COMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR:

MINDING THE GAP COMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR: GOVERNANCE ASSURANCE AND PERFORMANCE.

1. INTRODUCTION AND CONTEXT Providing, delivering and developing the highest standards of care is an ambition shared across the Community and Older People s Mental Health Service in providing a complex range of inpatient and locality services to the communities we serve. The range of services delivered across many localities and disciplines requires a systematic approach to support staff to have the information they need to provide safe, high quality care as well as an opportunity to directly influence the way in which services are developed and governed. Minding the GAP is a structured approach to support the governance and communication across and within the Care Group, but also to provide a direct link to the wider Trust Governance Structure. Minding the GAP utilises the Care Quality Commission Key Lines of Enquiry (KLoE) to structure an approach to care group governance which aims to support all staff to understand, contribute to and achieve the highest standards of care, the structure will help us to answer the 5 key questions: - Are we safe? - Are we effective? - Are we caring? - Are we responsive? - Are we well led? Linked to the Trust Clinical Governance and Quality Reporting Structure (Appendix 1) Minding the GAP extends the structure of clinical governance and performance management to all services and staff within the care group in a network of structured conversations designed to support effective, safe, compassionate, responsive and well led services. Section 2 below describes the system to be established to achieve these aims.

LOCALITY TEAM 2. Minding the GAP Community and Older People s Mental Health Governance Assurance and Performance Structure TRUST CARE GROUP Drugs and Therapeutics Committee COPMH Rep: Michelle Cooke Healthcare Associated Infection Group COPMH Rep: Mark Preston Deteriorating Patient and Resuscitation Committee COPMH Rep: Mark Preston Medical and Clinical Equipment Devices Group COPMH Rep: Helen Cammish Clinical Audit and Effectiveness Committee COPMH Rep: Janet Woodhouse Operational Risk Management Group COPMH Rep: Jan Smith Humber Safeguarding Forum COPMH Rep: Jan Smith Patient Experience Group COPMH Rep: Jan Smith CLINICAL FORUM CHAIR: TRISH BAILEY DEPUTY: INPUTS: Performance Reports, budgets, contract compliance, Staffing, Training compliance. INPUTS PALS, Compliments and Complaints, FFT CARE GROUP CLINICAL NETWORK SAFE AND EFFECTIVE CHAIR: MARK PRESTON, DEPUTY: JANET WOODHOUSE CARE GROUP PERFORMANCE AND ASSURANCE GROUP WELL-LED CHAIR: JAN SMITH DEPUTIES: MICHELLE COOKE/HELEN CAMMISH CARE GROUP PATIENT EXPERIENCE GROUP CARING AND RESPONSIVE CHAIR: JAN SMITH DEPUTY: JANET WOODHOUSE LOCALITY GOVERNANCE GROUP CHAIR: MICHELLE COOKE LOCALITY GOVERNANCE GROUP CHAIR: HELEN CAMMISH TEAM TEAM MEETING MEETING TEAM MEETING TEAM MEETING TEAM MEETING TEAM MEETING TEAM MEETING TEAM MEETING TEAM MEETING TEAM MEETING

3. CARE GROUP MEMBERSHIP AND TERMS OF REFERENCE Establishing a membership which is representative of the Care Group supports clear communication and dissemination but also and as importantly provides clinical perspective and collective understanding within the Governance, Assurance and Performance frameworks. In addition to the named representatives and deputies detailed above the Care Group Meetings will provide for an inclusive approach with standard core membership and terms of reference for the: Care Group Clinical Networks Care Group Performance and Assurance Group Care Group Patient Experience Group Locality Governance Groups Team Meetings The Terms of Reference for each of these structured meetings are defined below.

