be addressed; exceptional work had taken place to ensure that the Division was now in a greater position of control.

50. Mrs Robinson noted that there was an error on page one of the report, confirming that Local Services should be reported as being underspent.

51.


Recommendations approved by the Committee, namely: • Note the report.

Further actions required: • Correction to page one of the report to reflect an

under-spend in the Local Services Division.

M Hindle

Oct-17

Due Oct-17

C3 DIVISIONAL CHANGE PROCESS

52. Mr Taylor provided assurance to the Committee that the governance processes for the transition of the STAR Unit and the Community Learning Disability Teams in Liverpool

Agenda Item No: F1

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and Sefton were in place and there was a programme of work to enable the performance reporting systems to align to the Specialist Learning Disability Division.

53. Mrs Robinson advised that Wavertree Bungalow would only transfer to the SLD Division from January 2018 and requested that this was noted.

54.


Recommendations approved by the Committee, namely: • Note the content of this report. • Note the concern in relation to a potential delay in the

work that needs to be completed by the Business Intelligence Team to align the performance reports


D1 BUSINESS PLANNING 2018/19

55. Mrs Edwards delivered an update on development of the Operational Plan 2018/19 to the Committee in order to set out the proposed approach to the refresh of the Trusts two-year operational plan for 2018/19.

56. Mrs Edwards confirmed that there were no intentions to change the priorities already identified within the current plan; however changes in the environment in which the Trust operated needed to be taken into account, as well as the progress already made in order to best focus resources and effort.

57. Mrs Edwards noted that further updates to the Committee would be provided prior to the final draft of the Operational Plan 2018/19, which would be presented to the Board of Directors’ in March 2018.

58.


Recommendations approved by the Committee, namely: • Approve the refresh of the Operational Plan as

described in this paper; • Anticipate further briefings and a draft of the

Operational Plan prior to approval by the Board of Directors in March 2018;


D2 DIGITAL STRATEGY

59. Dr Patel provided and update on the development of the Digital Strategy and advised that a further update would be provided and discussed at the next meeting of the Performance, Investment and Finance Committee.

60. Dr Patel concurred with comments on changes within the digital landscape, adding that these needed to be addressed via consolidation and harmonisation of the systems currently in place. Dr Patel noted that the Digital Board was being strengthened and requested that any digital investment requests should be subject to discussion at the

Agenda Item No: F1

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Digital Board to ensure that appropriate debate and challenges could be applied prior to progression.

61.




D3 STP WORKSTREAMS & GOVERNANCE UPDATE

62. Mrs Edwards delivered the STP Workstreams and Governance Update to the Committee in order to provide an update on the leadership, workstreams and governance of Cheshire and Merseyside Sustainability and Transformation Programme (STP).

63. Mrs Edwards explained that there had been changes within the leadership of the STP, with a review of the priorities and governance being undertaken by the new Executive Chair.

64. Mrs Robinson detailed recent requests and changes that had been made, specifically in relation to the classification of Out of Area Treatments (OATs), which were significant but disjointed.

65.


Recommendations approved by the Committee, namely: • note the update provided in this report; • Consider the intelligence and/or assurance it requires

from the STP workstreams in the future;


D4 MANAGEMENT OF NW BOROUGHS SUB-CONTRACT

66. Mr Walker updated the Committee in relation to the management of the North West Boroughs Health Care sub-contract, explaining that quarterly meetings were now being held to manage this.

67.




Agenda Item No: F1

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E1 COMPLAINTS REPORT 2015 - 2017

68.


Recommendations approved by the Committee, namely: • Note the contents of the report • Clarify that the actions taken by the Divisions and

complaints department to manage complaints are acceptable.

• Request further assurances as required.


E1 BUSINESS DEVELOPMENT PIPELINE AND SERVICE REVIEWS

69.


Recommendations approved by the Committee, namely: • review the report and note and/or approve the

opportunities as detailed in the body of the report (as applicable)

• share any intelligence that may affect the Trust’s decision to engage in a competitive procurement process

• note requirements from their area of responsibility • note the timescales associated with each business

opportunity and agree to progress/reject • keep contents confidential.


G1 HEALTH RECORDS SUB-COMMITTEE MINUTES AND CHAIR’S REPORT

70. The minutes and chair’s report of the Health Record Sub-Committee were received and noted.

G2 HEALTH AND SAFETY COMMITTEE MINUTES & CHAIR’S REPORT

71. The minutes and chair’s report of the Health and Safety Committee were received and noted.

G3 JOINT SIRO AND INFORMATION GOVERNANCE COMMITTEE MINUTES AND CHAIR’S REPORT

72. The minutes and chair’s report of the Joint SIRO and Information Governance Committee were received and noted.

G4 OPERATIONAL MANAGEMENT BOARD MINUTES AND CHAIR’S REPORT

73. The minutes and chair’s report of the Operational Management Board were received and noted.

Agenda Item No: F1

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G5 PATIENT SAFETY COMMITTEE MINUTES AND CHAIR’S REPORT

74. The minutes and chair’s report of the Patient Safety Committee were received and noted.

H1 ANY OTHER BUSINESS

a. STAFF SURVEY 75. Mrs Oates informed the Committee that the Staff Survey had been circulated for

completion.

b. INFLUENZA VACCINATIONS 76. Mr Walker confirmed that good progress was being made in relation to staff uptake of

the influenza vaccinations. Mr Walker explained that organisations were now being requested to ask staff who did not wish to receive the vaccine to formally decline this, however it was unclear as to whether these formal declines would be accounted for within the trusts compliance level.

H2 ISSUES FOR CONSIDERATION BY AUDIT AND / OR OTHER COMMITTEES



Agenda Item No: F1

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Quality Assurance Committee

Date of Meeting: Wednesday 13 September 2017 Chair: Dr R Beardall

Summary of key issues from this meeting: The Quality Assurance Committee received assurance in respect of: • An update in relation to the Quality Framework Review process, noting the process now

incorporated organisational development and Perfect Care; • Nursing staff’s CPD (Continued Professional Development) and the associated costs,

noting that although individuals were responsible for their own revalidation, the Trust aimed to support this process;

• A summary of the key issues that had been the focus of the surveillance process, the Quality Review Visits, the CQC 5 Domains Self-Assessment Process, Complaints, claims and incidents through the Quality Report; key highlights included but were not limited to: o Concerns/ complaints that had been raised which could be resolved locally were now

being addressed by the Patient Advice and Liaison Service (PALS), where they would be logged via the PALS information module on Datix;

o Increasing numbers of wards were reporting above the 85% threshold for bed occupancy;

o 3 of the 4 Clinical Divisions were currently under the target of 7.5% for delayed discharges with the current Trust position of 5.21%, (including SSCS);

o Falls on Ward 35 (SSCS Division) were above the national average (8.43 per occupied bed day) at 11.3; a falls reduction plan was in place and being monitored.

• The Quality Improvement and Clinical Audit programme noting the following key issues: o All quality improvement posts had now been filled; o All clinical audits were completed in line with programme, where there had been

slippage, there were plans for completion around revised timelines; o The opinion from MIAA following their review was provision of significant assurance; o There are plans in place to improve reporting to the Committee with greater

emphasis on outcomes; • An update on CQUIN delivery, specifically that the Trust had been advised that the

Accreditation Programme for Psychological Therapies Services (APPTS) had not accredited the Trust’s IAPT service. This decision was being appealed in line with procedures.

• Sub-Committee minutes and chairs reports.

The Quality Assurance Committee discussed and noted: • The findings of the multi professional strategic staffing review across inpatient wards; • An overview of the 2017 PLACE (Patient-Led Assessment of the Care Environment)

findings including comparison with the 2015 and 2016 assessments and were advised that the Trust had performed within the national average range within all categories and achieved an improved internal position across all categories;

• An update report on the current year’s Quality Account, noting that monitoring arrangements were in place and each priority area had an identified lead. Progress on the 5 priority areas was summarised as follows: o Priority 1: No Force First – on track to deliver within timescale; o Priority 2: Towards Zero Suicide – on track to deliver within timescale; o Priority 3: Improvements in Physical Health Pathways – on track to deliver

within timescale; o Priority 4: A Just and Learning Culture – one objective (72 hour review

Agenda Item No: F1

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reporting) was behind schedule. The Lead was confident that this would deliver by quarter three;

o Priority 5: Reduction of Community Acquired Pressure Ulcers. This additional priority was included following the transaction of

South Sefton Community division and had one objective behind schedule (grade two pressure ulcer reduction) and the Lead was closely monitoring progress;

• An update in relation to progress on delivery of the 2017/18 Staff Engagement Plan, noting that due to the identified ‘disconnect’ resulting from the delay in staff survey results being provided, an interim solution had been introduced where staff were requested to anonymously indicate their mood, the results of which were collated and analysed bi-weekly. Development of a technical solution was being sought.

• Progress made in achieving compliance with the Triangle of Care standards for carer engagement and support.

• An update regarding the Trust’s agreed response and action plan submitted to the CQC (Care Quality Commission) on 3 August 2017. The Committee were advised that the initial submission was accepted and received positively overall, although the CQC had requested additional details be added to the action plan. This had been addressed and resubmitted with final approval by the CQC anticipated on 21 September 2017.

• A verbal update on activity following the Quality of Consultation paper provided to the July 2017 Committee by the Service User/Carer representative.

• The Quality Risk Report which provided information that allowed the Committee, on behalf of the Board of Directors, to undertake detailed scrutiny of those strategically significant risks that could compromise patient safety or the delivery of outcomes and quality of care. Key highlights reported were:

That the report contained 38 quality risks of which 29 had an impact score of 3 or more.

o 9 other risks had an overall score of 15+ and/or were included on the Board Assurance Framework.

o There were 2 clinical risks with a score of 15+, one of which had reached the highest score for some time of 20. Scrutiny had been undertaken and mitigation plans developed.

o Another risk had been identified which was not yet reflected in the report, specifically the inability to implement the Smoke Free policy in Supported Living Services (SLS) Housing. Work was on-going to address issues identified.

The Quality Assurance Committee approved: • Changes to the 2017/18 Q1 CIP (Cost Improvement Plans); • The Serious Untoward Incidents Annual Report 2016/17;

Agenda Item No: F1

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Status of these minutes (check one box): Paper No: QAC17/18/

Draft for Approval: ☒ Report to: Quality Assurance Committee



Quality Assurance Committee Date: Wednesday 13 September 2017 Time: 1.30pm

Venue: Room 3, V7 Building, Kings Business Park, Prescot, Merseyside, L34 1PJ


Present: Robert Beardall Cath Green Gaynor Hales David Fearnley Amanda Oates Ray Walker

Non Executive Director (Chair) Non Executive Director Non Executive Director Medical Director Executive Director of Workforce Executive Director of Nursing

In Attendance: Gerry O’Keeffe Steve Morgan Sandra O’Hear Helena McCourt Don Bryant Zoe Prince Jenny Hurst Andrew Sedgwick Michael Crilly Bridget Clancy Sudip Sikdar Michele McGee Mel Higgins Sarah Jennings Paula Murphy

Non Executive Director Director of Patient Safety Deputy Director of Nursing Deputy Director of Nursing Service User/Carer Lead for Nursing and Quality Deputy Director of Nursing Associate Medical Director Director of Social Inclusion & Participation Head of Nursing and Patient Experience Consultant Head of Estates and Facilities Associate Medical Director Deputy Trust Secretary Corporate Governance Compliance Manager (Minute Secretary)

Apologies Received: John Whelan Mandi Gregory

Service User/Carer Staff Side Representative

ISSUES CONSIDERED 2017 A1 APOLOGIES FOR ABSENCE

1. The apologies for absence received were noted as above.


2. There were no declarations of interest raised.

Agenda Item No: F1

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A3 MINUTES OF THE LAST MEETING HELD ON 12 JULY 2017

3. The minutes of the last meeting, held on 12 July 2017, were accepted as an accurate record.

4.


Recommendations approved by the Committee, namely: • Approve the minutes of the meeting held on 12 July

2017.

Further actions required: • None Identified.

A4 MATTERS ARISING

a. Quality Framework Review (QUILS)

5. Mr Walker advised the Committee that a review of the Quality Framework was undertaken annually and following a suggestion made at the previous Committee (Jul-17), the title of the process had been amended from Quality Information Learning and Support System (QUILS) to Quality Framework Review and the process now incorporated organisational development and Perfect Care. A review of data was undertaken on a weekly basis and an update report would be provided to the Executive Committee in October and the Quality Assurance Committee in November.

6. Mr Walker agreed to circulate the updated Quality Review Process diagram to the Committee for information.

b. Nursing Revalidation Costs

8. Mr Walker referred to discussion in the previous meeting regarding nursing staff’s continued professional development (CPD) and the associated costs and confirmed that work was in progress across Cheshire and Merseyside to support staff in CPD and although individuals were responsible for ensuring their own revalidation, the organisation aimed to support this process.

7.



Further actions required: • Circulate the updated diagram to QAC for

information.

R Walker

Sep-17

Completed

9.




Agenda Item No: F1

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10. Mr Morgan provided an update of quality information to enable the Committee to discharge its responsibilities relating to the measurement of quality. Mr Morgan stated that figures relating to the South Sefton Community Services (SSCS) Division had now been included in the report.

11. Mr Morgan highlighted key issues as follows:

a) as part of joint initiative across trusts, concerns/ complaints that had been raised which could be resolved locally were now being addressed by the Patient Advice and Liaison Service (PaLS), where they would be logged via the PaLS information module on Datix;

b) Increasing numbers of wards were reporting above the 85% threshold for bed occupancy;

c) Staff vacancy rates were reported as an issue for local but less so within the Secure and SLD Divisions;

d) 8 Quality Review Visits (QRV) were cancelled during the reporting period, 6 of which were due to lack availability of managers in the Local Division and 2 due to QRV Lead sickness;

e) 3 of the 4 Clinical Divisions were currently under the target of 7.5% for delayed discharges with the current Trust position of 5.21%, (including SSCS);

f) In Jul-17 for all levels of incidents, District Nursing was the highest reporting service within SSCS and the highest reported category related to pressure ulcers, which was now being monitored via an improvement plan;

g) Falls on Ward 35 (SSCS Division) were above the national average (8.43 per occupied bed day) at 11.3; a falls reduction plan was in place and being monitored.

12. In response to clarification sought by Mrs Hales regarding Quality Review Visits

(QRVs), Mr Walker confirmed that the growth of the organisation had created challenges in relation to facilitating QRVs and the ability to continue these visits had been compromised. Work was on-going to develop an improved escalation process and a report would be provided to the Executive Committee in due course outlining a risk based approach to the QRV process.

13. Ms Green referred to page 20, paragraphs 80 and 81 of the report, querying the impact of divisions reporting under target for delayed discharges and the high levels of incidents of pressure ulcers within the District Nursing element of the SSCS Division and raised concerns that the report did not provided sufficient assurance that measures were being taken to address these issues. Mr Walker concurred and noted that there was a need to cross reference the data, actions and mitigations across reports to provide the assurance Committee members required.

14. Ms Green referred to page 29, (patient experience within Local Division inpatient

services by theme) and queried the category ‘other’. Mr Morgan confirmed that this was a bespoke category and could be utilised differently in different wards, but a breakdown could be provided to Ms Green outside of the meeting.

15. Ms Green referred to page 30 (cleanliness) and queried the deterioration to a score of

53% for Boothroyd Ward. Mrs Prince confirmed that the score reflected a specific time (snapshot) and a poor score could often relate to very individual and isolated issues on a particular ward. Mrs Prince assured the Committee that each ward had its own cleanliness plan which was audited on a monthly basis.

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16. In response to a question from Ms Green, Mr Morgan advised that the Friends and Family Test (FFT) questionnaire was a national template and could not be changed. Mrs Clancy confirmed that the Trust’s FFT scores were consistent with the other secure services.

17. Mr Bryant referred to the overall patient experience scores noting the significant

improvement over the last 12 months, adding that the Trust should be commended on this achievement.

18. In response to Mr O’Keeffe regarding the chart at on the top of page 19 (physical

health screening for new admissions), Mr Morgan agreed to ensure charts were more visible in future reports. It was agreed that a detailed report would be provided to the Quality Assurance Committee in relation to physical health for new admissions.

19.


Recommendations approved by the Committee, namely: • Discuss the report • Identify any new risks • Identify any further assurances it requires

Further actions required: • A report in relation to a risk based approach to the

QRV process to the Executive Committee • In relation to P29 (Local Division Community Services

by theme by Month), ‘other’ section to be broken down and provided to Ms Green.

• Detailed report to QAC in relation to physical health for new admissions

S Morgan S Morgan J Hurst

Oct-17 Oct-17 Nov-17

On Oct-17 EC Agenda Due Oct-17 On Nov-17 QAC Agenda

B2 SIX MONTHLY INPATIENT STAFFING REVIEW

20. Mrs McCourt presented the findings of the multi professional strategic staffing review across the inpatient wards. The approach taken reflected the draft guidance published by the National Programme for Safe Sustainable and Productive Staffing and this guidance was due for publication in October 2017.

21. Mrs McCourt highlighted the key issues as follows:

o The Local Division reported a requirement of 5.26 WTE nursing/allied health

professionals. Significant investment has been in place since the previous review. The division reported that they had secured internal funding to meet this variance. There was no current variance for other professions reported.

o The Secure Division reported a reduction of 23 WTE unregistered staff. This reduction had been agreed at the quality review of the cost improvement approval process. There was no current variance for other professions noted.

o The Specialist Learning Disability Division reported a total requirement of 19.74 WTE nursing staff. A reduction of 4.20 WTE from the wards was associated with the retraction plan for the Whalley site. The requirement for an additional 23.94 WTE to support individual packages of care (IPC) had been highlighted to commissioners and additional funding streams were being discussed. There was no current variance for other professions noted.

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79. Mrs McCourt advised that the Community Staffing Review would be completed to incorporate South Sefton Community Services Division and will report to the January 2018.

22. Mrs Hales welcomed the report, querying what actions were being taken to bridge the gaps whilst the recruitment process was undertaken. Mrs McCourt confirmed that bank and agency staff were in place to address any gaps during this time. Mrs Clancy confirmed that 28 vacancies had been recruited to within secure services in terms of nursing, but these staff had not yet commenced in post.

23. In response to Ms Green, Mr Walker confirmed that the bank/agency staff required

varied by division and there was a focus on ensuring permanent staff were in place to reduce dependency on agency colleagues. Mrs Clancy confirmed that cancellations of activity due to staffing and associated risks were monitored daily.

24.


Recommendations approved by the Committee, namely: • Note the contents of the paper. • Note the proposed actions identified by divisions

which will be scrutinised by the Operational Management Board and overseen by Executive Committee.

• Identify any further assurances that may be required.


B3 PATIENT-LED ASSESSMENT OF THE CARE ENVIRONMENT (PLACE) FINDINGS & ACTION PLAN

25. Mrs McGee provided an overview of the Trust’s 2017 PLACE assessments including how performance compared with the 2015 and 2016 assessments and outlined how the Trust had performed nationally against other mental health and learning disability trusts.

26. Mrs McGee highlighted the key issues as follows:

a) The Trust had performed within the national average range across mental health and learning disability trusts within all categories and achieved an improved internal position across all PLACE categories compared to last years scores;

b) Dementia scores had improved both internally and nationally, however the national score was within the lower quartile;

c) Internal scores had improved within all categories, with a slight deterioration in cleanliness (less than 1%);

27. Mrs McGee advised that particularly with regard to dementia scores, issues relating to scoring of PLACE had been due to the applicability of some questions and incorrect answers. Further training and development around PLACE forms would be provided going forward.

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28. Mrs McGee confirmed that the action plan for 2018/19 was already underway and previous issues relating to cleanliness and food had been addressed, however there were on-going physical environment issues.

29. Mr O’Keeffe welcomed the report citing the good progress across the board, however

noted his disappointment to be in the lower quartile with regard to dementia. Mrs McGee explained that retrospective fittings at clock view in relation to the older peoples’ ward had been necessary. Mr Walker concurred, stating the issue had been raised approximately 2 years ago, adding that when Clock View was designed, Irwell ward was not originally to be used as a dementia ward and therefore work had to be carried out to address this in light of the change. Following works undertaken, it was not expected that those scores were still relevant to Clock View. Mr Walker confirmed that information could be provided in relation to improvements completed at Clock View.

30. In response to Mr Bryant, Mrs McGee confirmed that Scott Clinic was not fit for

purpose, but much work had been carried out to improve the facilities.

31. Mr Walker stated that progress had been made in every area since the last review, adding that this still put the Trust within the ‘average’ range and asked what needed to be undertaken to further improve this position. Mrs McGee confirmed that the Estates Strategy would address further issues, reiterating that the PLACE assessments provided only a 'snap shot' position.

32. In response to Mrs Hurst, Mrs McGee confirmed that previously, the infection control

team had been involved in PLACE inspections but this had not been the case this year; however this would be reviewed prior to the next assessment. Mrs McGee also confirmed that any new builds would automatically include the design features required and architects had been informed that all buildings must be dementia friendly.

33. Further to Mr Walker’s query in relation to Ward 35, Mrs Hurst confirmed that this was

assessed as part of University Hospital Aintree’s PLACE assessment and agreed to seek a copy of the report.

34. Dr Beardall proposed that narrative could be replaced with diagrams in the report and

requested that the national average be included in graphs to enable the Committee to identify the current position nationally.

35.


Recommendations approved by the Committee, namely: • Note the content of the report; • Note that action plans are in place to address the

areas requiring improvement.

Further actions required: • Obtain copy of the inspection report in relation to

Ward 35; • Circulate information in relation to retrospective works

completed at Clock View/ Irwell Ward;

J Hurst R Walker

Oct-17 Oct-17

Due Oct-17 Due Oct-17

Agenda Item No: F1

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B4 QUALITY ACCOUNT DELIVERY: QUARTER 1 2017/18

36. Mrs McCourt provided a progress report on the priority improvement areas from the current years Quality Account and reminded the Committee of the 4 priority areas plus a new priority (5) as below:

• Priority 1: No Force First – on track to deliver within timescale; • Priority 2: Towards Zero Suicide – on track to deliver within timescale; • Priority 3: Improvements in Physical Health Pathways – on track to deliver

within timescale; • Priority 4: A Just and Learning Culture – one objective (72 hour review

reporting) was behind schedule. The Lead was confident that this would deliver by quarter three; • Priority 5: Reduction of Community Acquired Pressure Ulcers. This additional priority was included following the transaction of South Sefton Community division and had one objective behind schedule (grade two pressure ulcer reduction) and the Lead was closely monitoring progress.

37. Mrs McCourt confirmed that monitoring arrangements were in place and each priority area had a lead identified.

38. In response to Mrs Hales query regarding avoidable pressure ulcers, Mrs Hurst confirmed that the 10% reduction target had been agreed with Liverpool Community Health prior to Mersey Care acquiring the service and no further negotiation had been undertaken at this stage. Mrs Hurst confirmed that a 'deep dive' in relation to pressure ulcer reduction would be undertaken. Mr Walker agreed to review this further and return with a proposal for performance improvement to the November 2017 Committee. Mr Walker stated that the next quarter’s Quality Account would include the Trust’s own more ambitious target.

