AGENDA A Meeting of the Foundation Trust Public Board th

Trust Board Public

08/07/20

AGENDA

A Meeting of the Foundation Trust Public Board 8th July 2020, 2pm-4pm, via Microsoft Teams

Members of the Public are welcome to observe the meeting of the Board in public, via a virtual platform. You are asked to please note that there will not be an opportunity during the meeting for members of the Public to ask questions of the Board.

60.20 Public Introductions and Apologies for Absence

Ian McPherson Verbal

61.20 Public

Declarations of Interest

Ian McPherson Attached

62.20 Public Approve the Minutes of the meeting held on 10th June 2020 Ian McPherson Attached

63.20 Public

Matters Arising


64.20 Public Chief Executive and System Update

Fiona Edwards

Attached

PERFORMANCE OVERSIGHT

65.20 Public Managing Covid 19 – Recovery and Reformation

Graham Wareham Attached

66.20 Public Quality and Safety Report

Heather Caudle Attached

67.20 Public Activity and Performance Report

Toby Avery Attached

68.20 Public Quality Improvement Quarterly Report Helen Rostill Attached

69.20 Public Risk Report Heather Caudle Attached

70.20 Public Value for Money Report

Graham Wareham Attached

Strategy Delivery

71.20 Public Children and LD System Quarterly Update

Trudy Mills Attached

Approval Items

None

Items for Information

72.20 Public Audit Committee Update June 2020 Jennifer Seeley Attached

73.20 Public Any Other Business All Verbal

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Trust Board Public

08/07/20

Confidential

AGENDA A Meeting of the Foundation Trust Board Held in PRIVATE

8th July, 11am-12pm, via Microsoft Teams

Exclusion of the Press and the Public from the meeting. In accordance with our Constitution, members of the public are excluded from the meeting of the Board of Directors, for special reasons by resolution of the Board of Directors, on the grounds that publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted, or for the other special reasons stated in the resolution, and arising from the business or nature of the proceedings.

42.20 Private Resolution to Exclude the Press and Public from the meeting Ian McPherson Attached

43.20 Private Introductions and Apologies for Absence Ian McPherson Attached

44.20 Private Declarations of Interest


45.20 Private Minutes of the Meeting held on 10th June / 18th June


46.20 Private Matters Arising


47.20 Private Chief Executive Update

Fiona Edwards Verbal

48.20 Private Exceptional Items

49.20 Private Any Other Business

Date of Next Meeting

Wednesday 9th September 2020

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Item: 61.20 Public

Voting Directors’ Declarations of Interest July 2020

Status Name Declared Interests

Voting Ian McPherson Chairman • Trustee, Cardiomyopathy UK

• Trustee, Birmingham Mind

Voting Jennifer Seeley Non-Executive Director

• Fellow of the Chartered Institute of Public Finance and Accountancy

• Associate Teacher for the Chartered Institute of Public Finance and Accountancy

• Fellow of the Chartered Institute of Procurement and Supply

• Assessor for the Chartered Institute of Procurement and Supply

• Mental Health Act Manager

Voting Rahul Jaitly Non-Executive Director

• Board Advisor, Ignitho Technologies UK Limited

• Expert Peer, Virtuoso Peers (A Crimson and Ignitho Joint Initiative)

• Board Mentor, Nuivio Ventures Inc

• International Collaborator, Amnick Social Enterprise

• Trustee, Change Grow Live

Voting Stephen Firn Non-Executive Director

• Programme Director, NHS England

• Non-Executive Director, Look Ahead

Voting Susan Scholefield

Non-Executive Director

• Independent Member, Sussex Police and Crime Panel

• Chair, Audit and Risk Assurance Committee

• Chair, Competition Appeal Tribunal

• Magistrate, Sussex Family Panel / West Sussex Adult Panel

• Visiting Professor at the University of Surrey, Politics Department

Voting Vivek Govil Non-Executive Director

• Interim Managing Director, Oxford University Press

• Director, Liveorg Ltd

• Chair, Child Rights and You

Voting Andrew George

Non-Executive Director

• Owner and director of AJTG Ltd

• Non-Executive Director of Health Education England

• Non-Executive Director of Health Research Authority

• Chair Imperial College Health Partners

• Trustee Epilepsy Society

• Governor (and Chair Designate) Richmond Hillcroft Adult Community College

• Chair of the Board of Governance, Oxford Business College

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Item: 61.20 Public

Status Name Declared Interests

Voting Fiona Edwards Chief Executive • Lead for Frimley ICS

• CQC Executive Reviewer

Voting Graham Wareham

Chief Finance Officer

• Trustee Friends of Chambo Seminary

• Member of Chartered Association of Management Accountants

Voting Helen Rostill Chief Innovation Officer and Director of Therapies

• Advisory Board Member – SCAMPI (Self-care Advice, Monitoring, Planning, Intervention)

• Visiting Professor at the University of Surrey, Department of Clinical Medicine and Ageing

• NICE Fellowship – National Institute for Health Care and Excellence

• Executive Director of Integrated Commissioning for Adult Mental Health

Voting Justin Wilson Chief Medical Officer

• Trustee of Charity Sport in Mind

• Founding Senior Fellow of the Faculty of Medical Leadership and Management

Voting Lorna Payne Chief Operating Officer

• Trustee of Fulham Good Neighbours

• Trustee on Board of Standing Together against Domestic Violence

Voting Heather Caudle Chief Nursing Officer

• Trustee of Cavell Nurses Trust

• Lay Member - Joint Royal Colleges of Physicians Training Board ; Specialist Advisory Committee in Palliative Medicine

• Council Member (Southern Representative) - National Mental Health Nurse Directors Forum

July 2020

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Item No: 62.20

DRAFT Minutes of a Meeting of the Foundation PUBLIC Trust Board held on

10th June 2020, 2:30pm-4:30pm, via Microsoft Teams

Present Directors Voting: Ian McPherson Trust Chairman Fiona Edwards Chief Executive

Graham Wareham Chief Finance Officer / Deputy CEO Justin Wilson Chief Medical Officer Lorna Payne Chief Operating Officer

Helen Rostill Chief Innovation Officer / Director of Therapies

Heather Caudle Chief Nursing Officer Leslie Morphy Non-Executive Director (left at 3:45pm)

Rahul Jaitly Non-Executive Director

Vivek Govil Non-Executive Director

Jennifer Seeley Non-Executive Director

Stephen Firn Non-Executive Director / Deputy Chair

Susan Scholefield Non-Executive Director / Senior Independent Director

In Attendance:

Julie Gaze Director of Governance and Planning Toby Avery Chief Digital and Information Officer

Victoria Bishop Interim H.R. Director

Lynn Richardson Freedom to Speak up Guardian (for item no. 52.20)

Michaela Lockley Governance Manager (Minutes)

Apologies:

Trudy Mills ICS Director for Children’s and LD Services (CFHS)

Members of the Public and Governors in attendance:

Michele Amoah-Powponne Deputy Lead Governor

Margaret Hicks Public Governor

Jim Poyser Public Governor

Leanda Hargreaves Carers and Families Governor

Andrew Jackman Public Governor

Rosemary Moore SaBP FoCUS Carer Representative

Glenis Nay Member of the Public

Mary Davies Member of the Public

Tracey Hayes Member of the Public

Dilek Kale Member of the Public

Ref Item Action

40.20 Public

Introductions and Apologies for Absence Ian McPherson welcomed everyone to the Trust Board. Apologies were received and noted as above. Ian noted that it was good to see so many members of the public, and Governors joining the Board today. Ian advised the Board that Leslie Morphy was due to leave at the end of March but agreed to stay until the end of June, as we had not been able to interview for a replacement. He noted that interviews for a replacement Non-Executive Director will take place tomorrow, and a recommendation will be made to the Council of Governors on 18th June. Ian thanked Leslie for the fantastic contribution she has made to Surrey and Borders Partnership.

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Item No: 62.20

41.20 Public

Declarations of Interest The declarations of interest were noted. Ian McPherson reminded everyone that should any of their details change, they will need to complete an updated form.

42.20 Public

Minutes of the Meeting held on 8th April 2020 The minutes of the meeting held on 8th April were reviewed. They were agreed as an accurate record and approved.

43.20 Public

Matters Arising 32.20 Staff Survey Victoria to explore perception of bullying and harassment as reported by staff. Victoria advised that she provide an update at the next Board meeting. All other actions were noted to be complete.

44.20 Public

Chief Executive and System Update Fiona Edwards advised the Board that;

• There has been a large-scale response to the pandemic nationally and locally, and Fiona reflected on the amazing work of our staff, and partners to maintain access to services in innovative and flexible ways. This is an achievement in the face of significant loss and tragedy across systems and partners.

• The pandemic has exposed underlying inequalities for our Black, Asian and Ethnic Minority (BAME) communities, for those who we work with and those who work with us. One third of our workforce are from a BAME background and have seen the national impact of Covid-19, causing them to be anxious about the increased risk to themselves and their families. In addition, racism has been highlighted following George Floyd’s death in America, and we are working hard with staff to do better in regard to looking after them well, and in terms of addressing inequality and unequal treatment. We have held 2 conversations with staff, and have had good engagement from BAME colleagues, and a desire to make things better. A letter, co-signed by Fiona and Ali Khan (Chair of the BAME Network), will go out to BAME staff.

• There is also unequal impact of Covid-19 on people with a disability or long-term condition, and Helen Rostill is drawing together evidence on the relationship around mental ill health. A conversation took place this week, with support from the Disability and Wellness Network (DAWN), with people who have an interest in, or experience of, a disability or long-term condition, to ensure that we are focusing on any issues. The staff survey advised us that those who declare as disabled, or as having a long-term condition feel less happy about how they are supported in our organisation,than other staff so it is important to ensure that we are providing the right support.

• We have launched a Risk Assessment process across the Trust, and all staff are being asked to complete a form, even it they do not feel they are at risk. As we move forward with recovery and restoration work, we will be able to design workspaces that are more individualised, both in Trust environments and at home. Fiona expressed her thanks to all staff who have engaged to help us start to adapt our ways of working.

• We have agreed in the Private Board today to progress to a full business case (FBC) for the 24/7 re-build programme. This is an important milestone to providing a new purpose-built environment, which will improve the experience for inpatients and services. We have a process to ensure we are providing the right environment for people who use our services going forward, and will develop the FBC in the right way with safe decant options – more information will be provided on this as we move forward.

• , Sadly we have had the tragedy of the deaths of two people at the Abraham Cowley Unit (ACU). We are working with partners and regulators, and with staff internally to ensure that we work as safely as possible at the ACU, that

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Item No: 62.20

we learn rapidly, and make improvements as a result of these tragedies. We are also working closely with the families, and our hearts go out to them, as well as to our staff who were involved.

• We received a positive report from CQC, which confirms our rating as GOOD Jennifer Seeley noted her concern for the families and friends of those who have died under our care. She also acknowledged that it was good to have progress on the ACU redevelopment, as she felt this is really important. Jennifer noted that one third of our workforce are from a BAME background, but that 90% work in front line facing roles. She advised this is a big issue for us, and advised the Board that the meetings held were reassuring for staff affected. Rahul Jaitly acknowledged that this has been a challenging time for all involved. He asked how the system and voluntary sector have been engaging with us, people who use our services, and the wider population. Fiona advised that there has been a huge amount of partnership work in the system and in the voluntary sector. Helen Rostill added that social care, public health, voluntary and community sectors are all working in partnership, to put together an offer to support vulnerable communities. There has been focus on the voluntary workforce, and we have been building a support offer with volunteers in mind, including access to psychological support, access to mental health first aid, and providing training so that volunteers can support other people who are experiencing challenges. In Surrey there is a community helpline to support those who are isolated / dis-advantaged, and this is staffed by volunteers, some of whom have been redeployed from other services and may be new to the role. This is working well and shows team spirit for working together across sectors. In relation to the work taking place following the 2 deaths of two people at ACU, Vivek Govil asked if we have a timeline for when this will conclude. Lorna Payne advised that the Police requested that we set up an Incident Co-ordination Group, which included the Police, Care Quality Commission (CQC) and Surrey County Council. In addition, we arranged an internal safety summit, which considered safety in a wider context, and actions from this will report back into the Quality, Risk and Safety Committee. A circle of support has been put in place for Clare Ward, which was closed to new admissions. There have been a few admissions in the last week, however, they are still lower than capped levels of admissions. Heather Caudle added that the Chief Nursing Officer from Sussex Healthcare Partnership, carried out an independent review, and although we are still waiting for a formal report, we have received feedback which recommends we focus on our observations policy, and continue to address the ligature minimisation strategy. We have started to address the recommendations and will use the Inpatient Safety Collaborative to look at practice, and the Inpatient Improvement Board to continue to improve the environment. A review of the ligature minimisation strategy has commenced, and this is due to be updated next month. The Board noted the update.

Performance Oversight

45.20 Public

Managing Covid 19 - Summary Lorna Payne presented the paper, which highlights the Trust-wide response in relation to the pandemic. Lorna noted that:

• We have gone through a number of phases, including setting up emergency structures in Gold and Silver command, and the Clinical Reference Group (CRG), which have all been a critical part of how we have been able to manage changes that were needed at pace.

• We are now moving towards a restoration period, whilst still having to keep the emergency response team in operation.

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Item No: 62.20

• As an organisation, we have experienced low levels of sickness, and currently have only 26 staff absent related to Covid-19 symptoms.

• For the last 2 weeks, we have not had any positive or symptomatic patients on our wards. This highlights the good practices staff are following, and that they are using effective PPE. We recognise that we are on a journey, and we need to consider how we continue to support and engage with our staff.

• Sadly, there have been 5 deaths of people who use services in acute hospitals, 3 of whom were from older adult services.

• Where initiatives have not worked or been found not to be needed, we have stepped them down. 2 examples of this are the Covid + Ward, and the Emergency Mental Health Assessment Unit. We will look at learning from these initiatives and take it forward in a co-designed way.

• We have received excellent support from digital colleagues, and they have developed innovative solutions. Attend Anywhere has been rolled out, we have been able to continue with meetings and connect with people who use services remotely, and carry out Mental Health assessments virtually.

• Work around recovery and reformation has now started, and we are committed as an organisation to support people to work from home. Staff have been asked to complete a Risk Assessment, which will help us to understand individual circumstances. We are working to ensure that staff do not return to their normal place of work, until we are confident that we can manage numbers in our buildings. We are hoping that staff will be able to return to buildings at the end of this month.

Leslie Morphy noted that there has been a fantastic response from the whole team, and that everybody should be very proud. She noted that some practices that we have changed will go forward and become the way we do things and asked if it is too early to say what the learning from the pandemic might be. Lorna advised that for some things it is too early to say, but for other things we are already taking on board learning and moving forward. For example, we are considering how we can more flexible to support the way people will work, and a recent conversation that Fiona hosted, supported by DAWN, highlighted how we should think about the workplace very differently, in a more personal / individual way. In addition, Lorna advised that we have had support from GPs reaching into inpatient settings, which has improved the response to people in those settings. We are looking at how we can make this routine practice, which will in turn improve continuity of care. Graham Wareham advised that restoration plans are being developed, and that we expect them to build on the innovation from the Covid-19 response. In addition, we have been designing a survey with colleagues to capture the learning. Graham noted that restoration planning is an iterative process, and although we are not able to give the Board a sense of what this looks like at present, a plan will come to a future Board meeting. Justin Wilson highlighted the excellent work and dedication of clinical leaders who have been working with operational leaders to make the best possible decisions in difficult circumstances. He advised that they have stepped up and worked well with operations, including nurses, medical and therapy staff. Rahul Jaitly noted that communications have been shared daily internally with colleagues, and asked how we have kept families, carers etc. up to date, and advising them of the steps we are taking going forward. Lorna advised that in terms of making sure that people who use our services understand our offer, we have continued face to face appointments for those who have needed them. In partnership with Surrey County Council, we have reviewed a list of people who are shielding, and are reaching out to those on our list, as it is important to make sure we cross check those who are shielding with those in our services. Mental Health Trusts’ have been asked to step up their 24/7 telephone service, so they 8

Item No: 62.20

are available for anyone in crisis, and we had already launched this. Our communications go through system partners, to ensure we stay connected about changes we are making in our community. Helen Rostill added that recovery and reformation efforts are part of a system response and include adult social care, and the voluntary sector, to ensure we have a connected offer. We are working to develop innovation, including a virtual well-being hub on the Healthy Surrey website, and extending our Improved Access to Psychological Therapies (IAPT) offer. The Independent Mental Health Network is obtaining feedback from people who use services, asking how they have felt about service changes. Heather Caudle noted that we have been using Healthwatch to liaise with the wider population and carers, as well as the Carers Network, and FoCUS groups. In addition, there is a full list of the changes we have made on our website. Susan Scholefield commented on how wonderful our response has been and understands the stresses it has put on staff. She asked how we are sharing lessons learnt at a national level and more widely, as she felt that there are positive outcomes that could happen elsewhere. Fiona noted a positive outcome has been how easy it has been to connect with people through MS Teams. As such, weekly Chief Executive calls with Mental Health and Learning Disability Trusts, hosted by Claire Murdoch, have been able to take place, and we have been able to share our immediate changes, innovations and learnings from an early stage, as well as hearing about learning from other colleagues. Similar meetings have also taken place nationally with Chief Medical Officers, and Chief Nursing Officers, and good practice has been disseminated amongst groups. We have been approached by other Trusts about our approach to Mental Health Act assessments, as we are one of only a few Trusts who have been able to do this virtually. The Board noted the report

46.20 Public

Quality and Safety Report Heather Caudle presented the report. Rahul Jaitly noted that the statistical process control charts (SPC) charts in the report all tend to go to end of April and asked if there is anything in the May data which diverges from what we are seeing here and needs to be highlighted. Heather confirmed that the data is presented in this way due to timetables and availability of data when reports are written. She advised that we are aware of the two people who died by ligature harm that occurred (1 in April and 1 in May), and 1 unexpected inpatient death. In terms of data comparison, we are not able to do this until the data has been validated. Rahul asked if we are taking any precautions above and beyond normal activities, around the likely impact of unexpected deaths and self-harm as a result of Covid-19. Heather advised that we are quite mindful of the physical health component and have strengthened our physical health strategy. We are planning to implement a physical health care site practitioner, which will help us be more vigilant and able to support frontline staff. In terms of the wider community and mortality review, the weekly meeting (chaired by Justin Wilson) has been stepped up, so that our vigilance and scrutiny is quicker. In relation to our response to incidents that occurred at the ACU, we have stepped up the Inpatient Improvement Board, and Patient Safety Collaborative. Heather advised that the Chair of the Medical Advisory Committee has shared suicide prevention strategies across the sector, and we have asked for more people to come together around the agenda for suicide prevention and self-harm. As we are able to scrutinise some of the data more regularly, we are able to highlight learning in a more timely fashion.