CARE GROUP CLINICAL NETWORK Safe and Effective TERMS OF REFERENCE Aims and Purpose The Community Services and OPMH Clinical Network has been established to oversee and ensure the delivery of Clinical Governance and quality improvement across the Community Services and OPMH Care Group. The Community Services and OPMH Clinical Network will also be responsible for defining and achieving a set of overarching clinical priorities on an annual basis approved by the Care Group Clinical Forum. The annual Clinical Priorities will be set in line with national and locally agreed requirements and actions. To fulfil its aims and purpose the Community Services and OPMH Clinical Network will divide into two groups: Sub Group 1: The Community Services and OPMH Hospital and In patient based care services Clinical Network Sub-Group. Sub Group 2: The Community Services and OPMH Community Care based care Services Clinical Network Sub-Group. Community Services and OPMH Hospital and in- patient based Services Sub-Group Community Services & OPMH Clinical Network Community Services and OPMH community based Services Sub- Group

Community Services and OPMH Clinical Network Membership Community Services & OPMH Clinical Care Group Director Nurse Consultant (Dementia) Community Services & OPMH Care Group Medical Director OPMH Acting Clinical Lead Deputy Director Nursing and Quality ( or representative) Locality Matrons Community Services and OPMH In-patient Matron Community Services & OPMH Care Group Assistant Directors Community Services & OPMH Service Manager Representation Lead Clinical Pharmacist Psychology Representation Allied Health Professionals Member of the Nursing & Quality Team Healthwatch Representation (TBC) Training / Education Representative Clinical Speciality Group Chairs or Nominated Deputies (i.e. Bladder and Bowel, Tissue Viability, Palliative and EoL, OPMH) Quorum The group shall be quorate with 9 members including the Chair or Vice Chair Reporting Appendix 1 shows the organisation s clinical governance and quality reporting structure. The Clinical Care Group Director and the Nurse Consultant (Dementia) will report to and be a member of the Care Group Clinical Forum (CGCF) on behalf of the Community Services and OPMH Clinical Network. Chairs The Community Services and OPMH Clinical Network (the meeting which combines the Care Group s Hospital/In-patient based services sub group and the Community services based Care Services Sub-groups) will be chaired by the Clinical Care Group Director. The Nurse Consultant (Dementia) will fulfil the Vice Chair role. Sub Group 1: The Clinical Care Group Director will chair the Community Services and OPMH Hospitals and In-patient based services Sub-Group. The Nurse Consultant (Dementia) will fulfil the Vice Chair role. Sub Group 2: The role of Chair for the Community Services and OPMH Community based Services Sub-Group will rotate on a six monthly basis across the Sub-group s membership. The CHERY Locality Matron will share the Chair role for the first six months with the Bridlington Locality Matron.

The Nurse Consultant (Dementia) will fulfil the Vice Chair role. Frequency and Duration of Meetings Meetings will be 2 ½ hours duration The Clinical Care Group Director s Admin Support will arrange the meetings annually. The sub-groups will hold one separate meeting and one combined meeting per quarter. Virtual meetings may be held. For example, use of email to gather views / approve changes to clinical practice where timely responses are required. Where decisions have been made by this means the issue and the decision must be noted at the subsequent network meeting. The use of telecommunication will be utilised wherever practical and feasible to support cost efficiencies and improved productivity within the Trust. Duties Develop a Quality & Clinical Governance development plan for the Care Group based on clinical priorities incorporating patient, carer and staff views to drive quality improvement activities Ensure implementation of nationally mandated clinical standards that require action within the Care Group e.g. Professional body standards / CQC / NICE To ensure development, implementation and regular review of evidence based clinical pathways To ensure that the Trust is delivering safe and effective services that are continuously improving through the implementation of learning from incidents, national enquiries and other quality improvement feedback mechanisms. Develop, ratify, implement and review the effectiveness of clinical policies, guidelines and standards To provide scrutiny and sign-off for patient, carer and public information leaflets produced by clinical professional experts in the field (with or through appropriate clinical speciality groups) Prioritise, agree and monitor clinical audit activities for the Care Group in line with the Trust s Audit Strategy and ensure the recommendations from clinical audit are implemented and evaluated in terms of practice development and improvement. Inform and influence skills development and workforce transformation in line with local and national clinical standards and commissioning priorities. Identify and support areas for research and service evaluation to inform quality improvements. Meeting Structure Meetings will be structured around standing agenda items so that all aspects of Governance can be covered. The agenda will be arranged as follows:

- Welcome and apologies - Minutes from last meeting - Matters arising not covered by agenda - Quality Improvement (including patient and public participation, Clinical Priorities, clinical pathways, audit, research and service evaluation) - Risk Management (including quarterly review of incident data, complaints, SIs and SEAs, and identification of outcomes/learning) - Outcomes from Serious Incidents and Significant Events and organisational learning. - Patient Safety (including Essence of Care benchmarks, Quality Dashboards, NHS Safety Thermometer, staffing levels, continuity of care, Safeguarding, workforce skills and competencies) - National standards & clinical practice guidance (including benchmarking, gap analysis and action planning, uploading onto NICE Tracker, policies, guidelines and patient information) - AOB Reporting Arrangements Clinical Forum Responsible to: Quality & Patient safety Committee Review date Initial Review in three months (December 2015) then annually.

Aims and Purpose CARE GROUP PERFORMANCE AND ASSURANCE GROUP Well-Led TERMS OF REFERENCE 2015/16 The Care Group Performance and Assurance Group is accountable to the Operational Management Group and is responsible for the assessment of rates of performance and assurance across the care group. Structure See Section 2 (Minding the GAP). Membership and Attendance The membership of the Performance and Assurance Group will comprise: Care Group Director (chair) Assistant Director (deputy) Associate Medical Director Clinical Care Director Performance Lead Officer Finance Lead Officer Senior Human Resource Manager Deputies may attend but they must not attend more than the member they are representing over a rolling 6 month period. The Clinical Governance Group will invite other Care Group or corporate leads and advisors to attend meetings as appropriate. Chair Care Group Director Frequency Monthly Quorum The quorum necessary for the transaction of business shall be 4 members; this must include either chair or deputy.

In the absence of a duly convened meeting, the meeting may still take place, but all decisions will be ratified at the following meeting. Duties Monitor the Care Group compliance with national and local CQUIN objectives and plan action to deliver performance against agreed objectives. Monitor the Care Group financial performance against budget, planning and taking appropriate action to address budget pressures or areas of concern. Consider areas of significant risk to performance or assurance in the Care Group in relation to contractual or compliance frameworks. Advise on the robustness of mitigation plans and oversee the implementation; escalating concerns as appropriate. Ensure sound systems for performance management are in place in line with statutory requirements, national policy and guidance and that mechanisms for performance management and assurance, are appropriately addressed in all service developments/reconfiguration of services. Oversee the management of change and business development. Provide oversight and delivery of key performance improvements arising from inspection. Assess workforce capacity and capability, taking action to address identified areas of concern. Monitor compliance with key workforce data and information with particular reference to PADR and mandatory training compliance. Monitor and action adherence to absence management procedures and govern the continued reduction in unplanned absence. Monitor the use of bank and agency spend and set in place actions to govern use of flexible workforce. Meeting and Reporting Arrangements The Performance and Assurance Group will follow a standard agenda as set out below. The agenda and meeting papers will be circulated by email 5 days prior to the meeting. The secretary to the Group will be responsible for meeting arrangements, circulation of all documentation and minute taking. Minutes of the Performance and Assurance Group will be shared with the Locality Governance Groups. Review Date These Terms of Reference will be reviewed annually (next November 2016)

CARE GROUP PERFORMANCE AND ASSURANCE GROUP STANDARD AGENDA 1. Apologies for Absence 2. Minutes and Matters Arising 3. Monthly Performance Reports 4. Waiting Times Report 5. Monthly Finance Report 6. Human Resources Update 7. Inspection Reports and Action Plans 8. Feedback from Locality Governance Groups 9. CQUIN 10. Risk Register items for escalation and review 11. Any Other Business

