AGENDA. 1 APOLOGIES for absence: 2 Declarations of Interest. 3 Patient Story 3:00pm Page 2 Attached

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1 A MEETING OF THE BOARD OF DIRECTORS OF THE SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST WILL BE HELD ON 29 TH NOVEMBER 2016 AT 3:00PM, LEARNING CENTRE, MAUDSLEY HOSPITAL 1 APOLOGIES for absence: 2 Declarations of Interest AGENDA 3 Patient Story 3:00pm Page 2 Attached 4 Minutes of the Board Meeting held on 1 st November :10pm Page 4 Attached 5 MATTERS ARISING/ACTION POINTS REVIEW 3:15pm Page 12 App A PRESENTATION 6 Discuss R&D Update 3:20pm Page 15 App B STRATEGY 7 Discuss - South East London & South West London STPs 3:40pm Page 32 App C 8 Discuss Digital Services Update Report 3:50pm Page 33 App D QUALITY 9 Discuss Quality Improvement Programme Update 4:00pm Page 54 App E 10 Discuss - Homicide Review Report 4:10pm Page 57 App F 11 Receive BRC Update 4:20pm Verbal PERFORMANCE AND ACTIVITY 12 Approve Performance Report 4:30pm Page 67 App G 13 Approve Finance Report Month 7 4:35pm Page 90 App H GOVERNANCE 14 Approve Emergency Preparedness, Resilience and Response Policy 4:45pm Page 105 App I 15 Review Scheme of Delegation 4:50pm Page 146 App J 16 Information Briefing from the Quality Committee 4:55pm Page 167 App K 17 Information - Report from the Chief Executive Page 169 App L 18 Information - Update from the Council of Governors Page 176 App M INFORMATION 19 Actions summary from today s meeting Verbal 20 Reflections on today s meeting Verbal 21 Forward Planner and Draft Agenda for December Meeting Page 180 App N 22 Report from previous Month s Part II Page 187 App O 23 Any other business 5:00pm Verbal Items for information will be taken as read but with an opportunity for Q&A. Date of Next Meeting: Tuesday 20 th December :00pm, Learning Centre, Maudsley Hospital, Denmark Hill, London, SE5 8AZ Please send apologies to Alison Baker alison.baker@slam.nhs.uk Please note that minutes from this meeting are a public document and will be published on the Internet and may be requested under the Freedom of Information Act (2000). Any attendee that would like their name omitted from the minutes should discuss this with the minute taker. Note that it may not always be possible to oblige as this is dependent on the persons role and the business being discussed. web site: 1 of 188

2 You said We did and Patient Story Report (November 2016 Board) Westways Rehabilitation Inpatient Unit, Psychosis CAG Background Summary of feedback from team/ward use PEDIC quarterly report and any other local feedback mechanisms The Trust smoke-free policy was introduced in October 2014 and has been challenging for both patients and staff, especially on longer-stay units like Westways rehab ward. In January 2016, the team decided to implement the second stage of being smoke free. This included not facilitating any smoking activities and not storing tobacco and lighters for the patients. This meant that patients could not bring their tobacco and lighters to the ward. This was particularly challenging, with no smoking on site and no easy way for people to smoke on short leaves. The journey started with staff members and building their confidence and skills in implementing the policy and working with the cultural move from smoking to fresh air breaks. The team was trained up and worked together to implement the SLaM smoke free policy and effective management of tobacco dependence for those on the ward. Over 80% of staff members were trained in smoking cessation level 1 and two in smoking cessation level 2, giving them skills in facilitating smoking cessation groups. The team recognised that this was challenging for patients and identified ways of supporting patients and each other. Smoke-free advisors were invited to team meetings and patients community meetings to discuss possible challenges arising from the Trust initiative, what it means for individuals and how to manage. From January 2016, a smoking cessation group was started once a week. This group was co-facilitated by the Bethlem site smoke-free advisor and a level 2 trained member of staff from our team. The group was attended regularly by about 60-80% of the patients who smoked. It continues to be a challenge. Patients feed back in community meetings and 1:1 sessions that they feel their autonomy and choice are frustrated. Some want to continue smoking and there are attempts to get round the policy such as the smuggling in of odd cigarettes. On the other hand most want to improve their health and the team has been able to link in to this and promote all round wellbeing to break the reliance on smoking. People are not forced to stop smoking. Team efforts are geared towards helping people manage their tobacco dependence while they are in hospital. Rather than leaving them to crave for nicotine, staff help people to try different nicotine products to manage their withdrawal. It is a health-promotion intervention to support people to improve their physical and mental health. People are encouraged to talk and discuss their thoughts and ideas. The team is not saying they cannot smoke at all, rather that it will not facilitate them to smoke, in the same way it we would not facilitate them to use alcohol or legal highs. Patient story Summary / key points of patient story include quotes where possible Patient A raised in ward round on admission to the team earlier in 2016 that he was determined to meet his goal of not going back to smoking. The team listened to his goal in the context of the smoking cessation strategy and their desire to provide the best supportive environment. They worked with him to support his goal. I smoked 40 a day for almost 20 years I knew it wasn t good for me but I couldn t help it. Sometimes it was because I forgot I wanted to stop it was such a strong habit and there was no one to tell me what else I could do rather than picking up a cigarette. Having a patch given to me every day helped me to develop a habit of putting a patch on and kept my cravings to a manageable level. Being in charge of the medication myself helps me know how I am feeling and what to do. If I was tempted when others smoked I was able to talk to someone. I went every week to the smoking cessation group on the ward and shared my own story. This increased my motivation to stick to it because people looked up to me as an example. One year on from quitting the ward had a celebration for me and it felt very good. Farida Pirani and Jane Lyons Ward manager and Involvement Lead October of 188

3 What we did well Compliments Highlight positive comments / compliments from story The team embraced the smoke-free policy in detail and in the spirit of improving health and wellbeing. Staff undertook the training and we now have over 90% staff trained in smoking cessation level 1 and four staff trained in smoking cessation level 2. Currently 6/18 (33%) of patients on our ward smoke up to 5 cigarettes per day. This is 33% of our patient group, compared to up to 70% when smoking prevalence was recorded at an earlier stage before the smoke-free policy was introduced. Many of those who are smoking are also constantly trying to cut down or quit with support from the staff team. The approach was to help patients to increase their sense of autonomy and ownership of the change. The approach was always tailored to the individual. For example one patient was encouraged to self-manage with patches while another said she liked how cigarettes felt to hold so she has used e-cigarettes. Skills offered by the team that really helped included their use of motivational interviewing, positive encouragement, and providing knowledge and information. Building a supportive environment, with clear expectations, support groups, peer support. What we didn t do well Complaints Highlight complaints, negative feedback and suggestions for improvement Of the five or more in the smoking cessation group, not everyone has been able to give up, though some have cut down. Some people are ambivalent about wanting to stop but have been supported to start Nicotine Replacement Therapy. We need adequate staffing to support group and individual interventions. We need to do better on 1:1 support and encouragement this can be affected by staffing, including bank staff. Lack of access to e-cigarettes was a problem but these are now available in the BRH community centre. Actions No Action Owner Date due Closed Action to be taken INITIALS DD/MM/YY DD/MM/YY 1 More staff to do the training, to maintain high levels. FP on-going 2 Revisit how we have done so far with both staff and patients, to include reinforcement of the health promotion message with support for people to manage their cravings in the way they prefer, and open conversations to encourage people to feel as much control as possible. FP January 2017 Farida Pirani and Jane Lyons Ward manager and Involvement Lead October of 188

4 MINUTES OF THE HUNDRED AND FIRST MEETING OF THE BOARD OF DIRECTORS OF THE SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST HELD ON 1 NOVEMBER 2016 PRESENT Roger Paffard Dr Neil Brimblecombe Kristin Dominy Alan Downey Mike Franklin Louise Hall Duncan Hames Gus Heafield Dr Michael Holland Dr Julie Hollyman Prof Matthew Hotopf Altaf Kara June Mulroy Dr Matthew Patrick Anna Walker Prof Simon Wessely Chair Director of Nursing Chief Operating Officer Non-Executive Director Non-Executive Director Director of Human Resources Non-Executive Director Chief Financial Officer Medical Director Non-Executive Director Non-Executive Director Director of Strategy and Commerce Non-Executive Director Chief Executive Non-Executive Director Non-Executive Director IN ATTENDANCE Alison Browning Barbra Davidson Angela Flood Jo Fletcher Alice Glover Kathryn Hill Blod Jones Brian Lumsden Paul Mitchell Mary O Donovan Amanda Pithouse Dr Ranga Rao Louise Rabbitte Zoe Reed Gillian Sharpe Michael Wuestefeld-Gray Clinical Psychologist Council of Governors Council of Governors Service Director, CAMHS PPI lead Head of PPI Service User Consultant Council of Governors Trust Board Secretary Assistant Director Deputy Director of Nursing and Quality Clinical Director Safeguarding Adults Lead Director of Organisation and Community Council of Governors Business Manager, Trust Secretariat (Minutes) APOLOGIES Lillian Nsomi-Campbell David Norman Jo Kent Alison Beck Interim Director of Estates Estates Programme Director Service Director, Acute Care CAG Head of Psychology and Psychotherapy DECLARATIONS OF INTEREST There were no declarations of interests. 1 4 of 188

5 MINUTES The minutes of the Board held on 13 September 2016 were agreed, as an accurate record of the meeting. BOD 155/16 FIRST PATIENT STORY Sophie Browning, a clinical psychologist, presented to the Board on a new package for working with children in school to promote emotional wellbeing and resilience. The aim of the package is to prevent mental health problems escalating, given 10 to 20 per cent of children experience anxiety or low mood at some point and thresholds for access to CAMHS are increasing. Feedback from previous trials was that early intervention wasn t considered to be early enough for pupils and that mental health still has a stigma attached to it. By developing the package for schools the idea was to bring mental health to an environment where physical health needs are already addressed. The package is six sessions of cognitive behavioural therapy delivered to up to 30 children at a time. Children helped in the design of the sessions and receive workbooks that cover session content. Parents also get information sheets, and the programme capitalises on the opportunities for digital media. There is an interactive website and children have helped in the design of games that will reinforce what the children are learning. Feedback received so far has been very positive. Sessions are delivered by therapists and psychologists but there is a strong appetite among teachers and other school staff to learn about content and delivery. Action: the presentation given to be circulated. The Board noted the report and thanked Sophie Browning for her presentation. BOD 156/16 SECOND PATIENT STORY Alice Glover and Blod Jones presented to the Board on the Place of Safety. Service users and consultants talked to over 100 people about their experience of a place of safety. This fed discussion about creating centralised place of safety, involving local organisations and advisory groups. This in turn led to an open day in August Feedback was that staff should be well trained, friendly, and approachable in a crisis. Service users need information at each stage of a patient s journey so people know what is happening. Crisis plans are very important as is attending to patient s physical health care. Finally there is patients dignity. Access to clothes, food, a bed, and being able to keep clean were considered very important. Barbra Davison echoed the feedback service users had provided on the place of safety, based on her own work. 2 5 of 188

6 Action: the presentation given and supporting documentation to be circulated. The Board noted the report and thanked Alice Glover and Blod Jones for their presentation. BOD 157/16 MATTERS ARISING/AND ACTION POINTS REVIEW The actions were noted as being on track. No matters were raised. BOD 158/16 PLANNING GUIDANCE 2017/18 AND 2018/19 Gus Heafield (GH) presented. New planning guidance requires submission of draft plans by 24 November; and the final plan by 23 December. This is three months earlier than usual. In addition the submission is a two year plan. Contracts with commissioners need to be signed by 23 December. This is challenging as guidance is still being published on control totals and limits on agency spend. Because of the need to respond quickly to the detail of planning guidance at relatively short notice it was proposed that authority for the sign off of the control total was delegated to the Finance and Performance Committee, which has a role in ensuring the control total is delivered. June Mulroy (JM) commented that the Finance and Performance Committee cannot provide assurance of quality initiatives. GH confirmed that the Trust is not an outlier in terms of block contracts, but is seeking a model that minimises risk. Matthew Patrick (MP) said CCGs are not yet ready for the system to move from block contracts, but were moving at different speeds towards capitated commissioning and this would be supported by the Trust. Julie Hollyman (JH) noted that control totals had been reduced at least once in year. There is a risk that if the Trust agrees to a control total that aims for a break even position, it could then be reduced. The Trust should only agree to a control total if it is confirmed that it is not going to change. Anna Walker (AW) asked if commissioners were mature enough to effectively commission mental health services for the population the Trust serves, as commissioners are a key part of the system moving forward. MP agreed that in most cases that maturity is not there, but as mental health is relatively well defined it is a good place to start. A lack of capability limits the pace at which change can move. Alan Downey (AD) expressed unease with the planning guidelines, as the Trust was being asked to comply with financial targets that may not be achievable. There were also concerns about whether parity of esteem can be delivered within the current allocations proposed by commissioners. MP informed the Board that there is some push back by STPs and the deliverability of control totals so there will be an STP response to guidance. Roger Paffard (RP) noted from the paper the clinical negligence fund will not be agreed by the submission deadline. GH assured the Board that this was not material. The Board agreed to raise concerns about the pace of moves away from block contracts in the light of the risks it introduces given the need to develop and submit plans based on current planning guidance. 3 6 of 188