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Item No: 62.20

In terms of patient experience, Stephen Firn noted that the number of Patient and Liaison Services (PALS) contacts, compliments and complaints has all fallen since the start of pandemic and asked if this is causing us any concern. Heather advised that completing complaints investigations and responses were deemed as non-essential business at the start of the pandemic, and this was communicated to the wider population. She noted that we have been logging concerns and hope to see a return to people being more able to voice their concerns. Stephen also noted that we had been making good progress on clearing the backlog of complaints, and as we have stopped responding to complaints during the pandemic, asked how realistic it is that this has been an opportunity to catch up. Heather advised that the complaints team have been helping front line teams respond in real time to issues coming through. Over the last few weeks, we have stepped down some of the high-level meetings (i.e. Gold/Silver Command), so the team will now be able to start clearing the backlog. Jennifer Seeley noted that work with SPC charts is a work in progress, and felt it was important to ensure that we do not lose sight of normal variation and what is an acceptable / target level. For example, Jennifer advised that the chart which shows the number of people involved in care planning, is a tool which highlights that more work is required. Heather confirmed that with SPC charts there needs to be a narrative or indication for improvement target, and this will indicate progress. She added that some will not have targets, and we are keeping vigilant as to whether there is a spike outside of normal variation. If there is a decrease in quality, this will be corrected. The Board noted the report.

47.20 Public

Activity and Performance Report Toby Avery presented the report, noting that it shows data from March. Toby highlighted the following:

• Bed occupancy was low, and this has shifted over the last few months as we have responded to Covid-19. Currently we do not have any adult beds available.

• We have had to close some beds to ensure social distancing, and in response to the incidents on Clare Ward

• We have more out of area placements now, that were reported in March – as of yesterday we had 26. This shift will show in the reports over the next few months.

• Length of stay (LOS) remains above target, and we are struggling with Home Treatment Team (HTT) Gatekeeping. Both of these have been issues for a few months now, and we need to think about how we correct them and put more focus on these areas.

• In the coming months we will start to see a reflection of some of the virtual work we have been doing (i.e. consultations), and aim to make the dashboard more widely available, so that staff can review / understand the data in real time.

Vivek Govil noted that in relation to LOS, we had started to discharge those who had been on ward a long time and asked if we are continuing to make progress. He also asked if LOS is being impacted by Covid. Toby advised that there is still a focus on reducing LOS and discharging patients. Lorna advised that we had previously been having a weekly call for complex patients, which resulted in some people who had been on the ward for over a year being discharged. She confirmed that she has now been able to rejoin these meetings. A meeting took place yesterday, and Lorna reported that we have a significant number of delayed transfers of care (DTOCs), and there is increased pressure in the community. She advised that lots of providers are not taking people in, despite being able to test for Covid-19, and this is a challenge. In addition, we have stepped down 15 beds

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Item No: 62.20

to support social distancing, and had a reduction of 4 beds at Langley Green, meaning we have a reduction of 19 beds, which has led to an increase in out of area placements. Lorna advised that the meetings to review people with longe lengths of stay will continue, and that they do have an impact. She advised that the challenge in getting specialist placements for those with complex needs is difficult. In April the planned social care discharge teams became operational, and have been assisting with housing and providing support. Stephen Firn asked for more information on the 13 additional beds that have been commissioned from a private provider. Lorna advised that this initiative is directly related to Covid-19, and the beds were commissioned from a private provider in Surrey. They are taking people who are well enough not to be in an acute ward but have not been able to find a placement or return home. Lorna confirmed that this is a step-down facility and will be reviewed going forward as it is Covid-19 related only. Heather noted that this has been helping DTOCs in a positive way. Helen Rostill reflected on some of the longer standing issues that were highlighted (i.e. HTT Gatekeeping) and advised that, in the wake of the Covid-19 response, we are taking a step back to reflect on the crisis pathway. Work is underway with Dr. Deepa Deo and others, to think about processes internally, and to have wider conversations with stakeholders, to ascertain what else we can we do to optimise our crisis pathway Rahul Jaitly noted the introduction of Digital Change Agents, to promote and support the use of new applications, and asked what the experience has been like and how we will we push this forward. Toby advised that there has been a radical shift in how digital has been adopted, and significant work has taken place across the organisation in terms of how people use the tools we already have. Lots of Quality Improvement work has taken place, to enhance requirements around teams and services, and new applications have been developed to support testing, ordering PPE etc. In addition, Digital has deployed Attend Anywhere, webinars for training, and change agents, and recent events have demonstrated how dependent staff have become on new digital solutions, and how much they want them to work. Toby confirmed that there has been a good uptake from staff, and people are engaging with data in a different way. The Board noted the report.

48.20 Public

Mortality Assurance / Learning from Deaths Quarter 4 Report Justin Wilson presented the report, and the following points were highlighted:

• This report includes data from incident reporting, and data from the national spine, which includes people who have had contact with our services 6 months prior to their death.

• Some deaths related to Covid-19 are starting to be picked up, and it is anticipated that we will see this emerging in the coming months. Early data suggests that there is higher mortality related to Covid-19 for people with dementia and learning disabilities.

• All 33 serious incidents noted in the report are being investigated.

• In terms of learning, there have been improvements around risk assessments and documentation. Safeguarding and working with partners are themes that have been highlighted - progress is being made with QI initiatives and continued work is required to further improve these areas.

The Board noted the report.

49.20 Public

Care Quality Commission (CQC) Inspection Outcome Heather Caudle presented the report, noting that it is a further update to the published CQC report, following factual accuracy checks. The report shows some

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Item No: 62.20

positive elements and areas for improvement. We have submitted our action plan in response to the required improvements and are starting to work through the plan to ensure improvements are made. Stephen Firn noted that one of the 2 requirement notices related to improvements at the ACU and commented that we have approved the Outline Business Case to re-develop this environment. He asked if there were any specific elements highlighted by the CQC, or if it was more of a general observation. Heather advised that the CQC were accepting that we had plan in place for re-development but reflected on what staff and patients had said about the building. Heather confirmed that we are working to make it a better environment in the short term. She noted that we have already reduced the occupancy of dormitories at the ACU, and that this has been well received by staff and patients. Heather advised that that the action plan will address a greater level of detail. In terms of response times for minor breaches, Rahul Jaitly asked if we will get an extension and in terms of the long-term view how things may change in terms of CQC assessments and the National Institute for Health and Care Excellence (NICE) guidelines as we go through recovery and reformation. He asked if there is any dialogue with other bodies on how they may change. Heather advised we are seeing some changes already from the CQC. For examplethere has been a national issue around cross infection amongst clinical staff, and in response CQC have commenced spot inspections to ensure places are kept safe. NHS England and the Department of Health are asking Trusts to advise of best practice, and we are trying to collate all new ways of working to inform a regulatory approach. Helen Rostill added that organisations such as NICE look at emerging evidence and ascertain the impact of innovations. They will reflect on what has and has not worked in the crisis situation, and there will be some guidance coming from this. Jennifer Seeley noted that there are lots of things we are not going to be complacent about, and the report gives a good message about staff and how hard they are working. She was disappointed to note that the CQC did not acknowledge the contribution of families and carers as part of the package of care and feels this is missing. Heather advised that we contacted the CQC before they carried out their well-led interviews, to specifically ask them to include one of our Governors for Carers and Families. We have fed-back that we felt this element should have been included. The Board noted the report.

50.20 Public

Complaints and Compliments Quarterly Report Heather Caudle presented the report, noting that there are some indications of themes emerging from complaints that are fully or partially upheld. Ian McPherson noted that earlier in the meeting, we spoke about getting back to normal and asked if there are lessons learned that will enable us to deal with complaints, which are more responsive and will help to reduce waiting times. Heather advised that a structural change needs to happen that allows us to be more responsive. She informed the Board that we are going to have 2 senior nursing complaints leads, who will help the divisions shape their responses, become more coordinated, and reduce response times. Heather noted that we have not had many referrals to the Parliamentary Health Service Ombudsman and have received some compliments about our complaints process. She advised that demonstrating learning from complaints will happen more often and will be stronger going forward. The Board noted the report.

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Item No: 62.20

51.20 Public

Risk Report Heather Caudle presented the report, noting that the number of Covid-19 related risks has increased over time (there are currently 73 that are directly linked), and they are all being reviewed regularly. In terms of testing kits, Rahul Jaitly noted that we have a risk around availability, and noted issues around the timing of carrying out testing, the accuracy of the results, and the time taken to receive them. He asked what our thoughts are on how effective testing is, and if this is still a risk. Heather advised that knowing the status of patients and staff is beneficial, and that we still have uncertainties that we need to mitigate. Carriers can be asymptomatic, so we are stressing the importance of using the correct personal protective equipment (PPE), and regular / effective hand hygiene to address the risks. We have improved access to testing, and now have an efficient process in place, and anyone coming into inpatient settings are tested. Heather confirmed that test results are either positive, negative or inconclusive. When an inconclusive or negative result is received, a clinical conversation takes place to assess the presentation / symptoms, and a clinical judgement is made. Jennifer Seeley noted that one of the highest risks was PPE, and we were able to help other bodies in the NHS with supplies. The Government are now saying that face coverings are required for all staff and visitors, and some issues were raised about these in the recent conversation with staff who have a disability / long-term health condition. Heather felt that it is positive that there will be a level of mandation, as it will help to prevent the spread of the virus. She advised that the expectation was set on 5th June, guidance will be published tomorrow, and from 15th June face coverings will need to be used in clinical and non-clinical settings. Heather noted that for those with long-term conditions, breathing difficulties, and autism, we are testing the safety of face coverings with mouth visibility, and that we do have some in stock. Risk Assessments, that staff are being asked to complete, will enable us to take individual circumstances into account. Stephen Firn reflected that in the mortality report, one of the serious incidents related to carers and families, and that this is also a prominent theme highlighted in complaints that are upheld. However, Stephen noted that there is no risk that reflects this and ask if it should be added. Heather confirmed that complaints highlight that there is a disconnect with carers / families, and they are not always involved in treatment. Heather advised that this would be picked up by the Carers Advisory Group (CAG), and Improvement Collaborative, and that she would also log this on the risk register so that it is more visible. Action: Heather to add disconnect with carers / families, and involvement in treatment to the risk register. Susan Scholefield noted that there is a pressure to start rebuilding stockpiles in preparation for a 2nd spike, and that this coincides with winter pressures. She asked if there is a risk around the ability to do this in time. Heather confirmed that this is a risk, and that normal seasonal flu will have also an impact. Heather will articulate this and review the risk. Action: Heather to review the risk around supplies of PPE and articulate the impact of seasonal flu and winter pressures. Lorna Payne advised the Board that how we manage our stock of PPE is visible across the system. We have been asked to support with mutual aid, which we have done when we can, but we always keep sufficient stock of PPE in reserve, and stock is highly centralised and highly controlled. Lorna noted that we will review the use of face coverings and reiterated that it is important that staff do not

Heather Caudle Heather Caudle

13

Item No: 62.20

return too quickly, so that we can manage a return to buildings safely and on an individual basis. The Board noted the report.

52.20 Public

Freedom to Speak up Guardian Annual Report Lynn Richardson joined the meeting to present her report, which covers quarter 4, and an annual review. She advised the Board that:

• 23 concerns were raised in quarter 4 (compared to 18 in quarter 3) • 85 people have spoken up over the last year, and this is an increase from 71

in the previous year • National Guardian data for quarter 4 / year end is not available at present, as

there has been some flexibility on submissions. We expect to be near the top of our sector in terms of numbers of people speaking up, when the data is available.

• We only had 2 cases of anonymous speaking up throughout the year (compared to 4 last year), and this is a good indicator of our culture and climate.

• During the last year, case studies have been presented to the Board, and we have been able to review one National Guardian case review. This focussed on how organisations think about minority groups, and people with protective characteristics, and we have made a point in our organisation to address this.

• A list of our ambitions for this year is included, and the report tries to show where staff may speak up.

• Data from Human Resources has been provided, and there have been 6 allegations of bullying and harassment (4 have been resolved, and 2 are ongoing). When looking at staff survey results, we are below the sector and in a positive place for low levels of bullying and harassment. In addition, there have been 9 grievances, of which 2 have been resolved, three have been upheld in part, 3 are ongoing and 1 has been withdrawn.

• Counter Fraud received 7 referrals in the last year, and 2 of these progressed into a formal investigation.

Vivek Govil noted that staff survey results showed that 15% of people reported that they had faced bullying and harassment, but only 6 people had spoken up about it. Lynn advised that bullying is insidious, and people can feel intimidated – she felt there will always be an element of those who feel they are bullied but do not want to voice it, so there will always be a disconnect about what people report and what action they take. Victoria Bishop added that she has asked Liz Case-Green to look at the staff survey in relation to this and bring some more information back to the Board for clarification. Jennifer Seeley thanked Lynn for all of the work she has done throughout the year. She noted that the reports are very helpful and that the case studies help to get into the details and are a good thing for the Board see. Jennifer noted that the report states that an increase in people speaking up about fraud is a negative thing but felt this was positive. Lynn confirmed that it is positive to have higher numbers. Susan Scholefield asked about how the experience of Covid-19 might impact speaking up, as there is an area of vulnerability when people are under stress. She asked Lynn is she has seen any evidence of this yet. Lynn advised that there has been some speaking up about Covid, which was initially about PPE not being available, or social distancing not being right. However, Lynn advised as people are becoming more comfortable with the way we are working, the concerns that are now being raised are about behaviours. She added that she has not noticed

14

Item No: 62.20

an increase in bullying and harassment, and 14 concerns have been raised in the first quarter so far, which is in line with last year. Heather Caudle asked if Lynn collected demographic data for the concerns that were raised about PPE Lynn advised that she can get this data and will come back to the Board and advise – she added that she believes concerns were not raised by people from a BAME background. Action: Lynn to provide demographic data relating to the concerns raised about availability of PPE. The Board noted the report.

Lynn Richardson

53.20 Public

Value for Money Graham Wareham presented the report, noting that we are still being block paid, and that this will continue until the end of July. He advised that our costs are well managed. Rahul Jaitly noted that the top up payment is going back, and asked if this goes back to the centre, or if it used in the Integrated Care System (ICS) if someone is above the threshold. Graham confirmed that ICSs are not held to Control Totals, and that gains and losses go backward and forward. Stephen Firn referred to the additional out of area placements that we have, and the 13 beds that have been commissioned from a private provider and asked if these costs are covered by central Covid payments. Graham confirmed that these costs are covered by the block contract. He added that we have been paid for money spent last year, and the savings made are covering extra expenditure. Vivek Govil reflected that we have previously looked at agency spend and the view was that most of it was linked to setting up new projects. We previously advised that we would analyse the overspend, and Vivek asked if we would be able to look at a cause analysis of agency spend in a future Board meeting. Graham advised that the agency ceiling was increased in recognition of the dynamic nature of our service, and that we are completing an analysis on why we are above the ceiling. Results of this will be provided going forward. Action: Analysis on Agency Spend to be included in a future Board report The Board noted the report.

Graham Wareham

Approval Items

54.20 Public

Board Assurance Framework (BAF) Julie Gaze presented the report, noting that it looks back at our position as of 31st March 2020, and highlights the key risks to the delivery of our strategic objectives. The report also takes a forward look at the key risks for this year, and Julie advised that the Board will do further work on this and expects the draft risks to change. An update to this report will be presented to the Board in September. Julie noted that 1 red risk is shown at year end (property) and asked the Board to confirm that they are satisfied that the position reported is a fair reflection on how we ended the year. The Board confirmed that it is satisfied that the BAF reflects the status of risks at year end (31st March 2020) in line with our 19/20 Plan.

Items for Information

55.20 Public

Guardian of Safe Hours / Safer Staffing Quarter 4 Report Justin Wilson presented the report, noting that it is for information only. Justin wanted to pay tribute to junior doctors for the support they have provided during

15

Item No: 62.20

Chairman’s Signature that the Board Approved the minutes, subject to any amendments or corrections, which will be recorded in the minutes for this meeting.

