DRAFT A MEETING OF THE COUNCIL OF GOVERNORS WILL BE HELD ON THURSDAY, 16 MARCH FROM 1.30PM TO 3.30PM MAUDSLEY LEARNING CENTRE AGENDA

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1 Page 1 of 84 DRAFT A MEETING OF THE COUNCIL OF GOVERNORS WILL BE HELD ON THURSDAY, 16 MARCH FROM 1.3PM TO 3.3PM MAUDSLEY LEARNING CENTRE AGENDA Item Att Lead Time 1 Introductions, welcome to new Governors, apologies for absence and current position on Governor vacancies. RP Declarations of interest. 3 To agree the minutes of the meeting held on 15 December 216. A RP 4 Lead and Deputy Lead Governor JC / BL STANDING ITEMS Risk Focus 1: Staffing LH Risk Focus 2: Finance, including contracting rounds GH Non-Executive Directors (NED) Report: Business development/finance & Performance June Mulroy 8 Working groups and committee reports: Quality (Jenny Cobley) Membership and Involvement (including ToR update to reflect inclusion of ISR group) (Tom Flynn) Planning and Strategy (Angela Flood) Governance (Roger Paffard) Bids (David Blazey) Reports to be taken as read. Opportunity for Governor Q&A. GROUP WORK AND DISCUSSION 9 Group Work Effective communication DECISION 1 Nominations Committee Report To receive an update on membership. To confirm the process for the appraisal of the Chair and NEDs. B C JM TF 2.4 RP 3.5

2 Page 2 of 84 INFORMATION 11 Trust Reports: 3.1 Chair s report Chief Executive Report Including an update on the CQC visit. 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. 12 Future reports back from NEDs: Quality - June 217 Audit - September 217 D E F G RP MP / NB GH KD RP 13 Any other urgent business. RP Dates: Away Day Thursday, 23 March at 1.3am in Cambridge House, SE5 HF RP Next Council of Governors meeting - Thursday, 8 June at 5.pm in the Maudsley Learning Centre. Governors will have the opportunity to have a photo taken / sign up to Governors Forum both before and after the meeting. CMS/RE/February 217

3 Page 3 of 84 Attachment A COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 16 March 217 Name of Report: Author: Presented by: Minutes of the meeting held on 15 December 216 Rachel Evans, Director of Corporate Affairs Roger Paffard, Chair Purpose of the report: To agree the minutes and to note any matters arising.

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5 Page 5 of 84 DRAFT MINUTES OF THE MEETING OF THE COUNCIL OF GOVERNORS OF THE SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST (SLaM) HELD ON TUESDAY 15 DECEMBER 216 AT THE MAUDSLEY LEARNING CENTRE PRESENT Roger Paffard (RP) Chairman Elected Governors Mark Banham Service user Governor David Blazey Staff Governor Stella Branthonne-Foster Service user Governor Handsen Chikowore Public Governor Jenny Cobley (JC) Public Governor Angela Flood (AF) Carer Governor Tom Flynn (TF) Southwark Council Marnie Haywood Service user Governor Jeannie Hughes (JH) Carer Governor Francis Keaney Staff Governor Brian Lumsden (BL) Public Governor John Muldoon Public Governor Rosie Mundt-Leach Staff Governor Siobhan Netherwood Staff Governor Gill Sharpe Public Governor Appointed Governors Bert Johnson Nancy Kuchemann Ian Norman Luke Sorba (LS) Rethink Mental Health Southwark Clinical Commissioning Group (CCG) Kings College London Lewisham Council In Attendance Neil Brimblecombe (NB) Director of Nursing Valerie Chin-You Assistant Director of Nursing Tom Collins Member Alan Downey (AD) Non-Executive Director (NED) Rachel Evans (RE) Director of Corporate Affairs Mike Franklin (MF) NED Michael Holland Medical Director Julie Hollyman NED Matthew Patrick (MP) Chief Executive (CEO) Matthew McKenzie Member Paul Mitchell Trust Secretary June Mulroy NED Gabrielle Richards Head of Occupational Therapy Carol Stevenson (CS) Membership Officer Anna Walker NED Michael Wuestefeld-Gray (MWG) Business manager, CEO office Apologies Adam Black Service user governor Nigel Davies Bromley Council David Dawson Kings College Hospital Kris Dominy Chief Operations Officer Duncan Hames NED Gus Heafield Director of Finance Page 1 of 8

6 Page 6 of 84 Paul Heenan Dr Seb Kalwij Paula Swann Tom Werner Louisa Woodley Lambeth CCG Lewisham CCG Croydon CCG Staff governor Croydon Council Ref Issue Who MC/ INTRODUCTION, WELCOME TO NEW GOVERNORS AND APOLOGIES FOR 16/49 ABSENCE Roger Paffard (RP) welcomed attendees and wished them a happy Christmas and a prosperous New Year. The following new governors were introduced: Ian Norman, Dean of Nursing and Midwifery at Kings College London; Jeannie Hughes, Carer Governor; Siobhan Netherwood, Staff Governor; Luke Sorba, (LS) Councillor for the London Borough of Lewisham; Rosie Mundt-Leach, Staff Governor. Apologies were noted from Adam Black, Seb Kalwij, Louisa Woodley, Tom Werner and Paula Swann MC/ 16/5 MC/ 16/51 MC/ 16/52 DECLARATIONS OF INTERESTS No interests were declared. MINUTES OF THE MEETING OF 13 SEPTEMBER 216. With one minor correction the minutes were accepted as a true and accurate representation of the meeting. NED REPORT Mike Franklin (MF) presented the report and discussed first impressions of stakeholder and service user engagement, and how it is critical for effective service delivery. It is important to value the contribution that people are making and to work with families and communities. MF attended an event in West Norwood focussing on mental health engagement and explored how to encourage people to attend meetings and what should be discussed at those meetings. He also attended the Involvement and Social Responsibility Working Group where the Recovery College was discussed as a way to drive peer to peer support. The Trust is also developing a Patient and Public Involvement Policy. Better engagement leads to better service delivery so it is a priority area. Good communication means less jargon and actively demonstrating inclusion. Asked if service users should engage directly with the chairs of working groups and with non-executive directors, MF responded that methods of engagement should vary according to who was involved. He emphasised that people would stop coming to meetings if they were being talked at rather than actively engaged. Page 2 of 8

7 Page 7 of 84 Angela Flood (AF) said as a governor she would appreciate key messages being reported back to governors so they are aware of critical points when engaging with constituents. Tom Flynn (TF) agreed to do this via the Membership and Communications Working Group. He explained that the Working Group is looking at how information is communicated with governors. TF will report back to the next Council of Governors Meeting. TF Bert Johnson asked about the engagement with the hundreds of thousands of carers with great responsibilities. How could they be equipped, and what relationships could the Trust form so they could be supported and their value recognised. MF recognised the significant contribution of carers and highlighted the need to recognise the strain they are often under as well as the important role they play in recovery. The Trust s engagement strategy should specifically look at carers. MC/ 16/53 WORKING GROUPS AND COMMITTEE REPORTS Quality Group Jenny Cobley (JC) presented the Quality Group report which was taken as read. Membership and Communications TF thanked Dele Olajide and Mark Ganderton, the outgoing chairs of the Membership and Communications and Involvement and Social Responsibility working groups respectively. He encouraged governors to join the Working Group s Facebook discussion page, and also encouraged people to join the Working Group itself. RP noted the proposal to merge the Membership and Communications and Involvement and Social Responsibility working groups. Planning and Strategy AF reported. She said in 217 the Trust was looking at reducing the number of working groups and ensuring better alignment with the Board. Relationships have been moving forward in a positive way and there has been more involvement among group members and with stakeholders. She thanked Alan Downey (AD) for his contribution to the Working Group, and Paul Mitchell for his work as Trust Secretary. She also asked for more governors to join the Working Group. Page 3 of 8

8 Page 8 of 84 Governance RP said the Governance Committee has delivered improvement actions and that it was now proposed that the Committee would now meet quarterly. This was agreed by the meeting. RP thanked Adam Black for his contribution to the Committee s work. RP explained that the Chairs of Working Groups had been considering the direction of travel given time pressures and the need for more support. The options for the future were set out in the Governance Committee report and the meeting accepted the recommendation of option 2, with firm proposals to come to the next Council of Governors meeting. RP Bids David Blazey presented the report which was taken as read. The Smile For Health report included with the report of the Bids Committee was highlighted. He thanked Roger Oliver and Mark Ganderton for their contribution, and Paul Mitchell for his support as Trust Secretary. Brian Lumsden (BL) recommended that governors attend the Governwell Training that he and others had taken. Carol Stevenson will circulate any upcoming dates to governors. CS MC/ 16/54 GROUP WORK ON SUSTAINABILITY AND TRANSFORMATION PLANS Attendees identified the following questions in relation to STPs 1. What is so different about STPs and what are the key drivers and priorities? 2. Is it going to lead to more fragmentation of health services moving resources or managing them better? 3. Are STPs a way of moving toward privatisation? 4. Is the motivation quality or cost cutting? 5. How is the Trust managing the differences between the two STPs (SE London and SW London)? 6. How will the Trust manage the impact? 7. What happens when people don t agree e.g. is there an arbitration process? 8. Will STPs enhance or detract from King s Health Partners? 9. Is it more important to get the South London Mental Health Partnership right? Page 4 of 8

9 Page 9 of 84 RP said that STPs had generally been welcomed and the idea behind them was good. Whole system planning is better done in one place and STPs are of sufficient scale to promote dialogue between different parts of the system. The contracting process will also be improved through two year contracts and the process taking place earlier in the year. There needs to be a move to a different sort of commissioning because the resources required to make the current model work are not there. Francis Keaney asked how the Trust is involved in decision making. MP said that this depended on relationships. The Trust is well represented in STPs. South East London s STP plan is one of only four that have been rated as outstanding for mental health. The motivation is to improve value by improving quality, but because there is a large financial gap by 22 there is also a focus on financial balance. They are also not about opportunities for access by the private sector as these already exist. MP said STPs are both too big and too small mental health needs specialist provision, which is the reasoning behind the South London Mental Health Partnership. Relationships are also borough based and different boroughs are very different. The Trust is unlikely, for example, so see six boroughs enter into the same contract for community mental health services. On question 7, June Mulroy said the assumption is that NHS England will ultimately direct solutions if necessary. Given the plans in south west London, some form of arbitration process could be necessary. RP acknowledged the risk of mental health not being a priority, hence the heavy involvement of the Trust in STP plans. MP added that the risk approach is about mitigating unplanned consequences. RP assured governors that STPs do not overrule the statutory duties imposed on commissioners and providers. In answer to question 8, MP said this would largely depend on how King s Health Partners approaches this. It has a role in supporting the system, but this requires moving to a different set of priorities. There is a KHP board away day at the end of January to examine the purpose of academic health sciences centres within STPs. LS said some people see STPs as entirely savings driven, with the social transformation fund a bribe and the success regime as a stick. He added that savings forecasts could be regarded as wildly optimistic and that it was not clear what would happen if they were not delivered. MP acknowledged that resources are very limited and some aspirations may be undeliverable, but highlighted that everyone wants to improve quality and finances are not the only motivation. RP said responses to the questions will be circulated and any further questions should be sent to Michael Wuestefeld-Gray (MWG) MWG Page 5 of 8

10 Page 1 of 84 MC/ 16/55 GROUP WORK ON SOUTH LONDON MENTAL HEALTH PARTNERSHIP AD asked if the South London Mental Health Partnership was more important than STPs. MP said the partnership will focus on specialist service provision and efficiencies such as back office functions. It will not focus on local or community services so STPs and the Partnership are different in their purpose and approach. Specialised commissioning includes forensic mental health such as medium and high secure provision, tier 4 CAMHS, and perinatal mental health. Eating disorders, mood disorders and autism are further examples. Concentrating provision and expertise delivers better outcomes in these types of services. RP explained that approximately 2% of what is done at the Trust is commissioned centrally. Managing this through the South London Mental Health Partnership is more powerful than the Trust acting alone. There is also the opportunity to do payroll, communications and legal services at scale. However, he emphasised that the Partnership is not a merger and there will be no changes to governance structures. BL asked if there would be an opportunity for the governors or equivalent of all three trusts to meet in the new year to discuss potential governance challenges. The meeting agreed to look at the possibility of substituting a South London Mental Health Partnership governors meeting for one of the Kings Health Partners meetings in 217. RE Any further questions should be sent to MWG. MC/ 16/56 BEST PRACTICE VISITS Valerie Chin-You (VCY) presented. She highlighted the difference between PLACE visits and best practice visits as the latter also include clinical care and how well staff are improving. The visits support the delivery of CQC must do actions. Feedback goes direct to the ward, and the aim of the visits is to identify and recognise best practice. There is a three year rolling programme, currently prioritising inpatient care. Jeannie Hughes (JH) said she had been on a best practice visit and noted that the wards are given time to prepare. The visit did not reflect her previous experience as a carer which has been less good. There should also be spot checks to ensure an accurate picture of the service being provided. NB explained that the visits are one of a number of sources of information about performance on the wards. Anna Walker highlighted that spot checks are done for Mental Health Act visits and that this could be considered. Ian Norman highlighted that students also go on wards and also provide feedback on their experience. JC recommended that more governors should take part in the visits as they provide a useful experience. VCY explained that the time commitment is a day. There is a need to read a small amount of information, travel to the site, and the visit itself is three to four hours. There is a workshop in the new year for more reviewers and to look at what has been done so far. Any governors who wish to Page 6 of 8

11 Page 11 of 84 MC/ 16/57 be involved should contact Carol Stevenson. NOMINATIONS COMMITTEE REPORT The Council of Governors confirmed Ian Norman as a member of the Nominations Committee. The Council of Governors agreed the recommendation for the reappointment of Alan Downey as a non-executive director. Julie Hollyman took over this item at this point and the Council of Governors approved the process for the appraisal of the Chair and non-executive directors. It was noted the Committee needs governors to fill vacancies that will occur in 217 and the application deadline has been extended to the end of December. ALL MC/ 16/58 TRUST REPORTS Chair s Report RP took the report as read and introduced Rachel Evans, the Trust s new Director of Corporate Affairs Chief Executive s Report Matthew Patrick (MP) presented his report which was taken as read. He said all providers, CCGs and local authorities are very busy at this time of year, and they also have STPs as an additional planning vehicle. MP is on four planning groups on one STP alone, and they are only now getting to a point where they can begin to consult. In addition planning timelines have been brought forward and plans need to be submitted by 23 December. Contracts must also be signed by that date. These are two year contracts not one year, which means CCGs need to look forward to population based models of care. There are good collaborative relationships in the system but resources are limited so it is difficult to get a good solution for the system as a whole. Performance Report MP highlighted the trajectory toward stopping the use of overspill beds by the end of the financial year. It is important to both quality and finances that these numbers continue to fall. He also noted that the Trust is not hitting the recovery target for Southwark IAPT although there is a plan to rectify this. Finance Report MP said the Trust is still on plan to meet its control total, and it is committed to hitting financial targets. Out of area placements are the biggest threat to that, so the Trust is working hard to maintain its trajectory mainly by careful planning for the Christmas period. Overall the Trust is looking at a five to 1 year plan for sustainable service Page 7 of 8

