AGENDA. Items for information will be taken as read but with an opportunity for Q&A.

Transcription

1 A MEETING OF THE BOARD OF DIRECTORS OF THE SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST WILL BE HELD ON 20 TH DECEMBER 2016 AT 3:00PM, LEARNING CENTRE, MAUDSLEY HOSPITAL 1 APOLOGIES for absence: 2 Declarations of Interest AGENDA 3 Patient Story 3:00pm 4 Minutes of the Board Meeting held on 29 th November :10pm Attached 5 MATTERS ARISING/ACTION POINTS REVIEW 3:15pm Page 10 App A STRATEGY 6 Approve Public Sector Equality Duty Report 3:20pm Page 14 App B 7 Information Valuing Diversity: Community Engagement Pilot 3:30pm Page 26 App C QUALITY 8 Discuss - Learning Lessons Report Q2 3:35pm Page 33 App D 9 Discuss Public and Patient Involvement Policy 3:45pm Page 46 App E PERFORMANCE AND ACTIVITY 10 Approve Performance Report & Finance Report Month 8 3:55pm Page 58 App F GOVERNANCE 11 Approve Re-appointment of SLaM Museum Trustee 4:10pm Page 84 App G 12 Approve - Mental Health Law Management Annual Report 4:15PM Page 85 App H 13 Information Briefing from the QSC Meeting 4:25pm Page 97 App I 14 Information Briefing from the FPC 4:30pm To be tabled 15 Information - Report from the Chief Executive 4:35pm Page 99 App J 16 Information - Update from the Council of Governors 4:40pm Page 102 App K INFORMATION 17 Actions summary from today s meeting Verbal 18 Reflections on today s meeting Verbal 19 Forward Planner and Draft Agenda for January Meeting 4:45pm Page 104 App L 20 Report from previous Month s Part II Page 108 App M 21 Any other business Verbal Items for information will be taken as read but with an opportunity for Q&A. Date of Next Meeting: Tuesday 24 th January :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 112

2 MINUTES OF THE HUNDRED AND SECOND MEETING OF THE BOARD OF DIRECTORS OF THE SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST HELD ON 29 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 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 Commercial Non-Executive Director Chief Executive Non-Executive Director IN ATTENDANCE Stephen Docherty Mark Ganderton Dr Fiona Gaughran Brian Lumsden Paul Mitchell Murat Soncul Michael Wuestefeld-Gray Chief Information Officer Governor Director of Research and Development Governor Trust Secretary Information Governance Lead Business Manager Trust Secretariat (Minutes) APOLOGIES None DECLARATIONS OF INTEREST MINUTES There were no additional declarations of interests. The minutes of the Board held on 1 November 2016 were agreed, as an accurate record of the meeting subject to the following amendments: 158/16 amend paragraphs 2 and 4 as comments from Julie Hollyman and June Mulroy have been transposed. 163/16 final paragraph amend to The Board agreed the request to go to arbitration should it be necessary. 1 2 of 112

3 BOD 165/16 PATIENT STORY Mark Evans (ME) was a services user in Westways at Bethlem Royal Hospital for a year to July The unit provides care for people with a long term psychological illness, with stays usually of the order of nine months to two years. The Trust went smoke free in October 2014 with final implementation occurring in January This included the removal of all smoking related materials and not facilitating smoking breaks. Smoking cessation training was given to staff, and advice provided for patients. To support patients like ME who wanted to stop smoking the ward set up a group attended by a smoking cessation adviser. Trained staff supported patients on a oneto-one basis to develop an individual plan. ME said he was a heavy smoker until He made a plan and stuck to it to achieve his goals. He has been smoke free for five months since leaving hospital and now lives in Croydon with carers. Julie Hollyman (JH) congratulated ME on stopping smoking and asked if he would try to get others to stop smoking. ME said he would like to try in due course. Duncan Hames (DH) also offered his congratulations and asked what it was like to leave hospital after such a long inpatient spell. ME said he had been supported to reenter the community and had been prepared during his inpatient stay. The Board thanked Mark for his presentation. BOD 166/16 MATTERS ARISING AND ACTION POINT REVIEW Progress on the items listed was noted. The update on pathology services was moved to the December meeting due to pressure on the agenda. The workforce update will now come to the Board in January BOD 167/16 RESEARCH AND DEVELOPMENT UPDATE Fiona Gaughran (FG), Director of Research and Development, presented. She highlighted that the Biomedical Research Centre (BRC) had been awarded 66 million over five years from April Also the NIHR bid has been renewed at current levels. FG presented the plans for the year ahead, which included developing pathways to clarify R&D funding streams; using the R&D Committee to encourage uptake of research opportunities; and developing KPIs to measure R&D activity and incorporate it into core business. Consent for Contact was highlighted whereby the Trust seeks permission to contact users to participate in research. The Trust s BRC is led by Professor Matthew Hotopf (MaH). Dementia will be a key theme for the BRC going forward. Challenges over the next year include clarifying what proportion of work is funded by research, and linking strategic priorities to research spend. Currently there is no in- 2 3 of 112

4 house support for grant applications and the Trust is under-attributed in research papers. See also item 172/16 below. The Board of Directors noted the report. BOD 168/16 SOUTH EAST AND SOUTH WEST LONDON STPS Altaf Kara (AK) presented. He said most recent discussions have been on developing an STP wide control total. Now there is also a common voice developing for mental health across south London as a whole. MP said the south east London STP plan is one of only three rated as outstanding on mental health. Matthew Patrick (MP) reported that the governance structure for the south east London STP is being developed to include productivity and clinical transformation programme boards. Both STP areas will have a single overarching mental health plan focussing on implementing the mental health five year forward view. South east and south west London STPs are rather different. There are no plans in the south east to change organisational forms, but in the south west CCGs are moving towards single leadership and the provision of acute care. St George s Hospital is facing severe operational challenges. There is a debate about the deliverability of plans and control totals and delivery of financial balance. The biggest issue is a move to population based commissioning and a realignment of incentives. Roger Paffard (RP) commented that the next stage of development must focus on engagement and communications. The STPs were discussed at the joint governors meeting on 17 November and will be on the agenda for the upcoming Council of Governors meeting on 15 December. The Board of Directors noted the report. BOD 169/16 DIGITAL SERVICES UPDATE REPORT Stephen Docherty (SD) introduced the digital services update. He said the Trust s IT strategy is being implemented and systems are becoming more stable. This is partly through moving away from legacy systems and older hardware towards cloud based services. Teams have been sent to each site to identify and log IT issues, and to train people in Office 365 and EPJS. This will continue until all sites are covered. SD highlighted the challenge faced by the Trust in managing cyber-attacks and the threat poses. Murat Soncul (MS) discussed cyber security and information governance. The Cabinet Office has a 10 step programme on cyber security that the Trust has adapted into a local framework to help keep patient and personal information secure. The Trust has a computer audit programme and has changed its risk management approach to be mindful of cyber security threats. Mitigation is based on education and training. The Trust has also reviewed the information held and data flows. This is key preparation for privacy impact assessments which will be mandatory from of 112

5 MS highlighted the importance of communicating effectively with staff on information governance via quick tips rather than detailed policy and guidance. Louise Hall (LH) asked if there is an opportunity to review and improve mandatory and in house training. MS said cyber security is now included in staff induction. June Mulroy (JM) asked how data back-up and recovery works in cloud service and what is being backed up. SD explained that data are backed up in three different locations and there are additional security and encryptions in place to maintain the back-ups. The data come from on-premises storage and network shares like EPJS, finance and procurement. Cloud services allow security to be provided by vendors rather than through local security protocols. RP asked that assurance of this is made part of the audit work plan. DH supported this proposal. The board clarified that Gus Heafield (GH) is the Senior Information Risk Officer. DH noted progress and the risks to successful delivery. He asked if best practice would include all Board members using Trust accounts. MS suggested training for the Board and SD will take forward the provision of accounts to Board members. Anna Walker (AW) noted that there is an issue with access to information and speed of access which may need further discussion. SD said historically the Trust has had a very limited business intelligence function. New structures and cloud services allow data to be analysed and visualised better and this should be fully implemented by January The Board of Directors noted the report. BOD 170/16 QUALITY IMPROVEMENT UPDATE REPORT Michael Holland (MiH) presented a summary update on progress with the QI programme. He said 40 people have applied for the next round of training in February. The Trust is recruiting to an informatics post to help develop a data dashboard. The programme is looking at reducing length of stay and improving patient and staff experience. The QI team have engaged with staff, service users and carers. Future reports will include the violence reduction programme alongside large and mid-scale programmes. MP asked about leadership of the QI programme. MiH said it would be good to have a non-executive director involved. RP said they would discuss this at the next meeting of non-executive directors. The Board agreed that there would be a further QI update at the January Board meeting. BOD 171/16 HOMICIDE REVIEW REPORT Neil Brimblecombe (NB) introduced the patient safety team s thematic review. The report presented to the Board discusses some of the incidents over the last five years while emphasising that all incidents are a tragedy. 4 5 of 112

6 Examining data to the confidential enquiry, which goes up to 2013 shows that Trust is in the middle quintile for incidents but each of the four boroughs are in the top ten for murder rates. NB made the distinction between murder and manslaughter: murder means a homicide not primarily driven by a mental health problem. Numbers are low so it is difficult to derive statistically significant inferences from it. The Trust has met with victims families and learned how to support them better. Looking at the overall data has been useful for learning and the Trust has updated its policies to reflect this, and will continue to look at learning from all homicide investigations and reviews. NB noted a significant number of perpetrators were new to services and have a new diagnosis. The Trust should consider how to manage risks among this group. JH said the report is an improvement on the previous version and has clearer conclusions. She asked of the updated policies sign post to voluntary organisations on domestic violence. ND said these can be included. Mike Franklin (MF) highlighted the duty of candour and that the Trust should always support and involve families. A person should be appointed whose role is to provide that liaison. NB explained the Trust appoints a member of the panel to do this. The Board of Directors noted the report. BOD 172/16 BRC UPDATE This was partly addressed by item 167/16, above. MaH presented an update. The BRC is in the early stages of turning research into clinical practice. Examples include drug interaction studies and experiments. There is a strong interest in informatics as a basis for clinical improvement. Computer science allows the development of novel therapeutic interventions. Also treatment times can be shortened and care focussed more effectively if there is a greater understanding of genetics and social settings. There are opportunities to improve outcomes by, for example, using text mining to identify people at risk of self-harm. In addition there is the need to look at the interface between mental and physical health why service users die between 10 to 17 years earlier than the rest of the population. The BRC unit had recently been successful in receiving 66 million to support the programme over the next five years. It was understood that mental health receives 1 for every 150 that goes to cancer research. The bid panel wanted to see more on the interface with industry and with neuroscience. Translational informatics brings together clinical, biological and service informatics into a very powerful group that is now open for collaboration with partners. Alan Downey (AD) said it would be helpful to have more clarity on terms like translational informatics. It would also be helpful to have more on the desired outcomes and practical examples of progress being made. AW agreed that it would be helpful to see more on the priorities and the impact the research has had on care. FG explained that translational informatics uses pseudo-anonymised records to find people with a particular illness, while consent for contact proactively seeks consent 5 6 of 112

7 for inclusion in research programmes. MaH said the national initiative is to recruit people for studies based on their genetic makeup so permission is sought for genotyping. MF commented that great care should be taken when approaching people who are ill. He asked how this approach is done and how the Trust can be assured ill people are not being exploited. He also asked how consent is obtained and who owns the intellectual property rights. MH replied that in order to avoid the risk of exploiting patients feedback from service users and carers had been sought, and this had been used to change the strategy. Patient groups want the chance to take part in research, and mental capacity to consent is considered in approaches. The intellectual property belongs to the Trust. FG said the request is not to take part in research, but for consent to ask people to take part in the future. Advice is sought from clinical teams on the appropriateness of approaching a patient. The benefits are collective and applied in practice. JH noted that the minutes of the R&D Committee had also been provided. FG said it is in the Committee s terms of reference to present the minutes of meetings to the Board, but this can be reviewed. MP asked when genomics could be used in common therapies? MaH said five years ago there was virtually no genetic associations with mental health problems like psychosis. The Trust can now look at multi-genetic risk factors. The Board of Directors noted the report. BOD 172/16 PERFORMANCE REPORT Kristin Dominy (KD) updated the Board on the latest recovery indicators. She noted the risk relating to disinvestment in the Croydon bridge. There has been a recent spike in the use of private overspill beds. These numbers are of concern and the relevant teams are actively managing their reduction. The report also contains new indicators around acute and crisis care pathways for adults. The Trust has gone through a process of assurance for emergency preparedness with NHS England. Although the Trust is non-compliant, with one area rated red, it has been commended for progress made. The Emergency Planning Group is managing a work plan including training in hazardous materials. The Emergency Preparedness, Resilience and Response Policy has been updated with policy links and definitions of major incidents. There have been no other changes. Louise Hall (LH) reported that IT, Finance and HR staff are entering into a period of formal consultation linked to the infrastructure review. NB confirmed that information regarding the use of restraint is being considered by the Quality Sub Committee. RP asked that once this has been explored the outcome is provided to the Board. AW said the paper to the sub-committee had indicated some areas are high users of restraint, so it is an important issue. DH noted the fall in the use of overspill beds and congratulated the efforts made by staff within the acute care pathway but noted the data shows volatility in the use of 6 7 of 112

8 those beds. Is this due to key staff absence over half-term and missed opportunities for discharge; and if so can the Trust expect something similar for Christmas? MP replied that he has sought assurance on preparedness for the Christmas period and the February half-term. There is an action plan based on performance and risk management, but the plan also details cover arrangements, presence on wards and anticipated levels of activity. BOD 173/16 FINANCE REPORT MONTH 7 GH presented the report which was taken as read. He reported the Trust should hit its control total, but this may require the use of non-recurrent funding. The biggest risk is commissioners not meeting contractual obligations and the outcome of the contracting round. The Trust has until 23 December to submit the plan. Progress will be reviewed by the Finance and Performance Committee and the Board in December. BOD 174/16 EMERGENCY PREPAREDNESS, RESILIENCE AND REPONSE POLICY This was addressed in item 172/16 above. JH noted the accountable emergency officer was incorrect on page 7 of the policy. The policy was approved subject to that amendment. BOD 175/16 SCHEME OF DELEGATION The report was taken as read. The Board approved the Scheme of Delegation. It will be reviewed further and brought back to the Board in the spring of BOD 176/16 BRIEFING FROM THE QUALITY COMMITTEE 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. The Board noted the report. BOD 168/16 UPDATE FROM THE COUNCIL OF GOVERNORS Brian Lumsden presented the report. The level of mental health inclusion in the STP plans was noted. He suggested that a meeting of governors across the SLMHP could be useful. Mark Ganderton (MG) updated the Board on the work of the Involvement and Social Responsibility Group and noted it is merging with the Membership and Communications Working Group, which will necessitate a review of the terms of reference. RP thanked MG for his work over the three years he had been a governor with the Trust. The Board noted the report. BOD 169/16 ACTIONS SUMMARY ON TODAY S MEETING Paul Mitchell will circulate an updated actions log. 7 8 of 112

9 BOD 170/16 REFLECTIONS ON THE MEETING Due to pressure of time this was not discussed. BOD 171/16 FORWARD PLANNERS AND DRAFT AGENDA The draft agenda for the 20 December meeting was noted and no changes were requested. BOD 172/16 REPORT FROM PREVIOUS MONTH S PART II The report was taken as read. BOD 163/16 ANY OTHER BUSINESS No other business was raised. The date of the next meeting will be: Tuesday 20 December 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). 8 9 of 112

