A MEETING OF THE COUNCIL OF GOVERNORS WILL BE HELD ON TUESDAY, 13 SEPTEMBER FROM 3.00PM TO 5.00PM MAUDSLEY LEARNING CENTRE AGENDA. Item Att Lead Time

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1 Page 1 of 108 A MEETING OF THE COUNCIL OF GOVERNORS WILL BE HELD ON TUESDAY, 13 SEPTEMBER FROM 3.00PM TO 5.00PM MAUDSLEY LEARNING CENTRE AGENDA Item Att Lead Time 1 Introductions, welcome to new Governors and apologies for absence. 3:00 2 Declarations of interest. 3 To agree the minutes of the meeting held on 16 June A RP 3:05 STANDING ITEMS 4 Working groups and committee reports: B 3.10 Quality (Jenny Cobley) Membership and Communications (Dr Dele Olajide) Planning and Strategy (Angela Flood) Bids (David Blazey) Involvement and Social Responsibility (Mark Ganderton) Reports to be taken as read. Opportunity for Governor Q&A on the above. 5 Trust Reports: 3.25 Chair s report Chief Executive Report Lead Governor s report NED Report Anna Walker, Quality Finance Report - to receive an update on the Trust s financial position. Performance Report to receive an update on the Trust s performance. Reports to be taken as read. Opportunity for Governor Q&A on the above. Followed by Group Work on key issues facing the Trust with feedback from tables. (40 minutes). DECISION 6 Governance Committee Report To receive an update and approve recommendation To note the policy for support to Governors C D E F G H I RP MP CA AW GH KD RP 4.25

2 Page 2 of 108 To approve the recommendation within the development strategy To receive a site visits update To note the workplan review in December 2016 J INFORMATION 7 Questions from members written questions to be submitted in advance of the meeting. 8 Future NED reports: RP 4.50 RP Service user and stakeholder engagement December Business development March Any other urgent business. RP Dates RP Next meeting. Thursday, 15 December 2016, Maudsley Learning Centre between 11.00am and 1.00pm. AMM Tuesday, 20 September 2016, KIA Oval, between 10.00am and 3.00pm New Governor induction Tuesday, 4 October 2016, Maudsley Learning Centre, between 9.30am and 1.00pm Governwell training for new governors Friday, 21 October 2016, Maudsley Learning Centre, between 9.30am and 4.30pm Joint KHP meeting Thursday, 17 November 2016, Maudsley Learning Centre between 5.30am and 7.00pm. Board and committee meetings 2017 K PNJM/August 2016

3 Page 3 of 108 Attachment A COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 13 September 2016 Name of Report: Minutes of the meeting held on 16 June 2016 Author: Presented by: Paul Mitchell, Trust Secretary Roger Paffard, Chair Purpose of the report: To agree the minutes and to note any matters arising. Page 1 of 2

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5 Page 5 of 108 DRAFT MINUTES OF THE MEETING OF THE COUNCIL OF GOVERNORS OF THE SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST (SLaM) HELD ON THURSDAY 16 JUNE 2016 AT THE MAUDSLEY LEARNING CENTRE PRESENT Roger Paffard Chairman Elected Governors Chris Anderson Service user governor Adam Black Service user governor David Blazey Staff governor Stella Branthonne-Foster Service user governor Handsen Chikowore Public governor Jenny Cobley Public Governor Simon Darnley Staff Governor Angela Flood Carer governor Mark Ganderton Public governor Brian Lumsden Public governor Marnie Hayward Service user governor Francis Keaney Staff governor Matthew McKenzie Public governor Tom Werner Staff governor Appointed Governors Jim Dickson Lambeth Council Bert Johnson Rethink Mental Illness Nancy Kuchemann Southwark Clinical Commissioning Group (CCG) Paula Swann Croydon CCG In attendance Martin Baggaley Medical Director Neil Brimblecombe Director of Nursing Sarah Crack Head of Communications Robert Coomber NED Kristin Dominy Chief Operating Officer Mike Franklin NED Duncan Hames NED Gus Heafield Chief Financial Officer David James Business Manager Altaf Kara Director of Strategy and Commerce Paul Mitchell John Muldoon Julie Hollyman Matthew Patrick Zoe Reed Gabrielle Richards Paul Twyman Noel Urwin Anna Walker Jeff Worley Trust Secretary Public Governor NED Chief Executive Officer (CEO) Director of Organisation and Community Head of Occupation Therapy Member Member NED Member Apologies Ian Creagh Kings College London (KCL) Page 1 of 8

6 Page 6 of 108 Nigel Davies David Dawson Alan Downey Tom Flynn Robert Gay Alan Hall Seb Kalwij Shitij Kapur Raj Mitra June Mulroy Dele Olajide Roger Oliver Crada Onuegbu Gillian Sharpe Carol Stevenson Louisa Woodley Bromley Council Kings College Hospital (KCH) NED Southwark Council Service user governor Public governor Lewisham CCG NED Lambeth CCG NED Staff Governor Carer governor Lewisham Council Public governor Membership Officer Croydon Council Ref Issue Who MC/ 16/19 WELCOME Roger Paffard welcomed the three new NEDs to the Trust. They are: Anna Walker, Mike Franklin and Duncan Hames. He also informed the Council that Robert Coomber was stepping down as a SLaM NED after nine years of service and a farewell event will be held for him after the July Board (26 th ). MC/ 16/20 MC/ 16/21 DECLARATIONS OF INTEREST No declarations of interest were given. MINUTES OF THE MEETING OF 10 th MARCH 2016 Matters of Accuracy The minutes of the meeting of 10 th March 2016 were AGREED to be a correct record. The minutes of the meeting of 12th May 2016 were AGREED to be a correct record. Roger Paffard informed the Council that Julie Hollyman NED had been officially appointed as Deputy Chair and Senior Independent Director of the Trust. MC/ 16/22 WORKING GROUP REPORTS The Council received updates from the following working groups: Quality, Membership and Communications, Planning and Strategy, Bids and Involvement and Social Responsibility. Jenny Cobley introduced the report from the Quality Working Group. The report was taken as read. Note was taken of the Quality Account comments from the group and the information received from the Trust regarding peer support, complaints and the Well Led review. Page 2 of 8

7 Page 7 of 108 Brian Lumsden raised his concern at the on-going problems with the maintenance of shower and toilet facilities at the Ladywell unit in Lewisham. This situation was noted by the Council and agreed that a process needed to be developed for capturing such issues after visits. The report was noted by the Council. Paul Mitchell introduced the report from the Membership and Communications group. The report was taken as read. Some Governors terms come to an end in August 2016 and others in November. The election process will commence soon and it will accommodate Governors whose terms finish in August and November. A detailed plan and timetable will be circulated shortly by ERS the election administrators once finalised. PM A discussion took place on the availability of business cards for Governors. After a vote is was agreed that cards would not be produced for all Governors, but the facility would be made available for those Governors who requested them. Handsen Chikowore enquired if there would be any involvement of the Trust in Refugee Week (20 th to 26 th June 2016). Sarah Crack said there were no plans for this to take place. Mike Franklin observed that it was an event that the Trust might wish to consider involving itself with in the future. Marnie Hayward asked how the Trust was supporting Governors in communicating with each other. Sarah Crack advised the Council that a closed Facebook page was available, but Governor use of it had been limited. It was agreed further work was required in this area. ACTION: Governor communication to be discussed at the next Membership and Communications meeting (01/08/16). SC Tom Werner asked who would lead the group once Dele Olajide stood down. Paul Mitchell stated that Tom Flynn was the deputy and would step into the post once vacated. The report was noted by the Council. Angela Flood reported on the Planning and Strategy Working Group. The report was taken as read. The received reports regarding: The Operational Plan ; The Learning and Development Strategy ; The IT Strategy and were actively involved in 4 cross-borough meetings re-branded Have Your Say a You said, We did approach to community engagement. The report was noted by the Council. David Blazey introduced the report from the Bids Group. Note was taken of the awards made and the work of Roger Oliver, who is reaching the end of his term as a Governor, who has made a major contribution to ensure the smooth and efficient running of the previous scheme. Handsen Chikowore enquired what the budget for bids. David Blazey replied 100,000 was the budget. He added the assessment of each scheme is set Page 3 of 8

8 Page 8 of 108 against a scoring system to ensure equity. The report was noted by the Council. Mark Ganderton gave a verbal update on the Involvement and Social Responsibility Group. He reported that Mike Franklin will be attending the next meeting in July. There will also be a presentation on involvement within the Trust. The report was noted by the Council. ACTION: It was agreed that future Council meetings will keep these Group Reports high on the agenda. PM MC/ 16/23 CHAIRMAN S REPORT Roger Paffard introduced his report which included a diary summary for March, April and May He highlighted that the Trust will be losing its Medical Director and Trust Secretary in the next few months. He gave his thanks to the both Martin Baggaley and Paul Mitchell. The Council were advised that a process to appoint successors was underway. He noted, as mentioned earlier in the meeting, the Have your Say meetings in different boroughs have taken place and have been a success. Concern at social service cuts, particularly in Southwark, was raised. There has been an exchange of letters between the Chairman and the Council but no amendment to the planned reductions in council spending is expected. It was noted that Lambeth also planned cuts to services, but the interaction with the Trust was presently more co-operative. The report was noted by the Council. MC/ 16/24 CHIEF EXECUTIVE S REPORT Matthew Patrick took his report as read. He also gave thanks to the Medical Director and Trust Secretary who are leaving their posts. He also welcomed the Strategy and Commerce Director Mr Altaf Kara to the meeting. National developments were discussed in relation to the NHS deficit nationally of 3.4b and no or little expectation that the service will be in balance in 2016/17. Locally there were some severe challenges, particularly around the acute care pathway where the Trust was running hot with no spare beds. However, he stressed the importance of maintaining a long-term strategic view. Sustainability and Transformation Plans (STPs) are now being developed across London which will require savings to be achieved so that transformation can be delivered. It was noted that budgets were increasing but they were not matching increased demand. Page 4 of 8

9 Page 9 of 108 It was noted that with increasing demand the historical non-core activities of the NHS such as community and home care were becoming central as the focus of the NHS changes towards prevention and care within the community. ACTION: Future CEO Paper to focus on local effects of national Developments in Future. It was noted that a positive aspect of recent developments in the NHS is the increased profile of mental health both in the media and at a strategic level. The report was noted by the Council. MC/ 16/25 LEAD GOVERNOR S REPORT Chris Anderson gave a verbal report which covered current governance issues. He welcomed the new NEDs to the Trust and informed the Council that the 1 st Governor/NED meeting had taken place in April. Two further meetings were scheduled for July and November He noted the positive developments in PPi within the Trust and the public meetings referred to by the Chairman. He advised the Council that governance work was developing and the skills audit had been recently distributed to Governors. National interest in the Governors work at the Trust had been expressed at the National Governors Association meeting in April 2016 where both NHS Improvement and NHS Providers were in attendance. This reflected well on the hard work of governors. Finally congratulations were offered to all Chairs and Deputy Chairs of the working groups for all the work they had done. The report was noted by the Council. MC/ 16/26 STAFF RECOGNITION AWARDS Zoe Reed updated the CoG on the planning of an annual members meeting that would include staff recognition awards. The purpose of the report was to provide an opportunity for the Council of Governors and the Board of Directors to consider the arrangements for the Annual Members Meeting which are proposed by the Partnership Working Group. The group is undertaking the planning and delivery work for the Annual Members Meeting and Staff Recognition Award event on 20th September ACTION: The Council endorsed: the proposal that the Annual Members Meeting 2016 be augmented by the production and presentation of a report of the Council of Governors Year. The Council noted: that all Governors will be invited to vote for the Special Page 5 of 8

10 Page 10 of 108 Governors Staff Recognition Award Category. MC/ 16/27 FINANCE REPORT Gus Heafield, Chief Financial Officer, introduced the paper. At Month 1 of the new financial year the Trust is on plan, with the Trust reporting a deficit of 0.9m a favourable variance of 0.1m against its planned position. The variance was not unexpected and although it is very early in the year, nothing in the performance or finances indicates increased risk in delivering the planned outcome for the year The phasing of the plan is that the majority of the deficit is planned for the first six months ( 5.9m) with only a 0.4m deficit planned for the second half of the year. The drivers for this profile are: reducing trajectory for acute/picu overspill bed usage; Delivering on Cost Improvement Programmes and addressing infrastructure costs. The planned cost reduction for the year is 30m while maintaining or improving services. Jenny Cobley asked about estate developments. Gus Heafield replied developments must be affordable or they cannot progress hence the delay in some estate projects. Marnie Hayward asked if the Croydon Contract has now been agreed. Further discussions at Board level were to take place regarding this matter. Handsen Chikowore enquired about the issue of agency staff. The response was there is a drive to recruit to substantive posts, so as to reduce the need for agency staff. Brian Lumsden asked if the reintroduction of overtime would alleviate the need for agency staff, Gus Heafield responded all options would be considered. The report was noted by the Council. MC/ 16/28 PERFORMANCE REPORT Kristin Dominy introduced the latest performance report which included Monitor indicators; the Acute Care Pathway Activity; Quality Priorities and CQC Status. The report also included Commissioning and Contracts Update; the Programme Management Office Update and Safer Staffing along with the Transformation Dashboard; Quality & Performance Dashboard and Safer Staffing Levels. The paper was taken as read. The discussion focussed on the development of a central place of safety based on the Maudsley site. Brian Lumsden asked if there was a travel time issue for the facility for those living in other boroughs served by the Trust. Kristin Dominy advised that extensive consultation had taken place with the Police and they were supportive of the project. Stella Branthonne-Foster asked about the proposed location of the CAMHS within the place of safety. Kristin Dominy replied that decision as to where to place the CAMHS element of the service had yet to be made. Page 6 of 8

11 Page 11 of 108 The Council noted the comments made by the Overview and Scrutiny Committee and their request for further consultation on the proposed place of safety. Kristin Dominy replied that there had been extensive consultation with service users, but the OSC had requested a wider consultation, which the Trust had agreed to do. She also clarified that there had service user involvement within the Project Board for this scheme. The report was noted by the Council. MC/ 16/29 SOUTHWARK & LAMBETH INTEGRATED CARE (SLIC) PRESENTATION Merav Dover spoke to the presentation and due to time constraints she agreed she would return in September to give greater detail to the Council. The programme was described as a partnership of local commissioners and providers across health and social care, along with citizens, working together to improve the value of care for people in Southwark and Lambeth. SLIC came into being in 2012 and closed in March 2016 to make way for the next phase of the partnership the Southwark and Lambeth Strategic Partnership. The vision for the programme was to improve the way care is provided to the people of Southwark and Lambeth, supporting them to lead happier and healthier lives. The final report on the programme was yet to be completed, but once done it will be sent to the Trust Secretary for circulation to the Council PM ACTION: Further update on SLIC to come to September Council The presentation was noted by the Council. MC/ 16/30 UPDATE ON WORKPLAN Roger Paffard introduced the report. The contents were noted and no red flags were reported. The report was noted by the Council. MC/ 16/31 GOVERNANCE COMMITTEE REPORT Roger Paffard introduced the report. This updated the CoG on current activity relating to: NHS Foundation Trust Code of Governance, The reference guide for NHS FT governors, The Trust Constitution, Governors development strategy and programme and Forward plan. The report was noted by the Council. Page 7 of 8