12 Page 12 of 84 improvement and delivery. To do this it needs to be woven into STPs and mental health across south London. MP also thanked Paul Mitchell for his work as Trust Secretary. JC asked for a paper on how risks are being managed. MP said a report could be brought back to the next Council of Governors meeting. MWG In relation to risks around recruitment BL highlighted accommodation as factor in recruiting staff. MP said the Trust is working with housing associations to develop a housing strategy. There is work on recruitment across south London. Health Education England has awarded 8, for training allied health professionals and band 3 and 4 nurses. Neil Brimblecombe (NB) added that staffing risks exist across London and these will unfortunately continue for some time. RP asked that governors are informed and given a full briefing once the outcome of the contracting process is known. AF asked that this should include the impact on social care. MP explained this should be brought back separately to a future meeting. RP and MP will discuss the timing for this. MP RP MC/ 16/59 MC/ 16/6 MC/ 16/61 QUESTIONS FROM MEMBERS There were no questions from members. FUTURE REPORTS FROM NON-EXECUTIVE DIRECTORS The Council of Governors noted the scheduled future reports. ANY OTHER BUSINESS JC was thanked for her work as acting lead governor. The non-executive directors and executive directors were thanked for their attendance. JC thanked RP, Anna Walker and Julie Hollyman for their help and support, and Carol Stevenson and MWG for their support to committees and working groups. The Council of Governors recorded its thanks to Paul Mitchell for his work during his time as Trust Secretary. MC/ 16/62 DATES The next meeting of the Council of Governors will take place on Thursday 16 March 217 at 1:3, at the Maudsley Learning Centre. Page 8 of 8

13 Page 13 of 84 Attachment B COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 16 March 217 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 Involvement Working Group Planning and Strategy Working Group Governance Committee Bids Steering Group

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15 Page 15 of 84 Council of Governors Working Groups Report March Quality Working Group (Jenny Cobley and Marnie Hayward) The Group meets quarterly. Our last meeting was on 23 February, when we received reports on Patient Led Assessment of the Care Environment (PLACE) from Elaine Janas, Complaints and PALs from Edith Adejobi and Kathryn Hill, and the investigation and reporting of Serious Incidents from Anna Walker (NED). We also looked at the Quality Priorities for 216/17 and chose Risk Assessments as the local indicator for the external audit by Deloitte. The Group was concerned to hear that there had been little progress on the development of the Public and Patient Involvement Policy (PPI), but understand that this will be addressed at the next meeting of the Board s Quality subcommittee (QSC). On 23 February, Marnie Hayward was elected as the new Chair of the Group. We would welcome nominations for deputy chair, which should be sent to Carol Stevenson (deadline 5pm on 2 March). We would like to take this opportunity to thank all members of staff and Anna Walker (NED) who have attended our meetings and to Carol Stevenson and David James for administrative support. The Group sends a Governor Observer to the QSC. Marnie Hayward will take over this role from Jenny Cobley. Other governors may attend as non participating observers with prior agreement from the QSC Chair, Anna Walker. During the last 2 months we have asked questions about: care for mental health patients attending local Emergency departments, safeguarding adults at Bethlem, unexpected deaths among service users, use of prone restraint, requests for police assistance, delayed discharges, risks as shown in the Board Assurance Framework, and development of a PPI policy. All these issues are being addressed by the QSC or we have been told from whom to seek further information. Governors have been invited to take part in PLACE inspections and Best Practice (internal audit) visits to wards and community services. We had a report on the Quality Improvement (QI) project last year and would welcome the opportunity to receive training in QI, in order to understand how quality can be improved within the Trust. The next meeting of the Group will be at 5pm on Tuesday 9 May, all governors are welcome. 2. Membership and Involvement working group (Tom Flynn) The group has changed its name from Membership and Communications to Membership and Involvement, to reflect the integration with the Involvement and Social responsibility working group. Mike Franklin will be attending our meetings and his expertise is welcomed. The updated terms of Reference are attached. The election process for a service user governor (from outside the core boroughs) has been successful and we are pleased to welcome Sean Casey. We have been looking at using rather than post where possible, and the welcome letters sent to staff are now being sent by . We will also bring in next year for the data protection mailing the Trust sends to all members.

16 Page 16 of 84 Under-representation of certain groups in the membership is an area we have been investigating. The Council of Governors is also under-representative, especially of younger people, so this is another reason to welcome Sean. The Governor Forum has been poorly used, so we are taking the opportunity of encouraging governors to sign up at this meeting. Please see Tom or Sarah Crack if you have not signed up yet. Next meeting: Wednesday 1 th May, 3.3 to 5pm. 3. Planning and Strategy Working Group (PSWG) (Angela Flood) Background The PSWG represent the interests and views of different stakeholders - service users, carers, staff and appointed stakeholder organisations and aims to ensure that views are not only taken into account and help inform the development of the Trust s strategies, but also provide feedback on their effectiveness. The group last met on 14 February 217. The agenda included updates on three key items: Lambeth Alliance (Lucy Canning, Deputy Director of Strategy and Commercial) The Alliance is part of a collaborative approach which brings together NHS Trusts, local government and voluntary sector to oversee investments made into adult mental health across health, social care and the voluntary sector. It aims to help the people who use the services recover and stay well, participate on an equal footing in daily life and make their own choices. Enabling partners will carry risk and have decision making authority not the network providers. Questions/Comments: level of the Trust s liability within the total savings required; clarification that CAMHS is not part of the current Alliance; potential clash of Alliance plans with the SEL STP process; possible differences in outcomes sought between individual providers and the group as a whole; assurance that savings would not result in poorer services, and assurance that learning from the Alliance would be shared. Quality Improvement Programme (Altaf Kara, Director of Strategy and Commercial) The QIP is a vital part of the Trust s organisational strategy. Working collaboratively with partners the focus is on training; ward level improvements and large Trust-wide schemes covering safety and addressing issues connected to occupied bed stays. Progress has been slower than planned and the Board has been asked to agree acceleration of the programme with the necessary funding to support the rate of change required. Questions/Comments: assurance that service users and carers would be involved in the programme including training, project work and contributions to large scale schemes; opportunities to benchmark against other Trusts; impact of additional time commitment on already pressurised staff; variation in measurements used made it difficult to ascertain what the 2% target was in real terms, and possible challenges of team leaders not signing up to the programme. Estates Strategy (Altaf Kara, Director of Strategy and Commercial) Challenges include a large number of service locations, many of which are not fit for purpose, and the high cost of the modernisation agenda. Questions/Comments: Essentia, a consultancy service is advising the Trust on its strategic estates development; possible issues around community patients receiving care in acute settings; development of Douglas Bennet House dependent on Board agreement of the Estates Strategy; analysis of agile working/access to workstations needed revisiting with further interrogation of assumptions around nursing staff use of resources, and the contradiction between under-utilised buildings and Governors/NEDs struggling to find meeting rooms.

17 Page 17 of 84 PSWG 217 Agendas will aim to reflect the Trust business cycle to allow for group discussion prior to Board approval of various items and issues. The group also welcomes the opportunity to meet with the Lead and Deputy Lead Governors and other working group Chairs to improve inter-group communication, discuss programme content and ensure coverage of key areas and to provide an additional opportunity to identify and raise issues or concerns via the NEDs. The Director of Strategy and Commercial is in attendance at meetings. Alan Downey has had to step down as NED in attendance. We thank him for his valuable contributions and welcome June Mulroy, NED, continuing the link with BDIC and Finance and Performance. We also welcome Professor Ian Norman, Appointed Representative of KCL, who sits as Governor Observer on the Audit Committee. Congratulations to Dr Francis Keaney, Staff Governor, on becoming the group s Deputy Chair. Next meeting: Tuesday, 16 May 217, 5: 6:3 pm, Maudsley Boardroom. 4. Governance Committee (Roger Paffard) The Governance Committee formally met on Monday 27 February 217 after agreeing in November 216 that its meetings are now quarterly. Exit interviews for departing Governors The Committee discussed the process of gaining feedback from Governors when they step down from the Council. Further discussions will be held at the next meeting but the present proposal is that Governors leaving the Trust will have the option of feeding back to the Chairman, Director of Corporate Affairs or Lead Governor to enable improvements by the Trust and Council in supporting Governors Update on NHS Improvement and Care Quality Commission changes to the Well Led Framework The focus of the consultation is in line with the duty the CQC and NHS Improvement have to co-operate. The consultation has the following principles: Inspectorates should work together, while recognising that each organisation is legally and operationally independent; Achieve greater alignment between organisations so that definitions, measurement and operations are based on a single shared view of quality; Work to remove duplication between the organisations and focus on quality, and demonstrate that quality can be maintained and improved alongside financial sustainability. It was agreed the committee will consider a Governance review of the Council of Governors and its groups at the June 217 meeting. Training Offer to Governors There was recognition of the extent of the learning required to take on the role of Governor especially if the individual involved did not have an NHS background. Some of the observations at the meeting concerned the length of learning events and the large amount of content. It was agreed that the issue of training should come to the Council of Governors for consideration in June 217. Governor Representation on Board subcommittees The discussion noted that many see the representation as valuable, but it was accepted there was a danger Governors could be perceived as being part of the decision making process of the Trust. It was agreed the issue would be debated by NEDs and Governors at one of their quarterly meetings. Committee and Group status A paper by the Director of Corporate Affairs will come to the next meeting for discussion regarding the status and authority of CoG committees and working groups

18 Page 18 of 84 Governor to NED questions protocol There are a number of outstanding questions that could be addressed by NEDs at Governor/NED quarterly meetings. The Lead governor agreed to undertake consultations with colleagues and select a number of questions for debate at the next Governor/NED meeting in March Bids Steering Group (David Blazey) The Bids Steering Group met on 16 February. Operational issues relating to several bidders changed circumstances were discussed and resolved. The evaluation form was reviewed and a simplified revised version was developed and agreed for implementation. A programme of monitoring visits to selected projects was agreed. We would like to invite more Governors onto the group, (especially Service User and Carer governors) We would also like to invite Governors to join us on project visits, as we believe they provide a useful opportunity to see examples of positive work being supported by the Council of Governors and to meet constituents. Next meeting: Thursday 11 th May, 3.3pm Carol Stevenson Membership Officer March 217

19 Page 19 of 84 Membership and Involvement Working Group Terms of Reference [Feb 217] Overall aim or Purpose: Key objectives: To support the development and involvement of the membership of the Foundation Trust and improve and maintain communication with the membership. 1. To review the existing Membership Development Strategy, including the size and representativeness of membership. 2. To oversee and promote the involvement and social responsibility activities of the membership. 3. To advise and monitor progress of a PPI policy. 4. To particularly develop plans to target and improve the representation of under-represented groups. 5. To identify ways in which members could be more actively involved and could make a contribution to the Trust in the future. 6. To facilitate communication and reporting between the Trust, Council of Governors and the membership. 7. To advise on election planning 8. To monitor and review progress and report back to the Council of Governors meetings. Chair: Membership: Tom Flynn, Appointed, Council of Governors All those elected and appointed to the Council of Governors are eligible to attend these meetings Other persons may be co-opted as required. In attendance: Responsible to: Frequency of Meetings: Quorum: Record Keeping: Terms of reference review: Trust Secretary or Deputy Membership Officer Head of Communications and Media or Deputy. Head of Involvement or Deputy (when appropriate). Council of Governors Two to five times per year. Two representatives from the Council of Governors. The Membership Officer will prepare and retain the relevant papers and reports. Annually by the working Group.

20 Page 2 of 84 Revision log: Date Name Comments 1.1 P Mitchell Draft issued for comments. May 211 P Mitchell Finalised May 214 C Stevenson Revised draft May 214 C Stevenson Version -1 Finalised February 216 C Stevenson Revised draft May 216 C Stevenson Version -2 Finalised Feb 217 D James Draft version for Comms/ISR Feb 217 C Stevenson Amended draft including name change

21 Page 21 of 84 Attachment C COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 16 March 217 Name of Report: Author: Presented by: Nomination Committee Report Rachel Evans, Director of Corporate Affairs Roger Paffard, Chair Purpose of the report: To receive an update from the Nominations Committee.

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23 Page 23 of 84 Council of Governors Nominations Committee Report March 217 Nominations Committee In February, the Trust invited bids for the work to undertake a "36 degree" feedback exercise to inform the end-year appraisal for the Chair, Roger Paffard. Interviews with the bidders will take place in the next few weeks to appoint the successful contractor. Interviews are taking place in the week of the 6th March to select a new Governor member for the Nominations Committee. Further interviews will take place over the summer to ensure that we have Governors ready to fill any vacancies that might arise in November. If you are interested in being considered as part of that round - please get in touch with Rachel Evans, the Trust Secretary. Rachel Evans / March 217

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25 Page 25 of 84 Attachment D COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 16 March 217 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 December, January and February.

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27 Page 27 of 84 Diary Summary Roger Paffard, Chair December 216 Date Meeting/Event Purpose Outcome 6 th December Prof Ed Byrne, Principal, Kings College London. Chair of Kings Health Partners Stakeholder relations Progress review of Kings Health Partners (Chair & Vice Chair). Jeanie Hughes, Carer Governor Governor relations Informal one to one meeting and induction for new governor. Matthew Patrick Strategy & Governance Progress review Kings Fund Reception Stakeholder relations Networking event 8 th December Kings College Hospital Council of Stakeholder relations Attending as SLaMs stakeholder governor Governors Meeting 9 th December Marc Rowland Lewisham Clinical Stakeholder relations Progress review Commissioning Group Keith Groom, ICT Engineer Governance IT problem solving Dr Fiona Gaughran Research Director, SLaM & Kings College London Strategy Induction and introduction in role for newly appointed head of research & development. An ambitious vision for the future with an intention to rapidly accelerate clinical trials and applied research within SLaM. Induction Rachel Evans, new director of Governance corporate affairs. Prof Sir Robert Lechler, Executive Stakeholder relations Progress review. Strategies to accelerate KHP fundraising Director King s Health Partners proposal and centre for translational informatics agreed. 12 th December Business Development & Governance See minutes Investment Committee Financial & Performance Governance See minutes Committee Matthew Patrick Strategy & Governance Progress review Paul Mitchell Governance Progress review & Handover meeting 13 th December NHS Providers Chair & Chief Strategy & Stakeholder Executive Network Meeting relations Briefing on the new models of care and the STP (Sustainability & Transformation Plans) early learning. Validated the South London Mental Health Partnership as a positive and well-received initiative.

28 Page 28 of th December Second QI Leadership workshop Governance & Staff engagement Attended our second senior management QI workshop to support this mission critical cultural initiative with closing address. 15 th December Council of Governors Meeting Governance Positive feedback from a well-attended and very constructive Council of Governors meeting with active participation all round. Board Development Board development Review of 215 & 216 Board development. New focus on solving knotty, gritty intractable issues in 217 agreed. Proposals for 217 programme to be developed for May away day 16 th to 2 th Nursing Director candidate Governance and Board Candidates for Director of Nursing interviews fact-finding December briefings. development and background conversations 16 th December Rachel Evans Governance Progress review 19 th December London Mental Health Chairs Governance & Strategy Quarterly meeting of 9 London Mental Health Chairs for information and best practice sharing. Focus on Criminal Justice system & Housing/Accommodation for staff 2 th December Matthew Patrick Strategy & Governance Progress review Senior Registrar Training Staff relations Planning session for Mock Board training event in Arrangements January Board Meeting Part 1 public Governance & strategy See minutes Board Meeting Part 2 private Governance & strategy Topics covered included in January public board papers 21 st December Director of Nursing interviews Board development Final interviews for director of nursing to replace Neil Brimblecombe on his retirement in June 217. Beverley Murphy appointed from a strong field Rachel Evans Governance Progress review 23 rd December Matthew Patrick & Rachel Evans Strategy & Governance January Board Agenda review 2 th to 23 rd December 3 Finance & Performance virtual committees to review progress and sign off 2 year contracting round with 5 commissioners Governance 3 committees needed to be convened to support the executive team in some very last-minute challenges with our 4 Borough Clinical Commissioning Groups and NHSEngland. The gap was eventually closed between an unacceptable funding level and one which the Board had agreed as the minimum before arbitration triggered. Acceptable rather than good.