10 Board meeting 29 November 2016 action points App A Ref Issue Action By When Status RAG April 16 meeting 1 Deloitte Report. Updated Action Plan has been sent for peer review. Interviews to be held with Chair, CEO, one NED, deputy lead governor. PM Jan 17 Bring back to Board for final sign off. On schedule. June 16 meeting 2 Patient and Public Involvement (PPI) Policy. July 16 meeting To be presented at the December 2016 Board. NB/AP Dec 16 On agenda. 3 Pathology services. Now to come to the Jan meeting. MH Jan 17 On schedule. Moved due to pressure on agendas. September 2016 meeting 4 Carers Strategy Report to the Board on progress towards achieving the internal target of 50% of carers offered a NB Feb 17 On schedule. Page 1 of 4 10 of 112

11 Ref Issue Action By When Status RAG carers assessment. 5 Experience Report The redeveloped Trust website to include service user surveys, to improve real-time reporting and data collection. 6 Workforce Update The commercial offering in education and training for apprentices will come back to the Board when it is finalised. 7 Revalidation Annual Report Brief paper to be brought to the Board on the progress toward delivery of the organisational action plan. 8 Annual audit to be presented to the Board for assurance on revalidation systems at the Trust. NB Apr 17 On schedule. LH Jan 17 On schedule. MH Apr 17 On schedule. MH Apr 17 On schedule. 1 November meeting 9 Serious Incident Process Update. Review of reporting to Board and governors. 10 Freedom to Speak Up Guardian. Bring further report back in January 17. NB Dec 16 Take to QSC for consideration. ZR Jan 17 On schedule. Page 2 of 4 11 of 112

12 Ref Issue Action By When Status RAG 29 November meeting 11 QI Report. Further report covering acceleration of programme plan and leadership, including recruitment of a lead NED. 12 Finance Report. Review progress with developing financial plans to 23/12 deadline. 13 STPs and SLMHP. Produce briefing papers for the Council of Governors meeting. MH Jan 17 On schedule. GH Dec 16 On schedule. AK Dec 16 Completed. 14 IT. Re-run the staff survey. SD Dec 16 On schedule. 15 NED SLaM addresses. Review use. 16 EPRR. Circulate outcome of Datex review. PM Dec 16 On schedule. KD Dec 16 On schedule. 17 Scheme of delegation. Bring back in April 17. GH Apr 17 On schedule. Code: Page 3 of 4 12 of 112

13 Green completed Amber on schedule Red not on schedule PNJM/November 2016 Page 4 of 4 13 of 112

14 TRUST BOARD OF DIRECTORS SUMMARY REPORT B Date of Board meeting: 20 th December 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance) Author: Approved by: (name of Exec Member) Presented by: Meeting the Public Sector Equality Duty 2016 Report Strategy Macius Kurowski Matthew Patrick, Chief Executive Zoe Reed, Director of Organisation and Community Purpose of the report: 1) To provide a report on progress of recommendations made to the Board last year. 2) To approve new Trust equality objectives 3) To approve the annual equality information that the Trust is required to publish annually, by 31 st January, to comply with the specific equality duties. This includes 2016 Trust-wide information, 2016 Workforce equality information, 2016 ethnicity information reports for Croydon, Lambeth, Lewisham and Southwark. Recommendations to the Board: The Board is asked to review the detailed equality information in the hyperlinks with this report and agree the following priorities for 2017: 1. Improve access, experience and outcomes of BME service users, in particular by formally approving the Trust s involvement in Lambeth Black Health and Wellbeing Partnership 2. Improve the experience of disabled service users by a) improving NHS Accessible Information Standard compliance and b) publishing a Trust Learning Disability strategy. 3. Improve the use of equality impact assessments in business planning, service and strategy development. 4. Improve the experience of transgender service users and lesbian, gay, bisexual and unsure service users by a) promoting the Trust trans guidance more widely with staff, particularly inpatient services, b) developing a business case for rolling out successful LGBT awareness training as part of the Trust s suite of equality and diversity training and c) increasing recording of sexual orientation on epjs. 5. Approve new Trust equality objectives 6. Approve Trust equality information for 2016 for publishing in January 2017 Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: The Trust must comply with the equalities legislation and NHS requirements, including Monitor and CQC. Summary of Financial and Legal Implications: As a public authority the Trust must ensure it meets the general and specific equality duties set out in legislation 14 of 112

15 Equality & Diversity and Public & Patient Involvement Implications: This document focuses entirely on equality and diversity relating to both service delivery and workforce. Engagement, participation and involvement are essential components of this work. Service Quality Implications: Identifying and addressing the needs and experiences of service users with different protected characteristics will support the Trust s work to deliver safe, effective, caring and responsive services. 15 of 112

16 TRUST BOARD OF DIRECTORS REPORT ON MEETING THE PUBLIC SECTOR EQUALITY DUTY IN Context: 1.1 Legal Framework: The Trust s legal obligations under the public sector equality duty (Equality Act 2010) are: 1) General equality duty: to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations in policy, strategy and service development. The Trust needs to evidence how it has complied with this duty in all relevant decision making, including the timely use of equality impact assessments (EIAs). 2) Specific equality duties: to publish annual equality information and equality objectives at least every four years. 1.2 The state of mental health, equality and human rights in Great Britain Mental health features within the Equality and Human Rights Commissions (EHRC) five yearly statutory progress report to Parliament on equality and human rights in Great Britain 1. The evidence in this report identifies the following: Areas of progress: Access to psychological therapies; positive developments in the availability of high quality mental health care. Challenges: Lower life expectancy for people with serious mental illness or a learning disability. Increased suicide rate in England and Wales, resulting in a widening of the gap between men and women, with middle-aged men particularly at risk. Increased risk of poor mental health among adults in England, with high risk for : o People identifying as gay/lesbian/bisexual/other. o Black/African/Caribbean/Black British people had the highest rate of contact with specialist mental health services. o Black people were more likely to have been compulsorily detained under the Mental Health Act 1983 as part of an inpatient stay in a mental health unit. o Serious concerns about access to mental health services for children and young people. o Inconsistent care of prisoners with mental health needs. People with learning disabilities and/or autism placed in inappropriate settings for too long and a long distance from their family and home. Some people for example, transgender people and people from migrant communities experienced problems accessing healthcare services. While the Trust cannot solve these inequalities alone it needs to remain aware of these challenges and should seek to play its role in addressing them in all relevant Trust activity. This work is best achieved in partnership with other as in the Trust s work with Lambeth Black Health and Wellbeing Partnership and Independent Advisory Group. 1.3 NHS England policy on equality: 1 Is Britain Fairer? (EHRC, November 2015). Available at: 16 of 112

17 There are some mandatory equality requirements within the NHS Standard Contract: Implement the Equality Delivery System (EDS) 2 2 to review equality performance. The Trust has refreshed its EDS assessment for Implement the national Workforce Race Equality Standard (WRES) and report on this annually. Implement the NHS Accessible Information Standard requires the Trust to: 1) Ask all service users, carers or family members if they have a communication need arising from a disability 2) Record this in epjs 3) Have epjs flag up any communication need to staff 4) Share information on these needs with other providers with consent 5) Ensure the service user, carer or family member gets information in the way they need it 1.4 The Trust s equality infrastructure The Trust Board lead for Equality is Zoe Reed. There is a small team comprising of a Head of Planning and Equality and Equality Manager whose remit is to support staff on equality issues in service delivery and support the Trust to comply with its statutory equality obligations. Each CAG has a member of staff acting as a CAG Equality Lead alongside other, often PPI, responsibilities. Their role is to facilitate CAG activity on equality and support clinical teams to address equality issues in their service provision. The Trust s work on equality relies on this infrastructure being in place across the Trust and linked to CAG Executives and other decision making groups to enable communication and action on relevant equality issues. The role of Equality Lead is currently vacant in Acute Care, Addictions and BDP CAGs. There is a Trust-wide Equality and Human Rights Group that meets every two months. This brings together Equality Leads, staff from professional groups, HR, staff working on equality projects or networks. There is also a Psychologists and Psychotherapists Diversity Group that brings together staff with a passion or interest in diversity to support work on equality and diversity. 2. Review of 2016: Update on recommendations made to the Board in last year s report 2.1 Recommendation 1 for 2016: Improve the experience of Black and Minority Ethnic (BME service users). Update: Activity to achieve this included: Activity Publishing local ethnicity information to improve accountability with stakeholders on race equality issues in Croydon, Lambeth, Lewisham and Southwark. Continued partnership working with Lambeth Black Health and Wellbeing Commission Independent Advisory Group Partnership working with Croydon CCG, Croydon BME Forum and BME CDWs to deliver a BME CQUIN involving Outcome Improving accountability to local communities and encouraging greater consideration of ethnicity information by teams for service improvement. Improving accountability, communication and action in partnership with representatives of Black communities in Lambeth on shared priorities. Appreciative inquiry approach developed to improve understanding of access, experience and outcomes of teams to 2 A refreshed Equality Delivery System for the NHS (NHS England, November 2013). Available at: 17 of 112

18 promoting recovery, early intervention and home treatment teams in Croydon Updating guidance on interpreting for psychologists and psychotherapists and interpreters on delivering psychological therapy. Piloting cultural awareness training delivered by Croydon BME CDWs 21 Black History Month events were held across the Trust during October and November. Joint work with Latin American communities. Community Engagement Projects with Croydon IAPT, Lambeth OASIS, Lewisham CAMHS, Southwark MHOAD CMHT and Southwark IAPT Engagement by the Trust Nurse Consultant Violence Reduction with Lambeth Black Health and Wellbeing Commission IAG on PSTS strategy The development of a psychology and psychotherapy (P&P) inclusivity strategy and E&D P&P Bulletin. Examples of excellent equality practice displayed by teams: E.g. Lambeth IAPT audits on ethnicity and psychological therapy outcomes Improving interpreting and translation services through re-procurement, involving a carer and staff across the Trust. shape future action to improve this. Improving staff awareness and competency when working with interpreters in psychological therapy. Positive staff feedback and increased awareness and confidence in staff. Celebration of cultural diversity and promoting mental wellbeing by staff and service users. Improving links with communities and raising awareness of mental health services. Developing learning on approaches, benefits and resource requirements of increasing team engagement with local BME communities. Increased consideration of race equality in development and implementation of the strategy the PSTS Committee and CAGs. Setting aims and actions for improving diversity in P&P and promoting learning and good practice to P&P staff. Improved understanding of difference in outcomes for different ethnicities and follow-up work to improve this. Good quality interpreting; better data to monitor and improve the service; service user feedback on interpreters through translated surveys in top 50 languages. Recommendation 2 for 2017: There has been a lot of activity to improve services for BME service users and it s reassuring that experience reported through PEDIC surveys is broadly similar between different ethnic groups. But BME communities continue to report concerns and a lack of confidence in the Trust. It is therefore important to continue activity across the Trust to improve access, experience and outcomes for BME service users. This activity will be most effective when undertaken in partnership with BME communities. Therefore the Trust must continue active involvement in: The development of the Black Wellbeing Partnership for Lambeth; hosted by Healthwatch and to be led by a Steering Group comprising 50:50 Community Members and Statutory Agencies Seeking ways to build community involvement along similar lines as those in Lambeth, in Lewisham, Croydon and Southwark. 2.2 Recommendation 2 for 2016: Improve the experience of disabled service users. Update: Activity to achieve this included: Activity Outcome Creating a field for recording accessible Basic compliance with NHS Accessible communication needs on epjs; Standard. But currently recording by staff developing resources, guidance, training is very low which presents a risk to the and promotional communications to Trust if the CQC or other stakeholders 18 of 112

19 support staff implement NHS Accessible Information Standard and Reviewing Trust Patient Information policy An audit on reasonable adjustments for service users with hearing or visual impairments was undertaken. Initiating development of the Trust Learning Disability Strategy enquire about Trust performance in complying with this requirement. This identified good practice by staff and further areas for improvements. Developing a strategic approach to improve services for service users and carers with Learning disabilities in mainstream Trust services. The Trust has achieved basic compliance with the NHS Accessible Standard. But it does not appear that enough staff are asking whether service users have communication needs and responding to this need as there is very limited recording of this on epjs. PEDIC data shows service users with a hearing impairment, learning disability/difficult or visual impairment often report less positive experiences of care. The Trust has legal and contractual obligations to ensure reasonable adjustments are made in the way staff communicate with disabled service users and carers. The CQC is also likely to hold the Trust to account on its compliance with the NHS Accessible Information Standard in any future visits. The Trust must therefore continue to improve its performance on this. The development of the Learning Disability strategy is an opportunity for the Trust to take a more strategic and effective approach for improving the experience and outcomes of service users with learning disabilities in mainstream services. Recommendation 2 for 2017: The Trust should prioritise improving experience for disabled service users by: 1. Improve Trust-wide compliance with the NHS Accessible Information Standard by: a. Adding a request for information on accessible communication needs in all Trust referral forms. This would need to be done at many levels in the as a wide variety of referral forms across the Trust. b. Asking all service users about accessible communication needs in initial assessments through integrating this requirement into development of the epjs single assessment form. c. Proactively targeting all service users already recorded as having a hearing impairments or visual impairments on epjs about accessible communication needs. d. Improving relationships with disability-led organisations to improve partnership working on improving communication with disabled service users and carers. 2. Publishing the Trust Learning Disability Strategy being led by the Nursing Directorate. 2.3 Recommendation 3 for 2016: Prioritise improvements to the quantity and quality of the use of equality impact assessments (EIAs) in service and strategy development. Update: Activity to achieve this included: Activity Outcome EIAs have been used to inform Improved consideration of the equality some service developments implications of changes and what the service An EIA was used in the development of the Trust Promoting can do about these This increased the equality evidence available to inform development and delivery of the 19 of 112

20 Safe and Therapeutic Services Strategy Use of EIAs to inform policy reviews continues through the Policy Working group strategy. Greater consideration and sharing of evidence of the effect policies are having on service users with different protected characteristics and what the Trust can do about this. While there has been some good practice in the use of EIAs during 2016, there is still some lack of use / last minute use of EIAs resulting in less evidence, understanding and follow up action on equality, as well as the risk of legal challenge or the srutiny of stakeholders. Recommendation 3 for 2017: Continue to improve the use of equality impact assessments in business planning, service and strategy development. 2.4 Recommendation 4 for 2016: Increase recording of sexual orientation and religion and belief on epjs. Update: A new fixed field for recording sexual orientation has been added to epjs and a communication plan will be implemented encourage greater recording on this on epjs. There has been a decrease in the recording of ethnicity and religion and belief on epjs across the Trust. This could impact on the likelihood of clinicians addressing these areas within their clinical assessments or interventions and limits the data the Trust has available to understand access and outcomes. Previous audits have shown that religion is often well recorded in events or correspondence on epjs but not the fixed field for religion. Staff are under huge pressures to record a range of information on epjs. Therefore it may not be realistic or helpful for equality in making additional data recording requirements for both these characteristics. PEDIC feedback over the previous three years suggests that transgender service users and service users who are unsure about their sexual orientation report the poorest experience in a number of aspects of care. Work undertaken by the Trust in the last year to support LGB & T service users includes: Activity Developing guidance on supporting adult transgender service users Piloting staff LGB & T awareness training Outcome Increased awareness in staff and more advice seeking on trans issues Positive staff feedback and increased awareness and confidence in staff. Recommendation 4 for 2017: The Trust should prioritise improving experience for transgender and gay, lesbian, bisexual or unsure service users by: Promoting trans guidance with staff, particularly in the Acute CAG Developing guidance for supporting trans service users in CAMHS services Rolling out successful LGBT awareness training as part of the Trust s suite of equality and diversity training Increasing recording of sexual orientation for those aged 18 or over on epjs. 2.5 Recommendation 5 for 2016: Review the impact of Trust s equality objectives and developing new equality objectives. The Trust has a statutory obligation to publish one or more equality objectives at least every four years. Work has been undertaken in 2016 to review delivery of the previous equality objectives and develop new ones. 20 of 112

