AGENDA. Please send apologies to Alison Baker

Transcription

1 A MEETING OF THE BOARD OF DIRECTORS OF THE SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST WILL BE HELD ON WEDNESDAY 30 TH MARCH 2016 AT 3:00PM, BUDDY 2&3, LEARNING CENTRE MAUDSLEY HOSPITAL 1 APOLOGIES for absence: Emily Buttrum 2 Declarations of Interest AGENDA 3 Patient Story The Missing Ingredient Cawley Centre - MAP CAG 3:00pm Page 2 4 Minutes of the Board Meeting held on 23 rd February :10pm Attached 5 MATTERS ARISING/ACTION POINTS REVIEW 3:15pm Page 13 PRESENTATION 6 Approve - Trust Quality Priorities 2016/17 3:20pm Page 16 App A QUALITY 7 Discuss Learning Lessons Quarter 3 Report 3:40pm Page 21 App B STRATEGY 8 Discuss Workforce Report 3:50pm Page 33 App C 9 Information IT Update Report 4:00pm Page 48 App D PERFORMANCE AND ACTIVITY 10 Approve Finance Report Month 11 4:05pm Page 64 App E 11 Approve Performance Report 4:15pm Page 76 App F GOVERNANCE 12 Approve AHMs for approval from 1 st April :25pm Page 104 App G 13 Discuss Board Disciplines Review 4:30pm Page 108 App H 14 Information Update from Quality Sub Committee Meeting 4:40pm Page 119 App I 15 Information Update from the BDIC Meeting 4:45pm Page 122 App J 16 Information - Report from the Chief Executive 4:50pm Page 126 App K 17 Information - Update from the Council of Governors 4:55pm Page 131 App L 18 Discuss Declarations of Interest 5:05pm Page 138 App M INFORMATION 19 Actions summary from today s meeting Verbal 20 Reflections on today s meeting Verbal 21 Forward Planner and Draft Agenda for April Meeting Page 139 App N 22 Report from previous Month s Part II 5:15pm Page 143 App O 23 Director s Reports Verbal 24 Any other business Verbal Date of Next Meeting: Thursday 28 th April :00pm, Learning Centre, Maudsley Hospital, Denmark Hill, London, SE5 8AZ. Please send apologies to Alison Baker alison.baker@slam.nhs.uk Please note that minutes from this meeting are a public document and will be published on the Internet and may be requested under the Freedom of Information Act (2000). Any attendee that would like their name omitted from the minutes should discuss this with the minute taker. Note that it may not always be possible to oblige as this is dependent on the persons role and the business being discussed. web site: 1 of 134

2 The Cawley Centre The Missing Ingredient Patient Story Brief outline The Cawley Centre operates as a therapeutic community within the Maudsley. Its core programme centres around a range of activities, which include large groups (community meetings), small groups, individual work, anxiety management, psychodrama, cooking for the community, future prospects group, family therapy, art groups and gardening. All members are expected to participate and are provided with an opportunity to be involved in the day-to-day running of the community. It is important to understand this notion of the therapeutic community as it operates differently from many services; because decisions made at the Cawley Centre are often collaborative between staff and clients, the premise of You Said, We Did is slightly different for this patient story and perhaps more closer to You said, we all did. As highlighted above cooking is a key feature at the centre, it is a major part of the therapy and recovery process. For many years, the cooking happened every Monday and Wednesday. it involves important details such as shopping within budget, preparation and serving food for the whole community to enjoy together. Due to a number of issues, the whole Cawley community felt that the same people were always being left to undertake this task. The issue was raised and debated in the Monday Liaison (community business) meetings. The clients put together a small sub-group. Within this they developed an audit, surveyed the whole community about the cooking groups, whether or not they were wanted, etc. They fed back the results to the whole community and provided future steps forward. In summary, the Cawley community identified the problem; a few clients were empowered to seek out the issues and to collectively address the issue. The work undertaken by the service users, the support provided by the whole community, both clients and staff and the collective response outlines a patient story that not only supports the therapeutic framework but also aims to improve it. 2 of 134

3 MINUTES OF THE NINETY THIRD MEETING OF THE BOARD OF DIRECTORS OF THE SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST HELD ON 23 FEBRUARY 2016 PRESENT Roger Paffard Chair Dr Martin Baggaley Medical Director Dr Neil Brimblecombe Director of Nursing Robert Coomber Senior Independent Director and Deputy Chair Kristin Dominy Chief Operating Officer Alan Downey Non-Executive Director Gus Heafield Chief Financial Officer Dr Julie Hollyman Non-Executive Director Prof Shitij Kapur Non-Executive Director Dr Matthew Patrick Chief Executive (left after item 033/16) IN ATTENDANCE Adam Black Council of Governors Dr Alison Beck Head of Psychology and Psychotherapy Sarah Burleigh Assistant Director of Nursing Emily Buttrum Commercial Director Sarah Crack Head of Communications and Media Emily Finch Addictions CAG Clinical Director Mark Ganderton Council of Governors Danielle Glennon Specialist Clinical Service Lead (Item 028/16) Louise Hall Director of Human Resources Kay Harwood Head of Planning, Involvement and Equalities Shubhra Mace Chief Pharmacist (Item 032/16) Paul Mitchell Trust Board Secretary Zoe Reed Director of Organisation and Community Prof David Taylor Director of Pharmacy and Pathology (Item 032/16) Michael Weaver Business Manager, Trust Board Secretariat (Minutes) APOLOGIES Chris Anderson Lead Governor Lesley Calladine Non-Executive Director Jo Fletcher Service Director, CAMHS Cath Gormally Director of Social Care Jo Kent Service Director, Mood, Anxiety and Personality CAG June Mulroy Non-Executive Director David Norman Service Director, Mental Health Older Adults CAG Page 1 of 10 3 of 134

4 BOD 027/16 BOD 028/16 DECLARATIONS OF INTEREST Dr Martin Baggaley declared that he occasionally provides consultancy support via Deloitte and occasional chairs meetings for Johnson and Johnson. Prof Shitij Kapur declared an interest as a member of the CNS Scientific Advisory Board of Lundbeck Co and Roche Co. Prof Kapur advises and consults with pharmaceutical companies periodically. PATIENT STORY Roger Paffard welcomed Danielle Glennon, Service Lead for Outpatients and Day Care Eating Disorders to the meeting. Danielle Glennon introduced a patient story that served to illustrate the impact of an innovative new service for young adults with eating disorders, offering tailored online support and group-based therapy. FREED (First episode and Rapid Early intervention for Eating Disorders) aimed to facilitate rapid assessment and flexible tailored treatment for young adults with anorexia or bulimia in the early stages of their illness. Patients and carers are at the heart of the service and the aim of FREED was to enable rapid access to treatment for very unwell patients who were on the cusp of requiring intensive treatment. Once referred, patients were telephoned by a designated eating disorders clinician who would talk to the patient, their carers and family to assess and discuss their concerns. Patients would normally be able to access services within 2 to 4 weeks. An innovative feature of the service was the development of a social media document with support from the Trusts Communications and Media Team. The Board watched a film that featured a patient and her mother talking about challenges they faced when seeking help and the impact of the FREED Eating Disorder service. As a consequence of the advice, care and treatment provided the patient realised the root of their illness was more than just their relationship with food. Access to online services and carer workshops had helped the patient to understand and manage their illness and expand other parts of their life that included friends and family. The patient expressed their thanks to the service and spoke of the importance of early intervention. Members of the Board thanked Ms Glennon for presenting the patient story to the Board. Professor Shitij Kapur asked to know what made the FREED service exemplary. Danielle Glennon replied that the FREED service made active engagement upon receipt of referral and a number of holistic, innovative approaches that included help with preparation for university such as managing a budget, alcohol and diet. Professor Kapur asked to know what extra effort, time and money had been invested in the service. In addition to the existing team the service required one extra psychologist; such investment had not resulted in any impact on other eating disorder services. Dr Martin Baggaley asked to know the rationale for the target age group (18 to 25 years) that had access to the service. The treatment pathway had been designed to enable the smooth transition of patients for ages between 18 and 25 to ensure a smooth transition from school to university. Roger Paffard asked Ms Glennon to comment on arrangements with regard to the commissioning of services. Some commissioners had been very supportive of the service other commissioners less so. Whilst this could be understood in the context of limited resources this was a source of frustration. Roger Paffard thanked Ms Glennon and colleagues for her report and behalf of the Board offered congratulations for receiving an award of 500,000 from The Health Foundation in recognition of the success of the Pilot Project. Page 2 of 10 4 of 134

5 The Board of Directors thanked Danielle Glennon for bringing the patient story to the Board. BOD 029/16 REPORT FROM THE CHIEF EXECUTIVE Matthew Patrick reported on matters arising from the local health economy and nationally in the NHS and Social Care. Matters reported included reference to the Mental Health Taskforce report set up by NHS England and a report from an independent commission chaired by Nigel Crisp supported by the Royal College of Psychiatrists. Whilst Ministers had accepted all the findings of the Mental Health Taskforce report and the stated levels of investment in Mental Health services it was of note that such investment was not in addition to levels of investment already included in the baseline. There was, therefore, a significant risk that existing core services could suffer as a consequence of implementing new services. With reference to an independent commission, chaired by Nigel Crisp and supported by the Royal College of Psychiatrists Matthew Patrick asked members of the Board to note the recommendation to introduce of a maximum waiting time of four hours for admission to an acute psychiatric ward for adults or acceptance for home based treatment following assessment by October Given the current financial challenges facing all parts of the NHS it was important that the Mental Health Taskforce Report and the Independent Commission Report were treated equally and implemented alongside one another. Emily Buttrum asked the Board to note matters where it was reported that provider boards would need to increase their capability by investing in workforce and leadership, and in technology, innovation and research. Roger Paffard welcomed both reports. The Board of Directors noted the report BOD 030/16 MINUTES OF THE PREVIOUS MEETING AND MATTERS ARISING The minutes of the meeting held on 26 January 2016, were agreed as an accurate record of the meeting. Item 12 Recently established mobile working hubs for KCL students (ref. BOD 003/16) At its meeting on 26 January 2016 the Board agreed to follow up undergraduate access to facilities and computers at a number of Trust sites with the Director of Estates. Item 13 Revised format of Board meetings (ref. BOD 005/16) At its meeting on 26 January 2016 the Board noted the Trust Board Secretary would devise and circulate a questionnaire to evaluate the effectiveness of Board meetings to regular attendees of Board meetings. Paul Mitchell confirmed a questionnaire had been circulated and a number of responses had already been received. Results from the survey would be presented to the Board at its meeting on 30 March Item 18 South London and Maudsley NHS Trust Annual Public Meeting (APM) 2016 At its meeting on 26 January 2016 the Board noted and approved development of the Trust s first combined Annual Members Meeting and Staff Recognitions Award event to be held on 20 September Zoe Reed confirmed a partnership working group with representatives of the Council of Governors to develop and deliver the event had been established. Page 3 of 10 5 of 134

6 BOD 031/16 MEDICINES MANAGEMENT Dr Martin Baggaley welcomed Prof David Taylor and Shubhra Mace to the meeting. Prof Taylor introduced the Trust Medicines Report, a report on medicines use in the Trust for the period January 2015 to January Following their inspection in September 2015 the Care Quality Commission (CQC) reported that overall, medicines were well-managed in SLaM and that staff and patients spoke very positively about the support, guidance and training they received from the trust pharmacy team. One specific recommendation from the Lord Carter Independent report on operational productivity and performance in English NHS was that trusts develop a hospital pharmacy transformation programme to support hospital pharmacies to achieve medicines optimisation targets, outlined in the report by April The Trust pharmacy is reviewing the medicines optimisation guidance in the report and will publish a strategy later on in Prof Taylor reported on findings from patient safety audits and quality improvement programmes. In response to these findings quality improvement programmes were currently underway, led by the BPAD and CAMHS CAGs, with support from pharmacy. Prof Taylor asked the Board to note the number of medication errors (and as a proportion of total errors) reported to the National Reporting and Learning System (NRLS), by the Trust and other London mental health organisations. The data reported covered the period of October 2014 to March The Board discussed variations in rates of reported drug errors such as prescribing errors, medicine administration errors and dispensing errors between nursing, pharmacy and medical staff groups. A notable achievement in 2015 was a successful 6-month pharmacy pilot in the Trust s Chaucer team that showed an improvement in patient satisfaction and physical health monitoring, savings in drug expenditure and an overall reduction in occupied bed days. Drug expenditure was monitored by the Trust Drug and Therapeutics committee (DTC). Drug expenditure in 2015 was reported as circa 10m. Paliperidone long-acting injection continued to represent a cost pressure for the Trust and was now restricted to patients who fit the criteria for a risk-share scheme. Prof Taylor confirmed in response to a question from Prof Kapur that the risk share would be evaluated. Alan Downey asked Prof Taylor whether clinicians should receive data that allowed them to understand variations in prescribing habits. Prof Taylor reported existing arrangements for reporting data to clinicians. Dr Baggaley stated the need to introduce protocolisation. It was just as important to look at outcomes as much as cost. Prof Taylor agreed with the need for greater protocolisation and work was underway to progress this. Dr Neil Brimblecombe asked Prof Taylor to follow up on how the Trust could improve the level of medical drug error reporting The Board of Directors noted and approved the Medicines Report for The Board of Directors asked Prof Taylor and Shubhra Mace to provide a report on Medicine Error reporting at the Quality Sub Committee meeting for the QI Programme. The Board of Directors asked the Trust to arrange a visit for Non-Executive Directors to the Trusts Pharmacy Department. Page 4 of 10 6 of 134

7 BOD 032/16 PRIORITY PARTNERSHIPS At its meeting on 15 September 2015 the Board noted and agreed the approach for receiving and encouraging direct feedback from people who use Trust services, their friends, families, carers and communities, including the development of a feedback page on the website. Zoe Reed asked the Board to note the attached implementation plan that provided a summary of action taken, the Trust lead and timescales for action to be completed. A task and finish group co-chaired by Zoe Reed and Adam Black had met and reported back to the Engagement, Participation and Involvement Committee (EPIC). Monthly reports to the Board reflecting the you said we did approach would become available in October 2016, not June as stated in the paper presented to the Board. BOD 033/16 The Board of Directors noted the various work streams, the approach set out to increase direct feedback from people who use Trust services, their friends, families, carers and communities, including the development of a feedback page on the website and to support the next steps as described. QSC THEMATIC REVIEW FOR SERVICE USER AND CARER EXPERIENCE Zoe Reed presented a report that provided a thematic review of user and carer experience within the Trust for 2015 and outlines plans for 2016 that were presented to the January 2016 Quality Sub Committee (QSC). An implementation plan that included a summary of action taken, the Trust lead and timescales for action to be completed was attached to the previous paper report under item 033/16. Each CAG has many examples of involvement activities which have led to improvement in services. The Trust was working to produce a benchmarking system for CAGs to follow. Dr Neil Brimblecombe noted the number of involvement activities that included the use of technology for gathering feedback from users and carers. Roger Paffard asked to know why there were differences in the number of Patient Experience Data Intelligence Centre (PEDIC) surveys completed by CAGs. Kay Harwood and Zoe Reed confirmed that such differences were due to some CAGs preferring to use traditional paper survey tools rather than information technology (IT). The Board of Directors noted the thematic review, supported further activities to promote user and carer experience and noted the implementation plan as set out in the partnerships paper. BOD 034/16 FINANCE REPORT MONTH 10 Gus Heafield provided an update on the financial position of the Trust as at 31 January At Month 10 the Trust delivered 7.9m of EBITDA, an adverse variance of 2.4m against the planned position. Based on the month 10 position and positions going forward, the Trust was continuing to forecast an adverse EBITDA variance of 3.75m, in line with previous discussions with Monitor. Gus Heafield set out the main factors that continued to account for the Trusts current position that included the continued deterioration in the adult acute overspill position in January. Although the rapid increase reported in December had slowed down, the numbers still rose by a further 2 beds making January 2016 the highest month of the financial year with 61 overspill beds used at a cost of circa 1m. Other cost pressures remain but in some cases there had been a deterioration in performance. In particular over the last 2 months ward nursing costs had continued to rise with bank use up by circa 20% although agency costs had fallen. There had also been an increase in complex placements activity in Southwark although the positions in Lambeth and Lewisham had improved. The mitigation of these cost pressures form part of the Recovery Plan against which CAGs and infrastructure services were being monitored. Page 5 of 10 7 of 134

8 Robert Coomber commented on the use of non-recurrent solutions such as the use of reserves to manage the Trusts financial position and the extent to which this could be sustained in the future. Gus Heafield asked the Board to note the bottom line deficit of 8.75m assumed a 13-14m underlying pressure that would require a higher Cost Improvement Programme (CIP) for the 2016/17 financial year. It was also of note that the Trust would only have access to a potential 2m contingency for the 2016/17 financial year. Gus Heafield asked the Board to note the size of challenge going into the next financial year. Roger Paffard asked to know what measures the Trust was taking to ensure the Trust met its stated financial obligations. Gus Heafield outlined the programme of modelling work to tackle the Trusts underlying financial pressures and confirmed that there would be further opportunities for the Board and Board members to scrutinise the detailed plans in the run up to the final submission on 11 April. Dr Martin Baggaley asked the Board to note there been some successes in service transformation however such successes had been negated by increases in activity in other areas and delayed discharges. There are a number of diverse options for transformation that included an improvement in pathways and the re-expansion of internal capacity. A shortage of Psychiatric Intensive Care Unit (PICU) beds placed pressure on general beds. The Independent Commission Report highlighted a number of alternatives to the admission of patients. Prof Kapur stated the Trust needed extra internal capacity in order to run at a bed occupancy level of 95%. The Board of Directors noted and approved the report on the financial position for December 2015, noting progress made to date on the recovery plan and the year-end forecast position. BOD 035/16 PERFORMANCE REPORT Kristin Dominy introduced a report that detailed Trust performance against key metrics to the end of January Estates were expected to complete handover of the new Psychiatric Intensive Care Unit (PICU) on the 18 March The Trust had recruited all Band 3 staff (9 posts), Band 6 (4 posts), and an Acting Ward Manager and all staff were expected to start at the end of March. Of note was the need to recruit further staff as 10 Band 5 vacancies were yet to be filled. The next round of recruitment for band 5 posts would be taking place on the 24 February The introduction of the nationally mandated new Mental Health Service Data Set was underway with the first submission in February. This would replace the Mental Health and Learning Disabilities Data Set. Following a review of the national requirement and a gap analysis of epjs the Trust had been working in partnership with its supplier of epjs to make the required changes. The first iteration of epjs had been thoroughly tested and modifications are required. This will result in a delay of the epjs Upgrade. The Business Intelligence team was developing an interim data set in mitigation. This would present challenges in data completeness and the Trust was keeping Health and Social Care Information Centre (HSCIC) informed of the current position. To provide assurance an audit of the epjs had been commissioned for 2016/17. With regard to the Mental Health Stock Take the Trust had met with NHS England and the Lambeth, Lewisham and Southwark and Croydon (LSLC) Clinical Commissioning Groups (CCG s) in the beginning of February to review system performance and progress against new reporting standards, principally Early Intervention Pathways (EIP), Integrated Access to Psychological Therapies (IAPT), progress against Dementia Diagnosis rates (CCG led). The most recent data indicated that there continued to be significant pressure in the Adult acute pathway. The Trust was taking action to address the immediate issues and maintain the transformation programme. Contract negotiations with Commissioners were challenging but progressing. The Programme Management Office (PMO) was working with Trust and CAG leads to establish a Trust wide CIP Programme. A Senior Management Team (SMT) Page 6 of 10 8 of 134

9 programme portfolio board had been established and would be meeting monthly. Thirteen wards breached Safer Staffing levels in in December 2015 a reduction of two from the previous month. The main reason for the breaches continues to be availability of NHSP and Agency staff and action being taken to address these reasons. The impact of Junior Doctor Industrial action on 10 February 2016 was minimal, and Consultants were able to cover where required. This minimal impact was partly due to the 10 February being a Junior Doctor training day, and so very few appointments had been made. Dr Julie Hollyman asked to know whether the Trust had started in its preparation for the new Mental Health Service Data Set. Kristin Dominy confirmed the Trust had begun its preparation in good time and the subsequent delay was the result of challenges with the interpretation of the new data set. Roger Paffard commented it was good that today s report contained occupancy and length of stay data reported by borough. The Board of Directors noted and approved the report. BOD 036/16 TRANSFORMATION PROGRAMMES DASHBOARD The Board were asked to note the first Transformation Programmes Dashboard. The dashboard reports delivery of the transformation programmes identified within the Operational Plan 2014/16 and was designed to provide assurance and challenge at Board level. With reference to the IT Transformation Programme update, dated February 2016, Roger Paffard asked to know if the Trust would meet its public commitment to staff to replace Personal Computers (PCs). Gus Heafield agreed the Trust would provide an update on the IT Programme at the Board meeting on 30 March The Board of Directors noted the report, asked to receive an update on the IT Programme at its meeting on 30 March 2016 and as an interim measure asked to be updated on the current position before the Board meeting in March. BOD 037/16 STATEMENT OF READINESS (EMERGENCY AND MAJOR INCIDENT) In response to recent terrorist attacks in Paris on 13 November 2015, Dame Barbara Hakin National Director: Commissioning Operations for NHS England wrote to all Trusts requesting the Trust provide a statement of readiness i.e. Trust Preparedness for a Major Incident to their Trust Board. The Board of Directors noted and accepted the statement of readiness as assurance that the Trust would be prepared in the event of an Emergency, or Major Incident. BOD 038/16 DELOITTE REPORT AND ACTION PLAN UPDATE Paul Mitchell introduced the Deloitte report action plan. The final report on the External Review of Governance had been received by the Board in October The main areas for improvement had included the governance of risk management; connectivity between the corporate level of the organisation and the CAGs; and Board Committee coverage of financial performance. Paul Mitchell asked the Board to note the current status of the Trusts response to the high and medium recommendations. Alan Downey commented the narrative reported against items in the action plan did not provide sufficient evidence or assurance should the Trust be challenged to demonstrate the action it had taken to address each recommendation. Paul Mitchell suggested that links to evidence could be built into the report to provide this assurance. Robert Coomber advised that the action plan should be completed by April Page 7 of 10 9 of 134

10 The Board of Directors noted the report and asked the Executive to confirm their sections in the action plan, including links to evidence to enhance assurance and close the report by April BOD 039/16 SCHEME OF DELEGATION IMPLEMENTATION PLAN Gus Heafield presented a paper whose purpose was to present and seek approval of proposed areas where decisions are to be made only by the Board, to confirm those issues that are delegated to the Chief Executive and to set out the next steps in the development of the detailed Scheme of Delegation. Dr Neil Brimblecombe stated the Board should agree the Assurance Framework. Dr Julie Hollyman stated Capital Plans of a certain limit should be received and approved by the Board. Dr Neil Brimblecombe added the Board should approve appointments to outside bodies. The Board of Directors noted the report, asked the Trust to report the Board Assurance Framework to the Board of Directors Meeting on 28 April 2016 and noted the Board should have authority to approve Capital Plans above a certain limit and make appointments to Outside Bodies. BOD 040/16 FINANCE AND PERFORMANCE COMMITTEE The Board had received draft minutes of the first Finance and Performance Committee meeting held on 18 January 2016 that included a summary of key potential issues and actions proposed to address key issues. Gus Heafield sought approval of the draft Terms of Reference of the Finance and Performance Committee dated 1 December Robert Coomber stated the ToR should specifically mention responsibility for use of resources. Discussion took place regarding NED and CE membership of the committee. Roger Paffard agreed there needed to be a standard format for reporting from Board committees. The Board of Directors noted the report, approved the Terms of Reference subject to amendments as agreed at the Board meeting and a review in August 2016 The Board of Directors agreed the Trust needed to adopt a common format for reporting with Board Committee Chairs. BOD 041/16 QUALITY SUB COMMITTEE Dr Neil Brimblecombe presented a brief summary of key points discussed at a meetings of the Quality Sub Committee held on 19th January 2016 drawing the Board s attention to key points for consideration that included confirmation of the Trusts response to the Care Quality Commission (CQC) Inspection action plan that identified 33 must do actions and 115 should do actions. The Board of Directors noted the report BOD 042/16 COUNCIL OF GOVERNORS Mark Ganderton and Adam Black presented an update from the Council of Governors on behalf of the Lead Governor, Chris Anderson who had sent his apologies. Mark Ganderton reported on the outcome of the first joint visit with Non-Executive Directors to the Child and Adolescent Mental Health Services (CAMHS) that had been a successful example of joint working. Page 8 of of 134

