AGENDA. Time Item no. Item Lead Paper Preliminary business Welcome, introductions and apologies Neil Franklin N

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1 Leeds Community Healthcare NHS Trust Board Meeting (held in public) Friday 3 February 2017, 9.00am 12 noon Trust Headquarters, Stockdale House, Victoria Road, Leeds LS6 1PF AGENDA Time Item no. Item Lead Paper Preliminary business Welcome, introductions and apologies Neil Franklin N (71) Declarations of interest Neil Franklin N (72) Questions from members of the public Neil Franklin N (73) Patient s story: health visiting Marcia Perry N (74) (75) Minutes of previous meetings and matters arising: a. Minutes of the meeting held on 2 December 2016 b. Actions log c. Committees assurance reports: i. Audit Committee: 9 December 2016 ii. Charitable Funds Committee: 16 December 2016 iii. Quality Committee: 23 January 2017 iv. Business Committee: 25 January 2017 Neil Franklin Neil Franklin Jane Madeley Brodie Clark Tony Dearden Brodie Clark Y Y Y Y Y Y (76) (77) (78) (79) (80) (81) (82) (83) (84) Quality and delivery Chief Executive s report Thea Stein Y Seasonal resilience report Sam Prince Y Performance brief and domain reports Bryan Machin Y Safe staffing report Marcia Perry Y Care Quality Commission report: York Street Medical Centre Amanda Thomas Y Strategy and planning Quality strategy: implementation update report Marcia Perry Governance Significant risks and risk assurance report Thea Stein Y Board workplan Thea Stein Y Minutes Approved minutes for noting: a. Quality Committee: 21 November 2016 b. Business Committee: 23 November 2016 c. Audit Committee: 21 October 2016 d. Leeds Safeguarding Children Board minutes: 22 September 2016 e. Leeds Safeguarding Adult Board minutes: 13 October 2016 Neil Franklin Y Y (85) Minutes of the Annual General Meeting: 27 September 2016 Neil Franklin Y (86) Close of the public section of the Board Neil Franklin N Date of next meeting (held in public) Friday 31 March 2017, 9.00am -12 noon Trust Headquarters, Stockdale House, Leeds LS6 1PF

2 ` Leeds Community Healthcare NHS Trust Trust Board meeting (held in public) Boardroom, Stockdale House, Victoria Road, Leeds LS6 1PF Friday 2 December 2016, 9.00am 12 noon AGENDA ITEM a Present: Neil Franklin Thea Stein Bryan Machin Brodie Clark Dr Tony Dearden Jane Madeley Richard Gladman Elaine-Taylor-Whilde Marcia Perry Sam Prince Dr Amanda Thomas Ann Hobson Trust Chair Chief Executive Executive Director of Finance and Resources Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Executive Director of Nursing Executive Director of Operations Executive Medical Director Assistant Director of Workforce (deputising for the Director of Workforce) Apologies: In attendance: Minute taker: Observers: Members of the public: Sue Ellis Vanessa Manning Sarah Helmsley Liz Thornton Philip Boynes Mohammed Hussain Three members of the public were in attendance Director of Workforce Company Secretary Primary Care Manager, HMYOI Wetherby (Item 57 only) Board Administrator QPD Quality Lead Specialist Insight Programme participant Item Discussion points Action (54) Welcome and introductions The Chair welcomed Trust Board members, members of the public and observers attending the meeting. Opening remarks In his opening remarks, the Chair stated that the Trust would face some significant challenges in the coming months; a CQC inspection of some of the services in January 2017, ensuring and evidencing that that the Trust s services were safe, caring, effective, responsive and well-led, meeting the challenges of financial performance in the short and long term, meeting the challenges to grow and retain good leaders and working with partners to achieve change in the context of the sustainability and transformation plans. He advised Board members to reflect carefully on these strategic issues as they would provide context for the discussions during the meeting. Apologies Apologies were noted from Sue Ellis, Director of Workforce. 1

3 (55) (56) (57) Declarations of interest No declarations of interest were received. Questions from the members of the public: There were no questions from members of the public. Patient s story The Executive Director of Nursing introduced the patient s story item. She welcomed Sarah Helmsley, Primary Care Manager, to speak about the healthcare services provided by the Trust at HMYOI Wetherby. The Primary Care Manager attended the meeting to present a picture of the work carried out by the health team at HMYOI Wetherby and at Adel Beck in North Leeds. For the purpose of this story she focused on a young person who had been admitted to the unit with a number of chronic conditions and she spoke about the challenges the team faced in handling health and wellbeing. She highlighted in particular the safe and appropriate management of young people on admission and discharge to and from hospital in an emergency situation. The Trust s protocols and procedures for admission to hospital care from the secure units were very clear. In this particular case, difficulties had arisen when the young person was discharged back into the care of the health care team at HMYOI Wetherby following an emergency admission to hospital with limited information about continuing care plans and tests and other procedures carried out whilst the young person was under hospital care. This meant that a thorough re-assessment had to be undertaken when the young person arrived back into the care of the health care team at Wetherby. The limited information shared at the point of discharge had been a contributory factor to a further emergency admission to hospital being necessary. Unfortunately for this individual this had occurred on a number of occasions within a short period of time. The Executive Director of Operations said that she was concerned about the problems highlighted by the story. She advised that she would be making contact with colleagues at the local hospitals to explore what could be done to ensure that procedures for the admission and discharge of vulnerable young people in youth custody worked more smoothly and delivered continuity of care. The Chair thanked the Primary Care Manager on behalf of the Board for attending the meeting and presenting such a compelling picture of the work carried out by the health team in HMYOI Wetherby. The Board were impressed with the obvious care and commitment of the staff working within such a challenging environment (58a) Minutes of the previous meeting held on 7 October 2016 and matters arising. The minutes were reviewed for accuracy and agreed as a correct record. There were no matters arising. (58b) Items from the actions log The completion of actions from previous meetings were noted. There were no outstanding actions. 2

4 (58c) Assurance reports from sub-committees Item 58c(i) Quality Committee held on 21 November 2016 The report was presented by the Chair of the Committee and Non-Executive Director (TD) who drew the Board s attention to the key issues, namely: Quality and safety report - The number of incidents reported during October had been the lowest in the year to date at 517. The percentage of patient safety incidents had increased slightly but was still below the target of 70%. Pressure ulcers The number of pressure ulcers reported in October 2016 was 45, the second lowest reporting month to date. Falls reported falls decreased in October 2016 to 67 from 78 in August End of life care - significant progress had been made in end of life care where the preferred place of death had been achieved in 86.7% of patients between April and September SEND inspection Ofsted and the Care Quality Commission would be carrying out an inspection across Leeds on how the Council, NHS and the third sector work with children and young people with special educational needs and disabilities (SEND) and their families to assess and meet needs and to improve outcomes. The inspection would start on Monday 5 December 2016 and last for one week. Item 58c(ii) Business Committee held on 23 November 2016 The report was presented by the Chair of the Committee and Non-Executive Director (BC) who drew the key points to the Board s attention, namely: Staff turnover - stood at 14% for October 2016; this was against a target of 9-13%. An analysis of reasons for staff leaving had shown that substantial numbers were leaving for promotional reasons and there had also been a significant number of retirements. Sickness absence - the Committee had maintained its focus on monitoring sickness absence and had noted a worsened position for October 2016 at 5.9% against the Trust year to date target of 5.2%. Appraisal rates the figure for completed appraisals had reduced to 86.4% in October 2016; the figure had worsened over each of the previous three months. The Committee had asked for more information about the impact and effectiveness of the new appraisal system introduced in April 2016 for the next Committee meeting in January Neighbourhood teams staff turnover in three neighbourhood teams was recorded as over 20% the impact of which was exacerbated by high sickness absence levels with three neighbourhood teams reporting rates at over 10%. The Committee had noted that both sickness absence and recruitment and retention were noted as extreme risks on the Trust s risk register. Agency staff the Committee was pleased to note that the Trust was operating within its cap of 7.25 million for agency expenditure on a year to date basis, million against a target of million. Financial position and recovery plan the Trust was reporting a small underspend on budgets at the end of October Representing a continued improvement. The Executive Director of Operations reported that a plan was in place to improve capacity and reduce demand over the next three months, including more focused work with CLASS, more effective deployment of staff with nursing skills and a reduction in the requirement for non-essential training. 3

5 During December 2016, the Executive Director of Operations and the Acting Director of Workforce planned to spend a day working alongside managers in areas where there were the highest sickness absence rates. The Assistant Director of Workforce also advised that work was underway to review the sickness absence policy and its practical application; the actions managers are required to take and the time scale from first point of sickness absence to escalation through to a formal process. The Executive Director of Operations said that she was concerned about staff turnover and sickness absence levels into January and February 2017 particularly in the neighbourhood teams but was able to give a reasonable level of assurance that there were plans in place to mitigate any adverse impact. The Chair of the Committee reported that he and Non-Executive Director (RG) had met with the Chief Executive and Head of Organisational Development to discuss the organisational development strategy. A refreshed strategy including clear deliverables would be presented to the Business Committee and Trust Board in March Outcome: The Board noted the Committees reports and the matters highlighted particularly the work to review the sickness absence policy which would be ratified by the Senior Management Team (SMT) in January (59) Chief Executive s report The Chief Executive presented her report and invited questions from Board members. A Non-Executive Director (RG) asked about the response rate to the NHS staff survey The Chief Executive advised that the closing date for the survey was 2 December 2016 and the current response rate was 48%. She advised that the Trust had taken every opportunity to encourage a high response rate in order to maximise the number of views on all aspects of working life. The Chair was pleased to note that the staff safety posters had been made available for Board members at the meeting. The Board agreed that communicating the messages about personal safety to staff working at night and in the evening was a key priority. The Chief Executive advised that all the executive directors had spent time with the twilight nursing service and she believed that staff now had a much better perception of what support was available to them when working in the evening and overnight. A Non-Executive Director (TD) asked if there was any further information on the NHS Improvement: single oversight framework segmentation rating for the Trust. The Chief Executive advised that the most up to date information was contained in her report for this meeting and that the next set of ratings were due to be published in December Action: Board members to be advised of ratings once published in December Chief Executive 4

6 (60) Seasonal resilience report The Director of Operations presented the paper which described the arrangements put into place by the Trust to support service continuity throughout the year, including the Christmas and New Year holiday period. She reported that to ensure the organisation could respond to significant changes in demand each service within the Trust had a service specific business continuity plan which included scenario focused action plans to manage and mitigate the effects of additional demand on services, staff shortages and severe weather. A Non-Executive Director (JM) referred to the escalation triggers in the adult business unit and noted the well-established processes which were in place to bring system leaders together to support the flow of patients if any organisations across the city were experiencing extreme pressure. She asked about what would happen if exceptional pressures required the Trust to take action outside of the planned responses set out in the report. The Chief Executive advised that caseloads were assessed constantly in relation to clinical risk and by reference to the escalation levels to ensure that referrals were accepted appropriately and handled safely. She advised that the Board would be made aware if any action was taken outside of planned procedures. The Chair noted that the main risks to maintaining business continuity over the winter period was the availability of staff and staff absence; these risks and the mitigations to manage demand and capacity issues were detailed in the Trust s risk register. Outcome: The Board noted the paper and received reasonable assurance that plans were in place to ensure continuity throughout the year (61) Performance brief and domain reports The report was presented by the Executive Director of Finance and Resources; he advised that the report was in two parts: high level performance summary more detailed domain reports He reported that the Quality Committee had examined in detail the safe, effective and caring domains. The Business Committee had examined the responsive and well-led domains whilst maintaining an overview of performance across all key performance indicators. Effective domain A Non-Executive Director (JM) noted that the development of outcome measures in the adult business unit was behind schedule for quarter 2. Action: It was agreed that the reasons for the delay would be reviewed as part of the planning for the coming year. Well-led domain A Non-Executive Director (TD) observed that there was no data available for medical staff appraisals in October The Executive Medical Director advised that this was due to technical issues related to the recording of medical appraisals on the electronic staff record system. The report for the next quarter should provide a more accurate picture. Executive Director of Finance and Resources 5

7 Finance report The Executive Director of Finance and Resources reported that the Trust s financial position continued to improve. He advised that the forecast was for delivery of the planned surplus of 2.86 million however this was predicated on receiving 0.5 million from the Clinical Commissioning Groups (CCGs) to meet the stretch control total plus 0.86 million from the sustainability and transformation programme which could not be spent. A Non-Executive Director (JM) felt that it was essential to seek confirmation from NHS Improvement about the delivery of the 0.5 million to ensure that the Trust and the Board clearly understood the financial position. Action: It was agreed that confirmation would be sought from NHS Improvement about the delivery of the 0.5 million from the CGGs. The Executive Director of Finance reported that in October the position on pay had stabilised showing an increase in the cost of directly employed staff and a significant reduction in the cost of agency staff. The systems put in place to control expenditure on pay appeared to be delivering results and the Trust continued to scrutinise recruitment through the SMT. He advised that the Trust would need to continue to take all actions necessary to curb discretionary expenditure to mitigate the 2 million overspend on pay already incurred. A Non-Executive Director (JM) noted that the flu immunisation CQUIN requiring 75% of clinical staff to receive the vaccination was challenging. The Chief Executive reported that currently the take up rate was 69% and she was confident that the target could be met. Outcome: The Board noted the performance brief and domain reports. Executive Director of Finance and Resources (62) Patient experience: thematic report The Executive Director of Nursing presented the report which provided the Board with an update on the themes drawn from patient experience measures within the Trust between 1 April and 30 September It identified complaints, concerns, incidents and patient feedback; and set out the actions in place to address areas for improvement. Board members welcomed the report but concluded that it should be extended to demonstrate how lessons learned were introduced and embedded into practice. It was also important that changes in practice were measured and evidence of improvements in services were included in future reports. In summary, the Chair said the current report offered reasonable assurance that actions were in place to address areas of concern and make improvements. Action: Reports incorporating the changes discussed would be made on a monthly basis to the Quality Committee and to the Board twice a year. Outcome: The Board noted the report and welcomed further developments. Executive Director of Nursing 6

8 (63) Equality report The Executive Director of Nursing presented the report which identified the activity and progress that the Trust had made to ensure that the requirements of the Equality Act 2010 Public Sector Equality Duties (PSED) and the NHS Standard Contract were being met. Significant progress had been made against all the equality objectives during the reporting period and monitoring had taken place through the Business and Quality Committee agendas. A Non-Executive Director (BC) noted the reference to the analysis of patient equality data and the assurance given around the delivery of inclusive services. He asked for the data to be made available. Action: The Executive Director of Nursing to provide information arising from the analysis of patient equality data. A Non-Executive Director (RG) asked whether the delivery of the equality strategy was a strong theme within the business plans for each of the business units. The Chief Executive advised that equality objectives were a prominent feature in workforce plans and the high level business plans available to the Board. Workforce equality priorities would also be clearly articulated in the refreshed organisational development strategy. Outcome: The Board were satisfied with the level of assurance received and noted the progress made. Executive Director of Nursing (64) Sustainability and transformation plan and Trust s strategy The Chief Executive presented her report which outlined the sustainability and transformation plan (STP) for West Yorkshire and Harrogate 2016/21. She advised that the Trust had reviewed its strategic direction to achieve alignment with the wider STP and had re-stated its core purpose, capabilities and service offers ; this work had informed the development of the Trust s operational planning for 2017/18 and 2018/19. A Non-Executive Director (TD) asked about the formal accountability arrangements for the STPs. The Chief Executive said that currently there was no national guidance on associated governance arrangements for STP leadership. She advised that discussions were continuing between partner organisation to try and establish some clarity around these issues but emphasised that there was extremely positive collaboration amongst local organisations. A Non-Executive Director (BC) observed that there were clear benefits and value to establishing these arrangements across health and social care economies. He said that engaging with local communities was a key priority for STPs and how this would evolve remained unclear. A Non-Executive Director (JM) advised that she would be attending a meeting of local leaders to discuss the STP on Wednesday 7 December 2016 and hoped that more information about the contracting round would also be available at that meeting. 7

9 The Chief Executive advised that an update from the meeting would be provided at the next Board Workshop on 6 January Outcome: The Board noted the publication of the West Yorkshire and Harrogate STP and the work to develop the Trust s strategic direction in alignment with the STP (65) Medicines optimisation strategy The Executive Medical Director presented the report which described the Trust s first medicines optimisation plan which had been created to sit alongside the Trust s quality strategy. She advised that the strategy looked specifically at how the Trust delivered safe, efficient and effective medicines optimisation for patients and staff across the Trust during the period 2016/19. Outcome: The Board agreed to ratify the strategy (66) Significant risks and risk assurance report The report detailed information about all risks deemed to be extreme after the application of controls and mitigation measures and risk movement amongst high risks. The Board noted the escalation of one risk to extreme; this related to recruitment and retention in neighbourhood teams. The Board also received a summary of the Board Assurance Framework (BAF) describing the strategic risks and current level of assurance that risks were being actively managed. Referring to the BAF, a Non Executive Director (JM) commented on the risks grouped under the corporate objective related to the retention of services particularly in relation to using resources wisely and effectively. It was noted that strategic risks contained in the BAF would be reviewed to ensure alignment with corporate objectives for 2017/18 and 2018/19 as an output from the planning cycle. Action: The Company Secretary to review the strategic risks to ensure alignment with the Trust s objectives for 2017/18 and 2018/19. Company Secretary Outcome: The Board noted: the revisions to the risk register the current assurance levels provided by the BAF summary (67) Corporate governance report The Chief Executive presented the report which provided updates on a number of requirements to ensure that effective corporate governance of the Trust was in place. The report focused on: Board sub-committees: changes to membership and functions for incorporation into terms and reference development of aspirant non-executive directors changes to national arrangements for the appointment of external auditors the exercise of powers to make urgent decisions by the Chair and Chief Executive on behalf of the Board. 8

10 Outcome: The Board: approved changes to the membership and function of the Board s sub committees, for incorporation into terms of reference noted the involvement with a programme to develop future non-executive directors and the placement of a programme participant with the Trust noted three urgent decisions made by the Chair and Chief Executive (68) Board workplan The Chief Executive presented the Board work plan (conducted in public) which was for information. He said that the work plan would be revised, as and when required, in line with outcomes from the Board meetings. Outcome: The Board noted the work plan (69) (69a) (69b) (69c) (69d) (69e) (69f) (70) Approved minutes The Board noted the following final approved committee meeting minutes and formally received those minutes. Quality Committee: 26 September and 24 October 2016 Business Committee: 28 September and 26 October 2016 Audit Committee: 22 July 2016 Leeds Safeguarding Children Board minutes: 19 May 2016 Leeds Safeguarding Adults Board minutes: 4 August 2016 Leeds Health and Wellbeing Board Minutes: 6 September 2016 Close of the public section of the Board The Trust Chair thanked everyone for attending and concluded the public section of the Board meeting. Date and time of next meetings Wednesday 14 December pm pm (provisional). Middleton Park Health Centre, Middleton Park Avenue, Leeds LS10 4HT Friday 3 February 2017, 9.00am - 12noon Trust Headquarters Stockdale House Leeds LS6 1PF 9

11 AGENDA ITEM b Leeds Community Healthcare NHS Trust Trust Board meeting (held in public) actions log: 3 February 2017 Agenda Number Action Agreed Lead Timescale Status Meeting on 7 October (44) (48) Organisational development strategy Further consideration to be given to the means of delivery, timescales and identification of tangible outcomes. Safeguarding annual report 2015/26 Report on commissioners review of interaction between school nursing service and health visiting service in relation to safeguarding to be reported to Quality Committee. Meeting on 2 December 2016 Director of Workforce Workshop: January 2017 Board: March 2017 Executive Director of Nursing January 2017 April (59) (61) (61) (62) (63) (66) Chief Executive s report Board members to be advised of the single oversight segmentation rating for the Trust when published in December Performance brief and domain reports Effectiveness domain: Development of outcomes measures (adults business unit) to be reviewed. Performance brief and domain reports Finance report: NHSI to be contacted in order to gain confirmation of treatment of the 500K element of the 2016/17 control total. Patient experience: thematic report Report to be extended to demonstrate that lessons learned are introduced into practice, embedded and changes in practice are measured to evidence improvements (Quality Committee 23 January 2017 and Board 31 May 2017). Equality report Analysis of patient equality data (evidence of delivering inclusive services) to be made available to Non- Executive Director (BC). Significant risks and risk assurance report BAF: strategic risks to be reviewed for 2017/18 and 2018/19 to ensure alignment with the Trust s corporate objectives. Chief Executive Executive Director of Finance and Resources Executive Director of Finance and Resources Executive Director of Nursing Executive Director of Nursing Company Secretary December 2016 March 2017 January 2017 May 2017 Completed Completed December 2017 Completed March 2017

12 Key Total actions on action log Total actions on log completed since last Board meeting: 2 December Total actions not due for completion before 3 February 2017 progressing to timescale 4 Total actions not due for completion before 3 February 2017 achieving agreed timescales and/or requirements are at risk or have been delayed 1 Total actions outstanding as at 3 February 2017: not meeting agreed timescales and/or requirements January 2017

13 AGENDA ITEM ci Report to: Trust Board Report title: Audit Committee 9 December 2016: Committee s Chair assurance report Responsible Director: Chair of Audit Committee Report author: Company Secretary Previously considered by: Not applicable Summary This paper identifies the key issues for the Board arising from the Audit Committee 9 December 2016 and indicates the level of assurance based on the evidence received by the Committee. Internal audit The Committee noted completion of two audits as part of the 2016/17 internal audit plan: contract bid process and procurement. The latter had been assigned a reasonable assurance opinion. The contract bid audit had been an advisory review only and, whilst not assigned an assurance level the Committee noted that there were six important recommendations requiring implementation. It was noted that draft reports were awaiting finalisation for two further audits (data quality - patient experience and involvement and incident management and reporting) and audit fieldwork was underway for a further eight audits. The auditors and the executive expressed confidence that the audit programme can be completed in full prior to the year end. The executives follow-up report described the position in relation to implementation of recommendations contained in earlier audits. The need to maintain momentum and implement actions in a timely fashion was agreed by executive colleagues. The Committee was particularly keen to see progress with recommendations in relation to recruitment processes and activity recording (pending the roll out of EPR). External audit The Committee were advised of progress with the annual audit process. The Committee reviewed the indicative areas of focus in relation to the audit of financial statements and the value for money audit, including management override of controls, valuation of tangible assets, revenue recognition, contents of remuneration report and overall financial standing. Security management: self-assessment The Committee noted self-assessment ratings submitted by the Trust against the NHS Protect Security Management Standards 2016/17. All the self-assessment ratings were satisfactory except for two areas, namely: The organisation ensures that staff whose work brings them into contact with NHS patients are trained in the preparation and management of clinically related challenging behaviour; this was not currently the case but was being considered The organisation has a departmental asset registers and records for business critical assets worth more than 5,000; these were not in place and further consideration would be given through business continuity work as to the definition of business critical assets Assurance level Substantial Reasonable X Limited No Page 1 of 2

14 Information governance The six monthly report was received by the Committee. The report contained information about the status of serious incidents reported to the Information Commissioners Office (ICO) between June and December Two new incidents had been reported as meeting the threshold for external reporting, under the reporting requirements. Both incidents were being followed up by the ICO and could result in enforcement action or a fine. The Committee was advised that the requirement placed on the Trust (by the ICO) to ensure that all staff undergo information governance training annually was being discharged satisfactorily. However, outstanding actions included: provision of specific role-based training to staff and reviewing and updating of information governance policies and procedures. Assurance level Substantial Reasonable X Limited No Contracts register The Committee received an annual overview of all contracts awarded over the tender threshold of 50,000. Assurance level Substantial Reasonable X Limited No V2: 24 January 2017 Page 2 of 2

15 AGENDA ITEM (75cii) Report to: Trust Board 3 February 2017 Report title: Charitable Funds Committee 16 December 2016: Committee s Chair Assurance Report Responsible director: Chair of Charitable Funds Committee Report author: Executive Director of Nursing Previously considered by: Not applicable Purpose of the Report This paper identifies the key issues for the Board arising from the Charitable Funds Committee held on 16 December 2016 and indicates the level of assurance based on the evidence received by the Committee. Actions and Updates from Previous Meetings The Committee received updates on actions from the previous meetings. This included an update about potential opportunities for partnership working with Leeds Teaching Hospitals NHS Trust in relation to charitable funds and that there may be schemes for the benefit of people in Leeds that could be developed based on shared access to charitable funds. The Trust s Chair is to approach the Chair of the acute trust s charity at an appropriate point in the New Year. The Membership and Involvement Manager gave a positive update on the work of the Front of House team and the focus on cultural change and patient experience. An all venues newsletter was tabled. A discussion followed on the importance of customer service training and the Chair requested that external training was again considered. Patient experience of the welcome will be audited six monthly. More than a Welcome The More than a Welcome work has continued as planned. Work needs to continue to progress in relation to developing reception areas. This major initiative has involved supporting improvement linked to customer service training, front of house initiatives and improvements to the Trust s reception environments. The Committee was able to view a number of leaflets and documents that have been produced to support this work.there has been some unavoidable delays in progressing work in two in-patient areas due to the absence of the managers Substantial Reasonable X Limited No Funding Recommendations The Committee reviewed and scrutinised funding decisions made since the last Committee. Decisions were confirmed. It was noted that the new process of virtual review and decision making process appeared to be working well. Detail was provided about a number of initiatives where the charity s funds were being deployed, including: Giving Voice choir, Walking on Air Podiatry scheme and the Winter Warmth campaign. Work has progressed in relation to street fundraising. It was noted that the Walking on Air work in Podiatry has been nominated for an award. Substantial X Reasonable Limited No Page 1 of 2

16 Fundraising The Committee noted developments aimed at raising additional funds for charitable purposes, including: My Donate giving page, street collections (Leeds city centre 18 December 2016 and White Rose Centre 13 January 2017). Plans for 2017 were explored and include securing corporate donors, fundraising dinner and further collections. The potential to secure corporate donors is a positive direction of travel. Actions are on track against the revised trajectories that were agreed at the previous meeting. Substantial Reasonable X Limited No Financial Report The Committee received the primary financial statements for the charitable funds as at 30 November 2016, including the income and expenditure account, the balance sheet and memorandum note summarising funds available. Substantial X Reasonable Limited No V3: 26 January 2017 Page 2 of 2

17 AGENDA ITEM (75ciii) Report to: Trust Board 3 February 2017 Report title: Quality Committee 23 January 2017: Committee s Chair assurance report Responsible Director: Chair of Quality Committee Report author: Executive Medical Director Previously considered by: Not applicable Purpose of the report This paper identifies the key issues for the Board arising from the Quality Committee on 23 January 2017 and indicates the level of assurance based on the evidence received by the Committee where applicable. Service Spotlight: Health Visiting Service Members of the team gave a comprehensive and well planned presentation of the service. The service lead outlined the delivery of the Healthy Child programme to every child and family (0-5 years) in Leeds through a comprehensive evidence based programme of care in partnership with Leeds City Council. Among the team s successes are national recognition, embedding national policy and guidance and achievement of 100% attendance at initial child protection conferences for safeguarding children in Leeds. The team highlighted current risks and challenges including workforce capacity, increased public expectation, recommissioning and public health budget uncertainties. The team will continue the quality thread through the patient s story at Board. Director of Nursing (DoN): quality and safety report Service pressures The DoN report was written in the context of the unprecedented levels of pressure being experienced within the NHS both nationally and locally. For the first time, the Trust declared Reap Level 4 and instigated silver command on 1 January 2017 to manage the internal and system wide pressures. The committee was presented with a full account of the impact and actions of the Trust to ensure patient safety and, although the system and the Trust has de-escalated, the Trust continues to monitor in silver command mode to maintain patient safety. The Committee welcomed the comprehensive report on the quality journey in Neighbourhood Teams and acknowledged the challenges and the progress made. Assurance level Substantial Reasonable X Limited No Incidents The Committee noted the on-going work in relation to incident reporting and the progress made in relation to the timely closure of incidents. The number of incidents reported overall during December was 559 (YTD 531, November 603) and the percentage of reported no harm incidents (all incidents) remained stable in both November and December at 65%. Overall numbers of incidents reported in Q are comparable to 2015, although the numbers of patient safety incidents (PSIs) reported in 2016 were consistently lower than in the comparable time frame in 2015 and have had a downward trend since August No harm PSIs remain lower than 2015 (November 54%, December 59%, Trust target 70%). The clinical governance team continues on track with a programme of work to understand the change and reduction in reporting of no harm PSIs.

18 Moderate harm incidents were 12% in November and 8% in December with pressure ulcers (PU) remaining the highest number of reported incidents. There were 3 major harm PSIs (of 4 incidents in total) in November and 4 PSIs (of a total 5) in December. All 7 incidents were falls. Three SIs were reported in total in November and 4 in December (5 category 3 PUs, 1 fractured neck of femur and 1 misidentification of patient in Children s SLT). With the exception of October, the number of SIs reported since July has been consistently lower than the comparable time last year. The committee requested that the status for SI action plans should be updated as services reported a lag between the SI report being written and actions continuing to take place. The committee noted that the Reap Level and prioritisation of essential work is likely to impact on incident reporting and timely closure of incidents over the coming months. Assurance level Substantial Reasonable X Limited No Pressure ulcers The focus on reducing the incidence of avoidable pressure ulcers continues and progress was noted in relation to the incidence of avoidable pressure ulcers with harm. To date there are no avoidable category 4 pressure ulcers for Q2 and Q3. During December there were no pressure ulcers occurring in inpatient units or services based in a hospital setting. There was 1 occurrence in November in SLIC (category 2), this being the first reported incidence since June Assurance level Substantial Reasonable X Limited No Falls The focus on reducing the incidence of falls continues and progress was noted in relation to the incidence of falls with harm. 87.8% of falls in November and December resulted in no harm or minimal/low harm. However, falls within inpatient units have continued at the increased level in Q3 (29 November, 36 December) but the percentage of harmful falls continues to be lower than Q1 and Q2 at 21% in November and 17% in December. The spike appears to be due to a combination of factors to include a high risk group of patients and falls risks in patients who have capacity and are declining the use of monitoring interventions. The committee were provided with actions that are in place to address the falls rates in inpatient areas. Assurance level inpatient units Substantial Reasonable Limited X No Medication errors: insulin The administration of insulin by neighbourhood teams in community settings remains the area of highest concern of medication errors within the Trust. Insulin was involved in five of the eleven harm incidents reported during this quarter and a total of twenty missed insulin administration visits were reported by neighbourhood teams during the quarter. The Committee was provided with a report of actions taken to date and themes emerging from the use of the new Framework for Patient Safety Investigation Tool (launched in August 2016) to include: poor communication between staff, high workload and poor delegation, stress and feeling rushed in addition to undertaking a monotonous task or distractions when administering. Assurance level inpatient units Substantial Reasonable Limited X No Duty of candour (DoC) Of a total 56 applicable incidents over the 2 month period 32 apologies were recorded as given (57%). The Committee continues to be advised that services do provide an apology as appropriate but that this is not being consistently recorded and acknowledged that further work continues to be required to ensure that the data and recording of Duty of Candour matches the practice of staff. Assurance level inpatient units Substantial Reasonable Limited X No

19 Staff Influenza Vaccine Campaign The final uptake figure for Flu Vaccination in frontline staff was 76.82%, in excess of the 75% required to meet the CQUIN target, and top of all community trusts. The campaign has been widely applauded and has provided an opportunity to enhance relationships with partner statutory organisations. The committee noted and passed on their thanks and congratulations to the infection prevention and control team. CQC Reports York Street Health Practice The committee noted and passed on their congratulations to York Street Health Practice who were rated as Outstanding by the CQC following their announced inspection on 20 October 2016 Quality improvement The Committee received the quality improvement plan short report and noted the good progress in progressing the outstanding actions, approved the completion of three actions and the extensions for three actions. Assurance level Substantial Reasonable X Limited No Risk Register The Committee reviewed the risk register report, noting the clinical risks scoring 8 and above. Assurance level Substantial Reasonable X Limited No The discussion at Quality Committee was well triangulated across the Director of Nursing report, the risk register, the Quality Improvement plan and internal audit reports. 27 January 2017

20 AGENDA ITEM civ Report to: Trust Board 3 February 2017 Report title: Business Committee 25 January 2017: Committee s Chair assurance report Responsible director: Chair of Business Committee Report author: Executive Director of Finance and Resources Previously considered by: Not applicable Purpose of the report This paper identifies the key issues for the Board arising from the Business Committee 25 January 2017 and indicates the level of assurance based on the evidence received by the committee. Performance brief: heat map The Committee discussed the five service areas that had been rated as having the largest number of red rated high level indicators. The data showed that all of the five services are carrying out fewer contacts than the profile and are all missing targets for appraisals and statutory and mandatory training. Two services have significantly high levels of sickness (around 17%). Whilst the performance shortfalls are examined at business unit performance panels, evidence to provide assurance that these challenges are being addressed is to be provided for the February 2017 Business Committee. Assurance level Substantial Reasonable Limited X No Performance brief: financial position 2016/17 The Committee was advised that the Trust was reporting an underspend on budgets at the end of December 2016 representing a continued improvement in the Trust s financial position. Pay expenditure, agency nursing figures and overtime costs remain the focus of scrutiny. The Trust was now forecasting achievement of the control total. Assurance level Substantial Reasonable X Limited No Performance brief: sickness absence The sickness absence percentage for December 2016 had worsened to 6.3% (target 4.9%). The Committee indicated that this was disappointing and remained a key concern for the Trust. The Committee took some assurance from the various mitigations that were being developed - not least, the management meetings of the highest sickness teams; relevant training; compliance assurance arrangements and introduction of a new policy. Assurance level Substantial Reasonable Limited X No Page 1 of 2

21 Neighbourhood teams report The Committee noted the increased staff turnover. The overall vacancy position standing at 52.2 (whole time equivalents) had deteriorated further in December 2016 as a consequence of the low number of staff joining the Trust; the number of new starters per month having declined over each of the past four months. Proposals around overseas recruitment (in collaboration with other Trusts) and the potential benefit of reconsidering the agency arrangements (for example using alternative providers) were offered for further consideration Assurance level Substantial Reasonable Limited X No Seasonal resilience The Executive Director of Operations set out the deployment of contingency arrangements to meet the severe service pressures experience by the Trust in January The Trust, along with all health and care providers had met with high levels of demand for services (REAP level 4). The Committee took assurance from the implementation of escalation plans which had ensured the safe delivery of all essential care during this difficult period. Lessons learned and potential new ways of working would be brought to the next Business Committee meeting. There was a high level of confidence that all essential service would be maintained throughout the key problematic period. Assurance level Substantial Reasonable X Limited No Clinical activity The Committee heard about developments in relation to the activity improvement plan. Despite demand and capacity challenges, clinical contact activity remained above profile in neighbourhood teams. Following the earlier targeted work in neighbourhoods, there was a plan to examine other areas of the Trust where activity was at variance from plan, looking at activity levels, measures and impact including analysis of over provision and under delivery; starting with children s nursing and community neurology. Assurance level Substantial Reasonable X Limited No Waiting times The Committee noted: 18 week reportable waiting times - current performance 99.9%. This provided full assurance. 6 week diagnostic waits current performance 100% providing full assurance. 18 week non-reportable waiting times current performance 97.6% providing full assurance. In service waits, whereby there is a wait following initial assessment prior to subsequent referral or follow up appointments, was continuing to be validated as there were known complexities related to data capture. The Committee was apprised of waiting times for autistic spectrum conditions assessments and noted that the increase in referrals (192 in 2015/16 to forecast 240 in 2016/17) was impeding the ability to reduce the waiting times to the local target of 12 weeks. A range of additional initiatives were being effected to provide additional capacity. Assurance level Substantial Reasonable X Limited No Operational planning The Committee noted progress with the implementation of objectives for 2016/17 and progress with the preparation of the operational plan for 2017/ /19 including the drafting of objectives for the coming year. It was noted that the Committee would maintain oversight of the Trust s most significant programmes of change and projects including taking in depth reports on a planned basis. V2: 26 January 2017 Page 2 of 2

22 AGENDA ITEM Meeting Trust Board 3 February 2017 Report title Chief Executive s report Responsible director Chief Executive Report author Chief Executive Previously considered by Not applicable Category of paper (please tick) For approval For assurance For information Purpose of the report This report sets out the context in which the Trust works and helps to frame the Board papers. Main issues for consideration On this occasion, the report focuses on a number of local and national developments some of which are covered in more depth in later items. The main features of the report are: Care Quality Commission inspections Service pressures in Leeds Agency staff deployment and expenditure Listening to staff: concerns and achievements The Trust s performance National, regional and local strategic and operational planning processes National reports A further verbal update will be provided at the Board meeting. Recommendation The Board is recommended to: Note the contents of this report Page 1 of 12

23 1. Purpose of this report Chief Executive s report 1.1 This report sets out the context in which the Trust works and helps frame the Board papers. The paper describes a number of local developments and, in addition, refers to a small number of external or national announcements that have the potential to impact on the Trust. 2. Care Quality Commission inspections 2.1 The Trust has been participating in a Care Quality Commission (CQC) inspection (week commencing 30 January 2017). 2.2 In addition to a wide range of interviews and focus groups involving directors, service leads and a wide cross section of staff, the inspectors reviewed: Adult inpatient units: Community Intermediate Care Unit, South Leeds Independence Centre and the Community Rehabilitation Unit Adult community services: neighbourhood teams and some specialist services across eight health centres Children s community nursing inpatient unit: Hannah House Child and adolescent mental health services inpatient unit: Little Woodhouse Hall Specialist services: sexual health services Trust wide review of well-led domain 2.3 The Trust s York Street Medical Practice was inspected in the week of 20 October 2016 under the CQC s programme of inspection of primary care practices. The Trust was extremely pleased to receive a highly satisfactory report and to be assigned an outstanding rating in respect of this service. The inspectors noted much excellent practice and recorded that staff were particularly motivated and inspired to offer kind and compassionate care in the context of a clear vision which had quality and safety as a top priority. The full report appears as a standalone agenda item. 2.4 The Trust has also been involved in a city-wide inspection led jointly by the CQC and Ofsted which looked at services for children and young people with special educational needs and disabilities. The outcome from this inspection is still awaited but the interim letter is positive and includes the following high level themes: Leaders across services demonstrated significant commitment in working together; improved collaboration between health and schools was noted Feedback from interviews with children, young people, parents and carers highlighted that those with special educational needs and/or disability were proud to be citizens of Leeds and felt involved and part of influencing their care. They believed that they were listened to and had a heard voice and influence. The majority of parents believed that their child s needs were being met. Page 2 of 12

