Meeting of the Board of Directors in Public - EPUT · 3/23/2016 · MINUTES OF THE MEETING OF THE BOARD OF DIRECTORS IN PUBLIC . HELD ON 27 JANUARY 2016 AT TRUST HEADQUARTERS, STAPLEFORD

Meeting of the Board of Directors in Public

Wednesday 23 March 2016 from 09.00am Stapleford House, 103 Stapleford Close Chelmsford, Essex CM2 0QX

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This Page Deliberately Blank

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors to be held in Public on

Wednesday 23 March 2016 in the Seminar Room, Stapleford House, Chelmsford Essex CM2 0QX at 09.00am

Declarations and Minutes Lead Time Page

1. Apologies for Absence [Receive] CP 09.00 005

2. Declarations of Interest in Agenda Items [Receive] CP 09.00 006

3. a) Minutes of the Meeting held on 27 January 2016[Receive & Approve]

CP 09.00 007

b) Matters arising from the Minutes of the Meeting heldon 27 January 2016 [Discuss]

CP 09.05 019

4. Chief Executive’s Report [Receive] CB 09.05 021

Quality

5. CQC Quality Summit – Feedback [Receive & Note] CB/NH 09.25 023

6. CQC Action Plan Update [Receive & Discuss] NH 09.35 040

7. Monitor Investigation – Feedback [Receive] CB/DG 09.55 054

8. Staff Survey 2015 [Receive and Note] LA 10.05 061

9. Duty of Candour Update [Note] NH 10.20 066

Setting Strategy

10. Operational Plan 2016/17 - Update MC 10.35 081

11. Strategy Update [Receive] a) Delivery of The Trust Strategy ‘All Together Better’

[Note]b) The Success Regime [Consider & Support]

MC 10.45 085

12. Merger with South Essex Partnerhsip University NHS FT: Progress Report [Note and Agree]

MC 11.05 134

Comfort Break

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Monitoring

13. Finance Report for the 11 Months Ending 29 February 2016 [Note]

DG 11.20 139

14. Performance: a) Operational Performance Summary to 29 February

2016 [Receive & Note]DG/VM 11.30 154

b) Workforce Report [Receive & Note] LA 11.40 160

15. Quality Report [Note] NH 11.50 181

16. Ward Staffing Levels – January 2016 [Discuss & Note] NH 12.00 194

Governance

17. Nursing and Midwifery Council (NMC) Revalidation for Nurses [Discuss & Note]

NH 12.10 207

18. Medical and Non-Medical Education Update [Receive & Note]

MF 12.20 210

19. Insurance Arrangements 2016/17 [Note] DG/DMc 12.30 226

Items for Noting

20. Summary of Board Decisions [Note] DMc 12.35 231

21. Execution of Deeds [Note] DMc 12.35 265

Other Items

22. Any Other Notified Business [Discuss] CP 12.40 267

23. Questions from members of the public relating to items on the agenda only [Discuss]

CP 12.45 268

Date of Next Meeting in Public: 25 May 2016 from 09.00 at Stapleford House,

103 Stapleford Close, Chelmsford, Essex CM2 0QX

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North Essex Partnership University NHS Foundation Trust


Agenda item No: 1

Date: 23 March 2016

Title of Report: Apologies for absence

Lead: Chris Paveley, Chairman

Subject, Purpose and Recommendation: The Board of Directors is invited to receive any apologies for absence.

Finance Implications: N/A

Clinical Implications: N/A

HR Implications: N/A

Legal and/or Regulatory Implications: N/A

Equality Implications: N/A

Risks: N/A

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Agenda item No: 2

Date: 23 March 2016

Title of Report: Declarations of Interest in Agenda Items


Subject, Purpose and Recommendation: In accordance with Standing Orders the Board of Directors is asked to receive any declarations of interest from Board members relating to items on the agenda.






Risks: N/A

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Agenda item No: 3a

Date: 23 March 2016

Title of Report: Minutes of the Meeting held on 27 January 2016


Subject, Purpose and Recommendation: The Board of Directors is asked to receive and approve the minutes of the meeting held on 27 January 2016.

Any items of a non-material nature e.g. typographical errors should be communicated to the Trust Secretary in advance of the meeting.






