NO. ITEM LEAD PAPERS TIMING

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1 Board of Directors Meeting In Public AGENDA Date: 29 th March 2017 Time: 10:00 15:40 Venue: Boardroom, Elizabeth House, Fulbourn, Cambridge CB21 5EF Any Other Business: Committee members and attendees are asked to inform the Chair of any items they wish to raise under Any Other Business by 24 th March 2017 NO. ITEM LEAD PAPERS TIMING 1. Welcome, Introductions, Apologies for Absence and Declarations of Interest Trust Chair Verbal 10:00 2. Minutes Trust Chair Enclosed 10:05 3. Action Log and Matters Arising Trust Chair Enclosed 10:10 4. Chair s Report Trust Chair Enclosed 10:15 5. Chief Executive Report Chief Executive Enclosed 10:25 Governor and Public Questions 10:55 PATIENT/ STAFF STORY 6. My Story Patient Experience Lead Verbal 11:00 Governor and Public Questions 11:30 Break 11:35 QUALITY, WORKFORCE, PERFORMANCE AND FINANCE Quality, Safety and Governance Quality, Safety and Governance Committee Summary 7. Quality and Safety Exception Report Safer Staffing Report Single Sex Accommodation Business, Performance and Finance Business and Performance Committee Summary 8. Performance Report Finance Report Annual Statement of Fire Compliance 9. Revenue and Capital budget FY Agency Staffing report Director of Nursing and Quality/ Chair of QSG Director of Finance/ Chair of B+P Director of Finance Chief Operating Officer Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed 11:50 12:10 Enclosed 12:30 Enclosed 12:40

2 Lunch 12: Charitable Funds Charitable Funds Committee Summary Charitable Funds Report, Q3 Charitable Funds Log Committee Chair/ Deputy Director of Finance Enclosed Enclosed Enclosed 13: Revalidation of Doctors Medical Workforce Lead Enclosed 13: Education and Training of Doctors Head of Medical Education/ Head of Learning and To Follow 14:05 Development 14. Equality and Diversity Annual report Interim Director of Primary Care/ Equality and Enclosed 14:30 Diversity Officer 15. Mortality Committee Deputy Medical Director To Follow 14:45 Governor and Public Questions 15:00 GOVERNANCE for approval 16. Cycle of Business 17. Register of Interest 18. Service Visits 19. BAF annual agreement of (strategic risks). 20. Board Assurance Framework, bi monthly review (strategic risks) Interim Trust Secretary Interim Trust Secretary Interim Trust Secretary Interim Trust Secretary Interim Trust Secretary Enclosed 15:05 Enclosed Enclosed Enclosed Enclosed 15:15 15: AOB Verbal Trust Chair George MacKenzie Ward Improvements Enclosed 15:30 Governor and Public Questions 15:35 Close 15:40 Date of next meeting: 24 th May 2017

3 Minutes of the Board of Directors Meeting in Public held on 25 January 2017 from 10:00 until 15:20 at Conference Suite, The Cavell Centre, Peterborough, PE3 9GZ Members Present Julie Spence Aidan Thomas Deborah Cohen Sarah Warner Melanie Coombes Stephen Legood Mike Hindmarch Jo Lucas Julian Baust Simon Burrows Sarah Hamilton Trust Chair Chief Executive Director of Service Integration Chief Operating Officer Director of Nursing and Quality Director of People and Business Development Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director In Attendance Elizabeth Mitchell Lead Governor Alexandra Perry Deputy Trust Secretary (Minute taker) Mike Collier Governor, Public Cambridgeshire Andy Burrows Derek McNally Deputy Director of Finance Emma Dickerson Senior Programme Support Officer, NIHR CLAHRC East of England (Item 6) Joanne Croxford Social Recovery Project Manager (Item 6) Prof. Ed Bullmore Director of Research & Development (Item 12) Wendy Llaneza Senior Head of Quality & Compliance (Item 12) Dr. Nick Oliver Director of Psychological Services (Item 12) Apologies Chess Denman Scott Haldane Lauren MacIntyre Medical Director Director of Finance Trust Secretary ITEM DESCRIPTION ACTION BY 1. Introductions, Apologies for Absence and Declaration of Interests The Trust Chair welcomed those present to the meeting and noted apologies. Apart from the standing interests declared to Lauren MacIntyre it was noted that Jo Lucas had been appointed as the Chair of MIND in Cambridge. 2. Minutes The minutes from the Board meeting held on 30 November 2016 were agreed as a true and accurate record with the following amendments: Page 2, Action Log and Matters Arising, paragraph 4: 1

4 Stephen Legood informed the Board that the first strategic planning forum meeting was to take place in January 17. The Terms of Reference are being developed and membership agreed, through discussion at Executives Meeting. The Committee would formally report up to the Business & Performance Meeting. Page 6, Chief Executives Report, paragraph 3: Peterborough City Council commissioned social work services in Peterborough Prison Page 7, Quality, Safety and Governance Committee summary, paragraph 1: there had been high levels of activity under the Mental Capacity Act which would be reported routinely to Q,S&G with any exceptional issues raised at Board meetings Page 7, Quality, Safety and Governance, Exception report: paragraph 4: Medication side effects Page 10, Charitable funds committee summary: paragraph 1: He highlighted that at the meeting held on Page 10, Charitable funds committee summary: paragraph 2: The Board noted that the chaplaincy post which had been funded by Charitable Funds was, as agreed previously to be funded by CPFT The Trust Chair agreed to sign the minutes as an accurate record following amendments. 3. Action Log and Matters Arising Action 1: Sarah Warner told the Board that the Directorates were proposing a rise in Bank shift rates. Subject to staff organisation approval. Further updates would be taken to Quality, Safety and Governance Committee meetings. Action 3: Stephen Legood told the Board that with regards to the Trusts EU workers following Brexit a meeting had been held with Cathy Bonney (CCG HR Director) to further understand the system wide impact. The work was to feed into NHSE guidance and an update would be provided to the Board in May Stephen Legood Action 5: Action to be amended to read A report detailing wider work and new responsibilities in Peterborough Prison regarding the care act to the Board This was to be provided to the March Board meeting. Action 6: The Chief Executive agreed that the Sustainability Transformation Plan (STP) risk assessment would be circulated to the Board. The Trust would not create a new one as suggested in the action log. Action 8: Melanie Coombes informed the Board that the Trust had 2

5 achieved 52% staff uptake of flu jabs in 2016 which was lower than the national target of 75% and lower than the Trusts previous year (60%) It was noted that the uptake was spread evenly across community and mental health services. The Infection control team had conducted a lessons learned and had agreed to start the campaign in summer Discussion was held around this particularly the way in which reasons for the low uptake could be captured across the staff body. It was noted that it was partly due to changes in counting methodology by NHS England. It was noted that this would also affect the CQINN performance. Action 9: Derek McNally confirmed that the ARC service was not subject to a premium rate line but was an 0844 number. The BT charges for this line were per minute for landlines and 0-2:00 per minute for mobile phones. It was agreed that it should be investigated if this line could be transferred to 0300 for which no cost would be incurred. Derek McNally Action 10: The Board agreed with the recommendations from the Trust Secretariat, Board Sub committees were not to have individual annual reports. Action 11: It was noted that Alexandra Perry would circulate the evaluation of the employment training programme to the Board once received from Annie Ng, Head of Patient Experience. Action 12: Scott Haldane agreed to update the Board with regards to negotiations on the PFI contract in the Private Board meeting. Action 13: Deborah Cohen informed the Board that NED membership of the STP (System Transformation Programme) Oversight Committee had been agreed as Mike Hindmarch and Dr Amit Sethi. The Trust Secretariat was also seeking to co-opt a Governor observer. A further update was to be provided at the Board meeting on Action 16: It was agreed that the action to discuss Christian Dingwall s presentation to the Board in September 2016 had been completed and that the matter would be brought to the Boards attention as issues with general practice proceeded. All other actions were noted as complete or not yet due. 4. Chair s Report The Trust Chair presented her report, points of note as follows: It was requested that the Board contact Alexandra Perry with details of anyone whom may be interested in standing as Governor. Due to the agreed Board and Sub Committee dates and the annual report timetable the Board would approve the Annual Report via . The Trust Chair had met with the Bishop of Ely who had 3

6 discussed his support for CPFT and its services. He was keen to promote the Trusts work and Directors were invited to pass ideas for specific promotion to The Trust Chair or the Chief Executive. The Board The Board noted the content of the report. 5. Chief Executive s Report STP Update The Chief Executive informed the Board that the acute hospital Trust s had not been able to agree to the proposed risk share for elective care developed by the STP or their contribution to the planned 14m investment pot. Unless this is resolved the STP plan would not be viable. Consequently discussions were on-going. The Chief Executive informed the Board that bids had been submitted by the STP for National Transformation funding. The three areas applicable to the Trust that had been defined by NHSE were as follows: 1. Diabetes care: Primary Care Integrated Neighbourhoods (PCIN) development 2. Liaison Psychiatry: this was identified as a partial liaison service. 3. Learning Disabilities It was identified that there was an overall local plan for community and primary care services which encompassed three areas of long term conditions where the health economy performed badly; coronary heart disease, respiratory and diabetes. There were also proposals linked to emergency care which encompassed enhancing the Joint Emergency Teams (JET) services, Intermediate care and social care packages. The Chief Executive noted that research showed that investment in these areas had a big initial impact on admissions but that it would plateau in the long term. Real benefit could only be achieved through investment in the management of long term conditions, frailty and dementia in Primary and community services. The Board were told that an investment committee had been set up by the STP. The Chief Executive advised that there was finally some clarity and consensus around what services would look like in detail for the first time since the collapse of UnitingCare and the Board needed to explain to staff and the public the model of Care that all partners were now committed to. Control Total After discussion the Board agreed that if funding for the First Response Service (FRS) was not forthcoming the Trust should reject the proposed Control Total. Julian Baust encouraged the Board to engage with Diabetes UK (DUK) and it was agreed that he would discuss this with Julie Frake- Harris, Associate Julian Baust/ Julie Frake- 4

7 Director of Operations outside of the meeting. Harris The Board noted the contents of the report and agreed to support the rejection of the Control Total. 6. CPFT Women s Institute Initiative Service Evaluation Emma Dickerson presented her study, process, findings and evaluation to the Board as outlined in her report. Jo Croxford thanked Emma for her work and went on to highlight the importance of the work undertaken by telling the Board of one member of Rising Roses who s confidence was so low when she became a member that she struggled to leave her room. Since being a member she was able to speak to other Women s Institutes about the work at CPFT. Joanne also told the Board that Michael Whittecar was developing a Men in Sheds initiative to give men similar access to social capital. Jo Lucas added that this could be a great initiative following the example of fifteen successful Men in Sheds across Ireland. The Chief Executive and Trust Chair thanked Jo for her work on behalf of the Board. The Chief executive reinforced that the initiative worked on multiple levels including Recovery, social capital and anti stigma. Sarah Warner asked Jo how long term, non-mental Health service users had been included in the programme. Jo assured the Board that she was hoping to create a way for the WI fellowship to reach those who are less physically able in the community to attend meetings. This could include the creation of a neighbourhood based WI. Jo Lucas asked Jo what was in place in Fulbourn. Jo Croxford told the Board that the Fulbourn based Daisy Change WI was to be reinstated on a regular basis from April 2017 although it was noted that it had never officially disbanded. The Board also discussed Joanne Croxford s ideas around her succession planning as it was acknowledged that it was Joanne s enthusiasm and initiative that largely fuelled the Rising Roses. Julian Baust asked Jo Croxford what she needed from the Board in order to expand the initiative. Jo Croxford said that the most important thing would be to create stability and certainty by making her post substantive. The Board thanked Jo Croxford for her work and noted the presentation and recommendations. 7. Quality, Safety and Governance Quality, Safety and Governance Committee summary It was noted that Jo Lucas had chaired the Q,S&G committee meeting in Sarah Hamilton s absence, so she presented the committee summary to 5

8 the Board. Jo Lucas informed the Board of the difficulties experienced with the submission of papers and emphasised that the timeliness of submissions should be improved by those submitting them. Exception report Melanie Coombes presented the exception report to the Board and informed them that the meridian report had been circulated to the heads of nursing. Other points of note were as follows: Performance against the Friends and Family test had increased from 93.17% to 95.14% in December. The food score had decreased from 74% to 65% in December. It was noted that a meeting was to be held to discuss the way in which this could be improved. The target for information on side effects of medication had increased in the community services (96%) However this had reportedly dropped within inpatient services and as a consequence Clare Mundell, Chief Pharmacist was to investigate. Carers Experience had been added to the Quality Accounts; Melanie Coombes was to discuss this with Deborah Cohen. The Trust Chair requested that the lead Governor be involved in the meeting to ensure momentum for the Carers strategy. No seclusions or prone restraints had been reported. Level three Children s Safeguarding Training had dipped which was reportedly due to a number of the sessions having been cancelled. It was agreed that an update would be provided to the Board on Melanie Coombes/ Deborah Cohen/ Liz Mitchell Melanie Coombes Safer staffing report Melanie Coombes presented the report to the board and noted the following: Deep dives had commenced into incidents on Mulberry 1 and 2. The bed configuration at the Cavell centre had been altered from four to three in response to shortage of staffing. Furthermore it was noted that these wards were now all only mixed sex accommodation (as in Cambridge) and compliant with the mixed sex guidance. Leadership on the inpatients children s wards had been affected by maternity leave which created a temporary problem for the service. In regards to the Hard Truths report Melanie Coombes recommended that the Trust conducted an internal review of a similar nature every six months. However national guidance for Mental Health Services had not yet been released. There was little improvement noted in regards to recruitment and 6

9 retention however senior nurses were reportedly undertaking shifts on wards. Melanie Coombes reported that Nurse Associate roles had been publicised to Trust staff and externally on this had generated huge interest. The Nursing and Midwifery Council (NMC) Board meeting, held on was to decide who would fund their registration. It was also reported that a discussion had been held at the latest PRE meeting in which Ben Underwood had expressed the difficulty in recruiting medical staffing to old age psychiatry in the organisation. Julian Baust questioned the reported increase in physical assaults on staff. Melanie Coombes told Julian that it had been discussed at Q,S&G and that a deep dive and benchmarking exercise had been instigated. The Board noted the contents of the committee summary, Exception report and Safer Staffing report. 8. Business and Performance Committee Business and Performance Committee summary Julian Baust presented the committee summary to the Board and informed them that there had been issues in January 2017 around the Trusts accounts due to the unresolved Uniting Care liability. The Board held some discussion around this and were assured that this was being resolved. The Board noted the contents of the report. Integrated Performance report (IPR) Derek McNally presented the IPR to the Board highlighting the fact that data provided was from November The Board discussed the paper, highlights as follows: CPA 7 day follow up; The Trust was showing 92% which was lower than the NHSI indicator of 95%. It was noted that the numbers were small and that it took little fluctuation to change the score. It was reported that since the report the score had improved and the Information Performance had been working closely with the wards. Delayed transfer of care in community wards; The Trust had 100 beds in community wards, of which 32 patients were fit for discharge. This represented a significant increase on usual performance. It was reported that a weekly phonecall with social services had been actioned in order to monitor the levels. Deborah Cohen said that approximately 50% of the Children on the speech and language therapy (SALT) waiting list had been waiting for over 18 weeks. It was noted that SALT was not subject to the 18 week target but that nevertheless this was not acceptable. The Board were told that there was due to be a meeting with the Speech 7

10 and Language therapy team in January Issues around capacity and management of the waiting list had been identified. Discussion was taking place with commissioners about resources for SALT. It was agreed that an update was to be provided to the Board on and that an action plan was to be taken to a future Executive team meeting. Finance Report including an update on agency staffing Derek McNally presented the month nine position to the Board and informed them that there had been a small surplus of 0.253m against the planned surplus of 0.197m. Furthermore it was reported that the Trust was forecast to meet the control total of 1.445m surplus. Sarah Warner/ Julie Frake- Harris It was confirmed that not meeting the surplus would result in a penalty for that quarter alone. Derek also told the Board that NHSI had not confirmed if it was going to take figures from non -recurrent funded services into account in regards to the agency fund. Quarterly compliance returns, Q3 Derek McNally told the Board that the Q3 compliance returns had not been included within the board papers due to the Trust no longer being required to submit the compliance returns to NHS I. This was following the issue of the Single Oversight Framework in September Revenue Budget Derek McNally presented the proposed Revenue Budget to the Board in order for it to be signed off. The Chief Executive said that it reflected negotiations held around the STP at the end of The Board noted the content of the committee summary, IPR, Finance Report and Revenue Budget. The Board agreed to sign off the revenue budget for Agency Staffing Sarah Warner presented her report to the Board and informed them that the report provided context to the figures presented within the finance report and was written in the context of NHSI having issued additional guidelines around agency expenditure. The reports to NHSI showed a 9m spend against a 7m ceiling figure. Highlights of the report as follows: The majority of agency staff were appointed in order to fill difficult to fill vacancies. Corporate services largely used agency staff to fill short term specialist services such as the implementation of the neighbourhood IT plan. NHSI financial sustainability risk rating was reported as 3 due to this 8

11 agency performance. 1 being the most serious risk and 4 being the least. Medical Staffing use agencies that are compliant with the guidance if it ever were the case that the Trust needed to use a non compliant agency then it was to be signed off the Executive team. If it were the case that staff were employed from an agency on anything over 150 per hour then it would have to be first approved by the Chief Executive. It was confirmed that there were no staff employed on this level of cost. The Trust was average against the NHSI benchmarking exercise. However it was noted that it was not meeting the requirements within the Operational Risk Register which was something to be monitored. The Trust Chair commended the report noting that it brought to light context around the issues that the Trust was facing with Agency Staff. Sarah Hamilton asked Sarah Warner if there was a financial penalty for not hitting the NHSI target and Mike Hindmarch added that the CQC was interested in Trusts having a range of agency and substantive staff. Julian Baust questioned when the actions that were being pursued to reduce agency usage were expected to show in the reported numbers. The Chief Executive explained that the Trust would be unable to completely eliminate agency usage nationally as there was a shortage of staff. Furthermore he noted that the STP developments would be likely to mean the Trust would require agency staff to ensure service delivery of new services, important to the Health economy. Stephen Legood informed the Board that the Junior Doctors rotas had been altered to comply with the Carter Report and Melanie Coombes enforced the need for flexibility in rostering due to the varying acuity of patients. It was agreed that updates would continue to be provided to the B&P committee and an exception report detailing both positive and negative changes to the overall position would be taken to the Board meeting on Sarah Warner Governor and Public Questions Mike Collier informed the Board that there was a carer s box on the front page of the Addenbrookes website. He suggested that this may be worth considering in order to increase survey uptake. Mike Collier asked whether the other CQUINS for the Trust were on track to achieve their outcomes and funding. Stephen Legood Mike Collier asked questions about the 78 Care Plan Assessments not 9

12 being carried out in the required timescale and whether these were in a particular directorate and might it be connected to the turnover of Care coordinators. 10. Audit and Assurance Committee summary Mike Hindmarch presented the report to the Board and highlighted that the Terms of Reference had been reviewed by the committee with no changes to note. There were no other points of note raised. The Board noted the contents of the committee summary and approved the Audit and Assurance Terms of Reference for 2017/ Charitable Funds Committee summary Simon Burrows presented a verbal report to the Board. He informed the Board that the following three bids were approved: 1. Women s Institute (WI), social recovery project; one years extended funding for the Social Recovery Project Manager. 2. WI, social recovery project; Funding for 40 additional memberships. 3. Funding for the Recovery Coaching Team to become accredited. Furthermore Simon Burrows informed the Board that both the Terms of Reference and Investment Policy had not been approved by the committee and so once approved were to be circulated electronically with requested changes highlighted for ratification. The Board noted the update. Derek McNally 12. Research and Development Update Professor Ed Bullmore presented the report to the Board and highlighted the five strategic themes and theme lead as follows: 1. Communicating R&D outcomes and information clearly to all: Cathy Walsh. 2. Building on our clinical data analytics infrastructure: Rudolf Cardinal. 3. Growing our NIHR and commercial portfolios: John O Brien, Ben Underwood. 4. Strengthening the voice of lived experience: Steve Kelleher. 5. Empowering all CPFT staff to use R&D to improve outcomes for CPFT service users: Ed Bullmore. Ed told the Board that the fifth objective was the most innovative, challenging and had the potential to have the biggest impact. The Board were told that two service users sat on the supervisory board and that studies related to old age was the biggest area of growth for R&D. Future plans included inviting service users to put forwards ideas of research projects as well as R&D getting out talking to teams about 10

13 research in localities. Ed Bullmore asked the Board to comment, endorse the proposal and provide guidance as to the level of monies in the budget. The Chief Executive commended the report and informed the Board of the following: Professor Peter Jones was to join the Board in an advisory capacity. The Trust had increased involvement in Cambridge University s Hospital Partnership (CUHP) The Wider Leadership Meeting forum now included a regular presentation on a research topic. Jo Lucas said that she was delighted that the service user voice was included in plans however that the voice of the carer must emphasised. Simon Burrows asked about the commercial portfolio and asked how success of this nature was measured. He went on to use South London and Maudsley NHS Foundation Trust (SLAM) as an example of somewhere that focused on one of its strengths Chronic Fatigue Syndrome and gained publicity through this focus. Ed Bullmore explained that R&D was measured against targets in regards to the numbers of studies and the numbers of patients recruited to studies for example. Not hitting prescribed targets caused the department to lose funding in the long term. Ed agreed that the Trust would be able to commercialise elements of its research, its treatment of both physical and mental health played into this as a one stop shop for those with complex Mental and Physical health problems. Wendy Llaneza informed the Board that it was intended to integrate the work of R&D with the work of the Quality team in order to make information accessible. Nick Oliver endorsed the discussion and said that the Physical and mental health link was vital. Furthermore Psychological Wellbeing already collected data which should be utilised. Nick also said that he was keen involve psychological professionals in the work in order to extend the focus beyond Bio Medical research. The Board noted the contents of the report, endorsed the strategy and agreed that further discussion should be held with Ed Bullmore at a future Executive Team meeting to clarify a proposed budget for Board approval. Chief Executive/ Jane Sansom 13. Board Assurance Framework The Deputy Trust Secretary presented the Board Assurance Framework to the Board and notified them that due to committee dates it was unchanged from the Audit and Assurance Committee meeting. Mike Collier asked if risk ref 1476 around the failure to deliver the planned CIP and the additional CIP to support the STP was to be increased due to 11

14 developments within the STP. It was confirmed that the risk was to be reviewed and Deborah Cohen highlighted that the STP posed a risk to the Trust Strategy. There was brief discussion around risk ref 2408 which detailed the failure to provide all in and out of hours doctor cover due to clinical demand and vacancies. The Board agreed that clarification was required regarding the service referred to. Chess Denman requested that the risk was removed from the register as a revised rota had been issued. The Board noted the Board Assurance Framework and approved its content. 14. Service Visits The four service visits submitted to the Board were approved for distribution to staff with no amendments. Julian Baust said that he had not had reports back on two visits that he had conducted: , Huntingdon Neighbourhood Team and ; SPA Huntingdon MASH. It was agreed that Alexandra Perry would investigate and, ensure that they were processed inform Julian of the outcome. Alexandra Perry 15. My Story Due to illness the My Story item was not presented to the Board. Instead it was agreed that it would presented to the meeting on AOB Jo Lucas informed the Board that MIND Peterborough, Cambridge and Fenland were due to merge. Signed.Dated.. Name Title 12

15 Board of Directors meeting in Public Agenda Item: 3 Action log number Date of Meeting Agenda Item January Action Log and Matters Arising January Action Log and Matters Arising ACTION LOG updated from meeting held 25 January 2017 Action Due Date Lead Status Following the meeting with Cathy Bonney provide an update to the Board regarding work ongoing into the Trust s EU workers. Review the 0844 number currently used within ARC services. Possibly use an 0300 number January Chair s Report The Board to forward interested contacts onto Alexandra Perry regarding standing in the upcoming Governor elections. May 2017 March 2017 March 2017 Stephen Legood ONGOING: Work is ongoing both nationally and locally. Derek McNally Whole Board COMPLETE: This has been reviewed by Associate Director IT (Richard Matt) who has advised that the 0300 number is not free and is dependent on the same issues as the current 0844 number regarding call charges, and therefore no benefit in changing from current arrangement. Interested Board Members can find full details of call charges on the.gov website COMPLETE: All suggestions have been received and contacted where appropriate.

16 4. 25 January Chief Executive s Report January Quality, Safety and Governance Committee summary January Quality, Safety and Governance Committee summary January Integrated Performance Report January Integrated Performance Report January Agency Staffing Report January 2017 Governor and Public Questions Julian Baust and Julie Frake- Harris to discuss the engagement of the Trust with Diabetes UK. Melanie Coombes, Deborah Cohen and Liz Mitchell to discuss the addition of the Carers Experience to the Quality Accounts. Provide an update to the Board regarding the dip in Level three Safeguarding Training undertaken by Trust Staff. In regards to the speech and language children s waiting list an update to be provided to the Board on and that an action plan was to be taken to a future Executive team meeting. The format and measures listed on the IPR to be discussed at a future Exec s meeting. Ongoing updates to be provided to the B&P committee and an exception report detailing both positive and negative changes to the overall position to be taken to the Board meeting on Mike Collier to be informed whether all of the Trust s CQUINS were on track to achieve their outcomes and funding. March 2017 March 2017 March 2017 March 2017/ May 2017 March 2017 March 2017 April 2017 Julian Baust/ Julie Frake- Harris Melanie Coombes, Deborah Cohen and Liz Mitchell Melanie Coombes Sarah Warner/ Julie Frake - Harris Jane Sansom/ Jonathon Artingstall Sarah Warner ONGOING: Julie Frake- Harris and Julian Baust to meet on to discuss. A joining DUK/ PWS visit is also to be arranged. ONGOING: A verbal update to be provided at the meeting on ONGOING: A verbal update to the provided to the Board on ONGOING: A verbal update to be provided at the Board meeting on ONGOING: JS and JA have met to discuss. Work on the IPR is ongoing and so will be taken to Execs when appropriate. COMPLETE: This has been included as part of agenda item 11. Stephen Legood ONGOING: MC is in touch with Nicky Brookes Jones to discuss further.