24 Progress has been made towards ensuring parents only need to tell their story once. The developing shared system between hospitals and community health providers and the local authority was positively recognised. The early stages of this work were considered promising to allow access to a better range of information about children s care. There was concern that insufficient resources and increased demand had resulted in children and young people experiencing unacceptable delays in accessing services. These challenges were noted in speech and language therapy, mental health and assessment for autism 2.5 At the very end of 2016, the Trust s child and adolescent mental health services (CAMHS) were inspected in respect of their compliance with aspects of the Mental Health Act (as applicable). Again, the outcome of this inspection is awaited. In addition, in January 2017, the inpatient unit has been peer reviewed by QNIC (quality network for inpatient CAMHS); informal feedback comments on the commitment and dedication of the inpatients team and indicates positive views from patients. 3. Seasonal service pressures 3.1 The Trust, along with the vast majority of health service providers across the country, has and is continuing to experience severe service pressures. 3.2 The extreme position, that has existed since the start of the new year, arose as a result of a number of factors including high levels of patient demand on all areas of healthcare (GPs, community nursing, hospitals etc), bank and agency staff not attending for work when booked to do so and unusual levels of seasonal sickness absence amongst staff. All of this created significant pressures across all of the thirteen neighbourhood teams. 3.3 For the first time, the Trust declared that its services were at resource escalation action plan (REAP) level 4. This national indicator of pressures in an NHS organisation triggers specific measures to help manage services during a period of sustained and significant pressure. 3.4 The Trust responded well and instigated a number of contingency arrangements including optimising the deployment of permanent and temporary staff, re-allocation of work so as to make sure that all essential patient care was covered and, in some cases, restricting non-urgent referrals to defined services. 3.5 Throughout the period, the Trust worked collaboratively with partner organisations, particularly the acute trust and primary care. 3.6 On Wednesday 18 January 2017, the level of severity was de-escalated to REAP Level 3 representing moderate pressure. This is as a result of improved sickness absence levels and effective patient flow through neighbourhood teams and community beds. Internally, the Trust continues to operate as though at REAP level 4 in order to manage the tail of the surge which is expected to be in the system for another month. Page 3 of 12

25 3.7 Without question, all managers and staff have worked tirelessly to cope with the demands placed upon them during January 2017 and deserve enormous praise and thanks. 4 Staff influenza vaccination campaign The Trust takes very seriously its responsibilities to safeguard the health of its patients and staff. As part of this commitment, the Trust has worked hard to maximise the uptake of staff flu vaccinations. 4.2 Public Health England has reported that, across the country, a total of 594,700 frontline care workers have been vaccinated for the flu virus so far this season. 4.3 The results, which are measured from 1 September 2016 to 31 December 2016, account for 61.8% of eligible healthcare workers in England. This is the highest figure to date both in percentage and total numbers vaccinated. These results reflect the impressive effort from trusts in encouraging as many frontline NHS staff to be vaccinated as possible in order to protect patients as well as the workforce. 4.4 Leeds Community Healthcare NHS Trust has officially topped the leader board for the most frontline staff vaccinated in a community trust. The Trust has achieved an excellent figure of 76.8% (compared to 62.9% in 2015). The figures are thanks to the heroic efforts of the Trust s infection prevention and control team. 5 Agency staff costs 5.1 One of the ways in which trusts manage variation in patient demand and shortfalls in available staff (whether due to increased service demand, staff vacancies or sickness absence) is to deploy temporary resources. 5.2 Agency workers can provide vital cover for clinical services, however, there has been increasing concern over the past year about the level of use and costs. As a consequence, NHS Improvement has put in place a set of rules, requiring trusts not to pay above set price caps and to only source agency workers from framework agencies. 5.3 NHS Improvement has also introduced a requirement for boards to complete a self-certification checklist relating to agency expenditure to ensure that plans and actions to reduce expenditure are receiving regular board consideration and challenge, supported by high quality, timely information. 5.4 The agency ceiling set by NHS Improvement for the Trust for is 7.25millions. As shown in the performance report, the Trust has reported year to date expenditure of 4,796,000 against the capped figure of 6,048,000. Page 4 of 12

26 5.5 To tackle the financial and quality challenge, the Trust has introduced a range of measures which includes: an escalation process whereby all requests for temporary staffing must be discussed with the on-call manager who ensures a robust evaluation of alternative options before approval, an agency review meeting held two weekly with director level presence and monthly statistics reported to the Director of Workforce. 5.6 NHS Improvement (North region) has now begun to produce monthly comparative data. The monthly regional agency comparison performance for the Trust, to the end of November 2016, shows that the Trust continues to perform well against the agreed ceiling for the year. The Trust is 19.4% below the agreed agency expenditure relative to ceiling measure for the year. 5.7 The Trust ranks 13th across the region for the agency spend vs ceiling % this is an improvement of three places from the previous month s position. The agency spend vs ceiling % ranked position is higher than the two comparable community trusts in the region Liverpool Community Health NHS Trust (ranked 18) and Bridgewater Community Healthcare NHS Foundation Trust (ranked 59). The total spend % of total staff cost rank is 58 this is a slight improvement from last month rank 59. This is a lower position than both Liverpool Community Health NHS Trust (ranked 28) and Bridgewater Community Healthcare NHS Foundation Trust (ranked 55). 6 Listening to staff: Ask Thea analysis 6.1 In the last report, the Board was reminded about the 2016 national NHS staff survey. As part of this annual exercise, the Trust surveyed all staff to gain views on all aspects of working life. The results from the survey will not be known until 2017 (and will be reported to the Board on 31 March 2017) but, once known and analysed, the survey outcomes will continue to inform the Trust s work to engage staff in all areas of the Trust s business. 6.2 The Trust has worked hard during 2016 to address the key issues emerging from the 2015 staff survey and to deliver on the pledges which will be well known to Board and are displayed across the Trust. A revised approach to staff engagement was produced under the heading Our working life and relates to the seven behaviours How we work, contained in Our The Board has also been advised, in December 2016, about the appointment of a freedom to speak up guardian as part of local arrangements to support a culture where lessons are learnt and services improved from any concerns that may be raised. This is an important initiative for the Trust and provides a conduit for staff to be able to raise concerns in a safe way. 6.4 A further means by which staff can informally raise concerns, make comments or ask questions is through the Ask Thea approach. This on line mechanism is accessed through the Trust s intranet (Elsie) home page and allows any member of staff to post a comment or ask a question (which may be anonymous) direct to the Chief Executive. Page 5 of 12

27 6.5 This is a well-used facility; Ask Thea consistently features in the top five most visited pages on the Trust s intranet site (Elsie). Between 1 April 2016 and the end of December 2016 there have been 117 questions all of which have been personally answered by the Chief Executive, maintaining a standard of answering all queries within five to ten days. 6.6 The table below shows a breakdown of queries against a broad range of categories. The analysis is a broad summary only and in some cases there is an overlap of issues, for example an enquiry about availability of tablet devices and whether training is available. The analysis will be repeated in August Question theme Questions by theme HR processes and implementation of policies 11 Staff morale 9 Staff support/recognition 3 Communications 16 Sickness absence 5 Infection prevention and control 3 Annual or special leave 2 Training 13 Pay and expenses 12 Job security 2 Service reviews 5 Costs 5 Resources 5 Equipment 9 Safety 3 Car parking 4 IT and systems 9 CQC 1 Total By way of illustration, here are some examples of questions posed in the three largest categories Communications The Trust s thank you awards attracted 114 nominations, a manager suggested that all nominees should receive a personal note advising them that they had been nominated by way of recognition; this was done in January 2017 An enquirer asked whether staff could be kept better informed about groups of staff being moved in and out of buildings A clinician asked about access to smart phones as an aid to staff working in community settings; costs of upgrading are relatively low and are part of local managers budgets Page 6 of 12

28 6.7.2 Training A busy nurse said that she felt that there was a lack of statutory and mandatory training courses available sufficiently far ahead to allow for effective planning of rotas etc; as a result of this query training slots (eg for infection prevention and control training) are now available six months ahead A correspondent asked whether multiple statutory and mandatory training topics could be organised as a single day s training; this is being undertaken on a bespoke basis for teams that choose this route A number of questions relate to straightforward enquiries about the availability of training on specific topics eg medicines administration, dementia awareness etc Pay and expenses There were a number of questions related to travel expenses, for example queries about discrepancies between the mileage calculated by the expenses software (shortest journey) and the actual mileage travelled (quickest journey); as a result the system has been adjusted to allow flexibility of up to 10 miles Staff have queried the non-payment of (higher) overtime rates for staff working extra hours, particularly when the same person could receive a higher rate through an agency; currently, reflecting exceptional staff shortages, hours over fulltime are being paid at overtime rate The date for Christmas pay day was raised 7 Staff awards 7.1 The Trust continues to be very proud of its award-winning staff. Here are some of the recent winners Congratulations to Leeds Improving Access to Psychological Therapies (IAPT) service which is a finalist in the mental health category of the Medipex NHS Innovation Awards for developing a computerised system that helps therapists monitor how patients are responding to feedback. The winner will be announced on Thursday 23 March Congratulations to the Facilities Administration Team on achieving the Gold Standard with their 2016 involvement plan. The involvement champions have been working alongside the Trust s charity to support the More than a Welcome campaign and look at new ways of making staff, patients and carers feel more welcome in health centres The Palliative Care team have been shortlisted in the collaborative working category for the LTHT Time to Shine awards. The Rapid Discharge Plan (RDP) for Urgent Care - Supporting Dying patients to achieve their preferred place of care nomination involves the work of some of our neighbourhood palliative care leads a great example of partnership working. The Leeds Dying Matters partnership, in which the Palliative Care Team is involved, has won an award for best collaboration at Comms2Point0 awards ceremony this week. The panel was very complimentary about the breadth of membership in the partnership and also about the range of activities for the campaign. Page 7 of 12

29 Congratulations to podiatry colleagues for winning the Yorkshire Evening Post Best of Health Community Health Award for the Walking on Air initiative which helps to provide foot care to homeless and destitute people in Leeds. Funded by the Trust s charity, service users at York Street Health Centre and charities including St George s Crypt were given essential early treatment, basic education on foot care as well as kits including soap, socks and clippers. The Duty and Advice Team at Westgate (which includes safeguarding nurses, social workers, administration staff and police) were delighted to have their good work recognised by winning the Team Achievement of the Year at the Awards for Excellence at Leeds City Council. The team receive referrals from professionals and the public where children are at risk of harm and investigate the referrals and decide upon the most appropriate support or action. 8 Performance and finance overview 2016/ Despite the current sustained pressures being experienced within the NHS both nationally and locally, the Trust has continued to maintain a focus on ensuring it delivers a range of performance targets and therefore evidencing it provides safe, caring, effective, responsive and well-led services. 8.2 From a quality perspective, the following remain the main areas of focus and are covered in more detail in the performance report: A focus on reducing the incidence of avoidable pressure ulcers and falls. This month there has been progress in relation to the incidence of avoidable pressure ulcers and falls with harm. On-going work in relation to incident reporting. The data demonstrates progress. Progress also continues in relation to the timely closure of incidents. Further work is required to ensure that the data and recording of duty of candour reporting matches the practice of staff. 8.3 The Trust continues to perform very well in respect of all of its responsive indicators. There is continued good performance against all statutory and non-statutory waiting times. For example, IAPT waiting times are above national targets. The Trust as a whole is currently reporting activity levels within 5% of profile. 8.4 A number of workforce related indicators remain a concern. Sickness absence (6.3%) and staff turnover (15.7%) are subject to particular scrutiny; further detail is contained in the performance report. 8.5 The finance measures remain satisfactory. The Trust is 53,000 ahead of the planned surplus at the end of December The Trust is confident of delivering the planned surplus of 2.86m control total. The use of resources risk rating (1) represents the lowest risk position. Page 8 of 12

30 8.6 NHS England and NHS Improvement have developed a single oversight framework for trusts. Information is collected (both directly and from third parties) on trusts performance, against a range of metrics. Trusts are then categorised in one of four segments according to the scale of issues and challenge each trust faces. The segments range from 1 to 4 whereby 1 equates to no evident concerns and 4 indicates critical issues. The Trust has been categorised as category 2; this is the same category as Leeds Teaching Hospitals NHS Trust and Leeds and York Partnership NHS Foundation Trust. 9 Operational planning 2017/18 and beyond 9.1 NHS England and NHS Improvement published planning guidance (NHS Operational Planning and Contracting Guidance for ) in September The planning and contracting timetable had been brought forward to enable earlier agreement and the first draft 2017/18 and 2018/19 operational plan was submitted on Thursday 24 November Following Board discussion on Friday 2 December 2016, a further iteration of the plan was submitted on Friday 23 December 2016; submission was approved by the Chair and Chief Executive as an urgent decision exercised under the provisions of the Trust s standing orders (section 5.2). 9.3 The Trust was also able to meet the requirement to sign two year contracts with commissioners by Friday 23 December The Board will receive a further version of the operational plan at its meeting on Friday 31 March 2017, at which time it will be asked to approve the plan, objectives and budgets for the coming year. 10 Sustainability and transformation planning 10.1 The development of the Trust s operational planning for 2017/18 and 2018/19 required the Trust to review its strategic direction to ensure alignment with the sustainability and transformation plan (STP) for West Yorkshire and Harrogate 2016/ The STP for West Yorkshire and Harrogate is one of 44 across the country which describes how local services will evolve and become sustainable over the next five years. The aim being to achieve the Five Year Forward View (2014) vision of better health, better patient care and improved NHS efficiency. Health and care organisations have worked together to develop STPs which will help drive sustainable transformation in patient experience and health outcomes in the longer term. Page 9 of 12

31 10.3 The STP sets out nine priorities which will benefit from collaborative work across the wider area. These are: prevention and early intervention, primary and community services, mental health, stroke, cancer, urgent and emergency care, specialised services, hospitals working together and standardisation of commissioning policies. Underpinning all these are a number of key enabling workstreams Simon Stevens (Chief Executive, NHS England) and Jim Mackey (Chief Executive, NHS Improvement) wrote to providers on 12 December 2016 outlining the approach being taken in terms of next steps for STPs The letter emphasises the importance for each health community to move from proposals (current position) to plans (through the contracting round and other formal engagement and consultation mechanisms) to implementation partnerships. The letter refers to a range of evolving approaches to collective leadership and shared decision-making supplementing the ongoing role of individual boards; it is clear that there is to be a variety of approaches and pace of change. 11 Learning candour and accountability: CQC report into patient deaths 11.1 The Care Quality Commission has published a report following a national review of the quality of investigation processes led by NHS trusts into patient deaths. The quality regulator raised significant concerns about the processes undertaken by many trusts and the failure to prioritise learning from deaths so that action can be taken to improve care for future patients and their families The review focused on five key areas: involvement of families and carers identification and reporting decision to review or investigate reviews and investigations governance learning 11.3 The report, which provides an insight into system-wide and local challenges to effective investigations, greater candour, transparency and learning from deaths across the NHS, made a series of recommendations and identified the need for improvement in a number of areas, including: reporting requirements on a standardised set of information to be collected and published quarterly by providers on all deaths and serious incidents working to a single framework for identifying, reporting, investigating and learning from deaths in care ensuring that investigations of deaths are thorough to avoid missing opportunities to improve care and genuinely involving of families and carers identification of a board member as a patient safety director to take responsibility for this agenda and a non-executive director to take oversight Page 10 of 12

32 11.4 The Trust already has a mortality surveillance group (a sub-group of the Quality Committee) which reviews deaths in the Trust and extrapolates any learning from the reviews undertaken. The Executive Medical Director is the lead executive director for the Trust. 12 CQC consultation on the next phase of its regulatory approach 12.1 The CQC is currently consulting on the next phase of its regulatory approach, following the near completion of its comprehensive inspection programme. The proposals put forward in this consultation build on the CQC s five-year strategy for The consultation describes how the CQC intends to move to smaller and more targeted inspections From April 2017, the CQC intends to carry out annual inspections of at least one core service for each NHS trust. The core services inspected will be chosen based on previous inspection ratings, as well as wider intelligence that points to either risk or improvement in the quality of care provided. The consultation also proposes a set of principles that will inform how the regulator will adapt its approach in response to emerging new care models and complex providers The CQC and NHS Improvement are also jointly consulting on their approach to leadership and use of resources by NHS trusts. Under the proposals in this consultation, NHS Improvement will lead on an annual use of resources assessment to determine how effectively providers are using their resources to deliver high quality, safe and efficient care for patients, which would then inform a rating by the CQC. The proposed approach to carrying out use of resources assessments will initially be introduced for acute trusts only In addition, the two regulators have developed a new joint well-led framework, building on the framework currently used by the CQC to assess and rate trusts on the extent to which they are well-led. The consultation sets out views on the structure and content of the new framework and also how the CQC and NHS Improvement will make use of the well-led framework in their regulatory and oversight activities. 13 National strategy for allied health professionals (AHPs) 13.1 On Wednesday 17 January 2017, Suzanne Rastrick, NHS England s Chief Allied Health Professions Officer launched AHPs into Action. This is NHS England s strategy for AHPs from 2016/17 to 2020/ The strategy has been developed through crowdsourcing over 16,000 contributions some of which will have been from this Trust s staff. The strategy recognises the diversity of the AHP offer. The document is aimed at leaders and decision makers to inform them about how AHPs can be best utilised to support future health, care and wellbeing service delivery. It describes the impact of efficient and effective use of AHPs for people and populations, commitment to the way services are delivered and priorities to meet the challenges of changing care needs. Page 11 of 12

33 13.3 The document is in two parts. Part one describes the impact AHPs can have and part two gives a framework to use when developing or planning services. There are around 53 separate examples of where AHPs have been used innovatively to address a problem Much of the content of the strategy aligns well with the Trust s professional strategy for clinical staff which was approved by the Board in October Recommendation 14.1 The Board is recommended to: Note the contents of this report Page 12 of 12

34 AGENDA ITEM Meeting Trust Board 3 February 2017 Category of paper Report title Seasonal Resilience Responsible director Executive Director of Operations Previously considered by N/A For approval For assurance For information Purpose of the report This paper describes the situation affecting neighbourhood teams and related teams during a period of escalation in January It describes the process employed to manage the situation and gives an account of actions taken to ensure safe delivery of care throughout the period. Main issues for consideration The adult business unit faced a period of considerable service pressure in January As a result our resilience escalation plan (REAP) level was increased to level 4. A daily Silver Command meeting was instigated to managed demand and ensure the continuity of service provision The response from staff from all teams and departments, not just those directly affected, has been tremendous Recommendations The Board is recommended to: Receive the briefing on the period of escalation Note the actions taken to manage the situation Note the excellent response from staff

35 SEASONAL RESILIENCE 1.0 Purpose of this report 1.1 This paper describes the situation affecting Neighbourhood teams and related teams during a period of escalation in January It describes the process employed to manage the situation and gives an account of actions taken to ensure safe delivery of care throughout the period. 2.0 Background 2.1 On the lead up to the festive period careful attention was being paid to capacity in the neighbourhood teams to manage demand. As reportedly previously, the situation was tight and individual teams were reporting severe pressure. This situation was managed effectively by sharing resources firstly between portfolios (ie 2-3 neighbourhoods) or between hub areas (4-5 neighbourhoods). During this time the Trust remained at REAP (resource escalation action plan) level 3 moderate pressure. 2.2 In the period between Christmas and New Year, pressure in teams grew to the point that every portfolio (7 teams) was experiencing pressure. This was caused by an increase in staff sickness and an inability to secure sufficient temporary resources and agency staff giving backword. The ability to take admissions in South Leeds Independence Centre and Community Intermediate Care Unit was also limited. On 1 January 2017 the Trust escalated the REAP (resource escalation action plan) level to 4 severe pressure. The Trust returned to REAP level 3 on 18 January The system in Leeds was also under significant pressure. Following a period at REAP level 5 Leeds Teaching Hospitals NHS Trust de-escalated to REAP level 4 on 23 December The Trust re-escalated to REAP level 5 on 28 December 2017 and returned to REAP level 4 on 20 January Silver Command 3.1 Daily silver command meetings were instigated from 3 January The purpose of silver command is to plan and coordinate the internal response across the organisation over each forthcoming 24 hour period. Silver command has met daily at usually chaired by the Director of Operations (or another Director when not available). 3.2 During silver command meetings a situation report is gathered from each neighbourhood team, each bed base and specialist team. The number of referrals waiting in the single point of urgent referral (SPUR) and the number of people waiting for community intermediate care (CIC) beds is also considered. 3.3 The silver command team then reviews the situation across the city to ensure all essential work is undertaken and that teams are working together to support this as necessary. It has been very positive to see how teams have worked flexibly to support each other during this time. Many staff have worked additional hours or volunteered to support teams under pressure. Where necessary support is provided to ensure the resources are in place to complete essential work. It is important to note that all essential work has been completed and maintained during this time. The REAP level is reviewed and agreed.

36 3.4 Key messages are then fed into the daily system OPEL (Operational Response Escalation Level) teleconference call. This is the system wide escalation framework. 4 Actions arising from silver command 4.1 As per the Trust s escalation policy when REAP level 4 was declared a number of activities were deferred to increase capacity (in adult business unit only): Statutory and mandatory training Appraisals Meetings not immediately required for the provision of safe services The impact of deferring training and appraisals is understood and a recovery plan will be agreed 4.2 Defining essential work It is important that the organisation has a clear and published framework for defining essential care and how work with be prioritised. The Deputy Director of Nursing facilitated a rapid review and worked with staff to publish the refreshed framework to clarity what constitutes essential work. Teams have reported this as very supportive 4.3 Prioritisation of workload Throughout the period we continued our usual practice to prioritise our referrals as follows: The first priority for all teams must be to maintain the current caseload safely to ensure nobody is admitted to hospital unnecessarily. Palliative patients with fast track status Urgent referrals for people in community (including Community rapid referrals to prevent a hospital admission) Referrals from ED or Assessment floor to prevent a hospital admissions Hospital/CIC discharges Routine visits these are being deferred where appropriate and necessary (and will be managed as soon as possible). 4.4 Mobilising staff throughout the period Staff have been excellent in responding to the challenges of the last month. Teams aligned to the Neighbourhood Teams eg Palliative Care Leads have worked closely and flexibly with local teams to ensure patients needs were met. A request for support was circulated by and through Elsie/Community Talk and this generated a very pleasing and significant response from staff working in different teams across the organisation (both clinical and non-clinical) The application of overtime rates has been reconsidered for the period to incentivise staff and the opportunity to use annual leave flexibly has also encouraged to staff to offer support

37 Due to the level of voluntary response it has not been necessary to require staff to move from a non-neighbourhood Team. However this issue is being explored by the leadership team to enable freer movement of staff in the future should the need arise. There has also been a good response from senior leaders in the organisation and there has been leadership presence in teams at weekends throughout the period. 5 Staff Welfare 5.1 This has been a very difficult and challenging time for our staff and members of the adult business unit leadership team and senior management team have been as visible as possible to thank and support staff. In addition silver command has arranged: Wellbeing hampers for each team (tea, coffee, biscuits etc) Workplace wellbeing sessions (hand, shoulder massage etc) Monday lunches A small survival kit has also been provided to all leaders involved in managing the situation 6 Communication 6.1 Effective communication is particularly important when a system is in a period of escalation. Daily system-wide teleconferences have been held to ensure the whole situation is understood by all partners; mutual aid is offered and the appropriate escalations are made to NHS England. There are risks around miscommunication due to the pressures people are under. During this time there have been numerous formal meetings and informal telephone calls with partners to increase awareness and ensure that they are clear about the plans in place and actions being taken. In addition formal letters have been sent to GPs to ensure they are also aware of the situation. 7 Lessons Learned 7.1 As this is the first occasion that the organisation has declared REAP level 4 there has been much to learn in terms of process. A full review of learning will be undertaken in the next few weeks. 8 Recommendations 8.1 The Board is recommended to: Receive the briefing on the period of escalation Note the actions taken to manage the situation Note the excellent response from staff

38 AGENDA ITEM Meeting: Trust Board 3 February 2017 Report title Performance Brief and Domain Reports Responsible director: Executive Director of Finance and Resources Report author: Head of Business Intelligence Previously considered by: Senior Management Team, 18 January 2017 Quality Committee, 23 January 2017 Business Committee, 25 January 2017 Category of paper (please tick) For approval For assurance For information Purpose of the report This report provides a high level summary of performance within the Trust during December It highlights any current concerns relating to contracts that the Trust holds with its commissioners. It provides a focus on key performance areas that are of current concern to the Trust. It provides a summary of performance against targets and indicators in these areas, highlighting areas of note and adding additional information where this would help to explain current or forecast performance. More detailed narrative on each of the individual indicators will be available in the domain reports. Main issues for consideration Safe The measures rated as red are the same as in the last report: o Patient safety incidents reporting as no harm o Percentage VTE risk assessments completed; it is thought that these assessments are taking place, but are not being recorded on the clinical information system. New processes are being put in place to more closely monitor completion of this information o Falls reduction target for inpatient beds (December 36, compared to 29 in November 2016) For the third consecutive month, the Trust is achieving the targets set for avoidable category 4 pressure ulcers and category 3 pressure ulcers. The percentage of incidents applicable for Duty of Candour dealt with appropriately has moved above target and stands at 82% Caring The Trust is currently meeting its targets for all measures in the caring domain. The percentage of patients recommending care is high (100% inpatients and 95% community) however, overall response rates remain low. Effective There is no change in the ratings for the effective indicators this quarter. NICE guidance compliance remains a red rated indicator. Nine pieces of NICE guidance were published in Q3 2015/16 that are relevant to the Trust. Full compliance has been achieved with two (NG 16 dementia, disability and frailty in later life - mid-life approaches to delay or prevent onset and NG 30 oral health) within the last twelve months. Work is ongoing to ensure compliance with the seven other relevant pieces of guidance: Page 1 of 2

39 Responsive The Trust continues to perform very well in respect of all of its responsive indicators of which there are eight. Seven of these relate to waiting times; there is continued good performance against all statutory and non-statutory waiting times. For example, IAPT waiting times are above national targets The Trust as a whole is currently reporting activity levels within 5% of profile. Well Led The measures in the well-led domain remain at the same RAG ratings as October and November 2016 with the exception of staff turnover. Staff turnover increased from 14.0% in October to 14.8% in November to 15.7% (a red rating) in December 2016 Sickness absence remains a red-rated indicator; the total figure is 6.3% for December 2016 (target 4.9%). Appraisal rates stand at 85.7% - against a year to date target of 93% Finance The finance measures remain rated the same as the last full report (October 2016). The Trust is 53k ahead of the planned surplus at the end of December 2016 and therefore the net surplus/deficit is rated green The Trust is confident of delivering the planned surplus of 2.86m control total. The use of resources risk rating (1) is rated green and represents the lowest risk position Capital expenditure in comparison to plan and CIP delivery are rated red Recommendations The Board is recommended to: Note present levels of performance Page 2 of 2

40 Leeds Community Healthcare NHS Trust Performance Brief, December 2016 Trust Board 3 rd February

41 Executive Summary This report provides a high level summary of performance within Leeds Community Healthcare (LCH). It highlights any current concerns relating to contracts that LCH holds with its commissioners. It provides a focus on key performance areas that are of current concern to the Trust. It provides a summary of performance against targets and indicators in these areas, highlighting areas of note and adding additional information where this would help to explain current or forecast performance. More detailed narrative on each of the individual indicators will be available in the Domain Reports. These papers follow this report. Contents 1. High Level Performance Summary Page Summary of Performance against KPIs Page Statutory Breaches Page Regulatory Requirements Page Heat Map Page 6 2. Contract Related Issues Page 7 3. Key Areas of Focus Page Appraisals Page Influenza Vaccination Campaign Page 9 2

42 High Leve l Performa nce Summary 1. High Level Performance Summary 1.1 Summary of Performance Against High Level Indicators 1.1 S ummary of Performa nce Against High Lev el Indicators Please note that the charts included below do not represent the CQC key lines of enquiry. They do reflect the Trust s high level indicators which are aligned to the CQC domains Safe In the safe domain the measures are rated red are the same as in the last report: Patient safety incidents reporting as No Harm Percentage VTE Risk Assessment Completed; it is thought that these assessment are taking place, but are not being recorded on the clinical information system. New processes are being put in place to more closely monitor completion of this information Falls reduction target for inpatient beds The Trust is achieving the targets (green rated) set for: Avoidable category 4 pressure ulcers Category 3 pressure ulcers Serious incidents; the trust has moved up from an amber rating to achieve its year to date target this month The Trust is within trajectory to achieve our year end targets (amber rated) for the following measures: Percentage of incidents applicable for Duty of Candour dealt with appropriately. Harm Free Care (Safety Thermometer); this measure has fallen into an amber rating since it was last reported Caring The Trust is currently meeting its targets for all measures in the caring domain. 3

43 1.1.3 Effective There is no change in the ratings for the effective indicators this quarter with the exception of compliance with Technology Appraisals. As there were no relevant appraisals to implement there is no rating for this measure. Information on the CQUINs relating to outcomes was not available at the time of this report as it is aligned to separate reporting schedule. Information will be included in this report once it becomes available Responsive The Trust continues to perform very well in respect of all of its responsive indicators of which there are eight. Seven of these relate to waiting times. The Trust as a whole is currently reporting activity levels within 5% of profile Well Led The measures in the well-led domain remain at the same ratings as October with the exception of staff turnover. This has increased from 14.0% (an amber rating) in October to 15.7% (a red rating) in December. Information on the agency cap was not available at the time this report was produced, but will be included in due course. 4

44 1.1.6 Finance The measures examined under finance remain the same as they did in October. Net surplus vs deficit and the Use of Resources Risk Rating are rated green and Capital expenditure in comparison to plan and CIP delivery are rated red. All measures with the exception of CIP delivery are forecast to be green by year end. 1.2 Statutory Breaches 1.2 St atutory breach es Leeds Community Trust is currently performing within all nationally set targets. In November and December there was one patient waiting beyond the 18 week deadline. This patient was waiting to be seen in Community Paediatric Clinics. The patient had cancelled one appointment and did not attend another. A third appointment is booked for the 18 th January. In December one patient was seen after the 18 week deadline and was subsequently entered into a period of active monitoring. No reason for the delay in the initial contact has been provided. There were no breaches in the 6 week waiting time for diagnostic tests in Children s Audiology or for 18 week waits in IAPT. 98.1% of patients were seen within the 6 week waiting target for IAPT and 97.7% of patients were seen within 18 weeks. These are comfortably above the national targets. 1.3 Regulatory Requirements 1.3 R egulatory Req uirements Last month s Performance Brief reported that the Director of Finance had made the case to NHS Improvement for re-categorising the Trust s provider segmentation rating from 3 to 2 due to the improved financial position and the Trust forecasting meeting the planned surplus at year end. Segmentation ratings range from 1: no concerns, maximum autonomy to 4: serious/complex concerns, providers placed in special measures. NHSI has now up-graded our rating to 2 which reflects the Trust s CQC requires improvement rating. A SEND inspection took place in early December. The final report has not yet been released however, overall the hard work of all the health teams from universal through to specialist, from community to hospital has been recognised. Capacity issues are real, but they have not stopped 5

45 delivery high quality support for children and young people. We will continue working together with our colleagues in all organisations and each other to take the next steps in ensuring children and young people with SEND in Leeds reach their full potential. 1.4 Heat Map The heat map shows those services that have the most red ratings in a set of high level indicators. The purpose of this is to highlight these services and to elicit a conversation about those services and why these ratings are the way they are. The graph and table below show those services with the most measure rated red. Continence, Urology & Colorectal (CUCS) Diabetes Services Leeds Community Wound Prevention and Management Service Children's Speech & Language Therapy York Street Practice These data show that all of the services listed with the most red ratings are carrying out fewer contacts than their profile. Also, they are all missing targets for appraisals and statutory and mandatory training. This may be an indication of pressure on staff time and patient appointments being prioritised. CUCS and the Diabetes Service have high levels of sickness, both around 17%. This is highly likely to be contributing to the difficulties the services are having in meeting activity, appraisal and training targets. It is a surprise to see York Street given their recent "outstanding" rating by CQC. However their position in the top 5 services is due to DNAs and patient safety incidents which may be due to the nature of the service and the population it serves. Similarly the Wounds Service is likely to have a high level of incidents reported due to the nature of the service. Interestingly Neighbourhood Teams are not highlighted by this report. Generally the Neighbourhood Teams are rated red in the measures for sickness, appraisals and training and patient safety incidents, but none reach the current threshold of 5 red rated measure. This may be because we are examining December data and the full impact of winter pressures was not felt until part-way through the month. The Heat Map will be monitored through January and February to ensure that it is highlighting the appropriate services. Developments will be implemented if it is not. 6

46 2. Contract Relate d Highlig hts 2. Contract Related Highlights 2.1 Progress on Risk Reserve CCG Progress on the risk reserve remains positive. December s activity is currently 1.8% above profile and for the Risk Reserve period to date activity is currently 6.0% above profile. The year-end financial position will be decided on the month 12 position with reconciliation to take place in May Therefore should there be any application of the financial penalty this will be applied in the 2017/18 financial year. 2.2 Contracting Round for 2017/18 and 2018/19 The Clinical Commissioning Group Contract has been successfully agreed and signed. One minor element that is still to be agreed relates to the allocation of 0.25% CQUIN funding. This will be agreed before the 2017/18 contact year commences. The majority of NHS England contracts have been agreed at least in principle. However we are awaiting notification of intentions on the community dental element. 2.3 Leeds City Council Leeds City Council have issued contract variations for extension of a number of public health contracts, however we are still in discussion as they also include 10% public health funding cuts. 2.4 Prisons, Wetherby Youth Offending Institution and Adel Beck Secure Children s Home As reported in last month s report there is currently a disagreement between the Trust and NHS England on covering additional costs for escort and bed watch. Escort and bed watch has been removed from the 2017/18 contract, but NHS England are unwilling to discuss 2016/17 cost pressures in isolation from total contact funding. 2.5 Leeds Sexual Health Service Leeds City Council have proposed that the transfer of the GP contract be postponed to the 2018/19 contract year, but that the pharmacy contract transfer takes place in April None of the fundamental concerns raised by the Trust have been addressed. It is therefore unlikely that we will be in a position to take these services on as per Leeds City Council s intentions. No further progress on Preventix and other cost pressures has been made, but discussions continue. 7

47 Key Area s of Focus 3. Key Areas of Focus 3.1 Appraisals At November s Business Committee, the Chair asked for a brief assessment of how effective the new appraisal forms were in supporting development and team working. This qualitative information is being gathered by a variety of ways:- National Staff survey results due end of February 2017 Feedback from 50 voices forum Q4 Staff FFT results closing on 14 March 2017 Analysis of feedback from leaders who attended the Improving performance, one conversation at a time session (15 sessions), on how they have embedded the learning into practice and in what way the training has had an impact on their behaviours and helped with appraisal discussion will be completed by end of January 2017, which will be fed back to the Quality Committee. As there is a range of feedback/results from various surveys being collated over a similar time period of two months, it is recommended that to enable a proper and full triangulation of all relevant information, that a comprehensive paper is submitted to March Business Committee, to address the question posed above. Meanwhile, at the end of December 2016, 85.7% of available staff were registered as having had an appraisal within the last 12 months, which is a slight reduction on last month s figure of 87.6%. It is normal for this to reduce due to the Christmas holiday period and winter pressures. There continues to be a targeted discussion at the Performance panels and information made available via Business Intelligence. 8

48 3.2 Flu Vaccination The Staff Flu Vaccination campaign been completed with a final uptake figure of 76.8% for frontline staff. This is in excess of the 75% required to meet the CQUIN target a target that was widely accepted to be difficult for a community trust to achieve. The Infection Prevention and Control (IPC) Team hit the target with weeks to spare. Their campaign was a success for many reasons; They varied their approach to promotion of the flu vaccine They ensured that LCH staff members knew why the campaign was important to them, their families and their organisation by telling authentic stories of why vaccination matters They had fun and thought creatively about engagement, with some staff members even dressing up as flu bugs. Their enthusiasm for the campaign showed and drew people in They embraced social media and new forms of communication to get their message across The campaign has been widely applauded and has provided an opportunity to enhance relationships with partner statutory organisations. The team have been asked to share what worked well at a national level as our campaign was deemed so successful. 9

49 Safe and Caring Domain Re port Leeds Community Healthcare NHS Trust Director of Nursing Report & Safe and Caring Domain Report Safe - people are protected from abuse and avoidable harm Patient Safety Incidents Reported in Month Reported as "No Harm" YTD Target YTD Q1 Q2 Oct Nov Dec Forecast 2016/ % 56.7% 56.8% 58.8% 48.5% 55.7% 70% 2015/ % 64.5% 67.3% 67.2% 68.0% 60.7% 2016/ Potential Under Reporting of Patient Safety Incidents / / % SI Reduction Target / / % 96.1% 96.3% 94.9% 91.8% Harm Free Care (Safety Thermometer) 95% 2015/ % 94.2% 93.8% 93.2% 94.4% Percentage New Harms (Safety Thermometer) 2016/17-3.3% 2.7% 1.9% 0.0% 1.6% TBC 2015/16-3.3% 2.6% 3.4% 4.3% 2.0% 2016/ % 88.8% 82.8% 94.4% 74.6% Percentage VTE Risk Assessment Completed 95% 2015/ % 90.2% 80.0% 95.5% 91.4% 10% Falls Reduction Target for Inpatient Beds 2016/ / / % Category 3 Pressure Ulcer Reduction Target / Avoidable Category 4 Pressure Ulcers Percentage of Incidents Applicable for DoC Dealt with Appropriately 2016/ <=3* 2015/ /17 78% 79% 75% 75% 75% 82% 81% 2015/ * Target shown is for the period from October 2016 to March 2017 Caring - staff involve and treat people with compassion, kindness, dignity and respect YTD Target 2016/ % 73.7% Percentage of Staff Recommending Care (Staff FFT) 73% 2015/ % 78.0% YTD Q1 Q2 Oct Nov Dec Forecast 2016/ % 93.9% 100.0% 96.0% 100.0% Percentage of Inpatients Recommending Care (FFT) 95% 2015/ % 96.0% 95.4% 94.7% 100.0% Percentage of Community Patients Recommending Care (FFT) Written Complaints - Rate 2016/ % 95.2% 91.4% 95.6% 95.0% 95% 2015/ % 93.8% 93.6% 95.5% 94.5% 2016/ TBC 2015/ Introduction The report is written in the context of the current sustained pressures being experienced within the NHS both nationally and locally. For the first time the organisation has instigated silver command at New Year and business continuity plans to manage the current and on-going pressures. There is a specific section in the report which sets out the issues and response to the current Reap Level and whole systems pressures at this time. It is anticipated that this situation could have a knock on affect over the next few weeks to complaints and incidents and in particular time scales for investigations. It is also likely it will have an impact on things such as Friends and Family Test response rates etc. as staff have to focus on delivery of critical patient facing services. The report sets out that the following main areas of focus and activity remain: A focus on reducing the incidence of avoidable pressure ulcers and falls. In month there has been progress in relation to the incidence of avoidable pressure ulcers and falls with harm. The 10