29 Page 29 of 84 Diary Summary Roger Paffard, Chair January 217 Date Meeting/Event Purpose Outcome 4 th January Rachel Evans, Director of Governance Progress review Corporate Affairs 9 th January Matthew Patrick Strategy & Progress review governance Rachel Evans Governance Progress review 1 th January Joanna Moriarty, Green Park Governance Follow up on NED recruitment in 216.Reflections on how the Interim & Executive Search process could be improved particularly in the area of diversity. Peter Allanson, Trust Secretary, Guys & St Thomas Governance Structured interview as part of the review of progress made since the 215 Deloittes Well-Lead Review. 11th January Dr Julie Hollyman, Senior Governance Progress review Independent NED & Deputy Chair Prof Chris Ham, Chief Executive, Strategy Facilitator briefing for Kings Health Partners board away-day The Kings Fund and KHP board away-day facilitator Jill Locket, Director of Performance Strategy & Preparation and agenda setting for Kings Health Partners board and Delivery, Kings Health Partners & Matthew Patrick Stakeholder relations away-day 12 th January King s Health Partners Board Governance & Reviews included: Fundraising (where the priority for Mental Meeting Stakeholder relations Health in Children & Adults was re-confirmed); International Education opportunities; Child Health Strategy. 17 th January Quality Sub Committee Governance 6 monthly observation of the workings of one of the subcommittees of the Board as part of due diligence. Good progress since last visit in 216. clear plans in place for further improvements in information quality and flow. Staff Fora Bethlem Royal Hospital Staff relations Lively debate with concerns about morale, training, travel and the infrastructure review being raised and discussed. Non-Executive Director visit Acute CAG Lambeth Service and relations visit Staff First opportunity for NEDs to meet the new Acute CAG senior leadership team and visit 2 acute wards at Lambeth. Very encouraging progress being made. Frustrated that CQC visit 2 months too early for significant changes designed to provide strengthened 24/7 clinical leadership.

30 Page 3 of th January Matthew Patrick Strategy & Progress review governance Rachel Evans Governance Progress review Rosie Mundt-Leach, Governor Governor Relations Informal one to one & induction for new governor 19 th January A mock Board held with myself, Dr Julie Hollyman, Dr Matthew Patrick, Dr Michael Holland & Mike Franklin Staff Relations Very interesting, well-attended and lively event which stimulated good engagement and debate amongst the junior doctors. The participants took their roles very seriously and sometimes forgot as part of the quality Senior that they had an audience. Registrar development programme 2 th January Mandatory Training Governance Completion of Information Governance and Fire, Health & Safety modules 23 rd January Estates Steering Group Strategy Launch of major estates strategy development for the next 15 years. Information gathering and objective setting phase 24 th January Follow up to BME Equalities Meeting Presentation by Roger Kline Snowy White Peaks Dr Siobhan Netherwood, Staff Governor Staff Relations Good feedback from initial meeting late 216. Agreed to follow up session to report progress on commitments made and visits to high performing trusts on diversity. Informal one to one & induction for new governor Governor Relations Remuneration Committee Governance Review of recruitment & retention challenges. Board Development Board Focus on Serious Incidents and lessons learnt from serious Development incidents from a clinical perspective. Board Meeting Part I Strategy & See Minutes governance Board Meeting Part 2 Strategy & Topics covered in February public board minutes governance 25 th January Matthew Patrick Strategy & Progress review governance 26 th January Oxleas Board Away day Strategy & governance 27 th January Bob Kerslake, Chair, Kings College Hospital Hugh Taylor, Chair, Guys & St Thomas Strategy stakeholder relations Strategy stakeholder & & Invitation from Oxleas for me (and David Bradley chief executive of SW & St Georges) to present SLaM perspective on the South London Mental Health Partnership to their Board & Senior Management Team and participate in the discussion. Opportunity to stress that this was a co-operation amongst equals and there is no appetite from our Board for a merger or organisational change which was welcomed. Preparation for KHP Board away day Preparation for KHP Board away day

31 Page 31 of 84 Kings Health Partners Joint Board Away day 3 th January Lewisham Parliamentary Scrutiny & Liaison Meeting relations Strategy stakeholder relations & Governance & stakeholder relations The first strategic away day that I have participated in since joining the Board as Vice Chair 2 years ago. A very stimulating and encouraging event with significant progress made and agreed prior to re-tendering in Autumn 218. Particularly positive that Regular twice yearly health & social care scrutiny opportunity for Lewisham MPs under the chairmanship of the Mayor to challenge and understand the local NHS position. Main concern was the decommissioning of homeless services which we share! Rachel Evans Governance Progress review Matthew Patrick & Rachel Evans Governance February Board Agenda review meeting

32 Page 32 of 84 Diary Summary Roger Paffard, Chair February 217 Date Meeting/Event Purpose Outcome 1 st February NHS Providers Engagement Event for CQC & NHSI oversight consultation s Governance Participation and input into engagement event as part of the consultation by both CQC and NHSI oversight and monitoring regime. Well-lead review to become an annual review led by CQC with a minimum of one core services to be reviewed every year. 2 nd February John Nicholson Board Development Debrief on 216 board development. Agreement that objectives achieved and programme completed. New programme to be entered into in 217 to be co-ordinated by Director of Corporate affairs Rob Wright & Moira Johnston - NHS Leadership Academy Governance Opportunities for director/ned recruitment Professor Sir Robert Lechler Executive Director King s Health Partners NEDs, Governors and Lay Members STP Event at the Ortus Strategy Regular progress review and follow through from KHP board January strategy away day on 27 January Governance & Strategy & Governor relations First South East London STP engagement event for Governors, NEDs and Lay Members. Well attended high levels of frustration that this event should have happened earlier and communications throughout needed to be more open. 3 rd February CQC Feedback Governance Informal feedback at the end of the CQC inspection of 7 th February Andy Trotter Chair Oxleas NHS Foundation Trust CUES Ed Project, Surrey Square School 8 th February Professor Matthew Hotopf Non Executive Director Governance & strategy Service visit Strategy & Stakeholder relations acute services. Promising if cautious. Visit to new Place of Safety at the Maudsley site and exploration of further opportunities and next steps on governance for the South London Mental Health Partnership. Inspirational visit to one of the pioneer primary schools in Old Kent Road to witness (and participate in) the delivery of the programme in Year 4. Opportunity to discuss rollout options with the SLaM team and the joint headmistresses of the school. Preparation for Maudsley Master Class conference

33 Page 33 of 84 9 th February Maudsley Masterclass, Kings College Strand Campus Stakeholder Relations Opening address for annual event hosted by SLaM showcasing innovative research in Mental Health to distinguished audience of over 1 UK & International researchers. Intimidating but enjoyable experience! Informal one to one and induction for new governor Sue Scarbrook Council of Governor Relations Governor carer governor Rachel Evans, Director of Governance Regular Progress Review Corporate Affairs David James, Interim deputy Governance & Preparation and agenda setting for the CoG governance director of corporate affairs Governor relations committee 1 th February Mike Franklin Non Executive Governance Progress review Director 2 th February Second Estates Steering Group Strategy Very promising interim review of major estates strategy development for the next 15 years. Ursula Grueger Programme Governance & Strategy Review of progress on the activities and governance of Director South London Partnership the South London collaboration with SLaM, Oxleas & SW Dr Deji Ayonrinde Consultant Psychiatrist 21 st February Staff Fora 332 Brixton Road with Kris Dominy Non-Executive Director/Council of Governors visit to Learning Disabilities senior team. 22 nd February Supporting Integration & Transformation Stephen Dorrell Chair of NHS Confederation & KHP NED. 23 rd February South London Mental Health and Community Partnership Board Staff Relations Staff Relations Staff & Governor Relations Strategy Governance & Strategy & St Georges. Exit Meeting 24 th February Matthew Patrick Governance & Strategy Regular Progress Review Rachel Evans Governance Regular Progress Review Gus Heafield, Chief Financial Governance & Strategy Regular Progress Review Lively, honest and open conversations about the growing challenges of delivering community services out of outdated not-fit-for purposes premises when support from social care and housing is reducing. Fascinating insight into a broad range of services covered in Learning Disabilities together with their challenges and opportunities. No wonder this pathway was rated outstanding by CQC. Sadly, no governors attended a pity. Observations on the key drivers of system wide success in transformation. Agreement that social care and local authorities needed to be much better engaged and involved. Inaugural meeting of the 2 monthly partnership board charged with overseeing the progress, effectiveness and governance of this new initiative. Agreed that SLaMs representatives would be Matthew Patrick and Duncan Hames NED Chair of the Audit Committee.

34 Page 34 of 84 Officer Olivia Howarth, commercial Strategy Input into business case for the Maudsley education and manager. training business due to come to the Board this spring. Altaf Kara, Strategy & Commercial Strategy Regular Progress Review director Janet Davis Council of Governors public governor Governor Relations Informal one to one and induction for new governor 27 th February Council of Governors Governance Governance See minutes Committee Governor Relations Matthew Patrick Governance & Strategy Regular Progress Review 28 th February Remuneration Committee Governance Annual Review of benchmarking of director salaries. Charitable Funds Committee Governance Annual observation of the workings of one of the subcommittees of the Board as part of due diligence. Huge progress since last visit in 216 now a professionally chaired and structured meeting with strong participation. Non-Executive Only Director Meeting Governance & Strategy Review of NED roles & responsibilities Board development plans for 217 Serious & Board level Incidents Board Development Meeting Board Development Focus on Safety and Lessons learnt from Serious Incidents Board Meeting Part 1 public Governance & Strategy See Minutes Board Meeting Part II private Governance & Strategy Topics covered included in March public board papers

35 Page 35 of 84 Attachment E COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 16 March 217 Name of Report: Author: Presented by: Chief Executive s Report Rachel Evans, Director of Corporate Affairs Matthew Patrick, Chief Executive Purpose of the report: To receive an update report from the Chief Executive of the Trust.

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37 Page 37 of 84 Chief Executive s Report March CQC re-inspection On the 23 rd January, we received the important news that the Care Quality Commission would be carrying out a re-inspection of our acute care services. This was an opportunity for the CQC to follow up on some of the issues that were raised during the main inspection in September 215. At that time the Trust received an overall rating of good, but three pathways - including acute inpatient provision - were identified as requiring improvement. The re-inspection started on 3 th January and it was an extremely pressured and busy week for the large numbers of our staff who were directly affected. The inspections were wide-ranging and involved groups of inspectors spending many hours on the wards alongside our staff. We were pleased to hear from the inspectors at the end of the week that they had had a good experience and felt very welcomed to the Trust. After an inspection such as this the CQC take up to 8 weeks to produce their report. Our intention is to explore some of the themes from the initial feedback during a specific Board update on the re-inspection, but I want to thank everybody involved in the inspection for their hard work over the past few weeks and people across the organisation for their commitment to improving care and service user outcomes on a daily basis. 2. Inquest into the death of Mr. Olaseni Lewis The inquest into the tragic death of Mr. Olaseni Lewis began on the 6 th February. Olaseni Lewis died on 4 September 21 following his restraint by a number of Metropolitan Police Service officers who had been called to the Bethlem Royal Hospital. Olaseni was aged 23 and an IT graduate with a promising career ahead of him and without any history of mental health problems. The Trust has again communicated messages of condolence to the Lewis family and we remain fully committed to working closely with the Coroner throughout this inquest so that the full circumstances and facts surrounding Mr Lewis's death can be

38 Page 38 of 84 established. It is important to note that there is only one person remaining on the board or senior management team who was here at the time. For this reason, we are ensuring that a member of the senior management team is present on each day of the inquest so that we establish real continuity with the events of 6 ½ years ago, and ensure that all learning is properly embedded. I have personally met with the Lewis family and have been clear that we are not interested in defending historic reputations but very much interested in ensuring that to the best of our abilities such an event never happens again. 3. Finance and Contracting Thanks to tremendous effort by the Operations, Finance and CAG teams, the Trust was able to sign all necessary contracts before the December 23 rd deadline. This was achieved without arbitration but the negotiations were very challenging. Heads of Terms were agreed with each of our local commissioners in Lambeth, Southwark, Lewisham and Croydon and with NHS England for Forensic and Specialised Mental Health Services. Each contract covered the provision of services across both 217/18 and 218/19. On the basis of these contract agreements, the Trust submitted an operational plan which met the control totals issued by NHSI for 217/18 and 218/19. We work in an extremely challenging health economy. One of our CCGs has declared publicly that they are unable to meet the expectations of the national guidance for increases in investment by commissioners in mental health services in line with their allocations and the Five Year Forward View for Mental Health. Three others have declared the guidance met but with investment going to other parts of the mental health system. The result is some net disinvestment from the Trust for three out of four of our CCGs in 217/18, an issue that is most acute in Croydon, where the level of net disinvestment will amount to 3.3m in 217/18. Since then, NHS England have written to Clinical Commissioning Groups (CCGs) and to Chief Executives of mental health providers setting out how they will approach the assurance of the national commitments for mental health. The letter sent on the 15 th February confirms that Chief Executives of mental health providers are being asked to jointly sign a letter from their CCGs confirming that their mental health returns are an accurate reflection of the investment in mental health and ensure a joint commitment to meeting the national expectations set out in the Five Year Forward View. This has led to further detailed discussions with each our Clinical Commissioning Groups.

39 Page 39 of Prime Minister s speech The Prime Minister made her first formal speech on health on 9 th January, focusing on social care and the government s commitment and support for people with mental illness. The speech was part of the government s formal response to the recommendations made by NHS England s mental health taskforce. In her speech, the Prime Minister focused heavily on CAMHS and announced that: Every secondary school is to be offered mental health first aid training. There will be trials on strengthening the links between schools and NHS specialist staff, including a review of children and adolescent services across the country, led by the Care Quality Commission. Mental health campaigner Lord Stevenson and Paul Farmer, chief executive of the charity Mind, are being appointed to carry out a review on improving support in the workplace. Employers and organisations will be given additional training in supporting staff who need to take time off for mental health reasons. There will be an increased focus on community care, with an extra 15m towards this, and less emphasis on patients visiting GPs and A&E. Online services will be expanded to allow symptom checks before getting a face-to-face appointment. There will be a review of the "health debt form", under which patients are charged up to 3 by a GP for documentation to prove they have mental health issues The BBC included a section of an interview with one of our community psychiatrists Dr Phil Timms in their coverage. In this piece, Dr Timms mentioned how mental health is underfunded and the importance of ensuring adequate resources. 5. Launch of staff recognition awards 217 Nominations for the Trust s staff recognition awards 217 opened on Tuesday 14th February. The aim of our awards is to recognise the efforts and achievements of our dedicated staff who go the extra mile to improve the lives of the people and communities we serve. We are asking staff, service users and carers to shine the spotlight on the great work of a colleague, service or team that has gone to extraordinary lengths to help provide

40 Page 4 of 84 exceptional service, care and support. Nominations can be submitted by visiting our website: Dr Matthew Patrick Chief Executive

41 Page 41 of 84 Attachment F COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 16 March 217 Name of Report: Author: Presented by: Finance Report (Month 1 FY16/17) Tim Greenwood, Mark Nelson Finance Directorate, BRH Gus Heafield Purpose of the report: To receive the Finance report.