21 Update: The key learning for the Trust in reviewing delivery of the equality objectives includes: Reflections Learning and recommendations for the Trust The Trust did not always hear views representing all protected characteristics Develop a wider range of ways of getting feedback on equality including targeted outreach to address key gaps. through its engagement. Encourage greater involvement from diverse groups and explicit, relevant equality questions in The EDS consultation was process is too broad and did not help to define or monitor specific and measurable objectives. Setting broad objectives and action plans resulted in: 1) Patchy knowledge among staff of equality objectives 2) Limited increase or mainstreaming of activity on equality attributable to equality objectives 3) Limited change attributable to equality objectives 4) Some duplication and unhelpful demands on CAGs and staff 5) No additional resources all Trust involvement and engagement activity. Differentiate consultation on equality objectives with consultation on the Trust s overall equality performance. The Trust should use existing evidence (including what people have told us over the last 3 years) to identify priority areas before consulting on what improvement would look like and what could be done to achieve this. Consultation and involvement on equality objective development should initially be more targeted on key stakeholders with relevant expertise to identified priorities. Clearly frame equality objectives within wider equality work and improve Trust-wide and CAGspecific communication. CAGs should develop a maximum of one realistic but SMART equality objective that is developed, acted on and governed by the CAG. CAGs to define and monitor outcome measures as well as activity/process measures Align activity and learning with QI programme wherever possible Providing CAGs timely information and sufficient time to respond to requirements Seek opportunities for influencing future resource allocation (e.g. Business planning, CQUINS, partnership working, funding bids) Performance management should be part of CAG PMR process Recommendation 5 for 2017: The Trusts new equality objectives are: Addictions: To increase access to drug and alcohol treatment for men who have sex with men (MSM) in the Borough of Wandsworth within one year of opening the new clinic. BDP: To improve the physical health for BME people in the Forensic Pathway CAMHS: Ensure equitable access, experience and outcomes for Asian, African and Caribbean females in CAMHS Community Services in LB Croydon and LB Southwark by MHOAD: SLIMS will ensure equally positive experiences and outcomes for African and African Caribbean service users in Southwark and Lambeth when compared to service users of other ethnicities Psychosis: To increase access for the over 35s to the Early Intervention Service in Lambeth during 17/18 (and then in the other three boroughs by 19/20). To ensure equitable access to EI services for those over 35 in relation to ethnicity and gender. 21 of 112

22 The legal purpose of equality objectives is to help the Trust comply with aims of the public sector duty by delivering SMART objectives that accelerate the achievement of positive outcomes for people with protected characteristics. They do not constitute all of the Trust s work on equality and should be seen as distinct quality improvement projects within this. Work to define SMART action plans and outcome measures for each objective continues in each CAG. This will be completed by the end of December with the aim of delivery of objectives to begin in January An EIA of service delivery equality objectives and map of equality activity in 2017 has been produced to show the coverage of these across protected characteristics and local boroughs. There currently appears to be less activity in relation to pregnancy and maternity and religion and belief and less activity in Lewisham. The Equality Manager will work with staff across the Trust to address gaps through other Trust activity for example: Promotion of the Trust policy on the care of pregnant women with serious mental illness Development of spirituality guidance for staff by the Spiritual and Pastoral Care service Development of equality objectives by Acute Care and PMIC CAGs. This was delayed to allow time for the new CAGs to be established. These CAGs will develop equality objectives for delivery to begin in April Publishing 2016 equality information The following reports have been produced for inclusion in the Trust s annual equality information to be published on 31 st January Trust wide equality information Workforce equality information ethnicity information reports for Croydon, Lambeth, Lewisham and Southwark. 3.1 Summary of 2016 Trust-wide equality information Headlines from the report include the following: The Trust-wide diversity profile of service users is broadly similar to the year before. Most service users would recommend the Trust to family and friends if they need these services. Most service users reported positive experiences of care on other questions. Overall feedback for all questions, except safety, improved. At a Trust-wide level, PEDIC data suggests the experience of service users with different protected characteristics has been broadly similar over the last three years with some variations in reported experience. Key issues include: o Friends and Family Test: service users who disclosed their sexual orientation as unsure were least likely to recommend the Trust in the current year to date. o Involvement in care: In the current year to date service users who disclosed their sexual orientation as unsure were least likely to report that they felt involved in their care. Transgender service users were also less likely to report this than cisgender service users. o Kind and caring staff: In the current year to date service users who disclosed their sexual orientation as unsure were least likely to report that staff were kind and caring. Transgender service users were also less likely to report this than cisgender service users. o Consideration of individual need: In the current year to date service users who disclosed their sexual orientation as unsure were least likely to report that their individual needs had been considered. Transgender 22 of 112

23 service users were also less likely to report this than cisgender service users. o Safety: Overall this has been the area of least positive feedback over the past three years. The percentage of service users feeling safe decreased in the year to date 16/17, with the small number (11) of Hindu service users reporting the largest decrease in feeling safe (-23.4%). Service users who disclosed their sexual orientation as unsure were least likely to report feeling safe. Transgender service users were also less likely to report this than cisgender service users. It will be important to consider this trend within the delivery of the Trust s Promoting Safety and Therapeutic Services Strategy and 4 Steps to Safety. There has been an increase in Foundation Trust membership. There were no significant changes in the diversity of the Trust s membership. There has been an increase in the number SLaM volunteers. There were no significant changes in the diversity of the Trust s volunteers. 3.2 Summary of 2016 ethnicity information reports for Croydon, Lambeth, Lewisham and Southwark These reports provide ethnicity information on service users accessing 11 of the Trust s services in Croydon and feedback from Croydon service users and examples of what the Trust is doing to improve services for BME service users. The Trust is publishing these reports as part of its work to improve services and build confidence and trust among BME service users, carers and local communities. The information can help staff, service users, carers, partner organisations and people local communities in working in partnership to achieve this reports are broadly similar to last year s. But following feedback from staff and stakeholders we have added data for forensic services and information on interpreters used by SLaM services in each borough. What the data tells us across the four boroughs The report highlights there are limitations to what can be concluded about changes in access to services from just two snapshots of data over time. Taking that into account, the data in the reports show BME service users are accessing the Trust s services in broadly similar patterns to last year s reports. This needs regular consideration of caseload and other data over a longer period of time to get a more accurate picture. There continues to be a high proportion of Black service users in promoting recovery teams, acute and crisis wards and home treatment teams. There are also a high proportion of Black service users, in comparison with the local population, accessing support at an earlier stage of psychosis through the early intervention team. It is reassuring that reported experience is broadly similar between ethnic groups. But there are some differences so it will be important to continue to monitor this to identify any trends of consistent poor experience and take action to address this. We anticipate that response rates to surveys will continue to increase for service users of all ethnicities during 2017/18 and will continue work to increase this further to improve our evidence base. As in last year s report, the data in this report reiterates the importance of continuing work to deliver services that are appropriate and responsive to the needs of BME service users to enable the Trust to deliver effective services to service users of all ethnicities. Consideration of the ethnicity data in the local reports and other data on ethnicity can help the Trust achieve this. What the data tells us about Croydon 23 of 112

24 In comparison to the year before, older adult community mental health teams recorded a greater proportion of ethnicity. There was a lower proportion of ethnicity recorded by Croydon CAMHS community teams, the Assessment and Liaison team, Early Intervention team Home Treatment team and Memory services. The majority of Croydon service users from all ethnicities would recommend the ward or teams to friends and family if they needed similar care or treatment. The majority also reported positive experiences to the other four PEDIC questions. Where ethnicity was disclosed, overall experience has generally improved slightly in the last three years. It s reassuring that experience is broadly similar between different ethnic groups but there are fluctuations in the experiences reported by service users of different ethnicities. What the data tells us about Lambeth In comparison to the year before, there was a lower proportion of ethnicity recorded by Lambeth CAMHS community teams, Integrated Psychological Therapy Teams (IPTT teams) and Assessment and Liaison teams. The majority of Lambeth service users from all ethnicities would recommend the ward or teams to friends and family if they needed similar care or treatment. Most Lambeth service users also reported positive experiences to the other four PEDIC questions. Where ethnicity was disclosed, overall experience has generally improved in the last three years, except in relation to feeling safe on wards. It s reassuring that experience is broadly similar between different ethnic groups but there are fluctuations in the experiences reported by service users of different ethnicities. What the data tells us about Lewisham In comparison to the year before, there was a lower proportion of ethnicity recorded by Lewisham CAMHS community teams, IPTT teams and Assessment and Liaison teams. The majority of Lewisham service users from all ethnicities would recommend the ward or teams to friends and family if they needed similar care or treatment. Most Lewisham service users also reported positive experiences to the four other PEDIC questions. Where ethnicity was disclosed, overall experience has not changed significantly in the last three years in relation to all survey questions. It s reassuring that experience is broadly similar between different ethnic groups but there are some fluctuations in the experiences reported by service users of different ethnicities. What the data tells us about Southwark In comparison to the year before, the IAPT and Southwark and Lambeth Memory Service (SLIMS) recorded a greater proportion of ethnicity. But there was a lower proportion of ethnicity recorded by Southwark CAMHS community teams, the Assessment and Liaison team, IPTT, Early Intervention team and older adult community mental health teams. Where ethnicity was disclosed, overall experience has generally improved in the last three years, except in relation to feeling safe on wards. Service users of all ethnicities reported feeling less safe than the year before, particularly the small number of Asian service users who reported a large decrease in feeling safe. Experience is broadly similar between different ethnic groups for the other questions but there are fluctuations in the experiences reported by service users of different ethnicities. What the reports say the Trust will do Continue to consider and analyse ethnicity data on access and experience and respond accordingly to any potential race equality issues that are identified. Work will begin to deliver the Trust s new equality objectives and embed equality within relevant Trust Quality Improvement projects. Increase recording of ethnicity on epjs, particularly in CAMHS community teams, Assessment & Liaison teams, IPTT and memory services to help improve our understanding of access to services. 24 of 112

25 Continue to ensure services are appropriate and responsive to the needs of BME service users through relevant auditing, training, guidance and reflective practice. Seek to increase the amount of service user feedback collected through surveys conducted by all teams. Use this evidence alongside feedback through other means to better understand service users experiences and improve our services accordingly. Continue to work in partnership with key stakeholders and partners such as Lambeth Black Health and Wellbeing Partnership; Lambeth Black Health and Well Being Commission Independent Advisory Group; Croydon BME Forum and Croydon Community Development Workers. Seek feedback on the reports from stakeholders and staff to improve it. Publish local ethnicity information in January 2018, as part of our annual equality information to show what we have done and what has changed during Conclusions 2016 was another busy and challenging for year for the Trust on equality as with other key aspects of service delivery. The Board is encouraged to recognise the commitment and hard work of many members of staff across the Trust to address equality issues in service delivery in addition to all the daily challenges they face. However mental health inequalities in society are a key challenge that the Trust must continue to play its part in addressing; the Trust s stakeholders have identified the need for further equality improvements by the Trust and there remain some weaknesses in the Trust s approach to equality. By supporting and monitoring the implementation of the recommendations set out in section 2 during the next year the Board can help lead the Trust to address these challenges and build on the progress achieved to date. 25 of 112

26 TRUST BOARD OF DIRECTORS SUMMARY REPORT C Date of Board meeting: 20 th December 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance) Authors: Approved by: (name of Exec Member) Presented by: Valuing Diversity: Community Engagement Pilot Strategy Tony Coggins, Ermias Alemu, Juney Muhammad Altaf Kara Zoe Reed Purpose of the Report: The purpose of the report is to provide an update on the community engagement pilot originally presented to the Board in September It provides an overview of progress against the action plan, shares learning to date and makes some interim recommendations informed by the pilot and the recent NICE guidelines on community engagement. The final report and recommendations will be produced in April Interim Recommendations to the Board: Community engagement should be integral and embedded within services and teams to improve patient care, experience and outcomes rather than be a separate service The link worker model should be continued and extended, but with the understanding that community engagement requires time and the commitment of the whole team/service. The approach should be for Teams to identify a few key community groups and develop an on-going and regular dialogue rather than one off contacts with a number of groups Any future rollout should follow a phased approach, initially focusing in key priority areas/teams/services to be identified in the final report. Resources will be required if the Trust wishes to roll out of the community engagement approach. The resource implications will be outlined in the final report due in April. There needs to be a dialogue with CCGs about how SLaM can be commissioned to undertake community engagement to create the space and time needed Future training and support provided should include cultural competence training 26 of 112

27 Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: Not continuing the programme is likely to increase risk of poor relationships with local communities and potentially CCGs particularly in Croydon, it may affect our ability to deliver on the Lambeth Black Health and Wellbeing Commission recommendations. Summary of Financial and Legal Implications: There are no obvious legal implications. A roll out of the community pilot will have resource implications these will be outlined in the final report in April If people from BME communities access services earlier rather than in crisis it is likely to have a positive financial impact as well as improving access, experience and outcomes for the people concerned. Equality & Diversity and Public & Patient Involvement Implications: The pilot is aimed at the BME communities facing the greatest health inequalities and about improving relationships with our local BME communities. It contributes towards the Trust responsibilities around equality and diversity. Service Quality Implications: The project is designed to improve the access and experience of people from BME communities through developing good relationships between the Trust and local communities. By engaging with people earlier in their illness it is likely to lead to improved outcomes and experience for BME service users. The project includes up-skilling and practically supporting staff in community engagement and cultural awareness. 27 of 112

28 VALUING DIVERSITY: COMMUNITY ENGAGEMENT PILOT EXECUTIVE SUMMARY The community engagement pilot was developed to support the Trust to meet its long-term strategic goal to transform the nature of local services through partnerships that deliver around the needs of individuals and communities. It also forms part of the Trust response and commitment to meeting the recommendations of the Lambeth Black Health and Wellbeing Commission report. The objectives of the pilot were: To Identify teams in each Borough [Croydon, Lambeth, Lewisham, Southwark] to pilot a community engagement approach To identify priority communities to engage with To Identify key local community organisations to develop an on-going relationship with To develop and deliver local engagement action plans for the pilot teams To build the skills and confidence of Trust staff to engage effectively with local communities To build a sense of trust and on-going dialogue with local BME communities The pilot started late due to the length of time taken to recruit pilot teams and identify link workers. The project is on track to be completed at the end of March Five pilot teams have been supported to identify priority populations to engage with and then have been supported to develop a relationship with one or two local community organisations that are well connected to the priority population. A series of meetings and events have taken place in partnership with the community organisations to start to build an on-going dialogue and improve awareness and accessibility of our services. Learning so far highlights the importance of having an identified community link worker with a supportive manager and team committed to support community engagement. Barriers to community engagement include consultation fatigue and a sense of nothing happens as a result from a community perspective, mistrust of the system particularly for black men and a lack of local community knowledge in our teams. The ability of our teams to engage differently with communities is hampered by caseload work pressures and a lack of knowledge and confidence in working in communities. That said the pilot is progressing well and the interim recommendations are to extend the pilot to other teams/services and put in place a 3 year strategy with some central resource to support teams to embed community engagement in their practice. PROGRESS AGAINST THE ACTION PLAN Action Plan Board commitment for the development of a community engagement strategy Scoping the pilot internally: Discussion with CAG s about involvement in the pilot Identification of senior level CAG lead Identification of pilot teams Consultation with pilot teams Identification of training and support needs for SLaM staff Progress Complete: Complete: 5 SLaM teams have signed up to the community engagement pilot project across the four boroughs and they are: 1.MAP: Southwark IAPT 2 MAP: Croydon IAPT 3 Psychosis: Oasis Lambeth 4. CAMHS: Lewisham 5. MHOAD: Southwark 28 of 112