50 committee will note the exceptional drop in timely response to complaints. This is due to a specific issue; due process is being followed and remedial actions are in place On-going work in relation to incident reporting. The data demonstrates that we are starting to make progress. Progress also continues in relation to the timely closure of incidents. However this may be impacted by the current Reap Level and prioritisation of essential work and leadership time focussed on front line service delivery Further work is required to ensure that the data and recording of Duty of Candour matches the practice of staff The infection prevention team are to be commended for the achievement of 76.8% flu vaccination this year and ahead of schedule. This commendable action has attracted national interest York St practice are to be commended for achieving outstanding in the recent CQC inspection 2. Duty of Candour Twenty eight incidents (of 37) triggered DoC in November and 28 (of 44) again in December. Of the total 56 applicable incidents over the 2 month period: 32 apologies were recorded as given (57%) 12 apologies were not given, with an inappropriate reason recorded (21%) 11 records were incomplete (20%) 1 incident no apology given patient deceased and no known NOK (2%) This shows a static improvement in recorded DoC actions as required. Inappropriate reasons recorded have been reviewed and this will inform the actions that follow below. Datix reports for Q2 and Q3 have been produced enabling identification of those teams with incidents that fall under duty of candour and how they are recording their communications with patients. Briefing sessions have continued during Q3. These have been delivered to a total of 1817 staff in the past 15 months through team briefing cascade, Trust induction and by the quality lead for Specialist Services attending 20 service and BU meetings. Specific guidance has been developed for incident handlers/investigators on process to follow when completing DoC section on Datix to ensure that there is accurate recording of communications with patients. This has been cascaded via the quality leads to the BUs in October and November. The Quality Lead for Specialist Services is working with the Deputy Director of Nursing to address inconsistencies in approach to applicable/non-applicable incidents within the Adult Business Unit. 2. Pressure Ulcers Numbers of pressure ulcers in total reported in November was higher than average at 63 in November, stabilising to 46 in December (YTD average 53.8). The increase in November was primarily attributable to category 2 (10) and unstageable (17) pressure ulcers. Whilst occurrence of reported new category 2 and 3 pressure ulcers decreased in December compared to November, both number and percentage is comparable for the YTD period showing a stable incidence in pressure ulcer occurrence. Numbers are also reflective of the pattern of overall incidents reported. To date there are no avoidable category 4 pressure ulcers for Q2 and Q3, demonstrating positive assurance with regards to prevention of category 4 pressure ulcers. During December there were no pressure ulcers occurring in inpatient units or services based in a hospital setting, with 1 occurrence in November in SLIC (category 2), this being the first reported incidence since June

51 3. Falls Falls overall in November were 68 and December 87 (YTD average 80.7). Of these 155 cases those falls 87.8% resulted in No Harm or Minimal/Low Harm. This shows a positive picture with regards to falls resulting harm (overall). Eleven falls (7% of all falls) caused moderate harm during the November-December period (YTD average 8.1%): Location of Moderate Harm Falls Patients Home 7 Nursing/Residential Home 3 CICU 1 Falls in inpatient units have continued at an increased level in Q3 (November 29 and December 36); however the percentage of harmful falls continues to be lower than Q1 and Q2 at 21% in November and 17% in December. One inpatient fall resulted in moderate harm (December), 11 resulted in minimal harm and 53 caused no injury, over the 2 month period. The spike in these falls appears to be from a combination of factors, as detailed in the last report including: a group of patients at high risk falls risks in patients who have capacity and are declining the use of monitoring interventions. The number of injurious falls per 1000 occupied bed days for the inpatient units is 3.1, which falls within acceptable tolerance levels. Falls per 1000 OBDs will continue to be monitored for the emergence of any trends. Injurious Falls per 1000 OBDs in Inpatient Units (all Adult Business Unit) Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Injurious Falls Occupied Bed Days Falls per 1000 OBDs Actions are in place to address the falls rate in the inpatient areas, as detailed in the last report: The Falls Clinical Steering Group have agreed that there will be a focus now on looking at information being available to raise awareness of falls prevention with staff in a way that replicates the educational drive held with pressure ulcer prevention New style major falls panels have commenced and new RCA documentation for falls has been implemented mirroring that used for pressure ulcer panels 12

52 The Head of Service for the SLIC is working with the service manager to perform spot checks to ensure all preventative measures are in place to prevent falls; this will commence from this month (January 2017) Daily safety huddles are held with a current focus on falls and high risk patients; and a consultant leading one huddle per week Staff competency monitoring in falls prevention equipment, and updates in falls Tier2 training The senior team are providing feedback throughout each shift and a focus of the intentional rounds is falls prevention A team meeting is planned which will focus on falls and discuss a recent 6 month audit, communication and how the team works together to prevent falls The inpatient areas are ensuring that patients at high risk are being cared for in supervised cohorts with adequate, working falls prevention equipment. When looking at the Trust Sign up to Safety pledge and Quality Account priority (2016/17) to reduce falls causing avoidable harm in inpatient units by 10% there remains concern following a quarterly increase in falls causing harm in Q2. This has however turned around in Q3 making progress on track against the given target: Q1 = 5.8% of falls in inpatient units caused avoidable harm Q2 = 11.7% Q3 = 2.0% 4. Infection Prevention and Control 4.1 MRSA Bacteraemia and Clostridium Difficile To date in 2016/17 there have been no cases of MRSA Bacteraemia assigned to LCH. During the reporting period there have been 3 MRSA bacteraemia cases identified within the wider community economy, all of which have been subject to a full multi agency Post Infection Review (PIR). None of the case reviews identified lapses in care associated with LCH care delivery teams. One element of learning for the West 2 Neighbourhood was to ensure that any decision making process relating to a patient s own management of wound site was well documented. The team were complemented for the way in which they had dramatically improved a problematic wound site. No cases of C difficile infection have been assigned to LCH during the report period. For the year to date there has been one case assigned to LCH. This case was identified at SLIC during October and was previously discussed in the last report. 4.2 Outbreaks An outbreak of respiratory illness was reported at SLIC during November, attributable to Respiratory Syncytial Virus (RSV). This outbreak in SLIC coincided with a wider outbreak in the community with a total of 8 patients and 1 staff member being symptomatic. Control measures enabled SLIC to remain open, but restrictions had been placed on patient movement within the orange corridor. 4.3 Legionella Update Morley Health Centre A two week programme to remove a water tank and other risk elements of the plumbing system began on the 10 January Currently water treatment has been undertaken using chemical and thermal treatment. 13

53 4.4 Infection Prevention and Control Mandatory Training Update Work continues to increase the IPC Mandatory Training uptake to increase compliance from the current 87% up to the required 90% compliance. Following a review and refresh of the educational package, a programme of bespoke training The offer of bespoke training in for services has been shared widely. 4.5 Leeds Teaching Trust Pathology Computer Failure The Leeds Teaching Trust Pathology computer failure reported in Novembers DON has been resolved by the introduction of a new IT system. 4.6 Sharps Safety Issues The Team continue to monitor all incidents relating to needle stick injuries within LCH and have a programme in which all injured staff are followed up for a period of 6 months after injury. During Q3 2016/17 there were 5 incidents where staff had sustained an injury from a medical sharp (8 in Q1, 4 in Q2). There were no common themes to the injury episodes, with causation ranging from staff rushing as a result of high workloads to the inappropriate use of a patient s own diabetic non safety stylet. Work has continued to promote the sharps safety message throughout the organisation. The issue has been highlighted at the recent IPC week and continues to be promoted as a key message of the IPC mandatory training sessions. 4.7 Staff Influenza Vaccine Campaign Update This year s influenza campaign is detailed as a key area of focus in the Performance Brief section Environmental Cleaning Standards The IPC Environmental Audit programme continues to monitor the standards of environmental cleaning within facilities managed/occupied by LCH Teams. As previously raised in the November DON report, the standards of environmental cleanliness in the following areas had caused concern. Hannah House, CRU, Little Woodhouse Hall St Georges Outpatient Unit During December the IPCT facilitated an in-patient area managers meeting to improve internal monitoring processes, an enhanced understanding of responsibilities and due diligence monitoring and reporting. An unannounced IPC review on 23 December 2016 of J31 CICU identified concerns relating to excessive dust loading on some surfaces. Remedial action was requested and a subsequent follow up review on the 28 December 2016 found that satisfactory standards had been achieved. Hannah House cleaning resource requirements and updating of the cleaning schedule has been completed. A follow up audit confirmed an improvement in standards. 14

54 5. Friends and Family Test (FFT) Month 5.1 FFT performance response rates The Trust has a Quality Account Priority to: A. Increase survey response rates, to bring about an improved level of understanding of patient experience and satisfaction B. Demonstrate three services in each business unit using patient feedback or co-production to change the shape of services to improve patient care During Q3 the Organisational FFT response rate was 8.3% 5.2 Action plans Work continues within the Business Units to increase response rates to FFT, with action plans being driven by QPD Quality Leads. During Q3 it was planned that: Response rate Comments received % that would recommend services to Friends and Family November Services 6.3% % Inpatient 16.9% % December Services 4.5% % Inpatient 4.6% % YTD Services 4.6% % Inpatient 12.5% % 1) Specialist Business unit would submit an options paper to SMT regarding alternative to the FFT for Police Custody Suites. The Police Custody Suites have commenced, as an alternative to the FFT, a qualitative process to collect feedback from patients as agreed by the Director of Nursing. A review will take place on the new process at the end of Q4 2016/17. 2) The Clinical Governance Team will provide an options paper to SMT regarding the use of technology for gathering FFT data As a consequence of the delayed roll out of the IPhone app the paper has been delayed until a cost and date of launch can be confirmed. 3) The Clinical Governance Team will develop and share a SOP for staff to enable patients to complete survey on Fujitsu laptops This has been completed and has been made available for staff on Elsie. Since the end of October 2016 the Clinical Governance Team has been working with North 1 and West 1 Neighbourhood teams to increase their response rates. The graphs below show that there was an initial increased response rate for FFT; this further assessed with January s data. will be 15

55 North 1 FFT Response Rates April to December 2016 West 2 Response Rates April to December FFT developments A steering group is being coordinated with QPD Quality Leads to look at further action to produce the desired increased response rate Services are being offered the opportunity to input their own FFT, providing an opportunity for ownership and increased awareness of the FFT data An anomaly was identified by the FFT manager in the reporting of data and the inconsistency between different reports available on the FFT database. The database provider identified and rectified the cause of the inconsistency. The increased number of services FFT data reporting to NHS England continues to be provided via UNIFY. This data is published the following month after submission on the NHS England website. 6. Patient Opinion and NHS Choices No comments were recorded for LCH on Patient Opinion in November, however in December there was one positive comment registered for SLIC which has been shared with the service lead. 16

56 Effective Domain Report On NHS Choices in December one positive general comment was posted in connection with LCH. Presently we are unable to identify which service the author of the comment is referring to, we have asked the author via NHS Choices to contact us. 7. Coroners Inquests Two inquests were held over November and December 2016: Synopsis Outcome Costs Prisoner at HMP Leeds was found by prison staff in July 2015 in his Awaiting official cell, suspended from a water pipe, with a ligature made from cord. outcome Prisoner was cut down and placed in the recovery position. Health care staff attended but did not attempt CPR as rigor mortis had set in. Ambulance arrived and confirmed death. LCH investigation and the PPO report found no contributing factors to the incident or lapses in healthcare. A patient who had been under the care of IAPT receiving a group stress control course was reported to have died at home with a cause of death of head and neck injuries from a possible fall. The LCH investigation identified some issues with the process and timeliness of contacting patients after a session if risk scores had increased or were of concern, however, it was not possible to determine whether they directly contributed to the patient s death. Coroner recorded Death by Misadventure One past LCH staff member attended as witness, but no legal representation required. Legal review of documentation. One LCH staff member attended as witness with CGT support but no legal representation required. Each case is carefully reviewed in relation to the need for any legal input. Where legal input is required, discussion takes place regarding the required level and seniority of handler with the Trust s (NHS appointed) legal representatives. Of the 27 Inquests year to date, 12 remain open with 5 of these listed to commence between January 2017 and July For those cases listed; 1 does not require legal input and four require full legal support as identified below: Synopsis Death of LCH patient; Multiple pressure ulcers / safeguarding concerns November 2015 Death in Custody; (HMP Leeds) Wheatfields Hospice February 2016 Death in Custody; HMP Leeds December 2013 Death in Custody; HMP Leeds November 2015 Death in Custody; HMP Leeds January 2016 Inquest Scope of Legal Representation Date 18/01/17 Review of records and SI investigation / preparation and attendance at pre-inquest briefing for two witnesses 15/02/17 None required LCH witness stood down no witnesses attending 20/03/17 Initial scope and review of PPO, investigation and Clinical Review reports/preparation and attendance at pre-inquest hearing review / preparation and attendance at pre-inquest briefings for eleven witnesses/preparation and attendance at 5 week inquest 02/05/17 Initial scope and review of PPO, investigation and Clinical Review reports/preparation and attendance at pre-inquest hearing review x 2/preparation and attendance at preinquest briefings for eight witnesses/preparation and attendance at 3 week inquest 03/07/17 Initial scope and review of PPO, investigation and clinical review reports, preparation and attendance at pre-inquest hearing, preparation of 4 witnesses, attendance at inquest. 17

57 Effective Domain Report Leeds Community Healthcare NHS Trust Effective Domain Report Effective - people's care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence YTD Target 2016/17 13% 40.0% Compliance with Other NICE Guidance Within 1 Year 67% 2015/ / Total Number of Audits / /17 65% 72.5% Compliance with Clinical Supervision 65% 2015/ / / / / / / / Number of Unexpected Deaths in Bed Bases /16 - YTD Q1 Q2 Oct Nov Dec Forecast 2016/17 100% 100.0% - Compliance with Technology Appraisals Within 3 Months 100% 2015/16 - Development of Service Outcome Measures for Adult Community Services (CQUIN 4a) Development of Service Outcome Measures for Specialist Services (CQUIN 4b) Development of Service Outcome Measures for Children's Services (CQUIN 4c) Number of Sudden Unexpected Deaths in Infants and Children on the LCH Caseload 2016/ / % % Compliance with NICE guidance 1.1. Technology appraisals There were no NICE Technology Appraisals were published in Q2 2016/17 that were relevant to the Trust Other NICE guidance Nine other pieces of NICE guidance were published in Q3 2015/16 that are relevant to the Trust. Full compliance has been achieved with two (NG 16 dementia, disability and frailty in later life - mid-life approaches to delay or prevent onset and NG 30 oral health) within the last twelve months. Work is ongoing to ensure compliance with the seven other relevant pieces of guidance: NG 22 Older people with social care needs and multiple long-term conditions: o CICU team working to review guidance and assess compliance with relevant recommendations; o Full compliance for Neighbourhood Teams, Community Geriatricians and SLIC. NG 23 Menopause: diagnosis & management: o Community Gynaecology Service have reviewed the guidance in detail. All members of the medical team have attended relevant update training. Guidance has been discussed within clinical supervision sessions. Plan in place to audit evidence of implementation; o Full compliance with relevant recommendations for York Street Health Practice. 18

58 NG 26 Children s attachment: o Community Paediatrics team working to review guidance and assess compliance with relevant recommendations; o Full compliance for Children Looked After Team NG 27 Transition between inpatient hospital settings and community or care home settings for adults with social care needs: o This guidance is mainly applicable to the Acute Trust, however, there is an action plan in place for Neighbourhood Teams and CICU. Gaps include citywide planning and work streams to improve discharge planning and transitions between acute and community settings and reorganisation of the discharge teams within LCH and LTHT; o Full compliance with relevant recommendations for SLIC. NG 28 Diabetes type 2 in adults: management: o Community Diabetes Service working with colleagues and commissioners across primary and secondary care to implement required pathway changes; o Full compliance with relevant recommendations for York Street Health Practice. NG 31 Care of dying adults in the last days of life: o The Neighbourhood Palliative Care Team are working with the citywide Managed Clinical Network to implement a review of the last days of life symptom management guide. The care in the last days of life assessment template has been revised in line with the new NICE guidance. NG 32 Older people: independence and mental well-being: o CICU team working to review guidance and assess compliance with relevant recommendations; o Full compliance for Neighbourhood Teams and SLIC. Oversight of compliance at a service level is reported to the Quality Committee on a quarterly basis. 2. Audit Compliance against the Trustwide clinical audit database is the following: Q3 Audit Status All Business Units Started 37% Completed 29% Not started 34% The documentation audit results are as follows: Business Unit Overall Compliance Number of Records Audited Number of Services Adults 93% 27 2 Children and Families 91% 33 2 Specialist 92% Trust Total 92% All registered Clinical staff in the Neighbourhood Teams are attending Holistic Assessment training in Oct 2016 to establish the standard of comprehensive clinical assessment in the NTs and improve the quality of clinical assessment and documentation in both paper and EPR care records. Neighbourhood Teams plan to undertake the documentation audit during February

59 The Children s Business Unit are submitting documentation audits and identifying additional information that will inform any reconfiguration of the documentation audits going forward into next year. They will be submitting data during Q4. Documentation audit is on the agenda for the Specialist Business Unit Clinical Forum for discussion in December where they will also monitor progress against the action plan. Actions plans for 15/16 audits continue to be implemented by services. 5 services have submitted their documentation results even though six services have undertaken their record keeping audits in quarter 3 and 14 are due to be undertaken in Q4. No audits are overdue. For the Trust overall the actions that were included in Q2 performance brief have made an impact on the data submitted for Q3. All business units have identified when their services plan to complete theirs. It is expected that the compliance rate will be 100% at the end of Q4. 3. Clinical Supervision 68% of LCH staff are receiving regular clinical supervision. This is down from 75% in quarter /17. An organisational target of 75% has been set to be achieved by March 2017 with differential targets for specific business units/services. 4. CQUINs Information on progress against CQUINs for Q3 2016/17 is not yet available, but will be included in this report in due course. 5. Mortality Surveillance Work is ongoing to examine how reliable information on deaths on community caseloads can be obtained from Datix and the impact of recording this information in Datix on services. The data collection template on Datix has been updated to include a field for known mental health issues and a field for known learning disability, in line with the recommendations following the investigation into deaths at Southern Health NHS Foundation Trust. In December 2016, CQC published a report, Learning, Candour and Accountability: A Review of the way NHS Trusts Review and Investigate the Deaths of Patients in England. There were no recommendations applicable to LCH. 20

60 Responsive Doma in R eport Leeds Community Healthcare NHS Trust Responsive Domain Report Responsive - services are tailored to meet the needs of individual people and are delivered in a way to ensure flexibility, choice and continuity of care YTD Target YTD Q1 Q2 Oct Nov Dec Forecast Patient Contacts - Variance from Profile 2016/17 0 to ± 5% 1.0% 1.5% 1.5% -2.3% 5.8% -4.0% 2015/16-4.4% -8.0% -5.5% -5.1% -3.1% -0.7% Percentage of patients treated within 18 weeks (Consultant-Led) Percentage of patients currently waiting under 18 weeks (Consultant-Led) Number of patients waiting more than 52 Weeks (Consultant-Led) Percentage of patients waiting less than 6 weeks for a diagnostic test (DM01) % Patients waiting under 18 weeks (non reportable) Cancellation Rate IAPT - Percentage of people treated within 18 weeks of referral IAPT - Percentage of people treated within 6 weeks of referral 2016/ % 99.8% 99.7% 100.0% 99.8% 95% 2015/ % 99.9% 100.0% 99.9% 99.9% 2016/ % 99.9% 100.0% 99.9% 99.9% 92% 2015/ % 99.9% 99.8% 99.9% 99.9% 2016/ / / % 100.0% 100.0% 100.0% 100.0% 99% 2015/ % 100.0% 100.0% 2016/ % 98.7% 98.0% 97.8% 97.6% 95% 2015/ % % 99.0% 98.6% 2016/17-7.5% 8.0% 8.3% 8.3% 8.7% TBC 2015/16 6.3% 6.1% 6.4% 6.5% 5.1% 6.7% 2016/ % 98.9% 98.4% 99.8% 98.1% 95% 2015/ % 100.0% 100.0% 100.0% 100.0% 2016/ % 98.3% 99.8% 98.7% 97.7% 75% 2015/ % 98.7% 97.8% 98.6% 99.2% Each of the measures for discussion in the Responsive Domain Report are addressed in the Performance Brief this month. Please see section 1.2 for information on waiting times and section 2.1 for information regarding progress on the risk reserve. 21

61 Well Led Domain Re port Leeds Community Healthcare NHS Trust Well Led Domain Report Well Led - leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture YTD Target YTD Q1 Q2 Oct Nov Dec Forecast Overall Safe Staffing Fill Rate - Inpatients 2016/17 97% % 100.6% 100.0% 98.2% 100.1% 2015/ % 100.9% 100.0% 102.1% 101.0% Staff Turnover Rolling Year 2016/17 9% to 13% 14.6% 13.9% 14.0% 14.8% 15.7% 2015/ Executive Team Turnover 2016/17 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% / Short term sickness absence rate (%) 2016/17 1.6% 1.3% 2.0% 2.4% 2.2% 2.3% 2015/ Long term sickness absence rate (%) 2016/17 3.6% 4.4% 3.1% 3.5% 4.0% 4.0% 2015/ Total sickness absence rate (%) 2016/17 4.9% - 5.7% 5.1% 5.9% 6.2% 6.3% 2015/16-5.0% 5.2% 6.0% 5.7% 5.8% AfC Staff Appraisal Rate (12 Month Rolling - %) 2016/ % % 87.2% 86.4% 87.6% 85.7% 2015/ Medical staff appraisal rate (%) 2016/17 100% 86.4% 93.3% 98.0% 2015/ universal Statutory and Mandatory training 2016/ % % 86.5% 88.6% 89.8% 89.9% requirements 2015/ % 87.6% 88.9% 89.8% 81.1% 87.2% 2016/17 4,796k 1,926k 3,576k 382k 419k 419k Total agency cap 6,048k 2015/ /17 8.6% 9.6% 8.5% 5.9% 6.7% 7.3% Percentage Spend on Temporary Staff / Percentage of Staff that would recommend LCH as a 2016/17 57% % 42.8% place of work (Staff FFT) 2015/ % 44.0% Response Rate for Staff FFT 2016/17 23% % 21.0% 2015/ % 23.0% Response Rate for Inpatient FFT 2016/17 TBC - 9.7% 8.0% 12.3% 3.5% 2015/16-2.7% 2.1% 2.4% 2.1% 2.5% Response Rate for Community FFT 2016/17 TBC - 5.1% 3.0% 3.2% 2.5% 2015/ % 18.2% 20.0% 17.3% 1.0% 1. Appraisals The Trust s current position in relation to appraisals is included as a key area of focus in the Performance Brief section Statutory & Mandatory Training The level of staff compliance with universal statutory & mandatory training has increased slightly from 89.8% last month to 89.9%. The individual topics report as follows: Information Governance training is the highest compliance rate at 96.36% Equality and Diversity training is above target with a compliance rate of 94.96% Health and Safety (Slips, Trips and Falls) training has increased to 91.56% 22

62 Fire Training, Infection Prevention and Control and Moving and Handling are all below target compliance rate at 84.15%, 85.72% and 86.52%. A review is being undertaken with a couple of benchmarking Trusts to see what improvements could be made either around frequency/format of mandatory training. This is due for completion mid-january 2017 and an update will therefore be reported at Februarys Business Meeting. 3. Turnover The figure for the rolling year has increased from 13.9% at the end of Quarter 2 to 15.7% and remains above target. Work continues to progress the Organisational Development plan and determine priorities. A leadership development programme (LEAD) was launched in October 2016 to support leaders in their continued professional development. The FFT, Staff Survey, and Leaver s Conversation have all identified management as a key determinant of engagement, satisfaction, and intention to leave/turnover. The LEAD Programme aims to address this by investing in our leaders and building on the leadership potential in LCH. Turnover was a key area of focus in the last performance brief where the three services with the highest turnover rates were reported on. 4. Workforce Race Equality Standard (WRES) The trust target is based on the 2011 census which reports a Black and Ethnic Minority (BME) working age population at 19.2%, or 18.9% of the overall population. As at 2015/16 the trust reported a 12.02% BME workforce which is not reflective of the population it serves. The trust is required to report annually. Work continues to develop the BME networks and train managers in Unconscious Bias. 5. Staff FFT As the National Staff Survey is undertaken during Q3, the Trust does not send ask staff to complete the FFT. Q4 Staff FFT will be launched 21 February 2017 with a closing date of 14 March The paper which will be submitted at March Business Committee, in relation to appraisal and staff (as outlined in section 3.1 of the Performance Brief), will incorporate these results. 6. Sickness absence Sickness absence target for December 2016 is 4.9%. Sickness absence rate for December was 6.27%, which is broken down into Long-term absence at 4.02% and Short-term absence at 2.25%. Business Unit Adult Children Specialist Corporate and Executive Directorate Estates & Ancillary Staff (Operations) December 2016 absence rate 7.05% 4.63% 5.51% 5.47% 7.16% Following discussion with the Executive Director of Operations and Acting Director of Workforce with Chair of Staff side and subsequent discussion at Novembers JNCF, this has resulted in changes being made to the Managing Attendance Policy. 23

63 The changes include earlier support for staff on long term sick and earlier intervention for the management of short term sickness absences, which considers staffs ability to attend work on a regular basis, in order to fulfil their contract of employment, rather than questioning the validity of the absence. During December 2016, the Executive Director of Operations and Senior HR Manager met with 8 Leaders of teams with the highest rate of sickness absence to have a supported conversation about their sickness caseload and to:- Learn more about the culture of sickness management in the organisation Identify best practice Identify areas where practice could be improved upon both in individual team and across the organisation. The outputs from these sessions have been incorporated in a variety of ways such as revision of policy, incorporating difficult conversation training into sickness absence training, additional temporary resources to upskill managers and a myth-buster handy pocket guide for managers being produced. On-going support to managers to attend twice weekly drop-in sessions is also being introduced. Meanwhile, the new OH provider is in place, which is proving to provide more timely and comprehensive support to managers with a nurse led service, with access to a multi-disciplinary team. This encourages a more appropriate intervention in managing staff s health and well-being. From January, they will also be providing counselling support for staff. 24

64 Finance Re port Leeds Community Healthcare NHS Trust Finance Report Finance Net surplus (-)/Deficit (+) ( m) - YTD YTD Target YTD Q1 Q2 Oct Nov Dec Forecast 2016/17-2.0m - 0.1m - 1.8m - 0.2m 0.2m - 0.2m - 2.0m 2015/16-0.3m - 0.3m - 0.1m - 1.0m 0.2m - 1.1m 2016/17-2.9m - 2.9m - 2.9m - 2.9m - 2.9m - 2.9m Net surplus (-)/Deficit (+) ( m) - Forecast - 2.9m 2015/ m - 2.2m - 2.2m - 2.2m - 2.7m 2016/17-1.5m - 1.5m - 1.5m - 1.5m - 1.5m - 1.5m Forecast underlying surplus -1.5m 2015/ m - 1.5m - 1.5m - 0.8m - 0.8m Capital expenditure in comparison to plan ( k) - YTD Capital expenditure in comparison to plan ( m) - Forecast CIP delivery ( m) - YTD 2016/17 740k 354k 510k 624k 676k 740k 2,060k 2015/ /17 2.1m 3.2m 3.2m 2.1m 2.1m 2.1m 2.6m 2015/ /17 1.1m 0.2m 0.4m 0.4m 0.7m 1.1m 2.9m 2015/ /17 1.8m 0.7m 0.7m 0.7m 1.4m 1.8m CIP delivery ( m) - Forecast 3.9m 2015/ / Use of Resources Risk Rating (from Oct 2016) / Summary & KPIs The Trust is 53k ahead of the planned surplus at the end of December. The position includes non-recurrent benefit from un-utilised redundancy provisions and a reduction in estates costs. Pay costs for December continue to be less than planned which means in month the vacancy factor was delivered. Expenditure on agency staff is the same as last month. The Trust has been notified that it can spend 2.581m on capital this year which is 569k less than had been originally planned. The better payment practice code has been met for all four measures in months and the new use of resources risk rating is 1 reflecting lowest financial risk. The Trust is confident of delivering the planned surplus of 2.86m control total. Table 1 Key Financial Data Year to Date Variance from plan Forecast Outturn Performance Statutory Duties Income & Expenditure 1.5% retained surplus ( 2.0m) plus NHSI ( 0.86m) ( 2.0m) ( 0.1m) ( 2.86m) G Remain with EFL of 2.765m 2.765m G Remain within CRL of 2.581m 0.7m ( 1.3m) 2.152m G Capital Cost Absorption Duty 3.5% 3.5% G BPPC NHS Invoices Number 95% 98% 3% 95% G BPPC NHS Invoices Value 95% 100% 5% 95% G BPPC Non NHS Invoices Number 95% 95% 0% 95% G BPPC Non NHS Invoices Value 95% 97% 2% 95% G Trust Specific Financial Objectives Use of Resources Risk Rating 1-1 G CIP Savings 3.9m recurrent in year 1.1m -62% 1.8m R CIP Savings 0m non recurrent in year 1.8m 100% 2.1m G 25

65 2. Income & Expenditure The year to date financial position continues to show a small underspending against plan. This indicates the measures that have been taken to reduce expenditure are being maintained. The Trust has 62 wte less staff in post than funded and agency costs continue to run circa 0.4m a month. Non pay expenditure is 1.2m underspent at the end of December. The reduction in the last few months pay costs is reflected in the revised forecast outturn on pay which is now expected to be 2.1m overspent at the end of the year. The Finance team has worked closely with Business Unit colleagues to inform the forecast outturn; however the additional measures in place for the Neighbourhood Teams in respect of REAP level 4 responses are difficult to estimate with any certainty. There continues to be a small under achievement of income forecast in respect of missed shifts in police custody services. The Trust is required to deliver 1% surplus of 1.5m plus and additional stretch target surplus required by NHSI of 0.5m. It was agreed with NHSI that this would be delivered if the Trust received additional non recurrent funding from the CCGs, which we have, and a further 360k surplus is expected in respect of pass through of STP monies which cannot be spent. Given the reduction in expenditure over the last 4 months the Trust will be able to meet the control total without the need for additional savings. Table 2 Income & Expenditure Summary Income December Plan December Actual Contract YTD Plan YTD Actual Variance Annual Plan Forecast Outturn This Month Variance Forecast Variance last month WTE WTE m m m m m m m Contract Income (103.3) (103.2) 0.1 (137.7) (137.6) Other Income (7.6) (7.1) 0.5 (10.2) (9.5) Expenditure Total Income (110.9) (110.3) 0.5 (147.9) (147.1) Pay 2, , Non pay (1.2) (0.9) (1.1) Reserves & Non Recurrent (1.2) (1.8) (2.0) Total Expenditure 2, , (0.5) (0.6) (0.6) EBITDA 2, ,604.8 (3.8) (3.8) 0.0 (5.3) (5.1) Depreciation (0.1) (0.1) (0.1) Public Dividend Capital (0.0) (0.0) Profit/Loss on Asset Disp Interest Received (0.0) (0.0) 0.0 (0.0) (0.0) Retained Net Surplus 2, ,604.8 (2.0) (2.0) (0.1) (2.9) (2.9) Variance = (61.5) 2.1 Income Contract income for the year to date is running marginally behind plan as a result of penalties on the police custody contracts. This is driving the forecast underachievement for the year. The shortfall of other income relates to CICU, for April and May 0.1m. At this time the Trust is forecasting achievement of all CQUIN income and to deliver sufficient activity so the neighbourhood teams risk reserve penalty is not applied. The flu immunisation CQUIN requiring 75% of clinical staff to receive the vaccination was challenging but has been achieved. As the Trust has achieved its planned surplus at the end of Quarter 3 it will receive the next tranche of the Sustainability and Transformation Plan funding 215k which is included in the position reported here. The Trust has received payment of the 430 for the Quarter 2 tranche. 2.2 Pay Table 3 below illustrates the total pay costs by category. The underspending on substantive staff in post continues however the combined level of pay expenditure does not deliver the vacancy factor for the year to date; however during December the Trust underspent on pay costs by 70k after delivery of the vacancy factor. 26

66 Table 3 Last Month Forecast YTD Plan YTD Actual YTD Variance YTD Variance Outturn Variance Annual Pay Costs by Category k k k k k Cost of staff directly employed 76,798 73,634 (3,163) (2,630) Seconded staff costs Vacancy Factor (4,939) 4,939 4,390 Sub-total Direct Pay 72,395 74,244 1,849 1,811 Bank Staff 132 1,343 1,211 1,065 Agency Staff 6,048 4,796 (1,253) (999) Total Pay Costs 78,576 80,383 1,807 1,877 2,115 All business units continue to be overspent on pay at the end of December. Specialist services: Children s services: Adult services: QPD Clinical: 955k (Nov 912k, Oct 897k, Sep 773k) overspending mostly police custody and non-delivery of the vacancy factor for health and justice offset by an underspending in other specialist services. 862k (Nov 854k, Oct 803k, Sep 789k) overspending being mostly the nondelivery of the vacancy factor (2016/17 new target plus the historic target not being achieved) speech and language therapies and consultant paediatricians. 478k, (Nov 535k, Oct 689k, Sep 712k) overspending was on neighbourhood teams which are now underspending. 303k (Nov 212k, Oct 158k, Sep 137k) overspending. Work continues with the senior operations leadership to explore options for mitigations including additional senior review panels for all vacancies; these consider the quality impact of holding vacancies, look for alternatives to recruitment and the financial impact if the post is deemed essential. The Business Units have looked to reduce all variable staffing costs including agency bank and overtime usage. The main drivers for the overspending on pay are the increase in substantive staff in post, no real reduction in agency expenditure despite the increase in substantive staff and the requirement to reduce expenditure to meet the additional vacancy factor CIP. Table 4 Month on Month Pay Costs by Category April May June July August Sept Oct Nov Dec k k k k k k k k k Directly employed staff 8,260 8,445 8,298 8,258 8,132 7,964 8,252 8,031 7,994 73,634 Seconded staff costs Bank staff ,343 Agency staff ,796 Total Pay Costs 9,409 9,058 9,146 9,015 8,861 8,757 8,823 8,652 8,661 80,383 Agency costs overall are 419k this month which is the same as last month. There has been a reduction in the run rate of agency costs for all business units since June. The main areas of agency expenditure and associated staffing positions are: Specialist BU 1,497k (Nov 1,349k, Oct 1,231k) 6.07 wte more than planned Children s BU 720k (Nov 696k, Oct 673k) wte more than planned Adult s BU 1,347k (Nov 1,214k, Oct 1,119k) wte less than planned QPD Clinical 435k (Nov 345k, Oct 280k) 7.41 wte less than planned Corporate 521k (Nov 538k, Oct 464k) wte less than planned The Trust planned for agency expenditure of up to 6,048k to the end of December (to replace essential substantive staff vacancies) as part of the 8,064k agency cap. The Trust has spent 1,253k less than this. Agency staff are funded from underspendings on substantive staff as they provide the alternative capacity to 27 YTD Actuals k

67 enable services to continue care provision; an additional 0.5m has been included in planned pay costs in respect of an agency cost premium. 2.3 Non Pay Non-pay expenditure remains broadly consistent with last month. Over all non-pay is 1.1m underspent reflecting efforts to curb discretionary expenditure and this level of underspending will need to continue if the Trust is to achieve its planned surplus for the year. Table 5 3 Reserves & Non Recurrent Last Month YTD Variance Forecast Outturn Variance YTD Plan YTD Actual YTD Variance Year to Date Non Pay Costs by Category k k k k k Drugs (32) (9) Clinical Supplies & Services 6,860 6,703 (157) (215) General Supplies & Services 1,875 1,782 (93) (87) Establishment Expenses 4,802 4,511 (291) (285) Premises 10,213 9,669 (543) (444) Other non pay 1,628 1,588 (40) (42) Total Non Pay Costs 26,363 25,206 (1,156) (1,082) (934) The Trust has 3.0m in reserve at the end of December; of which 1.2m is committed; the balance of the reserves has been released into the financial position. 4 Service Line & Contract Performance Table 6 Annual Actual YTD YTD YTD YTD YTD YTD Budget Variance Correlation Budget Contract Budget Actual Variance Plan Actual Variance Service Line m WTE WTE WTE m m m Activity Activity Activity Specialist Services , ,130 (27,098) Childrens Services , ,062 12,188 Adults Services (25.6) , ,423 31,746 QPD Clinical (7.4) ,857 16,940 (3,917) Ops Management & Equipment (9.2) Service Line Totals , ,296.4 (6.9) ,305,635 1,318,555 12,920 Corporate Support & Estates (54.6) (1.1) Total All Services , ,604.8 (61.5) ,305,635 1,318,555 12,920 Operational Services have 6.9 less wte in post than planned in December with the 25.6 less in the Adult Business Unit offsetting overstaffing elsewhere. The services are a net 1.9m overspent year to date which is 0.1m reduction on the position reported at the end of October. All operational budgets continue to overspend year to date. At the end of December activity continues to run ahead of plan for Children s and Adult services and less than planned for Specialist and QPD Adult services. The Trust has a risk reserve in respect of Adult NT activity from August; given the performance year to date there is no financial impact of underperformance in the outturn forecast. Specialist services activities are 7.1% less than planned, Children s services activities are 4.6% more than planned, Adult NT services activities are 5.0% more than planned, and QPD Clinical services activities are 18.8% less than planned. 5 Cost Improvement Plans The majority of the cost savings for 2016/17 were planned to come from underspendings on pay as a result of the level of staff turnover and the reduction in agency costs as a consequence of more substantive staff being in post following successful recruitment campaigns. The current overspending on pay means the additional vacancy factor for 2016/17 isn t being delivered in full; however the reduction in pay expenditure means that the vacancy factor is now being partially delivered. 28

68 All other efficiency savings are being delivered as planned. Given the forecast overspending on pay costs is 2.1m there is 1.1m forecast vacancy savings for 2016/17. Table 7 6 Capital Expenditure 2016/17 YTD Plan 2016/17 YTD Actual 2016/17 YTD Variance 2016/17 Annual Plan 2016/17 Forecast Outturn 2016/17 Forecast Variance NHS Improvement has confirmed the Trust is permitted to spend 2.581m in 2016/17; the Trust had originally requested permission to spend 3.15m but has curtailed expenditure at NHS Improvement s request; pending notification of the approval limits. The forecast outturn capital expenditure has been reviewed and stands at 2.1m; further work continues to finalise this with the Estates and IT teams. Now the CRL has been agreed the Trust has been able to release capital equipment funds. In month expenditure has been on the electronic patient records project. 2016/17 Forecast Variance Savings Scheme k k k k k k % Vacancy factor 2, (1,807) 3,195 1,080 (2,115) -66% Drugs % Non Pay % Estate maintenance % Travel % Total Efficiency Savings Delivery 2,937 1,130 (1,807) 3,915 1,800 (2,115) -54% Table 8 Scheme YTD Plan m YTD Actual m YTD Variance m Annual Plan m Forecast Outturn m Forecast Variance m Estate maintenance (0.4) (0.3) Equipment/IT (0.3) (0.1) Electronic Patient Records (0.6) CAMHS Inpatients Estate (0.8) NHSI adjustment - approved spend (0.6) 0.6 Totals (1.3) (0.5) 7 Statement of Financial Position Table 9 has the statement of financial position as at the end of December. The balance sheet continues to run marginally ahead of plan in respect of the variance on the Income and Expenditure account. Trade and other receivables are 2.3m above plan and trade and other payables, including provisions for redundancies 0.8m above plan. The variances in working capital against plan and the adverse variance on I & E mean that the cash position is 1.6m lower than planned. The main reason for this is the payment of the leases for LIFT premises where the Trust has agreed a different payment schedule to the one originally planned. Trade receivables total 9.5m at the end of December. The largest debtor is Leeds City Council which owes 2.9m. Accrued income totals 2.4m, made up of 0.7m for CQUIN income and 1m for non-contract income. Contract income can be broken down between 0.2m for Leeds City Council and 0.1m for police. The non-contract income is with the CCGs. The payment of the leases for LIFT premises has led to a prepayment of 1.6m. Trade payables total 10.8m at the end of December. Accrued expenditure totals 4.6m, made up of 1.5m for property charges and various other smaller accruals. 29