39. In response to Mr O’Keeffe, Mrs McCourt confirmed that the quality account

dashboard (currently in development) would provide the details requested in relation to how actions had influenced the priority areas.

40. Mr Bryant highlighted the link between suicide and deprivation and the importance of providing people with meaningful employment, adding that there was no mention of contact with other agencies/departments within the report. Mr Bryant stated that evidence was required within the report of contact made with the employment service or social care. Mr Walker agreed that that this was an important area of focus and suggested that this be reflected in the annual report to the Committee on the Suicide Prevention Strategy.

Agenda Item No: F1

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41.


Recommendations approved by the Committee, namely: • Discuss the report. • Note the areas of progress. • Identify areas where further assurance is required

Further actions required: • Proposal for performance improvement in relation to

avoidable pressure ulcer reduction to be presented to QAC;

• Details of joint working with other agencies/departments in relation to suicide prevention and meaningful employment to be reflected in the Annual Report to the Committee on the Suicide Prevention Strategy.

R Walker R Walker (J Kilcoyne)

Nov-17 TBC

On Nov-17 QAC Agenda TBC

B5 STAFF SURVEY ACTION PLAN DELIVERY

42. Mrs Oates updated the Committee on the progress of delivery of the 2017/18 Staff Engagement Plan and provided insight into future plans to meet the challenge of employee engagement utilising a new staff engagement approach.

43. Mrs Oates stated that results in relation to the annual staff survey, results were provided to the Trust several months after the survey had concluded and therefore there was a disconnect evident. Mrs Oates advised the Committee of an interim solution introduced, which was the ‘How was your day’ initiative, where staff were requested to anonymously indicate their mood, the results of which were collated and analysed on a bi-weekly basis. Meanwhile, development of a technical solution was being sought.

44. Mr O’Keeffe queried when assurance would be provided of a long term solution. Mrs Oates confirmed that the technology has been purchased and work was on-going, adding that questions would be aimed towards staff engagement and advocacy.

45.


Recommendations approved by the Committee, namely: • Note progress against the 2016 Staff Survey Action

Plan • Note progress against the 2017 – 18 Staff

Engagement Plan • Endorse the new approach to planning and

monitoring engagement activity and use of pulse checks and analytics.


B6 TRIANGLE OF CARE UPDATE

46. Mr Crilly provided an update on progress made in achieving compliance with the Triangle of Care standards for carer engagement and support, noting that the Trust-wide percentage of applicable Triangle of Care criteria assessed as ‘Green’ for quarter 1, 2017-18 was 78.23%, which was an improvement compared to the quarter 4, 2016-

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17 position of 77.35%. In addition, the percentage of wards/teams who reviewed Triangle of Care for quarter 1, 2017-18 was 87.69%, which was an improvement compared to quarter 4, 2016-17 position of 80%.

47. Mr Crilly confirmed that the South Sefton Community Services (SSCS) Division were yet to begin implementation of the Triangle of Care, adding that although this was a mental health tool, other services operated by the Trust were expected to adopt this process.

48. There had been a fluctuation in consistency of reporting in relation to the Local Division, but work was on-going to address this and meetings to ascertain the accuracy of data continued.

49. With regard to an on-going issue relating to consistency of training, Mrs Oates advised that a new learning management platform could be considered, which would enable a carer to be filmed delivering the training in an interactive way. Mr Crilly welcomed this proposal and confirmed that this would assist in improving the uptake and effectiveness of training.

50. Mr O’Keeffe referred to Triangle of Care Performance (point 6 of the report, page 3) and queried if 78.23% assessed as ‘green’ should be considered as good. Mr Crilly concurred stating that this included new data from the Specialist Learning Disability (SLD) Division, adding that given the progress this division had made, a considerable improvement was anticipated to be evident in the next quarterly update.

51. In response to Mr O’Keeffe, Mr Crilly confirmed that as this was a self assessment tool, audit of the quality and accuracy of this was complicated. The second wave of RIO implementation would include drop down boxes which would enable audit more routinely and going forward, further work would be undertaken with the performance team in order to provide assurance to the Committee.

52. Mr Bryant noted the importance of ensuring the ‘spirit’ of the Triangle of Care was entered in to, adding that carers would welcome the opportunity to assist in achieving this.

53. In response to Mr Walker, Mr Crilly confirmed that the Trust was 5 years into the implementation of the Triangle of Care tool and agreed that a review could be undertaken to explore other models available which may provide more meaningful engagement and data. Mr Crilly added that as implementation of the tool was not a statutory requirement, funding had been limited.

54. Mr Crilly stated that since the Board had adopted this as a standard, learning had moved on, therefore Mr Crilly agreed to explore other mechanisms of ensuring carer engagement and would report back to the Committee in January 2018.

Agenda Item No: F1

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55.


Recommendations approved by the Committee, namely: • Note the content of the report.

Further actions required: • Research alternatives to Triangle of Care and report

back to the QAC.

M Crilly

Jan 2018

On Jan-18 QAC Agenda

C1 CQC INSPECTION ACTION PLAN

56. Mrs O’Hear provided an update regarding the Trust’s agreed response and action plan which had been submitted to the Care Quality Commission (CQC) as required on 3 August 2017. Mrs O’Hear advised that whilst the initial submission was accepted and received positively overall, the CQC had requested some additional details be added within the action plan. This had been addressed and resubmitted with final approval by the CQC anticipated at the next scheduled engagement meeting on 21 September 2017.

57. Mrs O’Hear stated that there had been discussion and agreement with Divisions and action plans for each core service were being developed to ensure improvements continued across the divisions. Some ambitious targets had been set and work was on-going with leads for longer term targets to ensure maintenance of the ‘outstanding’ score for Specialist Learning Disabilities (SLD) Division and to ensure further improvement continued.

58. In response to Ms Green, Mrs O’Hear stated that the plan had been updated further since this report was produced and going forward, a different format would be used to ensure achievements and progress were clearly evident. The template to be used outlined ‘must do’s’, ‘should do’s’ and ‘could do’s’ to ensure continued improvement.

59. Mrs Oates stated that sharing good work and successes across the Trust would inspire learning. Mrs O’Hear concurred, adding that the intention was to work closer with the Centre for Perfect Care to support more developmental areas and to target areas requiring improvement.

60.


Recommendations approved by the Committee, namely: • Receive a copy of the Trust’s response and agreed

actions to be taken in response to regulatory breaches identified within the published reports.

• Note the planned method of responding to the contents of reports received for each of the divisions’ core and non-core services and receive the supporting action plans for all areas where service improvements have been identified.

• Identify any further actions and assurances required by members of the Quality Assurance Committee.


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C2 2017/18 COST IMPROVEMENT PLANS – UPDATE AND Q1 CHANGES

61. Mr Walker provided an update in relation to the 2017/18 CIP progress to month 4 and sought approval for changes to 2017/18 CIP plans, highlighting key issues as follows:

o The Trust’s 2017/18 CIP target was £6.210m. o As at month 4, CIP plans of £1.789m were currently not implemented or at risk of

non-delivery. o Replacement plans of £0.092m had been identified for approval. o Alternative plans of £1.697m were required. Of this, £1.462m related to the Local

Division and £0.235m related to the Corporate Division. o The Local Division had confirmed that alternative plans were being developed and

would be taken to the Executive Committee in October 2017 and the Quality Assurance Committee in November 2017 for approval.

62. In response to Mr O’Keeffe, Mr Walker confirmed that the issues in relation to delivery of CIPs the Local Division had been raised with the Performance, Investment and Finance Committee.

63.


Recommendations approved by the Committee, namely: • Note the contents of the report. • Approve the replacement plan of £0.092m.

Further actions required: • Update report in relation to Local Division’s

alternative plans to Executive Committee in Oct-17; • Update report in relation to Local Division’s

alternative plans to QAC in Nov-17;

R Walker R Walker

Oct-17 Nov-17

On Oct-17 EC Agenda On Nov-17 QAC Agenda

C3 QUALITY IMPROVEMENT AND AUDIT PROGRESS REPORT UPDATE

64. Mrs O’Hear provided an update in relation to the Quality Improvement and Clinical Audit programme as of 31 August 2017 and updated the Committee on the feedback from the recent MIAA review, highlighting key issues as follows:

o All quality improvement posts had now been filled; o All clinical audits were completed in line with programme, where there had been

slippage, there were plans for completion around revised timelines; o The opinion from MIAA following their review was provision of significant

assurance; o There are plans in place to improve reporting to QAC with greater emphasis on

outcomes;

65. Mr Walker acknowledged the significant work led by Ms Bull to ensure improvement and provide assurance to the Committee. Mr O’Keeffe concurred.

Agenda Item No: F1

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66.


Recommendations approved by the Committee, namely: • Note the findings/actions and areas for improvement

from the 17/18 Clinical Audit Programme. • Note to feedback from MIAA and recommendations


C4 CQUIN DELIVERY UPDATE

67. Dr Fearnley provided the CQUIN delivery update, highlighting key issues as follows:

• The trust has been advised that the Accreditation Programme for Psychological Therapies Services (APPTS) had not accredited the Trust’s IAPT service. The Trust was currently appealing this decision in line with the APPTS procedures;

• In 2017/19 the Trust had six main contracts, totalling twenty-nine schemes. The total CQUIN value is £5.695m;

• Details of the 2017/19 CQUIN schemes were provided; • The Trust reported Quarter one CQUIN targets to commissioners on the 31st July.

The Trust reported green for all CQUIN schemes; • There was a risk the Trust may not achieve the Corporate CQUIN, Improvement

of Health and Wellbeing of NHS staff, Staff Survey indicator and the Local Division National Physical Health CQUINs;

• Under this year’s contractual arrangements, a maximum of £0.35m may be identified to reinvest back into the CQUINs to improve performance.

68. Dr Fearnley stated that CQUIN delivery was progressing well and a significant amount of work had been undertaken to achieve this.

69. In response to Mr Walker, Dr Fearnley stated that it was unknown at this stage as to why IAPT accreditation was being disputed as there were no issues around quality, but agreed to explore this following the meeting.

70.


Recommendations approved by the Committee, namely: • Note the contents of the report. • Note the progress of the 2017/19 CQUIN schemes.


C5 QUALITY OF SERVICE USER AND CARER CONSULTATION – RESPONSE / IMPROVEMENT PLAN

71. Mr Crilly provided a verbal update on activity following the paper provided to the last Committee by Mr Whelan which highlighted issues in relation to the quality of consultation and mechanisms to feed back to service users and carers following

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consultation. Mr Crilly confirmed that Mr Whelan’s paper had been shared with the Board of Directors and discussion had taken place regarding the points raised. It had subsequently been agreed that Mr Whelan, Mr Meadows and Mr Crilly would undertake a full review of the various methods of consultation across the organisation and the mechanisms available for feedback to service users and carers. It was noted that a more significant long term goal was to move beyond consultation and into active co-production with service users and carers. Mr Crilly stated that it had been recognised at the Board that the Trust needed to adopt a definition of co-production and this would be further discussed at the full board development day scheduled to take place in December 2017 and outcomes put before the full Board in January 2018 for approval.

72. Mr Bryant noted that from a service user and carer point of view, there was no ambition to be involved in every decision, but instead to be included in those decisions where the service user and carer perspective would be beneficial. Mr Bryant added that it was important that when opinions were not taken into account, to explain the rationale behind that decision.

73. Mr Walker stated that it was important to also include the staff’s perspectives when undertaking consultations. Dr Beardall concurred and proposed the term ‘tri-production’ was adopted.

74. Mr Crilly confirmed that work was on-going to address the issues raised in Mr Whelan’s paper and further meetings would take place between now and November 2017 to progress a solution.

75.




D1 QUALITY RISKS REPORT

76. Mr Morgan provided information which allowed the Committee, on behalf of the Board of Directors, to undertake detailed scrutiny of those strategically significant risks that could compromise patient safety or the delivery of outcomes and quality of care; provide assurance that actions were being taken in relation to those risks; to implement controls to reduce risks to a level consistent with the Board’s appetite for risk; and where actions had not taken place within an agreed timescale, to confirm mitigating actions had been put in place.

77. Mr Morgan highlighted that the report contained 38 quality risks of which 29 had an impact score of 3 or more. 9 other risks had an overall score of 15+ and/ or were included in the Board Assurance Framework.

78. There were 2 clinical division risks with a score of 15+ (‘If clinic letters and discharge summaries are delayed then there is a risk of inadequate communication leading to

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clinical care being negatively affected’ – LOC118 and ‘If improvements are not made to the environment of Park Lodge then there is a risk of breaches in Safety Regulations, increased in health related, security and safety incidents, reduction in staff morale, service users experience and damage to reputation’ – LOC116) one of which had reached the highest score for some time, of 20 (LOC116). Scrutiny had been undertaken and mitigation plans developed. Dr Sedgwick added that the score of 20 pertained to the clinical impact and confirmed that there had been no direct increases in incidents and this score was likely to be reduced to 16 with the mitigations in place. Dr Sedgwick confirmed that with regard clinic letters and discharge summaries, the backlog was being outsourced and it was anticipated that this would be cleared by the next meeting of the Committee and there was an aim to reduce the score to 12.

79. Mr Morgan advised the Committee of one risk that had been identified but was not yet reflected in the report pertaining to the inability to implement the Smoke Free policy in the Supported Living Services (SLS) Housing and there was a concern from staff and staff side regarding passive smoking. Mr Morgan confirmed that the landlord was unwilling to change the tenancy agreements regarding smoking in their own housing. Work was on-going to review what could be done to assure staff and enhance their safety. Consideration was also being given to how to assist service users in SLS Housing to reduce/stop smoking or to provide a safer alternative for smokers. Mr Morgan confirmed that work was on-going to ascertain if the mitigations were sufficient.

80.


Recommendations approved by the Committee, namely: • Confirm that the risks are being identified

appropriately; • Identify any risks that need to be escalated to the

Board as part of the Board Assurance Framework;


E1 MENTAL HEALTH ACT MANAGERS COMMITTEE MINUTES AND CHAIR’S REPORT (12/07/17)

81. Mr Morgan stated that the Committee had demonstrated significant improvement over recent months and an ‘away day’ was planned for January 2018. A paperless pilot for the meeting had also been successfully undertaken.

82. The Committee received and noted the minutes and chairs report.

E2 DRUGS & THERAPEUTIC COMMITTEE MINUTES AND CHAIR’S REPORT (17/07/17)

83. Dr Fearnley stated that work had been undertaken with regard to the ability to prescribe in a more timely manner through the EPMA system. Following a question from Dr Beardall, Mrs Prince confirmed that there were ‘super-users’ in place for the

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system. Mrs Clancy confirmed that the system had proved to be a successful innovation and positively received. Mr Walker proposed that lessons were identified from the success of this scheme.


E3 INFECTION PREVENTION & CONTROL COMMITTEE MINUTES AND CHAIR’S REPORT (29/06/17)

85. Mrs Hurst highlighted the key issues within the minutes including a global shortage of the Hepatitis B vaccine. This risk had been included on the Risk Register and plans were in place to address any likely issues arising, including an isolation facility.


E4 SAFEGUARDING STRATEGY GROUP MINUTES AND CHAIR’S REPORT (08/08/17)

87. Mrs O’Hear highlighted key issues, including the added pressure of work following the acquisition of the South Sefton services.


E5 MORTALITY COMMITTEE MINUTES AND CHAIR’S REPORT (11/08/17)

89. Mr Morgan confirmed that work had been completed in relation to the Learning from Deaths policy and the policy would be ratified by the Board of Directors in September 2017 in line with the national requirement.

90. With regard to mortality reviews, Mr Morgan stated that the majority of care the Trust provided was either good or excellent, with 2.5% being poor. Following a comment from Mr Walker, Mr Morgan concurred that 2.5% related to 25 people and work was on-going to address any issues and themes identified.


F1 SERIOUS UNTOWARD INCIDENTS ANNUAL REPORT

92. The Serious Untoward Incidents Annual Report 2016/17 was received, noted and accepted by the Committee.

G1 RISK REFLECTION

93. No additional risks were identified.

G2 ISSUES FOR CONSIDERATION OF AUDIT AND / OR OTHER COMMITTEES

94. No issues were identified.

G3 ANY OTHER BUSINESS

95. No further business was discussed.


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CHAIR’S REPORT AND MINUTES FOR THE Performance and Investment Committee

Date of Meeting: Friday 20 October 2017 Chair: Mr N Williams

Summary of key issues from this meeting: The Performance and Investment Committee received and discussed: • An update in relation to staffing/agency, confirming the agency rating of the Trust was

now at level 3 which was reflective of the downward trend in agency spend. Recovery plans had been requested from areas still reporting high agency spend and MIAA were also completing a piece of work to enable lessons to be learned. Robust plans were in place, however benefits of these would not be realised until 2018/19.

• A summary of Trust performance to 30 September 2017 including details of inpatient staffing levels against those clinically required and performance against quality; workforce; finance and external indicators. Key highlights included, but were not limited to: Local Division: o New GP referrals above plan at 1022 (against plan of 963); o 3 out of area placements for Sep-17; o Division on target to meet its key financial targets for budget as at 30 Sept 2017 o Division not meeting their CIPs as at 30 Sep-17;

Secure Division o Deterioration for in-month staff sickness; o Deterioration in friends and family test compared with Aug-17; o Vacancies against budgeted plan in Sep-17 was above plan; o Division on target to meet its key financial targets for budget and CIPs as at 30

Sep-17; Specialist Learning Disabilities Division o Discharges remained significantly below plan (since Feb-17: 18 discharges against

a plan of 85); o An improvement in-month staff sickness; o Vacancies against budgeted plan in Sep-17 remained above target; o Division not on target to meet its key financial targets for budget as at 30 Sep-17;

South Sefton Community Division o 2 Grad 3 CAA Pressure Ulcers reported in Sep-17 against a plan of 1; o Completion of the malnutrition universal screening tool was reported as below

target in Sep-17; o % of rejected referrals from urgent care was reported at 32.90% in September

2017 which was a deterioration when compared with August 2017 (14.50%). This was above the target of 10%;

o Division was not on target to meet its key financial targets for budget as at 30 Sep-17;

• A detailed report on the financial performance of the trust as at month 6, 2017/18 confirming that the Trust had achieved all financial performance targets. Key highlights included:

o Achieved planned surplus of £3.240m; o Cost pressures relating to Out of Area Treatments (OATs) remained; o Some improvement in relation to Trust agency spend, although this was still

considered a significant risk; • An update in relation to arrangements for the Digital Strategy to become part of the

Global Digital Exemplar Programme along with an update on progress with implementation of the 2015/16 to 2020/21 Digital Strategy including an overview of the current IT landscape;

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• A verbal update in relation to the Liverpool Community Services transaction, noting that an identical approach was being taken as with the previous acquisitions of Calderstones and South Sefton Community Services including weekly meetings and updates;

• An update on the New Care Models, providing progress of the work to develop the PROSPECT Partnership and the wave 2 pilot being developed;

• An update in relation to the Medium Secure Unit (MSU) and Low Secure Unit (LSU) development programmes;

• An NHS Resolution Insurance Update, informing the Committee of recent changes in both national and Trust based practice with NHS Resolution regarding claims management;

• Those strategically significant risks that could result in a failure to safeguard assets or impacting adversely on the Trust’s financial viability and capability for providing services. There were currently 11 financial risks with an impact score of 3 or more across all the Divisions, 6 of these were identified within the Board Assurance Framework (BAF);

• A Data Quality Update which provided current information on the arrangements in place within the Trust to provide assurance of data quality, noting that plans had since been put into place to ensure that indicators were audited every 3 years;

• An update on delivery of Transformational Programmes within the clinical divisions, the corporate division transformation programme and the Cheshire and Merseyside Sustainability and Transformation Programme. The Committee also received separate updates in relation to Local, Secure, Specialist Learning Disabilities and South Sefton Community Services Divisions;

• Notice that there would be a review of the Digital Board terms of reference (ToR) in respect of duties/responsibilities and these updated ToR would be circulated following the review;

The Performance and Investment Committee agreed: • The advanced funding required to allow for the procurement of building materials to the

sum of £450k in order to keep the MSU project on track;

Agenda Item No: F1

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Status of these minutes (check one box): Paper No: PIC17/18/306

Draft for Approval: ☒ Report to: Performance, Investment & Finance Committee

Formally Approved: ☐ Meeting Date: 22 December 2017


Performance, Investment & Finance Committee Date: Friday, 20 October 2017 Time: 9.30am

Venue: Rooms 2 & 3, V7 Building, Kings Business Park, Prescot, L34 1PJ.


Present: Nick Williams Cath Green Gerry O’Keeffe Elaine Darbyshire Mark Hindle Amanda Oates Neil Smith

Non Executive Director (Chair) Non Executive Director Non Executive Director – via telephone dial-in Executive Director of Communications and Corporate Governance Executive Director of Operations Executive Director of Workforce Executive Director of Finance / Deputy Chief Executive (up to and including C2)

In Attendance: Beatrice Fraenkel Gaynor Hales Trish Bennett Wendy Copeland-Blair Louise Edwards Des Johnson Chris Lyons Ian Lythgoe Andy Meadows Steve Morgan Asim Patel Donna Robinson Ashley Crossland

Chairman Non Executive Director Director of Integration Head of Performance Improvement and Customer Relationship Management Director of Strategy Chief Operating Officer – Secure Services Division Programme Director Associate Director of Finance Trust Secretary Director of Patient Safety Chief Information Officer Chief Operating Officer – Local Services Division Corporate Governance Assistant (Minutes Secretary)

Apologies Received: Matt Birch Neil Kelley Ray Walker

Non-Executive Director Service User / Carer Representative Executive Director of Nursing


A1 APOLOGIES

1. The apologies for absence received for this meeting are detailed above.



Agenda Item No: F1

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A3 MINUTES OF THE MEETING HELD ON 25 AUGUST 2017

3. The minutes of the previous meeting were accepted as an accurate record, with the following amendment made:

a. Paragraph 78: Action Lead should be noted as Chris Lyons.

4. Mr Hindle and Mrs Robinson updated the Committee in relation to the Action Log, confirming that the action dated 23 June 2017 relating to Talk Liverpool was scheduled to be discussed at both the October and December 2017 Board of Directors’ meetings. Mrs Oates affirmed that the action dated 25 August 2017, relating to Staff Sickness had been completed.

5.


Recommendations approved by the Committee, namely: • Approve the minutes of the previous meeting

Further actions required: • Amendment to be made to Paragraph 78 of the

previous minutes. • Action log to be updated to reflect progress reported.

A Crossland A Crossland

Oct-17 Oct-17

Completed Completed

A4 MATTERS ARISING

a. STAFFING / AGENCY UPDATE REPORT 6. Mrs Oates delivered a verbal update in relation to the Staffing / Agency Report in order

to provide information on the current performance against agency price and wage caps and clarity on new requirements in relation to agency expenditure ceilings, as well as provide an update on progress made by the divisions in regards to reducing agency usage.