29 and resource implications Scoping of pilot with community groups: Identification of key local community groups for each pilot team based on the needs of local population and service usage Consultation and conversations with local community Scoping Report Development of an action plan for engagement with each team including measures and evaluation Production of a board update with resource implications for approval Implementation of a programme of engagement with local community groups Implementation of staff community engagement training and support plan Quarterly review of progress and presentation to relevant forums: Long-term Community Engagement Strategy produced for Board approval Training needs identified and funding agreed for: 2 days a month (band 6) back backfill funding for each team Community Engagement training Central support from community engagement specialists Small community engagement budget for each team Complete: Identified key priority population groups to focus on by analysing and triangulating the latest census data, service usage and staff views. Established links with host organisations, who have good working relationships with the target groups. These organisations include the following: North Brixton Islamic Centre in Lambeth Golden Oldies in Southwark BME Forum and Imagine in Croydon Mummies Republic in Southwark A school community where there is high unmet needs Complete: Developed an action plan with each of the teams in partnership with community organisations On-going: All the teams are currently: Engaged at least with one BME community host organisation per pilot team Have allocated identified link worker Have in place an agreed working action plan Conducting different activities and events based on the agreed plan in each pilot area On-going: Link workers in place in each team Link workers were brought together to share learning and development and to receive initial training Teams supported to meet with community organisations/groups Team supported to identify community partner organisations On-going: Regular reports to the equality and human rights group Outstanding: Due to the extra time it has taken to identify teams, link workers and community organisations (discussed below) the pilot started late and is now due to be complete by 31 st March Therefore this interim report has been produced. The final report will be available in April of 112

30 LEARNING FROM THE PILOT Work pressures and demands All the pilot teams had their own clinical demands and pressures arising from caseloads and targets to be met and for some staff the concept of community engagement could have been felt an additional burden, affecting their ability to respond. This has led to difficulty in arranging meetings as other priorities have had to be addressed and arrangements to be cancelled or delayed, hence the delay in starting the pilot. Often the community meetings and events were in the evening and at weekends and on occasions this presented challenges to the pilot services in providing staff to attend. If the Trust is to take a community engagement approach it will need to provide some protected staff time to enable them to work in a different way. We see that this sort of work needs to be done by clinicians and that it be integrated into clinical work, but we are not commissioned for this approach, so how can we work with commissioners to help them understand that SLaM wants to work towards a more holistic approach Link worker. Trust staff and community engagement Each of the 5 pilot teams identified a community engagement link worker. It has been important that there is a consistent worker, who the partner community organisation can get to know. However in order to have meaningful impact a team approach is required where attending and contributing to community meetings and events is shared. The understanding and value individual members and the teams gave to the importance of community engagement varied and, whilst many staff have been enthusiastic about engaging with local communities, there was often a nervousness about working with communities as opposed to working on a one-to-one basis with people who have been referred. Team relationships with local communities and networks appear at times have been non-existent and required a lot of support and mentoring in initial stages. The pilot involved staff working across community organisations and agencies with different organisational cultures requiring staff to communicate and work with where people are at and do things differently, where this has happened staff have found it valuable. I found it very helpful and meaningful talking to people on a very individual one to one level and listening to their genuine concerns without the pressure of assessing them for professional reasons or the expectation to make an entry on EPJs or report to the team. The manager s role in embedding community engagement into the team is crucial. In one pilot team the manager allocated senior clinical nurse specialist to take a lead in the pilot and also led by example by joining him to attend in a Black History Month celebration event organised by partner community organisation. We found that often staff did not know the local area in which they were working very well e.g. whether the ward had high levels of unemployment, whether the schools had high rates of children from BME communities which is important context for effective engagement. Likewise many community groups were not aware of local SLaM services so consequently our services can appear quite detached to communities. 30 of 112

31 Going out to talk to people in the community made me think about how we communicate SLaM Clincian Identifying priority groups The Trust Mental Health Promotion Service worked with each of the teams to decide which population group they should prioritise for engagement by triangulating public health population data, team service usage information and staff views. For example MHOA identified people from African and Caribbean communities tend to present later to the service when their dementia is more developed. There is a double cause for concern as people from African and Caribbean communities tend to develop dementia earlier due to the increase prevalence of vascular disease, Hyper-tension and Diabetes, which are all significant risk factors for dementia. The service data suggested that people from African and Caribbean communities as significant users of the service, but the team felt that a key issue was late presentation to the service. Obtaining good information and data is important to inform engagement and good practice. However in some cases it was difficult to access the data around service usage either due to poor data collection or where it was just not readily available. Working with community partners The pilot project identified local community organisations that have good relationships with the priority groups identified. In partnership with the host organisations, a series of events and meetings were held to establish relationships and build trust. Examples include: Community event about OASIS and its services was held at North Brixton Islamic Centre Staff held a focus group at the Luncheon Club, and Southwark MHOA team members attended Black History Month event with Golden Oldies at Walworth Methodist Church Community conversations about barriers to engagement and how to overcome them was held at Croydon BME Forum with BME leaders Facilitated community meeting with Mummies Republic and Southwark IAPT team Open forum event held by Lewisham CAMHS to facilitate discussions with members of the community and organisations on how to improve services to meet their needs It was very good meeting with the Golden Oldies group in such a relaxed and not so formal setting. It was my first time to attend and I found it beneficial that my interactions were just spontaneous unplanned and open ended. SLaM Clinician Meeting with the groups raised a number of common issues. Some groups were sceptical about engaging with the Trust due to previous experience where they felt the Trust had consulted but not taken any action. Some of the groups and their communities were not aware of the Trust, or its services or if they did their knowledge was limited. Community leaders thought that their members (particularly Black men) were not seeking help because of stigma, taboo related to mental health and due to general mistrust of the system, which they defined as including health services, Criminal Justice and the Police. There was more trust in small BME voluntary groups, faith communities and organisations like MIND. Community leaders highlighted the high level of health inequalities existing among the BME groups in the localities. They emphasised, the importance of a holistic approach that takes into account and addresses physical health and the wider determinants and challenges to health that groups face, for example access to housing. 31 of 112

32 Developing an on-going dialogue It is important that an on-going relationship and dialogue is maintained with key local community organisations to address the existing impression that the Trust is not listening. For example the North Brixton Islamic Centre in Lambeth invited Oasis to make a presentation to its congregation, this is a significant invitation but it is only the first step, the mosque s expectation is it is a beginning of a relationship and not one off intervention. There is untapped rich knowledge and information within our local community groups, which are key local assets that could help improve mental health service engagement. For example one of the small community groups in Croydon working with young offenders from Black community is happy to share learning on how to engage and work with young men. Measuring success The following success criteria have emerged through discussion with pilot teams and communities: An increase in knowledge and confidence of Trust staff to engage diverse local communities Increased knowledge of community engagement approach in Trust staff An increase in links with local community groups Increased sense of trust in SLaM services Increased communication and awareness among the groups of SLaM services At the end of the pilot interviews/survey will be conducted with the link workers, pilot team managers and community partners to measure progress against the above criteria INTERIM RECOMMENDATIONS Community engagement should be integral and embedded within services and teams to improve patient care, experience and outcomes rather than be a separate service The link worker model should be continued and extended, but with the caveat that community engagement requires time and the commitment of the whole team/service. The approach should be for Teams to identify a few key community groups and develop an on-going and regular dialogue rather than one off contacts with a number of groups Any future rollout should follow a phased approach, initially focusing in key priority areas/teams/services to be identified in the final report. Resources will be required if the Trust wishes to roll out of the community engagement approach. The resource implications will be outlined in the final report due in April. There needs to be a dialogue with CCGs about how SLaM can be commissioned to undertake a community engagement to create the space and time needed Future training and support provided should include cultural competence training 32 of 112

33 Learning Lessons from Incidents, Inquests, Claims and Complaints - Quarter Two Report: 2016/17 TRUST BOARD OF DIRECTORS SUMMARY REPORT D Date of Board meeting: 22 December 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance) Author: Approved by: (name of Exec Member) Presented by: Learning Lessons Report Q2 Quality Lucy Stubbings Dr Neil Brimblecombe Dr Neil Brimblecombe Purpose of the report: To inform the Trust Board of Lessons Learned over Q2 with updates from recently concluded comprehensive (level 2) investigations. To ensure dissemination of good practice and to highlight lessons learned during Q2 Recommendations to the Board: Report contains information about incidents, complaints, claims and inquests within the Trust. To note the report and support identified actions. Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: This report relates to the following areas of the Assurance Framework: 1) Safety of patients, staff and public - Moderate 2 Failure to provide services in line with best practice - Moderate 3) Patient Experience - Moderate 4) Activity - Moderate 7) Estates Responsiveness - Moderate 8) ICT Infrastructure - Moderate Summary of Financial and Legal Implications: Financial risk if identified actions in service areas are not delivered. The report identifies information on operational performance and areas of concern. Equality & Diversity and Public & Patient Involvement Implications: As part of the management of investigations across the Trust the implications for patients, carers and othersare considered. Where there may be a specific impact on these groups this is managed during the course of the investigation. Service Quality Implications: Lessons learned are a catalyst for service improvement across the Trust. Learning from the most serious investigations is shared at a senior level and themes identified to enable a strategic and targeted response to areas requiring improvement. Page 1 of of 112

34 Learning Lessons from Incidents, Inquests, Claims and Complaints - Quarter Two Report: 2016/17 Learning Lessons from Incidents, Inquests, Claims and Complaints Quarter Two Report: 2016/17 Page 2 of of 112

35 Learning Lessons from Incidents, Inquests, Claims and Complaints - Quarter Two Report: 2016/17 Executive Summary 1. Introduction This is the aggregated report outlining details of and lessons learnt from serious incidents, complaints and claims within South London and Maudsley NHS Foundation Trust during the 2016/17 quarter 2 (Q2): July, August and September The data compiled for this report is from the Datix reporting database and is the data reported within Q2. 2. Summary of Serious Incidents Reported During Q2 Incidents may be re-graded once further information is received from the clinical area. Therefore there may be differences in the grades of incidents reported in later reports. Serious incidents are any incidents graded A-C. Figure 1 Incidents by Severity and Quarter Over the past three financial years the number of A and B grade incidents has remained relatively static with most variation in E and C grade incidents. Table 1 Q1 Serious Incidents by Severity and Borough 1 Brom Croy Lamb Lew Sout Ton Wand Bexl Green Total A - Death B - Severe C - Moderate Total The service borough location may differ from the patient s commissioner. Page 3 of of 112

36 Learning Lessons from Incidents, Inquests, Claims and Complaints - Quarter Two Report: 2016/17 Key Brom Bromley Ton Tonbridge Croy Croydon Wand Wandsworth Lamb Lambeth Bex Bexley Lew Lewisham Green Greenwich Sout Southwark Herts Hertsmere/ Three Rivers 3. Findings and lessons learnt from Serious Incidents Some Lessons Learned, when taken out of context, may appear tangential to the description of the incident. This is because they address root causes that have the potential to contribute to further adverse outcomes. Investigations are completed using root cause analysis, the purpose of which is not simply to identify human omissions or errors but also to consider underlying system failures that may have contributed to those omissions or errors making an eventual adverse outcome inevitable. These problems are more effectively addressed by remedying or eliminating their underlying causes, rather than treating the obvious symptoms associated with human error. 21 investigations were submitted to CCGs in Q2; 2 comprehensive and 19 concise. Figure 2 Submission of SI Reports to CCGs Of these 12 related to patient death, 2 absconsions and a delay in admission and two incidents of suspected arson. The majority of these were A grade incidents 51 recommendations were made from these investigations on the following themes: Page 4 of of 112

37 Learning Lessons from Incidents, Inquests, Claims and Complaints - Quarter Two Report: 2016/17 Figure 3. Themes of recommendations 4. Lessons from Comprehensive Investigations Concluding in Q2 The table below outlines an overview of recent board level inquiries within the Trust, themes and recommendations from these. Within each case actions have been identified for the recommendations given and are in the process of being completed. Table 2 Overview of Themes from Recent Comprehensive Investigations WEB39033: Psychosis, Lewisham CMHT - Confidentiality Breach [8 September 2015] Report received from investigator 1 March June 2016 ratified report sent to Lewisham CCG, response awaited. WEB41547: MHOA, Croydon CMHT - Suspected murder of patient [11 November 2015] Patient fell down the stairs at home and was killed. His wife arrest on suspicion of causing his death and has since been admitted to hospital on s2 Investigation signed off by SLaM BLI Part 2 6 April CSU report agreement 25 July The MHOAD CAG to provide further education to staff in recognising and responding to domestic abuse in older adults and where males are suspected to be the victims of female perpetrators. 2. A facilitated reflective learning event to take place at Croydon CMHT for Older Adults to support the team to reflect on the findings of the investigations and to create a CMHT action plan in relation to key areas. 3. Where the next of kin or carer are identified as being a potential safeguarding risk, practitioners to identify an appropriate alternative significant other to communicate with or involve an advocate, for example, an IDVA or IMCA if the person lacks capacity. 4. In CMHTs, the need for information to be recorded on assessment about who the patient wishes information to be shared with was identified. Due regard to be given to the patient as being the primary person that all communications are addressed to unless the patient has indicated otherwise or does not have full capacity, 5. All Trust CAGs to ensure that all staff are aware of up to date information, policy and guidance available on the SLaM Intranet Safeguarding pages and to ensure that staff have access to robust and timely safeguarding expertise in the CAG. 6. To review the management support structures in Heavers CMHT for medical, health Page 5 of of 112

38 Learning Lessons from Incidents, Inquests, Claims and Complaints - Quarter Two Report: 2016/17 and social care when incidents are escalated within the team 7. To have follow up with individual practitioners regarding their role in the care and treatment of the patient in this case. 8. The Trust to write to Croydon Adult Social Care to outline the areas of concern raised by the investigation. WEB41588: BDP/Addictions, Bexley/Signpost Suspected Homicide involving four service users [18 November 2015] Patient fell from bedroom window, denied that this was an attempt to end his life Investigation concluded. Report revised following BLI Part 2 strategy meeting 27/07/ /08/2016 CAG challenges to the report preventing its progress to the CCG/Local Authority WEB43532: BDP Corydon Community Forensic Team Suspected poisoning of an infant [11 January 2016] Patient recently given an absolute discharge from s37/41 was arrested and charged with GBH Investigation concluded. Signed off subject to amendments at BLI Part 2 16 June Sent to CSU for evaluation/agreement August Feedback awaited. WEB44925: Psychosis, Nelson Ward Suspected suicide of sectioned inpatient, AWOL from a ward. [17 February 2015] Investigation concluded. Signed off subject to amendments at BLI Part 2 strategy meeting 12 August Sent to CCG for evaluation/agreement August Feedback awaited. WEB44400: Psychosis, Southwark High Support Team/The Dene Suspected suicide of sectioned inpatient.[31 January 2016] Investigation underway to be presented at BLI Part 2 strategy meeting 4 October 2016 WEB46281: Psychosis, Powell Ward Suspected suicide of sectioned inpatient, AWOL from a ward. [26 March 2016] Investigation scheduled to conclude September 2016 WEB47877: BDP, Norbury Ward/Croydon University Hospital AWOL of a patient detained under section 37/41 [10 May 2016] Investigation scheduled to conclude September 2016 WEB47938: Investigation scheduled to conclude September 2016 WEB48508: Psychosis, John Dickson Ward escape onto the roof of the Maudsley Hospital. [10 May 2016] Investigation scheduled to conclude September 2016 WEB48644 Investigation underway. WEB51397: Psychosis/MAP/Psych Med Maternal Death [17 August 2016 Investigation underway. WEB51536: EDU suspected suicide 5. Summary of Lessons Learned from Inquests in Q1 There were 14 inquests completed, 2 of which lasted 2 days or more and 1, the CB Inquest, lasted 7 days. Staff were required to attend 11 of the hearings - 33 witnesses in all. Reports and statements from 11 other Trust witnesses were read into the evidence at the various inquests. Two other inquests due to be heard in this period were adjourned to dates to be set. There still remain 112 inquests outstanding. The Trust were also involved in 3 Pre-Inquest Reviews at the Coroner s Court. A Pre- Inquest Review is a preliminary hearing to decide the issues to be considered at the Inquest and the evidence and documents required. Page 6 of of 112