Signed:

Date:

the Covid-19 pandemic. Ian McPherson noted that he has been very impressed with junior doctors, who have been able to step up during this period. Rahul Jaitly noted the increased use of locums in the East and asked if recent work from digital, in terms of virtual consultations, would help reduce the numbers. Justin noted this point and advised he would explore this further. Action: Justin to explore if the use of video consultations will help to reduce the need for locums in the East. In terms of Safe Staffing, Rahul noted that in Working Age Adult services decisions are taken reacting to staff availability and asked if we have an audit trail of this information, and if we look at the rationale for making changes. Heather advised that she chairs the Safer Staffing group fortnightly, and that there is a governance structure in place. She noted that evidence for decisions made, and the rationale to support them, is logged. The Board noted the report.

Justin Wilson

56.20 Public

Quality Assurance Committee Update – March and May 2020 The Board noted the report.

57.20i Public

Audit Committee Update – March 2020 The Board noted the report.

57.20ii Public

Audit Committee Annual Report The Board noted the report.

58.20i Public

Mental Health Act / Mental Capacity Act Committee Update – January 2020 The Board noted the report.

58.20ii Public

Mental Health Act / Mental Capacity Act Committee Update – April 2020 The Board noted the report.

59.20 Public

Any Other Business There was no other business

16

Item No: 63.20 Public

Matters Arising Meeting Held in Public – 10th June 2020

Ref

Item: Action Status

51.20 Public

Risk Report • Heather to add disconnect with carers / families, and involvement in

treatment to the risk register. • Heather to review the risk around supplies of PPE and articulate the

impact of seasonal flu and winter pressures

Heather Caudle Heather Caudle

Complete Complete

52.20 Public

Freedom to Speak up Guardian Annual Report • Lynn to provide demographic data relating to the concerns raised about

availability of PPE

Lynn Richardson

Lynn is not able to confirm this until feedback forms are received. However, based on conversations with the staff who raised concerns about difficulties with PPE in the early stages, she believes that 1 of the 5 is from a BAME background.

55.20 Public

Guardian of Safe Hours / Safe Staffing Quarter 4 Report • Justin to explore if the use of video consultations will help to reduce the

need for locums in the East Justin Wilson

This has been discussed with the Guardian of Safe Hours, Director of Medical Education and Head of School of Psychiatry. The vast majority of ‘locums’ providing cover involve existing staff carrying out additional sessions rather than agency doctors. The availability of video consultation does not reduce the need for this cover in the East as much of the work relates to physical health issues on older people’s and learning disability wards, requiring attendance and, often, physical examination.

17

Item No: 63.20 Public

Meeting Held in Public – 8th April 2020

Ref

Item: Action Status

32.20 Public

Staff Survey • Victoria to explore perception of bullying and harassment as reported by

staff. Victoria Bishop

Details circulated to the Board on 26th June 2020. Complete

18

Version 1.3

Trust Board in Public

Date 8th July 2020

Item No 64.20

Paper Title Chief Executive’s Report

Director Fiona Edwards, Chief Executive

Report for Discussion/Information

Discussed to date and next steps This report has been prepared specifically for the Board.

Purpose of the paper This report shares with the Board some of the Chief Executive’s reflections on our recent work, and draws the Board’s attention to some of the critical features of the environment within which we are working currently.

How does this proposal meet our values?

Our Chief Executive’s report draws the Board’s attention to key aspects of our work in line with our values.

Health/Social Impact – Contribution to our objectives

Our ability to deliver our strategy and make a difference to people’s lives will be impacted by the environment in which we work.

Risk Assessments and Mitigations

The report helps to keep the Board sighted and up to date on those issues, which the Chief Executive believes they need to be aware of, to ensure our Trust is well led.

Data Protection Impact Assessment (DPIA) (only to be completed if personal data is being shared)

This is not applicable to this report.

Outcome of Equality Analysis (for items requiring a decision or change in practice)

This is not applicable to this report.

Financial Implications There are no financial implications as a result of this report itself. The report may comment on the financial implications of items included where relevant.

Executive Summary The Chief Executive’s report shares with the Board updates and reflections on key national, local and internal (Trust) issues currently impacting on our work.

Positive Findings

• Our colleagues have continued to respond with compassion, creativity and dedication throughout our Covid-19 response; our focus is now on recovery and the restoration and reformation of our services

Areas for Improvement

• The Care Quality Commission (CQC) conducted an unannounced inspection of two wards in our Abraham Cowley Unit (ACU) on 26th June following the two serious incidents which resulted in the deaths of two people whilst in our care at the Unit in April and May

• We are working carefully to move into the recovery phase in line with national guidance and emerging evidence,

whilst ensuring we could step back up again swiftly should the need arise, alongside planning to meet the anticipated

increased mental health needs of the communities we serve following the pandemic and its expected longer term

impact.

19

1.0 Purpose of this Paper

This report shares with the Board some of my reflections on our recent work and experiences, and draws the Board’s attention to some of the critical features of the environment within which we are currently working.

2.0 Reflections 2.1 National and System

• Covid-19 Response – Recovery, Restoration and Reformation - The focus of our response has now turned to the restoration and reformation of our services as we move to the next phase in line with the national situation. We are, as you would expect, looking further into the future to sustained new ways of working made possible, and necessary, by what we have learned so far. We are also planning how we will meet the anticipated increased mental health needs for the communities we serve that have emerged as a result of the pandemic and its expected longer term impact. An update on our work and approach to date is provided as a separate agenda item at this meeting.

2.2 System

• Frimley Integrated Care System (ICS) and Surrey Heartlands Integrated Care System (ICS) - As I mentioned in my last report, our ICS’ are at the heart of our potential to secure real change in the health of our communities through their focus on population health. Professor Helen Rostill is at the forefront of recovery planning in both Heartlands and Surrey, considering, with partners, the anticipated increased demand for emotional and mental health and well-being support for the most vulnerable and also those of our wider communities. The Board is aware of the evidence, growing all the time, which makes clear the inequalities brought into sharp relief by the pandemic. Tackling these as part of the system must be our priority, in line our clinical strategy, to help people live better lives. I continue to take part in regular regional and national forums in my ICS Lead role and as a member of Surrey Heartlands. Recently this included sharing examples of the innovative work and approaches being successfully delivered locally.

• Dave Hill, Director of Children’s Services Surrey County Council – It is with great sadness that I must advise the Board of the tragic death of Dave Hill. As the Board will be aware Dave has been a driving force for positive change and improvement in Children’s and Young People’s services in Surrey since his arrival. As one of our key partners many of us have worked closely with Dave and know how much he will be missed by all those whose lives he touched. We share the determination of many that his legacy will live on in the work we continue to do to improve the lives of children and families across Surrey. We have extended offers of support to Joanna Killian, Chief Executive, and Dave’s colleagues at the County Council. Our thoughts are with Dave and his family at this very sad and difficult time.

2.3 Our Trust

• Care Quality Commission (CQC) Inspection 26th June 2020 – The Care Quality Commission undertook an unannounced inspection on 26th June 2020. The CQC visited two wards at the Abraham Cowley Unit (ACU) following the two serious incidents which resulted in the deaths of

20

two people whilst in our care in April and May. At the time of writing this report we await their feedback.

• Health and Well Being of our Staff – I have continued to be impressed by the dedication and

compassion of our colleagues as they do everything they can to support people who use our services, families and each other during these unprecedented times. I am very mindful of the potential negative toll such hard work can take on the health and well-being of our staff, particularly those whom we know are particularly vulnerable to Covid-19. We have therefore been making sure we are supporting colleagues well now and continue to do so over the weeks and months ahead. At the heart of this is our risk assessment which we launched following its development with, in particular our Black and Asian Minority Ethnic Staff Network, which we are encouraging all staff to complete.

3.0 Recommendation The Board is asked to consider the Chief Executive’s update.

21

Version 1.3


Date 8th July 2020

Item No 65.20

Paper Title Covid-19 Response – Recovery and Restoration Plan Update

Director Graham Wareham, Chief Finance Officer/Deputy Chief Executive

Report for Discussion

Discussed to date and next steps This paper has been prepared for the Board bringing together a summary of discussions being held as part of our Covid-19 response arrangements and workstreams, and with system partners.

Purpose of the paper This paper has been prepared to provide an update summarising our work to recover and restore our services and plan for the future demand to date. The paper takes the format of powerpoint slides.


Our governance arrangements help ensure we run our business in line with our values and in the best interests of people who use our services, their cares and families.


Good governance is an essential part of our risk management. If our governance arrangements are ineffective we may not spot emerging risks and will not make sound decisions.


It is essential that our governance arrangements enable us to fulfil our Emergency Preparedness Resilience and Response (EPRR) responsibilities and act safely and in keeping with our values at all times.


An assessment is not required as part of this review.


An analysis is not required as part of this review.

Financial Implications Decisions to commit finance during our response will be subject to our usual Standing Financial Instructions and delegated authorities for officers set out in our Scheme of Delegation.

Executive Summary This paper provides an overview of our approach and work to date to support the recovery and restoration of our services and new ways of working in line with the progress of the national and local pandemic response.

Positive Findings

• Our approach to recovery and restoration is underpinned by our clinical strategy and values and developed with our clinical and managerial leadership community

• We are working proactively with partners, as system leaders, to consider the forecast impact of Covid-19 on our communities and to plan for the expected increased demand as a result of people’s experiences of the pandemic

• We are commencing the restoration of some further services (i.e. in addition to those sustained throughout the pandemic as deemed essential) and restricted access to Trust premises for those critical and important activities where attendance in person is needed

• We have been active in providing a range of additional support for our staff’s health and well-being, as well as colleagues in the wider system


• As lockdown measures start to lift it is imperative that we move to recover and restore services in a way that promotes safe working for all our colleagues, people who use services and carers and their families

• Initial demand modelling so far with system partners suggests there could be a c20% increase in demand for our services as the year progresses as a result of the negative impact Covid-19, in both health and socio-economic terms, is likely to have had on our communities.

22

Restoration and

Recovery Update

July 2020

23

Contents

Overview

Our values, clinical strategy and leadership

Demand and capacity forecasting

Restoration of services and safe places of work

Wellbeing support for our staff

24

Overview

Vaccination starts

May June July August Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

2020 2021

Restrictions gradually easedJune 2020

Apr-May 2020

First Peak

Second Peak

Oct 2020

Immunity becomes known

Recovery is a priority

Shielding Ends?

Q1 2021

New normal

Apr

1 – Prolonged response

2 – Gaining control

3 - Exit

4 – Reinvention and recovery

Planning for second peak

Sep

Increased NHS capacity reduces deaths

New Treatments come online

Adapted from Hertfordshire Public Health

In Reality – recovery is likely to not, in fact, be so linear; with potential further peaks and phases of “lockdown” measures 25

Our values, clinical strategy and leadership (1)

Our clinical strategy will remain

core to the restoration of

services

Our restoration plans are being

developed by local clinicians

and managers in line with our

values

We will be using a quality

improvement methodology of

plan, deliver, study and act

26

Our values, clinical strategy and leadership (2)

We are seeking to capture both

how people feel

And to ensure that we do not

just return to where we were

We want to ensure we keep the

innovative and enterprising work

of our colleagues in the new

normal

We have launched our survey to

inform our work

27

Mental Health and Emotional Wellbeing Demand Modelling and Demand Mitigation

6

28

COVID-19 Surrey Vulnerability

Psychological impacts of COVID-19

• Population estimates are difficult but 7 - 53.8% of Chinese population experience psychological impact of Covid-19 • 49.6% adults in UK expressed increased anxiety in April but this is expected to reduce.• 7% increase in complex bereavement expected due to the impact on normal grieving rituals. • 20% of people treated in critical care are expected to have a post-traumatic reaction.• BAME patients account for 24.9 per cent of the patients admitted to UK intensive care units due to COVID-19 and it is reasonable to expect they will

experience a significant negative psychological reaction• People with existing mental health problems and/or drug and alcohol dependency at greater risk.• 20% of people unemployed say they are not coping and have experienced suicidal thoughts. Employment is a strong indicator of mental health.• People in lower socioeconomic bracket are likely to be more affected.• Approx. one in three people infected by COVID-19 are health and social care workers.• 50% of health workers feel their mental health declined and over 20% are more likely to leave the sector as a result of Covid-19

29

Almost all services showed a significant decrease in demand and referrals from early March until late April, reflecting a reduction in presentations at GP surgeries and Emergency Departments. It is likely that there will be some deferred/suppressed referrals that will create additional demand in coming weeks. 31% of all bed requests are from local Acute Trusts – this fell to 23% between March and the end of April. Average bed requests per day during Lockdown (Points 1-3) = 5.9. Either side of Lockdown Average request = 8.4

The demand for Community Crisis Services (CRHTT), Mental Health Act assessments, and Inpatient services (hospital beds) has seen less of a decline and significant increases in recent weeks may reflect the impact of the Lockdown for some people.

COVID-19 Activity Snapshot

30

Modelling Assumptions:• Use 19/20 referral data as baseline• Calculate shortfall from Mar-May 19/20 (COVID – supressed activity)• Assume 75% of these referrals translate into new referrals in June-Sept and apply differentially. June-November

(between 5 and 30% based on seasonality and possible impact of Lockdown easing & recessionary impact (i.e. greater in October and November)

• Also assume 10% new demand p.a. (0.83% per month)

Approximately 20% busier (in terms of referrals and caseload sizes) to manage supressed demand from July 20-August 21. Underlying demand will cause additional pressure as well.

2020/2021 2021/2022

COVID-19 Generate Activity Modelling June 2020 to May 2021

31

Graph indicates referrals only

• Impact of suppressed referrals and a 10% increased in demand (p.a.) = 17% more referrals in August 21 than might have been predicted.

• Impact of suppressed referrals and a 30% increased in demand p.a = 19% more referrals in August 21 than might have been predicted.

• As trendline shows – underlying projected demand (based on referral trends) was increasing pre-COVID. HeadlinesApproximately 20% projected increase in demand for community services and 5% increase in beds needed. Equivalent to the costs of ½ a ward and approximately 2 community teams (across service lines) - additional £3m annual pressure? If Agency or OAPS are used then real cost will be closer to £5m. Longer-term impact of recession etc on depressive/anxiety conditions.

COVID-19 Generate Activity Modelling June 2020 to May 2021

32

Restoration of Services

and Safe Work for All

33

Safe working for all

34

The guiding principles of Safe work for all are:

Principle: The work or service is essential and has been

approved to operate by the Executive Board or Incident

Command Centre

Person: Staff should continue to work remotely (ie from

home) as much as is possible

Place: Only work that cannot take place remotely should

be carried out in a physical workplace.

35

Stepping back up towards new sustained ways of working

Lockdown

• Urgent & essential

services only.

• Virtual by default.

Phase 1

• Urgent & important

essential services

only restored.


• Return to Trust

premises for face to

face/in person only

where there is a

need.

Phase 2

• All remaining services

restored.


• Return to Trust

premises for face to

face / in person only

where there is benefit

New way of Working

• All services

restored.

• New business as

usual (BAU)

36

Route map – towards service restoration

Plan

Ap

pro

val

My Restoration Plan

Service Stepped Up

PrincipleThe work or service has been approved to operateWhat you need do :- Completed service readiness assessment for next step up

PersonStaff should continue to work remotely (i.e. from home) as much as is possibleWhat you need to do:- Completed staff risk assessments

PlaceAccess to buildings will be restricted and only allowed for the specific reasons What you need to do: Approved application for physical space

Submit Request to Step

Up

37

Wellbeing Support

for our colleagues

38

Support for our colleagues

Risk assessment

Health and Well being offer

Conversations supported by our Networks

Survey of experiences so far

Home working support

39

Psychological Mental Health Assessment and Intervention - IAPTEscalation if symptoms severe or risk increasing - GPCrisis lines and safe havens are available on this page https://www.healthysurrey.org.uk/mental-wellbeing/adults/crisis

IAPT - Anxiety, depression, bereavement ,Post Traumatic Stress Disorder: https://www.nhs.uk/service-search/find-a-psychological-therapies-service/HR | Occupational Health advice | Employee Assistance Programs 0800 919 709 (24 hrs) Pastoral Team Support – Nigel Copsey via SABP switchboardWell-being Support Line | National Line 0300 131 7000.For 24/7 Line text FRONTLINE to 85258Drug and alcohol misuse support also found on healthy surrey

Check out the Healthy Surrey website healthysurrey.org.ukThis includes online training and apps covering Well-being, Mindfulness, sleep, Info and guidance (also see resource pack)

Guidelines to help maintain well-being | Emotional First Aid PPE, Breaks, Self care, Food https://www.healthysurrey.org.uk//professionals/covid

Staff Support Framework

40

https://www.nhs.uk/service-search/find-a-psychological-therapies-service/

https://www.mentalhealth.org.uk/publications/looking-after-your-mental-health-during-coronavirus-outbreak

https://www.healthysurrey.org.uk/professionals/covid

762 (28%) of SABP’s 2,400 staff are from BAME communities. A risk assessment tool has been developed

for SABP. This tool will be used to inform steps to lower risk for these vulnerable staff such as more home

working, possible redeployment or prioritised access to testing.