7 The Board approved the approach and high level timetable and process for preparing the two-year draft and final plans before 23 December. The Board approved the delegation of sign off of the plan to the Finance and Performance Committee including formal acceptance of the control totals and agreed that, if required, this will be followed by a conference call open to all Board members for formal approval. The Board noted the principles in the approach to planning and contract negotiations for the two year contracts to be signed by 23 December and the priorities and key issues emerging from the planning guidance. BOD 159/16 SERIOUS INCIDENT PROCESS UPDATE Neil Brimblecombe presented. He explained the Trust follows NHS England s serious incident (SI) framework for recording and reporting SIs. There were 12,865 incidents recorded on Datix last year and 87 of those were serious incidents. 18 of those were of the most serious category, which go for Board Level Inquries. There are challenges with the process regarding timeliness. The general environment for investigations is complex, particularly as there can be more than one investigation into an incident. Such complexity can cause delays. There is pressure to introduce more external presence into investigations. This can involve asking staff from another CAG to investigate, or for more specialised areas, involving people external to the Trust. The Trust is looking at a formal arrangement with the two other mental health trusts in South London. CCGs are now responsible for signing off all SI investigation reports, at SI panels, using a standardised tool that measures thoroughness and appropriateness. The Trust is looking at bringing that tool in-house. The Trust has also reflected on current communications and media practices in the light of recent incidents and the requirements of the duty of candour. JH suggested that following a review of communications it was recommended that all Board level incidents should be communicated to Board members. RP added that communications should be visible to governors as well. The Board noted that risk assessments and care plans keep coming up in SI investigations and reports to the Quality Committee. While risk assessments are judgment calls it is important that the Trust keeps up to date with best practice in this area and should be built into training programmes. Michael Holland explained that the Trust is developing a single risk assessment process, informed by looking at the approach of other organisations which are considered to do this well, such as Partners in Care. AW said there are a series of possible solutions to a number of problems including quality assurance, independence, timeliness, and communication both publicly and to Board members and governors. The Board is responsible for ensuring processes are completed and implemented Trust wide. The Trust needs to look at its capability to trigger SI reports quickly. Action: The SMT will take these points away for further consideration. 4 7 of 188

8 Mike Franklin commented that the paper focusses on what the Trust can do better, and asked how the Trust can be open and maintain the integrity of the investigation, while also meeting timescales. Also, what will the Trust do if the family or carers object to, for example, the terms of reference of an investigation? The Trust should consider notifying MPs of deaths or suicides. Also, the Trust should consider having specialists who act as advisers to investigations rather than being investigators themselves, as this could help with the speed of investigations. Action: AW and NB will pick up on these points at the Quality Committee. The Board noted the report. BOD 160/16 TRUST SAFEGUARDING ADULTS ANNUAL REPORT 2015/16 Louise Rabbitte (LR), the Trust s Safeguarding Adults Lead presented the report. The Trust is working to systematically capture data required to comply with the Care Act and also for the Government programmes Channel and Prevent. The data show the main risks to service users are from other service users and carers. Training compliance has also improved from less than 70% in quarter /15 to 85% in quarter /16. The Trust is currently above that level. Feedback on the training has been good. Each CAG has a safeguarding lead and as the implementation of safeguarding processes continues better data should become available, allowing analysis of trends and demographics. The Board noted there is a variation in reporting by borough, which is due to variations locally in recognising safeguarding concerns. RP asked if there was a mechanism for identifying unintended harm. For example, if people decided not to access services because of Channel or Prevent. LR explained that there have been approximately 20 cases flagged through Channel, most of which were raised by other agencies. Safeguarding approaches are multi-agency. Feedback from clinicians has been generally positive and the Board can be provided with case studies. MF said Prevent is being queried in schools and it would be useful to see those case studies. JH noted that engagement with the London Borough of Bromley around Bethlem Royal Hospital was overdue. LR said the Care Act gives local authorities a statutory duty and agreement is being reached with Bromley incrementally as the Borough needs to examine data to determine allocation of resources. The Trust is now also an attendee at Bromley s Safeguarding Board. The Board noted the report. 5 8 of 188

9 BOD 161/16 INVOLVEMENT STRATEGY UPDATE The strategy was taken as read. AW noted there is a question about whether carers are as engaged with other groups as feedback from governors suggests that they need more involvement. Governor expertise could be useful in this area. The Board noted the report. BOD 162/16 EPIC ANNUAL REPORT Amanda Pithouse presented the second annual report, which highlighted the work of the Task and Finish Group which was asked to review the EPIC terms of reference. Currently the involvement policy and the process to take EPIC forward are being developed. The Board noted the report. BOD 162/16 FREEDOM TO SPEAK UP GUARDIAN IMPLEMENTATION OF PILOT Zoe Reed (ZR) reported to the Board on the pilot initiative to introduce the Freedom to Speak Up (FTSU) Guardian function into the Trust. The pilot sought to examine, amongst other things, how much work FTSU might generate. In addition a National FTSU Guardian has been appointed and provided a model job description for the local Guardians. There is now a need to increase the awareness of the function as this supports a culture of openness. The model job description set out the work areas for the role and the intention was to work through these and ensure that FTSU was embedded in the Trust s systems and processes. Further work is needed to determine how best to support people who raise concerns. MP said research indicated that the development and training of staff in middle management roles was crucial to changing organisational culture. The Board should consider how to engage the whole organisation with FTSU. He also asked to see anonymised case studies on the concerns that have been raised during the pilot period. MF asked how FTSU guardians would deal with matters that have already been fully considered. ZR explained FTSU guardians role is to support and advise people to raise concerns, not to influence the outcome of processes. The point is to ensure people are listened to. AD also asked for details on costs. Action: a further report will be made to the Board in January 2017 that addresses these points. The Board noted the report. 6 9 of 188

10 BOD 163/16 PERFORMANCE REPORT Kristin Dominy (KD) presented the report and highlighted the single oversight framework that came into force on 1 October and the new quality indicators. It was noted delayed transfers of care will continue to be reported to the Board. These are still high in Croydon and Lewisham. Also highlighted was the performance management framework. The Board noted the scale of QIPP at 9 to 10 million, and considered that this will be undeliverable if the schemes are just about cost reduction. KD advised that pushing back on QIPP could lead to the Trust going to arbitration. Croydon CCG wants to take out additional funding. Block contracts hide issues of subsidy from other boroughs. Moving from that model means it may not be possible to reach agreement with Croydon CCG. The Trust considers that QIPP can be delivered through a QI led transformation programme, rather than through reductions at the contract stage. Duncan Hames noted that the data on overspill beds for September, which were more recent than in the finance paper. There was a spike in overspill beds in Lambeth which had recovered. He asked whether this was due to work in Lambeth that could be replicated elsewhere? KD explained that Trust is working to better understand the reasons for variation. Keeping patients in beds allocated to their local boroughs can help reduce pressures. The Board agreed that the Trust could go to arbitration regarding the Croydon QIPP if necessary. BOD 164/16 FINANCE REPORT MONTH 6 GH presented the report, which was taken as read. Data on the quarter 2 submission to NHS Improvement was included in the report. The Trust is on plan but is mindful of the challenges in the second half of the year. JH asked about the housing summit. KD said this was held on 6 October. Agreement was reached on a set of issues to look into in more detail and a strategic partnership document will be drafted. RP confirmed that Non-Executive Directors will be fully involved in considering the ongoing financial challenges. The Board noted the report and gave formal thanks for keeping on plan to date. BOD 165/16 REPORT FROM THE AUDIT COMMITTEE The report was taken as read. The Board noted the report. BOD 166/16 REPORT FROM THE FPC SEPTEMBER MEETING AND TOR The report was taken as read. The Board noted the report. BOD 157/16 REPORT FROM THE CHIEF EXECUTIVE The report was taken as read. MP highlighted that the Trust is in one of the top 10 research trusts active in the UK, and that the GMC has written to thank the Trust for the quality of its medical education. The Board noted the report of 188

11 BOD 158/16 UPDATE FROM THE COUNCIL OF GOVERNORS The report was taken as read. The Board noted the report. BOD 159/16 ACTIONS SUMMARY ON TODAY S MEETING Paul Mitchell will circulate an updated actions log. BOD 160/16 FORWARD PLANNERS & DRAFT AGENDA The draft agenda for the 28 November meeting was noted and no changes were requested. BOD 161/16 REPORT FROM PREVIOUS MONTH S PART II The report was taken as read. BOD 162/16 ANY OTHER BUSINESS No other business was raised. The date of the next meeting will be: Tuesday 29 November 2016 at 3pm at the Learning Centre, Maudsley Hospital. Representatives of the press and members of the public were asked to withdraw from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest. (Section 1 (2) Public Bodies Admission to Meetings Act 1960) of 188

12 Board meeting 1 November 2016 action points APP A Ref Issue Action By When Status RAG February 2016 meeting 1 Scheme of Delegation. Scheme of delegation to come to the October meeting. Moved to November. GH Nov 16 On agenda. April 16 meeting 2 Deloitte Report. Independent assurance to be sought before the Action Plan is signed off by the Board. PM Nov 16 Peer review arranged. Back to Board in Dec. June 16 meeting 3 Patient and Public Involvement (PPI) Policy. July 16 meeting To be presented at the December 2016 Board. NB/AP Dec 16 On schedule. 4 R&D report To come to the Nov meeting along with a BRC update and update on pathology services. MH Nov 16 On agenda. Pathology moved to December. 5 Homicide Report. Move to November meeting. NB Nov 16 On agenda. Page 1 of 3 12 of 188

13 Ref Issue Action By When Status RAG September 2016 meeting 6 Carers Strategy Report to the Board on progress towards achieving the internal target of 50% of carers offered a carers assessment. 7 Learning Lessons Report To include incidents where good behaviour by staff was exhibited in response to handling of complaints/incidents. 8 Experience Report The redeveloped Trust website to include service user surveys, to improve real-time reporting and data collection. 9 Workforce Update The commercial offering in education and training for apprentices will come back to the Board when it is finalised. 10 Revalidation Annual Report Brief paper to be brought to the Board on the progress toward delivery of the organisational action plan. Annual audit to be presented to the Board for assurance on NB Feb 17 On schedule. NB Dec 16 On schedule. NB Apr 17 On schedule. LH Dec 16 On schedule. MH Apr 17 On schedule. MH Apr 17 On schedule. Page 2 of 3 13 of 188

14 Ref Issue Action By When Status RAG 1 November meeting revalidation systems at the Trust. 11 Planning guidance. FPC to inform the Board if the Trust can sign up to control totals. Arrange board via con/call if required. GH PM Nov 17 Nov 17 Meeting took place. Calls scheduled to finalise the decision. 12 Serious Incident Process Update. Review of reporting to Board and governors. 13 Freedom to Speak Up Guardian. Bring further report back in January 17. NB Dec 17 Take to QSC for consideration. ZR Jan 17 On schedule. Code: Green completed Amber on schedule Red not on schedule PNJM/November 2016 Page 3 of 3 14 of 188

15 TRUST BOARD OF DIRECTORS SUMMARY REPORT B Date of Board meeting: Name of Report: Heading: - Author: 29 November 2016 R&D Update Presentation Fiona Gaughran / Gill Dale Approved by: (name of Exec Member) Presented by: Fiona Gaughran Purpose of the report: To provide the Board with an update on R&D activities including through the R&D Committee Minutes (Slide pack and Minutes included) Recommendations to the Board: To note for information Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: Objective 8 of the Assurance Framework (financial) - maximising potential R&D income sources. Summary of Financial and Legal Implications: To note the financial risk of maintaining R&D funding streams from the Department of Health (NIHR) via the Clinical Research Network and Research Capability Funding Equality & Diversity and Public & Patient Involvement Implications: Key strategic objective for R&D is the reduction of stigma and discrimination, and to give all of our service users the opportunity to take part in research. Service Quality Implications: Research needs to be at the core of our clinical services in order that our clinical practice is based on the best evidence and to facilitate the opportunity for better treatments, service improvements and innovation. 15 of 188

16 R&D Update South London and Maudsley NHS Foundation Trust Board Of Directors 29 November 2016 Fiona Gaughran Director of Research and Development Gill Dale Director of Research Quality 16 of 188

17 Highlights 2016 New Biomedical Research Centre award 66M over 5 years, a 23.5% increase on current funding Starts 1 April 2017 Centre for Translational Informatics Launched June, 2016 NIHR Clinical Research Facility Awaiting outcome of renewal bid BRC Bioresource: Most effective centre in NIHR Bioresource in recruiting NHS patients and samples. 17 of 188

18 Highlights 2016 (continued) Expanded clinically-relevant applications of Clinical Record Interactive Search (CRIS): e.g. devising new automated referral pathways to cessation services for Trust patients who smoke Consent for contact (CFC): 69% of those asked and 47.5% of active patients say Yes NIHR Research Activity League Table: Highest Recruitment in a Mental Health Trust However, drop in numbers compared to last year Now above average in Department of Health metrics for research pathway targets 18 of 188