69 Table 9 Plan 31/12/16 Actual 31/12/16 Variance 31/12/16 Opening 01/04/16 Planned Outturn 31/03/17 Forecast Outturn 31/03/17 Forecast Variance 31/03/17 Statement of Financial Position m m m m m m m Property, Plant and Equipment (1.5) (0.8) Intangible Assets (0.0) Total Non Current Assets (1.5) (0.8) Current Assets Inventories Trade and Other Receivables Cash and Cash Equivalents (1.6) Sub-Total Current Assets Non-Current Assets held for sale Total Current Assets TOTAL ASSETS (0.6) (0.1) Current Liabilities Trade and Other Payables (11.9) (10.5) 1.4 (13.5) (11.1) (10.2) 0.9 Provisions (0.2) (1.0) (0.8) (1.3) (0.2) (1.0) (0.8) Total Current Liabilities (12.1) (11.5) 0.6 (14.8) (11.2) (11.1) 0.1 Net Current Assets/(Liabilities) TOTAL ASSETS LESS CURRENT LIABILITIES (0.0) (0.0) Non Current Provisions (0.1) (0.1) 0.0 (0.1) (0.1) (0.1) 0.0 Total Non Current Liabilities (0.1) (0.1) 0.0 (0.1) (0.1) (0.1) 0.0 TOTAL ASSETS LESS LIABILITIES (0.0) (0.0) TAXPAYERS EQUITY Public Dividend Capital Retained Earnings Reserve (0.3) General Fund Revaluation Reserve (0.0) TOTAL EQUITY (0.0) Working Capital Chart 1 reflects the Board approved financial plan submitted to NHS Improvement 29 June The planned, actual and forecast cash positions until the end of March 2017 are illustrated. The Trust s cash position is strong at 14.4m however the prepayment of leases and the working capital position from above means there is 1.6m less than planned this month. Chart 1 Table 10 Cumulative Performance This Month Cumulative Performance Last Month Target RAG Measure NHS Invoices By Number 98% 99% 95% G By Value 100% 100% 95% G Non NHS Invoices By Number 95% 95% 95% G By Value 97% 98% 95% G The Trust s performance against the Better Payment Practice Code target of 95% continues to be met at December. 30

70 9 Use of Resources Risk Rating Table 11 reports the Trust s financial performance calculated using the single oversight framework; which has revised criteria to determine an overall use of resources risk rating. This replaces the old sustainability and financial risk rating (SFRR). The Trust continues to score 1 at the end of quarter 3 which is the lowest risk. Table 11 Criteria Metric Performance Rating Weighting Score Liquidity Liquidity ratio (days without WCF) % 0.2 Balance Sheet sustainability Capital servicing capacity (times) % 0.2 Underlying performance I&E margin 2% 1 20% 0.2 Variance from plan Distance from plan % 0.2 Agency spend above ceiling Agency -21% 1 20% 0.2 Overall Use of Resources Risk Rating 1 10 Conclusion on Financial Performance The continued reduction in overall costs has meant the Trust continues to be marginally ahead of its planned surplus at the end of December as the recovery plan actions have taken effect and pay costs have reduced following staff turnover and a reduction in agency costs and the Trust is now confident of achieving the control total set by NHSI. 31

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72 AGENDA ITEM Meeting Trust Board 3 February 2017 Report title Safe Staffing Responsible director Executive Director of Nursing Report author Executive Director of Nursing Previously considered by Not applicable Category of paper (please tick) For approval For assurance For information PURPOSE OF THE REPORT The paper describes the background to the expectations of boards in relation to nurse staffing, outlining where the Trust is meeting the requirements and where there is further work to be undertaken. The report is written in the context of the current system and local pressures MAIN ISSUES FOR CONSIDERATION The report sets out progress in relation to maintaining safe staffing over the last six months. Updates are provided on the additional key areas of agency staff expenditure and development of the e-rostering tool. Safe staffing has been maintained across all inpatient units for the time period. Units have also continued to provide safe and caring high quality care. Detail is provided in relation to neighbourhood teams and current pressures both internally and across the system as a whole. A detailed update was provided to Quality Committee on 23 January 2017 as to how safe patient care has been maintained during this time. The health visiting service has been making good progress in relation to caseload size in line with recommendations. Changes to commissioning intentions mean that the progress will be challenged going forward RECOMMENDATIONS The Board is recommended to: Note the recruitment drive and work to support new staff Note the national monthly collection and publication of staffing data as recommended in Hard Truths Note that staffing levels are kept under constant review to maintain and ensure they are safe Note the contents of the report and the progress being made and support six monthly reviews in a public Board meeting. 1

73 1.0 BACKGROUND 1.1 In line with the NHS England requirements and the NQB recommendations, this paper presents the six monthly nursing establishment s workforce review and sets out the approach taken by the Trust to ensure that there is sufficient nursing capacity and capability in all in-patient areas to meet the needs of our patients and maintain safe staffing across services. 1.2 Staffing levels are kept under regular review on a shift by shift basis by the nurse in charge or Operational Manager in liaison with Clinical Lead and monitored in operations across the Trust on a daily basis. The staffing levels are monitored by senior staff and detailed in the monthly performance panels and in-depth bi-annual report. 1.3 The determination of safe staffing levels is not a single process but rather an on-going review taking into account clinical experience in running the wards or team, the quality of service as determined by outcomes, including patient experience and national guidance and development of further tools. The Trust awaits further national guidance following the reframing of the national work that was being undertaken by NICE. There are also important changes ahead post the removal of the student bursary for nurses in training. This may have significant implications in terms of numbers and the profile of those coming forward to take up nurse training. Funded places will also end for post registration programmes such as the specialist practitioner pathway. 2.0 AGENCY SPEND AND CAP The government continues to issue guidance and work to drive down agency costs and agency caps and rules remain in force. 2.1 Figure 2: Agency spend % by Business Unit 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% CBU % Spend on Agency % Spend on Agency Target 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% ABU % Spend on Agency % Spend on Agency Target 2

74 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% SBU % Spend on Agency % Spend on Agency Target 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% LCH % Spend on Agency % Spend on Agency Target 2.2 The Trust shows a downward trend from September 2016 onwards towards the 4% ceiling. Across the business units, of note is the high spend on agency in the Adults Business Unit which is reducing. Within Children s the levels of agency spend has significantly decreased; this is due to the reduction of spend on medical staff where a small proportion of a medical time creates a high spend. 2.3 The Trust has undertaken work across a number of areas in to reduce agency spend. There has been on-going dialogue with staff and information in weekly messages to ensure that staff are aware of the work to ensure that we maintain focus on quality but also work within the guidance and towards financial requirements. This has seen the Trust ranked 14 th in the region against agency spend against the agreed target. 3.0 SAFE STAFFING 3.1 Although this paper focuses on nursing numbers and a crude separation of registered from non-registered staff, it is of course recognised that staffing levels to provide a high quality service rely on much more than the simple numbers. Other factors that need to be taken into account include the multidisciplinary team including, in particular, medical and therapy staff, the skill mix of all the staff within the team, the leadership and engagement of the staff on the unit or in the team. This is within an overall Trust wide culture which enables staff to feel supported in delivering high quality care, empowered to bring about necessary changes and having no concern about escalating issues to senior colleagues. 3.2 The Trust provides a small number of inpatient beds across care of the older person/rehabilitation, respite care for children with a disability and child and adolescent mental health services (CAMHS) inpatients. The Trust also provides a wide range of community services and home based care. As there is no national definition of safe staffing, a unit or team will be considered to have safe staffing numbers if the numbers of staff allow the following to occur:- Patients can be treated with care and compassion. All patients have a thorough and holistic assessment of their needs All patients have a care plan which sets out how the goals for their admission, care plan or treatment episode will be set. 3

75 Staffing numbers allow full and timely implementation of the care plan. Staff numbers are sufficiently robust to allow the team or unit to function safely when faced with expected fluctuations and with the inevitable occurrence of short term sickness of staff. Operational Managers and Unit Managers are able to call upon additional resources if this is required by the particular needs of the inpatient group on a particular shift. A clear system of outcomes focussed on patient experience, patient safety and patient outcomes are in place and the information from these measures informs how the Operational and Clinical Leads run services. There is not an undue reliance on temporary staff to fill nursing rotas. The agreed processes for clinical prioritisation are followed in periods of escalation 4.0 THE NATIONAL PICTURE ON SAFE STAFFING 4.1 Following on from the CNO s expectations, a joint letter from NHS England and CQC was sent to all Trusts in March 2014 setting out expectations on the delivery of the commitments. Whilst much of the guidance is focussed at acute hospitals and / or ward environments, it is expected that the principles are rolled out across all settings. In addition the National Quality Board (NQB) published guidance in November 2013 in relation to nursing, midwifery and care staffing capacity and capability, How to ensure the right people, with the right skills, are in the right place at the right time. This was followed in March 2014 by the Hard Truths Commitments regarding the publishing of Staffing Data Timetable of Actions, which made a number of commitments to make nurse staffing levels more publicly available. The document provides guidance on the information which Trusts should aim to cover in the 6 monthly establishment review. 4.2 NQB Hard Truths Requirements and the LCH Compliance Hard Truth Expectation Compliant 1 Presentation of nursing establishment review to the Board, every six Y months 2 Staffing information displayed at ward level (planned & actual) Y 3 Presentation of actual and planned staffing levels & exception Y report to the Board each month 4 Submission of monthly staffing data via Unify Y 5 Publication of the monthly report on the Trust website & NHS Choices Y In addition to the NQB requirements, the NQB (2013) document How to ensure the right people, with the right skills, are in the right place at the right time, provides guidance on what information the six monthly establishment review should contain for the Board report. 4.3 NQB Guidance and LCH Achievement What the Board must Do Details to be covered in the Board Report 1 The difference between current establishment and recommendations following the use of evidence based tool(s) (Expectation 3) 2 What allowance has been made in establishments for planned and unplanned leave (Expectation 6) Achieved Partial due to lack of evidence based tools for community Yes 4

76 3 Demonstration of the use evidence based tool(s)(expectation 3) Partial as 1 4 Details of any element of supervisory allowance that is included Yes in establishments for the lead Sister / Charge Nurse or equivalent (Expectation 6) 5 Evidence of triangulation between the use of tools and Yes professional judgement and scrutiny (Expectation 3) 6 The skill mix ratio before the review, and recommendations for Yes after the review (Expectation 3) 7 Details of any plans to finance any additional staff required Yes (Expectation 9) 8 The difference between the current staff in post and current Yes establishment and details of how this gap is being covered and resourced 9 Details of workforce metrics - for example data on vacancies (short and long-term), sickness / absence, staff turnover, use of temporary staffing solutions Yes 10 Information against key quality and outcome measures - for Yes example, data on: safety thermometer or equivalent for nonacute settings, serious incidents, healthcare associated infections (HCAIs), complaints, patient experience / satisfaction and staff experience / satisfaction 5.0 THE LOCAL PICTURE ON SAFE STAFFING 5.1 In line with the NHS England requirements and the NQB recommendations, this paper presents the six monthly nursing establishment workforce review and sets out the approach taken by the Trust to ensure that there is sufficient nursing capacity and capability in all service areas to meet the needs of our patients and maintain safe staffing. 5.2 The Trust has complied with NQB recommendation that monthly planned and actual staffing data is uploaded to Unify (appendix 1). The planned and actual, qualified and care staff hours are calculated to provide a fill rate. A number of months are currently being reviewed as unit managers believe there was a higher fill rate than reported. This is likely due to not updating when shift patterns and staffing models are altered in a timely way. The unit managers are assured safe staffing was maintained. 5.3 Several systems need to be in place to support the delivery of safe nursing numbers on each service area. These include, but are not limited to: The Trust operates a staffing bank and works in partnership with other staffing agencies, which enables managers to call upon additional skills as required whilst complying with the new agency rules and requirements. Work is on-going to develop and increase bank staff through, for example, opening opportunities to practice nurses who may be looking for additional work. The Trust continues to invest in nurse recruitment and as reported previously has moved to a position of very low vacancy levels in summer. This picture has changed significantly for a number of possible reasons. This is in part due to the anticipated numbers of nurses not taking up post in the Autumn and the rolling recruitment programme was temporarily suspended. For the first time a number of neighbourhood teams are requiring daily support and review to ensure that essential work and safe care is maintained. This is undertaken against a set of published criteria and monitored on a daily basis. 5

77 The Trust continues to develop new opportunities and engage in planning Leeds work such as the successful nursing associate pilot. Ten staff recruited internally have just started the programme this month Clear systems are in place to ensure that there is feedback from patients and carers who use the services and that reflection and concerns from patients and carers are acted upon. The Quality Challenge self-assessments have been completed and some teams are on to their second peer visit. The Trust continues to develop the electronic allocation system to support safe staffing Reporting systems and escalation continue to be reviewed and developed in the Adult Business Unit (ABU) 6.0 WORKFORCE METRICS 6.1 The Trust reports separately on a monthly basis to Board on figures in relation to staff sickness, absence and recruitment and retention and these are included within the relevant sections of the report. 6.2 Workforce Management: the Trust is investing in a workforce management project, a key part of which is set to procure and implement an e-rostering application for the Trust. This will help to streamline work around rostering of staff, providing enhanced management information, improve demand and capacity management both within Neighbourhood Teams and across the city and deliver improved patient safety, clinical effectiveness and efficiencies through increased productivity and is in line with recommendations being made within the work of Lord Carter. 6.3 Once the initial pilot services have been fully implemented and the system brought up to the complete standard, there will be wider roll out across the Trust with an initial focus around the Adult Business Unit. The scope of e-rostering with several key benefits will be coming to fruition and functionally continue to expand. The roll out process will complete in 2019/20. The timeline is based on assessment of a number of work streams underway and services capacity to cope with further significant change. The project implementation will be monitored via SMT and Business Committee. 7.0 CURRENT POSITION 7.1 The Board receives information on a monthly basis for inpatient units as part of the integrated performance report. The Trust began collecting data on each of its inpatient units in April 2014, with the first staffing report published externally in May The units included are: Community Intermediate Care Unit Hannah House Little Woodhouse Hall Community Rehabilitation Unit South Leeds Independence Centre (SLIC) 6

78 7.2 There have been a number of changes in relation to inpatient beds over the last six months. As the Board are aware, Ward J31 (CICU) returned to LCH on 5 June The commissioners continue to review the provision of community intermediate care beds and may choose to go down a re-procurement route. This has potentially significant implications for the Trust. 8.0 SLIC Following discussions in October and November 2015 with commissioners SLIC returned to the model originally proposed of 30 nursing and 10 residential beds. The agreed model was up to 8 high, 12 moderate, 10 low dependency beds and 10 residential beds, with some flexibility of the exact proportions of these numbers when supported by the unit manager after a review of the current patient dependency levels. Over the months the reality has been that the unit typically runs with high dependency patients and the residential beds have been difficult to fill. In December 2016 in response to system wide pressure it was agreed to trial opening the 10 residential beds to those with identified longer term care needs and whilst waiting for placement or packages of care. The care needs and intensity should not be different but the individuals are not felt to have rehabilitation potential. The staffing model remains: Daytime 2 wings / 1 floor will be assigned for the higher needs individuals with staffing levels at 2 RNs and 3 CSWs. Daytime 2 wings / 1 floor will take only low dependency and residential people with staffing levels at 1 RN and 2 CSWs. There is an agreement that staffing levels can be increased on a short term basis to support the changes introduced in December based on the assessment of the unit manager with the service lead. At night the staffing levels are 3 RNs and 2 CSW for 40 beds across 2 floors. The staffing levels are supported during the daytime period by the Therapy staff that work across the 7 day week. Safe staffing levels are monitored on both the day and night shifts on a daily basis and escalated to the service lead and reported through the daily escalation. Safe staffing is now also recorded on the quality board. Any short and longer term shortages are primarily filled by the LCH bank CLaSS Service. The approach is to limit the use of agency staffing whenever possible. 8.1 Agency Staffing The unit remains dependent on a small group of consistent agency staff to cover some long-term staff absence and vacancies. This picture will vary dependent on the outcome of commissioning plans and intentions 8.2 Key Quality Indicators The unit has increased a 4% increase in admissions. All patients have an expected discharge date on admission. The unit has maintained safe staffing levels and for example in December data for accuracy. 7

79 The unit continues to provide safe care. The unit is using its quality board to monitor this and provide a focal point for safety huddles. In-patient falls per 1000 bed days fell to its lowest level 3.1 over December. Indicator July Aug Sept Oct Nov Dec FFT 98% 98% 98% 98% 98% 98% Safety Thermometer 79.5% 90.0% 96.6% 92.0% 96.2% 92.6% Complaints Concerns PALS Incidents Serious Incidents 9.0 COMMUNITY NEUROLOGICAL REHABILITATION UNIT 2 fractures from falls 1 Grade 3 pressure ulcer This regional unit consists of five inpatient beds and five day case places with additional community based services. Patients are typically admitted to the unit for two week episodes of care and assessment. The unit has reviewed its staffing model in line with the model of care. Safe staffing levels are maintained. 9.1 Activity The data below reflects the change to the model of care and reduction to five inpatient beds from ten and increase in day case and community services 8

80 The unit provides safe care as indicated in the matrix below. The service uses a quality board. Patients care plans are reviewed at the weekly multi-disciplinary team meeting. Indicator July Aug Sept Oct Nov Dec FFT 100% 100% 100% 100% 100% 100% Safety Thermometer Complaints Concerns PALS Incidents (LCH only reported in month) Serious Incidents HANNAH HOUSE The specialist unit provides short breaks for children with complex disabilities and long term health needs. The unit has continued to experience some challenges around long term staff sickness and absence. The unit maintains safe staffing through use of a small bank of staff. Agency workers are rarely used and there is a careful induction process prior to using any agency registered nurse where not known directly to the unit. The clinical lead for the business unit has also been providing additional support in the absence of the unit manager. The unit has maintained safe staffing Key Quality Indicators The unit introduced a quality board in December which is being embedded into daily practice. The unit continues to provide safe care. One complaint was made to the CQC in this quarter and this was fully reported and investigated. 9

81 Indicator July Aug Sept Oct Nov Dec FFT 100% Complaints, Concerns Pals Incidents Serious Incidents LITTLE WOODHOUSE HALL Little Woodhouse Hall provides the CAMHS inpatient service. Due to the specialist nature of the unit and needs of the young people safe staffing levels are maintained at all times. Where young people have complex needs or in line with the individual risk assessment additional staff may be rostered Key Quality Indicators The unit has been subject to two unannounced inspections by the CQC. This highlighted areas of concern in particular in relation to the identification of ligature risks and same sex accommodation. As a result LCH commissioned a further external independent review of ligature risks. An improvement plan was developed and overseen by the clinical team with corporate support. A major estates programme was instigated and the unit closed to new admissions for a period of weeks to complete a programme of anti-ligature work. All incidents are also reported to the commissioner as per the contract specification. Very often incidents are related to an individual and the unit has a careful process of risk assessment and care planning review in place. Indicator July Aug Sept Oct Nov Dec FFT 100% Complaints, Concerns Pals Incidents Serious Incidents NEIGHBOURHOOD TEAMS As previously stated there are no nationally agreed staffing levels for community teams or evidence based tools. The Trust continues to develop the work to set safe staffing levels in community teams. The work remains in development and there can be anomalies between what the data is reporting and the felt experience of staff on the ground. Nationally it is hoped that safe staffing indicators for community teams may be published in 2017 towards the year end. A major programme of work has been led by the Executive Directors of Operations and Nursing to support the leadership team and neighbourhood teams. This work is reported through quality committee and business committee 10

82 12.1 System Escalation Over the New Year week-end Reap Level 4 was declared in response to both systems wide and internal pressures. For the first time safe staffing was challenged across all teams. As stated previously this was compounded by a number of factors such as the intense sustained system wide pressure, fewer new nurses taking up post and sickness levels in a number of teams. Rolling recruitment has been reinstated. We continue all recruitment activity and attendance at recruitment fairs. Extensive efforts were made via agencies and partners to source additional staffing. A suite of measures has been implemented to support safe staffing. This includes additional hours, paying overtime and using staff from across business units to support. Staffing levels have been reviewed daily at silver command to ensure all essential work is covered and in accordance with the escalation framework Neighbourhoods Demand & Capacity Tool The Neighbourhood teams operate 24 hours a day, 7 days a week, 365 days a year. The service is delivered in two component parts - the daytime service operates across thirteen neighbourhoods from 07:00-21:45 hrs. There is a single city-wide night service which operates 21:00-07:30 hrs to ensure effective handover. Some elements of the service - the community Matron service and the Adult Physiotherapy service - operate 08:00-17:00, Monday Friday. Work continues to develop and refine the Neighbourhood s Capacity & Demand Tool. The EPR programme also continues to roll out, although at an agreed slower pace and this provides important information. The Director of Operations and Director of Nursing met with the leadership teams for each cluster in November and December to review performance across all domains and identify any additional support needs and required actions. The majority of teams are reporting increased activity and referral levels. Ongoing work is required in relation to outcoming in order to continue to demonstrate this. Indicators such as preferred place of death and increase in numbers achieving this also evidence increased intensity and complexity of care. 11

83 12.3 Safe Staffing The table below provides information on current establishment and compliance. To ensure consistency with information provided to other forums the administrative establishment has been included in the table. However to allow direct comparison with previous months (April-September), the analysis in the following paragraphs relates solely to clinical staff. The overall vacancy position stands at 52.2WTE. This is a significant deterioration in the position reported at the end of October The graph below shows the movement in the overall staffing position by highlighting starters and leavers and the net position. As discussed at the last Business Committee the Trust expected a larger influx of new starters (newly-qualified staff) in September/October than actually started in post. In anticipation of a period of over-recruitment the rolling recruitment was paused and only commenced again in late October. A recruitment drive is underway with 13 WTE in the recruitment pipeline and a further 17 candidates have been invited for interview in the next week. This will not address the gap in supply. A recruitment summit will be held to consider initiatives to improve recruitment and retention. The Adult Business Unit has a plan in place to attract staff who wish to work in the evening only; to attract third year students to 12

84 clinical assistant posts; to support recent retirees with revalidation; to block book CLaSS staff, etc. The Clinical Lead has reviewed all the vacancies in the teams and the reasons why the last postholder left. The key reasons were: Internal movement (15/53) Retirement (6/53) Relocation (5/53) Work life balance (6/53) Morley, Woodsley, Seacroft, Middleton (3) Didn t want to work shifts or change role or travel (4/53) Private sector/gps (7/53) The level of maternity leave has increased by 4 WTE since end of October. The level of vacancy and maternity leave results in a shortfall of 11.7% against establishment. The overall sickness absence rate for Neighbourhoods was 43 WTE, which equates to 7% of establishment. The following tables show the sickness rate by Neighbourhood Team in December and year to date (YTD). 13

85 Reducing the sickness level remains a key objective in ensuring the necessary capacity to meet patient need; however despite tightening up on process within the Business Unit there has been no improvement in the position. In December the Director of Operations and Senior HR Manager interviewed the managers of the eight teams with the highest year to date sickness in the Trust (up to end September 2016). At that time this included Seacroft, Kippax, Wetherby Neighbourhood Teams and the Night Nursing Service. Key themes from the interviews included: many examples of understanding and compassionate management of sickness absence; however there was a tendency to sympathise with the member of staff who was absent rather than the stretched team having to pick up the individual s work excellent practice but also reluctance from some to move through the policy to the formal stages, particularly if it was felt that the absence was legitimate. Many cases where staff had not been referred to occupational health in a timely manner Lack of appetite to visit/contact people whilst off sick Some managers felt ill-equipped to have difficult conversations On balance the proposed changes to the sickness absence policy would be helpful around the cultural aspects. It is recommended that there was difficult conversation training commissioned particularly for managing sickness absence Quality Indicators The data below is taken from the performance report that is being developed. There is further work to be completed to ensure that data sources are consistently used. The detailed complaints data for example is reported on a monthly basis to quality committee. A major programme of work in the ABU has been in place since summer to support the delivery of safe and effective care across all neighbourhood teams. Quality boards and safety huddles have been introduced and positively received by teams. A number of teams have had harm free months across the major harms and the reported data is much more detailed and appropriate to the safety thermometer. Each team now has a quality portfolio setting out progress against our agreed measures and monitored via the Friday morning Neighbourhood Clinical Quality Leads Meeting 14

86 13.0 HEALTH VISITING Caseload size recommendations are based on Lord Laming s report following the death of Victoria Climbie and reviewed following Baby P s death. The national average for caseloads should be 400, with a reduction to 250 for the most deprived areas. Across the country there are many differences, London obviously struggles the most and have had huge caseload sizes. North York has caseloads sizes of approx 400 but covers a huge area. Leeds made very significant progress under the Health Visiting Call to Action and this work has been positively received regionally and nationally. With the end of the programme the commissioning landscape has changed significantly. The Family Nurse Partnership has been decommissioned. The commissioners have indicated that they wish to review the service and there are potentially significant risks around caseload size. The uncertainty has meant it was not possible to offer last year s 14 students posts. The service presented an overview of the service to Quality Committee in January and will be providing the patient story to February board. Beeston (Parkside) Average Caseload 281 Bramley/Pudsey Average Caseload 424 East Leeds/Halton Average Caseload 308 Harehills/Leafield Average Caseload 404 Kirkstall Average Caseload 408 Yeadon Average Caseload 532 Chapeltown/ Meanwood Average Caseload 317 Middleton Average Caseload 394 Morley Average Caseload 515 PE/Seacroft/Wetherby Average Caseload 469 Thornton Average Caseload 320 The teams in GREEN are in the high priority areas of the city. 15

87 14.0 CONCLUSION This paper presents the second six monthly reviews to Board in relation to safe staffing. The paper demonstrates that the Trust has maintained safe staffing in the six months. It also sets out and describes where the Trust has work in place to support and further develop work. The current pressures and challenges are set out and an overview of how these are being managed. The Trust will continue to monitor national guidance as released as this is likely to have significant impact RECOMMENDATIONS The Board is asked to support to: Continue to develop the staff bank to improve the responsiveness in providing appropriately trained area specific staff when needed and ongoing reduction in the need for agency usage Continue the recruitment drive and work to support new staff Continue to meet the national monthly collection and publication of staffing data as recommended in Hard Truths Keep staffing levels under constant review to maintain and ensure they are safe Note the contents of the report and the progress being made and support six monthly reviews in a public Board meeting 16

88 Appendix 1 17

89 Appendix 1 18

90 AGENDA ITEM Meeting Trust Board 3 February 2017 Report title CQC inspection report: York Street Practice Responsible director: Executive Medical Director Report author: Executive Medical Director Previously considered by N/A Category of paper (please tick) For approval For assurance For information Purpose of the report This paper provides the Board with the final report of the Care Quality Commission (CQC) inspection of York Street Practice carried out in October The report from was received by the Trust in December Main issues for consideration The CQC carried out an announced inspection of York Street Practice on 20 October The report from the inspection, received in December 2016, gave the service an overall rating of Outstanding. This overall rating was derived from ratings against each of the five domains used by the CQC to rate services. The breakdown for each domain is as follows: Safe-outstanding Effective-good Caring-good Responsive-outstanding Well led-good. The full report is attached. This is a very welcome outcome for a highly valued service and reflects the hard work and dedication of the local team. Recommendation The Board is recommended to: Note the CQC inspection report Page 1 of 1

91 York Street Health Practice Quality Report 68 York Street Leeds LS9 8AA Tel: Website: Date of inspection visit: 20 October 2016 Date of publication: 20/12/2016 This report describes our judgement of the quality of care at this service. It is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information given to us from the provider, patients, the public and other organisations. Ratings Overall rating for this service Outstanding Are services safe? Outstanding Are services effective? Good Are services caring? Good Are services responsive to people s needs? Outstanding Are services well-led? Good 1 York Street Health Practice Quality Report 20/12/2016

92 Summary of findings Contents Summary of this inspection Overall summary 2 The five questions we ask and what we found 4 The six population groups and what we found 9 What people who use the service say 13 Outstanding practice 13 Detailed findings from this inspection Our inspection team 15 Background to York Street Health Practice 15 Why we carried out this inspection 15 How we carried out this inspection 15 Detailed findings 17 Page Overall summary Letter from the Chief Inspector of General Practice We carried out an announced comprehensive inspection at York Street Health Practice on 20 October Overall the practice is rated as outstanding. Our key findings across all the areas we inspected were as follows: Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised. Six monthly thematic reviews of reported incidents were undertaken and actions identified to minimise reoccurrence. All staff attended a daily huddle meeting to discuss any issues which had arisen in the 24 hours preceding the meeting and to review and action any outstanding issues. We saw evidence of minutes from meetings and an up-to-date and ongoing action log. There were comprehensive safeguarding systems in place to enable staff to identify any areas of concern, act upon them in a timely manner and protect patients and staff from abuse. All clinical staff had formal safeguarding supervision with a member of the local safeguarding team on a regular basis. The practice actively reviewed complaints and how they were managed and responded to. There was open access to the practice manager where complaints could be dealt with as they arose. The practice had good facilities and was well equipped to treat patients and meet their needs. Patients emotional and social needs were seen as equally important as their physical needs. Patients said they were treated with compassion, dignity and respect. There was wide-ranging evidence of multi-agency working, where the practice worked closely with other organisations, such as outreach services, refugee councils and homeless shelters, in ensuring services were provided to meet patients needs. We received numerous extremely positive testimonials to support this. 2 York Street Health Practice Quality Report 20/12/2016

93 Summary of findings The practice had regular liaison with the Home Office and refugee camps to ensure there was a cohesive approach and the refugee/asylum seekers had timely access to care and support. The practice had strong and visible leadership and governance arrangements in place. Staff said felt very supported by management and the team as a whole and there were supportive mechanisms in place. All staff had access to a psychologist once a month and counselling sessions were available as needed. Staff were supported to attend mindfulness courses. There was a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff. We saw several areas of outstanding practice including: There were comprehensive systems in place to support safe practice. The whole team was engaged in reviewing and improving safety and safeguarding systems. The review of all incidents and the learning which arose from those was shared with their provider and external agencies, depending on the appropriateness and confidentiality aspects. There was an ongoing RAG rated action plan used to capture and ensure all issues or status reports were discussed or actioned at all meetings. (RAG is a system based on Red, Amber and Green colours used to rate issues.) Staff were motivated and inspired to offer kind and compassionate care. For example, they provided suitable clothing for children and adults, food parcels, Christmas gifts, paid for transport for patients to attend appointments and raised money to aid patients as needed. The practice had won several awards for the delivery of compassionate care. Most recently, as part of the Pathway Group of organisations who provide services for homeless people, they had recently received the 2016 Kate Granger award for delivering outstanding compassionate care. The practice delivered weekly outreach sessions for the homeless. Twice a month clinicians worked through the night, to provide access to health care and support for street sex workers. Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice 3 York Street Health Practice Quality Report 20/12/2016

94 Summary of findings The five questions we ask and what we found We always ask the following five questions of services. Are services safe? The practice is rated as outstanding for providing safe services. Risk management was comprehensive, well embedded and recognised as being the responsibility of all staff. The whole team were engaged in reviewing and improving safety and safeguarding systems. All events were discussed at the daily huddle, weekly practice meetings and the monthly clinical meetings. The practice used every opportunity to learn from incidents and to support improvement. Learning was based on thorough analysis and investigation. The practice could evidence changes which had been made as a result. Six monthly thematic reviews of reported incidents were undertaken and actions identified to minimise reoccurrence. For example, there had been three immunisation errors, which had been discussed with staff and a review of the process undertaken. This had resulted in significant improvements. There was an ongoing RAG rated action plan used to ensure all issues or status reports were discussed or actioned at all meetings. The practice undertook individual case reviews of unexpected deaths of patients. The review of all incidents and the learning which arose from those was shared with their provider Leeds Community Health Care Trust. Relevant learning was also shared with external agencies, such as secondary care services, the Home Office, refugee councils or homeless workers; depending on the appropriateness and confidentiality aspects. There was a daily 'sign in and out' board so everyone knew where individual staff were, for example if they were participating in outreach services or visiting a patient. All clinical staff had safeguarding supervision with a member of the local safeguarding team on a regular basis. There were comprehensive systems in place and regular audits undertaken with regard to medicines management and the prescribing of opioids (potentially addictive pain relief medicines). Outstanding Are services effective? The practice is rated as good for providing effective services. Good 4 York Street Health Practice Quality Report 20/12/2016

95 Summary of findings Our findings at inspection showed that systems were in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines. We saw evidence where these were discussed at meetings and an ongoing log was kept to audit what actions had been taken in response to new guidance. We also saw evidence to confirm that the practice used these guidelines to positively influence and improve practice and outcomes for patients. For example, following guidance relating to liver cirrhosis in the over 16s, the practice had identified patients who may be at risk and had reviewed the management of their care to ensure all appropriate patients were referred for treatment accordingly. The practice were proactive and worked with other local providers to understand and meet the range and complexity of patients needs. For example, the practice had organised access to a number of bed spaces in a local homeless shelter. The practice undertook a programme of clinical audits which were relevant to their patient population and could demonstrate quality improvements. The practice employed a full time mental health nurse who provided intensive support for patients. As a result of their interventions and the use of a comprehensive mental health assessment, the practice could evidence a 26% reduction in anti-depressant prescribing and improved wellbeing of some patients. There was continuing development of staff skills and competence and knowledge was recognised as integral to ensuring high quality care. Staff were proactively supported to work collaboratively and share best practice. All the GPs participated in a six monthly internal appraisal system, which they found to be a supportive process. All staff had annual appraisals and access to other development and support networks. Are services caring? The practice is rated as good for providing caring services. Good Staff were motivated and inspired to offer kind and compassionate care. For example, they provided suitable clothing for children and adults, food parcels, Christmas gifts, paid for transport for patients to attend appointments and raised money to aid patients as needed. 5 York Street Health Practice Quality Report 20/12/2016

96 Summary of findings Patients emotional and social needs were seen as important as their physical needs. We heard many examples from patients and external agencies to support this. Patients told us that if they did not have a permanent address they were able to use the postal address of the practice to stay in touch with their families and other agencies. We saw evidence to support this. Patients said they were treated with compassion, dignity and respect. We observed staff treat patients in a respectful, kind and caring manner. Patients were greeted by name and staff were aware of their personal circumstances and were able to offer support and assistance to individuals. We spoke with several professionals who worked alongside the practice and received many written testimonials from others. All comments were extremely positive about how caring staff at York Street Health Practice were. The practice had won several awards for the delivery of compassionate care. These included being the first GP practice nationally to receive the 2015 City of Sanctuary Health Stream Award (which recognises the important role played by the health services in the lives and well being of asylum seekers). As part of the Pathway Group of organisations who provide services for homeless people, they had recently received the 2016 Kate Granger award for delivering outstanding compassionate care. (This award was to individuals, teams and organisations who demonstrated outstanding care for their patients.) The practice worked closely with palliative care services to support end of life care for patients and to find an appropriate setting for that care to be delivered to those who were homeless. Are services responsive to people s needs? The practice is rated as outstanding for providing responsive services. Outstanding The practice responded to the complex needs of patients in a timely and appropriate way. The mental health nurse offered consultations in areas away from the practice where the patient felt more comfortable and was more likely to attend the appointment. The practice delivered weekly outreach sessions for the homeless. Twice a month clinicians worked through the night, to provide access to health care and support for street sex workers. 6 York Street Health Practice Quality Report 20/12/2016

97 Summary of findings There was daily liaison with the local hospital and accident and emergency department to identify any people who were homeless and unregistered with a GP and to support cohesive discharge planning. Vaccination catch up programmes were delivered for all new arrivals into the country who had incomplete vaccination histories. There was dedicated time to process the registration of UNHCR (United Nations High Commissioner for Refugees) arrivals. This allowed the registration of the whole family at a time that was suitable and caused as little stress as possible. We were told of several instances where the practice had liaised directly with the refugee camp to ensure urgent care was provided for patients upon their arrival into the country. There were ring fenced appointments for patients who were identified by other agencies as needing timely access to care and treatment, such as newly arrived refugees. Patients comments we received indicated they found it easy to make an appointment with a clinician, there were open access appointments. Urgent cases were dealt with when needed. Staff regularly liaised with a homeless shelter in Leeds and ensured people staying there received medical care and support as needed. There was a separate waiting area for families with small children or for patients who were distressed. There was wide-ranging evidence of multi-agency working, where the practice worked closely with other organisations, such as outreach services, refugee councils and homeless shelters, in ensuring services were provided to meet patients needs. Are services well-led? The practice is rated as good for being well-led. Good There was a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff. The practice had strong and visible clinical and governance arrangements in place. There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk. 7 York Street Health Practice Quality Report 20/12/2016

98 Summary of findings The provider was aware of and complied with the requirements of the duty of candour. There was a culture of openness and honesty. The practice had systems in place for notifiable safety incidents and shared information with staff to ensure appropriate action was taken The practice proactively sought feedback from staff and patients, which it acted on. There was a strong focus on continuous learning and improvement at all levels. Staff said they felt very supported by management and the team as a whole. We were informed of the supportive mechanisms in place; staff had access to a psychologist once a month, counselling sessions were available as needed and staff had attended mindfulness courses. 8 York Street Health Practice Quality Report 20/12/2016

99 Summary of findings The six population groups and what we found We always inspect the quality of care for these six population groups. Older people The practice is rated as good for the care of older people. Good Compared to other practices, they had a small number of registered patients who were over the age of 65 years. However, proactive, responsive and personalised care was provided to meet the needs of these patients. Reviews of care were undertaken and any concerns were discussed at the daily huddle. The practice worked with other agencies, such as outreach and homeless services, to support the needs of these patients In liaison with the local palliative care team, end of life care was provided for individuals as needed. Influenza and pneumococcal vaccinations were offered to everyone in this population group. People with long term conditions The practice is rated as good for the care of people with long term conditions. Good We were informed that many of the patients were not always in a position to manage their long term conditions until some stability had been achieved in their lives. Health advice and support was given by all clinicians to patients, taking into account their individual life circumstances. Patients had personalised care planning suitable to their needs. Patients at the practice presented with high levels of lung, liver and kidney disease. These could be linked to issues such as poor diet, alcohol and drug misuse. Staff had specific competencies in these areas and were able to support patients accordingly. There was an experienced nursing team who provided specialist wound care for venous ulcerations. Blood borne virus screening was undertaken. The practice had good liaison with the viral hepatology teams to improvement engagement of patients for Hepatitis C treatment. Families, children and young people The practice is rated as good for the care of families, children and young people. Good 9 York Street Health Practice Quality Report 20/12/2016