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43 Page 43 of 84 REPORT TO THE TRUST BOARD: PUBLIC 28th FEBRUARY 217 Title Finance Report As At 31 st January 217 Author Accountable Director Tim Greenwood & Mark Nelson Gus Heafield Purpose of the paper The Finance Report provides an update on the financial position of the Trust as at 31st January 217 (month 1). The summary financial statement and calculation of the Use of Resource rating from the month 1 NHSI in year reporting return is attached to the report in Table 1 The Board is asked to approve the report including consideration of the pressures, risks and mitigations in place to meet the NHSI control total. Executive summary 1) Current Position The Trust remains on plan reporting a ytd deficit of 2.8m after excluding items not included in the NHSI control total. This represents a favourable movement from Plan of.9m in the month. The movement was driven principally by a reduction in acute overspill coupled with.6m of backdated overseas visitors income, improvement in the PMIC and B&D CAGs (improved income, vacancies and release of provisions), lower restructuring costs than originally planned and payment of outstanding 1:1 observation debts by West Hampshire CCG. The Trust is currently rated by NHSI as a 2 against use of resources (where 1 is best out of a 1-4 range see also Table 1). The rating will remain at a 2 provided the Trust delivers on its current forecast which would then attract an NHSI incentive payment equal to the forecast favourable variance from Plan. The exact details and amount of incentive available are still to be confirmed. 2) Main Issues Acute overspill continued to fall (by 8 beds in the month) which together with backdated overseas visitor income and a review of overspill provisions resulted in an underspend in the month. However overspill is likely to increase over the remaining 2 months as the CAG reconfigure the ward estate and temporarily lose bed capacity. The Southwark placements position continued to deteriorate and is forecast to overspend by over.7m after application of risk shares and repayment of QIPP. However, this position is yet to be fixed due to the CCG and Local Authority reviewing the placements made since June and reassigning their financial responsibility, dependent upon the clients health/social care needs. This work is continuing and is not expected to complete before March. Despite the measures being taken, the use of agency staff in the Trust increased in January (up by 59k compared to December). Additional measures are being introduced

44 Page 44 of 84 in February but given the current run rate the Trust is now forecasting it will not stay within 25% of the NHSI target ceiling. This will impact on one element of the use of resource rating (although not the overall score) and may result in some form of NHSI intervention. The improvement in the overspill position and recognition of income that had been held to cover risks that are no longer expected to arise, has improved our position against the CIP target. It is now forecast to deliver 8% of the target. The overall position remains a significant shortfall of 5.8m largely due to worse than plan use of overspill beds and delayed savings from infrastructure schemes. The Trust recently commissioned the District Valuer (DV) to undertake a revaluation of its assets and this month s position includes the results of that exercise. These are subject to a DV review again in March when official price indices are published but the initial report has resulted in a 6.5m impairment being taken into the I&E account this month. This was offset by a 2m profit on the disposal of David Pitt House. The net 4.5m cost has impacted on the Trust bottom line but not against our NHSI control total which excludes such impairments and gains/losses. The reduction in value will improve our capital charges position by.35m this year and is reflected in our latest forecast. 3) Forecast The Trust is forecasting to meet its deficit control total of 3.9m. This includes allowing for a write down of fess and other associated costs concerning the redevelopment of Douglas Bennet House, the original scheme having been superseded. These costs will be included in next month s financial position. Overall there remain risks to the forecast particularly around Activity driven costs such as acute overspill and placements but as the number of days reduce towards year end, so the risk of forecasting and the impact of adverse movements lessens. Outstanding income from CCGs. In Southwark, risk share and QIPP arrangements with the CCG around placements are expected to be upheld in line with contract discussions. It is expected that all CCGs will honour risk share arrangements around acute obd activity which are estimated to be 1.3m ytd. The Trust has also identified additional income due under overseas visitor protocols. Guidance is being sought from the Department of Health as to how this income can be reclaimed via our host commissioner (Lewisham CCG). Although the Trust faces continuing cost issues in a number of areas, additional in year savings generated from tight controls and close monitoring, combined with the non-recurrent utilisation of contingency reserves and the release of balance sheet provisions means that the Trust remains on track to achieve its control total for the year.

45 1) Financial Summary Service Analysis Page 45 of 84 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 ( ) 1. Psychosis 51,493,1 4,488,6 98,2 43,677,2 717,7 2. Acute Care Pathw ay 5,913,9 3,853,5 (37,1) 46,495,8 3,922,7 3. P Med & Integrated Care 26,8 (23,7) (212,7) 159,2 (29,6) 4. Behavioural And Dev. Psych (11,1) (273,1) (269,) (297,1) (284,) 5. Child & Adolescent Service 35,4 272,1 18, (522,5) (591,4) 6. MHOA And Dementia 313,6 17,1 (24,) (4,3) (235,9) 7. Addictions 3 (11,5) (11,5) 13, 12,7 8. Clinical Support Services 2,178,3 23,6 51,9 1,876,9 56,1 9. Infrastructure Directorates 54,874,4 4,73,4 143,5 45,489,4 73,3 1. Corporate Income (11,38,5) (8,64,2) (15,9) (84,715,1) (278,7) Operational Deficit 58,939,2 4,499,8 (51,6) 52,172,5 3,362,9 11. Corporate Other (8,136,4) (6,756,5) 488,7 (62,576,3) 3,72,2 12. Contingency - planned 2,, (166,667) (1,666,667) 14. Other reserves/provisions 6,51,1 (25,233) (5,348,33) Corporate Other (72,85,3) (6,756,5) 71,8 (62,576,3) (3,942,5) EBITDA (13,146,1) (2,256,7) (429,8) (1,43,8) (579,6) 15. Post EBITDA Items 19,638, 5,924,2 4,25,1 16,927,4 1,596,6 Trust Financial Position 6,491,9 3,667,5 3,775,3 6,523,6 1,17, Items Not Included In NHSI Target (2,511,) (4,81,552) (4,757,574) (3,771,29) (2,178,183) NHSI Target 3,98,9 (1,134,52) (982,274) 2,752,31 (1,161,183) Area 216/17 Mth 6 Variance 216/17 Mth 7 Variance 216/17 Mth 8 Variance 216/17 Mth 9 Variance 216/17 Mth 1 Variance 216/17 Total Variance CAGs (761) 1,386 (5) 382 (544) 3,514 Infrastructure Directorates (444) (77) Corp Income (619) 72 (151) (279) Other reserves/provisions 1,826 (1,176) ,72 released Use of Reserves (589) (1,74) (694) (442) (417) (7,15) Total EBITDA 42 (11) (232) 536 (43) (58) 2) Key Cost Drivers (unmitigated by alternative income, risk shares etc.) Area 216/17 Mth 6 Variance 216/17 Mth 7 Variance 216/17 Mth 8 Variance 216/17 Mth 9 Variance 216/17 Mth 1 Variance 216/17 Total Variance Ward Nursing* ,548 Agency 2%** ,152 Acute Overspill**** (673) 4,328 Unmet CIPs*** 244 1,387 1, ,44 Placements**** ,364 CPC/C&V Income (82) (1) (51) 45 (29) (724) Total 1,696 1,898 2,111 2, ,18 * includes safer staffing funding ** costs built into the plan ***see Section 3 **** before application of risk shares

46 Page 46 of 84 Performance against the main cost drivers is detailed below Acute/PICU Overspill Overall 12 overspill beds were used by the Trust in December, a decrease of 8 compared to the previous month and only 5 beds above our original plan which envisaged using 7 external PICU beds at this stage. In addition a recent review of overseas visitors legislation has identified the potential to increase our level of overseas visitors income. This would impact on risk share arrangements but still enable a net income benefit to be derived. The net benefit of c 3k is included in this month s position. Overspill, however, is expected to increase over the remaining 2 months due to the closure of Foxley Lane and the imminent closure of Bridge House part of the reconfiguration of acute beds in the Trust. A short term increase in overspill is therefore now included in the forecast financial position. The use of all acute/picu beds (internal and external) by CCG is shown in the tables below: After a slight increase in December overall bed usage fell in January to 335, a decrease of 15 from the previous month. Whilst Croydon remained stable, bed numbers across the other 3 CCGs all fell. Bed usage is now at its lowest level for the year. Use of Agency Staff Plans to reduce agency expenditure are one of the conditions attached to accessing the NHSI Sustainability and Transformation Fund. For SLaM, NHSI have set a ceiling to spend no more than 17.4m on all agency staff. Based on this target the Trust has spent 18.9m ytd compared to a target of 15.7m. At month 1, 9% of agency expenditure was occurring in the CAGs with 1% in corporate directorates. This is illustrated in the table below which shows the use of agency by wte (whole time equivalent) since 215/16 -

47 Page 47 of 84 Type of Staff U s e o f A g e n c y S t a f f 215/16 216/17 216/17 Change From April Jan Average Actual Actual 215/16 wte wte wte wte Consultants Trainee grades Qualified nursing Support to nursing Psychology, Pharmacy, OT Managers and infrastructure Any others Total The gap between actual and ceiling continues to increase (by 1m in the month). Based on current run rates this will put the Trust over 25% above the ceiling and would flag up to NHSI as being of significant concern. The Trust is therefore taking further measures to try and reduce its agency spend by c 1m over the remaining 2 months. These include: o o o o Reviewing all current agency staff (all professions and non-clinical) with a view to transferring to bank or stopping all together All annual leave, unless booked to be carried over to next year (unless leave can be taken without backfill) In certain circumstances using overtime rather than agency No new agency from this point on - alternative means must be used such as bank or fixed term contracts. However, where specific non recurring funding has been made available by CCGs to reduce waiting times over the next 2 months it is likely that additional agency staff will be employed negating the impact of the measures being taken above Ward/Unit Nursing Costs At month 1 ward nursing costs overspent by 336k ( 1.5m ytd), still below the 215/16 average but above budgets that have been set at both safer staffing levels and adjusted to take account of additional costs in the PICUs of providing place of safety. As in previous years, January has seen a significant upswing in costs. The majority of the overspends have occurred in the ACP CAG including the PICUs ( 78k over in the month) despite the new standalone Place of Safety Unit being up and running. Following further discussion, Southwark CCG have now agreed to cover unfunded staffing costs at Ann Moss Domus in 216/17 as well as 217/18.

48 Page 48 of 84 Cost per Case/Cost and Volume Income Following a small deterioration in December, income picked up in January following the holiday period. The main areas of concern remain in Psychosis Heather Close is 178k below target levels and is not filling its 5 cost per case beds Psych Medicine & Integrated Care not meeting activity/income targets in several outpatient services particularly neuro psychiatry ( 242k ytd), eating disorders ( 292k ytd) and Cawley Day Service ( 32k ytd) B&D improvement in both ADHD and Behavioural Genetics activity in the month following a poor December but year to date shortfall of 374k remains a concern The issues above are well known about and are being picked up by the Chief Operating Officer through monthly performance management meetings. CAG Income Target Actual Surplus/ Surplus/ Invoiced Deficit(-) Deficit(-) At Month 1 At Month 1 At Month 1 At Month 9 ' ' Psychosis 6,462 6, Behavioural & Developmental 17,988 18, Psych Med & Integrated Care 23,877 23,44 (474) (524) CAMHS 17,594 17, MHOA Addictions TOTAL 67,77 67, Complex Placements Both Lambeth and Lewisham placements remain within budget. The main area of concern continues to be Southwark which overspent by 1.5m (before risk shares) in 215/16 and which is forecast to overspend by over 2.3m in 216/17, based on forecast expenditure of 7.5m. At month 1 the total overspend (prior to risk shares) was 1.8m, split between the CCG (.9m) and the local authority (.9m). This is a deteriorating position and is further complicated by o o the impact of a CCG QIPP (.4m), phased to be taken from October but expected to be fully repaid by the CCG given the QIPP is not achievable and a 1% risk share arrangement with the local authority but which is accessed via the CCG contract

49 Page 49 of 84 o an agreement between the CCG and local authority to re-examine how each individual placement is funded i.e. are they a CCG funded, a local authority funded or a jointly funded placement and if so what % split is applied. Despite the funding being pooled, both commissioners operate different risk share arrangements which means retrospective shifting of responsibility will impact on the Trust s year end financial position. Monthly discussions continue with the CCG to establish the position going forward and actions being taken. In the 217/18 contract, a new QIPP has been agreed and will require significant action to be undertaken over the next 12 months if financial targets are to be met. 3) Cost Improvement Programme (CIP) At month 1, the Trust has recorded savings of 17.1m against a target of 22.5m (76%). The year to date shortfall of 5.4m breaks down as to 3.7m for the CAGs (of which 2.9m is ACP principally due to overspill, Psychosis.3m, BDP.2m and PMIC.2m).7m for Corporate departments (principally CEO, Estates and Nursing) and Trust and CAG wide schemes 1.1m ( 3.1m delay in infrastructure review schemes, net of favourable variances including locked in underspends). The forecast delivery against the target of 29.2m now stands at 23.4m (8%). This represents a significant improvement compared to the month 9 position (73%). This is principally due to an improved outlook on overspill as a result of backdated income for overseas patients and the recognition of income (combined with the release of a provision) that had been held to cover risks that are no longer expected to arise. The overall position remains a significant shortfall of 5.8m primarily predicated on a worse than planned level of overspill beds net of risk share and NCA/overseas income( 2.7m) and delayed savings from infrastructure review schemes ( 4.7m), net of additional savings principally from lock ins (a substantial proportion of which are non-recurrent). As stated earlier in this report, despite this shortfall the Trust is on track to achieve its control total for the year, as a result of additional savings not reflected in the CIP reporting generated from tight controls and close monitoring, combined with the non-recurrent utilisation of contingency reserves and the release of balance sheet provisions.