Risks: N/A

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NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST MINUTES OF THE MEETING OF THE BOARD OF DIRECTORS IN PUBLIC

HELD ON 27 JANUARY 2016 AT TRUST HEADQUARTERS, STAPLEFORD HOUSE, 103 STAPLEFORD CLOSE, CHELMSFORD CM2 0QX

Present: Amanda Sherlock, Non-Executive Director and Deputy Chairman Andrew Geldard, Chief Executive Charles Beaumont, Non-Executive Director Mike Chapman, Director of Strategy Dr. Malte Flechtner, Medical Director David Griffiths, Director of Resources Natalie Hammond, Director of Nursing & Quality Jan Hutchinson, Non-Executive Director Brian Johnson, Non-Executive Director Peter Little, Non-Executive Director

In Attendance: Lisa Anastasiou, Director of Workforce & Development Martin Cresswell, Associate Director Communications Pippa Ecclestone, Public Governor Uttlesford Elizabeth Mabbutt, Executive Assistant to CEO & Chairman (Minutes) Vince McCabe, Director of Operations* Dermot McCarthy, Trust Secretary James Moore, Associate Director, Commercial & Service Integration* Andrew Smith, Public Governor, Epping Forest Cathy Trevaldwyn, Public Governor, Chelmsford Brian Weavers, Public Governor, Harlow Clive White, Lead Governor & Public Governor, Colchester

* = Part of Meeting

2016/150 Apologies for Absence Apologies for absence were received from Chris Paveley, Chairman.

2016/151 Declarations of Interest There were no Declarations of Interest.

2016/152 Minutes of the Meeting held on 25 November 2015 2015 The minutes of the meeting held on 25 November 2015 were agreed as a correct record and signed by the Deputy Chairman.

2016/153 Matters Arising from the Minutes of the Meeting held on 25 November 2015

a) Service User and Patient Experience and Involvement – Mike Chapmanconfirmed that the Quality & Risk Committee (QARC) would present anoverview of progress to the Board every May and November. Lisa Anastasiouadvised that, as agreed, an emphasis on customer service was now includedin Corporate Induction.

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b) Finance Report for the 7 Months Ending 31 October 2015 – Vince McCabe advised that the Finance Report and Journeys Evaluation were included on the agenda (Items 11 & 13 of Part 2).

c) Nursing Agency Rules – Lisa Anastasiou advised that this was included on the agenda (Item 14).

d) Questions from Members of the Public - Ligature Point Management and Removal (item g) – Natalie Hammond confirmed that the appropriate levels of support and consultancy had been pursued and were highlighted in Item 6.

The Board of Directors noted the matters arising. 2016/154 Chief Executive’s Report Andrew Geldard highlighted: a) Regulatory Issues: NEP’s submitted financial Monitor Risk Ratings for Quarter 3

was Financial Sustainability Risk Rating (FSRR) ‘1 – Under Review’ reflecting slippage in the sale of Severalls from December to January 2016. This was planned to revert to a ‘2’ by year-end. NEP’s Governance Risk Rating was ‘Under Review’, pending further information from the CQC inspection and the Quality Summit on 04 February 2016. In addition Monitor were expected to carry out an investigation with a two day site visit planned for early February 2016.

b) Assurance and Governance: The Trust had very good relationships with the Trades Unions and was creating an environment where the Junior Doctors could make their protest, but with appropriate systems in place to maintain the quality of services to patients.

c) Business Development: The bid for Suffolk IAPT/Care Cluster 1-4 type services was progressing (value c.£8m).

d) Contracts: Negotiations continued with Commissioners for funding re the second half of 2015/16.

e) Severalls: Andrew Geldard advised Brian Johnson that formal exchange of contracts was scheduled for 29 January 2016.

The Board of Directors noted the Chief Executive’s Report. 2016/155 Nominations Committee Report re the Appointment of an Interim Chief Executive Amanda Sherlock advised that the unanimously preferred, and highly experienced candidate, Chis Butler, would join the Trust on 22 February 2016 to allow a hand-over with Andrew Geldard. The Board of Directors received the report on behalf of the Nominations Committee. 2016/156 Chief Inspector of Hospitals Care Quality Commission (CQC)

Inspection August 2015: Publication of Final Report on 26 January 2016

Following publication of the CQC’s final reports on 26 January 2016, Andrew Geldard and Natalie Hammond gave a presentation covering the process, reporting structure, scores across the five domains, actions to date and next steps arising from the CQC Inspection in August 2015. The “requires improvement” rating was not unexpected and the key issues centred on the adult inpatient wards. The CQC

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would host a Quality Summit on 04 February 2016, jointly chaired with Monitor, where they would present their findings and NEP would present its response and action plan. Amanda Sherlock expressed concern that the CQC’s statement re the report indicated that the Trust had not implemented actions that they had previously recommended, including works at the Linden Centre. Andrew Geldard commented on a previous CQC report re the Linden Centre (May 2015) which had subsequently been withdrawn, which had been generally positive. Andrew Geldard emphasised the need to ensure that the CQC was now confident their recommendations were being acted upon. Natalie Hammond reassured Brian Johnson that the Trust was “on track” to achieve the action plan, a significant piece of work, by the middle of the year.