17 January Charitable Funds Committee Summary January Research and Development Update and Strategy ToR and Investment Policy to be amended and re circulated to the Board including highlighted amendments. Invite Ed Bullmore to a future Exec s meeting to discuss the R&D strategy and agree guide costings January Service Visits Ensure that Julian Baust s service visit forms: and have been processed November Chief Executives Report November 2016 Governor and Public Questions November Quality, Safety and Governance Committee summary A report detailing wider work and new responsibilities for prisons as outlined in the care act to the Board. The STP risk assessment to be presented at a future Board of Directors meeting. Updates to be provided in the interim. Circulate a calendar of events to all Governors February 2017 May 2017 February 2017 January 2017 March 2017 Derek McNally Aidan Thomas/ Jane Sansom Alexandra Perry Deborah Cohen Aidan Thomas COMPLETE: These were circulated to Trust Board Members by Rachel Nunn, Assistant Trust Secretary on COMPLETE: EB has been invited to an Execs meeting in April COMPLETE: The visit undertaken on was circulated to the Board in November 2016 for approval prior to being forwarded to the service. The visit on was circulated for approval on ONGOING: A report will be provided at the meeting on ONGOING: This has been included as an appendix to Agenda item 5 in the Private Board meeting Louisa Bullivant ONGOING: Discussions were held with Governors at the development session in November 2016 and again at CoG in December Work is underway to create a calendar of upcoming events and interests. The Board is asked to inform Louisa of any events in

18 November Exception report A report on medical side effect reporting to be presented to the Quality, Safety and Governance committee September Chief Executive s Report September Sustainability and Transformation Programme An update to Private Board on the PFI contract after SH meets with provider. Create a strategic planning forum to consider STP governance July My Story Service User panels to be implemented through HR and the Board to be updated in a year s time January Spirituality Strategy Update Muslim Chaplain to be invited to the Board meeting in March 2017 to update the Board after a year in service that they would want the Governors to attend. May 2017 Claire Mundell ONGOING: This will be discussed at the Q,S&G Committee meeting to be March 2017 November 2016 July March 2017 Scott Haldane Deborah Cohen Alexandra Perry, Annie Ng Deborah Cohen held on ONGOING: An update to be provided to the Private meeting on ONGOING: Meeting was held between Mike Hindmarch, Deborah Cohen and Amit Sethi on , ToR was circulated for comment on and the first meeting has been scheduled for NOT YET DUE ONGOING: It has been arranged for the Muslim Chaplain to attend the Board meeting on

19 Agenda Item: 4 BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Chair s Report Date: 29 th March 2017 Author: Julie Spence, Trust Chair Lead Director: Julie Spence, Trust Chair Executive Summary: Chief Executive Retirement Governor elections Annual Report 2016/17 Non -Executive Directors Executive Directors Recommendations: The Board of Directors is asked to note the contents of the Chair s report 1

20 Relevant Strategic Goals and Objectives (please mark in bold) The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by 2019 Links to BAF / Corporate Risk Register Details of additional risks associated with this paper (may include CQC Fundamental standards, NHSLA, NHS Constitution) Financial implications / impact Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details As above N/A N/A NHS Improvement requires foundation trusts to complete a well-led governance review every three years. Newly appointed NEDs, EDs and elected governors will have an impact on public engagement. Also the Annual Report affects public engagement of the Trust. None No 2

21 Chair s report 29 th March 2017 Chief Executive Retirement The Chief Executive, Aidan Thomas has confirmed, by letter, his intention to retire from July That said he has agreed to remain in post beyond this, if necessary to ensure an orderly handover to his successor. The timetable for the recruitment process has been set:- Throughout February and until March 6th 2017 I undertook open forums with staff across a number of locations within the Trust in order to give staff the opportunity to tell me the traits they would want from a new CEO, I was also contacted via by some staff. This information has helped to shape the specification for the job and will continue to shape the process. 23 rd March: Publication of the advert nationally via NHS Jobs for 3 weeks. In addition this will also be advertised in the Health Service Journal and on line. 24 th April: Shortlisting. 11th and 12th May: Interviews. Governor elections There are 16 Governor posts up for election this year. In addition to nine currently vacant posts seven of our current Governors are shortly to complete their three year term of office and so are required to stand for reelection. These positions are broken down below within the following constituency/ classes: 2 Patients - Carers 2 Patients - Service Users Cambridgeshire 1 Patients - Service Users Peterborough 1 Patients - Service Users Rest of England 5 Public - Cambridgeshire 2 Public - Peterborough 1 Public - Rest of England 2 Staff Louisa Bullivant has been doing some sterling work in endeavouring to encourage more people to become a Governor. In addition to suggestions put forwards by the Board Louisa has held multiple Information Stalls across the Trust as well as at a membership event, this has proved successful as it raised over 30 expressions of interest. She has remained in contact with this group and has continued to encourage the individuals to nominate themselves. 3

22 She has also worked on promotion through social media with the support of the Communication team; this has involved short videos of the Trusts current Council as well as the re design of the Trust s Governor information leaflets and posters. The Trust Secretariat intends to continue to develop this work following the elections. Coordinated with the publication of the election on 8 th March 2017, through UK Engage, Louisa has contacted, with nomination leaflets, posters and adverts over 90 General Practices, 20 local 6 th form colleges, 35 Parish Councils, 7 Hospitals, libraries and job centre s. In addition to many of these organisations agreeing to advertise the elections Healthwatch Peterborough and Cambridgeshire have included the advertisement in their newsletter. The timetable is:- Deadline for nominations, 5.00pm on Friday, 24 March Notice of withdrawal, 5.00pm on Wednesday, 29 March Close of poll, 5.00pm on Monday, 8 May Annual Report 2016/17 The Annual Report remains on task and within timeline. The first draft version of the Annual Report was circulated to members of the Board Sub-Committees; Quality, Safety and Governance and Business and Performance Committees on the 27 March 2017 for commentary. However and as previously discussed, this version will exclude elements that require data which unavailable until the year end. A draft version of the Sustainability Development Plan will also be included in this draft. This element is newly required by NHS Improvement. Non -Executive Directors Professor Peter Jones joined the Board on 1 st March 2017as a NED to support the research and medical dimensions of our discussions and work. His role is half of the normal NED role at 1.5 days per month. Executive Directors Kit Connick has now joined the Board in a one year interim role as Interim Director of Primary Care. Kit will be responsible for Primary Care and Corporate Development. 4

23 Agenda Item: 5 BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Chief Executives Report Date: 25 th March 2017 Author: Aidan Thomas, CEO Lead Director: Aidan Thomas, CEO Executive Summary: A summary of activity since the previous Board report. Overview of contracting position for 2017/19 Update on general Trust activity Recommendations: The Board is asked to note the content of the Report 1

24 Relevant Strategic Goals and Objectives (please mark in bold) The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by 2019 Links to BAF / Corporate Risk Register Details of additional risks associated with this paper (may include CQC Fundamental standards, NHSLA, NHS Constitution) Financial implications / impact As above Additional risks are outlined in the report. The purpose of this report is to inform the Board of the financial implications of the topics within. Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details The purpose of this report is to inform the Board of the legal implications of the topics within. The following sections detail work which will have an impact on the Trust s public engagement: Trust Strategy, GP engagement, STP, collaboration with CCS, Cavell Centre, staff engagement. No, although individual topics have been discussed in other forums. No 2

25 Chief Executives Report 1. Purpose This paper summarises key elements of the Trusts work since the last Board meeting. 2. Background The Report covers events during February 2017 and the first weeks of March Update on STP The STP investment committee has been considering some of the business cases drawn up after considerable consultation by the Primary Care and Integrated Neighbourhoods Delivery Group and the Urgent and Emergency Care Delivery Group. A summary of the outcomes for PCIN is attached. At the time of writing the Investment committee and the Health Care Executive (HCE) had already agreed funding for the expansion of JET including provision of Integrated Care Workers, and the continuation of the Mental Health First Response Service (FRS). The decisions will now need ratification by the Health care Executive group of the STP. It is clear that there are significant positive implications for services provided by CPFT and the Trust intends to ramp up its support for HR and programme management immediately to ensure successful implementation. Details of a number of other bids which are currently under consideration will be discussed in the Private Board Meeting. 4. Sustainability Transformation Programme (STP) Trust Internal Oversight Board The first meeting of the Trust STP Oversight Board will include ensuring alignment of the Trust Strategy with the STP. There are concerns at the CCGs insistence on reviewing STP proposals as part of its governance proposals in contravention of the STP MOU. This is being taken up with the CCG. 5. Contracting and Control Total Agreement to fund the FRS removes the need for the Trust to reconsider agreement to its control total. At the time of writing the CCG had not yet agreed to fund Byron B temporary ward facility. The Trust is preparing to give notice of closure subject to CCG agreement to fund. A copy of the CQUINN agreements for 2017/18 is available at 3

26 6. Acute sector A+E challenges NHSE continues to intervene directly in the delivery of services to support A+E and have requested trajectories of the expansion and performance of JET from the CCG. 7. Recruitment and Retention The Trust is considering a number of options to respond to temporary staff shortages in its inpatient children s unit. At the time of writing a number of options were being considered. The Trust has also temporarily closed its adult eating disorder services to new admissions for the same reason. 8. GP Engagement The Trust is engaged in developing an MCP bid with Peterborough Federation. More details are included in the report to the private Board 9. Staff Engagement Feedback A summary of the Staff Survey outcomes has been circulated; the Staff survey is to be discussed at the Quality, Safety & Governance Committee meeting on 04 th May The Collective and Collaborative leadership report is to be discussed amongst the Trust s Wider Leadership on Monday 27 th March Both will be discussed by the Board at the next available date. 10. Agency Spend & return to NHSI. A paper on Agency usage is attached. 11. Collaboration with Cambridge Community Services (CCS) on children s services The meeting of senior staff has led to a revised draft MOU which will be presented to the next Board meeting by Christina Richardson the transformation Manager for children appointed jointly by both Trusts and commissioners. In the meantime a number of areas of specific collaboration on the interests of the service have been identified and are being taken forward. 12. Cavell Centre Progress Health have demanded that the Trust pay the non-availability retention withheld as a result of the fire prevention remedial work. The Trust has refused and sent a clear justification for retaining the retention. At the time of writing no further response had been received from Progress Health. 12. Service Visits Since the last report I completed a visit to the St. Ives Neighbourhood team which was very impressive. In particular the professionalism of the District nurse I accompanied but also the 4

27 very impressive work of the Modern Matron (Case Manager) were clearly impacting on the wellbeing of patients and reducing hospital admissions. I also completed a partial shift on Oak 1 at the Cavell which was humbling given the severity of the illness of some of the clients cared for there. Deborah Cohen completed a visit to Peterborough Prison Social work service which was carrying out some very impressive family work including support to a terminally ill prisoner and her family. There were issues with recruitment and links with mainstream social work support. The Service itself was praised by the governor, along with the Trusts MH team. Julie Frake- Harris has been visiting a number of the Trusts mental health Services in her new role, across the County and in Peterborough. 13. Funded Care Packages The disputes with the CCG recorded in this section of the last report have now been escalated to NHS England. At the same time the NHS has announced more funding for Social Care. Some details are included in the attached letters from NHS improvement and NHSE. (See Appendix 5.1) 5

28 14. Communications Update CPFT Communications Board Report For the period of 17 January 17 March (11 weeks) External communications The Trust has received some very positive coverage in the local and regional media in the past 11 weeks. There was widespread coverage of the new nursing associate programme which the Trust is leading in conjunction with other health providers in the area. The First Response Service allowing callers to access immediate mental health advice by calling 111 and selecting option 2 also continues to attract coverage, especially the recent milestone that 4,000 calls had been received since last September. The impending retirement of CEO Aidan Thomas was reported across the area, and a television report on an art exhibition by a former patient helped promote not only her inspirational story, but the Trust s recovery ethos and fine work of our occupational therapy team. That was mirrored in another TV report about how our community mental health team had helped a patient turn their life around, and she is now taking part in charity events. The appointment of Chair Julie Spence s as Lord Lieutenant of Cambridgeshire also helped to promote her work with CPFT. Media activity Total media hits: 24 (Target: 2 per week averaging 2.2 per week) Top positive stories: - More than 4,000 call 111 mental health team Cambridge News, Heart Radio - New recruits join CPFT-led nursing programme Peterborough Telegraph, Ely Standard - Trust CEO to retire Cambridge News, Peterborough Telegraph - Art exhibition to reduce stigma BBC Look East Media hits Total value of print and broadcast coverage : 11,200 Positive Neutral Negative Facebook New likes: 746 to 829 Total posts: 144 Audience reach: 279,777 Twitter New followers: 2,141 to 2,253 Total Tweets: 98 Total interactions: 344 Audience reach: 50,600 LinkedIn New likes: 903 to 967 Instagram Followers: 125 Internal communications The Communications Team is supporting a range of internal programmes including Rebranding a revised Trust logo and documents associated to each Directorate have been approved by the Executive team, and we are now engaging with staff, governors, In-house design and branding service Jan 2017 to March 2017 Design hours: 131 hours Total cost saved from providing the stakeholders, and patient groups. A paper will be presented to the Board in May The annual Staff Awards The 2017 NHS Staff Survey and Collective and Collaborative Leadership report Quarterly PRIDE Awards attending by more than 60 colleagues A review of the Trust s Research communications Support for jobs fairs in Milton Keynes and London 6

29 BY 17 March 2017 To all NHS provider CEOs Chief Executive and Chairman's Office Wellington House Waterloo Road London SE1 8UG Tel: Dear colleague Social care investment Apologies for sending another letter, but I wanted to ensure that we maximise the benefit to patients of the Social Care Investment announced in last week s budget. We have seen a significant increase in the rate of DToC across the country over the last few years and know that this DToC figure masks a much larger number of medically fit patients in your hospitals. This was a material factor in the pressures felt over winter for patients, staff, operational performance and the financial position. This investment has been agreed to address this issue, and fragility in social care generally. So, following on from the note Simon and I sent last week, we need every provider to actively engage with social care colleagues as a matter of urgency, to work together to agree how this investment can be deployed to best effect. We need as many as possible of the 2,000-3,000 blocked beds to be freed up and flowing smoothly going into winter. We have attached an estimate of the number of beds by provider that could be freed up if this investment is deployed to assist the NHS to best effect. This does not include patients who are medically fit for discharge and is therefore likely to underestimate lost capacity in many cases. We plan to make data like this available on a more regular basis to help you engage with local partners. The social care allocation for local authorities can be found here. In addition, it is clear that models such as discharge to assess and trusted assessor need to be implemented consistently, and we should also aim to eliminate delays for patients that are waiting for NHS care or transfer. Please engage with the relevant providers and commissioners in your area to ensure that this is also addressed urgently. We will be working with colleagues to determine how best to make the benefits of this investment, including the impact we would expect it to have on delays, more transparent. More detail will follow when this is agreed. I hope you will appreciate how important this is. Please let me know if you need our help. Yours sincerely Jim Mackey Chief Executive, NHS Improvement NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams.

30 All NHS Provider Trust Chief Executives All CCG Accountable Officers All CCG Clinical Leaders Copy to Local Authority Chief Executives Gateway Reference: th March 2017 Dear colleague, Action to get A&E performance back on track We are writing to thank you and your staff for your work over what has been a highly pressurised winter, and - following the Chancellor s Budget statement yesterday - to let you know about the action now needed to turnaround A&E performance in Further detail will be provided in the NHS Delivery Plan being published in three weeks time. Throughout this winter, there have been three consistent themes relating to urgent and emergency care: difficulties in discharging inpatients when they are ready to go home; rising demand at A&E departments, with the fragmented nature of out-of-hospital services unable to offer patients adequate alternatives; and complex oversight arrangements between trusts, CCGs and councils. To avoid a repeat next winter of this past winter, we need to make concrete changes on all three fronts. Freeing up hospital bed capacity First, we know that difficulties with discharging emergency inpatients has reduced the effective availability of beds in which to care for both emergency patients presenting in A&E, as well as patients needing planned surgery. It is therefore vital that, together with our partners in local government, we ensure that the extra 1 billion the Chancellor has made available for social care is in part used to freeup in the region of acute hospital beds. We would ask that you immediately now engage with the senior leadership of your local adult social care departments to discuss how those patients stuck in hospital needing home care or care home places can access those services. High quality care for all, now and for future generations

31 It is also, however, indisputable that there are places which have still not adopted best practice to enable appropriate flow, including better and more timely handoffs between A&E clinicians and acute physicians, discharge to assess, trusted assessor arrangements, streamlined continuing healthcare processes, and seven day discharge capabilities. You now need to ensure these happen everywhere, and well before October Managing A&E demand Some estimates suggest that between 1.5 and 3 million people who come to A&E each year could have their needs addressed in other parts of the urgent care system. They turn to A&E because they are unclear about the alternatives or are unable to access them. You therefore now need to: Ensure every hospital implements a comprehensive front-door streaming model by October 2017, so that A&E departments are free to care for the most urgent patients. Yesterday s Budget has made available an extra 100 million of capital to be deployed in the next six months to support this. Proposals will need agreement with the Department of Health and we will be letting you know proposed allocations of this within the next six weeks. Strengthen support to your Care Homes so as to ensure that they have direct access to clinical advice, including where appropriate on-site assessment. We are making available 30 million to support universal rollout of this model via 111, in order to reduce the risk of care home residents being admitted to hospital. Implement the recommendations of the Ambulance Response Programme by October 2017, freeing up capacity for the service to increase their use of Hear & Treat and See & Treat, thereby conveying patients to hospital only when this is clinically necessary. Proceed with the standardisation of Walk-In-Centres, Minor Injury Units and Urgent Care Centres, so that the current confusing array of options is replaced with a single type of centre which offers patients a consistent, high quality service. Roll out evening and weekend GP appointments, to 50% of the public by March 2018 and 100% by March Increase the number of 111 calls receiving clinical assessment by a third by March 2018, so that only patients who genuinely need to attend A&E, or use the ambulance service, are advised to do this. Aligned national support and oversight Given the national importance of improving NHS urgent and emergency care performance, we intend to simplify the focus of the 30% performance element of the Sustainability and Transformation Fund (STF) for 2017/18, so that it will focus on A&E rather than requiring providers to focus on multiple objectives. For individual trusts it will be linked to effective implementation of the actions set out above as well as achieving performance before or in September that is above 90%, sustaining this, and returning to 95% by March 2018.

32 In order to ensure complete alignment between NHS England and NHS Improvement in supporting and overseeing urgent implementation of the above actions, we have appointed Pauline Philip as the single national leader accountable to us jointly. Furthermore, from 1 st April we are nominating a single, named Regional Director drawn from NHSI and NHSE to support this implementation work and hold accountable both CCGs and trusts through their local STP s A&E Delivery Boards. Each RD will therefore act with the delegated authority of both NHSI and NHSE in respect of urgent and emergency care. Thank you for your ongoing leadership on this critical part of what the NHS does for the people of this country. Yours sincerely Simon Stevens CEO, NHS England Jim Mackey CEO, NHS Improvement

33 Agenda Item: 7.1 BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Date: 29th March 2017 Author: Lead Director: Quality, Safety and Governance Committee meeting dated 2 nd March 2017 Sarah Hamilton, Chair Mel Coombes, Director of Nursing Executive Summary: Agenda items included Joint Emergency Team (JET) service update Carer Programme Workforce Report Medical Staffing Report Mental Health Law Quarterly Quality Assurance & Compliance Report CQC Action Plan Update Quality Accounts 2017 update report Quality, Safety and Clinical governance exception report First response team update Recommendations: To note this report and the quality and safety issues raised in the committee papers 1

34 Relevant Strategic Goals and Objectives (please mark in bold) The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by 2019 Links to BAF / Corporate Risk Register Details of additional risks associated with this paper (may include CQC Fundamental standards, NHSLA, NHS Constitution) Financial implications / impact As above. N/A Whilst this report does not have direct financial implications, items/ discussions summarised within the report may have financial implications to the Trust. Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details Whilst this report does not have direct legal implications, items/ discussions summarised within the report may have legal implications to the Trust. N/A Whilst this report has not been presented before, it is a summary of the Q, S&G Committee meeting, held on 02/03/17. No 2

35 1. Purpose The purpose of this report is to highlight issues raised at the March meeting of the Committee which it is felt should be drawn to the Board s attention 2. Background Sub-Committee of the Board established to review Quality and Safety issues and performance for the Trust in accordance with the established terms of reference 3. JET update There had been a detailed review of the JET service with 15 staff members interviewed and 20 other statements taken. The review had highlighted six issues to be addressed as well as a number of positives. The team are content with the conclusions and solutions that had come out of the review, work will continue with the team to ensure changes are embedded in practice. The Committee was assured that the team was capable of meeting the targets set. 4. Carer Programme The Committee agreed the recommendation from Elaine Young that the e-learning package for Carer Awareness Training to become mandatory for clinical staff, to be added onto the dignity and respect e-learning module. The Committee were asked to support the publication of CPFT Carer Handbook: this had been developed through Charitable Funds and it was now ready to publish. It was agreed that we would need to know the cost of this before we could approve this publication. It was agreed that the Carer e-learning package would be available available on the public facing website. 5. Workforce Report An increase in sickness was noted due to seasonal issues and increase in cases of diarrhoea and vomiting. Staff have to be symptom free for 48 hours before they can return to work. There was a discussion around the flu vaccine. Education will start earlier this year. The Trust was working with Serco on contracts and occupational health regarding time to fill delay. In order to improve retention rates the Trust was introducing higher banded clinical roles as well as a clear career pathway for administration staff. 3

36 6. Medical Staffing Report Chess Denman highlighted some key hotspots including a general lack of clinicians, and the fact that fill rates for trainees were poor. The CAMHS services were currently managing in terms of medical staffing as they had more flexibility across the service. Discussion around the recent review of administration services in Adult and Specialist Directorate. 7. Mental Health Law Quarterly Quality Assurance & Compliance Report Orna Clark presented the report highlighting that Section 136 numbers had grown slightly as had the number of individuals visiting the Sanctuary as part of the vanguard project. The Police and Crime Bill will mean changes to section 135 of the Mental Health Act including a change in who could be detained under a s135 at a police station so that no under 18s were included, more powers to detain in other public spaces without a s135 warrant and reducing the time that patients could be held under a s136 for up to 72 hours. The CQC is visiting 12 Trusts (not CPFT) regarding the increase in s136 detentions, looking at AMHP arrangements around the country, and to get a feel of what might be driving the year on year increase in detentions. Deborah Cohen will keep the Trust updated as more information comes through. 8. CQC Action Plan Update The CQC are looking to hold an inspection with the Trust at the end of Q1 FY17/18 focusing on the areas marked as needing improvement - Children s Services and safety. The outstanding actions from the previous inspection were quite small but we need to ensure that all the actions have been evidenced correctly. 9. Quality Accounts 2017 update report The committee noted and agree the timeline for this years Quality account. It was noted that the pressure ulcers data was an area of concern. There had been a couple of SI s in one particular team and a number of actions had been undertaken to resolve any issues with service provision. On a positive note the number of incidents also reflected better reporting of said incidents. There is currently a national focus on pressure ulcers. Discussion around insulin targets. These incidents mostly occurred around weekend discharges so the Trust were not informed that service user s needed insulin. 10. Quality, Safety and Clinical governance exception report. The reporting of serious incidents had been at 100% for 3 months which was a very positive result. 4

37 Discussion around staff not attending courses and training events which led to some being cancelled. 11. First response team update. Sharon Johnson reported that the First Response Team had taken 5,000 referrals. 72% of referrals were managed by phone. 61% were self-referrals, with a significant amount also from GP s and emergency services. The team consisted of six band 7 staff members, 14 band 6 staff and 12 band 3. They would also be taking apprentices in the near future The Sanctuary has an Outreach service in Huntingdon three nights a week. There had been over 800 visits to the Sanctuary services since the service had launched with positive feedback from service users. The team is still currently a Vanguard project, the Trust are waiting for confirmation of on going funding form the commissioners. 5

38 BOARD OF DIRECTORS MEETING IN PUBLIC Subject: Agenda Item: 7.2 REPORT Quality, Safety & Clinical Governanceexception report Date: 29 th March 2017 Wendy Llaneza, Senior Head of Quality & Compliance Author: Annie Ng, Head of Patient Experience Nishaal Abraham, Head of Patient Safety & Complaints Lead Director: Mel Coombes, Director of Nursing and Quality Executive Summary: This paper provides a summary of the Trust s performance on key quality and safety measures for January and February Please refer to Appendix 1 for a more detailed summary. Patient Experience Highlights FFT Those who would recommend Trust services has decreased from 94.35% (Jan) to 92.59% (Feb), with a 6% and 2% reduction in A&S and CYPF inpatients, respectively and just over 2% reduction in OPAC community; and a 3% and 2% improvement in A&S and OPAC community, respectively. Overall patient satisfaction decreased from 93% (Jan) and 92% (Feb). The 4% reduction in the A&S inpatients was offset by the 4% increase in the OPAC inpatients, with a 1% reduction in the OPAC community scores. o Food satisfaction scores increased from 67% (Jan) to 71% (Feb) o Evening and weekend activities increased from 69% (Jan) to 73% (Feb) o Told side effects of medication Inpatients decrease from 64% (Jan) to 59% (Feb) Community increase from 94% (Jan) to 95% (Feb) o Info on vocational activities decrease from 67% (Jan) to 52% (Feb) o Out of hours contact number static at 91% Carers experience The number of surveys completed increased from 94 (Jan) to 106 (Feb) while the overall satisfaction decreased from 91% (Jan) to 87% (Feb). Patient Safety Highlights Complaints o 13 complaints registered compared to 5 in January o 92% of the complaints were acknowledged within 3 working days Patient safety and Serious Incidents o 942 incidents were reported in February, a decrease when compared to 1060 in January. 56% (n=529) resulted in no harm and 34% (n=321) in low harm. o 5 SIs were opened in February: OPAC = 1; AS = 4 o Self harm incidents have gone down from 191 (Jan) to 129 (Feb), of which 27 was from A&S, 30 from CYPF and 5 (from 6) in OPAC. Timeliness of SI report submissions 75% (completion within 60 days). One SI was submitted late by 2 days (OPAC) and another remains outstanding, late by 25 days (Adult & Specialist). Inquests one new case opened relating to the Adult & Specialist Directorate Page 1 of 13