100 Summary of findings The practice currently had 61 patients who were under the age of 18 years. This population group fluctuated dependant on the numbers of UNHCR refugees allocated to the practice. It was acknowledged that this group of patients were particularly vulnerable. There were clear systems in place to identify and follow up children and families living in disadvantaged circumstances and who were at risk. For example, those females at risk of female genital mutilation (FGM) or human trafficking. There was a child safeguarding lead and a process in place to review all patient records for those aged under 18, in order to highlight and act on any safeguarding issues. There was a named health visitor attached to the practice to ensure continuity of care for families and young children. There was a separate waiting area for families with small children or for patients who were distressed. Working age people (including those recently retired and students) The practice is rated as good for the care of working age people (including those recently retired and students). Good Over 90% of patients were noted to be of working age but there was a very high unemployment rate. This group included the homeless, asylum seekers and refugees. Flexible services were provided for these patients. For example, outreach services were provided on the streets, both during the day and night to enable patients to access clinicians. The practice supported people who were sleeping rough and could offer them temporary shelter through dedicated beds they had at a charitable homeless hostel based in Leeds centre. Patients were provided with flexible care and support to meet their individual needs. Health promotion and screening were offered opportunistically. People whose circumstances may make them vulnerable The practice is rated as outstanding for the care of people whose circumstances may make them vulnerable. Outstanding The practice held a register of patients living in vulnerable circumstances including homeless people, gypsy travellers and those with a learning disability. The practice offered longer appointments for patients who needed them. 10 York Street Health Practice Quality Report 20/12/2016

101 Summary of findings The practice worked consistently, proactively and sensitively with multidisciplinary teams and other agencies, such refugee councils, homeless charities and poverty services, in the case management of vulnerable patients. Through their outreach sessions, the clinicians provided support and care in areas where homeless people were known to gather. Those people who were identified as being vulnerable and who were not registered with a GP were referred to York Street Health Practice by other agencies. The practice worked closely with local substance misuse services to support patients to access treatments as befitted their needs. Staff knew how to recognise signs of abuse in vulnerable adults and children. They had a comprehensive understanding of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours. Staff had attended training sessions on FGM awareness and trafficking. They could demonstrate a good understanding and awareness of how to approach those at risk. There was evidence of working alongside other agencies to identify and support those patients as befit their needs. People experiencing poor mental health (including people with dementia) The practice is rated as outstanding for the care of people experiencing poor mental health (including people with dementia). Outstanding The practice had no known patients who had dementia, however, they had high levels of patients who experienced mental ill health or psychological distress and treated them as appropriate. Staff had a good understanding of how to support patients with mental health needs and consistently worked with multidisciplinary teams in the case management of these patients. They also worked closely with teams providing support through counselling and psychological therapies. Patients were actively assisted to access various support groups and organisations, including social and housing support. The practice employed a full time mental health nurse who had professional experience of working with patients who had complex needs. They arranged to see those patients who were most likely to not attend an appointment, outside of the practice environment, such as a coffee shop, to support their health needs. 11 York Street Health Practice Quality Report 20/12/2016

102 Summary of findings The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health or were vulnerable. These patients were discussed in the daily huddle meetings and care plans updated. 12 York Street Health Practice Quality Report 20/12/2016

103 Summary of findings What people who use the service say The national GP patient survey (published in July 2016) distributed 338 survey forms of which 35 were returned. This was a response rate of 10% which represented less than 3% of the practice patient list. The results showed that for the majority of questions, the respondent satisfaction levels were below the local clinical commissioning group (CCG) and national averages. The lower than normal responses may be reflective of the demographics and transient nature of the practice population group. For example: 75% of respondents described their overall experience of the practice as fairly or very good (CCG 82%, national 85%) 64% of respondents said they would definitely or probably recommend their GP surgery to someone who has just moved to the local area (CCG 76%, national 79%) 63% of respondents described their experience of making an appointment as good (CCG 70%, national 73%) 94% of respondents said they found the receptionists at the practice helpful (CCG 85%, national 87%) 87% of respondents said they had confidence and trust in the last GP they saw or spoke to (CCG 94%, national 95%) 90% of respondents said they had confidence and trust in the last nurse they saw or spoke to (CCG 96%, national 97%) However, patients comments we received on the day were consistently positive. The most recent Friends and Family Test results showed that 100% of patients would recommend the practice. As part of our inspection we asked for Care Quality Commission (CQC) comment cards to be completed by patients prior to our inspection. We received 13 comment cards, 12 of which were all positive about accessibility to the service and the standard of care received. Many said the service was essential in supporting the needs of homeless people. They cited staff as being extremely helpful, courteous, caring and professional. Only one card was negative saying they were not happy to queue. We spoke with three patients on the day, who were all very positive about the service and care they received. They gave us several examples to highlight how they had been helped by staff to sort out some of the complex issues they encountered. Patients told us how they had been treated in a professional, non-judgemental and caring manner and that they had trust in the staff and felt relaxed in the practice environment. They said this was important to them. The general view of patients we received both from the comment cards and by speaking with them, was that they felt valued and respected as individuals by all the staff. We also spoke with several professionals who worked alongside the practice and received many written testimonials from others. All comments were extremely positive about the work York Street Health Practice were doing and how they worked collaboratively to support better outcomes for patients or help them to be safe on the streets. Outstanding practice There were comprehensive systems in place to support safe practice. The whole team was engaged in reviewing and improving safety and safeguarding systems. The review of all incidents and the learning which arose from those was shared with their provider and external agencies, depending on the appropriateness and confidentiality aspects. There was an ongoing RAG rated action plan used to capture and ensure all issues or status reports were discussed or actioned at all meetings. (RAG is a system based on Red, Amber and Green colours used to rate issues.) Staff were motivated and inspired to offer kind and compassionate care. For example, they provided suitable clothing for children and adults, food parcels, Christmas gifts, paid for transport for patients to 13 York Street Health Practice Quality Report 20/12/2016

104 Summary of findings attend appointments and raised money to aid patients as needed. The practice had won several awards for the delivery of compassionate care. Most recently, as part of the Pathway Group of organisations who provide services for homeless people, they had recently received the 2016 Kate Granger award for delivering outstanding compassionate care. The practice delivered weekly outreach sessions for the homeless. Twice a month clinicians worked through the night, to provide access to health care and support for street sex workers. 14 York Street Health Practice Quality Report 20/12/2016

105 York Street Health Practice Detailed findings Our inspection team Our inspection team was led by: a CQC lead inspector. The team included a GP specialist adviser, a practice nurse specialist adviser and a second CQC inspector. Background to York Street Health Practice York Street Health Practice is a member of Leeds South and East Clinical Commissioning Group. The provider of the service is Leeds Community Healthcare Trust (LCHT). Alternative Provider Medical Services (APMS) are provided under a contract with NHS England. This is a locally negotiated contract which allows NHS England to contract services from non-nhs bodies. The practice are also a member of Pathway (a UK homeless healthcare charity); a group of organisations who specifically work with and support people who are homeless. The practice does not participate in the Quality and Outcomes Framework (QOF). (QOF is a voluntary incentive scheme for GP practices in the UK, which financially rewards practices for the management of some of the most common long term conditions.) However, the practice has its own Key Performance Indicators (KPIs) which are submitted on a quarterly and annual basis to their provider LCHT. The practice provides a range of primary care services for: homeless people people in temporary or unstable accommodation refugees or those seeking asylum street-based sex workers people who find it hard to access the health care and support they need due to chaotic and complex lifestyles The staff worked closely with other organisations and with the local community in ensuring bespoke services are provided to meet patients needs. The Homeless Admissions Leeds Pathway (HALP) is operated under York Street Health Practice in partnership with St George s Crypt Homeless Hostel (a charity in the centre of Leeds who work with the homeless and vulnerable and can provide intermediate care beds). The practice had negotiated to have access to three beds there where patients who are in urgent need can be sent. Patients are often referred to the practice by other agencies or identified through hospital admissions, prison release or word of mouth. In addition, those people seeking asylum status or refugees are also registered. The practice has close links with refugee camps in Syria and the identification of those refugees who are suitable to arrive in Leeds is undertaken in conjunction with the Home Office. At the time of inspection there were 1,315 patients registered with York Street Health Practice (1,083 male and 232 female). Due to the transient nature of this patient group the practice experiences a high turnover of registered patients, with 15 to 20 new registrations per week. Over 61% of the patient population are homeless and 31% are asylum seekers/refugees. The majority of patients are in the 26 to 65 years age range; with 4% under 18 years of age, 13% aged between 18 and 25 and 1% aged over 65. There is a mixed ethnicity of patients, including white British, African, Asian and Syrian. The practice is open from 8.30am to 6pm on Monday, Tuesday and Friday. On Wednesday and Thursday the opening times are 9am to 5pm. Patients can access appointments and clinicians during these times. The practice is closed daily between 1.30pm and 2pm to enable all staff to attend a daily meeting known as the huddle. In 15 York Street Health Practice Quality Report 20/12/2016

106 Detailed findings addition, there is open access to clinicians and patients can be seen outside of the practice as befit their needs. When the practice is closed the telephones are directed to local care direct. We were informed that due to restrictions in their provider contract, they were unable to offer extended hours access. However, outreach and night services are operated, where clinicians engage with members in the community, such as the homeless or sex workers, who may or may not be registered with the practice. Why we carried out this inspection We carried out a comprehensive inspection of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act How we carried out this inspection Before visiting, we reviewed a range of information that we hold about the practice and asked other organisations, such as NHS England and Leeds South and East CCG, to share what they knew about the practice. We reviewed the latest national GP patient survey results (July 2016). We also reviewed policies, procedures and other relevant information the practice provided before and during the day of inspection. We carried out an announced inspection on 20 October During our visit we: Spoke with a range of staff, which included three GPs, a clinical lead nurse, a practice nurse, a mental health nurse and a health care assistant. We also spoke with the practice manager and the administration manager. We reviewed questionnaires sent to staff prior to the inspection. Reviewed CQC comment cards and spoke with patients regarding the care they received and their opinion of the practice. Observed in the reception area how patients, carers and family members were treated. Looked at templates and information the practice used to deliver patient care and treatment plans. Spoke with other organisations who work alongside York Street Health Practice in supporting patients. Attended the daily huddle as an observer. To get to the heart of patients experiences of care and treatment, we always ask the following five questions: Is it safe? Is it effective? Is it caring? Is it responsive to people s needs? Is it well-led? We also looked at how well services were provided for specific groups of people and what good care looked like for them. The population groups are: Older people People with long term conditions Families, children and young people Working age people (including those recently retired and students) People whose circumstances may make them vulnerable People experiencing poor mental health (including people with dementia). Please note that when referring to information throughout this report, this relates to the most recent information available to the CQC at that time. 16 York Street Health Practice Quality Report 20/12/2016

107 Outstanding Are services safe? Our findings Safe track record and learning The practice had a systematic and comprehensive approach for reporting, recording and acting upon significant events. There was good analysis of incidents and evidence that changes had been made as a result. There was a genuinely open culture in which all safety concerns raised by staff and people who used the services were highly valued as integral to learning and improvement. When reporting an incident, staff told us they would complete the electronic recording form, which was available on the practice computer system, and would also verbally inform the practice manager. The whole team were engaged in reviewing and improving safety and safeguarding systems. All events were discussed at the daily huddle, weekly practice meetings and the monthly clinical meetings. In addition, panel meetings were also held where incidents or safeguarding risks to patients could be discussed on an individual basis. We saw evidence of formal minutes which identified the incident, relevant information, actions and by whom. The practice had an ongoing RAG rating (auditable) action plan used to ensure all issues or status reports were discussed or actioned at all meetings. We saw evidence that six monthly thematic reviews were undertaken and actions had been taken to minimise reoccurrence. For example, in the preceding six months it had been noted there had been several prescribing errors. This had been discussed in the clinical team meeting and a review of the systems undertaken. An evaluation of any improvements as a result was to be undertaken at the next thematic review in March The practice had seen an increase in incidents where patients had been aggressive or violent. Staff were actively encouraged to report all incidents to ensure procedures were being followed in those instances. The practice undertook individual case reviews of deaths of patients. This was to identify whether any were unexpected, there were any themes, or any preventative work which could have helped and any learning arising from these. The review of all incidents and the learning which arose from those was shared with their provider Leeds Community Health Care Trust. Relevant learning was also shared with external agencies, such as secondary care services, the Home Office, refugee councils or homeless workers, depending on the appropriateness and confidentiality aspects. We reviewed safety records, incident reports, patient safety alerts and minutes of meetings where these were discussed. Lessons were shared and action was taken to improve safety in the practice. For example, it had been noted there had been an error in resetting the vaccine fridge temperature. The medicines management team had been contacted for advice regarding the vaccines. There had been a review of records to ensure that patients had not been affected. There had also been retraining of staff. Overview of safety systems and processes There were comprehensive, clearly defined and embedded systems, processes and practices in place to keep patients and staff safe and safeguarded from abuse. We saw evidence of: Arrangements, which reflected current legislation and local requirements, were in place to safeguard children and vulnerable adults from abuse. Policies clearly outlined whom to contact for further guidance if staff had concerns about a patient s welfare. We saw posters displayed in the reception area and consulting rooms, advising patients and staff of what safeguarding is, what to do if there were any concerns and who to contact. There were separate clinical leads for adult safeguarding and children s safeguarding. The practice had strong links with the local safeguarding authority and reports for case conferences were provided where necessary. There was a process in place to review all patients records for those aged 18 and under, in order to highlight any safeguarding issues. All clinical staff had safeguarding supervision with a member of the local safeguarding team on a regular basis. In addition to issues being discussed at the daily huddle meeting, quarterly dedicated safeguarding meetings were held. The practice had a good working relationship with the named health visitor, who they regularly discussed any child safeguarding issues or concerns with. All the GPs and nursing staff were trained to level three safeguarding and non-clinical staff were trained to level two. There was evidence of staff attending additional training, such as awareness of FGM and human 17 York Street Health Practice Quality Report 20/12/2016

108 Outstanding Are services safe? trafficking. All staff could demonstrate a good understanding of safeguarding and gave us numerous examples where concerns in respect of patients had been raised and actioned. Notices advising that a chaperone was available if required were displayed in all patients areas throughout the practice and were in a variety of languages suitable to the patients countries of origin. (A chaperone is a person who acts as a safeguard and witness for a patient and health care professional during a medical examination or procedure.) All staff who acted as chaperones were trained for the role and had received a Disclosure and Barring Service check (DBS). (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.) Appropriately maintained standards of cleanliness and hygiene in the practice. There was a comprehensive cleaning schedule in place, which was adhered to. There was a clinical lead for infection prevention and control (IPC) who liaised with the provider s IPC team. They attended IPC meetings and kept up to date with best practice. There was an IPC policy in place and all staff had received up to date IPC training. Annual IPC audits were undertaken and we evidence that action was taken to address any identified improvements. Safe and effective arrangements for medicines management, which included obtaining, prescribing, recording, handling, storing, security and the disposal of medicines within the practice. There were safe processes and standard operating procedures for handling repeat prescriptions which included the review of high risk medicines. We were informed of the comprehensive procedures in place for the initial and repeat prescribing of opioid medication, such as methadone; which was used in the treatment of heroin addiction. The practice could evidence a clear audit trail of the prescription forms used for methadone prescribing. This ensured there was safe prescribing and a minimised risk of patient misuse. All patients prescribed these medicines were reviewed between weekly and three monthly intervals as a maximum, depending on individual circumstances. Prescription pads and blank prescriptions were securely stored and there were systems in place to monitor their use. The practice carried out regular and thorough medicine audits to ensure prescribing was in line with current guidelines and to support positive patient outcomes. For example, antipsychotic monitoring and the prescribing of antidepressants to patients on methadone. We observed that action had been taken with regard to these audits, such as the reduction and eventual withdrawal of medication, under supervision, in specific patients. Patient Group Directions (PGDs) had been adopted by the practice to allow nurses to administer medicines, in line with legislation. (PGDs are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment.) We reviewed three personnel files and found appropriate recruitment checks had been undertaken prior to employment, in line with the practice recruitment policy. For example, qualifications, reference, proof of identification and DBS checks. Monitoring risks to patients Risks to patients were assessed and well managed. We saw evidence or procedures in place for monitoring and managing risks to patient and staff safety. For example: Health and safety risk assessments, such as the control of substances hazardous to health, fire risk and legionella. (Legionella is a bacterium which can contaminate water systems in buildings.) There were processes in place to check that all electrical and clinical equipment was in good working order and safe to use. We checked a sample of equipment and found them to have been tested and calibrated. Arrangements were in place for planning and monitoring the number of staff and mix of staff needed to meet patients needs. Staff worked flexibly to cover any changes in demand, for example annual leave, sickness or seasonal demands. There was a proactive approach to anticipating and managing risks to people who used the service. Staff rotas were discussed at the daily meeting. The practice planned when additional staff may be needed, for example when numbers of refugees from the camps were expected. Arrangements to deal with emergencies and major incidents The practice had arrangements in place to respond to emergencies and major incidents. We saw: 18 York Street Health Practice Quality Report 20/12/2016

109 Outstanding Are services safe? There was an instant messaging system on the computers in all the consultation and treatment rooms which alerted staff to any emergency. There was a daily 'sign in and out' board so everyone knew where individual staff were, for example if they were participating in outreach services or visiting a patient. There was a comprehensive lone worker policy to support staff working outside of the practice premises. All staff were up to date with fire and basic life support training. There was a defibrillator available on the premises and oxygen with adult and children s masks. A first aid kit and accident book were available. Emergency medicines were stored in a secure area which was easily accessible for staff. All the medicines and equipment we checked were in date and fit for use. The practice had a business continuity plan in place for major incidents such as power failure or building damage. The plan included emergency contact numbers for staff and was available on the practice intranet and as a paper copies. 19 York Street Health Practice Quality Report 20/12/2016

110 Are services effective? (for example, treatment is effective) Good Our findings Effective needs assessment The practice assessed needs and delivered care in line with relevant and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) best practice guidelines. We saw evidence that that guidance was a driving force behind many of the practice audits that were undertaken. Our findings at inspection showed that systems were in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines. We saw evidence where these were discussed at the daily meetings and wider practice meetings. There was an ongoing log to audit what actions had been taken, or audits undertaken, in response to any new NICE guidance. We also saw evidence to confirm that the practice used these guidelines to positively influence and improve clinical practise and outcomes for patients. For example, as a result of guidance issued relating to myocardial infarction (heart attack) an audit had been undertaken to identify that all newly diagnosed patients had a follow-up review with a clinician, a rehabilitation assessment and assessment of further risk. There had been five patients identified at the time and care management plans were put in place for all. The practice continued to review any new cases. Management, monitoring and improving outcomes for people The practice did not participate in the Quality and Outcomes Framework (QOF). However, the practice had its own Key Performance Indicators (KPIs) which were submitted on a quarterly and annual basis to their provider Leeds Community Healthcare Trust (LCHT). These were used by the provider to ensure the practice was performing in line with locally agreed objectives and outcomes. The practice provided evidence to support this. Information submitted regarding the KPIs related to delivering safe, person centred, multidisciplinary collaborative care for patients registered at the practice. These included access, right care right time, reduction in inappropriate bed stays, safe and cost effective prescribing. In addition to CCG prescribing audits or external LCHT audits, the practice undertook a specific and continual programme of clinical audits which were relevant to their patient population and could demonstrate quality improvements. Findings were used by the practice to improve services. We looked at five completed audits, three of which were two cycle. These showed where improvements had been implemented, shared and monitored. For example, as a result of some published guidance, an audit had been undertaken regarding the prescribing of gabapentin and pregabalin (medicines used to treat seizures) in patients on methadone (medicine used in patients to assist withdrawal from heroin or other addictive drugs). An initial audit had shown there were 33 patients identified. These patients were supported to reduce their dosage with a view to stopping. A second audit showed that this number had reduced to 16. Findings showed that two had been initiated by the practice and 14 had been initiated elsewhere, such as secondary care services. After the initial audit a policy had been put in place stating the reduction and withdrawal process which would be undertaken with current and all new patients. All clinical staff were informed of the policy and patients were discussed at clinical meetings. There was a three monthly search undertaken of all appropriate patients. A third reaudit showed the practice were adhering 100% to the policy and there had been no new initiations made by the practice. A mental health nurse was employed who provided intensive support for patients, including those patients who suffered from depression. There was a standard operating procedure in place that all patients received a comprehensive mental health assessment before commencing any treatment with antidepressants. In addition, all patients who were currently prescribed antidepressants (156) were reviewed and also supported to reduce their medication. As a result the practice could evidence a 26% reduction (40 patients) in the rates of antidepressant prescribing without a reported decrease in those patients wellbeing. There was continual auditing of antipsychotic prescribing and the monitoring of relevant patients. (Antipsychotics are medicines used in complex mental health cases such as schizophrenia and bipolar disorder.) All patients were 20 York Street Health Practice Quality Report 20/12/2016

111 Are services effective? (for example, treatment is effective) Good invited or seen opportunistically for reviews of their physical and psychological health. Some of these patients were seen through the outreach and night sessions undertaken by clinicians. The practice informed us that due to the transient nature, ad hoc attendance and vulnerability of some patients, every opportunity and contact with their patients was used proactively. Staff provided health promotion and prevention, advice on how to keep safe on the streets and reviews of care and treatment plans. Patients gave several examples where they had been supported to improve their health and wellbeing. For example, with the help of both the practice staff and a substance misuse worker a patient had successfully managed to stop taking drugs. Effective staffing Staff had the skills, knowledge and experience to deliver effective care and treatment. The practice had an induction programme for all newly appointed staff. This covered such topics as safeguarding, infection prevention and control, fire safety, health and safety and confidentiality. There was continuing development of staff skills and competence and knowledge was recognised as integral to ensuring high quality care, this included mandatory training such as safeguarding and health and safety. Staff were encouraged and supported to attend any training which would improve care delivery for patients. For example, how to recognise signs of abuse or torture. Some nursing staff had undergone additional training in leg ulcer management. All staff had undergone conflict resolution training to assist them in managing difficult situations. Staff were proactively supported to work collaboratively and share best practice. The learning needs of staff were identified through a system of appraisals, meetings and reviews of practice development needs. Staff had access to appropriate training to cover the scope of their work. This included ongoing support, one-to-one meetings, coaching and mentoring and clinical supervision. Staff who administered vaccines and took samples for the cervical screening programme had received specific training which had included an assessment of competence. Staff who could demonstrate how they stayed up to date with changes to the immunisation and screening programmes, by accessing online resources and discussion at practice meetings. All staff had annual appraisals and access to other development and support networks. All the GPs participated in a six monthly internal appraisal system, which they found to be a supportive process. Coordinating patient care and information sharing The information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way through the practice s patient record system and their intranet system. This included care and risk assessments, care plans, medical records and investigation and test results. Staff worked with other health and social care services, voluntary groups, local charities for the homeless and refugee agencies, to understand and meet the complexity of patients needs. This included when patients moved between services, including when they were referred, or after they were discharged from hospital. We saw evidence that patients were discussed in the daily meeting, clinical and multidisciplinary meetings. Care plans were updated as necessary and sharing of information with other agencies was agreed in line with patient consent. In addition, the practice undertook regular panel meetings with multidisciplinary staff as needed. These meetings were ad hoc, based on when there was a need to urgently discuss issues regarding a patient, specifically those who were known to be aggressive or physically violent. We saw evidence of the minutes and actions taken. For example, in some instances the police had become involved. Consent to care and treatment Staff understood the relevant consent and decision-making requirements of legislation and guidance, such as the Mental Capacity Act Patients consent to care and treatment was sought in line with these. Where a patient s mental capacity to provide consent was unclear, the GP or nurse assessed this and, where appropriate, recorded the outcome of the assessment. 21 York Street Health Practice Quality Report 20/12/2016

112 Are services effective? (for example, treatment is effective) Good When providing care and treatment for children 16 years or younger, assessments of capacity to consent were also carried out in line with relevant guidance, such as Gillick competency and Fraser guidelines. These are used to decide whether a child is able to consent to his or her own medical treatment, without the need for parental permission or knowledge. We saw evidence that when a patient gave consent it was recorded in their notes. Supporting patients to live healthier lives The practice identified patients who may be in need of extra support. These included patients with complex mental health needs, sex workers, homeless people, asylum seekers and refugees. We were informed that many of the patients were not always in a position to manage their health adequately until some stability had been achieved in their lives. Health advice and support was given by all clinicians to patients, taking into account their individual life circumstances. Patients had personalised care planning suitable to their needs and were signposted to other services as appropriate, such as housing benefit and care navigators. Blood borne virus screening was undertaken. The practice had good liaison with the viral hepatology teams to improvement the engagement of patients for Hepatitis C treatment. Influenza and pneumococcal vaccinations were offered to appropriate patients. There was a targeted outreach approach which also aimed to identify homeless patients or those vulnerable patients not already registered with a GP practice. There was an experienced nursing team who provided specialist wound care for venous ulcerations, which were frequent in homeless patients or those with substance misuse issues. Cervical screening was offered to eligible females and we saw evidence that 113 patients had attended for smears during the period November 2014 to October Due to the transient nature of the patients, it was not easy to establish the exact numbers of patients who would have been eligible during that period. The practice also acknowledged that some patients did not have a fixed address which could make recall difficult. Most children who were registered at the practice were refugees/asylum seekers and often arrived with incomplete vaccination histories. Vaccinations were provided in line with the national childhood immunisation programme. At the time of inspection there were 49 under 16 year olds registered; 37 of whom were up to date with their immunisation programme, one was a newborn baby and 21 were new arrivals and had incomplete histories and were commenced onto the programme. 22 York Street Health Practice Quality Report 20/12/2016

113 Good Are services caring? Our findings Kindness, dignity, respect and compassion During our inspection we observed that: There was a private room should patients in the reception area want to discuss sensitive issues or appeared distressed. Curtains were provided in consulting and treatment rooms to maintain the patient s dignity during examinations, investigations and treatment. Doors to consulting and treatment rooms were closed during patient consultations and that we could not hear any conversations that may have been taking place. Chaperones were available for those patients who requested one. Results from the national GP patient survey showed respondents rated the practice below CCG and national averages. The data below is based on 35 responses received, which was a response rate of 10% and less than 3% of the practice patient list. The lower than normal response rate may be reflective of the demographics of this practice s patient population. However, these results did not align with what patients told us on the day of inspection. For example: 76% of respondents said the last GP they saw or spoke to was good at listening to them (CCG 87%, national 89%) 74% of respondents said the last GP they saw or spoke to was good at giving them enough time (CCG 85%, national 87%) 78% of respondents said the last GP they spoke to was good at treating them with care and concern (CCG 82%, national 85%) 74% of respondents said the last nurse they saw or spoke to was good at listening to them (CCG and national 91%) 80% of respondents said the last nurse they saw or spoke to was good at giving them enough time (CCG and national 92%) 72% of respondents said the last nurse they spoke to was good at treating them with care and concern (CCG 90%, national 91%) We received 13 CQC comment cards, 12 of which were all positive about accessibility to the service and the standard of care received. Only one card was less positive saying they were not happy to queue. Many said the service was essential in supporting the needs of homeless people. They cited staff as being fantastic and felt they were treated with dignity and respect. There were several examples where patients said they felt care and support provided by staff had been over and above and a life saver. We spoke with three patients on the day, who were all very positive about the service and care they received. They gave us several examples to highlight how they had been helped by staff to sort out some of the complex issues they encountered. Also how they had been treated in a professional, non-judgemental and caring manner. Patients told us they felt they could trust the staff, felt relaxed in the practice environment and how important it was to them. During the inspection feedback from patients about their care and treatment was consistently and strongly positively. We observed a strong patient-centred culture and one where patients were obviously comfortable speaking with staff. We saw and heard staff speaking to patients on a first name basis, providing reassurance and giving general health and wellbeing advice to those patients. We were informed of many positive examples to demonstrate how staff cared for and responded to patients above and beyond expectations. For example, the provision of suitable clothing for children and adults, food parcels, Christmas gifts and the raising of money to aid patients as needed. A patient we spoke with told us how a member of staff had given them a hat to keep their head warm, and how appreciative they had been of this simple gesture. Patients also told us how they had been supported to find housing and how to manage from a practical aspect. We also heard where patients no longer registered at the practice would attend and inform staff how they were managing and the changes they had helped them to make. We also spoke with several professionals who worked alongside the practice and received many written testimonials from others. All comments were extremely positive about the work York Street Health Practice were doing and how they worked collaboratively to support better outcomes for patients. The practice had won several awards for the delivery of compassionate care. These included being the first GP practice nationally to receive the 2015 City of Sanctuary Health Stream Award (which recognises the important role 23 York Street Health Practice Quality Report 20/12/2016

114 Good Are services caring? played by the health services in the lives and wellbeing of asylum seekers). As part of the Pathway Group, they had also recently received the 2016 Kate Granger award for delivering outstanding compassionate care. (This award was to individuals, teams and organisations who demonstrated outstanding care for their patients.) Care planning and involvement in decisions about care and treatment Patients told us they felt involved in decision making about the care and treatment they received. They also told us they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them. Patient feedback from the comment cards we received was also positive and aligned with these views. However, results from the national GP patient survey showed respondents rated the practice below CCG and national practices, for some of the questions. The data below is based on 35 responses received, which was a response rate of 10% and less than 3% of the practice patient list. The lower than normal response rate may be reflective of the demographics of this practice s patient population. However, these results did not align with what patients told us on the day of inspection. For example: 65% of respondents said the last GP they saw was good at involving them in decisions about their care (CCG 80%, national 82%) 75% of respondents said the last GP they saw was good at explaining tests and treatments (CCG 84%, national 86%) 76% of respondents said the last nurse they saw was good at involving them in decisions about their care (CCG 84%, national 85%) 85% of respondents said the last nurse they saw or spoke to was good at explaining tests and treatments (CCG 89%, national 90%) Staff told us that interpretation and translation services were available for patients who did not have English as a first language. There was information provided in the practice to inform patients of this service and staff arranged interpreters as necessary. There was a multitude of leaflets available in several languages suitable to patients country of origin. There were dedicated time slots for patients who were refugees or asylum seekers, to give them the time and support to be involved in decisions about their care. We also saw that care plans were personalised to take into account the complex needs of individuals. Patient and carer support to cope emotionally with care and treatment Leaflets and notices were available in the practice which told patients how to access a number of support groups and organisations. For example, support for mental health, domestic abuse, substance misuse, sexual health, homeless services. Patients gave us several examples where they felt they had been extremely well supported by practice staff during an emotional and distressing time. Some patients had been rehoused in areas outside of the practice. However, due to the complexity of some of those patients, the practice had kept them on their patient list to maintain continuity of care or until stability in their circumstances was embedded. We were informed that if a patient was a carer it would be identified on their patient record. Written information was available to direct carers to the various avenues of support available to them. We were informed that due to the transient nature of the patient population there were very few patients who said they had a carer. If a patient had a next of kin or an identified support worker this would be recorded in their record. The practice liaised with a Leeds based charity which provided psychotherapy, complementary therapies and advocacy support to the survivors of persecution and exile, many of whom have been traumatised by inhumane atrocities. Feedback from patients was extremely positive. Staff worked closely with palliative care services to support end of life care for patients and to find an appropriate setting for that care to be delivered to those who were homeless. Support, or signposting to relevant services, was offered for those families who had experienced bereavement. 24 York Street Health Practice Quality Report 20/12/2016

115 Are services responsive to people s needs? (for example, to feedback?) Outstanding Our findings Responding to and meeting people s needs The practice reviewed the needs of its local population and engaged with their provider and other local agencies to secure improvements to services. Practice staff worked closely with other organisations and with the local community in ensuring bespoke services were provided to meet patients needs. These agencies included Leeds based charities who dealt with the homeless and those who experienced substance misuse; refugee organisations, poverty services, gypsy traveller services and other Leeds outreach services. The practice had integrated pathways with some of these agencies, to aid responsive care and support for patients. Patients were often referred to the practice by other agencies or identified through hospital admissions, prison release or word of mouth. In addition, those people seeking asylum status or refugees were also registered at the practice. The practice had developed close links with refugee camps in Syria and worked in conjunction with the Home Office to ensure refugees were safely registered with the practice. These patients were eventually discharged from the service when they were housed outside of the area. However, each patient was dealt with on a case by case basis, dependant on their individual needs and ability to integrate effectively into mainstream services. This had resulted in some patients remaining with the practice longer to maintain continuity of care. The practice worked collaboratively with UNHCR regarding those refugees who were allocated to the practice. It was acknowledged that this group of patients were particularly vulnerable; consequently there was dedicated time to process the registration of those patients. This allowed the registration of the whole family at a time that was suitable to their needs to cause as little additional stress as possible. We were told of several instances where the practice had liaised directly with the refugee camp to ensure urgent care was provided for patients upon their arrival into the country. For example, a patient who had been identified as having cancer whilst they were in a refugee camp. The practice had organised urgent access to care and treatment upon their entry into the UK. They had then subsequently supported the patient as appropriate. Appointments were offered based on the needs of the patient. For example, a longer appointment had been arranged for a patient who was non-english speaking and also had hearing and speech impairments. Interpreters and sign language personnel were organised at a time suitable for the patient. Some members of staff were multilingual and could support the translation of information for patients as needed. Before vulnerable patients were discharged from hospital, a clinician would liaise with ward staff and review the personal and social circumstances of the patient, such as whether they had a home to go to. This supported effective discharge planning and having an appropriate aftercare management plan in place. The practice would then liaise with other services as necessary, for example in finding suitable accommodation. They also had a number of dedicated bed spaces at a local homeless shelter where the practice could support patients if they were requiring additional medical support. Patients had access to a mental health nurse who had professional experience of working with patients who were homeless, had substance misuse or mental health issues; specifically personality disorders. There was an experienced and specialist trained nurse who was employed by the practice in ensuring that patients received comprehensive sexual health services and advice. Staff had attended training sessions on FGM and trafficking. They could demonstrate a good understanding and awareness of how to approach those at risk. There was evidence of working alongside other agencies to support those patients. Therapeutic, physiotherapy and advisory services were available at the practice for patients to access. The practice participated in local health and wellbeing events, such as the men s health week during which they had engaged with 102 participants. Access to the service The practice was open from 8.30am to 6pm on Monday, Tuesday and Friday. On Wednesday and Thursday the opening times were 9am to 5pm. Patients could access appointments and clinicians during these times. However, 25 York Street Health Practice Quality Report 20/12/2016

116 Are services responsive to people s needs? (for example, to feedback?) Outstanding the practice was closed daily between 1.30pm and 2pm to enable all staff to attend a daily meeting known as the huddle. When the practice was closed the telephones were directed to local care direct. There were 15 minute appointments as standard, however, there was flexibility dependant on the need of the patient. Appointments were pre-bookable, book on the day and there were also open access appointments with the clinicians and therapists based at the practice. There were ring fenced appointments for patients who were identified by other agencies, such as those supporting the homeless, as needing access to care and treatment. In addition, weekly outreach sessions were provided for homeless patients from 5am in a morning. Clinicians also worked through the night twice a month, to provide access to health care and support for street sex workers. A review of demand and capacity was regularly undertaken and also discussed at the daily meeting and practice meetings. We saw evidence of the ongoing logs to support this. Results from the national GP patient survey showed respondents satisfaction rates regarding access were variable compared to CCG and national averages. The data below was based on 35 responses received, which was a response rate of 10% and less than 3% of the practice patient list. The lower than normal response rate may be reflective of the demographics of this practice s patient population. For example: 67% of respondents were fairly or very satisfied with the practice opening hours (CCG 77%, national 78%) 69% of respondents said they could get through easily to the surgery by phone (CCG 68%, national 73%) However, 100% of respondents said the last appointment they got was convenient (CCG 91%, national 92%) Patients comments we received on the day told us they were able to get appointments when they needed them. We were given several examples where the practice had fitted them in or seen them urgently. Listening and learning from concerns and complaints The practice had an effective system in place for handling complaints and concerns. Its complaints policy and procedures were in line with recognised guidance and contractual obligations for GPs in England. There was a designated responsible person who handled all complaints in the practice. We saw that information was available to help patients understand the complaints system. We saw there had been no complaints received in the preceding 12 months. However, there was evidence the practice reviewed survey responses and comments made by patients in general. For example, some patients had commented they felt others were being seen before them. This had related to refugee/asylum seeker patients who had dedicated time slots to reduce anxiety for those patients. As a result staff informed patients as appropriate. In addition, the practice manager had dedicated time where patients could speak with them to share any concerns, comments or thoughts. This was advertised in the waiting room and promoted by staff. Patients we spoke with told us they would speak with the practice manager or a member of staff if they had an issue. The practice manager kept a log of any issues raised by patients and these were discussed in the daily meeting. However, we were informed that many of the patients just wanted to chat. 26 York Street Health Practice Quality Report 20/12/2016

117 Are services well-led? Good (for example, are they well-managed and do senior leaders listen, learn and take appropriate action) Our findings Vision and strategy The practice had a clear vision which had quality care and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff. Staff were clear about the vision and told us they were inspired and motivated to achieve it. Their mission statement and values were to be dedicated to providing healthcare that meets the needs of people who were homeless, vulnerable, refugees or seeking asylum in Leeds. There was a collaborative approach to working in partnership with other agencies that could support the social wellbeing of patients and help the practice to improve care outcomes. Governance arrangements The practice had strong and visible clinical and governance arrangements in place. There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk. The practice had: A clear staffing structure in which all staff were aware of their own roles and responsibilities. Embedded policies in place which were available to all staff. A programme of continuous clinical and internal audit used to monitor quality and to make improvements. Comprehensive systems in place for identifying, recording and managing risks, issues and implementing mitigating actions. A system in place where all actions arising from meetings, significant events or any identified risks, were on a RAG rated continuous action plan, which was easily accessible for staff and also provided a clear audit trail. Leadership and culture On the day of inspection the practice as a whole, demonstrated they had the experience, capacity and capability to ensure high quality care was provided for patients. We were informed they prioritised safe and compassionate care. There was a high level of strong collaboration with other agencies and support for all staff in having a common focus on improving quality of care and patient experiences. The practice had been nominated for and won several awards over the preceding two years for the delivery of compassionate care. These included being the first GP practice nationally to receive the 2015 City of Sanctuary Health Stream Award (which recognises the important role played by the health services in the lives and well being of asylum seekers). In addition, the nursing team had won an award for support to primary care and the practice manager had been awarded an Honorary Doctorate for their work with the homeless. All staff had a visible presence in the practice and were approachable. We were informed that the managers were available and took the time to listen to staff. There were regular meetings, including the daily huddle, which all staff attended and were supported to raise any issues, discuss any concerns and share experiences and learning. Staff informed us there was an open culture within the practice and they felt respected, valued and supported. There were supportive mechanisms in place; staff had access to a psychologist once a month, counselling sessions were available as needed and staff had access to mindfulness courses, of which many had attended. We were informed there was a strong culture of openness and honesty. This was supported by the systematic and comprehensive approach we saw for the reporting, recording and acting upon significants. The practice was aware of, and had systems in place to ensure compliance with, the requirements of the duty of candour. When there were unexpected or unintended incidents regarding care and treatment, the patients affected were given reasonable support, truthful information and a verbal and written apology. Seeking and acting on feedback from patients, the public and staff The practice encouraged and valued feedback from patients and staff. Feedback was proactively sought from: Patients through day to day engagement with them. The NHS Friends and Family Test (FFT), complaints and compliments received. 27 York Street Health Practice Quality Report 20/12/2016