39 Learning Lessons from Incidents, Inquests, Claims and Complaints - Quarter Two Report: 2016/17 Coroners are continuing to investigate these cases in great detail resulting in greater scrutiny of the Trust s systems and practices and more information, documents, records and policies being required. A large number of reports/statements are being requested as a result and more witnesses being required to attend court. An SUI investigation is carried out in most of the cases that result in an inquest involving the Trust and in the majority of these Coroners are requesting that at least one of the authors of the reports attends to give evidence on their investigation and their findings, criticism and recommendations, together with a witness to deal with the implementation of the recommendations in the Action Plans. As a consequence of the increased scrutiny the Trust are being declared an Interested Person in the majority of inquests which means that the Trust may be open to criticism and subject to a potential Preventing Future Death report by the Coroner. As an Interested person the Trust can take an active role in the Inquest by viewing all the evidence, crossexamining witnesses and making representations and submissions to the Coroner. Legal representation is therefore being required in a greater number of cases. In the CB inquest the Coroner decided that there were several failures in the care and treatment provided that amounted to Neglect (failures that more than minimally contributed to a patient s death). The Trust were able to show that lessons had been learnt with several changes to practice having been put in place before the inquest. No Preventing Future Death (PFD) reports were issued in this quarter, although in the CB Inquest the Coroner asked for submissions before considering making a PFD report. The Coroner s decision on this is still awaited. 6. Analysis of serious incidents in Q1 The recorded sub-categories of incidents are used to provide more detail and specific information about the exact nature of the incident. This information allows themes to be identified. Table 3 A Grade Incidents by Category and CAG Acute Add BDP CAMHS MHOAD PMIC Psych Total Probable Suicide Natural Causes Death Due To Accidental Overdose Homicide (Murder) BY Patient Alleged Murder OF Patient Total CAMHS suicide reported under STEIS. Of the probable suicides reported in PMIC and MHOA some occurred pre presentation. The Homicide (Murder) by Patient was notified on STEIS, however the incident is currently on hold as the patient has been bailed to their home address. Probable suicides drilled down 7 incidents were not notified on STEIS under the categories highlighted below. Page 7 of of 112

40 Learning Lessons from Incidents, Inquests, Claims and Complaints - Quarter Two Report: 2016/17 Table 4 Sub Category of Probable Suicide Current Community Patient Under Care Of SLaM Services 2 In-Patient But Incident NOT On Ward 1 Patient's Death 6 Months Post Discharge From All SLaM Services 5 Patient's Death Within 6 Months Of Discharge From all SLaM Services 7 Referred To SLaM services - Not Yet Seen 1 Grand Total 16 Table 5 B Grade Incidents by Category and CAG Acute BDP CAMHS MHOAD PMIC Psych Corp Total Tribunals Abscond - Sectioned Patient Assault By Patient Attempted Suicide Patient Information Prescribing Of Medication Actual Self-Harm Administration Or Medication On Clinical Units (Wards & HTT's) Incorrect Hospital Stated On AMHP Application Patient - Fire (Inc. Fire Alarms) Assault By Other (e.g. Visitor, Member Of Public) Security - Contraband/Prohibited Items Challenging Behaviour Sexual Assault By PATIENT Issuing Of Medication From Clinical CMHT's & HTT's Patient Unwell/Illness Patient - Unknown Injury Sexual Assault By OTHER Patient Monitoring (Including Pressure Ulcer/Wound) Total of the above incidents were not reported on STEIS as they did not meet the category for patient safety incidents. E.g. patient on staff assault. 2 x of a serious case review involving SLaM for a patient who was not known at the time of the incident. 1 incident reported combining two b grade incidents Page 8 of of 112

41 Learning Lessons from Incidents, Inquests, Claims and Complaints - Quarter Two Report: 2016/17 Table 6 Top ten reported C grade Incidents by CAG Acute Add BDP CAMHS MHOAD PMIC Psychosis Total Assault By Patient Challenging Behaviour Actual Self-Harm Staffing Issue (Including Staff Unwell/Illness) Abscond - Sectioned Patient Administration Or Medication On Clinical Units (Wards & HTT's) Patient Unwell/Illness Assault By Staff (Inc. Alleged) Patient Information Attempted Suicide Total Over the past three financial years, the highest reported category of C grade incidents has been Assault by Patient which has been the highest reported category throughout the time period. Figure 4 Top five reported C grade Incidents 2014/ /17 7. Notification of serious incidents The Patient Safety team and CAGs review reported incidents on Datix to ascertain if they are notifiable to the CCG using the Serious Incident Framework (NHS England 2015). The Trust uses the Strategic Executive Information System (STEIS) to ensure that key external stakeholders are promptly notified of the most serious incidents. Incidents notified on STEIS are subject to a 60 day timeframe for investigation. Concise investigations (level 1) are conducted internally to the CAG but externally to the service area. Comprehensive investigations (level 2) are conducted externally to Page 9 of of 112

42 Learning Lessons from Incidents, Inquests, Claims and Complaints - Quarter Two Report: 2016/17 the CAG and are led by the Trust s Investigation Facilitators. These are subject to two Board Level Strategy meetings to plan and sign off the investigation report, after which the ratified report is shared with the CCGs. A 72 hour report is compiled and sent to the commissioners following notification of the incident. The Trust Fact Finding report is used as the foundation of these reports. During Q2 32 incidents were reported on STEIS. Table 2 Incidents notified on STEIS by Category and CCG leading oversight Lambeth Croydon CCG CCG Lewisham CCG Southwark CCG Total Comprehensive (Level 2) Assault By Patient Homicide (Murder) BY Patient Patient Information Probable Suicide Concise (Level 1) Abscond - Sectioned Patient Administration Or Medication On Clinical Units (Wards & HTTs) Assault By Patient Attempted Suicide Challenging Behaviour Death Due To Accidental Overdose Natural Causes Patient - Fire (Inc. Fire Alarms) Patient - Medical Devices & Equipment Patient Records Patient Unwell/Illness Prescribing Of Medication Probable Suicide Security - Contraband/Prohibited Items Total Of the comprehensive investigations one of these is on a Stop the Clock. 8. National Reporting and Learning (NRLS) System The Trust uploads anonymised patient safety incidents onto the NRLS on a weekly basis. This data is used by NHS England and other agencies as a useful benchmarking tool. Clinicians and safety experts within NHS England analyse the information provided to identify common risks to patients and opportunities to improve patient safety. Page 10 of of 112

43 Learning Lessons from Incidents, Inquests, Claims and Complaints - Quarter Two Report: 2016/17 The table below provides an overview of the Type of incident reported to NRLS in Q2. Table 3 NRLS Reported Incidents in Q2 Type Violence/Aggression/Assault 236 AWOL/Abscond/Failed To Return 241 Clinical Care (Inc. Substance Misuse/Pressure Ulcer/Wound) 141 Medication 122 Self-Harm 197 Death 8 Patient Accidents/Health & Safety/Fire 202 Staff Accidents/Health & Safety/Fire 0 Security 43 Confidentiality/IT/Health Records 51 MHA Breach 32 Staff Issues 154 Totals: Other Areas Monitored by the Patient Safety Team 9.1. Pressure Ulcers All reported pressure ulcers during this quarter were from the MHOAD CAG. There has been further refinement of the sub category used to report pressure ulcers to ensure it is adequately distinguished where the pressure ulcer was acquired. There were 3 pressure ulcers reported in this quarter, each has been reviewed, a care plan put in place and the wound monitored with support from tissue viability services. Table 4 Reported pressure ulcers in Q2 Pressure Ulcer - Acquired In SLaM Care Total Grade 1 - Skin Red And Intact 1 1 Grade 2 - Partial Skin Thickness Of Dermis 2 2 Total Safeguarding Adults Q1 Table 5 Safeguarding Adult identified in incident 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 Total Acute Care Addictions Behavioural & Developmental Psychiatry Child and Adolescent Mental Health Services MHOA and Dementia Psychological Medicine & Integrated Care Psychosis Corporate Total Page 11 of of 112

44 Learning Lessons from Incidents, Inquests, Claims and Complaints - Quarter Two Report: 2016/ Safeguarding Children Q1 Table 6 Safeguarding Children identified in incident 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4 16/17 Q1 16/17 Q2 Total Acute Care Addictions Behavioural & Developmental Psychiatry Child and Adolescent Mental Health Services MHOA and Dementia Psychological Medicine & Integrated Care Psychosis Corporate Total The Trust has identified leads in each of the CAGs for Safeguarding Adults and Children. Reported incidents are reviewed by the leads and CAG teams to ensure appropriate action is taken if the incident does not lead to a safeguarding inquiry or referral. 10. Summary of Claims Received during Q1 Table 7 Claims by Type and CAG in Q1 CNST Public liability Staff Total Acute Care Behavioural & Developmental Psychiatry Psychological Medicine & Integrated Care Corporate Total Figure 2 Overview of Claims Page 12 of of 112

45 Learning Lessons from Incidents, Inquests, Claims and Complaints - Quarter Two Report: 2016/ Summary of Complaints Received in Q2 Table 8 Complaints by CAG Q2 Figure 3 Complaints by Borough and Subject (primary) 12. Central Alerting System Alerts Of the alerts received in Q2, 12 were in relation to patient safety issues. 9 alerts resulted in completed actions or it was deemed that action was not required, 3 remain open as assessing relevance or action is on-going. Page 13 of of 112

46 TRUST BOARD OF DIRECTORS SUMMARY REPORT E Date of Board meeting: 20 th December 2016 Name of Report: Heading: Author: Approved by: (name of Exec Member) Presented by: Public and Patient Involvement Policy Quality Kay Harwood/Kathryn Hill Dr Neil Brimblecombe, Director of Nursing Amanda Pithouse, Director of Patient Experience and Quality/ Deputy Director of Nursing Purpose of the report: To present the Trust Patient and Public Involvement Policy which sets out a high level policy and framework, outlining the principles for involving people who use services, their friends, families and carers and members of the public Recommendations to the Board: The Board is asked to approve the content of the report Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: SO5 Clinical Transformation High Summary of Financial and Legal Implications: Not specifically applicable to the report Equality & Diversity and Public & Patient Involvement Implications: The Involvement Policy confirms the Trust s commitment to involve people who use services and their friends, families and carers and members of the public Service Quality Implications: The Involvement Policy delivery plan will be closely aligned to the QI programme and will allow involvement of people who use services, family friends and carers and members of the public to be embedded within the Trust at all levels. 46 of 112

47 Patient and Public Involvement Policy Version: 1 Ratified By: Date Ratified: Date Policy Comes Into Effect: Author: Responsible Director: Responsible Committee: Target Audience: Review Date: Trust Board TBC TBC Kay Harwood/Kathryn Hill Amanda Pithouse/Altaf Kara EPIC/Friends and Family Service users, Carers, members of the public, staff TBC Equality Impact Assessment Assessor: Macius Kurowski Date: 16/12/2016 HRA Impact Assessment Assessor: Anthony Konzon Date: 16/12/2016 PPI Policy version 1 12/16 Page 2 of of 112

48 Version Control Document History Version No. Date Summary of Changes Major (must go to an exec meeting) or minor changes Author Consultation Stakeholder/Committee/ Group Consulted PPI Leads Meeting Friends and Family Date 29/11/16 17/11/16 Changes Made as a Result of Consultation Service Users/Carers consulted Date Changes Made as a Result of Consultation Plan for Dissemination of Policy Audience(s) Dissemination Method Paper or Electronic Person Responsible Key changes to policy: PPI Policy version 1 12/16 Page 3 of of 112

49 Contents 1. Introduction Definitions Purpose and Scope of the Policy Roles and Responsibilities Main Body Of The Policy Describing Policy Specific Information Freedom of Information Act PPI Policy version 1 12/16 Page 4 of of 112

50 1. Introduction The Trust has long recognised the importance of involving service users, their friends, family and carers, staff, the public and all stakeholders in the planning and delivery of services. While many people have worked hard over the years to embed good practice of involvement we recognise that our response has been variable. As this policy is about both patient and public involvement it initially sets out the guidance, legislation, values and the levels of involvement [ladder of participation] that is common to both; and is followed by two distinct sections; Section A focusing on public involvement and Section B focusing on patient involvement. Both public and patient sections of the policy set out our levels and standards for involvement, by which we will hold ourselves to account, and so that people who have an interest in the services provided by the Trust can participate in a meaningful way. At the heart of our approach to successful involvement we recognise that relationships between service users and those who deliver services should be based on the concept of No decision about me without me. Our purpose Everything we do is to improve the lives of the people and communities we serve and to promote mental health and wellbeing for all. This is in keeping with our five commitments, which all staff employed by the Trust are expected to demonstrate in all their interactions with service users, their friends, families and carers, the general public and each other. Our five commitments To be caring, kind and polite To be prompt and value your time To take time and listen to you To be honest and direct with you To do what I say I m going to do 2. Guidance and Legislation The NHS Constitution, which was updated in 2013 in the light of the Health and Social Care Act (2012) and the findings of the Francis Report (2013), sets out the principles and values of the NHS in England, and details the rights of patients, the public and staff. The following extracts in the Constitution set out clear expectations around the importance of involvement: NHS Values: The value of working together for patients is a central guiding service provision in the NHS and other organisations providing health services. Patients must come first in everything the NHS does. All parts of the NHS system should act and collaborate in the interests of patients, always putting patient interest before institutional interest, even when that involves admitting mistakes. As well as working with each other, health service organisations and providers should also involve staff, patients, carers, local communities to ensure they are providing services tailed to local needs. Principle 5: The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population. PPI Policy version 1 12/16 Page 5 of of 112

51 A duty to consult the public Section 242(1B) of the National Health Service Act 2006 as amended by the Local Government and Public Involvement in Health Act 2007, provides as follows: Each relevant English body must make arrangements, as respects health services for which it is responsible, which secure that users of those services, whether directly or through representatives, are involved (whether by being consulted or provided with information, or in other ways) in: (a) The planning of the provision of those services (b) The development and consideration of proposals for changes in the way those services are provided (c) Decisions to be made by that body affecting the operation of those services. Subsections (b) and (c) need only be observed if the proposals would have an impact on: The manner in which the services are delivered to users of those services; or The range of health services available to those users Equality Act 2010 The Trust recognises the importance of engagement with service users, carers, the public and communities on equality considerations relating to access, experience and outcomes. The Trust also recognises the importance of encouraging participation and involvement of underrepresented groups. This is at the heart of both advancing equality of opportunity and enhancing experience and outcomes through achieving the benefits of diversity. The Five Year Forward View for Mental Health [Feb 2016] states: The Trust is committed to ensuring there is Co-production with clinicians and expertsby-experience. This should be at the heart of commissioning and service design, and involve working in partnership with voluntary and community sector organisations. Applying the 4PI framework of Principles, Purpose, Presence, Process and Impact developed by the National Survivor and User Network will help ensure services or interventions are accessible and appropriate for people of all backgrounds, ages and experience. 3. Purpose and Scope of the Policy The purpose of this policy is to provide a clear framework for involvement at all levels. This policy applies to all employees of the Trust including Non-Executive Directors, Governors, bank staff, temporary staff and volunteers, individuals on secondment, placement and trainees. The Trust aims to ensure that the services we provide are of high quality and that they are delivered in a comfortable, caring compassionate and safe environment, while operating in a constantly changing landscape. This new landscape has highlighted the importance of having common principles to the continuing development of involvement opportunities. PPI Policy version 1 12/16 Page 6 of of 112

