Board of Directors. 28 th June 2017 Public

Transcription

1 Board of Directors 28 th June 2017 Public

2 BOARD OF DIRECTORS MEETING IN PUBLIC To be held on 28 th June 2017 at 11:30 In the Training Centre, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP This meeting will be live streamed members of public will not be filmed AGENDA TBP24/17 INTRODUCTION ACTION 11:30 TBP24.1/17 Chair s Welcome and Introduction 11:31 TBP24.2/17 Apologies for Absence & Declaration of Interests 11:32 TBP24.3/17 Questions from Members of the Public 11:33 TBP24.4/17 Patient Input TBP25/17 STRATEGY 11:50 TBP25.1/17 Clinical Strategy (Nick Lake, Clinical Director) For information A 12:00 TBP25.2/17 CQC Compliance & Strategic Assurance (Diane Hull, Chief Nurse) For assurance B 12:15 TBP Sustainability and Transformation Plan (Sam Allen, Chief Executive) For information C 12:25 TBP25.4/17 Communications Strategy (Dan Charlton, Director of Comms) For information D TBP26/17 ASSURANCE (QUALITY & PERFORMANCE) 12:35 TBP26.1/17 Chief Executive Report (Sam Allen, Chief Executive) For assurance E 12:45 TBP26.2/17 CDS Quality Assurance (Simone Button, Chief Operating Officer) Safe Staffing Appendix For assurance F G 13:00 TBP26.3/17 Annual Mortality & Serious Incidents Report (Diane Hull, Chief Nurse) For assurance H 13:10 TBP26.4/17 Serious Incidents Assurance Report (Diane Hull, Chief Nurse) For assurance I TBP27/17 STAFFING & WORKFORCE 13:20 TBP27.1/17 Framework on Agency Use (Sue Esser, Executive Director of HR & OD) For information J

3 TBP28/17 FINANCE 13:30 TBP28.1/17 To receive the Finance Report (Sally Flint, Chief Finance Officer For information K TBP29/17 GOVERNANCE 13:45 TBP29.1/17 Strategic Risk Register (Adam Churcher, Head of Corporate Governance) For information L 13:55 TBP29.2/17 Minutes of the Board of Directors held on 24 th May 2017 and matters arising (Caroline Armitage, Chair) For approval M TBP30/17 ANY OTHER BUSINESS Date and Venue for Next Meeting: 26 th July 2017 TBC Training Centre, Swandean, Arundel Road, Worthing, West Sussex BN13 3EP

4 Report to Board of Directors Agenda item: TBP25.1/17 Attachment A EHRIA code Date of meeting 28 th June 2017 Format of Paper Title of paper Author Presenter Clinical Strategy: June update Dr Nick Lake, Clinical Director Dr Nick Lake, Clinical Director Committees/meetings where this item has been considered Purpose of report (tick all that apply) Written Oral Presentation Clinical Strategy Programme Board To provide assurance For decision Regulatory requirement To highlight an emerging risk or issue To canvas opinion For information To provide assurance To highlight patient, carer or staff experience Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care 3. Put research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Living within our means Summary of Report This report provides an update on the progress made by the Sussex Partnership NHS Foundation Trust s Clinical Strategy programme against the objectives set. The Board is asked to: 1. Review the clinical strategy summary document and the 10 priority workstreams 2. Sign off stage one of the clinical strategy programme 3. Review and approve the work-plan for stage two of the clinical strategy programme 4. Make any recommendations for changes or additions to either the strategy itself or the proposed programme of work that will lead to its implementation 5. Give approval for the programme of work to proceed as described N/A Recommendation The Board is asked to give their support to the ongoing programme of work described

5 1. WORKPLAN 1. THE CLINICAL STRATEGY SUMMARY PAPER Appendix 1 2. STAGE ONE: PROGRAMME COMPLETION AND SIGN OFF Stage one of the Clinical strategy programme has been completed Objective Target Date Achieved by target date 1. Develop CS PID 31 st Dec 2016 Yes 2. Establish Programme Board 31 st Dec 2016 Yes 3. Agree terms of reference and governance 31 st Dec 2016 Yes 4. Establish Clinical Strategy leadership team 31 st Dec 2016 Yes 5. Establish workstream leads and workstreams 14 th Jan 2017 Yes 6. Secure CDS buy in 26 th Jan 2017 Yes 7. Gain Exec and Board approval on initial plan 26 th Jan 2017 Yes 8. Initial staff engagement event workstream 2 nd Feb 2017 Yes feedback and establishing staff goals 9. Service user and carer event - workstream feedback 22 nd Feb Yes and establishing service users and carer goals 10. Commissioner engagement event - workstream 16 th Feb 2017 Yes feedback and establishing partner goals 11. Appoint patient lead to the programme 1 st Feb 2017 Now achieved 12. Appoint commissioner lead to the programme 1 st Feb 2017 Yes 13. Cross workstream leads review meeting to agree 13 th Mar 2017 Yes cross workstream targets and strategy 14. Hackathon stage 2: service user, carer and staff 17 th Mar 2017 Yes workstream review event 15. Deadline date for workstream leads to submit work 21 st Mar 2017 Yes 16. Deadline for final draft of the strategy to be submitted 31 st Mar 2017 Yes to graphic designer 17. Deadline for completion of graphic design work and 7 th April 2017 Yes publication of the first draft of the strategy 18. Stage 1 programme review completed 30 th April 2017 Yes 19. Ongoing engagement events planned 30 th April 2017 Yes 3. STAGE TWO There are three key components in stage 2 of the clinical strategy programme. These are: Engagement with a wide group of stakeholders to review and seek feedback on the first draft of the strategy. To publish a final draft that takes into account this feedback. Review and implementation of the clinical strategy workstream work plans. This includes an identification of the priority areas and the development of a new Project Initiation Document and project plan to support the delivery of the strategy. Engagement in, and integration of, the outputs of the STP mental health review programme, ensuring alignment of the clinical strategy and the STP recommendations mental health workstream.

6 Stage 2 objectives Target Date Achieved by target date 1. Identify 10 CS workstream priorities and begin 31 st May 2017 Yes implementing the work-plans for these priority areas 2. Complete clinical strategy summary document 31 st May 2017 Yes 3. Complete final communications message to staff 30 th June 2017 tbc having produced the clinical strategy briefing videos and set up and registered a new Clinical Strategy twitter account 4. Review progress of all workstreams, agree next 30 th June 2017 tbc stage workstream action plans, and complete new PID and stage 2 project plans 5. Louise Patmore, Clinical Strategy Patient Lead, to 31 st July 2017 tbc complete review of patient and carer feedback and develop recommendations 6. CDS and wider commissioner engagement plans 31 st July 2017 tbc completed and all feedback received 7. Professional leadership engagement completed and 31 st July 2017 tbc all feedback received 8. To integrate the clinical strategy with the new STP 30 th Sept 2017 tbc mental health planning priorities once they are identified 9. Publication of the final draft of the clinical strategy. A separate paper will describe how we have responded to the feedback received 30 th Sept 2017 tbc 4. UPDATE PRIORITY WORKSTREAM OBJECTIVES The following table provides an overview of the progress made against the ten priority workstream objectives: Objective Progress and next steps 1. Developing teams Working group on team development formed and led by Dr Adrian Whittington to develop resource package and guidance for all team development work across the Trust. Organisational development practitioners fully involved and linked into this group via Jonathan Beder. Good pilot work already taking place to set as examples - including organisational development practitioner involvement in supporting the development of the operational services leadership team and the Trust review of professional leadership. To link this workstream activity with workstream 10 outputs (clinical intelligence) to gain clarity on: What a team is and what a pseudo team is How we want to form ourselves into teams 2. Implementing new roles Ensuring everyone is part of at least one team That the responsibilities of teams including ownership of performance and data are clearly spelt out Work plans going ahead in new roles working group led by Sue Esser. To agree new roles and workforce planning priorities with CDSs that will:

7 3. Integrated community, crisis and acute services 4. Creating capacity and moving care upstream Have maximum impact on filling difficult to recruit to posts Help reduce agency spend Take forward key aspects of the clinical strategy Determine which early implementer projects will be taken forward and evaluated in each CDS West Sussex AMHSs acting as the early implementer site. To form an adult services clinical pathway modelling and planning group for this workstream to further identify models of service delivery that will enable us to achieve our ambitions in this area. To agree how this work will be taken forward within all CDSs, including identifying and evaluating progress already being made. All Adult CDSs beginning to test out how they might develop and implement stricter criteria within their services and how the wider healthcare system might work differently to enable this. This requires: CDSs recording data more accurately particularly around care clusters CDSs to work with local commissioners to agree plans for addressing service gaps Good example of this work is the development of the new step 3 plus service within Brighton. Dr Jason Read is also leading on a specific project reviewing the current role and function of medical outpatient appointments. Recommendations to be implemented in due course. This will also an important area of work being considered within the STP mental health review and planning work supported by Carnal Farrar 5. Youth services Early implementer sites receiving excellent feedback and the issue of how to build on these plans is being considered within STP commissioning plans. Dr Rick Fraser and Ruth Hillman developing a new project plan with the support of the Youth Services development group which describes the next stage of planning and implementation work. 6. Crisis care pathways 7. Reducing length of stay and standardising admissions 8. Access (could we please put this third in the list) 9. Working more effectively with our communities New working group formed that links the Access and Crisis care workstreams. Workstream being led by Michael Mergler. Model being implemented initially in Brighton and Hove. New Service Development Improvement Plan to be developed and agreed. Role and function of the inpatient services group being taken forward by Rebecca Hills. To review the leadership of this workstream and to secure appropriate resources to take this forward. Options appraisal being finalised by Jonathan Beder and full business plan will be ready by the end of September. All CDSs fully engaged. Outputs will be key to developing our plans for crisis services. Working with communities group are revising their plans and securing additional input from CDSs. The group are aiming to: Describe the commitments that the Trust should be making in this area and the opportunities that are

8 10. Clinical care pathways and clinical care intelligence likely to have maximum impact on helping to deliver the clinical strategy To identify and support examples of good practice and early implementer sites To support each CDS to begin to develop their own work plans in this area To input proposals directly into the STP mental health workstream SDIP agreed and programme meeting current objectives. Michael Mergler leading on this workstream and ensuring appropriate links between the performance and information team, Hilary Charlton s care pathways work, the CAG work, and operational services strategic planning work. 3. NEXT STEPS To report back to the Board at quarterly intervals

9 CLINICAL STRATEGY SUMMARY THE NEXT STEPS IN OUR JOURNEY : CONTENTS INTRODUCTION Over the last three years we ve been trying to change the way we work to promote more positive staff, service user and carer experience. This includes: l developing values to guide the way we work with each other and with people who use our services l developing an overarching strategy Our 2020 Vision to deliver outstanding care and treatment you can be confident in l overhauling the way our clinical services are managed by creating Care Delivery Services which are designed to support more effective and empowered local decision making in partnership with local stakeholders The first iteration of our clinical strategy builds on all this work. It outlines the type and range of clinical services we want to offer by 2020 to deliver the best possible care to patients. The proposals have been developed by our service users and carers, our staff, and our partners. 2: WHY DO WE NEED IT? WE WANT TO BE THE BEST WE CAN BE We want to ensure that we are all delivering excellent services, with high quality and consistent standards of care and treatment set across Care Delivery Services, and with processes and mechanisms in place to ensure that we can all learn from examples of best practice from across the organisation. The clinical strategy will help us achieve this ambition. CHANGING FOCUS OF CARE In order to continue providing the best possible care, we also need to think and work differently. Across the NHS and social care system, we need to focus more on: l health promotion and early intervention l delivering evidenced based interventions l treating people in the community rather than in hospital l working much more effectively in partnership

10 CLINICAL STRATEGY SUMMARY : KEY PRIORITIES The proposals set out in the clinical strategy are detailed and ambitious and ALL will need to be delivered in full partnership with service users and carers (this will be supported by our People Participation workstream). The top priorities are: OBJECTIVE RATIONALE Developing teams Implementing new roles Access Integrated community, crisis and acute services Creating capacity and moving care upstream Youth services Crisis care pathways Reducing length of stay and standardising admissions We are putting team development and support at the heart of our clinical strategy in the belief that good teamwork is an essential component of high quality, effective clinical care. All teams will have the equivalent of two days out per year to work on improving their effectiveness We will create new roles to help us manage recruitment difficulties and use resources most effectively. We ll test the impact of these new roles using Quality Improvement methodology. New roles will include non-medical prescribers, multi-professional RC clinicians, associate lead practitioners, peer workers, assistant practitioners, nursing associates, medical associates and graduate mental health workers We will provide a single point of access to help people in crisis get help from us 24 hours a day. We will also ensure that we have a fewer number of access points for our non-crisis services. We will explain this clearly and publicise details. People will never be turned away without being supported to access the care and support they need. We will also review our systems and processes, learning from best practice in the Trust and elsewhere, so that access points are safe, effective and efficient We will create more joined up care pathways between community, crisis and acute services. This will enable staff to accompany service users through their care journey (a key request from service users). Community services will also take responsibility for managing resources across the whole care pathway, supported by specialist acute and crisis care staff. A single, integrated care pathway will lead to far fewer divisions between teams, increased flexibility in the use of resources, and fewer gaps in services We will identify how we will create capacity in community teams so they can spend more time on the needs of people with more severe and acute mental health problems. This will help us take pressure off crisis and acute services. We will take a different approach to meeting the needs of people with mild to moderate mental health problems or people who have longer term mental health problems but who have been stable and managing well for some time. We will explore alternative ways of meeting their needs in partnership with the wider healthcare and community support system We will introduce new care pathways, and some new services, for people aged We will introduce new crisis home treatment and mental health liaison services, and work towards providing 24/7 mental health crisis care for everyone who needs it We will make some significant changes to our acute services to ensure that we make best use of our beds. Admissions will have clearly stated objectives set against clear standards with community services playing a much greater role in developing the treatment plan. We will reduce average length of stay through new partnerships with community services, recovery colleges, and other partner organisations. We will review our approach to ward rounds, and will look at how peer workers can help us to further improve the quality of care we provide

11 CLINICAL STRATEGY SUMMARY OBJECTIVE RATIONALE 9 10 Working more effectively with our communities Clinical care intelligence We will work on developing closer relationships and new ways of working between our services and the wider community network of which we are part. We will describe how more effective partnership working with the third sector, community groups (including faith groups), as well as families and friends, improves patient experience, increases effectiveness and reduces costs. We will do the same in relation to more joined up commissioning between health, local authority and voluntary sector services We will help teams collect and use clinical and outcomes data to improve services, learn from best practice elsewhere, create jobs that are manageable, better match capacity to demand, and develop a culture of continuous improvement in services based on clear outcome data 4: YOUR VIEWS It s important that the clinical strategy is owned by the people who work here, by the people who use our services, and by partner services who work with us to provide care for people with mental health problems. This will give it a better chance of success in improving the care we provide. Staff, service users, carers, and other partners, have all been instrumental in developing the first version of the clinical strategy. But this is just the first step. We now want to involve as many people as we can in conversations about the strategy including how it might be improved and what we need to do to make it happen. We will seek to get as many views as possible from people over the next couple of months. We ll do this through engagement meetings organised by CDSs, in smaller professional meetings organised by professional and corporate leads, and through receiving feedback directly via communications@sussexpartnership.nhs.uk. Please can you let us have your feedback by the end of July Following comments received and discussions with people over the summer, we ll publish an update on the strategy in September You may want to contact the workstream leads directly and / or get involved in the work-plans that are being developed to move our ambitions forward. The workstream contacts are: Access to Care Jonathan Beder Primary Care Claire Newman Secondary Care Community Dr Brian Solts Rehab Dr Sophie Holmes Caring for staff, Teams, and Workforce Sue Esser Pathways of Care & Outcomes Hilary Charlton Digital by Design Karl Goatley Working with Communities Andrew Cole Integrated Physical and MH services Dr Jason Read Urgent / crisis care Lindsay Towle Wellbeing Colleges Dr Adrian Whittington People Participation Bryan Lynch Clinical Care Intelligence Dave West Medicines optimisation Ray Lyons

12 Report to Board of Directors Agenda item TBP25.2/17 Attachment B EHRIA code Date of meeting 28 th June 2017 Format of Paper Title of paper CQC Compliance & Strategic Assurance Written Author John Rosser, Director of Improvement and Innovation Presenter Diane Hull, Chief Nurse Presentation Committees/meetings where this item has been considered Purpose of report (tick all that apply) To provide assurance For decision Regulatory requirement To highlight an emerging risk or issue To canvas opinion For information To provide assurance To highlight patient, carer or staff experience Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care 3. Put research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Living within our means Summary of Report Oral The following report provides an update on progress with the CQC Improvement Programme. It includes key elements; Response to the CQC Inspection of Acute Adult Inpatient Services Updated CQC Must Do Action plan Quality and Safety Reviews CQC Roadshows KLOE Masterclasses Key Work Streams - Risk Assessment - Care Planning - Ligature Risk Management and Reduction - Mandatory Training - Eliminating Mixed Sex Accommodation Well Led review Recommendation The Board of Directors is asked to note the progresses made, and raise any issues requiring additional assurance. N/A TBC 1

13 2. REPORT Response to the CQC Inspection of Acute Adult Inpatient Services The CQC undertook a comprehensive focused inspection of the 12 Adult Acute Inpatient Wards between 4-5 April The Trust was invited to comment on the factual accuracy of the draft report (appendix 1). A workshop was held on 15 May 2017 where issues of accuracy were explored and a draft action plan created. The factual accuracy report was submitted to the CQC on 19 May 2017 as requested. The final report was published by the CQC on their web-site on 2 June 2017 which had taken account of the Trust feedback. The report concludes that the core service failed to meet the Trust s threshold of 75% (factual correction to 85%) compliance in 4 of the 22 mandatory training subjects on site fire training, PMVA, BLS and ILS. There is noted improved in Rapid Tranquilization but some gaps in physical health monitoring were identified. Medication management was found to be generally satisfactory but some missed doses were identified, notably on Amber Ward. 11 of the 12 wards inspected were able to demonstrate learning from incidents, however Woodlands was unable to demonstrate the learning from a serious fire and subsequent implementation of the smoke free policy. Concerns were expressed about the seclusion room at Amber Ward, This centred on the CCTV, intercom and the mattress not being secured which in the view of the CQC meant this could potentially pose a hazard. The inspection also noted that staff weren t routinely recording patients clothing when leaving Maple ward. The report acknowledges good use of observation policies. All areas were found to have current ligature risk assessments and ligature footprints which were present and displayed in 11 of the 12 ward offices. Wards and bedrooms were generally clean and well furnished. Infection Prevention and Control audits were complete and clinics were found to be clean and fully equipped with emergency equipment. The CQC noted progress and the current recruitment drive to address vacancies and the use of temporary staff cover. Staff reported adequate medical cover. Patients commented that they were treated with respect, felt safe and staff were generally caring and approachable. They were mostly involved in care planning but there were some comments that staff were sometimes too busy. The CQC noted examples of Innovative practice; key ring used on Caburn Ward, the use of the Broset Violence Scale at Regency, safety huddles on Coral Ward and in addition to the learning events, the Quality Improvement work across Langley Green which had resulted in a sustained reduction in patient safety incidents. The Trust was asked to respond to the regulatory breaches highlighted in the report and summarised above as follows; Regulation 12: Health and Social Care Act 2008 (Regulated Activities) Regulations Safe care and treatment Staff on Coral ward did not record eyesight observations made on patients following their admission to the ward prior to the patient s observation review with the ward consultant. Staff did not record observation times for two patients on intermittent observation levels on one occasion on Regency ward. 2

14 Patients on Woodlands ward had access to cigarette lighters despite the trust having a smoke-free policy and that these were risk items following a fire incident on the ward in December Staff on Jade and Amber wards did not always ensure that physical health and general observations are recorded accurately for patients. Amber ward did not have an investigation or improvement plan to monitor the high levels of missed medicine doses identified in the March2017 Mind The Gap audit carried out by the ward pharmacist. This is a breach of Regulation 12 (2)(a) Regulation 18: Health and Social Care Act 2008 (Regulated Activities) Regulations Staffing This core service did not reach the trust s training completion target in four out of 22 mandatory training subjects. This is a breach of Regulation 18 (2)(a) The clinical leads/managers have been asked to complete local detailed improvement plans to supplement the high level improvement plan. Which was submitted to the CQC 20 June The high level action plan is attached (appendix 2) Quality and Safety Reviews The programme of Quality and Safety Reviews is now established. These reviews are well received by the service having the review and those staff conducting the review. They are however, administratively heavy necessitating the preparation of a detailed data pack, arranging a review team and preparing the report. We are investigating a commercially produced App which can be tailored to any local audit/review schedule and which when completed provides a real time report. The system also provides for bespoke reports which can focus upon specific services or elements of the review. This is being explored in more detail and any decision will be predicated upon a business case. The services that have been reviewed so far include; Beechwood Ward Heathfield Ward Brunswick Ward Meridian Ward Burrowes Unit Larch Ward Orchard Ward Opal Ward St Raphael Ward High Weald & Lewes Assessment and Treatment Service Eastbourne Crisis Resolution and Home Treatment Team Cavendish House Assessment and Treatment Service Linwood Assessment and Treatment Service Chichester Crisis Resolution and Home Treatment Team Chichester Assessment and Treatment Service Basingstoke Child and Adolescent Mental Health Service East Brighton Assessment and Treatment Service 3

15 A representative cross section of all services will be reviewed by the end of September Whilst these reviews are now established, they are seen as an element of the CQC Project. It is proposed to mainstream the reviews as part of the CDS assurance programme. CQC Roadshows The CQC Roadshows promote a continuous conversation across the Trust about the CQC and our improvement programme. Roadshows have been conducted in the following services; Linwood Assessment and Treatment service Uckfield Unit Newhaven Assessment and Treatment service Shoreham Assessment and Treatment service Bognor Assessment and Treatment service Chichester Assessment and Treatment service Andover Child and Adolescent Mental Health Service The Roadshows have in the main been loosely scripted preferring to provide a more open dialogue. The CQC Project Group undertook a review of progress and proposed that the Roadshows should support the Well Led preparation work. A presentation is being prepared that highlights the key lines of enquiry alongside what the CQC characterise as what good looks like for each of the Key Lines of Enquiry (KLOE) prompts in turn. The audience will be asked to explore what they have in place and their local experience and demonstrate how they measure, report and respond to the impact. Key Lines of Enquiry (KLOE) Masterclasses A series of KLOE Masterclasses have been introduced. The purpose of the masterclass is to collectively examine each of the CQC Quality Domains and KLOEs in turn. Thereafter those in attendance have an opportunity to consider the KLOEs in respect to their service. The first Masterclass focused upon the Safe domain which took place 10 May 2017 where 30 middle/senior operational staff attended. The second took place on 5 June 2017 and focussed on Effectiveness. A similar number and grade and mix of staff attended. In response to feedback, the Effectiveness event included a discussion led by Forensic Healthcare staff on their approach to this domain as they were rated as Outstanding by the CQC in September. An invitation will be extended to support services for future events. It is planned that there will be a rolling programme of Masterclasses which will increasingly use front line staff to showcase their work. Key Work Streams Mandatory training It is clear that significant progress has been made since the initial Wave Inspection inspection in January The most recent inspection of the Adult Acute Wards reported that of the 22 core subjects, the Trust was failing to achieve 75% completion in 4 areas and onsite fire training was less than 65% (red) in a number of wards. The emphasis has been in the adult inpatient areas but there are similar challenges across other inpatient and community services. The Education and Training team along with operational and support services are working hard to improve the completion rates across all subject areas but there is perhaps a limit what can be achieved with the current approach. At the CQC Project meeting on 9 June 2017, it was proposed to hold a workshop to undertake a review of the subject areas, 4

16 content and method of delivery. This workshop is being organised to ensure that each CDS and subject area is represented. Risk Assessment and Care Planning The early progress with the risk assessments has been maintained but this appears to have plateaued in recent weeks. This is largely related to the number of patients seen solely by doctors in outpatient clinics where the risk assessment has been incorporated in the GP letter which will follow an agreed format. These letters will be referenced in the risk assessment section of care notes providing the reader with access to the clinical information. Progress with care plans has been more sporadic. In part this relates to the plans to use the GP letter as evidence of a care plan and the sheer numbers of individual services users and young people involved. It should be noted that there are reservations about the use of the GP letters as evidence of risk assessment and care plans. The concerns relate to the quality of the risk assessment and care plan which can be inconsistent as they may not follow the prescribed model as detailed within Carenotes. This could potentially undermine the assurance programme which will need to be mitigated through audit. Further, it risks compromising future improvements and changes to the system as narrative files will not lend themselves to future development in Carenotes or sharing with partners. However, the senior medical staff are engaged in this issue and have signalled their support to this approach which is a positive step and one which improves patient safety and is a step forwards. Ligature Risk Management and Reduction All inpatient ligature risk assessments were completed at the end of May 2017 and there is a programme for reviews going forward. This Ligature Risk Reduction Group is chaired by the Executive Directive of Finance and Strategy. This is group includes estates, facilities, clinical and governance staff and provides assurance on the management of ligatures across the Trust. Well Led Inspection The CQC have been consulting upon the future inspection regime and have recently published the future criteria against which services will be judged. The revised set of standards or Key Lines of Enquiry and prompts are as follows; The leadership, management and governance of the organisation assure the delivery of high-quality and person-centred care, supports learning and innovation, and promotes an open and fair culture. Is there the leadership capacity and capability to deliver high-quality, sustainable care? Is there a clear vision and credible strategy to deliver high-quality sustainable care to people, and robust plans to deliver? Is there a culture of high-quality, sustainable care? Are there clear responsibilities, roles and systems of accountability to support good governance and management? Are there clear and effective processes for managing risks, issues and performance? Is appropriate and accurate information being effectively processed, challenged and acted on? Are the people who use services, the public, staff and external partners engaged and involved to support high-quality sustainable services? 5

17 Are there robust systems and processes for learning, continuous improvement and innovation? The CQC Well Led domain standards straddle each of the CQC quality domains and focus upon governance and how the Trust ensures that the full range of standards are managed. A series of workshops are being arranged where operational and support services staff can explore the Well Led domain in detail and define the standards using a Donabedian model for each KLOE/prompt; Structure - systems and policies we have in place, Process - operational application Outcome performance and assurance. Rather helpfully the CQC have published a series of short statements which characterise what each of the prompts that underpin the KLOE might look like when rated as; outstanding, good, requires improvement or inadequate. Each core service (as defined by the CQC) will be asked to undertake a self-assessment against the standards/prompts. As mentioned previously we will use the Roadshows to explore the standards defined within the Well Led KLOE. This will support a Trust wide conversation on what systems are in place, how these work locally and what evidence we use to assure ourselves that the high standards of practice are maintained. We will explore how the OD practitioners may be able to assist CDSs and support services with their preparation programmes. This will be explored in more detail through the CQC project group. This new inspection routine will require some preparation with the Board of Directors, Executive team and Service Delivery Board. A range of options are currently being considered. These may include presentations, self-assessment, external reviews and mock interviews. NHS Improvement have recently published guidance on Developmental reviews of leadership and governance using the well-led framework (appendix 3 & 4). 3. NEXT STEPS The CQC have signalled that their future inspection programme will comprise smaller focussed inspections which will be used to inform the Well Led inspection likely to occur in the Autumn This will include the areas currently rated as Requires Improvement; - Adult acute wards and community services - Older peoples wards and community services - CAMHS community services, and one service rated as good to ensure standards are maintained. A engagement programme has been agreed with the CQC with the first meeting taking place 20 June The CQC Project Team will progress the plans as set out previously. 6

18 Sussex Partnership NHS Foundation Trust Quality Report Trust Headquarters Swandean Arundel Road Worthing West Sussex BN13 3EP Tel: Website: Date of inspection visit: 4-5 April 2017 Date of publication: This is auto-populated when the report is published Core services inspected CQC registered location CQC location ID Regency Ward Caburn Ward Pavilion Ward Amberly Ward Bodiam Ward Coral Ward Jade Ward Amber Ward Maple Ward Rowan Ward Mill View Hospital Department of Psychiatry Langley Green Hospital Meadowfield Hospital RX213 RX2E7 RX2P0 RX277 Woodlands Ward Woodlands Ward RX2L6 Oaklands Centre for Acute Care Oaklands Ward RX26N This report describes our judgement of the quality of care at this provider. It is based on a combination of what we found when we inspected, information from our Intelligent Monitoring system, and information given to us from people who use services, the public and other organisations. 1Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

19 Summary of findings Mental Health Act responsibilities and Mental Capacity Act/Deprivation of Liberty Safeguards We include our assessment of the provider s compliance with the Mental Health Act and Mental Capacity Act in our overall inspection of the core service. We do not give a rating for Mental Health Act or Mental Capacity Act; however, we do use our findings to determine the overall rating for the service. Further information about findings in relation to the Mental Health Act and Mental Capacity Act can be found later in this report. 2Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

20 Summary of findings Contents Summary of this inspection Overall summary 4 The five questions we ask about the services and what we found 6 Our inspection team 7 Why we carried out this inspection 7 How we carried out this inspection 7 Information about the provider 8 What people who use the provider's services say 9 Good practice 9 Areas for improvement 9 Detailed findings from this inspection Findings by main service 11 Action we have told the provider to take 19 Page 3Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

21 Summary of findings Overall summary The service had taken most of the action that we required them to take following the September 2016 inspection. The most notable exception was that the trust had not ensured that all staff had undertaken mandatory training. We found the following issues that need to improve: All staff had access to mandatory training. However this core service did not meet the trust s own 75% mandatory training compliance target in four out of 22 subjects. The trust monitored training through a RAG (red, amber green) rating scale to monitor progress across all mandatory training subject areas for all trust services. Wards generally followed National Institute for Health and Care Excellence guidance and the trust s rapid tranquilisation policy when monitoring patients physical health after administration of rapid tranquilisation. However there were gaps on three physical health monitoring records across Coral, Amber and Pavilion wards, so these did not demonstrate that these checks had been carried out. Although medicines management practice was generally satisfactory across all of the wards, on Amber ward an audit carried out in March 2017 indicated that in 33 (48%) of the medicine administration charts there was an error. Eleven out of 12 wards we inspected demonstrated learning from incidents. However, a patient had set fire to their room on Woodlands ward in December During our inspection we observed patients of Woodlands using their own cigarette lighters smoking in the courtyard. Staff we spoke with told us they did not encourage or enforce patients to hand in lighters following leave from the ward, or carry out searches, which did not demonstrate learning from this incident. Of all the wards we visited, Woodlands ward was the only one that had not implemented the trust smoke-free and smoking cessation policy, in place since 8 March The seclusion room on Amber ward in Langley Green Hospital did not have a mirror or closed circuit television to enable staff to monitor the blind spots in the room. The seclusion room mattress could be used by patients to block the window or the door. However, the trust had a plan in place to renovate this seclusion room. Staff on Maple ward did not record what patients were wearing prior to them leaving the ward on escorted or unescorted leave. This could have assisted staff to identify a patient if they went absent without leave in the community. This was a recommendation in the trust s leave of absence policy. However, we also found the following areas of good practice: The wards had good observation policies and procedures to minimise risks to the safety of patients. Risk assessments and risk monitoring of patients had improved and was good across all the wards. All 12 wards had developed detailed ligature risk assessments that clearly identified the risk areas and mitigation in place to minimise risks. A ligature point is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation. All wards developed a risk footprint ward map. These maps were colour coded to indicate the risks in the environment, such as ligature points and levels of staff observations required in these areas to maintain patient safety. All 12 wards were generally clean, well furnished and well maintained. Wards carried out regular infection control and prevention audits. The clinic rooms across all the wardswere clean, fully equipped with functioning equipment and emergency medicines. The trust undertook a focussed recruitment drive and wards across the core service were becoming permanently staffed. All ward managers told us that they were able to increase staffing levels daily to meet the changing needs of the patient groups across the wards, for example when there was increased risks and need for increased patient observations. 4Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

22 Summary of findings Staff told us that there was adequate medical cover on all wards day and night to attend quickly if there was a medical emergency. 5Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

23 Summary of findings The five questions we ask about the services and what we found We always ask the following five questions of the services. Are services safe? Please see above 6Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

24 Summary of findings Our inspection team Our inspection team was led by: Team Leader: Linda Burke, Inspector (mental health) Care Quality Commission (CQC) The team that inspected these services comprised of one CQC head of hospitals inspection, one CQC inspection manager, six CQC inspectors and four specialist advisors who were senior nurses with experience of working in mental health services. Why we carried out this inspection We undertook this inspection to find out whether Sussex Partnership NHS Foundation Trust had made improvements to the safety of their acute wards for adults of working age and psychiatric intensive care units since our last comprehensive inspection of the trust in September We had also received notification of the death of a person who had been cared for on the wards, and we followed up the findings of a recent Coroner inquest. We therefore needed to assess what actions the trust had taken in response to their investigations of the circumstances of these deaths. When we last inspected the trust in September 2016, we rated acute wards for adults of working age and psychiatric intensive care units as requires improvement overall. We rated the core service as requires improvement for safe, effective, responsive and well-led, and good for caring. For the purposes of this inspection, we only inspected against the Safe key question for this core service and in accordance with Care Quality Commission methodology, we will not be applying a rating for the findings from the inspection in April When the CQC inspected the trust in September 2016, we found that the trust had breached regulations. We issued the trust with three requirement notices for acute wards for adults of working age and psychiatric intensive care units. These related to the following regulations under the Health and Social Care Act (Regulated Activities) Regulations 2014: Regulation 10 Dignity and respect Regulation 12 Safe care and treatment Regulation 18 Staffing Following our last inspection, we told the trust it must take the following actions to improve acute wards for adults of working age and psychiatric intensive care units: The trust must ensure that medicines and equipment are in date and in working order. The trust must ensure that medicines prescribed to people detained under the Mental Health Act are documented and include the route of administration and the maximum dose to be administered. The trust must ensure that mandatory training compliance across all subjects meets the trust s compliance targets. This was a requirement following our inspection in September The trust must ensure that all patient risk assessments are updated and patients at risk of harm to themselves are kept safe. The trust must ensure that patients on Amber ward have access to phones to make calls in private while on the ward. The trust must ensure that sufficient action is taken to manage ligature risks to patients. How we carried out this inspection We asked the following question of the service: Is it safe? Before the inspection visit, we reviewed information that we held about these services. During the inspection we sought feedback from patients in individual and focus group settings. 7Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

25 Summary of findings During the inspection visit, the inspection team: visited all 12 of the wards at the six hospital sites and looked at the quality of the ward environments and observed how staff were caring for patients spoke with 40 patients who were using the service spoke with the managers or deputy managers for each of the wards spoke with 75 other staff members; including doctors, nurses, health care assistants, junior doctors, a physical health lead, pharmacist, occupational therapists, domestic staff and hospital matrons looked at 99 patient medicine records carried out a specific check of the medicines management on all 12 wards reviewed 72 risk assessments for patients on all wards attended two shift handovers and one ward round meeting looked at a range of policies, procedures and other documents relating to the running of the service. Information about the provider The acute wards for adults of working age and psychiatric intensive care units at Sussex Partnership NHS Foundation Trust provide 199 beds across six sites throughout Sussex. There are two psychiatric intensive care units: 12 male and female beds on Amber ward at Langley Green Hospital and 10 male beds on Pavilion ward at Mill View Hospital. The acute wards are outlined below: Mill View Hospital: Regency ward is a 20 bedded male adult mental health inpatient service. Caburn ward is a 20 bedded female adult mental health inpatient service. Pavilion ward is a 10 bedded male psychiatric intensive care unit. Department of Psychiatry, Eastbourne General Hospital: Bodiam ward is an 18 bedded male adult mental health inpatient service. Amberley ward is an 18 bedded female adult mental health inpatient service. Woodlands Conquest Hospital: Woodlands ward is a 23 bedded mixed gender adult mental health inpatient service. Oaklands Centre for Acute Care: Oaklands ward is a 16 bedded mixed gender adult mental health inpatient service. Meadowfield Hospital: Maple Ward is a 17 bedded mixed gender adult mental health inpatient service. Rowan Ward is a 17 bedded mixed gender adult mental health inpatient service. Langley Green Hospital: Amber Ward is a 12 bedded mixed gender psychiatric intensive care unit. Coral Ward is a 19 bedded mixed gender adult mental health inpatient service. Jade Ward is a 19 bedded mixed gender adult mental health inpatient service. Following our previous inspection in September 2016, we rated this core service as requires improvement. This was because: Amber ward did not meet the fundamental standards related to dignity and respect of patients (Regulation 10). The wards did not meet the fundamental standards related to safe care and treatment of patients (Regulation 12) or staff (Regulation 18). We issued requirement notices in respect of Regulation 12 and 18, and a warning notice in respect of Regulation 12 for the trust to take action. 8Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

26 Summary of findings What people who use the provider's services say Patients we spoke with generally told us that staff treated them with respect and dignity. They told us they felt safe and that staff were caring and supportive towards them. However, two patients told us that they were not involved in their care and did not understand why they could not leave their ward despite asking staff on several occasions. Patients we spoke with reported that the wards and their bedrooms were clean and that domestic staff always asked permission to clean their rooms before entering. Patients told us they found staff approachable and that there was enough staff available for them to speak with, although two patients on Amber ward told us that nurses were often busy writing notes in their offices. Patients on Coral and Jade ward told us that staff were always present and out on the wards. Good practice Staff had brought in a number of innovative practices aimed at reducing patient stress, for example use of a coping therapeutic key ring, protected patient and staff time from Monday to Friday, and a Friday pampering evening on Caburn ward. Staff used mindfulness techniques with patients while in seclusion on Pavilion ward. Staff on Regency ward use the Broset violence scale to help predict violence and aggression on the wards which helped them be better prepared to avoid incidents on the ward. Staff on Coral ward in Langley Green Hospital met every morning after handover to have a huddle meeting to review and discuss risks associated with all patients on the wards. This was also an opportunity to review observations levels and support communication regarding risk across the team. The senior managers at Langley Green Hospital told us of the quality improvement work they had undertaken with staff to reduce incidents at the service. They showed the data collated in regard to this work, which showed that incidents had reduced gradually across all three wards during the period November 2016 to February 2017.This supported a renewed effort of staff to build supportive and therapeutic relationships with patients. For example, on Jade ward there were 22 incidents in November 2016, 17 in December 2016, 15 in January 2017 and eight in February The matron in Langley Green Hospital held monthly lessons learnt sessions to enable staff to discuss changes and learnings following incidents and informed the public of these discussions via the hospital s twitter account. Areas for improvement Action the provider MUST take to improve The trust must ensure that all staff follow the trust s smoke free policy by asking patients to hand in their cigarette lighters. The trust must ensure that physical health and general observations are noted accurately for patients as required. The trust must ensure that Amber ward has an investigation and improvement plan to manage high levels of missed doses identified in the March 2017 Mind The Gap audit. The trust must ensure that all wards meet the trust s training completion targets for all mandatory training and ensure that all staff receive fire patient (onsite) training, as the compliance target rate of 65% of staff was low. 9Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

27 Summary of findings The trust must ensure that staff record eye sight observations as required according to the trust s patient observation policy. Action the provider SHOULD take to improve The trust should ensure that corridors and public areas in Mill View Hospital are routinely cleared when patients are escorted from Caburn ward to the seclusion room to protect their privacy and dignity. The trust should ensure that all patients have photographic identification on their medicine records as recommended by the trust s photographs in medication administration policy or indicate if the patient has declined to have a photograph taken. The trust should ensure that patient bedrooms are tidy on Amber ward. The trust should ensure that ligature risk assessments contain detailed narrative on how ligature risk locations on wards are mitigated by staff and the estates department. The trust should ensure that incident reports are submitted following incidents involving rapid tranquilisation. The trust should review the mattress used in the seclusion room on Amber ward to minimise risks of barricading and creating additional hazards within the room. There should also be a fully operational two way intercom, closed circuit television monitoring and convex mirrors. The trust should ensure that staff record what patients are wearing prior to them leaving the ward on escorted or unescorted leave as recommended in the trust s leave of absence policy. 10 Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