11 A Governors only meeting was scheduled for 24 February. Adam Black made reference to items that would be discussed at the Governors only meeting. In his report to Board Adam Black referred to concerns raised with the process for recruiting a Service User Champion (Non-Executive Director) to the Board. With regards to a recent public event Adam Black asked the Board to note concerns with regard to understanding how the Trust would undertake to analyse the qualitative data. Of concern was the Trusts capacity to undertake an appropriate level of thematic analysis. A Governors report on the recent CQC Inspection and the External Review of Governance would be reported to the Board in due course. The adoption of National Involvement Standards offered great potential for involvement and engagement across the Trust. There needed to be more routine service user feedback aside from the present tendency to target service user feedback. With reference to the key findings reported in the External Review of Governance Adam Black asked the Board to note the need for Governors and Non- Executive Directors to meet and agree locally agreed arrangements and work must continue to clarify the information flows within the Trust. The Board of Directors noted the report. BOD 043/16 DIRECTOR S REPORTS None received. BOD 044/16 ACTIONS SUMMARY FROM TODAY S MEETING Paul Mitchell would circulate the actions from the meeting. BOD 045/16 REFLECTIONS ON TODAY S MEETING Comments included: The Board agenda was more balanced however there needed to be more time for discussion at the meeting held in private. The choice of patient stories presented at Board should present a balance of case studies that illustrated arrange of service user experiences, positive and negative The venue for today s meeting was too noisy due interruptions from windows automatically opening during the meeting. Members of the Board discussed the use of microphones at future meetings. Roger Paffard commented on the need for more pithiness and consistency about the front cover sheets for Board reports It would be helpful to receive a one page summary of the patient story to be presented at the meeting. The Board of Directors noted comments in relation to the meeting that included action to ensure a balance of user experience in the patient story and a decision to trial the use of microphones at future meetings. BOD 046/16 FORWARD PLANNER AND DRAFT AGENDA FOR FEBRUARY MEETING The Forward planner was noted. BOD 047/16 REPORT FROM PREVIOUS MONTH S PART TWO The report from the previous month s Part II was noted. Page 9 of of 134

12 BOD 048/16 ANY OTHER BUSINESS None declared. BOD 049/16 DATE OF NEXT MEETING Date of Next Meeting: Wednesday 30 th March :00pm, Learning Centre, Maudsley Hospital, Denmark Hill, London, SE5 8AZ. Representatives of the press and members of the public were asked to withdraw from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest. (Section 1 (2) Public Bodies Admission to Meetings Act 1960). I confirm that the minutes of the Board of Directors meeting of 23 February 2016 are a true record Signed Date: Roger Paffard, Chair Page 10 of of 134

13 Board meeting 23 February 2016 action points Ref Issue Action By When Status RAG November meeting 1 QI. Review governance arrangements once partner appointed. NB Apr 16 On schedule. December meeting 2 Workforce report Devote future time at a board for feedback from equality and diversity analysis. Take report to the Board quarterly, more focussed on KPIs. Include workforce dashboard as part of performance report. 3 Health and Safety Deep dive on H&S for board development session in spring. LH Mar 16 On agenda. LH Mar 16 On agenda. LH/KD Mar 16 Included. KD Apr 16 On schedule. Bring report back in June. KD June 16 On schedule. 4 Simulation Centre Discussion at charity committee. RC Apr 16 On schedule. 5 Safer Staffing Bring back after consideration by SMT. NB Mar 16 To be taken to SMT. Page 1 of 3 13 of 134

14 Ref Issue Action By When Status RAG January 2016 meeting 6 Recently established mobile working hubs for KCL students. Discuss access to hubs with Director of Estates. GH with DN Mar 16 Done. 7 Revised format of Board meetings. Seek feedback from regular attendees and report outcomes. PM Mar 16 On agenda. 8 Template for mortality reviews. Introduce an updated template. NB May 16 On schedule. 9 BLI trend analysis. Produce analysis for consideration by the QSC. 10 CQC action plan. Bring back the CQC action plan in 6 months. 11 Physical health care. Immediate focus on high level visible action. NB May 16 On schedule. NB Jul 16 On schedule. NB May 16 On schedule. 12 APM 16. Take to CoG for approval. PM Mar 16 Done. February 2016 meeting 13 NED visits. To include pharmacy. KD Apr 16 On schedule. 14 Medicines error reporting. To be considered by the QSC. NB/DT Apr 16 On schedule. 15 IT roll out and replacement. Send round update and report to March. 16 Deloitte report. Exec leads to confirm for their sections. GH/SD Mar 16 On agenda. All Apr 16 On schedule. Include links to evidence to PM Apr 16 On schedule. Page 2 of 3 14 of 134

15 Ref Issue Action By When Status RAG enhance assurance. Close the report by April. PM Apr 16 On schedule. 17 Scheme of Delegation. Include BAF and bring back to April meeting. GH Apr 16 On schedule. Capital plans reserved to board. Appointment to Outside bodies. 18 Board committee reports to the Board. Ensure there is a common format for reporting with Board Committee chairs. 19 Meeting arrangements. Trial use of microphones for meetings. 20 Patient story. Add schedule to F/P. Not always good story. Produce one page briefing paper on the service background for each patient story. RP/PM Apr 16 On schedule. PM Mar 16 Being booked. ZR Feb 16 On agenda. ZR O/G Done for March. Code: Green completed Amber on schedule Red not on schedule PNJM/February 2016 Page 3 of 3 15 of 134

16 TRUST BOARD SUMMARY REPORT Date of Board meeting: 30 th March 2016 A Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance) Author: Approved by: (name of Exec Member) Presented by: Trust Quality Priorities Presentation Amanda Pithouse, Deputy Director of Nursing Dr Neil Brimblecombe, Director of Nursing Dr Neil Brimblecombe Purpose of the report: The Board is required to agree annual Quality Priorities, this paper presents the Quality Priorities for 2016/2017 to the Board to review and agree Recommendations to the Board: The Board of Directors is asked to approve the Quality Priorities Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: The Priorities will be measured through audits and patient surveys to provide assurance that the Priorities are being taken forward. Summary of Financial and Legal Implications: None at this point Equality & Diversity and Public & Patient Involvement Implications: Equality & Diversity and Public & Patient Involvement will be consistently monitored through existing systems Service Quality Implications: The Trust quality priorities for 2016/17 complements the Trust s five year strategic plan and reflects national and local priorities as well as expectations of service users, carers, staff, commissioners and regulators. The priorities continue to build on the work that has been undertaken to improve quality in our services over the past year of 134

17 Quality Priorities 2016/2017 Introduction The Trust sets quality priorities each year in order to ensure that the quality of services provided is of a high standard and quality improvement processes are in place where needed. This report provides the proposed quality priorities for 2016/17 for review by the Board prior to the wider consultation process. The CQC inspection and subsequent action planning has formed the quality agenda for the Trust going forward into 2016/2017. Many of the issues raised by the CQC as areas for improvement also mirrored the issues that were raised at the Quality Stakeholder event held on the 12 th November The Trust quality priorities for 2016/17 complements the Trust s five year strategic plan and reflects national and local priorities as well as expectations of service users, carers, staff, commissioners and regulators. The priorities continue to build on the work that has been undertaken to improve quality in our services over the past year. Quality Priorities In reviewing the quality priorities for next year a number of national frameworks, policies and guidance as well as local priorities on quality, have been taken into account, these include: Trust five year Quality Strategy Positive and Proactive Care: reducing the need for restrictive interventions The national mental health strategy No Health Without Mental Health The Francis Report into the failings at Mid Staffordshire NHT FT, and the government response to the Francis report The Commissioning for Quality and Innovation framework [CQUIN] Quality schedules in our contracts with Clinical Commissioning Groups The quality priorities have been arranged under the three broad headings which provide the national definition of quality in NHS services, there are three priorities under each of these areas: Patient safety Clinical effectiveness Patient experience 2 17 of 134

18 Patient Safety Priorities 1. Patient Safety Priority (This is a new priority) Quality Priority Rationale To reduce the use of restrictive interventions applied to service users within in-patient settings. NICE guidance Positive and Safe initiative DoH (2014) CQC action Target Reduce the use of restraint, prone restraint and seclusion by 20%. Measure Datix incidents data analysis How we will achieve this Implementation Safe and Therapeutic Services strategy Roll out of Four steps to safety 2. Patient Safety Priority (This is a new priority) Quality Priority Rationale Target Measure To ensure that in-patient services have adequate staffing levels to provide safe and effective care. National QB guidance CQC action To reduce the number of wards breaching agreed minimum safe staffing requirements by 30%. Safer staffing monthly returns - Safecare How we will achieve this Process and system improvements to recruitment Improved advertising Efficient use of e-roster 3. Patient Safety Priority Quality Priority Rationale Target To improve rates of completion of risk assessments and associated risk management plans for all service users requiring risk assessment. CQC action Serious incident reviews. 85% of service users in in-patient services and community service users under CPA will have a full risk assessment completed for each in-patient admission or CPA review. Measure This will be measured through clinical audit in Q of 134

19 How we will The risk assessment tools within PJS are currently being achieve this reviewed in order to improve the efficiency of use. Clinical risk training Clinical Effectiveness Priorities 4. Clinical Effectiveness (Pending confirmation of CQUIN for 2016/17) Quality Priority Rationale Target Measure How we will achieve this To provide effective physical healthcare assessment and intervention for in-patient service users and early intervention service users related to the cardio-metabolic risks associated with severe mental illness. CQUIN CQC action Parity of esteem 90% of in-patients service users and 80% of early intervention service users audited will have had an assessment of each of the key cardio metabolic parameters. Internal audit. CQUIN targets EPJS review Electronic observations roll out 5. Clinical Effectiveness Priority Quality Priority Rationale Target To reduce the number of service users supported by Home Treatment Teams (HTT) who require admission to hospital. It is necessary to ensure that avoidable hospital admissions are prevented. No more than 15% of service users who have been supported by HTT will require admission to in-patient services (in boroughs where the AMH model has been established). Measure We will measure this by reviewing admission data in Q How we will achieve this Adult Mental Health programme 6. Clinical Effectiveness Priority (This is a new priority) Quality Priority Rationale Target Measure We will develop our electronic systems to improve the delivery of care Improve consistency, efficiency and effectiveness of physical and mental health observations. 50% of inpatient teams using electronic observations in practice No. of wards using eobs How we will achieve this Roll out of eobs project across all inpatient wards of 134

20 Patient Experience Priorities 7. Patient Experience Priority Quality Priority Rationale Target Measure How we will achieve this To ensure that service users are involved in the planning of their care. CQC action Service user feedback 90% of service users will state that they feel involved in their care. This will be measured through the patients survey results in response to the question Do you feel involved in your care? Development of care planning standards and training review Review documentation within PJS to ensure that care planning is effective for service users and staff. 8. Patient Experience Priority Quality Priority Rationale Target Measure How we will achieve this Identified carers will be offered a carers assessment and associated care plan. NICE guidance for Psychosis and Schizophrenia in adults. Service user and carer feedback. Care Act (2014) CQC action 30% of identified carers will have been offered a carers assessment and a carer s care plan. This will be measured through internal audit. Implementation of Carers strategy Review of carer assessment documentation across 4 boroughs 9. Patient Experience Priority Quality Priority Rationale Target Measure How we will achieve this We will continue to improve the quality of the environments within our in-patient services. CQC action Service user feedback. Patient Led Assessments of Care Environments (PLACE) audit scores will achieve over 95% in all areas PLACE audit reports and hotel services Spot Light reports will be monitored and reviewed. The full redesign of some clinical services is underway (e.g. Douglas Bennett block). Ligature reduction programme window replacement Refurbishment programme. Food contract renewal Conclusion Following discussion at the Board and further stakeholder consultation the quality priorities will be shared with commissioners and other key stakeholders for comment and reported within the Quality account for 2016/ of 134

21 TRUST BOARD SUMMARY REPORT B Date of Board meeting: 30 March 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance, Information) Author: Approved by: (name of Exec Member) Presented by: Learning Lessons Report Q3 Quality Lucy Stubbings, Head of Patient Safety Neil Brimblecombe, Executive Director and Julie Hollyman, Non-Executive Director Neil Brimblecombe Purpose of the report: The Board is required to monitor the clinical safety of Trust services and ensure that lessons are learned from errors and incidents. This paper provides details of and lessons learnt from serious incidents, complaints and claims within South London and Maudsley NHS Foundation Trust during Quarter 3: October, November, and December 2015, for the Board to consider. Action required: To ensure dissemination of good practice and to highlight lessons learned during Q3. Recommendations to the Board: To note the report and support identified actions. Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: This report relates to the following areas of the Assurance Framework: 1) Safety of patients, staff and public - Moderate 2 Failure to provide services in line with best practice - Moderate 3) Patient Experience - Moderate 4) Activity - Moderate 7) Estates Responsiveness - Moderate 8) ICT Infrastructure - Moderate Summary of Financial and Legal Implications: Financial risk if identified actions in service areas are not delivered. The report identifies information on operational performance and areas of concern. Equality & Diversity and Public & Patient Involvement Implications: As part of the management of investigations across the Trust the implications for patients, carers and others are considered. Where there may be a specific impact on these groups this is managed during the course of the investigation. Service Quality Implications: Lessons learned are a catalyst for service improvement across the Trust. Learning from the most serious investigations is shared at a senior level and themes identified to enable a strategic and targeted response to areas requiring improvement. Page 1 of of 134

22 Learning Lessons from Incidents, Inquests, Claims and Complaints Quarter Three Report: 2015/16 Page 2 of of 134

23 Introduction This is the aggregated report outlining details of and lessons learnt from serious incidents, complaints and claims within South London and Maudsley NHS Foundation Trust during the 2015/16 quarter 3 (Q3): October, November and December The report outlines: 1. A summary of the serious incidents reported, claims and complaints received during Q3. 2. A summary of the lessons learnt from inquests 3. The findings and lessons learned from some of the serious incident investigations undertaken in Q3 which have been ratified at Clinical Academic Group (CAG) serious incident panels or at Board Level Strategy Meetings 4. Key lessons learned from investigations into complaints and claims during Q3 5. Local and National Research and Development related to patient safety The data compiled for this report is from the Datix incident reporting database and is the data reported within Q3. Incidents may be re-graded once further information is received from the clinical area. Therefore there may be differences in the grades of incidents reported in later reports. Serious incidents are any incidents graded A-C. Summary of Serious Incidents Reported During Q3 The number of serious incidents report during Q3 has decreased by 9%,from 865 in Q2 to 788 in Q3. The number of reported incidents had steadily increased between Q4 2014/15 until Q3 of 2015/16. In comparison to the same quarter in 2014/15 the number of reported incidents has reduced by 13% from 910 to 788. Q1 Q3 in 2014/15 saw a peak in the numbers of reported serious incidents. The average number of reported incidents, A-E grade from Q1-3 in 2014/15 was 3063 and 2015/16 was This indicates that while the grading of incidents may have varied but the number of reported incidents overall remains broadly similar. Figure 1 Incidents by Severity and Quarter Page 3 of of 134

24 Figure 1 shows the main variation in reported serious incidents are C grade incidents, which have a larger fluctuation in the numbers reported. These have decreased slightly from Q2 but the number of reported C grade incidents remains between per quarter. SLaM provides services across a number of boroughs, table 1 outlines the reporting of incidents across these 6 boroughs. Table 1 Q3 Serious Incidents by Grade and Borough Severity BROM CROY LAMB LEW SOUTH TON WAND BEX GREEN OTHER Total A - Death B - Severe C - Significant Total Analysis of serious incidents in Q3 The recorded sub-categories of incidents are used to provide more detail and specific information about the exact nature of the incident. This information allows themes to be identified. Table 2 A Grade Incidents by Category and CAG Category ADD BDP CAMHS MHOAD MAP PMED PSYCH Total Probable Suicide Possible Suicide Actual Suicide (Proven) Natural Causes Homicide (Murder) BY Patient Alleged Murder OF Patient Death As A Result Of A Road Traffic Accident (RTA) Total Several incidents are being taken forward as investigations under the SI Framework. We link with other healthcare providers to review the care and treatment of patients under both organisations care. Natural causes deaths are not routinely reviewed as part of a structured investigation, these are reviewed within the CAGs and a fact finding report completed if necessary. Table 3 B Grade Incidents by Category and CAG Category ADD BDP CAMHS MHOAD MAP PMED PSYCH Total Assault By Patient Attempted Suicide Patient - Falls, Slips & Trips Patient Information Abscond - Informal Patient Actual Self-Harm Patient - Fire (Inc. Fire Alarms) Assault By Other (e.g. Visitor, Member Of Public) Page 4 of of 134

25 Attempted Self-Harm Sexual Assault By PATIENT Sexual Assault By STAFF Patient - Unknown Injury Harassment By STAFF Security - Other Patient - Road Traffic Accident Total Category Incidents that are reported as B grade are often downgraded or upgraded following review. The category with the highest number of reported incidents is C grade. The table below shows the top 10 reported C grade incidents from Q3 2013/14. Table 4 Top ten reported C grade Incidents 2013/ /16 13/14 Q3 13/14 Q4 14/15 Q1 14/15 Q2 14/15 Q3 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 Assault By Patient Challenging Behaviour Administration Or Medication On Clinical Units (Wards & HTT's) AWOL - Sectioned Patient's Failure To Return From Authorised Leave (Deactivated ) Staffing Issue (Including Staff Unwell/ Illness) Patient Unwell/Illness Absconded - Sectioned Patient Left Ward/Service Without Permission (Deactivated ) Actual Self-Harm Attempted Suicide Assault By Other (e.g. Visitor, Member Of Public) Total As with previous quarters reported incidents under the category assault by patient remains highest reported, with an average number of reported incidents at 121 per quarter. Total Page 5 of of 134

26 Figure 2 Top ten reported C grade Incidents 2013/ /16 Notification of serious incidents The patient safety team and CAGs review reported incidents on Datix to ascertain if they are notifiable to the CCG using the Serious Incident Framework (NHS England 2015). Incidents are notified to the CCG and a structured root cause analysis undertaken at either a concise (level 1) or comprehensive (level 2) level. The Trust uses the Strategic Executive Information System (STEIS) to ensure that key external stakeholders are promptly notified of the most serious incidents. Incidents notified on STEIS are subject to a 60 day timeframe for investigation. Concise investigations (level 1) are conducted internally to the CAG but externally to the service area. Comprehensive investigations (level 2) are conducted externally to the CAG and are led by the Trust s Investigation Facilitators. These are subject to two Board Level Strategy meetings to plan and sign off the investigation before sharing the ratified report with the CCGs. A 72 hour report is compiled and sent to the commissioners following notification of the incident. The Trust Fact Finding report is used as the foundation of these reports Q3 saw a decrease in the number of incidents reported externally. There were 18 serious incidents notified on STEIS during Q3 compared to 27 in Q2. Table 5 Incidents notified on STEIS by Category and Reported CCG Bexley Croydon Lambeth Lewisham Other Southwark Total Assault By Patient Attempted Suicide Patient Information Probable Suicide Staffing Issue (Including Staff Unwell/Illness) Patient - Fire (Inc. Fire Alarms) Possible Suicide Natural Causes Homicide (Murder) BY Patient Page 6 of of 134

27 Sexual Assault By PATIENT Alleged Murder OF Patient Other MHA Paperwork Error Other MHA Trust Error Patient - Unknown Injury Total Of the notified incidents, one incident was deescalated as the Trust was subsequently informed that the death was a natural cause s death. One incident of those listed above was reported by SLaM and de-escalated as KCH took the lead for the incident investigation and SLaM participated in their investigation. The patient safety team will be closely monitoring the decrease in externally reported incidents in Q4 to review any changes. Two notified incidents required a comprehensive investigation undertaken by a Trust Investigation Facilitator. National Reporting and Learning (NRLS) System The Trust uploads anonymised patient safety incidents onto the NRLS on a weekly basis. This data is used by NHS England and other agencies as a useful benchmarking tool. Clinicians and safety experts within NHS England analyse the information provided to identify common risks to patients and opportunities to improve patient safety. The table below provides an overview of the Type of incident reported to NRLS in Q3. Table 6 NRLS Reported Incidents in Q3 Category 15/16 Q3 Violence/Aggression/Assault 212 AWOL/Abscond/Failed To Return 73 Clinical Care (Inc. Substance Misuse/Pressure Ulcer/Wound) 117 Medication 76 Self-Harm 165 Death 3 Patient Accidents/Health & Safety/Fire 121 Staff Accidents/Health & Safety/Fire 0 Security 37 Confidentiality/IT/Health Records 18 MHA Breach 7 Staff Issues 11 Totals: 840 NRLS published the most recent patient safety incident report 1 in September 2015, which covered the reporting period 01 October 2014 to 31 March During this period there were delays in the upload of incidents to NRLS with half of reported incidents reported 34 days after the incident occurred. Improvement work is currently underway in Q4 on the Datix incident reporting system. This 1 Available from: Page 7 of of 134

28 includes streamlining the external reporting process to ensure incidents are reported in a timely and efficient manner. Other Areas Monitored by the Patient Safety Team Pressure Ulcers Table 7 Reported pressure ulcers in Q3 CAG GRADE1 GRADE2 GRADE3 GRADE4 Total MHOA and Dementia Psychosis Totals: There has been a continued decrease in the number of reported pressure ulcers. Of those reported here, the grade 3 and 4 ulcers were identified and reported on admission to the ward. Each patient with a pressure ulcer will be reviewed and a care plan put in place to ensure adequate care is taken and the wound is monitored. Safeguarding Alerts Safeguarding Adults Q3 Table 8 Safeguarding Adult identified in incident CAG 15/16 Q1 15/16 Q2 15/16 Q3 Addictions Behavioural & Developmental Psychiatry Child and Adolescent Mental Health Services Mood, Anxiety & Personality Disorder MHOA and Dementia Psychosis Psychological Medicine Totals: Safeguarding Children Q3 Table 9 Safeguarding Children identified in incident CAG 15/16 Q1 15/16 Q2 15/16 Q3 Addictions Behavioural & Developmental Psychiatry Child and Adolescent Mental Health Services Corporate Mood, Anxiety & Personality Disorder MHOA and Dementia Psychosis Psychological Medicine Totals: The Trust has identified leads in each of the CAGs for Safeguarding Adults and Children. Reported incidents are reviewed by the leads and CAG teams to ensure appropriate action is taken if the incident does not lead to a safeguarding inquiry or referral. Summary of Claims Received during Q3During Q3 one claim was received by the Trust in CAMHS categorised under slips, trips and falls.the number of claims received during Q3 has dropped significantly from those received over the past 3 financial years. Page 8 of of 134

29 Figure 3 Overview of Claims Summary of Complaints Received in Q3 Table 10 Complaints by CAG Q3 CAG October November December Addictions Behavioural & Developmental Psychiatry Child and Adolescent Mental Health Services Corporate Mood, Anxiety & Personality Disorder MHOA and Dementia Psychosis Psychological Medicine Totals: Figure 4 Complaints by CAG and Subject (primary) Trust wide concerns about Treatment and Care accounted for 35% of complaints (down from 44% in the previous quarter and 51% for Q1), staff attitude for 18% (no change), Page 9 of of 134

30 communication for 8% (a 3% decrease) and assault/violence 5% (a 6% decrease) of complaints received during this period. Lessons Learned from Complaints in Q3 Complaints about staff attitude and communication are taken seriously by the Trust. The impact on the patient s experience of concerns that the patient or carer did not feel involved or listened to by staff are always acknowledged and details of actions taken to improve efforts by identified staff are set out in responses. These have included specific steps to more proactively encourage patient engagement with community meetings and ward rounds to facilitate patient involvement in discussions about their care and treatment. Summary of Lessons Learned from Inquests in Q3 There were 18 inquests completed, 2 of which lasted 2 days or more. Staff were required to attend at 10 of the hearings - 28 witnesses in all. Reports and statements from 18 other Trust witnesses were read into evidence. There remain 106 inquests still to be heard. There were also 3 Pre-Inquest Reviews, which is a preliminary hearing to decide the issues to be considered and the evidence and documents required. Coroners are generally investigating these cases in greater detail requesting more information, documents, records and policies, resulting in greater scrutiny of the Trust s systems and practices, more reports/statements being requested and more witnesses being requested to attend court. An SI investigation is carried out in most of the cases that result in an inquest involving the Trust and in the majority of these Coroners are requesting that at least one of the authors of the reports attend to give evidence on their findings, criticism and recommendations, together with a witness to answer questions about with the implementation of the recommendations in the Action Plans. As a consequence of the increased scrutiny the Trust are being declared an Interested Person in the majority of inquests which means that the Trust may be open to criticism and subject to a potential Preventing Future Death report by the Coroner. As an Interested Person the Trust take an active role in the Inquest by viewing all the evidence, crossexamining witnesses and making representations and submissions to the Coroner. Legal representation is, therefore, being required in a greater number of cases. No Preventing Future Death reports were issued in this quarter. Findings and lessons learnt from Serious Incidents 21 Structured investigations concluded and were submitted in Q3. 16 of these were concise, level 1 investigations, of which 5 related to assault by a patient. Carer s Support and Assessment Support structures for families and acknowledgment of the vulnerability of families when patients are unwell. Risk Assessment and care planning Completion and review of risk assessments in line with Trust policy including HCR- 20. Recovery and Support plans emphasis of individualised care, risk monitoring and joining up with other agencies within these. Page 10 of of 134