Supporting the physical and mental wellbeing of health, social care and key worker staff and volunteers as

they respond to the COVID-19 outbreak is a top priority in Surrey Heartlands. An enhanced offer has been

developed to support staff from NHS, voluntary sector and Local Authority partners, other key workers and

volunteers. The Healthy Surrey Website www.healthysurrey.org.uk provides dedicated professional and

volunteer support information

Supporting Staff Wellbeing

41

http://www.healthysurrey.org.uk/

Psychological Support offer

Wellbeing Information and

resources - Healthy Surrey

Website and Trust Toolkit

Health and Well-being support

session N = 13 in one week

Webinars and Workshops N= 9

Face to Face. Videos available

Well-being check for you and

your team

Psychological PPE Plan

Team support sessions N = 10

42

https://www.healthysurrey.org.uk/professionals/covid

https://sabpnhs.sharepoint.com/sites/Intranet/SitePages/coronavirus-staff-support.aspx

SYSTEM OFFERS

• Risk Assessment Structured Interview and Training for BAME peers who will assist with risk assessments | Bespoke Training| Psychological PPE | Staff Support Sessions | COVID Workshop Development | Psychological First Aid Training | 28% SABP staff from a BAME background - 42% front line

BAME

• Managers/ Leads Training & Resources | Proactive calling /support | Self-help packs/easy to read info/resources | Team Interventions

CARE HOMES

• Call handlers – Access to resources, training & workshops | Materials prepared | MH First Aiders - Workshop - refresher on MH First Aid/relation to COVID | Social care staff – resources shared e.g. psychological PPE Plan, Wellbeing check

SOCIAL CARE

• Resources | Courses for volunteers and for managers developed| Bereavement course being developed for staff | BAME risk assessment materials and info shared | Presentations and webinars shared

THIRD SECTOR

• Individual staff support | Medical Leaders Consultation and Support at ICU | Well-being system wide consultation | Support for Well Being Leads

ACUTE CARE

43


Date 8th July 2020

Item No 66.20

Paper Title Quality and Safety Report

Director Heather Caudle, Chief Nursing Officer


Discussed to date and next steps Many of the issues outlined in this report have been discussed in the Quality, Risk and Safety Committee, and at the Executive Board.

Purpose of the paper Information provided and progress on areas of quality and safety.


To give assurance that Risk, Safety and Quality are being monitored to ensure we provide high standard safe clinical services.


The critical analysis of all incidents and safety activities and changes to reporting is essential to ensure that our Trust has clear oversight of any emerging themes/issues that may affect the delivery of positive outcomes for people using our services.


A robust review of our quality metrics will ensure we target our attention on those areas of emerging risk and put measures in place to mitigate and adverse effects.


Not applicable for this report


Not applicable for this report

Financial Implications No new financial implications related to this report.

Executive Summary The report outlines the areas of compliance that are reviewed and discussed in the monthly Quality, Risk and Safety Committee. It highlights the number of reported incidents and areas of compliance with agreed standards.

Positive Findings

• At the time of this report we do not have anyone using our inpatient services or our residential social care homes who

is symptomatic or who has tested positive for Covid-19.

• Reduction in episodes of seclusion has been sustained since June 2019 and we are now seeing common cause

variation within the new control limits. In addition, the reduction in restraints has been sustained since June 2019.

• The reduction in incidents relating to inpatients failing to return from leave has been sustained since Febuary 2019.


• There was a second death of an inpatient at Clare ward at our Abraham Cowley Unit (ACU) in May 2020. A Safety

Summit was held to bring together all agencies involved including the Care Quality Commission to collaborate

around the improvement actions taken following this death and the previous death in April 2020.

44

This report reviews quality control dashboards for our services. It merges other quality indicators previously reported separately, such as positive and safe metrics, and experience and workforce data. All contractual key performance indicators will be presented in a separate performance report. 1. Early warning signs (EWS) and CARE excellence accreditation

No update for this period due to Covid-19 focus

2. Policy assurance update

A review has been undertaken of all policies which are overdue or are soon to be overdue. The Policy assurance co-ordinator has contacted policy leads to ascertain if the policy remains the same and just requires reformatting into the new policy format, or if it requires significant review. If the policy simply needs a brief review and re-formatting the Policy co-ordinator will support them with this so it can be approved by the Policy Assurance Group (PAG). If the policy needs significant review this will be undertaken in the usual way but may require more time due to Covid 19. This process will help provide assurance with regards to our policy compliance. Those policies which were near completion prior to Covid 19 have been chased to see what support, if any, is required. Any high priority policies will be reviewed by the Policy Assurance Group remotely.

3. Safety

3.1 Serious Incident – Clare Ward

There was a second serious incident which resulted in the death of an inpatient at Clare ward at our Abraham Cowley Unit (ACU) in May 2020.

A Safety Summit was held to bring together all agencies involved including the Care Quality Commission (CQC), to collaborate around the improvement actions taken following this death and the previous serious incident resulting in a death on Clare ward in April 2020.

Actions:

• Full re-review of the ligature risk assessment at ACU.

• Clare ward paused to admissions (and bed numbers capped at 14).

• Peer review commissioned and undertaken by the Executive Director of Nursing and Quality from a neighbouring Trust – we await the full report.

• Care Quality Commission virtual review held with positive feedback received. CQC spoke with 16 people using services and Clare ward staff.

• Oversight maintained through the Inpatient Improvement Board including a sub-committee to bring together clinicians and property colleagues to work through the outcome of the ligature re-review.

• Circle of Support for Clare ward has been initiated with the involvement of the full multi-disciplinary team to step through how best to support the improvement journey for Clare ward including review of the skills mix and levels of experience of staff in order to make any changes sustainable.

• A second Incident Coordination Group was held on 12th June as per the multi-agency processes.

• Section 42 safeguarding adult enquiry has been initiated.

• Serious incident investigation commenced with family liaison support.

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Safety – SPC Reporting

This chart is showing special cause as April’s data point is outside of the lower control limit. Although this does not mean that we have a reduction, we know that the number of incidents reported for April 2020 is lower than we would expect. 521 incidents were reported overall in May 2020, an increase of 81 compared to the 440 reported in April. This is the first increase in overall monthly reported incident data since January 2020.

The increase in overall monthly data is attributable to a slight increase in reported numbers across several domains: safeguarding adult referrals increased by 27, slips, trips and falls increased by nine, falls resulting in harm increased by five, incidents of restraint increased by five, violence against staff and medicines related incidents both increased by four each.

This chart is showing common cause variation, therefore it is currently stable and predictable. Nine serious incidents were registered on STEIS in May 2020, which is the same number as in April. Of the nine serious incidents (Sis) registered in May, six were in relation to unexpected deaths in the community, one was an inpatient death on Clare ward. One incident was in relation to an alleged homicide by a person known to i-access East and the final SI was in relation to a health and safety incident on Juniper ward whereby a person climbed on a wall using furniture to assist.

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This chart is showing common cause variation, therefore it is currently stable and predictable. Seven deaths were actually registered as serious incidents in May in 2020 (one more than the chart depicts). One of the deaths was an inpatient death pertaining to one adult on Clare ward at the ACU. Two of the community deaths were in relation to two people known to Epsom and Mole Valley Community Mentla Health Recovery Service (CMHRS). The fourth death was in relation to an adult who was known to Runnymede and Spelthorne CMHRS who was found deceased in their home. The fifth death was in relation to an adult who was known to Guildford CMHRS. The sixth death was in relation to an adult who was known to i-access NW. Concerned neighbours called the police for a welfare check. The seventh death was in relation to an older adult who was known to CMHT-OP Runnymeade. Further review revealed no discernable link for these deaths to COVID-19 during this reporting period.

The reduction in restraints has been sustained since Jun 2019, however there is special cause in March 2020 (this point exceeds the upper control limit), therefore the number of restraints in March were higher than we would normally expect. In May 2020, 37 incidents of restraints were reported across our Trust. This represents a small increase (n-five) compared to 32 such incidents reported in April 2020. The increase was mostly to facilitate the administration of intra muscular (IM) injections. The restraints were mostly by arm holds.

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Baseline at the beginning of the chart is incorrect and if corrected we may not have a reduction. We need to liaise with our digital colleagues to get this amended. It may be that we need one more data point to see a reduction in prone restraints from November 2019. One incident of prone restraint was reported in May 2020, a decrease of one compared to April. The one episode of prone restraint was briefly used on Juniper ward to facilitate administration of an IM injection for an adult who was very distressed, causing damage to property and refusing oral medications.

This chart is showing common cause variation, although we have zero tolerance of violence against staff, the data would suggest that it remains predictable and stable. 26 incidents of violence against staff were reported in May 2020, a slight increase (n-4) compared to 22 in April. This increase followed a four month period of downward trajectory in the number of reported incidents of violence against staff between January and April 2020.

This decrease follows a pattern of overall sustained reduction in reported violence against people who use services since February 2019. This reduction continues to be sustained. 16 incidents of violence against people who use our services were recorded in May 2020, a decrease of seven compared to 23 reported in April.

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Reduction in episodes of seclusion has been sustained since June 2019 and we are now seeing common cause variation within the new control limits. Five incidents involving the use of seclusion were reported in May 2020, a slight increase of two, compared to the three reported in April. Incident one involved an adult on Rowan ward (PICU) who was violent and caused damage to property. Incident two involved an adults on Juniper who was aggressive and caused damage to property. Incident 3 involved a person on Magnolia ward who assualted staff and other people on the ward. Incident 4 involved the same person, now on Rowan ward, who remained very aggressive, attacked staff, damaged property and refused oral medication. Rowan ward (where the seclusion suite is situated) has now been returned to its substantive function as a PICU ward from its temporary function as a dedicated Covid ward. We are regularly undertaking clinical reviews into each seclusion episode to look at any immediate learning for the individual and the team.

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This chart shows special cause in Jan and Feb 2020 as the two data points are outside of the upper control limits (this is known to be linked to the medicines audit work post CQC inspection). This does not mean that there has been an overall increase but instead that the number of medication incidents is greater than we would expect.

33 medication incidents were reported during May 2020. (There were 29 medication incidents during April and 30 during March).

This chart shows special cause in March 2020 as the data point is outside of the upper control limits. 52 incidents of inpatient self-harm were reported in May 2020. This is a slight decrease of four and follows on the back of a substantial reduction of 34.8% (n-30) decrease in April.

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This chart is showing common cause variation, the data is predictable and stable. In May 2020, there were two incidents of serious self-harm that led to hospital attendance, which is the same as the reported numbers in April and a decrease to March numbers. The first incident was in relation to an adult who absconded from Juniper ward. The second incident was in relation to an adult on Magnolia ward who sustained injuries due to violence to objects. Our advanced nurse practitioners and resuscitation officer are working with other colleagues to provide specific guidance to frontline SABP clinicians on how to support people in physical health emergency.

This chart is showing common cause variation at the moment, however we need one more data point below the centreline to see a reduction. There was one reported abscond incident in May 2020, down from two April. The one AWOL incident was in relation to an adult on Rowan ward (PICU), who absconded from the ward and the unit and ultimately from the hospital, causing substantial damage across a number of departments at Farnham Road Hospital, in the process.

The reduction in failure to return from leave has been sustained since Febuary 2019. We are now seeing common cause variation within the new control limits. There was no report of a failure to return from leave in May 2020. This is due to our COVID-19 response where, in the main, leave arrangements have been suspended.

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There is special cause in May 2020 as this data point exceeds the upper control limit and is therefore greater than we would normally expect. However, following clinical review, the number of falls resulting in harm is actually eight and are in the low harm caterogy. Three of these low harm incidents occurred on Spenser ward and two related to the same person whose care had been reviewed. The falls data from datix which feeds the SPC charts will be reviewed in a more timely way for the next report to avoid this issue reoccuring.

4. Infection Prevention Control Highlights (IPC)

4.1 Outbreak – Two staff from Epsom CMHRS reported diarrhea and vomiting symptoms and the team were in outbreak mode for six business days between 12th and 19th May, with a total three staff affected. Our IPC nurse has been offering increased support to ACU-based teams around use of Personal Protective Equipment (PPE). During the twice weekly visits, staff have been updated about the definition of ‘sessional use’, reminded not to wear surgical face masks outside the ward areas and good practice rewarded. A team of seven FFP3 fit-testing staff (including the Interim Head of Nursing Quality and Assurance, the Accreditation Guide, Interim Co Director of Education, the Named Nurse Safeguarding Children, FGM & Prevent Advisor and the IPC team members) have been demonstrating correct FFP3 mask donning to prepare staff for their use during aerosol generating procedures. Approximately 114 staff have been fit tested since and whilst reporting the data about this activity is challenging due to inadequacy of contextual information provided, it is estimated that approximately over 60% are nursing staff, 20% medical and 12% support workers. Testing remains a time intense process requiring multiple sessions sometimes for each candidate to be successfully fit-tested to a mask. Some staff have been fit-tested by neighboring Acute Trust Hospital under the mutual aid program of support. A very small number of staff (single figures) have not been able to be fit-tested and power hoods remain

their only option, which are being procured. The offer of mask fit testing continues.

At the time of this report we do not have any person using our inpatient services or our residential social

care home who are symptomatic or tested positive for Covid-19.

5. Physical health

5.1 NEWS2 – Rowan ward continue to use NEWS2 and record via the new SABP chart; the feedback has been positive and we await the arrival of the iPad Touch monitors so that the E-obs pilot can commence. At ACU approximately 50% of all staff have been trained and suggested further training dates throughout June have been offered to the ward managers to meet the need there.

0

20

40

60

Staff fit-tested by Division

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5.2 Physical Health – Smoking cessation support via remote consultation has been offered and delivered to Margaret Laurie House (MLH) as people who use services struggle to cope with Covid-19 restrictions. Requests for increased use of e-cigarettes during the night (once the venue is secured at night) are made by people who are not making a quit attempt, causing staff to feel conflicted and pressured into supporting these requests and ultimately leading to increased nicotine use. Our Physical Health Practitioner is offering weekly remote in-reach support to people who use services and the staff team.

Mouthcare support has also been offered remotely to people experiencing some mouth related discomfort at Margaret Laurie House.

Our Lead Nurse for Quality and Practice, reported on the Guildford and Waverley CCG funded In-Reach GP to Farnham Road Hospital; running since 6th April 2020, supporting the WAA wards and 136 Suite via daily consultation, has now been evaluated positively. An update of the trial of weekly virtual ward rounds suggested more proactive use of the service should be encouraged across the 24hour frame period to further prevent un-necessary A&E presentation. A formal evaluation of the service is being scoped.

Wound Care – an individual is in recovery due to experiencing a pressure ulcer as an inpatient at our Older Adult Dementia unit, The Meadows. Due to the unusual presentation it was initially considered to be a possible malignancy; requiring further tests. This person is recovering well with support from our lead physical health nurse and the multi-disciplinary team. Further exploration is underway by our Physical Health lead nurse into any care and treatment concerns that may need highlighting to the team. A Datix incident report was raised.

5.3 Physical Health Site Practitioners

We have developed a proposal for the introduction of Physical Health Site Practitioners to enhance knowledge, training and competency in physical health interventions in the current Covid-19 context. This proposal has broad support from Silver command and will be re-presented at our Physical Health Strategy Group, Clinical Reference Group and then Gold command for final approval.

6. People’s Experience

People’s Experience – SPC Reporting

This SPC chart shows a stable, predictable system as there is currently common cause variation.

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We have a reduction in the average number of complaints, which is demonstrated by the reduction in the centreline from August 2019. We have further special cause in April 2020 as this data point is outside the lower control limit.

Special cause occurred in August 19 - Oct 19 as we had one data point exceeding the lower control limit and two out of three points in the lower third. We also have special cause variation in Feb-May 2020 as all of these data points are outside the lower control limits. We have a downward trend from Nov 2019 – April 2020 as we have six points decreases in value. This does not mean we have a reduction in compliments as it isnt a shift as we need two more data points below the centre line to see a formal reduction/shift. However, this reduction is likely to be related to the reduction in face to face contacts due to our Covid-19 response.

Special cause variation in August – October 2019 as the data points exceed the upper control limit. We will explore this variation further. The April 2020 data points is outside of the lower control limit therefore this chart is demonstrating further special cause variation. Please note there is further commentary in the Complaints and PALS section.

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This SPC chart shows a stable, predictable system as there is currently common cause variation. It is important to note that the Your Views Matter (YVM) charts are based on much fewer respondents than usual, across a smaller range of services. This is due to the reduced use of our iPADS in our services due to reducing the risk of viral transmission and the reduction in face to face contacts in the community.

The increase in carers who are satisfied with our services has been sustained and this chart is now showing common cause variation at this new level. We did not have any responses during April and May therefore if this was charted it would be special cause as the data would be zero and outside of the lower control limits. We need to review this and do a piece of work around improving the use of Your Views Matters as we step back into delivery of essential services and more face to face contacts a part of our Covid-19 response.

This SPC chart shows a stable, predictable system and is consisent at the mean of the control limits.

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This SPC chart shows a stable, predictable system as there is currently common cause variation.

6.1 Complaints and Patient and Liaison Services (PALS)

6.2 Complaint timeframe Leading up to the Covid-19 outbreak and subsequent lockdown we had been working to clear several ageing complaints which existed due to lack of capacity in the complaints and operational teams to undertake often complex complaint investigations during the summer of 2019. There remains several longstanding complaints awaiting scrutiny and approval but these are delayed due to the capacity of our Directors and Executive colleagues due to Covid19 and resources focused on frontline services. There are currently 8 complaints awaiting allocation to investigators, these in the main are for WAA Division. Since COVID-19, we have seen a reduction in complaint activity, with many people agreeing to support the necessity to focus services and staff on the frontline as the priority. However, through May, there has been a slight increase in the number of PALS enquiries and local resolution (informal complaints). These early interventions addressed by the local Service areas, have helped the complaints team support individuals’ concerns and complaints immensely well. Early interventions have been supported from local services, which is greatly appreciated by the PALS and Complaints Team.