7. In response to the challenges from Mr O’Keeffe at the last meeting of the Committee, Mrs Oates reported that the agency rating of the Trust was now at a level 3, which was reflective of the downward trend in agency spend. Mrs Oates explained that in order to further improve, recovery plans had been requested from those areas still reporting a high agency spend, adding that Mersey Internal Audit Agency were also completing a piece of work in relation to agency spend in order for the Trust to learn further lessons around this. Mrs Oates confirmed that it would be highly unlikely that the Trust would witness an improvement within the medical agency spend during the current financial year, however affirmed that there were robust plans in place, which included mitigations; however the benefits of these would not be realised until 2018/19.

8. Mrs Oates agreed to provide more detail to the next meeting of the Committee by means of a paper.

Agenda Item No: F1

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9.



Further actions required: • Paper on Staffing / Agency Spend to be presented to

the next meeting of the Committee

A Oates

Dec-17

On Dec-17 PFIC agenda.


10. Mr Hindle presented the Care at a Glance Report in order to provide the Committee with a summary of Trust performance to 30 September 2017.

11. Mr Hindle highlighted the divisional key issues of the report and gave a brief summary in relation to these, which were:

Local Division • The number of new referrals from GP continued to be above plan at 1022 for

September 2017 against a plan of 963. • Adult Mental Health bed occupancy had deteriorated slightly in September 2017

at 93.72% when compared with August 2017 94.87%. • The number of Out of Area Placements for September 2017 was three. • An improvement had been observed in September 2017 for in-month staff

sickness (7.14% to 6.50%). • The % on caseload on clusters 1, 2 and 3 continued to be above plan (3.83%)

at 5.95% in September 2017. An upward trend could be observed from March 2017.

• The % of vacancies against budgeted plan in September 2017 was reported as 12.06%. This remained above target.

• Patient Experience Friends and Family had deteriorated in September 2017 to 93.81% against a plan of 95%.

• The Local Division was on target to meet its key financial targets for budget as at 30 September 2017.

• The Local Division was not meeting their CIP as at the 30 September 2017. Secure Division

a. Deterioration had been observed in September 2017 for in-month staff sickness (7.03% to 7.49%).

b. The % likely to recommend the trust to friends and family (patient experience) in September 2017 was 78.43%. This was a deterioration when compared with August 2017 at 84.62%.

c. The % of vacancies against budgeted plan in September 2017 was reported as 6.07%. This remained above plan (5.00%).

d. The Secure Division was on target to meet its key financial targets for budget and CIPs as at 30 September 2017.

Specialist Learning Disabilities

a. The number of service users discharged remained significantly below plan (22) at five discharges in September 2017. Since February 2017, altogether there had been 18 discharges against a plan of 85.

b. An improvement had been observed in September 2017 for in-month staff sickness (8.61% to 8.07%).

Agenda Item No: F1

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c. The % of vacancies against budgeted plan in September 2017 is reported as 17.31%. This remained above target.

d. The SpLD was not on target to meet its key financial targets for budget as at 30 September 2017.


a. There had been two Grade 3 CAA Pressure Ulcers reported in September 2017 against a plan of one.

b. The completion of the falls risk assessment tool in September 2017 was reported as 92.87%. This was below the target of 95%.

c. The completion of the malnutrition universal screening tool in September 2017 was reported at 94.45%. This was below the target of 95%.

d. The % of rejected referrals from urgent care was reported at 32.90% in September 2017 which was a deterioration when compared with August 2017 (14.50%). This was above the target of 10%.

e. Staff sickness in September 2017 was 1.86% this was a result of under reporting.

f. The % of vacancies against budgeted plan in September 2017 was reported as 7.94% (August 2017 8.01%). This was above the target of 5%.

g. SSCD was not on target to meet its key financial targets for budget as at 30 September 2017.

2. Mr Hindle noted the significant work undertaken across all the Divisions, despite the current challenges being faced, adding that the issues within the Local Services Division were high on the agenda at the present time with a detailed report being delivered to the October meeting of the Private Board of Directors’ in relation to this. In response, Mrs Fraenkel requested that specific information was provided in relation to what challenges were currently being faced in order to better understand and address these accordingly.

3. In relation to recruitment and staff retention, Mrs Oates confirmed that the Trust were working in conjunction with NHSI, in order to create and maintain links with colleagues within the system and agree on a set of principals. Mrs Oates referred to private sector organisations trying to entice NHS staff into “attractive” employment packages by advertising near to Trust premises. In response to Mr O’Keeffe, Mrs Oates explained that a number of staff had come back to the Trust following leaving to take up these private sector posts and consideration was being given into asking these staff members to share the reasons why they had reconsidered their employment in order to provide a more realistic picture to staff thinking of applying for them in the future. Mr O’Keefe concurred with this idea; however he further suggested that any trends in constraints keeping the Trust from retaining its staff should be taken to the Board of Directors’ for discussion and resolution, which Mrs Oates noted. In order to provide further assurance to Mr O’Keeffe and Mr Williams, Mrs Oates also confirmed that work was being undertaken to produce a recruitment and retention plan, which would be presented to a future meeting of the Board of Directors. Mrs Fraenkel asked that any relevant “Brexit” implications were considered when producing the plan, which Mrs Oates noted.

4. In relation to the Urgent Care Referral Rejections reported, Mrs Bennett explained that this related to Ward 35 and confirmed it was a measure that had been set by the Clinical Commissioning Group, adding that discussions were continuing around this

Agenda Item No: F1

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and confirming that more information would be brought to the Committee once these discussions had concluded.

5. Mr Williams drew attention to the staff sickness figures, querying the huge improvement reported in relation to this and questioning whether this could be validated. Mrs Oates explained that the sudden rise in improvement could be a result of the SSCS Division staff moving onto the SVL system.

6. Mrs Copeland-Blair referred to the amendment to the Performance Assurance Framework 2017 / 2018, detailing the changes and explaining that this had been approved by the Executive Committee. The Committee confirmed ratification of the amendments.

7.


Recommendations approved by the Committee, namely: • The assessment of performance • The Committee is asked to ratify the amendment to

the Performance Assurance Framework 2017-18 subject to confirmation of approval by the Executive Committee.

Further actions required: • Specific detail on the individual challenges being

faced by each Division to be considered and included in future reports / discussions.

• Consideration to be given to trends in constraints being faced in the recruitment and retention of staff, with the Board of Directors being made aware of these.

• “Brexit” implications to be considered in the production of the Recruitment and Retention Plan, which is to be presented to the Board of Directors on completion.

• Further information on Urgent Care Referral Rejections to be presented to the Committee following the completion of on-going discussions relating to this.

M Hindle A Oates A Oates T Bennett

Dec-17 and on-going As required On-going Dec-17

Due Dec-17 and on-going On-going, as required On-going Due Dec-17

B2 FINANCIAL PERFORMANCE REPORT

8. Mr Lythgoe presented the Financial Performance Report in order to provide the Committee with an update on the Trust’s financial performance at month 6, 2017/18.

9. Mr Lythgoe highlighted the key issues of the report, confirming that as of the end of September 2017, the Trust had achieved all financial performance targets, which included a planned surplus of £3.240m. Mr Lythgoe affirmed that the cost pressure relating to Out of Area Treatments (OATs) remained, with issues still surrounding the Talk Liverpool service, along with the STAR Unit. Mr Lythgoe explained that although there had been some improvements in relation to the Trust agency spend, this was also currently considered a significant risk. Mrs Oates suggested that Mrs Bridget Clancy, Head of Nursing & Patient Experience – Secure and SLD Divisions, should give some consideration to staffing in order to provide more efficiency, which Mr Hindle noted.

Agenda Item No: F1

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10. Mr Hindle referred to the discharging of patients from the Whalley site and highlighted that commissioners needed to be reminded of the complexity of the patients still requiring discharge from the site. Mr O'Keeffe added that a more realistic approach to the retraction from Whalley needed to be presented to commissioners given that the current plan was not deliverable. Mr Hindle concurred and advised that service users continued to be admitted into the service. Mrs Fraenkel expressed her concern in relation to the retraction of services on the Whalley site and highlighted that more focus was required. Mr Meadows suggested that a paper relating to this issue was presented to the November meeting of the Board of Directors.

11. Mr Lythgoe confirmed that there remained a cost pressure associated with out of area treatments in addition to financial issues within the Talk Liverpool service and STAR Unit. Despite this, the forecast overspend for Local should be a breakeven position, however there were a series of cost pressures that required consideration that would impact in 2018/19.

12. Mr Williams expressed his concern in relation to the financial position of the Trust going forward, reiterating that a number of financial gains made this financial year were non-recurrent and therefore questioning the amount of deficit this would suggest for the next financial year. Mr Smith noted this point, adding that signficant work was still required in terms of service efficiency from a financial perspective.

13. Mr O’Keeffe noted that the work being undertaken by KPMG to review appropriateness and delivery of the transformational plan in the Local Division was due to conclude imminently and queried the potential findings of this review. Mrs Robinson explained that, although some further savings could be identified, these would not be sufficient to offset the £1.2m deficit created by the non-delivery of a number of CIPs, adding that recovery schemes had been drafted in relation to this and these were awaiting approval by the Quality Assurance Committee, which would be meeting in November 2017. Mrs Oates added that the medical staffing budget recovery plan had also uncovered potential savings of approximately £1.5m, which would materialise within the 2018 / 2019 financial year.

14.


Recommendations approved by the Committee, namely: • Note the current financial position and planned

achievement of the control total. • Agree the recommendation for replacement CIP

schemes to be presented to the Quality Assurance Committee in November by the Chief Operating Officer of the local division, the Medical Director and Executive Nurse Director.

• Note the risks associated with the financial position and require the following to be presented at the October Performance, Investment and Finance Committee :

o Chief Operating Officer to provide assurance of the financial position for Local and specialist learning disabilities division

o Medical Director to provide a recovery plan for the local medical staffing budget.

• Proposed plans for the remaining revaluation

Agenda Item No: F1

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reserves funding of £1.267m to be presented at the Performance, Finance and Investment Committee in December by the Executive Director of Finance.

Further actions required: • Paper relating to the SLD Retraction Plan position to

be delivered to the November meeting of the Board of Directors.

M Hindle

Nov-17

On Nov-17 BoD agenda

B3 2017/18 CIP – Q2 CHANGES

15. Mr Lythgoe confirmed that there had been no changes to the Quarter 2 CIPs position, adding that further changes would occur within Quarter 3 when a further update would be provided.

16.



Further actions required: • Further update on CIP changes to be reported during

Quarter 3 of the financial year 2017/18

N Smith

Dec-17

On Dec-17 PIFC agenda

C2 DIGITAL STRATEGY - STOCKTAKE

17. Mr Smith introduced Dr Patel, Chief Information Officer to the Committee, who presented the Digital Strategy Stocktake in order to provide the Trust with arrangements for the Digital Strategy to become part of the Global Digital Exemplar Programme, update on the progress with implementation of the 2015 / 2016 to 2020 / 2021 Digital Strategy and provide and overview of the current IT landscape.

18. Dr Patel highlighted the key issues of the report, reiterating that in September 2017 the Board of Directors’ approved the status of Global Digital Exemplar that was the de-facto Digital Strategy, which would need to be revisited in light of the growth of the organisation, as well as the requirement to support the integration of mental health and physical services now provided by the Trust.

19. Dr Patel explained that the IT landscape of the Trust had dramatically changed within the last 12 months due the acquisition of new services. Dr Patel confirmed that work needed to take place to identify the systems currently in place within the various Divisions with a view to harmonising these in the most effective, productive and efficient ways possible. Dr Patel detailed the intention to produce an options appraisal for each domain, along with a future target system landscape, which would be presented during February / March 2018.

20. Dr Patel detailed the significant work which had already taken place around IT systems, noting the impending go-live of the RiO system, as a replacement to EPEX, within the Addictions, Asperger’s and ADHD Teams of the Local Services Division. Dr Patel added that system consolidation was one of the key areas being explored as part of the on-going work, adding that a synergy in terms of renegotiating a full contract with one of the current providers could be a possibility.

Agenda Item No: F1

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21. In response to a query raised, Dr Patel confirmed that he would look into the Malware protection currently in use within the Whalley site.

22.


Recommendations approved by the Committee, namely: • Note the progress on implementing the 2016/17-

2020/21 digital strategy • Note the need to consolidate and harmonise clinical,

corporate systems and infrastructure acquired through growth and acquisitions. An option appraisal for each domain and future target system landscape will be presented in February 2018.

• Note the requirements for the Global Digital Exemplar programme and its strategic vision to incorporate the growth in services, changing landscape and to support the integration of physical and mental health services. This will be drafted by March 2018.

Further actions required: • Update on the Digital Strategy, IT landscape and

system harmonisation proposals to be presented to the February meeting of the Committee.

A Patel

Feb-18

On Feb-18 PIFC agenda

C2 LIVERPOOL COMMUNITY HEALTH UPDATE

23. Mr Lyons provided a verbal update to the Committee in relation to the Liverpool Community Services transaction.

24. Mr Lyons informed the Committee that an identical approach was being taken as with the previous acquisitions of Calderstones and South Sefton Community Services, confirming that weekly meetings and updates had been put into place to ensure a safe and functional alignment of services.

25. Mr Lyons confirmed that a full business case would be required, along with completion of a robust due diligence exercise, the results of which would be reported to the Board of Directors. Mrs Bennett added that the date of transaction completion had been set as 1 April 2018.

26. Mrs Fraenkel emphasised that under a management contract, the Trust should be careful to ensure conflicts of interests were managed effectively and highlighted that the Trust remained a “stand-alone” body should the acquisition not take place. Ms Green concurred, detailing conversations that had taken place between Mr Meadows and herself in relation to concerns around the governance in place.

27. Mr Lythgoe advised that the Committee should receive the findings of the due diligence exercise at the December 2017 meeting.

28. Mrs Fraenkel highlighted the need to consider whether the acquisition would trigger a CQC inspection and noted that the public pressure for this to take place would likely be high.

Agenda Item No: F1

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29.




C3 NEW CARE MODELS

30. Mrs Edwards delivered a report on the New Care Models in order to update the Committee on the progress of the work to develop the PROSPECT Partnership, the wave 2 pilot being developed under the New Care Models for tertiary mental health programme (i.e. low and medium secure mental health services).

31. Mrs Edwards highlighted the key issues of the report, explaining that following the first meeting of the Partnership Board, an Operational Delivery Group would now be established to implement new ways of working, set out within the new care model programme, as these became business as usual. Mrs Edwards confirmed that there were a number of outstanding points remaining in relation to the agreement of a financial baseline position for the programme and noted that formal commencement of the new care model programme would be delayed, pending agreement of these issues. Mrs Edwards affirmed that two clinical task and finish groups had been established to support the development of the PROSPECT model of care, with representation from each of the five providers within the Trust’s partnership, with a proposal for service user and carer co-design to be brought to the November meeting of the Partnership Board.

32. Mrs Edwards confirmed on-going work taking place with other Trusts in order to exert more control, adding that the go-live date had now been extended to 1 April 2018. Mrs Edwards explained that the information currently being provided by NHS England was insufficient and thus the Trust could not ascertain whether sufficient funding would be provided for the care to be delivered to the service users and in the current situation this remained the responsibility of the Partnership however, once the contract variation had been signed the Trust would become liable for this. In this context, the Trust had so far refused to sign such variation and so far, no other Trusts within Phase One of the programme had signed for this reason.

33.


Recommendations approved by the Committee, namely: • Note the updates in the paper.


C4 LSU and MSU Update

34. Mrs Darbyshire delivered a verbal update to the Committee in relation to the current position of the Low and Medium Secure Units.

Agenda Item No: F1

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35. Mrs Darbyshire explained that the timeline in relation to the approval of the Medium Secure Unit had slipped, stating that although NHSI had signed off the business case, there had been a delay from the Department of Health, meaning that Ministerial approval would not now be granted until the end of November 2017. Mrs Darbyshire emphasised the potential implications of this if no action were to be taken by the Trust, which included the contract programme not being met, a significant increase of Kier’s guaranteed maximum price (GMP) value by an amount in the region of hundreds of thousands of pounds due to inflation and the potential loss of contractors and the assigned project team. In order to prevent this, Mrs Darbyshire requested that the Committee approve £450k of advanced funding, which would be used to procure materials that would ultimately be used on the project. In response to Mr O’Keeffe, Mr Lythgoe confirmed that although spending this sum of money on materials for the as yet unapproved unit, the costs that would be incurred should the project be delayed would most likely be of around the same sum, if not greater and therefore choosing to do nothing would most likely result in a greater financial impact, coupled with the further risks in terms of overall disruption to the project. Mr Williams noted that the procurement of the materials to the sum of £450k was an appropriate option.

36. Mrs Darbyshire referred to the planned Low Secure Unit, explaining that NHS England had requested that the Trust progress with an outline business case for the 40 bed Low Secure Unit for the provision of learning disability services, to be located at Maghull. Mrs Darbyshire reiterated that the Department of Health had issued a number of conditions in relation to the original business case, confirming that these were brought to the attention of the last meeting of the Committee. As a result of this, Mrs Darbyshire explained that there were now two key decisions which were required around the preferred clinical model for NHS England and the availability of capital for the LSU.

37. In respect of the Trusts financial position, Mr Lythgoe confirmed that the Trust was at its full capacity in terms of its borrowing limit.

38.


Recommendations approved by the Committee, namely: • Note the verbal update provided. • Note the risks created should the MSU project be

allowed to fall behind as a result of the delayed DoH and Ministerial sign-off.

• Agree to the advanced funding required to allow for the procurement of building materials to the sum of £450k in order to keep the project on track.

Further actions required: • Further updates in relation to the LSU situation to be

provided to the Committee.

E Darbyshire

Dec-17

On Dec-17 PFIC agenda

C5 NHSLA INSURANCE UPDATE

39. Mr Morgan presented the NHS Resolution Insurance Update in order to inform the Committee on recent changes in both national and Trust based practice with NHS Resolution (NHSR, formally NHS Litigation Authority) regarding claims management.

Agenda Item No: F1

Page 75 of 94

40. Mr Morgan highlighted the key issues of the report, explaining that the Trust’s legal claims continued to be dealt with by the NHS Litigation Resolution, whose purpose was to provide indemnity cover for legal claims against the NHS, along with assisting with risk management and lessons learned to its members. Mr Morgan confirmed that the Trust’s Legal Team had met with NHSR and regional learning leads in order to discuss recent changes and how these would work within the Trust. As a result of these discussions, Mr Morgan detailed how the Trust had entered into a learning project led by NHSR and AQuA, which would utilise NHSR data relating to the Trust in order to generate new possibilities to learn and understand more about how safety could be enhanced. In addition to this, the Trust’s Patient Safety Team had been working with Lockton and NHSR in order to review the current systems of incident management, risk and potential and actual legal claims, which involved the Trust and this work had led to the development of a new process, which aligned with the Just and Learning Culture programme and would assist with the management and support of staff who were involved in an incident or adverse event that could potentially lead to litigation against the Trust.

41. In response to questions surrounding the financial implications of claims against the Trust, Mr Morgan explained that the majority of claims were considered as low level from a financial perspective, with the highest claim currently being £550k. Mr Morgan confirmed that assaults made up the majority of claims.

42. Mrs Oates welcomed the new approach, explaining that early resolution of claims gave a positive sense of self-worth to staff involved. Mr Morgan confirmed that all Trusts were covered by NHSR unless they formally opted out in preference of a private scheme, adding that Liverpool Community Health NHS was also covered.

43. In response to Mr Williams, Mr Smith explained that there was an excess in respect of claims and there were links between the Finance and Claims Departments in order to coordinate this.

44.


Recommendations approved by the Committee, namely: • Note the content of the report.


D1 FINANCIAL RISK REPORT

45. Mr Morgan delivered the Financial Risk Report in order to provide information to allow the Committee, on behalf of the Board of Directors, to undertake detailed scrutiny of those strategically significant risks that could result in a failure to safeguard assets or impact adversely on the Trust’s financial viability and capability to provide services.

46. Mr Morgan summarised the current position of the Trust, confirming that there were currently 11 financial risks with an impact score of 3 or more across all of the Divisions, adding that six of these were identified within the Board Assurance Framework.

Agenda Item No: F1

Page 76 of 94

47. Mr Morgan confirmed that following recent suggestions, details of mitigations against risks had been included within all such reports across the Trust.

48. Mr Meadows drew attention to 3.2 on page two of the report and for clarity, confirmed that this had been discussed and a decision made during item C4 of the agenda. Mr Williams expressed that, although he was content to approve the recommendations of the report, further information was required detailing a breakdown of the £450k advance funding, which had been agreed during earlier discussions in order to provide complete transparency. Mr Meadows agreed to obtain this and circulate to the Committee.

49.





Further actions required: • A breakdown of the £450k advanced funding in

relation to the MSU to be obtained and distributed to the Committee.

A Meadows

Oct-17

Cascaded via email 30/10/2017

D2 DATA QUALITY UPDATE

50. Mrs Copeland-Blair delivered the Data Quality Update to the Committee in order to provide current information on the arrangements in place within the Trust to provide assurance of data quality. Mrs Copeland-Blair advised that the paper provided an update to that delivered to the June 2017 meeting of the Committee, explaining that plans had since been put into place to ensure that indicators were audited every three years.

51. Mrs Copeland-Blair advised that work was on-going to take steps to deplete the amount of work required to produce information by manual methods. In addition, Mrs Copeland-Blair confirmed that the Trust had developed an action plan in response to two recent audits of clustering, by CHKS, an external provider of data quality and financial assurance programmes, with the latest version of the action plan to be signed off by the Local Services Division in November 2017. Mrs Copeland-Blair added that an Information Assurance Improvement Plan would be generated at a workshop, which was to be held on 27 October 2017, with a view to this being ratified at the December meeting of the Digital Board.

52. In response to questions relating to the auditing of PACE, Mrs Copeland-Blair explained that this was not currently reported as part of Care at a Glance and therefore would not be prioritised for audit testing; however Mrs Oates added that this could be requested via MIAA if deemed necessary.

53. In response to Mrs T Bennett, Mrs Copeland-Blair confirmed that she was working to address more focus on community health services, adding that there were meetings in place to facilitate the discussions around requirements. Following queries raised during further discussion, Mrs Copeland-Blair and Dr Patel agreed that they would

Agenda Item No: F1

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meet in order to hold a conversation around data warehousing and other related issues, which required refreshing.

54.


Recommendations approved by the Committee, namely: • Note the contents of the report.

Further actions required: • A meeting to take place in order to discuss data

warehouse refreshment and other related requirements.

W Copeland-Blair / A Patel

Dec-17

Due Dec-17

E1 UPDATE ON TRANSFORMATIONAL PLANS

55. Mrs Edwards delivered an Update on Transformational Plans to the Committee in order to provide a summary of information regarding progress in the delivery of transformation programmes within the Clinical Divisions, Corporate Division and the Cheshire and Merseyside Sustainability & Transformation programme.

56. Mrs Edwards briefly summarised the current position within each of the decisions, confirming that changes were particularly apparent within the Secure Division. In addition, Mrs Edwards detailed the complex issues that were prevalent within the Local Services and SLD Divisions.

57. Mrs Edwards explained that the Corporate Services Division review would commence in December 2017.

58. In relation to the Sustainability and Transformation Programme (STP) Mrs Edwards explained that new leadership was in place, along with new processes which have drawn on more collaborative working and more focus on mental health.

59.