19 Maudsley Biomedical Research Centre Led by Prof Matthew Hotopf 66 million award Plus Research and Capability Funding (currently 18%) Incorporates work of BRU- Dementia (BRUs have been disontinued) Strategic elements: Precision Psychiatry Novel Therapeutics Translational Informatics Mental/ Physical Interface Themes Psychosis and Neuropsychiatry Dementia and Related Disorders Child and Neurodevelopmental Disorders Affective Disorders and Interface with Medicine Neuroimaging Patient and Carer Involvement and Engagement Translational Therapeutics Bioinformatics and Statistics Clinical and Population Informatics Mobile Health Obesity Substance Use Pain Bioresource Biomarkers and Genomics CRF Training and Capacity Development 19 of 188

20 Centre for Translational Informatics Functional interface between analytics, software development and implementation to promote digital innovation in mental health. Links IoPPN research groups with the Trust s IT dept. Mainly funded through BRC-Maudsley Programme board co-chaired by IoPPN Executive Dean and SLaM CEO. Will establish the Trust & KCL as the forefront institution internationally for mental health informatics and accelerate engagement with digital and life science industries. 20 of 188

21 Centre for Translational Informatics 21 of 188

22 BRC BioResource for Mental Health Now the largest recontactable mental health cohort in the world. Largest recruiter of all National BioResource centres 5442 new patients/volunteers in (>30,000 by March 2017). Psychosis: n=4292 (19.7%) Bipolar disorder: n=508 (2.3%) Depression & anxiety disorders: n=2763 (12.7%) Child Psychiatry: Autism, ADHD: n=1130 (5.2%) Other Neurological disorders: n=1372 (6.3%) Eating disorders : n=890 (4.1%) Miscellaneous: n=1036 (4.8%) Alzheimer s Disease: n=1202 (5.5%) Healthy older controls: n=6103 (28%) Local population controls : n=2499 (11.5%) 22 of 188

23 Consent for Contact (C4C) Moving from research activity to part of clinical practice under Trust governance Funded by Maudsley BRC Best performance in CAGs that have senior clinician C4C lead and active management (CAMHS top) 23 of 188

24 SLaM NIHR income (NHS Support costs and infrastructure / overheads) 24 of 188

25 CAG R&D Data Dashboard The R&D office now provides quarterly reports to CAGs: C4C data Listing of active studies Participant Recruitment into individual studies with RAG rating for recruitment time and target R&D income data Trust Research Metrics now all above National Average Initiating research (interventional clinical studies) consistently above national position for 70 day benchmark: Rapid turn around of approvals in R&D Office Improving time to recruit first patient after approval Delivering research commercial trials to time and target. 100% (2 of 2) closed trials meeting time & target for Q4. 25 of 188

26 The year ahead Develop pathways to clarify R&D funding streams Use R&D Committee to encourage uptake of research opportunities and provide CAGs with data on R&D finance and performance Create system for PPI inclusion in R&D committee Develop KPIs to measure CAG R&D activity and performance and incorporate R&D as core business Work with IOPPN, CRN, BRC and CLAHRC and Trust Education & Training to create system to support Trust-led research activity and strengthen overall research capability Increase clinical trial activity and collaboration with industry Actively work with Trust clinical academics to ensure appropriate attribution of the Trust on research papers 26 of 188

27 DRAFT MINUTES OF THE SLaM Research & Development Committee Meeting Thursday 17 th March 2016 Seminar Room 6, main IoPPN, 14:00 16:00 Present: Tom Craig (TC), Chair Gill Dale (GD) Ranga Rao (RR) Paolo Fusar-Poli (PFP) John Strang (JS) Grainne McAlonan (GM) Allan Young (AY) Emily Finch (EF) Robert Stewart (RS) Philip McGuire (PM) Khalida Ismail (KI) SLaM Director of R&D Director of Research Quality Psychological Medicine Clinical Director Psychosis CAG Clinical representative Addictions CAG Academic lead B&D Psychiatry CAG Academic obo Declan Murphy MAP CAG Academic lead Addictions CAG Clinical Director MHOAD CAG Academic lead Psychosis CAG Academic lead LCRN Division 4 Leadership representative In attendance: Melissa Grout (MG) Jenny Liebscher (JL) Lauren Moult (LM) Adriana Fanigliulo (AF) Saliha Afzal (SA) Carol Cooley (CC) Farzena Khanom (FK) R&D Finance Business Partner, SLaM R&D Governance Manager, SLaM/IoPPN R&D Funding Manager SLaM/IoPPN R&D Governance Facilitator, SLaM/IoPPN BRC Manager R&D Governance Facilitator, SLaM/IoPPN R&D Administrator SLaM/IoPPN Apologies: Matthew Hotopf Gus Heafield Martin Baggaley Marinos Kyriakopoulos Jean O Hara Declan Murphy Anthony Cleare Emily Simonoff Simon Wessely Shitij Kapur Psychological Medicine CAG Clinical Academic/BRC Director Director of Finance Medical Director CAMHS CAG Clinical representative B&D Psychiatry CAG Clinical Director B&D Psychiatry CAG Academic Lead MAP CAG Clinical representative CAMHS CAG Academic lead Psychological Medicine Academic lead Dean, IoPPN 27 of 188

28 Item Business Item Action by 1. Welcome and apologies Received as above. 2. Membership Update The committee formally welcomes the new MHOAD CAG Clinical Academic lead, Professor Rob Stewart, to the SLaM R&D Committee. TC informed the committee that Dr Jean O Hara has stepped down from the committee. 3. Paper 1 received for discussion Review of minutes from SLaM R&D Committee meeting 28/10/2015 and matters arising Minutes are approved by the committee. There is one outstanding action point. TC to invite Andrew Pickles/Caroline Murphy to next R&D meeting to discuss the KHP- CTU. This action point has been deferred due to ongoing KHP internal review processes, which will be reported to the committee at a later date. 4. Paper 2 received for discussion SLaM R&D Funding flows: a guide for CAG leads GD presented paper 2 to the committee which outlines the SLaM arrangements for distributing R&D budgets to CAGs. GD highlighted the two funding streams - the Research Capacity Funding (RCF) stream and the Local Clinical Research Network Funding (LCRN) stream. The RCF funding is allocated in proportion to the total amount of NIHR income received by SLaM during the previous year. The majority of SLaM s RCF allocation has been used to contribute towards existing staff salaries which are already part-funded by the BRC or NIHR. CAGs will need to plan to maintain and increase RCF income by encouraging applications for NIHR funding. LCRN Funding is allocated to Trusts based on activity in terms of participants recruited into NIHR Portfolio projects. SLaM s funding allocation for 2015/2016 is 1.43 million. LCRN funding is used to meet NHS Support costs with a focus on recruitment of participants. CAGs can influence CRN funding by increasing the number of NIHR Portfolio projects, particularly those studies which recruit high numbers and are interventional. Recruitment data entry by research teams should be accurate and timely and clinical teams should be encouraged to assist with recruitment to research projects. If CAGs are not sure about the eligibility of research studies for NIHR funding, they should check with the SLaM/IoPPN R&D office or the CRN as there may be some flexibility in the inclusion criteria. The Committee noted that recruitment is recorded where the NHS patients are based so in the case of liaison psychiatry, credit will be often be with the acute Trust. It would be helpful in such scenarios where SLaM clinical teams are supporting patients in acute Trusts if the relevant CAG (most usually Psychological Medicine) could flag studies to the SLaM R&D Office which may then be in a position to launch negotiation discussions within the CRN, especially if patient numbers are large. The committee noted that there is an ongoing problem with excess treatment costs and excess treatment savings. GD advised that it is possible to apply for NHS subvention costs TC advised the committee that there is currently a CRN R&D Director position advertised and he would encourage applicants from SLaM to represent mental health on the CRN panel. 5. MH CRN specialty group PI training module KI informed the committee that the national MH CRN specialty group have developed an excellent Principal Investigator training module which aims to inform senior clinicians about what is involved in being a PI. The training has been rolled out in other Trusts with the aim to increase Trust involvement in research projects. The overview of the training is as follows: KI & SA and TC 28 of 188

29 Item Business Item Action by Discover what it takes to be a Principal Investigator - An opportunity to get involved in research Understand skills and attributes required Acquire a better understanding of clinical research (NHS and academic) Roadmap the steps to becoming a PI Discover further training opportunities Network. Share. Learn The committee agreed that it would be beneficial to provide the training at SLaM and that clinicians should be encouraged and motivated to participate in research. The committee noted that marketing of the training would be important and suggested that podcasts and videos could be produced to encourage non-academic clinicians to become collaborative in research. Action Point: The committee agreed that KI and the BRC should implement the training programme at SLaM. KI (or a CRN representative) will give the training and engage the SLaM Communications team to advertise The committee noted that protected time in SLaM NHS job plans for research is not currently well implemented, unlike in other Trusts where 1 or even 2 PA (programmed activities) are set aside in consultant s contracts for research activity and formally reviewed as part of the annual appraisal cycle. Such an arrangement would help to increase the number of NHS consultants willing to take on PI roles, especially in large clinical trials. Inclusion in the job planning cycle would mean it should also be possible for clinicians to plan around posts and be able to return the PA to clinical activity after a period on a research project. Action Point: TC to engage Martin Baggaley and instigate discussion on job plans for PI s. 6. Item for discussion NIHR R&D metrics update (including CRN recruitment targets) GD updated the committee on SLaM s Performance in Initiation and Delivery (PID) of research. In terms of meeting the 70 day benchmark target for clinical trials, SLaM is performing better than the national average, however, for the median days of NHS Permission to First patient, SLaM is performing lower than the national average. In some cases, this can be attributed to non-trust related delays (for example, sponsor-related delays). Trusts can potentially incur financial penalties (RCF funding cuts) for underperformance. Good performance in delivering research will hopefully make the NHS attractive to commercial studies. Feasibility assessments and setting realistic recruitment targets should improve performance. The committee duly noted the update. 7. Item for discussion Provision of R&D data reports to CAGs GD presented an overview of the proposed provision of R&D data reports for CAGs and asked for feedback on what would be useful. Data on C4C and recruitment of participants to research projects, both Portfolio and non-portfolio studies was presented to the committee. This did not include information on service evaluations as this is not available to the R&D office. MG informed the committee that financial spreadsheets are provided on an annual basis and these do not change significantly on a quarterly basis, they are therefore not included in the quarterly reports. BRC requested that funding information provided uses a common identifier, i.e., the funder grant reference, for easier identification between KHP organisations. The committee agreed that reports would be helpful to CAGs and should be sent to CAGs on a quarterly basis, approximately 6 weeks after the end of quarter. All CAG data would be sent to all CAGs. The committee also requested the inclusion of data for commercial studies. The reports should be sent to CAG leads clinical, education support and academic leads. The R&D team plan on visiting CAGs individually in April/May to discuss the provision of these reports in greater detail. 29 of 188

30 Item Business Item Action by 8. Paper 3 received for discussion Finance Report (standing item) The committee duly noted the finance report provided by MG. 9. Item for discussion - BRC application process SA updated the committee regarding the BRC re-application process. This year s application guidance places greater emphasis on Themes, more so than before. Each additional theme in a BRC will yield an extra 1 million/theme/year. In light of this, 4 additional themes have been added to the existing structure: Substance Misuse led by John Strang Obesity and Lifestyle led by Ulrike Schmidt Mobile Health led by Richard Dobson Pain Theme led by Peter Goadsby BRUs will be merged into a single BRC. The pre-qualifying questionnaire for SLaM was submitted on 15 th February this year, the outcomes of this will be announced in April. The main application deadline is 6 th June 2016, with interviews to be held in July. The final outcome will be announced in September Paper 4 tabled at the meeting - KHP Clinical Trials Office Review GD provided an overview of the draft KHP-CTO Review 2015 to the committee and provided a copy of Report of Recommendations for the committee s review. GD highlighted a number of points relevant to SLaM The CTO should be available for regulatory advice and support to all KHP partners for hosted as well as sponsored CTIMP studies. The CTO Operational board should comprise two representatives from each partner organisation A finance subgroup should be established and each organisation should have a finance representative as soon as possible. The committee duly noted the KHP Clinical Trials Office Review. 11. Item for discussion HRA update streamlining CAG approval processes JL provided an update for the committee on the HRA approval process. The process will be in place from 1 st April following a phased roll-out. The approval process will require essentially the same documents with the addition of the statement of activities and the schedule of events. Costings will be more transparent for CAGs. The expectation is that separate application forms will not be used for each CAG and that all the necessary information will be provided up-front by the study teams for multi-centre trials. The R&D office has arranged training sessions for researchers on the new approval process. The committee duly noted the update. 12. Item for discussion R&D office staffing update The committee noted the changes in R&D office staff Farzena Khanom: R&D Administrator 30 of 188

31 Item Business Item Carol Cooley: Research Governance Facilitator There will be an additional KCL-funded Research Governance Facilitator starting from early April. Action by 13 Item for discussion R&D Directorship Arrangement The committee noted that TC will be retiring at the end of June this year. Expressions of interest in the role of R&D Director should be sent to Martin Baggaley before end of March. 10. Date of next meetings TBC 31 of 188