Brian Johnson and Peter Little commented on the potential for further investment in wards and staffing. Andrew Geldard commented on NEP’s significant capital investment in new facilities (Crystal Centre, Edward House and St. Aubyn Centre). There was now a capital programme of c.£2m in place to address ligature and single sex issues. Andrew Geldard added that further priorities included the S.136 suites, however funding for the future capital programme was an issue because of externally set constraints. In terms of the current programme of works David Griffiths advised that Estates Department had a work plan and progress re urgent issues was monitored weekly. Vince McCabe added that senior managers were walking the wards regularly and reporting any issues for action to the local Quality Improvement Panels (QIPs). Natalie Hammond advised Jan Hutchinson that there was no national guidance on safe staffing levels for mental health as yet. Natalie Hammond then commented that nurse recruitment was a key challenge in the current recruitment market. Amanda Sherlock expressed the Board’s disappointment at the overall assessment of the Trust by the CQC as “requires improvement”. She commented that the balance between quality and finance was always challenging and maintaining a safe service was paramount. She hoped that an Essex-wide Mental Health Strategy would illustrate the key issues for future commissioning. The Board of Directors received the final report from the Chief Inspector of Hospitals Care Quality Commission (CQC) Inspection in August 2015 published on 26 January 2016. 2016/157 Mortality Review at Southern Healthcare FT and Implications for

NEP Andrew Geldard outlined the events at Southern Healthcare FT relating to the death of a learning disability patient which resulted in publication of a report by NHS England in December 2015. The Trust had commenced its own review of mortality resulting in:

• Establishment of a Mortality Policy and Mortality Review Panel • Robust reporting and governance mechanisms to report mortality to the Board

and NHS England through the Board’s Quality & Risk Committee (QARC).

Dr. Malte Flechtner explained the difficulties of defining “unexpected” deaths and justifying the decision whether to investigate or not. Brian Johnson commented on

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the importance of this issue from a reputational perspective. This would be discussed further at the Quality and Risk Committee (QARC). The Board of Directors: i) Received the report outlining themes from the recent Southern Healthcare

Report; ii) Noted and approved the actions that are now being taken with the Trust;

and iii) Agreed to discuss this further at the Quality and Risk Committee (QARC). 2016/158 Patient-Led Assessment of the Care Environment (PLACE) Inspection 2015 David Griffiths advised that inspections of all inpatient units were carried out between 09 March and 26 June 2015 and the mandatory obligation to publish the results and action plan on the Trust’s website had been met. He highlighted that ‘Privacy, Dignity and Well-being’ continued to be challenging at 78.4% against the National Average for Mental Health and Learning Disability Trusts of 90.7% and ‘Condition, Appearance and Maintenance’ (87.84% against 91.1%). Brian Johnson congratulated staff on the improvement in ‘Food & Hydration’ scores. In answer to a question from Brian re the ‘Privacy, Dignity and Well-being’ scores, David Griffiths assured him that a clear, prioritised annual work plan was developed by the Associate Director of Estates which was triangulated with the Director of Nursing & Quality and Operational Managers. David assured Jan Hutchinson that the items showing a target date of “immediately” on the action plan were monitored weekly. Natalie Hammond confirmed that the Quality Improvement Panels (QIPs) received ward level information on maintenance issues. In response to a comment from Peter Little regarding Reunion House, Andrew Geldard agreed that some Community Team bases required upgrading and a piece of work prioritising investment was moving forward. The Board of Directors noted the confirmed PLACE 2015 results and the Trust’s action plan update. 2016/159 NHS Benchmarking Network – Mental Health Benchmarking – 2015 Benchmarking of the 2014/15 Reference Cost Submission David Griffiths explained that the report provided the Board with the latest information relating to the 2014 NHS Reference Cost, i.e. the unit cost to the NHS of providing secondary healthcare to NHS patients which are then used to set prices. For 2014/15 the National Reference Cost Index (RCI) for NEP was 105 i.e. above the national benchmark of 100. David outlined the main findings for adult and older adult services; concluding that CCG commissioned core services were below the national average of 100 which indicated efficient use of resources. However, specialised services, such as Perinatal and Drug & Alcohol, were above the RCI of 100 and this would be reviewed in readiness for the 2015/16 submission. Mike Chapman apologised that the detailed NHS Benchmarking Network Report 2015 was not attached to the report and undertook to circulate this via “Friday Round-up” on 29 January 2016.

Action: Mike Chapman, Director of Strategy

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Mike Chapman advised that this was the largest NHS analysis of mental health provision ever undertaken and covered bed numbers, occupancy, admissions, length of stay, emergency readmissions, clustering, community teams, qualified nurses and serious incidents/complaints. Brian Johnson requested that the report be amended to include insight about the consequences for the organisation and be brought back to the Board.