12 Page 12 of 108 MC/ 16/32 NOMINATIONS COMMITTEE REPORT Roger Paffard introduced the report which updated the CoG on NED recruitment and the appraisal of the Chair and NEDs. The presentation discussed the alignment of NEDs (including the new appointments) to the current committee structure which will be completed by the end of June The second stage of the appraisal of NEDs will include agreement to three or four specific corporate and personal objectives modified to reflect the recognised role of NEDs. A review of the updated skills mix matrix highlighted the general improvement of the Board skill profile except in the area of academic board and research which will be reduced significantly when Prof Shitij Kapur leaves the Board. In the longer term it was suggested that the Dean of the IoPPN should automatically become a NED on the SLaM Board. Therefore it would be desirable to increase the number of NEDs from seven to eight to accommodate this development. This recommendation was put to the Council of Governors for approval as it will necessitate a change in the FT Constitution. If agreed this will be taken to the Board of Directors for approval. ACTION: CoG unanimously agreed to the proposal that the number of NEDs on the SLaM Board be increased from 7 to 8. RP/PM MC/ 16/33 The Council agree due to time constraints that the Audit Committee Report, Francis Update and NED report on Finance and Performance be deferred. MC/ 16/34 MC/ 16/36 MC/ 16/37 QUESTIONS FROM MEMBERS There were None. ANY OTHER BUSINESS There was None. NEXT MEETING Tuesday 13 th September 2016 at 5pm in the Maudsley Learning Centre. DJ/June 2016 Page 8 of 8

13 Page 13 of 108 Attachment B COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 13 September 2016 Name of Report: Author: Presented by: Working Groups Report Working Group Chairs Carol Stevenson, Membership Officer Working Group Chairs Purpose of the report: To receive an update on the activity of the Working Groups: Quality Working Group Membership and Communications Working Group Planning and Strategy Working Group Bids Steering Group Involvement and Social Responsibility Working Group Page 1 of 2

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15 Page 15 of 108 Council of Governors Working Groups Report September Quality Working Group (Jenny Cobley and Marnie Hayward) The Quality Working group usually meets quarterly. We are pleased that Anna Walker and Amanda Pithouse are now members of our working group. We are also grateful for active executive support from Amanda Pithouse, useful informal meetings with Mary O Donovan, Cath Gormally and Edith Adejobi, and administrate support from Carol Stevenson. Our last meeting was held on 7 July when we discussed the Limited Assurance Quality Report from the External Auditors (Deloitte) and received an update on the CQC Action Plan from Amanda Pithouse. Four members of the Working Group met with the auditors on 22 July to discuss their report. At our previous meetings we have had presentations on Complaints and the Quality Improvement Programme. In February we agreed that Carers Assessments should be the Local Indicator Quality Priority for 2016/17. We also reviewed the draft Quality Accounts and a reply was produced for inclusion in these Accounts. The group has invited Cath Gormally to give a presentation on the implications of the Care Act for SLaM at our next meeting on 8 November. In future we are also due to look at complaints procedures, PEDIC data and to undertake more scrutiny of quality data. We look forward to a training session on the Quality Dashboard at the Governors AwayDay on 10 October and to involvement in best practice visits to wards and community services. Current concerns a. PPI policy. The Group fully supports the development of a PPI policy. This will be introduced as a result of the CoG s review of the Trust s response to the Francis Report. b. Facilities on some wards. Governors were invited to join PLACE teams at the Maudsley and Ladywell and were concerned by the poor facilities on some wards and poor maintenance at Ladywell. We hope that the current estates programme will continue to improve facilities for patients. c. Staff recruitment and retention. Governors are concerned that it is difficult to maintain safe staffing levels on some wards. We have suggested that it may help to offer more accommodation to staff, bearing in mind the high cost of housing in London. It has been suggested that KCL might be able to help with this. d. CQC report. The Group welcomed the 'Good' report from the CQC and recognise the determined efforts of the Trust to provide safe, effective, caring, responsive and well led services. However, governors have had a number of questions about some of the findings in the CQC report. Many of these have been answered by the Action Plan and Amanda Pithouse s presentation to our AwayDay in April. We are grateful to NEDs and others who have recently answered the remaining questions. Date of our next meeting: Tuesday 8 November at 5pm in the Maudsley Boardroom, all governors are welcome. 2. Membership and Communications working group (Dele Olajide) Governor elections Elections for the Council of Governors have been held and the results were announced on 5 th September.

16 Page 16 of 108 We are pleased to welcome: Jeannie Hughes and Susan Scarsbrook (carer governors), Barbra Davison and Zoe Rafah (service user-local boroughs governors), Janet Davies (public governor) and Siobhan Netherwood and Rosie Mundt-Leach (staff governors) to the Council of Governors. Susan, Janet and Rosie take up their terms in December, the others have already started. Congratulations to Chris Anderson, Angela Flood and Tom Werner on being re-elected. We would also like to thank Mark Ganderton, Chris Collins, Nash Momori, Matthew McKenzie and Iyoni Ranasinghe for all the work they have done with the Council of Governors over the past three years. Finally, we would like to pay tribute to Crada Onuegbu, Lewisham Councillor, who had been an appointed governor since the earliest days of the Council of Governors. Sadly Crada died last month and she will be missed. IT surgery dates A list of IT surgery dates have been circulated to all governors. Have Your Say meetings The Southwark return Have Your Say meeting took place on 5 th September. The return meeting for Lewisham will be held on 27 th September and Lambeth on 28 th September. Recommendations for a further round of meetings will be taken to the Board in November. Annual Members Meeting and Staff Recognition Awards This will be on 20 th September 2016 at the KIA Oval. Date of next meeting Monday 7 November at 4pm in the Maudsley Boardroom. 3. Planning and Strategy Working Group (PSWG) (Angela Flood) Background The members of the Planning and Strategy Working Group represent the interests and views of different stakeholders - service users, carers, staff and appointed stakeholder organisations. The group welcomes Altaf Kara, Strategy and Commercial Director, and Alan Downey, Non- Executive Director, who will be in attendance at the meetings. The last meeting took place on 5 th July. The Agenda included two key presentations which, although different in content, demonstrated shared issues connected to service delivery, patient care and new models of care: a. SLaM Strategy and Commercial Director: early impressions of Trust strengths and opportunities alongside the challenges of medium term sustainability, adult overspill and nurse staffing, involvement, communication and engagement with our stakeholders, emerging priorities and the need for effective processes to underpin them. b. Croydon CCG Chief Officer: Mental health in Croydon and the 2016/17 priorities: impact of high numbers of older people, looked after children, asylum seekers (children and adults), high prevalence of severe mental illness; higher spend on inpatient services; joint SLaM/CCG review has been commissioned to better understand the drivers behind increasing pressures; the STP presents both opportunities (prevention and early intervention), and challenges (improving access and care redesign).

17 Page 17 of 108 In addition: c. ToR update: requests were made to: add the NED to the list of members; add the scope to join meetings via conference calls or Skype; review license conditions, Board assurance framework and approach to risk management. d. Have Your Say meetings data: we are pleased that the reports from all four borough meetings have now been completed and circulated. e. Meeting with Deloitte 22 nd July: a very informative meeting focusing on the Findings and Recommendations from the 2015/16 NHS Quality Report External Assurance Review. Discussions highlighted: the importance of the trail and timing of key papers and consistency and quality of associated Minutes; importance of Governors receiving timely information; data being collected by several people in several departments potentially impacting on consistency. As Trust priorities, structures and roles develop and change, the PSWG will aim to move forward and respond by supporting a common purpose, building capacity through our members and stakeholders, connecting and working in partnership internally and externally and, through challenge and support, ensuring good governance. Date of next meeting Tuesday 15 November, 5pm, in the Maudsley Boardroom. 4. Bids Steering Group (David Blazey) During August, the Steering Group and a few additional volunteers assessed the 182 bids received. Carol Stevenson has analysed the results of this process in the tables below. It was agreed to award funds to all bidders who scored 14 or above. Following a review of some of the lower-scoring bids, one was reassessed and given a higher score, resulting in 123 successful bids a success rate of approximately 68%. The process of informing bidders of the outcome of their applications has now begun and new projects will soon be underway. Let s Smile Bids analysis Bids assessment Award to assessment score: Cost of making awards* Total number of awards % awarded ** Comments 21 23, % Very good bids 20 36, % 19 45, % Good bids 18 55, % 17 61, % 16 71, % Worthwhile bids, 15 77, % some might need 14 81, % a bit of support , % Bids scoring at 12 91, % 11 93, % this level and below are likely to struggle. * A couple of bids had mathematical errors and the amount asked for did not match the details. The figures have been adjusted to take this into account. ** Two bidders pulled out before assessment so this is based on 182 bids.

18 Page 18 of 108 Agreed: to make awards to all bids scoring 14 and above. Comparisons with earlier bids schemes. Year Expressions of Interest Applications received Bids awarded Cut off score Amount awarded 32, , , , , % of people 39% 53% 50% 56% 61% expressing an interest who put in a bid % of bidders who were successful 64% 65% 63% 65% 68% Date of next meeting Tuesday 22 November at 3.30pm in the Conference Room, 115 Denmark Hill. 5. Involvement and Social Responsibility Working Group FOR INFORMATION The group met on 19 th July having deferred the previous meeting due to other operating commitments. These involved management changes, requests for data, joint working group operations and further consultation on the PPI policy proposal. The well attended meeting heard updates on peer support from Gabrielle Richards, Chair of the Social Inclusion and Recovery Board (SIR) and Kirsty Giles on the Recovery College. This forms part of an ISR strategy to identify data sources (and omissions) to enable routine reporting of involvement activity. The meeting was also attended by Mike Franklin, our new stakeholder and engagement NED. It was agreed that: 1. Mike will become associated with ISR as our lead NED; 2. ISR will propose a new member to serve as SIR observer to replace Nash Momori; 3. Routine business (for example, reviewing concerns over commissioning barriers to peer support) will need to allow the development of the PPI policy to enjoy primacy until December when the Board is due to have the policy presented for ratification; 4. We continue clarifying with the Quality working group where particular service user and carer metrics should be received, for example: Service User experience data (PEDIC), Involvement benchmarking using 4Pi, Patient Reported Outcome measures PROMs) development etc. The next meeting will be at in the Boardroom om Monday 19 th September. Principals meeting: developing the PPI policy Convened by the new Director for Organisation, Altaf Kara, the Chair and Deputy were invited to join the Director, the board lead NED Julie Hollyman and Kay Harwood. Julie gave a presentation on the nature of the new policy and we agreed on some important fundamental characteristics such as the promotion and creation of local fora and the development of a democratic representational structure. Inevitably, concerns persist at the extremely demanding lead time that must be met as the board will consider the draft policy at its December meeting. There will be only one additional meeting in October for EPIC delegates to consider proposals.

19 Page 19 of 108 Engagement, Involvement & Participation Committee (EPIC) FOR INFORMATION There were meetings on 23 rd June and 2 nd September attended by the Chair and the Deputy. The lead governor also attended the latter meeting. The following is a summary report of both meetings. Recommendations to split EPIC into closed strategic management and open operational groups had been reported to EPIC by the governance sub-group. A decision to act on the matter has been twice deferred by Epic due to some significant developments. The Director for Organisation and Community (DoC) has changed, with Altaf Kara taking over from Zoe Reed. Formal responsibility is to further change with the Director of Nursing over from Zoe Reed. It is intended to transfer formal responsibility from the DoC to the Director of Nursing, Neil Brimblecombe., delegated through the Deputy Director (Nursing), Amanda Pithouse. Kay Harwood will hand over operational responsibility to Kathryn Hill. We wish to place on record our thanks to Zoe and Kay for their considerable contributions. As reported earlier, the approval by the Board at their June meeting to develop a Patient and Public Involvement (PPI) policy (to be considered for ratification by December) could impact the possible development of the entire (if virtual) PPI network including EPIC itself. The main recommendation had been to develop a technical/strategic group to manage oversight of all involvement activity (including volunteering, Involvement Register, Peer Support, Recovery College, as well as other involvement by service users and carers). Matters relating to developing 4Pi Benchmarking, Friends and Family test, Patient Experience Data Intelligence Centre (PEDIC) and other external survey sources were recommended to be retained within this management group. The second group would focus on trust-wide operational matters relating to service user involvement and operate more informally as a forum for stakeholders to network and consider aspects of involvement reported up from the Clinical Academic Group s (CAG) Service User/Carer Advisory groups (SUAG). Have Your Say planning group FOR INFORMATION This group met on 1 st August and was attended by the Chair and Deputy. It was not possible to reach a consensus on the priority that should attach to the poor attendance figures to date, but especially service users. Further representations have been made to the group s chair, Dele, and also to Roger and Matthew. The board are to receive a status report on the events where it is hoped that these themes will be further rehearsed. Have Your Say second Governor Feedback Event (Southwark) FOR INFORMATION The fifth of eight events, Cambridge House hosted the second Southwark meeting on 5 th September. It was calmer than the first but similarly poorly attended by service users. It was disappointing that only one service user had attended both Southwark events. Nor was it apparent whether representatives from borough MH charities, Healthwatch or Southwark CCG had attended. We will confirm attendance details when available. These events do represent a slight gain in both quality and overall attendance relative to the previous year, but there is a considerable improvement still required before we feel that they will be fit for purpose. Mental Health Act Law Committee FOR INFORMATION Gill Sharpe (CoG observer) is due to report back on the next meeting scheduled for 15th September. Council will be updated at the December meeting. Carol Stevenson Membership Officer September 2016

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21 Page 21 of 108 Attachment C COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 13 September 2016 Name of Report: Author: Presented by: Chair s Report Roger Paffard, Chair Roger Paffard, Chair Purpose of the report: To receive an update report from the Chair of the Trust including a diary summary for June, July and August. Page 1 of 2