32 TRUST BOARD OF DIRECTORS SUMMARY REPORT C Date of Board meeting: 29 November 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance) Authors: Approved by: (name of Exec Member) Presented by: SWL and SEL STPs Strategy Altaf Kara (cover sheet) Matthew Patrick, Chief Executive Altaf Kara, Director Strategy and Commercial Purpose of the report: To allow the Board to discuss submission and next steps regarding our STPs. Recommendations to the Board: To note the STPs have been submitted to NHS England for SWL and SEL and have now been published. To publicly endorse the documents (previously discussed at the previous P2 meeting). To authorise the development of timescales for implementation. To develop an associated communications plan for the Trust. Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: Relates to the strategic risk of Failure to deliver a fit for purpose strategy for the organisation (Currently moderate assurance; aiming for high when strategy is completed), and Financial strategy risk (currently moderate assurance). In both cases the impact of the STP is as yet indeterminate. Summary of Financial and Legal Implications: Current financial modelling proposes SLaM achieves its current control total for FY and forecasts achievement of proposed control totals as inputs for FY17-18 and FY Equality & Diversity and Public & Patient Involvement Implications: There are no equality and diversity implications yet as delivery plans are insufficiently detailed. Service Quality Implications: STPs are intended to deliver the same or higher quality services at lower cost but there is insufficient implementation detail to verify at this point. 32 of 188

33 TRUST BOARD OF DIRECTORS SUMMARY REPORT D Date of Board meeting: 29 November 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance) Author: Approved by: (name of Exec Member) Presented by: Digital Services Update Report Strategy Stephen Docherty & Murat Soncul Gus Heafield Stephen Docherty & Murat Soncul Purpose of the report: To inform the Board of the progress of the IT Department since the IT Strategy was agreed in March 2015 Recommendations to the Board: To make note of progress against the IT Strategy and to bring two elements to the attention of the Board for Cyber Security & Disaster Recovery (in relation to data loss) Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: One item on Assurance Framework. Principal Risk: Failure to deliver improvements in the collection of information, communication and technology (ICT) and decision support and act on it An update will be provided regarding the protection of our data and progress of specific programmes related to this. Summary of Financial and Legal Implications: No implications. Equality & Diversity and Public & Patient Involvement Implications: Considered but there are no specific implications. Service Quality Implications: Staff are being provided with access to enterprise tools such as Office365 and associated online collaboration tools, old equipment is continually being replaced with a mix of PCs, Laptops & Tablets, all of which will allow Trust staff to become more mobile, more efficient, and therefore able to deliver better services. The IT Service overall, is transforming in order to provide a professional, innovative function for the Trust. Additionally, a number of programmes will deliver new services for the Trust such as Business Intelligence (and data visualisation), epjs Mobile App and increased internet bandwidth (managed service) as we fully utilise cloud services. Page 1 of 1 33 of 188

34 Digital Services Update Update to the Trust Board 29 November 2016 Stephen Docherty Chief Information Officer 34 of 188

35 Setting context This report is aimed at providing the Trust Board with an update on the progress of SLaM Digital Services (formerly ICT). It should be noted that the Trust Board was presented with and agreed to the IT Strategy back in March The IT Strategy set out a direction and the need for a number of programmes that would be undertaken to transform IT Services over a 24-month period. 35 of 188

36 Projects Progress so far (%) Comments Progress Office 365 Device replacement IT Restructure Digital brand All staff migrated to O365 Completed, over 2,000 aged devices replaced Completed, now engaged in Trust-wide review Completed Wi Fi 70% Wi Fi coverage, update in Appendix 1 Balanced Scorecard BI Platform epjs external hosting epjs mobile app eobs CRIS/CDLS Healthlocker 10% 30% 30% 30% 70% 100% 100% 100% 100% 100% 100% Service trends for the last 16 months. Appendix2 Final phase, build resilience & performance test Contract signed, environment being built Pilot underway using ipads Pilot underway in 2 wards using Miocare devices Completed, service model implemented Contract signed, development in progress 36 of 188

37 Digitising the workforce PITstops Flightdecks Mobile Working Programme 25 have taken place so far Over 300 staff in attendance Engineer walkarounds at each attended site 6 more sites scheduled to end of 2016 More dates to be scheduled in 2017 One session held to date 12 Staff attended (Poor Communications) Bethlem and Lambeth are planned before end of March 2017 Good positive feedback from attendees SLaM Digital Services are providing technology enablement for the Trust mobile working programme. This includes provision of appropriate technology and epjs re-design, which will support operational change and transformation as described by the programme. 37 of 188

38 Planned Services Infrastructure New VPN Service for external devices New Remote Working Solution for Trust issued devices Technology Refresh (network/storage) Communications and Connectivity New Government Secure Network Wi Fi distribution for KHP Increased managed internet capacity Clinical Systems epjs mobile app Integration of clinical decision support for care pathways Local Care Record Service Management New Service Management Platform (Service Desk) Azure Cloud (BI/Data storage) Slough Datacentres (hosting services) Back-up and Disaster Recovery as a Service Enhanced Cyber Detection Managed Firewall Service Managed Telephony ecorrespondence Integration EPMA Solution ereferrals eobs Programme Management Online project tracking and collaboration tool Information Governance Cyber Security Assurance Clearance House Model (Cloud Services) IG Communications Plan IT Risk Dashboard Privacy Impact Dashboard 38 of 188

39 Current Priorities Although Digital Services have a number of priorities and workstreams inflight, it was felt necessary to bring two specific areas into focus for the Trust Board. In light of recent events and specific items in the media, the number of organisations suffering cyber attacks is increasing, whilst colleagues at KCL suffered a severe disruption to IT systems as a result of hardware failures. The next few pages will inform the Trust Board on the specific programmes that Digital Services have undertaken over the last 12 months with respect to Cybersecurity & Disaster Recovery (data backups). 39 of 188

40 Cyber Security Murat Soncul Head of Information Governance 40 of 188

41 Cyber Security Framework EU GDPR 28 May 2018 UK Government Cabinet Office 10 Steps to Cyber Security NHS Digital Cyber Security Services National Cyber Security Centre (NCSC) of the GCHQ National Cyber Security Strategy billion investment There will always be attempts to exploit weaknesses to launch cyber attacks. This threat cannot be eliminated completely, but the risk can be greatly reduced to a level that allows society to continue to prosper, and benefit from the huge opportunities that digital technology brings. 41 of 188

42 SLaM Cyber Security Programme 42 of 188

43 Acquired Specialist Skills The Healthcare Information Security and Privacy Practitioner SLaM Digital Services secured a position in the national pilot in 2015, which has led to the NHS Digital national professional network. IT Transformation Programme Digital Services management and governance structures have been reviewed in line with the latest IT Strategy, which led to the development of: Education and Training IT Operating Model, IT Risk Assurance Framework, Management of Data Assets and Data Flows, Assurance and Privacy focused expertise Professional Network Engagement CareCERT & CareCERT React SLaM is an early adopter Professional support, advice, guidance and real time updates from central cyber security resources in NHS Digital National Cyber Security Centre Weekly threat reports and cross-sector notifications 43 of 188

44 Workforce Awareness (implemented) IG Communications Plan A programme of brief and clear guidance on cyber security, data protection and digital privacy (Appendix 5). Education and Training - E-Booklets: Guidance on scams, phishing, baiting and Whaling (for Senior Management) - Regular cyber threat updates on known threats (Intranet/Yammer) - Cloud Security Training: Introductory training session on O365 security as part of IT Flightdeck sessions - Classroom IG Training: Induction and annual mandatory training refresher sessions - Amber Light Bulletins: Learning lessons from incidents - IT Bulletin and SLaM enews 44 of 188

45 IT Risk Assurance Framework IT Risk Dashboard Monthly overview of IT related risk (appendix 4) Clearance House Model Process for risk mitigation for secure data management on the cloud Privacy-by- Design Privacy Impact Assessments Risk assessment with focus on online security and digital privacy. Secure Data Flow Mapping Review of data flows to mitigate associated risk Register of Information Assets Monitoring of data assets and data security controls Responsibility and Accountability Governance structures with clear accountability structure and staff who are aware of their roles and responsibilities 45 of 188

46 Work in progress Spam filtering (50,000 more spam caught by SLaM Digital since the intelligence developed over phishing incidents over 1 week) Clear, concise and simple data security policies Public awareness of cloud and digital technology Engagement with health and social care partners for regional cyber action Digital tech reviews in the IT assurance programme (e.g. cyber security drills, hack days, PEN testing etc) White chalk days Weekly operational cyber security group Monthly information security committee chaired by CIO 46 of 188

47 Disaster Recovery and Backup Daily, Monthly and Yearly back-ups, recovered from tape/disk. Services are categorised dependent on Recovery Point Objectives and scheduled as above. Scheduled, 31 st Nov / 1 st Dec, tape based disaster recovery (DR) test and results to be presented at the Emergency Planning Group in Jan DR test is based on a total loss of SLaM IT infrastructure. This involves the recovery of services to a remote location provided as part of the DR contract. The test process will inform the overall recovery process for the Trust and the recovery of its systems. Monthly random section selection integrity tape tests Backup Policy has been updated and to be presented to IT Ops for sign-off 21 st Nov Data replication in the cloud, up to 3 locations 90-day retention in the cloud, on deleted files (note: all users receive 1TB storage) OneDrive and Share Point online supports the above statement Investigating enhanced enterprise archive solution Assurance epjs recoverable from tape/disk: complete weekly restore of epjs DB for BI. 47 of 188

48 External Focus STP / LDR: With the recent submissions & publication of the STPs, SLaM Digital Services have had significant involvement in the Local Digital Roadmap (LDR) activity Mental Health CIOs: We regularly host the CIOs from the mental health Trusts in London and the next meeting in December will discuss areas for collaboration and synergy Shared Services: Our Out-of-hours and Weekend Switchboard is now provided by WLMHT. South London Partnership: We have had preliminary conversations with Oxleas & SWLSTG and will look for areas of collaboration and synergy for IT Services London CIO Council: SLaM CIO is the recently-appointed Chairman of the group, a collective of IT Leaders across London NHS providers KHP Informatics: We are working with our colleagues to develop our analytics capability to deliver insight and benefit for population health management (concept phase) 48 of 188

49 Appendix 1 Wi Fi coverage 49 of 188

50 Appendix 2 Balanced Business Scorecard 50 of 188

51 Appendix 3 IT Risk Assurance 51 of 188

52 Appendix 4 IT Risk Dashboard 52 of 188

53 Appendix 5 Cyber awareness resources 53 of 188

54 TRUST BOARD OF DIRECTORS SUMMARY REPORT E Date of Board meeting: 29 th November 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance) Author: Approved by: (name of Exec Member) Presented by: Quality Improvement Programme Quality Helen O Kelly Michael Holland/Neil Brimblecombe Michael Holland/Neil Brimblecombe Purpose of the report: This paper is a summary update to the Board on progress with the QI programme. Recommendations to the Board: The Board is asked to note progress with the QI programme. Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: Summary of Financial and Legal Implications: No new implications Equality & Diversity and Public & Patient Involvement Implications: Consideration of equality and diversity will be considered as part of projects taken forward as part of the quality improvement programme. The programme will encourage use of the principles of coproduction to engage service users, carers and families. Service Quality Implications: The intended impact of the programme is to improve outcomes for people using our services, and to improve the quality of our services. 54 of 188

55 Quality Improvement Programme plan: Board paper Summary This paper is a summary update to the Board on progress with the QI programme. Introduction Our vision is to create and sustain a culture with continuous quality improvement. We aim to become an organisation with a culture of improvement that is based on service users, carers, staff and key partners working together to improve the delivery of care to deliver the outcomes that matter to people using our services, and carers and families. We have undertaken a procurement to contract a partner to help us deliver a trust wide quality improvement programme to achieve this vision over the next three years, embedding this culture in our organisation permanently and ensuring value for money in everything we do. The partner will support us to deliver a programme that will be service user focused, flexible in delivery and provide economies through standardisation of our methods and continuous efficiency improvement. Update on progress Objective Description High level actions: progress Building a culture of Using the model for improvement which will continuous involve training at all December. improvement levels in one improvement Being transparent to methodology Modeled by leadership at all levels of the organisation and across boundaries to achieve constancy of purpose Confident staff, who feel they have permission to act to improve outcomes, working with people who use our services Making space for improvement by: Fix some basics that are distracting frontline staff Consider what activity of lower value can be stopped to make room for teams to take on improvement Development of data to drive clinical decisions, Leadership workshop: held in July for the Board and executive team. This is to be repeated in Improvement Science in Action (ISIA) aimed at frontline staff leading QI projects began in September with 80 people attending the course and approximately 40 projects now under way. These cover a wide range of project ideas, such as nurse handover, supporting patients to improve physical health, reducing restrictive practice, supporting carers and patient experience. Next steps will be to develop further training; including working with the Recovery College for all staff and people who use services. The QI team have been running a campaign, Your time matters for staff to come up with ideas of things that they could stop doing. This has prompted a range of suggestions for improvement projects and also examples staff have already implemented that they want to share with other. Data dashboards that are used by staff to monitor impact and drive improvements in 55 of 188