31 Documentation All clinical discussions, wherever they take place (to include supervision or team meetings), must be documented on epjs to reflect the decision making process and provide an audit trail of decisions. No initial risk assessment was completed. Moreover, when the patient was transferred from GP Shared care to LHH opiate team the risk assessment was not reviewed Disengagement management All points of contact should be utilised before discharge from services including writing to GP Within MAP all team members were reminded of the integrated pathways discussions and agreements in Lambeth. These have been re circulated to the teams to ensure MDT consider frequent attenders/non engagers with, different approaches to engagement; to include, PLN, A&E, LAS, Triage, GP and CMHT Considerations and comments made on patient s care Consideration of offering an informal admission following a MHA assessment. The use of a CTO on discharge to ensure medication management. Access to culturally revelant activities. The investigating team think that Patient A may benefit from activities which are culturally relevant but respect that this has probably been considered.by the care team. Could the family members become more involved in Patient A s care? Lessons from Board Level Inquiries Concluding in Q3 The table below outlines an overview of recent board level inquiries within the Trust, themes and recommendations from these. Within each case actions have been identified for the recommendations given and are in the process of being completed. Table 11 Overview of Themes from Recent Board Level Inquiries Datix Ref CAG/ Service WEB31327 CAMHS & Psychosis Johnson Unit INCIDENT TYPE/DATE & PART 2 DATE Absconding of young person while being transferred from place of safety to ambulance Incident date: 16/01/2015 Part 2 date: 13/10/2015 Theme of Recommendations 1. Clinical Records Access: epjs in Lewisham Place of Safety 2. Training: PSTS refreshers on transfer of patients Johnson Unit nursing staff to receive regular training refreshers regarding the transfer of patients. 3. Training: working with young people in place of safety enlisting help of CAMHS 4. Communication: ensure systems in place to share risk information with new ambulance provider. WEB34334 CAMHS Lewisham East Suspected suicide Incident date: 24/04/2015: Part 2 date: 13/11/2015 Theme of Recommendations 1. Evaluation of services: The CAMHS community services to implement a process for evaluation of the efficacy of the interventions offered to families so that work can be reviewed and refocused when required. 2. Risk Assessments and Care Plans: reviewing risk assessments and care plans in MDT forums or supervision in response to significant events or changing circumstances 3. Communication with external agencies: including primary care and schools. 4. Communication with young people & families: electronic resource containing literature that can be give families about young people who self-harm and how to support them. CAMHS to consider how to make this more accessible to families/ carers and young people 5. Policy Update: Copying Letters to Patients Policy is revised to include guidance on advance discussions with young people and their Page 11 of of 134

32 families/carers/guardians about their contact preferences taking into account any Gillick competency, capacity or safeguarding issues WEB34721 Suspected Homicide BDP Incident date: 04/05/2015 Prison In reach Part 2 date: 08/09/2015 Theme of Recommendations 1. Operational Policy: The Operational Policy, June 2015 is updated to include arrangements for supervision and appraisal of bank/agency staff and consultant psychiatrist s e.g. peer group supervision and annual appraisals and a regular audit of supervision for all staff groups. The role of the administrative staff in supporting good communications within the team is more clearly defined in the policy with a clear summary of and with other services in the prisons. The revised role definition is agreed with St George s. 2. Communication with partner agencies: When a referral is accepted the contact details of the referrer must be clearly documented. The referrer must be informed of the outcome of their referral and correspondence must be attached to the patient record. 3. Support for Agency Staff: In-reach Mental Health Clinical Lead to follow-up support arrangement with the agency mental health nurse s employers. The Director of Nursing will circulate advice to services about how to provide support to Locum and Agency staff in the short term and the long term. Suspected suicide of prisoner WEB35787 Incident date: 08/06/2015 BDP Prison In reach Part 2 date: 08/09/2015 Theme of Recommendations 1. Documentation: review of processes at OHC SLaM to ensure these meet the standard in CMHT 2. Induction systems: to include accessing HMP Wandsworth ACCT documentation, to be aligned for permanent and locum staff. 3. Supervision 4. Risk Information Sharing: relevant contents of ACCT to be detailed in patient notes (scanned) and to be used in MDT discussions 5. Team Structure: review of structure of team 6. Incident investigation: follow up with St Georges regarding serious incident investigation and access to prison personnel and relevant documents. 7. Additional Actions: follow up of actions from thematic review on suicide. Patient Unwell/ Illness WEB36296 Incident date: 12-May-2015 Lewisham Triage Part 2 date: 25/11/2015 Investigation report awaiting finalisation, amendments required following receipt of evaluation from CCG. WEB38373 BDP Effra Ward Escape Incident date: 20/08/2015 Part 2 date: 10/12/2015 Investigation report submitted to NHSE, awaiting evaluation before recommendations can be finalised. WEB38900 Accidental Self Harm Psychosis Incident date: 06/09/2015 AL3 Part 2 date: 23/12/2015 Action Taken - appropriate remedial work has been undertaken on all the bedroom windows in Aubrey Lewis House. 1. Survey. It is recommended a survey of the windows of Aubrey Lewis House is undertaken by Estates and Facilities in liaison with the local Health & Safety Advisor. 2. Update bi-monthly Health and Safety checks checks undertaken by ward based health and safety champions are revised to include an assessment of the safety of windows within the ward environment not limited to the ligature hazards. 3. Preserving the scene of an incident. It is recommended that a blue light bulletin is drafted by the patient safety team to provide guidance on the collection of evidence to record the scene at the time of an incident prior to remedial work being undertaken. 4. The trust will provide documented guidance when a facility (such as a patient room) should be withdrawn following an incident and the multiservice assessment required for it to be reinstated. This guidance will be commissioned and agreed by the Quality Sub-Committee and will be available as a resourced on Patient Safety; Health & Safety and Estates and Facilities/Planning webpages WEB38989 Alleged sexually inappropriate behaviour BDP Incident date: 07/09/2015 FIPTS Part 2 date: 08/12/2015 Investigation report submitted to Southwark CCG, awaiting evaluation before recommendations can be finalised. Central Alerting System Alerts During Q3 39 CAS Alerts were received by the Trust Health & Safety Risk Manager. Of these 32 were deemed not to require action, 3 are undergoing assessment for relevance, 1 has on-going action to address and 3 have completed actions. Of these 6 were medical devices alerts and 5 patient safety alerts. Page 12 of of 134

33 TRUST BOARD OF DIRECTORS SUMMARY REPORT C Date of Board meeting: 30 March 2016 Name of Report: Heading: - Author: Approved by: Presented by: Workforce Update Strategy Louise Hall Matthew Patrick Louise Hall Purpose of the report: To update the Board on progress in the last quarter and to highlight the ongoing concerns around nursing recruitment focus and gaps. To recognise progress made in infrastructure agency reductions and absence management and to provide information on the learning management system progress. Recommendations to the Board: The Board is asked to note the report and to acknowledge the progress made to date. The Board is also asked to recognise the key focus areas and support these activities. Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: The workforce makes up 70% of the Trust s costs and a stable, skilled and motivated workforce is key for us to be able to deliver the strategic priorities. If we do not address the recruitment, retention and training needs of our staff, this leads to risk to our patient safety, financial performance, engagement levels and our ability to function effectively. Summary of Financial and Legal Implications: In order to operate efficiently, we need to ensure we have a stable workforce with minimal agency use. We will minimise legal exposure by operating in a clear and fair employee relations context, as well as working collaboratively with our unions and in the quality assurance and compliance frameworks. Equality & Diversity and Public & Patient Involvement Implications: The way the workforce is managed and treated has significant impact on the Equality and Diversity agenda. Service Quality Implications: The workforce behaviours, skills and engagement levels have a significant impact on service quality and service user experience. 33 of 134

34 Board Update Report on Workforce March EXECUTIVE SUMMARY The Trust Board requested an update on workforce related performance and metrics in the March Board report and this paper constitutes that update on key activities and progress. The main challenges are to continue to address agency use and nursing recruitment but good progress has been seen across the board due to dedicated focus on all workforce areas. 2 BACKGROUND Workforce costs are 70-75% of our overall expenditure and sustaining the current costs is an increasing financial challenge. At the 29 th June 2014 Board we proposed a three phase approach to workforce planning: Phase 1: short term tactical activities to reduce costs as soon as possible, without impacting our ability to transform our workforce going forward. Phase 2: medium term activities to realign our organisation to reflect the known and forecast service changes. Phase 3: medium term strategic activities to align our organisation with our developing commercial strategy. The December 2015 Board update clarified progress on these activities but two workstreams in particular remain critical and current. These are the use of temporary and agency staff and the need to recruit to the substantive workforce. In addition, there is a further update on workforce initiatives that are as a result of external pressures and changes at the end of this report. 2.1 FOCUS MORE STRONGLY ON PERFORMANCE AND ABSENCE Trust sickness currently stands at 4.92% in January 16 (this is equivalent to the 3.00% using the more common HSCIC measure). This is only 0.03% above the previous month which was the lowest figure recorded for the Trust since the Trust collected sickness data in this format in June We will continue to focus on managing sickness, however we are not expecting to see significant reductions from our current levels. Maintaining the existing status quo will be challenging as we believe that significant progress has been made here and we are now at an acceptable level of absence without staff feeling under undue pressure to come to work if they are unwell. 2.2 FOCUS ON PERFORMANCE AND RECOGNITION The Trust is currently preparing for the roll out of the 2016 appraisal round which commences on the 1 st April. We should expect to repeat the 99% achievement from the last annual appraisal round. 34 of 134

35 2.3 RECRUITMENT, BANK AGENCY AND OPEN POSITIONS Historically when restructures or new service provisions have taken place, a reduction in permanent heads has been filled by bank and agency staff. This action disguises the true cost of running the function. There has also been a reluctance to fill open roles to act as a buffer in case future cuts need to be made. Bank and agency use is already being limited to some extent to an agreed flexible/contingency level. Where a job has been cut, it will not be automatically backfilled by temporary resources. We are now communicating to managers at all levels of the organisation the relative costs/benefits of using establishment, bank and agency workers to backfill roles so they understand the true cost of temporary staffing. We also need to actively manage regretted attrition in order to minimise this and ensure we retain our best people, which in turn will reduce the need for use of bank and agency. Greater levels of control and governance are being applied for backfilling closed posts and new roles are only being agreed with high levels of scrutiny. We are also ensuring that the candidate pool is at the right level by working with NHSP and our agencies to provide a quality and ample resource pool. The Safer Staffing reviews have led to an increased need for nurses and we are actively recruiting to these levels but also by ensuring that we are recruiting and attracting the best candidates. With a few exceptions the Trust appears to be successful in filling most vacancies. However, like many Trusts, nurse recruitment particularly at Band 5 inpatient and Band 6 Community are particularly challenging. In this update we are therefore specifically focusing on nurse recruitment Nursing Recruitment Update Band 5 Recruitment Update Since September 2015, the Trust has approached Band 5 recruitment differently instead of having a generic advert for all nursing positions, we now promote 5 different roles (CAMHS, B&D, AMH, Forensic [Place of Safety/Triage/PICU] and MHOAD) each month and encourage the candidates to specify which specialism they want. Off the back of the December campaign, the Trust reciceved nearly 100 applications for Band 5 nurses, which is a very good result. Of these, 74 were invited for assessment (66 expected to attend). Attendance remains a problem for assessments however and of the 33 candidates who attended on the day, 18 passed and 11 have been successful placed into wards. We were pleased to see an even spread of candidates across the CAGs. This is the best month for Trustwide recruitment since April candidates were invited for an assessment centre in February. 35 of 134

36 In Q1-Q3 2014, a total of 96 Band 5 and 6 nurses were hired across the Trust. In the same period in 2015, a total of 156 nurses have been hired. This includes an 85% increase in numbers of Band 6 s year on year. Cumulative Registered Nurse Recruitment Band 5-7 Nurse Recruitment Q1-Q Band 5-7 Nurse Recruitment Q1-Q Band 5 Nurses hired Q1-Q3 (2014 vs. 2015) Band 6 Nurses hired Q1-Q3 (2015 vs. 2016) Q1 Q2 Q3 Band 5 (2014) Band 5 (2015) Q1 Q2 Q3 Band 6 (2014) Band 6 (2015) Current Nurse Vacancies Reported By CAGs February s Recruitment Planning Meeting identified the following vacancies for Band 5 and 6 nurses. Some areas have yet to provide vacancies for their CAGs. These vacancies may or may not include vacancies that are currently actively going through the recruitment process. CAG Band 5 Band 6 Psychosis Psychological Medicine B&D 14 N/A CAMHS 7 3 MAP N/A N/A MHOA 3 N/A Trust Total of 134

37 Current Live Vacancies Active on the Trust s Recruitment System The Trust s recruitment system (Trac) identifies all vacancies actively being recruited to. Using current information (23 Feb 16) the Band 5 and Band 6 vacancy breakdown is as follows: CAG Band 5 (FTE) Band 6 (FTE) Addictions 1 0 Psychosis Psych Med 2 8 B&D 3 0 CAMHS 4 2 MAP 2 8 MHOA 1 0 Trustwide 18 0 Trust Total Additionally some vacancies which pre-date Trac are being processed manually. There are 11 manual vacancies in the offer stage awaiting completion of pre-employment checks. Band 5 Nursing 2016/17 Forward Forecast Data used in creating the Band 5 forecast for 2016: Vacancies: Minimum 112 Band 5 vacancies currently across the Trust Turnover: 8.8 leavers per month (based on attrition July 2015 January 2016) Shortlisting: 80% of candidates are shortlisted from application Assessment Centre Attendance Rate: 54% (October 2015 to date) Pass rate: 47% (June 2015 to date) Hire rate: 7.6 per month (April December 2014), 11.6 per month (April - December2015). Band 5 recruitment is not constant throughout the year and is heavily affected by graduation dates for students. Traditionally, May/June and August/September are the busiest recruitment periods which see the highest number of candidate applications. Increase in Assessment Centre Frequency Starting April, the proposal is to double the number of Trustwide assessment centres to two per month for CAMHS, MHOA, Acute, AMH and B&D. As with the current system, additional specialist roles will be able to be included in these (e.g. MBU, EDU, Complex Care etc.). The target is to increase Band 5 nurse recruitment by 30%. This would require an increase in average from 11.6 hires/month to 15 hires/month. Based on known information, the forecast monthly Band 5 vacancy position (not including MAP) for 2016 is: Date Applications Shortlisted Interviewed Offers Leavers Net recruitment ± (-112) April May June July August of 134

38 September October November December January February March Total Trajectory of Demand and New Services It is difficult to predict exactly the number of nurses the Trust needs to recruit next year as we do not have a full understanding of vacancy rates at the current time and demand seems to be led more by turnover of staff rather than new services opening. However, we are aware that there are new services planned for PICU and Place of Safety and will adjust our marketing accordingly. The movement of treatment out of hospitals and into the community has also lead to an increase in demand for Band 6 Community Psychiatric Nurses and we expect this trend to continue. Branding Update Since late June 2015, we have used a social media tool called SNAP to promote nursing roles across the Trust. This initially targeted nurses for roles within the Psychosis CAG but quickly changed to attract candidates for all Band 5 and Band 6 posts across the Trust. The trial period throughout July and August was a real success with a significant increase in year-on-year visits to the Careers section of the website (average: 321/day vs. 116/day). It is evident that SNAP has a direct effect on the number of visitors to our site - in late August 2015, we stopped using SNAP for two weeks and saw the number of visitors drop back to 2014 levels. The social media campaign was backed by an extensive outdoor campaign throughout the Christmas period which prompted record numbers of visitors to the careers page of the SLaM website. Christmas is considered to be a quiet time of year for recruitment; however, our research showed that nurses were still happy to engage. Visits were up around 550% year on year. Recruitment Systems Recruitment has a vital role to play in ensuring a pipeline of skills and staff in key areas. Historically we have had a very labour intensive model, which is perceived to be slow and cumbersome and which relies on a number of different systems and processes in order for it to be successfully managed. In October we successfully procured an applicant tracking and recruitment management system that has been built specifically to meet the needs of NHS Trusts. We are pleased to report that the Trusts new recruitment system went live on time and on budget on the 25 th January Feedback from users has been extremely positive and we are already reaping benefits of the new system through greater transparency and control of vacancies. Automation of many of the lower value recruitment process will also result in reduced hire times together with higher levels of engagement of new starters. 38 of 134

39 Potential Barriers to Band 5 Recruitment Assessment Centres The Trust is currently failing around 50% of candidates at assessment centre stage. Whilst we should ensure that we only employ the highest quality staff, the assessments need to be reviewed and updated. The current assessments have been in place for a number of years and may not be as relevant to the roles as they used to be. It is important that the assessment centres are used to remove those inappropriate for the role but we may be missing out on good quality candidates through our assessment process. Advertising Funding Market research shows that we are perceived as a quiet Trust in terms of recruitment. This image was improved throughout 2015 but could easily return if investment is not upheld. ROI documents have been submitted to request further funding to promote the Trust next year. Staff Turnover Recruitment of nurses is up by around 60% year on year but vacancies rates have remained constant. There is a market place for nurses that can be engaged, but it is critical that the turnover of nurses is reduced. We can continue to recruit aggressively and would see a dramatic improvement of safe staffing levels if we could retain more effectively. Manager Engagement Despite recruitment being one of the main priorities of the Trust, management engagement needs to be prioritised by the CAGs. There are a number of examples of poor quality shortlisting, missed deadlines or last minute organisation for Band 5 recruitment. Shortlisting is currently held by the Heads of Nursing who also have responsibilities to support the assessment centres. The interviews are conducted by local managers and there is often a gap in communication to ensure these run efficiently to ensure the best candidates experience. This should improve with the implementation of TRAC, however we should be looking to introduce new managers to the Band 5 recruitment process and ensure they are well briefed about the importance of the project. We struggle to get consistent attendance at the monthly recruitment planning meetings and those that attend often do not have accurate information about their vacancy rates. This makes it difficult to have a clear picture of what the Trust requires. 2.4 REVIEW THE USE OF CONTRACTORS AND AGENCIES IN NON-CLINICAL AREAS AND TARGETED CLINICAL AREAS We have a clear view of all contingency workers (Agency, Bank and Contract) engaged by the Trust, contract terms, period of engagement, the business case for their continued employment and alternatives for backfilling with lower cost resources. Contracts were historically extended beyond their initial planned duration without review and re-authorisation and we have put a process in place to address this. We have already identified contractors and agency staff and commenced a review of all agency or self-employed staff who have been employed for a period of over one year. 39 of 134

40 What we have achieved to date 1. Identified accurately the cost premiums of using agency staff and cost savings of using bank staff. Typically based on an analysis of nursing agency costs - some staff are c 30% more expensive than establishment. Changed the perception of senior manager s understanding of each option as a result. 2. It has proved challenging to accurately identify vacancies from ESR / Finance systems; however we have identified long term bank and agency usage from a combination of NHSP and the Finance ledger. 3. Developed a clear and transparent view, Trustwide, by CAG, Directorate, and team and individual of bank and agency usage. 4. Reviewed long term agency usage by CAG / Directorate to identify any possible tactical savings. Some reductions and conversion of agency to staff as a direct result, some roles have been filled by permanent employees and some agency workers have left the Trust. 5. Developed a prioritised list of roles we should focus on to reduce agency usage, the top priority being Band 6 Community Psychiatric Nurses (CPN) where bank and agency premiums were costing the Trust 1.2 million per annum. Additionally CPNs represents approximately 75% of or total registered nursing agency use. 6. Initiated a cross functional senior level project team in December 2014 to start to take a strategic approach to addressing the CPN vacancy issue. The project team has developed a multi faced project plan to addressing our CPN recruitment with all the elements having been delivered. 7. As the result of the CPN project we have commenced targeted recruitment particularly in the area of highest use (Psychosis) and ensuring the correct skills were being requisitioned from NHSP in other areas particularly Psych Med. These actions have started to show a reduction of bank and agency CPN use with a resultant reduction in employment premium. We expect this trend to continue as recruitment continues and more substantive CPNs commence employment with the Trust. However, CPN establishment numbers continue to increase driven by increase treatment in the community. Recent examples include Croydon Adult Mental Health and additional funding for Early Intervention posts. The demand for nurses to provide these services, occurs within weeks, however recruitment of CPNs takes on average five and a half months during which posts are covered by agency nurses. 8. Based on action taken to reduce CPN bank and agency spend since April, monthly savings are currently estimated to be c 25K/month 40 of 134

41 9. Based on recruitment commitments from the CAG in October, the forecast was that we should be able to reduce CPN agency to 50 WTE or better by the financial year end. This forecast now looks optimistic, however we are currently progressing each agency works status on a named basis and we are still confident that we will significantly reduce our CPN agency usage. 10. As outlined previously, we are we have successfully rolled out a Trustwide project plan and timetable to increase the recruitment levels of Band 5 nurses, which will also reduce our registered nurse agency spend. 11. We have also implemented robust agency control process in Corporate areas for roll out which started August All agency new Corporate agency use requires the sign off from three Directors. This alone has resulted in 198K of savings between this date and February. We have also targeted the conversion of existing agency/ bank workers to substantive and terminated a number of other agency workers which has resulted in savings of approximately 330K. Potential Risks to Agency Reduction New Services Commissioner s investment in new or additional funding for existing services creates and almost immediate need for staff. In the case of some categories of nurses the recruitment timescales average five to six months. To bridge this period, managers understandably look to agencies to meet these needs further increasing our agency usage. Specific Skills Issues There are a small number of specific skills shortages in the Trust, which in some areas are severe. These may be local as in the case of nursing in CAMHS in Kent or Trustwide e.g. Older Adults, Liaison or Home treatment Teams. Additionally there are some Corporate roles which are difficult to fill with candidates of the right quality for example in IT. In such cases we look to run targeted recruitment campaigns. 2.5 PERFORMANCE AND TALENT MANAGEMENT (LMS SYSTEM) - SEE APPENDIX MANAGING EFFECTIVELY : A FOCUSED PERFORMANCE AND POTENTIAL PLAN FOR OUR BAND 7 AND 8 MANAGERS Nearly all first level and second level managers in clinical areas have developed and promoted through professional excellence, often will little managerial development. Employees therefore experience differing qualities of management and a lack of consistency in the way it has been applied. There is significant amount of data from the employee survey and other sources that tells us that employees are not being managed as effectively or efficiently as they should. If we are to deliver our two year operational and five year strategic plan there is an expectation that managers would be required to manage people and budgets in a more focused and consistent way, 41 of 134

42 it is therefore recognised that there is a need to provide our people managers with the skills and knowledge to enable them to do this effectively. It is critical to the delivery of our long term plan that line managers at all levels of the organisation display, support and live the expected managerial behaviours, How well our managers inspire their people to perform and grow will be a critical success factor in determining our personal and collective futures. What we have achieved to date 1. Undertaken background work to develop business case, project and engagement plan 2. Reviewed our existing portfolio of leadership and management development learning with the aim of rationalising and streamlining resources. 3. Consulted with CAG Education and Training Leads to validate need and identify draft content. 4. Validated that the programme is required and broadly our initial thoughts on content and need were seen to be valid 5. Identified all known people managers in the Trust and analysed their formal learning since We have successfully developed the high level content of the programme, consulted with key stakeholders and agreed the business case for the programme. 7. We have developed and implemented an application process for the programme to ensure appropriate employees attend the appropriate learning. 8. We are currently waiting for the evaluation of the programmes that have been run so far in order to establish next steps, especially in the light of reduced funding locally and nationally. 3 NEXT STEPS The project work has now been completed on the sickness /absence workstream and has been transferred to Business as Usual, however we will continue to monitor our performance to ensure the progress to date is sustained. Going forward our focus will be proactively looking to improve Health and Wellbeing, which complements the Trust s clinical strategy of focusing on prevention before treatment. It is also clear that we need to reflect the same principles of early intervention for staff members as well as service users who develop physical or mental health conditions. The 5 year Forward View recognises that we need to make the NHS a healthier workplace. There are recommendations within this to help our staff to stop smoking, eat more healthily, take more exercise, use the Trust s facilities, make better use of Occupational Health and promote us being part of the Workplace Wellbeing Charter. We will start to do all of these and additionally will develop guidance for managers to manage Mental Health within their own staff. We will also leverage the tools that are being developed internally such as the Wheel of Wellbeing and build a more informative intranet site for those looking for help and information. The next phase of the work on Performance Development will be to build on the success of 2015 appraisal year in 2016, maintaining the completion rates but focusing on improving the quality of the appraisal conversations and the level of mandatory training compliance. Once this is complete we will look to implement Maximizing Potential a Trustwide talent management programme. 42 of 134