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23 Page 23 of 108 Diary Summary Roger Paffard, Chair June 2016 Date Meeting/Event Purpose Outcome 7 th June Michael Holland Strategy Update on Quality Improvement programme & launch Bob Coomber Governance Deputy Chair progress review Chris Anderson phone call Governor relations Lead Governor progress review 8 th June Extra Nominations Committee Governance NED & Chair annual review process 9 th June NHS Providers Chairs & CEO Network Meeting Strategy Briefing on Mental Health Taskforce, Sustainability & Transformation Plans progress & National policy updates Progress Review Dr Matthew Patrick SLaM chief Governance executive 10 th to 29 th June Medical director candidate Governance & Board 9 face to face and telephone background meetings meetings development with potential medical director candidates 10 th June John Nicholson Board development Planning 2016 board development plans & new NED introduction & induction programme Dr Marc Rowland Lewisham Stakeholder relations Progress review with Chair of one of our 4 lead Clinical Commissioning Group CCGs. Accepted invitation to join Lewisham Health & Chair Wellbeing Board. 13 th June Dr Shitij Kapur Governance NED progress review and IOPPN update Simon Darnley staff governor Governor relations Informal face to face meeting Medical Director Longlisting Governance Agreed list of 7 for medical director assessment centre interviews from strong field. Matthew Patrick Governance & Strategy Progress Review Sir Hugh Taylor Chair of Guys & Stakeholder relations & Progress review. Agreement on importance of Mind Thomas s FT Strategy & Body priority within KHP. 14 th June Kings College Hospital FT Chair Governor Breakfast session Stakeholder relations Attendance as SLaMs stakeholder governor representative at informal governor breakfast briefing hosted by Sir Bob Kerslake Board development & Induction strategy Altaf Kara new SLaM director of strategy & policy Brian Lumsden public governor Governor relations Informal face to face meeting

24 Page 24 of 108 Duncan Hames new SLaM NED incoming Chair of Audit committee David James questions from Governors Board development Governor relations Induction Progress review on formal Governor questions progress and allocation of lead NEDs to new questions. 15 th June Gill Sharpe public governor Governor relations Informal face to face meeting June Mulroy NED Chair of Finance Governance Progress review and agreement on FPC priorities & Performance committee and outgoing Chair of Audit Committee Anna Walker new NED chair of Governance & Board Induction Quality committee development Dr Sridevi Kalidindi Strategy Briefing on SLaMs progress with local stakeholders on housing & social strategy 16 th June Board Development Board development Focus on board ways of working; governor relations; NED portfolios & priorities. SLaM Housing Strategy Strategy Meeting with external advisors who assisted SW & St Georges Mental Health Trust on their housing strategy Board Development- Charity Governance Focussed board development session on the future of the Maudsley Charity including the regulator s recommendation that NHS charities should be more independent. Council of Governors Meeting Governors & Governor Lively and stimulating CoG meeting with much better relations governor feedback and wider participation than recent CoGs 17 th June Prof Sir Robert Lechler chief Stakeholder relations Regular progress meeting executive of KHP (Kings Health Partners) Dr Faisil Sethi Staff relations Briefing by chair of medical advisory committee Anna Walker new NED chair of Quality committee Governance Progress review & de-briefing on Quality Committee status and previous Chairs priorities for development of committee Julie McNamara Bethlem Museum Personal development Really enjoyable tour of museum and gallery at Bethlem. Highly recommended. 20 th June London Mental Health Chairs Stakeholder relations & Regular quarterly meeting to agree policy and Group strategy campaigning priorities for Londoners mental health Finance & Performance Committee Governance See minutes Paul Mitchell Governance Regular progress review

25 Page 25 of 108 Mike Franklin new NED Board development & Governance 21 st June Medical Director Assessment Board development & Centre Governance Induction Participation in medical director candidate s assessment centre leading to final interview panel shortlist of nd June Dr Shitij Kapur NED Governance NED succession planning 23 rd June Joint Kings Health Partners Board meeting (Vice Chair) Governance & Stakeholder relations & Strategy Regular KHP board meeting this time dominated by mental health informatics and the refresh of the Mind & Body strategic priority. 24 th June Matthew Patrick Governance & Strategy Regular progress review Altaf Kara Strategy Briefing on strategy paper for board 27 th June John Nicholson Board development Progress review Ben Travis/Andy Trotter chief executive & chair of Oxleas mental health FT & Matthew Patrick. Spiritual and Pastoral Care in Mental Health Graduation Event 28 th June Board Meetings and Board development Day 30 th June Medical Director Final Panel Interviews Stakeholder relations Stakeholder relations Governance & Strategy Chris Anderson lead governor Governor relations Progress review Board development & Governance Paul Mitchell Governance Regular progress review Matthew Patrick Governance Regular progress review Progress review on joint commissioning of forensics project and identifying future potential projects for joint working in south london. Uplifting evening awards ceremony in Lambeth. Just fabulous. Long day. See minutes Agreement to appoint Dr Michael Holland as medical director to succeed Dr Martin Baggaley on his retirement after 9 successful years in the post. A strong field of 4 candidates.

26 Page 26 of 108 Diary Summary Roger Paffard, Chair July & August 2016 Date Meeting/Event Purpose Outcome 1 st July Jo Fletcher CAMHS service director Strategy Briefing on Abu Dhabi services John Nicholson Board development Planning July & September board development Matthew Patrick Governance & Strategy Regular progress meeting 4 th July General Medical Council Dinner Stakeholder relations Review of medical training and workforce planning 5 th July David James Governor relations Governor questions & site visits 7 th July NHS Providers Governance Personal development National developments Conference 8 th July Keith Groom IT Governance IT security Tom Werner staff governor Governor Relations Informal face to face meeting Jenny Cobley public governor Governor Relations Informal face to face meeting deputy lead governor Paul Mitchell Governance Regular progress review 11 th July Zoe Reed/Kay Harwood Stakeholder relations & Briefing on social care Governance Sally Dibben & Amanda Pithouse Staff relations Briefing on staff arbitration and staff survey findings Older Peoples (SUCAG) service Staff & Stakeholder Attending regular SUCAG meeting and providing user & carer advisory group relations short presentation on governance with Q&A Neil Robertson Interim Service Staff relations & strategy Induction Director Psych Med & MAP service director Matthew Patrick Governance & Strategy Annual review 12 th July NHS Providers Mental Health Group Public Mental Health Fundraising Discussion at Guys & Thomas Strategy & Governance Strategy 14 th July Kings Health Partnership Pre- Governance Meeting KHP Joint Board Meeting Stakeholder Relations & Quarterly Board meeting Briefing on parity of esteem funding shortfall & national commissioning pilot programmes on Forensics and CAMHS that we are participating in. Exploratory session with all stakeholders to shape the fundraising and funding ask for mental health awareness, early intervention and 2mind & body interventions Pre-meeting to agree recruitment of NED with international commercial experience.

27 Page 27 of 108 Strategy 18 th July Matthew Patrick Governance & Strategy Regular progress meeting John Nicholson Board development September agenda 20 th July Paul Mitchell Governance Regular progress meeting Triangle of Care Meeting with Julie Hollyman organised by Matthew McKenzie Governor relations 21 st & 22nd July QI Leadership Meeting Governance & Board development Useful review of Triangle of Care benefits, standards and benchmarking. Agreed to be more active affiliate for next year while we complete current carer strategy. 2 day training session on the QI programme with board members and large senior management cohort. Successful launch of major priority for SLaM for the next 5 years. Informal face to face meeting at her GP surgery 25 th July Dr Nancy Kuchemann stakeholder governor Governor relations Matthew Patrick Governance & Strategy Regular progress meeting 26 th July Board Development Meeting Board development meeting Chris Anderson & Jenny Cobley Governance & Governor relations governor Governors/NEDs Meeting Governance & governor relations Informal progress review with lead & deputy lead Second of our new initiative to have regular informal sessions between the NEDs and some governors (chairs & deputy chairs of working groups). Good progress on a number of initiatives including site visits, governor questions & working group liaison. Board Meeting Parts I & II Governance See minutes Celebration and thank you event for retiring NEDs Bob Coomber & Dr Shitij Kapur A joyful celebration of the outstanding contribution to SLaM from Bob (9years) and Shitij (6years) 27 th July John Nicholson Board development Endorsement of next steps towards greater independence for Maudsley Charity over the next 2 years. 28 th July Peter Molyneux & Andy Trotter chairs of SW & St Georges and Oxleas Strategy 15 th August Matthew Patrick Governance & Strategy Regular progress review Paul Mitchell Governance Regular progress review Informal meeting to explore all 3 organisations appetite and approach to more collaborative working across the South London footprint in the wake of our successful joint bid for Forensic commissioning. Cautious endorsement where the South London footprint would lead to better service delivery.

28 Page 28 of th August Psych Med CAG executive meeting Governance & Staff relations Attended regular CAG executive as an observer as a result of a general invitation from CAG leaders to NEDs at the 2 day QI event in July. 19 th August Matthew Patrick Governance & Strategy Agenda planning for September board and away days 24 th August Julie Hollyman NED deputy chair Governance Annual review process for NEDs and Chair 26 th August Anna Walker NED Chair of Quality committee Governance Input into proposals to strengthen the Quality committee 30 th August John Nicholson Board development Finalising the September board away day agenda Matthew Patrick & Tania Eber Staff relations Agreeing format for Calman training event for junior doctors on January 19 th 2017 Matthew Patrick Governance & Strategy Regular progress review Paul Mitchell Governance Regular progress review 31 st August Chris Anderson & Jenny Cobley Governance & Governor Informal progress review with lead & deputy lead relations governor Altaf Kara director of strategy & policy Strategy Input into strategic review element of board development session on 12/13 September Alan Downey NED Chair of Governance Committee progress review Charitable Funds & Business & Investment Development Committee

29 Page 29 of 108 Attachment D COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 13 September 2016 Name of Report: Author: Presented by: Chief Executive s Report Paul Mitchell, Trust Secretary Matthew Patrick, Chief Executive Purpose of the report: To receive an update report from the Chief Executive of the Trust. Page 1 of 2

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31 Page 31 of 108 Chief Executive s Report September NHS finances at Quarter 1 NHS Improvement last week published the financial performance figures for the first quarter of 2016/17, which revealed that the number of NHS providers showing a financial deficit fell by 20%. First quarter results have been poor in recent years, and this strong performance has resulted from hard work locally and a clear national plan. However, a survey conducted of finance directors gives strong reason to be cautious about the rest of the year. The survey found that finance directors from almost four in 10 trusts are not confident of meeting their control totals for the end of 2016/17, and further doubts about the sustainability of the first quarter results were raised by the way trusts can access sustainability and transformation funding. As a number of finance directors pointed out in the survey, there are significant incentives on trusts to declare they are on track at quarter one to ensure access to the sustainability and transformation funding, which they might otherwise lose. 2. Sustainability and Transformation Plans The overall national finance position has led to increased media coverage of local Sustainability and Transformation Plans. Whilst these plans are being made when funding is tight they are being driven by the need to modernise services to match people s changing care needs. NHSP have commented that it is inevitable during such important changes that some services will be moved, reduced or enhanced. I would like to emphasise that I and other SLaM representatives have been pressing hard in all our discussions to ensure that mental health is given sufficient prominence in the plans and also that any eventual proposals are subject to the normal consultation arrangements. 3. London Health Board I am delighted to report that I have been invited to join a Steering Group to advise the London Health Board, chaired by the Mayor of London, Sadiq Khan, on developing a collective citywide vision for mental health. The aim of this vision is to put London at the very forefront of improving mental health and wellbeing for all Londoners across the life-course. During an initial engagement exercise to inform the development a roadmap for London, the enthusiasm and appetite for change was clear. There is increasing consensus on how to improve mental health and wellbeing. This presents a superb opportunity to ensure whole system leadership on this agenda and to build upon and align our existing strategies to promote good mental health, intervene early, meet complex needs and reduce the treatment gap. 4. Industrial action The British Medical Association has announced further plans for five-day strikes over the coming months in the dispute over the imposition of a new contract for junior doctors in England. At the time of writing next week s Junior Doctors strike has been called off by the BMA after NHS England warned it needs more time to arrange cover during the period of action. Page 1 of 6

32 Page 32 of 108 Three further five-day strikes planned for October, November and December will go ahead unless the government drops plans to impose a new contract that was rejected by junior doctors, the BMA has warned. The Trust will continue to negotiate with local staff representatives to ensure that we mitigate any adverse impact on service users. 5. Our Sustainable Future - review of non-clinical infrastructure services The trust is undertaking a review of its corporate, non-clinical services. The review is part of the trust s Our Sustainable Future Programme to deliver 29m in savings and transformation in order to achieve our financial target for the year. The review will look at how the trust can reduce infrastructure costs and improve support to CAGs and front line staff at the same time. Following workshops with members of staff, as well as discussions with managers, and the Joint Staff Committee, the trust s Senior Management Team (SMT) have agreed that there will be three phases to the review. Each phase will address different areas of corporate services across the trust. Phase one will consider those functions that directly support CAGs; phase two will review central trust services; and phase three will address trust leadership and support based in the trust headquarters. Each phase of the review will involve a 45 day informal consultation to agree the design of the services, followed by a 45 day formal consultation to agree the make-up of the services. Phase one began on the 5 September with the start of the informal consultation. The formal consultation stage for phase one will close on 5 December The SMT will be keeping staff and the trust board up to date with developments. 6. Bedlam: the asylum and beyond at Wellcome Collection The Trust and Maudsley Charity have been working in partnership with Bethlem Gallery and Museum and the Adamson Collection Trust to support a new exhibition at Wellcome Collection. Bedlam: the asylum and beyond explores the history of the mental health hospital through the lens of Bethlem Royal Hospital, opens on 15 September and runs to 15 January The exhibition follows the rise and fall of the mental asylum and explores how it has shaped the complex landscape of mental health today. The exhibition has been co-curated by Mike Jay a Trustee of Bethlem Museum of the Mind, author and historian, alongside Wellcome Collection s Bárbara Rodríguez Muñoz. A key part of the project is the collaboration between Bethlem Gallery & Museum and Wellcome Collection which sees a number of works on display by Contemporary Artists as well as objects from the historical archives on display. 7. New NICE guidance to deliver the best care for people using NHS mental health services New guidance from NICE says mental health staff, working in hospitals and in the community, need to build good relationships as early as possible with people who are moving between services. Page 2 of 6