0

10

20

30

40

50

60

70

Ageing Complaints open for over 50 days

Complaints backlog Trajectory

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6.3 Immediate Actions

• A proposal will be submitted to Silver command with recommendations how to step back into our full complaints offer to the people, carers and families we serve.

• Additional support from medical staff supporting complex complaint investigations. Complaint Coordinators participating in regular monthly review meetings with medical support from Dr Sean Fernandez and Quality Assurance Group (QAG) meetings, where complaints and compliments are discussed and monitored.

• Increased communication with people and families to manage people’s expectations in terms of time frames.

• To mitigate the risk of poor experience, we are agreeing individual timescales with people following a new complaint that are realistic and reflect the level of input that is required in the investigation.

• A range of training (virtual) with practitioners to learn about Attention Deficit Hyperactivity Disorder (ADHD) and Autism, and behaviours associated with their conditions which may help us to deal and support people complaining about our Trust and its services or staff.

• All complainants informed via letter of the pause to complaints during COVID-19 lockdown.

• Information updated on our Trust website advising people of the implications and working practice, and delays in responding with complaint responses from the PALS and Complaints Team during COVID-19 lockdown.

6.4 Ombudsman We currently have no complaints with the Ombudsman for investigation. We have communicated, via email and telephone conversations, with the Liaison Officer for our Trust, discussing our partnership work with advocacy services and best practice and guidance for our communication methods with our complainants. They have shared best practice with us and have suggested an opportunity of training to complaint coordinators and potential investigators to aid improvements to our complaint investigations and response letters.

7. Workforce

7.1 Staffing

Vacancy rates for May 2020 were not available at the time of writing this report however in April 2020 the rate was17.07%.

The number of leavers for the past six months have been slightly below average. however our starters are slightly above average this month. The average over the last six months (December – May 2020) was 31 leavers headcount per month. All Divisions continue to actively recruit to their vacancies.

Values related to staff leaving within the first 12 months present little consistency or pattern, but they are reducing over time. During May, 26 employees left and five of those had less than 12 months service.

7.2 Safe Staffing and Rostering Our safer staffing approach has been strengthened by updating our terms of reference and governance structure. We will be undertaking safer staffing reviews in collaboration with operational services through spring 2020 using the assessment tools of the National Quality Board. We are moving to the evaluation stage of the SafeCare pilot with the four teams who are piloting this new approach. Findings will be taken to the Safer Staffing meeting for review: however, this had to be paused due to the impact of Covid-19. Once we are satisfied that SafeCare is working as it should be, a roll-out for the rest of the rostered team will be established.

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8. Care Quality Commission

We submitted our action plan in response to the three regulatory breaches from our most recent core service and well-led inspection on 1st June 2020. 9. Safeguarding Safeguarding remains ‘business as usual’ and staff continue to identify where there are safeguarding concerns and refer to appropriate agencies. 9.1 Safeguarding Children Training

The data below is our current Safeguarding Children training compliance. We are currently in the process

of agreeing how we provide the Safeguarding Children Level three face to face in-house training during this

period of social distancing. This was recently discussed at the Clinical Reference Group (CRG) meeting.

The proposal will be amended, discussed at CRG and the Tactical Advisory Group (TAG) before its

implementation.

Assignment

Count

Required Achieved April

Compliance

March

Compliance

Change in

Compliance

%

Safeguarding

Children Total

2320 2320 2127 91.68% 93.12% -1.44%

Safeguarding

Children - Level 1

278 278 266 95.68% 95.07% 0.61%

Safeguarding

Children - Level 2

870 870 817 93.91% 95.45% -1.54%

Safeguarding

Children - Level 3

1172 1172 1044 89.08% 90.90% -1.82%

9.2 Prevent

We have recently completed our Prevent returns and our training compliance is in the table below. Managers

must continue to encourage all staff to complete the Prevent Mental Health Level 3 e-learning on ESR to

ensure staff remain compliant with the training requirement.

Assignment

Count


Compliance

March

Compliance

Change in

Compliance

%

Preventing

Radicalisation

Total

2320 2320 2141 92.28% 92.43% -0.15%

Preventing

Radicalisation -

1148 1148 1069 93.12% 93.72% -0.60%

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Assignment

Count


Compliance

March

Compliance

Change in

Compliance

%

Basic Prevent

Awareness

Preventing

Radicalisation -

Prevent

Awareness

1172 1172 1072 91.47% 91.16% 0.31%

9.3 CDOP (Child Death Overview Panel)

We have received 26 requests for information on child deaths since 1st January 2020. Seven of the 26

families had family members known to our services.

9.4 Referrals to External Agencies by Services

The data shows that 92 referrals have been made to external agencies between January to May 20.

9.5 Reporting Historical Sexual Abuse

We have continued to work with local Police about how we report historical sexual abuse without the consent

of the person who uses our service. It has become evident that we cannot have a statement that will cover

all cases. Therefore, if a team is unable to reach a decision as to whether to inform the police without the

consent of the person who uses our service, this will be discussed with the Safeguarding Leads to agree

the process to be followed.

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Date 8th July 2020

Item No 67.20

Paper Title Activity and Performance Report

Director Toby Avery: Chief Digital and Information Officer Author: Digital Health Leadership


Discussed to date and next steps This paper summarises performance information to provide the context for mental health performance from a system perspective.

Purpose of the paper The Board is asked to note the following within the report:

• How we compare in the system

• Positive performance

• Challenges

• Work to improve our Quality Standards


The Mental Health measures are a proxy for excellent clinical services which is implicit in our values.


Performing well against these measures are a proxy for excellent clinical services which is implicit within our values.


Being clear on our performance relative to our peers and targets is helpful in providing context in how we are performing.


Not applicable for this paper


Not applicable for this paper

Financial Implications None for this paper

Executive Summary

This report describes the performance of the Trust. It focuses on areas identified in the 5 Year Forward View and NHS Long Term Plan and details our position with our Quality Standards.

Positive Findings

• Early Intervention in Psychosis (EIIP) Wait Times remain good

• Reduction was seen in the Child and Adolescent Mental Health Services (CAMHS) Single Point of Access (SPA) caseload, although demand may be being delayed

• Hard, complex, beneficial work across bed management processes

• Quality Standards are holding up remarkably well despite the new ways of working


• Gatekeeping by Home Treatment Teams (HTT) continues to be a concern

• There are huge challenges dealing with Delayed Transfers of Care (DTOCs) during the epidemic

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1. Introduction The Activity and Performance paper for Trust Board monitors Surrey and Borders Partnership Trust’s performance across a range of measures. We use Statistical Process Control (SPC) methods to help understand whether this month’s performance is in line with expectations, shows a sustained increase or decrease, or if it indicates that the process is no longer under control. Where we do not have SPC charts, we use longitudinal run charts to help understand month-on-month changes.

To help understand the nature and meaning of the metrics in this paper, we categorise each as either Access, Efficient or Effective. This month’s paper includes “Access” measures for Bed Occupancy and Child and Adolescent Mental Health Services (CAMHS) Single Point of Access (SPA), an “Efficiency” view of Length of Stay and Care

Programme Approach (CPA) 12-month reviews, and “Effective” analysis of Home Treatment Team (HTT) gatekeeping of inpatient admissions, Out of Area Placements and Delayed Transfers of Care. June’s paper reviews data from April. We identify monthly performance trends, highlight areas of success and report on areas where improvement is required. Where possible we provide operational commentary to provide insight into the reasons for the levels of performance seen.

Inpatient Activity

2. Bed Occupancy Bed Occupancy across all divisions was lower in April at 83%. Bed Occupancy does include the 12 beds at Shrewsbury Court, which is further described below. Note that we can start to see the occupancy for May and June. These will be re-assessed in future papers.

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3. Length Of Stay (LOS)

Surrey and Borders Partnership Foundation Trust has been working to reduce the average Length of Stay of people in the Adult Mental Health (AMH) Acute beds; the average length of stay across AMH Acute wards, excluding Psychiatric Intensive Care Unit (PICU) admissions and including leave, was 43 days for all people discharged during 2019/20, which was 2 days less than 2018/19. NHS England has set a target for the average LOS to be 32 days (acute care, including leave and excluding PICU admissions/stays). During the latter part of 2019/20, a multiagency, multidisciplinary meeting was created to support complex discharges, which facilitated the discharge of many people with long length of stays. From April 2019 to September 2019 SABP discharged 490 people with the total average LOS of 37 days;

October 2019 to March 2020 saw 459 people discharged (less than the previous 2 quarters), however

the average LOS increased by 11 days to 48 days. An increased LOS demonstrates the success of the

meeting; SABP’s consistently lower LOS (March 2019 to September 2019) omitted any person with a

long stay who could not be discharged due to complex discharge needs and delays. April 2020’s average

LOS (SABP Adult Acute Wards) was 56.8 days; 31% of the discharges accounted for 80% of the total

LOS of all people discharged in April 2020 (4089). One person was discharged from Langley Green with

a LOS of 9 days and no one was discharged from Shrewsbury Court and Cygnet during the month of

April 2020.

Further work has taken place to increase the visibility of activity such as Langley Green beds now being

captured on SystmOne and all Out of Area Placements placed visible on SystmOne as virtual wards.

Home Treatment Teams have started work on digitising their processes to increase visibility around

people referred for assessment, and of the number of people referred, how many people required a bed.

In addition, we are starting to capture how long someone must wait from referral for an assessment to

being admitted to an acute bed. Further work and engagement is required from the HTTs to get this

process up and running.

SABP’s bed base and profile changed during the month. On 1st April 2020 12 additional beds were

commissioned at Shrewsbury Court. These are being used as step-down beds for people with discharge

delays. However, due to the dormitory layouts on some of our wards, a decision was taken to reduce the

number of beds to enable social distancing. This means that towards the end of April 2020 bed numbers

on Anderson, Blake and Clare wards reduced, with 14 beds being closed.

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Another change was temporarily decommissioning of Rowan as a PICU ward, to create an exclusive

COVID-19 ward. Six replacement beds were commissioned through Cygnet sites at Woking and

Maidstone. People who were admitted to SABP PICU were transferred over to their care. Eight people

were admitted to these externally provided PICU beds. Rowan2 (the COVID-19 ward) opened on the 27th

April 2020. This has since returned to its PICU function as thankfully the Covid-19 ward was not needed.

4. Out of Area Placements (OAP)

Adult For the month of April, we have 10 out of area placements, 3 are ongoing, 2 females with Autism Spectrum Disorder (ASD) who are challenging to secure placement and 1 gentleman with physical health challenges. We had to close 14 beds in April due to COVID-19 and patients being able to social distance on the wards. The Bed Management team and Social Care team are working together for the management of all patients who are medical fit for discharge. Many supported accommodations have now paused to admissions due to COVID-19 and staffing issues. Many hotels and B&Bs are currently closed, which has impacted on the homeless and delays in discharging patients. Every effort is being made to move the out of area placements back to a local bed as soon as possible. Older People One person was treated in a private hospital in April.

Delayed Transfer of Care (DTOC)

There were 317 delayed days in April affecting 12 individuals. The ward with the most delays was Victoria, with 120 days for 4 people (each being delayed for the whole month). The main reasons for delays were awaiting funding and finding suitable placements. There is a DTOC escalation process for each division with inpatient beds, which allows for escalation within the Trust and at the Clinical Commissioning Groups (CCGs). Victoria Ward continued to struggle to discharge these patients, one of whom was on the ward for almost 2 ½ years. The correct escalation procedures were being followed. The cases were very complicated, two of

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which required delegated commissioning involvement, and they were reported monthly in the bed occupancy report.

Adult Mental Health

5. Gatekeeping by Home Treatment Team (HTT)

86.4% of admissions to Adult Acute / PICU wards were gate-kept by the HTT. There were 8 breaches where there is no evidence in the patient record of gatekeeping. The HTT are investigating this continuing trend and working with teams to ensure all people admitted go through the gatekeeping process. There is an ongoing issue with clinicians selecting the wrong admission source so the Digital Health Advisors continue to check these numbers and validate the outcomes. Further training is happening in the teams to address this and the Digital Health Advisors will support the clinicians in getting this right.

6. Early Intervention In Psychosis (EIIP) Wait Times

The time-series chart below illustrates our April performance as shown on our Data Analysis and Reporting Tool (DART). 19 people started treatment in April and 95% waited two weeks or less to access treatment. One person waited more than two weeks. The person was an inpatient on Mulberry ward. The EIIP service attended a ward round via a video call on the 15th day after referral. We consistently achieve the waiting time standard for each contracted CCG.

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Children and Adolescent Mental Health Services (CAMHS)

7. CAMHS Single Point of Access (SPA) Referrals

There has been a drop in the number of referrals to SPA to 289 in April. This is due to the

impact of Covid-19 and children not being at school or taken to their GPs. Most referrals

come from GPs, with schools being the second highest referral source. The caseload has

now reduced to under 600 (June) due to the reduction in referrals. There has however been

more activity internally within teams leading to this reduction in the caseloads

8. Quality Standards

Quality Standards have been affected by the way in which consultations now take place. Most measures look for face-to-face contacts but since Covid-19, telephone and Attend Anywhere appoints have been the main mode of contact. As an example, Elmbridge CMHRS recorded 30 telephone calls in February. In April they recorded 327. CAMHS teams continue to struggle with the measure for recording a Care plan within one week of referral. These percentages have only increased very slightly since last month and remain low. The

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Children and Young Peoples Service (CYPS) AD is launching a new outcomes group to try and address this ongoing issue. In Older People (OP) services there has been a slight drop across all Key Performance Indicators (KPIs), this may be expected given the current COVID-19 situation. Whilst teams are attempting to “see” and assess as many people as possible over the phone or virtually, there are issues with this when working with an ageing client population hence a slight drop in figures. Hearing/communication issues and limited access to technology also has an impact. 10. Attend Anywhere As an example of the changed way of working since Covid, Elmbridge CMHRS recorded 30 telephone calls in February. In April they recorded 327. There were 1.2 thousand Attend Anywhere consultations in April and 2165 across the organisation by the beginning of June.

11. Care Programme Approach (CPA) 12 Month Reviews (Fig 1)

For Older People Services there has been a slight drop from 76% to 71% which accounts for 8 patients. Facilitating a CPA meeting with our client group is problematic for reasons already mentioned with many patients and their carers shielding due to age. Going forward it has been agreed that CPAs will be held virtually via Attend Anywhere for both inpatient discharges and regular reviews and it is hoped this will have a positive impact on performance against the CPA KPI. Adult mental health is at 77% with 190 people being overdue a review. Similar challenges face the AMH clinicians as not everyone is able to or wants to have their CPA meeting carried out remotely.

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12. Summary The Digital Team submits this report for discussion. The report outlines activity in the Trust from April. Some of the performance was affected by the Covid 19 response during April but new ways of working are being embraced and we would hope to see an improvement in performance as this becomes the normal way of working.

Digital Health Leadership Team June 2020

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Clinical Efficiency – 12-Month CPA Reviews

Figure 1 - CPA 12-month Reviews

Clinical Efficiency

In this appendix, we provide a copy of the table showing CPA 12-month review performance during April 2020. We continue to highlight the fact that Adult Mental Health have more than 10 times as many CPA patients on their caseloads compared with the next biggest service, CYPS. This means that any failure to review a CPA in time for CYPS, OP, LD or Specialist will have a larger impact on their overall performance. We also include March’s data for comparison. This shows that maintenance of CPA reviews has not dropped off significantly despite COVID restrictions.

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Clinical Effectiveness / SPC Reporting

Clinical Effectiveness

In this appendix, we review the SPC charts for clinical effectiveness. The first shows the rates of non-attendance at appointments across our services. Interestingly, there was a marked decrease in non-attendance which is particularly noticeable in OPCMHT and CTPLD, although Adult CMHRS and CAMHS CT are also down. However all changes are within current process limits. Fewer appointments were being booked and others were being cancelled rather than recorded as DNAs (did not attend).

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In this appendix, we provide a copy of the SPC charts for clinical effectiveness. These charts show the time from referral to first appointment trends. There are no changes outside of process limits.

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In this appendix, we provide a copy of the SPC charts for clinical effectiveness. These control charts look at the average length of stay on discharge from our Older People and Adult wards. The length of stay for Adult services approached the upper limit, but overall the process appears to be functioning within expected parameters.

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Version 1.3


Date 8th July 2020

Item No 68.20

Paper Title Quality Improvement (QI) Quarterly Report

Director

Helen Rostill, Chief Innovation Officer / Director of Therapies Authors: Simon Whitfield, Director of Quality Improvement and Medicines Optimisation and Emma Binley, Head of Participation, Experience and Improvement


Discussed to date and next steps Continued discussion across various committees including the Quality Risk and Safety Committee.

Purpose of the paper To provide an overview of Quality Improvement activity across the organisation.


An ongoing assessment and awareness of potential hazards and risks will ensure sufficient mitigation is in place to deliver services in line with our values.


By embedding QI in the heart of our organisation, we aim to be the safest and most reliable provider of mental health and learning disability healthcare by 2022.


Not Applicable


Not Applicable


Not Applicable

Financial Implications Continued subscription to Institute for Healthcare Improvement (IHI) Health Alliance Europe (£9K)

Executive Summary This report provides a high-level summary of our progress with delivering Quality Improvement across the organisation and the wider networks the team are connected to.