43 4 USE OF TEMPORARY AND AGENCY STAFF Progress to date Since January 2015 the number of temporary registered nursing shifts has increased by 3.2% overall. This excludes Healthcare Support Workers where there has been an increase of 20% over the period of which 88% are bank. This is result of safer staffing requirements, increases in demand and a shrinking pool from which to source substantive staff. Despite this increase in requirement the increase in bank which has been 15% and there has been a corresponding decrease in agency particularly CPNs of 21% over the year. For Administration & Clerical, from October 2015 to January 2016 there has been a 21% reduction in the number of shifts overall for this group. The agency A&C has reduced by 24% from 2420 shifts in October and 1837 shifts in January and the bank shifts have reduced by 9% from 1533 shifts in October and 1420 shifts in January. We are expecting the number of agency shifts to reduce further by the end of the financial year as a number of agency workers undertaking the ICT transformation programme will cease to be used once the programme approaches completion. Risks and Issues The Monitor agency nursing cap of 12% is due to reduce to 10% for the 2016/2017 financial year. Presently the Trust is within the cap at 11.3% but this will cease to be the case from April 2016 when the threshold lowers. Each month that we exceed the 10% cap for agency nursing we will have to claw back in the following months to balance at year end. The Monitor price caps for agency introduced from November 2015 with two further staged reductions in February 2016 and April 2016 has resulted in a number of overrides where some agency staff cost more than the Monitor price cap. These are reported to Monitor on a weekly basis with an explanation of the reasons for the overrides. Whilst there were a limited number of overrides in November we have witnessed an increase in overrides from February especially for medical staff and for Allied Health Professions. We expect a further spike in overrides from April when the final staging comes into effect and we anticipate issues arising with temporary junior doctor agency cover because the Monitor cap rate will have almost halved the hourly pay compared to November From April 2016 Monitor will be introducing a ban on the use of any non-framework agency. This may have an impact of specific services and projects where it has been difficult to source temporary agency staff from framework agencies. The concentration of non-framework agency workers tends to be in non-clinical areas so the impact will be minimised to a degree. See also Appendix 2 for the analysis on corporate agency usage over the past 6 months. 43 of 134

44 Appendix 1 Learning Management System Update Background Our workforce goal is to have the right people with the right skills in the right place at the right time and at the right cost. If we are to deliver our short and long term workforce strategy we need to ensure that we have systems and processes to support the development and management of our workforce. There are a number of critical areas of focus where we need to considerably improve our processes as part of the deployment of the Learning, Performance and Talent Management application. These are: We want to significantly increase the automation of induction for new starters and those transferring into new roles within the business. This will help us provide information in a timely manner and increase the rate at which employees reach full effectiveness. It will also ensure that we capture all new employees to complete mandatory and role specific learning. SLaM s Education and Training team commission and deliver high quality education for existing staff to meet mandatory training requirements together with essential training and development of all Trust staff identified through Personal Development Plans and detailed in CAGs and directorates annual training plans. Currently we are using a range of ad hoc systems to deploy and manage our learning, little of which is integrated. This makes the management and reporting very labour intensive and error prone. The solution is single platform to deploy, administer and track all learning and consolidating all learning activities on to this single central platform. SLaM is a high profile organisation which is a national provider for a number of clinical and associated services. As a result, SLaM is a recognised commercial provider of high quality training tools in a number of fields including Mental Health Simulation, Mental Health Act, PSTS, Smoking Cessation, and Mental Health Awareness and Wellbeing. A key requirement is to develop an effective ecommerce platform to streamline the marketing and administration of all learning and development activities offered by the Trust to external clients. The external offer includes: face-to-face training events, pay-per-view elearning, print and electronic text books and training packs as well as face-to-face and blended short courses. We recognise that individually and collectively we need to focus our performance on those things that contribute most to the Trust s overall strategic plan and the care of our service users. Over the last two years we have made great strides in improving the quality and quantity of performance conversations, including this financial year where we have implemented incremental pay progression, improved processes and the support available to managers. Until 2014 we have not consistently recoded performance reviews Trust wide, but to truly manage performance we not only need to ensure that reviews take place and fair evaluations are given, but that quality objectives are set. With no robust performance management system, this becomes very difficult. SLaM as an organisation is rapidly evolving, often completely reshaping the way we structure and deliver healthcare. In places where we haven t developed home grown talent to fill these new roles, it is inevitable that we will need to recruit externally. SLaM will not be the only organisation looking for these key skills; most healthcare providers will also be 44 of 134

45 looking to acquire the same scarce resources. In an increasingly competitive London job market, we cannot just rely on our excellent reputation to fill key roles externally, we need to do more we need to actively manage our talent. To do this effectively we need a system linked to help identify, develop and provide visibility of our next generation of talent. Our procurement strategy was designed to ensure that we captured market leaders of both leaning management and integrated talent management. Procurement Strategy In November 2015 Procurement, with HR, reviewed a number of potential routes to market to procure this system in an exploratory exercise to determine whether GCloud7 was a sufficient vehicle to make this award. Timescales 15th December 2015; Exploring route to market - Letter sent out to suppliers on G Cloud short list; 15th January 2016; suppliers to provide informal responses by; Six vendors responded, four did not; 18th 22nd January; Trust to reviewed responses and identified two suppliers to invite into demos; 1st 12th February; Supplier demos and discussions including commercial aspects; 15th 19th February; internal review of demonstrations and commercial aspects; 22nd 26th February; Internal discussions to decide direct award against GCloud7; 29th February 18th March; Following internal approvals make award in accordance with GCloud7 procedures; We are currently examining the detailed responses and finalising questions on vendor s proposals. We have now finalised the detailed business case and are ready to award the contract and start the detailed project planning process. 45 of 134

46 Appendix 2 Impact on corporate agency use from September 2015-March 2016 Function September WTE February WTE WTE Change % Change 09. Clinical Support Services % A1) Estates & Facilities % B) NURSING & QUALITY % C) Information & I.T % D) Finance And Corp Governance % E) Human Resources % F) Strategy And Business Dev % G) Chief Executive % H1) Medical & Clinical Govern % I) Professional Heads % L) Chief Operating Officer % M) Commercial Directorate % TRUST RESEARCH & DEVELOPMENT % Grand Total % This shows that a significant impact has been made on the use of corporate agency use since September of 134

47 Appendix 3 New workforce initiatives for the Board to be aware of: Mutually Agreed Resignation Scheme (MARs) Our overhead costs are relatively high compared to other Trusts and our commissioners are already challenging us on this. If we are to protect frontline services, we need to reduce our infrastructure cost base, streamlining corporate management, infrastructure and support functions, including those within CAGs. We also need to look across organisational boundaries to find opportunities to achieve greater efficiency in these areas by collaborating with other providers. 70% of our total costs are staffing costs so our biggest savings opportunities are in reducing staffing levels but we need to do this without compromising patient safety and outcomes. A MARs (mutually agreed resignation) scheme is therefore planned to be launched imminently that will reduce the number of staff we have in infrastructure and corporate roles and which will need to align with the infrastructure review on how we work best and most efficiently. Apprentices From 1 April 2017, a new levy will be introduced on all large employers, to encourage them to employ apprentices. We estimate that we will be expected to recruit c150 apprentices and the levy imposed whether we recruit or not will be 0.5% of the pay bill. In return, we receive certain allowances towards paying for this new staff group. More details on this will be shared with the Board throughout this year and as more details become available but it is expected that this new type of employee will be part of the core workforce and we are already factoring this into our workforce projections. We would also like to bring in a cohort of apprentices with learning disabilities that will be working with the B&D CAG. Junior Doctors and rotas The new Junior Doctor contract is due to be issued from August Analysis of current working patterns and banding against future proposed working patterns and the associated payments does not highlight a significant reduction in salary based on the NHS Employers calculator. The rotas for the core trainee doctors (CT1-3) will need to be reviewed to take into account the new proposed rota patterns for shifts. The rotas and working patterns for the higher trainees (ST4-6) are likely to remain the same as banding for this group will be protected in accordance with the NHS Employers calculator. This may be all subject to change given the recent announcement of further industrial action by the junior doctors. Flexible benefits We need to remain as an employer of choice and we recognise that our staff have different requirements from the benefits that we offer. We already have a wide range of options, including buying extra leave for example but we are looking to work with some of our NHS colleagues to increase the choice that we offer, whilst maintaining our principles around what a fair and ethical offering would look like. 47 of 134

48 TRUST BOARD OF DIRECTORS SUMMARY REPORT D Date of Board meeting: 30 March 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance) Author: Approved by: (name of Exec Member) Presented by: IT Update Report Strategy Stephen Docherty Gus Heafield Stephen Docherty Purpose of the report: To inform the Board of the progress of the IT Department since the IT Strategy was agreed in March 2015 Recommendations to the Board: To make note of progress against the IT Strategy Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: No relation to the Assurance Framework Summary of Financial and Legal Implications: No implications, although a brief summary of the Financial position for year-ending FY15/16 is included in the report. Equality & Diversity and Public & Patient Involvement Implications: Considered but there are no specific implications. Service Quality Implications: Staff are being provided with access to enterprise tools such as Office365 and associated online collaboration tools, we have been replacing old equipment and providing PCs, Laptops & Tablets, all of which will allow Trust staff to become more mobile, more efficient and therefore able to deliver better services. The IT Service overall, is transforming in order to provide a professional, innovative function for the Trust. Page 1 of 6 48 of 134

49 Executive Summary: The following report is an update on progress over the last year for the IT Department. The Trust Board signed off on the IT Strategy back in March 2015, which triggered multiple initiatives to transform IT Services over an month period. This update takes into consideration the timeline between March 2015 and March 2016, the first year of the programme. It should be noted that prior to the initiation of the IT Strategy (transformation programme), IT Services were problematic, significant system failures were commonplace resulting in lost productivity and overall IT Services were providing a poor experience for Trust staff. There was a lack of vision for the IT department and the inherent culture was one of command & control, whilst a blame culture was also prevalent. The make-up of the IT department had a heavy reliance upon contract staff, which not only brought about financial pressures, but also made it difficult to achieve stability. The new vision for the IT Service was to achieve Silent Running and provide a resilient, enterprise service. The IT Strategy set out to not only stabilise the department and the IT Service, but to be forward thinking with the view of future-proofing the platforms and services, whilst digitising the workforce, and thus supporting the Trust s strategic objectives. This IT Strategy & vision underpins SLaM s objectives in achievement of the recommendations in both the Five Year Forward View published by NHSE and the Personalised Health and Care 2020 published by the National Information Board. Page 2 of 6 49 of 134

50 Report Details: The following narrative provides additional context to supplement the IT Summary Report (included) which was sent out previously to Board members via an link to the document, stored and shared from SLaM s Microsoft Cloud environment. SLaM moved to Microsoft Cloud: SLaM s service was built upon Microsoft Exchange 2003 and the supporting hardware & infrastructure was significantly aged (10yrs+) and was never designed to support an organisation with 6,000+ mailboxes. This represented a major risk for SLaM as was used as the primary mode of communication across the Trust. Significant failures were occurring resulting in frustration and days of lost productivity. A proposal was put forward to the Trust Exec in March 2015, and was included in the IT Strategy. The proposal had three options: Build a new platform and manage internally Work with the HSCIC and migrate to the new NHSMail2 platform which was being touted for delivery in Summer of 2015 Move to the Microsoft Cloud and adopt the additional communication and collaboration tools As a Trust, the decision was taken to move to the Microsoft Cloud. This was the best decision, given that NHSMail2 is looking at being 1 year late on delivery. Note: NHSMail2 is now being built on the Microsoft Cloud platform anyway. This decision is further appreciated by the fact that a number of Trusts have been asking SLaM s CIO and IT team for advice on moving to the Microsoft Cloud, as we are now being seen as leaders in cloud adoption. IT Restructure: In order to stabilise the IT Department and develop staff, whilst identifying any skills gaps to deliver the IT Strategy and Service, a consultation took place in July/August 2015 and ended in November Staff were appointed to roles after successful interview and vacant positions were posted. It should be noted that the IT Department consisted of a large number of contract roles, which brought additional financial pressures. A significant exercise has taken place to convert around 15 contract staff to permanent, which is positive in that those converting want to go on the journey with the IT department as we transform. We have also recruited new staff, although it still remains challenging to recruit into some positions/locations. Date Contract Perm Vacant Posts Mar Mar Page 3 of 6 50 of 134

51 We are currently active in recruiting for Service Desk & Desktop Support Staff to reinforce the quality of delivery and further develop a Service Management culture. Business Intelligence: It became evident to the SLaM CIO (and many others) that the flow of information across the Trust was dysfunctional, especially from source (epjs) to Business Intelligence, to CAGs, through to Performance Management and Contracting. We appeared to be living hand-to-mouth for important information, scrambling to pull together cohesive reports, often ending up with differing data sets and a distrust of the source data, mainly down to multiple layers (and perceptions) that had been built up over the years. In July 2015, the CIO brought in a project manager dedicated initially to perform a review of the data & information flow across and beyond the Trust. This resulted in a number of initiatives including the formation of a Business Intelligence Steering Group and an Information Analyst Network, a review of the Data Warehouse and associated tools, and brought about a focus on achieving a Single Source of Truth for the Trust. Shortly after this review period the COO joined the Trust and also provided a strong focus on requirements for real data, especially for the Activity & Capacity Planning process which is critical to the Trust. As a CIO, it is important to push the message around data visualisation to quickly understand and make sense of the data. As we looked to review and understand which platforms and tools were available in the market, we also held conversations with Microsoft. As a result, we are now going to adopt and run an initial pilot (Q1 FY16/17) on the Microsoft Azure Cloud platform with PowerBI tools, which will allow the querying and visualisation of data. We will also be decommissioning the existing legacy platform by the end of Q2 FY16/17, as we fully deploy the Azure solution. It should be noted that the BI department has worked extremely hard in the last few months with more demand being placed upon them, with the same number of staff, and have taken on additional work from the Contracts department which has reduced its headcount. The Trust is also required to submit a new national data set to the HSCIC, which has added to increased multiple demands. Numerous Projects: There are multiple projects that have been running concurrently in order to deliver the transformation of IT Services. The IT Programme Management Office (PMO) has been in operation since January This ensured that appropriate governance levels were in place on a per-project basis, standardised reporting was introduced and progress was tracked. Below is a list of some of the key Projects: PC Replacement Programme (2,100 devices) Office365 Migration (5,000+ accounts migrated) Internet and inter-site communication links upgrade Page 4 of 6 51 of 134

52 KHP Online Outsourced Managed Print Wi-Fi upgrades Mobile phone rollout and provider consolidation Firewall upgrades eobs (Digital Observation in wards) Work Hubs epjs Redesign and external hosting, and continuous improvements myhealthlocker 2.0 Service Desk: At the beginning of 2015, there was a large backlog of tickets and some Staff could not get through to the Service Desk due to the volume of calls. There was a focus on providing a better service to Trust Staff which saw a major clearing of the backlog of Service Desk tickets between February June This enhanced both the perception and real experience of staff accessing IT Services. As the Trust was still using an old platform which represented a major risk, the decision was made to rapidly expedite the migration to the Microsoft Cloud. Unfortunately, despite many communications, we still took a hit on the volume of calls to the Service Desk in October - December when staff were migrated to the new platform. At the same time, the Trust experienced a Phishing cyber attack in November 2015 which resulted in an additional increase in calls (300+). Finances: 8.8M Revenue 8.0M 8.4M Agreed in March 2015 to deliver IT Strategy for FY15/16 Anticipated in November 2015 as part of cost reduction Projected end of FY15/16 (5% variance on 8M) Variance factors include: Difficulty in recruiting some positions especially Business Intelligence Contract staff being used for longer than anticipated due to recruitment difficulties NHSP issues; accruals missed for several months now being added Managed Print Service; Project Management costs not allowed to be capitalised The critical need to migrate off legacy platforms meant that we could not manage without certain contracted skillsets Page 5 of 6 52 of 134

53 In summary: We are pleased with progress to date and have removed the risk of the legacy platform and associated infrastructure. The IT team have performed well under demanding circumstances. We are the no.1 Trust in the UK for Microsoft Cloud adoption and have been invited to be one of the first UK organisations to preview the Azure Platform in the UK. This means we will be able to store data in the UK as opposed to the EU. We will eventually move our Business Intelligence to the UK platform once we have configured, tested and deployed it within the EU platform. There is a really positive morale and exciting culture forming within and around IT, sickness levels are very low, many staff have converted to Permanent employees and the IT team are really up for transformation. Motivating factors such as the use of new Cloud enterprise tools, the pending launch of the CTI and the digital transformation are contributing to a strong IT team being developed. We still need to do better in terms of Customer Service, and this next quarter is crucial in digitising the workforce with Tech Adoption Days, helping Trust Staff become more efficient and taking advantage of online collaboration tools to really change the way we communicate and work with each other. We will also focus on the redesign of epjs and the migration of the onpremise platform to a cloud platform, provided by the Carenotes vendor. This will also help to enhance the User Experience (UX) as we will work in partnership with the provider to redesign the interface and the pathways, whilst supporting the Value-Based Healthcare Programme. Stephen Docherty Chief Information Officer Page 6 of 6 53 of 134

54 TRUST BOARD OF DIRECTORS SUMMARY REPORT Date of Board meeting: 30 th March 2016 Name of Report: Heading: Author: Approved by: (name of Exec Member) Presented by: Finance Report (Month 11 FY15/16) Performance & Activity Tim Greenwood, Mark Nelson Finance Directorate, BRH Gus Heafield Gus Heafield Purpose of the report: The Finance Report provides an update on the financial position of the Trust as at 29th February 2016 (month 11 FY 15/16). Recommendations to the Board: That the Trust Board approves the report on the financial position for February 2016, noting progress made to date on the recovery plan, and agrees to the year end forecast position. Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: The report is a key component of risk item 6 of the Board Assurance Framework (ensuring financial sustainability) in terms of the effective and efficient management of resources. The level of assurance provided by the report is currently moderate. Summary of Financial and Legal Implications: The Trust must make the best possible use of public money and meet regulatory requirements and deliver to plan. The Operational Plan for the Trust requires it to meet an EBITDA target of 12.4m at Q4. A new Risk Assessment Framework (RAF) was introduced by Monitor subsequent to the submission of our 2015/16 Operational Plan. The new RAF is being used to assess the Trust financial performance for the rest of the year including the requirement to submit monthly financial returns and an annual financial forecast. Equality & Diversity and Public & Patient Involvement Implications: The report identifies activity and financial pressures that if not resolved as part of the delivery of the FY15/16 plan may have implications on the Trust s ability to deliver its equality, diversity and patient involvement commitments as set out in the Annual Plan Service Quality Implications: The report identifies activity and financial pressures that if not resolved may have implications on the Trust s ability to deliver its quality commitments as set out in the Annual Plan 54 of 134

55 m's m's - (2) (4) (6) (8) (10) (12) (14) m's Income and Expenditure YTD YTD Plan Forecast FY Plan Financial Sustainability Risk Rating (from 4) from M05 Headlines EBITDA 9.1m 11.4m 8.7m 12.5m Continuity of Service Risk Rating (from 4) discontinued M04 I&E (deficit) surplus -6.2m -4.5m -8.7m -4.7m cover x Balance sheet sustainability - Debt service cover 1) At Month 11 the Trust delivered 9.1m of EBITDA, an adverse variance of 2.4m against its planned position. EBITDA margin 2.7% 3.4% 2.4% 3.4% 3.0 Based on the month 11 position and positions going forward, the Trust is continuing to forecast an adverse Debt service cover EBITDA variance of 3.75m, in line with previous discussions with Monitor. Cumulative EBITDA M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 actual forecast plan under-lying Cumulative Net Retained Surplus (deficit) M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 actual forecast plan under-lying Nurse agency H2 efficency target Days (5) (10) SLaM - Financial Overview as at 29th February 2016 (Month 11) Financial Position M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 actual forecast plan Rating 4 Rating 3 Rating 2 (15) M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 cover x Liquidity rating actual forecast plan Rating 4 Rating 3 Rating 2 Operational performance - I&E margin M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 2) The financial performance of the Trust is assessed by Monitor through the Financial Sustainability Risk Rating. Both the Plan and our performance against the Plan (ytd and forecast) are rated at a 2. A rating of 2 is defined by Monitor as likely to represent a material level of risk 3) This month has seen an improvement in the adult acute overspill position with bed numbers down from the highpoint reached in January (although partly due to it being a shorter month). However initial figures for the beginning of March are indicating that this trend has not been maintained and overspill numbers remain high. Going into 2016/17 the Trust is planning to reduce lengths of stay and ensure that the Home Treatment Teams are fully operational. The expectation is that overspill numbers will therefore fall rapidly over the next 4 months with CCG contract discussions based around this plan. 4) The complex placements position is expected to improve by year end with Lewisham CCG making additional payments in recognition of activity overperformance. In Southwark the CCG are anticipating recovery of overperformance under a Section 75 risk share arrangement. The placements position in Lambeth largely falls under the Lambeth Alliance contract. Here to the position has improved following a non recurring transfer of underspends from other partners in the Alliance. The Trust remains in discussion with Croydon CCG regarding its commitment to parity of esteem and the use of mental health investment slippage to help offset significant acute overperformance 5) Ward nursing costs remain a concern. They have been consistently higher than 2014/15 and although they fell back in February it is clear that those elements of the recovery plan concerned with reviewing current nursing rotas that are above safer staffing establishments, are not impacting as expected. All CAGs have clear ward establishments they should be working to based upon the safer staffing exercise undertaken by the Director of Nursing in 2014/15. Commentary 6) New Monitor targets around the use of qualified nurse agency staff came into play from October. The target set for SLaM is for no more than 12% of the total cost of qualified nursing expenditure to be agency between October and March. In December the Trust, overall, was 0.8% below the 12% target. 7) The Trust year end capital expenditure forecast is in line with the Plan (102%)The programme is fully committed to high priority strategic projects to improve environments and safety across the Trust M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 actual forecast plan 12% target 8% target (plan) 12% target (plan) m's Cost Improvement Programme 20 cover x m's 80 actual forecast plan Rating 4 Rating 3 Rating 2 Performance against plan - I&E margin M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 actual forecast plan Rating 4 Rating 3 Rating 2 Working Capital Key Financial Drivers Performance v CIP - 3.8m - 21% < target Ward Nursing - 2.4m overspent Acute Overspill - 5m overspent including impact of risk share Complex/Non Secure Placements - 1.9m overspent Cost per Case/Cost & Volume - 1.1m ytd > target Other Metrics Forecast FSRR less than 3 in next 12 months Yes Capital expenditure < 85% or > 115% revised plan Unlikely Debtor Days 15 days Better payment practice code (non-nhs by value) 79% Cash at bank and in hand 55.2m m's Capital spend against plan of M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 actual forecast plan - M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 receivables payables plan cash cash Net assets - M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 actual forecast plan Monitor risk <85% plan

56 South London and Maudsley NHS Foundation Trust Finance Report 2015/16 February 2016 (month 11) Section A Headlines & Key Issues At Month 11 the Trust delivered 9.1m of EBITDA, an adverse variance of 2.6m against its planned position. Based on the month 11 position and positions going forward, the Trust is continuing to forecast an adverse EBITDA variance of 3.75m, in line with previous discussions with Monitor (and equating to a bottom line deficit of 8.7m) The financial performance of the Trust is assessed by Monitor through the Financial Sustainability Risk Rating. Both the Plan and our performance against the Plan (ytd and forecast) are rated at a 2. A rating of 2 is defined by Monitor as likely to represent a material level of risk and depending upon their level of concern may require action to be taken and/or closer monitoring and collection of additional information. The Trust remains in close discussion with Monitor and regularly shares details of its recovery plan and detailed financial position. This month has seen an improvement in the adult acute overspill position with bed numbers down from the highpoint reached in January (although partly due to it being a shorter month). However initial figures for the beginning of March are indicating that this trend has not been maintained and overspill numbers remain high. Going into 2016/17 the Trust is planning to reduce lengths of stay and ensure that the Home Treatment Teams are fully operational. The expectation is that overspill numbers will therefore fall rapidly over the next 4 months with CCG contract discussions based around this plan. The complex placements position is expected to improve by year end with Lewisham CCG making additional payments in recognition of activity overperformance. In Southwark the CCG are anticipating recovery of overperformance under a Section 75 risk share arrangement. The placements position in Lambeth largely falls under the Lambeth Alliance contract and the position has improved following a non- recurring transfer of underspends from other partners in the Alliance. The Trust remains in discussion with Croydon CCG regarding its commitment to parity of esteem and the use of mental health investment slippage to help offset significant acute overperformance. Ward nursing costs remain a concern. They have been consistently higher than 2014/15 and although they reduced in February it is clear that those elements of the recovery plan concerned with reviewing current nursing rotas that are above safer staffing establishments, are not impacting as expected. All CAGs have clear ward nursing establishments they should be working to based upon the safer staffing exercise undertaken by the Director of Nursing in 2014/ of 134