118 Are services well-led? Good (for example, are they well-managed and do senior leaders listen, learn and take appropriate action) Staff, through meetings, discussions and the appraisal process. Staff told us they would not hesitate to raise any concerns and felt involved and engaged within the practice to improve service delivery and outcomes for patients. Other agencies and organisations the practice worked collaboratively with. Despite the complex nature of patients, the practice had managed to develop a patient participation group, although it was in its infancy stages. We saw minutes of a recent meeting held in September, where feedback was provided from the patients. Generally, patients felt they had access to clinicians, the receptionists were always helpful. However, they felt the building itself was too small for the numbers of patients registered. Continuous improvement There was a focus on continuous learning and improvement at all levels within the practice. The practice team was forward thinking and part of local partnership working to improve outcomes for patients in the area. The practice consistently and tirelessly worked with other agencies to ensure those patients with complex needs were supported appropriately. For example, working with a local charity organisation in Leeds in the provision of temporary beds for homeless people and ensuring they received timely medical care and treatment. Also working with a refugee council to ensure new arrivals were registered and supported before moving onto mainstream services. 28 York Street Health Practice Quality Report 20/12/2016

119 AGENDA ITEM Meeting Trust Board 3 February 2017 Report title Quality Strategy Implementation update Responsible director Executive Director of Nursing Report author Professional lead for AHPs Previously considered by Quality Committee 23 January 2017 Category of paper (please tick) For approval For assurance For information Purpose of the report This is the first report to Board providing an update on the progress of implementing the quality strategy. The purpose is to assure the Board that work to deliver the strategy is in progress. Main issues for consideration Twenty one action areas were identified to support the achievement of the quality strategy. Half of these are complete or not due for completion but progressing on track. Eleven actions are not due for completion with some concern that they may go off track. Four main themes link the actions that require further or on-going attention Embedding processes and practices: time and support for staff to make sustainable changes in practice Changes in the neighbourhood teams: the volume of concurrent changes and the capacity to manage in the current climate Data: access to and understanding of how to use data for continuous quality improvement Staffing: ensuring the Trust has enough of the right staff with the right skills at the right time. Each of the above themes are referenced on the risk register and board assurance framework accordingly with clear explanations and mitigations. Recommendation The Board is recommended to: Note and accept the update of the implementation of the quality strategy. Page 1 of 4

120 Update Report of the Implementation of the Quality Strategy 1.0 PURPOSE OF THIS REPORT 1.1 The quality strategy was approved at the Board meeting on the 5 February Updates on progress in implementing the strategy were provided to Quality Committee in June and October 2016 and January Achievements made in implementing the quality strategy in the first year along with further action to be taken are described below; a spreadsheet providing comprehensive detailed plans has been reviewed by the Quality Committee. This paper reviews current progress highlighting areas of concern. 2.0 BACKGROUND 2.1 The quality strategy describes quality improvement ambitions aligned to the organisation s strategic objectives. Six action areas are identified to meet the ambitions of the strategy and each of these is further broken down into work that is currently under way and work that needed to be started. 3.0 CURRENT POSITION 3.1 Twenty one action areas are identified to support the achievement of the quality strategy. Applying the RAG rating used by Board and committees, five of these are recorded as complete, five not due for completion but progressing on track and eleven not due for completion with some concern that they may go off track. 3.2 The five completed actions included: refreshing the quality challenge selfassessment and visits, setting up quality dashboards in all inpatient and neighbourhood teams, refreshing the organisational development strategy, launching our 11 and continuing with the 50 voices group. Ongoing actions are associated with each of these. These actions will be implemented and monitored through the usual running of the organisation with accountability through the relevant director and reported through the appropriate route. 3.3 The five progressing to timescale (green) relate to: developing and implementing the professional strategy for clinical staff; actioning the quality improvement plan; developing and delivering the middle management training programme; work to reduce pressure ulcers and work to demonstrate learning from incidents and complaints. Work has been progressed in each of these areas with more still to be completed. Each of these areas is monitored through separate updates provided to either Quality Committee, Business Committee or SMT either separately or as part of a wider paper. 3.4 The eleven actions not due for completion with some concern that they may require additional attention (amber) are discussed below. Page 2 of 4

121 3.5 Two of the amber actions require the embedding of processes and practices across services to be successful. These are increasing the response rate for friends and family test (FFT) and embedding the recording of duty of candour conversations and letters. Action plans for both these areas are being reviewed and refreshed. The lead for FFT will work with the quality leads for each business unit to sustain an increase in response rates. The quality lead in specialist services is working closely with the clinical leads in each business unit to embed processes and practice around the recording of duty of candour apologies given. Progress in each of these areas will be monitored via the director of nursing report. 3.6 Three of the eleven amber actions, (new models of care, neighbourhood teams and individualised person centred care) are dependant on embedding changes in the neighbourhood teams. Specific action plans are in train to achieve these actions such as the detailed electronic patient record programme, the role out of holistic training or the development of outcome measures each of which have clear governance structures. Capacity to deliver these changes while maintaining productivity is challenging in the current context and puts achievement of these actions at risk. Appropriate risks have been noted on the risk register (353, 639 and 837) 3.7 Staff are engaged in delivering new models of care as commissioned by CCGs. Some services are due for recommissioning this year. Success of both of these requires engagement and networking with commissioners both in terms of demonstrating new models are successful and influencing change for the future. Similar to 3.6 above, current capacity puts the achievement of these quality improvement actions at risk. There is a continued need for SMT to balance the internal focus on delivery with the external focus required to ensure sustainability. 3.8 A further three of the eleven amber actions have data as a theme. They are: continuous quality improvement, mortality review and benchmarking. Significant work has been undertaken to review the performance brief and ensure that the organisation has access to data that reflects the quality of services offered. Work has progressed in developing quality impact assessments and in embedding quality discussion and reviews at a service level. There are still some areas that are in development such as agreeing the data set required for mortality review and establishing the most relevant benchmarking data for a community organisation. The organisation is actively involved in networks to develop this. 3.9 To develop continuous quality improvement within the organisation, further work is required to develop staff s understanding of what this is, how to use data to drive improvement and to provide service level access to measurement for improvement rather than just data for performance. The quality improvement and quality and professional development teams are working on this. Risk relating to data sufficiently reflecting the quality of services provided are recorded on the risk register (risk 816) Page 3 of 4

122 3.10 Staffing is a concurrent theme of the remaining amber actions, safer staffing, education and training and recruitment and retention. Significant work has been completed in a number of areas covering these actions such as: the development of the professional strategy, a review of capacity and demand tool, a review of agency use, joint recruitment and attendance at recruitment fairs with partners in the city and engagement in the development of new roles The education and training team has been restructured to reflect the needs of the organisation and this now needs to be developed further to be responsive to the services. Safe staffing data is reported to the Board and published regularly on the Trust s website. Maintaining the right number of staff with the right skills and competencies is a challenge for this organisation as it is for others organisations in the city. More work is underway to ensure that the Trust has enough staff (including roll out of e- rostering), as well as ensuring the Trust has the right competencies required The rate of staff leaving within the first year of employment remains higher than the Trust would like but similar to other community trusts. From a clinical perspective, more work needs to be done around preceptorship and ensuring that this reaches across all professions. The challenges around ensuring that the Trust has the right staff with the right skill in the right place at the right time are recorded on the BAF (risks 2.2, 3.1 and 3.4) 4.0 IMPACT 4.1 Financial/Resource Clinical staff and staff capacity are the biggest risks to achieving the quality strategy. A number of actions are in place to mitigate this including being responsive to the development of new roles such as the nursing associate and opportunities through the apprentice route. Data analytical skill for continuous quality improvement is limited to the performance team. Understanding of what continuous quality improvement is and how to use data to identify this needs to be developed at a service level. 4.2 Risk In developing the quality strategy, care has been taken to ensure that work already under way in the quality improvement plan, quality account and sign up to safety was considered. Much of this work is already monitored through the Quality Committee. A failure to deliver on this strategy will impact on services being able to demonstrate the characteristics of good described in the CQC five domains of safe, effective, caring, responsive and well led. 5.0 RECOMMENDATION 5.1 The Board is recommended to receive the report Page 4 of 4

123 AGENDA ITEM Meeting Trust Board 3 February 2017 Report title Significant risks and risk assurance report Responsible director Chief Executive Report author Risk Manager Previously considered by Senior Management Team 18 January 2017 Category of paper (please tick) For approval For assurance For information Purpose of the report This report is part of the governance processes supporting risk management in that it provides a source of assurance about the effectiveness of the risk management processes and that adequate controls are in place to manage the Trust s most significant risks. The report provides the Board with the current risk profile. It details the Trust s risks currently scoring 15 or above, after the application of controls and mitigation measures. It provides an analysis of all risk movement, presents the risk profile, identifies themes, and links these material risks to the strategic risks on the Board Assurance Framework (BAF). The Board Assurance Framework (BAF) summary advises the Board of the current assurance level determined for each of the Trust s strategic risks. Main issues for consideration There are no new or recently escalated risks scored as extreme risks. The risks on the risk register have been analysed for this report and themes have been identified. These themes are staff capacity, performance, patient safety, medication, and finance (see section 9). The themes have been linked to the strategic risks on the BAF, where appropriate. This themed approach gives a more holistic view of the higher level risks on the risk register and will assist the Board in understanding the risk profile. The emergence of material risks could mean that the BAF controls put in place to manage strategic risks are not sufficiently robust. A copy of the revised BAF is attached which describes the strategic risks and links them to corporate objectives. It shows current risk scores, lead directors and the committee charged with responsibility for monitoring each strategic risk. Recommendations The Board is recommended to: Note the contents of the risk register Note the themes identified in this report Note the current assurance levels provided in the revised BAF summary Page 1 of 14

124 1.0 Purpose of this report Significant risks and risk assurance report 1.1 This report, which is presented at Senior Management Team (SMT) monthly, and every two months to the Board provides an overview of the Trust s risks currently scoring 15 or above after the application of controls and mitigation measures. The report also provides a description of risk movement since the last register was presented to the Board on 2 December The paper also provides a section detailing risks scoring 12. Whilst these do not meet the definition for inclusion in the risk register extract reported to the Board, they have been detailed as they evidence those matters of high risk and are scrutinised closely by the Board. In addition, there is a short summary of those risks scoring 8 or above whether clinical or non-clinical and which are reported in full at the Quality Committee or Business Committee at each meeting. 1.3 The risks on the risk register have been analysed for this report and themes have been identified, which link these material risks to the strategic risks on the Board Assurance Framework (BAF). The BAF has been recently revised and this paper provides a summary of the current BAF. 2.0 Background 2.1 Risks showing a current score of 15 or above (extreme) are reported to the Trust s Board at each meeting. Prior to Board scrutiny, the Senior Management Team (SMT) consider and moderate the risks at 15 and above (monthly). Senior Management Team also receives a summary of risks graded 12. In exceptional circumstances, a director can request inclusion of any risk onto the register received by the Board. 2.2 Risks recording a current high or extreme score (8 or above) and designated as clinical risks are reported to the Quality Committee for scrutiny. The Business Committee discharges a similar role in respect of non-clinical risks scoring 8 or above. 2.3 The Board Assurance Framework (BAF) is a significant tool in helping the Board hold itself to account, understand the implementation of strategy and the risks that might impede delivery of its strategy and brings together: The Trust s strategic goals as set out in the Trust s longer term plans, its annual operational plan and the strategic priorities of business units Strategic risks that might prevent the Trust from meeting its strategic goals and corporate objectives; their causes and effects Controls and sources of assurance in place to manage risk and so support the delivery of those goals and objectives Actions to remedy gaps in controls or assurances Page 2 of 14

125 2.4 The full content of the BAF has been reviewed by individual directors and then collectively by SMT. SMT agreed the strategic risks, the controls, and the sources of assurance. The revised BAF template and reporting schedule was endorsed by the Audit Committee at its meeting on 22 July 2016 and a full BAF was scrutinised by Audit Committee on 21 October Summary of current risks scoring 15 or above 3.1 There are two risks with a current score of 15 (extreme) or above on the Trust risk register as at 5 January These are as follows: Table 1 Extreme risks (scoring over 15) Risk ID Risk type Risk detail Risk 224 Risk 872 Nonclinical Nonclinical Reduced level of care due to the prevalence of staff sickness in particular services and or across the Trust. Risk score 16 Difficulties recruiting to and retaining staff within neighbourhood teams. Risk score Full details of these two extreme risks are given in appendix 1 (risk register extreme risks). 4.0 Changes to the risk register for risks scoring 15 or above 4.1 Senior Management Team reviewed a register of risks scored 15 or above at its meeting on 16 November 2016 and agreed to deescalate risk 859 (CAMHS inpatient unit risk environmental concerns) and to add a new extreme risk (Risk 872 Difficulties recruiting to and retaining staff within neighbourhood teams). Further to this, the Board received a revised risk register report at its meeting on 2 December New or escalated risks (scoring 15+) 5.1 Since the last report generated in December 2016, there has been no new risks recorded at 15 or above. 5.2 There have been no escalated risks. 5.3 No risk descriptions have been refined. 6.0 Closures, consolidation and de-escalation of risks (scoring 15+) 6.1 Since the December 2016 report, there have been no closed or deescalated risks previously recorded at 15 or above. Page 3 of 14

126 7.0 Summary of risks scoring 12 (high) 7.1 High clinical risks (scoring 12) To ensure continuous oversight of risks across the spectrum of severity, consideration of risk factors by the Board is not contained to extreme risks. Senior managers are sighted on services where the quality of care or service sustainability is at risk; many of these aspects of the Trust s business being reflected in risks recorded as high and particularly those scored at The table below details clinical risks currently scoring 12 (high risk). Risks 876 and 877 have recently been added to this list as new risks. Table 2 High clinical risks (scoring 12) ID Title Rating (initial) Rating (current) Rating (Target) Increased risk of falls due to not having an effective falls reduction programme / workplan in place Lack of information sharing between organisations for children with complex long term neuro disabling conditions Risk of non delivery of childhood immunisation programme (BCG) Diabetes service backlog waiting times for podiatry - risks exceeding 18 week target. Waiting times (non-reportable) beyond 18 weeks in Community Urology and Colorectal service (CUCS). Impact on health visiting service of cancellation of Family Nurse Partnership (FNP) contract. NEW: Insufficient nursing resource within the Inclusion Nursing Service NEW: Risk of reduced quality of patient care in neighbourhood teams due to need for prioritisation High non-clinical risks (scoring 12) Continuous oversight of risks across the spectrum of severity is applied to nonclinical risk areas too. The Board considers services where service and/or financial sustainability is at risk where these aspects of the Trust s business is reflected in risks recorded as high and scored at 12. Page 4 of 14

127 7.2.2 The table below details non-clinical risks currently scoring 12 (high risk). Risks 869, 874 and 875 have recently been added to this list as new risks. No non-clinical risks have a revised (higher) current risk score. Table 3 High non-clinical risks (scoring 12) ID Title Rating (initial) Rating (current) Rating (Target) 253 Retention of services in competitive tenders Maintenance of childrens equipment is not commissioned Electronic Patient Record (EPR) non-delivery of benefits Risk of failure of achieving national Improving Access to Psychological Therapies (IAPT) target Nurse call alarm system at Little Woodhouse Hall requires improvement Risk of breach of agency expenditure cap Staff capacity at Wetherby Young Offenders Institute (WYOI) and Adel Beck MindMate single point of access (SPA) service referral waiting times risk. NEW: Actual and predicted further overspend on drugs budget in young offender healthcare NEW: Sickness levels - Neighbourhood Teams including Neighbourhood Night Nursing Service. NEW: Children s Community Dysphagia Service capacity to manage increased number and complexity of referrals 8.0 Summary of all risks currently scoring 8 or above 8.1 The following sections aim to appraise the Board of risks with a current score of 8 (after the application of controls and mitigations) or above. 8.2 Presently the Trust s risk register comprises 54 risks at risk score 8 or above assigned to the Trust s three business units and all directorates providing corporate and headquarters functions. This is an increase compared to the 46 risks on the risk register in December 2016 s report. 8.3 Clinical risks scoring 8 or above The chart below shows the number of clinical risks (26) by business unit, logged on the Trust s risk management database (Datix) as at 5 January Table 4 Clinical risks by business unit Business unit Risks scored 8-12 High Risks scored 15+ Extreme Adults 4 0 Children s 5 0 Specialist 14 0 Corporate and HQ functions 3 0 Totals by risk severity 26 0 Totals by business unit Page 5 of 14

128 8.4 Non-clinical risks scoring 8 or above There are 29 non-clinical risks by directorates providing operational, corporate and headquarters functions as at 5 January 2017 (shown below). Table 5 Non-clinical risks by directorate Directorate Risks scored 8-12 High Risks scored 15+ Extreme Totals by directorate Finance and resources Operations Quality and professional development Workforce Totals by risk severity Summary of current risks (themes) 9.1 For this report, the current material (the here and now ) risks scoring 8 or above have been themed where possible according to the nature of the hazard and the effect of the risk and then linked to the strategic risks on the BAF, where appropriate. This themed approach gives a more holistic view of the higher level risks on the risk register and will assist the Board in understanding the risk profile. The emergence of material risks could mean that the BAF controls put in place to manage strategic risks are not sufficiently robust. 9.2 Theme 1. Staff capacity There are ten material clinical risks and twelve material non-clinical risks on the risk register relating to staff capacity, which is an increase in comparison to the six clinical and seven non-clinical staff shortage risks recorded on the previous themed risk report (October 2016) Issues identified within the twelve risks are long-term sickness, vacancies not being recruited, retention of staff in a competitive market, and capacity not meeting demand for services Staff capacity is included on the BAF within two strategic risks: BAF risk 3.1 If we do not have suitable and sufficient staff capacity (recruit, retain, skill mix, development) then we will not maintain quality and transform services BAF risk 3.3 If we fail to address the scale of sickness absence then the impact will be a reduction in quality of care and staff morale and a net cost to the Trust through agency expenditure Page 6 of 14

129 9.3 Theme 2. Performance Three material clinical risks include reference to the risk of activity levels not being achieved and or the risk of waiting list limits being breached. This is a reduction compared to the five performance risks noted in the October 2016 report. Risk of under-recording of activity' in district nursing service Waiting lists (non-reportable) beyond 18 weeks in Community Urology and Colorectal service (CUCS). Waiting lists (non-reportable) beyond 18 weeks in Diabetes Service These performance risks link to the BAF strategic risk: BAF risk 4.3 If we do not deliver contracted activity requirement then commissioners may reduce the value of service contracts, with adverse consequences for financial sustainability. 9.4 Theme 3. Patient safety There are three material patient safety risks relating to the care being provided to patients: Increased falls risk within Adult Services Increased referrals to IAPT resulting in a backlog of patients awaiting screening Wetherby YOI prison regime and lack of escort staff is impacting on ability of young people to access secondary healthcare These patient safety risks link to the BAF strategic risk: BAF risk 1.3 If we do not achieve a 'good' CQC rating then there will be an impact on our reputation and progress of FT application 9.5 Theme 4. Medication There are three material medication risks: Risk of non-delivery of childhood immunisation programme Controlled drug licences for prisons and police custody suites - termination of supplies of drugs International shortage of BCG vaccine These risks link to the BAF strategic risk: BAF risk 4.3 If we do not deliver contracted activity requirement, then commissioners may reduce the value of service contracts, with adverse consequences for financial sustainability. 9.6 Theme 5. Finance Two risks concern possible overspend. These are risk of breach of agency expenditure cap and actual and predicted overspend on the drugs budget in young offenders healthcare. Page 7 of 14

130 9.6.2 These risks link to the BAF strategic risk: BAF risk 4.4 If we do not deliver the income and expenditure position agreed with NHS Improvement then this will cause reputational damage and raise questions of organisational governance Risk profile - all risks 10.1 There are 38 open clinical risks on the Trust s risk register and 45 open non-clinical risks. The total number of risks on the risk register is currently 83. This is an increase compared to the 71 clinical risks reported to the Board in October 2016 (previous indepth risk register report). The table shows how all these risks are currently graded in terms of consequence and likelihood and provides an overall picture of risk: Table 6 Risk profile across the Trust. 1 - Rare 2 - Unlikely 3 - Possible 4 - Likely 5 - Almost Certain Total 5 - Catastrophic Major Moderate Minor Negligible Total Board Assurance Framework Summary 11.1 The purpose of the BAF is to enable the Board to assure itself that risks to the success of its strategic goals and corporate objectives are being managed effectively Definitions: Strategic risks are those that might prevent the Trust from meeting its strategic goals and corporate objectives. A control is an activity that eliminates, prevents, or reduces the risk. Sources of assurance are reliable sources of information informing the Committee or Board that the risk is being mitigated ie success is been realised (or not) Directors maintain oversight of the strategic risks assigned to them and review these risks regularly. They also continually evaluate the controls in place that are managing the risk and any gaps that require further action SMT, the Quality and Business Committees, and the Board review the sources of assurance presented to them and provide the Board (through the BAF process) with positive or negative assurance The BAF summary (appendix 2) gives an indication of the current assurance level for each strategic risk, based on sources of assurance received and evaluated by committees and the Board, in line with the risk assurance levels described in appendix 3 (BAF risk assurance levels). Page 8 of 14

131 11.6 Since the last report in December 2016, the current level of assurance for the following BAF risks has been adjusted as follows: BAF risk 1.3 (relating to CQC rating) assurance level is now reasonable. This is a cautiously optimistic evaluation based on the outstanding CQC rating given to York Street Practice, and on the extensive and well-regarded preparatory work that has been completed within the Trust in advance of the CQC inspection due at the end of January BAF risk 3.2 (engaging and involving staff) assurance level is still limited but there are slight indications of an improving situation evidenced in the staff survey. The response rate is 48%, providing reasonable assurance. This year's national response rate is not yet known however, last year it was 41%. Business Committee chair's assurance report in November 2016 indicates limited assurance as appraisal rates have worsened over each of last three months. BAF risk 4.2 (retaining existing business and/or winning new business), the assurance level is still reasonable, but slightly less than the previous BAF report indicated. The reason for this is a recent internal audit on the contract bid process undertaken in quarter two highlighted six important action points Risk management activity 12.1 A workshop held in December 2016 aimed to provide managers with a better understand of their responsibilities for completing and maintaining lone-working risk assessments. This was well attended and feedback was positive The winter edition of Risky Business the Trust s risk management newsletter was published and distributed in December This latest edition draws readers attention to the risks of wearing less than sensible shoes, warns of the consequences of accessing patients records without a legitimate reason, and the risk of patients being given incorrect medicines from a compliance aid (dosette box). It gives a roundup of recent activity within services to reduce risks. There is also a link to an on-line test to see if staff can spot a phishing an that impersonates a genuine business or institution Impact 13.1 Quality Risks recorded on the Trust s risk register are regularly scrutinised to ensure they remain current. Risk owners are encouraged to devise action plans to mitigate the risk and to review the actions, risk scores and provide a succinct and timely update statement. There are no known quality issues regarding this report Resources Any financial or other resource implications are identified and managed by the risk owner/lead director responsible for individual risks. Page 9 of 14

132 13.3 Risk and assurance This paper seeks to reassure the Board that there is a robust process in place in the Trust for managing risk. Evidence that risks are proactively identified and managed in the Trust can be seen in the shifting profile of the risk register, with new risks being added and subsequently updated, risk scores amended and risks being closed Next steps 14.1 The Risk Manager will continue to monitor risk review dates and remind risk owners of their responsibility to review and update risks appropriately The BAF strategic risks are being reviewed alongside the and operational plan, to ensure the BAF risks remain relevant. A revised draft BAF will be presented to the Board on 31 March 2017 alongside the operational plan Reporting schedule 15.1 Set out below is the risk register and BAF reporting schedules to which this report conforms: Risk register reporting schedule Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec RRG FULL FULL FULL FULL FULL FULL Meeting type SMT FULL SUMMARY SUMMARY SUMMARY FULL SUMMARY SUMMARY SUMMARY FULL SUMMARY SUMMARY SUMMARY QC FULL SUMMARY SUMMARY SUMMARY FULL SUMMARY SUMMARY FULL SUMMARY SUMMARY BC FULL SUMMARY SUMMARY SUMMARY FULL SUMMARY SUMMARY FULL SUMMARY SUMMARY Board FULL SUMMARY FULL SUMMARY FULL SUMMARY FULL Summary = in depth report = snapshot report = information flow BAF reporting schedule 16.0 Recommendations 16.1 The Board is recommended to: Note the contents of the risk register Note the themes identified in this report Note the current assurance levels provided in the revised BAF summary Page 10 of 14

133 Significant risks (15+) Appendix 1 ID Risk Owner Director Opened Description Controls in place Lead Directorate: Operations Portfolio: Adult Services 872 Rowlands, Megan Prince, Sam 23/11/2016 Title: Difficulties recruiting to and Management reports in each service retaining staff within neighbourhood area. teams. Oversight at weekly Ops meeting, There is a high turnover of staff within monthly Performance Panels and neighbourhood teams. There is a risk of weekly at SMT not having enough staff capacity to Establishment Control process meet the demands on the service, a risk Service specification plans in place of missed visits / delayed appointments impacting on patient safety, a risk of having a less experienced and reduced workforce causing additional pressures on remaining staff, which will impact on staff wellbeing, a risk of a reduced offer impacting on activity levels and finances. There is a particular risk and impact where there are issues with recruitment and retention of senior clinical staff who provide leadership as well as direct clinical care. Weekly management consideration of workload. Support with prioritisation. Movement of staff between teams to offer more balanced capacity. Proactive recruitment plan in place Team coaching in place to support local leadership team with issues relating to staff morale Key clinical skills training matrix and enhanced training support in place Adequacy of controls Adequate Latest update Risk level Rating (initial) (initial) Risk level (current) Rating Risk level (current) (Target) Review of information at weekly ops suggests range of reasons for leaving trust. Consideration of citywide options to support to reduce risk of leaving. Seeking additional short term capacity via agency and CLASS to reduce workload pressures on clinical teams. availability of short term resource is limited. Additional senior clinical support for teams with clinical competency sign off once training undertaken supporting more neighbourhood team staff to have essential clinical skills Additional short term capacity from across the organisation released in response to recent service pressures escalation. Recruitment summit planned to test out options for further skill mix, maximising opportunities through the apprenticeship programme. (updated 23/01/2017) Extreme 20 Extreme 16 Low 3 Rating Review (Target) date 31/03/2017 Lead Directorate: Workforce Portfolio: Corporate & HQ functions 224 Hobson, Ann Ellis, Sue 01/01/2012 Title: Prevalence of staff sickness: Regular monthly reporting by individual Due to current high levels of staff team to managers.monthly discussion sickness absence across the Trust, there of absence by teams at business unit is a risk of greater reliance on agency performance meetings.monthly cover and a risk of remaining staff being discussion of absence by Business unit under pressure to manage an additional at operational performance meetings, workload. SMT, Business Committee and The impacts are the financial cost of Board.Health and wellbeing team in agency cover and an effect on staff place to support managers. Greater morale and wellbeing scrutiny within business units re compliance with return to work interviews. Limited The audit that Tiaa Internal Auditors were undertaking on nine areas to test the process and systems for management of long term absences, has been paused by the Auditors, currently awaiting a new timescale for delivery. Following presentation at SMT of the HWB programme on the very positive results, SMT have agreed to continue the funding for the programme, which will be re-launched in the New Year. Extreme 16 Extreme 16 High 9 28/02/2017 Further in-depth analysis is being undertaken on areas of high sickness to determine what further support is required. (updated 01/11/2016) Page 11 of 14

134 Board Assurance Framework (summary) Appendix 2 Corporate Objective Risk Likelihood Consequence Risk Score Risk movement Responsible Director Responsible Committee Current Level of Assurance (denoted by ). Additional Information Ensure the foundations are in place to consistently deliver and improve high quality care (as defined by CQC Good and Outstanding ). RISK 1.1 If we do not have effective systems and processes for assessing the quality of service delivery and compliance with regulatory standards then we may have services that are not safe or clinically effective. RISK 1.2 If we do not implement and embed lessons from internal and external reviews and reports, then we may compromise patient safety, we may experience intervention or damage to our reputation and relationships. RISK 1.3 If we do not achieve a 'good' CQC rating then there will be an impact on our reputation and progress of FT application (high) MP QC (high) MP QC (high) AT QC No Limited Reasonable Substantial Cautiously reasonable. York Street were rated as 'Outstanding' by the CQC following its October 2016 inspection. CQC preparation is going well according to update to Board in December Consolidate and develop the integrated neighbourhood teams. Influencing system transformation and new models of care. RISK 1.4 If we do not deliver our quality targets to achieve CQUIN income ( 2.3m) then we may risk income loss, leading to financial instability. RISK 2.1 If we do not maintain relationships with stakeholders, including commissioners and scrutiny board then we may not be successful in new business opportunities. The impact is on the Trust's reputation and on investment in the Trust. RISK 2.2 If we do not effectively transform and integrate services then the impact will be that benefits to quality and finance will not be realised. RISK 2.3 If we do not engage patients and the public effectively in Trust decisions, the impact will be difficulties in transacting change, and reputational damage (high) MP SMT (high) TS Board (high) SP QC (moderate) TS QC Some assurance remains limited as the flash reports presented to SMT in December 2016 highlight some issues within transformation projects. Limited assurance (but towards reasonable) as whilst there is sufficient engagement activity, the effectiveness is not currently being evaluated at committee level. Friends and Family test response rates remain low. RISK 2.4 If we do not respond to the changing commissioning landscape and the scale and pace of the emerging development of primary care, then opportunities for business development could be lost (moderate) SP BC There are currently very few sources of assurance to be evaluated, hence this assurance score is tentatively given as reasonable. Page 12 of 14

135 Continue to improve staff engagement and morale. Retain services which we expect to be tendered in 2016/17 (CAMHs T4, Community Dental, York Street, Healthy Living Services, IAPT, West Yorkshire Police Custody). RISK 3.1 If we do not have suitable and sufficient staff capacity (recruit, retain, skill mix, development) then we will not maintain quality and transform services. RISK 3.2 If we do not fully engage with and involve staff then the impact will be low morale and difficulties retaining staff and failure to transform services. RISK 3.3 If we fail to address the scale of sickness absence then the impact will be a reduction in quality of care and staff morale and a net cost to the Trust through agency expenditure. RISK 3.4 If we do not invest in developing leadership capability in operational services then this may impact on effective service delivery and staff wellbeing. RISK 4.1 If we do not improve productivity, efficiency and value for money then we may not be successfull in bids for retendered services leading to loss of business. RISK 4.2 If we do not retain existing business and/or win new business competitively, or in partnership with commissioners, then we may not have sufficient income to remain sustainable. RISK 4.3 If we do not deliver contracted activity requirement, then commissioners may reduce the value of service contracts, with adverse consequences for financial sustainability. RISK 4.4 If we do not deliver the income and expenditure position agreed with NHS Improvement then this will cause reputational damage and raise questions of organisational governance. RISK 4.5 If there is insufficient managerial capacity across the Trust to deliver all planned change programmes, then organisational priorities may not be delivered (high) SE BC (high) TS SMT (extreme) (high) SP SMT (high) SP BC (high) BM BC (moderate) (high) BM BC (high) BM BC SE SP BC BC Limited assurance as Business Committee chair's assurance report in November 2016 concluded limited assurance re staff turnover. The monthly turnover figures for neighbourhood teams gave the Business committee limited assurance in November. Internal audit of leaver process has provided reasonable assurance to the Audit Committee in October Business Committee chair's assurance report in November 2016 indicates limited assurance as appraisal rates have worsened over ecah of last 3 months. The staff survey response rate is 48%, providing reasonable assurance. This year's national response rate is not yet known however last year it was 41%. Business Committee chair's assurance report in November 2016 indicated limited assurance for sickness absence. Reductions in agency spend provided reasonable assurance in October An internal audit on the contract bid process was undertaken in Q2. Whilst the audit did not provide an overall level of assurance, as it was an advisory, it highlighted 6 important action points. Limited assurance as the flash report for SMT December 2016 shows the E- rostering project is on schedule, however the EPR project showed some slippage indicating limited assurance. Page 13 of 14

136 Appendix 3 Glossary- BAF risk assurance levels Risk assurance levels Definition Substantial Reasonable Limited No Substantial assurance can be given that the system of internal control and governance will deliver the clinical, quality and business objectives and that controls and management actions are consistently applied in all the areas reviewed. Reasonable assurance can be given that there are generally sound systems of internal control and governance to deliver the clinical, quality and business objectives, and that controls and management actions are generally being applied consistently. However, some weakness in the design and / or application of controls and management action put the achievement of particular objectives at risk. Limited assurance can be given as weaknesses in the design, and/or application of controls and management actions put the achievement of the clinical, quality and business objectives at risk in a number of the areas reviewed. No assurance can be given as weakness in control, and/or application of controls and management actions could result (have resulted) in failure to achieve the clinical, quality and business objectives in the areas reviewed. Page 14 of 14

137 Leeds Community Healthcare NHS Trust Trust Board public workplan Version 6 5 January 2017 Agenda item (83) Topic Frequency Lead officer 2 December February March May August October December 2017 Preliminary business Minutes of previous meeting every meeting CS X X X X X X X Action log every meeting CS X X X X X X X Committee's assurance reports every meeting CELs X X X X X X X Patient story every meeting EDN X X X X X X X Quality and delivery Chief Executive's report every meeting CE X X X X X X X Performance Brief every meeting EDFR X X X X X X X Operational plan including capital programme 2 x year EDFR Draft considered in private X Care Quality Commission inspection reports as required EMD X Quality account annual EDN X Staff survey annual report annual DW X Safe staffing report 2 x year EDN X X Infection prevention control annual report annual EDN X Emergency preparedness and resilence report and major incident plan annual EDO X Patient experience: complaints and incidents report 2 x year EDN X X X Freedom to speak up annual report annual CE X Safeguarding annual report annual EDN X Equality annual report annual EDN X X Strategy Service strategy as required EDFR X Quality strategy annual EDN X OD strategy 2 x year DW X X Research and development strategy annual EMD X Other strategic developments as required EDO Governance Well-led framework 2 x year CS X X CE report Medical Director's report: doctors' revalidation annual EMD X Nurse revalidation annual EDN X Annual report annual EDFR X Annual accounts annual EDFR X Letter of representation annual EDFR X Audit opinion annual EDFR X Audit Committee annual report annual CS X Standing orders/standing financial instructions review annual CS X X Annual governance statement annual CS X X Going concern statement annual EDFR X Committee terms of reference annual CS X X Board and sub-committee effectiveness annual CS X Register of sealings annual CS X Declarations of interest/fit and proper persons test/gifts and hospitality annual CS X Board development programme annual CS X Board workplan every meeting CS X X X X X X X Significant risks and risk assurance report every meeting CS X X X X X X X Corporate governance update As required CS X Decisions for ratification as required CS X Reports Approved minutes of committees, Safeguarding Boards, Health and Wellbeing Board, Children's Trust Board every meeting CS X X X X X X X Key CE EDFR EDN EDO EMD DW CELs CS Chief Executive Executive Director of Finance and Resources Executive Director of Nursing Executive Director of Operations Executive Medical Director Director of Workforce Committees' Executive Leads Company Secretary

138 Leeds Community Healthcare NHS Trust Trust Board public workplan Version 6 5 January 2017 Agenda item (83) Topic Frequency Lead officer 2 December February March May August October December 2017 Preliminary business Minutes of previous meeting every meeting CS X X X X X X X Action log every meeting CS X X X X X X X Committee's assurance reports every meeting CELs X X X X X X X Patient story every meeting EDN X X X X X X X Quality and delivery Chief Executive's report every meeting CE X X X X X X X Performance Brief every meeting EDFR X X X X X X X Operational plan including capital programme 2 x year EDFR Draft considered in private X Care Quality Commission inspection reports as required EMD X Quality account annual EDN X Staff survey annual report annual DW X Safe staffing report 2 x year EDN X X Infection prevention control annual report annual EDN X Emergency preparedness and resilence report and major incident plan annual EDO X Patient experience: complaints and incidents report 2 x year EDN X X X Freedom to speak up annual report annual CE X Safeguarding annual report annual EDN X Equality annual report annual EDN X X Strategy Service strategy as required EDFR X Quality strategy annual EDN X OD strategy 2 x year DW X X Research and development strategy annual EMD X Other strategic developments as required EDO Governance Well-led framework 2 x year CS X X CE report Medical Director's report: doctors' revalidation annual EMD X Nurse revalidation annual EDN X Annual report annual EDFR X Annual accounts annual EDFR X Letter of representation annual EDFR X Audit opinion annual EDFR X Audit Committee annual report annual CS X Standing orders/standing financial instructions review annual CS X X Annual governance statement annual CS X X Going concern statement annual EDFR X Committee terms of reference annual CS X X Board and sub-committee effectiveness annual CS X Register of sealings annual CS X Declarations of interest/fit and proper persons test/gifts and hospitality annual CS X Board development programme annual CS X Board workplan every meeting CS X X X X X X X Significant risks and risk assurance report every meeting CS X X X X X X X Corporate governance update As required CS X Decisions for ratification as required CS X Reports Approved minutes of committees, Safeguarding Boards, Health and Wellbeing Board, Children's Trust Board every meeting CS X X X X X X X Key CE EDFR EDN EDO EMD DW CELs CS Chief Executive Executive Director of Finance and Resources Executive Director of Nursing Executive Director of Operations Executive Medical Director Director of Workforce Committees' Executive Leads Company Secretary

139 Quality Committee Monday 21 November 2016 Boardroom, Stockdale House, Leeds 09:30 12:30 AGENDA ITEM (84a) Present Dr Tony Dearden Committee Chair / Non-Executive Director Dr Amanda Thomas Executive Medical Director Marcia Perry Executive Director of Nursing Neil Franklin Trust Chair Thea Stein Chief Executive (Items 55 59a) In Attendance Mo Drake Professional Lead for Allied Health Professionals (AHP) and Head of Patient Experience Caroline McNamara Clinical Lead for Adult Services Philip Boynes Quality Lead, Specialist Services Carolyn Nelson Head of Medicines Management Vanessa Manning Company Secretary Karen Worton Clinical Lead for Children s Services Abigail Eaves Service Manager HMYOI Wetherby (Item 56a only) Francesca Skirrow Primary Care Team Lead and Specialist Nurse HMYOI Wetherby (Item 56a only) Sarah Blakeley Qualified Nurse HMYOI Wetherby (Item 56a only) Dr Liz Allen Research Manager Observer Em Campbell Membership and Involvement Manager Minutes Lisa Rollitt PA to Executive Medical Director Apologies Elaine Taylor-Whilde Non-Executive Director Sam Prince Executive Director of Operations Stephanie Lawrence Deputy Director of Nursing Item no Discussion item Actions Welcome and introductions (55a) Welcome and Apologies The Chair opened the meeting and welcomed everyone. (55b) Apologies were received from Elaine Taylor-Whilde, Stephanie Lawrence and Sam Prince. Declarations of Interest There were no declarations of interest received. (55c) Minutes of meeting held on 24 October 2016 The minutes were reviewed for accuracy and agreed as a true record of the meeting with the following amendment: Item (49a): Director of Nursing: quality and safety report Falls: amend paragraph 4: The Clinical Lead for Adult Services Executive Director of Nursing said that falls screening was a mandated element of patient assessment. She also referred to an enquiry from the CCG s quality group which had enquired about the categorisation and recording of falls over reporting of falls. 1