56 enable the organisation and improve Improving and reducing variation in care and treatment Building a culture of inclusion and engagement for staff and people using services relevant to clinicians and people who use our services, at team level and scalable to enable Trustwide accountability Reduce variations between team and clinicians and their practices, into a single best practice Developing a Trust way to do things underpinned by value methodology Build will and belief through early engagement of staff Use principles of coproduction to engage service users, carers and families Use stories of improvements to encourage and inspire others direct patient care: under development The adult mental health pathway will be the focus for the first large scale improvement project Existing programmes to reduce violence on the inpatient wards and electronic observations will be rolled out with QI methodology and oversight within this programme 40 team level QI projects are under way from the first wave of QI training in September, with the ability to spread this learning (of successes and failures) to teams across the Trust. The second wave of training in February will see a further set of project set in train Comprehensive communications activity is now underway with a newsletter and intranet site in place. Both are used to share information about the programme and learning to date. A website is planned. The QI team have engaged with over 1000 staff, service users and carers in the first six months in events, attending meetings and drop in sessions. This has provided an opportunity to introduce the programme and its aim, recruit people to attend QI training and use in their work, and to reflect and adapt the programme from what we have heard. Risks Risk Developing the systems to support quality improvement, particularly to enable data for learning. Context of the organisation multiple change programmes with different objectives Ability of staff to engage affected by morale, turnover, staffing levels and wariness of new initiatives Mitigation A statistician has been being recruited to the team. Options are being considered for data analytics support as this has been difficult to recruit to. Close working with Business and Intelligence and Biomedical Research Centre Communications strategy for both QI programme and transformation programmes reflect nuance. Impact of communication activity by QI team is starting to have an impact, which will grow as more people are involved in QI projects. Consistent messages from senior leaders re longevity of programme 56 of 188

57 TRUST BOARD SUMMARY REPORT F Date of Board meeting: 29 November 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance, Information) Author: Approved by: (name of Exec Member) Presented by: Homicide Review Quality Lucy Stubbings, Head of Patient Safety and Abigail Fox-Jaeger, Trust Investigation Facilitator Neil Brimblecombe, Executive Director and Julie Hollyman, Non-Executive Director Neil Brimblecombe Purpose of the report: To inform the Trust Board of the thematic review that was commissioned as part of the Trust s mortality review strategy and was undertaken by the patient safety team. The review was presented at the QSC on 14 July 2016 and has been amended in line with the committee s feedback. Action required: For review by the Trust Board Recommendations to the Board: To note the report and support identified actions, for dissemination of learning across the Trust. Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: This report relates to the following areas of the Assurance Framework: 1) Safety of patients, staff and public Low assurance 2) Failure to provide services in line with best practice Moderate assurance Summary of Financial and Legal Implications: The report highlights areas of potential risk which may result in litigation and affect the Trust financially. Equality & Diversity and Public & Patient Involvement Implications: As part of the management of investigations across the Trust the implications for patients, carers and others are considered. Where there may be a specific impact on these groups this is managed during the course of the investigation. Service Quality Implications: Learning from serious incidents will reduce future risks in services. Page 1 of of 188

58 1.0 Introduction Homicide Review This thematic review was commissioned as part of the Trust s mortality review strategy and was undertaken by the patient safety team. Homicides although rare are always tragic and have a prolonged and devastating impact on those involved. This review aims to establish whether there are any patterns of homicides across the Trust, what learning needs to take lace and what further actions are required, additional to those already established for each case. 2.0 Background SLaM provides mental health services primarily across four boroughs, as well as providing regional and national services. On average the Trust sees 57,890 patients a year, with an additional 24, 680 through IAPT services. The four core Boroughs that the Trust services have some of the highest overall homicide rates amongst all London Boroughs. Investigation processes The Trust has a clear process for the investigation of homicides linked to our services as outlined in the Serious Incident Framework (NHS England 2015). In the event of a homicide where an alleged offender has had contact with our services within the three months prior to the incident, a Board Level Inquiry process is established. In this a Board member oversees the investigation, sets the terms of reference and challenges and finally agrees the recommendations arising. Before finalisation, the reports go to the relevant CCGs and NHS England who offer critiques of the report which helps to ensure the robustness of the final report, the general recommendations from which are then reported onto the Quality Sub Committee and the Board itself (as well as being considered within the relevant CAG or CAGs). The Trust will engage in any concurrent review processes such as Domestic Homicide Reviews and Serious Case Reviews where these take place. In line with police guidance the Trust will engage with those affected to offer apologies under Duty of Candour, on-going support, updates on the investigation and feedback on learning. NHS England may also commission external homicide reviews, although these commonly take place sometime after the end of any court proceedings. A decision is made by NHS England based on a number of factors including the Trusts own SI investigation report and outcomes from the court case. The outcomes of any external investigations are subsequently published. Data The data was drawn from offences committed between 1 January 2011 to 30 June 2016 by one or more persons who were in receipt of services from SLaM at the time of the offence or had been discharged in the previous three months. For the purposes of this report these people will be referred to as offenders. 3.0 National Mental Health Homicide Data The graph below is the safety scorecard relating to SlaM which indicates that the homicide rate for the Trust falls into the average quintile (based on data) compared to other mental health trusts in England. It is important to note that this analysis has not been risk adjusted for the population. It is likely that there will further national benchmarking available in the future. Page 2 of of 188

59 Table 1 NciSH scorecard relating to homicide from in June 2015 (Trial) SlaM Homicide rate The homicide rate was 0.3 (per 10,000 mental health contacts*) between and in the average quintile group compared to other mental health providers in England All data reported by trusts in England was categorised into 5 equal groups (quintiles) and show the range of actual results across the country. SlaM is placed at the high limit of the Average quintile for the period 2011 to Contacts* represent patient episodes in the prior 12 months. 4.0 Methodology The Trust data sample comprised 22 offenders who had been convicted in relation to 20 offences of manslaughter or murder between January 2011 and June SlaM service users were arrested and charged with murder during this period in relation to twenty three homicides. Three offences were excluded because 1) the service user was found not guilty at trial or 2) the offenders (x2) had been referred to the Trust and offered appointments but were never seen. Therefore this review focused on twenty offences committed by 22 people who were in receipt of services at the time of the offence. There is one further case where the Coroner brought in a verdict of suicide and unlawful killing, this case is referred to at 8.0 below. Of our patients convicted of homicide 50% were found guilty of murder, and 50% found guilty of manslaughter on grounds of diminished responsibility. Of those convicted of murder any mental health issues that they were suffering from were not found by the Court to have been a significant factor that lead to the victims death. Criteria: demographics clinical care, the nature of the incident, investigation recommendations internal/external blockages to implementation of action plans Sources of Information: epjs Datix DHR and Independent reports External media reports Benchmarking information from Niche thematic review of Independent homicide investigations ONS data Page 3 of of 188

60 5.0 Sentencing and convictions Table 2 Services by conviction Murder 10 A&E Mental Health Liaison Service, KCH 1 Assessment & Treatment Service, Tamworth Road (Croydon East) 1 Child & Adolescent Targeted Service (Croydon), Christopher Wren House 1 Drug and Alcohol Team, Blackfriars (Southwark North) 1 Drug And Alcohol Service (Bexley) 2 Lambeth CAMHS YOS 1 Northover (Lewisham) ABT - MAPD 1 Psychosis Promoting Recovery Team - Lewisham Neighbourhood 2, 62 Speedwell St 1 Psychotherapy, STT 1 s37/ Southbrook Road 1 Assessment & Treatment Service, Tamworth Road (Croydon East) 1 Clare Ward, Ladywell Unit (Locality Ward) 1 Mental Health Liason Service - St Thomas' 1 Northover (Lewisham) ABT - MAPD 1 Northover CMHT 1 Psychosis Community Service (Lambeth South), 380 Streatham Road 1 Psychosis Community Service (West Croydon),Tamworth Road (Was based at W/Ways) 1 Queens Res. Centre - Early Intervention Service - Croydon (COAST) 1 Wandsworth Prison 1 The majority of offenders who received a murder conviction were either recent presentations to crisis services, such as A&E or involved with Drug and Alcohol services. The mental health disposals were largely in receipt of secondary mental health services under Psychosis and MAP CAGs. Figure 1 Sentence by Year of Offence Half of the offenders were found guilty of murder, suggesting that any mental health issues that they were suffering from were not found by the Court to have been a significant factor that lead to the victims death,.while the remainder were convicted of manslaughter on the grounds of diminished responsibility. The latter were sentenced under the Mental Health Act [s37/41] with the exception of one offender who was given a life sentence because his mental disorder was not considered to be treatable. The frequency of offences year by year was found to be variable as were the convictions Page 4 of of 188

61 and sentences. The number of offences reviewed limits the ability to analyse any potential trends further. The highest yearly incidence was recorded in In 2012 there was a reduction in murder convictions with the same number of manslaughter convictions. The lowest number of offences were committed in 2013 this subsequently increased in 2014 with a three- fold increase in murder convictions. In 2015 the picture changed with an increase in manslaughter convictions with mental health disposals. 6.0 The Offenders Figure 2 Age and gender of offender at the time of the offence The majority of offences were committed by males (80%). Two young people were convicted of murder while adult offenders were predominantly in age ranges % [8] and % [9]. No one over the age of 50 was convicted of an offence Table 3 Spread across the Trust/CAG/CCG/ and day of the week Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total Add 3 3 Bexley 2 2 Southwark 1 1 BDP 1 1 Wandsworth 1 1 CAMHS Croydon 1 1 Lambeth 1 1 MAP Croydon Lambeth 1 1 Lewisham Pmed Lambeth 1 1 Southwark 1 1 Psychosis Croydon Lambeth 1 1 Lewisham Total The above table refers to the borough (location) of the service. The peak day of offence is Wednesday, which implies there is not a direct correlation with the availability of mental health services at weekends. MAP and Psychosis CAGs reported the highest incidence (6). The area where the highest number of incidents occurred was Lewisham. It was noted that only in two cases did the area in which the client was receiving care differ from the area in which the offence was committed. Page 5 of of 188

62 Figure 3 Offender s diagnosis at the time of the offence 33% had not received a diagnosis before the offence was committed. This was due to a variety of factors: they were under CAMHS services; had only been seen in A&E or had recently been referred to secondary mental health service. Where the victim was unknown to the offender 50% already had or were later given a diagnosis of paranoid schizophrenia Table 4 Service and months spent under that care of services Length of Patient episode Number of Patients Figure 4 Ethnicity Ethnicity of all offenders Ethnicity of offenders receiving a mental health disposal 8 of the 22 offenders were white British, of these 2 received a mental health disposal while the remaining 6 were convicted of murder. Page 6 of of 188

63 7.0 The Victims Table 5 Relationship of Victim to Offender and gender Relationship Male Female Associates 4 1 Cellmate 1 - Ex-partner - 2 Girlfriend - 2 Husband 1 - Mother - 2 Wife - 1 Unknown (robbery) 1 1 Unknown 4 TOTAL 11 9 In comparison with Office of National Statistics [ONS] data where 21% of victims were unknown to the offender, the SlaM review has shown 30% of the victims were unknown to the offender. The majority, 40%, of victims were in a domestic relationship with the offender e.g. wife, mother, partner. This is lower than the ONS data where around 60% of victims were in a domestic relationship with the offender. Since numbers are small statistically, these differences may not be significant. Figure 5 Relationship of victim to principal suspect by sex of victim, year ending March 2015 (England and Wales) Source: Homicide Index, Home Office 1 35% of SlaM cases were subject to Domestic Homicide Reviews. Not all review reports have been published at the time of writing. Within these cases there were 2 additional assaults during the offence and the victims were female relatives. 8.0 Unlawful killing of a child The Trust investigated one incident of suicide where the patient s child also died as a result of the patient s actions. This was subject to a Board level inquiry, Serious Case Review and 1 nces/yearendingmarch2015/chapter2homicide#relationship-between-victim-and-principal-suspect Page 7 of of 188

64 is currently undergoing an NHS England commissioned independent homicide investigation. The Coroner s inquest verdict for the patient was suicide and for her child was unlawful killing. 9.0 Themes from Investigation/Recommendations Figure 6 Themes from Investigation/Recommendations The 47 recommendation made in the internal reports were themed and grouped in the chart above. Top Three Recommendations from 20 internal Sis from SlaM Homicides (from 2011) 1.0 Operational Policy(23%) 2.0 Domestic Violence Understanding and Policy (Policies/Guidelines and Implementations (18%) 3.0 Interagency working (13%) The finding are broadly consistent with a review of independent investigations (not specific to SlaM) undertaken by Niche Niche thematic review of homicides 2 review of 78 recommendations from reports on 9 homicides (from 2012) 1.0 Communication (19) with Primary care, prison, probation, internal (between teams within organisation) 2.0 Policy Management (13) Local and 8rustwide policy development assurance systems 3.0 Practice/Risk (13) Risk assessment/management standards, documentation and information sharing. 2 Page 8 of of 188