Action: Mike Chapman, Director of Strategy The Board of Directors noted the 2014 NHS Reference cost benchmarking report. 2016/160 Update on Merger Mike Chapman confirmed that following discussion at NEP and SEPT’s Board meetings in December 2015, a final version of the Outline Business Case (OBC) was agreed and submitted to Monitor on 08 January 2016. Andrew Geldard commented that it would become increasingly difficult for NEP and SEPT to operate as autonomous mental health providers within the financially challenging environment. Commissioners also needed to implement the ‘Parity of Esteem’ agenda for mental health. A Governors’ briefing session had been held and it was important that the Board provide leadership in demonstrating that this was the best way forward and continue to include Governors in the journey. The Board of Directors noted the update re the merger and confirmed the decision to proceed. 2015/161 Finance Report for the 9 Months Ending 31 December 2015 David Griffiths advised that the Trust had an EBITDA of £1.69 million, with an underlying deficit of c£1.52m. to date (£1.8 m lower than plan, but a £0.5m improvement on Month 8). The updated year-end forecast was for a c£3.4m deficit and a final accounts surplus of c.£12m (£5.4m below plan), following the sale of Severalls. The cash position remained strong at £7.0m with a year-end forecast of £6.4m. As reported by the Chief Executive, Monitor’s Financial Sustainability Risk Rating (FSRR) of NEP was a “1 – Under review” due to the sale of Severalls slipping from December 2015 to January 2016, and the underlying challenges of the I&E position. Andrew Geldard advised that the financial difficulties related directly to loss of income re MH Care Clusters 1-4 and CAMHS. The NHS Framework would help to reduce agency costs; however recruitment and retention was a significant challenge. The Board of Directors noted the Finance report for the nine months ending 31 December 2015. 2016/162 Operational Performance Summary to 31 December 2015 Vince McCabe reported that overall performance against the key clinical quality targets agreed with regulators and CCGs was good, noting that the position post the publication of the Board report (as at 22 January 2016) was: • KPI 4 Inpatient Access to CRHT 97.7% (95% at Q3) • KPI 8 Carers Assessments Completed 93% (72.1% at Q3) • KPI 11 ICD Diagnosis 98.2% (89.2% at Q3) • KPI 18 Care Plan Shared 95.5% (94% at Q3)

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Vince McCabe explained that limiting beds at the Linden Centre in October to 18 per ward had been very successful in mitigating pressures at the unit. This had however resulted in 22 private placements before Christmas; this had now fallen to 5. He commented on good co-operation within the system to support discharges and advised Charles Beaumont that the recorded 40% occupancy of PICU was due to the inadvertent inclusion of capacity at Shannon House, which was closed. Vince clarified that NEP currently had 7 PICU beds available, all of which were full; an additional 2 beds would be available shortly at the Crystal Centre. The Board received and noted the Trust’s Operational Performance at Month 9. 2016/163 Workforce Report Lisa Anastasiou introduced the report advising that:

• Turnover had fallen from November, sitting at 12.7% (9.5% excluding retirements); no trends had been identified.

• Sickness absence at 3.8% (threshold 4.5%) - remained low, especially for the winter months, compared to other Trusts.

• Mandatory training stood at 82.0% (threshold 90.0%). Work was in place to address this, including policy changes and nationally recognised compliance standards would be taken to the Quality and Risk Committee (QARC) in February 2016.

• PDR completion at 74.2% had improved slightly since August 2015 (threshold 90.0%). February 2016 was being promoted as “Appraisal Month”.

• Bank & Agency Staff - 70% of registered and 83% of unregistered shifts had been covered by Bank staff; Agency staff were only used where these could not otherwise be filled.

• The level of vacancies (18.72% FTE) remained a challenge, with 111 RMN vacancies Trust-wide. Strategies for encouraging staff to join the bank were in place and beginning to show benefits, particularly for Health Care Assistants (HCAs).

In answer to a question from Brian Johnson, Lisa Anastasiou explained that “London Weighting” mitigated in favour of neighbouring trusts in a competitive recruitment market. Natalie Hammond advised Peter Little that measures such as the greater use of support workers and allied health professionals, were already being implemented. Lisa confirmed that recruitment was an item for discussion at the Board Seminar Agenda on 24 February 2016.

Action: Lisa Anastasiou, Director of Workforce and Development The Board of Directors received and noted the Workforce Report. 2016/164 Monitor Compliance – Finance & Governance Return for Q3 2015/16 David Griffiths advised that this was part of the standard cycle of quarterly reporting. The submission supported the following ratings;

• Financial Services (FSRR) of 3 not confirmed • Governance Risk Rating of Green.