39 Prone position Face Down restraint Highlights Nil prone position face down restraints were reported during February. Seclusion Nil seclusions were reported for February. Infection Prevention and Control Highlights There were no cases of MRSA bacteraemia and Clostridium difficile in February which is the same as the previous month. Cleaning scores remains above the national standards for all levels. 100% compliance with Essential Steps audit. 90% compliance with MRSA Decolonisation Treatment; 2 patients required treatment in February - 1 patient on Lord Bryon A received 100% appropriate treatment and 1 patient on Intermediate Care Unit Peterborough received 80% appropriate treatment. Safeguarding training (target 90%) Safeguarding Adults Training remains above target at 97.29%. Safeguarding Children s Training Level 1 remains above target at 93.69% while Level 3 training compliance is below target at 88.90%. Mental Capacity Act and DoLS training remains below target; Level % and Level %. Recommendations: To note and discuss the contents of the report. Key issues to note are o Slight decreases in the overall patient experience survey scores (FFT & Overall Satisfaction) o There were increases in satisfaction to food, evening & weekend activities and medication side effects in the community scores; while there was a 5% and a 15% reduction in medication side effects in inpatients and information on vocational activities, respectively. o Complaints response rates have decreased to 92% from 100% in January (87% in December). The average response times have gone down significantly to 35 days Trust wide from 47 in January. All complaints received for the OPAC Directorate were responded to within 17 days against the target of 30 days. o 11% reduction in the number of incidents reported from the previous month (942 from 1060). The top incident type for February was pressure ulcers comprising 16% of total incidents followed closely by self harm incidents at 14%. o 32% reduction in the number of self harm incidents (129 from 191) and a 13% reduction in physical assaults involving patient to staff (62 from 71). o Overall timeliness of SI reporting has decreased to 88% and 75% of SIs were resolved within the national timescale of 60 days, after remaining at 100% for the previous three months. o While there was a significant reduction in the number of SIs opened in February (5 from 13), there was an increase in the number of Clinical Reviews (4 from 1). o Nil prone restraints or seclusion were reported February o Continued slight increases in the Safeguarding Adults training and Safeguarding Children Level 1, while compliance with MCA & DoLS training and Safeguarding Children Level 3 remain below target. Page 2 of 13

40 Relevant Strategic Priorities (please mark in bold) The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by 2019 Yes Links to BAF/Corporate Risk Register Details of additional risks associated with this paper (may include CQC Essential standards, NHSLA, NHS Constitution) Financial implications/impact Some of the safety and quality indicators contained in this report are also reflected in the Integrated Performance dashboard (IPR), and are also included in the quality metrics reported to the CCG. Staffing was identified as a safety issue requiring improvement following the CQC inspection. Some of the indicators have also been identified as requiring improvement in our Patient and Staff Surveys. N/A Legal implications/impact Partnership working and public engagement implications/impact Committees/groups where this item has been presented before Has a QIA been completed? If yes provide brief details N/A N/A Clinical Governance and Patient Safety Group N/A Page 3 of 13

41 Patient Experience Appendix 1 Key Quality & Safety Indicators Summary February 2017 Relevant additional information is provided in the page indicated. Indicators Patient s FFT - National data (% recommend score) Mental Health Community Patient s FFT* % recommend score Q1 16/17-92% Q2 16/ % Q3 16/ % Overall Patient Satisfaction Survey No. of responses Score Q1 16/17-90% Q2 16/ % Q3 16/ % Target Performance Dec 16 Jan 16 Feb 17 88% 98% May 16 Jun 16 Jul 16 Highlights Aug 16 Sept 16 Oct 16 Nov 16 Dec 16 CPFT 84% 85% 86% 88% 86% 86% 85% 88% Nat l 87% 87% 88% 88% 87% 88% 88% 85% Community groupings CPFT 96% 98% 98% 97% 95% 97% 97% 98% Nat l 95% 95% 95% 96% 95% 95% 95% 96% note: National data is not directly comparable due to flexibility in FFT collection methods and variation in local populations >60% 95.14% 94.35% 92.59% Directorate Dec 16 Jan 17 Feb 17 Adult & Specialist Mental Health Directorate Inpatient Community 78.41% 91.19% 76.40% 86.39% 70.27% 89.77% % % % Thresholds: green %, amber 89-60%, red 59-0% For indicators where there is no agreed target on performance * Reported in the Trust s Integrated Performance dashboard Children Young People & Families Directorate Inpatient Community Older Peoples & Adult Community Directorate Inpatient Community 75% 94.20% 84.44% 98.15% 70% 90.73% 88.68% 97.14% 68.18% 93.28% 88.14% 94.37% Directorate Dec 16 Jan 17 Feb 17 Adult & Specialist Mental Health Directorate Inpatient Community Children Young People & Families Directorate Inpatient Community Older Peoples and Adult Community Directorate Inpatient Community 88% 94% 86% 98% 75% 97% 84% 93% 84% 97% 75% 95% 80% 93% 84% 97% 79% 94% RAG Page 4 of 13

42 Patient Experience Food rating* Heat map data highlights ward feedback over the past three months. Evenings/weekend activities Heat map data highlights ward feedback over the past three months. Possible medication side effects inpts Heat map data highlights ward feedback over the past three months Possible medication side effects Comm Extracted heat map data highlights those community teams with lower scores based on current month. Information on vocational activities Heat map data highlights ward feedback over the past three months Out of hours contact number Extracted heat map data highlights those community teams with lower scores (ie 74% besides below) based on current month. 75% 65% 67% 71% - 70% 69% 73% - 73% 64% 59% - 96% 94% 95% - 67% 67% 52% - 94% 91% 91% Adult & Specialist Mental Health Directorate: Mulberry 2 satisfaction scores have reduced further. Older People & Adult Community Directorate: Willow scores are low. All other wards 75% or above. Children, Young People & Families Directorate: Darwin/Phoenix scores continue to remain very low over the last three months. Adult & Specialist Mental Health Directorate: GMH, Mulberry 2/3 show signs of dissatisfaction. Older People & Adult Community Directorate: Maple scores are particularly low. Children, Young People & Families Directorate: Satisfaction remains very low this month for Phoenix. Adult & Specialist Mental Health Inpatients: Patients on several wards including GMH and Mulberry 1 have poor responses to this question. Older People & Adult Community Inpatients: Peterborough Intermediate/Trafford/Maple patients have low satisfaction rates. Children, Young People & Families Inpatients: Phoenix continues to show signs of dissatisfaction. Adult & Specialist Mental Health Community: HMP Peterborough has decreased scores this month. All other teams are 75% or above. Older People & Adult Community: A number of teams have decreased/low scores this month. Note: Data excludes Children, Young People and Families Community who are not asked this question in their Directorate survey. Adult Mental Health Inpatients: Several wards remain dissatisfied in response to this question. Mulberry 2, Oak 1/2- indicates all service users have responded negatively to this question. OP & Adult Community Inpatients Maple scores have improved this month. Note: Data excludes Specialist Mental Health/ Children, Young People & Families this question not included in Directorate inpatient survey. Adult & Specialist MH Community: A small number of teams have low satisfaction in response to this question. Older People & Adult Community: An increased number of teams indicate low scores.. Note: Data excludes Children, Young People & Families Community this question not included in Directorate community survey. Page 5 of 13

43 Patient Safety Patient Experience Carers survey overall satisfaction Q1 16/ % Q2 16/ % Q3 16/ % Responses Q1 16/ Q2 16/ Q3 16/ PALS enquiries received Q1 16/ Q2 16/ Q3 16/ Compliments - 93% 92 91% 94 87% Directorate responses Adult & Specialist Mental Health Directorate Children, Young People & Families Directorate Older People & Adult Community Directorate Dec 16 Jan 17 Feb From June 2016 onwards, each team has been given the target of collecting 2 carer surveys per month. Nov figure adjustment retrospective survey inputs. By Directorate Directorate responses Directorate responses Dec 16 Jan 17 Feb 17 Adult & Specialist Mental Health Directorate Children, Young People & Families Directorate Older People & Adult Community Directorate Corporate Dec 16 Jan 17 Feb 17 Adult & Specialist Mental Health Directorate Children, Young People & Families Directorate Older People & Adult Community Directorate Complaints received* Q1 16/17-41 Q2 16/17 49 Q3 16/ Directorate responses Adult & Specialist Mental Health Directorate Children, Young People & Families Directorate Older People & Adult Community Directorate Corporate Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Parliamentary Health Service Ombudsman (PHSO) The Trust received the final report for a complaint relating to a minor injuries unit. Acknowledged within 3 working days Q1 16/17-95% Q2 16/17 98% Reopened complaints During February there were no reopened complaints. 100% 87% 100% 92% 43% were responded to outside of the 30 working day timeframe but within the agreed extended timeframe. 43% were responded to outside of the 30 working day timeframe 14% were withdrawn by the complainant. Page 6 of 13

44 Patient Safety Average response time (working days) Q1 16/17-48 Q2 16/17-36 Q3 16/ Response Times Directorate Dec 16 Jan 17 Feb 17 Adult and Specialist Directorate 46 Days 36 Days 40 Days CYP&F Directorate 34 Days 50 Days 39 Days OPAC Directorate 36 Days 27 Days 17 Days Closed complaints Healthcare Professional Feedback (HPF) Incidents received Q1 16/ Q2 16/ Q3 16/ Avoidable Grade 3 or 4 PUs Self harm incidents Falls - moderate & severe harm IG breaches SIs Clinical reviews Of the 7, 2 were partially upheld, 4 were not upheld and 1 were withdrawn either due to a lack of consent or by the complainant. Degree of harm No harm 529 Top 5 types Developed a Pressure Ulcer Low 321 Self Harm 129 Moderate Severe 71 Death related to PSI 0 Death unrelated to PSI OPAC - NT Cambridge City North M=2 M=2 M= Physical 102 Slip/trip/fall 66 Treatment/procedure - use of control and restraint Directorate Dec-16 Jan-17 Feb-17 Adult and Specialist Directorate CYP&F Directorate OPAC Directorate Directorate Dec-16 Jan-17 Feb-17 Adult and Specialist Directorate CYP&F Directorate OPAC Directorate Adults & Specialist - PDCS 36 Page 7 of 13

45 Patient Safety Physical assaults Patient to patient Patient to staff Patient to Patient Dec-16 Jan-17 Feb-17 Adult and Specialist Directorate CYP&F Directorate OPAC Directorate Patient to Staff Dec-16 Jan-17 Feb-17 Adult and Specialist Directorate CYP&F Directorate OPAC Directorate SIs overall timeliness of reporting Q1 16/17 94% Q2 16/17 95% Q3 16/17 100% 100% 100% 100% 88% SIs resolved within national timescale (60 days)* Q1 16/17-87% 100% 100% 100% 75% Q2 16/17 88% Q3 16/17 100% Serious incidents reported (open)* Serious incidents closed Clinical reviews (SIs) open Stop the Line Directorate Dec-16 Jan-17 Feb-17 Adult and Specialist Directorate 100% 100% 92% Children's Directorate n/a n/a n/a OPAC Directorate 100% 100% 80% Directorate Dec-16 Jan-17 Feb-17 Adult and Specialist Directorate 100% 100% 80% Children's Directorate n/a n/a n/a OPAC Directorate 100% 100% 75% OPAC: 1 Pressure Ulcer( NT Cambridge City North) W71649/2017 A&S: 2 - Unexpected Death (PALT) W71601/2017; W71601/ Serious Assault (Forensic ) W71488/ Admission of a Minor (Oak1) W72105/2017 OPAC 4 A&S 4 Directorate Dec-16 Jan-17 Feb-17 Adult & Specialist Directorate Children's Directorate OPAC Directorate A&S: CRW70701:Care & Treatment Oak1 CRW72043 :Confidentiality Breach - PDCS OPAC: CRW71769:Practice Issue JET Page 8 of 13

46 Nursing Patient Safety Inquests New closed - - Claims received in the month* Safety thermometer harm free care* new harm free care number of patients Safer Staffing for inpatients* Prone Face down restraint % 93% 98% 1172 Above 80% Fill rate 0% by April % 96% % 96% 1115 RNs day = 97% RNs night = 94% HCAs day = 107% HCAs night = 110% Seclusion Revalidation Due in the month Successfully revalidated Removed from register - 100% bank worker left Trust New Inquest A&S: W72272/2017 Police received contact from patient s mother reporting concern as patient had not been to visit which he normally does daily. Mother reported that he 'suffers with schizophrenia and the past few days he has not been feeling so good, and has said he is hearing voices'. Police gained entry and found him deceased. Closed inquests A&S: 60453/2016 Inquest held Trust witness not required to attend. Cause of death - overdose. Conclusion suicide 64561/2016 inquest held no witnesses required. Cause of death unascertained. Conclusion open W Inquest held Cause of death COD 1a Status Asthmaticus; 2 Alcohol Intoxication. Conclusion natural causes OPAC: Death in care home (DoLS). Inquest held Feb) I witness called. Cause of death intracranial haemorrhage. Conclusion accidental Notes on current cases: A&S 828/SS Letter received from Claimant s solicitor on this case which is still at Inquest stage. Due to the engagement of Article 2 provisions, protective proceedings have been issued against CPFT and Cambridgeshire Constabulary. Because Cambridgeshire Constabulary would not agree to a moratorium, the Claimant s solicitor has sought consent from the Court to serve the Claim Form and Particulars until 3 months from last day of inquest 829/WB This claim relates to damages for loss of personal items which were alleged to have been stolen from the service user whilst he was staying on Oak 2. The February 2017 safe staffing return excluded 5% of total daily data required, as a result of the omission of data from ward sources via the on-line intranet tool. Mitigations have been put in place to prevent this moving forward. Page 9 of 13

47 Safeguarding IPaC MRSA Bacteraemia Clostridium difficile* MRSA screening 100% 100 % 100% 100% MRSA decolonisation % patients appropriately treated 100% 0 cases 93% 90% Essential Steps Audit 100% 96% 100% 100% in in-patient areas Cleaning scores Low risk Significant risk High risk Safeguarding Adults (Mandatory Training)* Mental Capacity and DoLS training L1 Mental Capacity and DoLS training L2 Safeguarding Children (Mandatory Training)* Outstanding Safeguarding Enquiries (Peterborough only) 75% 85% 95% 88% 93% 97% 90% 93% 96% 88% 93% 96% 90% 97.14% 95.88% 97.29% 90% 78.55% 77.33% 77.62% 90% 64.77% 63.05% 61.86% 90% L % L % L % L % L % L % patients- 1 on Lord Bryon A received 100% appropriate decolonisation treatment, 1 patient on Intermediate Care Unit Pboro received 80% appropriate decolonisation treatment Definitions Low risk outpatient and non-patient areas Significant risk most inpatient wards High risk high risk inpatient wards in the physical health services 22 outstanding from Adult and Specialist Mental Health Directorate 6 outstanding from Older People s and Adult Community Directorate Page 10 of 13

48 Key Quality & Safety Indicators Summary January 2017 Additional details where relevant 1. PALS & Compliments The trends for the PALS and compliments received are shown below Monthly PALS Data 2016/17 Apr Ma y Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ / / /17 Key themes from the concerns received by PALS were: Adult & Specialist Directorate (n = 10). Main themes related to long delay in assessment letter being sent to service user and GP and communication with staff member. Of the concerns received, 4 were in relation to the Personality Disorder Community Service. Children, Young People & Families Directorate (n = 1) Older People, Adult & Community Directorate (n = 17 ) main themes related to patients and their families not knowing the contact numbers for their local community team. Corporate teams (n = 9). Main theme related to accessing services. 2. Complaints received Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ / / /17 Page 11 of 13

49 3. Closed Complaints Average Response Times Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015/ /17 Themes The Trust wide themes continue to be related to dissatisfaction with the quality of care provided. Again the majority of the complaints included an element of poor, or a lack of, communication from staff with service users and their families/carers. Learning and Recommendations For staff to raise concern with Children s Social Care if minutes are not received in a timely manner and if despite requests for the minutes this does not happen then to escalate this with line manager and CPFT safeguarding team. Medication advice provided by doctors to General Practitioners should be specific. Staff should ensure patients have been provided with patient medication leaflets when medication is started, increased or the form has been changed to ensure patients have awareness of possible side effects. Any amendments to appointment letters after sending should be re-sent with changes. All staff to ensure clear introductions and explanation of roles takes place prior to an assessment commencing. All staff to be aware of non verbal interactions during assessment. All clinicians to affirm with clients understanding of assessment process. Page 12 of 13

50 4. Incidents Number of Incidents Reported by Directorate Children, Young People and Families Directorate Corporate Directorate 500 Older People's and Adult Community Directorate Integrated Governance Adult and Specialist Mental Health Directorate Service Integration Page 13 of 13

51 BOARD OF DIRECTORS MEETING IN PUBLIC Subject: Date: 29 th March 2017 Author: Lead Director: Safer Staffing inpatient settings Judy Dean, Head of Nursing Melanie Coombes, Director of Nursing & Quality Agenda Item: 7.3 REPORT Executive Summary: The Safer Staffing report is a regular exception report to the Board in respect of the national inpatient safer staffing publication. This covers all Trust bed-based services from across the Directorates and includes any reported impact on safety and quality. The report provides figures and an analysis of the Registered Nurses (RNs) and Health Care Assistants (HCAs) monthly average fill rates for day and night shifts, where these fall below or above threshold (ie. below 80% and above 120%). The data is derived from the Trust s on-line safer staffing reporting system, entered at ward level and collated centrally. The Average fill rates for January and February for both RNs and HCAs are as follows: Staff group Average day fill rate January Average night fill rate Average day fill rate January February RNs 99% 94% 97% 94% HCAs 112% 111% 107% 110% Average night fill rate February Key points to note: The February 2017 safe staffing return excluded 5% of total daily data required, as a result of the omission of data from ward sources via the on-line intranet tool. Mitigations have been put in place to prevent this moving forward. There were 21 Datix reports (15 Jan, 6 Feb ) related specifically to inpatient staffing levels (compared to 12 in November/December) of these all were graded as No Harm There were 4 complaints registered with the Trust from inpatient wards in January (n=1) and February (n=3). None were related to inpatient staffing. Deep Dives: There were no deep dives undertaken in any of the Trust s inpatient services Bed reconfigurations: The temporary closure of beds in the Cavell Centre Adult acute wards remains in place as of date of reporting. The Directorate has a recruitment plan in place, including the recruitment of Clinical Nurse Specialists and Occupational Therapists (OTs). A number of appointments have been made in this reporting period. The Older People & Adult Directorate are proposing a staged reduction of beds from 14 to 10 with appropriate measures put in place to understand the impact of the reductions at each stage of the process. This proposal will be going to the OPAC Directorate Management Team on the 20th March. Recommendations: The Board is asked to note the safer staffing exceptions and the decisions taken by Directorates to proactively manage staffing concerns. 1

52 Relevant Strategic Goals and Objectives (please mark in bold) The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by 2019 Nursing vacancies are included Links to BAF / Corporate Risk Register in the Board Assurance Details of additional risks associated with this paper (may include CQC Fundamental standards, NHSLA, NHS Constitution) Financial implications / impact Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details Framework CQC s Inspection regime assesses the safety and availability of nursing staff to respond to service users needs in line with NQB expectations. Some of the higher fill rates have resulted in cost pressures for those services N/A N/A N/A No 2

53 Safer Staffing Inpatient Services 1. Purpose This is a brief report, providing the Board with exceptions in respect of Safer Staffing for inpatient wards. Included in the report are themes on exception areas for context and an overview of incidents, complaints and/or Directorate actions arising from deep dives into services relating to staffing. 2. Background The background to this report is well known. The exceptions in this report are based on fill rates below 80% and above 120% against the National Safer Staffing tool monthly submissions to UNIFY. The data is derived from the on-line safer staffing tool, recorded at ward level and available daily on the Trust s intranet, including RAG rating based on professional judgement. Contextual narrative on exceptions is gleaned from the Directorates Staffing fill rates The average planned versus actual hours for RN and HCA ward staffing during the day and night have been uploaded onto Unify and are available on NHS Choices. The average fill rates for January and February for both RNs and HCAs are shown below: Staff group Average Day fill rate January The February 2017 safe staffing return excluded 5% of total daily data required, as a result of the omission of data from ward sources via the on-line intranet tool. To mitigate this instance in future months, a weekly summary report will be issued to ward managers confirming their on-line recording in the previous period, and highlighting any data omissions, requesting corrective action before the next weekly update. Exceptions: Registered Nurses Average Night fill rate January Average Day fill rate February RNs 99% 94% 97% 94% HCAs 112% 111% 107% 110% January 2017 February 2017 RNs (Registered Nurses) Average Night fill rate February Ward Low fill rates High fill rates Low fill rates High fill rates Day Night Day Night Day Night Day Night Mulberry 1 74% 76% Hollies 66% Oak 3 70% 71% Phoenix 128% 135% Denbigh 123% 124% GMH 64% 75% PICU 139% Springbank 79% 66% 3

54 Exceptions Health Care Assistants January 2017 February 2017 HCAs (Healthcare Assistants) Ward Low fill rates High fill rates Low fill rates High fill rates Day Night Day Night Day Night Day Night Denbigh 128% 127% Mulberry 1 144% Mulberry 2 127% Mulberry 3 127% Maples 147% 130% Hollies 154% 148% Oak 1 147% 147% 172% 207% Oak 3 246% 206% 185% 157% Oak 4 183% 223% 178% 204% Springbank 69% 78% The exceptions were for the following circumstances: Increased acuity of patients: requiring enhanced observations, (Oak 1 Oak 3, Oak 4, Denbigh, Maple Unit) Staffing of female corridor since reconfiguration (Oak 1) Increase in HCA fill rate reflecting increase in bed numbers following reconfiguration (Oak 4) Increase in RN fill rate on Denbigh as new RN starters were supernumerary in induction period Increased RN cover at night on PICU agreed as part of CQC feedback Low fill rate of RN on GMH reflective of lower patient numbers HCA cover utilised for the RN staffing vacancies, to cover annual leave, study leave, maternity leave and short and long term sickness by staff known to the wards and familiar with ward processes to provide continuity of care (Mulberry 1, Mulberry 2, GMH) Skill mix: HCA bank cover (trained in Physical Intervention: PI) preferred to RN bank/agency not PI trained (Oak 3) Lower bed occupancy reflecting need for less RNs and HCAs to cover the vacancies (Springbank) Directorate agreement to increase staffing at night to safely cover the separated male and female ward areas (Hollies) Changes in establishment possibly not reflected in on-line staffing tool. Ward Manager reviewing data (Phoenix) 4. Impact on Quality & Safety Wards continue to report staffing concerns via Datix and a weekly report detailing these is collated by the Trust s Patient Safety Team for the attention of the Director of Nursing, Deputy Director of Nursing and the Directorate Heads of Nursing. Staffing Reported Incidents In January and February there were a total of 22 Datix reports (Jan=15; Feb =6 ) related specifically to inpatient staffing (compared to 12 in November/December ). All of these were graded as No Harm. The rationale for datix reports covered the following: Bank or Agency requests unable to be filled Unpredicted rise in acuity and late staffing cover requests from other units via Duty Nursing Officer unable to be met 4

55 Substantive staff sickness (cover unable to be found at short notice) Gender mix of staff unpredictable unavailability of female staff at night on mixed ward Patient admitted to Addenbrooke s requiring 1:1 support from Fulbourn ward staff Bank staff not turning up for duty Miscommunication regarding regular staff availability to stay on to cover shortage Complaints There were 4 ward complaints registered with the Trust: Jan (n=1) and Feb (n=3), compared with 5 in Nov/Dec. Complaints were from Oak 1 (Jan), Maple 1, Oak 2 and Trafford wards (Feb). None of these were related to staffing. Stop The Line There were no inpatient Stop the Lines reported in January and February Deep Dives There were no deep dives prompted by staffing concerns undertaken in January or February. Bed reconfigurations In January the Board was informed that, in order to mitigate the increasing risks posed by vacant RMN posts, the Adult & Specialist Mental Health Directorate reconfigured beds at the Cavell in December. This resulted in a temporary closure of beds and the treatment and recovery wards becoming mixed sex in order to maintain the integrity of the 3:3:3 model. The temporary closure remains in place as of date of reporting. The Directorate has a recruitment plan in place, including the recruitment of Clinical Nurse Specialists and Occupational Therapists (OTs). A number of appointments have been made in this reporting period The Older People & Adult Directorate are proposing a staged reduction of beds from 14 to 10 with appropriate measures put in place to understand the impact of the reductions at each stage of the process. This proposal will be going to the OPAC Directorate Management Team on the 20th March. The Directorate have appointed a Practice Develop Lead, commencing in the end February, who will focus her time in supporting the practice development of the Denbigh team using the improvement plan already in place. This includes developing the teams skills and knowledge in dementia care. 5. Board Action The Board is asked to note the safer staffing exceptions and the actions taken by Directorates to proactively manage staffing concerns. 5

56 Agenda Item: 7.4 BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Eliminating Mixed Sex Accommodation Date: 29 th March 2017 Author: Judy Dean, Head of Nursing Lead Director: Melanie Coombes, Director of Nursing & Quality Executive Summary: It is a statutory requirement to declare and publish our compliance against the delivery of same sex accommodation standards on an annual basis and to inform commissioners of our compliance status. This paper provides: A definition of what the provision of single sex accommodation means in practice on our wards A summary of our Trust s compliance against the standards Narrative from wards requiring minor action A draft statement of compliance for 2017/18 for Board approval Recommendations: The Board is asked to: note the outcome of the Eliminating Mixed Sex Accommodation audit for 2017/18 note the status of our wards in 2017/18 approve the draft statement of compliance for 2017/18 and advise Trust Communications to publish on Trust public website by 1 st April