52 The Participation Ladder (NHSE) There are many ways in which service users, their friends, families and carers and members of the public can participate both formally and informally. The level of involvement will depend on personal circumstances and interest. The level of involvement will also depend on the type of involvement activity being undertaken within the system. All involvement activity on each step of the ladder is valuable although participation will be more meaningful the higher up the ladder it sits. Devolving Collaborating Involving Consulting Informing Placing decision making in the hands of the community and individuals e.g. Personal Health Budgets Working in partnership with communities and service users and carers in each aspect of the decision including the development of alternatives and the identification of the preferred solution Working directly with communities and service users and carers to ensure that concerns and aspirations are consistently understood and considered e.g. partnership boards, reference groups Obtaining community and individual feedback on analysis, alternatives and or decisions e.g. surveys, focus group Providing communities and individuals with balanced and objective information to support decision making Overall principles the Trust will work to Quality Improvement involvement demonstrably improves the quality of services and outcomes for people who use services Diversity the diverse range of people who use services and carers and seldom heard voices are actively engaged with Widening Participation involvement opportunities are shared widely to maximise the benefit Flexibility opportunities are flexible as people s health and availability fluctuate Wellbeing involvement contributes to recovery and wellbeing Empowered users coproduction and equal access to participation are embedded in all aspects of involvement through service user choice and not staff delegation Respect and Collaboration - participants will treat each other with respect and collaborate openly and with transparency, working within an agreed Code of Conduct which all participants will adhere to PPI Policy version 1 12/16 Page 7 of of 112

53 Connectivity through the sharing of themes, data and best practice across all levels of the Trust 4. Roles and Responsibilities This policy is owned by: The Director of Patient Experience and Quality The Director of Strategy and Commercial 5. The Policy 5.1. Section A: Public Involvement Introduction This section of the policy sets out the framework and standards relating to engagement and involvement with the public. In this document the word public includes, but is not limited to, service users, their friends, families and carers, the Trust membership, staff, members of the public, partner organisations, voluntary groups and communities. We want to hear the voice of service users and the public and to ensure that they have opportunities for involvement. There are many ways that people can be involved in the work of the Trust, including As a Governor Foundation Trust membership Attending our Annual Public Meeting and other public meetings that may be arranged for a specific purpose Sending comments, complaints and compliments Responding to surveys Posting on NHS Choices website Volunteering Responding to formal consultation Through the service user/carer involvement structures Framework When planning involvement staff should always consider how to work to strengthen relationships and build mutual trust with stakeholders. The following sets out expected standards when involving the public: Involvement standards: These standards set out a level of expectation of all staff who are responsible for involvement and engagement activities: Be clear about the purpose and scope of the engagement activity describing exactly what you would like feedback on, and what can change or not change Be clear about what expectations there are of the service user or public role, at each level of participation: What perspective is the individual expected to bring: their own experience as a service user or carer; representing a community of interest; representing a service user group/organisation or as a member of the general public? What time commitment and activity is expected, including meetings/events and actions between meetings/events? PPI Policy version 1 12/16 Page 8 of of 112

54 What are the confidentiality requirements of meetings? Consider who you need to reach as well as working with familiar/existing groups and networks. The Trust recognises the importance of and the need to go out to different locations to meet with and hear from seldom heard individuals and communities. Ensure that adequate resources to support involvement activities are identified. Good communication is paramount to ensure: A proactive and open approach, sharing information and emerging issues in a timely manner. The use of a variety of methods, appropriate to the context and circumstance, to convey key information. Honesty, openness and support Regularly check both your understanding of what you have heard and the understanding of stakeholders you are involving Listen carefully, exploring options and alternatives to achieve the best outcomes. Provide timely feedback that continues to keep stakeholders fully informed of progress. All events should have a transparent and workable evaluation and feedback process. This is to collect helpful feedback on involvement activity and to enable those involved to raise any issues. Always value the expertise, contributions and time of stakeholders Levels of the framework Systematic practice and a well-organised and thoughtful approach to public involvement is essential. Working within a framework enables us to be consistent, as well as improving transparency and accountability to our stakeholders. Level Arenas Activity Service Ward / team level Involvement in service delivery and redesign Operational CAG level Involvement in: Service delivery and redesign Pathway redesign Equality Impact Assessment to consider if a planned change may impact some groups of people [protected characteristics] more than others and prompts consideration of what can be done to mitigate this Trigger templates to identify who needs to be involved in a planned change Public consultation Strategic Trust-wide level Public consultations around major changes to service configuration Service delivery and redesign Relocation of services Trigger templates [see above] Equality Impact Assessment [see above] Strategy development PPI Policy version 1 12/16 Page 9 of of 112

55 5.2. Section B: Patient Involvement Introduction For the purpose of this section the word service user and carer relates to people who use services and their friends, families and carers. This section of the policy sets out a framework for patient involvement which uses: a) The 4PI National Standards for Involvement which is evidence and best practice based and can apply to an overall vision, strategy or policy as well as a single involvement activity such as being part of a selection and recruitment panel or helping with a consultation b) The Trust involvement Strategy as this sets out a number of must do s over the life time of the strategy that will improve the involvement experience of people who use services and their friends, families and carers Framework The 4PI National Standards for Involvement The 4PI framework was developed by mental health service users and carers and aims to share good practice and hard wire the service user and carer voice into the planning, delivery and evaluation of health and social care services. The Trust board signed up to the 4PI National Involvement Standards in September Principles Purpose Presence Process Impact There is a shared understanding about involvement underpinned by shared values Everyone understands why they are involved and there is clarity and transparency on decision making and authority A diverse range of service users, their friends, families and carers are involved at all levels in the organisation and are reflective of the local community Service users, their friends, families and carers are enabled to make the best contribution possible The Trust is able to demonstrate the impact/outcome of involving service users, their friends, families and carers The Trust Involvement Strategy The Trust Involvement Strategy was ratified by the Board in February 2016 and sets out how the Trust will involve people who use services and their friend s families and carers at a: Involvement in own care level Service level Operational level Strategic level Monitoring and evaluation PPI Policy version 1 12/16 Page 10 of of 112

56 By implementing the strategy the Trust will ensure that service users and staff are working together in co-production; service users are informed about and involved in their care and treatment, are treated with dignity and respect ensuring they feel they have a say in decisions about their care and treatment. The aims of the Involvement Strategy are: Ensuring that service users have a voice in decisions about their care and treatment. No decision about me without me. Making certain that peer support, co-production and self-management are central to the daily experience of treatment and care Using direct feedback from service users through a system to improve these services Ensuring service users are routinely given opportunities to participate meaningfully in the planning, commissioning and delivery of these services That the relationship between service users and those who deliver services is based on mutual respect for lived experience and professional knowledge That service users who come from groups whose voice is seldom heard are specifically supported to participate meaningfully in their own care and in the life of the Trust The Levels of Involvement This section of the policy sets out how the framework will operate in practice, where it is likely to happen and what the involvement activities might be (this is not an exhaustive list). Level Arenas Activity Involvement in Own Care Ward/team Level Shared decision making, active partner in care, treatment, and support, lived experience valued, person centred with compassion, care given at right time, right place, timely and accessible information self-management, peer Service Level Pathway, team/ward forums. support Service design, monitoring and evaluation, delivering training, consultation, service delivery, governance, recruitment and selection Operational Level CAG Wide Forums Service design, monitoring and evaluation, delivering training, consultation, service delivery, governance, recruitment and selection Strategic Level Trust wide Forums, Board meetings. Service design, monitoring and evaluation, delivering training, consultation, service delivery, governance, recruitment and selection There are a range of other activities which can support and inform these four levels of involvement such as Recovery College, Involvement Register, Service User Involvement and Training and Education (SUITE) and the Volunteering Service. The PPI Policy version 1 12/16 Page 11 of of 112

57 Trust recognises that these activities will evolve over time and therefore will continually be under review. 6. Monitoring Compliance What will be monitored i.e. measurable policy objective Method of Monitoring Monitoring frequency Position responsible for performing the monitoring/ performing co-ordinating Group(s)/committe e(s) monitoring is reported to, inc responsibility for action plans and changes in practice as a result Section A: Public Involvement Production of delivery plan Audit Committee where there will be a regular item on external relationships Section B: Patient Involvement EPIC/Family and Carers Committee Outline of Delivery Approach Group set up to agree a consensus statement on involvement in own care 7. Freedom of Information Act 2000 All Trust policies are public documents. They will be listed on the Trusts FOI document schedule and may be requested by any member of the public under the Freedom of Information Act (2000). PPI Policy version 1 12/16 Page 12 of of 112

58 TRUST BOARD OF DIRECTORS SUMMARY REPORT Date of Board meeting: 20 December 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance) Author: Approved by: (name of Exec Member) Presented by: Performance and Finance Report Performance and Finance Martin Black, Performance & Contracts Kristin Dominy, Chief Operating Officer Gus Heafield, Chief Financial 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 112

59 PERFORMANCE & FINANCE REPORT: October 2016 Performance Reviews and provisional November 2016 NHSI Indicators Executive Summary The report this month covers performance against key targets and financial performance. The report summarises the Trust s Performance Management Framework, identifies key issues and actions arising from the CAG Performance reviews for October and highlights risks and potential risks to performance NHS Improvement Indicators. 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. A brief summary of progress in relation to contract negotiation process is provided. Contents: 1. NHS Improvement Single Oversight Framework (SOF) Indicators 2. Finance 3. CAG Performance Reviews Summary 4. Safer Staffing 5. Commissioning and Contracts Summary 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 59 of 112

60 1. NHS Improvement indicators: November Provisional Performance The Trust s provisional performance 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 % Performance Pending: The following indicators are pending validation for November at the time of writing. Early Intervention Psychosis is due for submission on 19 December. 7 Day Follow up is currently being validated. Note: October s performance for 7 day follow up has been revised following audit to 95%. The most recent performance for these indicators is outlined in the table below. Table 2: NHSI Indicators % Performance 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. The development of reporting infrastructure and performance improvements in 2016/17 specified in the CQUIN is progressing well. Completeness Priority indicators (formerly outcomes) The Mental Health Services Data Set (MHSDS) indicator 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 2016/17. This is detailed within the risk section below of 112

61 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 since July has continued to exceed the Trust recovery trajectory and the 50% standard by a significant margin. The submission for November data is 19 December. 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 performance has exceeded the threshold in each of the previous three months. In October the implementation of the new 24-hour central triage function with embedded HTT went live. There continue to be further service developments within Home Treatment. 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 August figure of 48.4% and internal reporting indicates that the Trust is also below the 50% national standard. Performance improved in October (47.3% against the target of 50%), provisional performance in November was lower at 45.8%. It is anticipated recovery rates will continue to progress over the year as in previous years. A jointly agreed action plan is in place with Southwark CCG. Lewisham also has an action plan in place with the CCG for improving recovery and is on trajectory of 112

62 Chart 3: IAPT Recovery Rate The overall Trust result is based on all patients regardless of their responsible commissioner. MH Priority Indicators This risk in relation to this indicator is the implementation of the new minimum dataset earlier this year. Whilst Mental Health Services Dataset (MHSDS) submissions extract tool Ver. 2.7 has now been delivered by the AHC (PJS supplier) there are quality issues identified which need to be jointly rectified. The Business Intelligence has continued to work to improve data accuracy and is liaising closely with NHS Digital as the completeness of data impacts on the accuracy of both published statistics and experimental statistics of 112

63 2. Finance Performance Introduction Given the early nature of the Board meeting this month, the finance report has been incorporated within the Performance section of the Board agenda. Headlines & Key Issues At Month 8 the Trust remains on plan, reporting a deficit of 2.8m (after application of the Sustainability Fund). This represents a favourable YTD variance of 0.65m against our deficit control total and a favourable movement in the month of 0.3m. The favourable movement was largely due to invoicing NHSE for the element of QIPP that we believe should be returned under our risk share arrangement. Overall CAG and infrastructure services were 107k over in the month ( 3.7m YTD after transferring 3.6m of lock ins) but there remains a large Trustwide CIP target, held centrally, against which the Month 1-6 lock ins have been allocated. Although the Trust is currently on Plan, it is important to remember that the phasing of the Plan is such that 97% of the deficit was planned for the first six months. Each month a forecast position is estimated to ensure we are still on track to deliver and to highlight areas of risk. This forecast has been updated to take account of latest positions and information as at the beginning of December. The financial summary table in the section below highlights both the YTD and forecast position by service. The overall forecast continues to be that the Trust will meet its deficit control total. However within this there are number of risks and assumptions that need to be addressed or met. The main ones are highlighted below The use of adult acute/picu beds has fallen for the fourth month in a row and is reflected in a reduction in use of overspill beds. There was a reduction in overspill of 8 beds in the month (35 in the last 3 months) with further reductions expected in month 9. The forecast assumes a continued drop in overspill into the new year resulting in a forecast overspend of 3.7m (after taking account of CCG risk shares agreements). This forecast is underpinned by the work being undertaken in the new Acute Care Pathway CAG to eliminate overspill. However, despite this work, there remains a clear risk that overspill will not fall as expected with risk share arrangements only providing partial mitigation. 10.1m of CIPs are planned to be delivered as part of a Trustwide set of schemes. The majority of these schemes (88% by value) were not due to deliver until the second half of the year but it is clear that some schemes have slipped or are not expected to deliver the value of saving originally envisaged. In order to meet the deficit control total as set out in this forecast, we have built in some scope to mitigate against the risks of not achieving the full saving but this is limited, non recurring and requires continued progress against the 14 Trustwide schemes identified. The Trust needs to agree the share of risk on the savings proposal to reduce NHS England s use of external forensic placements. Currently 1m has been removed from the SLaM contract. The expectation in the forecast is that the majority of this 1m will either be saved or be returned by NHSE under the risk share agreement. Discussions continue with NHSE to establish the position. Other Commissioner issues are assumed to be resolved with no detrimental impact to the Trust. In particular, the savings required to bridge the funding shortfall on the Croydon CCG contract are expected to be made in full or recovered under the risk arrangements in place. The Trust is also expecting a satisfactory resolution to the funding of CAMHS Transformation work being undertaken in Croydon, where 6 63 of 112

64 commitments made to use 2015/16 ring fenced funding in 2016/17 are under discussion. In Southwark, risk share and QIPP arrangements with the CCG around placements are expected to be upheld in line with contract discussions. It is expected that all CCGs will honour risk share arrangements around acute OBD activity which are estimated to cost 1.5m YTD. Finance Analysis 1) Financial Summary Service Analysis Full Year Live Budgets ( ) Monthly Figures Current Month Actual( ) Variance From Live Budgets ( ) Year to Date Figures Year To Date Actual ( ) Variance From Live Budgets ( ) As At Mth 8 Forecast Variance ( ) 01. Psychosis 51,268,900 4,367, ,900 34,894, ,000 1,200, Acute Care Pathw ay 50,929,700 4,242,600 70,200 37,924,800 3,678,200 4,785, P Med & Integrated Care 169, ,900 (38,600) 271,800 91, , Behavioural And Dev. Psych (400) 30,300 29,400 34,800 37, , Child & Adolescent Service 356,500 (15,400) (142,000) (749,600) (632,300) (366,000) 06. MHOA And Dementia 317,700 9,100 (31,200) 23,200 (125,200) (211,000) 07. Addictions 300 (8,600) (8,600) 61,700 61,500 50, Clinical Support Services 2,178, ,700 25,900 1,483,000 19,800 (65,000) 09. Infrastructure Directorates 54,767,900 4,629,500 85,600 36,154,800 (9,600) 913, Corporate Income (101,455,500) (9,023,200) (548,900) (67,692,900) (200,600) 136,000 Operational Deficit 58,533,300 4,553,900 (442,300) 42,405,700 3,486,200 6,937, Corporate Other (80,136,400) (6,326,600) 975,000 (49,258,600) 1,983, , Contingency - planned 2,000,000 0 (166,667) 0 (1,333,333) (2,000,001) 14. Other reserves/provisions 6,457,100 0 (598,333) 0 (4,822,867) (4,739,999) Corporate Other (71,679,300) (6,326,600) 210,000 (49,258,600) (4,172,800) (6,187,000) EBITDA (13,146,000) (1,772,700) (232,300) (6,852,900) (686,600) 750, Post EBITDA Items 19,638,000 (133,200) (1,497,300) 9,690,700 (2,691,900) (11,570,000) Trust Financial Position 6,492,000 (1,905,900) (1,729,600) 2,837,800 (3,378,500) (10,820,000) Items Not Included In NHSI Target (3,931,000) (43,000) 0 (344,000) 2,720,000 10,820,000 NHSI Target 2,561,000 (1,948,900) (1,729,600) 2,493,800 (658,500) 0 Area 2016/17 Mth 4 Variance /17 Mth 5 Variance /17 Mth 6 Variance /17 Mth 7 Variance /17 Mth 8 Variance /17 Total Variance 000 CAGs (413) (928) 761 (1,386) 5 (3,676) Infrastructure Directorates 295 (30) 444 (435) (111) (11) Corp Income (662) (48) (10) (319) Other reserves/provisions (56) (43) (1,826) 1,176 (975) (1,983) released Use of Reserves 404 1, , ,156 Total EBITDA (432) 214 (42) of 112