Aims and Purpose CARE GROUP PATIENT EXPERIENCE GROUP Caring and Responsive TERMS OF REFERENCE To ensure that patient, carer, and the public views are heard at all levels and across all parts of the Care Group to help us to create and deliver better health and care services. Structure See Section 2 (Minding the GAP). Membership and Attendance The membership of the Performance and Assurance Group will comprise: Care Group Director (chair) Nurse Consultant (deputy) Assistant Director Associate Medical Director Clinical Care Director Complaints/PALS Lead Officer Governance Lead Officer Deputies may attend but they must not attend more than the member they are representing over a rolling 6 month period. The Patient Experience Group will invite other Care Group or corporate leads and advisors to attend meetings as appropriate. The Care Group will work to identify people who use our services who can be supported to attend or otherwise influence the work of this group. Chair

Care Group Director Frequency Monthly Quorum The quorum necessary for the transaction of business shall be 4 members; this must include either chair or deputy. In the absence of a duly convened meeting, the meeting may still take place, but all decisions will be ratified at the following meeting. Duties Monitor and analyse patient and carer feedback from all sources. Identify themes, trends and areas of concern and plan action to address. Maintain a focus on areas of best practice in patient and public engagement and promote shared learning. Consider and cascade information from the Trust Patient and Carer Experience Group. Monitor action plans from complaints and ensure delivery to improve patient experience. Meeting and Reporting Arrangements The Patient Experience Group will follow a standard agenda as set out below. The agenda and meeting papers will be circulated by email 5 days prior to the meeting. The secretary to the Group will be responsible for meeting arrangements, circulation of all documentation and minute taking. Minutes of the Patient Experience Group will be shared with the Locality Governance Groups. The Patient Experience Group will report to the Trust Patient and Carer Experience Group. Review Date These Terms of Reference will be reviewed annually (next November 2016)

CARE GROUP PATIENT EXPERIENCE GROUP STANDARD AGENDA 1. Apologies for Absence 2. Minutes and Matters Arising 3. Monthly Complaints Report 4. Monthly Compliments Report 5. Feedback from Trust Patient and Carer Experience Group 6. Feedback from Trust Equality and Diversity Group 7. Complaints Action Plans 8. Feedback from Locality Governance Groups 9. Best Practice and Innovations 10. Any Other Business

CARE GROUP LOCALITY GOVERNANCE GROUPS TERMS OF REFERENCE 2015/16 Aims and Purpose The Care Group Locality Governance Groups are responsible for the assessment of rate of assurance across the locality. The group provides the mechanism by which information is shared from clinical teams to inform and influence performance and assurance and to cascade relevant information from the Trust Governance Structure (appendix 1) to teams. Structure See Section 2 (Minding the GAP). Membership and Attendance The membership of the Performance and Assurance Group will comprise: Assistant Director (chair) Modern Matrons Service Managers Team Managers Performance Lead Officer Finance Lead Officer Senior Human Resource Manager

Deputies may attend but they must not attend more than the member they are representing over a rolling 6 month period. The Clinical Governance Group will invite other Care Group or corporate leads and advisors to attend meetings as appropriate. Chair Assistant Director Frequency 4 weekly. Quorum The quorum necessary for the transaction of business shall be 4 members; this must include either chair or deputy. In the absence of a duly convened meeting, the meeting may still take place, but all decisions will be ratified at the following meeting. Duties Assess the locality financial performance against budget, planning and taking appropriate action to address budget pressures or areas of concern. Consider areas of significant risk to performance or assurance in the locality in relation to contractual or compliance frameworks. Assess the robustness of and implement mitigation plans; escalating concerns as appropriate. Manage sound systems for performance management in line with statutory requirements, national policy and local guidance. Share developments and best practice in the involvement of patients and carers and maximise opportunities for collective responses. Review patient feedback from all sources and implement actions to address areas of concern. Delivery of key performance improvements arising from inspection. Govern compliance with key workforce data and information with particular reference to PADR and mandatory training compliance. Monitor the use of bank and agency spend and set in place actions to govern use of flexible workforce. Consider, report and action clinical developments arising from the work of the clinical Network. Receive feedback from teams responding and escalating feedback through the governance framework.