33 Page 33 of 108 The guideline highlights that this risk is particularly high in people who have to be admitted to a hospital away from where they normally live. It says there should be a named practitioner assigned from the person s home area who will work closely with their hospital team. They should be involved in regularly reviewing care plans and can help assess a person s suicide risk before discharge and set out how to best support them. The guideline says people with mental health problems should be involved in decisions when they are going into and out of hospital. 8. Alzheimers article There have been media reports that the first powerful treatment for Alzheimer s is on the horizon after a new drug was found to combat the changes to the brain that cause the disease. Scientists hailed the breakthrough as the best news in dementia research for a quarter of a century. People in the early stages of the condition are being signed up for a large-scale clinical trial of the monthly injection, which appears to break up the poisonous lumps that form in the brains of those with the disease. Early evidence shows the drug can also slow cognitive decline or even halt it altogether. Treatment could be available on the NHS in five years if the findings were confirmed on a bigger scale and the benefits were found to outweigh the side-effects. The study is expected to finish by the end of the decade, meaning that the drug could be approved in the early 2020s. 9. NHS Improvement framework NHS Improvement has published its new Single Oversight Framework for consultation. This aims to provide an integrated approach for both FTs and NHS Trusts, across regulation and performance management and to renew its offer of support. Under the proposals, all Trusts will be placed in one of four segments depending on their performance. The five domains within the framework are: Quality of care (using ratings in 4 of the 5 CQC domains plus progress against standards for implementing 7 day services) Finance and use of resources (being developed with the CQC and including progress against control totals and efficiencies) Operational performance (largely reflecting existing national targets and based on a Trust s agreed performance trajectory) Strategic change (a domain yet to be fleshed out in detail, this section will focus on progress on implementing STPs, and where applicable devo deals) Leadership and improvement capability (building on the existing well led framework to capture good governance and leadership and to introduce a focus on capacity for improvement) 10. Launch of the new Psychological Medicine and Integrated Care Clinical Academic Group Following the reconfiguration of Adult Mental Health CAGs resulting in the creation of an Acute Care CAG, headed up by Hugh Jones and Jo Kent, services from Psychological Medicine and Mood, Anxiety and Personality Disorder (MAP) CAGs have been merged to form a new CAG called Psychological Medicine and Integrated Care. The name is Page 3 of 6

34 Page 34 of 108 intended to reflect the two foci of the new CAG, namely mind and body interfaces, and community and locality facing services and integration. The leadership team is: Dr Ranga Rao Clinical Director Neil Robertson Acting Service Director Simon Darnley Acting Deputy Director Professors Matthew Hotopf & Alan Young Academic Directors 11. Forensic services I am delighted to confirm the announcement by NHS England that a south London partnership including SLaM has been chosen as one of six sites for testing new approaches to mental health care. In our case the work focuses on the forensic care pathway. We are all acutely aware that we have a shared responsibility to help prevent future south Londoners becoming the next generation of service users which is why we are working together to understand the wide-ranging needs of the population we serve and ensure that we do all we can to enhance their resilience and break the toxic cycle of assumed inevitability linked with poor education, poverty, crime and mental ill health. We will work together with patients to fundamentally reframe how secure mental health care services are commissioned and delivered across south London. We will do this by redesigning care to improve quality and experience, and increase the value for money of our services. To achieve our ambition we will: focus on bringing back into local care south Londoners who are being treated outside of south London; create a single point of referral for our services, linked to budgets; take a fresh look at how we can develop specialisms, such as women s services, across our geography; invest in the transition from inpatient to care closer to home, shifting care towards a strong community offer; build on our approaches to improving the quality of the care we provide. 12. NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London - Competition 2016 The Trust is tremendously proud of the fact that it hosts the only mental health Biomedical Research Centre (BRC) in the Country. The BRC is a partnership between the South London and Maudsley NHS Foundation Trust (SLaM), and King s College London (KCL), which houses the Institute of Psychiatry, Psychology & Neuroscience (IoPPN), Europe s Page 4 of 6

35 Page 35 of 108 leading academic centre for mental health research. This five year award is now coming to an end and the BRC team, led by Prof. Matthew Hotopf (BRC Director), has been working tremendously hard to fashion a strong application for renewal. The proposal for renewal of our BRC was submitted in June. The proposal targets mental health, pain and dementia which include 13 of the 25 most burdensome health conditions. Building on the successes of our BRC over the past five years, we will focus on four major aims: Precision Psychiatry Novel Therapies Translational Informatics Outcomes for people with both physical and mental illness On July 19 th I was part of a seven person team who presented to a large NIHR panel. We expect to hear about whether the Trust is successful in the autumn, but in the meantime I would like to pay tribute to the BRC team lead by Matthew who did an excellent job in creating a compelling plan for the future. 13. New Medical Director I am delighted to report that after and very competitive process, Dr Michael Holland has been appointed as the new Medical Director of the Trust. He is currently the Trust s Deputy Medical Director and Chief Clinical Information Officer. Prior to this he was Associate Medical Director and brings to the role very significant clinical leadership experience, most recently leading the Trust s work on quality improvement and revalidation. Dr Holland was first appointed as a consultant psychiatrist at SLaM in 2003, having finished his specialist registrar training within the Trust. Dr Holland is a Non-Executive Director at Recovery Focus and a visiting Senior Fellow at London School of Economics. He was a Fellow at the NHS Institute for Innovation and Improvement. He has also worked as an Improvement Advisor to the Improvement programmes delivered in NHS South West and NHS South. Michael will take up his post in the autumn following a handover period with Dr Martin Baggaley. 14. And finally Prof Shitij Kapur As previously reported Shitij will be leaving the Trust and King s College London to take up the position of Dean of the Faculty of Medicine, Dentistry and Health Sciences and Assistant Vice-Chancellor (Health) at the University of Melbourne. Shitij who is Dean of the IoPPN at King s, was first appointed to the Trust Board as a non- Executive of SLaM in September He has made an exceptional contribution to the work of the Trust, the IoPPN and has played a key role in developing the King s Health Partners vision to integrate mental and physical healthcare, education and research. Shitij will be missed greatly by all at SLaM who worked with him. He is a skilled academic and also a leader who displays great clarity of thought, integrity and a warm style that will be missed by all those on the Trust Board and by the organisation more widely. Page 5 of 6

36 Page 36 of 108 Dr Matthew Patrick Chief Executive June 2016 U / Board / Chief Exec report Sept 16 Page 6 of 6

37 Page 37 of 108 Attachment E COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 13 th September 2016 Name of Report: Author: Presented by: Lead Governor s Report Chris Anderson, Lead Governor Chris Anderson, Lead Governor Purpose of the report: To receive an update from the Lead Governor Page 1 of 4

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39 Page 39 of 108 Report We continue to have regular meetings with our Non-Executive Director colleagues and at the most recent meeting in July there were a number of discussions including Southern Healthcare and if the Trust would be able to offer support it in any way. It was agreed there was limited capacity at SLaM to do so, at this time. Subsequently the Chief Executive has agreed to mentor the new Accountable officer at Southern Healthcare as the incumbent CEO has stepped down. The next meeting with NEDs will be Tuesday, 1 November 2016 at 1.45 pm. Roger Paffard confirmed that joint Governor/NED visits have commenced and Governors will be involved in best practice visits in the future. Questions to NEDs are now governed by a protocol that was agreed by the Governance Committee. It has been accepted that some questions would be better taken up through the CoG working groups. However, regular updates of the question log will still come to the Governance Committee. It was confirmed that the Trust would be hosting the next KHP joint governors meeting on 17 November The view was that the meetings were useful and should carry on but there should be more opportunities for governor discussion. The agenda planning group would give some thought to the development of the programme. It was reported that some Governors have met with the external auditors to discuss the Quality Account. A copy of the final document will be made available to Governors. Terms of Reference for all groups/ committees are being reworked so as to become standardised and their remit clarified. There was a Governors only workshop focussing on finance 28 July with a presentation by Gus Heafield and June Mulroy (NED). A further workshop will be on the 10th October which will include a presentation on the quality dashboard. I would like to thank all those Governors who attended the July event and look forward to meeting colleagues in October. Have Your Say return meetings are planned for September my thanks to my Governor colleagues who are chairing these events, also to all Governors for attending. Thanks also go to Sarah Crack and her communications team for the tremendous work in marketing and support in organising these public engagement events. We will be looking to develop further opportunities for governors to engage with the public and our members, including Governor drop in days, further details will follow. I will be working with Paul Mitchell and Roger Paffard to implement the Governors Development Strategy, which will be going to the Board for ratification in the autumn. I have had further meetings with the joint project group on the new style of our Annual Public Meeting and Staff Awards ceremony to be held in September: The invite has been issued in the press; circulated in the member s bulletin and an e-invite will soon be circulated to key stakeholders. The engraved awards have been received from the designer; Filming of all short-listed staff has been completed and the organisation of the stalls is in hand. Page 3 of 4

40 Page 40 of 108 Regarding the Lead Governor s Network - There are planned meetings with NHS Providers and NHS Improvement staff in October These meetings will explore recommendations to enhance and implement better governance structures and working relationships with Trusts nationally, equally to find additional ways to support governors fulfil their statutory and non-statutory duties. As we approach challenging times ahead with new models of care and groups of Trusts joining together to deliver services, there will inevitably be increased governance awareness to ensure the patient experience is not compromised. Recommendations to be made to NHSP and NHS Improvement are: 1. To ultimately require an Association for Foundation Trust Governors; 2. To pilot this through the interim formal networking of Lead Governors; 3. To put in place the infrastructure and resources necessary to achieve this outcome. Page 4 of 4

41 Page 41 of 108 Attachment F COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 13 th September 2016 Name of Report: Author: Presented by: Finance Report Gus Heafield, Tim Greenwood, Mark Nelson Gus Heafield Purpose of the report: To receive an update report from the Chief Financial Officer of the Trust including: The latest financial position of the Trust; The financial workshops for Governors; and To seek approval from the Council of Governors to extend the external audit by one more year until September 2017 (audit of 2016/17) with a view to engaging the Council in a full procurement exercise for the audit of 2017/18 and beyond. Page 1 of 4

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43 Page 43 of 108 Chief Financial Officer s Report September 2016 Financial Performance in the Current Year (2016_17) The finance report for the period from 1 April 2016 to 31 July 2016 (month 4) is attached. The results how that we are currently on plan and forecasting that we will hit our planned deficit of 4m in line with the control agreed with NHS Improvement. We have to submit a number of completed financial returns to NHS Improvement (NHSI) each month. The last formal feedback we received was on the Quarter 1 return to the end of June 2016 which gave us a rating of 2 for the financial position (as planned) and green (i.e. no concerns) on governance. Currently the NHSI financial ratings are 1-4 with 4 being no action beyond monitoring performance. Whilst we score 2 at this stage of the year NHS Improvement have not indicated material concerns which would lead them to intervene under the Risk Assessment Framework - discussions with NHSI this year have been positive whilst acknowledging the ongoing risks. Our plan anticipates that we will return to a score of Financial Risk Rating score of 3 (i.e. improve) in the last quarter of the year. The finance report indicates the challenges in delivery of the plan in the second half of the year and the actions underway to mitigate risks which are emerging, in particular in managing pressures on adult acute beds, reductions in agency staff costs and delivery of the cost improvement programme (CIP) including the infrastructure review. The Finance and Performance Board sub-committee receives updates on these major programmes regularly and challenges performance and seeks assurance on the delivery in accordance with the plans. Our cash position is healthy with sufficient cover for contingencies and to continue our programme of investment in the estate, funding of developments and innovations such as the QI programme. Finance Workshops for Governors June Mulroy and I facilitated a workshop on finance at the Governors meeting on 28 July The session went well and the feedback was very positive. There was a good discussion on the financial context in which we operate. The slides from the event are available for any Governors who missed the session. We intend to hold a follow up session on the finances of the Trust, the application of the financial regime and interpretation of the finance reports at the Governors meeting on 10 October. In my recent discussions with the Lead Governor I have agreed to prepare a short summary for the benefit of the Governors to accompany the finance report at the Council of Governor meetings. We can continue to develop this in conjunction with the Council following the workshop on 10 October. We will also discuss with the Council and the chairs of the Audit and/or Finance and Performance Committees if there are any additional mechanisms whereby we can keep Governors briefed on any specific or emerging financial issues which affect the Trust. Page 3 of 4

44 Page 44 of 108 External Audit Annual Accounts and Quality Account Following a discussion between the Lead Governor and Audit Committee Chair I was asked to follow up on some of the issues which had been raised following a meeting between the Governors and the external auditors to review the annual accounts and quality account and to discuss the process for the appointment of the external auditor for 2016/2017. The Lead Governor and I had a discussion about external audit and in particular the follow ups to the recent meeting and agreed that there were some areas where we could support the Governors more effectively in their interaction with the auditors, for example; The Audit Committee chair and I could meet with those Governors attending any meetings with the auditors to give background and context on the issues, share the most up to date information and reports and ensure that the Governors get more out of the discussions. We can also review with the Governors how the Trust can more effectively support the consideration of the quality indicators to be selected by the Governors for audit and publish the result of their assurance work. Whilst NHSI guidance doesn t require auditors to publish their conclusions in all cases the Trust could consider doing so subject to the appropriate regulations or guidance from NHS Improvement. Appointment of External Auditors The Audit Committee report for 2015/16 was presented to the Council of Governors in June 2016 including an update on the appointment of external auditors. In 2015 the Council of Governors had agreed to the extension of the Deloitte contract until 2016 and with the support of the Audit Committee Chair and the Lead Governor I am seeking the approval of the Council of Governors to extend the Deloitte contract for one further year until September A key consideration in making this recommendation was the need to procure a new Internal Audit Contract to take effect from 1 April 2017 and the disruption and risks that would arise from potentially changing both sets of auditors at the same time. This longer timetable allows for the appropriate design of the process and engagement and involvement of representatives of the Council in the specification and selection of the auditor. The suggestions on the improvements for the process for the engagement between the auditors and the Governors described above would be implemented as part of the extension to the contract. Gus Heafield September 2016 Page 4 of 4