57 Table 1 summarises the recovery plan and forecast position at month 11. Recovery schemes totalling 6.2m were identified and are expected to be 1.3m off target by year end. The change from month 10 is largely due to a deterioration in the income performance where the Trust has taken a more prudent view of year end settlements with local CCGs regarding activity overperformance. New Monitor targets around the use of qualified nurse agency staff came into play from October. The target set for SLaM is for no more than 12% of the total cost of qualified nursing expenditure to be agency between October and March. In January the Trust, overall, was 0.80% below the 12% target. The Trust year end capital expenditure forecast is in line with the Plan (102%). The programme is fully committed to high priority strategic projects to improve environments and safety across the Trust. This position has been confirmed with Monitor. Gus Heafield Chief Financial Officer March of 134

58 Section B - Finance Analysis 1) Financial Summary Monthly Figures Year to Date Figures Service Analysis Full Year Live Budgets ( ) Current Month Variance From Year To Date Actual( ) Live Budgets ( ) Actual ( ) Variance From Live Budgets ( ) Variance Last Month ( ) 01. Psychosis 99,351,100 9,037,700 1,233,400 99,593,700 8,506,900 7,439, Behavioural And Dev. Psych 1,862,200 31,000 (280,500) 1,469,900 (239,000) (135,500) 03. Mood, Anxiety, Personality 1,756,200 (24,900) (176,500) 986,200 (618,700) (442,200) 04. Psychological Medicine (551,300) (143,700) (137,200) (734,400) (189,600) (41,300) 05. Child & Adolescent Service 2,231, ,700 (59,800) 1,202,700 (859,700) (799,900) 06. MHOA And Dementia 0 (49,900) (38,700) 288, , , Addictions 0 (23,100) (23,100) 464, , , Clinical Support Services 1,528,400 (171,000) (302,100) 1,685, , , Infrastructure Directorates 54,989,300 4,552,500 (65,100) 50,648, , , Corporate Income (99,885,800) (7,820,900) 199,500 (91,705,900) (105,800) (93,800) Operational Deficit 61,281,200 5,565, ,900 63,899,000 8,317,200 7,967, Corporate Other (77,852,700) (6,715,200) (92,600) (72,951,300) (1,713,400) (1,620,800) 12. Contingency - planned 2,000,000 0 (166,667) 0 (1,833,333) (1,666,667) 14. Other reserves/provisions 2,086, ,567 0 (2,150,167) (2,330,733) Corporate Other (73,766,200) (6,715,200) (78,700) (72,951,300) (5,696,900) (5,618,200) EBITDA (12,485,000) (1,149,800) 271,200 (9,052,300) 2,620,300 2,349, Post EBITDA Items 17,223,000 1,486,700 (17,100) 15,203,800 (701,300) (684,200) Trust Financial Position 4,738, , ,100 6,151,500 1,919,000 1,664,900 Area 2015/16 Mth 6 Variance /16 Mth 7 Variance /16 Mth 8 Variance /16 Mth 9 Variance /16 Mth 10 Variance /16 Mth 11 Variance /16 Total YTD Variance 000 CAGs (717) (1,131) (358) (1,009) (569) (517) (7,408) Infrastructure Directorates (126) 172 (52) (98) (803) Corp Income (24) (518) (200) (106) Other reserves/provisions 517 (349) (16) (225) ,713 released Use of Reserves (13) 3,984 Total EBITDA 312 (727) 205 (660) 187 (271) (2,620) 58 of 134

59 2) Key Cost Drivers Area 2015/16 Mth 6 Variance /16 Mth 7 Variance /16 Mth 8 Variance /16 Mth 9 Variance /16 Mth 10 Variance /16 Mth 11 Variance /16 Total YTD Variance 000 Ward Nursing* (195) (179) (68) (151) (474) (288) (2,369) Qualified Nurse Agency (144) (166) (146) (147) (128) (137) (1,498) Premium (@ 20%) Acute Overspill (454) (498) (350) (882) (912) (424) (5,020) Unmet CIPs** (466) (500) (436) (364) (346) (323) (3,869) CPC/C&V Income ,121 Placements (223) (219) (210) (206) (226) (275) (1,917) Total (1,367) (1,478) (968) (1,532) (1,690) (1,093) (13,552) * includes safer staffing funding ** see Section 3 Performance against the main cost drivers is detailed below Acute/PICU Overspill Pressure on beds remains but dropped in February from the high point reached last month. Overall, 53 beds (1,535 obds) were used outside the Trust in February, a decrease of 10 compared to the previous month. This is still 47 beds above our original plan (based on the contract baselines agreed with Lambeth, Southwark and Lewisham CCGs adjusted for the impact of AMH) and 27 beds above a revised capacity plan that was agreed in October. There is no risk share in Croydon where activity remains high (forecast of 2.2m above CCG funding) and despite risk shares with LSL CCGs, the excess pressure on the AMH pathway is resulting in a 5m overspend across Psychosis and Psychological Medicine. Looking ahead, a series of measures outlined in the 2016/17 Operational Plan are being implemented that aim to eliminate acute overspill by the 2 nd quarter of 2016/17 (only PICU overspill is planned to remain at around 7 beds). These plans are currently under discussion with our local CCGs to ensure that future demand and funded capacity are more aligned and with risk shares that are cover all our CCGs. The table below shows the planned overspill trajectory in 2016/17 that requires a period of sustained reduction through to July SLaM Adult Acute/PICU Bed Overspill (per month) Beds Month Actual Overspill Beds Original Overspill Beds Plan Revised Oct Capacity Plan Revised March Plan (at per activity/capacity planning) Ward/Unit Nursing Costs At month 11 ward nursing costs overspent by 288k ( 2.4m ytd). This position is after an additional investment over the last 12 months of 4.1m for safer staffing. The table below shows the impact that additional funding made in the middle of 2014/15 but since then, ward nursing costs have not been maintained within budget. Some elements of the recovery plan are concerned with reviewing current nursing rotas where staffing levels have consistently been above safer staffing establishments. 59 of 134

60 February saw a reduction from the high point reached in January but was still the third highest monthly overspend of the year. All CAGs have clear ward nursing establishments they should be working to based upon the safer staffing exercise undertaken by the Director of Nursing in 2014/15. SLaM Ward Nurse Overspend (per month) 500 Overspend/ 000s / / Month Nurse Agency Assuming an average 20% premium, the additional year to date cost of employing agency nurses above established is c 1.5m. Monitor have set nurse agency targets from October to ensure use of agency is not excessive and to bring about a reduction in usage over the next 3 years. The target set for SLaM is that no more than 12% of the total cost of its qualified nursing expenditure will be on agency between October 2015 March Between October and February the Trust has averaged 11.2% (10.8% in December). Complex Placements ( 1.9m overspent ytd) The adverse position in Southwark has accelerated with a further 235k overspend in the month ( 1.4m ytd) following resolution of a disputed Lambeth placement with the Lambeth Integrated Personalised Support Alliance (IPSA). Southwark placements were forecast to overspend by 1.6m. However the financial impact may be reduced after discussions with Southwark CCG and the local authority to agree the placement position and clarify the risk share arrangement the CCG has with the local authority. This could result in the Trust being able to reclaim funding via the CCG. Although Lambeth and Lewisham are less overspent than Southwark, both are still forecasting overspends at year end of + 0.2m. The Trust has agreed a transfer of funding from underspending members of Lambeth Integrated Personalised Support Alliance (IPSA) to help offset its overspend on both placements and inpatient rehab beds. The Trust has also reached agreement with Lewisham CCG about its current overperformance which will result in the forecast overspend being met by the CCG /16 Complex Placements Surplus(-)/Deficit (per month) 275 (000) (25) (100) Month Note - The rapid decline in the 14/15 line at month was as a result of a year end agreement to reimburse the Trust for placement costs over and above contracted levels 60 of 134

61 Cost per Case/Cost and Volume Income Overall the variance position has continued to improve largely due to high activity in the National Autism Unit, Mother and Baby and CAMHS services plus a backdated recharge to Southwark placements from the McKenzie Rehab Unit as mentioned above. CAG Income Target Actual Surplus/ Surplus/ Invoiced Deficit(-) Deficit(-) At Month 11 At Month 11 At Month 11 Last Month '000 ' Psychosis 5,353 5,322 (31) (170) Behavioural & Dev 19,020 19, Psychological Med 17,157 16,878 (278) (315) Mood and Anxiety 10,175 10,136 (39) (36) CAMHS 21,670 22, MHOA (110) (120) Addictions TOTAL 74,114 75,235 1, ) Cost Improvement Programme (CIP) The Trust plan required it to make 21m of CIP savings split 18.8m over the first eleven months of the year and 2.2m in the last month if the year. At month 11, savings of 14.9m have been realised, being a shortfall against the Plan of 3.9m (79.4%). The principal elements giving rise to this shortfall are an overspend on Complex Care Placements ( 776k), a lower than planned settlement from contract negotiations with NHSE ( 481k), lower than expected savings from workforce initiatives ( 527k) and shortfalls on CAG schemes ( 926k, principally Psychosis 497k, B&D 273k, MAP 114k and Psych Med 128k). These are from a combination of delays and where schemes with reduced values have not been fully offset by additional schemes. As the year progresses monthly variations in the forecast values of CIP schemes become much smaller. As such, and broadly in line with recent months, CIP plans are currently forecast to deliver total savings of 16.8m in the year, being a deficit of 4.2m (80%). This has been fed into the latest Trust wide outturn forecast. This forecast assumes that 2.1m of previously unidentified savings which represented shortfalls against the 2% local savings target set at the beginning of the year, will now be delivered. As set out above, a Recovery Plan, designed to reinforce or accelerate existing savings programmes, and to identify additional savings, not included in the saving plans in the CIP tracker, has been prepared. These recovery planning actions are expected to deliver further savings of 4.9m, significantly in excess of the 2.1m shortfalls against the local targets in the original plan. Delivery against these recovery plans are being monitored separately from the Trust s CIP tracker as set out in Table 1. As with the CIP tracker forecast, the forecast incremental savings from the Recovery Plan are factored into the Trust s outturn forecast. The recurrent impact, and full year effect, of both CIP and recovery plan savings have been built into the draft plan for 16/17. 4) Local CCG/NHSE Contract Positions As previously indicated, the two business cases that remain outstanding with Croydon CCG impact of the MHOA Home Treatment Team and implementing the AMH model are now being progressed under a jointly chaired Project Board. 61 of 134

62 The CFO and COO continue to meet with the local CCGs to seek funding support for significant activity pressures (such as placements and acute activity) as part of the 16/17 planning and contracting round. Tim Greenwood & Mark Nelson Finance Department, March 2016 Glossary AMH CAG CCG CIPs Continuity of Service Risk Rating (CoSRR) CPC/C&V EBITDA ICT MHOA OBD PICU PoS QIPP Triage YTD Adult Mental Health used in this report to cover a programme of investment in community schemes that aim to reduce the usage of acute/triage beds in the Trust Clinical Academic Group bring together clinical services, research and education and training into a single management grouping e.g. Psychosis Clinical Commissioning Group an NHS body responsible for the planning and commissioning of health services for their local area Cost Improvement Programme A combination of 2 indicators focussing on liquidity and ability to service capital and debt that help to indicate the level of risk to the financial sustainability of a Trust ranging from 1 (high risk) to 4 (low risk) Cost per Case and Cost and Volume income varies depending upon the amount of clinical activity being undertaken Earnings before interest, tax, depreciation and amortisation is an accounting measure used as a proxy for an organisations current operating profitability Information and Communications Technology Mental Health of Older Adults Occupied Bed Day is a unit of currency used to measure the use made of a bed (e.g. 1 obd = 1 bed occupied for 1 day by a patient) Psychiatric Intensive Care Unit - provide mental health care and treatment for people whose acute distress, absconding risk and suicidal or challenging behaviour needs a secure environment beyond that which can normally be provided on an open psychiatric ward Place of Safety under section 136 of the Mental Health Act, the police have the power to take an apparently mentally disordered person who is in a public place and is apparently a danger to himself or to other people, to a "place of safety" where they may be assessed by a doctor The Quality, Innovation, Productivity and Prevention programme is a series of schemes required by the CCGs and developed with SLaM to help reduce the cost of services to the CCG Triage ward used to admit patients for a short period of time where their needs are assessed before being either discharged to the care of community teams or transferred to an acute ward Year To Date 62 of 134

63 Table 1 SLaM - Progress Against Recovery Plan At Month 11, 2015/16 M7 Forecast Variance 000s Schemes Variance 000s M11 Forecast Variance Schemes 000s Other items 000s Brief Comment On Adverse Variances From Target Psychosis 9,511 (596) ,705 savings schemes in complex care placements/inpatient and Heather Close still not delivering as planned plus acute overspill continues to increase above previous forecast MHOA 803 (599) Additional 150k secured above recovery plan for Croydon HTT offsets ongoing non-delivery on memory disorder & Ann Moss savings. BDP 150 (152) 60 (148) (90) no material changes from M10 Addictions 540 (90) 34 (34) 450 no material changes from M10 CAMHS (636) 0-30 (606) no material changes from M10 MAP 57 (108) 24 (677) (704) Significant slippage on projected spending plans in IAPT teams. PMed (400) (419) (284) no material changes from M09 (previous variance is the Overspill transfer from Psychosis) CAG Sub-total 10,025 (1,964) ,812 overall 1.1m off target Estates 340 (793) PTS provision ICT 700 (400) planned reduction in non pay not being achieved Pathology 703 (200) - (172) 331 KCH repayment agreed leading to 160k improvement in year end position compared to M10 CEO 519 (178) no reduction in KHP contribution and ORTUS above plan, but other items improved on M10 R&D 1 (520) 35 (41) (525) no material changes from M10 CQUIN (498) (452) (728) Inlcudes a 325k provision for CQUIN underperformance in 15/16 Nursing Quality 124 (270) (14) (87) (247) no material changes from M10 HR Education Training (243) (180) (188) no material changes from M10 Professional Heads 12 (50) - (122) (160) no material changes from M10 Finance (100) (100) - - (200) no material changes from M10 Commercial (257) - - (27) (284) no material changes from M10 O&C (91) 25 no material changes from M10 COO 249 (134) no material changes from M10 Hotel Services 26 (96) (45) - (115) no material changes from M10 Pharmacy 1-9 (9) 1 no material changes from M10 Medical Additional clinical sessions, Pas and income shortfall Corporate Other (1,160) (1,160) Income - (774) (489) Corporate Sub-total 1,693 (4,147) (1,663) overall 0.2m off target Contingency/Reserve (1,787) (120) - (1,493) (3,400) 63 of 134 EBITDA 9,931 (6,231) 1,307 (1,257) 3,750 as per Monitor/Recovery Plan target

64 Table 2 February 2016 The South London and Maudsley NHS Foundation Trust - Operating Budgets F O R E C A S T Monthly Figures Year to Date Figures As At Mth 10 As At Mth 11 Change Service Analysis Full Year Live Budgets ( ) Current Month Actual( ) Variance From Live Budgets ( ) Year To Date Actual ( ) Variance From Live Budgets ( ) Variance Last Month ( ) Previous Forecast Variance ( ) Current Forecast Variance ( ) Movement In Forecast Notes 01. Psychosis 99,351,100 9,037,700 1,233,400 99,593,700 8,506,900 7,439,400 10,000,000 9,705,000 (295,000) 02. Behavioural And Dev. Psych 1,862,200 31,000 (280,500) 1,469,900 (239,000) (135,500) (100,000) (90,000) 10, Mood, Anxiety, Personality 1,756,200 (24,900) (176,500) 986,200 (618,700) (442,200) (521,000) (704,000) (183,000) 0.3m improvement in overspill forecast (to 5.1m adverse after risk shares) following an improvement in the position in February (53 overspill beds in the month versus a revised target of 26). Assumes no income from Swk Local Authority for placements overperformance pending resolution of activity data. High nursing costs ( 180k over in the month - PICUs 68k; Psychosis Unit 33k; AL3 30k) Forecast overall has remained stable although continued high nursing costs on Norbury. No savings to date in River House reception following investment in a new key management system. Recovery plan taking effect in the A&T teams ( 25k under in the month) with a reduction in locums. Additional IAPT funding but forecasting not to fully utilise it on additional staffing 04. Psychological Medicine (551,300) (143,700) (137,200) (734,400) (189,600) (41,300) (303,000) (284,000) 19,000 Forecast position takes account of block neuro day programme income being reduced by NHSE. Continuing pay underspends on HTT following recruitment issues. Position offset this month by internal recharge for cost of closing 3 Triage beds ( 45k in month) and high staffing levels ( 23k over in the month) on Croydon Triage following re-opening of beds 05. Child & Adolescent Service 2,231, ,700 (59,800) 1,202,700 (859,700) (799,900) (531,000) (606,000) (75,000) Additional 4 Borough transformation monies not yet taken account of and will require carry forward into 2016/ MHOA And Dementia 0 (49,900) (38,700) 288, , , , ,000 (127,000) Improvement in forecast largely due to the planned Croydon CCG QIPP on Chelsham not going ahead and funding being returned. Ann Moss pay expenditure remains a concern with 1:1 obs in excess of assumed position under safer staffing establishments. Greenvale currently meeting its income targets 07. Addictions 0 (23,100) (23,100) 464, , , , ,000 0 Deferring underspends in Lam, Greenwich & Bexley as part of year end agreements. Wandsworth income ( 300k) also deffered due to slippage at start of contract - requires contract discussion to determine its use 08. Clinical Support Services 1,528,400 (171,000) (302,100) 1,685, , , , ,000 (19,000) A further 200k credit from Kings following agreement on outstanding disputed invoices 09. Infrastructure Directorates 54,989,300 4,552,500 (65,100) 50,648, , ,200 (243,000) (345,000) (102,000) see below 10. Corporate Income (99,885,800) (7,820,900) 199,500 (91,705,900) 105,800 (93,800) (1,435,000) (489,000) 946,000 Forecast change in income due to increase in CQUIN provision and reduction in slippage from Croydon CCG Operational Deficit 61,281,200 5,565, ,900 63,899,000 8,317,200 7,967,300 8,136,000 8,310, , Corporate Other (77,852,700) (6,715,200) (92,600) (72,951,300) (1,713,400) (1,620,800) (679,000) (1,160,000) (481,000) Includes 1.4m of unmet CIPs. Position improved due to further provision releases and rev to cap transfers 12. Contingency - planned 2,000,000 0 (166,667) 0 (1,833,333) (1,666,667) (3,707,000) (3,400,000) 307, Other reserves/provisions 2,086, ,567 0 (2,150,167) (2,330,733) Corporate Other (73,766,200) (6,715,200) (78,700) (72,951,300) (5,696,900) (5,618,200) (4,386,000) (4,560,000) (174,000) Includes 1.024m of reserve release following delays in implementing schemes outside SLaM control plus Swk Weight Management and Lambeth Core 24 additional income. EBITDA (12,485,000) (1,149,800) 271,200 (9,052,300) 2,620,300 2,349,100 3,750,000 3,750,000 0 as per Monitor/Recovery Plan Target 15. Post EBITDA Items 17,223,000 1,486,700 (17,100) 15,203,800 (701,300) (684,200) 200, ,000 0 Change in redundancy provision Trust Financial Position 4,738, , ,100 6,151,500 1,919,000 1,664,900 3,950,000 3,950,000 0 Monthly Figures Year to Date Figures As At Mth 10 As At Mth 11 Change Corporate Analysis Full Year Live Budgets ( ) Current Month Actual( ) Variance From Live Budgets ( ) Year To Date Actual ( ) Variance From Live Budgets ( ) Variance Last Month ( ) Previous Forecast Variance ( ) Current Forecast Variance ( ) Movement In Forecast Notes A1) Estates & Facilities 17,235,500 1,612, ,600 16,382, , , , , ,000 A2) Hotel Services 10,269, ,200 (25,600) 9,299,300 (114,700) (89,100) (100,000) (115,000) (15,000) B) Nursing & Quality 3,235, ,700 (58,900) 2,763,100 (202,400) (143,500) (238,000) (247,000) (9,000) C) Information & I.T. 7,719, ,200 19,400 8,079,500 1,008, , , ,000 0 D) Finance And Corp Governance 4,535, ,500 (34,500) 3,828,000 (119,600) (85,000) (200,000) (200,000) 0 E) Human Resources 3,734, ,300 (51,700) 3,235,100 (184,500) (132,800) (138,000) (188,000) (50,000) F) Organisation & Community 1,743, ,500 14,200 1,604,500 6,100 (8,100) 8,000 25,000 17,000 Financial responsibility re patient transport service for Croydon MHOA ceased on 1st Feb and transferred to Croydon Council. There remains a risk that compensatory payments may be due to the contractor Forecast above recovery plan - although agency costs have come down the expected spend on non pay and continuing use of agency staff will exceed the control total issued by c 230k G) Chief Executive 4,026, ,500 12,300 4,196, , , , ,000 (64,000) H) Medical & Clinical Govern. 3,378, ,900 (57,800) 2,521,600 (570,200) (512,400) (606,000) (588,000) 18,000 I) Professional Heads 1,668, ,200 (8,800) 1,356,900 (172,800) (164,000) (128,000) (160,000) (32,000) J) Chief Operating Officer 1,712, ,100 39,500 1,731, , , , ,000 0 K) Commercial Directorate 869,300 44,500 (28,200) 519,300 (277,200) (249,100) (281,000) (284,000) (3,000) L) R&D (5,139,200) (429,600) (4,600) (4,869,400) (155,200) (150,600) (407,000) (525,000) (118,000) Infrastructure Directorates 54,989,300 4,552,500 (65,100) 50,648, , ,200 (243,000) (345,000) (102,000) L) Corporate Service (77,852,700) (6,715,200) (92,600) (72,951,300) (1,713,400) (1,620,800) (679,000) (1,160,000) (481,000) M) Trust Reserves 4,086, ,900 0 (3,983,500) (3,997,400) (3,707,000) (3,400,000) 307,000 Corporate Other (73,766,200) (6,715,200) (78,700) (72,951,300) (5,696,900) (5,618,200) (4,386,000) (4,560,000) (174,000) 64 of 134

65 Table 3 - SLAM summary CIP status report Feb-16 25,000 20,000 15,000 10,000 5,000 - Monthly Actual/Forecast v Plan M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12 Plan Actual/Forecast M12 M11 M10 M09 M08 M07 M06 M05 M04 M03 M02 M01 Plan Plan/Forecast by RAG per month - 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000 20,000 Red Amber Green 000s Plan YTD Actual YTD Value of YTD Additional variance Schemes from Plan YTD Full year Plan Full year Forecast Full year variance from Plan Full year Forecast of Additional Schemes CAG schemes: 6,185 5,258 (926) 741 6,768 5,820 (948) 680 Corporate schemes: 2,912 3, ,215 3, Trust wide schemes: 7,807 4,923 (2,884) - 8,755 5,387 (3,368) - Trust Total 16,904 13,364 (3,539) 1,165 18,738 14,663 (4,076) 1,062 Overview comment Most CAGs have downgraded their forecast savings either due to delays or reduced savings being delivered, not fully offset by additional schemes - Psychosis ( 0.5m), B&D ( 0.3m)and MAP/MED ( 0.2m) are all forecasting significant deficits with only MHOA forecast to be above Plan ( 0.2m) Overall Corporates are broadly on track but underlying this ICT ( 150k) and KHP contribution reduction ( 109k) are significantly down offset by a net surplus in Estates ( 0.3m). The pathology dispute has now been settled favourably. The YTD and full year shortfall primarily reflects overspends on Complex care Placements ( 846), lower than planned outcome from negotiations with NHSE ( 525k), reduced savings from workforce schemes ( 600k) and assigning no value to the unidentified CIPs of 1.4m. There is though limited risk of further downgrades. 65 of 134 2% Shortfall 1,880 1,550 (330) - 2,240 2,106 (134) - 18,784 14,914 (3,869) 1,165 20,978 16,769 (4,210) 1,062 In terms of identified schemes included in the CIP tracker there remains a significant shortfall against the 2% targets set. However, the balance of these shortfalls are now assumed in the forecast to be delivered as there are recovery planning actions identified which are significantly in excess of this shortfall. The shortfall at the planning stage has been reduced principally due to the identification of additional schemes net of downgrades on initially planned schemes that contribute towards the target. The impact of this is offset within the net variance on identified schemes above.