65 2) Key Cost Drivers (unmitigated by alternative income, risk shares etc.) Area 2016/17 Mth 4 Variance /17 Mth 5 Variance /17 Mth 6 Variance /17 Mth 7 Variance /17 Mth 8 Variance /17 Total Variance 000 Ward Nursing* (9) (219) (279) (157) (162) (1,171) Agency 20%** (315) (287) (313) (328) (300) (2,496) Acute Overspill**** (795) (1,011) (815) (357) (247) (4,639) Unmet CIPs*** (336) (355) (244) (1,387) (1,151) (4,300) Placements**** (13) (31) (127) (88) (88) (691) Total (1,468) (1,903) (1,778) (1,998) (1,948) (13,297) * includes safer staffing funding ** Costs built into the plan ***see Section 3 **** before application of risk shares Performance against the main cost drivers is detailed below Acute/PICU Overspill Overall 27 overspill beds were used by the Trust in November, a decrease of 8 compared to the previous month. This is still 20 beds above our original plan which envisaged only using 7 external PICU beds at this stage. In total, acute/picu overspill are now 4.6m YTD off plan excluding the impact of any risk shares. The aim is to bring overspill back in line with the original plan by January/February. The forecast net cost (after risk shares) of not meeting the original target is c 3.7m. The use of all acute/picu beds (internal and external) by CCG is shown in the tables below: The position continues to improve with a net reduction in beds used of 46 since July although the number of beds being purchased by LSL&C CCGs is also planned to reduce over the remaining 5 months from 312 in November to 305 by March of 112

66 Use of Agency Staff Plans to reduce agency expenditure are one of the conditions attached to accessing the NHSI Sustainability and Transformation Fund. For SLaM, NHSI have set a ceiling to spend no more than 17.4m on all agency staff. Based on this target the Trust has spent 14.9m YTD compared to a target of 13.6m. The gap between actual and ceiling continues to increase (by 0.5m in the month). Although the Trust continues to focus its attention on reducing reliance upon agency staff through enhanced control procedures and supporting recruitment of permanent staff, the target is reducing over the remaining 4 months making its achievement more difficult. Performance against the agency ceiling is also part of the Trust s financial risk rating. Ward/Unit Nursing Costs At month 8 ward nursing costs overspent by 162k ( 1.17m YTD), a decrease on the 2015/16 average but still above budgets that have been set at both safer staffing levels and adjusted to take account of additional costs of providing place of safety. Discussions continue with Southwark CCG regarding additional funding to cover unfunded staffing costs at Ann Moss Domus. Further information has been supplied to the CCG and decision is expected shortly of 112

67 Complex Placements The main area of concern continues to be Southwark which overspent by 1.5m (before risk shares) in 2015/16 and which continues to overspend in 2016/17. At month 8 the total overspend (prior to risk shares) was 1.1m, split between the CCG ( 0.5m) and the local authority ( 0.6m). The forecast position is deteriorating with new growth and planned step down taking longer to achieve than expected. The position is further complicated by o the impact of a CCG QIPP ( 0.4m), phased to be taken from October but o expected to be fully repaid by the CCG given the QIPP is not achievable and a 100% risk share arrangement with the local authority but which is accessed via the CCG contract Monthly discussions are taking place with the CCG to establish the position going forward and actions being taken. The placements issue forms a key part of the current contract discussions regarding our position over the next 2 years. 3) Cost Improvement Programme (CIP) It is recognised that there is likely to be a significant shortfall in the value of savings delivered in respect of the saving schemes included in the Trust s plans for the year. The two principal elements of this shortfall arise in respect of slippage into next year of a significant proportion of the infrastructure review scheme savings and the higher than planned levels of overspill. However, through close monitoring and tight controls, additional savings and underspends have been delivered which help to mitigate against this shortfall. These additional savings, combined with non-recurrent utilisation of contingency reserves and the release of balance sheet provisions, means that the Trust expects to be able to achieve its Financial Plan for the year despite the shortfall on planned saving schemes. The reliance placed on non-recurrent solutions does however impact the underlying deficit into next year. The Trust continues to explore all options from which to generate savings this year with a series of CEO led challenge sessions provide assurance and identification of further savings opportunities. The current CIP delivery position is as follows. At month 8, the Trust has recorded savings of 11.5m against a target of 15.8m (73%). As stated above, CIP performance continues to be impacted by the Trust s overspill challenges with the anticipated levels of reduction in overspill costs yet to be fully achieved. However, overspill continues to fall although it remains above the level in the original plan and as such continues to contribute to an increased shortfall in savings. The year to date shortfall breaks down as follows: ACP CAG 3m, (the majority of which relates to overspill), BDP 0.3m (a number of schemes delayed), Psychosis 0.2m (principally the Heather Close schemes), Corporate departments 0.5m (principally CEO, Estates and Nursing), Trust and CAG wide schemes 2m ( 1.4m infrastructure review) net of favourable variances of 1.8m from locked in underspends. At this point in the year, the infrastructure review scheme had been planned to be contributing substantial levels of monthly savings. Indeed the MARs scheme will deliver savings of 1m this year. Whilst IT, Finance and HR are currently undergoing a formal consultation on restructuring plans, savings from this and a number of other schemes are now unlikely to deliver significant incremental savings this year. Furthermore, some of the posts identified to be saved as part of this process were already being saved by holding vacancies. As such these savings whilst achieved, have been taken into account in the lock ins and elsewhere. Therefore, the forecast delivery against the target of 29.2m now stands at 22.5m (77%), slightly improved on the position at Month of 112

68 3. 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 Of the performance reviews held in November the main issues were: Delivery of CIP programmes and mitigation schemes where slippage has occurred External overspill Agency expenditure and the risk to the NHSI reduction trajectory Contracting challenges in particular adult acute in-patient activity and length of stay and Anne Moss (Older Adults) A brief summary of external overspill performance and delayed transfers of care is detailed below. 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 most recent performance is currently just above trajectory. 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 National submissions for out of area treatment are now being submitted to Unify 2 to support monitoring of the Mental Health 5 Year Forward view aim to eliminate inappropriate out of area treatments. The Trust has made submissions for October and November of 112

69 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 as days lost due to delayed transfers of care provides an additional operational pressure on in-patient beds. October performance was 5.2% a Trust level improvement on recent months. The management and prevention of delayed transfers of care is a core component of activity planning with commissioners during the negotiation round. 4. Safer Staffing (October) Nineteen of the wards breached safer staffing levels in the month of October in comparison to twenty-one in September and twenty-two in August. Chart 5: Safer Staffing The breaches are due to high RN vacancy rates, NHSP unable to cover shifts at short notice, sickness rates & bank staff cancelling shifts at short notice. The ward level detail of breaches is included as Appendix C. 5. Commissioning and Contracts Update Contracting The NHS England planning timeframe is to sign two-year contracts spanning in December 2016 and a range of meetings and activities have been scheduled to achieve this aim. The reduced timescale and longer duration of the contracts have intensified the contract activity process and presented additional risks. The QIPP requirements outlined by Lambeth, Southwark, Lewisham and Croydon for 2017/18 overall amounts to 13 million. At the time of writing there are significant gaps still to be resolved in relation to QIPP although progress is being made and issues escalated. Further to Chief Executive escalation the Trust believes the working relationships with commissioners are strong enough not to require registration for contract arbitration, although arbitration cannot be ruled out. Croydon have confirmed a need to reduce the budget and we will work collaboratively with them to understand the implications of this. Lambeth, Southwark and Lewisham have confirmed there will be no net dis-investment in the respective contracts and that the QIPP will be re-invested. NHS England recently advertised for expressions of interests as part of a process to achieve compliance with the new regulations for health care contracts (effective from 18 April 2016) issued by the European procurement regime (Public Contracts Regulations 2015). NHS England has advised interest from other parties has been received and a procurement process is being considered. NHSE have confirmed that contract negotiations should proceed in line with the planning timetable notwithstanding the call for expressions of interest. The Trust expects further clarification on this issue in the near future of 112

70 2016/17 Contract Issues The 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. The trajectory for the Adult Acute CAG has been revised following increased engagement with commissioners around broader pathway management, encompassing housing and social care needs. Croydon The financial risk of not meeting the full Croydon affordability bridge ( million) is 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 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 2017 for 1 year with an option to extend by an additional 9 years. The Board will be kept informed of progress. Southwark The contract variation for reconfiguring MHOA in-patient provision (Anne Moss) was presented to Southwark CCG who in turn requested further information. This is now progressing and is agreed in principle and the figures are being finalised. 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 has 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. The Trust is making a proposal to NHS England regarding the QIPP and CQUIN payments for 2016/17, the discussions for 2017/19 are on-going. 6. Programme Management Office (PMO) Plan assurance The Trust recently completed CEO led assurance reviews of all major CIP plans, supporting the Trust in agreeing its forecasts for 2016/17 and priorities for CAGs and departments into next year. The reviews have also offered insights into improvements into portfolio assurance that will be included in governance and assurance frameworks as we develop next year s plans. Infrastructure programme The programme has been re-profiled to align with the 2017/18 planning submission. Approximately 1m of the programme savings is accounted for in finance forecasts, 1m is forecast for delivery through the programme and the remaining 3.5m has been re-profiled to 2017/18. Primary reasons for programme slippage are: of 112

71 The main consultation was suspended, and will now complete 30 Jan; this was due to job descriptions not being available in time to meet the plan BI plans have been slowed down to include a proof of concept, to assure CAGs that proposed changes are workable Consultation delay resulted in delay to the leadership review while the corporate structures evolve A double count with estates vacancies in phase 2 of the consultation resulted in the saving transferring to budget forecast, rather than CIP delivery Acute Care Pathway An ACP two-year plan has been agreed by the senior management team. Availability of Estates capacity continues be a key dependency for ACP, particularly for the Assessment Referral Centre and accommodation in Lambeth, as Bridge House closes next year. The engagement process for Foxley Lane has begun, and consultation regarding Modern Matrons 24/7 consultation is planned to start in January. Resource management programme Work continues to develop performance reporting to enable transition to business as usual for roster efficiencies and agency-spend. Progress in realising savings has been impacted by delays in external agencies signing up to the London-wide London Procurement Partnership framework; the rescheduling of the phase 1 Infrastructure consultation is also likely to impact savings realisation. At the recent Resource Management assurance review the panel requested a change initiative be defined to focus on the drivers of agency use and plans to address root causes, with an overall aim to reduce the need for and reliance on agency staff. Programme definition is progressing, for initiation in the New Year. Mobile Working in Community teams Following preparation of an outline business case for the opportunities technology presents to support new ways of working in Community teams, the project team has worked with our external partners to explore alternative delivery paths and implementation timelines. Recommendations will be presented during December Planning The PMO is supporting the 2017/18 Planning and has initiated the process of identifying and developing the savings schemes that will deliver next year s savings targets. PMO planning and design work is underway to ensure delivery management continuity for the major programmes, and the creation of sustainable CIP portfolio assurance and delivery capability in 2017/ Social Care Social Work for Better Mental Health programme The first session of the Social Work for Better Mental Health programme was held on the 29 November 2016, led by Dr Karen Linde with social workers from Croydon and Lewisham participating. This was a successful initial meeting which focussed on professional roles and which will lead to an action plan to develop the role and practice of mental health social workers in integrated teams within the Trust. Follow up sessions are planned for February and March and will be led jointly by Dr Karen Linde and Dr Ruth Allen, CEO of the British Association of Social Workers. Professional social work seminars A small group of social workers met in November with the Director of Social Care to plan the establishment of professional social work seminars, open to all social workers across the Trust, whether employed by the local authority boroughs or SLaM. The benefits of the seminars will be: to raise the profile of professional social work; provide a dedicated forum for social workers to discuss professional topics which will count towards continuing of 112

72 professional development and provide an opportunity for social workers to network across the Trust. A survey using surveymonkey is to go out to all social workers to seek their views on topics for the seminars. The first seminar is planned for February 2017 and the Chief Social Worker for England will be invited. Carer s Assessments The new carers engagement and support plan form is now live on epjs and the old forms have been removed. A pilot is taking place in nominated teams across the CAGs and any refinement of the forms will be made, but so far clinical feedback has been very positive about the new format. In addition to the pilot, 20 forms have also been completed by other teams since the 17 November 2016, which is a positive indicator of improvement. A communications plan has been agreed with the Communications Team and will be rolled out on the week beginning 12 December The carers leads in the CAGs are supporting improvement in performance and a follow-up audit is planned for Central Place of Safety The draft memorandum of understanding is nearing agreement following further legal advice from the respective boroughs. 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 to them for final sign off. In the interim, a phased opening of the unit is being proposed to allow operational planning time for the borough AMHP duty services over the Christmas period, 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: The rolling 12-month period is 4.84% this represents a slight reduction on the previous months results of 4.91% and 4.96% Appraisals: 97.5% of staff in post at the beginning of April had their appraisal completed. CPN Usage: 86.2 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. Property Disposals: 1. Morland Road- 1.2m 2. Ann Moss Gate house 855k Properties under offer: 3. David Pitt house estimated sale circa 2.6m Properties for disposal: 4. Inglemere on the market but offers below the expected value. Agreed to fund a full planning application to increase the sale potential and re-market in Woodlands/Masters House. Pre-application completed. One offer in the region of 16m received but decision required on whether to obtain full planning consent to maximise value. Capital projects achievement against plan 1. Anti-ligature programme: Programme completed in accordance with the audit of 112