Positive Findings

• Continuing to run the Inpatient Safety Collaborative, great engagement from inpatient services/teams and ran our first virtual collaborative session in May 2020.

• Adapted our Suicide Prevention training and ran our first virtual training workshop in May 2020.

• Partnering with Q Community and our Connecting Improvers call had over 80 people join. Surrey Improvers Network is designing a Surrey Improvement Collaborative and we have been successful in a Health Foundation bid to financially support this.

• Great engagement and attendance at the Statistical Process Control (SPC) workshop from leaders and managers.


• There is a need to support teams with using data over time and measurement consistently throughout their projects. We will be running more workshops focused on SPC charts and interpreting data.

• Supporting more projects to use rapid cycle testing and achieve and sustain improvements. Supporting more projects to achieve and sustain improvements (increasing the number of QI projects where improvements have been achieved, change ideas implemented and results sustained).

• Teams capacity to support improvement work and embed people participation throughout the organisation and divisions. We have had a number of vacancies within the team.

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Reviewing our Quality Improvement (QI) strategy We had an away day in August 2019, and since then have been thinking about our vision and direction as a team going forward. We have been reflecting on our past improvement work and reviewing existing QI projects. In doing that we have been thinking about why projects do not result in sustained improvements and how we can address this. We have been able to identify that there are aspects of QI that we do really well as an organisation for example, building relationships, engaging a team, building the will, however there are areas we need to work on for example rapid cycle testing. Although we are ambitious about our approach to continuous improvement, we recognise that we need to spend some time focusing on building our QI Foundations as a Trust and strengthening our application of improvements methods/frameworks. Therefore, we are currently putting together our revised strategy document with a focus on how we build a strong structured approach to Quality Improvement work and build sustainable improvement work at all levels. We feel that in addition to reviewing our strategy/approach, the increased improvement skills and qualifications within the team will help embed a culture of continuous sustainable improvement and support the organisation with its recovery and restoration priorities as we move through the phases of the Covid-19 pandemic. The key areas we are focusing on within this strategy review are:

• Strengthening the culture of continuous improvement and the structures required to support that e.g. division level sponsors

• Fidelity to an improvement framework/approach and how we can improve the amount of sustained improvement work

• Connecting with other project support teams and providing people with the right tool/method for their problem/area of work

• Building capability within the QI Team and across different levels of the organisation including specific professional groups e.g. newly qualified nurses, students

• Priority areas of work and how we strengthen the connection with Trust priorities

• Our QI Networks and Improvement work/offer to the Surrey System. Our Quality Improvement Priorities Our Improvement Priorities include:

• Inpatient Safety Collaborative

• Suicide Prevention

• Physical Health

• Building improvement capability

• Connecting with Trust priorities, learning from other areas e.g. serious incidents and connection to annual planning

• Improving the number of projects that have sustained improvements and involve people who use our services and carers.

Updates on Trust wide/Strategic Improvement work

• Quality, Risk and Safety - We attend the Quality Risk and Safety Committee and provide regular updates on our improvement training, team capacity and our improvement priorities. We now also support the interpretation and analysis of Trust-wide Statistical Process Control (SPC) Charts during this meeting, this then helps us align our SPC charts to our narrative from the services. To help support this, earlier in the year we ran a workshop on understanding and interpreting SPC charts for Senior Leaders and Managers in the Trust. We are hoping to run further sessions in the future for those that were unable to attend and/or would like to attend again.

• Joy in Work – we have been supporting this work and guiding the group to focus on using improvement methodology. It is likely that this work is going to become part of the People Plan work, with improvement work aligning with each of the People Plan pillars. We are planning to develop a

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collection of measures for each pillar and encourage frontline teams to start Joy in Work improvement projects. We hope that we will have a number of Teams and services starting Joy in Work QI projects over the coming months.

• Inpatient Safety Collaborative – The Inpatient Safety Collaborative started towards the end of last year and prior to Covid-19 we ran two collaborative learning sets. Each of the wards and teams had identified an area/project to focus on relating to safety. Rowan ward is also part of the National Sexual Safety Collaborative. We ran our third collaborative learning set virtually last month and are looking into how we can best support the inpatient teams to continue with their improvement work. We have been developing a dashboard of safety measures and our overall aim is to improve inpatient safety by 25%. Suicide Prevention is one of the workstreams covered by the inpatient safety collaborative and we are working with inpatient colleagues to see how we can strengthen the connection between learning from serious incidents and quality improvement work. We will also be working on improving peoples experience in acute care as part of our Care Quality Commission (CQC) response.

• Physical Health – We have been supporting our Nursing Directorate with developing a Covid-19 Physical Health Strategy and we will be using quality improvement methods and tools to develop and implement this work.

• Divisional Support - Our QI Leads continue to support the variety of projects in the divisions and they attend the Quality Assurance Group (QAG) for each of their divisions. Divisional engagement at local project level with QI does vary and we are keen to develop sponsor roles to help with the reporting, oversight and engagement of QI across all the divisions.

Building QI Capability

Total trained (since it began)

Total in 2019/2020

Induction 1710 571

Foundations 215 70

Champs 44 12

We are currently reviewing our training offer now that we have more advanced improvement expertise in the team and QI has been part of the Trust for a number of years. We are developing our training course based on the following offer:

• Continue present on the Trust’s improvement culture at Staff Induction

• Foundation level training – this training is focused on introducing quality improvement, with a view to developing a culture of continuous improvement.

• QI Champions Training (name likely to be changed to Improvement Project Lead Training) – this provides staff with the tools and expertise to lead an improvement project and there is a requirement to do a project and/or apply the learning to a project throughout the duration of the course.

• Masterclass Series – a collection of masterclasses focusing on different improvement tool and topics e.g. Prioritisation/KanBan, advanced SPC charts and tools.

• Nightingale Challenge – we are leading on developing a nurse leadership and improvement course which is going to be offered to band 5 nurses.

We also continue to deliver suicide prevention training and have adapted this training course, so it can be delivered virtually. We are looking into developing a virtual Improvement Project Lead Training and we are designing a Quality Improvement Project Course and separate Coaching course for the Improvers Network/Collaborative. Training for the QI Team We have spent time developing our team’s improvement skills and expertise. Emma Binley (Head of Participation, Experience and Improvement) and Anna Smith (QI Team Manager) are both qualified Improvement Advisors (Institute for Healthcare Improvement (IHI)) and Emma is also a qualified Improvement Coach (IHI). They already had these qualifications prior to joining SABP. Earlier this year they

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both completed a Green and Black Belt course in Lean Six Sigma and are now qualified Black Belts. They are currently doing an online Agile Project Management course so that we can look to apply an Agile approach to working within the QI Team. Tope Forsyth (QI Manager for Suicide Prevention) is currently undertaking the IHI Improvement Advisors course and Simon Whitfield (Director of QI) is looking to start this later in the year (postponed due to Covid19 travel restrictions). One of our QI Leads is now a qualified Improvement Coach (completed the IHI Improvement Coach course 2019/2020) and we are hoping that our two other substantive QI Leads will be able to undertake the IHI QI Coaches course within the next year. Connections to wider Improvement work Surrey Improvers Network We have a leading role within the Surrey Improvers Network and Emma has been working very closely with Heather Bokota and Mark Hamilton in helping shape the network itself, and the network’s vision/direction. We have recently discussed the importance of the network being focused on doing a smaller number of things well and have agreed to primarily focus on establishing a Surrey Improvement Collaborative. The Improvers Network has been successful in securing a Health Foundation bid of £15,000 to support the proposal of setting up an Improvement Collaborative in Surrey. Emma is leading on developing and designing the surrey Improvement Collaborative and Improvement training course that will run alongside the collaborative. The view is that the different Improvement Leaders within the Network will help facilitate the collaborative learning sets and teaching of improvement topics/modules. We are keen to measure the impact of this work and are working on developing a set of measures to support this. In addition, Emma is also working with Mark to scope and develop an Improvement Coaches course that the network could offer and deliver across Surrey. This would be a course that combines different improvement frameworks, methods and tools and coaching. This will help increase the number of improvement experts/coaches we have across the wider Surrey system and help support the success of system wide improvement work. This course is likely to be most appropriate for individuals who already have experience of running improvement projects and have a good levels of improvement knowledge. Other QI networks and connections We continue to be part of the South of England Mental Health Improvement Collaborative. Simon is a faculty member and Emma is our Programme Manager. At the last collaborative meeting, Simon and Emma delivered a teaching session on the Lens of Profound Knowledge and we invited staff from inpatient services to attend the collaborative alongside our QI Team as the focus was on restrictive practices. We are hoping to join the next collaborative session, which is going to be run virtually. We are also part of the IHI European Alliance that meets four times a year at different locations. Unfortunately, the last in-person meeting was cancelled however we look forward to the opportunity to be able to connect with Alliance members again in the near future. During the Covid-19 period, we have set up a new network/group called Connecting Improvers in partnership with the Q Community. As an improvement team, we were discussing how it would be helpful to understand how improvement teams are and could support services during Covid-19 and set up a zoom call back in March. We had people join from different improvement teams across the country, who were keen for the conversation and network to continue. Q community offered their support to help with facilitating this and we had the second call at the end of May where we focused on developing virtual improvement training. Since then we have also set up a Q Community Special Interest Group to share learning and ideas around virtual training. We are planning the next call with a focus on how we connect with and engage people who use services and carers in improvement work. COVID-19 Recovery plans for QI Quality Improvement is a vital part of how we learn quickly, measure the impact of changes and sustain any improvements. The Improvement Team will be vital in helping support the Trust wherever possible with our recovery and restoration ambitions. Quality Improvement methods and tools will help us in taking forward

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new ways of working and testing changes within our services. We have been working closely with Working Age colleagues to think about how we empower frontline teams to lead on improvement work that has surfaced as being urgently required during this Covid-19 Pandemic and are looking into using an improvement approach to review observations in our inpatient services. Our Improvement Team and improvement methods/tools will be helpful and important in helping us adapt, implement, spread and sustain the innovations that have developed through the Trust’s response to COVID. We have strong knowledge and expertise in developing Quality Control Systems and scaling up/spreading changes that have evidently resulted in improvement. The members of our Quality Improvement Management Team are experienced in leading both project and strategic level Quality Improvement work and will be able to provide guidance and support to the Trust as we move forward with our recovery plan. Our QI Leadership team has meetings in the diary to plan and discuss recovery plans for QI. One of the things we are keen to think about is the best way to manage our team’s capacity and different skills/expertise. We are currently reviewing our training content and thinking about how we can adapt this to a virtual training course. Prior to Covid-19 we had discussed the possibility of another band 7 QI Lead as a 12 month secondment to focus on suicide prevention improvement work and a People Participation and Improvement Manager who would help us increase people participation work in the Trust and increase the number of improvement projects involving people who use services and carers. We know from other Trusts that projects are more likely to see sustained improvements if they involve people who use services and carers at the very beginning and throughout. We had to pause recruitment during the initial Covid-19 period but are keen to progress with this as part in the near future. Risks and Issues

Risk/Issue Possible solution

Team Capacity – we have had a Working Age Adult (WAA) vacancy for over 12 months, we have recruited into this post and they are starting in Sept. In addition, we need additional QI lead capacity to support the demand on the service.

• Recruiting into a lead People Participation and Improvement Manager (will have one day a week equivalent for QI) which will also release time for the head of Participation, Experience and Improvement to support QI work

• Possibility of recruiting into a 12-month secondment of a QI Lead to be additional floating QI support and/or another substantive QI Lead post.

Engagement with QI framework and models – varied adherence to QI models, we have many projects that do not use PDSA (Plan, Do, Study, Act) cycles and/or measurement

• Refocus on doing the basics/fundamental QI work well and revisiting training content to ensure focusing on this.

Use of data and measurement – a number of the SPC charts on DART are incorrect and we have different teams applying different rules to determine special cause variation.

• Agreeing to adhere to one set of rules (the rules we teach, based on IHI rules are the strongest statistically, 8 points for a shift, 6 for a trend).

• Strengthen connection and Head of QI be part of the discussions around the SPC platform to ensure it is able to produce accurate SPC charts.

Accountability and ownership at a divisional level

• Introduce QI Sponsor roles – those in leadership positions in the divisions, who are able to unblock barriers to a project progressing take on a sponsorship role. Each project has a QI sponsor.

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Date 8th July 2020

Item No 69.20

Paper Title Monthly Risk Report

Director Heather Caudle, Chief Nursing Officer Author: Bali Master, Risk Manager


Discussed to date and next steps Discussed at the Quality Risk and Safety Committee and Executive Board Next steps – Continued review and update of overdue risks and actions

Purpose of the paper The Board are asked to comment on and note the following: • The risk profile of the Trust including the Covid-19 risks • Current risks with extreme residual risk ratings • New risks


Effective risk management ensures the Trust’s ability to deliver safe and high-quality care


The high-level risk register is a critical component of ensuring that the Trust has clear oversight of its organisational risks, which demonstrate and deliver against the Key Lines of Enquiry (KLOE’s).


The report supports effective risk management.

Data Protection Impact Assessment (DPIA)

Not applicable

Outcome of Equality Analysis Not applicable

Financial Implications There are financial implications if the Trust does not manage risk effectively. This report supports effective risk management.

Executive Summary The Trust Risk Register holds a total of 142 approved risks compared to 145 reported in the previous month. A total of 107 risks, (previously 118) are of an Extreme, or High nature and therefore, meet the criteria for the ‘High Level Risk Register’

➢ 13 risks have a residual rating of extreme risk (previously, 18) ➢ 94 risks have a residual rating of high (previously, 100) ➢ 1 new high-level risk was recorded and approved for the high-level risk register ➢ 3 risks were considered as mitigated and therefore, closed

Positive Findings

• The Trust holds a robust risk register, which includes risks associated with Covid-19 that have the potential of having a detrimental impact on the Trust.

• In response to the disproportionate impact that Covid-19 is having on Black Asian and Minority Ethnic (BAME) colleagues and wider, the Trust recognises the potential consequences of this risk and in response has developed a ‘Risk Assessment Tool during the Covid-19 Pandemic – Working Together to Save Lives’ for staff to complete. This tool will help to understand individual risks to staff and respond accordingly. The two meetings hosted by the Chief Executive to discuss the impact of Covid-19 on BAME colleagues have been very successful. These meetings have given BAME colleagues and wider staff a platform to be able to feedback and directly share their experiences and concerns.


• All Divisions to ensure that overdue risk review requests are responded to in a timely manner.

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1. Introduction

This report is an executive summary of the Trust Risk Register for May 2020. The report highlights:

• Risks with residual risk scores assessed as extreme

• Risks associated with Covid-19

• The number of risks linked to staffing and capacity

2. Risk Register Report

The risk rating summary for all extreme and high-level risks across the Divisions and Corporate services:

Division TRR New Closed Adequacy of Controls

Residual Risk Score

AD PAR IN UN 8-12 15-25

Corporate 31 1 1 24 6 1 23 8

Children and Young People Services 22 13 5 4 20 2

Working Age Adult Mental Health 16 1 10 6 15 1

Older People Mental Health 19 18 1 17 2

Learning Disabilities 10 9 1 10

Directorate of Finance 1 1 1

Specialist Services 8 1 8 8

Totals - May-2020 107 1 3 83 18 4 2 94 13

Totals - Apr-2020 118 63 0 93 19 4 2 100 18

Totals - Mar-2020 55 6 3 41 13 0 1 46 9

Totals - Feb-2020 50 2 0 41 9 0 0 45 5

Totals - Jan-2020 48 18 3 39 9 0 0 43 5

Totals - Dec-2019 31 3 0 22 8 0 1 28 3

Totals - Nov-2019 32 0 0 23 8 0 1 29 3

Totals - Oct-2019 32 0 1 23 8 0 1 29 3

3. Extreme risks that were reviewed in May

Risk of Psychiatric Intensive Care Unit (PICU) patients being displaced due to Rowan Ward being designated as Covid-19 Ward leading to sub-optimal patient care The risk concerning Rowan Ward being used as a designated ward to support those in-patients who tested positive for Covid-19 was closed. This decision was evidence-based as the completion of a testing programme of all in-patients and new admissions showed that there were very low numbers of confirmed Covid-19 cases. Results from the wards revealed that 96.45% of all tests were negative, 0.39% were positive and 3.16% were inconclusive. Due to these very low numbers and unless, demand changes, Mulberry Ward will host Working Age Adults who are Covid-19 positive and Older People with Learning Disabilities will be isolated on their local wards and in exceptional cases will jointly use Primrose 3. Restoring Rowan Ward to a PICU has meant that timely care can be provided to people that require this level of support. A further five extreme risks relating to Covid-19 were reviewed, which all achieved a reduction in residual risk ratings and as a result, do not fall into the ‘Extreme Risk’ category. These risks are summarised in the table below:

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ID Opened Directorate Title Risk Review -Update Previous

Risk Rating

Residual Risk

Rating

2474 17/04/2020 Working Age Adult Mental Health

Risk of shortage of swab testing for Covid-19 leading to infection

[24/05/2020] Staff and patients have been tested as part of a national trial. This took place on 28th & 29th April and in excess of 500 staff and service users were tested. Processes remain in place for staff testing. Pilot at Gatton place starting 15/05/2020 to support plans for wider testing. Digital will be supporting the pilot to support efficiency of the process. The successful completion plan is to implement this across various sites across the localities. The plan is to test staff and high-risk service users going forward.