66 TRUST BOARD OF DIRECTORS SUMMARY REPORT Date of Board meeting: 30 March 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance) Author: Approved by: (name of Exec Member) Performance Report Performance Martin Black, Performance Kristin Dominy, Chief Operating Officer Presented by: Kristin Dominy, Chief Operating Officer Purpose of the report: To report the Trusts performance against a range of key indicators for 2015/16, identify any major areas of learning and success, identify and analyse underperformance and provide action plans to address such underperformance, and taking due account of benchmarking information as appropriate and available. Recommendations to the Board: To approve the report and note the performance and the ongoing development of the performance report. Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: The Performance Framework is an operational control with an assurance level of moderate. Summary of Financial and Legal Implications: Specified where relevant in the report. Equality & Diversity and Public & Patient Involvement Implications: The report identifies performance and activity issues that if not resolved may have implications on the Trust s ability to deliver its equality, diversity and patient involvement commitments as set out in the Annual Plan Service Quality Implications: The report identifies performance and activity and issues that if not resolved may have implications on the Trust s ability to deliver its quality commitments as set out in the Annual Plan 66 of 134

67 TRUST BOARD OF DIRECTORS PERFORMANCE REPORT: MARCH 2016 INTRODUCTION This report details the Trust s performance against key metrics to the end of February 2016 and areas of thematic review. The Key Metrics are: 1. Monitor indicators 2. Acute Care Pathway Activity 3. Quality Priorities 4. Care Quality Commission (CQC) Status This month s report also includes: 5. Commissioning and Contracts Update 6. Programme Management Office Update 7. Social Care Update 8. Safer Staffing Appendix A: Transformation Dashboard Appendix B: Quality & Performance Dashboard Appendix C: Safer Staffing Levels Detail (January and February) 1 67 of 134

68 1. Monitor The Board Performance report will be developed over the coming months as the new metrics for Board reporting are developed to reflect the Trust s priorities of Clinical Risk Assessment Recruitment and Retention Violence Reduction The Trust performance for Home Treatment Gatekeeping is below 95% in February. The target has to be achieved on a quarterly basis. Outlined below is the February update on Monitor performance indicators and any issues which are affecting performance against these standards: Chart 1: Home Treatment Gatekeeping and 7 Day Follow Up. Home Treatment Gatekeeping Trust performance was 94.9% in the month of February against a Quarterly threshold of 95%. Performance in January narrowly surpassed 95%. There were 11 misses in total and a slight reduction in the number of admissions in the month. There is a risk against achieving the threshold for the quarter. This is being closely monitored and remedial actions are being undertaken. At commissioner level Performance was below target in Southwark with 5 misses (90%) and there were 3 misses in Lambeth. Table 1: Home Treatment Team Summary by CCG CCG January Misses February Misses NHS CROYDON CCG 96% 2 96% 2 NHS LAMBETH CCG 92% 4 95% 3 NHS LEWISHAM CCG 94% 3 98% 1 NHS SOUTHWARK CCG 97% 2 90% 5 Other 95% 1 100% 0 Trust 95.1% % 11 A summary of the main issues and corresponding action are detailed below: 2 68 of 134

69 Police custody assessments There were 4 instances where patients assessed in police custody (during normal office hours) were not considered for, or referred to home treatment. Whilst the risks indicated the patients would not be suitable for Home Treatment the referrals were not made. This is a recurrent issue that if a patient is in police custody, referral to home treatment is not routinely considered. It should be noted that often police custody assessments are being carried out by Section 12 doctors not directly employed by the Trust (sometimes both of the doctors are independent) who might be unaware of the need to refer to home treatment. Admissions from Community Mental Health Teams (CMHTs) There were 5 direct admissions from the community which did not involve HTT (Home Treatment Team) gatekeeping. Place of Safety assessments Patients presenting in the Places of Safety are now being referred to Home Treatment, this has previously been an issue but is currently working well. Actions to be taken: a) Trust Specialist Registrars (undertaking HTT assessments after 10pm) to be reminded to document their decision regarding suitability for home treatment in the notes when assessing patients in places of safety or in police custody. b) Independent Section 12 doctors will be written to and reminded of the need to consider and document the decision about home treatment in PJS. c) All community staff will be reminded of the need to refer all potential admissions to home treatment. Seven Day Follow Up The Trust performance was 95.1% in February against a Quarterly threshold of 95%. There were a total of 6 misses. This is just within range for achieving the threshold by the end of the Quarter. CPA 12 Month Review The Trust is currently % against the threshold of 95% by the end of the Quarter. This is within the normal range for achieving the threshold by the end of the Quarter. Delayed Discharges Table 2: Delayed Discharges Delayed Discharges Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan % Days Lost 7.50% 4.0% 4.2% 3.9% 3.2% 3.1% 3.3% 4.2% 4.3% 3.9% 4.3% 4.6% Feb Prov 3 69 of 134

70 Overall the Trust wide position is well beneath the Monitor threshold of 7.5%. The overall Trust position is relatively low; the range within Psychosis CAG for the year to date is 4.8% 7.2%. The level of delayed discharge and its impact continues to be discussed in contract negotiations with commissioners as an area of concern. Chart 3: Days lost to delays by Borough The latest data indicates that DTOCs remain reasonably low with admissions and OBDs being driven by the changing nature of the presenting population, i.e. with a disproportionate number of new presentations with high levels of acuity and complexity. This is particularly the case in Croydon, where resultant private sector overspill compounds length of stay issues. Improving access to psychological therapies (IAPT) February results based on internal reporting indicate the results were met for each borough. HSCIC (Health & Social Care Information Centre) publish finalised results retrospectively. Chart 4: IAPT Waiting Times 18 weeks Standard 4 70 of 134

71 Chart 5: IAPT Waiting Times 18 weeks Standard New Monitor Risk Assessment Framework Measures: Early Intervention in Psychosis (EIP) The standard is that from April 2016, 50% of people experiencing a suspected first episode of psychosis will be treated with a NICE approved care package within two weeks of referral. Chart 6: Early Intervention Waiting Time Standards (January 2016) In common with other Mental Health Trusts, during the shadow period work is underway to refine the reporting mechanism in line with developing technical guidance and ensure our reporting is robust. In December and January reporting, it was identified that there was an issue around reporting around how face to face contact is counted, and also how those who are still waiting are counted. This has been reviewed and the methodology adjusted for the March reporting impacting on performance. This has been discussed with commissioners prior to review and the latest results are scheduled for discussion with them. In addition, questions have been raised with the London EIP clinical group to understand how other London Trusts are approaching these issues of 134

72 2. Acute Adult Pathway Activity The most recent data indicates there continues to be significant pressure in the Adult acute pathway and in particular in overspill. Private Overspill Chart 7 - Average Number of Patients in Overspill Note: the trend lines in the above chart are based on a two period moving average. Following on from the actions reported in January s Board report there has been a reduction in both acute and PICU (Psychiatric Intensive Care Unit) overspill in February but the results still remain higher than reported in November. Snapshots within March indicate a continued high level of patients in overspill with a significant proportion relating to Croydon patients. New PICU The new PICU ward continues to be on track for opening phase 1 (4 beds) in early April 2016, with the plan to increase bed capacity during May. The handover date from Estates remains 18th March 2016 although some minor works will be ongoing. This will support reduction in PICU overspill and easier access to beds. Staffing The Trust has recruited all Band 3 staff (9 posts), Band 6 (4 posts), 8 of the 14 Band 5 posts, and an Acting Ward Manager. However, as some of the Band 5 staff are not due to start until July or September due to graduation dates, while the service is on round 6 of recruitment, there continues to be a significant recruitment challenge. Therefore, to move to opening the full 10 beds as a matter of urgency, a number of different initiatives have been put in place including a call out to other areas of the Trust to provide up to 4 B5 staff of 134

73 Centralised Place of Safety The work on centralised place of safety continues to be progressed with Local Authorities. Engagement is still ongoing with the local borough Directors of Adult Social Care, Heads of Social Care and AMHP managers. A briefing has been held with Southwark local councillors, the chair of the Southwark Health Overview and Scrutiny committee and the cabinet member for social care. The Director of Social Care, Director of Organisation and Communities and Head of Pathways in SLaM, met with Southwark Healthwatch and agreed a plan to engage with other borough s Healthwatch and voluntary sector organisations throughout March. The Trust has a provisional date of the 6th April to present to the Joint Health overview and Scrutiny Committee on Place of Safety and impact on AMPH services. 3. Quality Priorities The Quality Priorities 2016/17 are being discussed at the Quality Sub-Committee in March. This table below details achievement and progress against the nine Quality Priorities set out in the Trust Annual Quality Account. These are reported on a quarterly basis. Table 2 Quality Priorities 2015/16 Quality Priority indicators Target Q1 Q2 Q3 1 Do you feel safe? (inpatients) 90% 79.8% 81.9% 80.7% 2 3 Do you know what to do in an emergency mental health situation? (community) Number of eligible inpatients and EI having six key metabolic cardio-vascular tests 75% 80.7% 80.9% 80.3% 90% CQUIN 4 Do you feel involved in your care? 83.5% 88.3% 86.1% 86.1% Number of carers who state they have had a carers assessment Improvement in environmental PLACE audit scores from 2014/2015 to over 95%. Risk assessment and informing decision making inpatients and community patients on CPA will have a full document risk assessment Reduce the number of people supported by HTT who required an admission (where the AMH model has been established) Patients with both and AUDIT (identification tool) and a drug and alcohol assessment complete (Adult acute inpatient and adult community) 4. CQC Status 30% Audit 95% Annual 75% Q4 Audit Under 15% Q4 Audit 50% Q4 Audit The action plans for the Must Do and Should Do recommendations raised at the CQC comprehensive inspection in September are reviewed and updated by the CAGs, with a report on progress at the monthly Quality Delivery Committee meetings. The actions have 7 73 of 134

74 been uploaded to the Datix system providing a dashboard which shows at a glance which action updates are overdue. 5. Commissioning and Contracts Lambeth, Lewisham, Southwark, Croydon (LSLC) CCGs Further negotiation meetings have taken place with the CCGs and reconciliation of negotiation agreements upon the Trust overall activity plan for Monitor has been undertaken. Matthew Patrick has shared a bridging document with the respective Chief Officers highlighting the gap between current contract proposals and forecasted activity (post mitigation). Croydon risk share arrangements have not reached agreement and discussions are ongoing. LSLC have been presented with a proposal for single system Older Adults inpatient services (Acute and Continuing Care). Negotiations are ongoing and NHSE are stipulating contract conclusion prior to the start of the financial year. NHS England London Region The contract negotiation review meeting is scheduled for 24 of March. A counter proposal has been submitted by the Trust in response to NHSE s offer. At present the difference is 1.8 million reducing to 1 million once adjusting for QIPP, CQUINS and inflation. Commissioning for Quality and Innovation (CQUINs) 2016/17 Negotiation on CQUINs are ongoing, a total of 11 CQUINs are under discussion including LSLC wide CQUINs relating to Physical Health, Outcomes, In-patient Patient Safety and Inpatient Patient Experience. There are a further number of CQUINs under discussion for the individual CCGs. A range of meetings and workshops are scheduled to finalise these. Mental Health Service Data Set The Trust successfully submitted the first Mental Health Services Data Set (MHSDS) submission. This was partially completed in line with the contingency plan as the AHC extraction tool was not available as scheduled. At a national level, Health & Social Care Information Centre (HSCIC) received 79 successful submissions and is in the process of analysing Data Quality. The initial indications are that the Trust s Data Quality in relation to key Data Fields will not show significant fluctuations, however there will be a reduction in Activity. Based on the lessons learned from the first submission, Business Intelligence is in a firmer position to complete the refresh submission this month and the next month s initial submission. The submissions will be manually populated until AHC Extraction Tool is available of 134

75 6. Programme Management Office (PMO) The main focus of activity in February and March has been on setting up the savings programme, delivery governance, assurance structures and reporting processes -making sure that work has started on the large Trust-wide programme. The following is a summary of progress during this reporting period: Portfolio delivery governance and assurance framework has been agreed by Senior Management Team (SMT) First SMT Portfolio Board meeting and terms of reference agreed First Portfolio Delivery Steering held (09 March 2016) to check, challenge and support project delivery. Infrastructure review - Work is underway to complete a functional audit of all corporate service and infrastructure departments. Service Directors have agreed the CAG functions to be included in the scope of the review Acute Care Pathway programme work is underway and is on track to deliver a pathway issues and opportunities workshop in March which will inform acute care pathway transformation plans and options PMO reporting processes and management controls has been set up and are in operation and the first reporting cycle has been completed to review progress across the entire project portfolio Quality Impact Assessment (QIA) requirements have been identified across the project portfolio and a panel chaired by the Medical Director and Director of Nursing has been set up to review all QIAs The main focus for the next reporting period will be: Hold kick-off meetings for all savings plans that are being delivered through CAGwide projects and ensure these are properly resourced Hold Portfolio Board plan review meeting Produce and implement portfolio communication plan Final adjustments and sign-off of the savings portfolio as part of the 2016/17 planning process and final submission to Monitor 7. Social Care Update This report will summarise the progress on the following work streams: Implementation of the Care Act 2014 The work of the Care Act Implementation group has now been transitioned into business as usual and the ongoing developments to embed the changes and compliance with the legislation is now continuing within CAGs. The Director of Social Care has taken on lead responsibility for the implementation of the Integrated Assessment tool and is working with social care leads, clinicians and the clinical systems lead, to ensure it meets the requirements of both health and social care and is compliant with the Care Act when doing a statutory assessment of the care and support needs of service users and carers of 134

76 Carers assessments It has now been agreed that the SLaM carer s assessment tool does not comply with the Care Act and cannot be adapted to do so. Therefore, a decision has been made to retire the tool from epjs and replace it with guidance for staff which is based on the good practice guidance of the Triangle of Care. The CPA (Care Programme Approach) policy will be also be revised to reflect the changes to the integrated assessment and carers assessment processes. Section 117 Policy The current Section 117 aftercare policy has been reviewed in light of the changes made to Section 117 of the Mental Health Act by the Care Act 2014, in relation to ordinary residence, definition of aftercare and accommodation. It has now been checked by SLaM solicitors and the legal advice has been incorporated into the document and a robust discharge process to ensure clear sign off by the aftercare bodies (local authority and CCG) has been recommended. It will now go through the respective governance processes for approval by SLaM and the boroughs. This will provide clear guidance for staff to ensure the Section 117 aftercare needs of service users are recorded, reviewed and discharged appropriately. This will also enable a register of service users who are subject to Section 117 to be held on a borough basis, as recommended by the Code of Practice to the Mental Health Act. SLaM Social Care Strategy A refreshed social care strategy for 2016/17 will be presented to Trust Board for in April 2016 to approve the key priorities for the coming year and a detailed work plan for 2016/17. Section 75 agreements The Director of Social Care is continuing negotiations with Lambeth, Lewisham and Croydon local authorities to progress the individual Section 75 agreements. Progress has been made in agreeing the template agreements for Care Act compliance and each borough is populating the schedules with staffing and resource detail and consulting their respective legal departments. SLaM has also sought legal advice which is currently being incorporated into the schedules. The internal Section 75 task and finish group is continuing to meet within SLaM and the Director of Social Care is working with the CAG operational teams towards final sign off. The Section 75 reporting arrangements have also been reviewed and recommendations are being made to establish a robust governance framework is in place to give performance assurance on social care to the local authority partners. This includes: the formal establishment of a Section 75 Delivery Board, local interface meetings between CAGs and the boroughs and local S75 monitoring meetings. All local authorities with social care responsibilities nationally are experiencing the competing challenges of meeting the requirements of the Care Act, rising demand for services and continuing financial reductions. The four boroughs that SLaM has partnership arrangements with are no exception and each is looking to service transformation and restructure to of 134

77 manage these challenges. It is important to continue to work in partnership with our local authority partners to maintain effective integrated arrangements which deliver the best social care offers for our service users and carers. Southwark local authority have not yet engaged in negotiations to develop the Section 75 agreements pending the outcome of the Southwark Mental Health Social Care Review, which was undertaken between March and July of last year. The review has now moved into implementation and a steering group has been set up by Southwark Local Authority to work towards a social care offer in mental health, which is more focussed towards primary care and aligned to Local Care Networks. A detailed proposal from Southwark is expected by mid-april, when SLaM and Southwark will meet to agree the next steps. Social Care Performance SLaM is required to provide social care activity data undertaken within the Trust on behalf of the local authorities in discharging the delegated statutory duties. This includes SALT (Short and Long Term support) returns and other social care indicators which local authorities are required to report and monitor under the Adult Social Care Outcomes Framework. The Director of Social Care has collaborated with the borough performance leads and the SLaM performance team and produced the attached social care performance dashboard which will report to Trust Board on a quarterly basis to give assurance that social care is performance managed within SLaM to improve outcomes for service users and carers. 8. Safer Staffing In February the Trust 16 wards which have breached safe staffing levels, the actions remain the same as last month; there has been a significant increase in breaches this month. Actions currently being taken to address these are: Michael Kelly, Deputy Director of HR is leading the work with NHSP (NHS Professionals) to review the recruitment of substantive nurses to NHSP on appointment with the trust. There is an on-going piece of work with regards to recruiting flexible staff to improve the filling of available shifts. NHSP and SLaM review progress and performance of NHSP through a monthly meeting. NHSP will be attending Trust recruitment events and have a presence at Induction to attract new nurses onto the bank. Max Barnard, Recruitment & Branding Manager is working with the Heads of Nursing is leading on the Trust-wide recruitment campaign for registered nurses for both inpatient and community. There was greater success in January s assessment centre with a higher level of attendance however, as in previous assessment centres there was a consistent 50% pass rate. The implementation of the SafeCare platform has been held back due to further work required for it to be used in real-time. Work on Duty Senior Nurse (DSN) involvement in SafeCare to support them in managing and redeploying staff across site is being progressed. We are presently piloting the SafeCare module on Snowsfields, John Dickson and Spring wards. We will then move to rolling this out on a site-by-site basis. Most of the breaches appear to be due to the fact that NHSP have been unable to provide staff to cover shifts of 134

78 Chart 8 - Safer Staffing The above chart details performance within the context of standard deviations, the amber and red lines. This is based on a rolling 12 month period. The full report is detailed in Appendix B for reference. 9. Report Conclusion In summary: Home Treatment gatekeeping performance was below 95% in February and remedial actions are being taken. There continues to be significant pressure within the Adult Acute pathway, there has been an improvement in the average number of patients currently in overspill beds in February but snapshot indications are that the number of patients in external overspill is high in March. Contract negotiations with respective commissioners are continuing alongside the development of the Operational Plan being finalised for Monitor. The Transformation Delivery Blueprint and associated CIPS (Cost Improvement Plan) delivery plan work continues. Martin Black Interim Performance and Contracts Manager of 134

79 Appendix A: Transformation Programmes Dashboard The dashboard reports delivery of the transformation programmes identified within the Operational Plan 2014/16 and is designed to provide assurance and challenge at Board level. 79 of 134

80 Summary AMH Programme Key Performance Indicator Target Performance Trend Workforce Key Performance Indicator Target Performance Trend OBDs excluding leave (of people known to the AMH teams) Referrals into our services from primary care (accepted referrals to A&L) -28% Sickness Absence 5.12% 4.96% Appraisal compliance 100% 99% Transfers back to primary care (discharges from MAP treatment teams and PRTs) 10% 34 Bank and agency utilisation and recruitment: CPN Bank & Agency usage -10% 106.2* WTE ICT Estates: Capital and Facilities Key Performance Indicator Target Performance Trend Key Performance Indicator Target Performance Trend Service desk open calls at the end of the month New 1305 Closed Reduce number of community properties and related operating costs - Refer to commentary PCs replaced at the end of the month 2100 FY 1500 Capital project achievement against plan Cost & Time Green: 4/4 Amber: 2/1 Red: 0/1 Number of users of Health Intelligence products count during the month Year on year improvement on PLACE scores 3 of 4 domains 80 of 134

81 Quality Improvement Key Processes Procurement of a partner with the right expertise to deliver this model. Recruiting a QI team in place Feb 2016 Timelines Start Sept Go Live Mar 2016 Adjusted now May 2016 Scoping and training exercises Our vision is to create and sustain a culture with continuous quality improvement. We aim to become an organisation with a culture of improvement that is based on service users, carers, staff and key partners working together to improve the delivery of care to deliver the outcomes that matter to our service users. We have undertaken a procurement to contract a partner to help us deliver a trust wide quality improvement programme to achieve this vision over the next three years, embedding this culture in our organisation permanently and ensuring value for money in everything we do. The partner will support us to deliver a programme that will be service user focused, flexible in delivery and provide economies through standardisation of our methods and continuous efficiency improvement. Commentary This programme will remain as a narrative update until the Trust have a defined set of KPIs agreed with our partner. Key Updates: IHI/Intermountain partnership have been appointed as suppliers for this contract. The contract was signed 29 th February Bi-weekly meetings are now held with Head of IHI, Pedro Delgado, to set up the diagnostic phase that will be used to inform the project plan. Facilitator interviews have been completed and 4 out of 5 posts have been appointed. Currently we have PSO and one facilitator in post, one facilitator and the programme Manager will start on 4 th April and the other two posts should be in post by May. We are also holding interviews for the statistician in the next month and currently the recruitment ad is live. We will leave the 5 th facilitator post vacant currently with a view either for a secondment post or for a data analyst post which will be discussed further with our partner. There will be subsequent phases including a scoping exercise, implementation including staff training and guidance on system changes. These phases and their timeframes will be agreed with our preferred partner over of the course of the procurement exercise and the scoping phase. We will provide regular updates to the board and relevant stakeholders when there is more detail around these key stages in the programme. To reach a better understanding potential scale of savings associated by March of 134

82 AMH Programme KPI Targets Previous (Month) OBDs excluding leave (of people known to the AMH teams) Referrals into our services from primary care (accepted referrals to A&L teams) 28% Reduction Performance (Feb) Trend 3,500 3,000 2,500 2,000 1,500 1, OBDs EXC Leave against target 28% reduction Discharges back to primary care (discharges from MAP treatment and PRTs) 10% reduction in caseload Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 ALL AMH TEAMs OBD Exc Leave 28% reduction Reporting Details Data Source AMH KPI Dashboard. The dashboard reports data in relation to Lambeth and Lewisham boroughs where the AMH model has now been running since September It includes data from the Assessment and Liaison teams, MAP treatment teams and Psychosis Promoting Recoveryteams. OBDs OBD by CMHT AMH report activity relates to AMH Lambeth and Lewisham.(Excludes A&L OBD days) Accepted referrals -Activity relates to the Assessment & Liaison Teams within MAP CAG in Lambeth and Lewisham. System has beenrevised to exclude any rejected referrals. 82 of 134

83 AMH Programme Update 1. OBDs Excluding Leave The data shows that OBDs (excluding leave) for the Lambeth and Lewisham AMH teams has remained relatively constant since September 2015, although there has been a reduction in the last 2 month this would need to continue forward to be considered a downward trend. The number of patients admitted to hospital from these teams is showing a reduction, however their length of stay has increased at times, off setting any impact on the number OBDs used. Community teams, including the Home Treatment Teams do have the ability to impact on length of stay, through efficient working with thewards to plan discharge and to support early discharge under home treatment wherever possible. However the increases in length are multiple and complex and the community teams are not able to influence all factors. Reasons for all of the increases in length of stay are not yet clear,further analysis is required; linking into the work on the acute pathway programme. A considerable amount of work and new reports are becoming available through the HI team which shows a significant difference in the pattern of admissions in the boroughs where AMH is yet to be implemented 2. Accepted referrals and Transfers to Primary Care: The number of referrals into the services continue to increased this month and discharges reduced therefore the numbers within each of the Treatment Teams (MAP and PRTs) continues to rise. This is not causing a significant problem to services at present except to the MAP treatment team in Lewisham. The MAP treatment team in Lewisham has a very high caseload per Care Co-ordinator which has caused a cost pressure within the team. This is being discussed with the CCG. 3. Brief update on Croydon and Southwark Services 3.1 Croydon Croydon services have been restructured to match the GP networks in the borough. AMH is to be implemented in 4 phases across3 years in Croydon. We have completed the implementation of phases 1 and 2. This includes establishing the assessment and liaison service, additional investment into the home treatment team and additional investment into the Primary Care MH support team. Phase 3 focuses on increasing capacity in primary care services and phase 4 focuses on increasing investment into the Promoting Recovery and MAP treatment teams. There is considerable pressure on beds in Croydon, we have therefore suggested that phase 4 implementation could be brought forwardahead of phase 3 as we believe the additional capacity in the community treatment teams will have a greater impact on supporting people to stay well and reducing hospital admissions. The Croydon Programme Board has been established jointly with the CCG to oversee all new initiatives in Croydon. 3.2 Southwark The assessment and liaison teams and MAP treatment services have been implemented in Southwark. We continue to negotiate the model for Home Treatment and Primary care facing services with the CCG. Once the models are agreedwewill be able to move forward with implementation. A monthly meeting is held with Southwark CCG to monitor implementation and agree next steps. The CCG have requested a view on the model for Promoting Recovery Teams should social care be moved into a standalone service, this has been provided. 83 of 134