28 Are services safe? By safe, we mean that people are protected from abuse* and avoidable harm * People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse Summary of findings See under Overall Summary. Our findings Safe and clean environment We carried out a tour of each of the 12 wards. All wards were clean, well furnished and well maintained. Wards carried out regular infection control and prevention audits. We found that nine of the wards had blind spots, where staff did not have clear lines of sight of all areas. The associated risks were mitigated by use of convex mirrors, closed circuit television monitors, and staff patrols. Ward staff adjusted observation levels regularly depending on patient and ward risk. There were good lines of sight on Maple, Rowan and Oaklands wards which were monitored by staff stationed at central points on each ward. When we inspected in September 2016 the trust did not meet the fundamental standard related to safe care and treatment with regards to managing ligature risks to patients (Regulation 12). At this inspection we found the trust had taken a number of steps to make the wards safer. All 12 wards had ligature risk assessments which detailed the location and risk rating for each ligature point throughout the ward. The risk assessments noted that each risk area was mitigated by staff observation and through individual risk assessment. However, some further work was needed to ensure that details of the actions the estates department would take and deadlines when the actions would be completed by were recorded. A risk footprint ward map was displayed in 11 out of 12 nursing stations. These showed all areas of the ward, which were colour coded to indicate the risk level due to environmental issues such as ligature points, and described staff observations levels required in these areas to maintain patient safety. A risk footprint ward map was not displayed in the nursing station on Amber ward which meant there was no visual prompt to remind staff where areas of risk across the ward were situated. We raised this with the ward manager during our inspection and they arranged for a copy to be displayed immediately. Ligature cutters were clearly displayed in the nursing stations and clinic rooms across all wards. Ligature cutters were also kept with the observation recording board on Woodlands ward so a member of staff had access to these in case of an emergency during each observation round. On two wards two bathroom doors had been replaced with foam non ligature doors. All wards we inspected complied with the Department of Health Eliminating Mixed Sex Accommodation guidance. There were no breaches at the time of our inspection. The ward manager of Oaklands mixed gender acute ward told us that on the rare occasion when they had to admit a member of the opposite gender onto a same gender ward, for example a male patient onto a female ward, due to an emergency admission, they completed an incident form and the guidance breach was reported to the daily bed management meeting. The matron then prioritised a move for that patient to a more appropriate gender specific ward. Coral ward was a mixed gender ward with separate male and female sleeping wings. During our inspection there were high numbers of male patients on the ward. This meant that three male patients were admitted to the female wing. Staff assessed all three male patients as low risk with no known risks towards females. Staff mitigated risks regarding the higher number of males on the ward by carrying out intermittent observations. However, after the first day of our visit we raised our concerns with the trust that the observation levels were not sufficient to ensure risks were minimised. Staff increased the observations levels from intermittent to eyesight with immediate effect. During our last inspection, we noted that some clinical equipment was missing, broken or out of date. At this 11 Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

29 Are services safe? inspection we found that the clinic rooms across all the wards were clean, fully equipped with functioning equipment and emergency medicines which were generally checked weekly to ensure they were fit for purpose and safe to use in an emergency. Staff at Langley Green Hospital checked their emergency resuscitation equipment daily. Handwashing guidance and information for staff was displayed in all clinic room areas. Staff checked the temperatures of clinic fridges daily and we found these to be within the required range to ensure the efficacy of the medicines stored. The seclusion room on Pavilion ward in Mill View Hospital allowed for clear observation, two way communication, had toilet facilities and had a clock. However, the seclusion room on Amber ward in Langley Green Hospital did not have a mirror or closed circuit television to enable staff to monitor the blind spots in the room. The communication intercom worked, however it took staff 15 minutes to get it to work during our inspection, where the staff identified this as an intermittent fault. The seclusion room mattress could be used by patients to block the window or the door. Staff told us they called the response team if patients blocked the door and staff needed to gain entry. The ward manager informed us that the trust had an approved refurbishment plan in place to improve the condition of the seclusion room. The seclusion room on Amber ward had anti ligature clothing and blankets for patients use if necessary. Health care assistants carried out daily ward environmental risk assessments. This included checking for broken furniture and items across the wards which could be used by patients to harm themselves or others. We reviewed Langley Green Hospital s environmental security checklist which required the nominated ward shift security nurses to check items such as door security, availability of hand gel and cleanliness of the sluice rooms across the wards. However, we found laundry detergent in the locked laundry rooms on Pavilion and Caburn wards in Mill View Hospital. We brought this to the attention of the matron during our inspection. All staff across the wards carried personal alarms. We witnessed staff using alarms to signal for assistance during our inspection. In all instances we observed team members attending quickly to offer support and interventions to keep patients and staff safe. Safe staffing During our inspections in January 2015 and September 2016 the trust used high numbers of agency and bank staff due to staff shortages. The CQC recommended at the time that the trust resolve its staffing issues to ensure consistency of delivery of care to patients. In April 2017 the trust reported they had reduced vacancy levels across a number of wards following a focused recruitment drive. Three out of 12 wards had nursing vacancies lower than the trust average vacancy rate of 13% (Regency 10%, Caburn 12%, and Rowan 13%) and two out of 12 for nursing assistant vacancies (Regency and Caburn wards). However, the number of vacancies on some of the wards had reduced since our inspection in September For example, nursing vacancies on Bodiam ward had reduced from 34% to 22%. The senior manager at Langley Green Hospital told us that recent recruitment had halved their use of agency staff in the past three months. Nursing assistant vacancies on Amberley ward and Oaklands wards had reduced from 41% to 36% and from 23% to 15% respectively. All wards used the National Institute of Health and Care Excellence guide for acute hospital staffing to estimate the number and grade of nurses required on each shift. Ward managers monitored staffing levels and reported this in a monthly safer staffing report to the trust board. Numbers of staff required for each shift on the wards were matched by the numbers on shift. All wards used bank staff when needed for increased observation levels or due to staff sickness. Wards used bank staff who were familiar to the wards and the matron of Langley Green Hospital told us they offered contracts to bank staff to enable consistency in the care provided to patients. All ward managers told us that they were able to increase staffing levels daily to meet the changing needs of the patient groups across the wards, for example when there was need for increased patient observation. 12 Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

30 Are services safe? A qualified nurse was present in communal areas during all shifts, and we observed this during the inspection. Staff and patients we spoke with told us that generally there were enough staff so that patients always had regular one to one time with their named nurse. There were enough staff across the wards to carry out physical interventions such as blood pressure and temperature monitoring. During our inspection in September 2016, staff and patients told us that activities were often cancelled due to lack of staff. At this inspection staff and patients across the wards told us that escorted leave and ward activities were rarely cancelled because of improved staff levels. Staff on Caburn ward in Mill View Hospital told us that the occupational therapist supported them to carry out art and other activities with patients to offer a range of groups if other activities were cancelled due to staff sickness or annual leave. However, patients and staff we spoke with on Oaklands ward said that activities and leave were cancelled due to staff shortages approximately once a week. Staff told us that there was adequate medical cover on all wards day and night to attend wards quickly if there was a medical emergency. However, the ward manager on Caburn ward told us there was a lack of consistency with junior doctors on that ward. They had junior doctors for four months and then they had a week without any cover. The ward manager told us that longer placements would help junior doctors input into their ward. When we inspected in September 2016 the trust did not meet the fundamental standard related to staffing with regards to mandatory training (Regulation 18). At this inspection we found that improvements were still needed in this area. The trust had set a target that 75% of staff should have completed training in most of the topics that the trust had deemed as being mandatory. There were four topics for which the trust had set a target of 65%. These were fire onsite (inpatient), fire onsite (non-inpatient), Mental Capacity Act, Deprivation of Liberty Safeguards and Mental Health Act training which was 65%. The trust did not meet its 75% mandatory training compliance target across this core service in four topics. These were adult immediate life support (ILS) (73%), medicines management for registered nurses (72%), moving and handling level 2 (40%) and prevention management of violence and aggression disengagement and conflict resolution (PMVA) (41%). This core service reached the trust s compliance training target for fire onsite (inpatient) of 65%, which is a low compliance target rate. Despite this, five individual wards did not meet this target (Oaklands 63%, Maple 43%, Rowan 59%, Amberley 48%, Bodiam 38%). This was a concern that not all staff received this training following a ward fire incident on Woodlands ward in December The trust informed us that delays in staff receiving PMVA training resulted from the trust taking time to re-train their PMVA training team to deliver the approved training model. The trust also took steps to develop an in-house ILS training team to make this training more available for staff and to reduce reliance on external training providers. This development led to low numbers being trained for a period of time leading up to our inspection, however a full training programme is now available for staff to attend. Each ward had a training champion who acted as a lead to ensure staff access the new training programme to ensure higher completion levels across all wards. The trust introduced a RAG (red, amber green) rating scale to monitor progress across all mandatory training subject areas for all trust services. This enabled managers and subject leads to identify areas which failed to meet the required standards and monitor improvements against agreed plans. The reports included the overall percentages and those for specific subjects.the executive team received weekly reports against which progress was monitored. Reports were presented to the executive assurance committee and trust board. Assessing and managing risk to patients and staff There were two seclusion rooms across this core service, one each on Pavilion and Amber psychiatric intensive care units (PICU) for the formal seclusion of patients. Between October 2016 and March 2017 there were 30 incidents involving seclusion for adult acute wards. Staff on the PICU had used seclusion on 50 occasions during the same period. Thirty-four of these had been on Pavilion ward. There were no incidents of seclusion noted for this period for patients from Amberley, Jade, Rowan and Oaklands wards. 13 Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

31 Are services safe? During the period October 2016 to March 2017 there were a total 247 incidents of restraint which involved 136 individual patients within the adult acute inpatient wards. Within the PICU wards, there were 63 incidents involving 34 individual patients for the same period. Woodlands and Caburn wards had the highest levels of restraint during this period with 57 and 47 incidents recorded respectively. The Department of Health s 2014 guidance Positive and Proactive Care states that providers should work to reduce the use of all restrictive interventions and focus on the use of preventative approaches and deescalation. At the time of inspection, across the trust acute wards, 21 of the restraint incidents involved 15 different patients using the prone (face down) position for six months to March 2017 (which was a reduction from 23 in the six months to September 2016). Across both PICU wards there were 16 restraint incidents with 12 different patients in the prone position for the same period. Pavilion ward had the highest level of restraint with nine recorded incidents. During the period October 2016 to March 2017 there were 105 incidents of rapid tranquilisation across the acute wards. During the same period, there were 15 incidents of rapid tranquilisation in the two PICU wards. The pharmacist in Mill View Hospital showed us a new medicine chart they had introduced since our inspection in September The new chart supported improvements in medicines management by offering staff guidance on how and when to review patients after the administration of intramuscular rapid tranquilisation. This practice was also monitored using a new internal inspection tool. Since our inspection in September 2016, the trust had introduced the practice of only validating intramuscular rapid tranquilisation prescriptions for a period of 96 hours. If the medicine was not used, then the responsible clinician cancelled the prescription. This was a significant change from the practice we reviewed during our September inspection when all patients were prescribed this medicine throughout their admission without clinical review to review the prescribing rationale. Wards generally followed National Institute for Health and Care Excellence guidance and the trust s rapid tranquilisation policy when monitoring patients physical health after nursing staff administered rapid tranquilisation. For example, carrying out physical observations at required intervals and observing approved minimum observations if the patient refused physical observations. However, some improvements were still needed in this area. On Pavilion ward the staff monitored the physical health of a patient following administration of rapid tranquilisation according to the trust s approved intervals, however the staff had not noted the timings of each observation. On Bodiam ward staff had not written up or submitted an incident form following an incident resulting in the rapid tranquilisation of a patient. We raised this with the ward manager during our inspection. On Rowan Ward we reviewed one patient record detailing physical observations made after the patient was administered rapid tranquilisation. On Jade ward one patient was administered with rapid tranquilisation. However, staff had not carried out any physical health observations during the first 90 minutes following the incident, as per the trust s rapid tranquilisation policy. On Amber ward staff recorded one patient s respiration levels but not their consciousness levels which should have been noted together as a minimum as the patient refused fuller health monitoring. This was not in accordance with the trust s rapid tranquilisation policy. Furthermore, staff recorded the patient s respiration levels on the seclusion records rather than on the physical health and rapid tranquilisation charts where they should have recorded the observation levels. When we inspected in September 2016, we found that the trust did not meet the fundamental standard related to safe care and treatment with regards to updating patients risk assessments following incidents (Regulation 12). When we inspected in in April 2017, we found that the trust had improved risk assessment and monitoring of patients across all the wards we visited. We reviewed 72 patient risk assessments. All patients were risk assessed by the consultant and lead nurse on admission using a risk assessment template on the trust s electronic system which was reviewed regularly. The risk assessments we reviewed were generally comprehensive, had clear risk management plans and were reviewed by staff regularly. Staff updated patients risk assessments with identified risks following incidents across the wards which were clearly reflected in patients care plans. However, one out of six risk 14 Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

32 Are services safe? assessments we reviewed on Caburn ward did not contain any detail of risks identified for the patient. We raised this with the matron and ward manager during our inspection. Staff on Coral ward in Langley Green Hospital met every morning after handover to have a huddle meeting to review and discuss risks associated with all patients on the wards. This was also an opportunity to review observations levels and support communication regarding risk across the team. Staff on Regency ward in Mill View Hospital trialled the use of the Broset Violence Checklist which assisted staff to predict imminent patient violent behaviour. Members of the ward team met each morning after handover to rate the observed behaviour of each patient on the ward. Staff formulated aggression management plans for patients who scored over a certain threshold for the coming shift. The consultant was involved in discussions if additional medicines were required. These meetings enabled staff to be prepared in the event of a patient becoming violent during the next shift and to identify which patients may need to move to more intensive observation in the psychiatric intensive care units. Staff on Regency ward said they built rapport quickly with patients and found that information sharing using the Broset checklist increased their confidence in managing aggression on the ward. The trust has sought to avoid blanket rules and the decision to allow patient s access to belongings that could potentially be used for self-harm, such as belts, is based upon individual risk assessment and safety planning. Staff reviewed risk assessments throughout patients admissions to ensure it was safe for them to have particular belongings, such as belts, and this was communicated to patients. Staff discussed risks associated with belts with patients, for example, in community meetings where some patients had their belts and some did not following risk assessments. This meant that patients could discuss the importance of keeping each other safe. A list of banned items, such as knives, scissors, drugs and alcohol, was displayed in each ward and was noted in the patient s handbooks Each ward entrance door displayed a sign explaining the rights of informal patients who wanted to leave the ward. Informal patients were able to leave the wards after discussion and risk assessment with the most senior member of nursing staff on duty. However, staff on Maple ward did not record what patients were wearing prior to them leaving the ward on escorted or unescorted leave.this could have assisted staff to identify a patient if they went absent without leave in the community. This was a recommendation in the trust s leave of absence policy. Maple, Rowan and Oaklands wards had open ward policies where the ward doors were unlocked unless patients were assessed as being at risk of leaving the ward without appropriate authorised leave. The door to Oaklands ward was locked on the day of our inspection to manage the safety of a patient who was assessed as being a high risk of leaving the ward un-supervised/without appropriate leave. The doors to Amberley and Bodiam wards were open to allow patients to move freely from their ward area to the communal hospital area. All wards had good observation policies and procedures. All new members of staff, including bank staff and agency staff, completed an observation skills and knowledge test to demonstrate that they understood the trust s observation policy prior to working on the wards. The test examined staff s understanding of different levels and types of observation used on the wards and how to observe patients when they were asleep. The tests were signed off by the nurse in charge. All staff we spoke with told us that all patients were placed on eyesight observations on admission until they were assessed by the consultant who then reviewed the observation levels required according to patient risk. However, we did not see that eye sight observation levels were recorded for patients immediately following their admission to Coral ward. We noted that one entry for each of two patients on Regency, who were on intermittent observation levels, was not made in their notes. Staff told us they reviewed patient observation levels in daily morning handover meetings and reviewed them throughout each shift. The health care assistants we spoke with in Mill View Hospital told us about their role in carrying out patient observations across the wards. They felt that their feedback to the wider team was valued and was added to risk management discussions at a senior level with the consultants and ward managers, for example to increase observations if there were concerns about a patient s safety. 15 Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

33 Are services safe? Two members of staff, who were the same gender as the patient being searched, searched patients belongings and clothing on admission and on return from ward leave using hand pat search technique over the patients clothing. Staff on Regency ward in Mill View Hospital told us they carried out more searches on patients to ensure they were not carrying lighters on the ward following the smoking ban recently introduced by the trust. However, staff on Woodlands ward told us they did not encourage patients to hand in their cigarette lighters after returning from leave despite this being a risk item on the ward and following a ward fire incident in December We raised this with the trust at the time of our inspection as this did not indicate learning following the previous fire incident. Staff we spoke with told us that they used de-escalation techniques including verbal communication and distraction techniques, such as use of the calm room, before restraint was used as a final option with patients. The psychologist on Caburn ward developed a coping keyring which staff used with patients. The keyring consisted of a number of small credit card sized cards which listed distraction techniques for patients to use alone or with the assistance of staff. Techniques included relaxation breathing exercises, encouraging statements, and lists of activities to do such as walking and reading. We reviewed four patient seclusion records on Pavilion and Amber wards. The seclusion paperwork was generally in good order and included details of physical health monitoring. We saw evidence that staff spoke with patients after periods of seclusion to discuss the incident and agree how further seclusion could be avoided. At Mill View Hospital staff escorted patients from Caburn ward along two corridors, through the hospital reception and past the hospital café to the seclusion room which was situated close to Pavillion ward. Staff we spoke with told us that, whenever possible, members of staff cleared the corridors ahead of the patient to protect their privacy and dignity. The trust submitted 16 safeguarding referrals for the wards we inspected between October 2016 and March 2017.Staff we spoke with knew how to make a safeguarding alert, and some shared examples of alerts they had made. Overall, the percentage of staff working in this core service who had completed children and adult safeguarding training was above the trust target of 75%. However, four out of 12 individual wards had children safeguarding level 3 training completion levels below the trust target of 75% (Oaklands ward 59%, Maple ward 55%, Coral ward 71%, and Amberley ward 67%). We reviewed 99 patients medicine records. There was generally good medicines management practice across all of the wards. This included how staff stored, dispensed and reconciled patients medicines. Pharmacists visit the wards most days and assisted in weekly and monthly audits. They also attended ward rounds to assist with reviews of patients medicines. Staff at Mill View Hospital and Langley Green Hospital told us that two nurses audited each other s medicine charts at the end of each shift to ensure that any errors, such as missing signatures, were corrected as a matter of urgency. However, we noted a date error that had not been picked up in these checks of the medicine chart for one patient on Amber ward, where staff wrote that a patient had received medicines twice on one day instead of on two consecutive days. Pharmacists carried out Mind The Gap audits on all wards to monitor missed doses and recording errors. On Amber ward an audit carried out in March 2017 indicated that in 33 (48%) of the medicine administration charts there was an error. We did not see evidence of an investigation or improvement plan to improve the outcomes. We raised this with the ward manager during our inspection. The pharmacist at Mill View Hospital told us they carried out internal inspections at six weekly intervals to review medicines management and physical healthcare focussing on issues such as medicines storage, evidence of patient falls plans being in place, and if medicine was administered at clinically approved intervals. The internal inspection identified that nurses did not always check previous doses administered to patients. This was raised as an incident on their electronic recording system and was discussed with the nurses in supervision and reflective practice. Patient photographs were not attached to four out of 17 medicine charts on Maple ward and two out of 15 charts on Oaklands. The charts also did not note why there 16 Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

34 Are services safe? were no photographs present. The trust s photographs in medication administration policy recommended that all medicine charts should have patient photographs to assist in the reduction of medicine errors. Mill View Hospital had a family visiting room. All visits were risk assessed and visits involving children were raised with the safeguarding team. Track record on safety There were 15 serious incidents during the period October 2016 to March All ward managers had incident sheets which displayed times, days, locations, types of incidents which enabled ward managers to identify trends in incidents occurring across the wards. Each serious incident form we reviewed noted event timelines, severity and likelihood of incident reoccurrence, and learning for each ward to ensure improved safety for patients, including the need for improved information sharing. The senior managers at Langley Green Hospital told us of the quality improvement work they had undertaken with staff since the last inspection to reduce incidents at the service. They showed the data collated in regard to this work, which showed that incidents had reduced gradually across all three wards during the period November 2016 to February This supported a renewed effort of staff to build supportive and therapeutic relationships with patients. For example, on Jade ward there were 22 incidents in November 2016, 17 in December 2016, 15 in January 2017 and 8 in February Reporting incidents and learning from when things go wrong Staff received feedback and de-briefs from ward managers following investigations and incidents. This was done immediately after an incident, in fortnightly team meetings, weekly reflective practice sessions and in written business bulletins. A serious incident occurred during our inspection. One ward manager explained to us that staff involved in the incident were de-briefed immediately after the event to ensure they were safe to return to work and a management briefing was held two hours after the incident to review actions taken and what could have been done differently. The matron in Langley Green Hospital held monthly lessons learnt sessions to enable staff to discuss changes and learnings following incidents and informed the public of these discussions via the hospital s twitter account. All substantive staff we spoke with knew how to recognise and report incidents on the trust s electronic recording system. Bank staff told us how they reported incidents to senior staff and assisted them during the reporting process. Ward managers reviewed all incidents and forwarded them to the appropriate general manager and matron who passed them to the patient safety team for further review. This system ensured that senior managers within the trust were alerted to incidents in a timely manner and monitored the investigation responses. Ward managers used incident information to monitor for themes in incidents, for example falls, aggression, ill health. The wards we inspected demonstrated learning from incidents. For example, the trust installed a security air lock to Caburn ward s entrance door following a review of a number of incidents when patients went absent without leave and where there were threats to patient safety from a small number of patients visitors. Caburn ward also noted that there was an increase of incidents on Friday evenings following new patient admissions. In response to this the occupational therapy team developed and introduced a Friday pamper evening for patients which included beauty treatment sessions and hot chocolate drinks in a relaxed and calm environment. Staff we spoke with reported a reduced number of weekend incidents following the introduction of this new programme which also encouraged patient selfcare. The trust replaced bathroom doors in two rooms with non-ligature foam doors on Woodlands and Caburn wards following incidents of self-harm.however, there was an exception on Woodlands ward where there was a lack of learning from an incident which occurred in December 2016 where a patient had set fire to their room. During our inspection we observed patients with access to cigarette lighters on the ward following return from leave. Staff told us they did not encourage patients to hand in their lighters despite them being a risk item. There was a risk that patients with lighters in their possession on the wards could use them to set fires or self-harm. This meant there was a lack of learning or change in procedure following the fire incident to ensure patient and ward safety. 17 Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

35 Are services safe? Staff were open and transparent and explained to patients when things went wrong. We saw evidence of letters from the ward manager to two patients on Regency ward explaining the next steps in investigations into incidents they were involved in. 18 Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

36 This section is primarily information for the provider Requirement notices Action we have told the provider to take The table below shows the legal requirements that were not being met. The provider must send CQC a report that says what action they are going to take to meet these requirements. Regulated activity Assessment or medical treatment for persons detained under the Mental Health Act 1983 Diagnostic and screening procedures Treatment of disease, disorder or injury Regulation Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment Staff on Coral ward did not record eyesight observations made on patients following their admission to the ward prior to the patient s observation review with the ward consultant. Staff did not record observation times for two patients on intermittent observation levels on one occasion on Regency ward. Patients on Woodlands ward had access to cigarette lighters despite the trust having a smoke-free policy and following a fire incident on the ward in December Staff on Jade and Amber wards did not always ensure that physical health and general observations were recorded accurately for patients. Amber ward did not have an investigation or improvement plan to monitor the high levels of missed medicine doses identified in the March 2017 Mind The Gap audit carried out by the ward pharmacist. This is a breach of Regulation 12 (2)(a)(b) and (g) Regulated activity Assessment or medical treatment for persons detained under the Mental Health Act 1983 Diagnostic and screening procedures Treatment of disease, disorder or injury Regulation Regulation 18 HSCA (RA) Regulations 2014 Staffing This core service did not reach the trust s training completion target in four out of 22 mandatory training subjects. 19 Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

37 This section is primarily information for the provider Requirement notices This is a breach of Regulation 18 (2)(a) 20 Sussex Partnership NHS Foundation Trust Quality Report This is auto-populated when the report is published

38 WORKING AGE ADULT INPATIENT WARD - MUST DO S SAFE Regulatory Breach Improvement Action Required Assurance Current Status / Next Steps By Whom By When Regulation 12 (2) (a)(b) and (g) Working Age Adult Inpatient Services Staff on Coral Ward did not record eyesight observations made on patients following their admission to the ward prior to the patients observation review with the ward consultant. Staff did not record observation levels for two patients on intermittent observation levels on one occasion on Regency Ward. Ensure that staff record eyesight observations as required according to the Trust s patient observation policy. Regency and Coral ward review and improvement plan is received by the CDS Leadership teams and shared across all CDSs All wards can evidence that the staff have received the confidential briefing and staff can explain the key learning points and are familiar with their responsibilities within the observation policy. The new observation policy is rolled out with records that staff have received the policy and complete the knowledge and skills checklist. Undertake a review of the observations on Coral and Regency wards and agree an improvement plan with assurance included. Recirculate SI confidential briefing to all wards and request confirmation that ward staff and MDT are familiar with the contents and the requirements of the Observation policy. Roll out revised Observation policy including the revised knowledge and skills checklist. Ward staff to confirm they have received a copy of the policy, understand their responsibilities and complete the knowledge and skills checklist. Clinical Lead Nurse/General Manager Deputy Chief Nurse Associate Director of Nursing Ward Managers 31 June June June July 2017 Training records confirm staff have completed training. Nurse in charge will ensure that observations are properly undertaken and records are fully completed for each shift. General Manager 15 June 2017 Random audits of observation record sheets Patients on Woodlands ward had access to cigarette lighters despite the Trust having a smoke free policy and following a fire on the ward in December Ensure that all staff follow the Trust s smoke free policy by asking patients to hand in their lighters. Woodlands progress report and current status received by CDS Leadership team. Local reviews are presented at the Smoke Free Steering group Each hospital/unit has a revised implementation/support plan. Report on progress with the action plan developed during the CQC inspection for Woodlands and report to the CDS Leadership team and CQC Project Team Reiterate the smoke free policy Each hospital unit to review their progress with the implementation and impact of the smoke free policy for presentation and discussion at the smoke free group Director of innovation and Improvement General Managers General managers 9 June June 2017 The smoke free policy is revised in light of feedback and experience Identify risks and challenges to implementation of the smoke free policy with each hospital developing a local improvement plan where indicated. Director of innovation and Improvement 9 June 2017 Staff on Jade and Amber wards did not always ensure that physical health and general observations were recorded accurately for patients. Ensure that physical health and general observations are noted accurately for patients as required. Audit of physical health records and NEWS post implementation Review smoke free policy in light of 3 months experience To review recording of physical health on Jade and Amber wards Care notes physical assessment module is now in place. The Trust has a programme for migrating from MEWS to NEWS which provides guidance to each area. Matron/Clinical Nurse Lead Head of Digital Development Associate Director of Nursing 30 July June 2017 In place In place Ward rounds will include a review of physical health in each ward The Physical Health Governance group will undertake an audit of physical healthcare. Associate Medical Director Associate Director of Nursing 30 June Sept Amber ward did not have an investigation or improvement plan to monitor the high levels of missed medicine doses identified in March 2017 Mind the Gap audit carried out by the ward pharmacist. Ensure that Amber ward has an investigation and improvement plan to manage the high level of missed medicine doses identified in the mind the gap audit Mind the Gap progress is reviewed by the local leadership teams and monitored by senior pharmacists with a monthly report presented to DTG and CDS Leadership Teams Amber ward had 2 gaps in April (33 in March) Apply a zero tolerance policy with charts reviewed in handovers Prescriptions Review each months Mind the Gap report with ward managers and adopt a QI approach monitored through trust wide run chart/s Clinical Nurse Lead LGH. Matrons Lead Pharmacist Matrons, Ward Pharmacists and AD- QI 31 July 2017

39 Regulation 18 (HSCA (RA) Regulations 2014 Staffing Working Age Adult Inpatient Services The core service did not reach the Trust s training and completion target on four of 22 mandatory training subjects. Ensure that all wards meet the Trust s training completion targets for all mandatory training and ensure that all staff receive fire patient (on-site) training as the compliance target of 65% of staff was low. Weekly my learning reports to Exec Mgt Team and CDSs. My Learning reports available to managers My learning reports are sent to CDS Leads on a weekly basis My learning performance reports are now established across the Trust as the single record of mandatory training compliance. The completion target is set at 85% (RAG rating; <65=R, 65-85=A, >85%=G) a The My learning team have established a process for amending reports where errors exist eg incorrect hierarchy and staff list errors. Head of Operations, Education and Training Executive Leadership Team Head of Operations, Education and Training In-place In-place In-place Addition trainer capacity has been provided to address limited capacity In-place Staff receive notification of pending lapses 3 months advance CDS leads mandate all staff to ensure mandatory training is prioritised to achieve target completion rate. Review those subjects and teams that fail to meet the 85% target and develop an improvement plan through a review workshop with CDSs and Subject leads. NB initial focus on safety related subjects as highlighted Head of Operations, Education and Training Service Directors Subject leads Head of Operations, Education and Training and AD QI In-place 30 June June 2017

40 Developmental reviews of leadership and governance using the well-led framework: guidance for NHS trusts and NHS foundation trusts June 2017

41 Delivering better healthcare by inspiring and supporting everyone we work with, and challenging ourselves and others to help improve outcomes for all. 2 Developmental reviews of leadership and governance using the well-led framework

42 Contents 1. Introduction 4 2. About this guidance 5 3. Managing reviews 8 4. The well-led framework and descriptions of good practice 10 Annex A: Scoping your developmental review 42 Annex B: Commissioning an external facilitator 45 Annex C: Carrying out a developmental review 47 Annex D: Accessing support and further reading 50 3 Developmental reviews of leadership and governance using the well-led framework

43 1. Introduction The boards of NHS foundation trusts and NHS trusts (referred to from here on as providers) are responsible for all aspects of the leadership of their organisations. They have a duty to conduct their affairs effectively and demonstrate measurable outcomes that build patient, public and stakeholder confidence that their organisations are providing high quality, sustainable care. Providers are operating in challenging environments characterised by the increasingly complex needs of an ageing population, growing emphasis on working with local system partners to create innovative solutions to longstanding sustainability problems, workforce shortages and the slowing growth in the NHS budget. As set out in Developing people improving care, these challenges require changes in how leaders equip and encourage people at all levels in the NHS to deliver continuous improvement in local health and care systems and gain pride and joy from their work. Robust governance processes should give the leaders of organisations, those who work in them, and those who regulate them, confidence about their capability to maintain and continuously improve services. In-depth, regular and externally facilitated developmental reviews of leadership and governance are good practice across all industries. Rather than assessing current performance, these reviews should identify the areas of leadership and governance of organisations that would benefit from further targeted development work to secure and sustain future performance. The external input is vital to safeguard against the optimism bias and group think to which even the best organisations may be susceptible. We therefore strongly encourage all providers to carry out externally facilitated, developmental reviews of their leadership and governance using the well-led framework every three to five years, according to their circumstances. 4 Developmental reviews of leadership and governance using the well-led framework

44 2. About this guidance This guidance on our updated well-led framework for leadership and governance developmental reviews sets out the process and content of these developmental reviews. It supports providers to maintain and develop the effectiveness of their leadership and governance arrangements. It replaces Well-led framework for governance reviews: guidance for NHS foundation trusts (April 2015), and applies to both NHS trusts and foundation trusts The guidance retains a strong focus on integrated quality, operational and financial governance and includes a new framework of key lines of enquiry (KLOEs) and the characteristics of good organisations. It provides strengthened content on leadership, culture, system-working and quality improvement. In a change from previous frameworks, and in support of our commitment to working more closely with our regulatory partners, the structure of our framework (KLOEs and the characteristics) is wholly shared with the Care Quality Commission (CQC), and underpins CQC s regular regulatory assessments of the well-led question. This means that information prepared for regulation can also be used for development, and vice versa. The main elements of this framework are also reflected in NHS England s improvement and assessment framework for clinical commissioning groups (CCGs). However, while CQC s regulatory assessments are primarily for assurance, developmental reviews are primarily for providers themselves to facilitate continuous improvement. Drawing on the latest research and evidence, we also describe updated good practice to help providers identify their own areas for development and key barriers to overcome. This good practice is not a checklist: a mechanical ticking off of each item is unlikely to lead to better performance. The attitude of organisational leaders to the review process, the connections they draw between the framework s different areas, and their judgements about what needs to be done to continually improve, are much more important. 5 Developmental reviews of leadership and governance using the well-led framework

45 We therefore strongly encourage providers to engage with the review processes openly and honestly, selecting an external facilitator to provide tailored support and prioritise actions arising from reviews. We also encourage providers to make more use of peer review, to utilise and enhance skills within the NHS, draw on learning from others and share learning back with the system. This is how providers individually and together will gain the greatest benefit from these reviews. A note on system working We know the increasing focus on working with partners across health and social care, for example in sustainability and transformation partnerships (STPs), creates a tension for providers as they continue to work on organisational performance as part of wider system performance. We maintain our focus on organisations because this is the statutory basis for service provision, but we have increased the emphasis in this guidance on working proactively with partners. Many of the principles of good governance at organisational level are applicable at system level and we encourage local system partners to use this framework for development if it is appropriate. 6 Developmental reviews of leadership and governance using the well-led framework

46 How to use this guidance: comply or explain This guidance is issued on a comply or explain basis. This means we strongly encourage providers to carry out developmental reviews or equivalent activities approximately every three years to ensure they identify potential risks before these turn into issues. Better performing providers are probably already doing this, and, for example, using internal audit functions to work on particular areas of concern. In keeping with the Single Oversight Framework we use to identify the level of support providers need, we are providing extra flexibility based on individual circumstances. This means we can agree longer timeframes for review (up to a maximum of five years) where risks seem lower and shorten the timeframe where risks seem higher, or where particular circumstances suggest a review may be necessary (eg significant turnover of board members, organisational transactions, or significant deterioration in some aspect of performance). On that basis: Comply means we strongly encourage all providers to carry out developmental reviews every three years or within the agreed timeframe agreed with NHS Improvement using this guidance. Explain means a provider needs to give a considered explanation if it uses alternative means to assure itself regarding its leadership and governance or chooses to omit material components of the framework (eg one or more of the eight KLOEs). Departing from the guidance may be justified where a provider can demonstrate it is meeting the actions expected under the guidance in a similar manner, for example partial reviews over consecutive years. We will always consider the circumstances of an individual case. 7 Developmental reviews of leadership and governance using the well-led framework

47 3. Managing reviews This section describes the common steps of a developmental review. Providers are free to tailor their approach to suit their organisational circumstances, provided they incorporate the principal areas of enquiry set out in the framework. Annexes A to D provide further detail as noted below. Stage Initial investigation to determine scope of review (see Annex A) Notes The board should reflect on its performance with an initial investigation that involves self-review against the framework. This should identify any areas in the framework or extra areas outside the framework (eg arising from internal and external audit review findings, annual or corporate governance statements) that require particular focus as part of the review. Clarifying the scope of the review will enable the board to engage external facilitators with appropriate skills. The board should be as honest as possible in this assessment as the congruence between the provider s self-review and the external facilitator s perception can indicate the provider s level of insight. Commissioning an external reviewer (see Annex B) External facilitation is a key part of developmental reviews: it provides objectivity and challenge that may not available within the provider. Choosing an external facilitator is the provider s responsibility. As well as the skills and experience needed to address specific areas of focus arising from self-review, the provider must ensure their supplier can take a holistic view of the organisation, connecting findings from different parts of the review and supporting action-planning, including suggesting appropriate interventions. Providers should also ensure reviewers are suitably independent of the board. This includes avoiding using reviewers who have done audit or governance-related work for the provider in the previous three years, unless there are suitable safeguards against conflict of interest 8 Developmental reviews of leadership and governance using the well-led framework

48 (ie information barriers). We also encourage providers to consider involving peer reviewers as part of their external facilitation team, where appropriate, to make use of and enhance leadership and governance capability in the NHS. Detailed review (see Annex C) Following review and discussion of the initial investigation, the external facilitator should carry out detailed review against relevant aspects of the framework using a variety of methods that offer insight into the provider s leadership and governance processes. Each of the eight KLOEs should be reviewed at a basic level and rated using a scheme that allows the prioritisation of findings and guides action-planning and the escalation of any immediate concerns. External facilitators should engage with peer reviewers, where commissioned, for specialist input (for example on clinical governance, leadership, culture, improvement). Board report and action planning Letter to NHS Improvement Implementing the action plan (see Annex D) The external facilitator should work with the provider board to prioritise the review findings, and agree recommendations and developmental actions in response. These should be detailed in a report for the board. We encourage providers to agree the format of the report with their facilitator at the start of the process. Once the action-planning is done, providers should send NHS Improvement a letter confirming they have completed the review, any material issues that have been found and/or any areas of good practice that could be shared with others, for example through a case study. By far the most important part of a review is what the provider does as a result, and how this is given priority among other organisational activities. We encourage providers to draw on the support offers and resources available from agencies across the NHS and more widely (see our Improvement Hub). 9 Developmental reviews of leadership and governance using the well-led framework

49 4. The well-led framework and descriptions of good practice The well-led framework is structured around eight key lines of enquiry (KLOEs): In the pages that follow, each of the framework s KLOEs is supplemented by characteristics of good organisations, and detailed descriptions of good practice. For read-across with CQC s assessment process, we have also included the prompts that CQC inspection teams use to assess each KLOE. Each section follows the format shown on the next page. 10 Developmental reviews of leadership and governance using the well-led framework

50 Key terms used in the descriptions of good practice The board: we use this term when we mean the board as a formal body. Senior leaders: we use this term when we mean the organisation s most senior internal leaders, ie formal board executive and non-executive directors and their direct reports. Leaders across the organisation: we use this term when we mean people at all levels in the organisation (including senior leaders as defined above) who have formal responsibility for the management of others, service delivery, or particular pieces of work. Staff members: we use this term to mean everyone in the organisation. Protected characteristics: this refers to the characteristics defined in the Equalities Act Developmental reviews of leadership and governance using the well-led framework

51 KLOE 1. Is there the leadership capacity and capability to deliver high quality, sustainable care? Leaders have the experience, capacity, capability and integrity to ensure that the strategy can be delivered and risks to performance addressed. Senior leaders can evidence how the organisation has the relevant capability, experience, expertise and capacity across its leadership to manage quality, operations and finance effectively at all levels across the organisation to ensure: development and delivery of the corporate strategy and any associated strategies and plans continuous organisational development and improvement. Senior leaders across the organisation, and especially executive and non-executive board members: are clear about their roles demonstrate personal values and styles aligned with the interests of patients, carers and frontline staff, and the seven principles of public life are self-aware and seek personal development and learning prioritise safeguarding and quality. The board is stable, diverse and members function effectively as a team with: clear role definition, communication and constructive challenge appreciation of diversity of thought, experience and background awareness of how their own behaviour affects the rest of the organisation awareness of the organisation's impact on the local health economy and environment regular time out together to identify, reflect and act on success and failures. The board regularly reviews its effectiveness (performance, governance, working relationships, skills) and impact on the organisation, and acts on the findings, sharing them openly with staff, patients and the public. All board subcommittees (such as the audit committee) and subgroups carry out and act on annual self-assessments of their effectiveness. 12 Developmental reviews of leadership and governance using the well-led framework

52 The leadership is knowledgeable about issues and priorities for the quality and sustainability of services, understands what the challenges are and takes action to address them. Senior leaders, especially board members, are able to describe: the quality, operational and financial issues and challenges the organisation faces, and the priorities within these the underlying reasons for these challenges, with reference to wider system factors and benchmarking what the organisation is doing to address these challenges and monitor progress in the short, medium and long term. Senior leaders can evidence that they engage and are encouraged to engage in rigorous and constructive challenge of each other on governance processes, including but not limited to the teams and executives responsible for them. The chair and non-executive directors participate fully in this challenge and review process, both through the board and by taking part in relevant board subcommittees (such as the audit committee) and subgroups. Compassionate, inclusive and effective leadership is sustained through a leadership strategy and development programme and effective selection, development, deployment and support processes and succession-planning. Senior leaders can evidence that the organisation takes a strategic approach to developing leadership and managing talent to ensure there are enough appropriately skilled, diverse and system-focused leaders to deliver high quality, effective, continuously improving, compassionate care. Senior leaders can evidence that a leadership strategy and succession plan are in place and regularly reviewed, based on quantitative and qualitative data. They should cover clinical and managerial leadership positions at board level and key roles below board level (such as clinical, operational, finance leads). Senior leaders can evidence that leadership development, coaching and mentoring programmes are accessible to leaders and potential leaders at all levels and support the development of high quality, sustainable care cultures by: bringing together clinical and managerial staff supporting team-working and system-working Continues Developmental reviews of leadership and governance using the well-led framework

53 ensuring leaders gain a broader systems perspective (for example through the use of secondments or stretch assignments) ensuring there is a balance of experiential learning alongside coaching and classroom-based learning focusing on knowledge, skills, attitudes and behaviours ensuring that those with protected characteristics are represented in the take up of development opportunities Leaders at every level are visible and approachable. Leaders across the organisation are described by staff members as visible, approachable and welcoming challenge. They are accessible through different channels (such as surveys, focus groups, workshops, patient safety walkabouts and approaches such as the 15 steps challenge). Senior leaders can evidence how their approach enables them to understand the issues staff face, and identify and address blocks to improvement. CQC inspection teams will consider the following prompts as part of their assessments in relation to this KLOE: W1.1 Do leaders have the skills, knowledge, experience and integrity that they need both when they are appointed and on an ongoing basis? W1.2 Do leaders understand the challenges to quality and sustainability and can they identify the actions needed to address them? W1.3 Are leaders visible and approachable? W1.4 Are there clear priorities for ensuring sustainable, compassionate, inclusive and effective leadership, and is there a leadership strategy or development programme, which includes succession planning? 14 Developmental reviews of leadership and governance using the well-led framework

54 KLOE 2: Is there a clear vision and a credible strategy to deliver high quality, sustainable care to people, and robust plans to deliver? There is a clear statement of vision and values, driven by quality and sustainability. It has been translated into a robust and realistic strategy and well-defined objectives that are achievable and relevant. Senior leaders can evidence that there is a clear, well-thought out, comprehensive picture of how the organisation s services will look in the future, centred on the people who use services and their carers, and they have mapped a route to achieving this. This is supported by a vision and values that present a clear and compelling picture of patient and service user centred care in the context of the wider local health and care system. Senior leaders can evidence a clear focus on continuous improvement, staff and user engagement and ambitions to be a learning organisation in a wider learning system. Senior leaders can evidence how the organisation s key quality, operational and financial priorities have informed the development of the strategy, which has a small number of clear quality, operational and financial objectives that steer the organisation sustainably towards its vision. The strategy covers: safety, clinical outcomes, patient experience, workforce capacity and capability productivity and efficiency, affordability, financial performance the organisation s part in delivering the priorities of the local health and care economy sustainable development in relation to the environment staff health and wellbeing. 15 Developmental reviews of leadership and governance using the well-led framework