50 Glossary Page 5 of 84 AMH CAG CCG CIPs CPC/C&V EBITDA ICT MHOA NCA NHSI OBD PICU PoS QIPP STF Triage WTE 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 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 Non Contracted Activity - a patient treated by SLaM where no contract exists between the Trust and the Commissioner (e.g. a Lewisham resident who has a Bromley GP will not be charged against the Lewisham contract but will be invoiced as an NCA to Bromley CCG) 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 Whole Time Equivalent is a concept used to convert the hours worked by several part-time employees into the hours worked by full-time employees e.g. 1 wte = 1 full time employee Year To Date

51 m's m's - (2) (4) (6) (8) m's Income and Expenditure Financial Position Commentary YTD YTD Plan Forecast FY Plan Use of Resources Risk Rating Summary EBITDA 1.4m 9.8m 13.1m 13.1m I&E (deficit) surplus -6.5m -5.5m -7m -6.5m cover x Balance sheet sustainability - Debt service cover YTD 1) At Month 1 the Trust made a deficit of 2.8m after excluding items not included in the NHSI deficit control. EBITDA margin 3.3% 3.1% 3.5% 3.5% 3.5 Debt service cover ) This represents a favourable movement from Plan of.9m in the month. The movement was driven principally by Cumulative EBITDA 2.5 a reduction in acute overspill coupled with.6m of backdated overseas visitors income, improvement in the PMIC PMIC and B&D CAGs (improved income, vacancies and release of provisions), lower restructuring costs than originally 2. planned and payment of outstanding 1:1 observation debts by West Hampshire CCG 1.5 New NHSI I&E control total surplus (deficit) M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 actual forecast plan under-lying NHSI target straightline Cost Improvement Programme M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 m's 6 5 Page 51 of 84 M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 actual forecast plan under-lying actual forecast plan Working Capital Days SLaM - Financial Overview as at 31st January 217 (Month 1) M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M actual forecast plan Rating 1 Rating 2 Rating 3 Rating 4 Liquidity rating YTD 3) The Trust is currently rated by NHSI as a 2 against use of resources (where 1 is best out of a 1-4 range. The rating will remain at a 2 provided the Trust delivers on its current forecast which would then attract an NHSI incentive payment 4) Acute overspill continued to fall (by 8 beds in the month) which together with backdated overseas visitor income and a review of overspill provisions resulted in an underspend in the month. However overspill is likely to increase over the remaining 2 months as the CAG reconfigure the ward estate and temporarily lose bed capacity. 5) The Southwark placements position continued to deteriorate and is forecast to overspend by over.7m 6) Despite the measures being taken, the use of agency staff in the Trust increased in January (up by 59k compared to December). Additional measures are being introduced in February but given the current run rate the Trust is now forecasting it will not stay within 25% of the NHSI target ceiling. This will impact on one element of the use of resource rating (although not the overall score) and may result in some form of NHSI intervention (5) 7) The improvement in the overspill position and recognition of income that had been held to cover risks that are no (1) longer expected to arise, has improved our position against the CIP target. It is now forecast to deliver 8% of the target. (15) M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 8) The Trust is forecasting to meet its deficit control total of 3.9m. This includes allowing for a write down of fess and actual forecast plan Rating 1 Rating 2 Rating 3 Rating 4 and other associated costs concerning the redevelopment of Douglas Bennet House, the original scheme having been % Operational performance - I&E control total margin superseded. These costs will be included in next month s financial position M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 actual forecast plan Rating 1 Rating 2 Rating 3 Rating 4 % variance Performance against plan - I&E control total margin M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 actual forecast plan Rating 1 Rating 2 Rating 3 Rating 4 % variance Agency ceiling target 17.4m 5 9) Overall there remain risks to the forecast particularly around - Activity driven costs such as acute overspill and placements but as the number of days reduce towards year end, so the risk of forecasting and the impact of adverse movements lessens. Outstanding income from CCGs. In Southwark, risk share and QIPP arrangements with the CCG around placements are expected to be upheld in line with contract discussions. It is expected that all CCGs will honour risk share around acute obd activity which are estimated to cost 1.3m ytd. The Trust has also identified additional income due under overseas visitor protocols. Guidance is being sought from the Department of Health as to how this income can be reclaimed via our host commissioner (Lewisham CCG) Key Financial Drivers Performance v CIP - 5.4m - 24% < target Ward Nursing - 1.5m overspent Acute Overspill - 4.3m overspent excluding impact of risk share Complex/Non Secure Placements - 1.4m overspent excluding impact of risk shares Cost per Case/Cost & Volume -.7m ytd > target Other Metrics Forecast FSRR less than 2 in next 12 months Yes Capital expenditure < 85% or > 115% of plan (no longer a NHSI mertic) Yes Nurse agency % against withdrawn target for 16/17 of 1% 14.1% Better payment practice code (non-nhs by value) 79% Cash at bank and in hand 47.7m m's Capital spend against plan (1) M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 receivables payables plan cash cash Net assets M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 actual % forecast % plan Rating 1 Rating 2 Rating 3 Rating M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 actual forecast plan

52 Page 52 of 84 Table 1 Summary of Financial Statements for South London and Maudsley NHS Foundation Trust units Audited PrevYE ending 31-Mar-16 Plan Month ending 31-Jan-17 Actual Month ending 31-Jan-17 Variance Month ending 31-Jan-17 Plan YTD ending 31-Jan-17 Actual YTD ending 31-Jan-17 Variance YTD ending 31-Jan-17 Plan Year ending 31-Mar-17 Forecast Year ending 31-Mar-17 Forecast Variance Year ending 31-Mar-17 Summary Income and Expenditure Account Operating income (inc. in EBITDA) NHS Clinical income, total m (4.741) (4.95) Non NHS Clinical Income, total m (.9) Non Clinical income (included in EBITDA), total m Operating income (inc. in EBITDA), total m (2.69) (1.394) Operating expenses (inc. in EBITDA) Employee Expenses, total m ( ) (22.243) (23.43) (.8) ( ) ( ).92 (27.949) (27.183).766 Non-pay expenses (excluding PFI/LIFT), total m (95.646) (7.465) (6.664).81 (78.789) (77.46) (93.853) (93.291).562 PFI/LIFT operating expenses, total m Operating expenses (inc. in EBITDA), total m ( ) (29.78) (29.77).1 (35.114) (32.469) (364.82) ( ) EBITDA m (.66) EBITDA Margin % % 2.42% 5.79% 7.6% 1.26% 3.12% 3.32%.2% 3.48% 3.47%.% Operating income (exc. from EBITDA) Donations & Grants received of PPE & intangible assets, total m Operating expenses (exc. from EBITDA) Depreciation and Amortisation, total m (9.39) (.792) (.793) (.1) (7.732) (7.841) (.19) (9.316) (9.43) (.87) Impairment (Losses) / Reversals net, total m (23.371) - (6.577) (6.577) (2.) (6.577) (4.577) (2.) (6.577) (4.577) Restructuring Costs m (.849) (.417) (1.368) (.783).585 (2.22) (1.451).751 Operating expenses (exc. From EBITDA), total m (33.61) (1.29) (7.37) (6.161) (11.1) (15.21) (4.11) (13.518) (17.431) (3.913) Non-operating income Finance Income (for non-financial activities), total m Gain/(loss) on asset disposals m Gains on transfers by absorption m Other Non-Operating income m Non-operating income, total m Non-operating expenses Interest expense (non-pfi / LIFT) m Interest Expense on PFI leases & liabilities m PDC dividend expense m (6.881) (.517) (.517) - (5.17) (5.17) - (6.24) (6.63).141 Other Finance Costs m (.52) (.54) (.54) - Non-Operating PFI costs (e.g. contingent rent) m Losses on transfers by absorption m Other non-operating expenses (including tax) m Non-operating expenses, total m (6.933) (.517) (.517). (5.17) (5.17). (6.258) (6.117).141 Surplus / (Deficit) after tax m (3.94).19 (3.668) (3.777) (5.58) (6.524) (1.16) (6.49) (6.995) (.55) Profit/(loss) from discontinued Operations, Net of Tax m Surplus / (Deficit) after tax from Continuing Operations m (3.94).19 (3.668) (3.777) (5.58) (6.524) (1.16) (6.49) (6.995) (.55) Memorandum Lines: Surplus / (Deficit) before impairments and transfers m (7.569) (3.58) (4.49) (.418) 4.72 One off income/costs m (23.868) (.417) (4.768) (4.351) (2.533) (4.134) (1.61) (4.195) (4.86) (.611) Normalised Surplus / (Deficit) m (7.72) (2.975) (2.39).585 (2.295) (2.189).16 Normalised Surplus / Deficit Margin % % (1.91%) 1.67% 3.42% 1.76% (.94%) (.76%).18% (.61%) (.58%).%

53 Page 53 of 84 units Audited PrevYE ending 31-Mar-16 Plan Month ending 31-Jan-17 Actual Month ending 31-Jan-17 Variance Month ending 31-Jan-17 Plan YTD ending 31-Jan-17 Actual YTD ending 31-Jan-17 Variance YTD ending 31-Jan-17 Plan Year ending 31-Mar-17 Forecast Year ending 31-Mar-17 Forecast Variance Year ending 31-Mar-17 Summary Statement of Financial Position Non-current Assets Intangible Assets, total m Property, Plant and Equipment, total m (1.361) (1.361) (9.677) On balance sheet PFI/LIFT assets, Non-Current, total m Other m Non-current assets, total m (5.92) (5.92) (5.224) Current Assets Cash and Cash Equivalents (excluding overdrafts), total m (5.449) (5.449) (7.352) Other current assets m (4.977) (4.977) Current assets, total m (1.426) (1.426) (5.315) Current Liabilities Overdrafts and drawdowns in committed facilities m PFI/LIFT leases, Current m Other borrowings m Other current liabilities m (57.79) (58.456) (63.23) (4.774) (58.456) (63.23) (4.774) (54.154) (58.613) (4.459) Current liabilities, total m (57.79) (58.456) (63.23) (4.774) (58.456) (63.23) (4.774) (54.154) (58.613) (4.459) Non-current Liabilities PFI/LIFT leases, Non-Current m Other borrowings m Other non-current liabilities m (6.594) (5.59) (6.267) (.758) (5.59) (6.267) (.758) (5.54) (6.34) (.764) Non-current liabilities, total m (6.594) (5.59) (6.267) (.758) (5.59) (6.267) (.758) (5.54) (6.34) (.764) Total Equity & Reserves m (21.86) (21.86) (15.762) Summary Statement of Cash Flows Surplus (Deficit) from Operations m (24.511).618 (5.15) (5.723) (1.279) (4.795) (3.516) (.372) (4.342) (3.97) Operating activities Non-operating and non-cash items in operating surplus/(deficit) m Operating Cash flows before movements in working capital m Movements in working capital m (14.43) (4.625) 9.85 (1.395) (.569).826 Increase/(Decrease) in non-current lines m (.42) (.57) (.45) (.327).123 (.473) (.344).129 Net cash inflow/(outflow) from operating activities m (6.427) Investing activities Capital Expenditure (Accruals basis) m (17.154) (3.51) (5.38) (1.987) (19.483) (11.932) (25.533) (13.51) Increase/(decrease) in Capital Creditors m (.15) (1.5) (1.96) (.856) (1.26) (1.838) (.578) Proceeds on disposal of PPE, intangible assets and investment property m (.5) (.7) (23.342) (23.597) (21.42) Other cash flows from investing activities m (.2) (.3) (.3) Net cash inflow/(outflow) from investing activities m (15.388) (4.532) (24.656) (11.787) (16.932) (.688) (1.216) (9.528) Financing activities Public Dividend Capital repaid m Repayment of borrowings m Capital element of finance lease rental payments m Interest element of finance lease rental payments m Interest paid on borrowings m Other cash flows from financing activities m (7.554) (1.879) (1.859).2 (4.981) (4.82).161 Net cash inflow/(outflow) from financing activities m (7.554)... (1.879) (1.859).2 (4.981) (4.82).161 Opening cash and cash equivalents less bank overdraft m Net cash increase / (decrease) m (12.941) (19.389) (3.161) (8.975) (5.814) 3.47 (4.311) (7.718) Changes due to transfers by absorption m Closing cash and cash equivalents less bank overdraft m (5.449) (5.449) (7.353)

54 Page 54 of 84 units Audited PrevYE ending 31-Mar-16 Plan Month ending 31-Jan-17 Actual Month ending 31-Jan-17 Variance Month ending 31-Jan-17 Plan YTD ending 31-Jan-17 Actual YTD ending 31-Jan-17 Variance YTD ending 31-Jan-17 Plan Year ending 31-Mar-17 Forecast Year ending 31-Mar-17 Forecast Variance Year ending 31-Mar-17 Use Of Resource Metric Capital Service Cover Revenue Available for Capital Service m Capital Service m (5.17) (5.17) - (6.258) (6.117).141 Capital Service Cover metric.x Capital Service Cover rating Score Liquidity Working Capital for UOR m (12.1) (7.83) Operating Expenses within EBITDA, Total m (35.114) (32.469) (364.82) ( ) Liquidity metric Days (11.72) (7.67) Liquidity rating Score I&E Margin Surplus/deficit adjusted for donations and asset disposals m (3.913) (2.752) (3.981) (3.133).848 Total operating income for EBITDA m (2.69) (1.394) I&E Margin % (1.24%) (.88%).36% (1.5%) (.83%).2% I&E Margin rating Score I&E Margin Variance From Plan I&E Margin % (.88%) (.83%) I&E Margin Variance From Plan %.36%.22% I&E Margin Variance From Plan rating Score 1 1 Agency Agency staff, total m (15.737) (19.4) (3.267) (17.395) (22.484) (5.89) Agency Ceiling m (15.767) (15.767) - (17.429) (17.429) - Agency metric % (.19%) 2.53% 2.72% (.2%) 29.% 29.2% Agency rating Score Use Of Resources Rating after overrides Score 2 2