65 4.0 Training(9) 5.0 Organisational learning(7) 6.0 Contact with families (7) 7.0 Misc (6) 8.0 Pathway development (4) 2.0 Progress on the action plans and/or blockages to implementation. To provide assurance that both recent and current actions arising from investigations had been completed, a review of evidence of completion was completed. Table 6 Action Plan Implementation CAG/ Year Addictions none WEB3208 none none WEB41588 WEB5714 B&D none none none none WEB34721 CAMHS DW28226 none WEB15912 none none MAP DW26123 WEB7835 WEB10414 WEB none Psychosis DW29849 DW37755 WEB8285 WEB22339 WEB36823 DW33890 WEB29811 DW Psychological Medicine DW25258 WEB2781 WEB14078 none none No Trust actions identified Domestic Homicide Review/ Serious Case Review All actions complete NHS England Independent Investigation Actions in progress Investigation notified and led by another NHS Trust Historical DHR led by partner agency 1 DHR published on 16/11/2016 on Lewisham LA website 2 WEB24550 includes actions for the on-going improvement of the epjs system. These actions are in progress as part of the programme of development for the system Conclusions data The peak day of offence is Wednesday. Although not definitive, this does not suggest a relationship between offences and an immediate lack of availability of clinical services. Court verdicts indicate that mental health issues were not found to have been a significant factor that lead to the victims death in 50% of cases. In comparison with Office of National Statistics [ONS] data where 21% of victims were unknown to the offender, the SlaM review has shown 30% of the victims were unknown to the offender. This is unlikely to be a statistically significant variation Page 9 of of 188

66 The majority, 40%, of victims were in a domestic relationship with the offender eg wife, mother, partner. This is lower than the ONS data where around 60% of victims were in a domestic relationship with the offender. A range of diagnoses were recorded at the time of the incident, however over a third had not received a diagnosis before the offence was committed. This was due to several factors such as: they were under CAMHS services; had only been seen in A&E or had recently been referred to secondary mental health service. The variance within relatively small numbers (compared to the whole population of service users) makes finding patterns in data between incidents generally difficult to interpret 11.0 Further Actions With every single death, it is vital that the Trust continues to ensure a thorough investigation and prompt delivery of the action plan. More generally, the Trust is also taking forward the following actions: 1. A full review has taken place of the involving of carers and significant others in the process of investigation to facilitate the Duty of Candour and to ensure that their voice is heard in the process. The final policy is near ratification 2. Annual reviews of Homicides will be instigated (in the context of other Serious Incidents and learning from other Trusts) to ensure that any patterns or common features are understood over time 3. Improving the recognition of the risk of being a victim of violent crime. The Trust s Domestic Abuse policy has recently been revised and as a result there is on-going work across the Trust to improve staff awareness and improve safeguarding for potential victims. 4. The Trust s Policy Working Group will review the process for development and sign off of local operating procedures across the Trust to ensure that production, there is a uniform and robust process within each of the CAGs. 5. When NHS England publishes an independent homicide investigation for any other Trust, SLaM will review the recommendations and actions for applicable learning. Any learning will be reported via the Lessons Learned report 6. There are a number of Domestic Homicide Reviews awaiting publication which will be reviewed on publication 7. Further work will be undertaken to examine Serious Incidents where the patient has no given diagnosis at the time of the incident, with a view to understanding the effect that this may have on the risk assessment process and whether any different approach is required. Page 10 of of 188

67 TRUST BOARD OF DIRECTORS SUMMARY REPORT Date of Board meeting: 29 November 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance) Author: Approved by: (name of Exec Member) Presented by: Performance Report Performance Martin Black, Performance & Contracts Kristin Dominy, Chief Operating Officer Kristin Dominy, Chief Operating Officer Purpose of the report: To report the Trust s performance against a range of key national indicators and identify and analyse under-performance and report action plans. The report also summarises the Performance Management Framework review meetings and identifies any major areas of learning and success. Recommendations to the Board: To approve the report noting the key performance issues, highlighted risks and remedial actions. Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: The Performance Framework is an operational control with an assurance level of moderate. Summary of Financial and Legal Implications: These are specified where relevant in the report. Equality & Diversity and Public & Patient Involvement Implications: The report identifies performance and activity issues that if not resolved may have implications on the Trust s ability to deliver its equality, diversity and patient involvement commitments as set out in the Annual Plan. Service Quality Implications: The report identifies performance and activity issues that if not resolved may have implications on the Trust s ability to deliver its quality commitments as set out in the Annual Plan of 188

68 PERFORMANCE REPORT: September 2016 and provisional October 2016 NHSI Indicators Executive Summary The report summarises the Trust s Performance Management Framework, identifies key issues and actions arising from the CAG Performance reviews for September and highlights risks and potential risks to performance. Quarter 2 performance in relation to NHS Improvement Indicators was reported to the Board on 1 November A brief summary is included here for reference. In-patient activity is being monitored closely and overspill reported weekly. The most recent performance is contained within the Finance report. Following agreement with the Board, the Transformation Dashboard detailing progress of key corporate programmes is now incorporated within this report. Contents: 1. Performance against NHS Improvement indicators 2. CAG Performance Reviews Summary 3. Safer Staffing 4. Commissioning and Contracts (including CQUIN) 5. Adult Benchmarking 6. Programme Management Office 7. Social Care 8. Key Corporate Programmes 9. Emergency Planning and Business Continuity 10. Conclusion The following Appendices are included: Appendix A: PMF Trust Summary Appendix B: QSC Quality Dashboard Appendix C: Safer Staffing: Ward Level Detail 2 68 of 188

69 1. NHS Improvement indicators: October Provisional Performance The Trust s provisional performance for October is outlined in the table below. Where a new indicator has been included in the Single Oversight Framework the available performance is reported, where possible, to provide a baseline indication for achievement against the Quarter 3 standard. Table 1: NHSI Indicators Summary Table Target Q1 Q2 Oct (Prov.) 1 IAPT Waiting Times 6 Week Standard 75% 90.7% 90.4% 90.1% 2 IAPT Waiting Times 18 Week Standard 95% 99.4% 99.3% 99.2% 3 IAPT Recovery Rate 50% % 47.3% 4 5 Early Intervention in Psychosis 2 week standard Admissions had access to crisis resolution / home treatment 50% 43.6% 71.3% 71.4% 95% 93.8% 93.1% 99.6% 6 CPA follow up within 7 days of discharge 95% 97.6% 97.0% 98.3% The following new indicators are included within the Single Oversight Framework, which came into effect from the 1 October Cardio-metabolic assessment and treatment for people with psychosis To be delivered routinely in the following service areas: i. Inpatient wards (Standard: 90%, Quarterly Achievement) ii. iii. Early intervention in psychosis services (Standard: 90%, Quarterly Achievement) Community mental health services (Care Programme Approach patients) (Standard: 65%, Quarterly Achievement) At present this indicator is to be assured by Board declaration. The national CQUIN on Physical Health in 2016/17 aligns to this measurement and could be used as supporting evidence of Board declarations. The development of reporting infrastructure and performance improvements in 2016/17 specified in the CQUIN is progressing well. Operational reports have been developed for a cohort of wards and community teams and this is being tested with CAGs and teams through the performance management framework process. Completeness Priority indicators (formerly outcomes) The Mental Health Services Data Set (MHSDS) submission has been adjusted and now comprises ethnicity, employment status (for adults only), school attendance (for CYP only), accommodation status (for adults only) and ICD10 coding. The standard is for 85% achievement by the end of 2016/ of 188

70 Risks Following failure to achieve the standards in Quarter 1 for Home Treatment Gatekeeping and Early Intervention recovery plans were developed and circulated to the Board in September for assurance. Progress against these plans is detailed below in the charts below. Charts 1 and 2: Performance against recovery trajectories Early Intervention in First Episode Psychosis The Early Intervention performance in Quarter 2 exceeded the Trust recovery trajectory and the 50% standard by a significant margin. The submission for October was made 19 November and performance continues to be above both the recovery trajectory and the standard. Commissioners were briefed at the 6-month review meeting on the risk of increasing caseloads in some boroughs and the potential impact on NICE guidance concordance based on the projected growth of caseloads against existing investments. Crisis Resolution / Home Treatment Team Gatekeeping The Home Treatment Gatekeeping indicator was not achieved in Quarter 2 but the target was exceeded in September. Following the implementation of the new 24-hour central triage function with embedded HTT, October performance was in excess of the threshold and close to 100%. This is the highest performance for this indicator in more than 18 months. Further HTT developments are planned for the autumn including: Increased focus on face to face assessments Standardised shift patterns Dedicated discharge co-ordination resources on all four hospital sites Standardised interface protocols with in-patient and community teams The following NHSI indicators also have associated risks: IAPT Waiting Time standards The risk to the IAPT access standards for Croydon patients continues as a result of the bridging work to meet the Croydon affordability gap. Work is underway within the Croydon Programme Management Board to define and agree the access target for the remainder of the financial year. The contract will end in March 2017 as part of the bridging work and the reduced service provision contains a degree of risk to the Trust s overall performance. IAPT Recovery Rate This indicator is included within the CCG Outcomes Framework and NHS Digital produces the official statistics for this measure. The most recent indicator of national performance is the July figure of 48.5% and internal reporting indicates that the Trust performance for Quarter 2 and October were both below the 50% national standard. Performance is improving and in October achieved 47.3% against the target of 50%. The recovery rates will continue to progress over the year as in previous years. A jointly agreed action plan is in place with Southwark CCG about improving the recovery rate of 188

71 Chart 3: IAPT Recovery Rate * The Trust result is based on all patients regardless of their responsible commissioner. MH Priority Indicators Mental Health Services Dataset (MHSDS) submissions extract tool Ver. 2.7 has been delivered by the AHC (epjs supplier); although there are quality issues identified which need to be jointly rectified. The Business Intelligence team is continuously testing the extract to identify and improve both the quality and accuracy of the dataset and the Trust has continued to liaise closely with NHS Digital over these issues, as completeness of data impacts on the accuracy of both published statistics and experimental statistics. 2. CAG Performance Reviews Summary: Month 6 This section summarises the main issues and remedial actions arising from the Operational Performance Reviews for September. The Performance Management Framework is comprised of Key Performance Indicators across: Finance (including cost improvements and cost reductions) Operations (workforce, activity and quality indicators) Patient and commissioner measures Learning and growth Key issues The main themes arising from the performance reviews were: Delivery of CIP programmes and mitigation schemes where slippage has occurred External overspill and acute inpatient care activity, focusing on length of stay Delayed transfers of care Home Treatment Team developments Agency expenditure Safer staffing Contracting challenges A brief summary of external overspill performance and delayed transfers of care is detailed below 5 71 of 188

72 External Overspill External overspill aligns closely to the Mental Health Five Year Forward View target and the Crisp report recommendation to eliminate out of area placements. Current performance against the September to December overspill trajectory to reduce external overspill is outlined in the chart below. The Trust trajectory is represented by the green segment, with actual performance represented by the black line and the exponential trend by the dotted line. The trajectory continues to assume 7 PICU patients remaining in private units from 1 January 2017 on an on-going basis. Chart 4: External overspill performance Delayed Transfers of Care (DTOC) This indicator is no longer included within the regulator s framework but continues to be an important measure for the Trust. October data is due for submission on 22 November to NHS England. There has been a significant increase in days lost due to delayed transfers of care in recent months and whilst this has been within the 7.5% threshold, it provides additional operational pressure on in-patient beds. The management and prevention of delayed transfers of care is forming a core component of activity planning with commissioners during the negotiation round, and a summit with Housing providers was held at the beginning of October to review potential options and models for delivery of housing support. 3. Safer Staffing (September) Twenty-one of the fifty two wards (40%) breached safer staffing levels in the month of September in comparison to twenty two in August. A summary of the reasons for these breaches is given below. Vacancies and Sickness Vacancies remain high in some wards as detailed in the September exception report. Where wards have 45% (or higher) vacancy rates for Registered Mental Health Nurses (RMNs), the Director of Nursing and Director of Human Resources meet with CAG directors and clinical services to discuss the reasons and review action plans. The sickness level and frequency on one particular ward is very high and is being addressed by the relevant CAG of 188

73 Recruitment The Bethlem recruitment open day saw 45 people visit the event and Human Resources are tracking the uptake of posts by those who attended. The Trust s Resourcing and Branding Manager is working closely with the Nursing Directorate and a plan is in place to attend job fairs in the coming months to promote the Trust and encourage additional applicants. Bank and Agency NHS Professionals (NHSP) attended the Bethlem Ward Manager and Team Leader event focusing on the advance booking of shifts wherever possible. This should be achievable when covering a vacancy although harder when a ward is covering sickness. Wards making bookings with only 24 hours notice make it less likely for the shifts to be filled by the NHSP Bank and can result in agency expenditure. The ward level exception report for September can be found in this report in Appendix C and includes information collated by the Nursing directorate on vacancy levels and the percentage of wards booking shifts with 24 hour or less notice. 4. Commissioning and Contracts Update Contracts Progress against the NHS England planning timeframe to sign two-year contracts spanning in December 2016 is on schedule. The reduced timescale and longer duration of the contracts have intensified this process and presents additional risks. The commissioning intention letters from Lambeth, Southwark, Lewisham and Croydon CCGs outlined a combined QIPP of 10 million. Currently, further clarity is being sought from commissioners to confirm there is not a proportion of QIPP that is a direct reduction in income, without corresponding efficiency savings or investment. The Trust has confirmed to commissioners that using QIPP schemes to reduce the funding envelope is a potential risk to service continuity when combined with 4-6% efficiency savings required next year. A key element of the contract negotiations has involved an active review of financing for the Implementation Plan for the Five Year Forward View Mental Health challenges. Key Contract Issues High levels of OBDs in the Adult pathway have continued and the forecast for the majority of CCGs will trigger risk share requirements to partially mitigate the higher than planned levels of activity. Commissioners have been notified and dialogue is on going. The trajectory for the Adult Acute CAG is being revised following increased engagement with commissioners around broader pathway management, encompassing housing and social care needs. Croydon The joint Croydon CCG and SLaM Programme Board has extended membership to the Local Authority and other key stakeholders and the priority is to work together to develop housing solutions to make a rapid impact on length of stay and occupied bed days. The financial risk of not meeting the full Croydon affordability bridge ( million) is now approximately 1 million, resulting from implementation delays. A Trust review of all Croydon teams has identified no further significant opportunities to recover this shortfall by March Alongside this, there has been an increase in payment disputes by Croydon CCG for high cost care, which is being evaluated and will be escalated for resolution. The Older Adult Outcomes Based Contract (OBC) has been delayed but remains on track for the revised contract date of December 2016 with implementation planned from April The Board will be kept informed of progress of 188