55 The strategy is aligned to local plans in the wider health and social care economy and services are planned to meet the needs of the relevant population. Senior leaders can evidence that the organisation s strategy clearly articulates the shared purpose and principles for working with other organisations, and the system s goals in the wider local and national context: the organisation s strategy should be aligned to plans for sustainability and transformation across the wider local health and care economy there should be an explicit link to the multiyear plans to maintain or achieve clinical and financial sustainability across the wider local health and care economy there is a narrative on how the organisation plans to respond to key NHS initiatives on quality, operational productivity and sustainability there is a narrative on how the organisation will meet the needs of and work to improve wider population health. Staff in all areas know, understand and support the vision, values and strategic goals and how their role helps in achieving them. Senior leaders can evidence how the strategy, vision, values and goals across quality, operations and finance have been shared and promoted across all parts of the organisation, supported by an appropriate communication plan. Staff members can explain the organisation s goals and initiatives to others when asked, and their own part in delivering the aspects relevant to them. External partners, including commissioners, key patient groups and service delivery partners, can describe the goals and initiatives relevant to them, and how they support delivery of local health and care economy and/or national priorities. 16 Developmental reviews of leadership and governance using the well-led framework

56 The vision, values and strategy have been developed through a structured planning process in collaboration with people who use the service, staff and external partners. Senior leaders can evidence that a structured approach has been taken to strategy development, integrating quality, operations (including workforce capacity) and finance. This includes evidence of how the organisation has understood: its current operating environment, its current weaknesses, and the future for which it needs to plan, both in a local health and care context, and in response to national priorities the goals and objectives that arise from this the determinants of its quality, operational and financial performance the options for change and how these are prioritised over the short, medium and long term (for example one year, two to five years and over five years), so that short-term responsiveness contributes to longer term aims. This also includes evidence of how it has planned to implement the proposed solutions and review the approach/adapt to a changing environment. Senior leaders can evidence how they have identified stakeholders and involved them in developing the strategy. This will include at least: people who use the services and their representatives staff external partners (such as health and local authority commissioners, other health and care providers, local Healthwatch, local politicians and MPs). These stakeholders are able to describe how their involvement has influenced the outcomes of the strategy development process. 17 Developmental reviews of leadership and governance using the well-led framework

57 Progress against delivery of the strategy and local plans is monitored and reviewed, and there is evidence of this. Quantifiable and measurable outcomes support strategic objectives, which are cascaded throughout the organisation. The challenges to achieving the strategy, including relevant local health economy factors, are understood and an action plan is in place. Senior leaders can evidence how the organisation s strategic goals and objectives, reflecting those of the local health and system, are cascaded through the organisation by informing the objectives and performance targets for business units, teams and staff members. Senior leaders can evidence that there are detailed delivery plans; progress against them is monitored and aggregated in a structured way, and the board and local health and care economy leaders regularly discuss and respond to them as appropriate, focusing on delivering the strategic goals and objectives. Senior leaders can explain and evidence how the strategy is regularly reviewed and refreshed, if needed, to ensure that it remains achievable and relevant. CQC inspection teams will consider the following prompts as part of their assessments in relation to this KLOE: W2.1 Is there a clear vision and a set of values, with quality and sustainability as the top priorities? W2.2 Is there a robust realistic strategy for achieving the priorities and delivering good quality, sustainable care? W2.3 Have the vision, values and strategy been developed using a structured planning process in collaboration with staff, people who use services, and external partners? W2.4 Do staff know and understand what the vision, values and strategy are, and their role in achieving them? W2.5 Is the strategy aligned to local plans in the wider health and social care economy, and how have services been planned to meet the needs of the relevant population? W2.6 Is progress against delivery of the strategy and local plans monitored and reviewed and is there evidence to show this? 18 Developmental reviews of leadership and governance using the well-led framework

58 KLOE 3 Is there a culture of high quality, sustainable care? Leaders at every level live the vision and embody shared values, prioritise high quality, sustainable and compassionate care, and promote equality and diversity. They encourage pride and positivity in the organisation and focus attention on the needs and experiences of people who use services. Behaviour and performance inconsistent with the vision and values are acted on regardless of seniority. Senior leaders can evidence that there is a compelling vision and a clear set of values across the organisation, with staff members demonstrating their commitment to high quality, effective, continually improving, compassionate and sustainable care. Senior leaders can evidence that staff recruitment, promotion and appraisal processes are aligned with the organisation s vision and values and behaviours and reinforce a culture of inclusive, diverse leadership. Leaders across the organisation develop positivity, pride and identity across the organisation through, for example: celebrating the successes of teams and individuals, including rewarding staff who consistently deliver care or perform beyond expectation emphasising how the work makes a difference to patients and the community building a sense of positivity about the future. Staff survey results demonstrate high levels of positivity and pride. Leaders across the organisation celebrate behaviour consistent with the organisation s vision and values, and address behaviour which is contrary to them, wherever and at whatever level this behaviour occurs. Senior leaders can evidence that there is a comprehensive induction programme for all staff groups (including junior doctor and agency staff) derived from the vision, values and strategy. Senior leaders can evidence that the provider has a culture of integrity and probity, including fraud awareness and prevention and appropriate standards of business conduct. 19 Developmental reviews of leadership and governance using the well-led framework

59 Candour, openness, honesty, transparency and challenges to poor practice are the norm. The leadership actively promotes staff empowerment to drive improvement, and raising concerns is encouraged and valued. Staff actively raise concerns and those who do (including external whistleblowers) are supported. Concerns are investigated sensitively and confidentially, and lessons are shared and acted on. When something goes wrong, people receive a sincere and timely apology and are told about any actions being taken to prevent the same happening again. Senior leaders can evidence that they look for and take appropriate and timely action to address issues arising from: reported incidents and concerns complaints and feedback from patients, service users and carers input from governors, patient groups, local Healthwatch networks internal and external reviews of its culture. Senior leaders can evidence that the reporting of errors and speaking up is normalised. Staff members are encouraged to raise concerns and report incidents, and to regard complaints and feedback from patients as means of learning for continuous improvement and innovation. They are supported to regard complaints positively. Senior leaders can evidence that there are appropriate and effective mechanisms, which staff members are aware of and have confidence in, for raising concerns and reporting errors and incidents. The national whistlebower policy has been adopted, and there is an accessible Freedom to Speak Up Guardian who provides regular updates to the board. Senior leaders can evidence that there are appropriate and effective mechanisms for turning concerns/incidents into improvement actions based on inquiry about the root causes of what has happened, where constructive challenge is welcome at all levels of the organisation, including the board. 20 Developmental reviews of leadership and governance using the well-led framework

60 There are processes for providing all staff at every level with the development they need, including high-quality appraisal and career development conversations. Senior leaders can evidence that they promote and demonstrate their commitment to continued learning and development for all staff members, so they have appropriate levels of quality, operational and financial skills, qualifications and understanding. Senior leaders can evidence they act on issues such as low training and appraisal rates. Senior leaders can evidence that there are processes to ensure that all staff members, including senior leaders, are able to: do any necessary mandatory training, including updating professional registration/revalidation understand functions across the range of activities in the organisation, not just their own (such as finance for non-finance managers) develop through leading or taking part in challenging projects or other appropriate learning opportunities, with rapidly increasing equality of access to these opportunities, especially for those with protected characteristics take part in high quality appraisal and career development conversations, aiming to help individuals achieve their potential. Senior leaders can evidence that staff have the freedom to work autonomously, where appropriate and safe, and there is appropriate devolution of decision-making and permission to experiment with new ways of working appropriate to their skills and grounded in a strong safety culture. Leaders model and encourage compassionate, inclusive and supportive relationships among staff so that they feel respected, valued and supported. There are processes to support staff and promote their positive wellbeing. All staff members demonstrate commitment to acting compassionately towards their colleagues through: using a variety of approaches to listen to staff views understanding where they need to improve support, engagement, wellbeing and staff feeling valued empathising and taking intelligent action in response to what they find. Seniors leaders can evidence ownership of an organisational development strategy, co-developed with staff across the organisation and regularly updated, that articulates what the organisation is doing to improve. Senior leaders can evidence that there are systems to monitor, manage and support staff pressure. 21 Developmental reviews of leadership and governance using the well-led framework

61 Equality and diversity are actively promoted and the causes of any workforce inequality are identified and action taken to address these. Staff, including those with protected characteristics under the Equality Act, feel they are treated equitably. Senior leaders can evidence that members of staff with protected characteristics are treated equitably, and can safely share concerns and be listened to in a meaningful and sustained way. They can evidence the organisation s commitment to inclusion and equality through: proactive engagement with staff, staff networks, trades unions and other staff organisations on the inclusion and equality agenda comparing metrics on staff engagement, bullying, harassment, recruitment and promotion among those with protected characteristics and the wider workforce ownership and regular monitoring of an effective equality and diversity strategy and plan, shared with all staff and other local interests as needed participating in developmental initiatives relating to building an inclusive workforce and wider healthcare services action on areas identified for development through any of these means. There is a culture of collective responsibility between teams and services. There are positive relationships between staff and teams, where conflicts are resolved quickly and constructively and responsibility is shared. Senior leaders can evidence that there are appropriate and effective mechanisms to enable effective team working at all levels in the organisation, including the board, and within and across teams (for example between finance and operations). In practice, this means: collaboration and co-operation within and across teams, role modelled by the leaders of those teams and senior leaders individuals and teams provide practical support to others, particularly in difficult circumstances conflicts are resolved quickly responsibility is shared to deliver high quality care shared leadership so that everyone contributes their experience and ideas clear objectives in collaborative work with different members or teams understanding each other s needs and responsibilities performance at team level is measured and understood by team members (or by individuals involved in any cross-team collaborations). 22 Developmental reviews of leadership and governance using the well-led framework

62 CQC inspection teams will consider the following prompts as part of their assessments in relation to this KLOE: W3.1 Do staff feel supported, respected and valued? W3.2 Is the culture centred on the needs and experience of people who use services? W3.3 Do staff feel positive and proud to work in the organisation? W3.4 Is action taken to address behaviour and performance that is inconsistent with the vison and values, regardless of seniority? W3.5 Does the culture encourage, openness and honesty at all levels within the organisation, including with people who use services, in response to incidents? Do leaders and staff understand the importance of staff being able to raise concerns without fear of retribution, and is appropriate learning and action taken as a result of concerns raised? W3.6 Are there mechanisms for providing all staff at every level with the development they need, including high quality appraisal and career development conversations? W3.7 Is there a strong emphasis on safety and well-being of staff? W3.8 Are equality and diversity promoted within and beyond the organisation? Do all staff, including those with particular protected characteristics under the Equality Act, feel they are treated equitably? W3.9 Are there co-operative, supportive and appreciative relationships among staff? Do staff and teams work collaboratively, share responsibility and resolve conflict quickly and constructively? 23 Developmental reviews of leadership and governance using the well-led framework

63 KLOE 4. Are there clear responsibilities, roles and systems of accountability to support good governance and management? Structures, processes and systems of accountability, including the governance and management of partnerships, joint working arrangements and shared services, are clearly set out, understood and effective. Board members can evidence that they understand their personal accountability for the quality, operational and financial performance of the organisation. Senior leaders can evidence that they are clear about who is responsible and accountable for the provision, quality and performance of services, including decision-making, delivery, and management of risks and issues in relation to quality, operations and finance. This is demonstrated in: clear and consistently applied levels of delegations and processes for recording decisions and escalation, which are monitored for compliance a clear organisational structure that cascades responsibility for delivering quality, operational and financial performance from board to front line to board clear policies in place to ensure that conflicts of interest are identified and managed. a clear management structure that defines accountabilities for use of resources (including workforce, financial budgets, IT, estates, etc) effective systems and processes that enable close working between quality, operational and finance functions clear processes for planning and budgeting for all income and expenditure the robust and timely implementing of controls in response to issues/concerns raised by internal or external audit, or encounters with serious fraud. regular reviews of governance processes across quality, operations and finance Senior leaders can evidence that there is a robust system of internal control, overseen by board subcommittees, to safeguard patient safety, service quality, investment, financial reporting and the organisation s assets. Working with partners Senior leaders can demonstrate that there are arrangements to ensure appropriate interaction with processes and governance systems that involve groups of partners and/or stakeholders from other local health and care organisations. Continues Developmental reviews of leadership and governance using the well-led framework

64 Senior leaders can evidence that all interested parties are clear about roles, responsibilities, structures and processes for planning, budgeting and reporting on any partnerships, joint ventures, shared services and sources of non-nhs income and understand, for example, protocols for: governing the use of any pooled budgets, with appropriate management structures to support and enforce the agreed practice the escalation and resolution of issues between parties dealing with overspends and underspends that are reviewed regularly. sharing data the termination of any arrangements. The board and other levels of governance in the organisation function effectively and interact with each other appropriately. The board operates as an effective unitary board demonstrating: clarity around its function, including the powers it reserves for itself and those it delegates to subcommittees and others stable and regularly attending membership (including non-executive directors) of a size appropriate to the requirements of the organisation appropriate balance between challenge and support, for example between executive and non-executive directors, and between governors and nonexecutive directors (where applicable) appropriate information flows supporting decision-making and the timely resolution of risks and issues that it operates within its terms of reference, and regularly reviews achievement against them. The board s agenda is appropriately balanced and focused between: strategy and current performance (short term and long term) quality, operations and finance making decisions and noting/receiving information internal matters and external considerations business conducted at public board meetings and that done in confidential sessions. 25 Developmental reviews of leadership and governance using the well-led framework

65 Staff are clear on their roles and accountabilities. Staff members understand the organisation s key quality, operational and finance priorities, and how their own goals and objectives contribute to the organisation s performance as a whole and how this is measured. Staff members understand they are accountable for delivering high quality, sustainable care, and optimising use of the organisation s resources. They are supported to identify and tackle obstacles in relation to these aims, escalating risks effectively. CQC inspection teams will consider the following prompts as part of their assessments in relation to this KLOE: W4.1 Are there effective structures, processes and systems of accountability to support the delivery of the strategy and good quality, sustainable services? Are these regularly reviewed and improved? W4.2 Do all levels of governance and management function effectively and interact with each other appropriately? W4.3 Are staff at all levels clear about their roles and do they understand what they are accountable for and to whom? W4.4 Are arrangements with partners and third-party providers governed and managed effectively to encourage appropriate interaction and promote coordinated, person-centred care? 26 Developmental reviews of leadership and governance using the well-led framework

66 KLOE 5. Are there clear and effective processes for managing risks, issues and performance? There is an effective and comprehensive process to identify, understand, monitor and address current and future risks. Leaders across the organisation are able to describe the current and future quality, operational and financial risks that relate to their areas of work, and the plans to mitigate them. Senior leaders can evidence that the organisation has effective, timely, horizonscanning, scenario-planning and reporting processes so that it is sufficiently aware of changes in the internal and external environment (including risks from the wider local health and care economy) that may affect delivery of strategy and/or affect quality and financial sustainability. Senior leaders can evidence that a board assurance framework and dynamic risk registers are in place and assessed by the board at least quarterly and demonstrate: attention to both internal and external risks, and their impact on planning a robust process for collating, evaluating, quantifying and reporting key risks a clear understanding of the board s risk appetite and tolerance, which is reviewed regularly (at least annually) and appropriately communicated to staff a commitment to learning lessons from inquiries (for example, safeguarding lessons from the 2015 Savile review), internal and external reviews of their own organisation, and of other organisations, and sharing this learning with staff, patients and the public. Senior leaders can evidence that there is a clear risk management process understood by staff members, including the board, its subcommittees and subgroups, so that they identify, assess, understand, assign responsibility for and act on risks relevant to their area of responsibility. This includes internal escalation and external escalation if the risks affect other organisations. Senior leaders can evidence that emergency preparedness/crisis management planning has been carried out and there is a robust business continuity plan. 27 Developmental reviews of leadership and governance using the well-led framework

67 Financial pressures are managed so that they do not compromise the quality of care. Service developments and efficiency changes are developed and assessed with input from clinicians so that their impact on the quality of care is understood. Senior leaders can evidence that service development or efficiency initiatives: are developed with relevant stakeholders (especially service users, their carers, clinical and operational staff), with due regard to the public sector equality duty. make use of relevant published research, evidence, benchmarking data and operational experience identify measures and early warning indicators to be monitored during and after implementation, with an associated risk management plan are assessed consistently according to their impact on quality and sustainability, including the cumulative and aggregate impact of smaller schemes on patient pathways or professional groups are monitored during implementation and afterwards, with mitigating actions taken if necessary. The organisation has the processes to manage current and future performance. Senior leaders can evidence that there is a performance management system for quality, operations and finance across all departments, which comprises: appropriate performance measures relating to relevant goals and targets reporting lines within which these will be managed, including how this will happen across teams (for example finance and operations) policies for managing/responding to deteriorating performance across all activities, at individual, team, service-line and organisational levels, with clear processes for re-forecasting performance trajectories a programme or portfolio management approach that allows the co-ordination of initiatives across the organisation, and with external partners as required a clear process for identifying lessons from performance issues and sharing these across the organisation on a regular, timely basis clear processes for reviewing and updating policies regularly to take account of organisational learning, and changes in the operating environment and national policy. 28 Developmental reviews of leadership and governance using the well-led framework

68 Performance issues are escalated to the appropriate committees and the board through clear structures and processes. Senior leaders can evidence that there are clear processes for: escalating quality, operational and financial performance issues through the organisation to the relevant committees as part of and outside the regular meeting cycle as required, linked to the organisation s risk matrix and consistent with the organisation s risk appetite. creating robust action plans, with clear ownership, timeframes and dependencies, all of which are monitored and followed up at subsequent meetings until they are resolved. Senior leaders can further evidence that: these processes are effective the appropriate individuals/management levels are aware of the issues and are managing them through to resolution themes arising from the most frequent risks and issues are analysed to identify barriers that need to be removed to drive improvement. Clinical and internal audit processes function well and have a positive impact on quality governance, with clear evidence of action to resolve concerns. Senior leaders can evidence that there is a clear, co-ordinated, continuous programme of clinical audit, peer review and internal audit, overseen and challenged by the board, which: aligns with priorities identified from risk intelligence and/or gaps in other assurance. competent individuals or teams (as appropriate) carry out to meet the needs identified is oriented to action, to address gaps from the audits in a timely manner and monitor them to ensure they are driving improvement ensures learning from the audits is shared across the organisation to facilitate wider improvement. 29 Developmental reviews of leadership and governance using the well-led framework

69 CQC inspection teams will consider the following prompts as part of their assessments in relation to this KLOE: W5.1 Are there comprehensive assurance systems, and are performance issues escalated appropriately through clear structures and processes? Are these regularly reviewed and improved? W5.2 Are there processes to manage current and future performance? Are these regularly reviewed and improved? W5.3 Is there a systematic programme of clinical and internal audit to monitor quality, operational, and financial processes, and systems to identify where action should be taken? W5.4 Are there robust arrangements for identifying, recording and managing risks, issues and mitigating actions? Is there alignment between the recorded risks and what staff say is on their worry list? W5.5 Are potential risks taken into account when planning services, for example seasonal or other expected or unexpected fluctuations in demand, or disruption to staffing or facilities? W5.6 When considering developments to services or efficiency changes, how is the impact on quality and sustainability assessed and monitored? Are there examples of where financial pressures have compromised care? 30 Developmental reviews of leadership and governance using the well-led framework

70 KLOE 6. Is appropriate and accurate information being effectively processed, challenged and acted on? Quality and sustainability both receive sufficient coverage in relevant meetings at all levels. Staff receive helpful data on a daily basis, which supports them to adjust and improve performance as necessary. Senior leaders can evidence that the board, its committees and subgroups as a core part of their meetings: receive and discuss information covering quality, operations and finance, and their inter-relationships; each committee s particular focus arising from its terms of reference appropriately challenge and interrogate the information and assumptions presented to inform decision-making, making use of benchmarking and other external sources as appropriate Senior leaders can evidence that core financial information is presented and robustly challenged throughout the organisation. This information is presented in the context of non-financial information, risks and mitigations, and there is a balance between actuals and projections, detail of cost and income categories, granularity of divisional/ locality/ business unit information, and links with operational drivers. Senior leaders can evidence that service line reporting approaches (ideally at patient level) are used for financial reporting and patient level costing has been or is being implemented. 31 Developmental reviews of leadership and governance using the well-led framework

71 Integrated reporting supports effective decision-making. There is a holistic understanding of performance, which sufficiently covers and integrates the views of people, with quality, operational and financial information. Senior leaders can evidence that the reporting approach integrates quality, operations and finance, appropriate to the size and complexity of the organisation. The board, its committees and sub-committees, use it to: ensure that the impact of all service development and efficiency programmes is understood on the quality and sustainability of all relevant areas of the organisation before decisions are made understand areas of good and under-performance support evidence-based decision-making, using sensitivity analysis where appropriate Senior leaders can evidence that there are monthly dashboards covering the most important indicators for the scrutinising committee. These dashboards are used effectively and: present the most recent (or recent enough to be relevant) data available where appropriate give preference to absolute data over relative data present both information for improvement and for assurance: o measurement for improvement means that data is presented using appropriate statistical methods to enable tracking of processes, balancing measures and outcomes over time, paying attention to variation rather than simply comparing against targets and thresholds at particular times o measurement for assurance means information is compared with target levels of performance (along with a red-amber-green rating), historic own performance and external benchmarks (where available and helpful). are frequently reviewed and updated to maximise effectiveness of decisions; and where useful metrics are lacking, the board commits time and resources to developing new metrics form a pyramid of reports, with increasing granularity that can be used to understand individual, business unit, service line, divisional and organisational performance as required. 32 Developmental reviews of leadership and governance using the well-led framework

72 Performance information is used to hold management and staff to account. Senior leaders can evidence that there are quality, operational and financial reporting procedures, which provide robust information on organisational performance and enable key strategic and operational risks to be identified and managed. This information can be accessed by any staff members who require it for their work. Senior leaders can evidence that the board, its committees and subcommittees regularly use information to understand and support the improvement of all areas of the organisation, including qualitative/ narrative text to explain outlying performance alongside the agreed metrics. This includes performance information relating to: divisions, localities, service lines and clinical units across patient pathways, internal and external the organisation s strategy and any associated plans. Senior leaders can evidence that they make use of relevant indicators in relation to the people or the human resources (HR) strategy, for example: safe staffing workforce capacity and capability to deliver the future strategy intelligence on values, behaviours and attitudes HR health indicators, including information on equality and diversity performance appraisal, training and development; and leadership. The information used in reporting, performance management and delivering quality care is usually accurate, valid, reliable, timely and relevant, with plans to address any weaknesses. Senior leaders can evidence that the information the board, its subcommittees and subgroups receive comes from reliable and suitable sources and covers an appropriate mix of qualitative and quantitative intelligence. Senior leaders can evidence that there are robust and reliable processes, systems and controls for producing the information covering data collection, checking, processing and reporting, which are captured in clear standard operating procedures. Senior leaders can evidence that arrangements for supporting how performance indicators are prepared and reported are reviewed regularly. 33 Developmental reviews of leadership and governance using the well-led framework

73 Information technology systems are used effectively to monitor and improve the quality of care. Senior leaders can evidence that, through dedicated chief information officer and chief clinical information officer leadership, the organisation is delivering higher quality, more effective and lower cost care through effective use of information technology (IT), data and analytics. Senior leaders can evidence that the organisation is constantly looking to learn from others both nationally and internationally on how best to identify and exploit the opportunities that IT, data and analytics provide to monitor and improve the quality of care. Senior leaders can evidence a mature understanding of the role of digital technology as a change management and improvement mechanism to transform operating procedures and care delivery models. Senior leaders can evidence that IT adheres to the latest standards of cyber security to minimise risk to patient care and organisational reputation. Senior leaders can evidence that the organisation s IT adopts all of the relevant data and information standards, enabling accurate timely and comprehensive use of data across the enterprise and effective sharing with trusted partners across the local health and care system. Staff members understand the benefits of working paper-free and have sufficient understanding of the role of IT, data and analytics to improve patient outcomes, organisational and system sustainability. Staff members demonstrate confidence in the use of IT, data and analytics relevant to their roles to support patient care. Data or notifications are consistently submitted to external organisations as required. Senior leaders can evidence that the relevant departments understand the routine and exceptional data requirements of external bodies. Senior leaders can evidence that there are appropriate and effective mechanisms for the collection, preparation and sign-off of the necessary information on routine and exceptional bases to support timely delivery to external organisations. There are robust arrangements for the availability, integrity and confidentiality 34 Developmental reviews of leadership and governance using the well-led framework

74 of patient identifiable data, records and data management systems. Senior leaders can evidence that there are an information governance (IG) framework and documented processes and procedures to support the co-ordinated and integrated care through appropriate and lawful information-sharing and the effective management of records. Senior leaders can evidence that the organisation is able to maintain the confidentiality and security of the personal confidential data it processes and all reasonable care is taken to prevent inappropriate access, modification or manipulation of that data. This includes ensuring there are arrangements to: secure against unauthorised access to data safeguard against unauthorised modification of data make readily accessible the required data to authorised users only. CQC inspection teams will consider the following prompts as part of their assessments in relation to this KLOE: W6.1 Is there a holistic understanding of performance, which sufficiently covers and integrates people s views with information on quality, operations and finances? Is information used to measure for improvement, not just assurance? W6.2 Do quality and sustainability both receive sufficient coverage in relevant meetings at all levels? Do all staff have sufficient access to information, and challenge it appropriately? W6.3 Are there clear and robust service performance measures, which are reported and monitored? W6.4 Are there effective arrangements to ensure that the information used to monitor, manage and report on quality and performance is accurate, valid, reliable, timely and relevant? What action is taken when issues are identified? W6.5 Are information technology systems used effectively to monitor and improve the quality of care? W6.6 Are there effective arrangements to ensure that data or notifications are submitted to external bodies as required? W6.7 Are there robust arrangements (including appropriate internal and external validation), to ensure the availability, integrity and confidentiality of identifiable data, records and data management systems, in line with data security standards? Are lessons learned when there are data security breaches? 35 Developmental reviews of leadership and governance using the well-led framework

75 KLOE 7 Are the people who use services, the public, staff and external partners engaged and involved to support high quality sustainable services? A full and diverse range of people s views and concerns is encouraged, heard and acted on to shape services and culture. Staff members are committed to actively seeking the views of patients, service users, carers and the public, both directly and via other groups (such as local Healthwatch organisations, patient representative groups, members and governors (where appropriate)) through a variety of channels and with due regard to the public sector equality duty. Senior leaders can evidence that these views, including those received as concerns and complaints, are regarded as a way to understand and improve performance, and routinely used to inform service development. The board receives and reviews quantitatively and qualitatively analysed data at least quarterly, triangulated with other risk intelligence, and addresses any risks or development areas identified. Senior leaders can evidence that the organisation communicates to the public fully, regularly, and in accessible ways: the decisions taken by the Board and the rationale for them performance measures and outcomes that include objective coverage of both good and bad performance. For foundation trusts, senior leaders can evidence how governors are enabled to hold the non-executive directors individually and collectively to account for the performance of the board of directors and to represent the interests of NHS foundation trust members and of the public. The service proactively engages and involves all staff (including those with protected equality characteristics) and ensures that the voices of all staff are heard and acted on to shape services and culture. Senior leaders can evidence that staff at all levels are actively involved in planning and delivery of significant service developments in a variety of ways and with due regard for the public sector equality duty. Senior leaders can evidence how staff input has influenced plans. Continues Developmental reviews of leadership and governance using the well-led framework

76 Staff members can describe how they are encouraged to feed back, through a variety of channels, on an ongoing basis as well as through specific mechanisms. This will include but is not limited to an annual staff survey. The Board reviews quantitatively and qualitatively analysed data, triangulated with other risk intelligence (such as complaints, incidents), and addresses any development areas identified. Senior leaders can evidence how stakeholder input has influenced plans. The service is transparent, collaborative and open with all relevant stakeholders about performance, to build a shared understanding of challenges to the system and the needs of the population and to design improvements to meet them. External stakeholders describe working relationships with the organisation as positive, underpinned by trust, respect and co-operation. Senior leaders can evidence that there are appropriate and effective mechanisms to enable the organisation to work proactively with local health and care system partners to: build a shared understanding of population health, patient needs and system challenges design improvements to create long term sustainability. Senior leaders can evidence their commitment to developing positive and effective working relationships with local health and care system partners by: dedicating appropriate face-to-face time to working with counterparts in other organisations to build trusting relationships regularly attending systems meetings from staff with appropriate capacity, experience and seniority engaging external stakeholders in formal internal governance committees where appropriate proactively seeking and acting on feedback on the quality of these relationships (for example through 360 stakeholder surveys) co-operating constructively with third parties with specific roles in relation to the organisation (such as commissioners and other providers). Senior leaders can evidence that the organisation responds with flexibility and agility to changes in the local health economy, and takes part in pooled activities which may include: Continues Developmental reviews of leadership and governance using the well-led framework

77 common quality improvement (QI) approach pooled transformation and improvement resources trust-building efforts for finance, clinicians, etc delegated decision-making local area talent management planning and leadership development local health economy plans delivery groups Senior leaders can evidence that the organisation proactively engages and shares data openly on relevant quality, operational and financial performance with all major external stakeholders (including health and local authority commissioners, Health and Wellbeing Boards, Healthwatch, patient groups and MPs). Senior leaders can evidence that the organisation s decision-making is transparent, and the processes in place enable stakeholders, including commissioners, to find out easily how and why the board has made key decisions in addition to responding to freedom of information requests. Staff members proactively engage with relevant delivery partners (general practitioners, local authorities, third sector providers, other community, mental health, acute and specialist providers) to identify improvement opportunities, performance or resourcing issues and to ensure overall quality along pathways. CQC inspection teams will consider the following prompts as part of their assessments in relation to this KLOE: W7.1 Are people's views and experiences gathered and acted on to shape and improve the services and culture? Does this include people in a range of equality groups? W7.2 Are people who use services, those close to them and their representatives actively engaged and involved in decision-making to shape services and culture? Does this include people in a range of equality groups? W7.3 Are staff actively engaged so that their views are reflected in the planning and delivery of services and in shaping the culture? Does this include those with a protected equality characteristic? W7.4 Are there positive and collaborative relationships with external partners to build a shared understanding of challenges within the system and the needs of the relevant population, and to deliver services to meet those needs? 38 Developmental reviews of leadership and governance using the well-led framework

78 W7.5 Is there transparency and openness with all stakeholders about performance? KLOE 8: Are there robust systems and processes for learning, continuous improvement and innovation? There is a strong focus on continuous learning and improvement at all levels of the organisation, including through appropriate use of external accreditation and participation in research. Leaders across the organisation can articulate and demonstrate their commitment to the organisation s improvement approach, across quality, operations and finance functions by: taking a proactive approach to innovation and improvement, including active engagement in the delivery of initiatives (some initiatives could be led personally by individual board members) setting realistic but stretching performance objectives for the organisation encouraging learning from sector, national and international best practice, the creation of best practice where it doesn t exist and sharing back learning widely. Senior leaders can evidence how they create a safe and hospitable environment for experimentation and learning, by: seeing failure not as a negative but as learning that can be embedded in future practice to deliver performance improvement taking time out to identify and act on the board s own successes and failures demonstrating how reviewing quality, operational and financial information has resulted in actions that have successfully improved performance. There is knowledge of improvement methods and the skills to use them at all levels of the organisation. Senior leaders can evidence that they actively encourage the use of a standardised improvement methodology embedded across the organisation to improve the quality, efficiency and productivity of services. This can be any method chosen by the organisation. Board members demonstrate at least a basic awareness of the key improvement concepts (such as variation and system thinking) and can show how they have used these in improvement initiatives (such as understanding performance in terms of variation). 39 Developmental reviews of leadership and governance using the well-led framework

79 Senior leaders can evidence that quality/continuous improvement training is offered to staff at all levels, and staff with appropriate leadership and analytical skills are available to lead and support improvement and innovation. Continues... Staff members demonstrate their confidence and competence by improving their services involving patients and carers, and by sharing their skills with others though coaching and training. The service makes effective use of internal and external reviews, and learning is shared effectively and used to make improvements. Senior leaders can evidence how the organisation has learned from internal and external reviews and the effectiveness of its response to recommendations from external auditors and assessors. Senior leaders can evidence how, where appropriate, external support networks and expertise are used to support ideas for development and improvement (for example use of benchmarking, working with patient groups, participating in peer learning networks on a range of topics, linking with healthcare providers and other improvement interventions and tools). Staff are encouraged to use information and regularly take time out to review individual and team objectives, processes and performance. This is used to make improvements. Senior leaders can evidence that: staff are clear about their personal priorities and objectives managers give timely and balanced feedback about progress towards objectives staff and teams are able to review these objectives against information and data there are appropriate and effective mechanisms for teams to work together to resolve problems, review team objectives, processes and performance on a regular basis. 40 Developmental reviews of leadership and governance using the well-led framework

80 There are organisational systems to support improvement and innovation work, including staff objectives, rewards, data systems and ways of sharing improvement work. Senior leaders can evidence that there is an improvement strategy that promotes the adoption of the chosen improvement methodology and ensures it is reflected in the organisation s systems and processes. This means that: improvement is seen as the way to address performance in teams, between teams, or along pathways as appropriate staff objectives and appraisal processes include innovation and improvement improvement and innovation successes are celebrated throughout the organisation and learning is shared widely in the organisation, with other organisations in the health and care system, and more widely though contributions to conferences and journals. Senior leaders can evidence that all staff members are supported to carry out improvement work with: appropriate resources (time and money) to deliver the projects they identify timely access to the data they need (such as service line data), the tools they need to analyse it (such as templates or software to generate statistical process control/run charts, etc) and analytical expertise to support them if required. CQC inspection teams will consider the following prompts as part of their assessments in relation to this KLOE: W8.1 In what ways do leaders and staff strive for continuous learning, improvement and innovation? Does this include participating in appropriate research projects and recognised accreditation schemes? W8.2 Are there standardised improvement tools and methods, and do staff have the skills to use them? W8.3 How effective is participation in and learning from internal and external reviews, including those related to mortality or the death of a person using the service? Is learning shared effectively and used to make improvements? W8.4 Do all staff regularly take time out to work together to resolve problems and to review individual and team objectives, processes and performance? Does this lead to improvements and innovation? W8.5 Are there systems in place to support improvement and innovation work including objectives and rewards for staff, data systems, and processes for evaluating and sharing the results of improvement work? 41 Developmental reviews of leadership and governance using the well-led framework

81 Annex A: Scoping your developmental review This annex summarises some points you should consider in preparing for a review. It is not exhaustive, but should help to start the process. Scope of the review The scope of developmental reviews should cover the eight KLOEs in this guidance at an appropriate level. There may also be development areas the provider is aware of outside the framework arising from, for instance, internal and/or external audit review findings, or information from the annual governance statement and the corporate governance statement. The board should tailor the scope, or place emphasis within the review accordingly. Self-review Purpose of regular self-review The purpose of regular self-review is to promote self-knowledge, reflection and vigilance, and the development and improvement of leadership and governance. It helps providers identify their strengths and development areas to deliver continuous improvement. High performing providers are likely to carry out some form of self-review of their leadership and governance regularly and frequently. As with the scope of the developmental review, boards are responsible for setting the scope of regular self-reviews, but we suggest they should cover the full scope of the well-led framework at an appropriate level. Ideally, selfreviews will be carried out annually but providers should determine this for themselves. Completing self-reviews A nominated provider lead or team may co-ordinate the self-review but it should be completed and signed-off by the full board. In practice, this could mean that a nominated board member works with the board secretary and 42 Developmental reviews of leadership and governance using the well-led framework

82 their staff to gather the information and the evidence against each question and present their findings and initial conclusions to the board for discussion and challenge. The whole board is responsible for arriving at an overall conclusion. The output of the self-review will include the self-review questionnaire (or equivalent), ratings and rationale for the ratings. This information may help inform the CQC well-led provider information request as part of the regular regulatory assessment process, but supplying the full self-review is not mandatory. Preparation for development reviews Self-review is an important first step in preparing for externally facilitated developmental reviews. Providers should assess themselves to provide insight for themselves and the external facilitator into how they gauge their own leadership and governance performance and identify any particular areas of interest or concern either within or outside the eight questions. A good self-review should help identify where the provider needs to focus and therefore inform the choice of external reviewer. During a developmental review, the self-review should be presented to the external facilitator for comments and further discussion. The reviewer will then agree areas for further scrutiny with the board. Rating the self-review Each of the KLOEs should be rated using a scheme that allows prioritisation of findings and escalation of concerns, informed by the good practice examples in the framework. Each judgement should be backed up by evidence where appropriate. Rating will aid prioritisation and ensure that issues are brought to the attention of the board. Boards should ensure that their approach facilitates continuous improvement rather than a compliance mindset. The reviews should not be about meeting a bar, but rather about prioritising improvement actions. 43 Developmental reviews of leadership and governance using the well-led framework

83 Key line of enquiry Priority rating Explanation of selfrating assessment How is the board assured? Evidence for assessment What are the principal actions/areas for discussion with your external review team 1. Is there the leadership capacity and capability to deliver high quality, sustainable care? 2. Is there a clear vision and credible strategy to deliver high quality, sustainable care to people, and robust plans to deliver? 3. Is there a culture of high quality, sustainable care? 4. Are there clear responsibilities, roles and systems of accountability to support good governance and management? 5. Are there clear and effective processes for managing risks, issues and performance? 6. Is appropriate and accurate information being effectively processed, challenged and acted on? 7. Are the people who use services, the public, staff and external partners engaged and involved to support high quality sustainable services? 8. Are there robust systems and processes for learning, continuous improvement and innovation? 44 Developmental reviews of leadership and governance using the well-led framework

84 Annex B: Commissioning an external facilitator This annex sets out what to consider when choosing an external team to facilitate developmental reviews against this framework. Boards need to assure themselves that the appointed external facilitator is independent and able to provide a robust and reliable judgement of a provider s leadership and governance. As part of the commissioning process, facilitators should also demonstrate: a clear and concise understanding of the purpose and objective of the review; knowledge of how to carry out a rigorous leadership and governance review, covering the specific areas detailed in the well-led framework; and the ability to use an appropriate range of tools and approaches relevant skills and experience, including: o credibility and experience in carrying out leadership and governance reviews at healthcare providers; ideally, the selected team will be multidisciplinary with a broad range of skills relevant to all aspects of board leadership and governance, such as strategic planning, quality governance, cultural assessment, organisational development and management information and analysis o experience in supporting healthcare providers to develop their leadership and governance with an understanding of continuous quality improvement and methodologies o knowledge of the healthcare sector, and the internal and external challenges faced by providers o knowledge of the regulatory framework the provider operates in o an ability to manage the review process: reviewers should provide a credible and detailed plan of the proposed project governance regime including the approach to the quality assurance of the work, risk

85 management, reporting and escalation lines, and evidence of clear leadership for the work with a named individual. o named personnel (and CVs in the response), and clarity about their role and what they will do during the review. Peer review input Our ambition is that, over time, making use of and participating in developmental reviews will become an integral part of the role of senior leaders across the NHS. This is one of the main ways in which we can share the valuable learning, experience and ideas within the NHS leadership community and make it accessible to everyone, across our organisations. This ambition will take some time to realise, but as a first step, we encourage providers where possible to involve, or to select suppliers who offer to involve, appropriately skilled peer reviewers as part of the external facilitation team. We will be providing further support and guidance about this in due course. We will also be compiling a list of peer reviewers and this list will be available on request. We will include details about this on our website later this year Developmental reviews of leadership and governance using the well-led framework

86 Annex C: Carrying out a developmental review This annex sets out: potential methods of carrying out a review the process of prioritising and rating your findings action-planning. There is no one size fits all approach to developmental reviews: we encourage providers to think about how to shape the methodology to support their needs. Providers are responsible for commissioning these reviews and so should assure themselves that the review tools and methods are suitable for their circumstances. Because of this, the guidance below provides examples of tools and is not prescriptive. Experienced reviewers can use their own tools and methods. Prioritising and rating findings The findings from the review will usually be presented in a report for the board, covering methodology, scope, findings, and areas of good practice or weakness against which to plan developmental actions. It is important that issues or concerns are prioritised but plans for maintaining good practice should also be considered. We encourage providers to agree the format in which they would like the findings to be presented at the start of the review process. Action-planning The board is ultimately accountable for delivering improvements, and so action-planning should involve the whole board. The board should consider how to track actions and the timeframe for resolution. Developmental reviews are most useful where issues are resolved in a timely manner. NHS Improvement has a range of support offers (see Annex D) that boards may draw on when addressing issues. 47 Developmental reviews of leadership and governance using the well-led framework

87 Examples of tools Tool Suggested components Purpose Desktop document review One-to-one interviews Stakeholder surveys Focus groups with internal and external stakeholders Board and key subcommittee agendas, minutes and papers; board assurance framework; audit reports; strategic documents, eg the provider s strategy and business plan, quality strategy, quality improvement plan and people strategy; and internal/ external audit reports, annual governance and corporate governance statements, alongside any other relevant reviews. All board members, the trust secretary, lead governor, head of quality governance, head of workforce, clinical directors and heads of business units, and local stakeholders (including clinical commissioning groups and patient representatives). Staff and patient groups, commissioners and providers Staff, patient groups, commissioners, contracted or outsourced suppliers To provide a view of: how ongoing issues and risks in the provider are communicated and managed the quality of information produced to support decision-making how the board prioritises issues at the provider and divides its attention. To gain individuals views of the provider s governance and to provide a safe environment in which to explore issues and discuss sensitive information, as appropriate. To get internal and external parties views of the provider s governance to cross-reference with the board s own views and test the board s awareness. To get internal and external parties views of the provider s governance to cross-reference with the board s own views and test the board s awareness.