Recommendations approved by the Committee, namely: • Note the update provided in the report.


E2 TRANSFORMATIONAL PLAN PROGRESS

a. LOCAL DIVISION UPDATE 60. Mr Lyons delivered the Local Division Update in order to provide the Committee with

information on progress regarding the implementation of the Local Division Transformation Programme, with particular focus being given to providing assurance that the programme is structured in a way to achieve its objectives and that robust internal control measures within the programme have been established to drive performance, as well as highlight current challenges and risks associated with this programme.

61. Mr Lyons summarised the content of the report and explained that during the initial scoping and analysis phase of the programme, it had become evident that inefficient practices had developed in three particular areas. Mr Lyons confirmed that the control

Agenda Item No: F1

Page 78 of 94

of access into clinical services was a significant problem, allowing service users who required low-level support the same access to services as those requiring more intensive support. This was resulting in delayed to access to a consultant appointment and larger caseloads than was necessary. Mr Lyons explained that the current care models result in service users often remaining in service longer than was required and discharges were often without sufficient focus and at times too cautious.

62. Mr Lyons drew attention to the areas where financial improvements could be made, explaining that significant use of Locum Consultants, as well as having to rely on Out of Area Placements, often due to delayed discharges, were areas of financial drain and it was clear that process changes could result in a vast saving for not only the Division, but the Trust.

63. Mr Lyons explained that a dashboard had been created and this provided a breakdown by location. Mr Lyons also confirmed that a number of task and finish groups were in place and their members continued to explore further efficiencies in practice.

64. Ms Green suggested discharge housing as a method of assisting with more timely discharges, with which Mrs Robinson concurred. Ms Green and Mrs Robinson agreed that they would discuss this further outside of the meeting.

65.


Recommendations approved by the Committee, namely: • Note the contents of the report.

Further actions required: • Discussion to take place in relation to discharge

housing

C Green / D Robinson

Dec-17

Due Dec-17

b. SECURE DIVISION UPDATE

66. Mr Johnson delivered the Secure Division Update in order to provide the Committee with progress relating to the Secure Services Division Transformation Programme.

67. Mr Johnson stated that there were no current issues or concerns within the Secure Division relating to the transformation plans. Mr Johnson confirmed that a response had been received from the CQC in relation to the Division’s challenge of their recent inspection grading, explaining that this had remained at “good”; however the CQC had issued an updated report to acknowledge the Division’s positive work.

68. Ms Green referred to her recent visit to Ashworth, conveying her praise to the positivity and professionalism exhibited by its staff and the service they provide.

69.


Recommendations approved by the Committee, namely: • Note that the transformation programme is

progressing and there are no significant risks to report.


Agenda Item No: F1

Page 79 of 94

c. SPECIALIST LEARNING DISABILITIES DIVISION

70. Mr Hindle delivered the Specialist Learning Disabilities Transformation Update in order to provide the Committee with information on the progress relating to the Transformation Programme within the Division.

71. Mr Hindle highlighted the key issues of the report, reaffirming that the discharge dates set by the commissioners were continuing to slip and drawing attention to the interdependencies on workforce, finance and the estates, which were now subject to weekly tracking.

72. Mr Hindle explained that the challenges faced by the Division were now becoming greater and suggested that thought should be given to presenting a paper to the Board of Directors’ to highlight the current situation and the growing pressures.

73.






d. SOUTH SEFTON COMMUNITY SERVICES DIVISION

74. Mrs Bennett delivered the South Sefton Community Services Transformation Update in order to provide the Committee with progress on the planned service reviews across the services commissioned by South Sefton CCG and provided by the South Sefton Community Services Division.

75. Mrs Bennett explained that there were to be reviews of all lines of service within the Division carried out, adding that so far the results of those carried out had been positive.

76. Mrs Bennett highlighted that both the Royal Liverpool University Hospital and Aintree University Hospital were going to be subject to acute bed reductions, losing 100 and 50 respectively and asked members of the Committee to be aware of the implications of this, which Mrs Oates agreed would present difficulties.

77.


Recommendations approved by the Committee, namely: • Note the terms of reference and programme for the

South Sefton Community Services Division service reviews.

• Note that progress reports will be provided monthly from the Divisional Programme Group.


Agenda Item No: F1

Page 80 of 94

F1 TERMS OF REFERENCE (DIGITAL BOARD)

78. Mr Meadows explained that there would be a review of the Digital Board terms of reference in respect of duties/ responsibilities. Mr Meadows detailed the proposed changes and confirmed that a copy would be circulated once the review had taken place.

79.


Recommendations approved by the Committee, namely: • Note the verbal update provided

Further actions required: • Terms of Reference to be circulated following review

(Digital Board).

A Meadows

Nov-17

Due Nov-17

G1 RISK REFLECTION


G2 ISSUES FOR CONSIDERATION BY AUDIT AND / OR OTHER COMMITTEES


G3 ITEMS OF ANY OTHER BUSINESS



Agenda Item No: F1

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Remuneration and Terms of Service Committee

Date of Meeting: Wednesday 27 September 2017 Chair: Mrs B Fraenkel

Summary of key issues from this meeting: The Remuneration and Terms of Service Committee:

• Considered and approved: o Settlement of a grievance claim following legal advice.


Remuneration and Terms of Service Committee

Date of Meeting: Wednesday 25 October 2017 Chair: Mrs B Fraenkel

Summary of key issues from this meeting: The Remuneration and Terms of Service Committee:

• Considered and noted: o The secondment arrangements planned to support the Management

Agreement with Liverpool Community Health.

Agenda Item No: F1

Page 82 of 94


Council of Governors Committee

Date of Meeting: Wednesday 25 October 2017 Chair: Mrs B Fraenkel

Summary of key issues from this meeting: The Council of Governors Committee approved:

• The establishment of a Governor Reference Group in relation to confirmation that the Trust had been identified by NHS Improvement as the preferred supplier for Liverpool Community Health Services.

• The unopposed election of Mrs Hilary Tetlow for a second year as Lead Governor. • A number of amendments to the Constitution. • The Governor Induction, Training and Development Plan. • Amendments to the Governor Handbook. • Amendment of the terms of office in respect of Non Executive Director, Dr Rob

Beardall. • The Council of Governors Annual Report 2016/17.

The Council of Governors Committee considered / discussed:

• An update on the financial and activity performance of the Trust noting that the Trust were performing well against the majority of key performance indicators, and the Trust had been assessed as ‘Good’ following the Care Quality Commission inspection in Mar-17.

The Council of Governors Committee noted: • An update from the Chairman, highlighting the official opening of the Life Rooms,

Walton by HRH The Duke of Cambridge; the proposed third Life Rooms base in Bootle in partnership with Hugh Baird College; and the renaming ceremony and official opening of the new Kevin White Unit, now named the Hope Centre. The Chairman informed the Committee that she had been nominated as the NHS Chair Representative on Mental Health Network Board with effect from 1 Oct-17.

• An update from the Deputy Chief Executive, highlighting the Board approved full business case for the development of a new 44 bed mental health facility and integrated community mental health hub in Southport and that the Trust had been identified as the preferred provider to deliver the Liverpool Community Health Services.

• That the Nomination and Remuneration Committee were to consider the revised process for Non-Executive Director appraisals to be undertaken in Jan-Apr-18.

• An update regarding the retraction of services within the Specialist Learning disability Division; details of discharge rates determined by commissioners and plans for new facilities, including medium and low secure learning disability beds and a step down and enhanced support service.

• An update in relation to progress on the delivery of the Trust’s Operational Plan 2017/18 and the proposed approach to the refresh of this two-year Operation Plan for 2018/19.

Agenda Item No: F1

Page 83 of 94

Status of these minutes (check one box): Paper No: COG17/18/

Draft for Approval: ☒ Report to: Council of Governors

Formally Approved: ☐ Meeting Date: 17 January 2018


Council of Governors Date: Wednesday, 25 October 2017 Time: 2:00pm – 3:30pm

Venue: Princes Royal Suite, Princess Royal Stand, Aintree Racecourse, Ormskirk Road, Aintree, Liverpool L9 5AS


Present: Beatrice Fraenkel Sayed Ahmed George Allen Paul Allen Johanna Birrell Mairi Byrne Tracey Cummins Sarah Finlayson Mandi Gregory Mike Jones David Kitchen Mark McCarthy John Mousley Brian Murphy Martin Murphy Garrick Prayogg Paul Taylor Hilary Tetlow Veronica Webster

Chairman (Meeting Chair); Staff, Medical (SLDD) Carer, Local (Liverpool, Sefton & Knowsley); Staff, Other Clinical/Therapeutic (SLDD) Service User, Local (Liverpool, Sefton & Knowsley); Public, Cumbria, Lancashire & Greater Manchester Staff, Nursing (SLDD) Staff, Other Clinical, Scientific, Technical & Therapeutic Staff Staff, Non Clinical; Staff, Non Clinical Staff, Other Clinical/Therapeutic Service User, Local (Liverpool, Sefton & Knowsley); Public, Sefton; Carer, Local (Liverpool, Sefton & Knowsley); Service User, Local (Liverpool, Sefton & Knowsley); Public, Cheshire, St Helens, Wirral, West Midlands & Wales; Service User, Local (Liverpool, Sefton & Knowsley); Carer, Local (Liverpool, Sefton & Knowsley) & Lead Governor; Appointed, Sefton, Local Authority.

In Attendance: Pam Williams Rob Beardall Gerry O’Keeffe Cath Green Gaynor Hales Elaine Darbyshire Mark Hindle Amanda Oates Trish Bennett Louise Edwards Neil Smith David Fearnley Andy Meadows Sarah Jennings Paula Murphy Alison Bacon Chris Lyons Charon Martin Alison Hobden Mary Braithwaite Diane Middleman

Non Executive Director; Non Executive Director; Non Executive Director; Non Executive Director; Non Executive Director; Executive Director of Communications and Corporate Governance; Executive Director of Operations; Executive Director of Workforce; Director of Integration Director of Strategy and Planning Executive Director of Finance & Deputy CEO; Medical Director; Trust Secretary; Deputy Trust Secretary; Corporate Governance Compliance Manager; Membership Manager; Project Director; Insight Programme; Insight Programme; Observer; Observer;

Agenda Item No: F1

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Apologies Received: Clare Austin Debra Doherty Judith Geddes Jayne Moore Maria Tyson Joe Rafferty Matt Birch Ray Walker Nick Williams

Appointed, Academic; Service User, Local (Liverpool, Sefton & Knowsley); Public, Ribble Valley; Public, Liverpool; Staff, Nursing Staff; Chief Executive Non Executive Director; Executive Director of Nursing; Non Executive Director;


A1 WELCOME

1. Mrs Fraenkel welcomed the Governors and attendees to the meeting, offering a special welcome to the newly elected Governors attending their first meeting today. At the request of the Chair, introductions were made around the room.

2. Mr Meadows advised that following elections, governors were subject to eligibility criteria and confirmed he would work through the process with governors over the coming weeks to ensure due process was followed in line with the Constitution.

A2 APOLOGIES

3. The apologies for absence received for the meeting were noted, as detailed above.


4. Mr Paul Taylor declared the following interests in his role as a volunteer for the Trust as follows:

o Life Rooms, Walton as a welcome and support volunteer; o Recruitment and Selection volunteer up to grade 8d; o Ashworth Hospital patient befriender volunteer;

5. There were no further interests declared.

A4 MINUTES OF THE PREVIOUS MEETING HELD ON:

o 27 April 2017 o 26 July 2017

6. The minutes of the meetings held on 27 April and 26 July 2017, were accepted as an

accurate record subject to the amendment of Mr David Kitchen’s job title on both sets of minutes.

Agenda Item No: F1

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7.


Recommendations approved by the Council of Governors, namely: • Approve minutes from 27 April 2017 and 26 July

2017.

Further actions required: • Amend Mr Dave Kitchen’s job title on both sets of

minutes;

P Murphy

Oct-17

Completed

A5 UPDATE FROM THE CHAIRMAN

8. Mrs Fraenkel stated that on 14 September 2017 His Royal Highness the Duke of Cambridge officially opened the Life Rooms Walton as part of a day long tour of Merseyside. The Duke had specifically requested to visit the service and had met with service users, volunteers and some of the Trust’s partner organisations prior to unveiling a commemorative plaque. Mrs Fraenkel stated that the Duke’s visit was recognition of the good work by Mersey Care in general and in the Life Room model in particular and the challenge now was to ensure both Life Room sites in Walton and Southport and the proposed third base in Bootle as part of a partnership with Hugh Baird College, became focal points for the community.

9. Mrs Fraenkel highlighted her attendance at the renaming ceremony and official opening of the new Kevin White Unit – now renamed the Hope Centre on the 28 September 2017.

10. On 17 October, Mrs Fraenkel had attended the Mental Health Network Board (NHS Confederation) in Manchester, and advised that she had been nominated as the NHS Chair Representative on the Board with effect from 1 October 2017.

A6 UPDATE FROM THE CHIEF EXECUTIVE

11. Mr Smith echoed Mrs Fraenkel’s welcome to new governors, stating that this was an exciting time to be involved in the Trust as the organisation undertook significant changes.

12. Mr Smith highlighted that in September 2017 the Board of Directors had approved the full business case for the development of a new 44-bed mental health facility and integrated community mental health hub on the former Southport General Infirmary site and it was anticipated that building would commence in late 2017.

13. Mr Smith confirmed that on 4 October 2017, the Trust had been identified as the preferred provider to deliver the Liverpool Community Health Services, adding that although there was significant work to be undertaken, including completion of due diligence, this was an exciting opportunity for the Trust. This would be discussed in more detail under agenda item C1 and as part of the joint strategy session with the Board later today.

Agenda Item No: F1

Page 86 of 94

B1 REPORT ON FINANCIAL AND ACTIVITY PERFORMANCE

14. Mr O’Keeffe presented the Report on Financial and Activity Performance to the Governors, which covered a 3-month period leading up to 31 August 2017 adding that at the time of writing the report, September 2017 data was not available.

15. Mr O’Keeffe confirmed that the Trust were performing well against the majority of key performance indicators and that the Trust had been assessed as ‘Good’ following the Care Quality commission inspection in March 2017.

16. Mr O’Keeffe summarised the key points as follows:

o Point 7, page 3 – NHS Improvement – Single Oversight Framework - the Trust had been assigned to segment 2 based on the CQC rating and operational performance. The Trust were not in the top segment due to currently being 42.80% above national spending targets for agency staff (as at 31 Aug 2017). Although the Trust had demonstrated improvement from 57.31% in July 2017, work was on-going to reduce this further. Mr O’Keeffe confirmed that this metric had only been in place for 18 months and the Trust’s figures were affected by recruitment issues being experienced. Governors were assured that recruitment and retention along with agency usage was under regular scrutiny at the Performance, Investment and Finance Committee and actions were being taken to address issues. The expectation was that a significant reduction in agency usage would not be evident until the 2018/19 financial year;

o Point 28, page 5 – statutory and mandatory training - the Trust remained below the 95% target at 81.50% in August 2017. All divisions had produced a plan which demonstrated how they aimed to reach trajectories determined by the Strategic Workforce Group. Clinical staff had shown significant improvement in the completion of training and further work was being undertaken to ensure corporate staff undertook the necessary core mandatory training.

o Point 32, page 5 – vacancy rates stood at 10.57% at the end of August 2017, with the highest rates (19.41%) relating to the Specialist Learning Disability Division. Processes to improve recruitment had been developed and detailed discussion had been undertaken at the Oct-17 Performance, Investment and Finance Committee to discuss recruitment and retention. A further update report would be provided to the next Performance, Investment and Finance Committee;

o Point 34, page 6 – resources – the Trust continued to meet its financial targets at a time when most NHS Trusts were failing to do so. Financial plans were already being considered for the next financial year, but it was acknowledged that this year, it had been significantly more difficult to achieve targets.

o Point 36-37, page 6 – suicides – it was proposed that a session in relation to the Trust progress towards its goal of zero suicides, including trends and national actions, be provided to the next Council of Governors meeting, lead by Dr David Fearnley.

Agenda Item No: F1

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o Point 38, page 6 – restrictive practices – Mr Hindle joined Mr O’Keeffe to advise Governors of the high priority objective of ‘No Force First’ which was linked to ground-breaking work around the reduction of violence and aggression. The Trust had seen a reduction in violence within the organisation and in particular, a significant reduction in incidents at the Whalley site. It was noted that as well as this approach being best for service users, it also improved quality, reduced incidents and reduced sickness absence amongst staff;

o Point 52, page 8 – CQC rating for the High Secure Division – following the Trust’s appeal to increase the CQC rating for High Secure to ‘outstanding’ from ‘Good’, the CQC had recognised that the Trust were at the forefront of developing innovative practice which had not been reflected in a way that was consistent with the ratings criteria and had subsequently amended their report to reflect the factual accuracy challenges, however this would not result in a change to the given ratings. Mr O’Keeffe highlighted that the Trust were significantly proud of the Specialist Learning Disabilities Division in achieving an ‘outstanding’ rating from the CQC;

o Point 59, page 8, South Sefton Community Division – following the successful acquisition of the South Sefton Community Services, Mr O’Keeffe confirmed that this service had continued to operate safely over the last 5 months and offered congratulations to Mrs T Bennett and her team;

17. In response to a question asked by Ms Finlayson regarding vacancies, Mrs Oates confirmed that work was on-going with NHS Improvement on a national programme for recruitment and retention and that staff retiring from the health service was a national issue. The Trust were taking a balanced approach and considering internal and external factors in relation to recruitment and retention.

18. Mr Prayogg queried if, apart from reaching retirement age, staff were leaving the services due to the inability to progress in their careers. Mrs Oates confirmed that the issue was multifaceted and acknowledged that there were issues in terms of internal opportunities in some fields. Consideration was being given to ways to enhance career opportunities that may currently be limited, including working with partners. Challenges were evident in relation to competing with terms and conditions offered by the private sector, however it had been recognised that some staff were returning to the NHS following taking up work in the private sector, which was encouraging. Work was underway to improve publicising the Trust to potential employees. Mr O’Keeffe confirmed that the Performance, Investment and Finance Committee had requested an update in relation to this issue and an update would also be provided to the next Council of Governors meeting.

19. Mr McCarthy raised a concern in relation to bed management and out of area transfers, requesting that this was a main focus of every meeting and proposed that ‘peak occupancy’ should be identified in future reports. Mr McCarthy added that it was vital that doctors made clinical decisions for the benefit of service users and not as a result of pressure in relation to the availability of beds. Mr Hindle acknowledged Mr McCarthy’s concerns, stating that the Trust were undertaking significant work in relation to bed management. There had been a 50% reduction in service users

Agenda Item No: F1

Page 88 of 94

needing to be accommodated in out of area beds in the current year and this was monitored on a daily basis. Bed managers had been employed and discharges were planned on the day of the service users’ admission. Mr Hindle stated that this was an important quality metric which had an impact on other areas of the service. Mr McCarthy highlighted the need for additional capacity and the importance of discharges being strictly clinically advisable. Mr O’Keeffe concurred, acknowledging that due to the significantly higher demand services were stretched, assuring Mr McCarthy that this issue was under constant discussion at every Performance, Investment and Finance Committee and agreed to ensure that going forward, an exception report would be provided to the Council of Governors.

20.


Recommendations approved by the Council of Governors, namely: • Note the content of this report

Further actions required: • Session on Zero Suicides to be provided to

Governors at the next CoGs; • Staff vacancies and recruitment/ retention update to

be provided to the next CoGs; • Finance and Activity Performance Reports to CoGs

to include an exception report in relation to bed management and out of area transfers;

D Fearnley A Oates R Walker (J Billingsley)

Jan-18 Jan-18 Jan-18 and on-going

On Jan-18 CoGs Agenda On Jan-18 CoGs Agenda Jan-18 and on-going

B2 SPECIALIST LEARNING DISABILITY DIVISION – RETRACTION PLAN

UPDATE

21. Mr Hindle provided an update regarding the retraction of services within the Specialist Learning Disability Division, confirming that within the national policy of transforming care, NHS England had stated it was imperative that the Whalley sight closed. The Trust were focussing on primary prevention and supporting people in their homes and community which would be beneficial to the service users and prevent the need for beds. Mr Hindle noted that currently, there was a small community team which in the future would be expanded to have capacity to support 6000 people in the community. Mr Hindle assured governors, that staff worked hard to provide the best service within a community setting as quickly as possible.

22. Mr Hindle referred to the discharge rates (page 2 of the report) which were currently at a 60% failure rate against the trajectory determined by commissioners. Within the Trust, service users were monitored against risk factors and it was the Trust’s responsibility to ensure service users were ready to be discharged and that the timescales for this were realistic.

23. Mr Hindle highlighted the continual challenge of recruiting staff, adding that safer staffing level details were regularly provided to the Board.

24. Mr Hindle highlighted plans for:

o NHS England’s confirmation to commission 40 learning disability beds in the proposed new medium secure unit at Maghull;

o NHS England’s confirmation to commission 40 low secure learning disability beds;

Agenda Item No: F1

Page 89 of 94

o Step down and enhanced support service – the Strategic Partnership Board would closely manage individuals’ discharge pathways as a priority and the Trust, with commissioners, had been asked to revise discharge trajectories for each individual, escalating any barriers;

o Specialist Support Teams (Community Provision) – Recruitment was actively underway for posts for Lancashire and Greater Manchester;

25. In response to Mrs Birrell’s question regarding the future of the Whalley site, Mr Hindle stated that there were plans to reuse some of the buildings on the site, but approval had not yet been received for this. Mrs Darbyshire added that the Trust were progressing well with the Medium and Low Secure Units and discussions were continuing with NHS England regarding the Whalley site. The Trust were keen to make use of the site, possibly for some community services and options were being considered. In response to Mrs Birrell, Mrs Darbyshire confirmed that although the site was a Trust asset, approval was required by the Treasury for any plans.

26.


Recommendations approved by the Council of Governors, namely: • Note the progress to date regarding the retraction

plan and the reasons for the delay’s; • Note the next steps around the planned work with

commissioners to progress timely and safe discharges;


B3 ANNUAL PLANNING PROCESS 18/19

27. Mrs Edwards provided an update on progress in the delivery of the Trust’s Operational Plan 2017/18 and the proposed approach to the refresh of this two-year Operational Plan for 2018/19. Mrs Edwards stated that governors had an active role in holding executives to account for the delivery of the plan and it was important that all governors were involved in the process.

28. Mrs Fraenkel stated that further discussion on this would be held in more detail in the development session taking place after today’s Council of Governors meeting.

29.


Recommendations approved by the Council of Governors, namely: • Note the update on delivery of the two-year

operational plan and the proposed refresh of the plan as described in this paper;

• Note that the draft Operation Plan 2018/19 will be considered by the Council of Governors in January 2018;


Agenda Item No: F1

Page 90 of 94

C1 LIVERPOOL COMMUNITY HEALTH UPDATE

30. Mr Meadows informed Governors that the Trust had now been identified by NHS Improvement as the preferred supplier for Liverpool Community Health (LCH) Services. Mr Meadows explained that this was the beginning of the process and the development session to be held after the Council of Governors meeting today would provide further details.