David Griffiths noted that on this occasion, the Board was required to submit an additional declaration by 29 January 2016, explaining why the Trust was unable to

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confirm an FSRR of ‘3’ for the next 12 months and the actions proposed to address this. There were no other relevant matters which had not already been reported to Monitor. The Board of Directors approved the Monitor Compliance Return for Finance & Governance for Quarter 3 2015/16, including the associated Board Declarations. 2016/165 NHS Improvement Agency Rules David Griffiths highlighted the significant variance shown to the plan submitted to Monitor. He explained the staged drops in agency framework rates from 1 February 2016 and 1 April 2016 and their likely impact. Lisa Anastasiou commented that the Framework Agencies were working to comply with the capped rates, adding that success depended on the whole system complying, including non-NHS providers. She confirmed that although the costs were reducing, the volume of staff required was growing. Andrew Geldard advised this would be discussed during Monitor’s site visit (09/10 February 2016). The Board of Directors noted the update in relation to the use of agency staff and rules issued by Monitor and the Trust Development Agency (TDA) (now NHS Improvement) in respect of the use of agency nurses. 2016/166 Quality Report Natalie Hammond advised that the Trust had recorded 44 Serious Incidents for the year to date. Recent developments included; the introduction of a Datix (reporting system) triage and daily monitoring. An incident review meeting was held 3 times a week to ensure that an appropriate review was in place for each incident. With regard to physical interventions, an action plan was in place to reduce the number of restrictive interventions centring on the implementation of Therapeutic and Safe Interventions (TASI) training. The clinical audit plan for the coming year would focus on patient outcomes and CQUIN. Andrew Geldard commented on the encouraging trends in the report. The Board of Directors received and noted the Quality Report. 2016/167 Ward Staffing Levels (November 2015) Natalie Hammond reported that 4 Wards were shown as “amber” and 1 (Brian Roycroft) as “red”. The new e-rostering system would come on stream in February 2016 and would help identify any inconsistencies re planning in the context of new Safer Staffing and E-rostering Policies which were in place. Peter Little commented on the high proportion (273%) of unqualified staff recorded for the Brian Roycroft Unit. Lisa Anastasiou advised that this ward had proved difficult to recruit to, and the high proportion of unregistered staff mitigated the low proportion of registered staff, and still met the safe staffing standards. The Board of Directors received the Ward Staffing Level report. 2015/168 Capacity and Capability Skill Mix Review Natalie Hammond advised that the Francis Report required that this information be shared with the Board every 6 months, and included:

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• Accountability and responsibility of Boards • Evidence based decision making • Supporting and fostering professional environment • Openness and transparency • Planning future requirements • Role of commissioning.

The Royal College of Nursing’s (RCN) recommended ratios were discussed, i.e. 1 qualified nurse to 6 patients was the ‘gold standard’ for acute hospitals, with 1-8 being more usual. Natalie outlined the 10 “expectations” contained in the report, drawing the Board’s attention to the summary table of ‘Current Staffing levels at NEP’. Natalie hoped that publication of the Carter Review (due in April 2016) would provide further guidance. Andrew Geldard commented on the additional £0.8m put into the nursing budget c.2 years ago. The Board of Directors:

• Noted the contents of the report and expectations for reporting staffing capability and capacity to the Trust Board

• Reviewed the methods used to address the capacity and capability of the Skill Mix Review

• Noted intended work on dependency/acuity, and to consider the outcome of this work at its July Board

• Agreed to receive for formal review on a six monthly basis staffing levels/skill mix report

• Agreed that a financial impact assessment of enhancing the skill mix is required for completeness

• Supported the recommendations in the report. 2016/169 Board Committee Verbal Reports a) Quality & Risk Committee (23 December 2015) Brian Johnson (QARC chairman) gave an overview of the main topics discussed on 23 December 2015:

• Natalie Hammond gave a presentation around the flow and escalation policy re bed pressures (standing item)

• Recruitment/Retention and staffing issues arising from the CQC inspection. It was agreed to debate 2 or 3 of the risks in detail at each future meeting

• An in-depth review of 2 serious incidents and the investigations into them • CQC Action Plan • Mandatory Training Matrix (a standing item).

The Board of Directors received the verbal report regarding the Quality and Risk Committee. b) Remuneration Committee (12 January 2016) Charles Beaumont (Remuneration Committee Chairman) confirmed that the remuneration package for the new Interim Chief Executive had been agreed. The Board of Directors received the verbal report regarding the Remuneration Committee.

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c) Audit Committee (14 January 2016) Charles Beaumont (Audit Committee Chairman) gave an overview of the topics discussed:

• Charitable Funds Forum accounts had been completed, with only minor changes.

• A detailed review of Month 9 accounts was nearing completion in preparation for the year-end and a detailed work plan for year-end sign-off was being progressed.

• Information governance issues raised via internal audit were being resolved via the appointment of the Freedom of Information (FOI), Information Security & Governance Manager.

• Internal audit reports had highlighted a number of recommendations which need to be resolved before the year end

• Jonathan Stewart, Associate Director of Business Infrastructure Services, gave a presentation re the Trust’s estate including the Derwent Centre development

• Vince McCabe attended to explain the CIPs process • The Raising Concerns at Work Policy (Whistleblowing) was reviewed.