88 Tool Suggested components Purpose Board and subcommittee observations Board skills inventory Board selfassessment Observations of at least one board meeting and relevant subcommittees, including audit and quality. Matching skills to the requirements of the board s work and identifying any gaps. Board members to rate how effective they believe the board is. To identify the dynamics of the board, including agenda management, depth and breadth of information used to make decisions and progress priorities, and the way they challenge and hold each other to account for the leadership of the provider. To ensure the board has the skills and experience needed. To provide a view of how effective the board believes itself to be. Peer practices On areas of governance in the sector, in similar organisations or providers. To assess how the provider compares against any known examples of particularly effective and robust governance practices. 49 Developmental reviews of leadership and governance using the well-led framework

89 Annex D: Accessing support and further reading New support offers are available all the time. The easiest way to find out about them is to visit the Improvement Hub: This includes resources from across the NHS, as well as discussion forums and case studies.

90 Further reading Good governance practice British Quality Foundation (2013) EFQM Excellence Model Committee on Standards in Public Life (1995) The 7 principles of public life Department of Health (2011) Board Governance Assurance Framework for Aspirant Foundation Trusts Department of Health (ongoing) Information Governance NHS Providers and DAC Beachcroft (2015) Foundations of Good Governance: A Compendium of Best Practice (3 rd edition) NHS Leadership Academy (2013) The Healthy NHS Board 2013: Principles for Good Governance NHS England (2017) Managing Conflicts of interest in the NHS Reviews and investigations Department of Health (2016), Operational productivity and performance in English NHS acute hospitals: Unwarranted variations (Lord Carter) Department of Health (2014), Examining new options and opportunities for providers of NHS care: The Dalton Review Department of Health (2014) Better leadership for tomorrow: NHS Leadership Review. (Lord Rose) Francis, R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Lampard K., Marsden E. (2015) Themes and lessons learnt from NHS investigations into matters relating to Jimmy Savile National Advisory Group on the Safety of Patients in England (2013), A promise to learn a commitment to act: Improving the safety of patients in England National Improvement and Leadership Development Board (2016) Developing People Improving Care: A national framework for action on improvement and leadership development in NHS-funded services Smith, E. (2015), Review of centrally funded improvement and leadership development functions, Final report of review on behalf of NHS England, Monitor, NHS Trust Development Authority, Health Education England, Public Health England and the Care Quality Commission.

91 Contact us: NHS Improvement Wellington House Waterloo Road London SE1 8UG improvement.nhs.uk Follow us on This publication can be made available in a number of other formats on request. NHS Improvement June 2017 Publication code: CG 32/17

92 Key lines of enquiry, prompts and ratings characteristics for healthcare services Key lines of enquiry and prompts: Page Safe... 3 Effective Caring Responsive Well-led Ratings characteristics:... Page Safe Effective Caring Responsive Well-led Key lines of enquiry, prompts and ratings characteristics healthcare services 1

93 Notes on this updated assessment framework CQC s inspection teams will use this updated framework to assess healthcare services, using the key lines of enquiry (KLOEs) and prompts where they are appropriate. This replaces the previous separate versions for different types of service, published in 2015, which duplicated many of the KLOEs and prompts. We have designed this to simplify the process for organisations that provide more than one type of service. The changes to KLOEs and prompts are the result of feedback following our Next Phase consultation. We have merged previous versions, added new content to strengthen specific areas and reflect current practice, and made some changes to the wording to improve and simplify the language to aid understanding. We have also aligned, as much as possible, the wording of KLOEs and prompts between the two assessment frameworks for healthcare services and adult social care services (referred to in this document as ASC). To help you update your own internal assessment and training materials, we have mapped the changes against the current frameworks and highlighted them. IMPORTANT: We will eventually use the updated assessment frameworks for healthcare and adult social care services for all settings within those sectors. We are publishing this document now to enable providers to prepare any changes to their internal assessment and training systems in advance. However, there is a transition period while consultations are ongoing, which means we will introduce this revised framework at different times across settings as follows: NHS trusts: NHS acute hospitals, NHS acute and specialist mental health, NHS substance misuse services, NHS community and ambulance trusts June 2017 Community and residential adult social care services November 2017 NHS GP practices and GP out-of-hours services, NHS 111 services, independent doctor services (primary medical services) November 2017 Primary care dental services from April 2018 Independent healthcare services: acute hospitals, single specialty acute services, independent ambulances, hospice services, independent specialist substance misuse services, independent doctor services (non-hospital acute services) 2018/19 (to be confirmed in consultation 3) Key lines of enquiry, prompts and ratings characteristics healthcare services 2

94 Key lines of enquiry and prompts: SAFE Notes: Where we refer to people, we include adults, young people and children, where applicable. Key to type of change No or minimal change to wording for clarity/moved or merged prompts Changed New Substantive change to wording New key line of enquiry or prompt, including those that are new for some, but not all, sectors Safe By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse. Code Key line of enquiry / prompt Reason for change Applies to S1 How do systems, processes and practices keep people safe and safeguarded from abuse? Moved within Safe (previous S3 & minimal wording change) S1.1 Substantive change How are safety and safeguarding systems, processes and practices developed, implemented and communicated to staff? S1.2 Substantive change How do systems, processes and practices protect people from abuse, neglect, harassment and breaches of their dignity and respect? How are these monitored and improved? Feedback from consultation and wording aligned with ASC Key lines of enquiry, prompts and ratings characteristics healthcare services 3

95 Key lines of enquiry and prompts: SAFE Code Key line of enquiry / prompt Reason for change Applies to S1.3 New How are people protected from discrimination, which might amount to abuse or cause psychological harm? This includes harassment and discrimination in relation to protected characteristics under the Equality Act. Wording aligned with ASC S1.4 New How is safety promoted in recruitment practice, arrangements to support staff, disciplinary procedures, and ongoing checks? (For example, Disclosure and Barring Service checks.) S1.5 Do staff receive effective training in safety systems, processes and practices? S1.6 S1.7 New S1.8 Are there arrangements to safeguard adults and children from abuse and neglect that reflect relevant legislation and local requirements? Do staff understand their responsibilities and adhere to safeguarding policies and procedures, including working in partnership with other agencies? Do staff identify adults and children at risk of, or suffering, significant harm? How do they work in partnership with other agencies to ensure they are helped, supported and protected? How are standards of cleanliness and hygiene maintained? Are there reliable systems in place to prevent and protect people from a healthcare-associated infection? NOT NHS 111 S1.9 Do the design, maintenance and use of facilities and premises keep people safe? S1.10 Do the maintenance and use of equipment keep people safe? S1.11 Do the arrangements for managing waste and clinical specimens keep people safe? (This includes classification, segregation, storage, labelling, handling and, where appropriate, treatment and disposal of waste.) NOT NHS 111 Key lines of enquiry, prompts and ratings characteristics healthcare services 4

96 Key lines of enquiry and prompts: SAFE Code Key line of enquiry / prompt Reason for change Applies to S2 Substantive change How are risks to people assessed, and their safety monitored and managed so they are supported to stay safe? Change to wording S2.1 How are staffing levels and skill mix planned and reviewed so that people receive safe care and treatment at all times and staff do not work excessive hours? S2.2 Substantive change How do actual staffing levels and skill mix compare with the planned levels? Is cover provided for staff absence? Change to wording S2.3 Do arrangements for using bank, agency and locum staff keep people safe at all times? S2.4 How do arrangements for handovers and shift changes ensure that people are safe? NOT: ambulance services, GP practices, GP out-of-hours, NHS 111 S2.5 S2.6 Substantive change S2.7 Are comprehensive risk assessments carried out for people who use services and risk management plans developed in line with national guidance? Are risks managed positively? How do staff identify and respond appropriately to changing risks to people, including deteriorating health and wellbeing, medical emergencies or behaviour that challenges? Are staff able to seek support from senior staff in these situations? How is the impact on safety assessed and monitored when carrying out changes to the service or the staff? Key lines of enquiry, prompts and ratings characteristics healthcare services 5

97 Key lines of enquiry and prompts: SAFE Code Key line of enquiry / prompt Reason for change Applies to S3 Do staff have all the information they need to deliver safe care and treatment to people? Feedback from consultation and wording aligned with ASC S3.1 Substantive change Are people s individual care records, including clinical data, written and managed in a way that keeps people safe? Feedback from consultation S3.2 Is all the information needed to deliver safe care and treatment available to relevant staff in a timely and accessible way? (This may include test and imaging results, care and risk assessments, care plans and case notes.) S3.3 When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols? S3.4 How well do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment? (This includes coordination between different electronic and paper-based systems and appropriate access for staff to records.) Feedback from consultation S4 New How does the provider ensure the proper and safe use of medicines, where the service is responsible? Feedback from consultation and wording aligned with ASC Key lines of enquiry, prompts and ratings characteristics healthcare services 6

98 Key lines of enquiry and prompts: SAFE Code Key line of enquiry / prompt Reason for change Applies to S4.1 Substantive change How are medicines and medicines-related stationery managed (that is, ordered, transported, stored and disposed of safely and securely)? (This includes medical gases and emergency medicines and equipment.) Feedback from consultation and wording aligned with ASC S4.2 Substantive change Are medicines appropriately prescribed, administered and/or supplied to people in line with the relevant legislation, current national guidance or best available evidence? Feedback from consultation and wording aligned with ASC S4.3 Substantive change Do people receive specific advice about their medicines in line with current national guidance or evidence? Feedback from consultation and wording aligned with ASC S4.4 Substantive change How does the service make sure that people receive their medicines as intended, and is this recorded appropriately? Feedback from consultation and wording aligned with ASC S4.5 New Are people's medicines reconciled in line with current national guidance when transferring between locations or changing levels of care? Feedback from consultation and wording aligned with ASC Key lines of enquiry, prompts and ratings characteristics healthcare services 7

99 Key lines of enquiry and prompts: SAFE Code Key line of enquiry / prompt Reason for change Applies to S.4.6 New Are people receiving appropriate therapeutic drug and physical health monitoring with appropriate follow-up in accordance with current national guidance or evidence? Feedback from consultation S4.7 New Are people s medicines regularly reviewed including the use of when required medicines? Feedback from consultation S4.8 How does the service make sure that people s behaviour is not controlled by excessive or inappropriate use of medicines? S5 What is the track record on safety? Moved within Safe (previous S1) S5.1 What is the safety performance over time? S5.2 How does safety performance compare with other similar services? S5.3 How well is safety monitored using information from a range of sources (including performance against safety goals where appropriate)? S6 Are lessons learned and improvements made when things go wrong? Moved within Safe (previous S.2) S6.1 Do staff understand their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them internally and externally, where appropriate? S6.2 Substantive change What are the arrangements for reviewing and investigating safety and safeguarding incidents and events when things go wrong? Are all relevant staff, services, partner organisations and people who use services involved in reviews and investigations? Wording aligned with ASC Key lines of enquiry, prompts and ratings characteristics healthcare services 8

100 Key lines of enquiry and prompts: SAFE Code Key line of enquiry / prompt Reason for change Applies to S6.3 How are lessons learned and themes identified, and is action taken as a result of investigations when things go wrong? Wording aligned with ASC S6.4 Substantive change How well is the learning from lessons shared to make sure that action is taken to improve safety? Do staff participate in and learn from reviews and investigations by other services and organisations? Wording aligned with ASC S6.5 New How effective are the arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations or reviews? Wording aligned with ASC Key lines of enquiry, prompts and ratings characteristics healthcare services 9

101 Notes: Where we refer to people, we include adults, young people and children, where applicable. Key lines of enquiry and prompts: EFFECTIVE Key to type of change No or minimal change to wording for clarity/moved or merged prompts Changed New Substantive change to wording New key line of enquiry or prompt, including those that are new for some, but not all, sectors Effective By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. Code Key line of enquiry / prompt Reason for change Applies to E1 Are people s needs assessed and care and treatment delivered in line with current legislation, standards and evidence-based guidance to achieve effective outcomes? E1.1 Substantive change Are people's physical, mental health and social needs holistically assessed, and is their care, treatment and support delivered in line with legislation, standards and evidencebased guidance, including NICE and other expert professional bodies, to achieve effective outcomes? Feedback from Consultation E1.2 What processes are in place to ensure there is no discrimination, including on the grounds of protected characteristics under the Equality Act, when making care and treatment decisions? Key lines of enquiry, prompts and ratings characteristics healthcare services 10

102 Key lines of enquiry and prompts: EFFECTIVE Code Key line of enquiry / prompt Reason for change Applies to E1.3 How is technology and equipment used to enhance the delivery of effective care and treatment and to support people s independence? E1.4 Are the rights of people subject to the Mental Health Act 1983 (MHA) protected and do staff have regard to the MHA Code of Practice? E1.5 Substantive change How are people's nutrition and hydration needs (including those related to culture and religion) identified, monitored and met? Where relevant, what access is there to dietary and nutritional specialists to assist in this? NOT: GP practices, GP out-of-hours, NHS 111 E1.6 Substantive change How is a person s pain assessed and managed, particularly for people who have difficulty communicating? Wording aligned with ASC NOT: specialist mental health services, specialist substance misuse services E1.7 New Are people told when they need to seek further help and advised what to do if their condition deteriorates? E2 How are people's care and treatment outcomes monitored and how do they compare with other similar services? E2.1 Substantive change Is information about the outcomes of people's care and treatment (both physical and mental where appropriate) routinely collected and monitored? E2.2 Does this information show that the intended outcomes for people are being achieved? Key lines of enquiry, prompts and ratings characteristics healthcare services 11

103 Key lines of enquiry and prompts: EFFECTIVE Code Key line of enquiry / prompt Reason for change Applies to E2.3 How do outcomes for people in this service compare with other similar services and how have they changed over time? E2.4 Is there participation in relevant quality improvement initiatives, such as local and national clinical audits, benchmarking, (approved) accreditation schemes, peer review, research, trials and other quality improvement initiatives? Are all relevant staff involved in activities to monitor and use information to improve outcomes? E3 How does the service make sure that staff have the skills, knowledge and experience to deliver effective care, support and treatment? Wording aligned with ASC E3.1 Substantive change Do people have their assessed needs, preferences and choices met by staff with the right skills and knowledge? Feedback from consultation Wording aligned with ASC E3.2 Substantive change How are the learning needs of all staff identified? Do staff have appropriate training to meet their learning needs that covers the scope of their work, and is there protected time for this training? E3.3 Are staff encouraged and given opportunities to develop? E3.4 E3.5 What are the arrangements for supporting and managing staff to deliver effective care and treatment? (This includes one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation.) How is poor or variable staff performance identified and managed? How are staff supported to improve? Key lines of enquiry, prompts and ratings characteristics healthcare services 12

104 Key lines of enquiry and prompts: EFFECTIVE Code Key line of enquiry / prompt Reason for change Applies to E3.6 New Are volunteers recruited where required, and are they trained and supported for the role they undertake? Wording aligned with ASC E4 Substantive change How well do staff, teams and services work together within and across organisations to deliver effective care and treatment? Feedback from consultation E4.1 Are all necessary staff, including those in different teams, services and organisations, involved in assessing, planning and delivering care and treatment? E4.2 How is care delivered and reviewed in a coordinated way when different teams, services or organisations are involved? E4.3 New How are people assured that they will receive consistent, coordinated, person-centred care and support when they use, or move between different services? Feedback from consultation & wording aligned with ASC E4.4 Are all relevant teams, services and organisations informed when people are discharged from a service? Where relevant, is discharge undertaken at an appropriate time of day and only done when any necessary ongoing care is in place? NOT: GP practices, GP out-of-hours, NHS 111 E4.5 New How are high-quality services made available that support care to be delivered seven days a week and how is their effect on improving patient outcomes monitored? NHS acute & independent hospitals only Key lines of enquiry, prompts and ratings characteristics healthcare services 13

105 Key lines of enquiry and prompts: EFFECTIVE Code Key line of enquiry / prompt Reason for change Applies to E5 New for hospitals (not PMS or NHS 111 How are people supported to live healthier lives and, where the service is responsible, how does it improve the health of its population? Moved from primary medical care to apply to all health Are people identified who may need extra support? This includes: E5.1 people in the last 12 months of their lives people at risk of developing a long-term condition carers E5.2 How are people involved in regularly monitoring their health, including health assessments and checks, where appropriate and necessary? E5.3 Substantive change Are people who use services empowered and supported to manage their own health, care and wellbeing and to maximise their independence? Feedback from consultation & moved E5.4 New Where abnormalities or risk factors are identified that may require additional support or intervention, are changes to people s care or treatment discussed and followed up between staff, people and their carers where necessary? Feedback from consultation E5.5 New How are national priorities to improve the population s health supported? (For example, smoking cessation, obesity, drug and alcohol dependency, dementia and cancer.) NOT: ambulances E6 Is consent to care and treatment always sought in line with legislation and guidance? Key lines of enquiry, prompts and ratings characteristics healthcare services 14

106 Key lines of enquiry and prompts: EFFECTIVE Code Key line of enquiry / prompt Reason for change Applies to E6.1 Substantive change Do staff understand the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005 and the Children s Acts 1989 and 2004 and other relevant national standards and guidance? Feedback from consultation E6.2 Substantive change How are people supported to make decisions in line with relevant legislation and guidance? Feedback from consultation E6.3 How and when is possible lack of mental capacity to make a particular decision assessed and recorded? E6.4 How is the process for seeking consent monitored and reviewed to ensure it meets legal requirements and follows relevant national guidance? E6.5 When people lack the mental capacity to make a decision, do staff ensure that best interests decisions are made in accordance with legislation? E6.6 Substantive change How does the service promote supportive practice that avoids the need for physical restraint? Where physical restraint may be necessary, how does the service ensure that it is used in a safe, proportionate and monitored way as part of a wider person-centred support plan? Feedback from consultation NOT: NHS 111 E6.7 Substantive change Do staff recognise when people aged 16 and over and who lack mental capacity are being deprived of their liberty, and do they seek authorisation to do so when they consider it necessary and proportionate? NOT: NHS 111 Key lines of enquiry, prompts and ratings characteristics healthcare services 15

107 Notes: Where we refer to people, we include adults, young people and children, where applicable. Key lines of enquiry and prompts: CARING Key to type of change No or minimal change to wording for clarity/moved or merged prompts Changed New Substantive change to wording New key line of enquiry or prompt, including those that are new for some, but not all, sectors Caring By caring, we mean that the service involves and treats people with compassion, kindness, dignity and respect. Code Key line of enquiry / prompt Reason for change Applies to C1 Substantive change How does the service ensure that people are treated with kindness, respect and compassion, and that they are given emotional support when needed? Change in wording previous C1 and C3 merged C1.1 Substantive change Do staff understand and respect the personal, cultural, social and religious needs of people and how these may relate to care needs, and do they take these into account in the way they deliver services? Is this information recorded and shared with other services or providers? Feedback from consultation C1.2 Do staff take the time to interact with people who use the service and those close to them in a respectful and considerate way? Key lines of enquiry, prompts and ratings characteristics healthcare services 16

108 Key lines of enquiry and prompts: CARING Code Key line of enquiry / prompt Reason for change Applies to C1.3 Do staff show an encouraging, sensitive and supportive attitude to people who use services and those close to them? C1.4 Do staff raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes? C1.5 Do staff understand the impact that a person s care, treatment or condition will have on their wellbeing and on those close to them, both emotionally and socially? C1.6 Substantive change Are people given appropriate and timely support and information to cope emotionally with their care, treatment or condition? Are they advised how to find other support services? Feedback from consultation C.2 Substantive change How does the service support people to express their views and be actively involved in making decisions about their care, treatment and support as far as possible? Feedback from consultation C2.1 Substantive change Do staff communicate with people so that they understand their care, treatment and condition and any advice given? Feedback from consultation C2.2 Substantive change Do staff seek accessible ways to communicate with people when their protected equality or other characteristics make this necessary? Wording aligned with ASC C2.3 Substantive change How do staff make sure that people who use services and those close to them are able to find further information, including community and advocacy services, or ask questions about their care and treatment? How are they supported to access these? Feedback from consultation C2.4 Substantive change Are people empowered and supported, where necessary, to use and link with support networks and advocacy, so that it will have a positive impact on their health, care and wellbeing? Feedback from consultation Key lines of enquiry, prompts and ratings characteristics healthcare services 17

109 Key lines of enquiry and prompts: CARING Code Key line of enquiry / prompt Reason for change Applies to C2.5 Substantive change Do staff routinely involve people who use services and those close to them (including carers and dependants) in planning and making shared decisions about their care and treatment? Do people feel listened to, respected and have their views considered? Feedback from consultation C2.6 New Are people s carers, advocates and representatives, including family members and friends, identified, welcomed and treated as important partners in the delivery of their care? Feedback from consultation C2.7 What emotional support and information is provided to those close to people who use services, including carers, family and dependants? C3 New How are people's privacy and dignity respected and promoted? C3.1 How does the service and staff make sure that people s privacy and dignity needs are understood and always respected, including during physical or intimate care and examinations? Aligned with ASC C3.2 Do staff respond in a compassionate, timely and appropriate way when people experience physical pain, discomfort or emotional distress? Aligned with ASC C3.3 New How are people assured that information about them is treated confidentially in a way that complies with the Data Protection Act and that staff support people to make and review choices about sharing their information? Feedback from consultation & aligned with ASC Key lines of enquiry, prompts and ratings characteristics healthcare services 18

110 Notes: Where we refer to people, we include adults, young people and children, where applicable. Key lines of enquiry and prompts: RESPONSIVE Key to type of change No or minimal change to wording for clarity/moved or merged prompts Changed New Substantive change to wording New key line of enquiry or prompt, including those that are new for some, but not all, sectors Responsive By responsive, we mean that services meet people s needs. The definition of responsive has changed from: By responsive, we mean that services are organised so that they meet people s needs. Service planning for population needs (previously the first two prompts of R1) will now sit in well-led (W2.5 and W7.4). Code Key line of enquiry / prompt Reason for change Applies to R1 Substantive change How do people receive personalised care that is responsive to their needs? Aligned with ASC R1.1 Do the services provided reflect the needs of the population served and do they ensure flexibility, choice and continuity of care? R1.2 Substantive change Where people s needs and choices are not being met, is this identified and used to inform how services are improved and developed? Feedback from consultation R1.3 Are the facilities and premises appropriate for the services that are delivered? Key lines of enquiry, prompts and ratings characteristics healthcare services 19

111 Key lines of enquiry and prompts: RESPONSIVE Code Key line of enquiry / prompt Reason for change Applies to R1.4 New How does the service identify and meet the information and communication needs of people with a disability or sensory loss? How does it record, highlight and share this information with others when required, and gain people s consent to do so? Feedback from consultation R2 Substantive change Do services take account of the particular needs and choices of different people? Feedback from consultation R2.1 Substantive change How are services delivered, made accessible and coordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances? Feedback from consultation R2.2 How are services delivered and coordinated to be accessible and responsive to people with complex needs? Feedback from consultation R2.3 New How are people supported during referral, transfer between services and discharge? R2.4 Are reasonable adjustments made so that people with a disability can access and use services on an equal basis to others? R2.5 New Do key staff work across services to coordinate people's involvement with families and carers, particularly for those with multiple long-term conditions? Feedback from consultation Key lines of enquiry, prompts and ratings characteristics healthcare services 20

112 Key lines of enquiry and prompts: RESPONSIVE Code Key line of enquiry / prompt Reason for change Applies to R2.6 Substantive change Where the service is responsible, how are people encouraged to develop and maintain relationships with people that matter to them, both within the service and the wider community? Wording aligned with ASC Community health services, specialist mental health services, specialist substance misuse services R2.7 New Where the service is responsible, how are people supported to follow their interests and take part in activities that are socially and culturally relevant and appropriate to them, including in the wider community and, where appropriate, to have access to education and work opportunities? Wording aligned with ASC Community health services, specialist mental health services, specialist substance misuse services Key lines of enquiry, prompts and ratings characteristics healthcare services 21

113 Key lines of enquiry and prompts: RESPONSIVE Code Key line of enquiry / prompt Reason for change Applies to R2.8 New How are services delivered and coordinated to ensure that people who may be approaching the end of their life are identified, including those with a protected equality characteristic and people whose circumstances may make them vulnerable, and that this information is shared? Feedback from consultation Acute and community health services only where the health service includes end of life care R2.9 New How are people who may be approaching the end of their life supported to make informed choices about their care? Are people s decisions documented and delivered through a personalised care plan and shared with others who may need to be informed? NOT: ambulance services, NHS 111, specialist mental health services Acute and community health services only where the health service includes end of life care R2.10 New If any treatment is changed or withdrawn, what are the processes to ensure that this is managed openly and sensitively so that people have a comfortable and dignified death? NOT: NHS 111, specialist Key lines of enquiry, prompts and ratings characteristics healthcare services 22

114 Key lines of enquiry and prompts: RESPONSIVE Code Key line of enquiry / prompt Reason for change Applies to mental health services Acute and community health services only where the health service includes end of life care R3 Can people access care and treatment in a timely way? R3.1 Do people have timely access to initial assessment, test results, diagnosis or treatment? R3.2 Can people access care and treatment at a time to suit them? NOT: ambulance services, NHS 111 R3.3 What action is taken to minimise the length of time people have to wait for care, treatment or advice? R3.4 Do people with the most urgent needs have their care and treatment prioritised? R3.5 Are appointment systems easy to use and do they support people to access appointments? NOT: NHS 111 R3.6 Are appointments, care and treatment only cancelled or delayed when absolutely necessary? Are delays or cancellations explained to people, and are people supported to access care and treatment again as soon as possible? Key lines of enquiry, prompts and ratings characteristics healthcare services 23

115 Key lines of enquiry and prompts: RESPONSIVE Code Key line of enquiry / prompt Reason for change Applies to R3.7 Do services run on time, and are people kept informed about any disruption? R3.8 New How is technology used to support timely access to care and treatment? Is the technology (including telephone systems and online/digital services) easy to use? Feedback from consultation NOT: ambulance services R4 How are people s concerns and complaints listened and responded to and used to improve the quality of care? R4.1 How well do people who use the service know how to make a complaint or raise concerns and how comfortable do they feel doing so in their own way? How are people encouraged to make a complaint, and how confident are they to speak up? Wording aligned with ASC R4.2 Substantive change How easy is it for people to use the complaints process or raise a concern? Are people treated compassionately and given help and support, by using accessible information or protection measures, if they need to make a complaint? Wording aligned with ASC R4.3 How effectively are complaints handled, including ensuring openness and transparency, confidentiality, regular updates for the complainant, a timely response and explanation of the outcome, and a formal record? Wording aligned with ASC R4.4 New How are people who raise concerns or complaints protected from discrimination, harassment or disadvantage? Wording aligned with ASC R4.5 Substantive change To what extent are concerns and complaints used as an opportunity to learn and drive continuous improvement? Wording aligned with ASC Key lines of enquiry, prompts and ratings characteristics healthcare services 24

116 Notes: 1. Where we refer to people, we include adults, young people and children, where applicable. Key lines of enquiry and prompts: WELL-LED 2. The new framework for assessing the well-led key question has been developed jointly with NHS Improvement. Therefore there are a number of changes to the previous version. Key to type of change No or minimal change to wording for clarity/moved or merged prompts Changed New Substantive change to wording New key line of enquiry or prompt, including those that are new for some, but not all, sectors Well-led By well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality and person-centred care, supports learning and innovation, and promotes an open and fair culture. Code Key line of enquiry / prompt Reason for change Service types applicable to W1 Is there the leadership capacity and capability to deliver high-quality, sustainable care? W1.1 Do leaders have the skills, knowledge, experience and integrity that they need both when they are appointed and on an ongoing basis? W1.2 Do leaders understand the challenges to quality and sustainability, and can they identify the actions needed to address them? Key lines of enquiry, prompts and ratings characteristics healthcare services 25

117 Key lines of enquiry and prompts: WELL-LED Code Key line of enquiry / prompt Reason for change Service types applicable to W1.3 Are leaders visible and approachable? W1.4 Are there clear priorities for ensuring sustainable, compassionate, inclusive and effective leadership, and is there a leadership strategy or development programme, which includes succession planning? W2 Is there a clear vision and credible strategy to deliver high-quality sustainable care to people, and robust plans to deliver? W2.1 Is there a clear vision and a set of values, with quality and sustainability as the top priorities? W2.2 Is there a robust, realistic strategy for achieving the priorities and delivering good quality sustainable care? W2.3 Have the vision, values and strategy been developed using a structured planning process in collaboration with staff, people who use services, and external partners? W2.4 Do staff know and understand what the vision, values and strategy are, and their role in achieving them? W2.5 Substantive change Is the strategy aligned to local plans in the wider health and social care economy, and how have services been planned to meet the needs of the relevant population? Feedback from consultation W2.6 Is progress against delivery of the strategy and local plans monitored and reviewed, and is there evidence to show this? W3 Is there a culture of high-quality, sustainable care? W3.1 Do staff feel supported, respected and valued? Key lines of enquiry, prompts and ratings characteristics healthcare services 26

118 Key lines of enquiry and prompts: WELL-LED Code Key line of enquiry / prompt Reason for change Service types applicable to W3.2 Is the culture centred on the needs and experience of people who use services? W3.3 Do staff feel positive and proud to work in the organisation? W3.4 W3.5 W3.6 Is action taken to address behaviour and performance that is inconsistent with the vision and values, regardless of seniority? Does the culture encourage openness and honesty at all levels within the organisation, including with people who use services, in response to incidents? Do leaders and staff understand the importance of staff being able to raise concerns without fear of retribution, and is appropriate learning and action taken as a result of concerns raised? Are there mechanisms for providing all staff at every level with the development they need, including high-quality appraisal and career development conversations? W3.7 Is there a strong emphasis on the safety and wellbeing of staff? W3.8 W3.9 W4 W4.1 Are equality and diversity promoted within and beyond the organisation? Do all staff, including those with particular protected characteristics under the Equality Act, feel they are treated equitably? Are there cooperative, supportive and appreciative relationships among staff? Do staff and teams work collaboratively, share responsibility and resolve conflict quickly and constructively? Are there clear responsibilities, roles and systems of accountability to support good governance and management? Are there effective structures, processes and systems of accountability to support the delivery of the strategy and good quality, sustainable services? Are these regularly reviewed and improved? Key lines of enquiry, prompts and ratings characteristics healthcare services 27

119 Key lines of enquiry and prompts: WELL-LED Code Key line of enquiry / prompt Reason for change Service types applicable to W4.2 Do all levels of governance and management function effectively and interact with each other appropriately? W4.3 Are staff at all levels clear about their roles and do they understand what they are accountable for, and to whom? W4.4 Are arrangements with partners and third-party providers governed and managed effectively to encourage appropriate interaction and promote coordinated, person-centred care? W4.5 Are there robust arrangements to make sure that hospital managers discharge their specific powers and duties according to the provisions of the Mental Health Act 1983? Specialist mental health services W5 Are there clear and effective processes for managing risks, issues and performance? W5.1 Are there comprehensive assurance systems, and are performance issues escalated appropriately through clear structures and processes? Are these regularly reviewed and improved? W5.2 Are there processes to manage current and future performance? Are these regularly reviewed and improved? W5.3 Is there a systematic programme of clinical and internal audit to monitor quality, operational and financial processes, and systems to identify where action should be taken? W5.4 Are there robust arrangements for identifying, recording and managing risks, issues and mitigating actions? Is there alignment between the recorded risks and what staff say is on their worry list? Key lines of enquiry, prompts and ratings characteristics healthcare services 28

120 Key lines of enquiry and prompts: WELL-LED Code Key line of enquiry / prompt Reason for change Service types applicable to W5.5 Are potential risks taken into account when planning services, for example seasonal or other expected or unexpected fluctuations in demand, or disruption to staffing or facilities? W5.6 Substantive change When considering developments to services or efficiency changes, how is the impact on quality and sustainability assessed and monitored? Are there examples of where financial pressures have compromised care? W6 Substantive change Is appropriate and accurate information being effectively processed, challenged and acted on? Feedback from consultation W6.1 Is there a holistic understanding of performance, which sufficiently covers and integrates people s views with information on quality, operations and finances? Is information used to measure for improvement, not just assurance? W6.2 Do quality and sustainability both receive sufficient coverage in relevant meetings at all levels? Do all staff have sufficient access to information, and do they challenge it appropriately? W6.3 Are there clear and robust service performance measures, which are reported and monitored? W6.4 Are there effective arrangements to ensure that the information used to monitor, manage and report on quality and performance is accurate, valid, reliable, timely and relevant? What action is taken when issues are identified? W6.5 Are information technology systems used effectively to monitor and improve the quality of care? W6.6 Are there effective arrangements to ensure that data or notifications are submitted to external bodies as required? Key lines of enquiry, prompts and ratings characteristics healthcare services 29

121 Key lines of enquiry and prompts: WELL-LED Code Key line of enquiry / prompt Reason for change Service types applicable to W6.7 Are there robust arrangements (including appropriate internal and external validation) to ensure the availability, integrity and confidentiality of identifiable data, records and data management systems, in line with data security standards? Are lessons learned when there are data security breaches? W7 Substantive change Are the people who use services, the public, staff and external partners engaged and involved to support high-quality sustainable services? Feedback from consultation W7.1 Are people s views and experiences gathered and acted on to shape and improve the services and culture? Does this include people in a range of equality groups? W7.2 Are people who use services, those close to them and their representatives actively engaged and involved in decision-making to shape services and culture? Does this include people in a range of equality groups? W7.3 Are staff actively engaged so that their views are reflected in the planning and delivery of services and in shaping the culture? Does this include those with a protected equality characteristic? W7.4 Are there positive and collaborative relationships with external partners to build a shared understanding of challenges within the system and the needs of the relevant population, and to deliver services to meet those needs? W7.5 Is there transparency and openness with all stakeholders about performance? W8 Are there robust systems and processes for learning, continuous improvement and innovation? Key lines of enquiry, prompts and ratings characteristics healthcare services 30

122 Key lines of enquiry and prompts: WELL-LED Code Key line of enquiry / prompt Reason for change Service types applicable to W8.1 In what ways do leaders and staff strive for continuous learning, improvement and innovation? Does this include participating in appropriate research projects and recognised accreditation schemes? W8.2 Are there standardised improvement tools and methods, and do staff have the skills to use them? W8.3 How effective is participation in and learning from internal and external reviews, including those related to mortality or the death of a person using the service? Is learning shared effectively and used to make improvements? W8.4 Do all staff regularly take time out to work together to resolve problems and to review individual and team objectives, processes and performance? Does this lead to improvements and innovation? W8.5 Are there systems to support improvement and innovation work, including objectives and rewards for staff, data systems, and processes for evaluating and sharing the results of improvement work? Key lines of enquiry, prompts and ratings characteristics healthcare services 31

123 Ratings characteristics: SAFE Ratings characteristics for healthcare services Safe By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse. Outstanding Good Requires improvement Inadequate People are protected by a strong comprehensive safety system, and a focus on openness, transparency and learning when things go wrong. People are protected from avoidable harm and abuse. Legal requirements are met. There is an increased risk that people are harmed or there is limited assurance about safety. Regulations may or may not be met. People are not safe or at high risk of avoidable harm or abuse. Normally, some regulations are not met. S1: How do systems, processes and practices keep people safe and safeguarded from abuse? Outstanding Good Requires improvement Inadequate There are comprehensive systems to keep people safe, which take account of current best practice. The whole team is engaged in reviewing and improving safety and safeguarding systems. People who use services are at the centre of safeguarding and protection from discrimination. There are clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse, using local safeguarding procedures whenever necessary. These: are reliable and minimise the potential for error reflect national, professional guidance and legislation Systems, processes and standard operating procedures are not always reliable or appropriate to keep people safe. Monitoring whether safety systems are implemented is not robust. There are some concerns about the consistency of understanding and the Safety systems, processes and standard operating procedures are not fit for purpose. There is wilful or routine disregard of standard operating or safety procedures. Key lines of enquiry, prompts and ratings characteristics healthcare services 32

124 Ratings characteristics: SAFE Innovation is encouraged to achieve sustained improvements in safety and continual reductions in harm. are appropriate for the care setting and address people s diverse needs are understood by all staff and implemented consistently are reviewed regularly and improved when needed. Staff have received up-to-date training in all safety systems, processes and practices. Safeguarding adults, children and young people at risk is given sufficient priority. Staff take a proactive approach to safeguarding and focus on early identification. They take steps to prevent abuse or discrimination that might cause avoidable harm, respond appropriately to any signs or allegations of abuse and work effectively with others, including people using the service, to agree and implement protection plans. There is active and appropriate engagement in local safeguarding procedures and effective work with other relevant organisations, including when people experience harassment or abuse in the community. number of staff who are aware of them. Safeguarding is not given sufficient priority at all times. Systems are not fully embedded, staff do not always respond quickly enough, or there are shortfalls in the system of engaging with local safeguarding processes and with people using the service. There is an inconsistent approach to protecting people from discrimination. There is insufficient attention to safeguarding children and adults. Staff do not recognise or respond appropriately to abuse or discriminatory practice. Care premises, equipment and facilities are unsafe. Key lines of enquiry, prompts and ratings characteristics healthcare services 33

125 Ratings characteristics: SAFE S2: How are risks to people assessed, and their safety monitored and managed so they are supported to stay safe? Outstanding Good Requires improvement Inadequate A proactive approach to anticipating and managing risks to people who use services is embedded and is recognised as the responsibility of all staff. Staff are able to discuss risk effectively with people using the service. Staffing levels and skill mix are planned, implemented and reviewed to keep people safe at all times. Any staff shortages are responded to quickly and adequately. Where relevant, there are effective handovers and shift changes to ensure that staff can manage risks to people who use services. Staff recognise and respond appropriately to changes in the risks to people who use services. Risks to safety from changes or developments to services are assessed, planned for and managed effectively. There are periods of understaffing or inappropriate skill mix, which are not addressed quickly. Agency, bank and locum staff are not used in a way that ensures people s safety is always protected. There is a risk that staff may not recognise or respond appropriately to signs of deteriorating health or medical emergencies. Substantial or frequent staff shortages or poor management of agency or locum staff increases risks to people who use services. Staff do not assess, monitor or manage risks to people who use the services. Opportunities to prevent or minimise harm are missed. Changes are made to services without due regard to the impact on people s safety. The following characteristics do not apply to GP practices, GP out-of-hours, and NHS 111 services People who use services and those close to them are actively involved in managing their own risks. Risks to people who use services are assessed, monitored and managed on a day-to-day basis. These include signs of deteriorating health, medical emergencies or behaviour that challenges. People are involved in managing risks and risk assessments are person-centred, proportionate and reviewed regularly. The approach to assessing and managing day-to-day risks to people who use services is sometimes focused on clinical risks and does not take a holistic view of people s needs. Key lines of enquiry, prompts and ratings characteristics healthcare services 34

126 Ratings characteristics: SAFE S3: Do staff have all the information they need to deliver safe care and treatment to people? Outstanding Good Requires improvement Inadequate The systems to manage and share the information that is needed to deliver effective care treatment and support, are coordinated, provide real-time information across services, and support integrated care for people who use services. People are able to transition seamlessly between services because there is advance planning and information sharing between teams. Innovative practice supports accurate and personalised information sharing. Staff can access the information they need to assess, plan and deliver care, treatment and support to people in a timely way, particularly when people are referred or when they transition between services. When there are different systems to store or manage care records, these are coordinated. People understand the information that is shared about them and, if possible, they have a copy. Staff have involved partner agencies and carers when sharing information. Systems to manage and share care records and information are cumbersome or uncoordinated, and there are delays in sharing information about people's care between staff or with carers and partner agencies. Staff do not always have the complete information they need before providing care, treatment and support. People have to repeat information or answer the same questions again. The information needed to plan and deliver effective care, treatment and support is not available at the right time. Information about people s care and treatment is not appropriately shared between staff or with carers and partner agencies. People have to repeat information or answer the same questions again and be re-triaged. S4: How does the provider ensure the proper and safe use of medicines, where the service is responsible? Outstanding Good Requires improvement Inadequate Staff not only meet good practice standards in relation to national guidance, they also contribute to research and development of national guidance. Staff meet good practice standards described in relevant national guidance, including in relation to non-prescribed medicines. People receive their medicines as prescribed. The service involves them in People do not always receive their medicines as prescribed. The service does not always follow relevant national guidelines around storing medicines, People are at risk because staff do not administer medicines safely or people do not receive them as prescribed. Medicines are not ordered, Key lines of enquiry, prompts and ratings characteristics healthcare services 35