31. Mr Meadows highlighted the key issues as follows:

a) “Preferred Acquirer” status did not mean that Mersey Care would automatically acquire LCH. As a ‘significant transaction’ the Trust was now required to go through an approvals process overseen by NHS Improvement;

b) If approved, Mersey Care would acquire LCH on 1 April 2017; c) This report outlined the timetable for the transaction and the role of the Council of

Governors; d) NHS Improvement had asked Mersey Care to assume responsibility for a

Management Agreement to support LCH from 1 November 2017;

32. Mr Meadows confirmed that full ‘due diligence’ would be undertaken to address the risks and mitigations associated with the transaction. Due to the changes proposed, Mr Meadows also advised that there was a need to review the Constitution in respect of the membership constituencies and Council of Governor vacancies, therefore proposed that a Governor Reference Group was established to progress this. Mr Meadows confirmed that an email would be circulated to all governors to request nominations for involvement in this group.

33.


Recommendations approved by the Council of Governors, namely: • Note the content of this report; • Approve the establishment of a ‘Governor Reference

Group’ and nominate Governors to be members of this Group;

Further actions required: • Email all governors requesting nominations for

Governor Reference Group;

A Meadows

Nov-17

Due Nov-17

D1 LEAD GOVERNOR ELECTION RESULT

34. Mr Meadows confirmed that nominations for Lead Governor had been requested and Mrs Tetlows nomination had been unopposed, therefore in line with the constitution and with the agreement of Governors, Ms Tetlow would continue as Lead Governor for a further 12 months.

35.


Recommendations approved by the Council of Governors, namely: • Note the unopposed nomination of Ms Tetlow and

agree to a further 12 months term of office as Lead Governor;

Agenda Item No: F1

Page 91 of 94


D2 GOVERNANCE UPDATE REPORT

36. Mr Meadows provided a Governance Update which included;

a) A number of amendments to the Constitution were proposed for approval by the Council of Governors;

b) Amended terms of office were proposed in respect of Non-Executive Director, Dr Rob Beardall;

c) Outcomes of the 2017 Council of Governor elections which had now concluded and subject to completion of the relevant eligibility checks, 9 new Governors would be appointed. Five vacant seats would remain;

d) An Induction, Training and Development Plan which had been developed to ensure Governors were provided with the skills necessary to undertake their role;

e) The minutes of the Membership and Engagement Committee which met on 11 August 2017;

f) An update on Non-Executive Director appraisals which would be undertaken in Jan – Apr 2018 and it was proposed that a revised process was considered by the Nomination and Remuneration Committee prior to presentation to the Council in Jan 2018;

g) The Governor Handbook which had been updated to incorporate the Council’s Committee’s Terms of Reference;

h) The Council of Governors Annual Report 2016/17 which had been prepared in line with good practice.

37. Mr Meadows assured Governors that the four proposed amendments to the Constitution had been agreed by the Board of Directors at its meetings on 26 July and 30 August 2017 and were recommended to the Council of Governors for approval as below: a) In relation to the Council’s quorum, Mr Meadows proposed that in line with

discussions held by governors in the Membership & Engagement Committee, the quorum was amended to 50% plus one of governors in post. Mr McCarthy raised a concern in relation to the potential loosening controls which may result from revising the quorum. Mr Meadows assured governors that the percentage would relate to all governors in post and omit vacancies only, adding that it was likely there would often be vacancies which impacted on the percentage of a quorum. In response to Mr McCarthy’s proposal relating to virtual attendance at Council meetings, Mr Meadows advised that virtual participation was not permitted for Council of Governor meetings. In response to Mrs Birrell, Mr Meadows confirmed that the Council of Governors were able to review the quorum as outlined in the Constitution at any time deemed appropriate by Governors or the Trust, adding that any proposed changes to the Constitution must be approved by the Board and the Council of Governors. Governors agreed the proposal.

b) Mr Meadows highlighted the proposal to disband and remove the Perfect Care and Wellbeing Advisory Panel from the Trusts governance structure as the panel had served its purpose and had not met in some time. Should the Council of

Agenda Item No: F1

Page 92 of 94

Governors be content to approve the proposal to disband the Advisory Panel, then paragraph 6.10.1 of Annex 9 (Standing Orders for the Board of Directors) of the Constitution need to be removed. In addition, the terms of reference for the Advisory Panel will be removed from Appendix G of the Trust’s Scheme of Reservation and Delegation of Powers. Governors agreed the proposal.

c) In light of the title of the Performance & Investment Committee being amended to

‘Performance, Investment & Finance Committee’, it was proposed that paragraph 6.9.5 of the Constitution be amended to reflect this change. Governors agreed the proposal.

d) Mr Meadows proposed that the term of office for newly elected Governor posts for

Calderstones be agreed at 3 years. Governors agreed the proposal.

38. Mr Meadows proposed an extension to the term of office of the Non Executive Director, Rob Beardall, which had not been included in the extension of other Non Executive Directors agreed by Governors previously. Mr Meadows assured Governors that there had been no issues with regard to Dr Beardall’s appraisal or performance which would give any cause for concern. Governors agreed the proposal.

39. At the request of the Chair, Mr O’Keeffe introduced himself to the Council as the Senior Independent Director and outlined the purpose of this role.

40.


Recommendations approved by the Council of Governors, namely: • consider and approve the changes to Annex 6, Annex

7, Annex 8 and the two changes to Annex 9 of the Trust’s Constitution, as described in this report (as recommended by the Board of Directors);

• consider and approve the proposed terms of office for Dr Rob Beardall outlined in this paper;

• note the outcomes of the 2017 Council of Governors elections (Appendix A);

• note the proposal for arrangements for elections for those Governors initially appointed a 2-year term of office

• consider and approve the proposed Governor Induction, Training and Development Plan (Appendix B);

• note the minutes of the Membership and Engagement Committee meeting held on 11 August 2017 (Appendix C);

• note the arrangements to review the Non-Executive Director appraisal process and report this to the Council of Governor in January 2018 for approval;

• consider and approve the amendments to the Governor Handbook (Appendix D);

• consider and approve the Council of Governors Annual Report 2017/18 (Appendix E).


Agenda Item No: F1

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E1 ANY OTHER BUSINESS

41. No other business was raised.


Agenda Item No: F1

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END OF DOCUMENT

Agenda Item No: G1

Page 1 of 4


To Note: ☒ For Assurance: ☒ Report to: Board of Directors’


REPORTING, MANAGEMENT AND REVIEW OF ADVERSE INCIDENTS

Accountable Director(s): Ray Walker, Executive Director of Nursing Report Author(s): Steve Morgan, Director of Safety



(STEEP)






Purpose of Report:

1. This document explains: - a) why the policy is necessary (rationale) b) to whom it applies and where and when it should be applied

(scope) c) the underlying beliefs upon which the policy is based

(principles) d) the standards to be achieved (policy) e) how the policy standards will be met through working

practices (procedure) 2. This policy and its implementation has been reviewed following

its initial launch in June 2003 and alterations made following discussions with clinicians, service users, carers, managers and external stakeholders to ensure continuous improvement of the process. This policy and procedure will be further developed and amended as per Trust guidelines


3. The effective management of adverse incidents is an integral part of the way the Trust meets its duty to minimise the risk to its service users, carers, staff and visitors, with the aim of maintaining their health and safety. This Policy has been developed to provide a systematic approach to maintaining compliance with all guidance on this topic area.

4. Its aim is to ensure that there is a well governed, structured and systematic approach to the reporting, logging, review, of incidents with an associated high standard for the ratification of incident reports and implementation of action plans. The objectives of the policy include: - That staff will know how and when to report an adverse

incident. That a thorough examination of Serious and Untoward

Incidents will take place with the aim of learning how systems and processes can be changed to reduce future harm being caused.

Agenda Item No: G1

Page 2 of 4

Individuals involved or affected by incidents will be actively engaged in the incident review process as per the Department of Health’s Duty of Candour policy.

That data on the level and type of reporting and associated harm experienced can be accessed easily by clinical and managerial staff so that they can monitor for trends and implement appropriate safety measures.

The Board of Directors and its Executive Directors will be made aware of risk issues related to the management of adverse incidents.

5. This Policy is applicable to all staff throughout the Trust and those engaged with it including contractors who work on behalf of the Trust whose activities give rise to incidents occurring.

Recommendation:

The Board of Directors is asked to: 1) Discuss and ratify the policy. 2) Identify any further assurances it requires


Continue to implement the key standards of the policy and enhance the ability of the Trust to implement associated learning.

Agenda Item No: G1

Page 3 of 4




Patient Safety

☒ ☐

Managing adverse incidents effectively is a key part of the way a Trust can show that wants to provide a safe care for its service users, carers and staff. Trust’s have a duty to learn from incidents by making changes to practice and systems to reduce the likelihood of a further similar incident occurring.

Clinical Effectiveness ☒ ☐

Patient Experience ☒ ☐


CQC Compliance ☒ ☐ CQC require trusts to have a robust policy and procedure for

managing and learning from incidents.


Legal / Requirements ☒ ☐ HM Coroner expects Trust’s to be able to share learning from

incidents during an inquest process.








☐






Agenda Item No: G1

Page 4 of 4

APPENDIX A – MANAGEMENT, REPORTING AND REVIEW OF ADVERSE INCIDENTS POLICY:

VERSION 2 – NOVEMBER 2017

Agenda Item No: G1

SA03 REPORTING, MANAGEMENT & REVIEW OF ADVERSE INCIDENTS (v2 Nov 2017) 1

TRUST-WIDE NON-CLINICAL DOCUMENT


(including serious untoward incidents and near misses)

Policy Number: SA03

Scope of this Document: All Staff

Recommending Committee: Patient Safety Committee

Approving Committee: Board of Directors

Date Ratified: November 2017

Next Review Date (by): November 2019

Version Number: 2017 Version 2

Lead Executive Director: Executive Director of Nursing

Lead Author(s): Director of Patient Safety


2017 – Version 2 Striving for perfect care for the people we serve

Agenda Item No: G1




Further information about this document:

Document name REPORTING, MANAGEMENT AND REVIEW OF ADVERSE INCIDENTS (SA03)

Document summary

The effective management of adverse incidents is an integral part of the way the Trust meets its duty to minimise the risk to its service users, carers, staff and visitors, with the aim of maintaining their health and safety. This Policy has been developed to provide a systematic approach to maintaining compliance with all guidance on this topic area. Its aim is to ensure that there is a well governed, structured and systematic approach to the reporting, logging, review, of incidents with an associated high standard for the ratification of incident reports and implementation of action plans. The objectives of the policy include: -

• That staff will know how and when to report an adverse

incident. • That a thorough examination of Serious and Untoward

Incidents will take place with the aim of learning how systems and processes can be changed to reduce future harm being caused.

• Individuals involved or affected by incidents will be actively engaged in the incident review process as per the Department of Health’s Duty of Candour policy.

• That data on the level and type of reporting and associated harm experienced can be accessed easily by clinical and managerial staff so that they can monitor for trends and implement appropriate safety measures.

• The Board of Directors and its Executive Directors will be made aware of risk issues related to the management of adverse incidents.

This Policy is applicable to all staff throughout the Trust and those engaged with it including contractors who work on behalf of the Trust whose activities give rise to incidents occurring.

Agenda Item No: G1


Author(s)

Contact(s) for further information about this document

Steve Morgan Director of Patient Safety

Telephone: 0151 473 2874 Email: [email protected]

Published by

Copies of this document are available from the Author(s) and

via the trust’s website

Mersey Care NHS Foundation Trust V7 Building

Kings Business Park Prescot

Merseyside L34 1PJ

Your Space Extranet: http://nww.portal.merseycare.nhs.uk Trust’s Website www.merseycare.nhs.uk

To be read in conjunction with

Policy and Procedure for the Management of Complaints and Concerns (SA06)

• Being Open Policy (SA13) • Policy and Procedure for the Reporting Management and

Investigation of Claims (SA05) • Health and Safety and Wellbeing Policy (SA07) • Risk Management Policy and Strategy (SA02) • Policy for the Recognition, prevention and therapeutic

management of Aggression and Violence (SD 18) • Policy For Safeguarding Adults From Abuse (SD17) • Procedure for the Systematic Approach to the Analysis and

Learning from Incidents, Complaints and Claims (SA32) • Policy and Procedure for Reviewing And Implementing The

Recommendations of National Confidential Enquiries/ Inquiries (SA33)

• Support / Information available to staff following their involvement in Complaints, Claims, Incidents and Inquests (Guidance Document)

• Major incident plan (SA31) • South Sefton Community Division guidance for the

Management of Incidents • Learning from Deaths Policy (SA45)

This document can be made available in a range of alternative formats including various languages, large print and braille etc

Copyright © Mersey Care NHS Foundation Trust, 2015. All Rights Reserved

Version Control: Version History:

2015 – Version 1 Board of Directors’ 2015 2017 – Version 1.1 LCH Update July 2017 2017 – Version 2 Policy Group October 2017

2017 – Version 2 Board of Directors November 2017

mailto:[email protected]

http://nww.portal.merseycare.nhs.uk/Pages/MCNHSHome.aspx

http://www.merseycare.nhs.uk/

Agenda Item No: G1

SA03 REPORTING, MANAGEMENT & REVIEW OF ADVERSE INCIDENTS (v2 Nov 2017)

4

SUPPORTING STATEMENTS

This document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESS

All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: • being alert to the possibility of child / adult abuse and neglect through their

observation of abuse, or by professional judgement made as a result of information gathered about the child/ adult;

• knowing how to deal with a disclosure or allegation of child / adult abuse;

• undertaking training as appropriate for their role and keeping themselves updated;

• being aware of and following the local policies and procedures they need to follow if they have a child/ adult concern;

• ensuring appropriate advice and support is accessed either from managers, Safeguarding Ambassadors or the trust’s safeguarding team;

• participating in multi-agency working to safeguard the child or adult (if appropriate to your role);

• ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;

• ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

EQUALITY AND HUMAN RIGHTS

Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.

The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy

Agenda Item No: G1


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Contents

Section Page No

1. Purpose and Rationale 6

2. Outcome Focused Aims and Objectives 7

3. Scope 8

4. Definitions 8

5. Duties 9

6. Process 14

7. Consultation 31

8. Training and Support 32

9. Monitoring 32

10. Equality and Human Rights Analysis 33

11. Supporting Documents 39

Appendices 40

Agenda Item No: G1


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1. PURPOSE AND RATIONALE

1.1 This document explains: -

a) why the policy is necessary (rationale) b) to whom it applies and where and when it should be applied (scope) c) the underlying beliefs upon which the policy is based (principles) d) the standards to be achieved (policy) e) how the policy standards will be met through working practices (procedure)

1.2 This policy and its implementation has been reviewed following its initial launch in

June 2003 and alterations made following discussions with clinicians, service users, carers, managers and external stakeholders to ensure continuous improvement of the process. This policy and procedure will be further developed and amended as per Trust guidelines.

Rationale

1.3 The reporting of adverse incidents is a key and fundamental aspect of the Trust’s

approach to enhancing the safety of service users, carers and staff. A comprehensive adverse incident reporting system acts as an ongoing method for identifying risks and thereby aids both reactive and proactive risk management: -

a) Reactive in terms of managing the situation and preventing further

damage/incidents occurring. b) Proactive in identifying actions that can be done to prevent a further adverse

incident occurring, or minimise the consequence of such incidents in the future. c) Failure to report incidents, or under reporting of near misses, could lead to adverse

incidents recurring, which may result in injury to service users, carers or staff.

1.4 The management of adverse incidents needs to ensure that learning is facilitated and achieved. Systems need to be in place to give staff, service users and carers the opportunity to critically evaluate practice and learn from adverse incidents that may occur.

1.5 The purpose of this policy and procedure is to ensure the prompt and effective

reporting and management of all adverse incidents. It establishes a framework for: -

a) Defining and classifying all adverse incidents. b) Reporting effectively all adverse incidents internally and to its partner agencies i.e.

NHS England, CCG, National Reporting and Learning System and Counter Fraud and Security Management Services.

c) Ensuring a thorough examination of adverse incidents takes place by those staff involved.

d) Bringing incidents to the attention of the Division. e) Enabling staff, service users, their families and carers to express their feelings

regarding incidents, being involved in the review process and receiving feedback on the reports findings. (Duty of Candour )

f) Ensuring that recommendations made following an SIRI review are implemented and are used to direct work to enhance service provision and that delays in completing these are noted, understood and removed.

g) Ensuring lessons are learnt and action plans are in place to address weaknesses

Agenda Item No: G1


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and prevent further occurrences of adverse incidents.

1.6 Mersey Care NHS Foundation Trust will be performance managed by the North West NHS England, Specialist Commissioners and Clinical Commissioning Groups with regards to the reporting and reviewing of Serious Incident Requiring Investigation (SIRI).

1.7 The Board of Directors will receive regular reports on all incidents reported to StEIS

and the progress made with reviewing and learning from their investigations.

1.8 The purpose of this policy and procedure is not to apportion blame in relation to any individual but to achieve the purpose set out above. However, should negligence be identified through the review process, this will need to be addressed appropriately. Any disciplinary procedures/investigations will be undertaken separately from the review of the incident.

1.9 This policy and procedure is intended to be compliant with the European Convention

on Human Rights where possible and insofar as it is applicable.

2. OUTCOME FOCUSED AIMS AND OBJECTIVES

2.1 This policy is based on the seven key principles of incident management as outlined by the Serious Incident Framework (2015) that all incidents must be managed: -

a) In an Open and transparent manner , for example Staff, service users, their

relatives and carers should, where appropriate, be given the opportunity to critically appraise incidents that have arisen and the outcomes of the review that has taken place.

b) With future prevention as a key aim, a culture of learning required in order for the Trust to develop and improve the way care is organised and delivered.

c) In an Objective style d) In a Timely and responsive way e) Based on systems as opposed to seeking to lay individual blame. f) Proportionately to the risks identified and outcomes experienced. g) Collaboratively, working closely with commissioners and other key

providers.

2.2 All adverse incidents will be: -

a) Reported using the Local Risk Management System b) Risk assessed to ensure the environment/ individuals involved are safe and secure c) Logged as appropriate within clinical records which will also be secured in relation

to fatal injures d) Assessed for seriousness, and where identified appropriate senior clinicians and

managers will be informed. e) Serious incidents will be investigated and if appropriate reported to performance

managers and the NHS Northwest via the Strategic Executive Information System (StEIS). Guidance for the SIRI reporting criteria is in the NHS England reporting framework.

f) All adverse incidents will be reviewed and approved on the Local Risk Management System in accordance with the guidelines enclosed.

Agenda Item No: G1


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2.3 Service users and carers will be empowered, where appropriate, to become involved in the investigations of serious and untoward incidents as part of the trust’s adherence to Duty of Candour guidance.

2.4 All staff directly involved in adverse incidents will be provided with the opportunity to

reflect on and learn from the incident in a non-judgemental and open environment as part of the review process.

2.5 Each Clinical Division has a system which reviews, agrees and monitors

recommendations, action plans, time scales and implementation process. The Trust’s Risk Management System’s action planning module will be used to track completion, a report is shared with the Quality Assurance Committee bi monthly which outlines all; actions outstanding and the reasons why

3. SCOPE

3.1 An adverse incident is defined as any event or circumstance that could have or did

lead to unintended or unexpected harm, loss or damage relating to service users, members of staff, the public, and the environment or Trust property. Incidents that did lead to harm are referred to as adverse events. Incidents that did not lead to harm, but could have are referred to as near misses (adapted from: National Patient Safety Agency, 2001).

3.2 The policy applies to all incidents that: -

a) Occur on Trust premises. b) Occur off Trust premises but involve persons employed by the Trust whilst on Trust

business. c) Involve any patient receiving care from the Trust – including joint mental health

services with local authorities. d) Involve any patient who has been open to one or more Mersey Care NHS

Foundation Trust services within the last 12 months e) All service user deaths f) Low level harms

4. DEFINITIONS

4.1 Serious Incident Requiring Investigation (SIRI) - Serious incidents requiring

investigation were defined by the NPSA’s 2010 National Framework for Reporting and Learning from Serious Incidents Requiring Investigation In summary, this definition describes a serious incident as an incident that occurred during NHS funded healthcare (including in the community), which resulted in one or more of the following;

a) unexpected or avoidable death or severe harm of one or more patients, staff or

members of the public; b) A never event - all never events are defined as serious incidents although not all

never events necessarily result in severe harm or death. (See Never Events Framework);

Agenda Item No: G1


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c) A scenario that prevents, or threatens to prevent, an organisation’s ability to continue to deliver healthcare services, including data loss, property damage or incidents in population programmes like screening and immunisation where harm potentially may extend to a large population;

d) allegations, or incidents, of physical abuse and sexual assault or abuse; e) loss of confidence in the service, adverse media coverage or public concern

about healthcare or an organisation.

4.2 Near miss - any unintended or unexpected incident that was prevented by some form of intervention and so resulted in no harm but without the intervention may have resulted in harm to one or more patients receiving NHS funded healthcare (NPSA).

4.3 Security incident - thefts, deliberate damage to property etc.

4.4 Environmental Incident – the release of a substance (either accidentally or by

malicious act) of a substance prohibited by environmental legislation or a substance released in sufficient quantities to cause environmental pollution or damage. For example, spillage of chemicals or oil, release of harmful chemicals to sewers or watercourses. A ‘major environmental incident’ would be one requiring the involvement of a regulatory authority due to the volume / toxicity of the substance released.

4.5 Data breaches, these should all be reported via the risk management system and

graded to ascertain if they need to be reported via StEIS, reported to the Information Commissioner’s Office (ICO) and investigated.

Never Events

4.6 In 2015 the Department of Health published updated guidance on “Never Events” for

use by Trusts and commissioners.

4.7 “Never Events” are defined as ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers’.

5. DUTIES

5.1 Chief Executive

a) Agrees the level of investigation to take place for some Serious and Untoward Incidents usually Homicides and inpatient deaths.

b) Agrees a communications plan, which includes drawing up a briefing paper for the Board of Directors.

c) Ensures that Level 3 Reports (Independent Investigations) into Serious and Untoward Incidents are presented to the Board of Directors and that the action plan is monitored by the Quality Assurance Committee (QAC).

d) Actively supports the effective management of the Adverse Incident Management process and is ultimately accountable for its implementation.

5.2 Executive Director of Nursing

a) Accountable Director for Adverse Incident Management.

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Agenda Item No: G1


b) Advises the Chief Executive on the outcome of the Serious Incidents (SI) investigations and any associated risk that have been identified.

c) Ensures that there is robust management of adverse incidents on a day to day basis and that a report is shard on a bi monthly basis with the Quality Assurance Committee on the number of adverse incidents reported and actions taken to prevent further similar ones occurring.