55 Table 2 Page 55 of 84 January 217 The South London and Maudsley NHS Foundation Trust - Operating Budgets Monthly Figures Year to Date Figures As At Mth 1 Service Analysis Full Year Live Budgets ( ) Current Month Actual( ) Variance From Live Budgets ( ) Year To Date Actual ( ) Variance From Live Budgets ( ) Variance Last Month ( ) Forecast Variance ( ) 1. Psychosis 51,493,1 4,488,6 98,2 43,677,2 717,7 619,5 979, 2. Acute Care Pathway 5,913,9 3,853,5 (37,1) 46,495,8 3,922,7 4,229,8 4,743, 3. P Med & Integrated Care 26,8 (23,7) (212,7) 159,2 (29,6) 183,1 (71,) 4. Behavioural And Dev. Psych (11,1) (273,1) (269,) (297,1) (284,) (15,) (135,) 5. Child & Adolescent Service 35,4 272,1 18, (522,5) (591,4) (771,5) (429,) 6. MHOA And Dementia 313,6 17,1 (24,) (4,3) (235,9) (211,9) (314,) Notes Re Mth 1 Swk placements were 1.8m overspent ytd (Local Authority & CCG) offset by 1.3m under the risk share arrangements. A further 145k QIPP is expected to be repaid by Swk CCG. Income targets not being met in Heather Close Rehab Unit ( 178k ytd) or on Non Contracted Activity. McKenzie closed in Sept but fixed costs and staff on sick leave still charged. Forecast unmet CIPs of 1m. Adverse acute overspill variance of 2.9m ytd comprising average of 27 beds over plan ( 4.4m but offset by risk share income of 1.4m), payment for unused block beds (.3m) and surplus on overseas/nca income target (.4m). 12 overspill beds used in Dec (reduction of 9 compared to Nov). Adverse nurse pay overspends on PICU units (Eden - 344k, ES1-24k Johnson - 237k and Croydon - 157k) after excluding place of safety costs. Assumes monthly overspill numbers increase over next 2 months due to changes in ward configurations resulting in Foxley and Bridge House being closed to admissions. Forecast unmet CIPS of.6m inc cost of new management structure Underspends on various community teams and IAPT offsetting an overall shortfall on cpc income particularly neuropsychiatry outpatients ( 242k ytd), ED outpatients ( 292k ytd) and Cawley Day Service ( 32k ytd). Behavioural Genetics & ADHD not meeting income targets (although improvement in month 1), community forensic unmet CIPs/pay costs ( 161k ytd) & CAG CIP targets not being achieved Community vacancies & outpatient income above target. Community underspends expected to reduce with recruitment to vacant posts taking place in 2nd half of the year. Release of provisions in mths 1-9 to be partly offset by new provison for service restructure Ann Moss overspend offset by CMHTs and memory services..3m contract variation for the cost of delaying continuing care plans in Swk has been agreed and is built into the forecast. 7. Addictions 3 (11,5) (11,5) 13, 12,7 24,2 75, Hertfordshire contract losing money ( 28k ytd) and mgt costs increasing due to transfer of senior medical staff from R&D funded cost centre 8. Clinical Support Services 2,178,3 23,6 51,9 1,876,9 56,1 4,2 19, Pay (agency) higher than expected in Pharmacy and revised pathology activity figures have impacted negatively on the forecast 9. Infrastructure Directorates 54,874,4 4,73,4 143,5 45,489,4 73,3 (7,3) 787, 1. Corporate Income (11,38,5) (8,64,2) (15,9) (84,715,1) (278,7) (127,8) (2,) assumes that 25k of the 1m NHSE QIPP will not be made or recovered under the risk share arrangement with NHSE Operational Deficit 58,939,2 4,499,8 (51,6) 52,172,5 3,362,9 3,864,3 5,454, 11. Corporate Other (8,136,4) (6,756,5) 488,7 (62,576,3) 3,72,2 2,58,6 1,319, forecast assumes Trustwide CIP and other savings of c 6m ( inc 1.1m MARS, 3.6m of Q1 and Q2 Lock Ins, 1.3m Trustwide) 12. Contingency - planned 2,, (166,667) (1,666,667) (1,5,) (2,,) 14. Other reserves/provisions 6,51,1 (25,233) (5,348,33) (5,97,7) (4,248,) Corporate Other (72,85,3) (6,756,5) 71,8 (62,576,3) (3,942,5) (4,17,1) (4,929,) Includes the release of contingency and release or increase of various provisions for bad debts and income deferrals EBITDA (13,146,1) (2,256,7) (429,8) (1,43,8) (579,6) (152,8) 525, excludes NHSI incentive payments 15. Post EBITDA Items 19,638, 5,924,2 4,25,1 16,927,4 1,596,6 (2,68,5) 439, Trust Financial Position 6,491,9 3,667,5 3,775,3 6,523,6 1,17, (2,761,3) 964, excludes forecast NHSI incentive payment of 459k - tbc Items Not Included In NHSI Target (2,511,) (4,81,552) (4,757,574) (3,771,29) (2,178,183) 2,582, (1,353,) the NHSI target excludes impairments, donated depreciation & gains/losses NHSI Target 3,98,9 (1,134,52) (982,274) 2,752,31 (1,161,183) (179,3) (389,) distance from NHSI Target (excluding incentive payment) The adverse variance in the month is due to a 6.5m impairment resulting from the District Valuers latest valuation of Trust assets ( 5.5m re buildings and 1m re land) offset by a 2m profit from the disposal of David Pitt House. The lower asset value will result in a lower cap charge at y/e Corporate Analysis Full Year Live Budgets ( ) Current Month Actual( ) Monthly Figures Variance From Live Budgets ( ) Year to Date Figures Year To Date Actual ( ) Variance From Live Budgets ( ) Variance Last Month ( ) As At Mth 1 Forecast Variance ( ) Notes Re Mth 1 A1) Estates & Facilities 16,34,3 1,474,3 161,9 13,858,4 442,8 28,9 767, Current position is being supported by pay underspends arising from a large number of vacancies, particularly the portering and maintenance teams offset by unfunded strategic capital costs, hire of vehicles, low staff accomodation income, increase in cost of new transport contract and unmet 16/17 CIPs. Forecast includes running costs of JW House (with little offset from transfer of existing services) A2) Hotel Services 1,246,4 834,5 (19,4) 8,471,2 (17,5) 1,9 (9,) New or extended catering/domestic contract likely to increase existing cost from Q4 B) Nursing & Quality 2,931,4 231,7 12, 2,4,3 74,3 62,3 85, Unmet historic CIPs and not achieving 16/17 CIP target C) Information & I.T. 8,571,7 767,1 53,3 6,929, (115,1) (168,3) (15,) D) Finance And Corp Governance 4,34,5 364,5 (3,7) 3,541,7 (62,3) (58,6) (74,) E) Human Resources 3,415,3 342,5 38, 2,622,9 (195,4) (233,4) (76,) F) Organisation & Community 1,415,1 125,4 4,6 1,11,7 (62,8) (67,4) 74, offset against commercial directorate underspend G) Chief Executive 3,55,4 293,9 39,1 2,837,6 291,8 252,6 42, use of Ortus above agreed funding, unfunded additional and upgraded posts H) Medical & Clinical Govern. 3,411,4 247,9 (37,4) 3,5,4 152,2 189,6 227, unfunded posts/commitments and increase in junior doctor on call expenditure I) Professional Heads 1,755,3 127, (3,6) 1,365,3 (75,6) (45,) (42,) J) Chief Operating Officer 3,26,7 215,4 (7,7) 2,376,9 (311,7) (241,) (344,) K) Commercial Directorate 391,7 23,5 (18,3) 233,4 (74,6) (56,3) (74,) L) Corporate Affairs 1,746,5 154,6 1,2 1,52,3 62,5 52,3 81, unfunded post M) R&D (5,71,3) (471,9) 4,5 (4,783,7) (35,3) (39,9) (8,) Infrastructure Directorates 54,874,4 4,73,4 143,5 45,489,4 73,3 (7,3) 787, N) Corporate Other (8,136,4) (6,756,5) 488,7 (62,576,3) 3,72,2 2,58,6 1,319, Trustwide CIPs not delivered, provision releases, new bad debt provisions and CCG income deferrals offset by Q1 and Q2 lock ins O) Trust Reserves 8,51,1 (416,9) (7,14,7) (6,597,7) (6,248,) Corporate Other (72,85,3) (6,756,5) 71,8 (62,576,3) (3,942,5) (4,17,1) (4,929,)

56 Page Table of SLAM 84 summary CIP status report Jan-17 35, 3, 25, 2, 15, 1, 5, - Monthly Actual/Forecast v Plan M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 Plan Actual/Forecast M12 M11 M1 M9 M8 M7 M6 M5 M4 M3 M2 M1 Plan Plan/Forecast by RAG per month - 5, 1, 15, 2, 25, 3, 35, Red Amber Green s Plan YTD Actual YTD Value of YTD Additional variance Schemes from Plan YTD Full year Plan Full year Forecast Full year variance from Plan Full year Forecast of Additional Schemes CAG schemes: 11,926 8,26 (3,666) 15 14,918 11,417 (3,51) % % Overview comment Forecast shortfalls in all CAGs apart from CAMHS. Principal adverse variances arise in ACP 2.7m (overspill), Psychosis (Heather Close), B&D (delayed start to schemes) and PMIC (PD pathway review and Eating Disorder schemes). Overspill reduction accounts for approx. 2.5m of this variance. Corporate schemes: 3,441 2,772 (669) 111 4,21 3,47 (739) % Significant anticipated shortfalls in Estates (Adamson Centre delays, Car parking scheme delays), CEO and Nursing (complaints scheme delay) Most trust and CAG wide schemes will fail to deliver the value in the Plan due to a combination of delays, over otpimism, double counting with other savings. The principal shortfalls are the infrastructure review scheme 4.7m (slipped to next Trust wide schemes: 7,146 6,42 (1,14) 3,5 1,15 8,483 (1,622) 4, % year), agency reduction.5m, CAG wide schemes.4m, mobile working.3m, new business.3m and others.3m. These shortfalls have in part been offset by additional in year budget savings of 3.6m and additional income and cost avoidance ( 1.25m). Trust Total 22,513 17,73 (5,44) 3,266 29,233 23,37 (5,863) 5, % No further lock ins were made at Q3 - but there are significant further underspends CIPs / Cost Reduction CIP Schemes 9,623 7,41 (2,213) 2,86 13,193 9,841 (3,352) 3,926 Cost Reduction Schemes 12,89 9,663 (3,227) 46 16,4 13,529 (2,511) 1,337 Trust Total 22,513 17,73 (5,44) 3,266 29,233 23,37 (5,863) 5,263

57 Page 57 of 84 Attachment G COUNCIL OF GOVERNORS SUMMARY REPORT Date of meeting: 16 March 217 Name of Report: Author: Presented by: Performance Report Harold Bennison, Director of Performance, Contracts and Operational Assurance Kristin Dominy, Chief Operating Officer Purpose of the report: To receive the Performance report.

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59 Page 59 of 84 REPORT TO THE TRUST BOARD: PUBLIC 28 February 217 Title: Author: Accountable Director Performance Report Harold Bennison, Director of Performance, Contracts and Operational Assurance Kristin Dominy, Chief Operating Officer Purpose of the report To report the Trust s performance for January 217 against a range of key national indicators and identify and analyse under-performance and report action plans. The report summarises the Performance Management Framework review meetings and identifies any major areas of learning and success. To report on current contractual matters arising. Recommendations to The Board To approve the report noting the key performance issues, highlighted risks and remedial actions. To note the outcome of the contracting round and the challenges this represents. To agree to the proposed adjustment to the Croydon CCG contract for Older Adult services and the South London Partnership proposals for delivering secure services. Executive Summary: The Trust met all Single Outcome Framework NHS Improvement indicators with the exception of the IAPT recovery rate in Quarter 3 and action plans are in place and being enhanced to address this. The results for Early Intervention in Psychosis and Seven Day follow up are to be confirmed. Having concluded an extremely challenging contracting process with all commissioners, plans are now being formulated to ensure that services are aligned to deliver the commissioned requirements in 217. The impact of the Croydon Affordability Gap is continuing to be worked through in collaboration with the CCG. There are a number of important contractual changes continuing to be worked on with the Board being asked to support the developments with the Croydon Outcomes Based Commissioning contract for Older Adults and the South London Partnership plans for delivering Forensic Services. Progress is evident with the numerous change programmes being delivered through the PMO, Estates, ICT and with regards emergency planning and business continuity. 1

60 Page 6 of 84 JANUARY PERFORMANCE REPORT Contents: 1. NHS Improvement Single Oversight Framework: Operational Performance 1.1. IAPT and gatekeeping (January data) 1.2. Early Intervention and CPA (Q3 data) 1.3. Cardio-metabolic assessment (Psychosis) 1.4. Mental Health Services Data Set submission 2. CAG Performance Summary 2.1. External Overspill and Delayed Transfers of Care 3. Safer Staffing (December) 4. Commissioning and Contracts 4.1. Imminent Contract Changes 4.2. QIPP (Quality, Innovation, Productivity, Prevention) 4.3. Croydon Affordability Gap 4.4. CQUIN (Commissioning for Quality and Innovation) 4.5. Five Year Forward View 5. Programme Management Office 5.1. Infrastructure programme 5.2. Acute Care Pathway 5.3. Organisational Development and Transformation (Drivers of Agency usage) 5.4. Mobile Working in Community teams CIP Plans 6. Key Corporate Programmes (formerly Transformation Dashboard) 6.1. Workforce 6.2. Estates and Facilities 6.3. IT Transformation 7. Emergency Planning and Business Continuity 8. Conclusion Glossary The following appendices are included: Appendix A: PMF Trust Summary Appendix B: QSC Quality Dashboard Appendix C: Safer Staffing: Ward Level Detail Appendix D: IT staff satisfaction survey 2

61 Page 61 of NHS Improvement Single Oversight Framework: Operational Performance The NHS Improvement Single Oversight Framework (SOF) replaced the Monitor risk assessment framework from 1 October IAPT and gatekeeping January data Fig 1: Single Oversight Framework Indicators with January data available - IAPT and gatekeeping assessment New KPI IAPT Waiting Times The IAPT waiting time standards were met. The risk to the IAPT access standards for Croydon patients continues as a result of the bridging work to meet the Croydon affordability gap. The reduced service provision contains a degree of risk to the Trust s waiting time performance as well as Croydon s performance against the national CCG 15% access for population with depression or anxiety disorders IAPT Recovery Rate This indicator is included within the CCG Outcomes Framework and NHS Digital produces the official statistics for this measure. The most recent indicator of national performance is the October result of 49%. Internal reporting indicates that the Trust remains below the 5% national standard with provisional performance for January at 45.9%. The overall Trust result is based on all patients regardless of their responsible commissioner. Fig 2: IAPT Recovery Rate by Responsible Commissioner Action plans are being developed with jointly agreed action plans already in place for Southwark CCG and Lewisham CCG with additional actions being developed and confirmed. A waiting list initiative has taken place and actions identified to achieve an increase in appointment attendance as well as an increased rate of problem descriptor completion. 3

62 Page 62 of 84 Additional measures being explored including applying exclusion criteria more strictly at the triage stage; the impact on the recovery rate will be monitored and reviewed Gatekeeping Assessment Following failure to achieve the standards in Quarter 1 for Home Treatment Gatekeeping, recovery plans were developed and circulated to the Board in September. The Crisis Resolution / Home Treatment Team Gatekeeping performance continues to exceed the target following the implementation of the new 24-hour central triage function with embedded HTT in October. Fig 3: Crisis Resolution and Home Treatment Team Gatekeeping Recovery Trajectory 1.2 Early Intervention and Care Programme Approach Follow-Up Q3 data These Single Oversight Framework indicators are pending validation at the time of writing. Early Intervention Psychosis performance is due for submission to Unify on 17 February 7 Day Follow up is currently being validated, available results indicate over 95% for the quarter. Fig 4: Single Oversight Framework Indicators Q3 data EI 2 wk standard and CPA follow up Early Intervention 2 week standard Following non-delivery of the standards in Quarter 1 for Early Intervention, recovery plans were developed and circulated to the Board in September. The Early Intervention performance has continued to exceed the Trust recovery trajectory and the 5% standard. For patients not seen within the 2 week time period, typical reasons include patients not attending an appointment, further assessment being required or a delay in initial internal referral. A summary narrative is shared with commissioners and used to inform internal service improvements when applicable. Commissioners were briefed at the 6-month review meeting on the risk of increasing caseloads in some boroughs and the potential impact on NICE guidance concordance (the 4

63 Page 63 of 84 second part of the standard) based on the projected growth of caseloads against existing investments. Fig 5: Early Intervention Recovery Trajectory 1.3 Cardio-metabolic assessment and treatment for people with psychosis Physical health in serious mental illness is a national priority as outlined in the Five Year Forward View for Mental Health, 216. As specified in the SOF, the Physical Health indicator is at present assured by Board declaration. A number of outcome measures are available which align to performance in the area and allow the measurement of improvement over time. The Trust has a robust physical health strategy which is reviewed and updated yearly and underpinned by a yearly thematic review which identifies quality priorities and outcomes. This is overseen by the Quality Subcommittee (QSC) which feeds back directly to the Trust Board. In 216, the Trust Board agreed a 5-year Physical Health Strategy which identified the key priorities for SLaM as providing robust mechanisms to ensure that there is: Routine physical health monitoring for ALL patients Identification/targeting of high-risk patients Reduction of exposure to known risk factors such as smoking Provision of health promotion interventions as early as possible in treatment Provision of appropriate physical healthcare for all SMI patients The national CQUIN on Physical Health in 216/17 aligns to the above priorities, with a focus on routine physical health monitoring and the CQUIN audit can be used to triangulate this. The Trust and local commissioners have prioritised within the CQUIN the development of the infrastructure in 216/17 to create a performance report to improve and inform practice. This is alongside other deliverables, including the development of clear pathways for interventions and signposting. The Trust has achieved the agreed deliverables for the LSLC CQUIN in Quarters 2 and 3. The current developmental reports have been developed as part of the 216/17 CQUIN, and use the Clinical Record Interactive Search (CRIS) system. There have been on-going engagement activities with CAGs to identify infrastructure and reporting developments. The initial results of the report have identified key areas of improvement that need to be made; this approach has allowed automatic rather than manual routine collection of physical health monitoring data. 5