127 Ratings characteristics: SAFE Compliance with medicines policy and procedure is routinely monitored and action plans are always implemented promptly. regular medicines reviews. Staff manage medicines consistently and safely. Medicines are stored correctly, and disposed of safely. Staff keep accurate records of medicines. administering them, and disposing of them. This includes in relation to nonprescribed medicines. transported or stored safely or securely. S5: What is the track record on safety? Outstanding Good Requires improvement Inadequate The provider has a sustained track record of safety supported by accurate performance information. There is ongoing, consistent progress towards safety goals reflected in a zero-harm culture. Monitoring and reviewing activity enables staff to understand risks and gives a clear, accurate and current picture of safety. Performance shows a good track record and steady improvements in safety. Information about safety is not always comprehensive or timely. Safety is not improved over time. Safety is not a sufficient priority. There is limited measurement and monitoring of safety performance. There are unacceptable levels of serious incidents, or significant or never events. S6: Are lessons learned and improvements made when things go wrong? Outstanding Good Requires improvement Inadequate There is a genuinely open culture in which all safety concerns raised by staff and people who use service are highly valued as being integral to learning and improvement. All staff are open and transparent, and fully committed to reporting incidents and near misses. The level and quality of Openness and transparency about safety is encouraged. Staff understand and fulfil their responsibilities to raise concerns and report incidents and near misses; they are fully supported when they do so. When something goes wrong, there is an appropriate thorough review or investigation that involves all relevant staff, partner organisations and people who use services. The service participates Safety concerns are not consistently identified or addressed quickly enough. There is limited use of systems to record and report safety concerns, incidents and near misses. Some staff are not clear how to do this or are wary about raising concerns. Staff do not recognise concerns, incidents or near misses. Staff are afraid of, or discouraged from, raising concerns and there is a culture of blame. When concerns are raised or things go wrong, the approach to reviewing and Key lines of enquiry, prompts and ratings characteristics healthcare services 36

128 Ratings characteristics: SAFE incident reporting shows the levels of harm and near misses, which ensures a robust picture of quality. Learning is based on a thorough analysis and investigation of things that go wrong. All staff are encouraged to participate in learning to improve safety as much as possible, including working with others in the system and where relevant, participating in local, national, and international safety programmes. Opportunities to learn from external safety events are identified. in learning with other providers within the system. Lessons are learned and communicated widely to support improvement in other areas where relevant, as well as services that are directly affected. Opportunities to learn from external safety events and patient safety alerts are also identified. Improvements to safety are made and the resulting changes are monitored. When things go wrong, reviews and investigations are not always sufficiently thorough or do not include all relevant people. Necessary improvements are not always made when things go wrong. The service does not always review or act on patient safety alerts or learn from external safety events. investigating causes is insufficient or too slow. There is little evidence of learning from events or action taken to improve safety. The service does not receive or comply with patient safety alerts. Key lines of enquiry, prompts and ratings characteristics healthcare services 37

129 Ratings characteristics: EFFECTIVE Effective By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. Outstanding Good Requires improvement Inadequate Outcomes for people who use services are consistently better than expected when compared with other similar services. People have good outcomes because they receive effective care and treatment that meets their needs. People are at risk of not receiving effective care or treatment. There is a lack of consistency in the effectiveness of the care, treatment and support that people receive. Regulations may or may not be met. People receive ineffective care or there is insufficient assurance in place to demonstrate otherwise. Normally, some regulations are not met. E1: Are people s needs assessed and care and treatment delivered in line with current legislation, standards and evidence-based guidance to achieve effective outcomes? Outstanding Good Requires improvement Inadequate There is a truly holistic approach to assessing, planning and delivering care and treatment to all people who use services. This includes addressing, where relevant, their nutrition, hydration and pain relief needs. The safe use of innovative and pioneering approaches to care and how it is delivered are actively encouraged. New evidence- People s care and treatment is planned and delivered in line with current evidence-based guidance, standards, best practice, legislation and technologies. This is monitored to ensure consistency of practice. People have comprehensive assessments of their needs, which include consideration of clinical needs (including pain relief), mental health, Care and treatment does not always reflect current evidence-based guidance, standards, best practice and technologies. Implementation of evidencebased guidance is variable. Care assessments do not consider the full range of people s diverse needs, People s care and treatment does not reflect current evidence-based guidance, standards, practice or technology. Care or treatment is based on discriminatory decisions rather than a full assessment of a person s needs, including those related to nutrition, Key lines of enquiry, prompts and ratings characteristics healthcare services 38

130 Ratings characteristics: EFFECTIVE based techniques and technologies are used to support the delivery of high-quality care. People who are detained under the Mental Health Act 1983 (MHA) understand and are empowered to exercise their rights under the Act. The provider supports staff to understand and meet the standards in the MHA Code of Practice, working effectively with others to promote the best outcomes with a focus on recovery for people subject to the MHA. physical health and wellbeing, and nutrition and hydration needs. The expected outcomes are identified and care and treatment is regularly reviewed and updated, and appropriate referral pathways are in place to make sure that needs are addressed. Where people are subject to the Mental Health Act 1983 (MHA), their rights are protected and staff comply with the MHA Code of Practice. Any departure from the Code of Practice guidance is clearly justified. including those related to nutrition, hydration and pain relief. Staff do not always adhere to the Mental Health Act Code of Practice. Deviation from Code of Practice guidance is not always clearly recorded. hydration and pain relief. Staff fail to comply with the Mental Health Act Code of Practice or other legislation. E2: How are people s care and treatment outcomes monitored and how do they compare with other similar services? Outstanding Good Requires improvement Inadequate All staff are actively engaged in activities to monitor and improve quality and outcomes (including, where appropriate, monitoring outcomes for people once they have transferred to other services). Opportunities to participate in benchmarking and peer review are proactively pursued, including participation in approved accreditation schemes. High performance is recognised by credible external Information about people s care and treatment, and their outcomes, is routinely collected and monitored. This information is used to improve care. Outcomes for people who use services are positive, consistent and meet expectations. There is participation (that includes all relevant staff) in relevant local and national clinical audits and other monitoring activities such as reviews of services, benchmarking and peer review Outcomes for people who use services are below expectations compared with similar services. The outcomes of people s care and treatment are not always monitored regularly or robustly. Participation in external audits and benchmarking is limited. The results of monitoring are not always used effectively to improve There is very limited or no monitoring of the outcomes of care and treatment. People s outcomes are very variable or significantly worse than expected when compared with other similar services. Necessary action is not taken to improve people s outcomes. Key lines of enquiry, prompts and ratings characteristics healthcare services 39

131 Ratings characteristics: EFFECTIVE bodies. Outcomes for people who use services are positive, consistent and regularly exceed expectations. and approved service accreditation schemes. Accurate and up-to-date information about effectiveness is shared internally and externally and is understood by staff. It is used to improve care and treatment and people s outcomes and this improvement is checked and monitored. quality. E3: How does the service make sure that staff have the skills, knowledge and experience to deliver effective care, support and treatment? Outstanding Good Requires improvement Inadequate The continuing development of the staff s skills, competence and knowledge is recognised as being integral to ensuring highquality care. Staff are proactively supported and encouraged to acquire new skills, use their transferable skills, and share best practice. Where relevant, volunteers are proactively recruited and are supported in their role. The service regularly updates its policies and processes for using volunteers and innovative practice, and the use of volunteers helps to measurably improve outcomes for people. All staff, including volunteers, are qualified and have the skills they need to carry out their roles effectively and in line with best practice. The learning needs of staff are identified and training is provided to meet these needs. Staff are supported to maintain and further develop their professional skills and experience. Staff are supported to deliver effective care and treatment, including through meaningful and timely supervision and appraisal. Where relevant, staff are supported through the process of revalidation. There is a clear and appropriate approach for supporting and managing staff when their performance is poor or variable. The service has effective policies and Not all staff have the right qualifications, skills, knowledge and experience to do their job. The learning needs of staff are not fully understood. Staff are not always supported to participate in training and development, or the opportunities that are offered do not fully meet their needs. There are gaps in management and support arrangements for staff, such as appraisal, supervision and professional development. Volunteers are recruited, People receive care from staff who do not have the skills or experience that is needed to deliver effective care. Staff do not develop the knowledge, skills and experience to enable them to deliver good quality care. Staff are not supervised or managed effectively. Poor performance is not dealt with in a timely or effective way. There is a lack of coordinated recruitment, support and training of volunteers. Key lines of enquiry, prompts and ratings characteristics healthcare services 40

132 Ratings characteristics: EFFECTIVE processes for recruiting, training and supporting volunteers where necessary. These are implemented and volunteers feel supported and understand their roles and responsibilities. but they are not given effective training or support. E4: How well do staff, teams and services work together within and across organisations to deliver effective care and treatment? Outstanding Good Requires improvement Inadequate Staff, teams and services are committed to working collaboratively and have found innovative and efficient ways to deliver more joined-up care to people who use services. There is a holistic approach to planning people s discharge, transfer or transition to other services, which is done at the earliest possible stage. When people receive care from a range of different staff, teams or services, it is coordinated. All relevant staff, teams and services are involved in assessing, planning and delivering people s care and treatment. Staff work collaboratively to understand and meet the range and complexity of people s needs. When people are due to move between services their needs are assessed early, with the involvement of all necessary staff, teams and services. People s discharge, transition and referral plans take account of their individual needs, circumstances, ongoing care arrangements and expected outcomes. People are discharged at an appropriate time and when all necessary care arrangements are in place. Where unexpected discharges, transfers and transitions occur, processes are in place that do not leave people unduly at There is limited participation in multidisciplinary working. Teams do not include all necessary staff, are not coordinated or do not meet frequently enough to provide effective care. Discharge, transition and referral planning is undertaken but is not timely or does not consider all of the person s needs. There may be delays or poor coordination when people are referred or discharged or when they transition to other services. Unexpected discharges, transfers and transitions are not managed effectively and the provider does not consistently make sure that unplanned departures or discharges do not leave Staff and teams provide care in isolation and do not seek support or input from other relevant teams and services. There are significant barriers to effective joint working between teams. The plans for people s discharge, transition or referral are incomplete or they do not reflect their needs. There are significant delays to discharge, transition or referral. The arrangements for discharge, transition or referral are unclear or discharge happens without having ongoing care arrangements in place. Unexpected discharges, transfers and transitions are Key lines of enquiry, prompts and ratings characteristics healthcare services 41

133 Ratings characteristics: EFFECTIVE risk, including communicating people s specific, individual needs. people unduly at risk. not managed and may place people at risk. E5: How are people supported to live healthier lives and, where the service is responsible, how does it improve the health of itspopulation, where necessary? Outstanding Good Requires improvement Inadequate Staff are consistent in supporting people to live healthier lives, including identifying those who need extra support, through a targeted and proactive approach to health promotion and prevention of ill-health, and they use every contact with people to do so. Staff are consistent and proactive in supporting people to live healthier lives. There is a focus on early identification and prevention and on supporting people to improve their health and wellbeing. There is limited focus on prevention and early identification of health needs and staff are not proactive in supporting people to live healthier lives. There is no focus on prevention and early identification of health needs. Staff are reactive, rather than proactive in supporting people to live healthier lives, and those who need extra support are not identified. E6: Is consent to care and treatment always sought in line with legislation and guidance? Outstanding Good Requires Improvement Inadequate Practices around consent and records are actively monitored and reviewed to improve how people are involved in making decisions about their care and treatment. Engagement with stakeholders, including people who use services and those close to them, informs the development of tools and support to help Consent to care and treatment is obtained in line with legislation and guidance, including the Mental Capacity Act 2005 and the Children s Acts 1989 and People are supported to make decisions and, where appropriate, their mental capacity is assessed and recorded. When people aged 16 and over lack the mental capacity to make a decision, best interests decisions are made in accordance with legislation. The process Consent is not always obtained or recorded in line with relevant guidance and legislation. There is a lack of consistency in how people s mental capacity is assessed and not all decision-making is informed or in line with guidance and legislation. Decision-makers do not always make decisions in Consent to care and treatment has not been obtained in line with legislation and guidance, including the Mental Capacity Act 2005 and the Children s Acts 1989 and There are instances where care and treatment is not provided in line with people s decisions about consent. Key lines of enquiry, prompts and ratings characteristics healthcare services 42

134 Ratings characteristics: EFFECTIVE people give informed consent. for seeking consent is appropriately monitored. The use of restraint is understood and monitored, and less restrictive options are used where possible. the best interests of people who lack the mental capacity to make decisions for themselves, in accordance with legislation. Restraint (where relevant) is not always recognised, or less restrictive options used where possible. Where appropriate, people s mental capacity has not been assessed and recorded. When people aged 16 and over lack the mental capacity to make a decision, best interests decisions have not been made in accordance with legislation. Restraint (where relevant) is not recognised and no attempts are made to find less restrictive options to provide necessary care and treatment. The following characteristics do not apply to ambulance services, GP practices, GP out-of-hours, and NHS 111 services Deprivation of liberty is recognised and only occurs when it is in a person s best interests, is a proportionate response to the risk and seriousness of harm to the person, and there is no less restrictive option that can be used to ensure the person gets the necessary care and treatment. The Deprivation of Liberty Safeguards, and orders by the Court of Protection authorising deprivation of a person s liberty, are used appropriately. Applications to authorise a deprivation of liberty using the Deprivation of Liberty Safeguards or through the Court of Protection are not always made appropriately or in a timely way. Applications to authorise a deprivation of liberty using the Deprivation of Liberty Safeguards or through the Court of Protection are not made appropriately or in a timely way. Key lines of enquiry, prompts and ratings characteristics healthcare services 43

135 Ratings characteristics: CARING Caring By caring, we mean that the service involves and treats people with compassion, kindness, dignity and respect. Outstanding Good Requires improvement Inadequate People are truly respected and valued as individuals and are empowered as partners in their care, practically and emotionally, by an exceptional and distinctive service. People are supported, treated with dignity and respect, and are involved as partners in their care. There are times when people do not feel wellsupported or cared for or their dignity is not maintained. The service is not always caring. Regulations may or may not be met. People are not treated with compassion or involved in their care. There are breaches of dignity and significant shortfalls in the caring attitude of staff. Normally, some regulations are not met. C1: How does the service ensure that people are treated with kindness, respect and compassion, and that they are given emotional support when needed? Outstanding Good Requires improvement Inadequate Feedback from people who use the service, those who are close to them and stakeholders is continually positive about the way staff treat people. People think that staff go the extra mile and their care and support exceeds their expectations. There is a strong, visible personcentred culture. Staff are highly Feedback from people who use the service, those who are close to them and stakeholders is positive about the way staff treat people. People are treated with dignity, respect and kindness during all interactions with staff and relationships with staff are positive. People feel supported and say staff care about them. Staff respond compassionately when people need help and they support them Some people who use the service, those who are close to them and stakeholders have concerns about the way staff treat people. People are sometimes not treated with kindness or respect when receiving care and treatment or during other interactions with staff. People do not feel cared for and feedback about staff interactions is negative. Staff are rude, impatient, judgemental, disrespectful or dismissive of people using their services or those close to them. People do not know how to seek help or are ignored when Key lines of enquiry, prompts and ratings characteristics healthcare services 44

136 Ratings characteristics: CARING motivated and inspired to offer care that is kind and promotes people s dignity. Relationships between people who use the service, those close to them and staff are strong, caring, respectful and supportive. These relationships are highly valued by staff and promoted by leaders. Staff recognise and respect the totality of people s needs. They always take people s personal, cultural, social and religious needs into account, and find innovative ways to meet them. to meet their basic personal needs as and when required. They anticipate people s needs. Staff support people and those close to them to manage their emotional response to their care and treatment. People s personal, cultural, social and religious needs are understood. People are supported to maintain and develop their relationships with those close to them, their social networks and the community. People s emotional, social, cultural or religious needs are not always viewed as important or reflected in their care, treatment and support. they do. Their basic needs are not met. People s preferences and choices are not heard or acted on. People feel isolated and disconnected from their lives. They do not receive support to cope emotionally with their care and condition. People s emotional and social needs are seen as being as important as their physical needs. C2: How does the service support people to express their views and be actively involved in making decisions about their care, treatment and support as far as possible? Outstanding Good Requires improvement Inadequate People who use services and those close to them are active partners in their care. Staff are fully committed to working in partnership with people and making this a reality for each person. People who use services, carers and family members are involved and encouraged to be partners in their care and in making decisions, and receive any support they need. Staff spend time talking to people, or those close to them. Staff communicate with people and There is a paternalistic approach to providing care. Some staff do not consider involving people, carers and their families as an important part of care. People say that staff do not always explain People do not know or do not understand what is going to happen to them during their care. People do not know who to ask for help. They are not involved in their own care or Key lines of enquiry, prompts and ratings characteristics healthcare services 45

137 Ratings characteristics: CARING Staff always empower people who use the service to have a voice and to realise their potential. They show determination and creativity to overcome obstacles to delivering care. People s individual preferences and needs are always reflected in how care is delivered. Staff recognise that people need to have access to, and links with, their advocacy and support networks in the community and they support people to do this. They ensure that people's communication needs are understood, seek best practice and learn from it. provide information in a way that they can understand. People understand their condition and their care, treatment and advice. People and staff work together to plan care and there is shared decisionmaking about care and treatment. things clearly or give them time to respond or help them to understand. Some people are not supported to understand the information they are given about their care and condition. This includes during referral, discharge, transition or transfers. The service is not prioritising a caring environment. People are not given information, access to advocacy or helped in other ways to be involved in their care and treatment. treatment and neither are carers or family members. People s preferences and choices are not considered in their care, support and treatment. The service does not support a caring environment and approach to people s care, treatment and support. C3: How is people's privacy and dignity respected and promoted? Outstanding Good Requires improvement Inadequate People are always treated with dignity by all those involved in their care, treatment and support. Consideration of people s privacy and dignity is consistently embedded in everything that staff do, including awareness of any specific needs as these are People who use services, those close to them and staff all understand the expectations of the service around privacy and dignity. Staff recognise the importance of people s privacy and dignity, respect it at all times and they challenge behaviour and practices that fall short of this. Staff develop trusting relationships with Staff do not see people s privacy and dignity as a priority. They do not always understand the need to make sure that people s privacy and dignity is maintained. While this may not be intentional, it results in people not always feeling People s privacy, dignity and confidentiality are not respected. There is a demonstrable lack of understanding of privacy, dignity and confidentiality. The routines and preferences of staff take priority and they have little Key lines of enquiry, prompts and ratings characteristics healthcare services 46

138 Ratings characteristics: CARING recorded and communicated. Staff find innovative ways to enable people to manage their own health and care when they can and to maintain independence as much as possible. People feel really cared for and that they matter. Staff are exceptional in enabling people to remain independent. People value their relationships with the staff team and feel that they often go the extra mile for them when providing care and support. people. People s confidentiality is respected at all times. Legal requirements about data protection are met. When people s care and support is provided by a mix of different providers, the service minimises risks to privacy and confidentiality. People are enabled to manage their own health and care when they can, and to maintain independence. People have free access to their family, friends and community. Any restrictions to this are unavoidable or demonstrably in their best interests. they are respected or valued. Staff do not always respect people's privacy and confidentiality. Staff may focus on the task rather than treating people as individuals. Services are inconsistent at times, and people do not always know who will be helping them. People are not encouraged to manage their own care. understanding of the impact of this approach on the wellbeing and needs of people using the service. Not treating people, including those that matter to them, with kindness, respect and compassion is usually serious and widespread. People are not involved in their own care or treatment. Key lines of enquiry, prompts and ratings characteristics healthcare services 47

139 Ratings characteristics: RESPONSIVE Responsive By responsive, we mean that services meet people s needs. Outstanding Good Requires improvement Inadequate Services are tailored to meet the needs of individual people and are delivered in a way to ensure flexibility, choice and continuity of care. People s needs are met through the way services are organised and delivered. Services do not always meet people s needs. Regulations may or may not be met. Services are not planned or delivered in a way that meets people s needs. Normally, some regulations are not met. R1: How do people receive personalised care that is responsive to their needs? Outstanding Good Requires improvement Inadequate People s individual needs and preferences are central to the delivery of tailored services. There are innovative approaches to providing integrated person-centred pathways of care that involve other service providers, particularly for people with multiple and complex needs. The services are flexible, provide informed choice and ensure continuity of care. The importance of flexibility, informed choice and continuity of care is reflected in the services. People s needs and preferences are considered and acted on to ensure that services are delivered in a way that is convenient. Services are not delivered in a way that focuses on people s holistic needs. There is some flexibility to take account of individual needs as they arise, but the service does not meet the needs of all the people who use it. Services are delivered in a way or at a time that is inconvenient and disruptive to people s lives. Services are planned and delivered without consideration of people s needs and preferences. Some people are unable to use the service because it does not meet their needs. Key lines of enquiry, prompts and ratings characteristics healthcare services 48

140 Ratings characteristics: RESPONSIVE The following characteristic does not apply to NHS 111 services Facilities and premises are innovative and meet the needs of a range of people who use the service. Facilities and premises are appropriate for the services being delivered. People find it hard to access services because the facilities and premises are not appropriate for the services being provided and action is not taken to address this. The facilities and premises do not meet people s needs or are inappropriate. R2: Do services take account of the particular needs and choices of different people? Outstanding Good Requires improvement Inadequate There is a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way that meets these needs, which is accessible and promotes equality. This includes people with protected characteristics under the Equality Act, people who may be approaching the end of their life, and people who are in vulnerable circumstances or who have complex needs. The needs and preferences of different people are taken into account when delivering and coordinating services, including those with protected characteristics under the Equality Act, people who may be approaching the end of their life and people who are in vulnerable circumstances or who have complex needs. Care and treatment is coordinated with other services and other providers. This includes liaising with families and carers and ensuring that all services are informed of any diverse needs that need to be addressed. Reasonable adjustments are made and action is taken to remove barriers when people find it hard to use or access services. There are shortfalls in how the needs and preferences of different people are taken into account, for example on the grounds of protected characteristics under the Equality Act and for people who may be approaching the end of their life, who are in vulnerable circumstances or who have complex needs. Reasonable adjustments are not always made. Information is not always accessible to all people. People are unable to access the care they need. Services are not set up to support people who may be approaching the end of their life, who have complex needs, who may need accessible information or people in vulnerable circumstances. Key lines of enquiry, prompts and ratings characteristics healthcare services 49

141 Ratings characteristics: RESPONSIVE R3: Can people access care and treatment in a timely way? Outstanding Good Requires improvement Inadequate People can access services and appointments in a way and at a time that suits them. Technology is used innovatively to ensure people have timely access to treatment, support and care. People can access the right care at the right time. Access to care is managed to take account of people s needs, including those with urgent needs. The telephone or online system is easy to use and supports people to make appointments, bookings or obtain advice or treatment. Waiting times, delays and cancellations are minimal and managed appropriately. People are kept informed of any disruption to their care or treatment. People find it difficult to use the appointment system to access services, either by telephone or using the online system. Some people are not able to access services for assessment, diagnosis or treatment when they need to. There are long waiting times, delays or cancellations. Action to address this is not taken quickly enough or is not effective. People are frequently and consistently not able to access services in a timely way for an initial assessment, diagnosis or treatment. People experience unacceptable waits for some services. R4: How are people s concerns and complaints listened and responded to and used to improve the quality of care? Outstanding Good Requires improvement Inadequate People who use the service and others are involved in regular reviews of how the service manages and responds to complaints. The service can demonstrate where improvements have been made as a result of learning from reviews and that learning is shared with other services. People know how to give feedback about their experiences and can do so in a range of accessible ways, including how to raise any concerns or issues. People who use the service, their family, friends and other carers feel confident that if they complain, they will be taken seriously and treated compassionately. They feel that their complaint or concern will be explored thoroughly and People do not find it easy to raise concerns or complaints, or are worried about doing so. Complaints and concerns cannot be made in completely accessible ways. When people raise complaints or concerns, the service may not always take People are not invited to express their views about their care and support. Complaints and concerns cannot be made in accessible ways. Complaints are not dealt with in an open, transparent, timely and objective way. The Key lines of enquiry, prompts and ratings characteristics healthcare services 50

142 Ratings characteristics: RESPONSIVE Investigations are comprehensive and the service uses innovative ways of looking into concerns, including using external people and professionals to make sure there is an independent and objective approach. responded to in good time because the service deals with complaints in an open and transparent way, with no repercussions. The service uses the learning from complaints and concerns as an opportunity for improvement. Staff can give examples of how they incorporated learning into daily practice. their views fully on board, investigate them thoroughly and in a timely way, or change practice to improve. The complaints system may be managed inconsistently and there is little evidence of the learning applied to practice within the service. service s response to complaints suggests a defensive attitude. People suffer discrimination, detriment and harassment if they complain. People sometimes suffer discrimination, detriment and harassment if they complain. Key lines of enquiry, prompts and ratings characteristics healthcare services 51

143 Ratings characteristics: WELL-LED Well-led By well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality and person-centred care, supports learning and innovation, and promotes an open and fair culture. Outstanding Good Requires improvement Inadequate The leadership, governance and culture are used to drive and improve the delivery of high-quality person-centred care. The leadership, governance and culture promote the delivery of highquality person-centred care. The leadership, governance and culture do not always support the delivery of high-quality person-centred care. Regulations may or may not be met. The delivery of highquality care is not assured by the leadership, governance or culture. Normally, some regulations are not met. W1: Is there the leadership capacity and capability to deliver high-quality, sustainable care? Outstanding Good Requires improvement Inadequate There is compassionate, inclusive and effective leadership at all levels. Leaders at all levels demonstrate the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. There is a deeply embedded system of leadership development and succession planning, which aims to ensure that the leadership represents the diversity of the Leaders have the experience, capacity, capability and integrity to ensure that the strategy can be delivered and risks to performance addressed. Leaders at every level are visible and approachable. Compassionate, inclusive and effective leadership is sustained through a leadership strategy and development programme and effective selection, deployment and support processes and succession planning. The leadership is knowledgeable about Not all leaders have the necessary experience, knowledge, capacity, capability or integrity to lead effectively. Staff do not consistently know who their leaders are or how to gain access to them. The need to develop leaders is not always identified or action is not always taken. Leaders are not always Leaders do not have the necessary experience, knowledge, capacity, capability or integrity to lead effectively. There is no stable leadership team, with high unplanned turnover and/or vacancies. Leaders are out of touch with what is happening on the front line, and they cannot identify or do not understand the risks and issues described by Key lines of enquiry, prompts and ratings characteristics healthcare services 52

144 Ratings characteristics: WELL-LED workforce. Comprehensive and successful leadership strategies are in place to ensure and sustain delivery and to develop the desired culture. Leaders have a deep understanding of issues, challenges and priorities in their service, and beyond. issues and priorities for the quality and sustainability of services, understands what the challenges are and acts to address them. aware of the risks, issues and challenges in the service. Leaders are not always clear about their roles and their accountability for quality. staff. There is little or no attention to succession planning and development of leaders. Staff do not know who their leaders are or what they do, or are unable to access them. There are few examples of leaders making a demonstrable impact on the quality or sustainability of services. W2: Is there a clear vision and credible strategy to deliver high-quality sustainable care to people, and robust plans to deliver? Outstanding Good Requires improvement Inadequate The strategy and supporting objectives and plans are stretching, challenging and innovative, while remaining achievable. Strategies and plans are fully aligned with plans in the wider health economy, and there is a demonstrated commitment to system-wide collaboration and leadership. There is a systematic and integrated approach to monitoring, reviewing and providing evidence of progress against the strategy and plans. Plans are consistently There is a clear statement of vision and values, driven by quality and sustainability. It has been translated into a robust and realistic strategy and welldefined objectives that are achievable and relevant. The vision, values and strategy have been developed through a structured planning process in collaboration with people who use the service, staff and, external partners. The strategy is aligned to local plans in the wider health and social care economy and services are planned to meet the needs of the relevant population. Progress against delivery of the strategy and local plans is monitored and The strategy and plans have some significant gaps or weaknesses that undermine their credibility, and do not fully reflect the health economy in which the service works. They may not have been recently created or reviewed. Staff do not always understand how their role contributes to achieving the strategy. The statement of vision and guiding values is incomplete, out of date, or not fully credible. Results of stakeholder consultation are not always taken into There is no current strategy, or the strategy is not underpinned by detailed, realistic objectives and plans for high-quality and sustainable delivery, and it does not reflect the health economy in which the service works. Staff do not understand how their role contributes to achieving the strategy. There is no credible statement of vision and guiding values. Key stakeholders have not been Key lines of enquiry, prompts and ratings characteristics healthcare services 53

145 Ratings characteristics: WELL-LED implemented, and have a positive impact on quality and sustainability of services. reviewed and there is evidence of this. Quantifiable and measurable outcomes support strategic objectives, which are cascaded throughout the organisation. The challenges to achieving the strategy, including relevant local health economy factors, are understood and an action plan is in place. Staff in all areas know, understand and support the vision, values and strategic goals and how their role helps in achieving them. account in strategies or plans. Staff are not always aware of, support, or do not understand the vision and values, or have not been fully involved in developing them. Progress against delivery of the strategy and plans is not consistently or effectively monitored or reviewed and there is no evidence of progress. Leaders at all levels are not always held to account for the delivery of the strategy. engaged in the creation of the strategy. Staff are not aware of or supportive of, or do not understand, the vision and values, or they were developed without staff and wider engagement. There is no effective approach to monitoring, reviewing or providing evidence of progress against delivery of the strategy or plans. The strategy has not been translated into meaningful and measurable plans at all levels of the service. W3: Is there a culture of high-quality, sustainable care? Outstanding Good Requires improvement Inadequate Leaders have an inspiring shared purpose, and strive to deliver and motivate staff to succeed. There are high levels of satisfaction across all staff, including those with particular protected characteristics under the Equality Act. There is a strong organisational commitment and effective action towards ensuring that there is equality and inclusion across the Leaders model and encourage compassionate, inclusive and supportive relationships among staff so that they feel respected, valued and supported. There are processes to support staff and promote their positive wellbeing. Leaders at every level live the vision and embody shared values, prioritise highquality, sustainable and compassionate care, and promote equality and diversity. They encourage pride and positivity in the organisation and focus attention on Staff satisfaction is mixed. Improving the culture or staff satisfaction is not seen as a high priority. Staff do not always feel actively engaged or empowered. There are teams working in silos or management and clinicians do not always work cohesively. Staff do not always raise concerns or they are not always taken There is no understanding of the importance of culture. There are low levels of staff satisfaction, high levels of stress and work overload. Staff do not feel respected, valued, supported or appreciated. There is poor collaboration or cooperation between teams and there are high levels of conflict. The culture is top-down and Key lines of enquiry, prompts and ratings characteristics healthcare services 54

146 Ratings characteristics: WELL-LED workforce. Staff are proud of the organisation as a place to work and speak highly of the culture. Staff at all levels are actively encouraged to speak up and raise concerns, and all policies and procedures positively support this process. There is strong collaboration, team-working and support across all functions and a common focus on improving the quality and sustainability of care and people s experiences. the needs and experiences of people who use services. Behaviour and performance inconsistent with the vision and values is identified and dealt with swiftly and effectively, regardless of seniority. Candour, openness, honesty, transparency and challenges to poor practice are the norm. The leadership actively promotes staff empowerment to drive improvement, and raising concerns is encouraged and valued. Staff actively raise concerns and those who do (including external whistleblowers) are supported. Concerns are investigated sensitively and confidentially, and lessons are shared and acted on. When something goes wrong, people receive a sincere and timely apology and are told about any actions being taken to prevent the same happening again. There is a culture of collective responsibility between teams and services. There are positive relationships between staff and teams, where conflicts are resolved quickly and constructively and responsibility is shared. There are processes for providing all staff at every level with the development they need, including high-quality appraisal and career development conversations. Equality and diversity are actively promoted and the causes of any seriously, appropriately supported, or treated with respect when they do. People do not always receive a timely apology when something goes wrong and are not consistently told about any actions taken to improve processes to prevent the same happening again. Staff development is not always given sufficient priority. Appraisals take place inconsistently or are not of high quality. Equality and diversity are not consistently promoted and the causes of workforce inequality are not always identified or adequately addressed. Staff, including those with particular protected characteristics under the Equality Act, do not always feel they are treated equitably. directive. It is not one of fairness, openness, transparency, honesty, challenge and candour. When something goes wrong, people are not always told and do not receive an apology. Staff are defensive and are not compassionate. There are high levels of bullying, harassment, discrimination or violence, and the organisation is not taking adequate action to reduce this. When staff raise concerns they are not treated with respect, or the culture, policies and procedures do not provide adequate support for them to do so. The culture is defensive. There is little attention to staff development and there are low appraisal rates. Key lines of enquiry, prompts and ratings characteristics healthcare services 55

147 Ratings characteristics: WELL-LED workforce inequality are identified and action taken to address these. Staff, including those with protected characteristics under the Equality Act, feel they are treated equitably. W4: Are there clear responsibilities, roles and systems of accountability to support good governance and management? Outstanding Good Requires improvement Inadequate Governance arrangements are proactively reviewed and reflect best practice. A systematic approach is taken to working with other organisations to improve care outcomes. The board and other levels of governance in the organisation function effectively and interact with each other appropriately. Structures, processes and systems of accountability, including the governance and management of partnerships, joint working arrangements and shared services, are clearly set out, understood and effective. Staff are clear about their roles and accountabilities. The arrangements for governance and performance management are not fully clear or do not always operate effectively. There has been no recent review of the governance arrangements, the strategy, or plans. Staff are not always clear about their roles, what they are accountable for, and to whom. The governance arrangements and their purpose are unclear, and there is a lack of clarity about authority to make decisions and how individuals are held to account. There is no process to review key items such as the strategy, values, objectives, plans or the governance framework. Staff and their managers are not clear on their roles or accountabilities. There is a lack of systematic performance management of individual staff, or appropriate use of incentives or sanctions. Key lines of enquiry, prompts and ratings characteristics healthcare services 56

148 Ratings characteristics: WELL-LED The following characteristic only applies to specialist mental health services CQC s Mental Health Act (MHA) reviewer reports are reviewed by nonexecutive members and the board is aware that any required action has been taken to address identified issues. Statistical information on MHA operation is monitored and statistical information on patterns of admission and length of stay is considered and compared with national data. The board receives reports on the performance of the MHA managers in reviewing detention and on second opinion appointed doctor (SOAD) requests and activity. Action is taken as required. The board makes sure that relationships with stakeholders, such as local authorities and the police, raise issues about MHA implementation. Mental Health Act (MHA) reviewer reports are not routinely reviewed and statistical information on the MHA is not always monitored and compared with national data. There are relationships with stakeholders around the MHA, but they are not formalised to address any issues of implementation. Reports on the performance of MHA managers are compiled, but not reviewed at board level. Second opinion appointed doctor (SOAD) requests and activity are not routinely reported to the board. Mental Health Act (MHA) reviewer reports are not reviewed by the board. Information relevant to monitoring the MHA, including performance of MHA managers and SOAD activity, is not robustly collected, not reviewed appropriately or action is not taken as a result. W5: Are there clear and effective processes for managing risks, issues and performance? Outstanding Good Requires improvement Inadequate There is a demonstrated commitment to best practice performance and risk management systems and processes. The organisation reviews how they function and The organisation has the processes to manage current and future performance. There is an effective and comprehensive process to identify, understand, monitor and address current and future risks. Performance issues are escalated to the Risks, issues and poor performance are not always dealt with appropriately or quickly enough. The risk management approach is applied inconsistently or is There is little understanding or management of risks and issues, and there are significant failures in performance management and audit systems and Key lines of enquiry, prompts and ratings characteristics healthcare services 57

149 Ratings characteristics: WELL-LED ensures that staff at all levels have the skills and knowledge to use those systems and processes effectively. Problems are identified and addressed quickly and openly. appropriate committees and the board through clear structures and processes. Clinical and internal audit processes function well and have a positive impact on quality governance, with clear evidence of action to resolve concerns. Financial pressures are managed so that they do not compromise the quality of care. Service developments and efficiency changes are developed and assessed with input from clinicians so that their impact on the quality of care is understood. not linked effectively into planning processes. The approach to service delivery and improvement is reactive and focused on short-term issues. Clinical and internal audit processes are inconsistent in their implementation and impact. The sustainable delivery of quality care is put at risk by the financial challenge. processes. Risk or issue registers and action plans, if they exist at all, are rarely reviewed or updated. Meeting financial targets is seen as a priority at the expense of quality. W6: Is appropriate and accurate information being effectively processed, challenged and acted on? Outstanding Good Requires improvement Inadequate The service invests in innovative and best practice information systems and processes. The information used in reporting, performance management and delivering quality care is consistently found to be accurate, valid, reliable, timely and relevant. There is a demonstrated commitment at all levels to sharing data and information proactively to drive and support internal decision making as well as system-wide working and Integrated reporting supports effective decision making. There is a holistic understanding of performance, which sufficiently covers and integrates the views of people with quality, operational and financial information. Quality and sustainability both receive sufficient coverage in relevant meetings at all levels. Staff receive helpful data on a daily basis, which supports them to adjust and improve performance as necessary. Performance information is used to hold management and staff to account. The information used in reporting, performance management and delivering quality care is usually accurate, The information used in reporting, performance management and delivering quality care is not always accurate, valid, reliable, timely or relevant. Leaders and staff do not always receive information to enable them to challenge and improve performance. Information is used mainly for assurance and rarely for improvement. Required data or notifications are inconsistently submitted to The information that is used to monitor performance or to make decisions is inaccurate, invalid, unreliable, out of date or not relevant. Finance and quality management are not integrated to support decision making. There is inadequate access to and challenge of performance by leaders and staff. There are significant failings in systems and processes for the management or sharing Key lines of enquiry, prompts and ratings characteristics healthcare services 58

150 Ratings characteristics: WELL-LED improvement. valid, reliable, timely and relevant, with plans to address any weaknesses. Data or notifications are consistently submitted to external organisations as required. There are robust arrangements for the availability, integrity and confidentiality of patient identifiable data, records and data management systems. Information technology systems are used effectively to monitor and improve the quality of care. external organisations. Arrangements for the availability, integrity and confidentiality of patient identifiable data, records and data management systems are not always robust of data. W7: Are the people who use services, the public, staff and external partners engaged and involved to support high-quality sustainable services? Outstanding Good Requires improvement Inadequate There are consistently high levels of constructive engagement with staff and people who use services, including all equality groups. Rigorous and constructive challenge from people who use services, the public and stakeholders is welcomed and seen as a vital way of holding services to account. Services are developed with the full participation of those who use them, staff and external partners as equal partners. Innovative approaches are used A full and diverse range of people s views and concerns is encouraged, heard and acted on to shape services and culture. The service proactively engages and involves all staff (including those with protected equality characteristics) and ensures that the voices of all staff are heard and acted on to shape services and culture. The service is transparent, collaborative and open with all relevant stakeholders about performance, to build a shared understanding of challenges to the system and the needs of the population and to design improvements to meet them. There is a limited approach to sharing information with and obtaining the views of staff, people who use services, external partners and other stakeholders, or insufficient attention to appropriately engaging those with particular protected equality characteristics. Feedback is not always reported or acted on in a timely way. There is minimal engagement with people who use services, staff, the public or external partners. The service does not respond to what people who use services or the public say. Staff are unaware or are dismissive of what people who use the service think of their care and treatment. Staff or patient feedback is inappropriately filtered or sanitised before being passed on. Key lines of enquiry, prompts and ratings characteristics healthcare services 59

151 Ratings characteristics: WELL-LED to gather feedback from people who use services and the public, including people in different equality groups, and there is a demonstrated commitment to acting on feedback. The service takes a leadership role in its health system to identify and proactively address challenges and meet the needs of the population. W8: Are there robust systems and processes for learning, continuous improvement and innovation? Outstanding Good Requires improvement Inadequate There is a fully embedded and systematic approach to improvement, which makes consistent use of a recognised improvement methodology. Improvement is seen as the way to deal with performance and for the organisation to learn. Improvement methods and skills are available and used across the organisation, and staff are empowered to lead and deliver change. Safe innovation is celebrated. There is a clear, systematic and proactive approach to seeking out and embedding new and There is a strong focus on continuous learning and improvement at all levels of the organisation, including through appropriate use of external accreditation and participation in research. There is knowledge of improvement methods and the skills to use them at all levels of the organisation. There are organisational systems to support improvement and innovation work, including staff objectives, rewards, data systems, and ways of sharing improvement work. The service makes effective use of internal and external reviews, and learning is shared effectively and used to make improvements. Staff are There is weak or inconsistent investment in improvement skills and systems among staff and leaders. Improvements are not always identified or action is not always taken. The organisation does not react sufficiently to risks identified through internal processes, but often relies on external parties to identify key risks before they start to be addressed. Where changes are made, the impact on the quality and sustainability of care is not There is little innovation or service development, no knowledge or appreciation of improvement methodologies, and improvement is not a priority among staff and leaders. There is minimal evidence of learning and reflective practice. The impact of service changes on the quality and sustainability of care is not understood. Key lines of enquiry, prompts and ratings characteristics healthcare services 60

152 more sustainable models of care. There is a strong record of sharing work locally, nationally and internationally. encouraged to use information and regularly take time out to review individual and team objectives, processes and performance. This is used to make improvements. fully understood in advance or it is not monitored. Ratings characteristics: WELL-LED Key lines of enquiry, prompts and ratings characteristics healthcare services 61

153 Report to Board of Directors Agenda item TBP25.3/17 Attachment C EHRIA code Date of meeting 28 th June 2017 Format of Paper Title of paper Author Sussex & East Surrey Sustainability and Transformation Partnership John Child- Programme Director- Strategic Commissioning Written Presenter Sam Allen- Chief Executive Presentation Committees/meetings where this item has been considered Purpose of report (tick all that apply) Oral N/A Sussex & East Surrey STP: Mental Health Strategic Support- MH Steering Group To provide assurance For decision Regulatory requirement To highlight an emerging risk or issue To canvas opinion For information To highlight patient, carer or staff experience Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care 3. Put research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Living within our means Summary of Report This paper provides an update to the Trust s Board on the current progress of the Sussex & East Surrey Sustainability and Transformation Partnership (STP). This paper provides further detail on the Mental Health STP work stream which is a 17 week project beginning in mid-may 2017commissioned by the STP Executive to complete a strategic review of mental health services across Sussex & East Surrey. The scope of this work is for adults and young people (from aged 14 upwards). As the STP s mental health work stream lead the Trust s CEO is the Senior Responsible Officer for this strategic review. Recommendation The Board is recommended to note the update on both the Sussex & East Surrey Sustainability and Transformation Partnership and the Mental Health STP work stream.