5.3 Chief Operating Officer / Associate Medical Director / Executive Director of

Operations

a) Ensures risk management procedures are in place. b) Ensures local induction is in place for new staff. c) Ensures that an adequate level of investigation is conducted within the Division in

accordance with this policy and procedure. d) Ensures that contact with families following serious incidents is maintained as per

the Duty of Candour directives. e) Ensures as a delegated responsibility that initial service management investigation

reports are verified and forwarded within the specified timescale of 3 days. f) Ensures as a delegated responsibility that divisional investigations into serious

untoward incidents are conducted and completed within 60 working days. g) Responsible for having systems in place which will ensure that action plans are

implemented within the timeframe and reported. h) Allocates a member of staff to be the Divisional Adverse Incident lead. i) Ensures that all staff in the Division are aware of and operate within the Adverse

Incident Policy (SA03)

5.4 Divisional Risk Lead

a) Will take delegated responsibility for ensuring that the adverse incident policy is understood and implemented in the Division

b) Attends and reports to the Divisional Adverse Incident /Risk Group. c) Attend the Trust Wide Patient Safety Group d) Identity gaps in the implementation of the policy and procedure and report to the

Chief Operating Officer. e) Identify trends in incident reporting and plan remedial monitoring activity. f) Close incidents on the Local risk management system. g) Develop, monitor the use of and support the divisional system which ensures that

every incident which occurs in the Division is reviewed, that identifies trends and highlights risks with Chief Operating Officer.

5.5 Divisional Managers /Operations Manager

a) Are responsible for ensuring that all staff members are aware of and operate within the Adverse Incident Policy (SA03).

b) They are responsible for notifying the Chief Operating Officer / Associate Medical Director of all serious incidents which may require reporting to external agencies.

c) They are responsible for the investigation of all serious incidents within their service and providing the final report to the divisions Risk Lead.

d) They are responsible for ensuring all incidents are reviewed on the local risk management system.

5.6 Director of Patient Safety

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Agenda Item No: G1


a) Is responsible for the management of the Trust’s adverse incident process on a day to day basis.

b) Provides advice and support to Divisional Teams. c) Coordinates investigations of serious untoward incidents d) Co-ordinates and oversees the management and investigation of serious untoward

incidents including the Trust inquiries. e) Supports systems of learning from serious incidents in order to reduce the risk. f) Ensures that reports submitted to the Coroner’s Office are clear and factually

accurate. g) Ensures that staff are supported in Coroner’s inquest proceedings and other formal

inquiries. h) Maintains a status report on all serious untoward incidents. i) Ensures the incident is reported to the host and commissioning CCG where

appropriate. j) Ensures all incidents are entered onto the Trust risk database (local risk

management systems). k) Ensures the quarterly incident trend analysis is presented to the Board of

Directors and its Committees. Adverse Incident Management Group and the Health & Safety Committee.

l) Ensures incidents are reported to the National Reporting and Learning System (NRLS).

m) To monitor human rights issues that emanate from severe incidents

5.7 Risk Management System Administrators

a) Once the Adverse Incidents Team become aware of an adverse incident they will: - i. Assess if external reporting or media briefing necessary? If yes, contact

the Communications Department. Report to outside agencies as required.

ii. Make final grading using NRLS classification system b) Share reports/incident data as appropriate with Specialist Departments c) Quarterly report on all adverse incidents prepared for Patient Safety Committee

and Chief Operating Officers d) Reports incidents of violence against staff to the Counter Fraud and Security

Management Service e) Highlight any identification of clusters of incidents and share with the Director of

Patient Safety.

5.8 Patient Experience Manager

a) Will lead the implementation of the Duty of Candour (DoC) process. b) Will ensure that all incidents that meet the criteria for DoC are shared with the

family as per national guidance. c) Will accompany reviewers to share the report and support those taking on the

role of Family Liaison Manager to do this. d) Will provide training for those undertaking the Family Liaison manager role. e) Will provide DoC information for the Quality Assurance Committee annual

report. 5.9 Serious Incident and Claims Lead

a) With the Senior Manager responsible, agree whether a serious incident investigation or reflective practice investigation is to be implemented

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Agenda Item No: G1


b) Monitor the timely completion of investigation reports and liaise directly with the lead CCG regarding request for extensions etc

c) Send investigation reports to the CCG / NHS England within the agreed timescales d) Monitor and update Actions Plans e) Collate Division responses for the CCG Quarterly Quality Report and produce the

report with the Director of Patient Safety f) Produce bi-annual report on all incidents for CQPG meeting with Director of Patient

Safety.

5.10 Mortality and Incident Review Practitioner Team (M.I.T.)

a) Monitor and cross reference deaths reported via the Trust’s risk management and clinical records system

b) Complete an initial assessment of all deaths that are in the agreed scope of the mortality review process.

c) Decide if further reviews are required to learn from any deficits identified and implement the Adverse Incident policy as required.

d) Ensure Duty of Candour responsibilities are undertaken for deaths. e) Ensure that learning is shared via the Mortality Review Group f) Act as family Liaison Managers to implementation DoC procedures. g) Undertake RCA reviews across the organisation which are referred to them by the

Clinical Divisions.

5.11 Modern Matrons / Clinical Team Managers

a) Modern Matrons have the responsibility for monitoring the adherence to the Adverse Incident Policy (SA03) within their service on a daily basis.

b) They have responsibility for ensuring that any appropriate training associated with Adverse Incident Policy (SA03) is undertaken by nursing staff within their service.

c) Modern matrons have responsibility for ensuring that all incidents are approved on the local risk management system.

5.12 Multidisciplinary Teams

a) The MDT discusses the incident and care plans amended as necessary. The process, outcome and rationale for not needing further investigation following the incident should also be recorded in the case notes.

b) They will become involved with Post incident investigations when required and will actively use information gained from Adverse Incidents in the management of their patients.

c) Where appropriate all seventy Two Hour Reports should be undertaken via the Multi Disciplinary Team process and agreed by the consultant involved.

5.13 The staff in charge of the area where the incident has occurred

a) The member of staff in charge of an area is responsible for managing any incident in line with the Adverse Incident Policy (SA03) including delegation to another, or managing the incident her/himself.

b) If the incident includes a patient they must ensure that the incident is discussed during the next multidisciplinary meeting for the individual and care plans amended appropriately. Any agency or bank staff must be made aware of Trust protocol and procedures.

c) Ensure members of staff involved in or discovering incident completes an incident

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Agenda Item No: G1


report on the trust’s Risk Management system. If a service user been involved clinical records should be completed.

d) If a contractor is involved the relevant Estates Manager must be notified along with the Health & Safety Manager. All incidents involving visitors, including relatives, must also be referred to the Claims Manager.

5.14 Staff working in the area where the incident occurs

On discovery of an adverse incident, a member of staff involved in or discovering the incident should inform the member of staff in charge of the area at the time. The member of staff in charge should then ensure that they make a contemporaneous record of events on the trust’s Risk Management System. Where appropriate photographs should be taken as evidence and forwarded to the Senior Manager Responsible for inclusion in the incident report.

5.15 All Staff within Mersey Care NHS Foundation Trust

All staff have a duty to report any incident involving themselves when it occurs on Trust premises or anywhere if they are undertaking Trust business. Staff must act in line with this policy and also report incidents they become aware of involving service users, carers, relatives, visitors, contractors or any other person involved in an incident. If a Carer raises concerns regarding an incident they have a responsibility of making certain this is reported in line with the Adverse Incident Policy (SA03).

Groups and Committees

5.16 Board of Directors

5.16.1 The Board of Directors is responsible for ensuring that the Adverse Incident Policy (SA03) is in place via its governance arrangements and that all staff working in the Trust are aware of, and operate within the policy.

5.16.2 Consider and approve identified Serious and Untoward Incident reports and Level 3

reports and their action plans which will be provided by the Divisions.

5.16.3 Quality Assurance Committee minutes will be shared with Board of Directors which will include reflections on adverse incident management.

5.17 Quality Assurance Committee

5.17.1 The Committee will receive an annual report on the occurrences of and management of adverse incidents which will include an analysis of protected characteristics.

5.17.2Will receive high level performance reports on the occurrence of Serious and

Untoward Incidents , achievement of set targets, any associated risk issues , analysis of incidents against protective characteristics and actions taken to enhance safety on a bi-monthly basis.

5.18 Patient Safety Committee

5.18.1 This Committee is chaired by the Senior Manager responsible for Adverse Incident

management within the Trust; its members have responsibility for monitoring the

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Agenda Item No: G1


effectiveness of the implementation of the Trust’s Adverse Incident Policy and adherence to national guidelines. Each Division is represented by their Adverse Incident Lead. This Group will: -

a) Share incident information across Divisions to share learning and risk information

and monitor the actions of Divisions. b) Disseminate external inquiry information / reports and monitor the actions of

Divisions c) Monitor the adherence to the trust’s Adverse Incident Policy. d) Develop new initiatives regarding the management of adverse incidents e) To monitor the effect of adverse incidents on human rights issues and

factors contributing to incidents related to breaches of human rights.

5.19 Divisional Governance

5.19.1 Each Division will have a forum that will oversee its management of and learning from Adverse Incidents, this Group will be chaired by its Adverse Incident Lead. It provides a vehicle to: -

a) Validate all incident investigation reports. b) Monitor trends and plan remedial action to reduce occurrence. c) Monitor the completion of actions plans. d) Monitor adherence to the Trusts Adverse Incident Policy.

5.20 Safe from Suicide Team

a) Support all investigations identified as either a suicide or a near fatal self harm b) Support members of staff charged with Duty of Candour responsibilities for families

bereaved by suicide. c) Identify appropriate avenues of support or treatment for bereaved families d) Support investigation team to feedback lessons learned. e) Identify trends and implement remedial action in conjunction with local risk leads

6 PROCESS

6.1 This is a corporate procedure to be applied within Local and Secure Divisions and Corporate Division in Mersey Care NHS Foundation Trust.

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Agenda Item No: G1


Reportable toSTEIS

Member of staff involved in or discovering an adverse incident

(Inform member of staff in charge (if not involved in incident)

Member of staff in charge 1. Prioritise remedial actions and risk assessment to ensure safety of persons

and area. 2. Informs service user / carer of incident 3. Informs Service Manager /on call manager. 4. Ensures Datix report form is completed. 5. If a service user was involved, ensure case notes / nursing records are

completed. 6. Agree any immediate action with those involved.

Service Line Manager Notified

Modern Matron Patient Safety Team

Chief Operating

Officer / Associate

Adverse Incident Team 1. Notifies Clinical

Division lead 2. Notifies specialist

teams of relevant incidents.

3. Notify Division’s of safeguarding incident

4. Report externally if necessary.

5. Liaise with Communication Dept.

6. Notify specialist teams of incidents relevant to their area.

7. With divisional risk lead identify type of review required.

Medical Director

Major Incident

Plan

Assess Severity of Incident

Is this a major incident?

Is this reportable to STEIS?

What level of investigation, if any is needed?

Minor Incident

8. Inform CCG Incident Lead who will agree a process for reviewing the STEIS.

9. Supply quarterly data to Division for them to identify trends and monitor actions taken

10. Monitor SI reviews. 11. Monitor Safeguarding

reviews

Investigation Required

Clinical Division 1. Reviews the incident on the Datix system 2. Ensure incident reviewed at MDT and care plans amended as

necessary 3. Ensure process and outcome recorded in case notes 4. Commence a Seventy Two Hour review as agreed with CCG and

Adverse Incident Team 5. Allocate Family Liaison Manager 6. Ensure staff involved receive a debriefing. 7. Ensure contact is made with other key stakeholders 8. Set up adverse incident Review/investigation where required

Modern Matron/Senior Manager 1. Approves the incident on the risk management system

Divisional Risk Group 1. Reviews incidents re trends and any associated report 2. Makes recommendations 3. Monitors completion and effectiveness of recommendations

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Incident Review & Approval

The Purpose of the Initial Incident Review & Approval

6.2 Each incident should be reviewed and approved by managers with knowledge or responsibility in area the incident occurred. The Division will decide who the reviewers and approvers will be. Typically a Ward manager would review an incident and the Modern Matron would approve it. However as Teams and Departments vary widely the Division has discretion to choose reviewers and approvers that meet their organisational needs.

The Purpose of the Review

6.3 The initial review is not an in depth analysis and should not be confused with a

Seventy Two Hour Review or a post incident review. The initial review will ensure that the management within the Division is aware of the incident and has made a judgement about its seriousness and whether it will need further investigation and what immediate actions should be taken to maintain safety. The steps are as follows,

a) Ensure the accuracy and completeness of the report. b) Seek updates and make corrections where information is inaccurate,

missing or incomplete. c) Grade the incident for severity using a five by five grid, Severity against

likelihood. d) Provide their view of what lead to the incident and what action has been

taken or should be taken to deal with the consequences and prevent it happening again.

The Purpose of the Approval

6.4 The incident is approved to provide oversight of the adverse incident process for the

Division. The approver should be checking the

a) Severity grading is appropriate b) The actions taken are adequate c) Decide if the issue needs to be raised further within the Division’s

governance structure.

6.5 Reviews should be completed within 4 days and the approval within 7 days

6.6 A reminder will be sent to the reviewers and approver for any incidents that are overdue on a weekly basis

Closing Incidents

6.7 The Division will set a closure date for the incident which will be when it is satisfied

that all matters related to the incident have been dealt with. This allows an incident to be approved in terms of the immediate consequences but kept open while such things as investigations or disciplinary investigations proceed.

Informing and Involving Service Users and Carers –Family Liaison Manager

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6.8 As part of Duty of Candour it is essential that the service user is informed that he/she has been involved in an incident of moderate or severe harm and asked if they would like their carer / next of kin or advocate to be informed. If the answer is yes, the Health Care Professional should liaise with the service user to decide how this is best achieved which will include the following decisions and actions, all incidents where a death has occurred will follow the directions below: -

a) Can information be shared by the telephone b) Should the service user let Carers know? c) Should a Health Care Professional let Carers know immediately or can

information sharing be delayed until the Carer can be seen face to face or working hours are resumed.

d) Actions must be documented on the local risk management system.

6.9 If the service user does not give their permission to contact their family/carer then they should not be told unless the service user / incident meets one of the following criteria:

a) The individual has been assessed as not having the capability and capacity to

make the decision. b) There is a pattern of behaviour that creates risk for the carers / relatives. c) The service user is mortally / seriously injured or a high potential for further

clinical deterioration exists. d) There is a pattern of the individual’s behaviour escalating putting their lives at

risk or that of others.

6.10 For incidents where moderate and severe harm/.death has occurred and a decision has been made to inform carers / relatives / significant others, the following should be undertaken: -

a) Within 48 hours of the incident being notified to the Service allocate a Family Liaison Manager who will take the lead for informing the carers / relatives personally verbally (whenever practicable) and then ensure that a follow up letter as per Duty of Candour guidance is sent to the carer /service user. (see below)

. b) Where any media briefings are made or information is shared with individuals

(staff, service users/carers, and other professionals) a record of information provided should be included in the incident file.

c) A follow up letter must be written by the senior manager responsible within 10 days of the incident being notified to the Service. This letter should contain (where appropriate):-

i. The Trust’s Condolences. ii. Clarification of those who have already contacted the Carers / Relatives. iii. Process for review and the desire to involve family / carers in the review iv. and how this will be done. v. Confirm name and role of Family Liaison Manager who has responsibility

for ensuring that the Relative / Carers / Service User receive a copy of the report and can comment on it and have access to on-going support (where appropriate).

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Reporting to StEIS and the Investigation of Serious and Untoward Incidents

6.11 All potential SIs should be reported to the Director of Patient Safety and on to the

local risk management system, immediately. The Director of Patient Safety or his delegate will formally confirm with the local risk management system administrator if the incident warrants reporting to StEIS.

6.12 The local risk management system Administrator will report the incident to StEIS and

send a briefing to the relevant Corporate and Divisional managers, within 48 hours (excluding weekends and Bank Holidays).

6.13 The Director of Patient Safety will liaise with the Communications Department if there

is the possibility of the incident attracting adverse media coverage.

6.14 Serious and untoward incidents will be allocated an investigation level, both by the CCG and Trust; any difference in opinion will be discussed and an agreement will be made.

6.15 Once the level has been confirmed, the Divisional Risk Lead in association with the

Adverse Incident Team will allocate a Review Team and set Terms of Reference.

6.16 The Serious Incidents and Claims Lead will also update relevant commissioners and NHS England / CCG / Specialist Commissioners. This update will consist of further clarification of details of the incident and how the review process is to be organised.

6.17 All incidents will be assessed by members of the Adverse Incident Team to ensure

that reporting to external agencies takes place.

6.18 The Communications Department will ensure all communications are completed within the required time-scales and issue any press/media briefings in conjunction with the Communications Department of the lead commissioners where necessary. The Communications Department will check with the relevant Senior Manager for the service to ensure that carers and relatives have been informed, where appropriate, before any contact is made with the press/media.

6.19 Trust Safeguarding Lead to liaise with relevant local authority to agree single

investigatory process if possible, with safeguarding expertise to be included within the panel and/or investigatory process.

6.20 A information brief should be shared with all Executive Directors following all Serious

and Untoward Incidents as well as those whilst not meeting the threshold for StEIS did have a potential for causing serious harm such as fire incidents .

Role of the Incident Manager and Incident File

6.21 Once the occurrence of a Serious and Untoward Incident has been identified the Division must identify an individual who will take the role of Incident Manager. During out of hours this will be the Silver on Call for that Division who will then hand over any actions to the Chief Operating Officer at the end of their period of duty. The Chief Operating Officer will allocate an individual to be the Incident Manager who will: -

a) Ensure that a safety check is undertaken / complete the safety check to assure the

19

Agenda Item No: G1


Division that other service users are not at risks from clinical or care deficits. b) Develop an initial timeline of the event, which can be incorporated into the safety

check. c) Take the lead in ensuring that family / Carers are informed of the incident and

provided with initial information. d) Communicate with external agencies as appropriate i.e. police. e) Communicate with internal colleagues to ensure that key staff are aware of the

incident and any developments - i.e. Gold on call, Chief Operating Officer, Lead for Patient Safety.

f) In the case of a death, ensure that the notes are collected and kept in a secure area.

g) Liaise with the Senior Manager for the Department to ensure that support for staff and other service user affected is provided as required.

h) Once a Lead Reviewer has been allocated share updated information on the incident with them.

i) Document all actions taken within an Incident file, information collated will include: -

i. Date and time incident occurred ii. Date and time , when informed of the incident iii. Date and time family / carers were informed and content of

conversation iv. Contacts with internal and external agencies, staff v. Directions given to colleagues vi. Immediate effect of the incident on staff and service users vii. Immediate actions taken – i.e. amend staffing levels, inform police etc.

6.22 The incident file should be kept updated for as long as activities which are being

undertaken can be linked with the active management of the incident. Once completed it should be kept by the Division as evidence of the actions taken during the incident.

Investigating Incidents

6.23 As stated above all incidents will be reviewed and approved on the local risk management system. In addition further investigation and reporting to external bodies may be appropriate depending on the severity or type of the incident. The types of investigations for incidents are as follows: -

Initial Safety Check - Reflective Practice Review - 72 hours

6.24 This system has been developed by the Trust to be used by the local Team to identify the chronology of the incident and identify initial causes of concerns and remedial actions that are required. The Team Manager and lead clinician should: -

a) Collate the information on the incident - what happened, when and how. b) Develop a time line of the incident. c) Invite staff involved in the care of the individual to share the information they have. d) Highlight any gaps in practice. e) Identify key types of treatment being provided such medication regime. f) Identify remedial action involved and implement. g) Must be signed off as accurate and valid by lead Consultant Psychiatrist and Acute

Care /Community Lead.

Agenda Item No: G1


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h) Share with Divisional Managers.

Level 1 – Concise investigation

6.25 This level of investigation can be used for incidents that have resulted in low or moderate harm to the service user.

a) Most commonly used for incidents, claims, complaints or concerns that resulted

in low or moderate harm to the patient. b) Also useful as an executive summary to communicate findings from full,

comprehensive or independent investigation reports, following actual or potential ‘severe harm or death’ outcomes.

c) Commonly involves completion of a summary or one page structured template. d) Includes the essentials of a thorough and credible investigation, conducted in

the briefest terms. e) Involves a select number of RCA tools (e.g. timeline, 5 why’s, contributory

factors framework). f) Conducted by one or more people (with a multidisciplinary approach if more

than one investigator). g) Should include person(s) with knowledge of RCA, human error and effective

solutions development. h) If a patient is directly affected, they / relative / carer must be given the

opportunity to be involved. i) Includes plans for shared learning – locally and/or nationally as appropriate.

Level 2 – Comprehensive investigation

a) Commonly conducted for actual or potential ‘severe harm or death outcomes from incidents, claims, complaints or concerns.

b) Conducted to a high level of detail, including all elements of a thorough and credible investigation.

c) Includes use of appropriate analytical tools (e.g. tabular timeline, contributory factors framework, change analysis, barrier analysis).

d) Normally conducted by a multidisciplinary Team, or involves experts / expert opinion/independent advice or specialist investigator(s).

e) Conducted by staff not involved in the incident, locality or Division in which it occurred.

f) Led by person(s) experienced and/or trained in RCA, human error and effective solutions development.

g) Includes patient/relative/carer involvement and should include an offer to patient / relative / carer of links to independent representation or advocacy services.

h) May require management of the media via the organisation’s Communications Department.

i) Includes robust recommendations for shared learning, locally and/or nationally as appropriate.

j) Includes a full report with an executive summary and appendices.

Chief Officers Investigation

6.26 This review will be conducted as per the comprehensive review but will be conducted when: -

Agenda Item No: G1


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a) The incident is of a high public interest. b) Service users of the Trust have been involved in an alleged Never Event. c) The incident involved the death of a service user whilst they were an inpatient. d) The Incident involves a service user within 72 hours of discharge from an

Inpatient Unit / Under Stepped up care or within 1 month of discharge from CMHT to primary care- where cause of death is deemed likely to be suicide.

6.27 The Chief Executive will agree the terms of reference for the incidents including the

panel convened to facilitate the review, which will: -

a) Be chaired by an Executive Level member of staff. b) Have an independent / external representative. c) Have a service user/ carer representative. d) Members will be representative of the professionals involved in the care

delivery. e) Be supported by an Administrator. f) The panel should not exceed more than six individuals. g) Be Supported by Safe from Suicide team (where appropriate)

6.28 The report will be formally validated by the Board of Directors.

Level 3 - Independent Investigation

6.29 NHS England on behalf of the Department of Health has a statutory responsibility to consider whether they should commission an independent review into certain serious and untoward incidents. HSG(94)27: Guidance on the discharge of mentally disordered people and their continuing care in the community and investigation of adverse events in mental health services provides guidance to the cases that should be considered and the scope of such a review. The NPSA clarify that: -

a) Reviews must be commissioned and conducted by those independent to the

provider service and organisation involved. b) Commonly considered for incidents of high public interest or attracting media

attention.

6.30 The Trust will allocate a Senior Manager to coordinate the Trust’s response with the aim of ensuring that the external team receive all information on a timely basis and all staff involved are supported appropriately.

Role of Service Users and Carers as Investigators

6.31 The Trust has provided Root Cause Analysis training to a small group of service users and Carers in order that they can actively participate in all levels of Incident reviews. They will have full access to all clinical records and take part in all aspects of the review process including the writing of the report, interviewing staff, service users, and carer’s external agencies. Service users and carers as part of this role will: -

a) Have an allocated mentor who they will see on at least a quarterly basis. b) Attend bi monthly Supervision/ Team meetings. c) Return all confidential material to the Trust for disposal. d) Keep all confidential material safely.