84 Workforce KPI Target Previous (Month) Performance (Feb) Trend Sickness Absence 5.12% 4.92% 4.96% Appraisal completion 100% 99% 99% Bank and agency utilisation and recruitment CPN Bank & Agency Reduction 99.6* WTE 106.2* WTE Commentary Sickness: is up 0.04% in February over January, but only 0.07% above the 4.89% in December 2015 which was the lowest level of sickness since records have been kept this way in June The cost of sickness in 2013/14 to the Trust was calculated as c 6,525,000 PA. A reductionof0.35% in sickness equates to 450K*. Current performance is ahead of 5.12% target. The Trust is not anticipating significant reductions beyond this level. Bank and Agency CPN reduction: Overall CPN Bank and Agency usage is up in February compared to January. Performance against the -10% October 14 baseline of WTE has been exceeded and against the stretch target of -20% the current reduction is -18.8% (once adjusted for incremental increases in headcount as a result of Croydon AMH and Early Intervention funding that are not included within the baseline is taken out. It was agreed that new service developments would be discounted from the overall target.) Appraisal Completion: Significant increase on 2014/15 completion rates. This will not alter until the next Appraisal season will be April June Alternative metrics are being considered to replace this. Reporting Details Absence: Sickness levels rolling year: The total cumulative sickness for the service (in the preceding 12 months). Source: HRDashboard using ESR. *The cost of sickness comprises two elements, the cost of bank/agency backfill to cover sickness and the cost of paying non productive staff. Appraisal Compliance - Completion rates for staff, excluding medical staff. Bank and agency utilisation and recruitment: *CPN Usage based on billing and accruals.. Note: due to changes in accruals over time, data may vary slightly month on month 84 of 134

85 Estates: Capital and Facilities KPI Targets Previous (Month) Reduce number of community properties and related operating costs Capital project achievement against plan Year on year improvement on PLACE scores - Time & Cost GIA 129,077 sq m Green: 5/4 Amber: 1/1 Red: 0/1 Annual - Performance (Feb) Refer to commentary Green: 4/4 Amber: 2/1 Red: 0/1 3 of 4 domains Trend Capital projects achievement against plan: This indicator is reporting on key projects. Projects Cost Time Anti-Ligature programme G G Centralised Place of Safety A R* Trust Wide Staff Attack Alarms G G Ladywell Phase 3 and Entrance G G Work Hubs - Maudsley G G Douglas Bennett Refurbishment A A Commentary Buildings are being highlighted to go on the disposal list, identifying properties for disposal, reporting occupancy utilisation, and factoring in organisational growth. Exception update:*centralised place of safety: Issues concerning the performance of the contractor have been resolved but this has resulted in slippage. The estimated completion of the scheme is now early May. The Trust has a provisional date of the 6th April to present to the Joint Health overview and Scrutiny Committee on Place of Safety and impact on AMPH services Capital planning: level 2 anti-ligature works complete other than the window replacements which is progressing. DBH pre-construction works temporarily suspended pending Outline Business Case Review to be completed in March. This to outline the impact on revenue of the scheme and provide assurance on affordability. Patient-Led Assessments of the Care Environment (PLACE): There has been year on year improvement in three of four domains. The Trust scores are all above the National averages. PLACE Assessments are annual in 16/17 these will be carried out Feb May. Hotel Services undertook 12 Mock PLACE Assessments across the Trust during late January & early February. The Trust has completed 2 PLACE Assessments from the 2016 schedule; both of these have been at Community sites. We were joined by members of Healthwatch for both assessments. We have been advised of 2 further community sites to assess. As yet we have not been notified the dates of any of the 4 main hospital sites that are to be assessed % 95.00% 90.00% 85.00% 80.00% PLACE Scores Cleanliness Food Privacy, Dignity & Wellbeing Condition Appearance & Maintenance Dementia 2014/ /16 Reporting details 85 of 134 GIA (Gross Internal Area): Freehold properties Capital projects achievement against plan comprises Key projects -RAG rating status for achievement against planned time and cost. Patient-Led Assessments of the Care Environment PLACE

86 IT Transformation Programme Key Performance Indicator Previous Month Performance (Feb) Trend PC Replacement Average number of concurrent epjs connections (per month) Number of users of Business Intelligence Products NHS Number Completeness % 99.36% Remaining, 600, 29% Replaced, 1500, 71% National Data Submission Compliance 100% 100% Service desk calls at the end of the month New: 3895 Closed: New 1305 Closed 86 of 134

87 Appendix B: Quality and Performance Dashboard Status: QSC Circulation Reporting Period: April-Jan Circulation Date: 11/03/2016 This dashboard provides a monthly summary of performance grouped by the CQC Key Lines of Enquiry New Items of Focus: Indicator No Indicator Name No new items of focus for this month. Issue Log: Issue Description Closure Date Responsible Owner First Reported Planned Resolution Indicator No Indicator Name Actions / Trajectory Status Responsible Owner First Reported Planned Resolution 41 Smoking Cessation Training: 85% of clinical staff will be trained to Level 1 and have annual refresher This training has recently been added to WIRED, current compliance has increased slightly to 34% but is still far below target. Engagement with the training is being addressed as there appears to be a lack of understanding that this module is mandatory for all clinical staff (it is mentioned in both the NICE guidelines and the Trust policy). An has been generated by the E&T team reminding all non-compliant staff that this module is mandatory and direct them to the available resources. The Level 2 training is class room based and Level 3 training is fully compliant. Feb 2015 QSC Ongoing monitoring 3 Number of Adult Acute Patients in Private Beds There continues to be significant pressure in the Adult acute pathway with an overspill average of 42.5 in January, this has fallen to 34.8 in February. PICU overspill also rose to an average of 23 patients per day in January falling to 16.4 in Feburary. The LOS within overspill is being closely monitored. The emergency meeting convened on the 18th January initiated a plan which to enable overspill levels to reduce over the proceeding weeks and determine how lower levels of overspill will be sustained at an operational level. This was followed up by a discussion by at Trust Bed Management on 20th January Specific actions include a focus on Home Treatment Team in reach at the local level on a daily basis. The Board is being kept updated through the monthly performance report. Sep 2015 QSC Physical Health CQUIN: Communication with GP CQUIN Discharge communications to GP The Trust is undertaking regular internal audits and feeding back team performance to support improvement. The Trust met CQUIN deliverables for Part A in Quarter 3 and there were no CQUIN deliverables for Part B in Quarter 3. Physical Health Care Nurse Consultant & CQUIN Lead April 2015 QSC 1 Do you feel safe?' [on the ward] target >90 % (2014/15 result was 81%) The Trust continues to experience difficulty in reaching the 90% target. This measure relates to inpatient wards. Performance continues to track at levels similar to 2014/15. AP / MH April 2015 QSC Wards where patients are expected to queue for medication. Target = 0 Wards where patients are expected to queue for meals. Target = 0 71 Mandatory Training 15 Child Need Risk Screening Patient Experience Reporting 1, 2, (PEDIC and Family and 43,48,49 Friends) The most recent audit has been completed - the methodology does differ to the audit undertaken for the 14/15 Quality account Audit. From the small audit sample 89% of patients did not queue for medication. 82% did not queue for meals. The CAET bulletin and recommendations has been circulated. A Communications was sent to all staff being outlining the requirement and trajectory target and the mandatory training linkage to appraisal. CAGS have submitted trajectories for meeting compliance where RAG rating is Red or Amber. Compliance is being addressed at the Trust wide Education and Training committee and via the Performance team. Performance is consistently below target - the policy has been updated and ratified at the QSC and disseminated to staff. Following the Trust changing provider for the data warehousing service for PEDIC (including the FFT) and the transition to the new supplier the return figures are lower than previously. This is most likely attributable to changeover of the data warehouse suppliers and the delays in returning devices back to the CAGs (due to difficulties in finding a solution to locking the devices so they are not web enabled). The majority of teams/wards now have their own devices and the outstanding ones have been ordered. Teams/wards are now able to offer surveys on paper, online and via a tablet. The number of surveys in quarters 1 and 2 of this financial year were higher than the same quarters of 2014/15. The central team will be working with the CAG PPI leads to develop action plans to increase the uptake in quarter 4 and therefore anticipate that there will be an overall higher number of survey responses for 2015/16. MO'D MO'D CAG Leads Feb 2015 QSC PPI April 2015 QSC Feb 2015 QSC Feb 2015 QSC Sep 2015 QSC TBC Ongoing monitoring Ongoing monitoring Closed issues: Indicator No 11 Safer Staffing 10 Indicator Name Issue Description The number of wards reporting that over 20% of shifts were breached. The vast majority of breaches continue to be the result of support workers covering for qualified nurses. Following the launch in September the first cohort started comprising four wards: Johnson, Acorn Lodge, Powell, Leo (Eden Ward, and Croydon Triage were successful at implementing it in the pilot). Monitoring of Four Steps to Safety outcomes and training uptake, incident levels, and effective (previously named Care implementation is ongoing. The second cohort, comprising Tony Hillis, Delivery System (Reduction in ES2, Heather Close, and Lewisham Triage is half way through the violent incidents)) facilitation process. A collaborative meeting of Cohort 1, 2 and 3 took place on the 29th January. Cohort 3 comprising McKenzie ward, Effra ward, Norbury ward, AL3, Luther king and Thames Ward undertook training on 14 January. Closure Date April 2015 QSC April 2015 QSC Reasons for closure Safer staffing continues to be reported monthly to the Trust Board. To address safer staffing breaches in the main the priority is improved recruitment and to ensure that recruitment processes are continuous. Funding of 0.5 million has been secured from the Health Foundation. The 1st cohort started in September and the 2nd cohort is undergoing the facilitation process and the 3rd cohort has been recruited too. A collaborative workshop was held end of January. 87 of 134

88 Safety Direction of travel key Improvement Stable Deterioration Monthly Indicator No. Indicator Governance Driver Target 2014/15 Q4 Apr-15 May-15 Jun-15 Q1 Jul-15 Aug-15 Sep-15 Q2 Oct-15 Nov-15 Dec-15 Q3 Jan-16 Direction of Travel RAG Thresholds Comment Patient Experience Use of private beds 1 Do you feel safe (In-Patients) Quality Priority 1 90% 81% 76.8% 81.9% 80.9% 79.8% 76.1% 85.6% 85.2% 82.1% 82.8% 79.2% 79.2% 80.7% 87.6% Do you know what to do in an emergency mental health situation (Community) Number of Adult Acute Patients in Private Beds (avg. per day for Month) Number of Adult Patients in PICU Private Beds (avg. per day for Month) Quality Priority 2 75% 73% 84.7% 82.9% 84.1% 80.7% 83.5% 80.7% 81.3% 80.9% 75.6% 84.0% 81.3% 80.3% 79.8% Safety monitoring TBC Refer to issues log Safety monitoring TBC (5.1) 6.8 (4) 9.9 (5.4) (5.8) 13.0 (6.2) 11.9 (3.4) (3.6) 13.8 (3.8) 20.2 (4.8) (4.5) Refer to issues log Follow up 5 Seven Day Follow Up Monitor 95% 97.4% 96.0% 96.8% 95.8% 96.2% 97.7% 99.1% 98.0% 98.2% 99.3% 96.0% 97.6% 97.6% 97.6% Incidents 6 New Serious Incidents Safety monitoring 7 Reported incidents % harm (categories A-C) Safety monitoring Staffing 11 Safeguarding 12 SIs Violence & aggression - patient physical assault on staff (categories A-C) SIs Violence & aggression - patient physical assault on patient (categories A-C) Four Steps to Safety (formerly Care Delivery System) Safer Staffing (Number of wards with 20% or higher of shifts breached) Absent - Detained (formerly recorded as AWOLs) Safety monitoring Safety monitoring SPC Trend SPC Trend SPC Trend SPC Trend 100% IP By Q /15 Avg: % 31.5% 28.0% 31.3% 30.2% 27.8% 23.50% 26.50% 25.90% 22.46% 21.90% 23.50% 22.60% - Under review following datix upgrade. 14/15 Avg: /15 Avg: Take up Refer to issues log Safety monitoring < 20% Fewer wards breaching Safety monitoring Brief & Full Risk Screen Safety monitoring 93.2% 92.4% 92.4% 92.6% % 92.7% % % 15 Child Need Risk Screen Safety monitoring 92.3% 91.5% 91.2% 91.3% % 92.3% 92.7% % 92.8% % G > 95% A 90-95% R < 89 G > 96 A R < 89 G > 96 A R < 89 Adjusted in previous months to discount failed attempts Safer Staffing: Wards Breaching 20% of Shifts Incidents (Categories A-C) Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Median + 2σ + 3σ -2σ -3σ 0 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Incidents (Categories A - C) Median + 2σ + 3σ - 2σ - 3σ Violence (Physical Assaults by Patient on Patient (A-C)) Violence (Physical Assaults by Patient on Staff (A-C)) Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Physical Assaults on Patients (By Patient) Median + 2σ + 3σ - 2σ - 3σ 0 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Physical Assaults on Staff (By Patient) Median + 2σ + 3σ - 2σ - 3σ 88 of 134

89 Effectiveness Direction of travel key Improvement Monthly Indicator Flow Physical Health Social Care No. QUeSTT Tool 27 Indicator Governance Driver Target 2014/15 Q4 Performance Apr-15 May-15 Jun-15 Q1 Jul-15 Aug-15 Sep-15 Q2 Oct-15 Nov-15 Dec-15 Q3 Jan Delayed Discharges Monitor 7.5% Monthly 3.1% 4.0% 4.2% 3.9% 4.0% 3.2% 3.1% 3.3% 3.2% 4.2% 4.3% 3.9% 4.1% 4.3% A: % 17 HTT Gatekeeping Monitor (and CCG Sanction 95% Monthly CCG Direction of Travel Stable Deterioration RAG Thresholds 95.6% 96.7% 96.4% 96.2% 96.4% 96.1% 96.6% 93.5% 95.4% 96.9% 96.7% 95.7% 96.4% 95.1% A: 90-95% 19 Inpatient annual Physical Health Screen. CCG Sanction 90% 93.3% 93.2% 94.4% 92.9% % 93.3% 91.0% % 91.9% 98.8% % 85-90% 20 Percentage of New Patients with the Ability to Consent that are Admitted to AMH Inpatient Services Offered a HIV CCG Sanction 30.00% M12: 43.2% 32.7% 37.0% 51.3% 41.6% 52.1% 42.5% 47.4% 48.3% 60.9% 51.6% 59.0% 60.0% 53.6% 30% Test 25 Settled Accommodation Assessment Completed (CPA patients) Contracts 95% 93.3% 93.0% 92.9% 92.8% % 90.2% 92.3% % 93.0% 90.9% % 26 Employment Assessment Completed (CPA patients) Contracts 95% 93.8% 93.5% 93.3% 93.1% % 90.7% 92.7% % 93.4% 91.5% % Total of wards with total QUeSTT score at level 2 and 3, where level 1 is good. QUeSTT Indicator The following indicators are reported on either a quarterly, bi-annual or annual basis (15) 8 (15) 7 (15) - 6 (15) 4 (15) 8 (15) - 10 (25) 10 (25) 10 (25) - 8 (30) - - Comment Figure in brackets refers to total cohort which has increased. % improvement has occurred. Quarterly Indicator No. Indicator Governance Driver Target 2014/15 Q4 Performance Apr-15 May-15 Jun-15 Q1 Jul-15 Aug-15 Sep-15 Q2 Oct-15 Nov-15 Dec-15 Q3 Jan-16 Direction of Travel RAG Thresholds Comment Home Treatment Physical Health Discharges Dual Diagnosis CQUINS Smoking Cessation Reduce the number of people supported by HTT who required an admission (where the AMH model has been established) In-patients: No of eligible patients having six key metabolic Quality Priority 3 c-v tests CQUIN (4a) & CQUIN Early Intervention: No of eligible patients having six key metabolic c-v tests CQUIN (4a) Physical Health Communication with GP CQUIN (4b) - 7 data items 32 Discharge communications to GP 33 Discharge communications to GP Quality Priority 8 < 15% 17% Quality Priority 3 & CQUIN Quality Priority 3 & CQUIN Patients with both an AUDIT (identification tool) and a drug and alcohol assessment completed (Adult acute inpatient Quality Priority 9 and adult community teams) Assuring the appropriateness of unplanned CAMHS admissions (Tier 4) - number of reviews held within 5 working days of unplanned admissions CQUIN (NHSE) 36 Adult Eating Disorders - Outcome measures Year 2 CQUIN (NHSE) 37 Dual Diagnosis Themes 1-4 SI Network 39 AMH Service Redesign & GP Network AMH Model CQUIN (Lewisham) CQUIN (Croydon) CQUIN (Lewisham) 40 Outcomes CQUIN (LSLC) Smoking Cessation Training: 85% of clinical staff will be trained to Level 1 and have annual refresher Smoking Cessation Training: 85% of Site Based Advisors will have completed Level 3 training Internal target 90% by Q4 - Each 90% 80% by Q4 TBC 75% Q4 75% Each 80% Q4 (AMH) 50% Q4 (OA, CAMHS, CF) 50% (Audit) 60% improvement 83% Met Met - - A: 70-90% Met Met - - Initial reports indicate good performance. Quality Account Audit planned for Q4/2016. LSLC Qtr 3 Deliverables have been met LSLC Qtr 3 Deliverables have been met 24% Met N/A - - A: 70-90% No Quarter 3 deliverables 59.6% Refer to issues log. 37.0% Refer to issues log. 18% Audit 33% D&A assessment Met Met - - Year 2 New New New New Met Met Met - - Local audits have commenced and meetings with CAG leads have occurred. Quality Account Audit planned for Q4/2016. Q3 submission made. Pending response NHSE. Q3 submission made. Pending response NHSE Met Met - - Q3 Deliverables have been met Met Met Met - - Deliverables have been met - Met Met N/A - - Deliverables have been met Met Met Met - - Deliverables have been met Internal target 85% New % 30.83% Refer to issues log. Internal target 85% New % % % of 134

90 Caring Direction of travel key Improvement Stable Deterioration Monthly Indicator No Indicator Governance Driver Target 2014/15 Q4 Apr-15 May-15 Jun-15 Q1 Jul-15 Aug-15 Sep-15 Q2 Oct-15 Nov-15 Dec-15 Q3 Jan-16 Direction of Travel RAG Threshold Comment Care planning, recovery and support Patient Engagement 43 Do you feel involved in your care? (IP & Community) Quality Priority 4 Increase on 14/ % 87.6% 90.0% 87.8% 88.4% 84.2% 88.1% 91.2% 88.2% 87.3% 86.4% 88.0% 87.1% 87.5% Updated data 44 CPA Formal Review within 12 months Monitor 95% Q4: 97.15% 97.1% % % % - 46 Copies of Care Plan given % (% of patients given / offered a copy of their CPA care plan) 47 New Complaints 48 Friends and Family Score 49 Number of Friends and Family Responses LSLC Contracts report - all CAGS National Standard National Standard National Standard 95% 95.1% 95.0% 95.0% 94.4% % 95.3% 95.1% % 94.6% 94.5% % Trend Avg. PM Trend - 84% 86% 82% 84% 78% 83% 85% 83% 85% 81% 80% 82% 82% Trend Target met for end of quarter. Refer to issues log. Unify data submission. The following indicators are reported on either a quarterly, bi-annual or annual basis Quarterly Indicator No. Indicator Governance Driver Target 2014/15 Q4 Performan ce Apr-15 May-15 Jun-15 Q1 Jul-15 Aug-15 Sep-15 Q2 Oct-15 Nov-15 Dec-15 Q3 Jan-16 Direction of Travel RAG Thresholds Comment Care planning, recovery and support Patient Engagement Risk Assessment & informing decision making - Inpatients and Community Patients on CPA Quality Priority 7 will have a full documented risk assessment. Number of carers who state they have been offered a carer s assessment 75% (Q4 Audit) 65.0% Quality Priority 5 30% (Audit) 20% Personalisation CQUIN Partial In-Patient Experience CQUIN (LSLC) Milestones Met Met Met Secure Service Users Active Engagement Programme (MH01) Perinatal specific involvement and support for partners/significant others (MH06) CQUIN (NHSE) Milestones Met Met - - CQUIN (NHSE) Milestones Met Met - - Quality Account audit planned for Quarter 4. Quality Account audit planned for Quarter 4. Qtr 1-3 Deliverables achieved Qtr 3 submission made - Pending NHSE response. Qtr 3 submission made - Pending NHSE response. Carers 56 Patients receiving an individualised service on Wards Mental health carer involvement strategies (MH08) Wards where patients are expected to queue for medication. Wards where patients are expected to queue for meals. CQUIN (NHSE) Milestones Met Met /15 Quality Priority 14/15 Quality Priority Qtr 3 submission made - Pending NHSE response. 24.0% A: 10-25% Refer to Issues log 32.0% A: 10-25% Refer to Issues log Do you feel involved in your care? New Complaints 100.0% 95.0% 90.0% 85.0% 80.0% 75.0% 70.0% 90.0% 91.2% 87.6% 87.8% 88.1% 87.3% 86.4% 88.0% 87.5% 84.2% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan /15 Result 2015/16 Monthly New Complaints Median + 2σ + 3σ - 2σ - 3σ 90 of 134

91 Responsiveness Direction of travel key Improvement Stable Deterioration Monthly Indicator No. Indicator Governance Driver Target 2014/15 Q4 Apr-15 May-15 Jun-15 Q1 Jul-15 Aug-15 Sep-15 Q2 Oct-15 Nov-15 Dec-15 Q3 Jan-16 Direction of Travel RAG Thresholds Comment 59 <18 week wait time AMH services CCG TBC % 91.4% 90.5% % 91.7% 90.0% % 91.1% 93.8% % TBC CCG Reporting Waiting Times Meeting commitment to serve new psychosis cases by early intervention teams Early intervention in Psychosis (EIP). 1st Episode Psychosis treatment within 2 weeks and concordance Monitor with NICE guidance 62 IAPT Waiting Times within 6 weeks (First Treatment) Monitor 63 IAPT Waiting Times within 18 weeks (First Treatment) Monitor Monitor 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% (Q4 onwards) 75% (Q3 onwards) 95% (Q3 onwards) % % 85.0% 88.0% 84.7% 88.7% 87.8% 83.6% % 89.6% % 98.9% 98.5% 98.6% 98.9% 98.9% 98.9% % 99.2% /16 Target to be agreed with CCG. Will be replaced by new EI national standard. New national requirement - the publication of national technical guidance was published in late December. Trust working group progressing work to achieve the standard. HSCIC reporting for 1st Treatments. Trust met the Monitor target for Q3 for completed treatments HSCIC reporting for 1st Treatments. Trust met the Monitor target for Q3 for completed treatments The following indicators are reported on either a quarterly, bi-annual or annual basis Quarterly Indicator Learning Disabilities Environment No. 64 Indicator Certification - requirements regarding access to healthcare for people with a learning disability (S) 65 PLACE results quality of the environments IP 66 Monitor progress of redecorate/refurbishment plan Ligature Points reduction works Governance Driver Target 2014/15 Q4 Performan Apr-15 May-15 Jun-15 Q1 Jul-15 Aug-15 Sep-15 Q2 Oct-15 Nov-15 Dec-15 Q3 Jan-16 Direction of Travel RAG Thresholds Monitor Compliance Met Met Met Met Quarterly reporting Quality Priority 6 Linked to Quality Priority 6 Linked to Quality Priority 6 95% Annual of 5 over 95% Comment Cleanliness 99.5%, Food 90.5%, Privacy, Dignity and Well Being 94.5%, Condition, Appearance and Maintenance 96.25%, Dementia 98.4% (new domain) PLACE lite assessments on a selection of wards each month on Food and Hydration are planned. Trust cleanliness audits are undertaken on a monthly basis for in the region of 60 wards per month. ES1 works: Phase 1 complete. Phase 2 in progress will complete 4th March. Phases 3-7 are out to tender for start in 16/17. Gresham PICU refurbishment/reconfiguration: Works in progress, handover on 18th March Gresham 2 Ascom and refurb: Ascom first fix complete, building works will start Monday 29th Feb and will take 16 weeks to complete All level ligature reduction works are complete. Surveys complete at Maudsley and Lambeth. Report with costs for replacement of windows being written for March CRG to seek approval to proceed. Gresham 2 is not scheduled to complete until March 2016 because the ligature works are included as part of a larger refurbishment project. 91 of 134