154 1. INTRODUCTION This paper provides an update to the Trust s Board on the current progress of the Sussex and East Surrey Sustainability and Transformation Partnership (STP). This paper provides further detail on the Mental Health STP work stream which is a 17 week project beginning in mid-may 2017commissioned by the STP Executive to complete a strategic review of mental health services across Sussex & East Surrey. The scope of this work is for adults and young people (from aged 14 upwards). As the STP s mental health work stream lead the Trust s CEO is the Senior Responsible Officer for this strategic review. 2. REPORT Sustainability & Transformation Partnership Background: NHS Planning Guidance for 2016/17 required each health and social care system to form their own STP to accelerate the implementation of the Five Year Forward View. The guidance set out the requirement for local leaders to work together to develop plans which address health and wellbeing, quality and finance. The Trust is a key stakeholder in the Sussex and East Surrey Sustainability and Transformation Partnership (STP). This STP consists of 23 organisations which include NHS providers, Clinical Commissioning Groups and Local Authorities. Working in new, formal partnership arrangements is a different way of working across the NHS and Local Government. The core purpose of the STP is to ensure that no part of the system operates in isolation, to improve both the health and wellbeing of the population within the footprint and the health and social care services and to make best use of the available resources. The STP footprint faces significant financial, quality, performance and health care challenges. The STP has a growing and aging population with increasing numbers of patients with multiple long-term conditions which include patients with serious mental illness and diagnoses of dementia. There are significant heath inequalities across the footprint which include above average smoking rates among young people, increasing adult obesity and increasing prevalence of dementia. There is a growing number of people experiencing mental health difficulties and there a lack of parity in life expectancy between those patients with a serious mental illness and those without. There are significant performance challenges in acute services within the STP footprint for both the A&E 4 hour waiting time standard and the 18 weeks Referral to Treatment standard; both NHS constitutional standards. In mental health services there remains significant pressure in acute services and demand and capacity challenges within community services. Workforce challenges are a feature across the NHS in both secondary care (acute and mental health) and within primary care. By working across organisational boundaries is it anticipated better joined up and innovative solutions can be found to these systemic issues. The STP, similar to wider public services, is currently experiencing a period of significant financial challenge. Across all the organisations in the footprint the total financial gap by 2020/21 is projected to grow to circa 900M. This figure has worsened in the latter months of 2016/17. This figure is the do-nothing scenario which is based upon increasing costs, increasing demands, extrapolation of existing deficits and reducing funding. The STP provides an opportunity for organisations to work collectively to meet these challenges for example driving forwards new models of care to further integrated community based care and as a consequence reduce the reliance on hospital based care.

155 Progress to date Further national guidance published in March 2017 (Next Steps on the NHS Five Year Forward View highlighted the need to strengthen STPs, their leadership and infrastructure. The guidance describes the move from Sustainability and Transformation Plans to Sustainability and Transformation Partnerships to formalise the relationships between organisations. The guidance further required the establishment of a STP Board with associated governance arrangements. This is now in place for the Surrey and East Surrey STP and includes a clinical board to ensure clinical oversight. A review of the STP plan was completed in April 2017 to ensure the pace and scale of change required to make significant progress on the challenges faced was in place. The review concluded that the four Placed Based Plans which make up the STP footprint (East Sussex Better Together, Coastal Care, North & Surrey Central Sussex and East Surrey Alliance) will be the primary vehicle for new developing and delivering new models of care with service planning being done on a Place Based level rather than by individual CCGs. The Place Based Plans will form the cornerstone of the wider STP and be led by CCGs and Local Authorities within each area. The review of the STP plan in April 2017 further developed the governance structures for decision and importantly resulted in the STP identifying priorities for 2017/18 including the need to further develop a strategic financial plan given the deteriorating financial position. The STP priorities identified for 2017/18 include: Further develop Place Based Plans for integrated health and care to manage population health and reduce hospital activity. Establish a collective approach across the STP for developing / sustaining primary care. Develop and implement a model for CCGs to commission more integrated care across a larger area and share resources. To improve mental health care, further develop a model of care for people with severe and enduring mental illness via the STP mental health work stream and the Trust s Clinical Strategy Improve services for urgent care, emergency care and cancer care Develop a specific strategy to ensure acute services are future proofed Coordinate plans for the Digital Roadmap and STP workforce and estates plans Develop a shared financial plan and implement productivity opportunities. STP Mental Health Work stream Both the STP and the emerging Place Based Plans have identified mental health as a priority during 2017/18 and beyond. As a result the STP has commissioned a strategic review of mental health services across the STP footprint. The mental health work stream is a 17 week project beginning in mid-may to complete a strategic review of mental health services across Sussex & East Surrey. The scope of this work is for adults and young people (from aged 14 upwards). As the STP s mental health work stream lead the Trust s CEO is the Senior Responsible Officer for this strategic review. The key outputs of the STP mental health work stream are: 1. Development of a case for change which includes an analysis of current mental health provision in terms of spend, activity and outcomes. It includes an identification of gaps in care; quality and finance, a baseline position of mental health spend across each CCG in comparison to complexity of population and outcomes. Each CCG and both the NHS mental health provider Trusts in the footprint are completing a detailed clinical audit against domains in adult acute, adult community and youth services which will inform the case for change. Analysis of CCG operating plans for 2017/18, ONS / benchmarking data, JSNAs, Health & Well Being Board Strategies,

156 specific mental health commissioning plans for CCGs and Local Authorities and the Trusts Clinical Strategies have been completed. 2. The development of a mental health strategic framework will be undertaken once the case for change has been completed. This will project future demand on mental health services based on population need, demographic and nondemographic growth (for example increased prevalence of patients with dementia diagnosis and associated health and care needs). It will also project future activity and cost / spend for mental health services. The strategic framework will identify what services / changes would need to be in place to close the quality and financial gaps identified in the case for change. The review is taking care to triangulate any analysis and subsequent proposals against both the Five Year Forward View (mental health) and the draft NHSE Mental Health Delivery Plan. The framework will include a set of opportunities / priorities for the STP with particular reference to impact on spend and associated activity. It is anticipated this will lead to a revised set of priorities for the Trust and a subsequent update of the Trust s Clinical Strategy. 3. The development of a delivery road map will build on the proposed short, medium and long term priorities for the STP and the Trust and will aim to outline requirements to deliver in terms of resourcing, governance, information etc. The road map will include a high level delivery plan with associated milestones and a set of initiatives to deliver these priorities. The STP Mental Health work stream has developed clear governance structures for the project. These are: Sussex & East Surrey Mental Health Steering Group: The mental health steering group holds overall responsibility for the project and provides the key links with the wider STP governance structures, the CCGs and the Trusts in the footprint. The steering group is chaired by the CEO of SPFT as the Senior Responsible Officer for the project. This group will review the outputs of the work and make recommendations as to how mental health services will be delivered in the future taking into account place based plans and national guidance. Clinical Steering Group: The Clinical Steering Group s key role is to provide clinical oversight and ownership of the project. Attendees of this group include clinical representatives from Trusts, professional groups, CCG Clinical Leads and patient / carer representatives. The meeting is chaired by the Trust s Chief Medical Officer. Finance & Modelling Group: The Finance and Modelling Group s key role is to take responsibility for overseeing the finance and activity reporting and modelling from provider Trusts, CCGs and Local Authorities. The group will review the financial and data analysis which will include prevalence modelling, demand and capacity and costed proposals. Scope of the project The scope of the project has been agreed by the STP Mental Health Steering Group with input from clinicians, CCGs, providers and Local Authorities within the footprint. The scope includes all adults and young people aged over 14 relating to the development of a strategic framework for a Youth Service Model.

157 The Trust and other partners are currently planning a wider review of Children and Young People s Services as a second phase to the project and clearly recognise the importance of this service area. Local Authority and Community / Voluntary Sector involvement All Local Authorities in the STP footprint are closely involved in the project. They are represented on the Steering Group by the Executive Director of Adult Social Care for East Sussex County Council and Executive Directors of Adult Social Care across the STP footprint contributed to the scope of the project. The Community & Voluntary Sector is represented on the Steering Group by Community Works which is an overarching membership organisation in Brighton & Hove and Adur & Worthing. Communication and Engagement Plan A Communication and Engagement plan is being reviewed by the Steering Group. This will include how we ensure this project fits within the communication and engagement strategies for the wider STP, the emerging Place Based Plans and local transformation plans such as East Sussex Better Together, Brighton & Hove Caring Together and Coastal Care. A Frequently Asked Questions and key messages will be included. Patient & Service User involvement Patient, carers and other stakeholders across the STP footprint have received a brief survey regarding their views as to existing mental health services. To date nearly 500 responses have been received. These will be analysed and themes will be included in the emerging Case for Change. Ensuring patient and service user involvement in the project is a key objective of the communication and engagement plan and to this end SPFT s patient leader is a member of the Steering Group. Healthwatch Brighton & Hove will attend the clinical workshop on behalf of Healthwatch branches across Sussex and inform future patient engagement. 3. NEXT STEPS The STP Mental Health Work stream project will produce the Case for Change which will be discussed at the Steering Group. Further updates on the STP and the mental health work stream will be brought to future Trust Board meetings over the coming months.

158 Report to Board of Directors Agenda item TBP25.4/17 Attachment D EHRIA code Date of meeting 28 th June 2017 Format of Paper Title of paper Communications Strategy Written Author Presenter Dan Charlton, Director of Communications Dan Charlton, Director of Communications Committees/meetings where this item has been considered Purpose of report (tick all that apply) Oral Presentation N/A Executive Assurance Committee To provide assurance For decision Regulatory requirement To highlight an emerging risk or issue To canvas opinion For information To highlight patient, carer or staff experience Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care 3. Put research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Living within our means Summary of Report At the half-way point in our five year strategy to develop outstanding care and treatment you can be confident in ( Our 2020 Vision ), it is timely to review our strategy for engaging / communicating with stakeholders. This paper summarises what we have done / are doing to improve this, and outlines current priorities. Recommendation The Board is asked to review the communications strategy and advise whether this fits with the overall strategic direction of the Trust.

159

160 Our communications strategy 1.0 Overarching strategic context At the half way point in our five year strategy to develop outstanding care and treatment you can be confident in ( Our 2020 Vision ), it is timely to review our strategy for engaging / communicating with stakeholders. Factors we need to take into account include: unprecedented clinical demand and financial pressure within health and social care: the population is ageing, more people are living with long term conditions and unhealthy lifestyles; at the same time the NHS faces rising costs and tight budgets; the need in the light of the above to develop new ways of working, innovative models of care and partnerships that go beyond traditional, institutional constructs; this will require changes to staff roles, operational services, individual organisations like Sussex Partnership and local health and social systems; the ambitious transformational programmes underway within our organisation, including the ongoing work to improve organisational culture and staff experience, as well as the development of our clinical strategy; and the opportunity to shape mental health strategic planning, commissioning and delivery through our involvement in the local Sustainability and Transformation Partnership (STP). Recent feedback from staff and the Care Quality Commission about the organisation s direction of travel is positive, but we cannot be complacent. We need to use innovative, evidence based communications techniques to engage people and support the process of continuous improvement. 2.0 Our communications objectives 1. Encourage clear, targeted, relevant internal communications to support meaningful staff engagement; 2. Communicate a clear, credible and compelling organisational narrative to promote confidence in our services and create a shared sense of purpose; 3. Ensure our messaging is aligned to our values and Our 2020 Vision, and centred on patient, carer / family and staff experience; 4. Help create a receptive and favourable environment in which information about the future of mental health services can be shared, absorbed, understood and discussed with stakeholders, including the patients, families and local communities we serve 1 ; 5. Promote organisational visibility, responsiveness and accountability through engagement activity such as media relations, events and social media. 1 Schiavo, R. (2007), Health communication: from theory to practice. San Francisco CA : Jossey Bass.

161 3.0 Internal communications / staff engagement 3.1 Strategic context One of the first steps on an improvement journey starts with changing the culture of the organisation; something best achieved by engaging and empowering staff in a way that is underpinned by shared values. 2 The way we communicate with each other within the organisation is an important component of our ongoing work to achieve this at Sussex Partnership. Over the last three years we have sought to move away from the command and control culture described by staff to one that is more collaborate. Accordingly, we involved people in shaping a new set of values and organisational strategy ( Our 2020 Vision ), as noted by the Care Quality Commission in their most recent full inspection of the Trust. 3 For our values to have meaning, they need to be evident in all our behaviours. We need to be relentless about aligning the values to everything we do for them to become part of the organisation s bloodstream : the rites, rituals, cultural norms and stories about how we do things around here. 4 Our communications strategy is based upon the principle (and evidence) that communications works best as a conversation. 5 Simply broadcasting messages from the corporate centre is an ineffective way of engaging with staff, not least because in the digital age people are overloaded with information from multiple sources. 6 We need to find creative, innovative ways to ensure staff are informed about what they need to know to do the best possible job on behalf of the patients / service users, families and local communities we serve. To achieve this we need to: 1. ensure messages we communicate are relevant, and centred on improving patient, carer and staff experience 2. use a wide range of channels to engage with people 3. constantly evaluate our internal communication channels to test their effectiveness 4. respond to and adapt how we communicate in the light of staff feedback. Competing for and retaining staff attention is not easy, not least because people are pressurised by factors such as clinical demand and recruitment problems. In this context, we need to give careful, constant though to who we are trying to reach and why (being clear about the call to action which defines what we want them to do as a result of the information we are sharing with them). 2 Care Quality Commission (2017). Driving improvement case studies from eight NHS trusts. 3 The CQC noted in December 2016 much work to improve the engagement of staff since our inspection in January This included drawing up a communication strategy Staff spoke of feeling more engaged (and) felt more able to raise concerns, as these were listened to and acted upon. Staff said the board were more accessible and approachable. 4 Steward, K. and West, M. (2015). Staff engagement: six building blocks for harnessing the creativity and enthusiasm of NHS staff. The King s Fund. 5 Fitzpatrick, L. and Valskov, K. (2014). Internal communications: a manual for practitioners. London UK: Kogan Page. 6 Hargie, O. (2017) Skilled Interpersonal Communication. Research, Theory and Practice. 6 th ed. Oxon: Routledge.

162 3.2 Actions We have reviewed and recalibrated the way we engage with senior leaders: having moved away from a monthly briefing to open staff fora (part of our drive to promote less hierarchical, more two way communications) we have now settled upon the middle ground of a quarterly CEO briefing for senior leaders to which all staff will be invited once a year this approach reflects feedback from staff; held our second Positive Practice Awards (attended by over 400 people) to recognise, celebrate and share the achievements of individual staff and teams; introduced a monthly briefing note from the Executive team to provide concise updates on key issues facing the organisation; made improvements to our key internal communication channels, including the redevelopment of the staff intranet and relaunch of our inhouse newsletter. In 2017/18 we need to continue to promote and embed our values in all our communications activity as part of our wider strategy to improve culture and recruit / retain staff; ensure our organisational narrative remains clear, current, credible and compelling, helping promote staff engagement 7 ; have robust, timely mechanisms in place for keeping staff briefed on key issues, such as our financial position and our participation in the Carter mental health pilot (without overloading them with information); harness our internal communication channels, briefing structures and events programme to promote the development of our clinical strategy, as well as individual campaigns on issues such as productivity (e.g reducing traffic and meetings); help the organisation know and understand itself by providing clear information about leadership structures (and by promoting the visibility of the Executive team a whole); provide guidance, support and training to support staff engagement within individual Care Delivery Services and support functions; use every opportunity to recognise, share and celebrate staff achievement, including our Positive Practice Awards. 7 Steward, K. and West, M. (2015). Staff engagement: six building blocks for harnessing the creativity and enthusiasm of NHS staff. The King s Fund.

163 4.0 Digital communications 4.1 Strategic context The extent of digital media take up and use in the UK is demonstrated by the fact almost nine in ten adults use the internet and spend an average of 21.6 hours online each week; with smartphones now replacing computers for internet use. 8 The internet plays a significant role in mental health information seeking; it has been used as a source of mental health information by over 10% of the general population and by more than 20% of those with a history of mental health problems. 9 We should provide patients, their families, commissioners and GPs with clear, comprehensive and engaging on line information about the services we provide, who they are for, their effectiveness and how to access them. Our online profile including our public facing website, use of social media and interactions on sites such as Patient Opinion also plays a critical role in supporting recruitment, promoting our brand and reputation. Effective use of social media supports collaboration, can make employees feel closer to their employer and encourage them to become brand ambassadors. 10 An outward looking approach where organisations reach out to their communities and encourage staff to use social media to share stories and interact with patients and public is also a feature of well led NHS trusts highlighted by the Care Quality Commission. 11 Increasing numbers of staff and services at Sussex Partnership are using social media as an engagement tool. Importantly, this has happened organically rather than as a management imperative (as has been attempted in the past within the Trust; an approach inevitably doomed to failure). We should encourage this without attempting to police it; providing support, advice / guidance (on issues like how to be safe online, safeguarding patient confidentiality, avoiding posting discriminatory / inflammatory material etc) and training where needed. 8 Ofcom (2016). Adults media use and attitudes report. 9 Powell, J (2006). Internet information seeking in mental health, Population survey. British Journal of Psychiatry 10 Dalbec, B. (2016). The benefits of internal social media? Engaged employees. APCO worldwide. Available from [Accessed May 2017]. 11 Care Quality Commission (2017). Driving improvement case studies from eight NHS trusts.

164 4.2 Actions We have continued to harness social media more effectively as an engagement tool, with increased activity on Twitter, Facebook, LinkedIn, YouTube and Instagram; designed and delivered stand alone social media campaigns e.g nurse recruitment; redeveloped the staff intranet this has involved the IT and communication teams working together to simplify the structure, review all 3,000 pages of content on the old system, reduce the amount of content significantly, improve the design and search engine; started live streaming our public Board of Directors meetings on Twitter to promote an open way of working / decision making; developed more multimedia material for use in our social media activity to help promote effective stakeholder engagement and support work programmes such as our clinical strategy. 12 In 2017/18 we need to use our public website as a platform for promoting our clinical, academic and teaching expertise more effectively, helping market ourselves as an employer and service provider; harness technology to help provide staff with easy access to the information they need to do their job (such as by launching a mobile app version of our staff intranet) in doing so, we should challenge the traditional default position that information needs to be written and printed in order to be disseminated; publish clearer, more comprehensive and interactive online information about individual care pathways, explaining how to access our services, what people can expect from us and what specific care and treatment involves; provide more digital self help, support and signposting, making it as easy as possible for people to get the help they need; explore other social media engagement techniques such as tweet chats with clinicians and people with lived experience on specific mental health topics. 12 We now have over 120 films on our YouTube channel which we promote via social media (one film with our chief nurse has received 500 views in two months).

165 5.0 Brand / identity 5.1 Strategic context Our brand is an expression of our values and the fact we want to be considered an organisation which is authentic, transparent and trustworthy. 13 Each aspect of communications activity described in this strategy from staff engagement through to media relations contributes to our corporate reputation and brand. This, in essence, in the purpose of the strategy: we need to be consistent in our approach to communications across all areas if we want to generate reputation goodwill and credibility (in the age of social media, for example, the days of treating internal communications and media relations separately are long gone). 14 We need to be bold, creative and innovative for our brand to stand out in a crowded, increasingly competitive market place. Part of this is about describing, with clarity and confidence, the unique attributes which distinguish us from other healthcare providers and which would make patients / commissioners want to use our services. We also need to be clearer and more engaging about describing what we can offer students who are about to graduate and embark upon their nursing career. There are examples from the private sector (e.g L'Oréal) where the influence and social media voice of staff have been used to promote the organisation s brand for recruitment purposes, on the basis that people trust their peers more than they do corporations. 15 Our approach to do something similar, through our nurse recruitment campaign, has not to date led to an increase in job applications. That said, the campaign was not without value: it generated a halo effect, with positive feeling about the organisation evidenced by engagement through social media 16. If we want to undertake further large scale campaigns of this nature we should invest in targeted audience research to develop and test our messaging. 13 Karmark, B. (2013). Corporate Branding and Corporate Reputation, in Carroll, C.E. (ed), The Handbook of Communication and Corporate Reputation, Chichester UK: Wiley Blackwell. 14 Arenstein (2017). 6 PR lessons from the British Airways shutdown. PR News online. Available from (accessed June 2017). 15 Simpson, J. (2015) How L'Oréal uses social media to increase employee engagement. EConsultancy. Available from [Accessed May 2017]. 16 Over a 28 day period, the campaign generated over 77k impressions in Twitter, a reach of 28k on Facebook and nearly 10k impressions on LinkedIn.

166 5.2 Actions We have continued to develop a modern, engaging, vibrant visual identity with flexibility about how it is deployed; as part of this we have adapted our brand guidelines in line with new NHS England guidance; developed bespoke brands (within the overarching Trust identity) for major work programmes such as our clinical strategy; launched a high profile nurse recruitment campaign which has helped promote our brand and achieved high levels of engagement on social media. In 2017/18 we need to ensure our brand narrative is clear, credible and relevant to staff, patients / service users and other stakeholders within this, we need to be able to describe how our clinical strategy is delivering tangible improvements to patient experience and outcomes, as well as why staff should want to come and work here continue to adapt and develop our visual identity so it remains vibrant; ensure that any bespoke brands (for individual services or work programmes) are clearly aligned to our overarching organisational brand / identity there will be some cases, such as Care Home Plus, where there is a need for greater flexibility; consider corporate social responsibility as part of our brand identity e.g how we engage local employers, schools etc to reduce stigma and promote early intervention (in line with our clinical strategy objectives); build on our nurse recruitment campaign to promote our offer to nursing graduates (and commission targeted audience research to hone our messaging, positioning and campaign collateral).

167 6.0 Stakeholder relations 6.1 Strategic context The challenges facing the health and social care system locally, regionally and nationally require us to work differently with our partners. Moreover, for there to be a true shift from competition towards integration, organisations across the health and social care system will need to learn to work together to make the best use of collective skills and knowledge. 17 Poor communication is one reason 70% of change programmes fail Achieving buy in to any changes we want to make to clinical services in future means we need to think of stakeholders as more than passive listeners whose task is to hear what we have to say and arrive at the same conclusion; effective collaboration involves listening, and doing so in a way that makes others feel they have been heard. 20 We then to show what we have done with this feedback. We must be clear about the rationale for any proposed changes to individual operational services. We should have one common story which aligns the plans across all our Care Delivery Services. Proposed changes to operational services need to be supported by robust mechanisms for engaging service users and carers and, in some cases, may require formal public consultation. Continued investment in our relationships with stakeholders will increase our influence and give us a better chance in the long term of gaining understanding and acceptance of our goals. 21 It will also place us in a better position to manage conflict constructively. 22 This is essential if we are to avoid debate about the future of mental health care becoming mired in a public relations war of attrition between those who are for or against changes to the way care is currently provided. One of our central messages to stakeholders is our commitment to participation and involvement; demonstrated in action through our Recovery College programme. Our engagement activity should be based on the principle of helping reduce the power differences inherent in traditional professional and patient relationships. 23 We also need to play a role in shaping the narrative around our STP, particularly in relation to mental health. This has not, to date, been well defined something which exposes us to a 17 Hulks et al (2017). Leading across the health and care system. King s Fund briefing note. Available from (accessed June 2017). 18 Nohria, N, and Beer, M. (2000) Cracking the code of change. Harvard Business Review. 78 (3), Balogun, J., Hope Hailey, V. and Gustafsson, S. (2016) Exploring strategic change. 4 th ed. Harlow, UK: Pearson Education Limited. 20 Shotter, J. (2009). Listening in a Way that Recognises/Realises the World of the Other. The International Journal of Listening. 23 (1), Hargie, O. (2017) Skilled Interpersonal Communication. Research, Theory and Practice. 6th ed. Oxon: Routledge 22 Morgan, R.M. and Hunt, S.D. (1994) The Commitment Trust Theory of Relationship Marketing. Journal of Marketing. 58 (3), Meddings, S., McGregor, J. Roeg, W. and Shepherd, G. (2015) Recovery colleges: quality and outcomes. Mental Health and Social Inclusion. 19 (4),

168 degree of reputational risk. STPs are developing across the country against a backdrop of financial and operational pressure 24, media coverage of proposed cuts to hospital services 25 and increasing public concern about the NHS. 26 Public opinion abhors a vacuum and in the absence of a clear, concerted, disciplined message about the STP and future mental health provision people will fill the gaps with their own assumptions, experiences and prejudices. 27 We need to be clear about the describing how the STP is relevant to staff, patient / service users and other stakeholders, and why we need them to become involved. It is also important to convey a clear sense of how the STP mental health work stream is owned by the partners who comprise our partnership; not least because the fact that mental health has been prioritised in this way is a positive development. The mental health workstream provides us with a valuable opportunity to demonstrate the principles of co production, partnership and transparency in action. As a matter of routine, we need to develop engagement strategies tailored to the needs of specific stakeholders; commissioners, for example, need to be sighted on any issues in their local patch about the quality and safety of services we provide. 24 King s Fund online (2017) Delivering sustainability and transformation plans. 25 Triggle, N. and Schraer, R. (2017) Hospital cuts planned in most of England. BBC online. 26 Ipsos MORI online (2017) Concern about the NHS jumps to the highest level since Betteridge, M. (2017) The NHS s biggest challenge is convincing the public it has a plan. Guardian online.

169 6.2 Actions We have ensured stakeholders were briefed proactively, in full and in advance of the publication of our thematic review; sought stakeholder involvement from staff, patients / service users, commissioners and other partners in key work programmes; these include the development of our clinical strategy, the Quality Summitt in relation to our most recent Care Quality Commission inspection (published December 2016) and the mental health workstream of our STP; developed a communications and engagement plan for our STP mental health workstream, advocating the importance of transparency, clarity of communication and partnership. In 2017/18 we need to deliver a stakeholder engagement plan regarding the next phase of public and media scrutiny we anticipate in relation to the thematic review (see Section 7); ensure stakeholders are assured about how we are using the CQC inspection process as a spur for continuous learning and quality improvement; develop a clear and coherent narrative aligned across all our Care Delivery Services explaining the changes we believe are necessary to individual clinical services to meet the needs of patients (and how these changes will safeguard quality and safety, at the same time as being financially sustainable); ensure our clinical strategy narrative aligns with the broader STP work on mental health strategy, commissioning and delivery; establish a regular channel of communication between our new CEO and local MPs to resolve issues as early as possible and ensure they are briefed on key issues; harness the expertise and experience of patients / service users, carers, members and Governors to promote public debate about mental health and wellbeing.

170 7.0 Media relations 7.1 Strategic context Despite falling newspaper circulation and concerns about fake news, the media remains an important factor in shaping public opinion and corporate reputation; and, most importantly, represents one mechanism for engaging with patients and public about our services. The media narrative about Sussex Partnership in 2016 was largely shaped by the thematic review, as well as the court case regarding the incident which preceded and prompted it. The thematic review and media handling strategy which supported it was about demonstrating through our actions, as well as words, we are genuine about wanting to listen to feedback, learn and improve. It is important to be open and transparent about organisational or individual shortcomings because that maximises our ability to learn, which can only be to the ultimate benefit of patients, staff and the NHS as an institution 28. This was the defining principle which underpinned the thematic review, and which should continue to shape the way we work with our stakeholders and the media. We jointly commissioned the review, published it in full, proactively shared it with media and engaged fully in public discussion about it. 29 That said, we will quite rightly continue to be held to account by our stakeholders and the media about whether we have done what we said we would do in response to the findings. A lot of work has been undertaken to embed the learning from the review; we need to be able to describe and demonstrate this (and to maintain momentum with the work once the media spotlight has moved on). The thematic review will be brought back into sharp focus in the year ahead in relation to scheduled independent inquiry report publications. We also need to remain alert to the possibility that incidents not directly connected to the review may nonetheless prompt media scrutiny of some of the issues raised within it such as risk assessments, working with families and care planning. More broadly, we need to continue focusing on proactively identifying positive opportunities to promote what we are doing to improve patient / service user and family experience. We have a positive story to tell, for example, about how we are creating opportunities for people with people with lived experience to work with us as equal partners. Promoting positive stories about patient care can create public awareness and understanding of mental health; help challenge stigma and discrimination; is good for staff morale because it values their efforts; and supports our drive to recruit new staff. 28 Underwood, J., and Nicholls, B. (2017). Sussex Partnership review. Centre for Health Communication Research and Excellence. 29 Following publication of the review, the BBC s national health correspondent Nick Triggle noted: What's interesting with this report is that the trust instigated the review itself. There was nothing to indicate Sussex was an outlier, but bosses expressed a desire to learn from what had happened. In that sense it is quite different from the Southern Health NHS Trust scandal over the deaths of its patients.

171 7.2 Actions We have continued with an approach to reactive media handling that avoids reliance on formulaic statements; managed publication of the thematic review, and associated high profile media coverage, in a way which demonstrated organisational openness and commitment to learning; evaluated our approach to engaging with stakeholders about the thematic review; held media training with members of the executive team; started planning a national broadcast documentary on our adult mental health services; continued to secure media opportunities to promote the work of the Trust, such as inviting BBC SE television news to Hellingly medium secure unit and Langley Green Hospital (both of which resulted in informed, positive coverage about mental health). In 2017/18 we need to strengthen the clinical voice in our media profile, supported by ongoing media training, to portray a broad and representative image of the organisation; develop targeted media campaigns to support nurse recruitment activity; identify more opportunities to bring the patient / service user and carer perspective to the fore, and to shape the wider public debate about mental health; maintain an open stance in response to further public, political and media scrutiny regarding the thematic review in order to promote public confidence in the quality and safety of care we provide; develop targeted media plans to promote developments and partnerships that demonstrate clinical excellence and our drive towards innovation and improvement; ensure Board members and Governors are provided with timely briefings on media issues which may generate public concern about the quality and safety of our services (and, most importantly, what we are doing to address this concern); continue to ensure that we align mainstream media opportunities with social media activity and internal communications. Dan Charlton, Director of Communications June 2017

172 Report to Board of Directors Agenda item TBP26.1/17 Attachment E EHRIA code Date of meeting 28 th June 2017 Format of Paper Title of paper Chief Executive Report Written Author Sam Allen, Chief Executive Oral Presenter Sam Allen, Chief Executive Presentation Committees/meetings where this item has been considered Purpose of report (tick all that apply) To provide assurance For decision Regulatory requirement To highlight an emerging risk or issue To canvas opinion For information To highlight patient, carer or staff experience Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care 3. Put research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Living within our means Summary of Report In this report the Chief Executive will update the Board of Directors on a number of areas relating to local, regional and national issues. N/A N/A Recommendation For the Board of Directors to note the report and ask any questions of the Chief Executive.

173 1. INTRODUCTION The purpose of this report is to provide a summary from the Chief Executive of information relating to Sussex Partnership colleagues, services and an overview of relevant regional and national items of interest. The key areas covered at the Executive Assurance Committee are also summarised. 2. REPORT 2.1 Sussex Partnership Colleagues Carers Week The week of th June was National Carers Week. During this week we have seen Sussex Partnership Teams undertake a variety of activities, training and recognition events to the value and support the work of Carers. I want to highlight three Trust examples and thank our brilliant colleagues for organising these events and the many more that took place across the Trust: 1) Making Families Count Training held on 13 th June. Over 120 of our frontline staff attended this impactful training. The experiences shared by families on this day are extremely powerful. Space and support was provided to help participants reflect on changes to practice and how they will share the learning. 2) The Carer Celebration Event at Langley Green. It was wonderful to see the participation and support from the local community; You can read more about this on the Langley Green Blog 3) The Parents and Carers Events (PACE) run by Hampshire CAMHS. These were a range of workshops covering areas such as substance misuse, gender identity and challenging behaviour. 2.2 Sussex Partnership Clinical & Support Teams Research and Development Our Research and Development (R&D) Department continues to design and deliver high quality research studies, and support the translation of research findings into practice. Design our three centres of excellence (Dementia, Youth Mental Health, Brain & Body) continue to attract grant income and we are building sustainable research workforces to support the work of Professors Banerjee, Fowler and Critchley. Professor Banerjee has recently been awarded a prestigious NIHR Senior Fellowship that will financially support his research activities over the next five years. Delivery we have established ourselves as one of the top three highest recruiting mental health trusts in England (alongside Oxford and South London & Maudsley), having been in the top three for the past three years. Translation into practice our Research Clinics for OCD (Primary Care) and Voice Hearing (secondary Care) continue to offer evidence-based psychological therapies to patients. These clinics have received approximately 1300 referrals over the past 3-4 years, and we plan to establish a further clinic in the near future. In addition, we are committed to developing sustainable infrastructure that can support the design, delivery and translation of high quality research in the years ahead. We have recently designed, piloted and launched our Research Opt Out that empowers patients in Adult Services to make their own decisions about research participation, and we are working with the local universities to establish a Joint Research Office that will encourage and facilitate more efficient partnership working.

174 The Sussex Caring for Carers Conference 2017 was held on 15 th June 2017, which highlighted a range of research across mental health, and the role of the involvement of carers. Group Treatment Service Brighton and Hove I spent the morning with the Group Treatment Service Team on 21 June. My thanks to Josie Webb for inviting me to visit the team following the last CEO Briefing. This is a dedicated team delivering evidence based group treatment. I was struck by their commitment to their work and effective team working. The Executive Team is committed to visiting services Professional Leadership Our Chief Medical Officer, Chief Nurse and I met with our Professional Leads this month to explore with them how we can strengthen their leadership and role across the Trust and within Care Delivery Services. Facilitated by two of our thirty new organisational development practitioners (Trust staff who have completed a development programme) this proved to be an excellent session. The next step is a joint workshop with CDS and Professional Leads in July. 2.3 Regional and national highlights CQC Engagement Meeting The Executive Team and representatives from Care Delivery Services met with our Regional CQC Inspection Team on 20 th June for the first of our new engagement meetings. At the meeting our Hospital Lead Inspector, Louise Phillips, gave us a very informative presentation on the Care Quality Commission (CQC) Deaths Review work following the transfer of responsibilities from the Health and Safety Executive to the CQC. Annual NHS Confederation Conference Simone Button and I represented the Trust at this annual conference. It was pleasing to note mental health featured strongly as a key priority in the speech the Secretary of State for Health delivered. In particular the importance of services for children and young people. The focus for the NHS remains on the delivery of the Five Year Forward View and the first Accountable Care Systems (ACS) across England were announced by Simon Stevens. Whilst none of the ACS announced are within the Sussex and East Surrey STP they are very much part of our developing work with partners in local places e.g. East Sussex Better Together. New Care Models Sussex Partnership has been successful with a range of NHS and Independent Sector partners with Wave 2 applications to NHS England for Child and Adolescent Mental Health and Secure and Forensic new models of care. There is much learning from the Wave 1 sites and a business case to be developed and considered by Trust Board.

175 2.4 Executive Assurance Committee The EAC met on 20 th June 2017 and items considered included: Care Quality Commission compliance and assurance Consultant Job Planning Communication Strategy Carers survey Reduction in use of agency and bank pay rates Finance report

176 Report to Board of Directors Agenda item TBP26.2/17 Attachment F EHRIA code Date of meeting 28 th June 2017 Format of Paper Title of paper Author Presenter CDS Quality Assurance Report Dave West, Performance Directors Simone Button, Chief Operating Officer Committees/meetings where this item has been considered Purpose of report (tick all that apply) Written Oral Presentation N/A CDS Quality Standards Meeting To provide assurance For decision Regulatory requirement To highlight an emerging risk or issue To canvas opinion For information To highlight patient, carer or staff experience Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care 3. Put research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Living within our means Summary of Report The Trust CDS Quality Assurance report, attached, provides a summary of Trusts performance against agreed quality standards and priorities, workforce, finance and patient indicators. The framework includes key information used by NHS improvement to assess the Trust against operational quality standards and quality of care (safe, effective, caring and responsible). Recommendation The Trust Board is asked to review the performance report and ask any questions of the Chief Operating Officer.

177 1. INTRODUCTION The Trust Quality standards report, attached, provides a summary of Trusts performance against agreed quality standards and priorities, workforce, finance and patient indicators. The framework includes key information used by NHS improvement to assess the Trust against operational quality standards and quality of care (safe, effective, caring and responsible). 2. REPORT The Trust total page describes the position for the Trust as a whole, and separate pages describe how each Care Delivery Service (CDS) has performed. These dashboards detail the quality rating for each CDS based on their actual performance in the quarter and a mitigated rating which takes account of the assurance provided in local action plans. A full explanation of the figures and visualisations is provided as Appendix 2. Appendix 1 describes the quality ratings for each CDS (in the first two columns), the frequency of meetings and the governance actions that are being taken with each CDS. Executive Assurance Committee review - June. The Executive Assurance Committee discussed how a number of teams across the Trust are currently reporting being very busy. An additional report will be provided next month to review caseloads and activity across the Trust community teams and to consider waiting times in Adult services. Each of the teams in the CDS who are struggling to meet their quality targets will provide an update to the Executive Assurance Committee next month detailing the issues and plans to mitigate any risks in future months. The Committee discussed the progress towards achieving the statutory and mandated training targets. Whilst some areas are making good progress, such as Forensic Healthcare, other areas have yet to achieve the target of 85%. Focused support will be provided to areas that are not achieving the targets. Consideration is being given to priority training that needs to be achieved by all services. Work is underway to redesign how reports are presented to the Board going forward. These will be organised around the CQC quality domains under a new quality framework. The reports will mirror the revised structure of the Trust Quality Committee which now has sub committee s that are designed to provide quality scrutiny and assurance around the safe, patient experience and effectiveness domains. 2.2 NHS Improvement Single Oversight Framework The NHS Improvement (NHSi) Single Oversight Framework came into operation on 1 st October. NHS Improvement s stated aim is to help providers attain and maintain CQC ratings of Good or Outstanding NHSi will use the Single Oversight Framework to identify the Trusts support needs. Trusts are rating from Segment 1 to 4. (1 being no support needs and 4 being for Trusts in special measures). Sussex Partnership has been allocated a rating of 2.

178 2.3 May Performance against NHSi operational performance quality standards. The performance against the NHSI operational quality standards is detailed below Indicator 1. Patients requiring acute care who receive a gatekeeping assessment by a crisis resolution and home treatment team (95% target) 2. People with first episode of psychosis begin treatment with a NICE recommended package of care within 2 weeks of referral (50% target) 3. Ensure that Cardio-metabolic assessment and treatment for people with psychosis is delivered routinely in the following service areas a) Inpatient wards (90%) b) Early intervention in psychosis services (90%) c) Community mental health services (people on CPA) (65%) Performance The Trust achieved 99.3% against a target of 95% in the quarter to May The Trust achieved 85.2% against a target of 50% receiving treatment in 2 weeks. A new report is being developed to enable the Trust to monitor whether all eligible patient have a confirmed Physical Health Assessment form on Carenotes. The plan is for this to go live by mid-q2. The report will enable information to be available from Board to ward. We understand that NHSi will be using the data we submit for the physical health CQUIN to populate their quality indicators. For the 17/18 CQUIN, it will not be possible to report on all patients from Carenotes as this will not give an accurate picture until April 2018 (i.e. once the physical health assessment form has been live for 12 months, as physical health assessments are annual). The Trust is therefore planning to complete the audit on a sample of patients (as in previous years), but to get the audit data from the Carenotes form where possible.

179 4. Complete and valid submission of the Monthly Mental Health Services Data Set submissions to NHS Digital Identified metrics (95%) Priority metrics (85%) The Trust is achieving the each of the components of the identified metrics at above the 97% level. However the outcomes indicators for employment and accommodation have fallen below target levels to 12.9% in the month. The process for capturing this information has been reviewed and Carenotes has now been updated to enable this information to be captured in the CPA care plans, which is in alignment with the clinical process. Clinical teams are being given guidance in how to complete this information. The Adult CDSs have been asked to achieve 50% by the end of Q2 and 85% by the end of Q April Performance against NHSi quality of care standards 7 day follows ups: The Trust has received a performance notice for inconsistent performance against this indicator across the Trust. Given the importance of this indicator from a safety perspective, the Trust has accepted the notice and taken the following action as agreed with Commissioners. Reviewed all of the 7 day follow up breaches over the past 12 months to understand the issues and enable a further deep dive review with the CDS s. Confirmed that none of the 7 day follow up breaches are directly linked to any serious incidents over the past 12 months. The Trust will propose a methodology for the deep dive and for improvement following the outcome of the deep dive, including a trajectory with milestones, to be implemented within a suitable timeframe. In addition the Trust has proposed to provide an assessment of requirements to deliver a proposed move of target from 7 days to 48 hours. 2.5 Review of Trust Performance in May notable issues Delayed Transfers of Care: NHSI/NSHE has requested that the Trust work with the CCGs to agree a stretch target for reducing delayed transfers of care to 4.5% by September, to be sustained until March The Trust has agreed to work towards a target of 4.5% delays which equates to approximately 25 patients per day. The Trust is in the process of agreeing trajectories with each CDS towards this goal. Agency Expenditure: The graphs attached to the dashboard describe the improvements that have been made in agency expenditure in Brighton & Hove, where agency expenditure equates to only 1.2% of pay, and East Sussex, where agency expenditure is a 1.6%. Agency expenditure in North West Sussex, at 16% in the month, is being monitored closely to ensure reductions continue. In addition the Trust has produced a formal framework that describes the Trusts process and controls for the management of bank and agency bookings.