74 Southwark The contract variation for reconfiguring MHOA in-patient provision has been presented to Southwark CCG who in turn have requested further information. The Board will be kept informed of progress. Lewisham Acute OBD over-performance and the risk share impact is a key issue for the CCG. Lambeth The implications of the proposed Living Well Network Alliance are being reviewed to ensure risk is appropriately managed. Lambeth CCG are undertaking further work in the development of the Alliance and is exploring re-tendering options. Acute OBD overperformance and the risk share impact are also key issues. NHS England The main area of concern remains the 2016/17 contract plan to repatriate Forensic placement activity to deliver a 1 million QIPP through the value of the repatriated work being transferred to South London providers. The risk is that the repatriation will not happen and that the 1 million would be removed from the contract. NHS England have confirmed in writing that they expect the QIPP to be delivered in full which is not the Trust s understanding of the original agreement and clarification is being sought. 5. Adult Benchmarking 2015/16 The Adult Benchmarking results for 2015/16 (for registered population) were published by the NHS Benchmarking Club on 2 November 2016 and are detailed here. The weighted population results and toolkit will both be available in November. A brief summary of key indicators, national trends and the Trust s position is outlined below. The Trust is represented in each legend as MH09. Length of Stay At a national level, Adult Acute and Older Adult length of stay are now the longest they have been in the last 5 years, with Adult Acute rising to 33.4 days in 2015/16 compared to 32.3 days in 2014/15. The Trust s average length of stay in 2015/16 was higher than this at 40.5 days. The length of stay for people admitted under the Mental Health Act is longer, with the National average at 44.6 days and SLaM at 53.1 days. As shown below, the Trust has one of the higher percentages of people admitted under the Mental Health Act at 48.8% of 188

75 Occupancy National bed occupancy remains high at 94% with a target of 85% recommended by the Royal College of Psychiatrists. There has been a slight increase in the number of beds per registered population but this may be a reflection on Mental Health Trusts increasing internal bed capacity to reduce use of the private sector. Delayed Transfers of Care The Trust has higher than average delayed transfers of care, but was not an outlier. Diagnostic The Trust is involved in the LUMENS Diagnostic for Acute and Urgent Care services commissioned by the Cavendish Square Group. The diagnostic involves nine London Mental Health Trusts and is focused on reducing the pressure on beds by identifying current best practice and identifying recommendations for organisational change in relation to Reducing admissions Reducing Length of Stay The scope covers service provision, effectiveness of pathway processes and service interfaces. The eventual aim is to reduce occupancy over the next 5 years to the RC Psych recommendation of 85%, and to deliver improved quality of care, productivity increases and revenue efficiencies. The diagnostics will be presented to the Cavendish Square Executive group this calendar year. 6. Programme Management Office (PMO) Update The Chief Executive Officer (CEO) and a senior panel has conducted a programme of assurance reviews with CAGs, infrastructure support areas and Trust wide programmes, focusing on confirmation of the yearend financial position, actions regarding savings plans shortfalls and an analysis of cost centres indicating overspend. Programme outcomes include setting a non-pay savings policy and target, requests to re-plan budgets to achieve 9 75 of 188

76 earlier savings, a pilot project to re-baseline a CAG budget and costs centres, and the agreement of specific recovery plans and in year targets. Infrastructure programme The IT and Finance Departments entered formal consultation on 21 October 2016 with process scheduled for completion on 5 December 2016 and final plans to be published on 13 December The benefits plan has been under continuous review and an approach with supporting delivery plan for each project will be completed in November. As each project enters its delivery phase, there is increased scrutiny to ensure schemes are fully supported, that they can be delivered to the programme plan and that savings are not counted elsewhere. As this work is carried out it is resulting in adjustments and changes to scheme profiles. To manage non-pay costs, a new pay panel will convene over the coming weeks to implement and track adherence to the policy determined by the CEO assurance panel. Resource Management programme The London Procurement Partnership (LPP) Framework was agreed on the 31 October A key performance indicator dashboard is being developed with the Allocate team and roster reviews continue as planned. Senior Management Team (SMT) has asked the Human Resources function to develop a new initiative to control agency spend under a wider initiative to create sustainable workforce capacity within the Trust. Mobile Working A business case for the introduction of mobile working in community teams has been presented to the Portfolio Board. The project team is exploring alternative implementation plans with a view to reducing the project delivery timeframe to 12 months. Acute Care Pathway The new CAG operating model design is under development with a plan to achieve 2.4 million savings. Estates Management Estates work continues including an invitation to tender for the management of car parking facilities and charging has been issued and logistics work continues to vacate the Adamson Centre. Further detail is provided in Section 8 of this report. The PMO continues to track individual CAG savings schemes and recovery plans through Portfolio Delivery Steering Group governance. 7. Social Care Professional Social Work Social Work for Better Mental Health programme: a date to start the first sessions of the Social Work for Better Mental Health programme has been set for 29 th November Carer s Assessments A carer s Lead has been nominated from each CAG who will support improvement in performance in relation to carer s assessments, advice, information and support /crisis plans. The new carer s engagement and support plan is now in the test environment in epjs and is being piloted by nominated teams across the CAGs. At the end of November, the existing SLaM carer s assessment form will be deleted from epjs and all staff will be required to use the new engagement and support plan. The Director of Social Care presented progress on the Carer s Assessment Audit Action Plan to the Council of Governors Quality Working group on the 8 th November of 188

77 Central Place of Safety The draft Memorandum of Understanding has been circulated to the legal departments of each Local Authority and comments and legal advice has been received back from the majority. The Director of Social Care is co-ordinating the process and when legal comment is received back from all of the Local Authorities, the final draft Memorandum of Understanding will be circulated for final sign off. This has taken longer than expected but should be finalised by the end of November In the interim, the place of safety has opened for Southwark residents only, with the agreement of local partners and the Joint Health Overview and Scrutiny Committee. 8. Key Corporate Programmes (formally The Transformation Dashboard ) Following agreement with the Board, the Transformation Dashboard detailing progress of key corporate programmes is now incorporated within this report and detailed below. Workforce Sickness: At 4.91%, this represents a slight reduction on the previous month s results of 4.96%. Appraisals: 97.5% of staff in post at the beginning of April had their appraisal completed. CPN Usage: 91.2 whole time equivalents. Estates Reducing the number of community properties and related operating costs The intention is to achieve 20m of capital planned through asset disposal in 2016/17, although the forecast may be affected by the impact on the property market caused by the Referendum outcome in June. The Trust has commenced marketing properties starting with Inglemere, David Pitt House and Ann Moss Gatehouse, and discussion on the disposal option for Woodlands/Masters House is taking place. The disposal list was reviewed and updated on 25 October Capital projects achievement against plan 1. Anti-ligature programme: This programme has been completed. Window replacement work at Maudsley and Lambeth hospitals is in progress. 2. Work hubs: Work on BRH 1 hub is in progress. 3. ASCOM: Awaiting Trust decision to progress to phase 2 of ASCOM. Capital projects achievement against plan - Progress report 1. Douglas Bennett House (DBH): The suspension of the DBH programme is impacting on other minor schemes including the ward refresh programme and some planned clinical moves. The revised Estates strategy /Douglas Bennett refurbishment is being presented at the Board meeting on 29 November Adamson Centre: Neuro-psychiatry and the IPPT team moved out of Guys & St Thomas (GSTT) into Blackfriars Road on 26 October The Liaison teams will remain in The Adamson Centre and a meeting has been scheduled with GSTT to agree the accommodation they will require. The IAPT service in the Adamson Centre is planned to move to Stockwell Gardens but some enabling works will be required. 3. Jeanette Wallace House: The exchange of contracts is scheduled for the end of November 2016 with completion expected in January Centralised Place of Safety: The Central Place of Safety opened on 24 October 2016 for Southwark patients. 5. Refurbishment of Fitzmary 1 This is planned to support Croydon patient overspill. 6. Refurbishment of Norbury ward There is a plan to decant Forensic services of 188

78 Hotel Services Catering and Domestic Tender: Hotel Services and the Procurement Team are working on the specifications for the catering and domestic tender. Aramark: The Procurement Team has formally requested that Aramark extend the present contract to 30 April 2017 to allow the retendering process to take place. Hotel Services continue to work in partnership with Aramark. Car Parking at Maudsley and Lambeth Hospitals Procurement: The tender to provide a new Automatic Number Plate Recognition (ANPR) system to replace the existing controls was officially issued on 17 October 2016, but due to lack of interest in the tender by suppliers the submission date was put back to 11 November In order not to allow the timetable to slip the evaluation phase was reduced from 2 weeks to 1 week, meaning the presentations were still scheduled for 15 November 2016 and the date to decide on the award notification was Friday 18 November Consultation: The consultation document was issued on 25 October 2016 and will run until 30 November The key areas under consultation are whether fees should be increased for the first time since 2007 and whether users of the car park at Lambeth Hospital should be charged for parking in the same manner as users of the Maudsley Hospital car park. IT Transformation Update IT Pitstop: Further IT Pitstop events which give employees the opportunity to talk to IT service desk staff about their IT issues are underway. Due to positive feedback, additional days have been advertised. Telephony Project: This is underway and will replace the current telephony system with a cloud voice solution. The project is in implementation stage. IT Risk Review: The Information Governance Team have completed the IT Risk Review and implemented an updated register for IT related risks on the DATIX system. The new register introduced a framework for IT risk management, which incorporates key information assets, secure data flow mapping and a process to assess privacy impact of new projects, services, applications and information systems. Cyber Solution Action Plan: As part of the Cyber Security Action Plan, new guidance was published for staff to identify scams and phishing attacks. The IT Service published regular updates on the latest phishing attacks to alert staff. The Flightdeck workshops organised by IT include a session on cloud security to improve staff awareness. Office 365: The risk assessment of the Office 365 enterprise has been completed and the Information Security Committee are overseeing actions arising from the review recommendations. 9. Emergency Planning and Business Continuity Update Following the Trust s Business Continuity (BC) and EPRR (Emergency Preparedness, Resilience and Response) annual assurance process submission to NHSE (London) on the 14th September 2016, the Trust has received feedback and has been given an overall rating of 'non-compliant' in the 2016/17 assurance process. Following this assessment, an action plan outlining items highlighted by the review team has been submitted to NHSE (London). This action plan will form part of the 2016/17 EPRR work plan, which will be presented at the November meeting of the Emergency Preparedness Group meeting. The Assurance Review Team commended the organisation for continuing to progress in embedding areas of EPRR and Business Continuity within the organisation and they acknowledged the high level of work that has been completed in the context of external influences and continuing internal change, specifically in relation to commitment by the Trust to EPRR of 188

79 Areas outlined as key priorities for the next twelve months include the necessity to develop all business continuity plans to include a business impact analysis, the identification of critical functions, recovery time objectives and maximum tolerable periods of disruption. We also need to develop a Trust HazMat (Hazardous Materials) and CBRN (Chemical, Biological, Radiological, and Nuclear) plan, including identifying personnel for training in these areas and to further develop Lockdown plans. 10. Report Conclusion The Trust met the key NHS Improvement indicators with the exception of IAPT recovery rate. Acute In-patient care activity is forecast to be above contract indicative activity plans for the majority of CCGs and there is increasing commissioner engagement in improving the position. There is additional work on going within the Adult Acute Pathway to reduce the pressure. The contract activity planning with commissioners for is underway and on schedule for signing in December of 188