45 Page 45 of 108 TRUST BOARD OF DIRECTORS SUMMARY REPORT Date of Board meeting: 13 th September 2016 Name of Report: Heading: Author: Approved by: (name of Exec Member) Presented by: Finance Report (Month 4 FY16/17) Performance & Activity Tim Greenwood, Mark Nelson Finance Directorate, BRH Gus Heafield Gus Heafield Purpose of the report: The Finance Report provides an update on the financial position of the Trust as at 31st July 2016 (month 4 FY 16/17). A verbal update on the month 5 position will also be provided to the Finance and Performance Committee and at the Trust Board meeting. Recommendations to the Board: That the Trust Board approves the report on the financial position for July 2016 Relationship with the Assurance Framework (Risks, Controls and Assurance) and level of assurance provided by the report - none, low, moderate, high: The report is a key component of risk item 6 of the Board Assurance Framework (ensuring financial sustainability) in terms of the effective and efficient management of resources. The level of assurance provided by the report is currently moderate. Summary of Financial and Legal Implications: The Trust must make the best possible use of public money, meet regulatory requirements and deliver to plan. The Operational Plan for the Trust is in line with its agreed NHSI target that allows a deficit of up to 4.05m to be made at Q4. A Risk Assessment Framework (RAF) is in operation with NHSI. This is being used to assess the Trust financial performance during the year and includes the requirement to submit monthly financial returns and an annual financial forecast. Equality & Diversity and Public & Patient Involvement Implications: The report identifies activity and financial pressures that if not resolved as part of the delivery of the FY16/17 plan may have implications on the Trust s ability to deliver its equality, diversity and patient involvement commitments as set out in the Operational Plan Service Quality Implications: The report identifies activity and financial pressures that if not resolved may have implications on the Trust s ability to deliver its quality commitments as set out in the Operational Plan

46 m's (2) (4) Page 46 of 108 Income and Expenditure SLaM - Financial Overview as at 31st July 2016 (Month 04) Financial Position YTD YTD Plan Forecast FY Plan Financial Sustainability Risk Rating Headlines EBITDA 2.1m 1.9m 12.5m 13.1m M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 New NHSI I&E control total surplus (deficit) 3) Although the Trust is currently on Plan, it is important to remember that the phasing of the Plan is such that the majority of the deficit is planned for the first six months. This is largely due to the expectation that acute/picu overspill bed usage would fall during Q1 and remain at a low level thereon, whilst a number of savings programmes would only deliver in the second half of the year. Last month a forecast position was estimated to ensure we are still on track to deliver and to highlight areas of risk. This forecast has now been updated to take account of latest positions and information as at mid August. Commentary I&E (deficit) surplus -3.1m -5.2m -7.1m -6.5m cover x Balance sheet sustainability - Debt service cover YTD 1) At Month 4 the Trust made a deficit of 3.1m, a favourable variance of 0.9m against the NHSI deficit control total EBITDA margin 1.7% 1.5% 3.3% 3.5% 3.0 Debt service cover ) The favourable variance is largely due to the release of a provision which covered the costs of the Mutually Agreed Resignation Scheme. The provision did not form part of the Plan as submitted to NHSI as it was still subject to m's Cumulative EBITDA audit approval at this time Excluding this the Trust was on Plan at month actual forecast plan under-lying Days (5) (10) M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 actual forecast plan Rating 4 Rating 3 Rating 2 Liquidity rating YTD (15) M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 cover x actual forecast plan Rating 4 Rating 3 Rating 2 Operational performance - I&E margin 4) The overall forecast is for the Trust to meet its deficit control total. However within this there are number of risks and assumptions that need to be addressed or met - * The use of adult acute/picu beds remains considerably higher than plan. A revised plan is taking shape under new Director of Acute Care Pathway with the aim of eliminating overspill (bar 7 PICU beds) by the end of December but this remains a high cost, high risk area for the Trust to manage * 10.1m of CIPs are planned to be delivered as part of a Trustwide set of schemes. The majority of these schemes 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 * The Trust needs to agree the share of risk on the savings proposal to reduce NHS England s use of external forensic placements. The expectation in the forecast is that 1m will either be saved or be returned by NHSE under the risk share agreement * 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 0.0 5) Given the risks to the financial position, additional measures are being taken to give ourselves some headroom (6) -0.5 and build in additional contingency. The Trust is - - Looking to lock in underspends at Q2 by removing budgets where possible (as per a similar exercise undertaken -1.0 in Q1) -1.5 (8) M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 - Undertaking a review of purchase cards with a view to reducing their number and use where appropriate Seeking opportunities to slow down investment where appropriate -2.5 actual forecast plan under-lying NHSI target - Stopping further discretionary expenditure by requiring more senior level scrutiny and authorisation -3.0 m's Agency target 17.4m monthly run rate Setting further savings targets to be addressed at a local level Reviewing the balance sheet for possible provision releases where that is prudent to do so M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M actual Rating 3 Rating 2 forecast plan Rating 4 Key Financial Drivers cover x Performance against plan - I&E margin Performance v CIP - 1.2m - 22% < target Ward Nursing - 0.3m overspent 0.5 Acute Overspill - 2.1m overspent excluding impact of risk share 1.0 Complex/Non Secure Placements - 0.5m overspent excluding impact of risk shares 0.0 Cost per Case/Cost & Volume - 0.4m ytd > target Other Metrics Forecast FSRR less than 3 in next 12 months Yes -1.0 Capital expenditure < 85% or > 115% of plan (no longer a NHSI mertic) Probably M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 Nurse agency % against withdrawn target for 16/17 of 10% 11.2% Better payment practice code (non-nhs by value) 79% -2.0 Cash at bank and in hand 42.9m actual forecast plan & NHSI target -2.5 M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 m's m's 28 Capital spend against plan actual forecast plan Rating 4 Rating 3 Rating 2 Cost Improvement Programme 30 m's Working Capital M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M (10) M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 actual forecast plan receivables payables plan cash cash Net assets actual forecast plan

47 Page 47 of 108 South London and Maudsley NHS Foundation Trust Finance Report 2016/17 July 2016 (month 4) Section A Headlines & Key Issues At Month 4 the Trust remains on plan, reporting a deficit of 3.1m (after application of the Sustainability Fund), a favourable variance of 0.9m against our deficit control total. The current favourable variance is largely due to the release of a provision which covered the costs of the Mutually Agreed Resignation Scheme. The provision did not form part of the Plan as submitted to NHSI as it was still subject to audit approval at this time. Excluding this, the Trust was on Plan at month 4. The Trust submitted its Q1 return to NHSI in July. This submission complied with the conditions attached to payment of the Sustainability and Transformation Fund (STF) and we anticipate payment of 0.57m shortly. The report has been updated to take account of the structural changes that took place in July to 3 of the Adult CAGs Although the Trust is currently on Plan, it is important to remember that the phasing of the Plan is such that the majority of the deficit is planned for the first six months. This is largely due to the expectation that acute/picu overspill bed usage would fall during Q1 and remain at a low level thereon, whilst a number of savings programmes would only deliver in the second half of the year. Last month a forecast position was estimated to ensure we are still on track to deliver and to highlight areas of risk. This forecast has now been updated to take account of latest positions and information as at mid August. Table 1 highlights both the ytd and forecast position by service including a brief narrative regarding their main financial issues and assumptions underpinning their forecast. Overall, the underlying position remains as before with the majority of services operating within budget at month 4 and expecting to continue to do so. However, the forecast helps to emphasise what existing and future pressures will need to be addressed if we are to meet the control total. The overall forecast is for the Trust to 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 o The use of adult acute/picu beds remains considerably higher than plan. With the planned trajectory of overspill beds rapidly reducing in Q2, the Trust is exposed should bed numbers not reduce and they are not reducing. At month 1 the Trust utilised 350 beds. By month 4 this had risen to 400 an increase of 50 beds. At the same time the contracted number of beds has fallen by 35. Although risk shares are in place, they mitigate the impact but do not eliminate it. A revised plan is taking shape under the new Director of Acute Care Pathway with the aim of eliminating overspill (bar 7 PICU beds) by the end of December. If this can be achieved, it would still leave the Trust c 3m off plan after the impact of risk shares. To substantially improve on the 3m estimate would

48 Page 48 of 108 require a significant reduction in overspill from now onwards. As from the 9 th August, the CAG intend to stop the future use of internal and external overspill in Lambeth, Southwark and Lewisham. This objective has been underpinned by a recent review of beds and set of procedures to ensure all necessary actions are taken before approval is given to overspill. o o o 10.1m of CIPs are planned to be delivered as part of a Trustwide set of schemes. The majority of these schemes 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. The MARs scheme is currently expected to contribute c 1m with the remaining amount to come from areas such as the infrastructure review, improved rostering of staff, mobile working and reductions in use of agency. 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. An implementation, consultation and engagement plan covering Trustwide schemes is being produced for sign off in August. 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 this 1m will either be saved or be returned by NHSE under the risk share agreement. 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. Given the risks to the financial position, additional measures are being taken to give ourselves some headroom and build in additional contingency. The Trust is therefore: o Looking to lock in underspends at Q2 by removing budgets where possible (as per a similar exercise undertaken in Q1) o Stopping further discretionary expenditure by requiring more senior level scrutiny and authorisation o Undertaking a review of purchase cards with a view to reducing their number and use where appropriate o Seeking opportunities to slow down investment where appropriate o Setting further savings targets to be addressed at a local level o Reviewing the balance sheet for possible provision releases where that is prudent to do so Progress on savings schemes and the actions being taken to reduce expenditure are being tracked through the Programme Management Office, Senior Management Team and Financial and Performance Committee of the Board. Gus Heafield Chief Financial Officer August 2016

49 Page 49 of 108 Section B - 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 ( ) 01. Psychosis 54,169,200 4,361,400 (12,100) 18,599, , Acute Care Pathway 48,317,600 5,108, ,600 19,129,000 2,429, P Med & Integrated Care 196,000 (109,600) (140,100) (67,900) (179,000) 04. Behavioural And Dev. Psych (400) (195,800) (184,800) 200 (16,700) 05. Child & Adolescent Service 851,600 (22,300) (125,000) (273,900) (213,700) 06. MHOA And Dementia 485,300 (30,300) (74,000) (110,100) (239,000) 07. Addictions 0 (49,300) (49,300) (4,600) (4,600) 08. Clinical Support Services 2,178, ,700 (12,500) 752,100 15, Infrastructure Directorates 54,061,400 4,257,600 (282,800) 17,925,500 (136,600) 10. Corporate Income (101,376,000) (8,114,200) 662,500 (33,501,800) 42,000 Operational Deficit 58,883,000 5,377, ,500 22,447,900 2,049, Corporate Other (80,372,600) (6,177,000) 55,600 (24,514,100) 314, Contingency - planned 2,000,000 0 (166,667) 0 (666,667) 14. Other reserves/provisions 6,343,700 0 (237,033) 0 (1,869,133) Corporate Other (72,028,900) (6,177,000) (348,100) (24,514,100) (2,221,100) EBITDA (13,145,900) (799,600) 432,400 (2,066,200) (171,700) 15. Post EBITDA Items 19,638,000 1,220,900 (46,200) 5,117,300 (2,004,000) Trust Financial Position 6,492, , ,200 3,051,100 (2,175,700) Items Not Included In NHSI Target (2,511,000) (43,000) 0 (172,000) 1,300,000 NHSI Target 3,981, , ,200 2,879,100 (875,700) Area 2015/16 Mth 12 Variance /16 Total Variance /17 Mth 1 Variance /17 Mth 2 Variance /17 Mth 3 Variance /17 Mth 4 Variance /17 Total Variance 000 CAGs (653) (8,061) (331) 158 (1,542) (413) (2,128) Infrastructure Directorates 306 (498) (257) Corp Income (14) 619 (662) (42) Other reserves/provisions (927) (422) (65) (56) (315) released Use of Reserves 119 4, , ,536 Total EBITDA (931) (3,551) 79 (11) 536 (432) 172 2) Key Cost Drivers (unmitigated by alternative income, risk shares etc.) Area 2015/16 Mth 12 Variance /16 Total Variance /17 Mth 1 Variance /17 Mth 2 Variance /17 Mth 3 Variance /17 Mth 4 Variance /17 Total Variance 000 Ward Nursing* (326) (2,695) (80) (112) (141) (9) (343) Agency 20%** (355) (4,272) (288) (330) (303) (315) (1,236) Acute Overspill**** (722) (5,742) (479) (184) (638) (795) (2,096) Unmet CIPs*** (481) (4,350) (250) (293) (284) (336) (1,163) CPC/C&V Income 298 1,419 (103) Placements**** (124) (2,041) (79) (176) (217) (13) (485) Total (1,710) (17,681) (1,279) (938) (1,429) (1,292) (4,939) * includes safer staffing funding ** Costs built into the plan ***see Section 3 **** before application of risk shares

50 Performance Page 50 of 108against the main cost drivers is detailed below Acute/PICU Overspill The 2016/17 Operational Plan is reliant upon previous levels of overspill falling rapidly over the first quarter. Planned acute activity trajectories have been agreed with all 4 local CCGs based on 2015/16 activity levels adjusted for a series of mitigations around length of stay and impact of our Home Treatment Teams. The graph below shows the planned overspill trajectory in 2016/17 that required a period of sustained reduction through to July However, as can be seen, the decrease in overspill seen since March was not maintained going into June and a revised trajectory, following the establishment of the new Acute Care Pathway CAG and review of the measures being taken to reduce overspill, has been determined. This aims to bring overspill back in line with the original plan by 31 st December The forecast net cost (after risk shares) of not meeting the original target is c 3m. Overall 53 overspill beds were used by the Trust in July, a decrease of 6 compared to the previous month. This is 46 beds above our original plan resulting in a 0.8m overspend in the month. In total acute/picu overspill are now 2.1m ytd off plan excluding the impact of any risk shares. Early figures for August show overspill levels still above 50 beds but reducing. 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 target to spend no more than 17.4m on all agency staff. Based on this target the Trust spent 7.6m ytd against all agency staff (after release of provisions in month 1) compared to a target of 7.8m. However the in month position was above target by 126k and with this target set to reduce over the remaining 8 months it is likely that we will be above target at some point in this quarter. Meanwhile the Trust continues to focus its attention on reducing reliance upon agency staff through enhanced control procedures and supporting recruitment of permanent staff. Ward/Unit Nursing Costs At month 4 ward nursing costs overspent by 9k ( 343k 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. Most wards/units continue to operate within plan. The main exceptions are the acute care pathway wards and MHOA acute wards which together are 0.4m overspent after 4 months ( 60k in the month). Out of 24 wards/units, 2 (Johnson Unit and ES 2) are still +20% above budget, a decrease of 2 in the month, with a further 7 wards +10% above budget. Work is underway to ensure that rostering of nurse shifts is being done as effectively as possible.