16 12

2481 20/04/2020 Corporate Risk of failings to provide governance arrangements to support efficient, effective & values driven decision making

[24/05/2020] SABP moved into Major Incident command governance structures early in response to Covid-19. Kept under continued review and enhanced in response to learning and experiences throughout e.g. early introduction of rotas to ensure key team members get rest, enhancement of arrangements with addition of CRG, work to clarify respective roles and responsibilities and decision-making authority as it became clear confusion existed. These arrangements have been reviewed at Exec Board regularly, informally by the NEDs and formally at the Board meetings which have / are taking place. The approach to Recovery and Reformation has been tested with our Leadership Forum community.

15 10

2495 21/04/2020 Learning Disabilities

Risk of increases to waiting lists due to lockdown leading to delays in access to treatment

[24/05/2020] This risk has reduced slightly, as the teams are making good use of Attend Anywhere to support urgent appointments.

15 12

2521 23/04/2020 Children & Young People Services

Risk of a lack of identifying Safeguarding issues concerning vulnerable service users leading to potential harm

[18/05/2020] Clinics are in place in Cobham. The service is also now commissioned to provide a consultation and advice line up until 10pm 7 days a week.

16 12

2523 23/04/2020 Children & Young People Services

Risk of shortage of swab testing for Covid-19 leading to infection

[18/05/2020] Currently there do not appear to be any shortages.

16 8

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4. Risks with Extreme Residual Risk Ratings

The risk rating summary for all extreme risks across the Divisions and Corporate services is provided in the table below. ID Opened Directorate Title Residual

Risk Rating

COVID-19 Risk

2465 01/04/2020 Corporate Risk of national shortage of Covid-19 testing kits leading to compromised service user and staff safety

20 COVID-19

2458 12/03/2020 Corporate Risk of CoVID-19 impacting business continuity leading to the potential of unsustainable services

20 COVID-19

2461 17/03/2020 Older People Mental Health

Risk of COVID-19 widespread among service users and staff leading to disruption to services, supplies and closure of premises

20 COVID-19

2410 23/01/2020 Corporate Risk of new social care referral pathways causing delays leading to an adverse impact on service user/carer experience.

16

2408 23/01/2020 Corporate Risk of reduced staff capacity as a result of Section 75 leading to compromised functioning of the Team

16

2534 28/04/2020 Older People Mental Health

Risk of reduced bed capacity as a result social distancing in dormitories leading to admissions elsewhere

16 COVID-19

2545 29/04/2020 Children and Young People Services

Risk of lack of provision because of Covid-19 of refeeding bloods leading to risk of refeeding syndrome – Adult Eating Disorders

15 COVID-19

2526 27/04/2020 Children and Young People Services

Risk of a lack of access to urgent medical testing (Bloods/ECG) leading to harm – Children Eating Disorders

15 COVID-19

1644 19/10/2016 Corporate Risk of Cyber-attack potentially leading to loss of data

15

2549 11/05/2020 Corporate Risk of people from a BAME background being disproportionately impacted by CV-19 leading to higher risk of harm from the virus

15 COVID-19

2466 03/04/2020 Corporate Risk of a national shortage of PPE due to high demand in response to Covid-19 leading to compromised clinical safety

15 COVID-19

2237 07/12/2018 Corporate Risk of unsustainable inpatient beds & bed occupancy (out of area) leading to potential poorer outcomes for people

15

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1817 31/03/2017 Working

Age Adult Mental Health

Risk of bed occupancy being consistently over 85% leading to delays in access to acute emergency treatment

15

5. New Risks

ID Opened Directorate Title Trust Action in Response Residual

Risk Rating

2549 11/05/2020 Corporate Risk of people from a BAME background being disproportionately impacted by CV-19 leading to higher risk of harm from the virus

1. Impact of Covid19 on BAME - Trust Response Meeting chaired by Fiona Edwards to be held on the 11/05/2020 at midday and a further meeting on the 04/06/2020. 2. A unique risk assessment tool has been developed, which Line Managers will use to assess individual staff and their risk factors to understand what support is needed.

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6. Risks Closed

The following three high level risks were closed during May:

ID Opened Directorate Title Residual Risk

Rating

Closed date

Rat

ion

ale

for

clo

sure

of

risk

s

2437 06/02/2020 Corporate Risk of over stretching our ability to deliver services well at the same time as introducing new ways of working

8 19/05/2020

[24/05/2020] As part of our response to Covid-19 we reviewed our annual plan projects to prioritise and accelerate those plans which could be implemented as part of our response. All other projects were paused with the exception of our 24/7 Programme which was adjusted to enable it to meet its target for OBC to Trust Board in June as planned as business critical. Covid-19 response in line with clinical strategy and delivery of LTP priorities. Planning suspended nationally whilst Covid-19 incident being managed. Final contract negotiations cannot be concluded until this resumes. We will take stock of Annual Operational Plan and status of key projects and reset priorities for the remainder of the year taking into account the accelerated progress and learning (gains) from Covid-19 into our plans for 2020/21. This will also include planning for potential second peak / rise in demand for mental health services across the system as a result of Covid-19 experiences. Risks to Plan delivery will be reviewed as part of this reset and any new risks identified.

2498 21/04/2020 Specialist Services

Risk of people with an alcohol dependency not being able to access alcohol leading to severe alcohol withdrawal symptoms

12 13/05/2020

[24/05/2020] The has been no indication of any shortages of alcohol and no reports from service users that they have not been able to obtain alcohol.

2548 30/04/2020 Working Age Adult Mental Health

Risk of PICU patients being displaced due to Rowan Ward being designated as Covid-19 Ward leading to sub-optimal patient care

16 01/06/2020

[01/06/2020] Rowan Ward has been restored as Psychiatric Intensive Care Unit.

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7. Thematic Review – All Risks Linked to Staffing and Capacity

A total of 31 risks (29% of all high-level risks) are linked to staffing and/or capacity. Of these, 11 are as a direct consequence of Covid-19.

ID Directorate Title Opened Residual

Risk Rating

1817 Working Age Adult Mental Health

Risk of bed occupancy being consistently over 85% leading to delays in access to acute emergency treatment

31/03/2017 15

1865 Corporate Risk of inability to deliver care at correct level due to the number of registered nurses in post being lower than required

06/06/2017 12

1891

Children & Young People Services

Risk of a national shortage of Tier 4 Child & Adolescent Mental Health Services beds leading to service users being placed out of area

20/07/2017 9

1949


Risk of unacceptable waits for treatment leading to negative impact for children with developmental disorders

02/10/2017 9

2051


Risk of the number of referrals exceeding contracted levels leading to compromised standards of care

21/02/2018 9

2237 Corporate Risk of unsustainable inpatient beds & bed occupancy (out of area) leading to potential poorer outcomes for people

07/12/2018 15

2263 Corporate Risk of the revised Section 75 agreement may lead to significant operational impact on current integrated services

04/02/2019 12

2279


Risk of insufficient substantive Psychiatrists leading to compromised quality of care

05/03/2019 9

2309 Learning Disabilities

Risk of delay in communication with people who use our services leading to delays in timely treatment

09/05/2019 8


Risk of reduced staffing levels leading to unsatisfactory levels of care impacting a number of primary services

25/06/2019 12


Risk of insufficient staffing levels due withdrawal of Section 75 leading to compromised patient safety

10/09/2019 12

2408 Corporate Risk of reduced staff capacity as a result of Section 75 leading to compromised functioning of the Team

23/01/2020 16

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2410 Corporate Risk of new social care referral pathways causing delays leading to an adverse impact on service user/carer experience.

23/01/2020 16

2411 Corporate Risk of a lack of Hospital Discharge Team leading to an increase in DTOCs/ALOS (and potentially additional OAPs)

23/01/2020 12

ID Directorate Title Opened Residual

Risk Rating


Risk of short staffing at Rosewood leading to stress to staff team and potential impact on quality of service delivery

23/01/2020 9


Risk of loss of 9 beds in East Surrey due to Notice of Termination leading to shortage of beds

27/01/2020 9


Risk of an unmet need of chest physiotherapy leading to compromised patient health

29/01/2020 8

2432

Older People Mental Health

Risk of reduced psychology provision in the SW team leading to an increase wait times

03/02/2020 12

2485


Risk of lack of clarity concerning staff redeployment leading to deteriorating staff morale

20/04/2020 12 Covid-19

2492 Specialist Services

Risk of staff shortages as a result of Covid-19 leading to inadequate service provision

21/04/2020 12 Covid-19


Risk of increases to waiting lists due to lockdown leading to delays in access to treatment

21/04/2020 12 Covid-19


Risk of reduced capacity for seeing new people in Adult ADHD Clinic leading to further access delays to service users

21/04/2020 12 Covid-19


Risk of increased waiting times leading to people waiting longer to be seen

21/04/2020 8 Covid-19


Risk of staff shortages as a consequence of Covid-19 leading to failure to provide adequate services

22/04/2020 9 Covid-19

2517


Risk of staff shortages to cover shifts leading to increased agency costs

23/04/2020 12 Covid-19

2518


Risk of staff resignations due to redeployment leading to deterioration in staff morale, retention and increased anxiety levels

23/04/2020 8 Covid-19

2520


Risk of reduced bed capacity due to care homes being affected by Covid-19 leading to delayed discharges

23/04/2020 9 Covid-19

2534


Risk of reduced bed capacity as a result social distancing in dormitories leading to admissions elsewhere

28/04/2020 16 Covid-19

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2540 Specialist Services

Risk of lack of clarity concerning staff redeployment leading to deteriorating staff morale

28/04/2020 12 Covid-19

2549 Corporate Risk of people from a BAME background being disproportionately impacted by CV-19 leading to higher risk of harm from the virus

11/05/2020 15 Covid-19

8. Conclusion and Recommendations

A total of 61 high level risks were reviewed and updated during May, which resulted in the following movements in residual risk ratings: -

Directorate Down Same Up Total

Older People Mental Health 1 16 17

Children and Young People Services 2 10 12

Learning Disabilities 3 5 1 9

Working Age Adult Mental Health 3 5 1 9

Specialist Services 7 7

Corporate 2 4 6

Directorate of Finance 1 1

Total 11 48 2 61

The 2 risks that resulted in increased risk were as a result of the following updates: -

ID Primary Service

Title Opened Risk Review -Update Residual Risk

Rating

2171 ADHD Surrey

Risk of long waiting lists for the Adult ADHD Service leading to people waiting a lengthy period for assessment and treatment.

27/09/2018 [24/05/2020] This risk has increased due to the reduction in face to face appointments as a result of Covid-19, we have implemented the use of Attend Anywhere to ensure we can continue to offer follow up assessments however it is not always possible to undertake new patient assessments in this way .

8

2479 Adult Mental Health – Trust-wide Risk

Risk of deteriorating mental health due to Covid-19 leading to increased pressure on services

17/04/2020 [24/05/2020] Recently there has been a 50% increase in calls coming through to the crisis line. Pressures on services are being regularly reviewed through our locality meeting.

12

Whilst there has been good progress in reviewing and updating risks during May, it should be noted that 40 remain overdue review. Therefore, it is recommended that these are completed to ensure that the Board are fully apprised of all risks held on the high-level risk register.

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Date 8th July 2020

Item No 70.20

Paper Title Value for Money (Month 02 – May 2020)

Director Graham Wareham – Chief Finance Officer


Discussed to date and next steps Value for Money performance is reviewed monthly by the Director of Finance and Chief Finance Officer. Finance Business Partners review performance monthly with Divisional Directors and their budget holders.

Purpose of the paper The Board is asked to note the report and the following matters in particular:

• A breakeven position for May


Control of our finances demonstrates a commitment to honesty, openness and integrity.


Delivery of the Trust’s financial targets will help to ensure the sustainability of services and that the Trust remains in control of its services.


All areas of savings have been assessed to ensure that there is no adverse impact on any particular group of staff or services users.


Not Applicable


No impact

Financial Implications The attached report highlights the current financial position and forecast to year-end.

Executive Summary This paper summarises key messages from the Month 2 (M2) financial results.

Positive Findings

• SABP reported a break-even position for May

• Strong cash position


• Covid-19 spend is 6.8% of our total expenditure for May

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1. 2020/21 Value for Money Headlines

1.1. As part of NHS Improvement/England (NHSI/E) response to Covid-19, NHSI/E have removed

local financial arrangements between commissioners and providers, and instead calculated block payments that commissioners should pay providers for the period of 1st April – 31st July 2020. NHSI/E have also made a central top up payment to providers.

1.2. Where providers expenditure exceeds their income, an additional central top up payment will be

made. Where providers expenditure is lower than their income, a payback of the top up payment will be made. This has been referred to as a true up exercise. Providers have been asked to accrue this top up income/payback into our April position to ensure providers report a break-even position.

1.3. As a result of this, the Trust reported a break-even position for May. This included a provision to pay back £1.3 million of the central top up payment. Of this £1.3 million, £1.2 million of the provision is due to an overpayment for one of our contracts, this has occurred due to the way the block contract was calculated.

1.4. The May spend relating to the Trusts response to Covid-19 totalled 6.8% of the Trusts total expenditure.

1.5. The Trust position is shown in Appendix 1.

2. Agency Usage

2.1. The Trust agency ceiling has increased from £5,810,000 per annum to £8,374,000 per annum in

2020/21.

2.2. The Trust’s year to date agency spend was £2,082,000; £868,000 above the ceiling. This equates to 49%.

3. Cash Flow

3.1. The Trust continues to manage its cash well and had a cash holding of £90.7 million at the end of

May.

4. Conclusions and Recommendations

The Board is asked to note the report.

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Appendix 1 – 2020/21 Financial Position

NHSI are monitoring us against a break-even budget during the Covid-19 response. There will be a slight discrepancy between our monthly budget for April and May, which will correct itself for June, the end of Quarter 1 (Q1). This is due to the phasing of FRF (Financial Recovery Fund), which has been phased in the budget to be received on a quarterly basis but will actually be received on a monthly basis as part of the NHSI (NHS Improvement) top up payment until July.

Trust Board Director Division

YTD Budget

£m

YTD Actuals

£m

YTD (Over) /

Under Spend

£m

Chief Operating Officer Adult Mental Health (6.822) (6.614) 0.208

Children and Young Peoples Services (0.010) (0.155) (0.145)

Chld and Fam Hlth Surrey (0.001) (0.076) (0.076)

Chief Operating Officer (0.084) (0.072) 0.011

Delegated Commissioning 0.068 0.196 0.128

Learning Disabilities Services (1.224) (0.879) 0.345

Older People Mental Health (2.605) (2.578) 0.027

Specialist Services 0.078 0.382 0.304

SCFHS Division (0.022) (0.022) 0.000

CAMHS T4 - 0.004 0.004

Chief Operating Officer Total (10.622) (9.813) 0.808

Chief Executive (0.165) (0.138) 0.027

Chief Information Officer (0.886) (1.001) (0.115)

Chief Medical Officer (0.678) (0.747) (0.070)

Chief Nursing Officer (0.613) (0.592) 0.021

Director of Workforce (0.594) (0.551) 0.043

Director of Innovation Innovation (0.302) (0.247) 0.055

Primary Care Mental Health 0.066 0.066 0.000

Chief Finance Officer Finance, Property, Procurement and Comms (3.239) (3.336) (0.097)

Corporate Total (6.411) (6.546) (0.135)

Chief Finance Officer Other (eg sale proceeds, PSF, Income) 16.778 16.360 (0.418)

Surplus / (Deficit) (0.254) 0.001 0.255

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1


Date 08th July 2020

Item No 71.20

Paper Title Briefing on current emotional wellbeing and mental health service delivery and CFHS due to Covid-19 (CV-19)

Director Trudy Mills, Integrated Care System (ICS) Director for Children's and Learning Disabilities (Children and Family Health Surrey (CFHS))


Discussed to date and next steps Contents of the paper have been discussed on the daily children’s CV-19 teams call – chaired by Trudy Mills

Purpose of the paper To note the service changes and performance in response to the CV-19 pandemic and ongoing planning for any further surges and transformation opportunities.


Caring: providing treatment for children and families closest to home and in the least restrictive environment Responsive: ensuring processes for can quickly respond to changes in children’s need Safe: providing the right environment for the needs of the patient with the oversight of professionals that know them Effective: providing prompt and outcome-based care in the right environment Well-led: joint approach between health and social care too oversee children with complex needs


We know we do our best for people when we do it in partnership with others. Partnership working helps us to deliver our clinical strategy of bringing mind and body health care together


ICS Project Management Office (PMO) weekly returns on decisions taken, risks and mitigations and CV-19 resource expenditure. All children services have followed national guidance and community prioritisation framework when taking any decisions to reduce, pause or continue services.