Agenda Item No: G1


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All Chief Officer Investigations will have a trained service user carer representative on the panel and as many level two reviews as possible. Lead reviewers and Panel Chairs will offer support and guidance to participating service users and if any concerns are apparent share these with the Director of Patient Safety.

Completion within Timescales

6.32 The Trust has 60 days (excluding weekends and bank holidays) to complete a Serious

and Untoward incident review from the time that the incident has been recognised and reported externally via StEIS. Extensions to this date can be negotiated with the commissioning CCG and or the NHS England but the rationale provided would need to reflect the complexity of the case, unexpected complications with evidence gathering or involvement with external agencies, rather than poor management of the review process. It is important that investigations are completed on time as: -

a) Delays can disrupt the flow and availability of evidence and make accurate

investigation difficult

b) Service users and Carers need to receive information about what happened, why and how in a timely manner to help them achieve resolution.

c) The findings of reviews need to be shared with services so that

improvement to practice can be made quickly in order to enhance the safety and quality of service provision.

d) The Trust is performance managed on the completion of investigations within the

allocated 60 days target. Issues that may delay an investigation

6.33 The involvement of the Police, Environmental Regulators, Safeguarding systems and / or Disciplinary procedure are likely to delay the commencement and / or completion of a serious and untoward incident review. All of the above can take priority over the Trust incident review. Negotiation with the above Agencies / Departments can occur to identify if parallel review can take place to ensure that clinical systems are checked and safely maintained. The Trust can organise a meeting with the Police and Health & Safety Executive under the Memorandum of Understanding. This process will allow the co-ordination of the work of the three organisations to take place and information shared.

6.34 Where a safeguarding investigation is involved Director of Patient Safety should liaise

with the Trust Safeguarding Lead plus the Trust Named Nurse, (if safeguarding children issues are apparent), who will liaise with the relevant Local Authority to ascertain if separate or joint investigations are appropriate.

6.35 Where the incident involves the serious and or fatal injury of a member of staff, service

user or member of the public, the Memorandum of Understanding between the Police, Health and Safety Executive and the NHS should be implemented. This will provide a vehicle for the engaged organisations to plan and share the management of the investigation process. The Director of Patient Safety will support the Executive Director of Nursing in the operation of this process.

Agenda Item No: G1


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6.36 It is important that a review process can be actioned in a manner that allows for safety

issues to be reviewed with minimum delay. Where a police or safeguarding investigation will delay the Trust investigation the lead Investigator should inform the Serious Incidents and Claims Lead / Director of Patient Safety who should in turn notify the CCG Trust of the delay where appropriate.

Incident Investigation Process

Root Cause Analysis

6.37 The Adverse Incident investigation process, by definition, is the health and social care services response to an adverse incident to facilitate organisational learning and to establish what, if any, changes are needed to systems, services, practice, resource allocation, the environment of the care or other contributory factors. The investigation, whilst basing its actions around the incident, needs to ensure that their actions are functionally separate from any concurrent or subsequent disciplinary proceedings, which may be necessary. Any litigation which ensues is separate from the investigation process and should be referred to the Claims Manager. Investigations will be sensitive to the timing of any coroner’s inquest. Delay in receipt of the Coroners verdict may not however, be a reason for delay in setting up and conducting an investigation. It is important though that information obtained is shared with the Coroners Office as requested.

6.38 The purpose of the Adverse Incident Investigation is to explore the circumstances

resulting in the incident, and to establish what, if any, lessons arising need to be incorporated into practice in order to prevent or minimise a reoccurrence of the incident. This includes not only areas of weakness but also areas of good practice that should be shared across the organisation. The original grading of the incident should be reviewed and if necessary the grading amended.

6.39 The Lead Investigator should ensure that the post incident investigation process is

commenced within 2 working days of the incident for inpatient areas and 5 working days for community areas. The Adverse Incident Investigation should be seen as a process rather than a one-off meeting. In some cases an initial meeting may be enough to complete the investigation process but more time may be needed in other cases.

6.40 Information should be gathered prior to the initial meeting to support the process.

Particular consideration should be paid to gathering information from service users and carers. Service users, relatives and carers should also be asked whether they have any particular concerns, and these should be addressed during the investigation.

6.41 The Lead Investigator must ensure that the process involves all relevant members of

the MDT, staff who were involved in the incident and any member of staff with specialist knowledge considered appropriate e.g. the Head of Risk & Resilience, or the Adverse Incidents Manager etc. Secretarial support should be provided from within the Division.

6.42 In some cases it may be appropriate to involve other external agencies in the

investigation process. The Lead Investigator is responsible for identifying and involving

Agenda Item No: G1


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any external stakeholders necessary to identify the root cause of the incident (for example, voluntary agencies involved in the care of an individual in an incident in the community or contractors involved in the installation of a collapsed roof). The Lead Investigator should ensure that information is sought from these agencies without compromising confidentiality. Where information sharing is essential or confidentiality cannot be maintained, the Lead Investigator must seek advice from the Trust’s Caldicott Guardian.

6.43 During the Incident investigation an analytical approach should be adopted using a

Root Cause Analysis model. Training in this style of approach is provided by Trust for band six and above staff of all disciplines.

6.44 The report and action plan of the Post Incident Investigation should be structured in a

standard format.

6.45 The Lead Investigator should ensure that the relevant staff, service users, relatives and carers are given an opportunity to check the information they have contributed to the report for factual accuracy.

6.46 The Lead Investigator should then forward the report to the Divisional Risk Lead. This

should happen within 60 working days of the initial reporting of the incident.

6.47 Where this is not possible within 60 working days, an extension will need to be requested from the Director of Patient Safety who will liaise with the Lead CCG. Any extensions required to complete the review should be requested no later than four weeks before the incident is due to be completed. Extensions will only be granted when serious disruption has taken place to the review process that has been out of the control of the reviewer and their managers.

6.48 The Divisional Risk Management Group should develop a provisional action plan

including time-scales and accountabilities based upon the findings of the Post Incident Investigation.

6.49 Practices, systems or other issues which the Investigation Team feel require immediate

attention should be reported urgently to the commissioning service manager so that remedial action can then be put in place.

6.50 The Trust actively supports the use of the Incident Decision Tree as it promotes a fair and

consistent approach to staff. The use of this tool is taught on the Trust’s RCA course.

6.51 A ratified copy of the report should be sent to the Commissioners and NHS England (where necessary) within 60 working days of the initial report of the incident. The Divisional Risk Management Group will also monitor the implementation of action plans as well as communicating issues that relate to the wider organisation.

Timetable for SI Investigations (Working Days)

6.52 Once the decision is taken that an incident is to be reviewed then the following timetable should apply by: -

a) Day 1: Lead Reviewer to be appointed by the Senior Manager for the service. b) Day 2: An update to be given to the Adverse Incidents Team including terms of

Agenda Item No: G1


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reference for the review. c) Day 20: An update to be given / requested from the Divisional Risk Lead / Serious

Incident and Claims Lead of whether the report will be completed on time. If difficulties are being experienced in the completion of the review either:

i. Remedial action should be put in place to ensure timely completion ii. Extension from the CCG can be requested by The Serious Incident and

Claims Lead; these are though only given in specific situations such as sickness of interviewees, investigators, involvement of the police etc.

e) Day 30 Completed chronology should be shared with staff involved in giving evidence; staff should be given seven days to respond.

f) Day 40 share initial findings with clinical /service team to engage them in making recommendations.

a) Day 45: Completed report to be submitted to the Senior Manager of the service. b) Day 48: Action Plan completed. c) Day 50: completed report to be submitted to be ratified by Divisional Adverse

Incident Group or Trust Wide Group. d) Day 52 any required amendments/clarifications requested from the author. e) Day 60: Report to be submitted to the NHS England (StEIS), the CCG and the file

closed by the Serious Incident and Claims Lead. f) Day 60: A letter of acknowledgement to be sent to the people involved in the

report.

6.53 If the report is delayed then an update on progress to be given to each Divisional Meeting highlighting reason and progress.

6.54 A report on delays to be supplied to each Quality Assurance Committee meeting.

6.55 Nomination and Responsibilities of Investigators

a) Data form for suicide/ attempted suicide to be completed by safe from suicide team.

b) The division’s Risk Lead is responsible coordinating the nomination process for reviewers to lead the Incident investigation process. They will need to link with the Associate Medical Director to ensure that a suitable clinician is allocated to the review.

c) For Chief Officer’s reviews the Director of Patient Safety will assist in the

development of a review panel and the writing of terms of reference.

d) The Lead Investigator should have completed the training provided by the Trust in undertaking advanced investigations.

e) A register of trained Advanced Investigators can be accessed via each division.

f) Service Manager will allocate a member of staff involved with the team to undertake

a 72 hour safety check / reflective practice review. They will be responsible for reviewing the written information available and along with the MDT discussing the care given. Any urgent safety issues must shared with the senior manager responsible so that remedial action can be put in place.

g) Two investigators should be agreed for all Level one and two incident reviews.

Where possible the second investigator should be from another service. One of the two investigators must have completed the advanced investigations training. This will add

Agenda Item No: G1


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an increased level of objectivity, share good practice and broaden the perspectives used during the review.

h) One of the members of the Review Team could also be a service user, carer or

representative who has completed the advanced investigations training.

6.56 The Lead Investigator will have the responsibility to co-ordinate the review process and ensure that it is facilitated in accordance with this policy and procedure and that the improvement of services is the key aim. They should be at least band seven level in the organisation. They will have completed the Root Cause Analysis Training Course, which will have information on how to undertake an analysis of whether human rights issues and the effect on protected characteristics contributed to the incidents /effected by the incident. Key responsibilities include: -

a) To provide and facilitate a process that is conducive to learning and analysis. b) Set the agenda in association with the Director / Service Manager responsible for

the Division. c) Keep the process to task and report on any delays in meeting the time-scales

set. d) Write the report and clarify that the recommendations have been agreed and

action plan developed with accountabilities and time-scales. e) The Lead Investigator must inform the Service Manager if they find risk issues

which are not managed effectively and if they expect any delays to occur.

6.57 The Assistant Investigator role is to: -

a) Provide support and assistance to complete the review. b) Take on board agreed and specified responsibilities during the review. c) Provide an independent viewpoint to the proceedings. d) To agree the final report. e) To contribute to the improvement of future reviews by participating in monitoring

feedback exercises. f) Sharing their views with the lead investigator thus creating a learning

experience for both individuals and the organisation. g) Provide specialist knowledge/skills (where appropriate), for example, Health

and Safety knowledge.

Panel Members

6.58 A panel of both external and internal individuals is brought together for Chief Officer’s reviews but could be convened for a Level 2 Investigations if it was felt that a broader membership would add to the quality of the investigation process.

6.59 The panel will usually consist of three or four individuals (not including the Lead and

Assistant reviewer) and will be chosen for their knowledge and experiences of the issues that have been initially identified. They will act as an advisory body. There will always be: -

a) Service user / carer Representative – They are full panel members but will

take a specific interest in the effect the care / treatment being investigated had had on the family and individual.

b) Chair – Chief Officers reviews will be chaired by a Board level director, executive

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or non executive. They will ensure that the review is conducted professionally, transparently and in accordance with this policy and procedure. They will lead the sharing of investigatory findings with the Board of Directors and other key stakeholders. They will not usually become directly involved in the investigatory process but act as a chair to the proceeding , that is ensuring that all evidence is considered and all members are able to input to the decision making.

c) External Specialist – Are always included in Chief Officer investigations and will offer specialist advice in their area, as well as consider the quality of service provision generally and whether it was provided to acceptable levels. Their involvement as with that of the service user/care representative will add objectivity to the process.

d) Internal Specialist – Will offer specialist opinion and knowledge as regards to the quality of care provided. Where the incident is a suspected suicide or near fatal self harm, this will be a member of the Safe from Suicide Team.

6.60 All of the above can be involved in interviews though the key remit of a panel is to act as

an advisory group which should play a key part in challenging the perspectives and views of the Lead/Assistant reviewers. The Panel will review the quality of the analysis and be active in developing recommendations. Panel members will be chosen to ensure that they have the right level of experience, specialist knowledge and professional background to cover the issues likely to be raised /explored via the investigation.

Report Writing

6.61 The report should be: -

a) Be simple and easy to read; b) Have an executive summary, index and contents page and clear headings; c) Include the title of the document and state whether it is a draft or the final version; d) Include the version date, reference initials, document name, computer file path and

page number in the footer; e) Disclose only relevant confidential personal information for which consent has been

obtained, or if patient confidentiality should be overridden in the public interest. This should however be considered by the Caldicott Guardian and where required confirmed by legal advice.

f) Include evidence and details of the methodology used for an investigation (for example timelines/cause and effect charts, brainstorming/brain writing, nominal group technique, use of a contributory factor Framework and fishbone diagrams, five whys and barrier analysis)

g) Identify root causes and recommendations; h) Ensure that conclusions are evidenced and reasoned, and that recommendations are

implementable; i) Include a description of how patients/victims and families have been engaged in the

process. j) Include a description of the support provided to patients/victims/families and staff

following the incident. k) The report should address the potential issue of human rights and protected

characteristics in relation to being contributory factors and how they were affected by the incident.

Checking for Factual Accuracy

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6.62 Once the Chronology has been established it is essential that this is shared with those individuals who have provided evidence to the Investigation Team. This process ensures that any analysis and recommendations formed are based on reliable and accurate information

Sharing findings with Clinical Team

6.63 The findings of the report should be shared with the team involved at the earliest possible opportunity this can be undertaken before the recommendations have been written , this will give the opportunity for staff to suggest what they think can be done to enhance safety

Action Plans

6.64 The Trust wants all recommendations to be written as outcomes as this helps managers and clinical staff develop actions that are achievable and measurable. The requirements for an action plan include the following: -

a) Action plans must be formulated by those who have responsibility for implementation,

delivery and financial aspects of any actions (not an investigator who has nothing to do with the service although clearly their recommendations must inform the action plan);

b) Every recommendation must be specific, measurable and realistic and have a clearly articulated action that follows logically from the findings of the investigation;

c) Actions should be designed and targeted to significantly reduce the risk of recurrence of the incident. It must target the weaknesses in the system (i.e. the ‘root causes’ /most significant influencing factors) which resulted in the lapses/acts/omissions in care and treatment identified as causing or contributing towards the incident;

d) A responsible person must be identified for implementation of each action point; e) There are clear deadlines for completion of actions; f) There must be a description of the form of evidence that will be available to confirm

completion and also to demonstrate the impact implementation has had on reducing the risk of recurrence;

g) Will be signed off and validated by Clinical Services Manager/at action planning meetings. h) Should contain clarity on the action required where human rights issues have been

identified.

Sharing the Findings of incident Investigations

6.65 The Trust has a desire to be open and transparent with service users, carers and staff to ensure that those involved have the opportunity to understand what has happened and where possible why the incident occurred. Information as regards how the Trust is going to improve practice and complete recommendations will also be shared with key stakeholders.

6.66 The process will include: -

a) Lead investigator and Commissioner of the investigator making an appointment to meet with staff involved and share the outline findings of the report. The full report (unless it is embargoed by the Coroner) will be left with staff so that staff can reflect further on the issues raised.

b) Lead Investigator and Service Manager will offer to meet with family and carers to

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share the outline findings of the investigator, leaving a copy with them for further exploration. Further meetings or ways of gaining clarification are also offered. The reports are shared with the proviso that they are treated in a confidential manner as they may contain confidential information.

c) Where possible service users who have incident reports written about them will be

asked to give their permission to share the investigations findings with family and carers.

d) If this permission is refused, legal advice will be sought as to the Trust’s ability to

provide information based on a public interest case. If this situation occurs a redaction of the policy may also be undertaken to keep the level of personal information shared to a minimum. If a public interest rationale is being used to share information the service user involved should be informed and shown the final version of the redacted development used.

Report Validation / Ratification

6.67 Investigation reports will go through a series of checks to ensure that they are of an acceptable standard, see diagram below and contribute to the governance of the organisation. Reports will be assessed using criteria agreed with the Lead CCG any gaps will be highlighted and amendments requested. The level of the investigation undertaken will effect whether scrutiny is facilitated by internal and or external processes: -

a) Level 1 - Reports – Validated internally by the clinical division and externally by

CCG b) Level 2 - Validated internally by the clinical division and externally by CCG / NHS

England (See Appendix 4 for template). c) Chief Officers Report- validated internally by the Board of Directors (checked for

accuracy and clinical validity by the Clinical division) d) Level 4 - validated by the Commissioners Board after a period of checking for

factual accuracy has taken place. The receiving Trust will share the findings of the document with its Board of Directors and validate the action plan developed in response to any recommendations made.

Recommendations from Investigations (from Complaints & StEIS)

6.68 Recommendations from all investigations are implemented by the Division involved. The

quality of evidence collected and level of rag rating given to each action will be validated by the Divisional Governance framework for levels 1 and 2 incident investigation. The Quality Assurance Committee will validate all Chief Officers reviews and 4 action plans and evidence collated

6.69 Each Division will input all actions onto the Risk Management Database. Divisions are

monitored by the Adverse Incident Team in their completion of actions plans, reminders are sent and evidence of changes requested.

6.70 Audit should be used to clarify the impact that the action is having on the safety of care

and improvements to the practice desired. 6.71 Any information given to individuals / families must be provided in a format appropriate to

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their needs.

6.72 Rag Rating guide: -

Red

6.73 The action has not been completed and or there is no evidence that a change to the system or identified practice has occurred.

Amber

6.74 The action has been partially or fully completed but changes to systems or practice have not been validated by auditing evidence/monitoring or occurs on an inconsistent basis.

Green

6.75 The action has been completed and there is evidence that changes to systems and or practice are in place and being undertaken on a consistent basis.

Oxford Model Events

6.76 These are sessions that are facilitated by the Division in association with the Director of Patient Safety. It is aimed at sharing either one incident or a group of similar incidents with staff. Attendees will be provided with the chronology of events and then will work on identifying the issues or concerns and actions to prevent a re-occurrence.

6.77 Staff should be invited who will be able to take learning back to their place of work and

effect changes. Partner Agency staff from CCGs, Police and Social Services etc should also be invited, where issues to be raised affect their organisations. Commissioners and Performance Managers are regularly invited to ensure transparency in the way the Trust deals with and learns from incidents.

6.78 Feedback on the Service’s response to the actions identified must be shared with all

those who attended and implementation of the action plan monitored by the Division.

Dare to Share Events

6.79 These sessions are normally scheduled for a day and will focus on one issue that the Trust recognises as being a concern; they can be identified from within the organisation or following the publication of a national report. They will usually focus on a board topic area and not on one or two individual service users they will though where possible always be service user focussed and aimed at identifying any future changes to practice required.

Quality Practice Alerts (QPA)

6.80 These are alerts that are shared across the organisation via electronic communication. The issues raised usually emanate from adverse incidents including safeguarding incidents, complaints or claims but not exclusively. It is important to note that this process will be used to disseminate and monitor the response to Safeguarding alerts.

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6.81 Any member of staff can request that a QPA is shared. The sharing of the alert is considered by the Director of Patient Safety, Datix Administrator and the staff member requesting the dissemination. It is important that QPAs are targeted at the most influential and appropriate audience.

6.82 In each case the QPA must clearly states the actions that should be taken and who

by. Timescales are given for feedback and the evidence of actions collated. QPAs that involve restrictions should be considered in relation to how a persons human rights will be maintained.

Cumulative Review

6.83 In order to prevent issues from being considered in isolation and common trends from

being missed, investigation reports and action plans will be reviewed collectively by Trust on a six monthly basis.

6.84 A more collective approach can help to make the delivery of multiple action plans more

manageable and can also help inform wider strategic aims.

News Letters

6.85 Each division will share learning from incidents via a monthly newsletter to all staff 7. CONSULTATION

7.1 This policy has been shared with staff from Divisions by Members of the Patient Safety

Committee: -

a) Modern Matrons b) Consultant Psychiatrists c) Legal Advisor d) Service User and Carer Complaints and Incidents Group e) Ward staff f) Community Staff

7.2 Information on issues requiring inclusion in the Policy was gained from discussion

within the Trust’s Incident Group.

7.3 Mersey Care NHS Foundation Trust recognises that all sections of society may experience prejudice and discrimination. This can be true in service delivery and employment. The Trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role our role as a major employer. The Trust believes that all people have the right to be treated with dignity and respect. The Trust is working towards, and is committed to the elimination of unfair and unlawful discriminatory practices. All employees have responsibility for the effective implementation of this policy. They will be made fully aware of this policy and without exception must adhere to its requirements.

7.4 Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human

Rights Act 1998.

7.5 All public authorities have a legal duty to uphold and promote human rights in everything

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they do. It is unlawful for a public authority to perform any act which constitutes discrimination.

7.6 Mersey Care NHS Foundation Trust is committed to carrying out its functions and service

delivery in line with the Human Rights principles of dignity, autonomy, respect, fairness, and equality.

8. TRAINING AND SUPPORT

8.1 The training the Trust provides on Adverse Incident includes: -

a) Awareness raising sessions within Mandatory and Induction Training. b) Root Cause Analysis Training. c) Specifically tailored training for Departments and Teams –developed on request or

through concerns regarding the level of reporting highlighted via trends analysis. d) Safeguarding Training

8.2 Specific detail regarding the above training and other types that is available and who it is

provided for can be found in the organisational training needs analysis which is incorporated within the Learning and Development Policy.

9. MONITORING

9.1 The implementation of this policy and the Trust’s adherence to national standards is

monitored both internally and externally. The Trust is performance managed on its management of adverse incidents by Liverpool Clinical Commissioning Group. They receive cumulative reports on the number and type of incidents reported in the Trust and the actions taken to reduce further occurrences. The CCG also monitors the quality and timeliness of Adverse Incident reports on an ongoing basis and reports back to the Trust any concerns it has. It has the ability to send an improvement notice to the Trust if it is failing to achieve locally and nationally agreed standards. The Trust meets monthly with the CCG to review its performance against standards.

9.2 The CQC during its review visits also scrutinises the quality of the reports undertaken to

investigate incidents and learn from them. It also assesses the knowledge of staff in relation to how and when to report and how learning is shared with staff.

9.3 The level of reporting of incidents in the Trust is monitored via the National, Reporting and

Learning System (NRLS), which reports nationally on a bi annual basis the number of patient safety incidents that are reported with in each NHS Trust. Comparative figures are used to enable Trust’s and external agencies to monitor the safety culture within each organisation.

9.4 The Trust’s Board of Directors and its sub committees oversee the implementation of the

Adverse Incident policy in relation to the quality of review undertaken, level of reporting and learning that has taken place to improve safety and quality.