57 Relevant Strategic Goals and Objectives (please mark in bold) The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by 2019 Yes, as above Links to BAF / Corporate Risk Register Details of additional risks associated with this paper (may include CQC Fundamental standards, NHSLA, NHS Constitution) Providing Single Sex Accommodation is included in CQC Regulations 10 (Dignity & Respect) & Regulation 15 (Premises & Equipment). Financial implications / impact Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details Single sex breaches result in financial penalties. Breaches identified during inspection may result in requirement notice or warning notice. Breaches identified may affect the trusts public and working engagement. N/A No 2

58 Agenda item: Eliminating Mixed Sex Accommodation 1. Purpose It is a statutory requirement to declare and publish our Trust s compliance against the delivery of same sex accommodation standards on an annual basis and to inform commissioners of our compliance status. This paper provides: A summary of our Trust s compliance against the standards Summary of the planned ward actions to ensure we have all the measures in place to demonstrate good practice and robust risk management in relation to the standards A draft Declaration of Compliance for Board consideration and publication on our Trust website 2. Background & Context Cambridgeshire and Peterborough NHS Foundation Trust is committed to a person centred approach to care through the provision of environments that promote and safeguard the privacy and dignity of patients. The Chief Nursing Officer and Deputy NHS Chief Executive require providers to declare by 1 st April 2017 that all hospital accommodation is same sex. The requirement covers sleeping accommodation, bathroom/toilet accommodation and (in mental health and learning disability providers) day rooms/lounges. Providers are required to report breaches relating to sleeping accommodation only to NHS England every month via Unify. The Trust is required to ensure that sleeping areas, toilets and washing areas are designated and clearly identified as either women or men only and provided in: Same sex wards where the whole ward is occupied by men or women only or Mixed sex wards where patients are cared for in single rooms with ensuite washing and toileting facilities or Mixed sex wards where patients are cared for in same sex bays with adjacent same sex toilet and washing facilities (good practice would suggest that bays are entirely enclosed with solid walls with a door that can be shut) used solely by males or females and On mixed sex wards with single or shared bedrooms giving out to one corridor, single bedrooms, toilet and bathing facilities are grouped to achieve as much gender separation as possible (for example, women towards one end of the corridor, men towards the other) and No-one should have to pass through rooms occupied by the opposite sex to reach their toilet and washing facilities near to their bedrooms and bed bays. The exception is toilet facilities used while in day areas where patients are fully dressed. If there are limited facilities for disabled people which need to be used by both men and women, people who may be vulnerable could be escorted by a member of staff and On mixed sex wards good practice requires a day lounge for use by women only (mandatory for services provided in facilities built or refurbished since 2000), as 1

59 well as spaces where men and women can socialise and take part in therapeutic activities together and Every effort is made to ensure the availability of staff who are the same gender as the patients they are caring for, especially for intimate care. In mixed sex mental health and learning disability environments, each ward will provide a clearly signed female only lounge Moreover, in With Safety in Mind: Mental Health Services and Patient Safety. Patient Safety Observatory Report (NPSA, July 2006), findings on sexual assaults within inpatient settings suggested that both women and men are vulnerable, for example men also report unwanted sexual pressure. This comes mainly from other men but occasionally from women. Therefore, it is also very important that staff teams are aware and are vigilant of individual risk issues, whatever the gender make-up of the ward. The CQC in their guide to inspection teams (May, 2015) advise that the provision of gender sensitive care applies to all ages and therefore includes children s and adolescent units; that boys and girls should not share bedrooms or bed bays and that toilet and washing facilities should be same sex. An exception to this might be in the event of a family admission on a children s unit, in which case brothers and sisters may share bedrooms, bathrooms and toilets. 3. Assurance The Eliminating Mixed Sex Accommodation Policy was harmonised in September 2015 to reflect transferred inpatient services from Cambridgeshire Community Services. The Trust policy reflects the MHA Code of Practice (2015), the needs of transgender patients and includes strengthened guidance on how ward staff manage breaches, including reporting and timely escalation to ensure Directorate awareness and Trust oversight. All incident reports relating to breaches of same sex accommodation must have the breach and resulting management plan signed off by the Directorate Heads of Nursing and for Corporate Assurance the Head of Nursing or Deputy Director of Nursing. 4. Methodology As in previous years, the Head of Nursing requested the completion of the Eliminating Mixed Sex Accommodation Checklist by Ward Managers (Appendix 2). Returns were received from all wards. The checklist includes guidance on both definitions and what constitutes acceptable and unacceptable breaches. As part of this assurance, the Head of Nursing contacted wards to confirm/clarify returns and visited a number of units including the assessment, recovery and treatment wards at the Cavell Centre, given that the temporary reconfiguration of adult inpatient beds in December has resulted in 2 of the wards moving from single-sex to mixed sex. Ward Managers were asked to identify any additional actions they would need to undertake to ensure good practice on their wards. 2

60 4. Trust Summary The following summary sets out our overall Trust position by Directorate with all All wards are included Single Sex Ward Total: Springbank & PICU Mixed Sex Wards Total: Adult & Specialist Directorate: Cavell Centre Site : AAU, Treatment Ward, Recovery Ward, Hollies Fulbourn Hospital: Mulberry 1, Mulberry 2, Mulberry 3, George McKenzie House Addenbrooke s Hospital: S3 Older Peoples, Adult & Community Directorate: Peterborough City Care Centre: Intermediate Care Unit Brookfields Hospital: Lord Byron A, Lord Byron B Princess of Wales Hospital, Ely: Welney Ward North Cambs Hospital, Wisbech: Trafford Ward Cavell Centre: Maple Unit Fulbourn Hospital: Denbigh, Willow Children s, Young People & Families: Ida Darwin : Phoenix Centre, Darwin Centre, Croft Breaches There have been no mixed sex breaches reported during 2016/17 Ward Checklist: notable narrative Adult & Specialist Directorate Assessment Unit (Cavell): All bedrooms for both males and females have ensuite shower rooms. The sole bathroom is in the female corridor and therefore use by males is risk assessed and males choosing to have a bath are escorted by staff. There is a female only lounge with signage. A business case is in progress proposing the remodelling of the existing day space to accommodate sufficient interview and MDT space for the high numbers of admissions/discharges and to ensure that MoD patients have access to their own lounge as per contractual requirements. Mulberry 3: All bedrooms are single rooms and the female bedrooms are also ensuite. The only bath on the ward is located in the male corridor and therefore use by females is risk assessed and females choosing to have a bath are escorted by staff. This bathroom is DDA compliant. S3: In the unusual circumstances of male(s) being admitted, the 3

61 patient is either allocated a part of the ward which has a single room with direct access to their toilet/bathroom or to a single bedroom with access to sole use toilet/bathroom across a mixed sex corridor. NHS England have clarified that their interpretation of the MHA Code of Practice regarding this matter is that passing through' would mean passing between beds or across the foot of the bed. So if bays are relatively well enclosed and feel separate from the corridor, this would not constitute a breach. There is a large single sitting room/lounge on S3 and due to the ratio of male to female patients (at most 12 females to 2 males), should a male be admitted, a small room off the main ward area is designated as a male only lounge, to ensure that the designated female only lounge is used as such. Older Peoples, Adults and Community Directorate Lord Byron A: All rooms are single with 2 rooms sharing an integral bathroom which cannot be accessed by patients outside of the bedrooms. These are single sex rooms and are flexed accordingly. The DDA bathroom is accessed by either gender and only with staff escort. A compliance poster for display at the ward entrance is being sourced. Lord Byron B: The ward has 4 side rooms and 3 bed bays with each bed bay having single gender bathroom and toilet facilities close by. A compliance poster for display at the ward entrance is being sourced. Trafford Ward: The ward has 3 bed bays and 5 side rooms (used mostly for infectious or palliative care patients), each bay has access to gender specific toilets/bathrooms. Sliding signage accommodates flexing of the sleeping accommodation. A compliance poster for display at the ward entrance is being sourced. Welney Ward: The ward has six side rooms and 2 gender designated curtained bed bays each with access to single gender toilets/bathrooms. To access the communal dayroom patients and visitors are requested to walk around (as opposed to through) the bays. A compliance poster for display at the ward entrance is being sourced. Maple Unit: Maple 1 has single ensuite bedrooms along 2 gender specific corridors. There is one DDA compliant bathroom with bath for use by both patients needing assisted bathing. Maple 2 also has single ensuite shower rooms though along 1 long corridor, with the male and female rooms separated by double doors. Signage identifying the sleeping areas is in place. Children s Young People & Families Croft : The Croft admits children along with at least one parent and sometimes a pre-school sibling as well. The admission is shared in order that the unit can work with mothers and fathers as well as the 4

62 whole family together. Usually children share a room with their parent, unless a child is older and it would be less appropriate for them to share with their parent of the opposite gender. With the whole family treatment approach adopted on the Croft it is not possible to have male and female designated areas, as then only fathers and sons or mothers and daughters would be able to be admitted or it would exclude certain family set-ups. The Croft advise parents and children about appropriate night attire and have bathrooms that can be allocated as single gender, although they are not permanently single gender as then parents would not be able to bathe their young children if they were not the same gender as them. In their inspection of Trust services in May 2015, the CQC accepted Croft s arrangements. Phoenix Male admissions to the Phoenix are uncommon. In this event the ward has several options to flex beds in order to facilitate access to single sex sleeping, toilet and washing facilities. There is a local risk management protocol in place to support staff decision making. 5. Statement of Compliance The Trust is in a position to declare and publish compliance on this basis. A draft statement for Board Approval is included as Appendix 1 to this report. 6. Monitoring Ward Managers are responsible for ensuring that their staff are aware and have an understanding of mixed sex accommodation guidance, policy and escalation processes and that they take the necessary actions to ensure that patients who are admitted are accommodated safely and with due regard to their privacy and dignity. Ward managers will ensure that with regard to delivering same sex accommodation the allocation of bedrooms ensures that men and women are, as far as is clinically appropriate accommodated in gender specific rooms/bays in clearly designated areas of the ward. Ward/Unit managers will ensure that bathrooms and toilets are appropriately designated with signage that is clear and that patients are orientated to ward facilities. In the Trusts Mental Health and Learning Disability wards, the ward manager will ensure that this area is restricted to single gender and not used for visitors. Data on Same Sex breaches is collected every month as part of our statutory responsibilities of reporting and included in the Trust s and CCGs performance dashboards. The Trust dashboard is reviewed with Directorates at the monthly Performance Review Executive (PRE) with any actions/shared learning being fed back to the Quality, Safety and Governance Committee 5

63 7. Recommended Next Steps The Board is asked to note the contents of this report and approve the draft statement of compliance for 2017/18. The Board is further requested to advise the Trust Communications Team of the need to publish this declaration on the Trust s public website without delay. 6

64 Appendix 1 Statement of Compliance: Eliminating Mixed Sex Accommodation 2017/18 CPFT is pleased to confirm that we are compliant with the Government s requirement to eliminate mixed-sex accommodation. We have the necessary facilities, resources and culture to ensure that patients who are admitted to wards on our sites will either have their own bedroom or only share the room/bay where they sleep with members of the same sex, and same-sex toilets and bathrooms are close to their bed area. If our care should fall short of the required standard, we will report it and act on it. CPFT monitors privacy and dignity through incident reports, through PALS and complaints and through patient experience visits and feedback. We will undertake an annual audit to ensure compliance with this standard, and we will publish our statement of compliance on our website. What does this mean for our patients? Same-sex accommodation means that patients admitted to wards on our sites at CPFT can expect to find the following: The room/bay where your bed is will either be a single room or, if shared, have only patients of the same gender as yourself If you are a transgender patient, you have equal rights to access single sex wards as any other man or woman and therefore should be admitted to a ward in accordance with your preferred gender.you will normally be treated according to your preferred gender, unless there are strong reasons to the contrary which will be discussed with you. Your toilet and bathroom will be just for your gender, and will be close to your bed area It is possible that there will be both males and female patients on the ward and you may have to cross a ward corridor to reach your bathroom, but you will not have to walk through opposite-sex areas You may share some communal living spaces, such as lounges or dining rooms, and it is very likely that you will see both male and female patients as you move around the ward. In mixed gender mental health and learning disability wards a female only lounge is provided in accordance with the Mental Health Act Code of Practice. Unless accompanied by nursing staff, visitors are expected to make use of communal day areas, lounges or other visiting facilities rather than patient bedrooms If you need additional help to use the toilet or take a bath (eg, you need a hoist or special bath) then you may be taken to a unisex bathroom used by both males and females, but a member of staff will be with you, and other patients will not be in the bathroom at the same time. Our commitment to privacy and dignity Every patient has the right to receive high-quality care that is safe, effective and respects their privacy and dignity. CPFT is committed to providing every patient with same-sex accommodation, because it helps to safeguard their privacy and dignity when they are often at their most vulnerable. CPFT also ensures that our staff are supported and trained to understand what privacy and dignity means in practice. How will we measure how we are doing? CPFT undertakes the national annual patient survey for the Care Quality Commission and uses the results of this to inform our service development work. In addition, we undertake our own surveys that include specific questions on same-sex accommodation and privacy 7

65 and dignity issues, and have developed a patient experience system so that patients and carers can give us feedback about privacy and dignity issues and other care issues. This feedback system is available directly to patients pre- or post-discharge, and also available through our website. We also make use of feedback through our PALs and complaints service to improve patient experience. Reports on all patient experience feedback and developments are made to our Quality, Safety and Governance Committee and to the Board, and made available to our commissioners. Privacy and dignity concerns - PALS We want to know about your experiences. Please contact CPFT's Patient Advice and Liaison Service (PALS) if you have any comments or concerns. The contact number is: Freephone T (during office hours) A confidential service is also available at pals@cpft.nhs.uk 8

66 Appendix 2: Eliminating Mixed Sex Accommodation Ward Checklist The following outlines our ward arrangements to ensure we are compliant with the requirement to eliminate mixed sex accommodation within our services and ensure the ward has processes in place to manage potential breaches Ward Name Site Date Criteria Y N Action Required Patients do not share a bedroom with a member of the opposite sex Patients do not share toilets and bathrooms with members of the opposite sex Patients do not need to walk through another patients bedroom to access their own bedroom Patients do not need to walk through another toilet or bathroom to access their own toilet or bathroom Posters Displayed stating compliance with Eliminating Mixed Sex Accommodation guidance Ward plan indicating bedroom allocation displayed in the ward/unit office Signage on Toilets and Bathrooms that are gender designated in pictorial form DDA Toilets/Bathrooms have signage which can show either male or female The ward has a women only lounge with signage (mental health and learning disability units only) There is a process in place for allocating bedrooms for patients Process and documentation in place for risk management in respect of potential mixed sex accommodation breaches Guidance Notes Definitions: 9

67 Same Sex Accommodation is where male and female patients sleep in separate areas and have access to toilets and washing facilities used only by their own sex. Same Sex Accommodation can be provided in single-sex and mixed-sex wards. In a same sex ward, the ward is occupied by either men or women and has its own dedicated toilet and washing facilities In mixed-sex wards, same sex accommodation can be provided either as: single rooms with same-sex toilet and washing facilities and Multi-bed bays or rooms occupied solely by either men or women with their own same-sex toilet and washing facilities. Additionally, patients should not need to pass through mixed communal areas or sleeping areas, toilet or washing facilities used by the opposite gender in order to get to their own facilities Guidance on Breaches Acceptable justification (Not Breach) In the event of a life threatening emergency, either on admission or due to a sudden deterioration in a patient s condition Where a critically ill patient requires constant 1:1 nursing care e.g. in ICU (Within CPFT this would relate to PICU environments) Where a nurse must be physically present in the room/bay at all times (the nurse may have responsibility for more than one patient. This would be unacceptable if staff shortages or skill mix were the rationale Where a short period of close patient observation is needed e.g. immediate postanaesthetic recovery, or where there is a high risk of adverse drug reactions On the joint admission of couples or family groups Unacceptable justification (Breach) Placing a patient in mixed-sex accommodation for the convenience of medical, nursing or other staff, or from a desire to group patients within a clinical specialty Placing a patient in mixed -sex accommodation because of a shortage of staff or poor skill mix Placing a patient in mixed- sex accommodation because of restrictions imposed by old or difficult estate/buildings Placing a patient in mixed-sex accommodation because of a shortage of beds Placing a patient in mixed-sex accommodation because of predictable fluctuations in activity or seasonal pressures Placing a patient in mixed-sex accommodation because of a predictable non-clinical incident e.g. a ward closure Placing or leaving a patient in mixed-sex accommodation whilst waiting for assessment, treatment or a clinical decision Placing a patient in mixed-sex accommodation for regular but not constant observation 10

68 Agenda Item: 8.1 BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Business and Performance Committee Report Date: 29 th March 2017 Author: Julian Baust, Non -Executive Director and Committee Chair Lead Director: Scott Haldane, Director of Finance Executive Summary: Agenda items included: Integrated performance report Finance and CIP report Operational Risk Register (B&P) Business development Capital and Infrastructure System Change Business case reviews: Agile working phase 2 Ida Darwin development George McKenzie Information Governance Review Cycle of Business and Terms of Reference Serco contract update Communications update AOB Recommendations: 1. Note the content of the report 2. Support the continued implementation of the agile working initiative. 3. Support further evaluation of the development options for Ida Darwin excluding Key Worker Housing. 4. Support the proposed building work at GMcK House, cost 354K plus VAT, which is in line with estates strategy and within capital budget. 5. Approve the B&P cycle of Business and Terms of Reference as proposed.

69 Relevant Strategic Goals and Objectives The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person-centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by 2019 Links to BAF Details of additional risks associated with this paper Financial implications / impact Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details Risk no.s: 2179, 2191, 2124, 1745, 1476, 1472, 1479, 1471, 1474, 1475 and 1458 N/A See Finance Report Breach of licence N/A N/A N/A

70 Business & Performance Committee Report 2nd March Purpose The purpose of this report is to highlight issues discussed at the March meeting of the Committee which it is felt should be brought to the Board s attention. 2. Background Sub-Committee of the Board established to review Business and Financial performance and plans for CPFT in line with established Terms of Reference 3. Agenda items reviewed Integrated Performance Report The committee reviewed the exception report which shows improvement and strong performance in a number of areas as detailed. Areas of concern for finance or business include: Agency spend, which continues to run above the target of below 4%. Discussions at PRE, work with TSS and Agency rate negotiations continue. It should be noted that the Trust is showing improvement vs the prior year outturn but we still have a long way to go. The idea of setting up our own Agency persists with the Chair. The Trust has still not received a response from NHSI regarding exclusion from the target of services commissioned on a limited term basis. Some disappointment was expressed by the Exec and the slow impact of TSS rate changes on the recruitment to Bank. Sickness and vacancy rates remain adverse to target with work ongoing to address these areas which impact both patient care and cost. Sickness has been benchmarked vs comparable Trusts who are showing 1% to 1.5% lower rates. Work to understand how they have achieved this is underway with a business case for additional OT and wellbeing resource being prepared. Vacancy rates show significant improvement vs last year s outturn but still have a way to go. Turnover has increased vs last year. Finance Report Ten months into the year the Trust is showing a year to date adverse variance of 31K vs plan. In month 10 the variance was 40K. Other costs were over plan in the month with a number of 'one-offs' plus an ongoing concern around the continued over use of Agency labour. Secondary Commissioning costs are above plan year to date by 0.5M. Cash is ahead of plan with Capital spend below target by 1.0M. Some concerns were raised around Aged Debt, which the Exec are following up.

71 The CIP programme continues ahead of plan by 0.6M year to date. However, there is still a heavy reliance on non-recurring savings as a result of vacancies. Plans are in place to address this. The Exec remain confident that the Trust will deliver on target for the Control Total of a surplus of 1.455M The Use of Resources Metric remains on plan at a 2. More detail was shared with the committee relating to the Executive portfolio s, explaining the variances. For more detail see the Finance Report. Operational Risk Register (B&P) No new or increasing risks were identified. Business Development The main contract negotiations with the CCG and NHSE were completed on time. Negotiations with the CCG regarding LDP have concluded with an 800 reduction in contract value. The IASS unit commissioned by the LDP remains temporarily closed. The MIU Contract Performance Notice has been closed. A proposal to restrict referrals to the Adult CEDS pending resolution of staffing issues has been made to the CCG. The Trust has written to West Essex to withdraw from contracting to provide adult mental health services on safety grounds. An update was given on a number of commercial opportunities including: - Norfolk Community Eating Disorder Service - Perinatal Mother and Baby Unit - Mental Health training for E of E Ambulance Service - Mental Health and Wellbeing provision for C&YP in Cams and Peterborough - Bedfordshire Community Services where we did not get past PQQ - Qatar (consultancy) - Dubai (consultancy) - Malta (consultancy)

72 100% of the Q2 CQUIN payment has been secured, Q3 looks good but Q4 which includes the Flu vaccination is unlikely to be paid. Capital and Infrastructure Minutes from the most recent Capital and Infrastructure Committee were presented and reviewed. Capital spend is now 1.0M below budget at the end of month 10. The Trust expects to finish the year on or below the revised plan. System Change Minutes from the System Change Committee were presented and reviewed. Business Case Reviews - Agile Working Phase 2 o In view of the strategic importance of the roll out of agile working, its positive impact on staff working and its link with the Estates Strategy, the committee agreed the continued roll out within the approved budget. A request was made for an overall assessment to be brought back to B&P as to the ROI and intangible benefits of the programme. - Ida Darwin Development o Overall the opportunity available to the Trust to release and re-use capital through the sale of part of the Ida Darwin site is disappointing. The disappointment comes from the low number of houses able to be built on the site due to planning constraints. The net of selling outright and then building the required accommodation for the Trust is a capital shortfall of 6M. Some rental income may reduce this shortfall but capital will still be required to fill the gap. o Discussion was held around staff housing on the site. Following discussions with staff and considering the complexities of rental to staff it was considered that a package to support staff with independent housing was preferable. o It was agreed that further work needs to be done to evaluate the options of sale and rental mix with intermediate housing, affordable housing or market housing. The evaluation to be brought back to B&P for further discussion. - George McKenzie House o The committee agreed to the proposed works at GM House. The works are desperately needed and fit within the long-term Estates Strategy. The works will be funded within the capital budget and will require final Board approval due to cost.

73 Information Governance The Trust remains on track to deliver a Level 2 satisfactory rating on the Information Governance Toolkit. The level of incorrectly addressed correspondence resulting in a potential confidentiality breach remain a concern. Work is ongoing in this area. Review Cycle of Business and Terms of Reference Pending a number of amendments the cycle and terms were agreed for recommendation to the Board. Serco contract update Contract negotiations continue with a detailed update to be brought back to B&P. Communications update A verbal update was given by the Communications team on the work that is underway in line with the recently developed strategy. The team shared an up-to-date media activity report. AOB The liquidation of Uniting Care has still not been completed which remains a concern.