Not Applicable


Not Applicable

Financial Implications Some COVID Expenditure

Executive Summary The children’s and young people’s (CYP) Child and Adolescent Mental Health Services (CAMHS) services response during the pandemic CV-19 continues. There has been an incredible response from all services ranging from early intervention and support to schools during lockdown – through to crisis support and work to support our Acute hospital to reduce admissions and A&E diversions. Work with our partners to anticipate predicted surge in demand with the phased return of schools re-opening has commenced alongside continued transformation of services. The CFHS partnership have responded to the CV19 pandemic in innovative and creative ways which has ensured that families in Surrey can continue to access vital services. The connection between operations in Developmental Paediatrics (SaBP) and First Community Health Care (FCHC) / Central Surrey Health (CSH) has strengthened over this period with valuable benefits for each service. Digital advances have been welcomed by all over this period but note that some families have not been able or not chosen to engage via this modality. Relationships between CFHS and other Surrey children’s providers have also strengthened through the course of the pandemic. Of particular note is the cross over between Education and CFHS in particular and this relationship is building steadily. Work is re-starting related to First 1000 Days, 0-4 SEND and the Autism Strategy in the coming week

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Positive Findings

• Significant improvement on Single Point of Access (SPA) backlog numbers/demand increasing

• Response to CV-19 – rapid transformational change across all service lines that is sustained

• Maintained service provision under very challenging circumstances supported by a RAG rating to ensure high/risk and vulnerable CYP are receiving support

• Further strengthened partnerships arrangements across the system (voluntary organisations and local authority) to support Early Interventions and the counselling offer

• Proactive management of increasing crisis cases

• Work has commenced to commission additional capacity to manage a backlog in the diagnosis of Autism Spectrum Disorder (ASD)

• Weekly CFHS calls and Women’s and Children’s calls to monitor risk and progress as well as plan restoration and recovery


• Waiting times for treatment and diagnosis of ASD – for some families attend anywhere and virtual appointments has not always been accepted or appropriate, therefore the waiting times for treatment have not reduced in the same way as demand has within the SPA.

• Possible significant impact delivery of immunisations in September due to CV-19

• Ventilator disposables/filters limited availability

• No clarity as to detailed phased return to school plans across the year groups which impairs planning

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Purpose of the report To provide an overview of the key issues and performance of the Children’s programmes within Surrey Heartlands ICSs (Integrated Care Systems) during the pandemic Covid-19.

Children’s emotional health and well-being services.

All services continue to run, albeit delivered slightly differently including making the most of digital technology. There is a daily children’s system call where Child and Adolescent Mental Health Services (CAMHS) identify any staffing and other risks. Workforce levels have remained stable with contingency plans in place if back up staff are required. There are sites that are working which can see high risk children and young people face to face, whilst abiding to Personal Protective Equipment (PPE) and social distancing rules as far as possible. CAMHS - Single Point of Access (SPA) performance update During the pandemic the number of referrals coming through the SPA had significantly fallen, but in the past 3 weeks have climbed and are now in line with previous year’s numbers. (see diagram 1) Diagram 1.

During weeks 51 and 52 of 2019-2020 and continuing into weeks 1 -8 of 2020-2021 there was a large drop in referrals coming into SPA. During this time the Covid-19 pandemic meant schools closed (except for vulnerable children and children of key workers) and members of the public were self-isolating at home. GP’s remained open and CAMHS SPA remained open to all referrals. Because of the reduced numbers of referrals, the team has successfully reduced the routine backlog (Diagram 2). Through the complexity and service changes that have put in place it has provided the team the opportunities, such as time and space to manage the backlog, develop new systems and expedite progress towards clearing the backlog and getting back to a steady state.

0

0.2

0.4

0.6

0.8

1

1.2

0

50

100

150

200

250

300

350

400

450

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

Annual referrals through CAMHS SPA

18/19 Hols 19/20 Hols 20/21 Hols 18/19 19/20 20/21

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• The total caseload as of the w/e 21/06 is 429

• 246 routine cases

• 183 Behavioural, Emotional and Neurodevelopment (BEN) cases – 160 of these cases relate to the return of clinical assessment questionnaires.

Diagram 2

There steady number of calls to the SPA which has slightly increased to approx. 300 per week in the last 2 weeks.

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Children and Young People (CYP) Covid-19 response

CAMHS Improvement and Development Highlights

Counselling Services Kooth have received 20% uplift to the contract to extend the service to children aged 10 years and above and in recognition of usage beyond contracted levels. Since May usage has risen to 96% of the new target. The following table details activity to each of the counselling partners that form ‘EIKON’. It is of note that a significant number (double the number of other partners) are triaged to Learning Space.

Three new partners have been included in the monthly figures for the new financial year. The new Partners are LYP, Leatherhead Youth Project, Matrix Trust – and E2W, East to West. Agreement has been reached for 19/20 activity with Eikon. A new role will be introduced to support triage for counselling in the CAMHS SPA. Additional in year resources will be required to support 20/21 demand and the anticipated surge.

To manage demand for Learning Space the criteria for access has been refined to cater for under 11-year olds. Other counselling partners will absorb the additional demand for over 11-year olds.

May 2020 data details the following waiting data which is a measure of how long CYP have waited once they have been seen:

Referral to assessment Assessment to treatment

Month BEN Pathway CT CAMHS BEN Pathway CT CAMHS

Apr-20 140 72 94 38

May-20 145 62 49 27

CAMHS Community Teams

The numbers of children and young people waiting for assessment and treatment has increased due to moving the backlog from CAMHS SPA. There is an increase in crisis presentations due to the impact of Covid-19 which has impacted on routine interventions.

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Teams responded rapidly to the pandemic providing alternative interventions with video and telephone appointments replacing clinic appointments. Face to face appointments have continued for Red rated cases to prevent young people escalating into crisis. Similarly work continues to ensure all young people are suitably ragged at a system level to support placements, mental health needs and young people who require social care support or have special educational needs. Teams are continuing to manage waits by introducing more group interventions as mentioned previously however, these are now being developed virtually and the digital team have been able to support us with improvements to teams to allow groups to start to take place. Feedback from children and families has demonstrated that some young people prefer the virtual offer especially those who are harder to engage such as our ‘Mindful’ cohort. RAG rating workshops are ensuring that we have a robust system to support young people waiting and our new divisional outcomes group plans to ensure that we are embedding a sound ‘I Thrive’ culture which is realistic, goals led and co-produced by children and families to minimize the need for a number of different interventions. Work has commenced around more assertive outreach posts particularly to manage the demand of behavior difficulties due to family and relationship issues acerbated by the restrictions of Covid-19 and school closures.

Psychiatry posts continue to be difficult to recruit to despite a comprehensive and assertive approach to marketing. We continue to expand the nurse prescribing development posts. Support to Education Primary Mental Health Workers and Child Wellbeing Practitioners have continued to support schools throughout Covid-19 and have developed a large range of on line resources for children, families and teachers. Children who are Looked After services The CAMHS children in care team have increased their support to social care teams, residential placements and foster carers to support placements for young people looked after as well as providing unique resource packs for this vulnerable group. The personal health budget pilot for looked after children has commenced and is being utilised well, and even with the impact of Covid-19 altering some of the potential community options, it appears to be delivering promising outcomes, with a plan to roll out to more young people and families.

Behavioral Emotional and Neuro Developmental Pathway

There are 1,160 CYP on the Autism Spectrum Disorder (ASD) pathway. The potential wait is at least 3 years. 389 CYP are on the Attention Deficit and Hyperactivity Disorder (ADHD) pathway. The team have continued to refine the pathway and CYP and families are supported to access available resources from our partners and nationally at the point of referral. Additionally, the team are developing a family perspective ‘journey to diagnosis’ fact sheet which we hope will provide clarity to empower families to access and apply needs led support. Commissioners from health and social care are working with us to support a revised pathway and to consider how we manage system expectations for CYP with neurodevelopmental need which includes the potential of contracting with a provider partner to undertake 600 ASD cases over a 5-month period. At a system level the Autism Strategy is being developed with revised governance arrangements and renewed emphasis on delivery.

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Children’s Eating Disorders (CEDs)

CEDs are doing the majority of work remotely. Patients are already risk assessed in both services and RAG rated according to MARSIPAN community guidance, with urgent and Amber cases prioritised and ‘seen’ more regularly. Initially, all green cases were paused but still risk managed. This is gradually starting to ease, as we all get more used to remote methods of practice. All patients that were able to self-monitor weights and BP, were given guidance and support on how to do this at home so that the focus of the work could be on the highest risk. CEDS are starting to re-introduce face to face assessments partially, as we noted that CYPS did better with this than on a remote platform. Both services have set up weekly Physical Health clinics to see the most vulnerable. All assessments, and assessment and treatment access waiting times (AWT) targets are being met but managed remotely.

Crisis Support

An Emergency Duty team triage nurse post was implemented at the beginning of the pandemic to broker calls to extended Hope, and provide signposting advice and consultation for young people and families who have been struggling, but who do not necessarily require extended Hope support. This has proved a valuable resource to reduce the need for young people presenting at accident and emergency units with about 50 calls made a week in the last 5 weeks. The crisis team was bolstered and offered alternative venues to assess children to deter from presenting at A&E. There is a notable increase in social care needs that was expected due to lockdown and anxiety due to returning to school and acute psychiatric liaison colleagues report an increase in domestic violence, and substance and alcohol use during the Covid-19 period. A Crisis Flow Chart details the 24/7 pathway for support to CYP in Crisis. This has been circulated again to all District General Hospitals (DGH’s) and Clinical Commissioning Groups (CCG’s). Successful Mental Health in Schools Team Bid Surrey Heath and Surrey Heartlands have been successful in their bid to host 3 Mental Health Support Teams (MHSTs) in Surrey. These teams are able to offer early intervention mental health support to parents of primary and secondary aged children and directly with secondary aged young peole with mild mental health problems. They will also work closely with the school staff to embed the Whole School Approach. Each team will consist of a clinical lead, four Education Mental Health Practitioners (EMHPs) and 2 early intervention workers. Training for the teams will be provided by Sussex University from mid-November and then to start their training in the school setting in early 2021.Each team will work with a small number of schools initially and then gradually increase to serve up to 8,000 primary and secondary aged children. Children and Family Health Surrey (CFHS) – Therapies Therapies funding In July 2019 the Surrey Collaborative agreed to the paediatric therapy investment to remove the over 18-week backlog of long waiters and to increase the recurrent Occupational Therapy baseline funding. This funding totalled £825k.

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The improvement trajectory has been revised and progress against this can be seen below. Regular monitoring calls have been reinstated and the data is being analysed through the BI portal, which includes both Central Surrey Health (CSH) and First Community Health Care (FCHC) data to provide a full picture on therapies performance. As part of the Special Education Needs and Disabilities (SEND) 0-4 Strategy meetings, there are plans to revise the ‘therapies’ pathways, and this is likely to start with Speech and Language Therapy (SLT). An initial workshop will take place on July 9th which will start with the ‘advice and access to SEND support’ element (Thriving and Getting Advice elements of iThrive framework), following which focus will fall upon how families ‘Get Help’ within SEND and hence pick up on this item. Digital CSH are working with EMIS and Care Plus suppliers to replace the two RIO (Electronic Patient Record (EPR)) systems and RIO Child Health Information System (CHIS) under one Clinical Systems’ Transformation Programme. The programme commenced in September 2019 and the CHIS element is progressing well and went live on 10th February 2020. The EPR replacement project is up and running and the fourth phase (of four) is to migrate children’s services to EMIS Web which was planned to roll out in September 2020. There have been unavoidable delays due to Covid-19 and therefore will be some slippage. A revised date for this work to be completed has not yet been communicated by providers. Operations and Performance Waiting Times- Therapies Work has been ongoing through Covid-19 to attempt to continue to reduce the therapies backlog. A number of families have ‘opted out’ of accessing appointments digitally for a number of reasons, such as; competing demands due to home schooling, working from home, preference to access face to face post Covid-19, lack of private space or IT equipment within the home. However, the therapies trajectories have been revised and are on track.

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The CFHS One Stop caseload has decreased significantly to a ‘business as usual’ caseload;

“Target” for context

Increase/ Decrease from the week prior or Date working on

Number Referrals Received

204

Pre Covid-19 = 350

Increase of 18

Number Referrals Completed

225 Target = 350 Decrease of 96

Estimated Caseload

209 Approx. 10-day caseload, Covid-19 adjusted = 400

Increase of 21

Routine Referral Process Time

7 days

Target is 10 days

Now at 10/06/20.

EHCP Process Time

1 day

Target = 2 days

Now at 19-6-20

Developmental Paediatrics Action Plan Tracking

• Did Not Attend (DNA) Rate 11.48%: after an increase in the DNA rate 2 months ago (14.58%) the team have seen 2 consecutive months of improvement in March and April. This may be influenced by the reduced amount of face to face appointments being offered during lockdown. This will continue to be monitored closely.

• Safeguarding Medicals within 24 hours: 95.00%. The team have seen a steady improvement following the successful move to centralise the Rota at Cobham Hospital.

• Number waiting for 1st appointment over 18 weeks (backlog): slight reduction from 209 to 229. Waiting times for some routine work have increased due to temporary suspension of some face to face work during Covid-19 lockdown.

• ADHD pathway: The transfer of ADHD cases to CAMHS is progressing and 150 cases have now been transferred to CAMHS Community teams. Work is now ongoing transferring the remaining cases to the NE and NW areas. There has been a slight delay in completing some of the transfers due to the impact of Covid-19.

• Initial Health Assessments (IHAs): 76% of IHAs were delivered within Key Performance Indicator (KPI) timescales required in April 2020. This is the best IHA performance for 4 months and will reflect the number of IHAS being successfully conducted as non- face to face during Covid-19 Lockdown. The team monitor IHA performance closely and liaise on a monthly basis with Surrey County Council (SCC) colleagues.

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CFHS Risk Register The three top partnership risks that score above 12 remain

• Waiting times - SLT and Dietetics are of particular note, historically this was predominantly workforce related

• Estates – Outstanding estates needs related to audiology

• EPR and CHIS systems - as above

School Aged Immunisations Programmes This was a service that ‘paused’ under the Children’s Covid-19 framework. Key headlines for restoration work;

• Recruitment of approximately 60 new staff, in preparation for childhood flu programme. Awaiting confirmation for the plans against year 7 cohort.

• Proposal made to NHS England for immunisations clinics to restart early and approval granted – working with SCC summer school programme.

• Schedule for September and beyond remains unknown at this stage.

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Version 1.3


Date 8th July 2020

Item No 72.20

Paper Title Report from the Audit Committee of June 2020

Director Jennifer Seeley, Audit Committee Chair / Non-Executive Director Graham Wareham, Chief Finance Officer / Deputy CEO

Report for Information

Discussed to date and next steps The Audit Committee met on 12th June 2020 and this report provides a summary of its business.

Purpose of the paper To ensure that the Board is informed about the work of the Audit Committee.


Reporting back to the board is part of behaving in an open and transparent way


An effective Audit Committee is an important part of our governance that ensures we are well led. The Committee is developing a Control Assurance Map in respect of our objectives


None directly arising from this report, though the work of the Committee is an important part of our risk management system.


Not applicable


Not applicable

Financial Implications None directly arising from this report though the work of the Committee is an important part of our financial and governance control environment.

Executive Summary This paper summarises the 12th June Audit Committee meeting.

Positive Findings

• Good quality statement of accounts, reflecting good input from the finance team working with external auditors


• Relatively little time between this Audit Committee meeting and the meeting of the Board to agree the accounts.

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Introduction

This report provides a summary of the business considered by the Audit Committee on 12th June 2020.

The purpose of the report is to ensure that the Board is sighted on the issues that are discussed by the Audit Committee, and on any emerging issues which may impact the Trust’s governance or controls environment. This was the first Audit Committee for Vivek Govil who is now one of three Non-Executive Directors who form the Committee.

Annual Report and Statement of Accounts

The main business of the Audit Committee was to examine the various documents and supporting reports which, taken together, form the Annual Report and Accounts for the Trust for 2019/10. These include the following:

• Annual report narrative: this includes information about the operation of the Trust, our objectives and performance, and also includes information about remuneration payments to Board Members.

• Independent Auditors’ opinion: this is the formal report from the Trust’s external auditors about their opinion about the accounts. The Trust received a ‘clean’ opinion to say the auditors had not identified any issues of concern.

• Independent Auditors’ report: a longer document which identifies how the external auditors reached their opinion.

• Letter of Representation: a letter to be sent from the Trust to the external auditors, covering some issues on which the auditors required a Trust Board view.

• Annual Internal Audit report: which summarises all the internal audit work completed in 2019/20.

• Head of Internal Audit’s opinion: which assures the Trust that we can have reasonable assurance the controls over the Trust’s activities are in place.

• Counter Fraud Annual report: which summarises counter fraud activity during the year and is a further assurance on the level of controls.

The Committee considered these matters in turn and questioned staff and auditors about their work. The following matters in particular were highlighted and discussed by the Audit Committee

• The agreed delayed capital receipt from the Chertsey land sale agreement.

• Request to highlight the in-year land sale of the West Park site, Epsom, in the foreword due to its significance.

• The limited nature of the valuation of the Trust’s land and property, due to the extraordinary and uncertain impacts of Covid-19 on the future values.

It was noted there had been significant work by staff in the finance team and communications team, as well as by the auditors, to ensure these reports could be produced to such high standard, and the Audit Committee expressed their thanks for this work.

The Audit Committee was content to recommend the reports, with various clarifications to the Board and the Board agreed these at their meeting on 18th June 2020.

Other items

The Annual Report and Accounts are significant items of work, so other business at this Committee was limited.

The Audit Committee received an update on prior year external audit recommendations which showed they had been implemented.

The Audit Committee received the Sealings Register recording the use of the Trust’s seal (a formal legal process) in respect of the sale of the West Park site.

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Identifying issues to the Trust Board This was one of the areas noted in the Audit Committee’s self-assessment. The Committee wished to highlight to the Board the Annual Report and Statement of Accounts, along with the effect of the discussions, and such changes as agreed by the Committee.

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Documents

AGENDA A Meeting of the Foundation Trust Public Board th