73 2. Window replacement at Maudsley and Lambeth hospitals completed. 3. Work hubs: BRH 1 hub in progress. 4. ASCOM: Awaiting Trust decision to progress for phase 2 of ASCOM. Capital projects achievement against plan - Progress report 1. The suspension of the DBH programme is impacting on other minor schemes for example the ward refresh programme and some planned clinical moves. The revised estates strategy and the options for Douglas Bennett refurbishment was presented to the Trust Board on 29/11/16 and will be discussed at the December Board 2. Adamson Centre: The IAPT service will be relocated to Stockwell Gardens in Q with some enabling works required. 3. A meeting is scheduled with GSTT to agree the accommodation required for the Liaison services. 4. Jeanette Wallace House Exchange of Contracts made and full completion will take place in January Refurbishment of Fitzmary 1 - To support Croydon overspill. 6. Refurbishment of Norbury ward plan to decant forensic services being developed. Some enabling works taking place at Bridge House to support this decant 7. ES1 Refurbishment: Work in progress 8. Ward Refresh programme: The proposal is start the phased construction works in April 2017 this will be carried out in a live environment. Car Parking at Maudsley and Lambeth Hospitals: Procurement: The tender to provide a new Automatic Number plate Recognition (APNR) system closed with the submission of a single bid. This has been assessed and scored and the company presented to the scoring panel on 22/11/16. The company asked to undertake additional site visits and have submitted a revised pricing structure. The tender recommendation report and price analysis will be submitted on Monday 05/12/16. The tender bid states that the supplier proposes a 10-week implementation project plan. Depending on approval this would give us a completion date early to mid-february Consultation: The consultation closed on 30/11/16. A total of 141 responses were received plus 2 petitions (both against the introduction of charging at Lambeth Hospital). An analysis will be undertaken of the responses and associated report to be completed by 09/12/16. Initial analysis shows a high level of hostility to the proposal from members of staff. Hotel Services & Catering and Domestic Tender: The Procurement Team has formally requested Aramark to extend the present contract to 30/4/17 to allow the retendering to take place. The Hotel Services continue to work in partnership with ARAMARK to manage the service and transition to a new supplier in 2017/18. Completed tenders are expected by on 19/12/16 and the project team will complete the scoring of the tenders by noon on Friday 6/1/17. A moderation session will be set up on the afternoon of the 6/1/17. On Monday 9/1/17 there will be a day of shortlisted bidders presentations, which all evaluators will attend. IT Transformation Update SLaM Digital Services (formerly ICT) provided an update report to the Trust Board on 29 November The report was presented by Stephen Docherty, the CIO The report provided an overview of progress on SLaM Digital Services Project Management Office, and current priorities with a special focus on cyber security, disaster recovery and back up. Ask the CIO is a new informal forum that has set up on Yammer where staff can direct questions to the CIO on SLaM Digital Services and to submit ideas for future services. Following the latest phishing attacks, further guidance to raise staff awareness on recognising cyber threats was published. SLaM Digital Services have set up a of 112

74 special mailbox for staff to direct suspicious and malicious s. The intelligence gained from this has caught an additional 55,000 spam per week. 9. Emergency Planning and Business Continuity The EPRR (Emergency Preparedness, Resilience and Response) action plan, as highlighted in the November 2016 Board Report was presented at the November meeting of the Emergency Preparedness Group on the 23rd November It was agreed by the group that the actions outlined by the recent NHSE London EPRR assurance process would form part of the 2016/17 EPRR work plan, and that every effort would be taken to achieve the objectives of this plan would be made. Key areas being the development of all Business Continuity Plans and Business Impact Analyses across the organisation, the development of a Trust HazMat (Hazardous Materials) and CBRN (Chemical, Biological, Radiological, and Nuclear) plan, which is to include relevant training for personnel 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 in November. Acute In-patient care activity continues to be forecast to be above indicative activity plans for the majority of CCGs. There is increasing commissioner engagement in improving the position alongside additional on-going work within the Adult Acute Pathway to reduce the pressure. In terms of finance at Month 8 the Trust remains on plan, reporting a deficit of 2.8m (after application of the Sustainability Fund). The contract activity planning with commissioners for is at a critical stage in the planning timetable and a significant degree of negotiation is on-going at the present time of 112

75 Abbreviation ACP ASCOM BI CAG CBRN CEO CCG CIP CPA CPN CQUIN CYP DTOC EI epjs EPRR GSTT HTT IAPT ICD10 LSLC MHOA MHSDS NHSE NHSI NHSP NICE OBD PICU PMF PMO POS / Section 136 QIPP SOF YTD Description Acute Care Pathway Alarm system Business Intelligence Glossary Clinical Academic Group bringing together clinical services, research and education and training into a single management grouping e.g. Psychosis Chemical, Biological, Radiological and Nuclear Chief Executive Officer Clinical Commissioning Group an NHS body responsible for the planning and commissioning of health services for their local area Cost Improvement Programme Care Programme Approach Community Psychiatric Nurse 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 Delayed Transfers of Care Early Intervention: First Episode Psychosis Electronic Patient Journey System: Clinical records system 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 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 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 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 Single Oversight Framework: NHSI assurance and performance mechanism Year to Date of 112

76 Oct-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, Private Delayed Sector Overspill Discharges Average Days Patients LostPer Day Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 M1 M2 M3 M4 M5 M6 Oct-16 M7 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% -600 Adult OBD Variance Medium Secure Low Secure OBD CAMHS OBD OBD Variance Variance Variance Older Adults Other Category Other Category OBD Variance A OBD Variance B OBD Variance MHOAD Days Lost Psychosis Days Lost Trust Days Lost Acute 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 76 of 112

77 Oct-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% 6 1 1, Achieved Missed Patients with valid review Patients with overdue review 95.0% of patients followed up within 7 days of discharge 84.8% of patients had a CPA review within 12 months 99.6% of patients received an HTT assessment 5% of discharges delayed 1.1% variation to the previous month -10.3% variation to the previous quarter 2.3% variation to the previous month -0.5% variation to the previous month IAPT (18 weeks) Target 95% Early Intervention % within 2 weeks (completed Pathways by CCG) IAPT (6 weeks) Target 75% 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% ()* 50% 96.9% 96.3% 50% 100.0% 100.0% 99.1% 90.1% 96.9% 99.2% 40% 80.2% 77.9% 40% %* 30% 30% 20% 20% 10% 10% 0% 0% Croydon Lambeth Lewisham Southwark Trust % % % % % % +,$* +-*,.*-' /*%%0 71% of patients received Psychosis treatment within 2 weeks 90.1% of patients completing treatment within 6 weeks 99.2% -5.2% variation to the previous month 0.4% variation to the previous month 0.0% 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Friends and Family Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 M10 M11 M12 M1 M2 M3 M4 M5 M % 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% % 88.6% Achieved Missed 91.5% 89.9% 85.2% 21,403 of patients completing treatment within 18 weeks variation to the previous month 89.5% 87.1% 87.4% Days Not Lost Days Lost 91.1% Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 M10 M11 M12 M1 M2 M3 M4 M5 M6 No. of FFT Responses FFT Score (%) Do you feel involved in your care? (%) QP Target %! "$ ()* %* %&' 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 77 of 112

78 Appendix B: QSC Quality Dashboard Period: October (M7) 2016 Circulation: Board circulation 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. Exception reporting: Safer Staffing: In October 19 wards breached - this is a slight reduction on previous months. The breaches are due to high RN vacancy rates, NHSP unable to cover shifts at short notice, sickness rates & bank staff cancelling shifts at short notice. Restraint: A datix system issue has been identified. When reviewing incident data relating to position of restraint the system was increasing the overall number of incidents. This issue has been addressed and we are assured the current figures presented are correct. The data identifies a reduction in the use of restraint and an ongoing downward trend. The reasons for this will be explored in the Trust Safe and Therapeutic Services committee meeting in December. We will aim to look at CAG level data to assess if this reduction is across the board or relates to specific CAGS. It will be important to review overall reporting trends to ensure that there has not been a reduction in reporting of incidents. 78 of 112

79 Safe Safer Staffing (Number of Wards Breaching 20% of Shifts) Acute CAG External Overspill Performance against Target 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 No. of wards Oct-16 Safer Staffing (No. of breached wards) Average (CL) UCL LCL Number of incidents Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 New Serious Incidents Average (CL) UCL LCL Feb-16 Mar-16 Apr-16 May-16 Full Risk Screen (CPA Patients) Jun-16 Jul-16 Completed Incomplete Aug-16 Sep-16 Oct-16 Child Need Risk Screen (CPA Patients) Completed Incomplete Apr-15 May-15 Jun-15 Unauthorised Absences (Detained Patients) Unauthorised Absences - Detained Patients 95.0% followed up within 7 days of discharge 96.1% of patients had a brief or full risk screen 98.2% of patients had a child need risk screen The restraint reporting has been changed following further analysis arising from the previous QSC New Serious Incidents "!! Jul-15 Aug-15 Sep-15 Oct-15 Nov-15! Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16! Jul-16 Aug-16 Sep-16 Oct of 112

80 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 Oct-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 Oct-16 Physical Assaults on Patients (By Patient) Average (CL) UCL LCL Physical Assaults on Staff (By Patient) Average (CL) UCL LCL Effective Days Lost Private Delayed Sector Overspill Discharges Average Days Patients LostPer Day M M M M M M M7 7% 6% 5% 4% 3% 2% 1% 0% 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. MHOAD Days Lost Trust Days Lost Trust Delays % Days Lost 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% Psychosis Days Lost Acute Days Lost 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 On-going investigation or disciplinary investigation 99.6% of patients with a HTT assessment Fitzmary 2 has scored 19 and therefore is in Level 2. This is due to increased vacancy rates, bank usage and sickness absence. The ward manager also reports unusual levels of demand beyond usual capacity and increased numbers of enhanced observations. The CAG Executive is working to deliver mitigations. 80 of 112

81 Caring!" $ % $% & '( &)!%%*!+, $% & $-()'!* *'-! '( '!* *'-!./ 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% &!%'!!( $% & '( $01-! %.12/ **&% IAPT (6 weeks) Target 75% 96.9% 96.3% 90.1% 80.2% 77.9% Croydon % Lambeth % Lewisham % Southwark % Trust % 100% 80% 60% 40% 20% 0% 84.8% 863 CPA 12 Month review (Target 95% by End of Quarter) 4817 Patients with valid review Patients with overdue review of patients had a CPA review within 12 months IAPT (18 weeks) Target 95% CPA performance in on track to meet the 95% threshold by the end of the quarter. NHS Improvement have now removed this indicator from the Single Oversight Framework % 100.0% 99.1% 96.9% 99.2% Croydon % Lambeth % Lewisham % Southwark % Trust % 81 of 112

82 Caring (continued) Early Intervention % within 2 weeks (completed Pathways by CCG) %! The Early Intervention performance in Quarter 2 exceeded the Trust recovery trajectory and the 50% standard by a significant margin. 1* 2-(9 20! Well Led ) *+!% $% & '( " " " " " " " $-()* 4!!1 1-!5* $-()* 4!!1-!5-( $-()* 4!!1-!56 *4!!.4! / %%-!.(%7! /./ 7 7 "7 7 7 " " " " "" " " For the core skills framework subjects a total of 24 tailored training courses are provided dependent on staff type and including skills refresh. The updated RAG rating has been applied whereby below 70% = Red, 71-84% = Amber, above 85% = Green (except IG which is 95%).!!%*+, " ))!8.!/ $% & '( $% & '(!%-./0 '( 82 of 112

83 !"$%& )!" $%&' $"! ''() * +,'-.' /!" "0% 1 $"! ''2%!2% 3 "' + '" ' + $"! 4' $"! ' $"!.''% 5*" 6+ / ''&' 7'."*"!"!"7"7 + * $"! 4"'(.')""8"9!))!" 2'&*" $"!! ' $( " 83 of 112

84 G TRUST BOARD REPORT Date of Board meeting: 20 December 2016 Name of Report: Author: Approved by: Presented by: Re-nomination of a Trustee for the Bethlem Art and History Collections Trust. Paul Mitchell, Trust Secretary. Paul Mitchell, Trust Secretary. Supported by Dr Nick Hervey, Chair of BAHCT Paul Mitchell, Trust Secretary. Purpose of the report: To agree the re-nomination of a SLaM nominee as a Trustee of the Bethlem Art and History Collections Trust (BAHCT). Under the BAHCT deed, SLaM nominates 5 of the 10 Trustees. Prof Hilary McCallion has come to the end of her 5 year term and has expressed an interest in serving another term. This is supported by the Chair and other Trustees. Recommendations to the Board: It is recommended that Prof Hilary McCallion be re-appointed for a further term of 5 years with effect from 20 December Relationship with the Assurance Framework (Risks, Controls and Assurance): There is a governance review underway as part of the wider project to integrate more closely the operations of BAHCT with the Bethlem Gallery which share the Bethlem Gallery and Museum building. This re-nomination would offer some stability when there may be risks developing during a period of change. Summary of Financial and Legal Implications: None. It is an honorary appointment. Equality & Diversity and Public & Patient Involvement Implications: Appointment would result in the gender balance of the SLaM nominees remaining 2 male and 3 female. 84 of 112

85 TRUST BOARD OF DIRECTORS SUMMARY REPORT H Date of Board meeting: 20 th December 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance) Author: Approved by: (name of Exec Member) Presented by: Mental Health Law Management Annual Report Governance Kay Burton Neil Brimblecombe, Executive Director and Julie Hollyman, Non-Executive Director Neil Brimblecombe Purpose of the report: To inform the Trust Board of Mental Health Law developments, activity and areas of concern for the year 2015/16. Recommendations to the Board: To approve the report. Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: Report contains information about incidents which have resulted from breaches in the use of the Mental Health Act and recommendations for action by the Care Quality Commission following Mental Health Act monitoring visits to Trust services These incidents and CQC MHA monitoring reports are reviewed at the Trustwide Mental Health Law Committee and local Directorate MHA Fora where actions taken following the recommendations made are monitored. Provides high assurance to the Trust. Summary of Financial and Legal Implications: The concerns highlighted within the Report, if unchecked, result in continuing poor compliance with the MHA in some areas and may result in litigation against the Trust. Equality & Diversity and Public & Patient Involvement Implications: The report contains information about the use of section by ethnic group. Service Quality Implications: The report outlines the way the MHA and MCA is monitored in the Trust through robust administrative processes and review of MHA issues at site based quarterly MHA Fora and the quarterly Trustwide Mental Health Law Committee. The report includes for the first time a summary about the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS). 85 of 112

86 MENTAL HEALTH LAW MANAGEMENT ANNUAL REPORT APRIL 2015 TO MARCH Introduction This is the seventeenth Mental Health Act Annual Report of South London and Maudsley NHS Foundation Trust (formerly South London and Maudsley NHS Trust). Included within this report is both qualitative and quantitative information relating to Mental Health Act (MHA) activity and issues which have occurred during 2015/16. This includes a summary of service development, information on training, policy development, new initiatives, operational issues, Care Quality Commission reports and Associate Hospital Managers activity plus statistical information and data. For the first time this report includes the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS). 2. Service Development Operational The management of late provision of reports for Tribunals was strengthened with Enforcement actions against individual clinicians report on Datix as a category C serious untoward incident necessitating a full investigation and response to the Tribunal. The joint monitoring of Associate Hospital Managers decision forms by the MHA Management Team and the AHM Leads continued through the year. Results from this informed the training topics for the sessions delivered to the AHMs through the year. The Key Performance Indicators for the MHA team continued to be reviewed quarterly at the MHA team meetings and revised. The MHA team underwent a Service Improvement Process supported by SLAM Partners during the year. This resulted in streamlined practice across the team, development of electronic management of MHA hearings and section 17 leave forms, with recommendations for further improvements to be taken forward into 2016/17. The MHA Float Team became established and was able to provide more flexibility in the administration team to provide support across the MHA offices at times of increased need. One member of the float team took on responsibility of the administration of DOLS. Quality Monitoring of Associate Hospital Managers hearings The system to monitor the quality of Associate Hospital Managers hearings was changed with a questionnaire being given to all attendees at the hearing. The findings of these is to be monitored and used during the AHMs annual performance reviews and at the Trustwide Mental Health Law Committee. Service Level Agreement acute trusts The Service Level Agreements for SLaM to provide MHA Administration to Kings Healthcare NHS Foundation Trust, Guys and St. Thomas NHS Foundation Trust and Lewisham and Greenwich NHS Trust continued and was renewed for a further year. Seclusion The Seclusion Policy was updated to reflect changes in the revised MHA Code of Practice issued in April Monitoring of seclusion was transferred to the Safe and Therapeutic Services Committee having previously been reported to the Trustwide Mental Health Law Committee of 112