74 Agenda Item: 8.2. BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Date: 29 th March 2017 Author: Lead Director: Integrated Performance Report February 2017 data Jonathon Artingstall, Head of Information and Performance Scott Haldane, Director of Finance Executive Summary: The CPFT Integrated Performance Report details a wide variety of performance metrics. This paper outlines notable areas of interest for these metrics, as reported in the February 2017 activity and performance data. This paper attempts to provide the Board with insight into reported performance issues and also highlight areas of good performance. Furthermore, the paper aims to offer assurance that where performance problems exist the Trust has plans in place to address and resolve the issues. Key highlights this period include: Continued compliance with all clinical NHS Improvement targets. Strong performance against the existing ASCOF indicators, although limited progress against Care Act measurements. Steady improvements with mandatory training compliance. The data presented in this report was validated at the Performance Risk Executive meetings on the 21 st and 22 nd February Recommendations: The Board of Directors is asked to note the content of this report. 1

75 Relevant Strategic Goals and Objectives (please mark in bold) The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value. Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT. A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by Links to BAF / Corporate Risk Register Details of additional risks associated with this paper (may include CQC Fundamental standards, NHSLA, NHS Constitution) Financial implications / impact Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details Yes, as detailed above. N/A The IPR highlights the Trusts performance figures. Failure to take note of these figures may lead to instances that have a financial impact on the Trust. The IPR highlights the Trusts performance figures. Failure to take note of these figures may lead to instances that have a legal impact on the Trust. The IPR highlights the Trusts performance figures. Failure to take note of these figures may lead to instances that have an impact on the Trust s working and public engagement. None N/A 2

76 Integrated Performance Report 1. Purpose The Integrated Performance Report (IPR) reports a variety of indicators covering both statutory requirements and clinical activity measures, with the aim to offer a review of the performance of the Trust over the last reporting period. This report condenses the output from individual directorate data reviewed at each PRE meetings, and aggregates and consolidates these measures to provide an overall summary of Trust performance. Grouping these measures into seven core areas, this paper accompanies the IPR dashboard to provide some relevant narrative and context to areas of notable CPFT performance. It should be noted that to reduce repetition, elements of the Quality and Safety metrics and the Financial indicators are not repeated in this report; narrative on these measures is provided elsewhere within the Board papers. The data presented and this supporting narrative relate to the period covering February Background As previously outlined, this current version of the integrated performance report is undergoing a review. Following on from the Well Lead Governance review, a series of workshops are scheduled to focus on an enhancement of this reporting output. These enhancements will aim to automate processing of this data via the Trust s data warehouse, review and refine the metrics reported and also to provide greater insight and analysis into the performance of the Trust. Whilst this work continues, the current reporting format will be continued, as below. 3. Areas of Underperformance Analysis and insight into the data from February has highlighted the following issues. 3.1 Diagnosis Whilst progress across all directorates continues for the recording of diagnosis, current performance falls short of the target. Internally, CPFT have specified that 95% of service users active within mental health services should have an ICD10 diagnosis (or Current View overview for children) recorded in the correct place within the Electronic Patient Record (RiO). Performance for February is reported at 80.7% for the Trust. Whilst still under target, Table 1 below shows a comparison of diagnosis rates for adult mental health services by NHS Digital (NHS Information Centre). Note that Children s services are excluded from the analysis, as only ICD10 codes (and not Current View) are reported by NHS Digital this is the reason for the difference in percentages. This analysis, taken from the statutory return of the Mental Health Services Data Set for latest published data (November 2016), shows a benchmark for diagnosis recording across neighbouring trusts and the national average. 3

77 PRIMARY_LEVEL_DESCRIPTION AMH01 - People in contact with adult mental health services MHS20 - People in contact with services with a diagnosis recorded % Diagnosis England Average % Cambridgeshire and Peterborough NHS FT % Hertfordshire Partnership University NHS FT % South Essex Partnership University NHS FT % North Essex Partnership University NHS FT % Norfolk And Suffolk NHS FT % Lincolnshire Partnership NHS FT % Table 1. MHSDS Nov-16 Final Submission; Diagnosis comparison against local mental health trusts. Source: Nationally, and excluding providers of less than 500 service users, CPFT are the 7 th best performing trust for diagnosis recording with the country. This context hopefully assures our performance against our internal target. 3.2 CAMHS Waiting List developments February s Integrated Performance Report indicates a breach on CAMHS Choice Waiting List target. After 10 months of compliance, one child is reported in February as having waited over 18 weeks. At the time of writing this child has now been assessment by the CAMHS service, having had a series of previous scheduled appointments moved at the request of the service user. The CAMHS Choice Waiting List profile has returned to under 18 week compliance, as demonstrated in Table 2 below. Also, actual waited times for assessment continues to show improvements, with the average time in February for waiting just over 7 weeks from referral to assessment. Table 2. CAMHS Choice Waiting List as of 13 th March Source: Mi Reports via CPFT data warehouse. Through the PRE meeting held on the 22 nd March, further issues were discussed about the Speech and Language Therapy waiting time within Children s services. Data on 378 waiters reported at the end of February was significantly different to the latest picture; a verbal update will be provided to the Board. 3.3 Care Act compliance This is a Trust Key Performance Indicator (KPI) introduced to monitor the presence of, and our engagement with, carers, recorded on our electronic care record systems. It is used to substantiate the Trust s initiative and efforts towards achieving the five outcomes that are set out in the National Carers Strategy published in 2008 and embedded in the Care Act The metric construct shows the proportion of our active caseload at month end who have a carer recorded in RiO (either through a Personal Contact with type = Carer or with relationship = Carer ), and of those, how many Carer Details forms are completed. 4

78 Whilst this indicator is currently used for internal mechanisms only, it is envisaged that this KPI will be included in the forthcoming revision of the Section 75 reporting requirements with the Local Authorities. As such, the PRE cycle focussed on the need to progress this performance. Detailed, patient level reports have been made available to all adult clinical services, with an expectation to significantly increase performance from April. 3.4 Mandatory Training compliance Mandatory training compliance for both core modules and also mandatory for role remain below internal targets. Whilst progress improves for core modules (up to 92.7% for up to 17 vocation specific modules), mandatory training for role has dropped slightly to 71.3%. Through the PRE cycle, mitigating circumstances have been raised. Firstly, some questions were raised about the accuracy of the source data and timing around updates to this data that may affect the denominator used. This issue is being investigated within the L&D department. Secondly, hotspots in the compliance around certain courses point to a shortage of some classroom based training courses. Furthermore, the time taken for some mandatory training courses (e.g. 5 days for CCC Safeguarding Children Training) are proving difficult to release staff for, whilst maintaining safe services. Particular focus next month will be on Good Governance training, due to the impact on the 95% target for the IG Toolkit submission on the 31 st March. Current performance is 93.8%, with a concerted push on the colleagues whose training is missing or, more commonly, expired. 3.5 Other indicators A number of other indicators are below target for this month. These measures (Food, SI reporting timeliness, Pressure Ulcers, Safety Thermometer) are described in the Quality report section, as are details of our Financial performance. 4. Areas of Strong Performance For the month of February, the following clinical metrics are demonstrating positive performance. 4.1 CHRT Gatekeeping Performance against this NHS Improvement indicator is reported at 100% for February; this is the fifth month out of the last six where performance has been at this level. This measure suggests that the Trust has robust processes for monitoring the appropriate use of inpatient beds. 4.2 CPA Seven Day Followup Following a difficult month in December, where compliance rates were below the 95% target, performance on this NHS Improvement suicide prevention measure has returned positive. A review following December had identified a change in monitoring processes, which when implemented in January and February have had a significant impact. This improved use of data is expected to continue to produce compliance over the coming months. Two short term patients with the Assessment and Advice Unit are the only breaches reported in February. Records show that each patient had multiple attempted contact following discharge, on each day since discharge, but all attempts were unsuccessful. Contact is still being attempted, through mobile telephones, friends and neighbours, and the GP for each patient. 4.3 ASCOF Indicators Performance against Employment and Settle Accommodation measures continue to produce positive results. Both measures, looking at a cohort of service users aged and on the Care Program Approach, continue to exceed national averages by some considerable way. The nationally produced Five Year Forward View Mental Health dashboard suggests a change in the definition of this metric is imminent, with a removal of the need for CPA patients only. Local reporting is being arranged to replicate this definition change, in preparation for national guidance. 5

79 4.4 Patients with a Cluster Score The Trust report a fourth month of positive results against target for active patients with a Mental Health Tool Clustering score (95.6%). Whilst discussions at national level continue regarding the implementation of Mental Health Payment by Results, this data is still useful for our annual Reference Costs submission in June and also an emerging piece of work on routine outcomes measurements. Led by the Clinical Effectiveness and Evaluation Group, the clustering of our caseload provides an assessment via the HoNOS (Health of the Nation Outcome Scales) tool, which can be used to investigate outcomes. Figure 1 below shows an example of the analysis that is possible. This data, which is still in development, measures paired assessments for each patient, looking at the assessment at referral and at discharge. The difference between these measures can be used to show improvement in outcomes, with a reduction representative of improving outcomes. HoNOS Four Factor Model Figure 1. Four Factor Model using HoNOS; sample 5423 pairs, lower better. Source: CPFT Data warehouse It is hoped that this data will be validated through feedback to clinical services, and then shared more widely in the coming months. 4.6 IG Toolkit As predicted, work on the CPFT IG Toolkit has enhanced the content of our submission. Compliance is now reported as Level 2, with an 81% total. This is unlikely to change significantly before the submission date of the 31 st March. 5. Board Action The Board of Directors is asked to note the contents of this report. 6

80 Dashboard: Integrated Performance Report Organisational level: Trust Reporting Period: February 2017 Reviewing committee/meeting: Business and Performance & Quality, Safety & Governance Review lead: Sarah Warner, Chief Operating Officer Next Review Date: 1st April 2017 YTD Agenda Item: Indicators Quality- Clinical Effectiveness Indicators Trust Board QSG B & P Target Owner Owner Director Source Info. Assurance Metric Outturn Mar 16 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Target CRHT Gate Keeping NHS I. SW SW % 97.9% 99.0% 100.0% 100.0% 100.0% 96.8% 98.9% 100.0% 98.9% 100.0% 100.0% 100.0% 100.0% >95% 99.4% Yr % Delayed Transfers of Care Mental Health NHS I. SW SW % 2.6% 4.3% 4.2% 5.0% 3.6% 3.7% 2.7% 2.3% 2.6% 1.9% 1.4% 1.3% 2.7% <7.5% 2.9% Yr % Delayed Transfers of Care Community Services Trust SW SW 13.3% 17.3% 14.3% 17.8% 13.5% 20.6% 24.4% 23.0% 24.3% 21.0% 15.3% 18.7% Delayed Service Discharge (Referrals no contact or progress notes (from Apr 16) in 7 months) Trust SW SW % TBA 274 Mth EIP Access Target - % waiting < 2 weeks (from April 2016) Monitor SW SW 50.0% 78.6% 61.5% 75.0% 70.8% 80.0% 80.0% 93.8% 73.3% 81.0% 70.6% 50% 75.5% 18 Weeks (PCC only) Trust SW SW % 100.0% 100.0% 100.0% 100.0% 100.0% 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% =>95% 99.6% Mth CAMHS Choice Waiting List >18 weeks CCG SW SW %,n 0.7% 0.68% (1) % (1) 0% 0.5% (1) Mth % Patients with a Cluster Score Trust CD CD % 95.3% 95.3% 88.1% 89.7% 89.1% 90.1% 95.0% 95.2% 94.5% 95.3% 95.7% 95.3% 95.6% =>95% 95.6% Mth % Patients with a Cluster within Cluster Review Period Trust CD CD % 78.1% 78.1% 69.2% 72.9% 72.8% 73.7% 77.4% 74.6% 71.5% 70.9% 70.4% 69.4% 69.3% =>95% 69.3% Mth Diagnosis recorded (% of Current referrals where Diagnosis recorded) Trust CD CD % 60.3% 60.3% 66.4% 69.8% 71.7% 72.2% 74.9% 76.3% 76.1% 77.0% 80.3% 81.0% 80.7% =>95% 80.7% Mth Psychological Wellbeing Service (PWS - previously known as IAPT) - Number of referrals CCG SW SW JC No Psychological Wellbeing Service (PWS - previously known as IAPT) patients entering treatment CCG SW SW JC No ASCOF(1E) Proportion in Employment (18-69, CPA) NHS I. AM AM % 13.27% 13.27% 12.24% 12.72% 12.97% 11.06% 10.91% 11.40% 11.60% 11.60% 11.50% 12.00% 11.30% 4.5% 11.30% Mth ASCOF(1F) Proportion in Settled Accommodation (18-69, CPA) NHS I. AM AM % 78.45% 78.45% 77.55% 76.95% 77.28% 77.95% 78.96% 78.80% 79.50% 78.70% 80.20% 81.20% 80.60% 75.0% 80.60% Mth Care Act - % Carers recorded Trust EY % 6.73% 6.74% 7.24% 8.01% 8.14% >=60% 8.14% Mth 1075 per month 1075 per month YTD Actual Year End Fcst Monitor Mth target change 1000 to 1075 in Oct Mth target change 1000 to 1075 in Oct-16 Quality- Patient Experience indicators Access to Health care for people with LD NHS I. SW SW Met Met Met Met Met Met Met Met Met Met Met Met Met Met Met Mth Number of New Complaints registered in period Trust MC MC AN No TBA 151 Mth Patient food Trust MC MC % 63.7% 71.7% 54.0% 67.4% 63.3% 72.4% 76.4% 74.4% 69.1% 74.4% 65.0% 67.2% 71.3% 75.0% 70.1% Mth Patient Experience - Friends and Family Question (% that would Recommend trust) Trust MC MC % 88.3% 92.0% 91.6% 91.3% 92.8% 93.0% 93.1% 91.2% 91.7% 93.2% 95.1% 94.4% 92.6% >60% 92.9% Mth Mixed Sex Breaches (Number of effected people) DoH MC MC JD No Mth % INCA Score Trust MC MC % 96.1% 96.1% 97.7% 97.9% 99.3% 98.0% 98.6% 99.0% 97.1% 99.0% 97.9% 97.0% 95.9% >95% 98.0% Mth Quality- Patient Safety indicators Number of Serious Incidents Recorded Trust MC MC AN No TBA 84 Mth Trust wide % Serious Incidents (reported to CCG) resolved within National timescales (Grade 2-60 days) Trust MC MC AN No 75.0% 75.0% 83.3% 91.0% 87.5% 85.7% 87.5% 90.0% 100.0% 100.0% 100.0% 100.0% 75.0% 100.0% 89.7% Mth CPA 7 Day Follow Up NHS I. CD CD % 96.2% 96.0% 93.1% 95.2% 98.2% 94.9% 95.0% 95.4% 96.1% 97.8% 92.6% 99.0% 97.9% >95% 96.0% Mth Service User CPA review 12 months NHS I. CD CD % 96.1% 96.1% 94.7% 95.7% 96.6% 97.1% 97.4% 96.8% 96.0% 95.4% 95.3% 95.0% 95.0% >95% 95.0% Mth % of Inpatient with a Risk Assessment Trust CD CD % 97.1% 98.1% 98.0% 98.6% 98.4% 96.4% 97.2% 97.0% 98.2% 98.6% 98.6% 99.4% 99.2% >95% 98.2% Mth % of Inpatients Physical Health check within 24 hrs admissions Trust CD CD % 91.9% 99.4% 97.7% 96.9% 97.4% 95.2% 95.1% 96.2% 98.5% 92.7% 92.7% 97.9% 96.2% >95% 95.2% Mth Staff trained in Children Safeguarding CCG SL SL RV % 94.9% 94.9% 95.8% 95.1% 95.0% 91.8% 91.0% 90.7% 90.7% 90.8% 90.7% 89.4% 90.0% >90% 90.0% Mth Staff trained in Adults Safeguarding CCG SL SL RV % 96.3% 96.3% 96.2% 96.7% 96.5% 96.6% 95.9% 96.7% 97.1% 97.1% 97.1% 97.1% 97.3% >90% 97.3% Mth Safety thermometer CCG MC MC JD % 93.7% 93.5% 94.1% 91.6% 91.0% 92.6% 92.5% 92.9% 93.0% 92.4% 92.7% 90.7% 91.0% >95% 92.2% Mth Never events Trust MC MC AN No Mth Coroner Schedule 5 Notices Trust MC MC AN No TBA 0 Mth Number of new legal claims Trust MC MC AN No TBA 15 Mth Avoidable Grade 3/4 Pressure Ulcers Trust MC MC LG No TBA 13 Mth MRSA Bacteraemia, confirmed case attributable to the Trust CCG MC MC Ns No Yr Clostridium difficile, confirmed case attributable to the Trust NHS I. MC MC NS No Yr HCAI Essential Steps Trust MC MC NS % 99.3% 100.0% 100.0% 100.0% 95.7% 100.0% 100.0% 95.7% 100.0% 100.0% 95.7% 100.0% 100.0% 100.0% 98.8% Mth Safe Staffing Levels (Registered and Unregistered) Trust MC MC RV Ratio 106.0% 106.0% 107.0% 107.0% 108.0% 108.0% 106.0% 102.0% 104.0% 104.0% 103.0% 105.0% 105.7% 80.0% 105.7% Mth Safe Staffing Levels (Registered) Trust MC MC RV Ratio 100.0% 100.0% 99.0% 98.0% 99.0% 99.0% 94.0% 92.0% 95.0% 97.0% 95.0% 98.0% 98.5% 80.0% 98.5% Mth Safe Staffing Levels (Unregistered) Trust MC MC RV Ratio 111.0% 111.0% 114.0% 116.0% 116.0% 116.0% 118.0% 112.0% 112.0% 112.0% 111.0% 112.0% 112.1% 80.0% 112.1% Mth CAS Safety Alerts Implemented Within Required Timescale Trust MC MC CM % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Qtr % Vacancy Rate Trust SL SL SD % 12.2% 12.2% 14.0% 14.9% 14.8% 11.5% 12.3% 11.8% 8.7% 6.5% 6.8% 8.7% 9.0% <5% 9.0% Mth % Sickness Rate Trust SL SL AF % 5.1% 5.5% 4.9% 4.9% 4.9% 4.6% 4.3% 4.6% 4.9% 5.1% 5.3% 5.4% 5.1% <4.35% 4.9% Mth % Spend Temporary Staffing- Agency Trust SL SL DM % 8.8% 8.8% 7.8% 6.5% 7.0% 7.1% 6.8% 6.8% 6.8% 6.8% 6.8% 6.9% 6.7% <=4% 6.7% Mth % Spend Temporary Staffing- Bank Trust SL SL DM % 2.4% 2.4% 3.6% 2.9% 2.9% 2.9% 3.4% 3.3% 3.4% 3.3% 3.4% 3.4% 3.4% <=4.6% 3.4% Mth % Compliance Overall Mandatory Training (core modules) Trust SL SL RV % 94.05% 94.05% 94.1% 94.0% 93.2% 89.5% 90.0% 91.4% 92.2% 92.5% 92.5% 92.2% 92.7% =>95% 92.7% Mth % Compliance - Mandatory Training for Role Trust SL SL RV % 66.6% 66.7% 66.7% 67.4% 67.9% 69.1% 71.4% 71.3% =>95% 71.3% Mth

81 Workforce Indicators Staff Net Promoter Score (recommend Trust to Friends and Family as a place to work) reported Quarterly Trust SL SL AF % 53.1% 53.1% Quarterly Figure 54.1% Quarterly Figure 55.8% Quarterly Figure 56.2% Quarterly Figure >60% 56.2% Mth Staff Net Promoter Score (recommend Trust to Care for Friends and Family ) reported Quarterly Trust SL SL AF % 68.1% 68.1% Quarterly Figure 69.5% Quarterly Figure 70.6% Quarterly Figure 68.1% Quarterly Figure >60% 68.1% Mth Cumulative turnover rate (12 month rolling) Trust SL SL AF % 13.9% 13.9% 14.2% 14.9% 15.0% 15.0% 14.7% 15.0% 14.7% 14.8% 14.6% 15.0% 14.9% < % Mth Average Number of Weeks to fill a vacancy (in Weeks) Trust SL SL SD No < Mth Financial- income and expenditure related Financial Efficiency - Deficit (Cumulative) NHS I. SH SH DM % 3748k 3748k 148k 160k 190k 237k 284k 338K 482k 596k 848k 1,001k 1,248k -1.6% 1,248k Mth Financial Efficiency - Adverse variance (position against where we expected to be) NHS I. SH SH DM % 3748k 3748k 72k 7k 7k 3K 2k 67K 25k 46k 9k 31k 4k -1.6% 4k Mth Cash position versus plan Trust SH SH DM % 97.7% 97.7% 125.0% 120.1% 130.9% 121.7% 119.5% 169.0% 162.8% 177.0% 154.6% 136.8% 139.2% =>90% =< 110% 139.2% YTD Capital Spend v plan ratings Trust SH SH DM % 70.4% 70.4% 24.6% 37.8% 40.1% 42.1% 48.9% 56.8% 65.3% 58.7% 68.7% 73.6% 55.0% <100% 55.0% YTD SERCO Contract Compliance with KPI's (SERCO dependant) Trust SH SH DM % DNP DNP DNP DNP DNP DNP DNP DNP DNP DNP DNP DNP DNP =>95% DNP Mth External Assessment Indicators FT Monitor- Financial Risk Rating (Continuity of Service- new) NHS I. SH SH DM No >=3 3 Mth Use of Resources - (New measure replaces measure above - rating 1-4, low is better) NHS I. SH SH DM No <=2 2 Mth FT Monitor- Governance Risk Rating NHS I. MC MC AP Green Green Green Green Green Green Green Green Green Green Green Green Green Green Mth FT Delivery of FT membership NHS I. NBJ NBJ NS on Target on Target on Target on Target on Target on Target on Target on Target on Target on Target on Target on Target on Target Met on Target Mth Information Assurance Data completeness: identifies MHSDS (Exc CAMHs) NHS I. SW SW % 99.2% 99.2% 99.1% 98.9% 99.1% 99.0% 99.3% 99.3% 99.3% 99.3% 99.2% 99.3% 99.3% >97% 99.3% Mth Data completeness MHSDS: Outcomes for Pts on CPA NHS I. SW SW % 87.7% 90.8% 87.6% 88.9% 89.8% 90.5% 91.9% 93.4% 93.8% 94.8% 95.3% 95.1% 94.8% >50% 94.8% Mth Compliance with IGT v14 (starts in June at 1 working to attain 2+ going forward) CQC SH SH KT % 2 2 (82%) N/A 1 (60%) 1 (60%) 1 (63%) 1 (63%) 1 (63%) 1 (63%) 1 (63%) 1 (68%) 2 (81%) 2 (81%) =>2 2 (81%) Mth Aidan Thomas Scott Haldane Chess Denman Deborah Cohen Keith Spencer Melanie Coombes Nicola Brookes-Jones Jonathon Artingstall Sarah Warner Stephen Legood Elaine Young AT SH CD DC KS MC NBJ JA SW SL EY Data Source Sanitised Data warehouse RiO SystmOne Legacy reporting From CPFT Manager/staff Other Source DNP = data not provided PI = Proposed KPI Information assurance Indicator has been audited within required cycle no issues found Indicator has been audited within required cycle - minor issues found that do not impact confidence in KPI Indicator has been audited within required cycle - significant issues found that do impact confidence in KPI Indicator to be audited. YTD figures in italics based on mean per month.

82 Agenda Item: 8.3 BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Summary Finance Report Month 11 Date: 29 th March 2017 Author: Lead Director: Derek McNally, Deputy Director of Finance Scott Haldane, Director of Finance Executive Summary: The attached report is a Summary Finance Report for Month 11. This highlights the following:- Month 11 surplus of 0.247m against a planned surplus of 0.212m. The Year to Date performance is 3k ahead of plan, with a 1.248m surplus against a planned surplus of 1.245m. Forecast outturn is to deliver Control Total target of 1.445m surplus. CIP performance in the month is 0.581m against the plan of 0.530m. The over performance in month improves the Year to Date delivery to 6.547m against a plan of 5.825m. Use of Resources Metric for the month is a 2, against a planned 2. Cash balance above plan at the end of the month. Recommendations: Trust Board is asked to note the Summary Finance Report for Month 11. A more detailed Finance Report is provided to members of the Business and Performance Committee on a monthly basis. 1

83 Relevant Strategic Goals and Objectives (please mark in bold) The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value. Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT. A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by Links to BAF / Corporate Risk Register Details of additional risks associated with this paper (may include CQC Fundamental standards, NHSLA, NHS Constitution) Financial implications / impact Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details As detailed above. N/A Report on progress against financial plan for FY17 N/A N/A N/A N/A 2

84 Summary Finance Report to 28 February 2017 (Month 11)

85 Summary Finance Report to 28 February 2017 Contents: Executive Summary Appendix 1 Use of Resources Metric Appendix 2 Directorate Report Appendix 3 Cost Improvement Programme Scott Haldane Director of Finance Corporate services Finance Report M11 2

86 Executive Summary Summary of Performance At the end of period 11, the Trust is reporting a net surplus of 1.248m, against a planned surplus of 1.245m. This financial performance generates a performance of 2 against NHS Improvement s (NHSI) Use of Resources Metric. The forecast outturn is to deliver the Trust s Control Total of 1.445m surplus. Key I&E issues: Income above plan in month 11 by 0.131m. Shortfall in year to date of 0.269m, mainly from cost dependent services. Operating Expenditure pay costs are 0.033m below plan in the period. Agency costs continue at a level greater than the Agency cap set by NHSI. Non-pay costs are overspent by 0.143m in month, which includes costs transferred from the Capital Plan in the period. Key Directorate issues: Clinical underspend in month 11 of 0.120m. Main contributor is the continuing level of vacancies in a range of services. See Appendix 2 for detailed analysis. Corporate underspend of in month 11. Again, see Appendix 2 for detailed analysis. Key Balance Sheet issues: Capex in-month capital expenditure is significantly below plan in month as costs previously capitalised were transferred to revenue in month. The year-to-date underspend in capital is 1.9m. Cash actual cash held at the end of month 11 is 4.0m above plan due to the capital underspend, the retention of part of the PFI unitary charge in response to the Fire remedial issues at the Cavell centre, and the System Transformation Funding. Use of Resources Metric: Performance against the Use of Resources Metric is a 2 for the period against a planned 2. Corporate services Finance Report M11 CIP: Over-delivery of 51k in month 11 bringing YTD performance to 722k above plan for further information please see Appendix 3. Progress has been made on identifying further recurrent schemes to reduce the reliance on non-recurrent mitigating savings. Key Risks and Actions: Income Continuing action to improve recovery against Variable Income targets. Expenditure continue to focus reduction in Agency expenditure. CIP further work to deliver recurring savings and address unidentified gap. Summary Key Financial Performance Indicators Month 11 Month 11 & Year to date Plan Actual Variance Favourable / (Adverse) Plan to Date Year to Date Actual to Date m m m m m m Income (0.269) Operating Expenditure (15.686) (15.796) (0.110) ( ) ( ) EBITDA (0.114) Financing (0.720) (0.707) (7.804) (7.686) Net Surplus/(deficit) EBITDA % 5.61% 5.69% 0.09% 5.00% 4.94% -0.06% I&E Surplus Margin % 1.27% 1.47% 0.20% 0.69% 0.69% 0.00% Agency Spend (0.422) (0.664) (0.242) (6.982) (8.529) (1.547) Agency Spend % 3.6% 5.7% -2.1% 5.5% 6.7% -1.3% Capex (0.329) (4.234) (2.327) Cash and Cash Equivalents Cost Improvement Programme Use of Resources 2 2 A detailed Finance Report is provided to members of the Business and Performance Committee on a monthly basis. Variance Favourable / (Adverse) 3