64 Page 64 of 84 All CAGs have been tasked with developing a physical health risk register of their patients so that those who are at particularly high risk of physical co-morbidity and at higher risk of mortality as a result, can be identified and targeted with relevant interventions. All CAG physical health leads are currently developing specific high risk registers for their service areas. There is confidence of having made good progress in the development of strong foundations to integrate psychical health within our clinical delivery and performance framework. 1.4 Complete and valid Mental Health Services Data Set submissions The Mental Health Services Data Set (MHSDS) indicator has been adjusted and now comprises ethnicity, employment status (for adults only), school attendance (for children and young people only), accommodation status (for adults only) and ICD1 coding. The standard is for 95% identifier metrics submitted and 85% achievement of priority metrics by the end of 216/17. The risk in relation to this indicator is the implementation of the new minimum dataset earlier this year. Whilst Mental Health Services Dataset (MHSDS) submissions extract tool Ver. 2.7 has now been delivered by the AHC (epjs supplier) there are quality issues that have been identified which need to be jointly rectified. Ongoing issues with implementation of version 2 of the MHSDS are being addressed within this process. The Business Intelligence Team has continued to work to improve data accuracy and is liaising closely with NHS Digital as the completeness of data impacts on the accuracy of both published statistics and experimental statistics. 2. CAG Performance Summary: Month 1 The Performance Management Framework is comprised of Key Performance Indicators across: Finance (including cost improvements and cost reductions) Operations (workforce, activity and quality indicators) Patient and commissioner measures Learning and growth The Trust summary for January is included as Appendix A Key issues Delivery of CIP programmes and mitigation schemes where slippage has occurred That cost reduction schemes are having sufficient impact. External overspill and Delayed Transfers of Care (DToC) Agency expenditure and the risk to the NHSI reduction trajectory Development of QIPP plans in response to commissioned schemes A brief summary of external overspill performance and delayed transfers of care is detailed below. 2.1 External Overspill and Delayed Transfers of Care External overspill aligns closely to the Mental Health Five Year Forward View target and the Crisp report recommendation to eliminate out of area placements. National submissions for out of area treatment are now being submitted to Unify 2 to support monitoring of the Mental Health 5 Year Forward View aim to eliminate inappropriate out of area treatments. The Trust has made submissions for October, November and December. CCG s are being monitored by NHS England on trajectories and assurance to reduce out of area placements. 6

65 Page 65 of 84 Performance against the September to March overspill trajectory to reduce external overspill is outlined in the chart below. The Trust trajectory is represented by the green segment, with actual performance represented by the black line. The trajectory continues to assume 7 PICU patients remaining in private units from 1 January 217 on an on-going basis. Fig 6: External overspill performance 6 Acute Care CAG external overspill performance against target Since January there has been a persistent low level increase in the use of external overspill. This has been recognised and the Chief Operating Officer instigated an urgent review across the three associated CAGs (Psychosis, Acute Care, Psychological Medicine and Integrated Care) to ensure a whole system approach is employed to tackle this. The three Deputy Service Directors are providing weekly updates. Whilst the DToC indicator is no longer included within the regulator s framework it continues to be an important measure for the Trust as days lost due to delayed transfers of care provides an additional operational pressure on in-patient beds. Days lost in December was 873 against 991 in November. The average number of discharges per week is being monitored and the most challenging area currently has been Croydon. 3. Safer Staffing (December) Fig 7: Safer Staffing (Number of Wards Breaching 2% of Shifts) 3 No. of wards Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Safer Staffing (No. of breached wards) Average (CL) UCL LCL 7

66 Page 66 of 84 There were 17 wards breaching over 2% of shifts in December, an increase of 1 ward compared to November. Ruskin and Lewisham Triage with their higher vacancy rates will have a Vacancy Review Meeting in February. Bridge House requested six agency staff which was arranged through NHS Professionals. Three wards breached without Support Workers providing cover due to short notice sickness. NHS Professionals are continuing to work with ward managers to improve the amount of notice given for booking shifts. The ward level detail of breaches is included as Appendix C. A Safe Staffing paper is being presented to the February QSC highlighting the impact of recent actions and setting out the action plan for January to June 217. The action plan will continue the work seeking out best ways to manage recruitment and retention and includes the use of the Care Hours Per Patient Day (CHPPD) measure and developing a comprehensive training programme to support the SafeCare element of the rostering system. 4. Commissioning and Contracts Update 4.1 Imminent Contract Changes Whilst 1719 contracts have been signed with all major commissioners, a number of plans were agreed involving contract variations in year: Croydon OBC - the Croydon Outcomes Based Commissioning (OBC) contract for older adults is planned to be signed by the end of March 217. SLaM has been actively involved with the development of the associated Alliance and the plan is to use the period until October 217 to produce a clear business case to support a final decision for the remaining nine years of an Alliance Contract by December 217. The impact for 217/18 is to move the clearly identified budget for older adults into a specific agreement as part of the Alliance and this will carry no additional risk for the Trust. Lambeth Alliance Lambeth CCG/LA are proposing to commence an Alliance Contract (starting April 218) for their entire spend on adult mental health. This will affect most CAGs and SMT has approved a Programme Management approach for engagement. Initial workshops are planned February / March. NSHE Forensic New Models of Care Secure Services - the associated business case applying to become a pilot for the national New Models of Care programme proposes a go live for the pilot of 1 April 217 with a new single contract as part of the South London Partnership. 4.2 LSL / NHSE QIPP (Quality, Innovation, Productivity, Prevention): A significant QIPP programme has been agreed between the Trust and Commissioners for Lambeth, Southwark and Lewisham. The total scale of this programme is million. The main schemes are: Southwark and Lewisham Placements million Lambeth and Southwark Adult Inpatient services million Lambeth and Lewisham Older Adult services -.57 million Lewisham IAPT -.47 million Lewisham Adult Community teams -.5 million For NHSE, the combined total is 2.166M, split between CAMHS, Forensic and other specialist services. There is no identified scheme from commissioners for the non-camhs, non-forensic services and the Trust is seeking to support NHSE in developing a scheme urgently. QIPP schemes will be delivered through the Programme Management Office and delivery assured via the Portfolio Programme Board. These delivery plans will include appropriate 8

67 Page 67 of 84 Quality Impact Assessments and are agreed with each commissioner who undertake their own assurance process further to their decision to commission the QIPP scheme. 4.3 Croydon Affordability Gap The Board is aware of the on-going discussions with Croydon regarding the affordability gap identified for 16/17 and the impact of the Croydon Bridge is understood. The challenges within the Croydon health economy continue and most 16/17 Bridge reductions were made permanent whereas the original plan had been for a temporary bridge. In fact, a further 2,729M was added for 17/18 given the CCG financial situation. In order to minimise the risk of delivering this additional reduction, we are asking for urgent clarification of details for how the schemes will deliver real cost reductions so we can work with the CCG to configure remaining services most effectively. A significant portion of the reduction is targeted at adult inpatient services. Croydon CCG is seeking to commission a significant reduction in tertiary services for 17/18 and we are awaiting confirmation of the allocation for CAMHS and Adult services. The Trust has provided feedback to the CCG to support development of a final proposition. A Quality Impact Assessment of the current CCG proposals is being undertaken to set out implications for safety and quality. The Croydon IAPT service funding has been further reduced with outcomes commissioned below the national targets. The service is being commissioned from April to September 217 and the CCG will be retendering ready for October. 4.4 CQUIN (Commissioning for Quality and Innovation) The agreed CQUIN programme is based on 5 national CQUINs and 2 local CQUINS for LSLC. A PMO process is being used to ensure each CQUIN has clear leadership in place to own the final negotiation process around the detailed targets and to ensure there is an associated delivery plan in place by 31 March. 4.5 Five Year Forward View Having been successful in securing funding for perinatal services, bids were submitted for Core 24 phase 2 funding with LSLC. 5. Programme Management Office (PMO): 5.1 Infrastructure programme The consultation was restarted on 5 January 217, with role descriptions supplied in an update on 1 January and communication issued on 3 January to mark the end of formal consultation. Decision communications and the new organisation structure were drafted on 1 February ready for the finalisation of details of the Finance Department in mid-february. Work is now underway scoping the schemes to review medical and clinical staff and the Institute of Psychiatry, Psychology and Neuroscience (IOPPN). 5.2 Acute Care Pathway The new CAG operating model design and consultation work streams are on target alongside the aim of achieving 2.4 million savings. The centralised Place of Safety opened in January

68 Page 68 of Organisational Development and Transformation (Drivers of Agency usage) The interim agency usage Programme Manager is in place. Several targeted agency reduction initiatives have been launched to support the Trust in meeting its commitments to limit agency spend. A tactical agency reduction plan has been agreed and implemented, with tracking and controls in place. Initiatives over the next month include the development of processes to transfer agency workers to permanent roles or onto the bank, and a case by case review of all longer term agency workers. 5.4 Mobile Working in Community teams The SMT has requested that the project team explores what would be required to achieve a shorter implementation timescale than those previously proposed with Channel 3 support. If supported, a revised presentation will be shared at the Portfolio Board later this month CIP Plans During January, savings schemes were identified for all CAGs and several non CAG departments. CAGs are in the process of developing a project timeline for each scheme. A number of non CAG schemes have been confirmed and intensive work is underway to further define and scale opportunities. An Estates disposal strategy review has been shared with the SMT with a workshop arranged for March 217 to confirm plans. Two Digital Services review workshops have taken place and a third meeting is planned for the end of February. While a significant number of schemes have been identified, there remains a shortfall in projected savings relative to the Trust s targets. The Finance Department is reviewing the Trust s scheme register and other planned commitments, to determine the proportion of the savings target for which further schemes will need to be developed. This is due for review by the Portfolio Board on 2th February Key Corporate Programmes (formerly 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: 6.1 Workforce Sickness: The rolling 12-month period is 4.71% compared to the previous period s results of 5.7% Appraisals: 97.5% of staff in post at the beginning of April had their appraisal completed. CPN Usage: 9.2 whole time equivalents (the first week of February). 6.2 Estates & Facilities - reduce number of community properties and related operating costs The intention is to achieve 2m of capital planned through asset disposal in 216/ Disposals: Morland Road - 1.2m Ann Moss Gate House - 855k David Pitt House - 2.6m 1

69 Page 69 of Properties under offer or available for disposal: No properties are currently under offer. Inglemere This property on the market but offers received have been below the expected value. It has been agreed to fund a full planning application to increase the sale potential and re-market this in 217. Woodlands/Masters House The pre-application has been completed. We have received one offer in the region of 16m but a decision is required as to whether to obtain full planning consent to maximise the value of the property Capital projects achievement against plan: Anti-ligature programme: The programme has been completed in accordance with the audit and we are currently awaiting funding to determine next steps. Work hubs: BRH 1 hub has been completed. ASCOM: We are awaiting the Trust s decision to progress to phase 2 of ASCOM Capital projects progress update against plan: Douglas Bennett House (DBH): The revised Estates strategy and the options for Douglas Bennett House refurbishment were presented to the Trust Board on 2 December 216. The Board agreed to progress Option 4 to pre planning advice service and at the same time to allow the Estates Strategy Review to reach a stage where the Board would be able to confirm that the Douglas Bennett House development was aligned with the revised Estates Strategy. High level designs are being progressed and meetings are being arranged with the Council to allow for the pre planning meeting. Adamson Centre: The IAPT service will be relocated to Stockwell Gardens in Q1 of 217/18 with some enabling works required. GSTT have been sent the details of the accommodation required for the Liaison services to remain at St Thomas Hospital. Jeanette Wallace House Completion took place on 9th January 217 and contractors are due to start work early February 217. Refurbishment of Fitzmary 1 Contractors are on site and the refurbishment of this ward will support Croydon overspill. Refurbishment of Norbury ward A plan to decant Forensic services is being developed with some enabling works to take place at Bridge House to support this move. ES1 Refurbishment: Work is in progress. Ward Refresh programme: The proposal is to start the phased construction works in April 217. This will be carried out in a live environment on ES2 ward. Car Parking at Maudsley and Lambeth Hospitals: The tender process for the car park project has been undertaken and a cost established for implementing the new schemes at Lambeth and Maudsley Hospitals. The staff consultation has also been completed which has raised a number of risks and concerns. To mitigate these risks, several alterations to the proposed car park management system have been proposed and these are likely to reduce the initial net income to be gained from the schemes. A briefing paper is being prepared for the SMT detailing the cost benefit analysis of the scheme. Hotel Services Catering and Domestic Tender: The Procurement team presented the Catering and Domestic tender to the Trust Board on 24 January 217 where it was agreed to award the contract to ISS from 1st May 217. The demobilisation of the Aramark contract and mobilisation of the ISS contract has commenced and the Hotel Services Department will work in partnership with Aramark to manage the current service and the transition to the new supplier. 11

70 Page 7 of IT Transformation Update Wide Area Network (WAN): The Wide Area Network upgrade is progressing. New circuits between the Bethlem and Maudsley Hospitals have been added to improve connections between the two sites, which will improve performance for the transfer of data and bring on board sites which were previously not on the trust network e.g Lee Health Centre. Power BI: Power BI offers exciting new visualisation capabilities which will revolutionise how the Trust uses its data, offering access to a single source of true data. Digital Services are currently undertaking technical assurance testing on the system. Cyber security: The Digital Services Operations and Information Governance Teams had 3 talk and chalk days on security and data retention policies provided by Microsoft for Office 365 platform. The policies are designed to monitor traffic with sensitive clinical and business information and apply security protocols when such information is detected. NHS Digital Technical Review: Digital Services have started the technical review as part of NHS Digital carecert cyber readiness programme. epjs: The new risk assessment tool and inpatient care plan on epjs were commended by the CQC during their latest visits. Over 45 members of staff took part in an IT satisfaction staff survey in December 216. A summary is included as Appendix D and shows improving satisfaction compared with 214. The survey also identifies clear training opportunities in use of Microsoft Office 365 and epjs. 7. Emergency Planning and Business Continuity Update The Emergency Preparedness Group (EPG) work plan was ratified on 25 th January 217. The work plan reflects the actions outlined by the recent NHSE London Emergency Preparedness, Resilience and Response (EPRR) assurance process As a follow up to the action plan, the development of a Trust HazMat (Hazardous Materials) and CBRN (Chemical, Biological, Radiological, and Nuclear) plan, along with the development of a training programme for relevant personnel across the organisation, is in progress and is being taken forward by the Health and Safety function of the Trust. A group has been formed to develop Lockdown guidance for the organisation and this approach to planning will also interrelate with HazMat and CBRN planning in the Trust. Progress is being made in the development of a universal template for Business Continuity Plans and undertaking Business Impact Analyses for the organisation. Supporting the organisation s commitment to EPRR, the Trust held a site based table top Business Continuity exercise on the 23 rd January 217. The exercise tested plans for severe weather on the Bethlem site, focusing on the mitigating actions in place for a number of possible scenarios that could occur due to the weather, and scenarios that were specific to the service user group based on the site. Lessons identified from the exercise and subsequent plans put in place on the Bethlem site would be replicated on other sites across the Trust. 12

71 Page 71 of Report Conclusion The Trust met all Single Outcome Framework NHS Improvement indicators with the exception of the IAPT recovery rate in Quarter 3 and action plans are in place and being enhanced to address this. The results for Early Intervention in Psychosis and Seven Day follow up are to be confirmed. Having concluded an extremely challenging contracting process with all commissioners, plans are now being formulated to ensure that services are aligned to deliver the commissioned requirements in 217. The impact of the Croydon Affordability Gap is continuing to be worked through in collaboration with the CCG. There are a number of important contractual changes continuing to be worked on with the Board being asked to support the developments with the Croydon Outcomes Based Commissioning contract for Older Adults and the South London Partnership plans for delivering Forensic Services. Progress is evident with the numerous change programmes being delivered through the PMO, Estates, ICT and with regards emergency planning and business continuity. 13