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10. Equality and Human Rights Analysis

Title: CORPORATE POLICY & PROCEDURE FOR THE REPORTING, MANAGEMENT AND REVIEW OF ADVERSE INCIDENTS (including serious untoward incidents and near misses)

Area covered: Trust-wide

What are the intended outcomes of this work? This Policy has been developed to provide a systematic approach to maintaining compliance with all guidance in the REPORTING, MANAGEMENT AND REVIEW OF ADVERSE INCIDENTS (including serious untoward incidents and near misses). To enhance the safety and security of its staff, service users and carers by ensuring that it has valid systems to report and learn from adverse events. Who will be affected? Staff directly People using the service indirectly. Evidence

What evidence have you considered? The policy only

Disability (including learning disability) Page 29-6.68 to include the requirement that any information given to individuals/ families and carers is provided in a format appropriate to the individual. See cross cutting Sex See cross cutting Race Page 29-6.68 to include the requirement that any information given to individuals/ families and carers is provided in a format appropriate to the individual. See cross cutting Age Page 29-6.68 to include the requirement that any information given to individuals/ families and carers is provided in a format appropriate to the individual. See cross cutting Gender reassignment (including transgender) See cross cutting Sexual orientation See cross cutting

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Religion or belief See cross cutting Pregnancy and maternity See cross cutting Carers Page 17- 6.8 Noted the inclusion of the need to work alongside carers – also addressing the issues of consent of the person and what to do for individuals who do not have the capacity. Other identified groups See cross cutting Cross Cutting Page 7 - 1.9 Noted Human Rights is mentioned as an important element to consider. Page 10 - 5.6 To include the requirement to monitor Equality and human rights issues in the role and responsibilities of the Director of Patient Safety. Page 13 - 5.17 To include the requirement to monitor protected Characteristics at a minimum annually and report the analysis to the Quality Assurance Committee. Page 13 - 5.18 To include the requirement to monitor Equality and human rights issues in the Patient safety committee Page 26- 6.58 and 6.59 Highlight the need to address the representation of investigators re the protected characteristics and the training /knowledge of equality and human rights issues. Page 27 -6.63 Highlight the need to ensure that the report provides clarity where human rights issues have been identified/action taken and considerations of decision making and proportionality. Page 31 -6.81 Noted the need to ensure that QPA’s that involve restrictions- implications for people human rights are included within the information and have a detailed decision making process which addresses legality, necessity and proportionality. Page 32- 8.1 To ensure that training provided includes equality and human rights considerations explicitly Page 32- 8.1 To ensure that key investigators and members of incident , mortality and suicide teams have training and skills re understanding equality and human rights issues for investigation and analysis purposes. Page 63 To add into report writing guide the need to consider and record equality and human rights issues.

Human Rights Is there an impact? How this right could be protected?

Right to life (Article 2) supportive of a HRBA

Further Human rights considerations included within cross cutting

Right of freedom from inhuman and degrading treatment (Article 3)

supportive of a HRBA


Right to liberty (Article 5) supportive of a HRBA


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Right to a fair trial (Article 6) supportive of a HRBA


Right to private and family life (Article 8)



Right of freedom of religion or belief (Article 9)



Right to freedom of expression Note: this does not include insulting language such as racism (Article 10)



Right freedom from discrimination (Article 14)



Engagement and Involvement

No engagement was noted. Summary of Analysis

Eliminate discrimination, harassment and victimisation This policy has sought to be inclusive and has indicated a number of areas to address where discrimination may be experienced. This will be enhanced through the recommendation within this analysis. Advance equality of opportunity This policy has sought to be inclusive and has indicated a number of areas to address where discrimination may be experienced. This will be enhanced through the recommendation within this analysis. Promote good relations between groups This policy has sought to be inclusive and has indicated a number of areas to address where discrimination may be experienced. This will be enhanced through the recommendation within this analysis. What is the overall impact? This policy seeks to address proactively discrimination issues and human rights issues.

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Addressing the impact on equalities The implementation of this policy needs to actively address representation and monitoring to have greater impact. Action planning for improvement

To improve on the impact of the actions to address possible discrimination and supporting people s human rights actions have been identified within the action plan below. For the record Name of persons who carried out this assessment: Meryl Cuzak - Equality and Human Rights Lead George Sullivan - Equality and Human Rights Steve Morgan - Director of Patients Safety Kim Bennett – Mortality and Incident Practitioner Date assessment completed: 13th November 2017 Name of responsible Director: Ray Walker Executive Director of Nursing Date assessment was signed:

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Action Plan Template This part of the template is to help you develop your action plan. You might want to change the categories in the first column to reflect the actions needed for your policy. Category Actions Target

date Person responsible and their area of responsibility

Monitoring

Page 10 - 5.6 To include the requirement to monitor Equality and human rights issues in the role and responsibilities of the Director of Patient Safety. Page 13 - 5.17 To include the requirement to monitor protected Characteristics at a minimum annually and report the analysis to the Quality Assurance Committee. Page 13 - 5.18 To include the requirement to monitor Equality and human rights issues in the Patient safety committee

Completed Completed Completed

Director of Patient Safety Director of Patient Safety Director of Patient Safety

Representation and visibility

Page 26- 6.58 and 6.59 Highlight the need to address the representation of investigators re the protected characteristics

Completed

Director of Patient Safety

Increasing accessibility

Page 29- 6.68b- to include the requirement that any information given to individuals/ families and carers is provided in a format appropriate to the individual.

Completed


Training and skills development

Page 26- 6.58 and 6.59, Page 32- 8.1 Page 32- 8.1 , To ensure that training provided includes equality and human rights considerations explicitly To ensure that key investigators and members of incident , mortality and suicide teams have training and skills re understanding equality and human rights issues for investigation and analysis purposes.

Completed


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Human Rights Assurance

Page 27 -6.63 Highlight the need to ensure that the report provides clarity where human rights issues have been identified/action taken and considerations of decision making and proportionality. Page 31 -6.81 Noted the need to ensure that QPA’s that involve restrictions- implications for people human rights are included within the information and have a detailed decision making process which addresses legality, necessity and proportionality.

Completed Completed

Director of Patient Safety Director of Patient Safety

Transparency

Page 63 To add into report writing guide the need to consider and record equality and human rights issues

Completed


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11. SUPPORTING DOCUMENTS

BS ISO/IEC 17799:2000 BS 7799-1:2000 Code of practice for information security management.

BS 7799-2:2002 Information security management systems — Specification with guidance for use.

Mersey Care NHS Foundation Trust (2003) Mersey Care NHS Foundation Trust

Major incident plan Mersey Care NHS Foundation Trust (2004) Fire Safety Policy

Mersey Care NHS Foundation Trust (2003) Health, Safety and Welfare

Policy Mersey Care NHS Foundation Trust (2011) Environmental Policy

Mersey Care NHS Foundation Trust (2007) Waste Management Policy

Mersey Care NHS Foundation Trust (2003) Policy on staff concerns at work about patient care or matters of business probity/conduct (whistleblowing)

National Health Service Executive (1994) Guidance on the discharge of mentally disordered people and their continuing care in the community HSG (94)27

National Health Service Litigation Authority (2002) Clinical Negligence Scheme for Trusts: Clinical Risk Management Standards

National Patient Safety Agency (2001) Doing Less Harm: Improving the Safety and Quality of Care Through Reporting, Analysing and Learning from Adverse Incidents Involving NHS Patients – Key Requirements for Health Care Providers Department of Health, London

BS ISO/IEC 17799:2000 BS 7799-1:2000 Code of practice for information security management.

NHS England Framework for reporting and Learning from Serious Incidents (2015)

Add open and honest DOC

.

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Appendix 1

Clinical Governance and Adult Safeguarding An Integrated Process

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1. INCIDENT DETECTION

1.1 Introduction

The Being Open process begins with the recognition that the service user has suffered moderate harm, severe harm or has died, as a result of adverse incident.

1.2 Detection

An adverse incident may be identified by:-

A member of staff at the time of the incident; A member of staff retrospectively when an unexpected outcome is

detected; A service user / carer may express their concern or dissatisfaction with

the service user’s healthcare either at the time of the incident or retrospectively;

Other sources such as detection by other service user, visitors, non- clinical staff or the service user’s General Practitioner.

1.3 Prioritizing Action

As soon as a patient safety incident is identified, the primary objective is to provide appropriate treatment and care and the prevention of further harm. The Trust upon identifying a patient safety incident will ensure that the processes for reporting, investigating and analysing the causes of incidents (RCA) will be implemented, including the principles of acknowledgement and apology.

1.4 Criminal or Intentional Unsafe Act

The Trust acknowledges that patient safety incidents are almost always unintentional. However, following an incident investigation it may be determined or suspected that harm is a result of a criminal or intentional unsafe act.

In such instances where this concern becomes apparent the lead for the RCA investigation team / Service Director will notify the Executive Director of Service Development and Delivery.

2. INITIATING THE BEING OPEN PROCESS

The Line Manager in association with the Director of Patient Safety will identify who will be the most appropriate individuals to contact the family. This individual will be chosen based on experience and skill in this area.

A letter will also be sent that advises the service user / carer on the investigation

processes and clarifies who will be the Lead Reviewer. It will confirm that they are very welcome to provide their views and given information as to how they can do this.

Appendix 2 MANAGING THE PATIENT SAFETY INCIDENT

IN ACCORDANCE WITH BEING OPEN

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A phone call or personal contact will also be made within the first 48 hours of the incident.

Ensure there is a consistent approach by all team members around

discussions with the service user/carers.

The Line Manager / Team Leader will identify immediate support needs for the healthcare staff involved.

2.1 The RCA Investigation Team will meet with the respective Multi Disciplinary Team

/ Line Manager as soon as possible after the event to:-

Establish the basic clinical and other facts.

Assess the incident to determine the level of immediate response.

Consider the appropriateness of engaging service user support at this early stage. This may include the provision of support being provided via:-

PALS Advocacy Service A Multi Disciplinary Team member Psychological Care and Intervention

2.2. Initial Assessment to Determine Level of Response

The Line manager and their Team should use the matrix overleaf to identify the actions that should be undertaken.

3. TIMING

3.1 The initial Being Open discussion with the service user / carer will occur as soon as

possible after recognition of the patient safety incident and no later than 10 days following the incident. The Multi Disciplinary Team and the RCA Investigation Team will consider the most appropriate timing of this discussion considering:-

Clinical condition of the service user;

Availability of key staff involved in the incident and in the Being Open process;

Availability of the service user and/or their family;

Availability of support staff, for example a translator or independent advocate, if

required;

Service user / carer preference (in terms of when and where the meeting take place and which Healthcare Professional leads the discussion);

Privacy and comfort of the service user/carers

Arranging the meeting in a sensitive location, usually in the home of the service

user/carer.

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4. CHOOSING THE INDIVIDUAL TO COMMUNICATE WITH THE SERVICE

USER AND/OR THEIR CARERS

The Healthcare Professional who informs the Service User/Carer about the Incident and proposed review process – Service Representative (Being Open)

4.1 The person nominated to undertake this role can be the service user’s Consultant

Psychiatrist and/or a senior experienced member of the Multi Disciplinary Team. It can also be a Line Manager or staff member external to the Service. The nominated person will have received training in communication of patient safety incidents and the principles of Being Open. The nominated person where possible will be:-

Be known to, and trusted by, the service user/carer;

Have a good grasp of the facts relevant to the incident;

Be senior and have sufficient experience and expertise in relation to the

type of patient safety incident to be credible;

Have good interpersonal skills, including being able to communicate with service users/carers in a way they can understand;

Be willing and able to offer, an apology (on behalf of the Trust), re-

assurance and feedback to service users/carers;

Be able to maintain a medium to long term relationship with the service users and/or their carers, where possible, and to provide continued support and information;

Be culturally aware and informed about the specific needs of the

service users and/or their carers.

Use of a Substitute Healthcare Professional for the Being Open Discussion

4.2 There may be circumstances when the nominated person who usually lead the Being Open discussion is unable to attend, on these occasions it will be appropriate to delegate this responsibility to an appropriate trained Deputy. The nominated Deputy will be of equivalent experience and expertise.

Assistance with the Initial Being Open Discussion

4.3 The nominated person communicating information about a patient safety incident

will be able to nominate a colleague to assist them with the meeting. Ideally this will be someone with experience or training in communication and Being Open procedures.

Consultation with the Patient Regarding the Healthcare Professional Leading the Being Open Discussion

4.4 If for any reason it becomes clear during the initial discussion that the service user

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would prefer to speak to a different Healthcare Professional, the service user/carer’s wishes will be respected. A Deputy with whom the service user / carer are satisfied will be provided.

Responsibilities of Junior Healthcare Professionals

4.5 Junior staff or those in training should not lead the Being Open process except

when all of the following criteria have been considered:-

The incident resulted in low harm only;

They have expressed a wish to be involved in the discussion with the service users/carers;

The senior Healthcare Professional responsible for the care is present for

support;

The service user / carer agree.

4.6 Where a junior Healthcare Professional who has been involved in a safety incident asks to be involved in the Being Open discussion, it is important they are accompanied and supported by a senior team member. It is unacceptable for junior staff to communicate patient safety information along or to be delegated the responsibility to lead a Being Open discussion unless they volunteer and their involvement takes place inappropriate circumstances (i.e. they have received appropriate training, direct support and mentorship for this role).

Involving Healthcare Staff who Make Mistakes

4.7 Some patient safety incidents resulting in moderate harm, severe harm or death will

result from errors made by healthcare staff while caring for service users. In these circumstances the member[s] of staff involved should NOT initially participate in the Being Open discussion with the service users and/or their carers. Where staff, who have made an error, wish to meet the service user / carer, this should be considered. If this is deemed appropriate, support should be offered to the member of staff. Where it is felt not to be appropriate due to levels of hostility, emotional state of the staff member, a personal letter of apology can be sent.

4.8 The same principles apply where the service user / carer demand/request to see

the staff. Managers in association with the Director of Patient Safety should make the decision based on the best interests of the service user / carer who require closure and the needs and safety of the member of staff. Where considered appropriate, the meeting should be planned carefully, the staff member accompanied and the focus maintained on the apology as an explanation will be or will have been provided via an incident review. If a meeting is not felt to be appropriate then as stated a letter of apology can be sent. The relatives will need to have an explanation of why a meeting cannot t be facilitated by a senior manager.

5. CONTENT OF THE INITIAL BEING OPEN DISCUSSION WITH THE SERVICE

USER AND/OR THEIR CARERS

5.1 The service users and/or their carers will be advised of the identity and role of all people attending the Being Open discussion before it take place. This allows

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them the opportunity to state their own preference. They will be informed of who their service link will be (Being Open Representative) and their role in: -

Providing a link with the Review Team and process. Gaining external support where requested. Providing initial information as it is known and appropriate.

5.2 It is likely to be appropriate, where possible, for the Lead Reviewer to attend the initial

meeting with the Service Representative. It is also good practice in cases where a death has occurred for a senior Clinician / Manager to attend. Where a homicide is the incident being managed, a senior manager will be the Being Open Representative.

5.3 There should be an expression of genuine sympathy, regret and an apology for

the harm or distress that has occurred. The commitment to truthfulness and clarity of communication, jargon free, timely, factual and an open manner of delivery will be underpinning principles of how the discussion is delivered by the healthcare staff.

5.4 The facts that are known about the adverse incident will be agreed by the Multi

Disciplinary Team / Service, prior to meeting with the service users/carers. It should be made clear to the service users/carers that new facts may emerge as the incident investigation proceeds.

5.5 The service users/carers understanding of what happened will be taken into

consideration, as well as any questions they may have.

5.6 There will be consideration and formal record made of the service users/carers’ views and concerns, and demonstration that these are being heard and taken seriously.

5.7 Appropriate language and terminology will be used when speaking to service users

and/or their carers. For example, using the terms ‘patient safety incidents or adverse event may be at best meaningless and at worst insulting to service users/carers. If a service users/carers first language is not English, it is important to consider their language needs - if they would like the Being Open discussion to be in their preferred language the Trust will make arrangements for appropriate interpreter services.

5.8 An explanation will be given about the next stages in the incident investigation

process and, where appropriate, any resulting recommendations and action plans.

5.9 Information on the possible short and long term effects of the incident (if known) will be shared. The latter may have to be delayed to a subsequent meeting when the effects/outcomes are known.

5.10 An offer of practical and emotional support will be made to the service

users/carers by signposting them to appropriate support agencies as offering more direct assistance in the first instance, e.g. PALS, Advocacy, Psychological Services.

5.11 Information about the service user and the incident will not normally be disclosed

to third parties without consent.

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5.12 It is recognised that service user/carers may be anxious, angry and frustrated

even when the Being Open discussions are conducted appropriately.

5.13 It is essential that the following does not occur:-

i. Speculation;

ii. Attribution of blame;

iii. Denial of responsibility;

iv. Provision of conflicting information from different individuals

5.14 The initial Being Open discussion is the first part of an ongoing communication process. Many of the points raised here will be expanded upon in subsequent meetings with the service user/carer.

6. NOTIFICATION

6.1 Family and Carers

Every effort must be made to notify family and carers when a serious patient safety incident has occurred as soon as possible after the event and no later than 10 days after the incident has been reported. The Manager who initially receives the report (Matron/Duty Manager) will take responsibility for ensuring that this happens.

Initial contact should be attempted by telephone (where available) and efforts maintained until contact established.

6.2 This will be followed up in writing by the Line Manager of the area where the

incident occurred on the next working day.

Copies of any completed investigation/review reports should also be

provided within 10 days of completion.

6.3 National Reporting and Learning System (NRLS)

There is a requirement to report all patient safety incidents through the National Patient Safety Agency’s (NPSA) NRLS. However, this will not be done until the incident investigation has been completed and the lessons learnt identified by the organisation. The Trust, however, may consider discussing such incidents with

NPSA patient Safety Advisor as appropriate.

6.4 Each Service will take responsibility for informing their Commissioners and Agencies such as the Mental Health Act Commission. The Trust’s DATIX Manager will share information with the Strategic Health Authority (SHA) via the use of the national reporting system STEIS. The Commissioners and SHA will be kept informed of the review process and receive a copy of the completed review document.

6.5 The Director of Patient Safety will meet quarterly with the SHA to monitor progress

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with all incident reviews and safety measures put in place.

7. INVOLVEMENT / LIAISON WITH CRIMINAL JUSTICE SERVICES

7.1 Some incidents that involve mentally ill service users will require the intervention of the Police and Crown Prosecution Service. The Trust will share information with the Police as is allowed under the Data Protection Act Section 29.

7.2 It is important that where a homicide or suspicious death is the incident, the Police

should be asked if it is acceptable for the Trust to continue with its investigation process. A senior manager should act as the Trust Liaison Officer and negotiate with the Police; Terms of Reference for an incident review that would not impede a Police investigation but would aid learning from a health care perspective.

7.3 The Trust will facilitate Memorandum of Understanding meetings in accordance with

national guidance where the incident requires Police involvement and may be of interest to the Health and Safety Executive. The Trust will be represented by a manager at Director’s level and will share information with other Agencies as required under the Terms of Reference.

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The role of the Family Liaison Manager has been developed to provide you with a person who is able to provide you with support and information at this very difficult and emotional time of your lives. Their remit is specifically about helping you to understand the processes that we use to review the care and treatment provided by the Trust. They will though be able to help you access information regarding other processes that may occur at this time such as the Coroners Inquest. You can contact them on the numbers below; they will also contact you during the review process to keep you updated on its progress. The completion of such reviews can be complex and it is important you are kept to up to date, that you are able to in put into its work and have an opportunity to see the findings.

The key role of any review is to try and find out from a health care perspective what happened and give answers to as many of your questions as possible. The Family Liaison manager has a key role in making sure that you understand how, why and what we do to achieve this. They are not directly involved in the review and therefore can focus on helping meet your individual needs.

The key roles of the Family Liaison Manager are -;

• To act as a link between the service user / family / friends involved and the review team

• To explain how the review process will work, who will be seen, who will be involved and

how long it will take.

• To explain how the review will be used, who it will be shared with and how it's quality is checked

• To update you on progress, give reasons for any delays and ensure you feel as involved

as possible.

• To link you with support agencies that you feel may be of help.

• To keep in regular contact with you or as agreed with you.

• To link with other agencies potentially involved such as the police and coroners office with the aim of ensuring that clear communication exists between these agencies to help provide you with unambiguous and accurate information at all times.

• To represent the Trust in all aspects of our work with you and to seek help and guidance

from senior colleagues and specialists where you request this or they feel it necessary.

• To do their very best to ensure that your confidentially is maintained at all times.

Appendix 3

Introduction to Family Liaison Manager Role

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Mersey Care NHS Foundation Trust

Root Cause Analysis Investigation Report (FOR LEVEL 1, 2 & 3 INVESTIGATIONS)

Incident Investigation Title

Incident Date:

Incident Number

Author(s) and Job Titles

Investigation Report Date

Appendix 4

Root Cause Analysis Investigation Report Template

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CONTENTS

Background and summarised history

Incident description and consequences

Terms of reference

Investigation team and advisors

Scope and level of investigation

Investigation type, process and methods used

Involvement and support of relatives

Support provided for staff involved

Information and evidence gathered

Chronology of events

Notable practice

Deficits in Care and Concerns Identified

Factors that contributed (led to) the concerns identified above.

Root causes

Actions already taken

Outcomes

Arrangements for sharing the report

Distribution list

Appendices

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MAIN REPORT

Background and summarised history – including how long in service, treatment, admissions, carers involvement etc.

Incident description and consequences

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Terms of reference

• Examine all the circumstances surrounding the care and treatment of …. as provided by

Mersey Care NHS Trust, up to the events of

• Establish the facts regarding the provision of mental health care up to the events of 18/07/2017

• Consider and comment on the appropriateness, or otherwise, of the care and treatment

received by… including:

His assessed mental health and social care needs

His assessed physical health care needs

His assessed risk of potential harm to himself and others including, where appropriate, safeguarding issues

His engagement with Mental Health Services

• Consider any specific issues, with due regard to confidentiality, that the family of … might wish

to raise.

• To consider whether appropriate support, following the incident was both available and

provided to carers and staff.

• To review the application of Trust and Local Policies and Procedures.

• To identify where improvements in practice/systems could be made to prevent a similar incident

occurring in the future.

• Prepare a report on your findings, establishing the root cause of any concerns, and make

recommendations if necessary. (Please note that they need to be clear, concise, achievable

and outcome focused).

• To alert the appropriate Service Lead to any immediate action required.

• To consider whether recent welfare reforms e.g. benefit changes, housing provision, changes to

care packages etc., have had an impact on the service user wellbeing and on the incident being

reviewed.

• An interim report is to be completed by Friday 6th October 2017 and a meeting to take place

with the appropriate service lead to go through the report and discuss progress and any

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recommendations

• A final report is to be submitted by Friday 13th October 2017 to the local services Risk and

Governance team to [email protected]. This will allow the report to go to the

local validation meeting before being sent to the CCG to meet their deadline.

• To share the review with the appropriate relatives within two weeks of validation of the report.

• To share the outcome of the review to the team within two weeks of the validation of the report.

Investigation Team and Advisors

Scope and Level of Investigation

Investigation type, process and methods used

Involvement and support of relatives – including details of Family Liaison Manager and Duty of Candour information

Involvement and support provided for staff involved

Information and evidence gathered – put any issues/problems in here

Chronology of events – 2 years with summarised critical points

Notable practice

Deficits in Care and Concerns Identified

Factors that contributed (led to) the concerns identified above.

mailto:[email protected]

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Root causes – The single most important factor

Actions already taken

Outcomes – This will lead to the recommendations and Action Planning

Arrangements for sharing the report

Distribution list

Appendices

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Documents

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