87 Appendix 1 Use of Resources Metric (UoR) The Single Oversight Framework published by NHSI in September replaced the Financial Sustainability Risk Rating (FSRR) with a new Use of Resources Metric. This builds upon the FSRR by including performance against the Agency Cap in the overall rating. The scoring has also been revised with a range from 1 to 4 with 1 being the best performance. The metrics and associated weightings are highlighted in Table 1, with the Trust s performance at Month 11 highlighted in Table 2. Table 1: Finance and use of resources metrics Table 2: CPFT Performance at Month 11 Use Of Resource Metric for CPFT units sense Plan YTD ending 28-Feb-17 Actual YTD ending 28-Feb-17 Capital Service Cover Capital service metric from UOR calc 0.0x Capital service rating Rating 2 2 Liquidity Liquidity metric from UOR calc m (9.542) (8.870) Liquidity rating Rating 3 3 I&E Margin I&E Margin metric from UOR calc % 0.70% 0.69% I&E Margin rating Rating 2 2 I&E Variance From Plan I&E Variance from plan metric from UOR calc % (0.01%) I&E Variance from plan rating Rating 2 Extract from Single Oversight Framework The overall finance and use of resources score is a mean average of the scores of the individual metrics under this theme, subject to any support needs being identified in value for money except that: - if a provider scores 4 on any individual finance and use of resources metric, their overall use of resources score is at least a 3 i.e. cannot be a 1 or 2 triggering a potential support need - if a provider has not agreed a control total, then where they are planning a deficit their use of resources score will be at least 3 (i.e. it will be 3 or 4). Where they are planning a surplus their use of resources score will be at least 2 (i.e. it will be 2, 3 or 4). As we continue to develop a shared approach to use of resources with CQC we may seek to revise the finance and use of resources metrics used in the Single Oversight Framework. If we do so, we will consult as needed. Agency Agency metric from UOR calc % 6.92% 30.79% Agency rating Rating 2 3 Use Of Resources Rating Overall rating unrounded Rating 2.40 If unrounded score ends in 0.5 Rating - Rounded score Rating 2 Use Of Resources Rating before overrides Rating 2 4 Rating Trigger for Use Of Resources Rating Text NO TRIGGER Use Of Resources Rating after 4 rating override Rating 2 Control total override - Control total accepted Text i Yes Control total override - Planned or Forecast deficit Text Control total override - Maximum score Rating Is the provider in Financial Special Measures? Text i No Use Of Resources Rating after overrides Rating 2 Corporate services Finance Report M11 Rating at Month 11 is a 2 4

88 Appendix 2 - Directorate Analysis Month 11 YTD Month 11 In-Month Variations Directorate / Service Annual Plan Plan Actual Variance Favourable / (Adverse) Plan to Date Actual to Date Variance Favourable / (Adverse) The Clinical Directorates are reporting a 120k positive variance in-month against plan, with a 912k positive variance YTD: m m m m % m m m % Clinical Directorates Adult and Specialist Mental Health (38.012) (3.243) (3.099) % (34.776) (33.990) % Children, Young People and Families (12.738) (1.109) (1.097) % (11.640) (11.376) % Older People's and Adult Community (59.631) (4.872) (4.907) (0.034) (0.7%) (54.740) (54.879) (0.139) (0.3%) Total Clinical Directorates ( ) (9.224) (9.103) % ( ) ( ) % Executive Portfolios Chief Executive Office (1.237) (0.107) (0.099) % (1.129) (1.313) (0.183) (16.2%) Chief Operating Officer (0.591) (0.061) (0.054) % (0.530) (0.717) (0.187) (35.2%) Director of Finance (30.770) (2.562) (2.268) % (28.200) (28.888) (0.688) (2.4%) Director of Nursing (2.438) (0.157) (0.132) % (2.282) (2.347) (0.065) (2.9%) Director of People Services (4.785) (0.397) (0.393) % (4.389) (4.263) % Medical Director (1.840) (0.153) (0.187) (0.034) (22.0%) (1.686) (1.844) (0.157) (9.3%) Social Care & Integration (0.723) (0.060) (0.070) (0.010) (16.3%) (0.663) (0.666) (0.003) (0.5%) Total Executive Portfolios (42.385) (3.497) (3.203) % (38.879) (40.036) (1.158) (3.0%) Trust Financing (0.006) (6.5%) (0.064) (6.0%) Research & Development (0.159) (0.012) (0.011) (6.1%) (0.147) (0.149) (0.002) 1.4% Reserves (0.620) (0.045) (0.000) (99.6%) (0.586) (108.4%) CIP Risk Reserve (0.800) (0.067) (100.0%) (0.733) (100.0%) Total Net Expenditure ( ) (12.749) (12.228) % ( ) ( ) % Block Contract Income (0.486) (3.7%) (1.054) (0.7%) Net Surplus / (Deficit) Adult & Specialist Mental Health has an underspend of 143k in-month. There are continuing vacancies across a range of services, particularly within the community teams and Psychological Wellbeing Service, and an overspend of 61k in the month on OATs. - Children, Young People and Families has an 11k underspend in Month 11, mainly driven by the level of vacancies across the services. Continuing Agency Medical costs and increased occupancy charges are also reflected in the position. - Older People s and Adult Community has an overspend of 34k in month. Continuing savings from Neighbourhood Teams and Long-Term Condition services have offset cost pressures from temporary staffing spend on Locum Medical Consultants and additional equipment costs in the month. The Executive Portfolios are reporting an underspend of 294k in the month. The underspend in the Finance Director portfolio includes the benefit from the Serco gain-share and the reduction in accruals for property costs being recharged for AOP premises. The Block Contract Income includes a provision for underperformance in the NHSE contract and for CQUIN under-recovery in the CCG contract. 5

89 Appendix 3 Cost Improvement Plan Analysis Month 11 Plan Identified Schemes (% of Plan) In-month 530k 498k 94% YTD 5.825m 5.164m 89% Achieved Recurrently (% of Plan) 329k 62% 2.955m 51% Achieved non recurrently (% of Plan) 252k 48% 3.592m 62% Total Achieved (% of Plan) 581k 110% 6.547m 113% Variance against plan (% of Plan) 51k 10% 722k 13% Month 11 delivery is above plan, bringing the YTD delivery to 722k ahead of plan. A review of schemes put forward for 2017/18 has identified a number of schemes that can be implemented early, helping to reduce the reliance on non-recurrent CIPs in the year. The YTD recurrent delivery has increased from 38% in Month 8 to 51% in Month 11. The shortfall in the full-year effect of recurring delivery is estimated at 15% and the Directorates are looking to address this over the remaining months of the year to ensure the c/f into FY18 is as low as possible. The table below shows the analysis of performance by Directorate and also type of Scheme. The target columns relate to the overall CIP target required to be delivered, and the planned columns show the value of recurrent schemes currently identified to deliver this target. The difference between these is the unidentified balance, for which work continues to identify plans to deliver. CIP REPORT Month 11 FY17 Scheme Plans by Directorate Annual Savings Target Value Annual Plans Identified Unidentified Balance Target Savings M11 Planned Savings M11 Actual savings M11 Recurrent Actual savings M11 Non Recurrent Variance M11 Target Savings YTD Planned Savings YTD Actual savings YTD Recurrent Actual savings YTD Non Recurrent Total Delivery YTD Variance YTD Adult & Specialist 2,055 1, ,884 1, ,452 2, Integrated Care 1,854 1, ,700 1, , Childrens Executive 2,440 2, ,237 2, ,144 1, CIP Risk Reserve TOTAL 6,355 5, ,825 5,164 2,955 3,592 6, Scheme Annual Savings Target Value Annual Plans Identified Unidentified Balance Target Savings M11 Planned Savings M11 Actual savings M11 Total Variance M11 Target Savings YTD Planned Savings YTD Actual savings YTD Variance YTD Plans by Type Workforce 2,755 2, ,525 2,228 1,513-1,012 Non Pay 3,000 2, ,750 2, ,992 Income Generation Business Development Non Recurrent delivery ,592 3,592 TOTAL 6,355 5, ,825 5,164 6,

90 Agenda Item: 8.4 BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Annual Certificate of Fire Compliance Date: 29th March 2017 Author: Alison Manton, Associate Director of Estates Lead Director: Scott Haldane, Director of Finance Executive Summary: The Trust Board needs to be assured that the estate is safe. Part of this assurance involves noting the Annual Statement of Fire Compliance. This is attached and confirms that: The organisation has developed a programme of work to eliminate or reduce as low as reasonably practicable the significant fire risks identified by the fire risk assessment The Board can also note that compliance reports for all areas of statutory compliance have been shared routinely at the Business and Performance Sub Committee of the Board. Recommendations: The Board is asked to note the Annual Statement of Fire Compliance attached. 1

91 Relevant Strategic Goals and Objectives The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by 2019 Links to BAF / Corporate Risk Register Details of additional risks associated with this paper (may include CQC Fundamental standards, NHSLA, NHS Constitution) Financial implications / impact Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details Safe and compliant estate N/A N/A N/A N/A Compliance is reported to B&P N/A 2

92

93

94 Agenda Item: 9 BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Revenue and Capital Budget FY18 Date: 29 th March 2017 Author: Louisa Ellington, Assistant Director of Finance Lead Director: Scott Haldane, Director of Finance Executive Summary: The Trust Board approved the Revenue Budget for FY18 at the January Meeting, based on the Financial Plan submitted to NHS Improvement in December There are no changes proposed to the Financial Plan at this stage, so the Revenue Budget remains as is. This paper provides further detail on the Trust s Capital Plan for FY18. The Capital Plan has been developed by Estates and IT Leads, with support from Finance and has been reviewed at the Trust s Capital and Infrastructure Committee. The Capital Plan addresses a range of key improvement areas across the Trust and is in accordance with the Estates and IT Strategies previously approved by the Trust Board. The Plan total is 5.29m, and will be funded from internally generated funds. Recommendations: The Board is asked to note there are no changes to the Revenue Budget at this stage, and to approve the Capital Plan for FY18. 1

95 Relevant Strategic Goals and Objectives (please mark in bold) The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by 2019 N/A Links to BAF / Corporate Risk Register Details of additional risks associated with this paper (may include CQC Fundamental standards, NHSLA, NHS Constitution) Financial implications / impact Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details N/A This paper outlines the Trust s Capital Plan for 2017/18 N/A N/A N/A N/A 2

96 Capital Plan 2017/18 1. Executive Summary The purpose of this summary is to outline the process that has been taken to formulate the Capital plan for 2017/18 (FY18) and to propose the capital budget to the Board for approval. As part of the formulation of this plan, the outline Capital plan for and have also been considered to ensure the schemes presented for FY18 are the Trust s key priorities in year 1. The FY18 plan does not currently reflect any of the Ida Darwin sale proceeds as the timing is still uncertain. The Capital plan is currently proposed at 5.29m for FY18 and will be funded by internally generated resources, predominantly depreciation but also planned asset disposals and a small cash contribution. The Trust intends to pursue the further disposal of several of its owned buildings over the next three years and if any of these come to fruition in year then these proceeds will either be used to fund any unforeseen pressures in the plan or will be used to improve the liquidity of the Trust, which in turn will fund future years capital requirements. 2. Introduction The proposed Capital Investment plan for FY18 has been developed by the CPFT Estates and Business Technology Associate Directors, supported by finance and with the involvement of service leads where required. The level of capital investment each year should be set within the resources affordable by the Trust and based on capital replacement plans for existing estates and equipment and approved or proposed business cases for new developments. The plan outlined in this paper has been reviewed by the Capital and Infrastructure Committee during the course of its development. 3. Source of Funds The sources of funding available to fund the capital plan are; (a) From internally generated resources (i.e. depreciation), (b) From external national funding, (c) Sales of assets, or (d) From cash balances. The Trust will be funding the FY18 plan through internally generated resources, asset disposals and a small utilisation of its cash balance. The planned level of disposals for the year has not yet been finalised, however it is intended to pursue sales for the following assets; Victoria Road; Drybread Road; Agenoria House; 169 London Road Depreciation on non PFI facilities is forecast to be 4.858m in FY18, which will be used to finance the Capital Plan. 1

97 4. Development of the Capital Plan The outstanding commitment of business cases and schemes approved in 2016/17 was the starting point for the FY18 Capital plan. To this, the Estates and Business Technology teams added all of their anticipated requirements for the year, also informed by the Directorate business planning meetings, discussions at the System Change Committee, and advice from SERCO in respect of backlog maintenance. This produced a list with a value that far exceeded the funding available and therefore schemes were then ranked in terms of priority, and whether they fell into high, medium or low categories, and the reason for these rankings (which included risk reduction, service redesign/cip delivery and CQC compliance) and went through a confirm and challenge process, firstly by Finance and secondly by the Capital and Infrastructure Committee, to ensure they agreed with the priorities assigned to each scheme. All high priority schemes were then included in the plan. Medium priority schemes were then reviewed to determine whether they needed funding in FY18 or could wait for future years. Medium schemes not included will be monitored throughout the year, and if there is any slippage in the high priority schemes it may be that some of these can be added into the plan if deemed necessary. Several small low priority schemes were included where these related to savings deliver or income generation. All schemes in the plan will still require a business case to be presented to the Capital and Infrastructure Committee where they meet the threshold criteria and a case has not already been presented. Detail of the proposed Capital schemes for FY18 is outlined in Appendix A Contingency is set at 250k to help mitigate unforeseen pressures on the plan. This is consistent with 2016/17 and within the draft plan itself there are a couple of items that may be removed after further review, and therefore these amounts would be added to the contingency balance. This small contingency is required to deliver the capital plan within the budget available, and close management of the plan will be required this year to ensure the Trust stays within budget. 5. Conclusion and Recommendations It is considered that the capital plan addresses the key issues in FY18 and fits with the longer term Estates and IT Strategies of the Trust previously approved by the Trust Board including supporting the ability for service redesign to deliver increased quality of services and efficiencies within the delivery of these services. It also avoids the short-sightedness of not funding some of the development work on the sites the Trust intends to dispose of in the medium term, as outlined in the Estates Strategy. Close management of Capital spend will be required in FY18 to ensure that the Trust can deliver this plan within budget. The Board are asked to approve the outline Capital Plan for FY18 having been reviewed and recommended by the Capital and Infrastructure Committee. 2

98 APPENDIX A 3

99 4

100 Agenda Item: 10 BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Board update on agency staff usage Date: 29 th March 2017 Author: Sarah Warner, Chief Operating Officer Lead Director: Sarah Warner, Chief Operating Officer Executive Summary: Key points: Agency spend in M11 was 8.53m ytd m relates to non recurrently funded services. Pay costs remain within budgeted levels within the clinical areas. The forecast agency spend for the year is 9.3 m, inclusive of 1.3m for the non recurrent schemes, against a ceiling of 7m. Schemes approved recently as part of the Sustainability and Transformation program will require extensive recruitment (c 80 additional posts) and are likely to make further use of agency staff until substantive staff are in place New HMRC rules coming into effect in April are likely to have a significant impact on temporary staff. HMRC will treat all public sector self-employed contractors using personal service companies as falling under IR35 and therefore treated for tax purposes as an employee. As a result of these new rules, Trusts will need to ensure all locum, agency and bank staff are subject to PAYE and on payroll from 1 April NHS Improvement has introduced a new standard as of 1 st April requiring Trusts to ensure that agency workers do not hold an NHS contract elsewhere, fixed term or substantive. The potential impact of this standard is as yet unknown, and the Trust may have to consider it s approach to compliance with this standard in view of any risks which may arise as a result. Actions in this period Reiteration of the agency staff booking and authorisation process to the clinical directorates Plans now in place to cease use of remaining non compliant agency for nursing staff within the Older Peoples and Adult Community Directorate Recruitment activity for medical staff is ongoing. Preparatory work underway for NHS Improvement and HMRC changes as detailed above. Board Action The Board is asked to note the contents of this report. Further updates will be provided to Board on a regular basis 1

101 Relevant Strategic Goals and Objectives The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value. Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT. A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by Links to BAF / Corporate Risk Register Details of additional risks associated with this paper (may include CQC Fundamental standards, NHSLA, NHS Constitution) Financial implications / impact Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details Links to 2807 on operational risk register N/A Supports achievement of NHS improvement agency spend ceiling. The Trust has legal responsibilities to its agency staff. Furthermore regulatory responsibilities in regards to agency staffing. N/A Verbal update at Business and Performance Committee 2 nd March 2017 N/A 2

102 Update on Agency Usage 1. Purpose This report ensures that the Board are fully aware of the current status of agency staff usage in the Trust and the actions that are being taken to reduce expenditure in this area. 2. Current status of agency staffing spend Agency spend in Month 11 was 8.53m ytd of which 1.13 m relates to non recurrently funded services. Pay costs remain within budgeted levels within the clinical areas. The forecast agency spend for the year is 9.3 m, inclusive of 1.3m for the non recurrent schemes, against a ceiling of 7m. Please see Appendix 1 for more detail. Schemes approved recently as part of the Sustainability and Transformation Program will require extensive recruitment ( c80 additional posts) and are likely to make further use of agency staff until substantive staff are in place The Trust is now required to monitor and report on the top 20 highest cost agency workers and use of long term agency ( > 6 months). See Appendices 2 and 3. New HMRC rules coming into effect in April are likely to have a significant impact on temporary workers. HMRC will treat all public sector self-employed contractors using personal service companies as falling under IR35 and therefore treated for tax purposes as an employee. As a result of these new rules, Trusts will need to ensure all locum, agency and bank staff are subject to PAYE and on payroll from 1 April In order to prepare for this within CPFT, letters have been sent to all approved agencies on behalf of Temporary Staffing Services. In addition, all framework agencies have been sent communications by the East of England NHS Collaborative procurement hub. It is currently anticipated that the staff groups most likely to be impacted upon by this change would be medical staff and allied health professionals, although it is difficult to accurately assess the consequences until after the regulations take full effect. In addition, NHS Improvement has introduced a new standard as of 1 st April requiring Trusts to ensure that agency workers do not hold an NHS contract elsewhere, fixed term or substantive. The Trust s Temporary Staffing Service are compiling lists of agency workers who regularly accept assignments within CPFT. The lists will then be sent to the relevant agency requesting they confirm if their registered worker has any type of NHS contract. The potential impact of this standard is as yet unknown, and the Trust may have to consider it s approach to compliance with this standard in view of any risks which may arise as a result. 3. Actions this period 3.1 To increase use of bank (rather than agency) staff Wherever possible, the Trust temporary staffing service (TSS) endeavours to fill empty shifts with bank, rather than agency staff. Agency staff are only used when shifts cannot be filled by bank staff. Further changes to bank rates have been implemented; In addition to registered clinical staff, Health care assistants on the trust s substantive payroll are now paid at substantive increment, rather than lower standard bank rates. Following the recent reviews of administrate staff structures across the trust which highlighted that 375k has been spent on agency administrative staff year to date, it has been agreed that resource will be allocated to focus on improving the process of procuring temporary administrative bank staff via Temporary staffing services. 3

103 3.2 Monitoring of agency usage The Chief Operating Officer has written to all directorates to remind clinical and service managers of the necessary controls and booking process for agency staff. Agency usage and expenditure continues to be monitored closely at Performance and Risk Executive (PRE) meetings Use of agency medical staff Although as at December 2016 we were able to demonstrate a month on month reduction in the number of shifts where the agency price caps for medical staff had been breached, the total number of shifts breaking glass increased again in January 2017, with Junior Doctor shifts being 65% higher than the average for the previous 6 months. However, in February 2017 the figures for Junior Doctor shifts were the lowest they have been since the agency caps came into place. The high use in January was mainly due to covering short term sickness absence. Work to fill consultant posts with the Older Peoples and Adult Community Directorate is underway, however recruitment to posts within old age psychiatry remains very challenging and it is likely that agency staff will continue to be used in this area. The Children s, Young Peoples and Families Directorate are also proceeding with recruitment to consultant posts which will assist the Trust in reducing the reliance upon agency doctors. Clinical Directors remain engaged with considering alternative ways of covering posts, and to driving down the use of agency staff in general, and each instance where the price caps have been breached has been due to unacceptable risks to patient safety should cover not be provided. The East of England NHS Collaborative procurement hub arrangement has been extended since late January 2017 with the result that there are now more agencies who have all contractually agreed to comply with the NHS price caps. In the past CPFT have had to engage medical locums from outside the hub simply because there have not been any suitable locums available from the small number of agencies who were part of it. Widening the pool has provided more opportunity to secure locums at a lower rate. Month Total number of medical staff agency shifts breaching price cap rules Career Grade Junior GP Jul Aug Sep Oct Nov Dec Jan Feb Average

104 3.2.2 Use of agency nursing staff Mental health bookings for nursing staff via agency continue to achieve both price and wage caps. There has been continued focus on the Older People s and Adult Community directorate which remains the largest area of agency nursing usage in the trust, with comparatively little use of bank staff made in the past. The directorate's Head of Nursing and Quality has taken an active role in leading this agenda within the directorate. Since April 2016, 354 staff from the Older People s and Adult Community directorate have registered with Temporary staffing services. The directorate has used a small number of staff from an agency which will not comply with the NHS wage and price caps in order to support the JET service. The directorate has now agreed to a planned withdrawal from this agency. 4. Further actions planned A number of further actions are planned. These include: The Trust will continue to focus on recruitment and retention, particularly in those areas which make most use of agency staff. A review of agency administrative staff use will be undertaken, with a view to reducing levels of spend in this area through ensuring that TSS arrangements for bank admin staff are robust. To monitor the impact of changes to HMRC rules and NHS Improvement standards with regards to agency workers. To ensure that any risks with associated options for mitigation are communicated and progressed. The Board will continue to receive regular updates on the management of agency staff across the Trust. 5. Board action The Board is asked to note the contents of this report. 5

105 Appendix 1 - Temporary Staffing Costs Temporary Staffing - Clinical Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Bank Agency Temporary Staffing - Corporate (100) (200) Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Bank Agency (106) The Temporary Staff Costs run rate highlights the spend on Bank and Agency across the Trust in both Clinical and Corporate areas. The Report includes the performance against the NHS Improvement set target for all Agency Spend, which is a total of 7m for the financial year. Agency spend in M11 was 664k which takes the YTD figure to 8.53m. However of this YTD figure, 379k relates to the Lord Byron B ward, 273k to One Call triage, and 481k for Hunts Winter Resilience service. The forecast agency spend for the year is 9.3m, inclusive of 1.3m for the non recurrent schemes, against a ceiling of 7m. 1, Total Agency Spend vs NHSI Ceiling Total Agency spend YTD as at 28/2/17 53% 12% 27% 8% Directorate Agency spend as a % of total pay YTD Agency spend as a % of total pay - Feb 17 Adult & Specialist MH 5.2% 5.8% Children, Young People & Families 4.2% 5.3% Older Peoples & Adult Community 8.9% 7.8% Corporate 6.7% 9.0% Trust Total 6.7% 6.9% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mth 12 NHSI Ceiling All other services NR commissioned Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Total NHSI Ceiling ,028 NR commissioned ,287 All other services ,992 Adult & specialist MH Older peoples & adult community Children, YP & families Corporate Within the clinical services, there are several areas of non-recurrent service provision where Agency is the preferred method of delivery and where funding from commissioners is based on this assumption. The overall amount spent on Agency Temporary Staffing in M11 represents 6.9% of the Trust s total Pay Costs (6.7% YTD). Agency costs include costs of Agency staff within R&D which are reported against R&D 1 Expenditure in the Operating Costs analysis in App1.2.