The Board of Directors received the verbal report regarding the Audit Committee. 2016/170 Nursing and Midwifery Council (NMC) Revalidation for Nurses Natalie Hammond advised that April 2016 would see the first cohort of NEP nurses go through this new 3-yearly process. Failure to revalidate within timescale was a significant potential risk, in that readmission to the register could take up to 6 weeks. During this period any nurse who had not complied was unable to work as a “registered” nurse, which could therefore impact on safe staffing levels. This risk was being mitigated via pro-active support to staff to develop the necessary portfolio of evidence. Andrew Geldard commented on the need to maintain a watching brief on the revalidation pipeline. The Board of Directors noted the update report dated 08 January 2016. 2016/171 Emergency Preparedness, Resilience and Response Assurance – Update on Action Plan David Griffiths advised that following the terrorist attacks in Paris last year, NHS England required all organisations to review their plans and make a number of public statements. For NEP the key issues concerned information cascade testing and transport arrangements. These were included in the Trust’s Emergency Plan. The Board of Directors noted the report and confirmed that the 2 assurances described (information cascade testing and transport arrangements) were adequately managed via the Trust’s Emergency Plan. 2016/172 Medical and Non-Medical Education Dr. Malte Flechtner gave a verbal update including: • Health Education East of England’s 3-yearly site visit was now scheduled for 20

May 2016, having been brought forward from October in view of the Trust’s merger plans. This review would gather evidence and consider issues including;

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university support, learning from serious incidents and the therapeutic environment. Andrew Geldard stressed the importance of the outcome of this visit as an incentive for trainees to join the Trust in the current difficult recruitment environment.

• NEP was the first trust to achieve Midlands and East of England Mental Health Act Approval Panel recognition for its Section 12(2) and Approved Clinician Training Course Content

• The Norwich Medical School (University of East Anglia) had expressed an interested in placing their 4th year medical students with the Trust.

The Board of Directors received the verbal update on Medical and Non-Medical Education. 2016/173 Policy for the Approval and Management of Policy Natalie Hammond explained that this was brought to the Board for approval in accordance with the Reservation of Powers to the Board (Item 3.5.1). This policy had been reviewed in light of the changes in the governance structure. The Risk and Governance Executive would monitor the policy review process The Board of Directors approved the Policy for the Approval and Management of Policy. 2016/174 Summary of Board Decisions The Board of Directors noted the Summary of Board Decisions. 2016/175 Execution of Deeds Dermot McCarthy advised that in addition to the report, 3 deeds relating to the sale of Severalls had been executed the previous day (26 January 2016) and would be formally reported at the next meeting. The Board of Directors noted the Execution of Deeds. 2016/176 Any Other Notified Business There was no other notified business. 2016/177 Questions from Members of the Public relating to Items on the Agenda Only

a) Ward Staffing Levels (Item 16) – In answer to a question from Cathy Trevaldwyn about the staffing of the Home Treatment Teams, Natalie Hammond agreed that post-discharge follow-up care was vital. Vince McCabe emphasised that achieving the balance between inpatient and community care was essential.

b) Ward Staffing Levels (Item 16) – Lisa Anastasiou confirmed to Pippa Ecclestone that structures and support were in place to enable staff to increase their qualifications e.g. via workplace learning, apprenticeships and/or university courses.

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c) Patient Led Assessment of the Care Environment (Item 8) – Cathy Trevaldwyn commented on the importance of the emotional environment, including volunteer involvement in projects such as gardening. Natalie Hammond advised that Glenn Westrop, Lead Occupational Therapist, was working on a project to develop patient contact with the third sector, individual volunteers, community groups and the Samaritans.

d) Mortality Review at Southern Health FT and Implications for NEP (Item 7)

– Andrew Geldard reassured Andrew Smith that the data provided re Mortality and Serious Incidents would be reconciled.

e) NHS Benchmarking Network (Item 9) – Natalie Hammond advised Andrew

Smith that given the work to address ligature risks within the Trust, a downturn in the rate of incidents was expected.

f) Operational Performance Summary (Item 12) – Cathy Trevaldwyn

highlighted the need for anyone receiving aftercare under Section 117 of the Mental Health Act should receive a review within 12 months.

g) CQC Inspections August 21015 – Publication of Final Report (Item 6) – Clive White complimented the Trust on its response to the final CQC report. Andrew Geldard stressed the importance of Governor involvement in assuring the timely implementation of the Action Plan.

h) Merger of NEP and SEPT (Item 10) – Clive White commented that

Governors’ views were mixed. Andrew Geldard noted that under the legislative framework the ultimate decision re whether to proceed rested with the Councils of Governors. He hoped that regular planned engagement would provide ample opportunities for Governors to raise concerns.

i) Chief Executive - On behalf of the Council of Governors, Clive White thanked

Andrew Geldard for his significant contribution to the Trust since 2002. On behalf of the Board of Directors, Amanda Sherlock thanked Andrew Geldard for his leadership and dedication to the Trust and wished him well for the future

The questions from members of the public were noted. Signed: Chairman 23 March 2016

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 3b Date: 23 March 2016 Title of Report: Matters Arising from the Minutes of the Meeting held on 27 January 2016 Lead: Chris Paveley, Chairman Subject, Purpose and Recommendation: The Board of Directors is asked to discuss matters arising from the previous discussions and actions of the Board, including any issues raised by members of the public (attached). Finance Implications: N/A Clinical Implications: N/A HR Implications: N/A Legal and/or Regulatory Implications: N/A Equality Implications: N/A Risks: N/A

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Matters Arising from the Minutes of the Meeting in Public held on 27 January 2016 Action Points 2016/159 NHS Benchmarking Network – Mental Health Benchmarking – 2015 Benchmarking of the 2014/15 Reference Cost Submission Mike Chapman apologised that the detailed NHS Benchmarking Network Report 2015 was not attached to the report and undertook to circulate this via “Friday Round-up” on 29 January 2016.