80 Glossary Abbreviation AEO ASCOM BC CAG CBRN CCG CIP CMHT CPA CPN CQC CQUIN CYP DATIX DTOC EI EPBC epjs EPM EPRR GSTT HTT IAPT ICD10 IPTT LA LPP LSLC MHOA MHSDS NHSE NHSEL Description Accountable Emergency Officer Alarm system Business Continuity Clinical Academic Group bring together clinical services, research and education and training into a single management grouping e.g. Psychosis Chemical, Biological, Radiological and Nuclear Clinical Commissioning Group an NHS body responsible for the planning and commissioning of health services for their local area Cost Improvement Programme Community Mental Health Team Care Programme Approach Community Psychiatric Nurse Care Quality Commission Commissioning for Quality and Innovation: A fund where payment is contingent on delivery on quality improvements and meeting milestones agreed with commissioners. Children & Young People Incident and adverse event reporting system Delayed Transfers of Care Early Intervention: First Episode Psychosis Emergency Planning and Business Continuity Electronic Patient Journey System: Clinical records system Emergency Planning Manager Emergency Preparedness, Resilience and Response Guys & ST Thomas NHS Foundation Trust Home Treatment Team Improving Access to Psychological Therapies Diagnosis coding: International Classification of Diseases (World Health Organisation). Currently iteration ICD10 Integrated Psychological Therapy teams Local Authority London Procurement Partnership Lambeth, Southwark, Lewisham & Croydon (CCGs) Mental Health of Older Adults Mental Health Services Data Set: National dataset submitted to NHS Digital (formerly known as the Health & Social Care Information Centre) NHS England NHS England London of 188

81 Abbreviation NHSI NHSP NICE OBD PICU PLACE PMF PMO POS / Section 136 QIPP RCPsych Section 75 SOF Description NHS Improvement: the new regulatory body overseeing all NHS providers as well as independent providers that provide NHS funded care NHS Professionals National Institute for Health and Care Excellence: provides national guidance and advice to improve health and social care Occupied Bed Day is a unit of currency used to measure the use made of a bed (e.g. 1 obd = 1 bed occupied for 1 day by a patient) Psychiatric Intensive Care Unit Patient led Assessments of the Care Environment Performance Management Framework Programme Management Office Place of Safety: Section 136 of the Mental Health Act allows for someone believed by the police to have a mental disorder, and who may cause harm to themselves or another, to be detained in a public place and taken to a safe place where a mental health assessment can be carried out. Quality, Innovation, Productivity and Prevention programme is a series of schemes required by the CCGs and developed with SLaM to help reduce the cost of services to the CCG Royal College of Psychiatrists: The professional body responsible for education and training, and setting and raising standards in psychiatry. Section 75 of the NHS Act 2006 (as amended), NHS Bodies and Local Authorities Partnership Arrangements: provision for local authorities and National Health Service (NHS) bodies to enter into partnership arrangements in relation to certain functions, where these are likely to lead to an improvement in the way the functions are exercised. Single Oversight Framework: NHSI assurance and performance mechanism of 188

82 Sep-16 Appendix A Performance Management Framework Trust Summary Finance & CIPs Please refer to Board Finance Report Please refer to Board Finance Report Workforce 2,500,000 Agency Cost (Phased NHSI Ceiling) Admin Vacancies, Bank & Agency WTE Usage 2,000, ,500, ,000, , Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M10 M11 M12 M1 M2 M3 M4 M5 M6 Spend Indicative Ceiling Value Admin NHSP Bank (WTE) Admin Agency (WTE) Admin & Clerical Vacancy (WTE) Safer Staffing: Wards Breaching 20% of shifts (YTD) Quality Priority to reduce to 10 wards Nursing Vacancies, Bank & Agency WTE Usage (YTD) Vacancy WTE Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 M10 M11 M12 M1 M2 M3 M4 M5 M6 Trust (total - out of 52) Nursing NHSP Bank (WTE) Nursing Agency (WTE) Nursing Vacancy (WTE) Sickness 6.00% 1 Annual Leave Planning -Annual RosterPerform Leave Data Planning (Excludes Doctors) Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep % 4.00% 3.00% 2.00% 1.00% 0.00% M10 M11 M12 M1 M2 M3 M4 M5 M6 Monthly Sickness (wte) Sickness Rolling Year % 0 Q1 Q2 Q3 Q4 Addictions BDP CAMHS MAP MHOAD Psych Med Psychosis Activity OBD Variance Against Monitor Plan (Latest) Days Lost 1,600 1,400 1,200 1, Jan-16 M10 Private Delayed Sector Overspill Discharges Average Days Patients LostPer Day Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 M11 M12 M1 M2 M3 M4 M5 Sep-16 M6 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% % Days Lost -700 Adult OBD Variance Medium Secure Low Secure OBD OBD Variance Variance CAMHS OBD Variance Older Adults OBDOther Category A Other Category B Variance OBD Variance OBD Variance MHOAD Days Lost Acute Days Lost Trust Days Lost Trust Delays % Days Lost Adult OBD Against Monitor Plan (excl. Private Overspill) Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 M10 M11 M12 M1 M2 M3 M4 M5 M6 Actual Plan 82 of 188

83 Sep-16 7 Day Follow Up (Target 95%) Appendix A Performance Management Framework Trust Summary NHS Improvement & Contract KPIs (Latest Month) CPA 12 Month review (Target 95% by End of Quarter) HTT Gatekeeping (Target 95%) Delayed Discharges Target Below 7.5% 9 6 1, Achieved Missed Patients with valid review Patients with overdue review 93.9% of patients followed up within 7 days of discharge 95.1% of patients had a CPA review within 12 months 97.3% of patients received an HTT assessment 6% of discharges delayed -2.5% variation to the previous month -0.3% variation to the previous quarter 8.1% variation to the previous month -0.3% variation to the previous month Early Intervention % within 2 weeks (completed Pathways by CCG) IAPT (6 weeks) Target 75% IAPT (18 weeks) Target 95% 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 96.6% 94.7% 50% 100.0% 99.6% 99.1% 97.6% 99.2% 89.8% 40% 80.5% 85.8% 40% 30% 30% 20% 20% 10% 10% 0% 0% Croydon Lambeth Lewisham Southwark Trust % % % % % 77% of patients received Psychosis treatment within 2 weeks 89.8% of patients completing treatment within 6 weeks 99.2% -2.5% variation to the previous month -2.3% variation to the previous month -0.1% 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Friends and Family Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 M10 M11 M12 M1 M2 M3 M4 M5 M % 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% % 88.6% Achieved Missed 91.5% 89.9% 85.2% 20,846 of patients completing treatment within 18 weeks variation to the previous month 89.5% 87.1% 87.4% Days Not Lost Days Lost 91.1% Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 M10 M11 M12 M1 M2 M3 M4 M5 M6 No. of FFT Responses FFT Score (%) Do you feel involved in your care? (%) QP Target % Learning and Growth Training Completions Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 M10 M11 M12 M1 M2 M3 M4 M5 M Number of Completions 83 of 188

84 QSC Quality Dashboard Period: September (M6) 2016 Circulation: QSC Circulation - FV for Approval Introduction The QSC Dashboard is presented for views and feedback from Quality Sub-Committee and Board members as to further developments. The key planned developments for the dashboard in 2016/17 are: Business Intelligence development on the new Power BI tool to allow drill down to CAG and Borough. Incorporation of development and learning arising from the QI programme. Benchmarking data will be drawn upon in line with publication and as indicated. The report is organised by the CQC Key Lines of Enquiry: Safe, Effective, Caring, Responsive and Well Led. The report will provide analysis and exception reporting as indicated. The report will also provide written updates on: The delivery of Commissioning Quality and Innovation (CQUINS) throughout the year. There will be regular updates on progress in meeting Quality Priorities and supporting activities (for instance Patient-led assessments of the care environment (PLACE) and the roll out of E-Observations across the wards). At present work is being undertaken in the development of interim monitoring reports for the following Quality Priorities: Carers Assessments and Full Risk Assessments (CPA patients) completed within policy timescales. The final measurement for these priorities will be by audit but the interim monitoring alongside CAG audits will support and identify potential for improvements throughout the year. CQUIN Update: The Quarter 1 and 2 CQUIN updates have been submitted to commissioners. The Trust achieved, subject to commissioner confirmation, the deliverables for the 4 Borough CQUINS: Physical Health, Outcomes, In-patient Patient Safety, In-patient Patient Experience, Dual Diagnosis. There are 6 other local CQUINS for Lambeth, Southwark, Lewisham and Croydon of which 4 had achieved deliverables and CAG assurances provided to Commissioners on delivery of the milestones for the remainder. For the NHSE CQUINS in Quarter 1 the Trust was successful in achieving these after a resubmission. The Quarter 2 returns have been made and the Trust position is that the deliverables have been achieved but we await confirmation from NHS England. Exception reporting: 1. Safer Staffing. Twenty-one of the fifty-two wards (40%) breached in the month of September in comparison to twenty-two in August. A summary of the breach reasons is given below. Vacancies and Sickness: Vacancies remain high in some wards as detailed in the September exception report detailed. Where wards have 45% (or above) vacancy rates for registered mental health nurses (RMNs) the Director of Nursing and Director of Human Resources will meet with CAG directors and clinical services to discuss reasons and action plans accordingly. The sickness level & frequency on 1 ward is very high and will be addressed by the CAG. Recruitment: The Bethlem recruitment open day saw 45 people visit the event and HR are tracking the take up of posts by those who attended. The resourcing and branding manager is working closely with the nursing directorate and a plan is in place to attend job fairs in the coming months to promote the Trust and encourage further applicants. Bank and Agency: NHSP attended the Bethlem and Ward Manager and Team Leader event focusing on advance booking wherever possible. Wards making bookings with 24 hours notice make it less likely for the shifts to be filled by NHSP Bank and can result in agency expenditure. Advance booking will be possible where the reason required is vacancy, but not when this is to cover sickness. The ward level exception report for September is included as Appendix C and includes information collated by the Nursing directorate on vacancy levels and the percentage of wards booking shifts with 24 hour notice. 2. Early Intervention in Psychosis and Home Treatment Team Gatekeeping: were below the 95% threshold for Quarter 1. Recovery plans were reported to September Board. There has been significant improvement in meeting the standards in September for HTT and improvements in EI maintained exceeding the trajectory and standard. 3. Seven Day Follow Up: Of the 9 instances where a follow up did not occur 4 related to the patient not attending appointment (this can include multiple Did Not Attend appointments) and a further instance where the patient did not supply the contact details as agreed. Misses are reviewed at performance reviews with the relevant CAGS. 84 of 188

85 Safe Safer Staffing (Number of Wards Breaching 20% of Shifts) No. of wards Overspill: For the most recent overspill position please refer to the Board Performance Report Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Safer Staffing (No. of breached wards) Average (CL) UCL LCL Full Risk Screen (CPA Patients) Completed Incomplete Child Need Risk Screen (CPA Patients) Completed Incomplete 93.9% followed up within 7 days of discharge 95.7% of patients had a brief or full risk screen 98.0% of patients had a child need risk screen Apr-15 May-15 Jun-15 Unauthorised Absences (Detained Patients) Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Unauthorised Absences - Detained Patients Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 New Serious Incidents Number of incidents Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 This is the first month we have shown the prone restraints and total restraints. Further discussions will be held at the QSC on this reporting. New Serious Incidents Average (CL) UCL LCL 85 of 188

86 Safe (continued) Patient Physical Assault on Patients (All Grades A-E) Patient Physical Assault on Staff (All Grades A-E) No. of assaults No. of assaults Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Physical Assaults on Patients (By Patient) Average (CL) UCL LCL Physical Assaults on Staff (By Patient) Average (CL) UCL LCL Effective There was significant improvement in September performance, although this was not sufficient to recover the Quarter 2 position. QUESTT addresses the following Metrics: New or no Ward Manager in post (within last 6 months) Vacancy rate higher than 7% Bank shifts is higher than 6% Sickness absence rate higher than 3% Level 0 (Score = 9 or less) Level 1 (Score = 10 16) Level 2 (Score = 17 23) No monthly MPT review of key quality indicators (e.g. peer review or governance team meetings Planned annual appraisals not performed Planned clinical supervision sessions not performed No formal feedback obtained from patients during the month (e.g. questionnaires or surveys) 2 or more formal complaints in a month No evidence of resolution to recurring themes Unusual demands on service exceeding capacity to deliver Number of hours of enhanced levels of observation exceed 120 Ward/department appears untidy/disrepair No evidence of effective multidisciplinary/multi-professional team working Ongoing investigation or disciplinary investigation 97.3% of patients with a HTT assessment QUESTT has now been rolled out to 45 wards and 4 Home Treatment Teams. Note 4 wards did not submit data in time to incorporate into the dashboard results. No ward scored Level 2 this month. Last month NAU and Fitzmary 2 were Level 2 following implementation of the agreed action plan both wards are in Level 1 for September and continuing with their improvement plans. In total 15 wards and 2 HTT scored Level 1. All wards at Level 1 develop local action plans within 2 weeks of the scores. These are developed by the ward manager and overseen by the service manager. Following the rollout of QUESTT a sample audit will be completed in December to test reliability and validity of completion of the tool. This will be reported to QSC dashboard in January / February. 86 of 188

87 Caring 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% IAPT (6 weeks) Target 75% 96.6% 94.7% 80.5% 85.8% 89.8% Croydon % Lambeth % Lewisham % Southwark % Trust % 100% 80% 60% 40% 20% 0% 95.1% CPA 12 Month review (Target 95% by End of Quarter) Patients with valid review Patients with overdue review of patients had a CPA review within 12 months IAPT (18 weeks) Target 95% CPA performance was achieved for Quarter % 99.6% 99.1% 97.6% 99.2% Croydon % Lambeth % Lewisham % Southwark % Trust % 87 of 188