106 As part of the Strengthening financial performance & accountability in 2016/17 initiative, NHSI have indicated the need for greater transparency on Agency spending across the NHS, and for measures to be put in place to ensure Trust Boards have sight of Agency spending at a detailed level to support holding executives to account on reducing agency spend. This Appendix identifies the highest cost Agency Workers and Long Term Agency Use (> 6 months) as at 31 st January Appendix 2 Agency Expenditure 5.1 : Highest Cost Agency Workers Highest cost agency workers Staff group Grade Department # months servi ce Hourly ra te Monthly cost Reason for usage Action taken 1 Me di ca l Cons ul ta nt CAMH ,800 Cove ri ng va ca ncy / Se rvi ce Ne e d 2 Me di ca l Cons ul ta nt CAMH ,300 Cove ri ng va ca ncy 3 Me di ca l Cons ul ta nt OPMH ,000 Cove ri ng va ca ncy 4 Admi n & Cl e ri ca l Proje ct Ma na ge r Es ta te s ,000 Es ta te s s tra te gy proje ct work CAMH re crui tme nt probl e ms, a dve rts ha ve be e n pl a ce d but no s ucce s s ful a ppl i ca nts. Curre ntl y re -a dve rti s i ng the pos t CAMH re crui tme nt probl e ms, a dve rts ha ve be e n pl a ce d but no s ucce s s ful a ppl i ca nts. Curre ntl y re -a dve rti s i ng the pos t Va ca ncy ha s be e n a dve rti s e d 3 ti me s wi th no s ucce s s Ca pi ta l funde d whi l s t worki ng on ICD e s ta te s proje ct. Contra ct due to e nd Ma r Me di ca l Cons ul ta nt CAMH ,000 Cove ri ng va ca ncy Re crui ti ng to va ca ncy 6 Me di ca l Cons ul ta nt Adul t MH ,000 Cove ri ng va ca ncy Re crui ti ng to va ca ncy 7 Me di ca l Cons ul ta nt Adul t MH ,000 Cove ri ng va ca ncy Re crui ti ng to va ca ncy 8 Cl i ni ca l 9 10 Cl i nca l Ma na ge me nt Admi n & Cl e ri ca l Se ni or Ps ychol ogi s t AfC B8a CAMH ,000 Cove ri ng va ca ncy Re crui ti ng to va ca ncy OPAC Ne i ghbourhood te a m ,000 Cove ri ng TM va ca ncy/stp Contra ct e nde d mi d Fe b 17 AfC B8a Informa ti cs ,400 Cove ri ng va ca ncy Pl a nne d e nd da te 23/2/17, re crui ti ng to va ca ncy. 11 Me di ca l Spe ci a l ty Doctor Adul t MH ,000 Cove ri ng va ca ncy Re crui ti ng to va ca ncy 12 Me di ca l Spe ci a l ty Doctor Adul t MH ,500 Cove ri ng va ca ncy Tryi ng to re crui t, di ffi cul t to fi l l pos t ba s e d i n the pri s on 13 Me di ca l Spe ci a l ty Doctor Adul t MH ,500 Cove ri ng va ca ncy Re crui ti ng to va ca ncy 14 Me di ca l Spe ci a l ty Doctor Adul t MH ,200 Cove ri ng va ca ncy Re crui ti ng to va ca ncy 15 Admi n & Cl e ri ca l AfC B8a Informa ti cs ,500 Sys te m One proje ct work 16 Ps ychol ogy AfC B8a CAMH ,000 Provi de rs of ne w s e rvi ce from Apr 16. Re qui re d s hort te rm pl a ce me nt to provi de cons i s te nt cl i ni ca l ca re whi l s t re crui ti ng to va ca ncy pe rma ne ntl y. 17 Ps ychol ogy AfC B8a Adul t MH ,800 Cove ri ng va ca ncy Adve rti s e d va ca ncy 18 Admi n & Cl e ri ca l AfC B7 Informa ti cs ,700 Sys te m One proje ct work One off proje ct work tha t re qui re s s pe ci a l i s t rol e s tha t a re di ffi cul t to re crui t to 1s t round of re crui tme nt wa s uns ucce s s ful, ha ve s i nce re a dve rti s e d a nd offe re d pos t. Contra ct i s e xpe cte d to e nd s hortl y whe n ne w a ppoi ntme nt ha s s ta rte d. One off proje ct work tha t re qui re s s pe ci a l i s t rol e s tha t a re di ffi cul t to re crui t to. Es ti ma te d e nd da te 28/2/17. Corporate services 19 Admi n & Cl e ri ca l AfC B7 Informa ti cs ,700 Sys te m One proje ct work 20 Nurs i ng AfC B7 Int Ca re Hunts ,800 Te mpora ri l y commi s s i one d s e rvi ce One off proje ct work tha t re qui re s s pe ci a l i s t rol e s tha t a re di ffi cul t to re crui t to. Di s cus s i on wi th commi s s i one rs to s e cure re curre nt fundi ng a nd a ppoi 2 nt to s ubs ta nti ve l y to pos t

107 Appendix 3 Agency Expenditure 5.2 : Long term agency use Long term agency use - please enter all individual agency staff employed for over 6 months Staff group Grade Department # months service Hourly rate Monthly cost Reason for usage Action taken 1 Admi n & Cl eri ca l AfC B8a Informa ti cs ,400 Coveri ng va ca ncy Pl a nned end da te 23/2/17, recrui ti ng to va ca ncy. 2 Admi n & Cl eri ca l Project Ma na ger Es ta tes ,000 Es ta tes s tra tegy project work 3 Medi ca l Speci a l ty Doctor Adul t MH ,500 Coveri ng va ca ncy 4 Admi n & Cl eri ca l AfC B7 Fi na nce , Communi ty Nurs i ng Communi ty Nurs i ng Communi ty Nurs i ng Communi ty Nurs i ng AfC B7 Intermedi a te Ca re ,500 AfC B7 Intermedi a te Ca re ,500 AfC B6 Intermedi a te Ca re ,500 AfC B6 Intermedi a te Ca re ,500 9 Phys i othera pi s t AfC B7 Intermedi a te Ca re ,300 Covered 2 cons ecuti ve ma terni ty l ea ve a nd now va ca ncy i n tea m Commi s s i oned non recurrentl y from wi nter pres s ures money Commi s s i oned non recurrentl y from wi nter pres s ures money Commi s s i oned non recurrentl y from wi nter pres s ures money Commi s s i oned non recurrentl y from wi nter pres s ures money Commi s s i oned non recurrentl y from wi nter pres s ures money 10 Admi n & Cl eri ca l AfC B8a Informa ti cs ,500 Sys tem One project work Ca pi ta l funded whi l s t worki ng on ICD es ta tes project Tryi ng to recrui t, di ffi cul t to fi l l pos t ba s ed i n the pri s on Recrui ti ng to va ca ncy 12 Admi n & Cl eri ca l Project Ma na ger Es ta tes ,000 Fi re Sa fety project ma na ger Ca pi ta l funded 13 Medi ca l Cons ul ta nt OPMH ,000 Coveri ng va ca ncy In di s cus s i on wi th commi s s i oners to s ecure l onger term fundi ng In di s cus s i on wi th commi s s i oners to s ecure l onger term fundi ng In di s cus s i on wi th commi s s i oners to s ecure l onger term fundi ng In di s cus s i on wi th commi s s i oners to s ecure l onger term fundi ng In di s cus s i on wi th commi s s i oners to s ecure l onger term fundi ng One off project work tha t requi res s peci a l i s t rol es tha t a re di ffi cul t to recrui t to Va ca ncy ha s been a dverti s ed 3 ti mes wi th no s ucces s 14 Pha rma ci s t AfC B8a Pha rma cy ,100 Coveri ng l ong term s i cknes s Ma na gi ng l ong term s i cknes s 15 Medi ca l Cons ul ta nt CAMH ,300 Coveri ng va ca ncy 16 Ps ychol ogy AfC B8a CAMH ,000 Provi ders of new s ervi ce from Apr 16. Requi red s hort term pl a cement to provi de cons i s tent cl i ni ca l ca re whi l s t recrui ti ng to va ca ncy perma nentl y. 17 Admi n & Cl eri ca l AfC B7 Informa ti cs ,700 Sys tem One project work 18 Admi n & Cl eri ca l AfC B7 Informa ti cs ,700 Sys tem One project work CAMH recrui tment probl ems, a dverts ha ve been pl a ced but no s ucces s ful a ppl i ca nts. Currentl y re-a dverti s i ng the pos t 1s t round of recrui tment wa s uns ucces s ful, ha ve s i nce rea dverti s ed a nd offered pos t. Contra ct i s expected to end s hortl y when new a ppoi ntment ha s s ta rted. One off project work tha t requi res s peci a l i s t rol es tha t a re di ffi cul t to recrui t to. Es ti ma ted end da te 28/2/17. One off project work tha t requi res s peci a l i s t rol es tha t a re di ffi cul t to recrui t to. Corporate services 3

108 Agenda Item: 11.1 BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Charitable Funds Committee Summary Date: 29 th March 2017 Author: Simon Burrows, Committee Chair and Non-Executive Director Lead Director: Scott Haldane, Director of Finance Executive Summary: This report presents key items discussed at the Charitable Funds Committee held 8 th March Items the Committee wish to bring to the attention of the Board include: Investment funds Overall financial position Bids for funding Future direction Recommendations: The Board of Directors is asked to note the items highlighted. 1

109 Relevant Strategic Goals and Objectives (please mark in bold) The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by 2019 Links to BAF / Corporate Risk Register Details of additional risks associated with this paper (may include CQC Fundamental standards, NHSLA, NHS Constitution) Financial implications / impact Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details As above N/A The Charitable Funds Committee considers bids to the Trusts Charitable Fund. Approval of these would directly affect the fund held by the Trust. The Charitable Funds Committee has a legal responsibility to the Trusts Charitable Fund. N/A Whilst this report has not been seen before it details discussions held at the Charitable Funds Committee meeting on N/A 2

110 CHARITABLE FUNDS COMMITTEE REPORT MARCH INTRODUCTION Key items to be drawn to the Board s attention, and as discussed at the Committees March meeting, are summarised below. 2. ITEMS DISCUSSED Investment Funds: the committee received a summary report of the charity s financial performance to January Investment yield overall remains positive. An updated Investment Policy has been circulated to the board. Overall financial position: (FYE2017) DM advised the committee of current financial performance. Donations have continued in decline. (FYE2018) Looking forward the charity has (I) agreed commitments of circa 126k (II) and a need to fund up to 30k (estimated) of expenditure related to strategy implementation. The committee accepted the advice of DM that any further financial commitments/funding awards should be deferred to later in the new financial year or onward. Bids for funding: 2 bids were reviewed. One rejected without recourse. One rejected based on the case presented. The committee rejected the application as was on the understanding a revised application would be submitted later in the year. Future direction: Clare Jones, the new (and first) Charity Manager was introduced. Clare will be heavily involved working with Kit et al to finalise a charitable strategy. 3. SUMMARY AND CONCLUSIONS The Board of Directors is asked to note the contents of this report. 3

111 Agenda Item: 11.2 BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Date: 29 th March 2017 Overview and Funds Analysis Author: Lead Director: Rosemary Walker, Finance Operations Manager, Serco Scott Haldane, Director of Finance Executive Summary: The Report outlines the movement in Investments within the Charitable Funds Portfolio and agreed expenditure for the period 1st April 2016 to 31st January Highlights of the period are:- Unrealised Gain on Investments of 109,233; Total Income of 250k; Total Expenditure of 244k. Recommendations: The Charitable Funds Committee is asked to note the Overview and Funds Analysis for the period from April 2016 to January

112 Relevant Strategic Goals and Objectives (please mark in bold) The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value. Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT. A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by Links to BAF / Corporate Risk Register Details of additional risks associated with this paper (may include CQC Fundamental standards, NHSLA, NHS Constitution) Financial implications / impact Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details N/A N/A Performance of CPFT Charitable Fund N/A N/A Charitable Funds Committee 8 th March 2017 N/A 2

113 Agenda Item: Cambridgeshire and Peterborough NHS Foundation Trust Report to the Charitable Funds Management Panel 8 March 2017 From: Scott Haldane Date: 23 February 2017 Subject: Overview and Fund Analysis For: Information 1 INVESTMENTS The price of investments increased/(decreased) by the following between 1 April 2016 to 31 January 2017: Responsible Global Equity Fund * COIF Property Fund Epworth Affirmative Fixed Interest 24.03% (4.25)% 0.87% The gains and losses to 31 January 2017 are made up as follows; UNREALISED GAIN ( ) Responsible Global Equity Fund * 133, COIF Property Fund Epworth Affirmative Fixed Interest (26,015.52) 1, TOTAL 109, * The Responsible Global Equity Fund was previously called F & C Stewardship 1

114 Market Value, Book Value and Unrealised Gains and Losses for Responsible Global Equity Investment to 31/01/17 Market Value, Book Value and Unrealised Gains and Losses for COIF Investments to 31/01/17 2

115 Market Value, Book Value and Unrealised Gains and Losses for Epworth Investment to 31/01/17 2 TARGET EXPENDITURE as at 31 January 2017 CCS CPFT TOTAL Target Expenditure 179, , , Actual Expenditure 39, , , Variance from target 140, (76,498.81) 63, Variance from target % (71.86) The expenditure target is one third of the opening balance split evenly across the year. 3 CASH DEPOSITS as at 31 January 2017 * At 31 January 2017 Current Interest % rate COIF Deposit 164, Epworth Affirmative Deposit Account 41, CafCash Account

116 3 SUMMARY FINANCIAL POSITION AT 31 January 2017 SUMMARY FINANCIAL POSITION AT 31 January Jan Jan Jan Mar- 16 ( '000) ( '000) ( '000) ( '000) CCS CPFT Total Balance brought forward at 1 April ,593 1,764 Income Investment income Sub Total ,843 2,222 Expenditure (39) (183) (222) (650) Admin (13) (9) (22) (9) Fund balances at January ,599 1,563 Unrealised gain on investments TOTAL 1, ,708 1,593 5 BALANCE SHEET A Balance Sheet as at 31 January 2017 is attached as Appendix 1. 6 FUND SUMMARY A detailed summary and analysis of funds is attached as Appendix 2. 7 CONCLUSION The Charitable Funds Management Panel is requested to note the financial position with regard to investment funds as at 31 January

117 Appendix 1 Charitable Funds Balance Sheet As at 31 January Jan Jan Jan Mar 2016 CCS CPFT Total ( '000) ( '000) ( '000) ( '000) Assets Debtors Investments (Market Value) ,452 1,343 Cash Deposits Cash at Bank and in Hand , ,837 1,726 Liabilities Creditors (26) (103) (129) (133) TOTAL 1, ,708 1,593 Reserves Income Funds Restricted ,438 1,392 Unrestricted Capital Funds: Endowment , , Notes: 1 % Asset Allocation 31-January % Investments - Equity based Property Fixed interest Deposits and cash Total

118 2 Book Value of Investments at 31 January 2017 is 933k Appendix 2 Charitable funds Summary of Funds As at 31 January 2017 CAMBRIDGESHIRE & PETERBOROUGH NHS FOUNDATION TRUST 31-Jan Jan Jan Mar 2016 CCS CPFT Total ( '000) ( '000) ( '000) ( '000) CAMBRIDGESHIRE COMMUNITY SERVICES NHS TRUST TOTAL FUND BALANCES ,028 1,028 Unrealised/Realised gain at 1 April Unrealised gain on investments Distribution account TOTAL BALANCE 1, ,708 1,593 6

119 Agenda Item: Ref No. Date of Application Date of Project/Event/ Actibity CF Project Title / Overview Contact Person Funding Amount Small Nose Productions "I had a Black Dog" - Funding Support to match fund Arts Council Funding. Event date Date Acknowl edged Date of mtg to be submitted Outcome (agreed / denied) Mark Curtis 5, Agreed Reason / stipulations / notes Company to provide Report on Use of Funds and Outcomes of Work to CPFT. Date outcome confirmed with requestee Date funding transfer requested Date evidence report expected Date evidence report submitted Date of mtg evidence report to be submitted CF N/A Daisy Change Membership for Cambridge and Peterborough - 50 members each at 76 per annum Joanne Croxford 3, Agreed Report on Outcome of funding to be presented to Charitable Funds Committee CF N/A Funding for Social Recovery Manager post in Recovery College for 12 month period. Deborah Cohen tbc Agreed CF N/A Funding for part-time Muslim Chaplain (0.6wte) to support Spirituality Strategy for 12 month period. John Nicholson 26, Agreed Report to the Charitable Funds Panel after 9 months providing evidence of worthiness of the post, and exploring other funding opportunities in the long term CF N/A Access to Emergency Fund to support Chaplain Service John Nicholson Agreed Review after one year CF Jun-15 CF36 N/A CF N/A Fulbourn Summer Celebration - Contribution. Event date June 2015 Peterborough Carers Support Service - Contribution Recovery College - Funding for Business Devpt/Fundraising Mgr Post (B7) for one year only Agreed N/A David Jordan Agreed Deborah Cohen tbc Agreed Serco in Confidence

120 CF N/A CF N/A CF CF Volunteer Mandatory Training - funding for Temporary post for 4 months to develop e-learning module Funding for Triangle of Care Project for 1 year to support Carer Events and fund Volunteer and Carer Expenses Funding to support Long Service Awards on 15th Feb Venue Hire and Staff Awards. (Retrospective Award) Funding to support Nurses Day Conference in May Venue Hire Annie Ng 3, Agreed Report back to next Charitable Funds Panel on progress of this project Elaine Young 6, Agreed Emma Byrom 14, Agreed N/A Judy Dean 1, Agreed CF N/A Funding to support Peer Educator Re-accreditation - Training Costs Sharon Gilfoyle 9, Agreed Report to be amended to reflect changes agreed in meeting 04/08/ CF N/A Funding to deliver two therapeutic participatory photography programmes to people accessing Recovery College East. Funding for WAVET (Work, Advice, Volunteering, Education and Training) a membership networking organisation Julia Johnson. 5, Agreed Catherine Langridge 3, Denied - changes needed Interim report expected back after first exhibition - March/April Further information about WAVET; where it is based and in what capacity it links to the Trusts services. 2. Clarity in regards to the way in which they intend to use the requested A financial breakdown that TBC CF N/A Funding for RCT - Recovery Coaching Team. To enhance the quality and validity of these services will require training in Coaching and the teams seek to become the first accredited Recovery Coaching Team from IIC&M. Emma Green 16, Agreed Review after 6 months, final report after one year 28-Dec Jan-17 28th May Tues 6th June CF N/A Rising Roses WI Block MembershipsJoanne Croxford 1, Agreed Review after 6 months, final report after one year TBC 28th May Tues 6th June Serco in Confidence

121 CF N/A Funding for Social Recovery Manager post in Recovery College for 12 month period. Joanne Croxford Agreed TBC 28th May Tues 6th June Serco in Confidence

122 Agenda Item: 12 BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Date: 29 th March 2017 Author: Lead Director: Medical Appraisal and Revalidation Annual Board Report James Claydon, Medical Workforce Lead Dr Chess Denman, Medical Director Executive Summary: The purpose of this paper is to: Report on the Trust s progress in Medical Revalidation in the year. Outline actions taken in by the Trust to support Medical Revalidation and appraisal processes. Highlight issues and action points for development in Recommendations: The board is asked to: Note the report, and that it will be shared with the Higher Level Responsible Officer. Consider any needs or resources required. To approve the Statement of Compliance (Appendix C) confirming that the Trust, as a Designated Body, is in compliance with the regulations. 1 of 14

123 Relevant Strategic Goals and Objectives (please mark in bold) The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by 2019 Links to BAF / Corporate Risk Register Details of additional risks associated with this paper (may include CQC Fundamental standards, NHSLA, NHS Constitution) Financial implications / impact As above. N/A Yes. Revalidation Dashboard. Appraiser Training. Legal implications / impact Partnership working and public engagement implications / impact Committees / groups where this item has been presented before Has a QIA been completed? If yes provide brief details Yes. The Trust has a statutory duty to comply with its legal obligations on Revalidation N/A Revalidation Committee No. 2 of 14

124 Medical Appraisal and Revalidation Annual Board Report Executive summary In the Appraisal year, the Trust employed or had a prescribed connection with 137 doctors, for whom it was the Designated Body for appraisal and revalidation. This included 112 Consultant grade, 11 SAS Doctors and 14 Locum, Temporary or Short-Term post holders. Completed Appraisals 97 doctors completed an appraisal between 1 st April 2015 and 31 st March Missed Appraisals 40 doctors were recorded as having missed appraisal in the year. 34 of these were new starters, or people joining from overseas who were not due for their first NHS appraisal, or people for whom this would be their first appraisal in grade. The remaining 6 doctors had extenuating circumstances including maternity leave, long term sickness absence and being on a career break. The Responsible Officer has approved the reasons for these 6 not having had an appraisal. Unapproved missed appraisal There were 0 doctors who missed appraisal without the approval of the Responsible Officer and the RO and Revalidation Committee are fully aware of the reasons for any missed appraisals and all reasons are recorded for audit purposes. The Appraisal rate for the year was 93.4%. The primary issues for were: Carry forward plans for implementation of appraisal quality assurance system Completed Establishing a Medical Revalidation Dashboard ongoing Implementation of the Taxi-rank system for appraiser allocation and selection Completed Fine tuning of the Taxi-rank system for maximum efficiency ongoing Providing GMC-approved appraiser refresher training for Trust s existing appraisers, and new training for new appraisers to bolster appraiser numbers Completed The primary issues for are: 3 of 14

125 Finalising the Medical Revalidation Dashboard Finalising the fine tuning of the Taxi-rank system for maximum efficiency Arranging an Independent External Verification Visit from another NHS organisation, to review our appraisal and revalidation processes, in accordance with NHS England s framework of Quality Assurance. Ensure sustainable systems and processes are in place in relation to locum doctors. 2. Revalidation Medical Revalidation was launched in 2012 to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical system. The process involves a five year cycle of annual appraisals, to support the Responsible Officer in making a recommendation to the GMC in relation to that individual s fitness to retain a license to practice. Between 1 April March 2017 a total of 6 doctors were due to be recommended by the RO and subsequently revalidated by the GMC. The RO submitted 2 deferral requests due to insufficient information and both of these will be due for revalidation in Background The Trust has a statutory duty to support the Responsible Officer in discharging their duties under the Responsible Officer Regulations and it is expected the Board will oversee compliance by: Monitoring the frequency and quality of medical appraisals in their organisations; Checking there are effective systems in place for monitoring the conduct and performance of their doctors; Confirming that feedback from patients is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and Ensuring that appropriate pre-employment background checks (including preengagement for Locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed. 4. Governance Arrangements From October 2014, a Deputy RO was appointed and a new Medical Revalidation Committee was formed consisting of RO, Deputy RO, Medical Appraisal Lead with representation from Medical Services. Meeting 6 weekly, this group assist the RO in making recommendations on revalidation 4 of 14

126 and managing systems relating to revalidation and appraisal. Medical appraisal and revalidation is supported by the Medical Services Team, and a dedicated Revalidation Administrator who has access to GMC Connect, to ensure the list of prescribed connections is correct and up to date. The Administrator supports medical staff in preparedness for their appraisals and Revalidation. In addition the Team has administrative access to the Equiniti online appraisal system to monitor progress on appraisal data and access an online portfolio of appraisal evidence and supporting information. The Responsible Officer is supported by a Medical Appraisal Lead. All complaints involving medical staff are notified to the Responsible Officer. a. Policy and Guidance The Trust ratified a Medical Appraisal and Revalidation Policy and Responding to Concerns Policy in Medical Appraisal a. Appraisal and Revalidation Performance Data ( ) Number of doctors: 137 Number of completed appraisals: 97 Number of doctors in remediation and disciplinary processes: 2 Details of exceptions are included in Appendix A; Audit of all missed or incomplete appraisals. b. Appraisers The Trust has a total of 29 appraisers who have attended a GMC approved revalidation-ready appraiser training course. The majority of these completed the course in November The Trust requires that appraisers undergo refresher training every 3 years to ensure they remain up to date with their skills to undertake the role. The Trust will coordinate refresher training in this timeframe for which all existing appraisers will be expected to attend and selected new appraisers will undergo a complete appraiser course for the first time before taking up appraiser duties. Areas in which the appraiser group would benefit from recruitment have been identified and applications requested. The Revalidation Committee continually monitor appraiser coverage and identify where new appraisers would be of benefit to the Trust. It was noted in 2015 that there were not sufficient appraisers in Liaison Psychiatry, and as a result two new appraisers were appointed. 5 of 14

127 The Trust has implemented a new Taxi Rank system for appraiser allocation / selection to spread the workload between appraisers as 2014 revealed certain appraisers were facilitating an inequitable number of appraisals. This has improved matters considerably and affords doctors a choice whilst ensuring that there can be minimal accusation of bias. However there is some finetuning to be done. Appraisers are supported in their role by the Medical Appraisal Lead and there are regular appraiser meeting during which time there is an opportunity for the group to harmonise the approach to appraising across the Trust whilst the Appraisal Lead can feedback on individual areas of improvement and development. c. Quality Assurance In April 2014 NHS England published an outline of quality assurance for appraisal and revalidation, summarised below: For the appraisal portfolio: Review of appraisal folders to provide assurance that the appraisal inputs: the pre-appraisal declarations and supporting information provided is available and appropriate -by whom and sign offs Review of appraisal folders to provide assurance that the appraisal outputs: PDP, summary and sign offs are complete and to an appropriate standard -by whom and sign offs Review of appraisal outputs to provide assurance that any key items identified pre-appraisal as needing discussion during the appraisal are included in the appraisal outputs -by whom and sign offs. As a result: All appraisal folders are made available for the Responsible Officer to review in detail, and quality assure against their sufficiency to support a positive recommendation to revalidate. The revalidation committee reviews all appraisals within the revalidation period to assure themselves that a robust and adequate set of appraisals have been conducted. Additionally an audit of random appraisals will be conducted on a regular basis. For the individual appraiser An annual record of the appraiser s reflection on appropriate continuing professional development. An annual record of the appraiser s participation in appraisal calibration events such as reflection on ASG (Appraisal Support Group) meetings 360 feedback from doctors for each individual appraiser how collected, reviewed, collated and fed back to the appraiser, how calibrated with the feedback for other appraisers? 6 of 14

128 The Medical Appraisal Lead will offer support and guidance to appraisers. The Equiniti online appraisal system provides a tool for appraisers and appraisees to submit their feedback on the quality of the appraisal meeting. The Trust promotes the idea of Individuals collecting 360 colleague feedback every 2 years. For the organisation Audit of timelines of process of appraisal by department System user feedback Review of lessons learned from any complaints Review of lessons learned from any significant events As a result: Appraisal progress is recorded and tracked by Medical Staffing, who keep individuals abreast of timescales and guide them with the requirements for their revalidation. As with Colleague feedback, the Trust encourages that Patient feedback by way of formal and anonymous questionnaires, is collected every 2 years. Since the launch of the Equiniti online system in 2014, the collection of colleague and patient feedback will be undertaken using a dedicated online module. The Responsible officer is notified of any complaints made against medical staff and appraisers report any concerns which may arise to the Responsible Officer. The Trust is working to establish a Medical Revalidation Dashboard that will aim to triangulate information from various governance systems including concerns, so that it is readily available to the Revalidation Committee. d. Access, security and confidentiality All completed appraisals and supporting evidence are stored on a secure server. No patient identifiable documentation is permitted as supporting evidence for appraisal, and all patient feedback is anonymised. e. Clinical Governance Doctors are provided with an outline of the documentation and supporting information required for their appraisal and revalidation by request from the Medical Services team, Responsible Officer and Appraisal Lead. All complaints are notified to the Responsible Officer. 6. Medical Revalidation Recommendations Number of recommendations between 1 April March 2017 Positive recommendations: 4 Deferrals requests: 2 7 of 14

129 Non engagement notifications: 0 See Appendix B; Audit of medical revalidation recommendations 7. Recruitment and engagement background checks The Trust undertakes all required pre-employment checks Including Occupational Health check, DBS clearance, references and GMC status, including checks on locums. For agency locums the Trust uses only Crown Commercial Service approved agencies who undertake pre-employment checks prior to a booking being made with the Trust. 8. Monitoring Performance The Trust has various formal and informal mechanisms to monitor performance of doctors who are employed by the trust to ensure that they remain fit for purpose. There are several key performance indicator dash boards that inform about individual services where the doctors work. Directorate leadership monitor performance through regular governance meetings and any issues around performance are dealt with straightaway. For individual doctors, CPD outcomes are reviewed on each appraisal with identification of progress or concerns and any remedial measures needed. Any issues highlighted are discussed at meetings of the Revalidation Committee and appropriate action agreed. The Revalidation Committee have commissioned a Revalidation Dashboard that will aim to Triangulate information from various governance systems so that it is readily available to the Committee when revalidation recommendations need to be made. Progress on this has been slower than anticipated as the Trust has so far been unable to allocate necessary development time. Investigation is taking place into possible external providers should it prove necessary to outsource the project. 9. Responding to Concerns and Remediation The Trust s Responding to Concerns policy was ratified in The Trust has a number of trained staff who have undertaken Maintaining High Professional Standards training in relation to Concerns. 10. Risks and Issues The Trust has the following risks in relation to revalidation and performance of doctors. 1) The size of the administrative support for the revalidation process is small in comparison to similar sized organisations. 8 of 14