51 Page 51 of 108 Complex Placements ( 485k overspend excluding risk shares) SLaM are currently responsible for expenditure on 4 main complex placement budgets: Lambeth Alliance (IPSA) a budget of 1.38m. Currently underspending by 68k with this forecast to continue despite having a 304k QIPP applied to it in 2016/17. Lambeth Forensic a budget of 0.91m. Following an underspend in 2015/16, the CCG reduced their funding by 200k in 2016/17. Currently underspending and supported by a small risk share (up to 200k) Southwark Complex Placements a budget of 5.25m jointly funded by the CCG and Local Authority. Overspent by 1.5m (before risk shares) in 2015/16 but no net increase in funding in 2016/17. There is a 0.25m risk share on the CCG element of the budget and a 100% risk share agreement remains in place on the Local Authority element via the CCG pooled funding arrangement. There is a current overspend of 578k (of which 309k is expected to be covered by the risk share arrangements) with a further 0.43m of QIPP due to be taken from October. Work is taking place with the CCG/LA to develop cost reduction measures and improve monitoring/reporting of the c155 placements Lewisham Complex Placements overspent by 0.2m in 2015/16 but brought under control during second half of the year. It is currently recording a small overspend. Monthly monitoring meetings take place with the CCG following their investment in Placement Coordinators and expectation that this budget will now remain in balance Cost per Case/Cost and Volume Income After a poor start to the year, the position has continued to improve particularly in B&D inpatient services where overseas activity has increased on the forensic inpatient wards and in Psychosis where activity on the rehab units has been maintained (partly through their use as overspill wards). The main areas of concern are in Psychosis Heather Close is 126k below target levels and a recovery plan is being drawn up. Psych Medicine & Integrated Care not meeting activity/income targets in several outpatient services particularly neuro psychiatry ( 116k ytd), eating disorders ( 61k ytd) and Cawley Day Service ( 161k ytd) B&D lower activity in ADHD ( 117k ytd) and Behavioural Genetics Clinic ( 108k ytd) than plan

52 The Page Chief 52 of 108 Operating Officer has requested recovery plans from those CAGs where income levels are significantly off target. CAG Income Target Actual Surplus/ Surplus/ Invoiced Deficit(-) Deficit(-) At Month 4 At Month 4 At Month 4 At Year End '000 ' Psychosis 2,696 2, Behavioural & Developmental 7,146 7, (23) Psych Med & Integrated Care 9,785 9,601 (184) (158) CAMHS 8,596 8, MHOA Addictions TOTAL 28,771 29, ) Cost Improvement Programme (CIP) In order to achieve its Financial Plan for the year, the Trust has set itself a challenging target of delivering savings and cost reductions of 29.2m. This target is split as to CAG schemes 14.9m, Infrastructure schemes 4.2m and trust wide schemes 10.1m. The phasing of these savings is as follows: Q1 3.5m, Q2 5.6m, Q3 10m and Q4 10.1m. At the end of Month 4, the Trust has recorded savings of 4.1m against a target of 5.2m. The shortfall has been significantly impacted by the Trust s on-going overspill challenges with the anticipated levels of reduction in overspill costs yet to be achieved. The ytd shortfall breaks down as follows - Old Psychosis 1m (overspill 725k, NCA income 100k and Heather Close), BDP 0.2m (a number of schemes delayed), Psychological Medicine 0.2m (overspill and Eating Disorders schemes), Corporate departments 0.2m (principally CEO and Nursing) net of favourable variances of 0.3m from locked in underspends principally due to vacancies and MARs savings earlier than in the Plan. Significant work has been undertaken to review and robustly challenge, in particular, the infrastructure review scheme and CAG wide schemes. Whilst this has provided a greater level of assurance on delivery it has also resulted in the value of some schemes being downgraded. The impact of these downgrades, continuing high levels of overspill and sundry other delays and downgrades to schemes means a forecast shortfall for the year of 4.2m against the target of 29.2m. The forecast adverse variance on activity and overspill related schemes alone is 3m (against which 0.5m of centrally held contingency has been allocated) and 1.3m in connection with the infrastructure schemes. Favourable variances elsewhere and potential mitigation, combined with the utilisation of contingencies means this shortfall can be accommodated whilst achieving the overall financial plan for the year. However, without headroom from additional savings scope to accommodate any further significant shortfalls is limited. 4) Local CCG/NHSE Contract Positions Although contracts with all our main purchasers have now been signed off, discussions are continuing with - Southwark CCG to input into various task and finish groups that are focussing on the development and delivery of savings plans and to review the on going management of placements Lewisham CCG to agree an obd rate for MHOA continuing care Croydon CCG to agree the detailed savings required to deliver services within the agreed financial envelope NHS England to agree the share of risk on the savings proposal to reduce NHS England s use of external forensic placements

53 Page 53 of 108 Glossary AMH CAG CCG CIPs Continuity of Service Risk Rating (CoSRR) CPC/C&V EBITDA ICT MHOA NHSI OBD PICU PoS QIPP STF Triage YTD Adult Mental Health used in this report to cover a programme of investment in community schemes that aim to reduce the usage of acute/triage beds in the Trust Clinical Academic Group bring together clinical services, research and education and training into a single management grouping e.g. Psychosis Clinical Commissioning Group an NHS body responsible for the planning and commissioning of health services for their local area Cost Improvement Programme A combination of 2 indicators focussing on liquidity and ability to service capital and debt that help to indicate the level of risk to the financial sustainability of a Trust ranging from 1 (high risk) to 4 (low risk) Cost per Case and Cost and Volume income varies depending upon the amount of clinical activity being undertaken Earnings before interest, tax, depreciation and amortisation is an accounting measure used as a proxy for an organisations current operating profitability Information and Communications Technology Mental Health of Older Adults NHS Improvement the new regulatory body overseeing all NHS providers as well as independent providers that provide NHS funded 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 - provide mental health care and treatment for people whose acute distress, absconding risk and suicidal or challenging behaviour needs a secure environment beyond that which can normally be provided on an open psychiatric ward Place of Safety under section 136 of the Mental Health Act, the police have the power to take an apparently mentally disordered person who is in a public place and is apparently a danger to himself or to other people, to a "place of safety" where they may be assessed by a doctor The 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 Sustainability & Transformation Fund that is intended to support providers to move to a sustainable financial footing Triage ward used to admit patients for a short period of time where their needs are assessed before being either discharged to the care of community teams or transferred to an acute ward Year To Date

54 Table 1 Page 54 of 108 July 2016 The South London and Maudsley NHS Foundation Trust - Operating Budgets 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 ( ) Variance Last Month ( ) As At Mth 4 As At Mth 3 Forecast Variance ( ) Forecast Variance ( ) Notes Re Mth Psychosis 54,169,200 4,361,400 (12,100) 18,599, ,300 { 1,749,400 1,097,000 5,770, Acute Care Pathway 48,317,600 5,108, ,600 19,129,000 2,429,700 { (37,500) 4,386,000 (50,000) 03. P Med & Integrated Care 196,000 (109,600) (140,100) (67,900) (179,000) { 44, Swk placements were 578k overspent ytd (Local Authority & CCG) offset by 348k under the risk share arrangements. Income targets not being met in Heather Close Rehab Unit ( 126k ytd). Forecast unmet CIPs of 1m. Recovery plan requested Adverse acute overspill variance of 2.2m ytd comprising average of 26 beds over plan ( 1.8m), payment for unused block beds ( 0.2m) and shortfall on overseas/nca income target ( 0.17m). Adverse nurse pay overspends on PICU units (Eden - 102k, ES1-89k Johnson - 104k) after excluding place of safety costs. Assumes monthly overspill numbers recover to Plan by 31/12/16. Forecast unmet CIPS of 0.8m Underspends on inpatient units and various community teams offsetting an overall shortfall on cpc income particularly neuropsychiatry outpatients ( 116k ytd) and Cawley Day Service ( 161k ytd). Forecast unmet CIPs of 227k 04. Behavioural And Dev. Psych (400) (195,800) (184,800) 200 (16,700) 168, , ,000 Behavioural Genetics & ADHD not meeting income targets & CIP targets not being achieved ( 0.16m) - recovery plan requested. 05. Child & Adolescent Service 851,600 (22,300) (125,000) (273,900) (213,700) (88,700) (221,000) (200,000) Community vacancies & outpatient income above target. Reduction in Kent beds from August will start to adversely impact on income targets 06. MHOA And Dementia 485,300 (30,300) (74,000) (110,100) (239,000) (165,000) (121,000) 0 Ann Moss overspend offset by CMHTs and memory services. Acute wards now beginning to overspend. Assumes 6 mth slippage to Ann Moss 07. Addictions 0 (49,300) (49,300) (4,600) (4,600) 44,700 37, ,000 Redundancies from termination of Swk contract, reduction in R&D income, and not covering cost of staff from outpatient activity (solution from Mth 5) 08. Clinical Support Services 2,178, ,700 (12,500) 752,100 15,000 27, ,000 91,000 Pharmacy CIP to reduce drug costs not yet agreed with CAGs 09. Infrastructure Directorates 54,061,400 4,257,600 (282,800) 17,925,500 (136,600) 146,000 1,538, , Corporate Income (101,376,000) (8,114,200) 662,500 (33,501,800) 42,000 (620,500) (1,003,000) (1,003,000) assumes 1m NHSE QIPP is made or covered under the risk share arrangement Operational Deficit 58,883,000 5,377, ,500 22,447,900 2,049,400 1,268,700 6,236,000 5,795, Corporate Other (80,372,600) (6,177,000) 55,600 (24,514,100) 314, , , ,000 assumes Trustwide CIP savings of c 5m after net 1.1m of MARs savings and 1.7m of lock ins 12. Contingency - planned 2,000,000 0 (166,667) 0 (666,667) (500,000) (2,000,000) (2,000,000) 14. Other reserves/provisions 6,343,700 0 (237,033) 0 (1,869,133) (1,632,100) (3,911,000) (4,025,000) Corporate Other (72,028,900) (6,177,000) (348,100) (24,514,100) (2,221,100) (1,873,000) (5,486,000) (5,045,000) Release of contingency and provision for bad debts EBITDA (13,145,900) (799,600) 432,400 (2,066,200) (171,700) (604,300) 750, , Post EBITDA Items 19,638,000 1,220,900 (46,200) 5,117,300 (2,004,000) (1,957,800) (750,000) (750,000) Restructure budget covered by MARs provision Trust Financial Position 6,492, , ,200 3,051,100 (2,175,700) (2,562,100) 0 0 Items Not Included In NHSI Target (2,511,000) (43,000) 0 (172,000) 1,300,000 1,300, the NHSI target excludes impairments (Douglas Bennet work not yet started), donated depreciation & gains/losses (Moorland Rd revaluation tbc) NHSI Target 3,981, , ,200 2,879,100 (875,700) (1,262,100) 0 0 distance from NHSI Target Corporate 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 ( ) Variance Last Month ( ) As At Mth 4 As At Mth 3 Forecast Variance ( ) Forecast Variance ( ) Notes Re Mth 4 A1) Estates & Facilities 15,846,500 1,345,100 14,300 5,565,900 99, ,000 1,128, ,000 Unfunded strategic capital costs, increase in Sunshine Hse costs, hire of vehicles, potential increase in cost of new transport contract and unmet historic CIPs and slippage against new schemes A2) Hotel Services 10,329, ,100 (38,700) 3,394,700 (48,500) (32,500) (89,000) (39,000) B) Nursing & Quality 2,656, ,800 46, ,200 17,500 (64,600) 114,000 (96,000) Unmet historic CIPs and not achieving 16/17 CIP target C) Information & I.T. 8,591, ,900 (156,900) 2,757,500 (123,800) (10,900) 0 40,000 D) Finance And Corp Governance 4,420, ,400 (1,000) 1,511,600 (1,400) (6,800) (30,000) (30,000) E) Human Resources 3,485, ,000 (79,800) 938,400 (162,300) (124,200) (286,000) (207,000) F) Organisation & Community 1,679, ,500 (14,200) 589,000 52,300 (14,400) 35,000 75,000 Redundancy cost not covered by net savings G) Chief Executive 3,768, ,100 4,600 1,385, ,600 83, , ,000 use of Ortus above agreed funding and unfunded posts and membership costs H) Medical & Clinical Govern. 3,103, ,500 5,600 1,207, ,500 72, , ,000 unfunded posts/commitments and increase in junior doctor on call expenditure I) Professional Heads 1,825,300 14,400 (127,500) 522,400 (55,700) 6,200 (41,000) (78,000) J) Chief Operating Officer 3,002, ,800 83, ,900 (35,000) (79,800) 0 (99,000) K) Commercial Directorate 451,700 20,400 (21,400) 92,600 (24,700) (38,600) (30,000) (50,000) L) R&D (5,099,400) (420,400) 2,300 (1,831,700) (143,800) (23,000) 0 0 Infrastructure Directorates 54,061,400 4,257,600 (282,800) 17,925,500 (136,600) (101,300) 1,538, ,000 L) Corporate Service (80,372,600) (6,177,000) 55,600 (24,514,100) 314, , , ,000 payment of 15/16 Swk overperformance and other provision releases M) Trust Reserves 8,343,700 0 (403,700) 0 (2,535,800) (351,200) (5,911,000) (6,025,000) Corporate Other (72,028,900) (6,177,000) (348,100) (24,514,100) (2,221,100) (157,600) (5,486,000) (5,045,000)

55 Page Table 55 of SLAM summary CIP status report Jul-16 35,000 30,000 25,000 20,000 15,000 10,000 5,000 - Monthly Actual/Forecast v Plan M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12 Plan Actual/Forecast M12 M11 M10 M09 M08 M07 M06 M05 M04 M03 M02 M01 Plan Plan/Forecast by RAG per month - 5,000 10,000 15,000 20,000 25,000 30,000 35,000 Red Amber Green 000s Plan YTD Actual YTD YTD variance from Plan Value of Additional Schemes YTD Full year Plan Full year Forecast Full year variance from Plan Full year Forecast of Additional Schemes CAG schemes: 3,642 2,251 (1,391) - 14,918 11,720 (3,198) - Overview comment Forecast shortfalls in all CAGs apart from CAMHS. Principal adverse variances arise in Psychosis (Activity/Overspill/Heather Close), B&D (delayed start to schemes) and MHOA (delay re specialist care). Corporate schemes: 1, (206) - 4,210 3,608 (602) - Trust wide schemes: ,105 9,744 (361) 1,660 Trust Total 5,232 4,069 (1,163) ,233 25,072 (4,161) 1,660 Significant anticipated shortfalls in CEO, Medical (proposed savings not materialised) and Nursing (complaints scheme delay) Following review, downgrades have been applied to the Medicines Management and New Business schemes, with a delay to the mobile working scheme. The infrastructure review (of which MARs will deliver in year savings of 1m) has been subject to detailed development and review, which has resulted in a downgrade in the forecast by 1.3m. In mitigation, budget savings of 1.6m have been made to reflect identified underspends. There remains a significant element of these savings which are at risk. CIPs / Cost Reduction CIP Schemes 1,442 1, ,193 12,002 (1,191) 1,660 Cost Reduction Schemes 3,790 2,400 (1,389) - 16,040 13,070 (2,970) - Trust Total 5,232 4,069 (1,163) ,233 25,072 (4,161) 1,660