180 3. NEXT STEPS The performance of the organisation is reviewed each month at CDS level and by the Executive Director of Service Delivery and Performance through quality and performance review meetings where the CDSs have amber or red quality ratings, or where the financial ratings require it. The quality and finance ratings are summarised in the table, provided as Appendix 1, which details support being provided to CDSs in accordance with the Trusts assurance framework.

181 CDS Quality Assurance Dashboard May

182 Trust Total Reporting Period: Mar 17 May 17 NHSI OUT IDN EIW IA18 IA6 7DF C12 GTK DTC Current Target Key Period 7DF 7 Day Follow Ups 95% 94.3% C12 CPA reviews in 12 months 95% 88.9% GTK Gatekeeping 95% 99.3% DTC Delayed Transfers of Care 7.5% 5.1% IA6 IAPT 6 Week Waits 75% 88.5% IA18 IAPT 18 Week Waits 95% 99.6% EIW EIS 2 Week Waits 50% 85.2% IDN MHSDS Completeness Identifiers 97% 96.8% OUT MHSDS Completeness Outcomes 85% 12.9% 12mth Trend LOCAL INDICATORS Key Target Current Period Refer to individual CDS Dashboards for performance against CLU Cluster Reviews 95% 83.1% other local indicators 12mth Trend WORKFORCE Sickness FINANCE Staffing Agency Costs Temporary Costs 3% Current Period Target 6.4% 11% 13.7% 0% 5% 10% 15% 4.3% Mandatory Training Target 85% Target: 3.5% 100% 0% 81% 78% Core Courses All Courses Target Budget Variance 000s SIP YTD '000s 1, ,000 2,000 3,000 2,500 2,000 1,500 1, A M J J A S O N D J F M Variance '000s Target A M J J A S O N D J F M YTD Achieved YTD Plan Performance against I&E Budget YTD Variance 553 SIP YTD against Plan '000s '000s YTD Plan 2,346 YTD Achieved 1,091 PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period Friends & Family Test Target: 85% Complaints responded to 82.0% on time Number of Complaints Received Care Planning Care Plans signed by Patient 65% CPA Reviews in 12 months 95% 86% Positive Response Rate Current Period Suicide Prevention 628 Number of Responses Same Period 7 Day Follow Ups 95% Last Year Patients with a Risk Assessment 95% Serious Incidents CPA Patients with a Crisis Plan 90% Target: 90% Physical Health 63% Completed and submitted to Duty of Candour Inpatients height, weight & BMI 90% commissioners in 60 days Inpatients Physical Health Assmt 95% Target Target 22% 65% New Report under development New Report under development 89% 95% 94% 95% 83% 87% 81% 90% Serious Incidents reported Level 2 Level 1 90% Compliance in period 4 Breaches in period Staff Wellbeing and Development Sickness levels 3.5% Annual Appraisals 90% 4.3% 3.5% 3.1% 90% Current Period Same Period Last year 42 Serious Incidents meeting criteria for Duty of Candour

183 TRUST TOTAL Reporting Period: Jun 16 May 17 7 Day Follow Up CPA Review in 12 months Delayed Transfers of Care 100.0% 95.6% 100.0% 20.0% 90.0% 90.0% 88.9% 15.0% 80.0% 80.0% 10.0% 70.0% 60.0% 70.0% 60.0% 5.0% 0.0% 4.7% NHSI IAPT 6 Week Waits Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 EIS 2 Week Waits Cluster Reviews 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 89.8% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 93.2% Local Indicators 100.0% 90.0% 80.0% 70.0% 60.0% 83.1% Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Agency Spend Sickness Absence Mandatory Training Workforce 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 6.9% 8.0% 6.0% 4.0% 2.0% 0.0% 4.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 77.5% Patient Indicators 100.0% 80.0% 60.0% 40.0% 20.0% % Friends & Family Positive Response Rate Friends & Family Number of Responses 83.4% 223 SIs Submitted in 60 days 100.0% 80.0% 61.1% 60.0% 40.0% 20.0% 0.0% Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May SIs Level SIs Level % 80.0% 60.0% 40.0% 20.0% % Complaints responded to on time Complaints received 83.5% 67 KEY TO CHARTS: Monthly Performance. Most recent month's performance is shown numerically at the end of the series. Median Monthly Performance (last 12 months) Indicator Target

184 Coastal West Sussex CDS Reporting Period: Mar 17 May 17 NHSI IND 7DF LOCAL INDICATORS ETH 4WK OUT C12 DTC GTK 5DY CLU Inner Wedge: Current performance Outer Rim: Mitigated Risk Inner Wedge: Current performance Outer Rim: Mitigated Risk Current 12mth Mitigated Current Target Target Key Period Trend Risk Key Period 7DF 7 Day Follow Ups 95% 94.7% 4WK 4 week waiting times 95% 97.7% C12 CPA reviews in 12 months 95% 88.7% CLU Cluster Reviews 95% 83.6% GTK Gatekeeping 95% 100.0% 5DY 5 day Urgent Care 95% 100.0% DTC Delayed Transfers of Care 7.5% 7.8% ETH Ethnicity Completeness 90% 96.4% IND MHSDS Completeness Identifiers 97% 96.3% OUT MHSDS Completeness Outcomes 50% 7.5% 12mnth Trend Mitigated Risk WORKFORCE Sickness FINANCE Staffing Vacancies Agency Costs Temporary Costs 3% 5% 5.1% Current Period Target 11.5% 11% 14.8% 0% 5% 10% 15% 20% 6.5% Target: 3.5% Mandatory Training Target 85% 100% 0% 80% 77% Core Courses All Courses Target Budget Variance 000s SIP YTD '000s A M J J A S O N D J F M Variance '000s Target A M J J A S O N D J F M YTD Achieved YTD Plan Performance against I&E Budget YTD Budget 5,636 YTD Variance 156 SIP YTD against Plan '000s YTD Actual 5,791 '000s YTD Plan 372 YTD Achieved 279 PATIENT INDICATORS Complaints QUALITY ACCOUNT Target: 85% Complaints responded to Friends & Family Test 83.7% on time Number of Complaints Received Care Planning Care Plans signed by Patient 65% CPA Reviews in 12 months 95% 90% Positive Response Rate Suicide Prevention Current Period 155 Number of Responses 7 Day Follow Ups 95% Same Period Last Year Patients with a Risk Assessment* 95% Serious Incidents 0 50 CPA Patients with a Crisis Plan 90% Target: 90% Physical Health 57% Completed and submitted to Duty of Candour Inpatients height, weight & BMI 90% commissioners in 60 days Inpatients Physical Health Assmt 95% Level 2 Level 1 Serious Incidents reported Current Period Same Period Last year 100% 8 Compliance in period 0 Breaches in period Serious Incidents meeting criteria for Duty of Candour Staff Wellbeing and Development Target Sickness levels 3.5% Annual Appraisals 90% 6.5% 3.5% 2.9% * Target of 95% for Risk Assessments applies from Jun 2017 as the Risk Assessment form was only available on carenotes from Jun Chart shows performance against target trajectory. 36% 65% New report under development New report under development 89% 95% 95% 95% 81% 87% 85% 90% 90.0% QUALITY RATING: 10 FINANCE RATING: 3 MITIGATED QUALITY RATING: 8.0

185 Coastal West Sussex CDS Reporting Period: Jun 16 May % 7 Day Follow Up 97.5% 100.0% CPA Review in 12 months 20.0% Delayed Transfers of Care NHSI 90.0% 80.0% 70.0% 90.0% 80.0% 70.0% 88.7% 15.0% 10.0% 5.0% 60.0% 60.0% 0.0% 4.2% Local Indicators 100.0% 90.0% 80.0% 70.0% 60.0% 4 Week Waits 96.8% 100.0% 90.0% 80.0% 70.0% 60.0% Cluster Reviews 83.6% 100.0% 90.0% 80.0% 70.0% 60.0% Ethnicity 96.1% Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Agency Spend Sickness Absence Mandatory Training Workforce 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 4.6% 8.0% 6.0% 4.0% 2.0% 0.0% 6.3% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 77.0% Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May % Friends & Family Positive Response Rate 91.7% 100.0% Complaints responded to on time 100.0% 10 SIs Level % 80.0% Patient Indicators 60.0% 40.0% 20.0% 0.0% Friends & Family Number of Responses % 40.0% 20.0% % Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Complaints received 11 5 SIs Level % 80.0% 60.0% 40.0% 20.0% 0.0% Risk Assessments % KEY TO CHARTS: Monthly Performance. Most recent month's performance is shown numerically at the end of the series Median Monthly Performance (last 12 months) Indicator Target

186 COASTAL WEST SUSSEX CDS SERVICE UPDATE A management restructure is underway in West Sussex which will be complete by September. This will provide focused support to the new federated service across West Sussex and support the introduction of the new clinical model. The Adur, Arun and Worthing team are underperforming against a number of indicators including CPA reviews and clustering. This is mainly as a result of high numbers of vacancies. Given that the current time to hire is 16 weeks, the service expects new staff to be joining in October to November. The team is developing an improvement plan and trajectory for recovery. ACHIEVEMENTS IN MONTH Friends and Family Test: 90% of patients gave a positive response to the Friends and Family Test. There were 155 responses in the quarter. Gatekeeping: 100% of patients are gate-kept by the crisis home treatment team before admission to an acute ward. This is to ensure that patients are supported in the least restricted environment and to avoid unnecessary inpatient admissions. Duty of candour: The service carried out the requirements of duty of candour in all cases necessary. There were three in the period. Routine waiting times: 97.7% of patients had an assessment within 4 weeks of referral. Urgent waiting times: 100% of patients on the urgent pathway were assessed in 5 days. Ethnicity completeness: 96% of patients have ethnicity recorded. AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE Sickness Absence: The service has a comprehensive plan in place to address sickness absence and consider the health and wellbeing of staff. The CDS has specifically reviewed how support is provided to teams with above average sickness. A Health and Wellbeing event is being held for staff in Chichester and Crawley. Serious Incidents: The dashboard figure of 57% details the proportion of incidents completed on time in the quarter, of those completed. There are currently no overdue reports outstanding in Coastal West Sussex. Agency Spend: Agency expenditure continues to be above target in Coastal West Sussex at 5.1% in the quarter. The service has a clear understanding of the areas where there are issues and are working to describe how improvements will be made. This is linked to the vacancy issues in the Arun, Adur and Worthing teams.

187 AREAS OF CONCERN / AREAS UNDER REVIEW Mandatory Training: 76% of staff have completed all of the mandated training against the 85% target. The completion of the required training has been delayed in areas where the service is describing high levels of demand. There are plans to take teams out to ensure the completion of mandatory training in this area. Delayed transfers of Care: 7.8% of inpatients in Coastal West Sussex have delayed transfers of care in the quarter. There have been significant reductions in the number of patient delayed in the past two months to 4.2% in May. The service is reviewing the reporting of delayed transfers of care to ensure consistent reporting. 7 day follow ups: The CDS followed up 94.7% of patients in 7 days in the last quarter, 97.5% in the month. The performance in the CDS has been variable over the last year as described in the graph. The CDS has seen improvements in the month by sending out daily alerts to teams. The CDS is engaging with the Trust-wide review to ensure that performance is sustained. Clustering: 83.6% of patient reviews were completed in the required timeframe. Some areas of the CDS have made good progress with this indicator. However a small number of teams are not achieving the required levels of clustering. The CDS are engaging with a service development improvement plan to improve data quality around clinical caseloads and clustering as agreed with Commissioners. Management of complaints: 83.7% of complaints were responded to in the agree timeframe. The service is reviewing the themes from complaints to ensure learning is achieved. In particular themes regarding the need to improve communication with service users and attitude of clinicians are being addressed. CPA Reviews: 88.7% of patients have had a CPA Reviews in the last 12 months at the end of April. The key area of concern is Adur, Arun and Worthing.

188 North West Sussex CDS Reporting Period: Mar 17 May 17 NHSI IND 7DF LOCAL INDICATORS ETH 4WK OUT C12 DTC GTK 5DY CLU Inner Wedge: Current performance Outer Rim: Mitigated Risk Inner Wedge: Current performance Outer Rim: Mitigated Risk Current 12mth Mitigated Current Target Target Key Period Trend Risk Key Period 7DF 7 Day Follow Ups 95% 90.7% 4WK 4 week waiting times 95% 92.1% C12 CPA reviews in 12 months 95% 81.4% CLU Cluster Reviews 95% 72.3% GTK Gatekeeping 95% 99.0% 5DY 5 day Urgent Care 95% 100.0% DTC Delayed Transfers of Care 7.5% 5.7% 5DY Ethnicity Completeness 90% 90.5% IND MHSDS Completeness Identifiers 97% 97.2% OUT MHSDS Completeness Outcomes 50% 13.0% 12mnth Trend Mitigated Risk WORKFORCE Sickness FINANCE Staffing Vacancies Agency Costs Temporary Costs 5% 3% 12.9% 11% Current Period Target 22.6% 23.9% 0% 10% 20% 30% 7.0% Target: 3.5% Mandatory Training Target 85% 81% 73% 100% 0% Core Courses All Courses Target Budget Variance 000s SIP YTD '000s A M J J A S O N D J F M Variance '000s Target A M J J A S O N D J F M YTD Achieved YTD Plan Performance against I&E Budget YTD Budget 2,271 YTD Actual YTD Variance 171 SIP YTD against Plan '000s 2,441 '000s YTD Plan 201 YTD Achieved 104 PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period Friends & Family Test Target: 85% Complaints responded to 66.7% on time Number of Complaints Received Care Planning Care Plans signed by Patient 65% CPA Reviews in 12 months 95% 87% Positive Response Rate Current Period Suicide Prevention 39 Number of Responses 7 Day Follow Ups 95% Same Period Last Year Patients with a Risk Assessment* 95% Serious Incidents CPA Patients with a Crisis Plan 90% Target: 90% Physical Health 25% Completed and submitted to Duty of Candour Inpatients height, weight & BMI 90% commissioners in 60 days Inpatients Physical Health Assmt 95% Level 2 Level 1 Serious Incidents reported 71% 2 Compliance in period Breaches in period Staff Wellbeing and Development Target Sickness levels 3.5% Annual Appraisals 90% 18% Target 65% 81% 95% 68% 69% New Report under development New Report under development 7.0% 3.5% 0.0% 91% 95% 87% 90% 90.0% Current Period Same Period Last year 7 Serious Incidents meeting criteria for Duty of Candour * Target of 95% for risk assessments applies from Jun 17 as the Risk Assessment form was only available on Carenotes since Jun Chart shows performance against target trajectory. QUALITY RATING: 11 FINANCE RATING: 3 MITIGATED QUALITY RATING: 11.0

189 North West Sussex CDS Reporting Period: Jun 16 May 17 7 Day Follow Up CPA Review in 12 months Delayed Transfers of Care 100.0% 100.0% 20.0% NHSI 90.0% 80.0% 70.0% 60.0% 87.2% 90.0% 80.0% 70.0% 60.0% 81.4% 15.0% 10.0% 5.0% 0.0% 4.5% Local Indicators 100.0% 90.0% 80.0% 70.0% 60.0% 4 Week Waits 85.6% 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% Cluster Reviews 72.3% 100.0% 90.0% 80.0% 70.0% 60.0% Jun 16 Jul 16 Aug 16 Ethnicity Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar % Apr 17 May 17 Agency Spend Sickness Absence Mandatory Training Workforce 20.0% 15.0% 10.0% 5.0% 0.0% 16.5% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 6.2% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 73.5% Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Friends & Family Positive Response Rate Complaints responded to on time 10 SIs Level % 100.0% 100.0% % 80.0% Patient Indicators 60.0% 40.0% 20.0% 0.0% Friends & Family Number of Responses % 40.0% 20.0% % Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Complaints received 58.8% Mar 17 Apr 17 May SIs Level % 80.0% 60.0% 40.0% 20.0% 0.0% Risk Assessments % KEY TO CHARTS: Monthly Performance. Most recent month's performance is shown numerically at the end of the series Median Monthly Performance (last 12 months) Indicator Target

190 NORTH WEST SUSSEX ADULT CDS SERVICE UPDATE A management restructure is underway in West Sussex which will be complete by September. This will provide focused support to the new federated service across West Sussex and support the introduction of the new clinical model. The Crawley and Horsham teams are underperforming against a number of indicators including CPA reviews and clustering. This is mainly as a result of high numbers of vacancies. Given that the current time to hire is 16 weeks, the service expects new staff to be joining in October to November. The team is developing an improvement plan and trajectory for recovery. ACHIEVEMENTS IN MONTH 5 day urgent care waiting times are on target at 100% Gatekeeping of admissions to inpatient units remains on target. The CDS is achieving the target for ethnicity completeness 5.7% of patient s discharges were delayed in the quarter.

191 KEY AREAS OF CONCERN / AREAS UNDER REVIEW 7 day follows ups: The CDS followed up 90% of patients in 7 days in the last quarter, 87.2% in May. Due to the small number of discharges in this CDS, more than one breach causes the CDS to fail the target. The CDS is working with the business manager and modern matron to improve communication and issues with recording and notifying of discharges. The CDS is engaging with the trust-wide 7 day follow up review. 4 week wait waiting times: 92% of patients had an assessment within four weeks. The CDS are developing a plan to bring about improvements and are monitoring performance against this target closely as cost improvement plans are leading to reduced capacity in the community teams. The CDS are carrying out a review of how staffing levels across the county to ensure they best match demand levels. Agency Spend: The service is experiencing high levels of agency expenditure. 12.9% of the pay bill in the quarter, and 16.5% in the month. The three highest areas of nonagency spend are in Jade, Amber and Coral ward. The service continues to work with finance, HR and management on options to decrease agency spend. Timeliness of responses to complaints: 66.7% of complaints have been responded to in agreed timeframes in the quarter, 58% in the month. Further training and work is underway to improve responsiveness and maximise opportunities to resolve concerns locally. Clustering: 72% of patients in this area have a valid cluster. Improvements have been seen in a number of teams, but completion of reviews remains low in the Crawley and Horsham community team at 48%. The CDS has actions in place to address going forward and is focusing on improvements in this area as well as on inpatient wards. Sickness Absence: The overall level of sickness absence remains high at 7.0% in the quarter. The service has been asked to complete a more comprehensive action plan to give assurance that appropriate actions are in place to support staff. The recruitment of an HR advisor for this area has been successful but will not start until July. Mandated training: 73% of all courses have been completed and 81% of the core training is complete which an improvement in the month. Performance against this indicator is particularly low in Crawley and Horsham community teams. The service is looking to take the teams out to focus on training over the next month. Serious incident reporting: 25% of serious incident reports were submitted on time.

192 Brighton & Hove CDS Reporting Period: Mar May 17 NHSI IND 7DF LOCAL INDICATORS ETH 4WK OUT C12 DTC GTK 5DY CLU Inner Wedge: Current performance Outer Rim: Mitigated Risk Inner Wedge: Current performance Outer Rim: Mitigated Risk Current 12mth Mitigated Current Target Target Key Period Trend Risk Key Period 7DF 7 Day Follow Ups 95% 96.0% 4WK 4 week waiting times 95% 94.1% C12 CPA reviews in 12 months 95% 89.4% CLU Cluster Reviews 95% 82.8% GTK Gatekeeping 95% 100.0% 5DY 5 day Urgent Care 95% 98.5% DTC Delayed Transfers of Care 7.5% 4.2% ETH Ethnicity Completeness 90% 90.5% IND MHSDS Completeness Identifiers 97% 96.5% OUT MHSDS Completeness Outcomes 50% 12.9% 12mnth Trend Mitigated Risk WORKFORCE Sickness FINANCE Staffing Vacancies Agency Costs Temporary Costs 3% 5% Current Period Target 6.3% 1.2% 8.7% 11% 0% 5% 10% 15% 3.9% Target: 3.5% Mandatory Training Target 85% 79% 100% 0% 81% Core Courses All Courses Target Budget Variance 000s SIP YTD '000s A M J J A S O N D J F M Variance '000s Target A M J J A S O N D J F M YTD Achieved YTD Plan Performance against I&E Budget YTD Budget 3,345 YTD Variance 59 SIP YTD against Plan '000s YTD Actual 3,404 '000s YTD Plan 259 YTD Achieved 141 PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period Friends & Family Test 88% Positive Response Rate Target: 85% Complaints responded to 83.3% on time Care Planning Care Plans signed by Patient 65% CPA Reviews in 12 months 95% Suicide Prevention 50 Number of Responses Same Period 7 Day Follow Ups 95% Last Year Patients with a Risk Assessment* 95% Serious Incidents CPA Patients with a Crisis Plan 90% Target: 90% 55% Level 2 Level 1 Completed and submitted to commissioners in 60 days Serious Incidents reported Current Period Same Period Last year Current Period Number of Complaints Received Current Target Physical Health Duty of Candour Inpatients height, weight & BMI 90% New report under development 80% Compliance in period 1 Breaches in period 5 Serious Incidents meeting criteria for Duty of Candour Inpatients Physical Health Assmt 95% New report under development Staff Wellbeing and Development Sickness levels 3.5% Annual Appraisals 90% QUALITY RATING: 10.0 FINANCE RATING: 2 MITIGATED QUALITY RATING: 8.5 Target 3.9% 3.5% 10.4% * Target of 95% for risk assessments applies from Jun 17 as the Risk Assessment form was only available on Carenotes from Jun 16 Chart shows performance against target trajectory. 39% 65% 89% 95% 96% 95% 74% 87% 82% 90% 90.0%

193 Brighton & Hove CDS Reporting Period: Jun 16 May 17 7 Day Follow Up CPA Review in 12 months Delayed Transfers of Care 100.0% 94.5% 100.0% 20.0% NHSI 90.0% 80.0% 70.0% 90.0% 80.0% 70.0% 89.4% 15.0% 10.0% 5.0% 60.0% 60.0% 0.0% 2.3% Local Indicators 100.0% 90.0% 80.0% 70.0% 60.0% 4 Week Waits 92.4% 100.0% 90.0% 80.0% 70.0% 60.0% Cluster Reviews 82.8% % 90.0% 80.0% 70.0% 60.0% Ethnicity 90.1% Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Agency Spend Sickness Absence Mandatory Training Workforce 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 2.1% 8.0% 6.0% 4.0% 2.0% 0.0% 3.4% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 79.0% Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Friends & Family Positive Response Rate Complaints responded to on time 10 SIs Level % 100.0% % 60.0% 81.8% 80.0% 60.0% 80.0% Patient Indicators 40.0% 20.0% 0.0% Friends & Family Number of Responses % 20.0% % Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Complaints received 8 10 SIs Level % 80.0% 60.0% 40.0% 20.0% Risk Assessments % % Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 KEY TO CHARTS: Monthly Performance. Most recent month's performance is shown numerically at the end of the series Median Monthly Performance (last 12 months) Indicator Target

194 BRIGHTON ADULT CDS ACHIVEMENTS IN MONTH Gatekeeping of inpatient admissions: 100% of patients admitted to acute wards were gate-kept prior to admission in the quarter. 7 day follow ups: 96% of patients received a follow up in 7 days in the quarter. 94.5% were seen in the required timeframe during the month. Agency expenditure: There has been a sustained improvement in recruitment in the service which has had a positive impact on agency usage. (1.2% in the quarter). Ethnicity: The recorded ethnicity target has been achieved. The service is focusing on the urgent care teams who have a high throughput of patients to ensure ethnicity is captured and patients are discharged from Carenotes in a timely manner. 5 day urgent referrals: 98.5% of patients that required urgent assessment were seen within 5 days. Delayed transfers of care: Delayed transfers of care have reduced over the quarter and are under the target in the month at 2.3% AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE Completion of Serious Incident reports: 60% of serious incident reports were completed on time. The method of completing and signing off reports has been reviewed in the CDS. There are currently no SI reports that are overdue in this CDS. AREAS OF CONCERN / AREAS UNDER REVIEW 4 week waiting times: 94.1% of patients received an assessment within 4 weeks of referral to the service in the quarter, 92% in the month. A revised action plan is in place. The service is developing demand and capacity capability to support the delivery of the plan. In addition the service is working with the CCG clinical lead to review referrals received by the service and the effectiveness of triage. Mandated training: 79% of staff has now completed the Core courses and 79% all courses. Plans are in place to ensure that desktop computers are available and training is monitored in supervision. A nurse development practitioner is maintaining a review in acute services. Training sessions are being planned to be held in Community team meetings. CPA Reviews: 89% of patients on CPA have had a review in the past 12 months. The service has not achieved their previous trajectory to achieve this indicator. Clustering: 82% of patients have had a current cluster review. Performance against this target has plateaued over the past 7 months. The Clinical Director is supporting the work of the clustering programme in helping to specify clustering reports that directly support teams to use the clustering information in a clinically meaningful way. The service has been asked to review their trajectory to meet the needs of the Service Development Improvement Plan the Trust is working towards which requires all clusters to be up to date by the end of Q2.

195 East Sussex CDS Reporting Period: Mar 17 May 17 NHSI IND 7DF LOCAL INDICATORS ETH 4WK OUT C12 DTC GTK 5DY CLU Inner Wedge: Current performance Outer Rim: Mitigated Risk Inner Wedge: Current performance Outer Rim: Mitigated Risk Current 12mth Mitigated Current Target Target Key Period Trend Risk Key Period 7DF 7 Day Follow Ups 95% 94.4% 4WK 4 week waiting times 95% 97.5% C12 CPA reviews in 12 months 95% 95.6% CLU Cluster Reviews 95% 86.8% GTK Gatekeeping 95% 98.6% 5DY 5 Day Urgent Care 95% 100.0% DTC Delayed Transfers of Care 7.5% 2.8% ETH Ethnicity Completeness 90% 91.7% IND MHSDS Completeness Identifiers 97% 96.4% OUT MHSDS Completeness Outcomes 50% 20.3% 12mnth Trend Mitigated Risk WORKFORCE Sickness FINANCE Staffing Vacancies Agency Costs Temporary Costs 5% 3% Current Period Target 1.6% 12.2% 11% 16.8% 0% 5% 10% 15% 20% 5.3% Target: 3.5% Mandatory Training Target 85% 81% 79% 100% 0% Core Courses All Courses Target Budget Variance 000s SIP YTD '000s A M J J A S O N D J F M Variance '000s Target A M J J A S O N D J F M YTD Achieved YTD Plan Performance against I&E Budget YTD Budget 4,602 YTD Actual 4,692 YTD Variance 90 SIP YTD against Plan '000s '000s YTD Plan 343 YTD Achieved 109 PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period Friends & Family Test Target: 85% Complaints responded to 82.9% on time Number of Complaints Received Care Planning Care Plans signed by Patient 65% CPA Reviews in 12 months 95% 84% Positive Response Rate Current Period Suicide Prevention 82 Number of Responses 7 Day Follow Ups 95% Serious Incidents Same Period Last Year Patients with a Risk Assessment* 95% CPA Patients with a Crisis Plan % Target: 90% Physical Health 81% Completed and submitted to Duty of Candour Inpatients height, weight & BMI 90% commissioners in 60 days Inpatients Physical Health Assmt 95% Level 2 Level 1 Serious Incidents reported 100% Compliance in period 0 Breaches in period Staff Wellbeing and Development Target Sickness levels 3.5% Annual Appraisals 90% 13% Target 65% New report under development New report under development 5.3% 3.5% 0.4% 96% 95% 94% 95% 66% 87% 80% 90% 90.0% Current Period Same Period Last year 16 Serious Incidents meeting criteria for Duty of Candour * Target of 95% for risk assessments applies from Jun 2017 as the Risk Assessment form was only available on Carenotes from Jun Chart shows performance against target trajectory. QUALITY RATING: 8.0 FINANCE RATING: 2 MITIGATED QUALITY RATING: 6.5

196 East Sussex CDS Reporting Period: Jun 16 May % 7 Day Follow Up 97.9% 100.0% CPA Review in 12 months 95.6% 20.0% Delayed Transfers of Care NHSI 90.0% 80.0% 70.0% 90.0% 80.0% 70.0% 15.0% 10.0% 5.0% 5.2% 60.0% 60.0% 0.0% Local Indicators 100.0% 90.0% 80.0% 70.0% 60.0% 4 Week Waits 97.6% 100.0% 90.0% 80.0% 70.0% 60.0% Cluster Reviews 86.8% 100.0% 90.0% 80.0% 70.0% 60.0% Ethnicity 91.0% Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Agency Spend Sickness Absence Mandatory Training Workforce 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 1.9% 8.0% 6.0% 4.0% 2.0% 0.0% 4.6% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 79.3% 2.0% Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Patient Indicators 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Friends & Family Positive Response Rate Friends & Family Number of Responses 80.0% % 80.0% 60.0% 40.0% 20.0% % Complaints responded to on time 84.6% Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Complaints received SIs Level SIs Level % 80.0% 60.0% 40.0% 20.0% 0.0% Risk Assessments % KEY TO CHARTS: Monthly Performance. Most recent month's performance is shown numerically at the end of the series Median Monthly Performance (last 12 months) Indicator Target

197 EAST SUSSEX ADULT CDS SERVICE UPDATE One of the street triage nurses, (recently retired but now working on the bank) is being awarded a Silver medal at the Police public bravery awards. She stepped in to support one of the street triage officers who was being assaulted. The I-rock service in Hastings is a joint youth project which has been nominated for a national award. East Sussex acute beds have been highly in demand during May. As a result, the service invoked Gold command and all resources have been deployed to manage the demand. Much improvement has been seen as a result of the Trust wide escalation and the team continue prioritise this work. ACHIVEMENTS IN MONTH 4 week waiting times: 97% of patients were assessed within 4 weeks of referral. 5 day urgent care: 100% of patients who needed to be seen urgently were seen in 5 days. Ethnicity completeness: 92% of patient ethnicity is captured. Gatekeeping: 98.6% of patients are gate kept by the crisis team prior to an acute admission. CPA Reviews in 12 months: 95.6% of patients on CPA have had a review of their care in the last 12 months, and their care plan has been updated. Having sustained the performance for patients on CPA, the CDS is now looking at personal support plans for patients on standard care and for inpatients. Agency costs: 1.6% of the pay bill was spent on agency staff in the quarter. AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE Serious Incident reporting: 81% of serious incidents were completed in the required timeframe in the quarter. SI s are reviewed by the responsible general managers. The service has 1 level 2 report outstanding. The CDS report and learn forum recent serious incidents and identified learning around documentation in patient records. Immediate actions included the lead nurse exploring what other Trusts do when carrying our physical observations of patients and to ensure that our ward staffs have observation training. Guidance for working with families has also been shared with staff. Mandated training: Mandated training is discussed at team and managerial level. Performance has improved. 81% of staff has completed the core mandated training and 79% have completed all courses. The requirement for mandated training is discussed with staff in supervision and managers use My-learning to review performance. Complaints responses: 82.9% of complaints have been responded to within the agreed timeframe. A clear plan is in place to review complaints in a timely manner. Sickness Absence: The service is reporting 5.3% sickness in the quarter, 4.6% in the month. The service has actions in place to reduce long term and short term sickness. Progress against the agreed actions is being closely monitored by the HR business partner.

198 AREAS OF CONCERN / AREAS UNDER REVIEW Clustering: 87.7% of patients have received a review in the required timeframe in the period. Clinicians have been asked to allocate two hours per week to clinical admin time to ensure reviews are updated. The service has been asked to ensure that actions are in place to meet the targets required by the service development improvement plan that the Trust is working to. This requires that all patients are clustered by the end of Q2. 7 day follow ups: 94.4% of discharges have received a follow up in the quarter. Following the reduction in performance in April, the CDS has taken actions against the reason for each breach to ensure the risk of this happening again is minimised. In month performance has improved to 97.9%. The service is engaging in the Trust wide review of breaches and development as required by the contractual notice. Delayed transfers of care: 2.8% of discharges were reported as being delayed for patients in this CDS. The Trust has become aware that there are 20 patients whose discharge is delayed in East Sussex which means that service is not reporting the number of delays accurately. This relates to them not being accepted by social care as delays which the CDS is rectifying. This is being escalated with the strategic lead for social care. as a number of patients delayed discharge is due to funding not being approved by social care,

199 Primary Care & Wellbeing CDS Reporting Period: Mar -May 17 NHSI LOCAL INDICATORS IA18 IA6 IAR Inner Wedge: Current performance Outer Rim: Mitigated Risk Inner Wedge: Current performance Outer Rim: Mitigated Risk Key Target Current Period IA6 IAPT 6 Week Waits 75% 88.5% IAR IAPT Recovery Rates 50% 52.9% IA18 IAPT 18 Week Waits 95% 99.8% 12mth Trend Mitigated Risk Key Target Current Period 12mnth Trend Mitigated Risk WORKFORCE Sickness FINANCE Staffing 0% Vacancies Agency Costs Temporary Costs 3% 5% 2% Current Period Target 11% 0% 5% 10% 15% 2.8% Target: 3.5% Mandatory Training Target 85% 100% 0% 75% 69% Core Courses All Courses Target Budget Variance 000s SIP YTD '000s A M J J A S O N D J F M Variance '000s Target A M J J A S O N D J F M YTD Achieved YTD Plan Performance against I&E Budget YTD Budget 34 YTD Actual 98 YTD Variance -64 SIP YTD against Plan '000s '000s YTD Plan 83 YTD Achieved 20 PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period Friends & Family Test Complaints responded to on time Target: 85% 0.0% Number of Complaints Received Care Planning Target Target 90% Positive Response Rate 10 Number of Responses Current Period Same Period Last Year Suicide Prevention Serious Incidents Target: 90% Nil Return Completed and submitted to commissioners in 60 days Duty of Candour Physical Health Serious Incidents reported Level 2 Level 1 100% Compliance in period 0 Breaches in period Staff Wellbeing and Development Sickness levels 3.5% Annual Appraisals 90% 2.8% 3.5% 0.9% 90% Current Period Same Period Last year 2 Serious Incidents meeting criteria for Duty of Candour QUALITY RATING: 2 FINANCE RATING: 3 MITIGATED QUALITY RATING: 2.0

200 Primary Care & Wellbeing CDS Reporting Period: Mar 16 - May % IAPT 6 Week Waits 89.8% 100.0% IAPT 18 Week Waits 99.8% NHSI 80.0% 60.0% 80.0% 60.0% 40.0% 40.0% Local Indicators Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May % 60.0% 40.0% 20.0% 0.0% IAPT Recovery Rates 51.3% Agency Spend Sickness Absence Mandatory Training Workforce 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 0.3% 8.0% 6.0% 4.0% 2.0% 0.0% 2.5% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 69.4% -2.0% Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Patient Indicators 100.0% % 80.0% 70.0% 60.0% 5 Friends & Family Positive Response Rate Friends & Family Number of Responses 100.0% % 80.0% 60.0% 40.0% 20.0% 0.0% SIs Submitted in 60 days 2 SIs Level SIs Level 2 0.0% % 80.0% 60.0% 40.0% 20.0% % Complaints responded to on time Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Complaints received Mar-17 Apr % May KEY TO CHARTS: Monthly Performance. Most recent month's performance is shown numerically at the end of the series. Median Monthly Performance (last 12 months) Indicator Target

201 PRIMARY CARE AND WELLBEING ADULT CDS ACHIVEMENTS IN MONTH 99.8% of treatment is provided within 18 weeks, meeting the NHSI indicator for the 18 week target. 88.5% of patients are treated in 6 weeks with is within the target. 90% of patients responded positively to the Friends and Family indicator in the period. (However, only 10 responses were received). The IAPT recovery rate has improved in the last quarter. 52.9% demonstrating recovery in the period meeting the expectations of local commissioners. Sickness absence is well managed. 2.8% sickness was reported in the quarter. AREAS OF CONCERN Mandatory training: 69% of staff has completed all the Core Training requirements. The service is putting in plans to ensure all staff complete Mandatory training and performance is improved. Actions planned by the service include circulation of reports to all supervisors, requesting specific training where it is required and ensuring the staff lists are accurate. Complaints responses: The service received one complaint and it was not responded to in the time frame. The service is reviewing the services process for responding to complaints. However last year Health in Mind received 12,500 referrals and only 8 complaints. This relates to the success of the service in resolving issues and areas of concern locally and avoiding a formal complaint from occurring. We are ensuring that this learning is shared with the other CDS to improve practice elsewhere.

202 ChYPS CDS Reporting Period: Mar 17-May 17 NHSI LOCAL INDICATORS OUT C12 ETH 4WS 4WH 4WK IDN EIW DTC CLU Inner Wedge: Current performance Outer Rim: Mitigated Risk Inner Wedge: Current performance Outer Rim: Mitigated Risk Key Target Current Period 12mth Trend Mitigated Risk C12 CPA reviews in 12 months 95% 86.6% 4WS 4 week waiting times - Sussex 95% 93.3% EIW EIS 2 Week Waits 50% 85.2% 4WH 4 week waiting times - Hants 95% 33.0% IND MHSDS Completeness Identifiers 97% 97.2% 4WK 4 week waiting times - Kent 95% 64.5% OUT MHSDS Completeness Outcomes 50% 11.1% CLU Cluster Reassessments - EIS 95% 94.1% Key Target Current Period DTC Delayed Transfers of Care 7.5% 3.6% ETH Ethnicity Completeness 90% 96.2% 12mnth Trend Mitigated Risk WORKFORCE Sickness FINANCE Staffing Vacancies Agency Costs Temporary Costs 3% 5% 10.3% Current Period Target 10.8% 11% 13.9% 0% 5% 10% 15% 2.8% Target: 3.5% Mandatory Training Target 85% 100% 0% 80% 76% Core Courses All Courses Target Budget Variance 000s SIP YTD '000s A M J J A S O N D J F M Variance '000s Target A M J J A S O N D J F M YTD Achieved YTD Plan Performance against I&E Budget YTD Budget 6,508 YTD Actual 6,335 YTD Variance 174 SIP YTD against Plan '000s '000s YTD Plan 269 YTD Achieved 138 PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period Friends & Family Test Target: 85% 91.1% Care Planning Care Plans signed by Patient 65% CPA Reviews in 12 months 95% 78% Positive Response Rate 192 Number of Responses Current Period Suicide Prevention Same Period Patients with a Risk Assessment 95% Last Year Serious Incidents CPA Patients with a Crisis Plan 90% Target: 90% 33% Completed and submitted to commissioners in 60 days Complaints responded to on time Number of Complaints Received Target Physical Health Duty of Candour Inpatients height, weight & BMI 90% Inpatients Physical Health Assmt 95% 17% Target 65% New report underdevelopment New report underdevelopment 87% 95% 93% 95% 84% 95% Serious Incidents reported Level 2 Level 1 100% Compliance in period 0 Breaches in period Staff Wellbeing and Development Sickness levels 3.5% Annual Appraisals 90% 2.8% 3.5% 3.7% 90.0% Current Period Same Period Last year 1 Serious Incidents meeting criteria for Duty of Candour QUALITY RATING: 9.0 FINANCE RATING: 3 MITIGATED QUALITY RATING: 7.0

203 ChYPS CDS Reporting Period: Jun 16 - May 17 NHSI 100.0% 80.0% 60.0% 40.0% CPA Reviews -EIS 86.6% Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 EIS 2 Week Waits 100.0% 93.2% 80.0% 60.0% 40.0% 20.0% 0.0% Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Local Indicators 100.0% 80.0% 60.0% 40.0% Cluster Reassessments - EIS 94.1% Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Local Indicators 100.0% 80.0% 60.0% 40.0% 4 week waits -SUSSEX 93.8% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 4 week waits -HANTS 33.2% Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 6 week waits -KENT 100.0% 80.0% 64.5% 60.0% 40.0% 20.0% 0.0% Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Agency Spend Sickness Absence Mandatory Training Workforce 20.0% 15.0% 10.0% 2 5.0% 0.0% 11.6% 8.0% 6.0% 4.0% 2.0% 0.0% 2.9% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 75.8% Patient Indicators Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May % 80.0% 60.0% 40.0% 20.0% 0.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Friends & Family Positive Response Rate Complaints responded to on time % 100.0% Friends & Family Number of Responses Complaints received Quality Account 10 SIs Level 1 5 SIs Level % 80.0% 60.0% 40.0% 20.0% 0.0% Risk Assessments % Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 KEY TO CHARTS: Monthly Performance. Most recent month's performance is shown numerically at the end of the series. Median Monthly Performance (last 12 months) Indicator Target

204 ChYPS CDS SERVICE UPDATES Overarching Issues The CDS continues to work with Kent and Medway staff on their exit planning and the three team events with NELFT will be complete by 16/6/17. The CDS has been asked to form part of the procurement project group which starts next week and have compiled an exit plan for submission next week. The recognition day is planned for 12/7 pm and invitations have been sent to the Board and all staff as well as the CDS Board. The CDS Board have identified 3 services, Manchester, Birmingham and Northumberland who have models and areas of service that the CDS would like to visit and explore as part of our work to review and refresh the delivery model principles across our services. National guidance around the Enhanced THRIVE model and changes to demand indicate a need for review and our staff are engaging in identifying areas for good practice elsewhere and internally. Visits will be undertaken over the summer and the next CDS Development Day with all leadership teams present in September will identify a proposed model for consultation. Commissioners are engaged in these discussions from the very beginning along with young people, carers and families. Hampshire CAMHS are holding a programme of activities in safe week, week commencing 14 th September, which includes suicide prevention. The Board are invited to attend these events. Brighton & Hove Service Redesign The agreed Phase 1 of new service model went live on the 1 st June as planned in partnership with the Community Wellbeing Service who are providing the access point for all emotional wellbeing and mental health referrals for children and young people across the city. In addition the team are providing enhanced response times to urgent and have introduced a new priority response to referrals i.e. seen within 5 days. The CDS are working with commissions of services to agree how the team will meet 8 week to treatment waiting times for new referrals in the future. ACHIVEMENTS IN MONTH Waiting times: The Early Intervention service has achieved the NHSI indicator for waiting times for treatment. 85.2% of patients received a treatment in 2 weeks from referral. Sickness Absence: Sickness absence in the period was at 2.8% Clustering for early intervention patients: 94% of clustering reviews were completed in the required timeframe. Risk assessments: The service has maintained the high percentage (93%) of risk assessments completed appropriately on Carenotes. Ethnicity completeness: 96% of patients have their ethnicity recorded. Responding to complaints: 91% of complaints were followed up in the required time in ChYPS in the last quarter.