Action: Mike Chapman, Director of Strategy

Mike Chapman advised that this was the largest NHS analysis of mental health provision ever undertaken and covered bed numbers, occupancy, admissions, length of stay, emergency readmissions, clustering, community teams, qualified nurses and serious incidents/complaints. Brian Johnson requested that the report be amended to include insight about the consequences for the organisation and be brought back to the Board.

Action: Mike Chapman, Director of Strategy 2016/163 Workforce Report Lisa confirmed that recruitment was an item for discussion at the Board Seminar Agenda on 24 February 2016.

Action: Lisa Anastasiou, Director of Workforce and Development

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 4 Date: 23 March 2016 Title of Report: Chief Executive’s Report Lead: Christopher Butler, Interim Chief Executive Subject, Purpose and Recommendation: The Board of Directors is asked to receive the attached update from Christopher Butler, interim Chief Executive. Finance Implications: N/A Clinical Implications: N/A HR Implications: N/A Legal and/or Regulatory Implications: N/A Equality Implications: N/A Risks: N/A

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Our Values: Humanity Our cause, our passion Strive for excellence Creative collaboration Commercial head, Community heart Keep it simple Our Commitments: To individuals and families: To work together, building on strengths, to improve mental health and wellbeing.

To our commissioners and key partners: We will listen, work with you, create ideas, demonstrate our effectiveness and flexibility, and earn recognition as provider of choice. To our Staff: We will value everyone individually, promote wellbeing, support involvement and encourage personal development and leadership; We will support teams in their delivery of best value, innovation and excellence.

All Together Better • “At NEP we work in partnership to enable people to be at their best in mind and body” • Our communities will have total confidence in our services, our staff feels a strong sense of belonging and satisfaction, and our partners be proud to work purposefully with us.

1. Income from specialist mental health services will rise year on year

With Phoenix Futures, NEP is currently managing the run-up to contract start for the Essex-wide “Offenders with Complex & Additional Needs” service; NEP is also awaiting the announcement on 25 March by commissioners of the preferred bidder for primary care mental wellbeing services out side the county.

2. The increase in the national profile of NEP can be demonstrated through its media and clinical/research profile

January and February saw much media activity impacting on the Trust. 11 news releases were issued covering the appointment of the new Interim CEO, the CQC Report, Trust staff short listed for national awards and NEP recruitment days. There were 94 mentions in printed and 154 on social media. Coverage mainly concerned the CQC report and the GMC hearing of a locum psychiatrist who was dismissed by NEP. The majority of the coverage was, therefore negative or indirectly negative. Visits to the website continue to increase (exceeding 6,000 in both months) and an average time on each page of around 1 min. The site also supports wider NHS campaigns and partner initiatives such as No Smoking Day and the Essex Domestic Abuse campaign. Current Facebook ‘likes’ are at 655 and Twitter followers 1,747.

7. A clear outcome measurement framework has been agreed and a baseline set for continuous improvement.

SWEMWEBS (Shorter Warwick & Edinburgh Mental Well-being Scale) and QAL-AD (Quality of Life - Alzheimer’s Disease) outcome measurements are now well-established for their relevant service user groups.

Strategic Objective 2 ‘NEP will be a system leader and a partner in the development and delivery of integrated community services’

Strategic Objective 3 ‘NEP will continue to improve patient experience

Performance, Targets & Outcomes: The latest published ratings from Monitor relate to Quarter 3 and are: • Governance Risk Rating (GRR) - Under Review • Financial Sustainability Risk Rating (FSRR): 1 – Under Review