72 Page 72 of 84 Glossary Abbreviation Description ANPR Automatic Number Plate Recognition ASCOM Alarm system BI Business Intelligence CAG Clinical Academic Group bringing together clinical services, research and education and training into a single management grouping e.g. Psychosis CBRN Chemical, Biological, Radiological and Nuclear CCG Clinical Commissioning Group an NHS body responsible for the planning and commissioning of health services for their local area CIP Cost Improvement Programme CPMS Car Park Management Service CPN Community Psychiatric Nurse Commissioning for Quality and Innovation: A fund where payment is contingent on CQUIN delivery on quality improvements and meeting milestones agreed with commissioners. CYP Children & Young People DTOC Delayed Transfers of Care EI Early Intervention: First Episode Psychosis epjs Electronic Patient Journey System: Clinical records system EPRR GSTT HTT IAPT ICD1 LSLC MHOA MHSDS NHSE NHSI NHSP NICE OBD PICU PMF PMO QIPP SOF YTD Emergency Preparedness, Resilience and Response Guys & ST Thomas NHS Foundation Trust Home Treatment Team Improving Access to Psychological Therapies Diagnosis coding: International Classification of Diseases (World Health Organisation). Currently iteration ICD1 Lambeth, Southwark, Lewisham & Croydon (CCGs) Mental Health of Older Adults Mental Health Services Data Set: National dataset submitted to NHS Digital (formerly known as the Health & Social Care Information Centre) NHS England NHS Improvement: the new regulatory body overseeing all NHS providers as well as independent providers that provide NHS funded care NHS Professionals National Institute for Health and Care Excellence: provides national guidance and advice to improve health and social care Occupied Bed Day is a unit of currency used to measure the use made of a bed (e.g. 1 obd = 1 bed occupied for 1 day by a patient) Psychiatric Intensive Care Unit Performance Management Framework Programme Management Office Quality, Innovation, Productivity and Prevention programme is a series of schemes required by the CCGs and developed with SLaM to help enhance services and improve their cost effectiveness Single Oversight Framework: NHSI assurance and performance mechanism Year to Date 14

73 Page 73 of 84 Dec-16 Appendix A Performance Management Framework Trust Summary Finance & CIPs Please refer to Board Finance Report Please refer to Board Finance Report Workforce 4. Admin Vacancies, Bank & Agency WTE Usage ! $ %$&&'(&&') " #. Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 Admin NHSP Bank (WTE) Admin Agency (WTE) Admin & Clerical Vacancy (WTE)!" #$ $ %& Nursing Vacancies, Bank & Agency WTE Usage (YTD)! " # Vacancy WTE Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 * +'','''-'. Nursing NHSP Bank (WTE) Nursing Agency (WTE) Nursing Vacancy (WTE) 35. Sickness 6.% 1 Annual $'()*+ Leave Planning Annual - RosterPerform Leave Planning Data!",! (Excludes Doctors) Apr-16 M1 May-16 M2 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 M3 M4 M5 M6 M7 M8 M9 M1 M11 Monthly Sickness (wte) Sickness Rolling Year % Mar-17 M12 5.% 4.% 3.% 2.% 1.%.% Q1 Q2 Q3 Q4 Addictions BDP CAMHS MAP MHOAD Psych Med Psychosis Activity Days Lost 1,6 1,4 1,2 1, Delayed Private Transfers Sector of Overspill Care: Number Average and Patients % of Lost Per Bed DayDays Apr-16 M1 May-16 M2 Jun-16 M3 Jul-16 M4 Aug-16 M5 Sep-16 M6 Oct-16 M7 Nov-16 M8 Dec-16 M9 Jan-17 M1 Feb-17 M11 Mar-17 M12 7.% 6.% 5.% 4.% 3.% 2.% 1.%.% Adult OBD Against Monitor Plan (excl. Private Overspill) Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 MHOAD Days Lost Psychosis Days Lost Trust Days Lost Acute Days Lost Trust Delays % Days Lost Actual Plan 7 Day Follow Up (Target 95%) NHS Improvement & Contract KPIs (Latest Month) CPA 12 Month review HTT Gatekeeping (Target 95%) Delayed Discharges Target Below 7.5% 5 Patients with valid review Achieved Missed Patients with overdue review 96.2% of patients followed up within 7 days of discharge 94.2% of patients had a CPA review within 12 months 1.% of patients received an HTT assessment 4% of discharges delayed -1.8% variation to the previous month -.9% variation to the previous quarter 1.2% variation to the previous month -.7% variation to the previous month 238 Total Achieved Total Missed 21,665 Days Not Lost Trust Days Lost # "! )( &&-,.&/!! ( $' 123' 14&+32' 34 5' '3 '((7+ '* +'* 6 &+ 3 ( 3 # "! IAPT Waiting Time (6 Weeks) #!/ #/ "/ / ( $' 123' 14&+32' 34 5' 6 &+'3 ( '3 # "! IAPT Waiting Time (18 Weeks) / ##/ ##/ #"/# ( $' 123' 14&+32' 34 5' 6 &+'3 ( '3 6% of patients received Psychosis treatment within 2 weeks 88.% of patients completing treatment within 6 weeks 99.5% Figures shown above are in one month in arrears.1% variation to the previous month.6% of patients completing treatment within 18 weeks variation to the previous month

74 Page 74 of 84 Dec-16 Appendix A Performance Management Framework Trust Summary Friends and Family Patient Surveys (PEDIC) 1.% 14 1.% % 9.% 12 8.% 8.% 89.9% 85.2% 89.5% 87.1% 87.4% 91.1% 87.6% 89.7% 88.4% 7.% 1 7.% % 6.% % 5.% % % 3.% 3.% 4 2.% 2.% 2 1.% 1.%.%.% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M12 No. of FFT Responses FFT Score (%) Do you feel involved in your care? (%) # "! " $ '* &&'*& ',$ '- ''* +'+--.8 $ '* &&'*& '9,$ ''+&-&'+--'+$'. 6 &+'3 ( '3 (&&':&+5 Learning and Growth " Training Completions Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 M1 M2 M3 M4 M5 M6 M7 M8 M9 M1 M11 M Number of Completions

75 Page 75 of 84 Appendix B QSC Quality Dashboard Period: December (M9) 216 Circulation: QSC Circulation February 217 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 216/17 are: Business Intelligence development on the new Power BI tool to allow drill down to CAG and Borough. Incorporation of development and learning arising from the QI programme. Benchmarking data will be drawn upon in line with publication and as indicated. The report is organised by the CQC Key Lines of Enquiry: Safe, Effective, Caring, Responsive and Well Led. The report will provide analysis and exception reporting as indicated. The report will also provide written updates on: The delivery of Commissioning Quality and Innovation (CQUINS) throughout the year. There will be regular updates on progress in meeting Quality Priorities and supporting activities (for instance Patient-led assessments of the care environment (PLACE) and the roll out of E-Observations across the wards). At present work is being undertaken in the development of interim monitoring reports for the following Quality Priorities: Carers Assessments and Full Risk Assessments (CPA patients) completed within policy timescales. The final measurement for these priorities will be by audit but the interim monitoring alongside CAG audits will support and identify potential for improvements throughout the year. CQUINS: The Quarter 3 submissions for the LSLC CQUINS were made. Further information on the Physical Health workstream is being reported to the QSC. Work on NHSE CQUINS was ongoing at the time of writing. Private Overspill: Patients placed in private beds continue to fall in line with the trajectory. Exception reporting: Safer Staffing: There were 17 wards breaching over 2% of shifts this is an increase of 1 compared to November. Ruskin and Lewisham triage with their higher vacancy rates thad the Vacancy Review meetings in January, the wards will have a Vacancy Review in February. Bridge House requested six agency staff which was arranged through NHS Professionals.Three wards breached without Support Workers providing cover this was due to short notice sickness. NHS Professionals are continuing to work with ward managers to improve the amount of notice given for booking shifts.

76 Page 76 of 84 Safer Staffing (Number of Wards Breaching 2% of Shifts) Safe Acute CAG External Overspill Performance against Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 No. of wards Safer Staffing (No. of breached wards) Average (CL) UCL LCL 96.2% followed up within 7 days of discharge 96.2% of patients had a brief or full risk screen 98.2% of patients had a child need risk screen Unauthorised Absences (Detained Patients) 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 Aug-16 Sep-16 Oct-16 Nov-16 Dec-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 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Full Risk Screen (CPA Patients) Completed Incomplete Child Need Risk Screen (CPA Patients) Completed Incomplete Unauthorised Absences - Detained Patients New Serious Incidents Average (CL) UCL LCL All Restraints Incidents Prone Restraints Patient Physical Assault on Patients (All Grades A-E) Patient Physical Assault on Staff (All Grades A-E) Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 No. of assaults No. of assaults Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Physical Assaults on Patients (By Patient) Average (CL) UCL LCL Physical Assaults on Staff (By Patient) Average (CL) UCL LCL

77 Page 77 of 84 Effective Days Lost Delayed Private Transfers Sector Overspill of Care: Number Average & % Patients of Bed Days Per Day lost Apr - 16 May - 16 Jun - 16 Jul - 16 Aug - 16 Sep - 16 Oct - 16 Nov - 16 Dec % 6.% 5.% 4.% 3.% 2.% 1.%.% Following the implementation of the new 24-hour central triage function with embedded HTT performance has significantly improved for this indicator. MHOAD Days Lost Psychosis Days Lost Trust Days Lost Acute Days Lost QUESTT addresses the following Metrics: New or no Ward Manager in post (within last 6 months) Vacancy rate higher than 7% Bank shifts is higher than 6% Sickness absence rate higher than 3% Trust Delays % Days Lost Level (Score = 9 or less) Level 1 (Score = 1 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 12 Ward/department appears untidy/disrepair No evidence of effective multidisciplinary/multi-professional team working On-going investigation or disciplinary investigation 1.% of patients with a HTT assessment PENDING Commentary: Bridge House score is influenced by having a new ward manager in place, high patient acuity, high vacancy rates, and high agency usage. This is compounded by a period of change with an anticipated relocation of the ward. The CAG has an action plan and continued monitoring and support will be offered at local and corporate level. Fitzmary 2 had been at level 2 for 3 of 4 months have provided a reviewed action plan and were level 1 in November. This will be monitored over the coming months by the Clinical Service Lead (CSL).

78 Page 78 of 84 Caring!" ##$#%&#%##'(!" )"#$#!%&*#&#!)%#+***!%&*#&#!)%###,-! "#$%&'%(! "#$%('%) CPA 12 Month review!" Patients with valid review Patients with overdue review NHS Improvement have removed this indicator from the Single Oversight Framework. Provisional data for end of Quarter indicates 94.2%..#/)%* #,/- 1/ /.#/)%* #,/- 1/ / 94.2% of patients with CPA review within 12 months 2 IAPT Waiting Time: 6 Weeks (Target 75%) 2 /&# )"3#.%*3)# 3.4# 2 IAPT Waiting Time:18 Weeks (Target 95%) /&# )"3#.%*3)# 3.4# 5%*#3 /#3 5%*#3 /#3

79 Page 79 of 84 Caring (continued) Early Intervention % within 2 weeks (completed Pathways) 2 /&# )"3#.%*3)# 3.4##3#//8*#6*#6 5%* 3 / 3 The Early Intervention performance in Quarters 2 and 3 exceeded the Trust recovery trajectory and the 5% standard. In December the Trust met the standard overall but results were below 5% for one CCG. The change in performance for other CCG's relates to their being no applicable patients in the previous month. For patients not seen within the 2 weeks typical reasons include patients not attending an appointment, further assessment being required or delay in initial internal referral. A summary narrative is shared with commissioners and used to inform internal service improvements if applicable. Well Led *%+, -!" )"#$#& 6%%#/** /)%7#+& )"#$#& 6%%#/)%7#)" )"#$#& 6%%#/)%7#8 &#6%%#,6%# -# ##)%,"#59#%# -#, !" 1, December data is provided by the LEAP system. 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 7% = Red, 71-84% = Amber, above 85% = Green (except IG which is 95%). -/ -% $$#%4**###,%##-!"!"

80 Page 8 of 84! "#$% &# % '( $!"! #! $ %&!#'!() **+## %$, -,. # */ **+*# %$, &!/!!+# 1 2 *" 1*!* *! "!) +(#. 3 -,.!. $ & * *! $ 5& "!/ / *! 2 " )! 6 6 '(#$)# %$ 7& #!* ) *&,-(# %$ &! * (+## %$ %. *) $ $ 1 8 " 18!/ *( ) %$ -7 " 9:$ --!# /!(+## $.! *6 * *& ;, < 6!) *! '(+##(#(##(#

81 Page 81 of 84 Appendix D: IT Staff Satisfaction Survey Background: Digital Services have been asked to provide a brief update to the Executive Board for the results of the IT Survey conducted in December 216. Initial IT Satisfaction survey December 214 Assessment of IT Service by CIO December 214 March 215 New IT Strategy signed off by Board March 215 SLaM Board ask for next survey November 216 IT Satisfaction survey conducted December 216 No. of respondents December 214 No. of respondents December (survey open 3 weeks) 459 (survey open 1 week) Q: Are you a Clinical or Non-Clinical member of staff? Are you a Clinical or Non-Clinical member of staff? 7.% 6.% 5.% 4.% 3.% 2.% 1.%.% Clinical Non-Clinical Q: Have you seen any improvements in Digital Services over the last year? 216 only Have you seen any improvements in Digital Services (IT) over the last year? 8% 7% 6% 5% 4% 3% 2% 1% % Yes No I don't know

82 Page 82 of 84 Q: When you contact Digital Services (IT) - do you receive a response in a timely manner? When you contact the IT dept, do you receive a response in a timely manner? When you contact Digital Services (IT), do you receive a response in a timely manner 1% 8% 6% 4% 2% % 1% Strongly agree 19% Somewhat agree 32% 15% Inconsistent Somewhat disagree 28% Strongly disagree 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % 29.2% Strongly Agree 47.3% Somewhat Agree 2.5% Inconsistent Somewhat Disagree 2.% 1.1% Strongly Disagree The charts above represent that staff now experience fast responses when contacting the Service Desk. Q: How would you rate the time it takes to have your issue or request fully resolved? How would you rate the time it takes to have your issue or request resolved? 43% 2% 9% 27% 19% Very fast Fast Neither fast or slow Slow Very slow How would you rate the time it takes to have your issue or request resolved? 3.5% 11.5% 13.7% 38.6% 32.7% Very Fast Fast It's Okay Slow Very slow The above pie charts show a significant improvement in how long it takes to have issues or requests resolved. Q: Does the Digital Services dept. (IT) come across as courteous and professional? Does the ICT department come across as courteous and professional? Does the Digital Services Department (IT) come across as courteous and professional? 34% 5% 4% 14% 43% Strongly agree Agree Inconsistent Disagree Strongly disagree.7%.7% 8.3% 39.2% 51.2% Strongly Agree Somewhat Agree Inconsistent Somewhat Disagree Strongly Disagree

83 Page 83 of 84 Q: Please rate your most recent experience of dealing with the Digital Services (IT) dept Please rate your most recent experience of dealing with IT. Please rate your most recent experience of dealing with the Digital Services (IT) Department 21% 21% 12% 28% 18% Very good Good Okay Poor Very poor 13.7% 48.4% 4.8% 33.1% Excellent Good Okay Poor The results above show that Trust staff are receiving a great service from the Digital Services dept. with 82% of respondents stating that recent experiences are either excellent or good. Q: Do you think you will require more use of Digital Services and Technology in the future in your job? 216 only Do you think you will require more use of Digital Services and Technology in the future in your job? 3.7% 1.5% Yes No 85.8% I don't know The question above was asked to gauge the perceptions of staff in the use of technology as services evolve.