205 AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE Waiting times to assessment: 93% of patients in Sussex were assessed in 4 weeks. The service is reviewing waiting times achievement as part of the service development work with the Brighton CCG. Medical Staffing: The service continues to find medical recruitment challenging and has developed a new medical staffing model which will be implemented in future weeks. There have been some recent successes in medical recruitment in these services. Waiting times in Kent: Whilst the service is not achieving the waiting times target, they are able to evidence that they are operating at full capacity. The service is monitoring this closely in the context of the transition of this service. Serious incident reviews: 33% of serious incident reports were completed in 60 days. Outstanding serious incidents are being reviewed weekly. The services have shared their latest quarterly update of learning though the CDS Board. There are currently no outstanding SI reviews. Mandatory Training: 80% of the core training and 76% of all courses have been completed in ChYPS services. Reports are being used to identify areas where greater uptake is required and have been themed into the course required. AREAS OF CONCERN / AREAS UNDER REVIEW Waiting times in Hampshire: The waiting times in Hampshire have dropped further in the month to 33% seen within 4 weeks. The service has met with Commissioners to request further funding to address the capacity gap in the service. The funding provided is just less than half the service has calculated is required to meet needs. The service is carrying out further review to consider whether there are changes to the service configuration that could achieve further productivity savings. This includes a review of the operation of the single point of access. The service is participating in safe week, on 14 th September to raise awareness of suicide. CPA Reviews for Early Intervention patients: 85% of patients CPA reviews have been completed in the agreed timeframe. The CDS has identified a number of patients who have transitioned to Adult services and are ensuring that the CPA reviews are completed appropriately. The data quality agent is doing a focused piece of work with the service to review the data and support the completion of the reviews.

206 Forensic Healthcare CDS Reporting Period: Mar 17-May 17 NHSI LOCAL INDICATORS DTC IND OCL ETH OCM Inner Wedge: Current performance Outer Rim: Mitigated Risk Inner Wedge: Current performance Outer Rim: Mitigated Risk Key Target Current Period 12mth Trend Mitigated Risk DTC Delayed Transfers of Care 7.5% 2.2% ETH Ethnicity Completeness 90% 97.3% IND MHSDS Completeness Identifiers 97% 97.2% OCM Occupancy - MSU 95% 95.6% Key Target Current Period OCL Occupancy - LSU 95% 95.9% 12mnth Trend Mitigated Risk WORKFORCE Sickness FINANCE Staffing Vacancies Agency Costs Temporary Costs 3% 5% Current Period Target 4.6% 11% 18.8% 17.2% 0% 5% 10% 15% 20% 5.1% Target: 3.5% Mandatory Training Target 85% 100% 0% 84% 88% Core Courses All Courses Target Budget Variance 000s SIP YTD '000s A M J J A S O N D J F M Variance '000s Target A M J J A S O N D J F M YTD Achieved YTD Plan Performance against I&E Budget YTD Budget 2,282 YTD Actual 2,304 YTD Variance -21 SIP YTD against Plan '000s '000s YTD Plan 116 YTD Achieved 33 PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period Friends & Family Test Target: 85% 90.9% Care Planning Care Plans signed by Patient 65% Target CPA Reviews in 12 months 95% Underdevelopment Under development 88% Positive Response Rate Current Period 51 Number of Responses Same Period Suicide Prevention Under development Last Year Patients with a Risk Assessment 95% Serious Incidents CPA Patients with a Crisis Plan 90% Underdevelopment development Target: 90% 80% Completed and submitted to commissioners in 60 days Complaints responded to on time Number of Complaints Received Target Physical Health Duty of Candour Inpatients height, weight & BMI 90% Inpatients Physical Health Assmt 95% Under development New report underdevelopment New report underdevelopment 81% 79% Serious Incidents reported Level 2 Level 1 100% Compliance in period 0 Breaches in period Staff Wellbeing and Development Sickness levels 3.5% Annual Appraisals 90% 5.1% 3.5% 2.1% 90.0% Current Period Same Period Last year 1 Serious Incidents meeting criteria for Duty of Candour QUALITY RATING: 4 FINANCE RATING: 3 MITIGATED QUALITY RATING: 2.0

207 Forensic Healthcare CDS Reporting Period: Jun 16 - May % 8.0% Delayed Transfers of Care NHSI 6.0% 4.0% 2.0% 3.1% 0.0% Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Local Indicators 100.0% 95.0% 90.0% 85.0% 80.0% Occupancy - MSU 93.4% 100.0% 95.0% 90.0% 85.0% 80.0% Occupancy - LSU 97.8% 100.0% 90.0% 80.0% 70.0% 60.0% Ethnicity 97.3% Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Agency Spend Sickness Absence Mandatory Training Workforce 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 3.8% 8.0% 6.0% 4.0% 2.0% 0.0% 4.3% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 84.0% Patient Indicators Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May % % 60.0% 40.0% 20.0% 0.0% Friends & Family Positive Response Rate Friends & Family Number of Responses 73.9% % 80.0% 60.0% 40.0% 20.0% 0.0% SIs Submitted in 60 days 5 SIs Level SIs Level % % 80.0% 60.0% 40.0% 20.0% % Complaints responded to on time Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Complaints received Mar-17 Apr % May KEY TO CHARTS: Monthly Performance. Most recent month's performance is shown numerically at the end of the series. Median Monthly Performance (last 12 months) Indicator Target

208 FORENSIC HEALTHCARE CDS SERVICE UPDATE Lewes Prison: There are now a number of vacancies in the service. Recruitment events are taking place in June for band 4 assistant practitioners and band 5 registered nurses. There has been a very good response to the advertisements. The team has recently received the prison standards quality network peer review report. There is a substantial improvement on last year. Overall the team met 78% of the standards. An action plan is being formulated for 2017/18. ACHIEVEMENTS IN THE MONTH Delayed transfers of care: The service has achieved the delayed transfer of care indicator in the period Ward occupancy: The occupancy levels remained within planned levels, 96% for low and 96% for medium secure services. Recording ethnicity: The service has achieved 97% coding. Response to complaints: 90% of complaints are responded to in the agreed timeframe. Duty of candour: 100% of the commitment to duty of candour has been achieved AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE Serious Incidents: 80% of serious incidents were responded to on time in the period. There are currently no reports outstanding. Staffing at Hellingly: The greatest temporary staffing pressure continues at Willow Ward. The greatest agency use has been located at the band 3 group and plans to reduce this are being targeted via rota management and substantive and bank recruitment. There are now 10 support workers who have been appointed to bank posts and 4 people appointed to substantive posts. The service is in the process of introducing graduate mental health practitioners who would be recruited to the next cohort of training in September. Care Planning: The service is working to a target for care plans to be reviewed every six months. Currently 94% of care plans met this target. Sickness Absence: Sickness is 5.1% in the quarter. The HR business partner is helping the service to review the effectiveness of existing health and wellbeing plan. Mandatory training: 88% of staff have completed the core courses and 84% have completed all required courses, which is an improved position. AREAS OF CONCERN / AREAS UNDER REVIEW Agency Expenditure: Agency expenditure was 4.6% in the quarter, 3.8% in the month. Additional agency costs were incurred at Hellingly in Willow ward where the level of vacant posts remains high. The service is developing a revised plan to provide assurance that appropriate actions are being taken to manage agency expenditure.

209 Learning Disabilities CDS Reporting Period: Feb 17 Apr 17 NHSI LOCAL INDICATORS DTC IND ETH 4WK Inner Wedge: Current performance Outer Rim: Mitigated Risk Inner Wedge: Current performance Outer Rim: Mitigated Risk Current 12mth Mitigated Current Target Target Key Period Trend Risk Key Period DTC Delayed Transfers of Care 7.5% 58.0% 4WK 4 week waiting times 95% 97.3% IND MHSDS Completeness Identifiers 97% 97.2% ETH Ethnicity Completeness 90% 84.6% 12mnth Trend Mitigated Risk Additional Local Indicators under development WORKFORCE Sickness FINANCE Staffing Vacancies Agency Costs Temporary Costs 3% 5% Current Period Target 5.4% 11% 13.5% 12.9% 0% 5% 10% 15% 4.4% Target: 3.5% Mandatory Training Target 85% 100% 0% 82% 76% Core Courses All Courses Target Budget Variance 000s SIP YTD '000s A M J J A S O N D J F M Variance '000s Target A M J J A S O N D J F M YTD Achieved YTD Plan Performance against I&E Budget YTD Budget 441 YTD Actual 457 YTD Variance 16 SIP YTD against Plan '000s '000s YTD Plan 26 YTD Achieved 1 PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period Friends & Family Test Complaints responded to on time Target: 85% 0.0% Number of Complaints Received Care Planning Care Plans signed by Patient or Carer Target 65% 3% Target 65% 95% Positive Response Rate 64 Number of Responses Suicide Prevention Target: 90% Nil Return Serious Incidents Completed and submitted to commissioners in 60 days Serious Incidents reported Level 2 Level 1 Current Period Same Period Last Year Patients with a Risk Assessment 95% Physical Health Duty of Candour Inpatients height, weight & BMI 90% Nil Return Compliance in period 0 Breaches in period Inpatients Physical Health Assmt 95% Staff Wellbeing and Development Sickness levels 3.5% Annual Appraisals 90% New report under development New report under development 4.4% 3.5% 15% 75% [VAL UE] 90% 0 1 Current Period Same Period Last year 0 Serious Incidents meeting criteria for Duty of Candour * Target of 95% for risk assessments applies from Jun 16 as the current Risk Assessment form was only available on Carenotes from Jun Chart shows performance against target trajectory. QUALITY RATING: 6 FINANCE RATING: 3 MITIGATED QUALITY RATING: 3.5

210 Learning Disabilities CDS Reporting Period: May 16 Apr % 80.0% Delayed Transfers of Care NHSI 60.0% 40.0% 20.0% 54.2% 0.0% May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 Local Indicators 100.0% 90.0% 80.0% 70.0% 60.0% 4 Week Waits 96.8% 100.0% 90.0% 80.0% 70.0% 60.0% Ethnicity 83.4% May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 Agency Spend Sickness Absence Mandatory Training Workforce 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 5.3% 8.0% 6.0% 4.0% 2.0% 0.0% 6.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 76.5% May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr % 80.0% Friends & Family Positive Response Rate 100.0% 100.0% 80.0% Complaints responded to on time 2 SIs Level % 60.0% Patient Indicators % 20.0% 0.0% Friends & Family Number of Responses % 20.0% 0.0% May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 Risk Assessments 100.0% 80.0% 60.0% 40.0% 20.0% 22.4% 0.0% % May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 Complaints received 0 2 SIs Level 2 0 KEY TO CHARTS: Monthly Performance. Most recent month's performance is shown numerically at the end of the series Median Monthly Performance (last 12 months) Indicator Target

211 LEARNING DISABILITIES CDS The Trust provides services for people with learning disabilities across Sussex. ACHIEVEMENTS IN MONTH Waiting times for routine assessment: The service is achieving the waiting times target, 95% of patients are assessed in 4 weeks in East Sussex. AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE Staffing concerns at the Partnership Domiciliary Care Agency (PDCA): 9 new starters have joined the PDCA in May The service is reviewing the high staff turnover rates at this service. Sickness rates have been high at the PDCA which has resulted in agency usage. Complaints: The one complaint achieved received was not responded to in the agreed timeframe. It has now been responded to. Delayed transfers of care: Clients who are at the Selden Centre and are ready for discharge are reported via each CCG to NHS England as part of their transforming care work streams. There are currently 5 patients whose discharge is delayed, 3 due to an inability to find a suitable placement, one due to patient choice and one awaiting a package of care in their own home. Sickness absence: Sickness has decreased to 5% in April. Of this 2% is short term absence and 3% relates to long term sickness. The principle cause of the sickness is musculoskeletal issues. Long term sickness is being managed on an individual basis. AREAS OF CONCERN / AREAS UNDER REVIEW Medical Staffing and agency spend: There is an ongoing need for an agency Doctor in East Sussex where a new model is being developed. Current agency use at the Selden Centre remains similar to last month and agency are being used to cover sickness at the PDCA. Ethnicity recording: The service has a plan in place to improve the recording of ethnicity, particularly in the neurobehavioral service. 84% of patients have recorded ethnicity against a national target of 90% Essential training: 78% of staff have completed the mandatory training, 83% for the core courses requirements. The service has been asked to write a written plan to describe how they will make step change in training.

212 Report to Board of Directors Agenda item TBP26.2/17 Attachment G EHRIA code N/A Date of meeting 28 th June 2017 Format of Paper Title of paper Author Presenter Appendix 2: Safe Staffing Exception Report Lindy Montandon. Lead Nurse for Safer Staffing, E Roster Diane Hull, Executive Director of Nursing and Patient Experience Committees/meetings where this item has been considered Purpose of report (tick all that apply) Written Oral Presentation To provide assurance For decision Regulatory requirement To highlight an emerging risk or issue To canvas opinion For information To provide assurance To highlight patient, carer or staff experience Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care 3. Put research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Living within our means Summary of Report This report provides an update on the May safe staffing levels across our inpatients wards. We have included in this report the quarterly update on recruitment and retention. For greater transparency, appropriate nurse quality measures such as falls, medication errors, complaints or incidents regarding nursing staffing level and patient experience information have been included as a baseline report. N/A Recommendation The Board of Directors is asked to receive the paper for information and note exception reporting for May and the quarterly update on recruitment and retention, key quality and safety measures and information.

213 1. INTRODUCTION This paper reports on the Trust s safe staffing from the month of May It provides a summary of our safe staffing levels within our inpatients wards across the Trust and includes exceptions relating to staffing level reported by the wards in relation to compliance with overall and RMN fill rate for each shift. Variation of overall fill rate of 10% and any RMN shifts below 95% are highlighted in red. This paper reports predominantly on RMN fill rates and vacancies. This is because the fill rate for HCA s is good. When safer staffing levels have not been met by the ward, the ward provides an account of this and steps they have taken to mitigate risks. 2. REPORT 2.1 The Trust Average Fill Rates The following table sets out the Trust level performance across our inpatient wards against the Safer Staffing standards for May May 2017 May % 100% 80% 60% 40% 20% 0% 94% 90% Qualified Nurses day Qualified Nurses Night 109% 115% HCA Day HCA Night 120% 100% 80% 60% 40% 20% 0% 92% Trust Overall Qualified Nurses fill rate 112% 103% Trust OVerall HCAs fill rate Trust Overall Qualified and HCAs fill rate In May, the Trust was unable to comply with both the RMN on day and night shift fill rate. To ensure cover for the unfilled RMN shifts, the wards used additional HCAs to achieve the overall staffing levels. The Trust currently has WTE RMN vacancies for the Adult inpatients wards and there is an ongoing strategy to support the wards with recruitment and retention. 2.2 Safer Staffing Performance by Care Delivery Service The following tables show the CDS s against the safer staffing standards for each ward. Wards unable to comply with the standards are highlighted in red East Sussex CDS Wards RMN fill rate day RMN fill rate night Overall fill rate (RMN and HCA) Amber stone Bodia m Woodlan ds Centre St Rapha el Brambl e Lodge Beechwo od Amberl ey Heathfi eld 92% 92% 74% 93% 93% 96% 104% 98% 108% 87% 102% 101% 100% 66% 63% 101% 102% 97% 97% 121% 97% 104% 106% 100% Two main factors affecting the RMN fill rate were vacancy in all the wards and high sickness rate on 4 wards. East Sussex has a total WTE RMN vacancies. Any unfilled RMN

214 shifts were compensated by booking additional HCAs to ensure appropriate staffing level. The notable area is Woodlands with WTE RMN vacancies West Sussex CDS Coastal West Ward s RMN fill rate day RMN fill rate night Over all fill rate (RMN and HCA) Orcha rd Grov e (D) Iris (D) 75% 88% 100 % Oaklan ds Burrow es (D) Connol ly House Rowa n Shephe rd House Mapl e Larc h 102% 95% 92% 97% 97% 97% 101 % 53% 97% 94% 92% 98% 100% 100% 100% 106 % 84% 110 % 115 % 98% 101% 110% 94% 90% 90% 93% 97% West Sussex Costal has WTE RMN vacancies across their 10 wards. Vacancies and sickness rates affected 5 wards. The acuity of the 3 dementia wards meant they booked additional staff to meet the demand of their patients needs. Orchard is carrying a significant 4.07 WTE RMN vacancies affecting both their RMN day and night fill rates North West Ward Opal Coral Jade Amber RMN fill rate 89% 103% 98% 96% day RMN fill rate 95% 90% 95% 98% night Overall fill rate (RMN and HCA) 82% 102% 100% 108% Langley Green Hospital has WTE RMN vacancies across the 4 wards. Temporary HCAs were booked to fill any unfilled RMN shifts to ensure the safety of the ward and patients Brighton & Hove CDS Ward Pavilion PICU Regency Caburn Brunswick Meridian

215 RMN fill rate day RMN fill rate night Overall fill rate (RMN and HCA) 93% 82% 94% 96% 105% 100% 101% 99% 100% 93% 113% 102% 106% 143% 121% Brighton and Hove has WTE RMN vacancies Forensic Healthcare CDS Ward Oak (H) Elm (H) Willow (H) RMN fill rate day RMN fill rate night Overall fill rate(r MN and HCA) Ash (H) Fir (C) Hazel (C) 85% 90% 89% 77% 92% 108% 98% Pine (C) 65% 59% 87% 106% 74% 56% 100% 90% 100% 98% 106% 103% 108% 97% Forensic Healthcare has WTE RMN vacancies. Pine was compliant with overall and RMN fill rates. The 4 wards at Hellingly (H) include 50% of their OT staff within their day shift staffing numbers which were not included in this nursing fill rate Children and Young Peoples Services CDS Chalkhill reported compliance with their overall and RMN fill rate Learning Disability Services CDS Selden reported compliance with their overall and RMN fill rate. 3 Quarterly updates (March to May 2017) 3.1 Inpatients Recruitment and Retention In May across the 30 Adult acute, older people integrated and dementia wards, we have a total of WTE nurses vacancies of which WTE are RMNs. Forensic Healthcare currently have WTE nursing staff vacancies across the 7 wards, of which WTE were for RMNs. Selden has 3.44 WTE RMN vacancies and Chalkhill has 0.88 WTE RMN vacancy. The key challenges for the Trust are the recruitment and retention of RMNs at Band 5 and 6. One of the Trust s recruitment strategies is to use existing and emerging talent to build our own workforce. Last September 13 of our HCAs from the inpatients wards were sponsored to complete the 4 years Open University BSc (Honours) Mental Health Nursing and are due to be complete in The new starters and leavers information had highlighted that more work is needed to try and retain our qualified staff.

216 Further analysis of the reasonss why the RMNs left indicates that 3 retired and 9 left for a range of professional and personal reasons. 3.2 Quality and Safety Measures Staffing data alone cannot assure anyone that safe care is being delivered. As a Trust, we are committed to providing safe care to our patients and have therefore included in this report falls, medication errors, complaints or incidents regarding nursing staffing level. Falls and drug error are two Key Performance Indicators (KPIs) regularly monitored and investigate ed by Ward Managers and the Matrons. The Nursing Governance team have been leading the Trust Quality and Safety reviews across the inpatients wards. They are a supportive process which have been well received by servicess and are a great opportunity for us to learn and share areas of good practice across the Trust. 3.3 Falls Patients in our care, especially older patients can experience falls at any time due to a number of factors such as environments, fragility, poor physical health and mental state and polypharm macy. We have a clinical guideline for falls prevention to support the management of falls within our wards. Patients at risk should have a fall risk assessment completed on admission with a care plan in place to manage any identified risks. The following showed the numbers of falls reported on the safeguard web from the wards between March and May.

217 3.4 Medication errors A total of 94 drug errors were reported by the wards between March and May via the ULYSSES. The top 3 causes (sub type) were: Administrationn at incorrect time Dispensing incorrect supply by pharmacy Administrationn of incorrect dose We aim to reduce drug errors by ensuring all staff attends mandatory medicine management and the ward pharmacists also support the wards by auditing and providing medication training. 3.5 PALS concerns raised or complaints received regarding nurse safe staffing level There was one PALS concern about staffing level in May. Regency ward (B&H) A patient had written to provide some feedback regarding two recent impatient stays he had. His feedback was largely positive but he did raise some concerns about the staff being stretched, visiting arrangements, and the provisionss of occupational therapy from one service to another. 3.6 Safety incidents reported about inadequate nurse staffing levels. There weree 3 incidents reported in March by Burrowes ward and 1 Incident reported in April by Hazel ward a Low Secure Unit from Chichester. For both wards, management had identified solution to prevent re-occurrence. The wards are to monitor staffing level in advance, daily and at every shift to request for covers at the earliest opportunity. 4 Conclusion The May fill rate for RMN day shift showed a slight decrease of 0.5% compared to last month largely due to vacancy and sickness rate. Appropriate systems are in place to enablee the wards to review their staffing levels continuously on a shift by shift basis to manage the ward and patients safety. Any temporary vacancies are reviewed regularly to ensure steps are taken to fill with the appropriate skill mix. Recruitment and retentionn across the Trust is ongoing with a number of strategies. The Chief Nurse is leading a thorough review of the skill mix, vacancy rates and establishm ments of all our inpatients services in the coming weeks. With the CDS leadership teams, they will support the Matrons and Ward Managers to continue and maintain safety and quality of the wards and patients until those nurses recruited are cleared to start on the wards. 3. NEXT STEPS We will continue to update the Trust Board with the monthly safer staffing exception reports and quarterly updates on recruitment and retention, key quality and safety measures.

218 Report to Board of Directors Agenda item TBP26.3/17 Attachment H EHRIA code Date of meeting 28 th June 2017 Format of Paper Title of paper Author Presenter Annual Mortality & Serious Incidents Report Justine Rosser, Deputy Chief Nurse Theresa Dorey, Associate Director of Nursing Standards and Safety Committees/meetings where this item has been considered Purpose of report (tick all that apply) Written Oral Presentation To provide assurance For decision Regulatory requirement To highlight an emerging risk or issue To canvas opinion For information To highlight patient, carer or staff experience Strategic Goals (tick all that relate) 1. Safe, effective, quality patient care 2. Local, joined up care 3. Put research, innovation and learning into practice 4. Be the provider, employer and partner of choice 5. Living within our means Summary of Report The purpose of this report is to provide an analysis of serious incidents occurring in Sussex Partnership NHS Foundation Trust during the past financial year (2016/17) which is set in the context of data from the preceding years. The report includes quantitative analysis of incidents reported, together with themes of learning drawn from the incidents. N/A N/A Recommendation The Board of Directors is asked to note the details of the information provided and actions being taken as a response to serious incidents and Prevention of Future Death reports (PFDs) to prevent reoccurrence within a limited timeframe.

219 1. INTRODUCTION The purpose of this paper is to enable the Quality Committee to obtain assurance as to the efficacy of the management of Serious Incidents across the organisation. This report concerns Serious Incidents reported during the period 1 April March The Trust Incident and Serious Incident Management Policy sets out the framework for reporting, which is in line with the Serious Incident (SI) framework (2015). The 2015 Serious Incident framework defined a serious incident as an incident that occurred in relation to NHS funded services and care, including acts or omissions, which resulted in an unexpected or avoidable death or an unexpected or avoidable injury resulting in serious harm to one or more patients, staff or members of the public. It also includes a provider organisation s ability to continue to deliver healthcare services; allegations or incidents of physical or sexual assault or abuse; adverse media coverage and/or one of the core set of Never Events. All Serious Incidents must be reported onto the National Strategic Executive Information System (STEIS) within two working days of the Serious Incident being identified, with submission of the final report within 60 days from entry onto STEIS. 2. REPORT 2.0 Analysis of Incident Activity Trust-wide the reporting of incidents has increased by 22% for 2016/17 when compared with 2015/16.. Figure 1: The chart below shows Trust-wide incident reporting for 2016/17.

220 3.0 Analysis of Serious Incident Activity 3.1 A total of 274 Serious Incidents were reported during the period from 1 April 2016 to 31 March 2017; this is an increase of 3% compared to 267 in the period from 1 April 2015 to 31 March As per figure 2 this is largely to do with a significant spike in May 2016 however the data suggests a downward trend since this point. 3.2 The average number of Serious Incidents in 2016/17 recorded per quarter was 69, compared to 67 in the year 2015/16. Figure 2: Total number of Serious Incidents reported in 2016/17 compared to the number in 2015/16 and 2014/ The recent CQC Learning, Candour and Accountability Publication (2016) and NHS England Serious Incident Framework Guidance (2015) puts the onus on ensuring the level of investigation is proportionate to the incident as well as focusing on where learning can be achieved. It is of note that the NHS England and CQC guidance is predominately based on deaths/ near deaths in physical healthcare settings where it is largely clear from the incident itself that there has been a serious incident. In contrast in mental health it is difficult to establish whether there has been a serious act or omission that led to the incident without completing an investigation. Due to this and to ensure that we review incidents where there is likely to be learning (all unexpected deaths) and/ or a concern that an act or omission has occurred, the CCG and the Trust have agreed principles based on the guidance which can be attributed to the gradual decline in the reporting of serious incidents.

221 Figure 3: Total number of Serious Incidents by Care Delivery Service in 2016/17 compared to the total number in 2015/16 and 2014/ East Sussex CDS have seen an increase in serious incidents reported in the last two years which resulted in a further analysis by the Performance/ Serious Incident Team. From initial analysis we were unable to establish any overarching themes, any specific team or service issues which may have resulted in this increase. However, the Governance Team in the East Sussex CDS will continue to monitor this. The gradual increase of serious incidents in East Sussex has a weighted population of 602,811 which compares to 357,557 in Brighton and Hove and 778,737 in Coastal and North West Sussex. 3.5 CAMHS have seen overall reductions in serious incidents reported in the last two years which is due to the removal of the requirement to report bed delays of over four hours. These are still reported as incidents and this are monitored via local contract and performance meetings. Figure 4 below demonstrates the reduction. 3.6 Complex Care and Substance Misuse Services are no longer commissioned by Sussex Partnership and is the reason none have been reported in the year 2016/17.

222 Figure 4: Total number of Serious Incidents by Cause Group in 2016/17 compared to the total number in 2015/16 and 2014/ This year the most frequently occurring serious incidents reported were: unexpected death, significant self-harm/suicide attempts, falls and AWOL incidents which largely the pattern across all three years. 3.8 Of note, the same numbers of self-harm and AWOL incidents were reported. There is now an expectation that all deaths of people under SPFT services need to be raised as an incident, including natural causes, which has given rise to the increase in the numbers of unexpected deaths recorded. 3.9 Over the last three years there has been a decrease in the numbers of fall/slip/trips and security and information governance breaches that met SI criteria. 4. Serious Incident Categories Analysis 4.1 Homicides There were no homicides reported in the period 2016/17 which compares to one homicide in 2015/16. In April 2016 an independent thematic review of investigations in to the care and treatment provided to patient s who committed a homicide and to a victim of a homicide was commissioned by NHS England. This included ten 10 homicides which were reported in the period from The outcome of the review was published in October 2016.

223 A homicide did occur in June 2016, however as the initial information received did not confirm the patient s had been actively involved in this incident it was not reported as a Serious Incident to Commissioners until April This was following charges being brought by Sussex Police. 4.2 Attempted Suicide/Self Harm Not all suicide attempts/self-harm are graded as a Serious Incident, one important criterion considered is actual harm done. Where incidents are not a Serious Incident they are always reported by the most appropriate means. We are actively encouraging staff to report incidents of significant self- harm so that proactive learning can take place to prevent further harm. Figure 5: Total number of Self-Harm Serious Incidents by CDS in 2016/17. CDS Number Brighton & Hove 12 CAMHS 22 Coastal West Sussex 4 East Sussex 20 Forensic Healthcare 7 North West Sussex 9 Primary Care 1 Total 75 CAMHS reported the highest number of serious incidents and 17 were in the context of overdosing. Figure 6: The number of Self-Harm Serious Incidents by Cause Group in 2016/17.

224 Self-harm incidents are the second highest number of Serious Incidents reported in the year. In total there were 75 significant self-harm incidents which is equal to the numbers reported in the previous year 2015/ AWOL/Missing in the community A total number of 505 AWOL incidents were recorded by teams in 2016/17 and of those, 12 incidents were deemed to meet Serious Incident criteria and reported to the CCG which was the third highest number of serious incidents reported. Figure 7: AWOL Serious Incidents by Ward in 2016/17. The highest number of AWOL incidents has been from Oaklands Ward in Chichester. Two involved sectioned patients who did not return from unescorted leave and one involved a vulnerable patient did not return to the unit for over a week. 4.4 Fall/Slip/Trip Resulting in Significant Harm The guidance issued by the Department of Health in 2013 requires trusts to report as serious incidents all falls that result in moderate/ severe harm to a patient. During 2016/17 there were 889 fall incidents reported, and there have been 11 incidents involving a patient who has fallen resulting in a fracture or serious injury and reported as a Serious Incident. This is a reduction from the last two years; 17 were reported in 2015/16 and 25 were reported in 2014/15. In response to the high rate of harm, a falls pilot scheme was developed to work alongside clinical teams to reduce risk by improving assessment and introducing a range of equipment to reduce harm. This has now been implemented across all inpatient settings and has helped reduced the number of fall incidents.

225 4.5 Mortality Review The Mazars report (Dec 2015), the CQC s Learning, Candour and Accountability publication (Dec 2016), the National Framework on Learning from Deaths (March 2017) and the Learning Disability Mortality Review (LeDeR) Programme places a significant responsibility on Trust s to ensure they are reviewing the deaths of people receiving care, whether by natural or unnatural causes. This is to ensure people are not dying sooner than expected and where there are concerns in regards to the provision of care or lessons to be learnt, these are shared and acted upon. From August 2016 the Trust lead by the Chief Medical Director, Chief Nurse, Deputy Chief Nurse and the Serious Incident Administrator reviewed all mortality incidents of people under the care of Sussex Partnership services. This meeting has been designed to agree actions and identify necessary learning points and is authorised by the Suicide & Homicide Prevention Strategy Group to take any decisions which fall within its Terms of Reference and are in accordance with the Scheme of Delegation Analysis In total from the 1 April 2016 to 31 March 2017, the Trust reported 1,287 fatalities; of which included 715 expected natural causes deaths and 296 of unexpected natural causes deaths and 123 were reported as a serious incident Unexpected Deaths The Trust classifies unexpected deaths as all those who were not subject to a specified and documented end of life care pathway. It includes those people who died whilst in receipt of care and those who had received care and treatment in the preceding 6 months for adults and 12 months for those under 18 in our Children and Young People s Service. A total of 122 unexpected deaths were reported in 2016/17, of those 5 were attributed to a physical health cause; this is a total increase of 26% from the previous year 2015/16 (90 unexpected deaths were reported in total). The table below shows a total number of 123 fatalities as this includes 1 expected death which was investigated as a serious incident. 1 of these deaths occurred within 3 days of discharge from one of our inpatient settings and two of these deaths occurred within 5 days of discharge from a ward. 9 of these patients died within 3 days of admission to an acute general hospital following injury or self-harm. In total there were 8 inpatient deaths.

226 Figure 8: Total number of fatalities reported as a serious incident by cause in 2016/17 compared to 2015/16. Cause 2016/ /16 Expected Death 1 1 Unexpected Death - Alcohol/Substance 16 4 Unexpected Death - Asphyxiation 4 3 Unexpected Death - Cause Not Currently Known 6 0 Unexpected Death - Collision With Train 6 7 Unexpected Death - Cut With Sharp Object 1 1 Unexpected Death - Drowning 5 3 Unexpected Death - Exposure To Fire 1 0 Unexpected Death - Fall From Height 9 9 Unexpected Death - Gas/noxious Substance 1 4 Unexpected Death - Ligature Unexpected Death - Natural Cause 5 9 Unexpected Death - Other Unexpected Death - Overdose (Illicit Drugs) 10 1 Unexpected Death - Overdose Non-Prescription Meds 4 6 Unexpected Death - Overdose Prescription Meds 10 9 Unexpected Death - Road Traffic Accident 2 0 Total Figure 9: Total number of fatalities reported as serious incidents by CDS in 2016/17. CDS Number Brighton & Hove 31 CAMHS 4 Coastal West Sussex 21 East Sussex 38 Forensic Healthcare 7 LDS 1 North West Sussex 18 Primary Care 3 Total 123 East Sussex CDS reported the highest number of fatalities followed by Brighton and Hove CDS. Seasonal spikes were noted in May and September. Of those who died, 85 were male and 38 were female. The highest number of patient s involved were aged between 41 and 50 (24%) and the second highest age range were patient s between 31 and 40 (20%).

227 Due to the apparent increase in fatalities by cause group of substance misuse, the Trust and CCG have agreed a review of the last three years investigations being led by the Clinical Safety Leads. 4.6 Inquests The number of inquests closed this year was 118. Prevention of Future Death Reports received by HM Coroner was The Coroners (Inquest) Rules 2013 made a number of changes to the Coronial system in England and Wales and came into force in July Figure 10: Total number of Prevention of Future Deaths (PFD) reports received. Year Number of PFDs 2014/ / / Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides Coroners with the duty (previously a discretion) to make reports to a person, organisation, local authority or government department or agency where the Coroner believes that action should be taken to prevent future deaths. Reports were formerly known as Rule 43 reports and are now Prevention of Future Death (PFD) reports (Regulations 28 and 19, Coroners (Investigations) Regulations Figure 11: Number of Inquests closed in the last three years.

228 4.6.4 Prevention of Future Death Reports received from HM Coroner in financial year 2016/17 Date of death PFD Received Conclusion & Area HM Coroner s concerns Response / Learning / improvement 28/05/15 15/06/16 Suicide East Sussex Observations not correctly undertaken or recorded. Observation Policy breached. Lack of managerial input in monitoring Staff training on the observation policy. Knowledge and skills test on observations. Matron checks. 06/03/16 05/09/16 Narrative Brighton & Hove Transfer between Langley Green and Mill View not considered in patient s best interests and patients views not considered. Poor documentation in relation to personal care, medication, obs, fluid and food. Physical disability not catered for (wheelchair bound one side paralysed). Rapid Tranquilisation policy not followed. Deterioration in physical health not detected. Admission and Internal Transfer Checklist developed and audited by Matron. Internal transfer of patients highlighted in daily ICD call. Carenotes used to record patient involvement. Rapid Tranquilisation guidance from Chief Pharmacist Strategy and Governance developed and rolled out to staff. Updated RT Policy. Audits of Health records re Care Plans. Local Improvement Plan for compliance with the Observation Policy. Review of Observation Policy. Ordering of specialist equipment needs identified prior to transfer and ordering information on intranet. Trust wide bed management being developed. 07/03/16 15/09/16 Narrative Staff did not recognise the significance of infected legs. Lack of close monitoring and treatment. Brighton & Hove Independent Expert in tissue viability and wound management site visit. Revised wound management care pathway and protocol. Training of staff undertaken. Dressing formulary to be added to electronic records system. Infection prevention and control inspection and audit. 07/03/16 14/02/17 Narrative No relevant policy, procedure or practice requiring faxes to be logged and scrutinised on receipt so it was not noticed that pages of referral were missing. No policy, procedure or practice requiring the Information Governance Training completed Posters with guidance on fax receipt Developed set of standards for accepting referrals with guidelines for staff Early contact with clients offering a choice around appointment times and venues Higher rates of engagement achieved

229 West Sussex referral to be read before the zoning meeting and initial risk assessment. No relevant policy, procedure or practice to confirm with the referrer the date on which contact with a newly referred patient will be. No SI / effective joint learning from the other Trust s SI. Telephone contact with referred client the next working day and agree a date and venue for contact Transition proforma developed Retrospective SI to be undertaken 05/06/16 17/02/17 Narrative Brighton & Hove Medication regimen not effectively addressed / no reasons for changes in meds recorded. Mental Capacity assessment forms not fully completed Falls risk assessment did not take into account information from family No Waterlow score until late in admission Thromboprophylaxis assessment not done until late in admission No bowel chart until late in admission Clinical recommendations and instructions not handed over, completed or documented MUST score not reviewed Referrals to specialists not recorded / made Mobilisation not encouraged Delay in enema Role of the Primary Nurse not clear / effective No review of Care Plan No appointment of care co-ordinator MDT Clinical Care Review template revised with audit Electronic records Carenotes introduced Role of administrator on the ward enhanced Contact with family by senior doctor on admission Weekly track and trigger checklist introduced for MDT Supernumerary nurse one day a week to carry out essential tasks from MDT New falls proforma and audit Ward Manager calls family and invites for introduction and info sharing Plan to visit at home before admission Training from Nurse Specialist Geriatrician attends ward weekly Weekly audit of waterlow and thromboprophylaxis assessments Enhanced Physical Health section on Carenotes Pressure ulcer pathway Equipment ordering system improved / possible equipment library going forward Training on bowel function Tabular list of diagnoses and common symptoms Briefing to staff with expected standards System of referrals to specialists reviewed Draft nutritional monitoring / food and fluid chart protocol Training on falls / audit and proforma Review of the role of Primary Nurse and guidance to staff and monitored in clinical supervision Improved MDT Clinical Care Review Care Co-ordinator requests to be in line with Care Programme Approach Policy, staff reminded and will be discussion in clinical supervision. 25/06/16 20/03/17 Narrative Brighton & Hove No record of cardiac problems that were reported to staff by family member Delay in obtaining full past medical history Staff briefing and education System for acute wards to make requests from primary care

230 5.0 Serious Incident Investigations 5.1 The Trust ran 3 Root Cause Analysis Training Courses in 2016/17 and trained an additional 39 members of staff to be able to undertake Serious Incident investigations. Across the organisation there are over 140 staff trained in RCA. 5.2 In 2016/17 there were 300 Final Serious Incident Reports presented at the Scrutiny Group Meeting, held fortnightly and attended by all quality leads from our commissioning groups and Clinical Safety Leads and Deputy Chief Nurse. Of the 300 reports, 39% were submitted within the 60 working day deadline or agreed timeframe (118). Figure 12: Average number of working days to submit SI Reports to the CCG by CDS CDS Number Brighton & Hove 76 CAMHS 61 Coastal West Sussex & Dementia 95 East Sussex 71 Forensic Healthcare Services 72 North West Sussex 97 Complex Care 141 LDS 60 Nursing Home Services 130 Primary Care 61 Corporate The table above shows the average number of days per CDS in each quarter for the completion and submission of serious incident reviews. Adult mental health services have particularly struggled to ensure compliance with reporting times. As the year has progressed an increasing number of serious incident reviews have been completed on time. 5.4 The figures below show how many Serious Incident Reports the CCG agreed closure/conditional closure at first time of scrutiny. Q1 73% Q2 64% Q3 100% Q4 100%

231 6.0 Themes of Identified Learning 6.1 Key themes of learning identified from SI investigations 2016/17 are record keeping, coordination of care, communication, risk assessment, patient / family / carer involvement, and care planning. Frequently identified patient factors included complexity of presentation, substance misuse, poly pharmacy, previous self-harm and difficulty in engaging. Figure 13: Themes from SI Action Plans in 2016/ Action Taken (Trust-wide) Theme Risk Assessment Patient / family / carer involvement Care Planning Action taken New interactive dashboard on carenotes has been produced to enable the clinician and team leader to view the current level of completed risk assessments/care plans etc... Training of family liaison leads 14 staff have been trained Trust-wide for the role of Family Liaison Lead to enable better communications Serious Incident Policy Integral to the new policy is the consistent involvement of families/carers within SI investigations. New Inpatient Care Plan Implemented A template has been developed which is patient focused, identifies strengths and coping strategies as well as areas of need/risk from both the patients and team members perspective. The care plan for use on the Dementia wards also contains a consideration of a person s capacity.