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57 Page 57 of 108 Attachment G COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 13 September 2016 Name of Report: Author: Presented by: Performance Report M Black and C Clarke Kristin Dominy Purpose of the report: To receive the Performance report. Page 1 of 2

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59 Page 59 of 108 TRUST BOARD OF DIRECTORS SUMMARY REPORT Date of Board meeting: 13 September 2016 Name of Report: Heading: - (Strategy, Quality, Performance & Activity, Governance) Author: Approved by: (name of Exec Member) Presented by: Performance Report Performance Martin Black, Performance & Contracts Kristin Dominy, Chief Operating Officer Kristin Dominy, Chief Operating Officer Purpose of the report: To report the Trusts performance against a range of key indicators, identify any major areas of learning and success, identify and analyse under-performance and provide action plans to address such under-performance, and take due account of benchmarking information as applicable. 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 and 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. 1

60 Page 60 of 108 PERFORMANCE REPORT: July 2016 Executive Summary This month s report summarises provisional July performance against the key indicators contained within the NHS Improvement (formerly Monitor) Risk assessment Framework. The report highlights the risks and potential risks to performance against these standards. The report also summarises Trust Performance Management Framework identifying key issues and actions arising from the CAG Performance reviews in July. The Quality Dashboard is also presented within this report alongside the Safer Staffing Report. The summary of contracting issues is outlined and of particular significance is the new NHS England requirement for 2 year contracts to be agreed by December In-patient activity is being monitored closely and overspill reported weekly. The most recent performance is contained within the Finance report. Following agreement with the Board the Transformation Dashboard detailing progress of key corporate programmes is now incorporated within this report. Contents: 1. Performance against NHS Improvement (formerly Monitor) indicators 2. CAG Performance Review Summary 3. Safer Staffing 4. Commissioning and Contracts (including CQUIN) 5. Programme Management Office 6. Social Care 7. Key Corporate Programmes 8 Emergency Planning and Business Continuity 9. Conclusion The following Appendices are included: Appendix A: PMF Trust Summary Appendix B: Quality Sub-Committee Quality Dashboard Appendix C: Safer Staffing: Ward Level Detail Appendix D: Recovery Plans: Home Treatment Gatekeeping and Early Intervention Psychosis 2

61 Page 61 of 108 Introduction The Chief Operating Officer is pleased to advise the Board that Harold Bennison has been formally appointed to the role of Director of Contracts, Performance and Operational Compliance. This is a pivotal role in leading on all matters relating to contracts and performance across the Trust as well as developing an operational compliance framework which will sit alongside the performance management framework. 1. NHS Improvement (formerly Monitor) indicators: Provisional July Performance The Trust has met the quarterly NHSI indicator thresholds in July with the exception of Access to Crisis Resolution / Home Treatment Team gatekeeping for admissions. The provisional performance for July is outlined below. Table 1: NHSI Indicators Summary Table Target April May June July (Prov.) 1 IAPT Waiting Times 6 Week Standard 75% 90.7% 91.3% 90.2% 92.1% 2 IAPT Waiting Times 18 Week Standard 95% 99.4% 99.6% 99.2% 99.6% 3 4 Early Intervention in Psychosis 2 week standard Admissions had access to crisis resolution / home treatment teams 50% 58% 19% 46.4% 60.6% 95% 95.1% 94.2% 92.4% 93.2% 5 CPA formal review within 12 months 95% 85.1% 90.8% 95.4% 86%* 6 CPA follow up within 7 days of discharge 95% 98.4% 98.4% 96.0% 96% 7 Minimising MH delayed transfers of care 7.5% 4.3% 3.9% 4.0% 5.6% * CPA results are within the normal range for achieving threshold of 95% by the end of the Quarter 2. Risks Home Treatment Gatekeeping and Early Intervention: The Trust did not meet the threshold for these indicators in Quarter 1. Performance in July for HTT was also below 95%. Recovery plans are included within the report as Appendix D for Board to note for assurance. The plans detail the actions planned and undertaken and the relevant trajectories for achieving these targets again. These plans will be shared with NHS Improvement. The following NHSI indicators also continue to have associated risks: IAPT Waiting Time standards: The Trust has communicated to Croydon CCG the risk to the IAPT access standards for Croydon patients as a result of the bridging work to meet the Croydon affordability gap. This also has a degree of risk to the Trust overall performance. MH Identifiers and Outcomes: Mental Health Services Dataset (MHSDS) submissions continue however due to the continuing supplier delaying the availability of the AHC extraction tool the returns continue to be completed by Business Intelligence. The Trust has continued to liaise closely with Health and Social Care Information Centre (HSCIC) over these issues as this impacts on published HSCIC results in relation to completeness of data, published KPIs and accuracy. 3

62 Page 62 of 108 Developments of Note: A summary of developments related to NHS Improvement indicators is given below. i) Accessible Information Standard: The accessible information standard came into legal effect on 31 st July The standard aims to ensure that people with a disability, impairment or sensory loss are provided with easily read or understood information to support effective communication. The standard places a legal obligation on organisations providing NHS care or social care to follow the accessible information standard. Prior to the introduction of the standard the Trust has undertaken the following actions: Accessible information field added to Patient Journey System Insight report created to monitor completion of this field and monthly updates on completion rates per CAG Intranet site developed with guidance, elearning and resources to help staff meet the requirements of the standard Regular communications to staff by s and SLaM e-news to raise awareness of the standard and its requirements Audit initiated to look at reasonable adjustments for service users with visual and hearing impairments ii) Early Intervention First Episode Psychosis: The Royal College of Psychiatrists have developed a self-assessment tool to measure progress against the guidance for this waiting time standard published in April The self-assessment rates concordance against NICE Quality Statement domains of: Timely Access Effective Treatment Well-managed service The Trust is completing the assessment prior to the 30 th September deadline. iii) Delayed Transfers of Care (DTOC): There has been a significant increase in days lost rising from 935 in June to 1275 in July based on the provisional data. Whilst this is within the threshold for the NHS Improvement Indicator it presents additional operational pressure on in-patient beds. A detailed clinical review of the delays is being undertaken in each borough throughout September, as the formal definition for agreeing and declaring a DTOC is not as clear as it could be and as such, we are seeking a consistent Trust-wide approach. The attribution of delays between NHS, Social Care and NHS & Social Care was consistent with the previous month respectively 70%, 20% and 10%. 2. CAG Performance Reviews Summary: Month 4 This section summarises the main issues and remedial actions arising from the Operational Performance Reviews occurring in July. The Performance Management framework comprises of key performance metrics across Finance (including cost improvements and cost reductions) Operations (workforce and key activity and quality indicators) Patient and commissioner measures Learning and growth 4

63 Page 63 of 108 Key issues The main themes arising from the performance reviews were: Delivery of CIP and cost reduction programmes Review of Acute CAG transition planning and progress 3. Safer Staffing (July) In June and July the Trust respectively had 20 and 21 wards breaching over 20% of shifts. The breaches are mainly due to the high vacancy rates. An open Day at the Bethlem in October 3rd in the Museum is hoped to boost the poor rates of recruitment in the Bethlem and Croydon areas alongside continuous recruitment and monthly assessment days. The ward level report for July is included as Appendix C. 4. Programme Management Office (PMO) Update A brief summary of the infrastructure review is given below: Phase 1: Consultation (HR, Finance and IT) started on 5 September, all staff members of all affected teams have received an informal consultation pack to gather feedback on the proposed new functional models. The informal period of consultation will last 45 days, finishing on 20 th October and a formal consultation period will start on 21 st October to review the staff structures required in the new functional models. Phase 2: Estates, contracts, performance and nursing and medical directorates has started with an aim to enter informal consultation by 30 th September. Phase 3: Trust HQ and leadership functions will start by 30 th October. Other work streams from the PMO are outlined below: Agency Cap: Following presentation to SMT a plan of action is agreed to try to systematically reduce use of agency for the Trust. Initially this will be by simultaneously targeting the high use areas. There is a project meeting booked for 8 September with all the leads from each department and CAG in order to get focus on the required actions. Shift cross over: The new shift pattern commenced on 5 th September The impact on savings will be confirmed once payroll has been confirmed for the month and pay protection confirmed. Band 5-4 Psychology assistants: It is anticipated that there will be limited savings on this project in year due to the slow turnover of staff from assistant psychology posts. There are currently 13 vacancies that are being recruited across the Trust at Band 4. Roster efficiencies: Leads have been identified from each of the clinical areas who are running 24/7 services to review roster rules, ensure all information on roster is accurate and up to date so that efficient roster principles can be applied. KPIs have been agreed for the project which will be monitored to demonstrate adherence to the process and impact on the savings target on a monthly basis. The full savings target is equivalent to an average of approximately 2 shifts per week, per ward until the end of financial year. On call rota: The review is now completed. A position statement has been drafted for the SRO with recommendations for change once the planned acute care CAG structure changes have been fully implemented. Mobile working: Following an accelerated open tender during August, specialist consultancy Channel 3 has been selected to lead the development of a business case for mobile working across CAG community services. Channel 3 will complete the bulk of their analysis during September and present findings to the portfolio board in mid-october. 5

64 Page 64 of 108 Medicines Management: Opportunities have been identified to reduce medicines wastage and improve supplier management. A proposal for a longer term project to target the use of Paliperidone PP4PY has been drafted to support a Pharmacy submission to the portfolio board in September. Car park management: Estates is developing a proposal requesting Portfolio Board approval to proceed with procurement. 5. Commissioning and Contracts Update (including CQUIN) Contracts: NHS England has specified the agreement of two-year contracts spanning to be agreed and completed in December. The Trust had scheduled an event end of September with Commissioners to share and forecast activity and commissioning intentions alongside Trust priorities. The forecast for in-patient bed usage is being worked up alongside the community activity forecasts for LSLC and NHSE and National/Specialist Services. Alongside this frequent contract negotiations have already been scheduled with 3 of the 4 LSLC Clinical Commissioning Groups. The reduced timescale for completing contracts and longer duration will intensify this process and present additional risks. These risks will be monitored and managed via SMT. Benchmarking: The Adult Benchmarking return was completed submitted to the NHS Benchmarking Club. The provisional results will be shared with the Trust for validation in September, and the final results will be published in October. This will be based on both registered and weighted populations. Key Contract Issues: A summary of specific key contract issues is outlined below by CCG. Croydon: Croydon Affordability Bridge ( million): Whilst the bridge has been agreed, implementation delays have been identified in a number of areas. At a meeting between Chief Financial Officers (CFO) confirmation of the CCG position for funding areas where they have delayed implementation or cancelled the opportunity has been sought. The approximate risk is 800,000 up to the end of the financial year. This risk has been escalated to the CCG CFO and Chief Officer. The independent diagnostic review of Croydon acute pathways and provision has progressed and the first iteration of the review became available on 2 September and the Trust response is being co-ordinated. The New Alliance for Older Adults has been delayed and the new plan for the CCG is to sign a contract in December with delivery commencing in April Southwark: The CCG has requested an options appraisal in relation to the potential closure of Ann Moss. There would be a 300,000 impact upon the Trust plan and a contract variation has been proposed by the Trust. This would create a significant deficit before the start of the contract negotiations. The Trust continues to work with both the CCG and Local Authority on the review of Mental Health Social Care outcomes as previously reported to the Board. 6

65 Page 65 of 108 Lewisham: An external review of Lewisham CCG plans highlighted a 350k gap in their QIPP reporting. There is a strong focus on ensuring delivery of the existing 16/17 QIPP plan (acute OBD and placements) and addressing this shortfall within the upcoming contract negotiation round. Lambeth: The implications of the proposed Living Well Network Alliance is being worked through to ensure risk is appropriately managed. NHSE: Progress on 220,000 under dispute from 15/16 (relating to CQUIN final payments and a technical value adjustment) has been narrowed to 65,000. The main area of concern is the 16/17 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. NHSE has confirmed in writing that it will review the actual delivery of the programme before removing money from the contract. The detailed memorandum of understanding to confirm the process is still outstanding from NHSE. Commissioning for Quality and Innovation (CQUIN): NHSE: The Trust submitted the Quarter 1 returns for NHSE CQUINS. The Trust position is that the deliverables have been met. NHSE have now challenged this position and raised queries in relation to two schemes. The Trust is intending the appeal the NHSE position. Lambeth, Southwark, Lewisham & Croydon CCGs: No quarter 1 deliverables were applicable as due to the delay in finalising the CQUINS it has been agreed with commissioners that these deliverables will occur in Quarter 2. Physical Health: Croydon CCG is in process of finalising the national CQUIN as the lead CCG. 6. Social Care Social care performance: The project plan for the delivery of the social care dashboard been incorporated within the broader automation project for the Performance Management Framework. The changeover to the new reporting system will be going live in October. Progress has been made on a number of indicators including the development of a Section 117 register. Section 117 refers to entitlement to aftercare if a patient was admitted to hospital under specific sections of the Mental Health Act. An initial report has been produced and the data has been shared with each borough. Delayed Transfers, and patients in employment and accommodation indicators are progressing. Further work is scheduled to progress the technical specification on the additional indicators. Once the full dashboard is complete, local improvement targets will be agreed operationally within CAGs to ensure improvement in social care outcomes is achieved in all areas. Section 75 agreements: The agreements are being actively progressed with Lewisham and Croydon and nearing completion. The London borough of Lambeth is currently undertaking a review of adult mental health social care and the section 75 agreement will be progressed following the 7