Meeting and Reporting Arrangements The Locality Governance Groups will follow a standard agenda as set out below. The agenda and meeting papers will be circulated by email 5 days prior to the meeting. The secretary to the Group will be responsible for meeting arrangements, circulation of all documentation and minute taking. Minutes of the Locality Governance Groups will be considered at the Performance and Assurance Group and Patient Experience Group. Review Date These Terms of Reference will be reviewed annually (next November 2016). CARE GROUP LOCALITY GOVERNANCE GROUP STANDARD AGENDA 1. Apologies for Absence 2. Minutes and Matters Arising 3. Minutes of and feedback from Patient Experience Group 4. Minutes of and feedback from Performance and Assurance Group 5. Minutes of and feedback from Clinical Network 6. Locality Management/Core Business 7. Best Practice and Innovations 8. Items for escalation/cascade. 9. Any Other Business

CARE GROUP TEAM MEETING TERMS OF REFERENCE 2015/16 Aims and Purpose The Care Group Team Meetings aim to both inform and take influence from clinical teams in the continuous development of safe, effective and well-led services. The team meetings will provide a focus for shared learning and information exchange. Structure See Section 2 (Minding the GAP). Membership and Attendance The membership of the Performance and Assurance Group will comprise: Team Manager (chair) Team Members The chair may invite other Care Group or corporate leads and advisors to attend meetings as appropriate.

Chair Team Manager Frequency 4 weekly. Quorum The quorum necessary for the transaction of business shall be 4 members; this must include either chair or a nominated deputy. In the absence of a duly convened meeting, the meeting may still take place, but all decisions will be ratified at the following meeting. Duties Assess the team financial performance against budget, planning and take appropriate action to address budget pressures or areas of concern. Implement sound systems for performance management in line with statutory requirements, national policy and guidance. Plan for development and best practice in the involvement of patients. Review patient feedback from all sources, report on areas of achievement and implement actions to address areas of concern. Delivery of key performance improvements arising from inspection. Undertake action to improve compliance with key workforce standards with particular reference to PADR and mandatory training compliance. Monitor the use of bank and agency spend and set in place actions to govern use of flexible workforce. Consider, report and action clinical developments arising from the work of the clinical Network. Receive feedback from Locality Governance Groups responding and escalating feedback through the governance framework. Meeting and Reporting Arrangements The Team Meetings will follow a standard agenda as set out below. The agenda and meeting papers will be circulated by the Team Manager. Minutes of the Team Meetings will be considered at the Locality Governance Groups. Review Date These Terms of Reference will be reviewed annually (next November 2016).

CARE GROUP TEAM MEETINGS STANDARD AGENDA 10. Apologies for Absence 11. Minutes and Matters Arising 12. Minutes of and feedback from Patient Experience Group 13. Minutes of and feedback from Performance and Assurance Group 14. Minutes of and feedback from Clinical Network 15. Team Business

16. Best Practice and Innovations 17. Items for escalation. 18. Any Other Business

APPENDIX 1 TRUST CLINICAL GOVERNANCE & QUALITY REPORTING STRUCTURE TRUSTBOARD MENTAL HEALTH LEGISLATION COMMITTEE EXECUTIVE MANAGEMENT TEAM INTEGRATED GOVERNANCE & AUDIT COMMITTEE Mental Health Steering Group QUALITY & PATIENT SAFETY COMMITTEE Report to EMT. Report to IG&AC for Assurance Purposes [Clinical Governance, Patient Experience, Quality Improvement plans and QA, Clinical Risk Management, complaints, clinical policy approval, safeguarding, Infection Control, Organisational Learning/closing the loop] Information Governance Committee Report to EMT. Report to IG&AC for Assurance Purposes Research & Development Committee Report to EMT. Report to IG&AC for Assurance Purposes ORMG [SIs, SEAs, Complaints Risk Register, Inquests] HCAI Group SAFEGUARDING GROUP [MCA/DOLs/ PREVENT/Training/ policies/standards] CLINICAL AUDIT & EFFECTIVENESS GROUP [NICE, Clinical Audit] Patient Experience Group [Production & implementation of the Patient Experience Strategy] Medical Devices Group Care Group Clinical Forum [Standards/Policy development/ horizon scanning/professi onal Education & Training, C Gov] Deteriorating Patient & Resuscitation Group Drugs & Therapeutics Committee