92 Well Led Direction of travel key Improvement (above 2.5% variation) Stable (within 2.5% variation) Deterioration (below 2.5% variation) Monthly Indicator No. Indicator Governance Driver Target 2014/15 Q4 Apr-15 May-15 Jun-15 Q1 Jul-15 Aug-15 Sep-15 Q2 Oct-15 Nov-15 Dec-15 Q3 Jan-16 Direction of Travel RAG Thresholds Comment 68 Staff Sickness rate % (rolling year %) Workforce < 5.12% 5.15% 5.21% 5.11% 5.07% % 5.09% 5.03% % 4.95% 4.89% % Workforce Mandatory Training 69 Vacancy Rate (WTE) Workforce TBC 19.5% 20.0% 19.7% 20.7% % 20.1% 20.6% % 19.80% 20.47% % 71 Appraisal Workforce 100% % 97% 99% Clinical Risk Level 2 Training % % 63.7% 68.0% % 69.9% 71.6% % 72 Mandatory Training- average overall compliance (bar Prevent, until 2018) 73 Adult Safeguarding Alerters (All Non Clinical Staff) 74 Adult Safeguarding Alerters Plus (All Clinical Staff) 75 Child Safeguarding Level 1 (All Non Clinical Staff) 76 Child Safeguarding Level 1 and 2 (All Clinical Staff) 77 Child Safeguarding Level 3 78 PSTS Team work inpatient staff 79 PSTS Awareness / Conflict Resolution 80 PSTS disengagement 81 Basic Life Support Level 1 (All Non Clinical Staff) 82 Basic Life Support Level 2 83 Immediate Life Support 85 Infection Control (Levels 1 & 2) 86 Information Governance 87 Health, Safety & Welfare 88 Equality, Diversity & Human Rights 89 Moving & Handling Loads 90 Moving & Handling Patients 91 Fire Safety Awareness Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training Trust Mandatory Training 65.3% 66.1% 68.7% 70.3% % 72.4% 76.9% % 78.1% 79.5% % 85% 78.2% 78.6% 80.7% 80.1% % 82.5% 83.9% % 84.1% 85.3% % 85% 61.0% 61.7% 64.1% 65.9% % 70.4% 76.5% % 79.9% 81.5% % 85% 81.5% 80.1% 83.2% 82.9% % 84.7% 87.2% % 86.7% 87.0% % 85% 89.1% 89.2% 90.7% 90.9% % 83.5% 85.0% % 87.4% 89.0% % 85% 79.2% 79.7% 81.9% 82.8% % 86.9% 90.6% % 92.7% 93.3% % 85% 68.5% 71.1% 68.8% 66.9% % 68.2% 71.7% % 74.2% 76.7% % 85% 89.3% 89.3% 91.0% 91.1% % 89.8% 91.8% % 91.5% 91.9% % 85% 61.1% 57.8% 60.1% 56.4% % 57.3% 61.1% % 62.7% 65.1% % 85% 84.1% 84.8% 87.9% 87.5% % 87.2% 89.2% % 90.2% 90.5% % 85% 56.1% 59.5% 63.6% 64.9% % 71.0% 76.8% % 78.6% 79.5% % 85% 50.3% 52.5% 54.4% 61.9% % 66.5% 73.4% % 77.0% 78.2% % 85% 65.6% 67.8% 70.1% 84.2% % 74.0% 79.5% % 78.5% 79.1% % 95% 47.5% 48.7% 52.3% 56.5% % 63.1% 68.8% % 68.9% 72.1% % 85% 75.7% 76.1% 78.5% 78.8% % 80.8% 83.0% % 85.3% 84.6% % 85% 57.1% 58.6% 62.3% 65.6% % 72.4% 76.7% % 79.4% 81.7% % 85% 59.0% 60.2% 60.4% 65.9% % 68.6% 71.7% % 72.6% 74.5% % 85% 33.1% 33.1% 33.3% 41.4% % 46.4% 53.5% % 56.5% 59.2% % 85% 67.5% 68.5% 71.8% 73.3% % 73.9% 80.2% % 79.1% 80.7% % G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 G: >85% A: 65-84% R: < 65 % change between end of 14/15 snapshot and current month shown below (unless specified): 15.0% 7.4% 20.4% 7.0% 0.8% 14.2% 8.7% 3.9% 6.0% 7.6% 22.7% 25.5% 11.3% 26.3% 10.9% 26.9% 17.3% 30.6% 12.9% 92 of 134

93 Staffing Levels in Inpatient Wards - January February 2016 Clinical Academic Group Behavioural and Developmental Psychiatry Child and Adolescent Mental Health Services MHOA and Dementia Psychological Medicine Psychosis Hospital Site Ward name January February Breach % Breach % Wandsworth Prison Addison ward 4% 18% Bethlem Royal Hospital Brook Ward 9% 4% Bethlem Royal Hospital Chaffinch Ward 1% 2% Bethlem Royal Hospital Effra Ward 5% 11% Bethlem Royal Hospital National Autism Unit (NAU) 0% 0% Bethlem Royal Hospital Norbury Ward 4% 11% Bethlem Royal Hospital Spring Ward 15% 17% Bethlem Royal Hospital Thames Ward 9% 13% Bethlem Royal Hospital Waddon Ward 4% 10% Lambeth Hospital Ward in the Community (WiC) 3% 4% Bethlem Royal Hospital Acorn Lodge Children's Unit 73% 62% Woodland House Ash Adolescent Unit 10% 14% Notes (February) 21% of total breaches planned due to decreased patient occupancy. Breaches due to short notice sickness and NHSP unable to provide staff Bethlem Royal Hospital Bethlem Adolescent Unit (BAU) 24% 21% Majority of breaches due to NHSP unable to provide staff Woodland House Oak Adolescent Unit 0% 27% Majority of breaches due to short notice sickness Maudsley Hospital Snowfields Adolescent Unit 10% 16% Ann Moss Way Ann Moss Specialist Care Unit 0% 7% Maudsley Hospital Aubrey Lewis 1 Ward (AL1) 9% 6% Bethlem Royal Hospital Chelsham House 9% 14% Voss Court Greenvale Specialist Care Unit 32% 24% 16% of total breaches planned due to decreased patient occupancy. Ladywell Unit Hayworth Ward 3% 3% Bethlem Royal Hospital Croydon Triage 13% 22% Majority of breaches due to NHSP unable to provide staff and unable to fill shift Bethlem Royal Hospital Eating Disorders Unit (EDU) 17% 6% Lambeth Hospital Lambeth Triage 87% 64% Ladywell Unit Lewisham Triage 23% 26% Bethlem Royal Hospital Lishman Unit 19% 21% Bethlem Royal Hospital Mother and Baby Unit (MBU) 10% 11% Maudsley Hospital Aubrey Lewis 3 Ward (AL3) 5% 10% Lambeth Hospital Bridge House 58% 68% Majority of breaches due to NHSP unable to provide staff and support worker covering for qualified nurse Majority of breaches due to NHSP unable to provide staff and unable to fill shift Majority of breaches due to NHSP unable to provide staff and support worker covering for qualified nurse Majority of breaches due to NHSP unable to provide staff and support worker covering for qualified nurse Ladywell Unit Clare Ward 2% 9% Lambeth Hospital Eden Ward 4% 4% Maudsley Hospital Eileen Skellern 1 Ward (ES1) 6% 42% Breaches due to NHSP unable to provide staff Maudsley Hospital Eileen Skellern 2 Ward (ES2) 9% 11% Foxley Lane Foxley Lane 0% 0% Bethlem Royal Hospital Gresham 1 Ward 11% 9% Bethlem Royal Hospital Gresham 2 Ward 1% 0% Heather Close Heather Close Rehabilitation Inpatient Ward 2% 3% Maudsley Hospital Jim Birley Unit (JBU) 3% 32% Majority of breaches due to NHSP unable to provide staff and decision not to fill shift Maudsley Hospital John Dickson Ward 3% 4% Ladywell Unit Johnson PICU 17% 21% Breaches due to NHSP unable to provide staff Lambeth Hospital Lambeth Early Onset Ward (LEO) 55% 53% Breaches due to NHSP unable to provide staff and support worker covering for qualified nurse Lambeth Hospital Luther King Ward 62% 60% Breaches due to NHSP unable to provide staff and support worker covering for qualified nurse Lambeth Hospital McKenzie Rehabilitation Inpatient Ward 12% 8% Bethlem Royal Hospital National Psychosis Inpatient Ward (Fitzmary II) 25% 38% Majority of breaches due to NHSP unable to provide staff and unable to fill shift Bethlem Royal Hospital Nelson Ward 40% 44% Breaches due to NHSP unable to provide staff and support worker covering for qualified nurse Ladywell Unit Powell Ward 10% 8% Maudsley Hospital Ruskin Ward 1% 2% Lambeth Hospital Tony Hillis Unit 47% 33% Breaches due to NHSP unable to provide staff and support worker covering for qualified nurse Bethlem Royal Hospital Westways Rehabilitation Inpatient Ward 4% 14% Ladywell Unit Wharton Ward 0% 2% South London and Maudsley NHS Foundation Trust 93 of 134

94 TRUST BOARD OF DIRECTORS SUMMARY REPORT G Date of Board meeting: 29 th March 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance, Information) Author: Approved by: (name of Exec Member) Presented by: Associate Hospital Managers Annual Review Recommendations for Approval Governance Kay Burton Neil Brimblecombe, Director of Nursing Dr. Julie Hollyman, Non-Executive Director Purpose of the report: To enable the Associate Hospital Managers to be approved to undertake the role to 31 st March 2017 Action required: To approve the names. Recommendations to the Board: To approve the names. Relationship with the Assurance Framework (Risks, Controls and Assurance): The Trust requires a group of Associate Hospital Managers, to ensure that the Trust is able to offer patients continued access to review of their detention. Summary of Financial and Legal Implications: The Board of Directors is required to approve all Associate Hospital Managers to carry out reviews of detained patients under Section 23 of the Mental Health Act 1983, as amended by Section 45 of the Mental Health Act 2007 as it applies to a Foundation Trust. Equality & Diversity and Public & Patient Involvement Implications: All approved Associate Hospital Managers are offered training at a Cultural Diversity Workshop run specifically for them with an emphasis on the work they carry out as Associate Hospital Managers. This ensures that all Associate Hospital Managers are fully conversant with the needs and cultures within the population served by the Trust. All Associate Hospital Managers are required to attend a refresher course every three years. 94 of 134

95 Associate Hospital Managers Annual Review Cycle and Recommendations for Approval Year Prepared by: Kay Burton Assistant Director of Mental Health Legislation of 134

96 Associate Hospital Managers Annual Review Cycle and Recommendations for Approval Introduction The Associate Hospital Managers have now been interviewed for their annual reviews. The process followed that of previous years and included some feedback from the competency based system introduced in September Process for 2015/16 Dr. Julie Hollyman, Non-Executive Director and Dr. Neil Brimblecombe, Director of Nursing reviewed the Associate Hospital Manager Leads for Maudsley/Ladywell, Lambeth and the Bethlem Site Groups. Their group leads reviewed the Associate Hospital Managers with Kay Burton for the Bethlem, Maudsley/Ladywell and Lambeth Groups. The review process included an assessment of the competencies needed to carry out the role of AHM Group Lead. Associate Hospital Managers were met with individually during which there was a structured discussion looking at areas of the role which they felt they did well; areas where they had experienced difficulties and discussion of possible development needs. For each Associate Hospital Manager a personal development plan was completed and training needs identified. There was also time during each meeting for discussion of any general points the Associate Hospital Manager wished to raise. A total of 32 annual reviews were undertaken Outcome of Annual Reviews Of the 32 annual reviews carried out, 30 are recommended for approval by the Board of Directors from 1 st April All had completed the minimum requirements expected of them in terms of hearings. Seventeen of these are recommended for approval with the proviso that they complete outstanding mandatory training by 31 st July The necessary training sessions will be scheduled before the end of July The commitment of Associate Hospital Managers to carry out the required number of activities and to attend numerous training sessions in addition to the hearings is commended. Two AHMs who attended their review had not completed the required number of hearings. They are therefore not recommended for reapproval. One of these AHMs has decided not to continue with the role and another is attempting to increase the number of hearings and will be further reviewed in April During the Ladywell and Maudsley groups combined into one group. There will be a change of group leads from 1 April Evelyn Clement-Elliott will be the Lead for the Lambeth group and Sue Dossa the Lead for the combined Maudsley/Ladywell group. Diana Stainbank will continue as the Lead for the Bethlem group. Eileen Thomson took the decision during the year to retire from the AHM role. Attached is the list of Associate Hospital Managers for whom approval is sought by the Board of Directors to enable them to carry out their functions from 1st April Kay Burton Head of Mental Health Act 11 th March of 134

97 ASSOCIATE HOSPITAL MANAGERS FOR APPROVAL BY TRUST BOARD FOR Name of Associate Hospital Manager Group Recommendation for Reapproval by Trust Board Condition attached AHM Group Leads for Evelyn Clement- Elliott Lambeth Yes None Sue Dossa Maudsley/Ladywell Yes Yes Diana Stainbank Bethlem Yes None Non-conditional recommendations Ali Assour Maudsley Yes None Shiv Banerjee Maudsley Yes None Caroline Beamish Maudsley Yes None Ann Davies Ladywell Yes None Danny Dennehy Bethlem Yes None Marion Down Ladywell Yes None Maria Lydia Bethlem Yes None McInnes Jennifer Smith Lambeth Yes None Anna Tapsell Lambeth Yes None Franklin Thomas Maudsley Yes None Conditional recommendations Fran Campbell Lambeth Yes Complete mandatory training Carl Chandra Lambeth Yes Complete mandatory training Pat Cook Bethlem Yes Complete mandatory training Annette Grunberg Bethlem Yes Complete mandatory training Yoke Hopkins Bethlem Yes Complete mandatory training Aslam Hussain Bethlem Yes Complete mandatory training Mike Ive Bethlem Yes Complete mandatory training Val Johnson-Bell Lambeth Yes Complete mandatory training Magnel Morgan Ladywell Yes Complete mandatory training Paul Nash Lambeth Yes Complete mandatory training Paul Ollendorf Bethlem Yes Complete mandatory training Arthur Samuel Ladywell Yes Complete mandatory training Rashmi Varma Maudsley Yes Complete mandatory training Raymond Singh Maudsley Yes Complete mandatory training Yousouf Tourap Lambeth Yes Complete mandatory training John Verdon Maudsley Yes Complete mandatory training Sandra Walter Maudsley Yes Complete mandatory training 3 97 of 134

98 TRUST BOARD - SUMMARY REPORT H Date of Board meeting: 30 March 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance, Information) Author(s): Approved by (name of Executive member): Board disciplines review Governance Paul Mitchell, Trust Board Secretary Dr Matthew Patrick, Chief Executive Presented by: Roger Paffard, Chair Purpose of the report: For the Board to note the outcome of the survey undertaken to assess how the Board disciplines agreed in March 2015 have been working in practice. Action required: To note and agree to develop further proposals for streamlining Board processes at a future Board development session. Recommendations to the Board: To receive the results of the survey carried out in Survey Monkey format in February out of 29 potential respondents took part in the survey. These included Board members as well as senior managers and governors who regularly attend the meetings. Overall respondents expressed satisfaction that progress was being made to implement the disciplines and that the meetings were moving towards an improved balance of discussion/decision and strategy/ operational performance. Immediate areas to highlight are: 1. A requirement to improve the quality of the summary sheets explaining better the purpose of the paper and the reason why it is being brought to the Board. 2. A desire for better clarity of papers and executive summaries which focus the Board s attention on decisions that need to be taken. 3. A lack of standardisation in the processes for producing and accessing the Board papers. A number of paper and electronic are now in operation. There is no strong case to change the length or frequency of Board meetings or the new agenda structure & disciplines. The footprint for 2017/8 should be similar to this year. There is a need to continue to experiment with location and setting to address concerns of acoustics and observer comfort. We should continue to plan to hold 2 meetings a year at Bethlem when the board room has been refurbished. Relationship with the Assurance Framework (Risks, Controls, and Assurance): Ongoing improvements to Board processes are a requirement of sound governance arrangements. Summary of Financial and Legal Implications: No direct implications although the lack of standardisation in accessing Board papers may have financial consequences that need addressing. Equality & Diversity and Public & Patient Involvement Implications: No implications in these areas. Service Quality Implications: No implications in this area. 98 of 134

99 Preparation and approval of the agenda P1. The process is open, fair and transparent and improved since the introduction of the premeeting with the Chief Executive Officer (CEO). The introduction of a clear timetable for the production of reports will allow for a little more time for the consideration by others of draft Board report. P2. The new timetable for non-routine papers should improve the Trusts ability to prepare as currently papers can be circulated at the last minute and implications cannot be fully scoped or assessed. P3. The agenda should be drawn from the forward planner and developed to include more detail on what the expectation for the agenda item is. Front cover summary sheets should be drafted in advance so the Trust can assess both the purpose of the item, agreement on the decision to be recommended to the Board and the correct time allocation. A well-balanced and manageable agenda P4. The agendas tend to be crowded and leave too little time for discussion, there needs to be a see a shorter agenda and more time to discuss the really important issues. There Board Survey 2016 Page 1 of of 134

100 are some items which could be purely for information and need not be discussed at all but just "noted" as long as Board members did not wish to ask a question. A more indepth review of fewer items would be better P5. The agenda is mainly clear and manageable within the allocated timescale providing that there is not an expectation of a serious debate as there is insufficient time for this. The average time per item is somewhere between 5 and 10 minutes. Papers are frequently unclear about what they are requiring of the board-decision/information or support. Report authors are in many instances not good at drawing out the main points which warrant board attention P6. Feedback from CoG is always towards the end and as with other items towards the end, time is sometimes limited Items for decision and items for information P7. It is not always clear what items for information means, if something is for information it does not necessarily mean that it should not be discussed, similarly items for decision may not just be for the decision alone. P8. I think often items are put down for decision before they are actually well developed enough for the board to be able to make a decision. The board should be ensuring that all large items have been discussed and agreed at a subcommittee prior to board being asking for 'approval'. P.9 We need to ensure we devote sufficient time to those items which are more discursive and developmental to cover the formal elements from the Board Development/Seminar sessions. Board Survey 2016 Page 2 of of 134

101 The standard of Board papers P.10 There is considerable inconsistency in the quality/length/style of report. Most however are prepared to a fair/reasonable standard. I am unaware of any advice given to report authors or any influence applied to report authors to deal with improvements when they are required. It would be helpful if reports had a summary page explaining why the report was required, its purpose, and its context in terms of governance or strategic objectives P.11 This has improved significantly recently however we don't get enough time to review internally before the deadline for circulation of the papers and some can be much better than others. We need to work more on the financial and other data content before these are presented at the Board. P.12 In some cases the board papers do not give enough evidence in order to assure the CoG's. The circulation of Board papers P.13 The sheer volume of paperwork can inhibit sufficient study before Board meetings. We still have less than five working days to read digest and prepare. P.14 I'm still not always finding it easy to see and use the board papers electronically. On the day I prefer paper although I have read them electronically beforehand. Board Survey 2016 Page 3 of of 134

102 Board summary sheets P.15 The quality of completion of these is still very variable. This requires urgent attention. We don't often push back at the Board that these are inadequate although in recent meetings this has been picked up. I think we are often pushed to make decisions in principle without complete information and don't often say no. There is a risk that the decisions are therefore unclear or still open to interpretation. We need a mechanism for clearly communicating these internally before the next Board meeting minutes are published. P.16 This needs further focus to ensure that the reason for the paper coming to the board is clearer and the outcomes required are spelt out. P.17 Front sheet still needs to be crisper and clearer on why the paper is coming to the Board BoardPad P.18 BoardPad is very good. Why can't we get other papers, including sub-committee papers and papers for governors' meetings, on BoardPad? I do not think it is used to its full potential P.19 I think everyone should use it with the option to have a hard copy agenda available. The lead should come from Chair and CEO who should abandon paper. Board Survey 2016 Page 4 of of 134

103 P.20 I don't use it. I don't use an ipad but my Trust laptop and have the papers on a pdf which I use in the meetings. The length of board meetings L.21 Given the constraints (public meetings, need to have certain items on the agenda), I think the meetings are of about the right length. They do sometimes feel rather rushed, because of the length of the agenda, but I would not be in favour of making the meetings longer. They are long enough L.22 Part 2 occurring before Part 1 is sometimes too short. More thought needs to be given to this in planning. I think 2 hours for Part 1 should be sufficient. A short comfort break between 1 and 2 would aid attention. L.23 The time devoted to board business seems right most of the time but we need to be sufficiently flexible to allow more time when important issues arise. We also need to be more flexible about the way that agendas are organised to reflect the different time requirements-even if this means leaving items off. It frequently feels like our role is to get through the agenda rather than make good decisions. The Board is not particularly good at 'scrutiny' even accepting the fact that much of this must go on at committee level. Neither are the NEDs good at asking for items to be put onto the Board agenda for reassurance or scrutiny purposes. Location, layout and acoustics Board Survey 2016 Page 5 of of 134

104 L.24 I prefer the Ortus - the Board Room is poorly temperature controlled. L.25 I understand why people like the Ortus building but the acoustics are terrible and some of the table plans make this worse. More thought needs to go into this. Miking the room might help and not having long and thin table layouts. Rooms with windows that open and close automatically are very distracting. The catering seems OK. L.26 February Board layout at Ortus was much better and preferable to the Board room at Bethlem. I do think we could and should have meetings at different locations across the Trust geography perdiocally. Room acoustics L.27 Acoustics don't help especially when person speaking is sitting down with back turned to participants. Consider microphones. L.28 The rooms used by the Board vary and this affects the acoustics also there are no arrangements to support people who have hearing difficulties. I believe the Board is considering use of microphones; equalities issue. Strategic Focus BD.29 I don't think a lot of what the Board discusses in the open session is particularly strategic, it feels more inward facing. Not necessarily a bad thing, but with all the changes that are Board Survey 2016 Page 6 of of 134

105 taking place it would be good to have more of a feel for what the Board is thinking and responding to things like The Five Year Forward View. BD.30 Some are and some aren't and that is in the nature of the breadth of the business and also the NHS dictats on the amount of monitoring that is obliged to be done at Board level. Not all strategic discussions can be done in public at an early stage. When there is a real strategic issue on the agenda I would prefer papers written to offer options with supporting arguments allowing the discussion to lead to a decision so that the people observing can understand the process better. BD.31 I'm not convinced that there is sufficient challenge by Board members on some of the key issues. Discussion of all aspects of business BD.32 The agenda is well balanced albeit it feels more input based at times. Whilst we receive a large amount of resource/service quality information we receive much less information about the outcomes for patients/ the effectiveness of treatment/ the volumes of treatment or the relative efficiency of our services. BD.33 I don't think we always cover all aspects of all papers and this is why we need assurance on each item - about where it has been discussed previously - as it is not always possible in the time of a 'GP appointment' to cover all those aspects! BD.34 Not sufficiently for the level of challenge that the sector and the Trust face. I'm not sure that those presenting sufficiently address all key aspects of the subject matter. Some items do not always take sufficient note of the long term financial and other matters into account. Whilst an item or strategy may appear to be good, the discussion does not take into account the fact that circumstances may change. Board Survey 2016 Page 7 of of 134

106 Analysis, challenge and debate BD.35 The only parties who should be automatically engaged in the process should be the Board members. Wider discussion should have taken place in advance if necessary to ensure Board members are informed. Others should be invited to clarify issues in the meeting. Some of the people attending are not members but act as if they are offering opinions without a specific invitation. As non-members are not accountable for the decision we should be careful about this. BD.36 I think the Board meetings discussions are open, people can debate and disagree and challenges are constructive but the quality of this is partly dependent on the quality of the papers and preparation time. BD.37 I am more concerned about ensuring that decisions are implemented and in a timely fashion. Identifiable decisions, with responsibility assigned for taking actions forward. BD.38 I agree with the first part of the question, less so with the second: accountability for taking things forward is not always clear. BD.39 I agree this is much improved so agree - we need to communicate these better post Board meeting BD.40 Action tracker very valuable. Board Survey 2016 Page 8 of of 134

107 Reports from Sub-committees of the Board BC.41 This is one of the next areas to look at. No clarity has been given to the sub committees, in terms of what the board wants or needs. Not sure all sub-committee report in to the board regularly BC.42 There is a balance to be struck between detail and high level exception reporting. The Board should receive a one page high level exception report covering issues for information and issues the Board or managers need to respond to. Board minutes PM.43 The content of minutes is generally OK at Board level. Much more variable at subcommittee level. I think draft Board minutes should be circulated to Board members a week after Board meetings as well as being included in the Board packs the following month PM.44 More clarity required on implementation and outcomes of actions agreed. PM.45 These have improved but we could circulate a digest of the meeting/key decisions more rapidly for wider circulation not just Board members. I don't think the minutes always (although this has improved) reflect the expectations for governance particularly on decision making or key issues if a third party or our regulators were to refer back to them to evidence a proper debate and discussion/ critical challenge. Board Survey 2016 Page 9 of of 134