66 Page 66 of 108 completion of the review. The review is being undertaken by an independent social work consultant with the full involvement of SLaM managers and the Director of Social Care in SLaM. Professional Social Work: Social Work for Better Mental Health programme: The Social Work for Better Mental Health programme will start in October 2016 with the involvement of social workers and managers employed by SLaM and the boroughs of Croydon, Southwark and Lewisham. Lambeth are not participating in the programme at this point due to the clash with the review of social care but the Director of Social Care will share outcomes and intelligence from the programme with Lambeth colleagues to support the review. Social Work Governance for SLaM employed social workers: The SLaM social work governance group is continuing to work on a governance framework for the profession of social workers employed by SLaM which is clear on regulatory and professional requirements including: Continuing Professional Development (CPD) for social workers and registration with the Health Care Professional Council. The group, along with social work colleagues in borough integrated services, is setting up professional social work seminars to engage social workers in current professional topical issues. These are due to start in October. Central Place of Safety Engagement Plan: The Central Place of Safety (CPOS) comprehensive engagement plan has addressed all the recommendations made by the Joint Health Overview and Scrutiny Committee in April: SLaM has worked in partnership with the four Healthwatch organisations across the boroughs to engage key stakeholders and partners with a particular focus on homelessness, people with no recourse to public funds and children and families. An open day was held on the 9 th August, in partnership with Healthwatch. The open day gave information about the development of the CPOS, invited feedback and gave tours of the CPOS site. Between 250 and 300 people attended the event feedback from visitors has been incorporated into an engagement report and the CPOS operational policy as appropriate. The Director of Social Care in SLaM has engaged with all the boroughs in drafting formal arrangements between the local authorities on Approved Mental Health Professional (AMHP) service models, housing, children and young people and people with no recourse to public funds (NRPF). A memorandum of understanding (which is a protocol between the four borough local authorities and the SLaM CPOS team) has been drafted and is currently being negotiated. A financial comparison paper to show the financial rationale for a CPOS was completed and sent to the Joint health Overview and Scrutiny Committee, directors of adult social care and joint commissioners as agreed. The date of the next Joint Health Overview and Scrutiny Committee is the 6 th October, where SLaM will be required to present the outcome of the last 3 months engagement and the work undertaken as outlined above. 8

67 Page 67 of 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: CPN Usage - There is a reduction in CPN usage based on the baseline measure, 85.4 WTE in July compared to 98.8 WTE in June. The data is based on NHS Professional reports. Appraisal - The initial figures for Appraisal indicate 97.5% of staff in post at the beginning of April have had their appraisal completed. HR Business Partners are following up instances of staff without a recorded appraisal to identify the reasons for this. Calibration of scoring to ensure consistency in rating is underway. At the end of July NHS Digital published sickness rates for English NHS bodies for April 15 - March 16. The Trust has the fourth lowest sickness rate out of 56 MH trusts. The Trust has managed to reduce sickness for the last three consecutive years. The costs of sickness relate to unproductive payroll and agency or bank costs. Reduction in sickness is considered likely to result in an increase in the quality of care we provide to our service users. 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. However the impact of the Referendum may have an impact on the property market and therefore each planned disposal is being reviewed with agents to assess the market. Pre-apps have been submitted to the relevant councils on four of the properties on the disposal list. Marketing the properties will commence in September Capital projects achievement against plan 1. Anti-ligature programme: Programme completed. Window replacement at Maudsley and Lambeth hospitals in progress. 2. Work Hubs Maudsley site: 4 work hubs complete. BRH 1 work hub in progress. 3. Trust Wide Staff Attack Alarms: Programme completed. 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 /Douglas Bennett refurbishment will be presented to the Trust Board September Adamson Centre- the project team is in discussion with the clinical teams to move into 151 Blackfriars Road the target date for the move is October 2016, the space for utilisation in Blackfriars and the Adamson Centre is being finalised and it is likely that some residual space in the Adamson centre will be required. 2. JWH the exchange of contracts is scheduled at the end of September Centralised Place of Safety: This is scheduled to open in October 2016 Hotel Services: Patient led Assessments of the Care Environment (PLACE) Scores The results of the PLACE audits were published in August In most categories the Trust scored above the national average. 9

68 Page 68 of 108 Catering and Domestic contract The Hotel Services and Procurement team are working on the specifications for the Catering and Domestic tender. The Procurement Team is formally requesting Aramark to extend the present contract to 01st April 2017 to allow the retendering to take place. IT Transformation Update: The IT Service Desk closed 100% of incoming 339 incidents and 96% of incoming 1012 requests in July. The rate of abandoned calls to the IT Service Desk is 8.9%, which is the lowest monthly rate in the last 12 months. The trust switchboard is picking up 97% of all incoming calls. The Business Intelligence Team completed all national data submission on time in July. The NHS number completeness rate has increased to 99.4%. As part of the MARS scheme, 9 staff members from IT left the trust in July. The PC replacement programme roll-out is anticipated to start in September. 8. Emergency Planning and Business Continuity The Trust will submit its annual Business Continuity (BC) and Emergency Preparedness, Resilience and Response (EPRR) assurance process return to NHSE (London) on the 14 September. This peer reviewed process is part of the wider Department of Health (DoH) EPRR process, and provides assurance to the DoH, NHSE (London), CCGs, and other partner organisations that the Trust has plans in place (including the level of readiness) to mitigate the effect of any such incidents that may require the activation of any such plans. As previously outlined, the Trust assures an on-going commitment to Emergency Planning, Resilience, and Response (EPRR), and Business Continuity planning (BC), where an ongoing bi-monthly schedule of exercises has been put in place to both test current plans, and to inform any future BC planning across the organisation. The organisation's continual testing of these systems is central to the annual assurance process, carried out by NHSEL, which feeds into the EPRR planning processes of NHSE, CCGs, and other partner organisations. The exercises, led by Kristin Dominy (in her capacity as SLaM s Accountable Emergency Officer (AEO)), with the support of Scott Yeomanson, the Trust s Emergency Planning Manager (EPM) commenced on the 14 July. The exercise itself (Operation Orchard) was based on a security incident (in the context of the biometric entry system) at River House. Both assurances were provided, and lessons identified from the exercises, and required actions escalated, as appropriate. The next exercise (Operation Silver) is due to be held in September Report Conclusion The Trust met the key NHS Improvement indicators with the exceptions of Home Treatment Team Gatekeeping in July. Recovery plans for Home Treatment Team Gatekeeping and Early Intervention in Psychosis have been developed and presented as Appendix D in this report. Safer staffing and the associated recruitment issues continue to be a key priority for the Trust. The Month 4 CAG Performance Reviews have been undertaken the key issues being: Delivery of CIP Programmes Review of Acute CAG transition planning and progress 10

69 Page 69 of 108 Jul-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 50) Nursing NHSP Bank (WTE) Nursing Agency (WTE) Nursing Vacancy (WTE) Sickness 6.00% 1 Annual Leave Planning -Annual RosterPerform Leave Data Planning (Excludes Doctors) % 4.00% 3.00% % 1.00% Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep % 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 1,400 1,200 1, Jan-16 M10 Private Delayed Sector Overspill Discharges Average Days Patients LostPer Day Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 M11 M12 M1 M2 M3 M4 M5 Sep-16 M6 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% % Days Lost -300 Adult OBD Variance Medium Secure Low Secure OBD OBD Variance Variance CAMHS OBD Variance Older Adults OBDOther Category A Other Category B Variance OBD Variance OBD Variance MHOAD Days Lost Trust Days Lost Psychosis 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

70 Page 70 of 108 Jul-16 7 Day Follow Up (Target 95%) Appendix A Performance Management Framework Trust Summary MONITOR & Contract KPIs (Latest Month) CPA 12 Month review HTT Gatekeeping (Target 95%) (Target 95% by End of Quarter) Delayed Discharges Target Below 7.5% , Achieved Missed Patients with valid review Patients with overdue review 96.0% of patients followed up within 7 days of discharge 86.0% of patients had a CPA review within 12 months 93.2% of patients received an HTT assessment 6% of discharges delayed 0.0% variation to the previous month -9.4% variation to the previous quarter 0.8% variation to the previous month 1.6% 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% 99.0% 96.9% 50% 86.4% 92.1% 100.0% 100.0% 99.7% 98.8% 99.6% ) 40% 83.6% 40% & $ ) 30% 30% 20% ) 20% 10% ) 10% 0% 0% ) Croydon Lambeth Lewisham Southwark Trust % ) % % % % &- ) 64$7) 67) 8$7) $7&&9).$) 61% of patients received Psychosis treatment within 2 weeks 92.1% of patients completing treatment within 6 weeks 99.6% 14.2% variation to the previous month 2.1% variation to the previous month 0.6% 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% 193 Achieved Missed 88.0% 88.6% 91.5% 89.9% 85.2% 89.5% 87.1% 21,677 of patients completing treatment within 18 weeks variation to the previous month Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 M10 M11 M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 Days Not Lost Days Lost No. of FFT Responses FFT Score (%) Do you feel involved in your care? (%) QP Target % Learning and Growth ) *) ) +) ) ) ) ) ) ) ) ) ), -$. /.0 1, -$.$$23 *) ), -$. /. 1, -$$!!$4-2 & $. /./$) ) ) &!5 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

71 Page 71 of 108 Appendix: B QSC Quality Dashboard Period: July (M4) 2016 Circulation: Board Circulation September 2016 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 At E-Observations present work across is being the undertaken wards). 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. The Quarter 1 submissions for NHSE CQUINS have been made and met. There were no LSLC CQUIN Quarter 1 deliverables. A status update is included in the main body of the performan Exception reporting: Early Intervention in Psychosis and Home Treatment Team Gatekeeping were below the 95% threshold for Quarter 1. Recovery plans have been developed and are included within the Board Performance report appendices. Safer Staffing performance in July rose by 1 ward to 21 wards compared to the previous month. Further detail is outlined in Board Performance report appendices.

72 Page 72 of 108 Safe Safer Staffing (Number of Wards Breaching 20% of Shifts) 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 No. of wards Safer Staffing (No. of breached wards) Average (CL) UCL LCL Brief or Full Risk Screen (CPA Patients) Child Need Risk Screen (CPA Patients) 150 Unauthorised Absences (Detained Patients) % followed up within 7 days of discharge 98.6% of patients had a brief or full risk screen 98.1% of patients had a child need risk screen New Serious Incidents Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Number of incidents Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Completed Incomplete Completed Incomplete Unauthorised Absences - Detained Patients New Serious Incidents Average (CL) UCL LCL Use of Prone Restraints 2016/17

73 Page 73 of 108 Safe (continued) Patient Physical Assault on Patients (All Grades A-E) Patient Physical Assault on Staff (All Grades A-E) 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 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 No. of assaults Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Physical Assaults on Patients (By Patient) Average (CL) UCL LCL Physical Assaults on Staff (By Patient) Average (CL) UCL LCL Effective Home Treatment Team Gatekeeping was below target for Quarter 1 and July. A recovery plan to sustain performance is contained within the Board Performance report appendices. QUESTT addresses the following Metrics: New or no Ward Manager in post (within last 6 months) Vacancy rate higher than 7% Bank shifts is higher than 6% Sickness absence rate higher than 3% Level 0 (Score = 9 or less) Level 1 (Score = 10 16) Level 2 (Score = 17 23) No monthly MPT review of key quality indicators (e.g. peer review or governance team meetings Planned annual appraisals not performed Planned clinical supervision sessions not performed No formal feedback obtained from patients during the month (e.g. questionnaires or surveys) 2 or more formal complaints in a month No evidence of resolution to recurring themes Unusual demands on service exceeding capacity to deliver Number of hours of enhanced levels of observation exceed 120 Ward/department appears untidy/disrepair No evidence of effective multidisciplinary/multi-professional team working On-going investigation or disciplinary investigation 93.2% of patients with a HTT assessment QUESTT Commentary: QUESTT has now been rolled out to all wards within the Trust and reporting will commence from September. ES1: ES1 has been at level 2 for three consecutive months and an action plan remains in place Addison: Gresham 1: In April Gresham 1 scored 17 (level 2) falling to 14 in May and is now scoring 12 (level 1) The action plan continues to take effect the new ward manager was appointed in April.

74 Caring 86.0% CPA performance is within range for achieving the threshold by the end of the quarter. of patients had a CPA review within 12 months! "# $! %& $##'!()! "# $! %& "*&%''%*+ %''%*!,-! "# $! "./* ' %& Page 74 of 108

75 Page 75 of 108 Caring (continued) Early Intervention results were below target for Quarter 1. Performance returned to target in July. A recovery plan to sustain performance is contained within the Board Performance report appendices. Well Led!"! #$ %&! "# $! %& "*&' 4//*!5 +' "*&' 4/*!5*& "*&' 4/*!56 '4,4 - ##!*!,&7#8 -, !" *%+, & %& 23 2 For the core skills framework subjects a total of 24 tailored training courses are provided dependent on staff type and including skills refresh. The updated RAG rating has been applied whereby below 70% = Red, 71-84% = Amber, above 85% = Green (except IG which is 95%). &('!"&! #$ )! "# $! %& 2 &'!9,-! "# $! %&

76 Page 76 of 108 Appendix C: Safer Staffing July! "!# $ % &'"%# ( %' ) &'*"# ' +, - '. ( %' ) /" /# 0( 1( $ '* 2'"2# -3 %' ) 2! 3 '* 2 +, 3 & ) &. 3 & ) *. & ) 4 03 %' ) 5 '* + * $ 6 &' ', & ). ' 0 7$ 8 8) ) :': )0) : )/)) )5%69 8 *) *): +' 1= *&&'!&$(-=.)&8& *568*9 * *!&') :%;&'< = ':&) ) :&) )) )** : ): >)' '*:) 8 ): =8 ) 8756! & 8 ) 888=

77 Page 77 of 108 Appendix D Context and Actions Description: Home Treatment Gatekeeping: Admissions to inpatient services had access to crisis resolution/home treatment teams Context: The Trust did not meet the target in Quarter 1 or July. Actions planned to achieve the target: August: Staff consultation with pilot phase offering a screening function within bed management (nights only). Limited operational changes. September: Feedback from staff and preparation for the implementation of the new model. Internal and external communication and feedback gathered. October: Soft launch of a new 24hr central triage function will be formed in order to provide swifter access to Home Treatment with increased effectiveness in processing referrals for assessment in the borough teams. The HTT triage function will be co-located with bed management at the Maudsley Hospital. This operational change creates a hub and spoke model where all referrals are triaged centrally in the hub before being progressed, if required, to the borough HTT team (spoke) for a face to face assessment, and where required processing of the admission. October: Bed management staff consultation and phase 2 of the change programme November/December: Acute Referral Centre is fully functional. The centre is the Trusts central management system for all acute referrals. Recovery Plan: Home Treatment Gatekeeping of Admissions Trajectory and Assurance Trajectory Chart 1 Recovery Trajectory. The trajectory above outlines that the 95% threshold will be narrowly met for Quarter 2 and maintained in Quarter 3 and 4 Assurance Controls Operational: Daily reports - HTT follow up Meeting with LEO Ward processes confirmed One Bed management staff upgraded to CSL to support live scrutiny CAG: Project group meeting weekly HTT Leadership Group meeting fortnightly CAG monthly meeting Monthly breach analysis for thematic review to inform improvements Trust: Performance Review Reporting to Board Responsible Leads Operational: Donna Hayward-Sussex Clinical: Dr Zain Sadiq