130 2) The Revalidation Dashboard is under progress but there is currently no agreed date for its completion. 11. Corrective Actions, Improvement Plan and Next Steps The key issues for development are: The Trust to arrange external review of appraisal and revalidation processes Establishing a Medical Revalidation Dashboard Fine tuning of the Taxi-rank system of appraiser allocation and selection Ensure sustainable systems and processes in relation to locum doctors 12. Prescribed connections The regulations that govern which doctors have a prescribed connection are complex and have changed recently. The process of establishing a connection is administered but not assured by the GMC. For a range of reasons doctors sometimes attempt to establish a connection with CPFT when this is not correct. While it is an individual doctor s duty to do this correctly the Trust regularly monitors and maintains the list and we are confident that we correct errors in the list rapidly. Another change is that the rules which establish a prescribed connection have changed in relation to doctors who work part time in the trust. We are reviewing this in order to help doctors be related to the correct organisation. 13. Board Actions The board is asked to: Note the report, and that it will be shared with the Higher Level Responsible Officer. To consider any needs or resources required. To approve the Statement of Compliance (Appendix C) confirming that the Trust, as a Designated Body, is in compliance with the regulations. 9 of 14

131 Appendix A - Audit of all missed or incomplete appraisals in year Doctor factors (total) 6 Maternity leave during the majority of the appraisal due window 2 Sickness absence during the majority of the appraisal due window 2 Prolonged leave during the majority of the appraisal due window 1 Suspension during the majority of the appraisal due window 0 New starter within 3 month of appraisal due date 0 New starter more than 3 months from appraisal due date 0 Postponed due to incomplete portfolio/insufficient supporting information 0 Appraisal outputs not signed off by doctor within 28 days 0 Lack of time of doctor 0 Lack of engagement of doctor 0 Other doctor factors 1 Appraiser factors 0 Unplanned absence of appraiser 0 Appraisal outputs not signed off by appraiser within 28 days 0 Lack of time of appraiser 0 Other appraiser factors (describe) 0 Organisational factors 0 Administration or management factors 0 Failure of electronic information systems 0 Insufficient numbers of trained appraisers 0 Other organisational factors (describe) 0 Total missed / incomplete appraisals of 14

132 Appendix B - Audit of medical revalidation recommendations in year Medical Revalidation recommendations between 1 April 2016 to 31 March 2017 Recommendations completed on time (within the GMC recommendation window) 4 Late recommendations (completed, but after the GMC recommendation window closed) 0 Missed recommendations (not completed) 0 TOTAL 4 Primary reason for all late/missed recommendations For any late or missed recommendations only one primary reason must be identified No responsible officer in post New starter/new prescribed connection established within 2 weeks of revalidation due date New starter/new prescribed connection established more than 2 weeks from revalidation due date Unaware the doctor had a prescribed connection Unaware of the doctor s revalidation due date Administrative error Responsible officer error Inadequate resources or support for the responsible officer role Other Describe other n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a TOTAL [sum of (late) + (missed)] 0 11 of 14

133 Appendix C - Statement of Compliance Designated Body Statement of Compliance - page 1 The Board of Cambridgeshire & Peterborough NHS Foundation Trust has carried out and submitted an annual organisational audit (AOA) of its compliance with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013) and can confirm that: 1. A licensed medical practitioner with appropriate training and suitable capacity has been nominated or appointed as a responsible officer; Dr Chess Denman 2. An accurate record of all licensed medical practitioners with a prescribed connection to the designated body is maintained; Yes 3. There are sufficient numbers of trained appraisers to carry out annual medical appraisals for all licensed medical practitioners; Yes 4. Medical appraisers participate in ongoing performance review and training / development activities, to include peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers or equivalent); GMC-approved appraiser training has been provided with refresher course to follow every 3 years to which all continuing appraisers are required to attend, in accordance with CPFT policy. Failure to refresh training will lead to cessation of appraiser role until training is done. 5. All licensed medical practitioners 1 either have an annual appraisal in keeping with GMC requirements (MAG or equivalent) or, where this does not occur, there is full understanding of the reasons why and suitable action taken; Yes 6. There are effective systems in place for monitoring the conduct and performance of all licensed medical practitioners 1, which includes [but is not limited to] monitoring: in-house training, clinical outcomes data, significant events, complaints, and feedback from patients and colleagues, ensuring that information about these is provided for doctors to include at their appraisal; Yes 1 Doctors with a prescribed connection to the designated body on the date of reporting 12 of 14

134 Designated Body Statement of Compliance - page 2 7. There is a process established for responding to concerns about any licensed medical practitioners 1 fitness to practise; Yes. A Responding to Concerns policy was ratified in There is a process for obtaining and sharing information of note about any licensed medical practitioners 1 fitness to practise between this organisation s responsible officer and other responsible officers (or persons with appropriate governance responsibility) in other places where licensed medical practitioners work; Yes 9. The appropriate pre-employment background checks (including pre-engagement for Locums) are carried out to ensure that all licenced medical practitioners 2 have qualifications and experience appropriate to the work performed; and Yes 10. A development plan is in place that addresses any identified weaknesses or gaps in compliance to the regulations. Yes Signed on behalf of the designated body: Signed: Signed: Julie Spence Chairman Aidan Thomas Chief Executive Officer Date: 1 Doctors with a prescribed connection to the designated body on the date of reporting 13 of 14

135 Agenda Item:14 BOARD OF DIRECTORS MEETING IN PUBLIC REPORT Subject: Equality and Diversity Annual Board Report Date: 29 March 2017 Author: Sue Rampal, Equality and Diversity Officer Lead Director: Kit Connick, Interim Director for Primary Care and Corporate Affairs Executive Summary: The core purpose of the Equality and Diversity Annual Board report is to fulfil the Trust s statutory obligations. To update the Board on key aspects of equality and diversity in the last 12 months and the progress of the Equality Delivery System 2 (EDS2). In being able to meet its business objectives and duties the Trust has adopted the national framework Equality Delivery System 2 (EDS2) and is committed to: Continually improve our equality performance by continuing to embed equality into our mainstream business Help us to meet the evidential requirements of the statutory public sector equality duty, contained within the Equality Act (2010) CPFT has completed the following actions to meet its Public Sector Equality Duty by: Publication of equalities data by 31 January 2016 Engaging with stakeholders to provide an assessment of progress through the EDS2 grading system Monitor progress on equality objectives Report annually on E&D performance to the Trust Board and then published report on the Trust website Highlights in : The Trust has completed the following achievements and actions to meet its Public Sector equality Duty (PSED) and to comply with the EDS2: Published equality data in March 2016 and in March % rate responses to the annual national staff survey 2016, compared with 46% in 2015 staff survey First bespoke CPFT Diversity calendar 2017 using images of staff across the Trust. Calendar used to promote local, national and international events and is available on the Intranet and Trust Website 1

136 Implementation of Accessible Information Standard (AIS) Actively participating in the Mindful Employer initiative Successful transfer from the Positive about Disability Two Ticks scheme to the new Disability Confident scheme. Achievement of the Disability Confident Employer award Engagement events: The EDS2 Engagement event grading event on 30 June, 2016, including consulting with local groups Provision of support to the Engagement Strategy Review Task and Finish group via Listening events throughout Cambridgeshire Celebrated Black History Month, hosted by the Raising Roses WI E&D training: Mandatory E&D training through E-Learning course 91.93% as of Jan 2017 staff are compliant with their training E&D Training delivered to the Trust Board Tailor-made Cultural Awareness training delivered to individual teams within the Trust E&D face to face training for staff in Cambridge and Peterborough. Training includes Unconscious Bias; Cultural Awareness; LGBT and Trans Chaplaincy Team training: 1-hour Introduction to Islam with our Muslim Chaplain in Cambridge, Peterborough, Wisbech and Huntingdon and Islam & Cultural Understandings, Black Magic, the Evil Eye & Jinns - Explained Staff support system in place: Wearing 2 Hats - three work streams- 1) peer support, 2) policy and procedures, and 3) anti-stigma Anti-stigma campaign launched with a series of video clips on Youtube/ twitter Wearing2Hats forum produced a staff stories book about being proud of their lived experience was published Oct 2016 Keeping Well at Work plan developed and implemented Recommendations: To update the board on progress and good work around equality and diversity in the last year. To provide assurance that the Trust is continuing to meet its legislative requirements through the implementation of the EDS2. 2

137 Relevant Strategic Priorities (please mark in bold) The development, commissioning and implementation of a new integrated service strategy from April 2016: We will work with patients, carers and key stakeholders to change our services to deliver innovative, integrated person centred care and support that represents the highest possible standards in safety, effectiveness and personal experience of our services. The design, development and implementation of the future CPFT workforce: Our staff will be a highly engaged, well trained, flexible and productive workforce who are able to deliver more at better value. Maximising the contribution of IT and the Trust estate: We will develop highly innovative and effective ways to use technology and the Trust estate in support of person-centred care and maximising the financial benefit for CPFT. A commercial and financial sustainability strategy: We will ensure sustainable services through delivery of a financial strategy based on increased cost effectiveness, value for money, growth and investment by Links to BAF/Corporate Risk Register Developing employee engagement Details of additional risks associated with this paper (may include CQC Essential standards, NHSLA, NHS Constitution) Financial implications/impact Legal implications/impact Partnership working and public engagement implications/impact Committees/groups where this item has been presented before Has a QIA been completed? If yes provide brief details Developing workforce capability Non-compliance with the Equality Duty, Equality Delivery System2 links directly to various CQC standards N/A Meeting the Requirements of the Equality Act 2010 and the Public Sector Equality Duty Requires regular partnership working with other NHS organisations across the region None No 3

138 Cambridgeshire & Peterborough Foundation Trust Equality & Diversity Annual Report March

139 Contents Contents Page 1. Executive Summary 6 2. Introduction 6 3. Legislative Context 6 4. Key Achievements and measures undertaken to improve equality in 2016/ Staff Survey Results Wearing 2 Hats 4.3 Diversity Network 4.4 Equality & Diversity training 4.5 Collaborative Leadership 4.6 Chaplaincy 4.7 Rising Roses WI 4.8 Recovery College 5. The Equality Delivery System 2 (EDS2) 5.1 The Workforce Race Equality Standard (WRES) The Accessible Information Standard (AIS) Equality Impact Assessments (EIA) Summary 8.1 Our Future Priorities Appendices EDS2 Goals and Outcomes APPENDIX 1 Equality and Inclusion Strategy APPENDIX 2 CPFT Diversity Network - Terms of Reference APPENDIX 3 Staff Equality Data 2016 APPENDIX 4 5

140 1. Executive Summary The purpose of the Equality & Diversity Annual report is to fulfil the Trust s legal obligations and report on the progress on the Equality Delivery System 2 (EDS2) and Workforce Race Equality Standard (WRES). Over the past year, Cambridgeshire and Peterborough Foundation Trust has continued to make positive progress to embed equality, diversity and inclusion throughout the organisation. This report provides a summary for 2016/17 with regards to both our service delivery and employment practices in the workplace. 2. Introduction Cambridgeshire and Peterborough NHS Foundation Trust is committed to providing an environment where all staff, service users and carers enjoy equality of opportunity. The Trust understands the importance of being compliant with the various pieces of equality legislation and acknowledges the benefits and contribution that managing equality and diversity makes to the achievement of its business objectives in the areas of employment, service planning and service delivery. Promoting equality, embracing diversity and ensuring full inclusion for people who use our services is central to the vision and values of the Trust. Promoting equal opportunities, preventing discrimination and valuing diversity are fundamental to building strong communities and services. The Trust is committed to: - Developing policies, processes, procedures, practices and behaviours which challenges all forms of discrimination and promotes equality of opportunity at all levels - Creating an organisation that harnesses the different perspectives and skills of all staff and provides a working environment free from discrimination, harassment or victimisation In this annual report we will illustrate how we continue to demonstrate our commitment to tackling inequality and removing barriers. 3. Legislative Context The key areas of our legal and regulatory obligation are the Equality Act 2010 and the Public Sector Equality Duty (PSDE). The Equality Act 2010 replaces previous antidiscrimination law with a single Act. It simplifies and strengthens the law, removing inconsistencies and making it easier for people and organisations to understand and comply with. The Public Sector Equality Duty applies to public bodies and others carrying out public functions, and requires these organisations to publish information to show their compliance with the Equality Duty. The information (including strategic Equality & Diversity objectives) must show that the organisation has due regards to the need to: 6

141 Eliminate unlawful discrimination, harassment and victimisation Advance equality of opportunity between different groups Foster good relations between different groups The nine protected characteristics covered by the Equality Act and PSED are: Age Disability Gender reassignment Marriage and civil partnership Pregnancy and maternity Race including nationality and ethnicity Religion or belief Sex Sexual orientation 4. Key Achievements and measures undertaken to improve equality in 2016/17 The Trust has completed the following achievements and actions to meet its Public Sector equality Duty (PSED) and to comply with the EDS2: Published the equality data in March 2016 The EDS2 Engagement event grading event on 30 June, 2016, including consulting with local groups Mandatory E&D training through E-Learning course 91.93% as of Jan 2017 staff are compliant with their training 50% rate responses to the annual national staff survey 2016, compared with 46% 2015 survey Celebrated Black History Month, hosted by the Raising Roses WI Staff support system in place: Wearing 2 Hats with three work streams- 1) peer support, 2) policy and procedures, and 3) anti-stigma Anti-stigma campaign launched with a series of video clips on Youtube/ twitter Wearing2Hats forum produced a staff stories book about being proud of their lived experience was published Oct 2016 Keeping Well at Work plan developed and implemented Implementation of Accessible Information Standard (AIS) Continue to provide interpreting & translation services to support patients in accessing services E&D Training delivered to the Trust Board Tailor-made Cultural Awareness training delivered to individual teams within the Trust E&D face to face training for staff in Cambridge and Peterborough. Training includes Unconscious Bias; Cultural Awareness; LGBT and Trans Chaplaincy Team training: 1-hour Introduction to Islam with our Muslim Chaplain in Cambridge, Peterborough, Wisbech and Huntingdon and Islam & Cultural Understandings, Black Magic, the Evil Eye & Jinns Explained 7

142 Provision of support to the Engagement Strategy Review Task and Finish group via Listening events throughout Cambridgeshire Actively participating in the Mindful Employer initiative Successful transfer from the Positive about Disability Two Ticks scheme to the new Disability Confident scheme. Achievement of the Disability Confident Employer award Development and design of the first bespoke CPFT Diversity calendar 2017, used to promote local, national and international events 4.1.Staff Survey Results 2016 Our final overall Trust response rate for 2016 was 50.80% Following the survey results, an action plan was created to address four main areas of concern. See the table below for a brief summary. Aim For staff at all levels to feel able to contribute to improvements Action Ensure all internal CPD courses and internal CPD applications have a focus on what improvements/ changes could be made back in the workplace. Build continuous improvement into the appraisal/supervision system. Implement rewards based on improvements to services/workplaces. Development of a Clinical Senate, to foster improvements and developments. Highlight changes and improvements teams and individuals have made linking with Quality Improvement. Launch and implement the Health and Wellbeing Strategy. To keep staff well and Develop support and guidance for line managers in keeping at work themselves and teams well. Ensure all teams are using the health roster system, ensuring more effective roster management. To ensure staff are safe, feel safe and are not discriminated against Ensure staff are aware of how to raise concerns. Embed a Zero Tolerance Culture around bullying, harassment and violence. Improve the appraisal process. Development of Succession Planning to support Talent For staff to feel more Management throughout the Trust. valued and supported Ensure staff feel appropriately rewarded and recognised. Establish the Management Skills Toolkit. Re-launch New Managers Induction programme. 8

143 4.2 Wearing 2 Hats The Wearing 2 Hats group is comprised of staff from across the Trust, in different roles, who have come together with a common goal - to support staff with their own lived experience of mental health challenges and other long term conditions. The group aims to develop guidance for managers and influence policy and strategy development in the organisation, as well as making good use of the lived experience many of our staff have of mental health challenges and long term conditions. Our core values are based on the principles of Recovery. The Wearing 2 Hats has: Over 40 staff members 3 work streams: 1) peer support, 2) policy and procedures, and 3) anti-stigma A Staff stories book has been published Keeping well at work form created and launched Anti-stigma campaign launched with a series of video clips on Youtube/ twitter etc Work undertaken with HR regarding policies and procedures to support staff with long term conditions Monthly peer support sessions available for staff to share stories and gain mutual support W2H buddy system implemented to support staff with long term conditions 4.3 Diversity Network The Equality and Diversity Steering group has been re-launched as the Diversity Network. It is comprised of a cross section of representation from across the organisation and has responsibility for the development and delivery of the Trust s Equality & Diversity agenda. The group is accountable to the Trust Board, via the Executive Team. The Diversity Network seeks to open its membership to every Trust employee and to make the equality and diversity agenda part of the daily work of the Trust, via social media, Diversity champions and aligning strategic programmes of work. 4.4 Equality & Diversity training The aim is to, where possible, try and ensure all Learning and Development activity reflects aspects of anti-discriminatory practice and addresses diversity and equal opportunities. This is done through building this into courses and delivering specific tailor made training. The Trust is committed to rolling out E&D learning through the e-learning course: Treating People with Respect. This includes all new employees, who would have undertaken the learning as part of their induction, students on placement, and those staff who need to refresh their knowledge in line with their mandatory training. Staff have to refresh the training every three years after induction. The staff training records are kept up to date by the Learning & Development Team who try and assist staff to identify and complete their mandatory training. 9

144 Face to face E&D training is also made available through the year and a range of subjects are covered, such as Cultural Awareness, LGBT & Trans awareness and Unconscious Bias. Face to face training provided in has included: E&D Training delivered to the Trust board Cultural Awareness training tailor made to suit individual teams within the Trust E&D face to face training for staff in Cambridge and Peterborough. Training includes Unconscious Bias; Cultural Awareness; LGBT and Trans Training supported by Chaplaincy team 1-hour Introduction to Islam with our Muslim Chaplain, in Cambridge, Peterborough, Wisbech and Huntingdon Islam & Cultural Understandings, Black Magic, the Evil Eye & Jinns - Explained HR Skills Module: E&D training 4.5 Collaborative Leadership The Trust has recently undertaken a significant piece of research into the understanding and application of Collective and Collaborative Leadership across the organisation. The diagnostic review was carried out through 1:1 interviews and an online survey; 43 and 102 staff took part respectively during November and December The report documents sets out the research conducted, outcomes, key themes and recommendations for action. There is a significant amount of rich data that will help to inform the equality and diversity work streams. The Diversity Network will ensure that the information and learning from the research is embedded into the E&D action plan for 2017/ Chaplaincy Recognising a person s spiritual dimension is one of the most vital aspects of care and recovery in mental health. The Spirituality Strategy for help to make spirituality meaningful for service users and staff. ensure that there are real service improvements as a result. CPFT ensure that spirituality is embedded in all its care pathways and that the action plans meet the needs of service users, carers and all staff. The chaplaincy team offers spiritual and pastoral support to people of all faiths, as well as people who do not have particular beliefs but who would like someone to talk to. The chaplaincy team is supported by community faith leaders and by volunteers. The chaplains are available to everyone - whether you are a patient, relative, friend, member of staff, and whatever your faith. 4.7 Rising Roses WI In 2014 staff at CPFT set up the Country's first WI initiative based in an NHS setting for staff, service users and the local community. The Daisy Change WI has since led 10

145 to the creation of Rising Roses WI, which now runs sessions every two weeks in Peterborough. The initial inspiration for the initiative came from the WI campaign, Care Not Custody, which saw the WI campaigning for better treatment of people with mental health issues. The campaign also saw the launch of WIs being set up in prison environments. The idea behind setting up WIs at CPFT was so that women could come together on an entirely equal footing. Rising Roses is a WI group that runs in Peterborough. It welcomes women from the local community as well as those both using and providing services at CPFT. 's 4.8 Recovery College Recovery College East provides a collaborative, educational learning environment and aims to convey messages of hope, empowerment and opportunity to all. It celebrates strengths and successes rather than highlighting deficits or problems. Courses vary in length from one-off workshops to those that take place weekly for a number of weeks. Courses currently on offer come under the headings: moving forward, the road to recovery, and developing knowledge and skills. The range of courses available each term vary as the college responds to the demands of its students 5. The Equality Delivery System 2 (EDS2) The EDS2 is a toolkit which aims to help organisations to improve the services they provide for their local communities and provide better working environments for all groups. There are four goals within the EDS2: 1) Better Health Outcomes 2) Improved patient access and experience 3) A representative and supported workforce 4) Inclusive leadership The goals are divided into eighteen outcomes. For most of these outcomes, the key question is How well do people from protected groups fare compared with people overall? (APPENDIX 1). The EDS2 grading process has allowed CPFT to undertake a thorough review of its practices and processes. The EDS2 action plan forms the monitoring process for the equality objectives. The EDS2 Engagement event grading event took place by consulting with the local groups on 30 June, An Engagement event for 2017 is being planned for June. 5.1 The Workforce Race Equality Standard (WRES) The WRES requires organisations to publish information against a number of indicators of workforce equality, and to demonstrate progress against them. The WRES highlights any differences between the experience and treatment of White staff and Black & Minority Ethnic (BME) staff in the HNS with a view to closing those gaps through the development and implementation of action plans focused upon continues improvement over time. 11

146 The Trust published its first report in July 2015, and the July 2016 report can be found on the Trust s website. The next WRES report will be provided to the Diversity Network in July 2017 for analysis and discussion. This will then be presented to the Trust Board. The CPFT staff ethnicity data 2016 (APPENDIX 4). 6. The Accessible Information Standard (AIS) During 2016 the Accessible Information standard was developed in response to the requirements of the Equality Act This standard requires the Trust to take appropriate steps or make reasonable adjustments in order to avoid putting a disabled person at a substantial disadvantage when compared to a person who is not disabled. There are specific duties under the Care Act 2014 with regards to the provision of information Information and advice provided under this section must be accessible to, and proportionate to the needs of, those for whom it is being provided. It is particularly relevant to individuals who are blind, deaf, who are deafblind and/or who have a learning disability. The Trust assigned a Task & Finish Group to embed the Accessible Information Standard across the Trust made up of representatives from services across the Trust following implementation. Monitoring will be undertaken by the Information Governance Team and escalated at the Information Governance Steering Group meeting. The Trust s two main Electronic Patient Administration Systems (RiO and SystmOne) are compliant with the standard; any future patient systems procurement processes will acknowledge that this is a requirement. The Trust has implemented the AIS as one of the equality objectives for An update on progress against the objective will be included in next year s report. 7. Equality Impact Assessments (EIA) An EIA is a tool aimed at improving the quality of local health services by ensuring that individuals and teams think carefully about the likely impact and consequences of their work on different communities or groups. The Trust recognises the ongoing importance of embedding equality and diversity within all our processes and continues to carry out EIAs to ascertain the impact of key decisions on people with protected characteristics. These help ensure that our services, systems and processes do not discriminate against people. EIA training is available to support this programme of work. 8. Summary Much has been achieved over the past year and the Trust seeks to continue to build on this good work by setting stretching targets for the forthcoming year. These are set out in the Equality Diversity & Inclusion Strategy for (APPENDIX 2), but an overview for 2017/18 is highlighted below: 12

147 8.1 Our future Priorities: To continue with the programme of work set out in our Equality, Diversity & Inclusion Strategy. Review and monitor the work undertaken on an annual basis Review and monitor of the Accessible Information Standard (AIM) Continue to improve collection of data across all the protected characteristics and focus on implementing processes to capture data of staff accessing nonmandatory training and CPD To review induction and training materials to ensure that they remain up to date and reflect all the requirements in accordance with the Equality Act To continue to provide bespoke training in the areas of Equality & Diversity To continue to carry out Equality Impact Analysis for policies, procedures and service redesign To organise and facilitate workshops to ensure staff and service users understand the wider equality and diversity agenda To retain Disability Confident Employer status and actively participate in the Mindful Employer initiative Continue to work towards a greater understanding of the barriers to providing excellent healthcare to all people with characteristic protect by Equality Act 2010 To embed the rebranded Diversity Network, embedding equality and diversity programmes into everyday work and projects Development of the CPFT Equality and Diversity brand; effectively marketing and publicising the positive work that is underway in the Trust The delivery of these priorities will be overseen by Diversity Network, which is chaired by the Interim Director of Primary Care and Corporate Affairs. The network is responsible for setting the strategic direction of the agenda, monitoring its delivery and championing the values and behaviours of the Trust, as set out in the revised Terms of Reference (APPENDIX 3). A further progress report (including the WRES data and Engagement Event feedback) will be reported to the Board in September 2017). 13

148 APPENDIX 1 Equality Delivery System 2(EDS2) - Goals and Outcomes EDS Goal 1: Better health outcomes for all 1.1 Services are commissioned, procured, designed and delivered to meet the health needs of local communities. 1.2 Individual patient's health needs are assessed and met in appropriate and effective ways. 1.3 Transition from one service to another, for people on care pathways, are made smoothly with everyone well informed. 1.4 When people use the NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse. 1.5 Screening, vaccination and other health promotions services reach and benefit all local communities. EDS Goal 2: Improve patient access and experience 2.1 People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds. 2.2 People are informed and supported to be as involved as they wish to be in decisions in their care. 2.3 People report positive experiences of the NHS. 2.4 People's complaints about services are handled respectfully and efficiently. EDS Goal 3: A representative and supported workforce 3.1 Fair NHS recruitment and selection processes lead to a more representative workforce at all levels. 3.2 The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their legal obligations. 3.3 Training and development opportunities are taken up and positively evaluated by all staff. 3.4 When at work, staff are free from abuse, harassment, bullying and violence from any source. 3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives. 3.6 Staff report positive experiences of their membership of the workforce. EDS Goal 4: Inclusive leadership 4.1 Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations. 4.2 Papers that come before the Board and other major Committees identify equality-related impacts including risks, and say how these risks are to be managed. 4.3 Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination. 14

149 APPENDIX 2 Equality and Inclusion Strategy Cambridgeshire & Peterborough Foundation NHS Trust 15