140 (55d) Matters arising and review of action log It was agreed that all completed actions would be removed from the action log (38a) (iii) Director of Nursing: quality and safety report The meeting to review pressure ulcers benchmarking data was yet to take place. Completion timescale amended to January (38a) (v) Director of Nursing quality and safety report The action was completed in relation to CAMHS service availability to schools (40c) Infection prevention and control annual report The action related to benchmarking data on sharps incidents was completed (49a) Director of Nursing: quality and safety report The completion timescale was amended to January (49b) Quality improvement plan The action was completed. Little Woodhouse Hall had been fully reopened to admissions. Service spotlight HMYOI Wetherby & Adel Beck (56a) The Executive Director of Nursing introduced colleagues from HMYOI Wetherby and gave an overview of the changes to the service over the last year. To introduce the service, the team presented a quiz to raise awareness of the service amongst Committee members. The Primary Care Team Lead and Specialist Nurse HMYOI Wetherby updated the Committee on the different units at HMYOI Wetherby. There were three main clinical risks identified: violence, self-harm and staffing. Staffing: It was reported that a recruitment video had been created. Outpatient appointments were being cancelled due to a lack of staff to escort the patients. Orthodontic appointments were also being cancelled for the same reason, but this was not classed as essential. Self-harm: A new trend for self-harm was discussed. It was noted that the Trust pays for escorts to hospital. Violence: It was reported that bespoke personal protection training was being rolled out to staff. It was also noted that nurses had attended 41 cell fires within the year. A fire officer had been recruited by the YOI to work for one day per week to try and address the issue of cell fires. It was reported that there had been 15,600 clinical contacts in quarter with an increase in Attention Deficit Hyperactivity Disorder (ADHD) medication prescriptions % of residents have a learning difficulty and the majority of these reside on the vulnerable unit. The incidence of long term conditions had risen from 23 to 97 in year and 697 patients were triaged in September

141 The prevalence of substance misuse was outlined and the Committee noted changes in the pattern of drug taking. To try and combat the issue of drugs in prisons, it was noted that visitors over the age of 18 years were searched. Sniffer dogs were deployed. It was noted that the service worked with several national bodies and organisations. The Service Manager HMYOI Wetherby informed the Committee of a situation where staff dealt with a young person on the vulnerable person unit who had been assaulted by two prisoners and had sustained injuries. The impact of the situation on the nurse involved and future support for staff who deal with trauma was discussed. Action: Executive Director of Nursing and Service Manager HMYOI Wetherby to discuss introducing a similar principle to a Schwartz round in the secure environment. Action: Executive Medical Director and Service Manager HMYOI Wetherby to discuss psychological support for staff. MP AT In response to a question from the Trust Chair, the Service Manager HMYOI Wetherby stated that the staffing issues at HMYOI Wetherby have the same impact on healthcare staff as it was experienced in adult prisons. The Executive Director of Nursing asked about the changes to educational requirements and the impact this had on the ability to deliver healthcare. The Service Manager HMYOI Wetherby stated that the changes gave limited access for providing healthcare, however for primary care; the work was seen as essential. The Chair acknowledged the wide scope of work that the staff undertake and thanked the service manager for her presentation. Quality governance and safety (57a) Director of Nursing: quality and safety report The Executive Director of Nursing presented the report which set out the main areas of focus: Incident reporting Duty of Candour (DoC) Pressure ulcers Falls Medication incidents Infection prevention Friends and Family Test (FFT) End of life care SEND inspection Incident reporting The Executive Director of Nursing reported that October 2016 had shown the lowest number of incidents reported in the year to date. Reporting of no harm incidents had increased in month but was below the target of 70%. A piece of work was underway to look at the recording of no harm incidents. There has been further training delivered around the categorisation of incidents. 3

142 The next steps would focus on validating information and further comparison of the last two years of data, benchmarking with other organisations. Duty of Candour Duty of Candour remains an ongoing area of work. The Executive Director of Nursing stated that she had met with the Quality Lead, Specialist Services and the Clinical Governance Manager to discuss the ongoing work and briefing sessions had been held with neighbourhood teams. Further guidance would be circulated to ensure the correct completion of the relevant sections on DATIX. In response to a question from the Chief Executive, the Executive Director of Nursing confirmed that there was liaison with other trusts on this subject to ensure consistency in reporting approaches. Pressure ulcers The proportion of avoidable to unavoidable pressure ulcers at panel was 50:50 in October It was reported that there were some individuals in teams who had not watched the training video and were not aware of the top ten tips. The Chair queried if common factors and lessons were being fed back to the teams. The Executive Director of Nursing stated that this was the case. The Trust Chair commented that he felt that managers at a local level needed to maintain focus to address the issue. The Executive Director of Nursing reported concern about the significant financial challenge within the Leeds Equipment Service. It was agreed that any issues in relation to the delay in supplying equipment would be escalated to the Chief Executive. Falls Reported overall falls decreased in October It was reported that the South Leeds Independence Centre (SLIC) had identified an increase in falls, however the Unit Manager had contacted the Executive Director of Nursing stating that work was underway to address the issue. The increase had impacted on the quality account target for falls reduction. The Clinical Lead for Adult Services referred to the safety huddles and stated that these needed to be embedded. The Executive Director of Nursing stated that a revised approach to falls steering groups and panels was being implemented, led by the Deputy Director of Nursing. Medication incidents Focus continued on insulin incidents. Work was underway to investigate how to increase knowledge and reduce the number of incidents. It was reported that a task and finish group had met twice to develop a piece of work around methods of allocation. Separate good practice guides were required for electronic and paper based teams. Infection prevention There had been a number of outbreaks which were being managed. Standards of cleanliness have been addressed and the Trust is working closing with contractors and the estates function. The Infection Prevention and Control team (IPC) continued to monitor all incidents relating to needlestick injuries. Benchmarking data has been collected from three 4

143 trusts. A common theme identified was the prescription of safety devices to patients. It was noted that the Trust was not an outlier. The staff flu vaccination campaign continued and uptake was at 60%. A communication plan was in place to ensure maximum uptake. The Executive Medical Director reported that NHS Employers were interested in the Trust s work and wished to attend the Medical and Dental Conference. Friends and Family Test (FFT) A number of papers would be submitted to the senior management team (SMT) to review: An alternative approach to the FFT for police custody suites The use of technology for gathering FFT data A procedure for staff to enable patients to complete the surveys on Fujitsu laptops. PALS and complaints Progress continues and the new process for recording PALS activity has been positively received. It was noted that thirteen complaints had exceeded the 40 working days timeline. The Committee noted that the key challenge was in completion of the action plans. Annual documentation audit progress The Chair commented that progress on the annual documentation audit was disappointing. The Executive Director of Nursing stated that a huge amount of documents were being audited and it was imperative to ensure data was captured correctly. End of life care The Executive Director of Nursing stated that she would be meeting with a family to discuss their positive experience. Special educational needs and disability (SEND) inspection The Clinical Lead for Children s Services gave an overview of the work she had been leading on. Inspections would take place by the Care Quality Commission (CQC) and Ofsted of all services across the country within the next 5 years, giving one week s notice. The inspection would focus on the reforms outlined in the Children and Families Act Action: The Clinical Lead for Children s Services to provide an update on SEND inspection to the January Committee. KW Adults (neighbourhood teams) business unit The Clinical Lead for Adult Services expressed her concerns with regards to vacancies and sickness over the next two months. Priorities and capacity were being reviewed. Deployment of pharmacy technicians The Executive Medical Director reported that it would be beneficial to increase the number of pharmacy technicians in the neighbourhood teams. Assurance level: Reasonable 5

144 (57a i) Performance brief and domain reports The Chair referred to the safe domain and commented that some of the measures were changing. The Executive Director of Nursing confirmed that the Trust would continue to complete the Safety Thermometer for in-patient units. The Chair referred to regulatory requirements and asked how the potential under reporting of safety incidents measure had been arrived at. The Executive Director of Nursing stated that she had reviewed the issue and confirmed that the figure was arrived at from the percentage of no harm incidents. The Professional Lead for AHP and Head of Patient Experience stated that benchmarking was higher than the national average. The Committee noted that the Trust has made significant progress in relation to end of life care. A new target had been set in terms of avoidable category 4 pressure ulcers, however, the overall objective for the measure remained at zero each month. (57a ii) Risk register: clinical risks The Company Secretary presented the paper. The Committee noted that the new clinical risk: waiting times for podiatry had since been de-escalated due to the application of controls and mitigating actions and no longer appeared as a high risk on the risk register. The Committee noted that the de-escalation of the Little Woodhouse Hall risk following completion of remedial actions would be shown in the next report. (57b) Quality account The Executive Director of Nursing presented the report and the Committee noted that, in relation to the 13 priorities at the end of Quarter 1: 10 were on target 2 were off target 1 had been discontinued. It was agreed that the item needed to be revisited at the meeting in January Action: Quality account to be added to the agenda for the January 2017 Committee MD Assurance level: Reasonable. (57c) Quality improvement plan The Executive Medical Director presented the progress report and asked the Committee to note the completion of four actions since the previous report and requested approval to remove the actions. CAMHS Tier 4 In-Patients service Significant progress had been made and there was a robust approach in place for identifying, assessing and mitigating ligature risks. In relation to mixed sex accommodation, it was reported that the outstanding actions would be addressed within the timeframe. 6

145 Action: Executive Director of Nursing to request weekly updates on the progress of actions and will update the Chair on completion dates. MP With reference to the CQC focused reinspection, it was noted that an update on the data required would be given within the week. The Committee discussed preparation arrangements. The Chair reported back on a service visit he had completed, expressing concern about stress at work and particularly about low levels of job satisfaction. There was also concern that the staff were not aware of their training matrix for competencies. The Trust Chair referred to the new management team in place, stating that he had a lot of confidence in them and their ability to embed a team ethos. The Clinical Lead for Adult Services stated that the Executive Medical Director s attendance at a recent clinical forum was helpful as it gave input from a senior level. It was noted that a sheet of information would be issued (weekly) to all clinical leads to be circulated at cluster meetings to help focus discussion of quality and safety topics. Action: Executive Director of Nursing to share the sheet of information with the Chief Executive. MP The Chair referred to action plan no. 16, PL289 Search Policy to be reviewed and queried why there had been a delay. The Clinical Lead for Children s Services stated that the issue was around the terminology that staff at Little Woodhouse Hall used in relation to searching. It was recognised that this was an immediate issue and would be resolved and included in the standard operating procedure. Action: Clinical Lead for Children s Services to update the Chair on action plan no 16, PL289. KW Assurance level: Reasonable Safety (58a) Complaints and incidents: themed report The Executive Director of Nursing presented the report which gave a thematic review of complaints and incidents in the Trust but also provided benchmarked data from previous years and amongst comparable trusts. She drew attention to the top five themes within the Trust and stated that complaints and incidents related to clinical care was not a key issue. Themes amongst other community trusts were similar. The only difference identified was that medication did not feature so highly. This was related to the fact that other trusts did not have prisons in their portfolio. The Trust Chair reported that he reviewed complaints with the Executive Director of Nursing each quarter and was assured that the process was correct. Assurance level: Substantial. 7

146 Clinical effectiveness (59a) Mortality surveillance presentation The Executive Medical Director gave a presentation on the Trust s work to review trends and data related to mortality (expected and unexpected); the aim being to promote quality care and identify suboptimal care, promote learning, create strategies to help reduce mortality and to ensure appropriate governance. Outcome: The Committee noted the presentation. Assurance level: Substantial. (59b) (59c) Patient group directions for ratification The Committee ratified all the patient group directions. Research and development strategy implementation update The Research Manager presented the report and the Chair commented that the number of accruals should be commended. With regards to maintaining the level of core allocation, the Research Manager stated that she would be meeting with the Finance Manager and the Clinical Research Network (CRN) within the week and was hoping to obtain an indication of the allocation. In response to a query from the Trust Chair, the Research Manager confirmed that funding was on a regional basis and that all CRNs were competing for funding. It was confirmed that the strategy would be revised in The Executive Medical Director reported that academic partnerships and networks had been developed. Assurance level: The Committee was substantially assured of progress. Patient experience Internal review on PLACE inspection programme (60) The Executive Director of Nursing presented the report and confirmed that significant progress had been made on the completion of actions identified. The ongoing challenges were around the complexity of buildings. Cleaning and estates continued to present challenges. The Chair referred to the buildings where the Trust are tenants and asked where issues were escalated to. The Executive Director of Nursing stated that any issues were escalated to herself and the Executive Director of Finance and Resources. A piece of work was underway with all inpatient managers in relation to their roles and responsibilities. 8

147 Policies, reports, minutes for approval and noting Board members service visits (61a) The paper was received for information and a positive visit from a Non-Executive Director was noted. (61b) Clinical Effectiveness Group minutes: 13 October 2016 Received for information. (61c) Safeguarding Children s and Adults Group minutes: 13 October 2016 Received for information. Quality Committee work plan Items from work plan not on agenda (62a) Mortality Surveillance Group minutes: 13 October 2016 (62b) Future work plan Received for information. (62c) Dates of future sub group meetings 2017 Received for information (63) Matters for the Board and other committees It was agreed that the following would be raised as matters for the Board: Staff sickness rates Key aspects from the Director of Nursing: quality and safety report CQC re-inspection (64) Any Other Business There was no other business to report. Dates and Times of Next Meetings (09:30 12:30) Monday 23 January 2017 Monday 20 February 2017 Monday 20 March 2017 Monday 24 April 2017 Monday 22 May 2017 Monday 26 June 2017 Monday 24 July 2017 Monday 25 September 2017 Monday 23 October 2017 Monday 20 November

148 Business Committee Meeting Boardroom, Stockdale House Wednesday 23 November 2016 ( noon) Agenda Item 2016/17 (84b) Present: Brodie Clark (Chair) Non-Executive Director (BC) Bryan Machin Executive Director of Finance & Resources Tony Dearden Non-Executive Director (TD Richard Gladman Non-Executive Director (RG) Ann Hobson Acting Director of Workforce Attendance: Sam Prince Executive Director of Operations Vanessa Manning Company Secretary Andrea North General Manager for Specialist Services (for item 62) Allison Tattersfield Business Manager for specialist Services (for item 62) Observer: Em Campbell Membership and Involvement Manager Apologies: Thea Stein Chief Executive Note Taker: Ranjit Lall PA to Executive Director of Finance & Resources Item Discussion Points Action 2016/17 (59) a) Apologies: Please see above. b) Declarations of Interest: None recorded. c) Minutes of last meeting: The public and private minutes of the meeting dated 26 October 2016 were approved by the Committee. d) Matters arising from the minutes and review of actions: 2016/17 (40d) workforce race equality standard action plan (WRES) It was noted that discussions were underway to share experiences between Deloitte and the Trust. Action was now closed. 2016/17 (44) Electronic patient record (EPR) It was reported that a dialogue had started with the Assistant Director of Business Intelligence to share learning and working together in the future with organisations bidding jointly for funding. A date of 13 December 2016 was confirmed for a Non-Executive Director (RG) to spend time with the EPR team. Action was now closed. 2016/17 (51a) Well led domain: friends and family test (FFT) A detailed discussion took place at the Senior Management Team (SMT) meeting on the FFT results. Work was ongoing to increase the response rate. The Acting Director of Workforce said it was agreed that the Executive Directors were to focus their discussions in their individual teams to reflect on some of the comments noted in the survey. The Chair asked for an update in January 2017 Committee meeting after the figures had been published. AH 1

149 2016/17 (51a) Workforce race equality targets The Acting Director of Workforce reported that there were no national percentages or national targets set for WRES. Each organisation set local targets with the aim of achieving a workforce more representative of the local population. Black and minority ethnic (BME) was 18.9% for Leeds and the Trust employed 12.2% based on the local figures. 2016/17 (51a) Health and safety compliance It was noted that the Health and Safety Group meeting focused on the health and safety training update across the organisation. Action was now closed. A Non-Executive Director (TD) referred to the previous minutes to seek clarification on the redesign of Improving Access to Psychological Therapies (IAPT) service in the city for all community based mental health services. The Executive Director of Operations said that a workshop on 30 November 2016 would focus on re-designing a single point of access. The Executive Director of Operations would provide further details to Non-Executive Director (TD) outside the meeting. SP 2016/17 (60) Performance management 60a Performance brief and domain reports The Executive Director of Finance & Resources introduced the performance brief and identified the main issues for consideration. The quality domains had been discussed at the Quality Committee meeting on 21 November It was noted that the Trust was currently performing within all national set targets and that there were no statutory breaches. A Non-Executive Director (RG) referred to the regulatory requirements update in the report and asked whether the Trust had received a reply from NHS Improvement (NHSI) on the re-categorisation from category 3 to category 2. The Executive Director of Finance & Resources said that he was looking forward with some degree of confidence to receiving satisfactory segmentation to the next rating. There were no further issues to report on the contract for 2017/18 and 2018/19 other than what was included in the performance brief. Some issues covering additional costs for escort and bed watches were reported. In terms of rolling forward to 2017/18 it was noted that prison bed watch costs were being transferred to Commissioners. Quality and safety A Non-Executive Director (TD) said that the Quality Committee noted positive work and good progress in the end of life care target and improved performance against the percentage VTE risk assessments. The Committee also discussed concerns of safety and quality matters relating to staff sickness absence particularly in regard to neighbourhood teams. Well-led: Turnover, appraisal and sickness absence rates The Acting Director of Workforce highlighted that the target the Trust had set itself was between 9% and 13%, and the rolling year turnover figure was over 14%. The SMT looked at various areas of turnover and had focused its discussions on the top two areas that were causing the greatest concern; nutrition and dietetic service and neighbourhood teams. 2

150 An analysis of reasons for staff leaving had shown that substantial numbers were leaving for promotional reasons and there had also been a significant number of retirements. The Acting Director of Workforce said that a task and finish group had been established to work across the Trust in nutrition and dietetics service and the business units to identify further actions to retain staff. The turnover in neighbourhood teams ranged from 19.5% up to 28%; highest area being Beeston over 28%; Armley over 23% and Yeadon over 21%. The recruitment team was analysing the reasons. It was noted that the high turnover in Beeston was mainly due to retirement and in terms of Armley and Yeadon; individuals were leaving for development opportunity with other employers. A Non-Executive Director (RG) asked whether the Trust s approved grading of posts was consistent with other Trusts. The Executive Director of Finance & Resources said that, in some cases, our pay bandings were less than other employers. In addition, for some professions, there was a highly competitive recruitment market. The Acting Director of Workforce confirmed that the exit interview process provided clarity on the reasons for leaving. The Acting Director of Workforce explained that a nutrition and dietetic task and finish group had been established and will come up with different options or alternative ways to improve staff turnover mechanisms. She said this was one measure that cannot be worked at in isolation, the turnover relates to multiple factors happening in the area. The next meeting for the task and finish group was early January The Chair said he would welcome an update on arising issues presented to the Business Committee in February The Chair asked about the new appraisal form, and whether staff were feeling supported in their development and team working that could contribute to their retention. The Chair asked for a brief assessment to see how effective the new appraisal forms were in terms of supporting development and team working for the next meeting in January AH AH A Non-Executive Director (TD) noted the very complex and challenging environment within the neighbourhood teams and was concerned with what action was currently in place. The Executive Director of Operations said that the main impact on this was staff sickness rate that made working environment extremely difficult. The Chair was disappointed to note the sickness absence percentage for October 2016 had increased to 5.9%. He asked about outcomes or further measures to address this following the Board workshop on 4 November The Acting Director of Workforce said that there had been follow up discussions at SMT. The Executive Director of Finance & Resources added that SMT had agreed to review the current sickness absence policy and its practical application; the actions management are required to take and the time scale from first point of sickness to escalation through to a formal process. Finance report The Executive Director of Finance & Resources was pleased to inform the Committee that the financial position continued to improve. He said that if the remaining five months of year were to continue as anticipated the Trust would achieve the position of 500k less than the control total and meet the financial target. 3

151 The October 2016 position showed an increase in cost of directly employed staff and significant reduction in agency staff. The Trust continued to scrutinise all posts for recruitment through SMT. The system put in place to control pay spending remained in place and appeared to be effective. The Chair was pleased to note the finance update and number of the methods and approaches taken delivered to achieve this improved position. 60b Neighbourhoods report and dashboard The Executive Director of Operations said the update was consistent with previous month s report but she was concerned about staff turnover rate; expecting another twenty leavers at end of the year. The Executive Director of Operations said that a significant plan was in place to improve capacity and reduce demand, including working with CLASS to block book people, looking at anyone who may have skills required to work in nursing to support demand and reduce requirement for non-essential training. She said it was essential to improve sickness absence rates. The Acting Director of Workforce and the Executive Director of Operations planned to spend a day in December 2016 to work alongside managers where highest sickness rates were noted. The Executive Director of Operations said that she was concerned about staff turnover levels going into December/January but was able to give some reassurance at this point that she had a plan in place to mitigate any adverse impact. The Chair noted the immediate actions defined to help mitigate reductions in staff and capacity. He was concerned about the measures in place over the next three months and asked that a written brief is provided of the actions being taken at the next Committee meeting in January SP It was noted that both sickness absence and recruitment and retention featured as extreme risks on the Trust s risk register. Outcome: The Committee noted the neighbourhoods report and particularly the high sickness absence and high turnover rates. 60c Agency staff update: Board self-assessment The Acting Director of Workforce presented a populated checklist which had been completed with input from finance, human resources, nursing and medical directors. It had been agreed at the last Business Committee meeting that the Committee would consider the comments and agree the final version, for the Chair and Chief Executive to sign off before submitting to NHS Improvement by 30 November 2016 and the decision being noted by the Trust Board on 2 December The Acting Director of Workforce said that the comments received back from a Non-Executive Director (TD) and SMT members had now been populated into the checklist. The Committee considered and amended the narrative and agreed the final version of the self-certification checklist. Outcome: The Business Committee reviewed the checklist and recommended the Chair and Chief Executive to approve, as amended, an urgent decision prior to submission. 4

152 60d Financial recovery plan 2016/17 No comments were noted. The financial position had been discussed earlier under the performance brief and domains report item (60a). 2016/17 (61) 61a - Business and commercial developments update 61 b&c - Control total and operational plan 2017/18 and 2018/19 Please see private minutes. 2016/17 (62) Specialist business unit in-depth review The Committee welcomed representatives from the specialist services business unit who described achievements and challenges including performance against a range of indicators across the service. The General Manager talked about the make-up of the specialist business unit and its position covering twenty-three diverse large and small services. The services ranged from young offenders institute at Wetherby, York Street GP practice, inpatient units and community services, and within that there were a number of services that were split into further services. Comments noted following the presentation: Concerns with non-reporting issues; the Business Manager assured the Committee that the specialist business unit was reporting on every service after setting up bespoke systems and within majority of those services they had access to a performance analyst. She said initially it had been a challenge to draw out some of that information but after further work and effort the unit was now confident in performance process, updating of electronic staff records and workforce matrix. The Executive Director of Operations said that internal auditors have been asked to do data quality checks in relation to the electronic staff records. Relationship with commissioners; the General Manager said that discussions usually took place with a number of different commissioners. The specialist business unit had a good and collaborative relationship with all the commissioners. Workforce planning; the General Manager said that at local level discussions were good and clear on priorities, but on the strategic level there were some challenges because of the need to plan collaboratively across health providers. Management capacity; the General Manager said that the services transfer from adult business unit was the right move and the feedback from the service was positive. Further reviews on all structures across services will continue in the next few months. Work would also continue looking at the challenges and aligning with corporate support. The Chair thanked the General Manager and the Business Manager for the presentation. 2016/17 (63) Governance Non-clinical risk register 8+ The risk register report provided the Business Committee with an overview of the Trust s non-clinical risks currently scoring 8 or above. Currently there were two extreme risks (15+); staff sickness absence and CAMHS inpatient unit risk. CAMHS risk had been downgraded to 10 since the paper was written. 5

153 The Company Secretary said that a new risk had been added to the risk register this week at 15+, which was recruitment and retention challenge in neighbourhood teams. Outcome: The Committee noted the contents of the risk register and themes identified in the report. 2016/17 (64) 2016/17 (65) 2016/17 (66) 2016/17 (67) Business Committee s work plan The work plan was reviewed by the Committee and no changes were requested. Minutes for noting Contract Management Board draft minutes of meeting dated 20 October 2016 were noted by the Committee. Matters for the Board and other Committees Staff turnover Sickness absence Finance Neighbourhood teams update. Any other business None recorded. 6

154 Audit Committee Boardroom, Stockdale House, Headingley Office Park, Victoria Road, Leeds, LS6 1PF Friday 21 October am am Agenda item (84c) Present: In Attendance Jane Madeley (JM) Richard Gladman (RG) Elaine Taylor-Whilde (ET-W) Bryan Machin Vanessa Manning Clare Partridge Peter Harrison Tim Norris Don Pritchett Beric Dawson Chair Non-Executive Director Non-Executive Director(from Item 32a) Executive Director of Finance and Resources Company Secretary External Audit Partner (KPMG) Head of Internal Audit (TIAA Limited) Internal Audit Manager (TIAA Limited) Counter Fraud Specialist (TIAA Limited) Counter Fraud Specialist (TIAA Limited) Minutes: Liz Thornton Board Administrator Item Discussion Points Action Welcome, introductions and preliminary business (31) The Chair welcomed attending members and self-introductions were made (31a) (31b) (31c) Apologies Jackie Rae, External Audit Manager (KPMG) Declarations of interest There were no declarations of interest. Minutes of the previous meeting 22 July 2016 The minutes of the meeting held on 22 July 2016 were reviewed and agreed as an accurate record. Outcome: The Committee approved the minutes of the previous meeting held on 22 July (31d) Matters arising and actions log The following outstanding actions were discussed and updates provided: Item (21a): Project management:2015/16 audit Actions within the report should be re-assigned and/or re-described in light of the closure of the project management office. Action: The Executive Director of Finance and Resources agreed to discuss the oversight of significant projects with the Executive Director of Operations and consider how projects can be monitored by the Business Committee. BM 1

155 (32a) Internal Audit Summary of internal controls assurance report The Internal Audit Manager introduced the report and reported that four audits had been completed since the Committee s meeting on 22 July 2016: off payroll contractors, data quality of end of life indicator, infection control (hand hygiene), and HR leavers process. The executive summary and management action plans for all four completed reports were included in the report. All indicated a reasonable assurance opinion. Progress against the annual plan for 2016/17 The Internal Audit Manager introduced the report; particularly noting that good progress had been made on the six reports in quarter two. Two draft reports were awaiting finalisation: contract bid process and incident management reporting. Audit fieldwork was underway for a further four audits as part of the work for quarter two. Terms of reference had been issued for nine audits scheduled for quarter three in 2016/17. A Non-Executive Director (RG) asked about the terms of reference for the 2016/17 audit of the neighbourhood teams. The Internal Audit Manager explained that a planning meeting had been arranged with the responsible executive lead to finalise the terms of reference and would be shared with Non-Executive Director (RG) once they had been agreed. Action: The Internal Audit Manager to share the terms of reference for the audit of the neighbourhood teams when agreed. TN Referring to the scheduling of forthcoming internal audits, the Chair asked whether it might be appropriate to review the timing of the audit of the neighbourhood teams in light of the CQC inspection. It was also concluded that the audit on CQC compliance should be postponed and/or removed from the plan. Action: The Executive Director of Finance and Resources to discuss with the Executive Medical Director the merits of re-scheduling the internal audit of the neighbourhood teams and the audit on CQC compliance in light of the CQC inspection. BM The Committee discussed the executive summary and management action plans for the audits finalised since the last meeting. The Chair asked that in the future the management action plans include the responsible director as well as the responsible officer against every recommendation. Action: The Internal Audit Manager to include the responsible director and responsible officer against every recommendation in the management action plan reports for future meetings. TN A Non-Executive Director (ET-W) raised concerns about the reasonable assurance opinion assigned to the compliance review of infection control hand hygiene given the zero tolerance on poor hygiene standards taken by the Trust. The Executive Director of Finance and Resources advised that the Executive Director of Nursing was monitoring this very closely and further reports would be made to the Quality Committee. Outcome: The Committee noted the contents of the summary internal controls assurance report, including progress on recommendations arising from the completed audits. 2

156 (32b) Internal audit recommendations update The Executive Director of Finance and Resources presented the report. He referred to the summary report for all internal audit recommendations that had an agreed implementation date by 30 September 2016 and the more detailed report on the outstanding actions. He noted that there were 12 recommendations to report this month that had not been completed by the due date. The overdue recommendations were reported in detail with an update on progress from the responsible manager; the current position had been RAG rated which indicated whether the action was considered virtually complete with some action still outstanding or related new issues(amber), or where there was insufficient confidence that the required action had progressed sufficiently (red). He added that overdue recommendations were reviewed by SMT. The Committee discussed the overdue recommendations paying particular attention to those rated as red. The Chair of the Committee re-emphasised her concerns about the number of outstanding recommendations and the progress made on implementation. The majority of comments did not explain the reasons for delays and why deadlines had been extended. The Committee discussed and agreed some enhancements to the report for future meetings. The Chair summarised these as: Priority rating of original recommendation Original due date and revised date (when amended) Updated comments column to address the initial recommendation Latest response to include actions to remedy under-delivery(not just the reason for delay) Action: The Executive Director of Finance and Resources to consider the format of future reports and discuss this with the SMT. BM Referring to the two outstanding recommendations relating to the audit on data quality. The Chair noted that a number of actions and activities were linked to the roll out of EPR by March 2017 and asked that the due dates for these recommendations be reviewed in light of the re-phasing of EPR roll out. Action: The Executive Director of Finance and Resources agreed to discuss review of the due date relating to EPR roll out with the Executive Director of Operations. BM (33a) (34) Outcome: The internal audit update report was received and the contents noted. Including progress against the internal audit recommendations. External Audit External audit technical update The External Audit Partner introduced the technical update paper. She noted the apprenticeship levy and the paper on golden opportunities from the greying population. Outcome: The Committee received and noted the update. Counter fraud and security management Counter fraud progress report The Counter Fraud Specialist introduced the progress report which summarised the work undertaken in line with NHS Protect standards and a workplan approved by the Audit Committee in April The Committee noted the training and communications actions to raise awareness of counter-fraud and bribery prevention amongst staff. 3

157 In relation to current investigations, the Counter Fraud Specialist referred to four current investigations all of which had been actioned and were pending closure. One related to the disposal of IT assets and three related to fraudulent claims for payment by employees. Outcome: The counter fraud progress report was received and its contents noted (35a) (35b) Governance Non-compliance with standing orders and standing financial instructions. There were matters of non-compliance to report. Board assurance framework The Company Secretary introduced the Board Assurance Framework (BAF); the strategic risks aligned to the Trust s corporate objectives had been reviewed by individual directors and collectively by the SMT. She advised that the key controls and sources of assurance had been re-appraised along with gaps in control and sources of assurance. A finalised, fully populated version of the BAF was presented to the Committee. Committee members made a number of suggestions for refining the content and these were noted for incorporation. Non-Executive Directors particularly felt that there were some controls or gaps in controls which did not appear; these related to: demand and capacity planning caseload scheduling and management clinical and operating models used in neighbourhood cost improvement plans Action: Company Secretary to consider inclusion of these additional requirements in conjunction with the relevant director. VM In addition a number of process matters were discussed, in particular: committees to be sighted on the risks assigned to each committee; conclusions on sources of assurance (positive and negative) to be collated from SMT, committees and Board discussions; SMT to review a cluster of risks every two months; SMT to review and re-calibrate (as necessary) target scores; movement in risk scores to be shown in future BAF reports. Action: The Company Secretary to ensure that committees were aware of the risks assigned to them and that committee workplans were aligned to ensure adequate consideration of the relevant sources of assurance. VM Outcome: The latest draft of the BAF was noted. The new approach, including the new combined significant risks and assurance report to the Board were seen as providing reasonable processes for the identification and management of strategic risk and the report and its presentation was welcomed (36a) Financial controls Tender and quotations waiver report The Executive Director of Finance and Resources introduced the report. He advised that the report presented an extract from the 2016/17 register of waivers completed during the financial year. He noted there had been two waivers since the last report in July 2016; the report contained details of the supplier, the rationale for the waiver and the processes within the Trust. Outcome: The Committee received the report and the content was noted. 4

158 (36b) Losses, claims and special payments report The Chair noted that there were 23 payments for the period July to September The Executive Director of Finance and Resources explained that 14 of these related to write off of old outstanding invoices totalling 1, The Committee took assurance that the 23 payments collectively did not amount to significant financial loss to the Trust. Outcome: The losses, claims and special payments report containing twenty three payments between July and September 2016 was noted (37a) (38) (39) Audit Committee work plan There were no matters removed from or changes made to the work plan. Matters for the Board and other committees The Chair of the Committee noted the following items to referred to Board colleagues: Progress on internal audits Scheduling of forthcoming internal audits in light of the forthcoming CQC inspection Risk management update: committees to be made aware of the risks assigned to them and their workplans to be aligned to ensure adequate consideration of relevant sources of assurance. Any other business There were no matters for discussion. Date and time of next meeting Friday 9 December am 11.30am, Boardroom, Stockdale House. 5

159 DRAFT Record of the meeting held on 22 September 2016 LSCB Board Meeting 22 September 2016 Mark Peel Nigel Richardson Jo Harding Andrea Richardson Max Lanfranchi Emma Howson Karen Rodger Marcia Perry Dick Biscombe Dee Reid Emma Whittell Sharda Parthasarathi Andrew Ottey Richard Hattersley Cllr Jane Dowson Sharon Yellin Amanda Thomas Peter Harris Karen Townend Rebecca Roberts Clare Linley Rachel Stanton Rebecca Gilmour Phil Coneron Karen Shinn Ruth Stevens Apologies for Absence Cllr Lucinda Yeadon Superintendent Sam Millar Steve Walker Dave Basker Amandip Johal Mariya Naylor Maureen Kelly Gill Marchant Shona McFarlane Andy Percival Andy Goulty Jonathan Darling Andrea Cowans LSCB Independent Chair LCC, Director of Children s Services Leeds West CCG, Director of Nursing and Quality LCC, Children s Services, Head of Service Learning for Life National Probation Service Lead Officer in Safeguarding, Public Health (for Bridget Emery) NHS England, Senior Nurse LCH, Executive Director of Nursing Wetherby YOI, Governor LCC, Head of Communication LCC, Communications NSPCC, Head of Service Leeds City College, Head of Safeguarding (for Andrea Cowans) LYPFT, Head of Safeguarding (for Anthony Deery) Deputy Executive Member, Labour Office of DPH, CDOP Chair Leeds CCG, Designated Doctor Primary Headteacher s Forum WYCRC Interim Legal Advisor to the LSCB LTHT, Deputy Chief Nurse (for Suzanne Hinchliffe) Head of Safeguarding, LTHT Leeds YOS, Deputy Service Manager LSCB Business Unit, LSCB Manager LSCB Business Unit, LSCB Manager LSCB Business Unit, Senior Administrator (minutes) Executive Lead Member for Children s Services West Yorkshire Police, Superintendent LCC, Deputy Director, Children s Services, Safeguarding, Specialist and Targeted Services LCC, Children s Services, Head of Integrated Safeguarding Unit CAFCASS, Service Manager Yorkshire Place 2 Be, Third Sector Reference Group Chair Leeds CCG, Interim Assistant Director of Nursing & Quality Leeds South & East CCGs, Deputy Head of Safeguarding Children & Adults (for Maureen Kelly) Adult Social Care, Chief Officer Access & Care Delivery Leeds Secondary Heads Group Leeds Secondary Heads Group Leeds CCG, Designated Doctor Leeds City College, Head of Safeguarding 1

160 DRAFT Record of the meeting held on 22 September 2016 Anthony Deery Rob McCartney Leeds and York Partnership NHS Foundation Trust, Director of Nursing LCC, Environment & Housing, Head of Housing Support Item Description Action 1 Introductions/apologies/new members Mark Peel welcomed everyone to the Board meeting and apologies were noted. Nick Page was introduced to the Board. 2 Serious Case Reviews (Confidential Session) 2.1 CC Report Nick Page introduced himself as the Independent Reviewer for the Learning Lessons Review into the murder of Ann Maguire by William Cornick. Nick stated that there were two aspects within the review that he had been asked to look at: 1 - The tragic incident and analyse if there was anything that could have been done in Leeds to predict the murder. Nick stated that there was nothing that could have predicted the murder. 2 - After the murder, how partners responded as a city and how people have people responded to and how they were supported. Nick noted that the intervention was a comprehensive response Nick stated that he was clear there was nothing anybody could have done to predict this happening and there were no deficits in agencies before or after in terms of response There are a number of learning points within the review, which are for the Board to review, discuss, analyse and, if it is felt sufficient, to develop recommendations for the wider system Mark Peel extended his thanks to Nick for the work that he had undertaken The Terms of Reference were lengthy and the review has met them. Generally learning lessons review (LLR) reports are much shorter and the length of this report reflects the complexity of what happened and the detail and substance of this LLR Mark acknowledged that at no point during the criminal case did Will Cornick say anything other than he was guilty, it is only through this process that he was willing to engage with and meet with Nick. Mark stated that Nick handled the review in a careful and sensitive manner There is nothing in the LLR to suggest that any method used by safeguarding agencies could have predicted that this was going to happen or identify Will Cornick as a murderer There were no deficits in the response of the city, this incident can be used as a way to evaluate how the partnership works to its furthest extent. Mark stated that the city should be proud of its response to an awful circumstance Mark stated that Nick has articulated the learning points in a way that gives the opportunity to look at them in a wider context and bring together learning locally and potentially nationally. This could be incorporated within a Chair s Summary which will knit together the learning points and make recommendations that the Board can proactively pursue The Board were asked if there were any questions. Nick stated that the report has been circulated to interested parties and their comments have been incorporated where appropriate Peter Harris had a few minor queries which he stated he would to Mark for Nick to consider Nigel Richardson echoed his thanks to Nick. He stated it was an extraordinary task and he was willing to take it on has to be respected Nigel stated that all the feedback he has had from people who were interviewed or PH 2

161 DRAFT Record of the meeting held on 22 September 2016 spent time with Nick was hugely positive. The timing of this report is unusual because normally it would be published after the Inquest, but the Coroner is awaiting the completion of this report before commencing the Inquest. When the review was initiated the authority had been assured that there would be no Inquest due to the clarity of information available. It is reassuring that the initial intuitive look and the court s look came to the same conclusions that Nick s report has come to, that nobody could predict this incident happening Nigel stated he was interested in the national aspect in terms of the channel of communication which Leeds opened with the Government. It was really positive and this could be brought into the national debate. The murder of a public servant by a pupil is unique and the learning from this could make a positive contribution to the debate Nigel noted that the review has been transparent with information but questioned the gaps in the Foreword Nick felt that in terms of the national learning it should be shared that how Leeds, as a big city, opened up channels to the government because it was recognised that it was an unprecedented event; Nick would endorse this as there is learning for the whole system. Nick noted that the gaps are Ann Maguire, as she is not here to tell her account, and the children and young people that witnessed the event. They are victims and their vulnerabilities are still there, it needs to be triangulated on how they are supported now that they are adults Mark stated he was more comfortable with the phrase because there is no such thing as a perfect inquiry or research, you can only do the best you can do with what is available. For the young people it would not have been a positive circumstance to interview them, therefore it is a justifiable gap Jim Stewart stated that from a national learning stance there has been deaths of mental health professionals being killed by patients, however there appears to be no reviews about them to share learning Marcia Perry felt it was really helpful to see the breadth and depth and was interested by the potential impact on the academic trajectory of the young people and whether the partnership could do more to support them. Mark felt this was a vital point as they will likely just have started jobs or University at the point where the Inquest will be reinitiated Nick wished to reiterate that the young people are victims as well and it will require a recommendation to the Leeds Safeguarding Adults Board, as it is a duty to understand how this support is followed through for all victims Nick stated that how the partnership provides care to these victims needs to be galvanised and how, when the young people go into adulthood, it can be flagged up on their records. This is a national issue that the Board could feedback on The learning point regarding children and young people to be encouraged to share information about a peer with a trusted adult is a national issue. Mark felt this this can be difficult because adolescents are feeling things for the first time and say things as a means of expressing and venting that they have no intention of doing. Mark noted that as adults we have more context to put things into perspective, so it is not unusual that the young people hearing this did not disclose There is no doubt in the report and the criminal case, that the only person responsible is Will Cornick; no other child or young person was present Dee Reid stated that, providing the Board are in agreement with the report, the next step will be publishing the report in the public domain. The Chair s Summary will be written and recommendations will be formulated for the Board to take forward. Dee stated there is a prospective date in November to publish. Nigel noted that the pre-inquest hearing is scheduled for 21 November 2016, so publication needs to be before this date Emma Whittell will draft a media release from the LSCB which will be shared with key partners and put on the LSCB website. The response to any questions will come from the 3

162 DRAFT Record of the meeting held on 22 September 2016 LSCB and media enquiries will be handled by the LCC Press Office Mark stated that everything he has heard and read regarding Ann Maguire shows this to be a truly positive reflection of who she was Mark acknowledged that the review has had a massive effect on Nick and that he was very grateful for the exemplary piece of work he has done On behalf of the Board Mark formally accepted the report. 2.2 CG Update Karen Shinn informed the Board that the Standing SCR Sub Committee had received further information regarding this case, therefore a new recommendation was considered and now a SCR will be undertaken. The SCR will follow the conclusion of the Inquest which is due to be held on 14 November The SCR will be known as Child B The process has begun with appointing a SCR Chair and Author, with all authors and Chairs on the accredited list on the AILC website being ed to seek their interest. 2.3 Child Z and A SCR Karen updated the Board on the progress of this review and stated that the trial has been delayed due to the defence wishing to appoint a medical expert. Authors of the agency reports have been asked not to approach witnesses until after the trial has concluded A panel meeting is due to be held on 23 September in order to take stock of the position of all agencies involved. 2.4 DHR DHR19 has been initiated and the first panel meeting was held 21 September LSCB and Children s Services agencies are represented on the Panel. Actions / Agreed Action: CC Report - Peter Harris to share his comments with Mark Peel. Agreed: CC Report - The report was formally accepted by the Board. PH 3 LSCB Training Report Karen Shinn talked to the Training Report stating that the report covers delivery in relation to need, the annual conference and the regional conference. Main points: There has been a significant period of challenge, there has been reduced capacity due to not being able to recruit due to HR restrictions. Jeni Roussounis has done a fantastic job doing a full time role on a part time basis Until April 2016 the LCC booking system was still being used which caused problems, as did the continuing fluctuation of the input and commitment to the multi-agency Training Pool Over 100 training courses were delivered in 2015/16 and over 1800 people were trained There were 20 Light Bite sessions and just under 600 people attended An annual and regional conference was also held The training evaluation was not as thorough, however there was a positive evaluation of training and the target of 90% or more for a positive training experience was achieved The impact evaluations, carried out 3 months after a course has run, had a low response rate and due to difficulties with the Business Support Centre and were put on 4

163 DRAFT Record of the meeting held on 22 September 2016 hold. The evaluations that were received back showed a positive response and some have fed back their training into practice There are series of recommendations that have been proposed and were agreed by the Learning and Development Sub Group, the Board was asked whether they were happy with them The Training Pool commitment is a continuing issue as there are 100 trainers signed up however 50% engage and 30% actually deliver. There are a number of reasons why input is less however there are some agencies where it is significantly lower and Jeni is working them Learning and Development Sub Group has a Task and Finish Group established to take forward the reviewing of the evaluation process to make it meaningful A Training Needs Analysis has not been completed for a couple of years instead courses have been tweaked and it feels time to do a thorough analysis now The internal QA of training was put on hold but this will be re-established Mark Peel gave his thanks to Karen Shinn and Jeni Roussounis for the work that has been undertaken over the past year. Comparatively, Leeds is doing an outstanding job for the numbers of people that are brought into the safeguarding conversation. Mark drew the Board s attention the report of the Annual Conference and felt that the evaluation for the event was indicative of the quality of training. Questions from the Board: Nigel Richardson gave his thanks for the work undertaken, but felt it needed to be pushed harder on examples back into practice. Nigel queried the clarity of the direct links and the themes that recur in SCRs and LLRs are implicit. Karen stated there is an ongoing programme of SCR briefings, there haven t been any specific briefings on cases but there is an opportunity when the CC report is published, but it is dependent on how appropriate that would be. The themes that appear in practice are sadly consistent Clare Linley stated that in previous reports the contribution of trainers is a recurrent issue. There is a theme where there is a struggle with resources and it could be about working smarter to address the issues LTHT are currently performing a training needs analysis and the audit of training requirement could be included in this. It is about the content of courses and how we support the partnership in delivering statutory training. 4 PMSG Quarter 1 Report Marcia Perry talked to the presentation and paper. It has been a busy quarter and Marcia thanked Lydia Anchen and Phil Coneron for their work and support. The main points were as follows: The way the Performance Management Sub Group meetings work has been restructured and the Sub Group meets less and work is being divided and progressed in Task and Finish groups. Key issues and trends: o There is a positive picture, good things have happened and there is continuing progress of safeguarding children and young people in Leeds o 6% increase in contacts to Duty and Advice. The percentage of re-referrals has decreased which is good o Q1 showed a lower number of children and young people subject to a CPP o A common feature for children and young people going back on to plans was due to domestic violence for the rationale 5

164 DRAFT Record of the meeting held on 22 September 2016 o There are 5 children and young people on CPP for more than 2 years. There was Smarter planning in core groups which is positive o Health Needs Assessments completed remained stable and dental checks increased o The response to CSE has generally improved and there highlighted improvement to working together. Challenges / Areas to focus: o The percentage of ICPC within 15 days has decreased as has the review of on timely case conferences o Children missing from home /care- only reliable data is Police (345 missing, 100 at risk CSE) o 491 open to CSWS (27 high, 109 medium and 355 low risk of CSE) o Attendance at A and E and inpatient self harm has slightly increased over the year o Increase in s.47 ABH assaults (Q1 14/ Q1 16/17 351) The PMSG has been working on how to gather rich data from all relevant agencies to create a more holistic picture. Questions from the Board were welcomed: Peter Harris questioned why there was such an increase in admittance for self harm episodes to LTHT. Rachel Stanton questioned whether the data was for just Leeds children and young people or just all admittances from the region as Leeds is an acute centre. Phil confirmed that these numbers have been checked and they are re Leeds. Phil will send the information to Rachel so she can link with the person who provided the data Clare Linley noted that the spike in data could be a natural variation and Marcia stated that this is where the Task and Finish groups will look at the data in more detail and question it to build a richer and more accurate picture. Clare felt that it was important to know how children and young people are supported after episodes of self-harm. Phil confirmed that the journey of a child or young person had been analysed and they are all offered CAMHS support, but there is a desire to look at the whole mental health support in terms of DNA and waiting times Mark Peel thanked the Performance Management Sub Group for the work that has been done. Actions / Agreed Action: Phil Coneron to share the link for LTHT data with Rachel Stanton. PC PC 5 DV Cluster Audit Marcia Perry talked to the DV cluster audit report. The main points were as follows: This was a smaller audit of 10 cases but there is a depth of detailed information. It was a round table methodology which everyone felt was helpful to facilitate discussion and maximise the learning The audit showed that clusters are working well, predominantly with women and children victims The majority of the work is done by support workers and assistants within clusters. There were variations in the response from clusters The audit showed individual clusters identified what the issues were, 30% of the women had mental health needs, 50% of the children and young people 6

165 DRAFT Record of the meeting held on 22 September 2016 had social / emotional / behavioural problems. The challenges were: o It is very difficult to engage perpetrators o There is a porosity of services for perpetrators o Services focus on female victims and may not be paying enough attention to other victim groups o There is a variation of working between clusters o There is a new service specification about to go live and this will hopefully address some of the issues and learning that has been identified. This report shows a small study but a really important one about local information and knowledge. Questions from Board Members: Mark Peel stated that he had recently received information about the Caring Dads group and this is one out of two schemes available locally that deals directly with perpetrators. These men are difficult to engage, but it is a 17 week programme of 2 hours sessions per week, which is a big commitment and a disincentive for men who are already reluctant to engage or admit there is a problem. Karen Townend stated that the WYCRC provide similar programmes via the court process called Building Better Relationships, it is 2 hours per week and can last up to 7 months. For lower risk perpetrators it is a 15 week programme Phil Coneron stated that it is clear that traditional domestic violence (male domestic violence on women victims), came out as a strong trend within the audit, but it is how the other forms of domestic violence are identified in the community and if felt like there is a lack of knowledge around this Some findings and questions were raised into the new Domestic Violence contract and they will work to raise the profile of the other groups that can be victims or perpetrators Cluster staff give a phenomenal response to people in the community to make sure victims and the children and young people who may be witnesses are supported. Phil felt the question needs to be addressed on how to educate young boys and men about appropriate relationships within school Rebecca Gilmour stated that adolescent to parent violence is a big issue but is underexplored. The YOT have been running a programme for mothers and boys and there is huge potential to expand the services for this issue but it needs to be a partnership approach. 6 CSE and Missing Report Elaine McShane and Sara Miles spoke to their report and presentation. Elaine stated that Nigel Richardson gave her a copy of an article regarding how children and young people at risk of CSE are responded to and raised the issue of how practitioners have to be open minded as to who can be exploited. Elaine informed the Board of a book called Trafficked, written by Sophie Hayes (pseudonym), which challenges the profile Nigel noted that the article was really important because it was about managing organisational anxiety, rather than trying to understand the real issue of identifying different vulnerable groups. Sara Miles provided information on CSE profile in Leeds: Overview: The CSE problem profile remains WB females, aged years old Perpetrators WB / Asian, aged 17-39, the smallest cohort is The victims have a number of high risk factors, experience of domestic violence, contact with abusive adults / environments outside of the family, family relationships (no boundaries, not reporting missing) 7

166 DRAFT Record of the meeting held on 22 September 2016 Prevalent models - Boyfriend / Girlfriend or Peers, Peer on Peer Sexual Exploitation (sexual violence, pornography, group situations) Locations - residential houses / homes, transport hubs, hotels / motels, parks, takeaways / fast food restaurants, retail / leisure parks and cinema complexes Acknowledged hidden groups, children with disabilities and South Asian groups. Key Progress: Development of the Safe Project Progression of a CSE transition pathway into Adult Social Care Safeguarding training for taxi licence holders Implementation of daily partnership intelligence meetings (PIMMS), this has highlighted the links between CSE and other vulnerabilities i.e. missing A proactive multi-agency response to CSE legacy cases Development of the Risk and Vulnerabilities team. Introduction of a FGM referral and assessment pathway The Return Interview Service has developed hugely and all children in Leeds will have an interview. Improved data and understanding of the problem profile. CSE and missing are interlinked with all vulnerable groups: Trafficking and Modern Day Slavery Forced Marriage & Honour Based Violence Harmful Sexual Behaviour peer on peer exploitation, sexual violence, teen domestic abuse, groups, offending behaviour. Missing Female Genital Multination & Unaccompanied Asylum seeking children. How the response to CSE has been restructured to try and address the issues: Strategic group Quarterly meetings Revised Action Plan - Identify, Prevent, Support and Protect, Prosecute Multi agency work stream meetings to progress action plan. Outstanding key priorities: Identify business of concern and agree disruption models Low risk cases data, management and responsiveness Agency reach & impact on harder to reach communities Increase the engagement of C&YP Enhance the problem profiles to progress strategic and operational safeguarding responses relating to all the strands. Key challenges: Develop the CSE problem profile Wider problem profiling perpetrators / crime, Police are worked with very closely to understand this and prosecute Children Looked After (CLA), Police wanting to move them to another area because this gives the victim a sense of rejection, this does not happen often now and Police will negotiate with social work. Children s Homes are not targeted in Leeds Missing Children CLA have close scrutiny and there is a balance of how their independence is 8

167 DRAFT Record of the meeting held on 22 September 2016 developed whilst at the same time balancing the risk factors Children with learning disabilities and difficulties, working with adult services as they become adults Information sharing protocol Information & Intelligence sharing, data & recording systems, joined up responses and resources. Challenge to the Board: What is it like to be an adolescent in Leeds? In the current climate how can statutory duties and national and local priorities be met? How can we better work together to progress the 4 strands? Comments were opened to Board Members: Nigel Richardson wished to provide some context for the progress in Leeds that when Ofsted came in 2015 there had just been a very negative report given by HMIC regarding the approach to CSE, therefore they had concerns, however when they left impressed with the response to CSE and the understanding, sensitivity, strength of partnership working and the comprehensive response Mark stated the LSCB Business Unit was shortlisted for an award for the Party Animals campaign which will hopefully be repeated this year. The campaign raised a lot of interesting questions about CSE Clare Linley queried what level of information or understanding is shared if a child or young person at risk arrived at an Emergency Department or a GP Surgery. Sara Miles stated that there is a local information sharing protocol of how we share information and if the Police are aware then this child or young person is flagged on Police systems. At the moment information is shared at tasking groups but how agencies get information is an area of progress. CSE information sharing protocols are being looked at for children and young people who are at risk, but not every young person Mark gave thanks to Elaine McShane and Sara Miles. 7 LSCB Annual Report and Student LSCB Annual Report Student LSCB Annual Report Dee Reid spoke to the Student LSCB s Annual Report and extended her gratitude to Lucy Chadwick for her work with the students: The Student LSCB comprises of 6 members - 3 male and 3 female They are all enrolled in public service courses at Leeds City College They have attended appropriate training regarding what the LSCB is and safeguarding, around working a team, presentation skills and restorative practice training. Achievements: Delivery of a workshop called Teen Trendz at the Annual LSCB Conference, which received good feedback They assisted in the production of the Mindmate website to give a young person s perspective on how it feels when using the site They held a focus group with year olds as part of the Party Animals campaign, which was subsequently shortlisted for a Public Sector award Assisting the recruiting of new members and helping with their induction. 9

168 DRAFT Record of the meeting held on 22 September Mark Peel stated that the fact that we have a Student LSCB allows an insight into what it is like to be an adolescent in Leeds. Mark Peel formally thanked Lucy Chadwick, Dee Reid and the Student LSCBs for their work. The report was accepted by the Board. LSCB Annual Report Mark Peel spoke to the Annual Report which is in a different, smaller format in an attempt to make it readable and more pertinent The one question the report needs to answer is is safeguarding in Leeds up to standard and are children and young people safe? There are always circumstances where things could be done better, but the data in Leeds suggests an outstanding job is being done. The quality of practice is demonstrable and high Mark stated that after Ofsted the partnership has continued to progress. Challenges to the Board: They have been limited carefully The challenges link to issues such as austerity and change. They also link to what we do, the way we do it and who does it: o An example of what we do - Wetherby HMYOI has grown in size, the number of young people is greater and the range of young people has grown o What we do will change as an actual nature, the way we do it is changing markedly due to the Wood review o Who does it? There will be a change of DCS and the Governor of Wetherby YOI, through these changes we can t lose the ethos of safeguarding in Leeds. Questions from Partners: Sharon Yellin stated that it is not known how good the partnership is at Early Help assessments and Children in Needs plans and whether they are effective Sharon noted her concern at the omission of Leeds City Council within Challenge number 2 regarding austerity; Mark noted that he would discuss this with Sharon outside of the Board meeting. 8 Minutes of previous meeting 19 May The minutes of the meeting on 19 May 16 were agreed. 9 Draft minutes of Executive Group meeting 9 June 16 and 18 August The draft minutes of the Executive Group were noted. 10 Action Tracker / Forward Plan 10.1 The action tracker and forward plan were noted. 11 AOB Mark Peel formally thanked Nigel Richardson for his support to the LSCB. He stated three things Nigel has offered to children s services and children and young people in Leeds: 1 - Doing the simple things well. The mantra of not forgetting about children and young people has permeated into the working culture of Leeds. 10

169 DRAFT Record of the meeting held on 22 September Seeing the bigger picture and how it works politically. 3 - The most impressive thing is how Nigel delivers a sense of authenticity Nigel extended his thanks to everyone and stated that these jobs are a massive responsibility, but a huge privilege also. Working in Leeds has been a pleasure Nigel stated that Steve Walker would cover in the interim, there is a formal process to be followed, which is member led and there will be a decision on Friday 23 rd September. Paul Brennan s post is being filled too, so the structure remains unchanged and it is politically committed. 11

170 Attended Item 1i) Leeds Safeguarding Adults Board Minutes 13 th October 2016 Board Membership Name Organisation Richard Jones CBE Independent Chair Leeds Safeguarding Adults Board Cath Roff (Member) LCC - Director of Adult Social Services Emma Stewart (Member) Alliance of Service Experts Shona McFarlane (Member) LCC - Adult Social Care Superintendent Sam Millar (Member) West Yorkshire Police DCI Mark Griffin (Member & SAR Subgroup Chair) Maureen Kelly (Member and L&I Subgroup Chair) Suzanne Hinchliffe CBE (Member) West Yorkshire Police Leeds South & East CCG Leeds Teaching Hospitals NHS Trust Gill Marchant Leeds CCGs Rachel Stanton Leeds Teaching Hospitals NHS Trust Anthony Deery (Member) Leeds and York Partnership NHS Foundation Trust Lindsay Britton-Robertson (Deputy) Leeds and York Partnership NHS Foundation Trust Marcia Perry (Member) Leeds Community Healthcare NHS Trust Debbie Reilly (Deputy) Tanya Matilainen (Member and CE Sub-group chair) Leeds Community Healthcare NHS Trust Healthwatch Leeds Lisa Toner (Member) West Yorkshire Fire and Rescue Service Diane Pellew (Member) HMP Wealstun Max Lanfranchi National Probation Service Sandra Chatters (Member) Sharna Duggan (Deputy) Community Rehabilitation Company Community Rehabilitation Company Mandy Sawyer (Member) LCC: Housing Leeds Philip Bransom (Member) Bridget Emery (Member) Gerry Gillen (In attendance) Third Sector Leeds and Advonet LCC: Public Health LSAB Legal Adviser Emma Mortimer (Ex officio) LSAPSU Kieron Smith (Ex officio) LSAPSU Amanda Loftus (Ex officio) LSAPSU 1

171 Item 1i) Item No. Item Action, Timescale and Person responsible 1. Chair s update and introduction Richard Jones, LSAB Independent Chair welcomed members to the Leeds Safeguarding Adults Board meeting. Members of the Board introduced themselves and apologies were noted. Richard introduced the agenda and the issues for consideration at today s meeting. Matters Arising: LSAB Memorandum of Understanding Richard noted that the Board had agreed previously that while this is an important area of work, it is not a current priority but would be useful if developed in time for the new financial year. Yorkshire and Humber ADASS Safeguarding Group Cath Roff reported that the regional ADASS Safeguarding Strategic Group is in need of Police representation. It was agreed that Supt. Sam Millar and DCI Mark Griffin would take this forward and provide a nomination to Cath. Yorkshire and Humber ADASS Self-assessment Leeds has participated in the ADASS Yorkshire and Humber Performance Self-Assessment in recent years and this piece of work is now due. Richard noted that the self-assessment is intended as a tool for boards to use to identify areas of development and it is not analysed regionally and comparators are not published. In the light of this, together with the Board s significant workload, coupled with capacity challenges in the Unit, he proposed that the Board should not undertake the self-assessment. He suggested that this would allow the Board to focus on the outcomes from the Board Development day and the significant work plan already in place. Discussion took place and Cath Roff asked about other activity being undertaken by the Quality Assurance and Performance Subgroup. Richard referred Cath to the actions described in the LSAB work plan. Cath Roff supported the proposal and other members concurred. Board Members - Safeguarding reflection Richard reminded members the Board has recently sought to begin meetings with a presentation by a member, focusing on safeguarding in their organisation and sharing learning. This approach has helped the Board to focus on the experience of citizens of Leeds. It had not been possible for a member to undertake this role at this meeting and Richard asked members for their views about continuing; members confirmed that they supported this approach. 2 Action: Supt. Sam Millar WYP Nomination to Y&H ADASS Group

172 Item 1i) Item No. Item Action, Timescale and Person responsible Minutes of the Leeds Safeguarding Adults Board meeting held on 8 th August 2016 Minutes were agreed as correct. Richard presented the actions from previous meetings providing updates:- It was agreed that the Executive Group will review the scheduling of Board meetings and would ensure that it does not meet in August. August 2016 Minutes: Actions Item 4) Local Government Association - Peer Challenge Review: ASC, PH and NHS CCGs to jointly present an overview of commissioning responsibilities in Leeds to the LSAB. Richard noted that this would be brought to a future board. Action: Executive Group: Scheduling Board Meetings Item 5: LSAB Strategic Plan Member Organisation Commitments Philip Bramson, Advonet to explore how the Third Sector can participate in the Strategic Plan member commitment process and report back to a future board. Members agreed that this is not an immediate priority and as such should be brought back to the December Board. Item 6ii) Leeds Safeguarding Adults Partnership Support Unit Learning and Improvement Sub-group to review the learning and development needs of the partnership, and the role of the Board and individual organisations, reporting back to Richard Jones, Independent Board Chair. Richard reported that the Learning and Improvement Sub-group had met and the needs of the Board had been discussed. Maureen Kelly, Learning and Improvement Sub-group Chair was not in attendance as she is on Jury service. When she has returned, a paper will be presented to the Board from that sub-group. On-going Actions: Item 1) Vice Chair of the Board to be appointed by April It was agreed that this is not a current priority and as such will be looked at again in Item 4) Richard to meet with Third Sector Leeds Richard reported that he had met with Third Sector Leeds and Action: L&I Sub-group: Review Learning Needs of Partnership 3

173 Item 1i) Item No. Item Action, Timescale and Person responsible Voluntary Action Leeds. This had been a very helpful and productive meeting. Following on from this meeting Richard reported that he will be also meeting with the Leeds BME Hub. He will report back to the Board once this meeting has taken place. Organisations subject to inspections: LYPFT: Lindsay Britton-Robertson reported that the inspection took place last week. Report pending. It was agreed that any issues relating specifically to adult safeguarding will be fed back to the December Board. Gill Marchant reported that Leeds Community Healthcare NHS Trust will be inspected on 31 st January LSAB Learning i) Savile Inquiries: Richard explained that Emma Mortimer and Kieron Smith have developed a Learning Pack to assist agencies and individuals to learn the significant lessons from all the inquiries that have taken place since Jimmy Savile s death and the disclosure of the abuse that he had perpetrated. Richard emphasised that the Learning Packs are designed for agencies share within their organisations; members are asked that they provide assurance that the pack has been disseminated. Emma Mortimer explained that the lessons learned in all the Savile inquiries translate across all organisations who work with vulnerable adults. Emma highlighted learning in respect of Issues around: Access Enabling people to speak up Complaints and advocacy protocols. Richard commented on the importance of the Board providing a clear message to the citizens of Leeds that abuse is not tolerated. It was noted that the pack is not intended to be onerous or to be a duplication of work already undertaken, rather to be helpful, to enable organisations to say, in Leeds this is what we ve done, and that we have done it properly, so that the Board can be assured that learning has been disseminated across all partner organisations. Richard sought reflection on the Learning Pack Individual and 4

174 Item 1i) Item No. Item Organisational Checklists. Gill Marchant asked if the checklist for individuals required them to complete it. Emma reported that this was not a requirement; the checklists are simply a means by which people can selfassess.. Lindsay Britton-Robertson reported that in relation to LYPFT a lot of the learning has been about how staff manage visitors, what the prompts are etc. and how to act in relation to celebrities or people in positions of power where staff may feel intimidated. She explained that there are now posters in all reception areas and as a result, staff have sought advice from the safeguarding team. Cath referred to the importance of creating a climate where it is expected that questions will be asked, even when an individual is an elected members or other people in positions of power. Richard summarised that, there appears to be some examples of good practice that have come directly from the learning. The Board s role now is about asking, in the wider context, what are the on-going needs for member organisations. Sam Millar commented that she liked the checklist and that it would be a very useful tool for the Police both for the organisation and the individual. She emphasised that she considers that there is no point in undertaking DHR s etc. if the learning doesn t impact. She commented, the question is has this Board, this city, learnt from Savile? Sam reflected that she wasn t confident that it had and felt that this type of abuse of power could still be happening. She asked other members whether they can demonstrate to each other that the learning had been embedded. We have to be able to evidence that we have made a difference otherwise what is the point?. The DHR/SAR process has to hold agencies to account. The learning has to be tangible. We have to be able to demonstrate that all of us have made a difference and are able to celebrate that out of something so horrendous some good has come. If we don t deliver that it will be a waste. We need to be excited about what we have done. Sam added that Lindsay has given a clear example of something that has made an immediate difference. Richard agreed, reiterating that it is about ensuring that organisations leaders take away the learning from this and ensure it makes a difference. At Board level we need to provoke thinking about further actions needed and how we ensure that good practice such as that that Lindsay has described is embedded across all agencies. We need to engage with it with an honest and open approach defining what has been done. Lisa Toner added that the feedback from the Fire Service is that the Learning Pack is very useful. This type of document is very useful to encourage thinking about safeguarding. Action, Timescale and Person responsible 5

175 Item 1i) Item No. Item Action, Timescale and Person responsible Marcia Perry stated that the Savile case has led to a fundamental review of policy within LCH around allowing access. Cath Roff emphasised the need to think the unthinkable. Emma Mortimer added that one of the main areas of learning from one of the Safeguarding Adults Reviews, which is currently being undertaken, is the need for professional cynicism i.e. thinking the unthinkable. Rachel Stanton commented that she felt that times had changed and that organisations now take people s concerns seriously and people can speak up. Sam stated that she wasn t sure that this is entirely true, commenting that power can still corrupt. Cath agreed and reiterated Sam s view that organisational cynicism is essential. Sam stated that this cynicism needs to be personal, professional and organisational. Marcia added that it is also about having the freedom to speak up to partners and promote the culture. To develop strategies and to never be complacent. Richard summarised the feelings in the room as being: 1) It s a useful pack. 2) A powerful conversation has been achieved, with lots of resonance for us to go off and consider across our individual agencies. Richard reflected that the meeting had heard some examples of a change in culture and practice and commented that members now needed to use this to reflect back on identify themes to consider at the Board Development day on 25 th October Richard said that he considered that these need to encompass: Enabling staff to feel confident and competent in their role For staff and their leaders to be brave and open. Richard emphasised that It is very much more than ticking boxes. Cath asked when this information was required back as she was of the opinion that a longer time period was needed to engage with staff groups. It was agreed that the assurance would be brought back to a future board meeting; Emma Mortimer would send out revised packs and advise of the response date. Gill asked if these forms had been shared with LSCB and city-wide. Emma confirmed that there were plans to do so. Action: Emma Mortimer to redevelop the pack on the basis of comments and share with LSCB. 6

176 Item 1i) Item No. Item ii) Mazars Review: Richard referred to the Mazars Learning Pack that Emma and Kieron had developed. Emma explained that this Learning Pack is not designed to focus on any single agency, rather, the messages relate to any organisation where an adult unexpectedly dies in their contact. Mazars Independent Review of Deaths of People with a Learning Disability or Mental Health Problem in Contact with Southern Health NHS Foundation Trust April 2011 to March 2015 was published in December The review resulted from the death of Connor Sparrowhawk who died while in the care of Southern Health NHS Trust. Lessons relate to engagement with families, transparency and a commitment continual learning and review. Marcia advised that the CQC is undertaking a lot of work around the review s findings it is due to publish a report and guidance in December This is from a project working with 12 NHS Trust and 4 Community Trusts of which LCH is one. NHS England is also developing a new framework and monthly reporting is now taking place. Sam commented that she was not sure that this case has been discussed at LSCB, commenting that it raises questions about definitions of abuse, neglect and unexpected death. Emma agreed to contact the LSCB and share the Learning Pack. Richard reflected that more work was underway in respect of this review, as described by Marcia. Cath pointed out that there is an issue around the timeframe and felt it would be prudent to respond properly and to do so; organisations need the capacity to respond thoroughly. Richard agreed to defer learning from this review until after the CQC report and NHS England guidance has been published. Cath highlighted the need for a City-wde understanding of the untoward death definitions and of associated reviews. Members agreed that when there is an unexpected death there needs to be clarity in relation to which pathway to take, Coroner, SAR, DHR etc. Currently, at a city level we do not have a clear landscape mapped and this is necessary. Action, Timescale and Person responsible Action: Emma Mortimer to share the Mazars Reviews Learning Pack with the LSCB Action: Emma Mortimer to review Learning Pack after publication of guidance and reports. Cath suggested that the Safeguarding Unit undertake a horizon scan of good practice around untoward deaths. She also referred to Sheffield as having undertaken some work around this topic. It was agreed that a piece of work be undertaken that demonstrates good practice both locally and nationally, mapping terminology, definitions and legal duties. This should be brought back to the Board. 7 Action: Safeguarding Unit to lead a review of good practice in learning from untoward deaths

177 Item 1i) Item No. Item Action, Timescale and Person responsible 3. Board Members Updates i) LSAB Partnership Support Unit Richard explained that Shona McFarlane is leading on this and detailed discussions took place at the August Board. He asked that Cath provide an update in Shona s absence Cath reported her concern that the change process had taken so long. She noted that Shona McFarlane was on leave but would be progressing the matter with unions on her return. ii) Other Members Updates Marcia reported that a CQC Inspection of York Street Practice will be taking place next week with a full three day focussed- inspection scheduled to take place at end of January Mandy Sawyer reported that LCC Housing is continuing to deliver safeguarding training, promote safeguarding and provide feedback to the safeguarding team. She added that more information from Adult Social Care in relation to outcomes of safeguarding referrals would assist in terms of learning and sharing risk. Cath reported that it is has been identified from feedback that people want to know more to know what happened after a referral has been made and we are taking a look at that. Yorkshire and Humber ADASS Group is undertaking a survey with a number of local authorities around MSP and the report will pull out key themes. The report will be available for purposes of learning in early Lindsay reported that LYPFT now has a new chief executive, Dr Sara Munro who previously worked in Cumbria. Operationally LYPFT is focussed on the outcomes of the CQC Inspection. Sam reported that following the recent homeless protest in the city, dubbed as Homeless City, West Yorkshire Police has decided to undertake a learning review. Sam noted that significant safeguarding issues will be a feature of this review and that there will learning for the city as a whole, Sam invited agencies to participate and Cath agreed, suggesting that Max Naismith, Head of Service in ASC would be the right person to be contacted. In addition, Mandy Sawyer, (Housing), Gill Marchant (CCG) and Rachel Stanton (LTHT) offered involvement. Sam welcomed the offers and agreed to bring the learning back to the Board. Action: Supt. Sam Millar to bring the Homeless City Review Learning back to the Board. 8

178 Item 1i) Item No. Item Action, Timescale and Person responsible Rachel reported that it has been difficult for LTHT to recruit to the safeguarding team, but that this had now been successful and recruitment is underway. Gill reported that the Domestic Violence and Abuse pilot of GP s undertaking a routine enquiry with all female patients has been very successful and NHS England is looking to roll out across all of the north Leeds regions. This should be happening in the next few weeks and is excellent news. Lisa Toner reported that a pilot scheme is running in Leeds around the rise in non-domestic building fires, especially prisons and YOI s which have significant implications for crews. A full time person has been seconded to work on these issues. DCI Mark Griffin noted that HMIC is inspecting West Yorkshire Police in early November He also advised that Leeds will experience a Joint Targeted Area Inspection of Children s experience of domestic abuse, noting that although focused on children, this will also have implications for adult safeguarding. 4. Leeds Safeguarding Adults Board, Strategic Plan i) Sub-groups Chairs updates Mark reported that a number of Safeguarding Adults Reviews are underway and highlighted that Review A17, (formerly DHR 7) is due to be concluded. The final report will be presented at the February Board. Mark noted that the current unprecedented number of reviews being handled by the Unit (four active, two due to commence, three under consideration) is an enormous resourcing challenge that is exacerbated by a lack of personnel and the delay in completing the Unit restructure. Richard acknowledged the difficulties and assured the Board that the challenges are not for want of effort in the Unit, commenting that until new staff are in post to meet the level of work required, there will a challenge in progressing the Board s work. Richard also advised that it was unlikely that the review would enable new staff to be in post before April Emma provided an update on the Learning and Improvement Sub-group in Maureen Kelly s absence. She reported that the Sub- group had met last week and discussions had taken place around the role of the subgroup and what the Board wants from it. 5. Leeds Safeguarding Adults Board, Annual Reports 2015/16 Kieron Smith reported that an easy-read version of the annual report is now available. 9

179 Item 1i) Item No. Item Action, Timescale and Person responsible This was welcomed by all members. 6. Leeds Safeguarding Week, 2016 Richard reported that Safeguarding Week would be taking place in Leeds from 17 th 23 rd October. It was hoped that this would be extended, in terms of activity in Board Development Day 25 th October 2016 Emma and Kieron outlined the purpose of the day. Emma explained that a number of workshops had been held over the last 6 weeks, asking the questions in relation to safeguarding what works well, what doesn t, what needs to be improved. She explained that a wide range of different stakeholders across the city have been consulted with, and as a result we have received feedback from a wide range of people along with ideas about what could be done as a city to meet the needs of citizens, commenting that there have been lots of of creative ideas. Eight workshops have been held and there have been over 200 participants. Clear themes have emerged across all consultation groups. Board members have been asked to complete their own assessment and survey have been sent to related organisations e.g. Karma Nirvana. Healthwatch has been asked to undertake interviews of citizens who have experienced the process, nominated via ASC. The Board Development day will be an opportunity for Board members to hear these voices and messages. Representatives from organisations who attended the workshops are being invited to come to the session and talk to the Board. This will be an opportunity for small group discussions around the safeguarding principles and there is an offer from the Learning Disabilities Partnership Board to come and talk from a service user s perspective Richard stated that this is a real opportunity to hear a range of perspectives and engage with what people want to say to us. Discussion took place about the date of Board Development Day being during half-term week. It was noted that this was agreed at the August Board meeting. Cath commented that the date also conflicts with the Council Scrutiny Panel and requested that in future the council calendar be consulted in the first instance. She also has the Corporate Leadership Team meeting in the morning, but will try to attend for at least half of the day. Shona McFarlane will be in attendance from ASC as well. After discussion, the overriding opinion was to go ahead and start the process. All members felt that it was important not to lose momentum. 10

180 Item 1i) Item No. Item Action, Timescale and Person responsible Cath requested that attendees be encouraged to bring someone with them. For example, Shona could bring a Head of Service. Richard said this this was a good idea. It was agreed to make the Board Development Day a half-day session. 8. For information Safeguarding Adults, Annual Report, England , NHS Digital Web address For information only. 9 Reflection Mandy stated that the mortality work is very interesting and the lessons learned are important. Sam commented that she had not attended the last couple of Board meetings due to other conflicting commitments, but considered that this had been a positive discussion. 10. Proposed Dates of future meetings Richard concluded: those that can attend the Board development Day it would be very much appreciated and we will use the Board in December to feedback on the day and discuss further. Next Meeting: 8th December 2016 All at: The Rose Bowl, Leeds Beckett University, Portland Crescent, Leeds LS1 3HB 11

181 Item 1i) Leeds Safeguarding Adults Board Actions from 13 th October 2016 Item No. Action Person / organisation responsible Target date Item 1 Matters Arising ADASS Y&H Safeguarding Froup Supt Sam Millar to nominate an officer from WYP to join the group. Supt S Millar 31/10/16 Item 1 Minutes: 4 th August 2016 LYPFFT to report any findings from the recent CQC Inspection of its services that relate to safeguarding to the LSAB. Anthony Deery December Board Item 2 LSAB Learning i) Savile Learning pack to be updated as discussed and redistributed Emma Mortimer Safeguarding Adults Partnership Support Unit 15/11/16 ii) Mazars Review of all death reporting processes in Leeds to be undertaken aping links and highlighting statutory requirements. Emma Mortimer Safeguarding Adults Partnership Support Unit December Board Item 3 Board Member Updates West Yorkshire Police WYP Homeless City Learning Review to include Supt Sam Millar, WYP Tbc 12

182 Item 1i) Item No. Action Person / organisation responsible statutory partners, particularly ASC, CCGs and Public Health and to link through the Partnership Support unit and the Learning and Improvement Sub-group to the Board, to ensure safeguarding learning is encapsulated. Target date NHS CCGs Domestic Violence and Abuse Routine Enquiry Pilot and Film to be brought to December Board for review and discussion. Gill Marchant December Board Item 4 LSAB Strategic Plan i) Sub-group chairs updates Sub-group chairs to report to the December Board on outstanding actions, likelihood of achievement in the financial year and level of associated risk. Sub-group chairs December Board Learning and Improvement Strategy and Quality Assurance Framework to be reported to December Board. Learning and Improvement Subgroup December Board 13

183 Item 1i) LSAB Minutes: Addendum Continuing Actions from Previous Board Meetings Board Date Agenda Item Action Lead Person/ Agency Target Date Comments December 2015 Item 7 Action: Vice Chair of the Board to be appointed by April LSAB 1 st April 2017 Richard Jones, Independent Chair to discuss with Cath Roff, DASS. 14