Monitor are seeking further information from the CQC prior to confirming a Governance Rating and are looking more closely at the Trust’s underlying financial position. In part the Q3 FSRR of 1 reflects the slippage in the sale of Severalls from December to January. We anticipate a final year-end rating of 2. Finance: At the end of February the Trust’s financial position indicates EBITDA of £2.82m, and an underlying I&E deficit (excluding profit on asset sales) of £3m, which is £3.1m lower than Monitor plan. The I&E deficit to date primarily reflects continued high usage of agency staff and CIP slippage, together with lower levels of income in respect of the main contract. Non-pay, Premises and IM&T pressures continue. £3.1 (82%) of CIPs have now been actioned. The forecast year-end underlying I&E position is a deficit of £3.5m, but allowing for profits on disposal of assets the Trust anticipates a surplus of £11.9m. The sale of Severalls has been completed with the first instalment received at the beginning of February. Assurance/Governance: The meeting of QARC on 9th February was cancelled due to Monitor’s visit and the re-scheduled meeting on 4 March postponed due to sickness. Work has been taking place in relation to QARC and its membership, including a working party to refine the work of QARC, defining its authority and key relationships; a recommendation that the Risk & Governance Executive becomes an ‘operational group’; future agendas for QARC being designed around the CQC’s domains; agreeing an annual schedule of business and supporting activities for QARC; and a review of the Board Assurance Framework for presentation in April. Business Development: Our out-of-hours service ,with calls routed via SEPT’s call centre, responded to 726 calls in February, the 2nd month of the pilot. The service is working smoothly, allowing clinicians to respond to more calls and offer a better out-of-hours service. Evaluation continues. The Outline Business Case (OBC) for a merger with SEPT has been received positively by Monitor. Work has started on the Full Business Case (FBC).

Contracts: The Trust has now agreed a “without prejudice” settlement with CCG commissioners for the second 6 months of 2015/16, although the underlying dispute around the pricing mechanism has not been resolved and is a major component of the 2016/17 negotiations. A key issue for commissioners remains the current level of external placements and the costs to the CCGs which have increased significantly in recent months. This is partly reflective of the change in working at the Linden Centre which has now moved onto a single room only basis. Regulator Issues - Monitor: Monitor continue to work with the Trust in relation to our financial position with an expectation that a ‘break-even’ recovery plan is produced. To this end they visited the Trust in February and conducted a focussed piece of work looking at our underlying financial position. We are awaiting formal feedback from Monitor. Regulator Issues - CQC: The CQC report was published on 25 January with “Requires Improvement”. The “Quality Summit” took place on 4 February and the CQC presented a balanced picture. NEP was rated “Inadequate” for safety but ‘outstanding’ for caring at the St Aubyn Centre and ‘good’ for community services. NEP presented a draft action plan covering all the ‘must do’ and ‘should do’s’. A further draft has been submitted to the CQC. Safety improvements in inpatient units are underway including reducing ligature risks, eliminating mixed sex accommodation where feasible, and redesigning places of safety. Action is being taken to improve activities/therapies and emergency responsiveness. We have joined the ‘Sign Up To Safety’ programme. Governor Activity: The proposed merger with SEPT continues to feature highly on Governor agendas, including a discussion at the CoG on 8 March. Membership: Currently 5,635 with 264 affiliate members; a slight drop. The first members’ meeting of 2016 on carers and how we can help them was held on 24 February in Chelmsford. The meeting for the Uttlesford Constituency, which will be on the subject of dementia, will be held on 23 March.

5. Engaging widely with local communities and key stake-holders, developing productive partnership with partner organisations and helping promote positive mental health 6. The proportion of Staff saying they are likely or extremely likely to recommend our services continually increases

Friends & Family Test now being collected from in-patient and community patients. Results continue to show a positive improvement with 3 month rolling average score (likely and extremely likely/unlikely and highly unlikely) now at 37.2, its highest ever. January return showed 82% of respondents saying they would be likely or highly likely to recommend the Trust. Total of 129 responses received, majority from community patients. February score continued to show steady increase with 89% of patients saying they were ‘highly likely’ or ‘likely’ to recommend the Trust. This increased overall Trust FFT score to its highest level, 51.6 and also saw another increase volume of returns at 184. Staff are invited to give feedback via an equivalent of the ‘Friends and Family Test’ 3 times a year (in addition to the Annual Staff Survey) on whether they would recommend our services. No survey was carried out in the 3rd quarter as this coincided with the National Staff Survey. The 4th quarter survey is underway. To improve take up the Trust has contracted the Piker Institute to do the field work, as their system is more personalised and allows for reminders to be sent. Early indications are positive in that we have already received more responses than for the previous survey.

Strategic Objective 4 ‘NEP will continue to improve patient outcomes’’

Risk Area Key Risks Mitigation Comment

External Relations

• New relationships • New ways of working • Emerging financial

positions

Establish personal contact. Understand CCG issues. Work constructively. Create value based proposals. Look beyond traditional MH base. Participate in ‘whole system’ responses

The Mental Health Strategic Review work has now concluded with significant recommendation for commissioning structures. A work plan for mental health services is also envisaged, however we are only seeing slow progress from Commissioners.

JOURNEYS Programme

Failure to properly engage staff, users, carers & external stakeholders in care pathway & service delivery model redesign.

Clear & extensive project plan in place with agreed milestones. Specific engagement & communication plan designed to inform & involve in decision making. Key work streams led by senior clinicians. Recommendations from staff, external stakeholders , carers & users of service will inform the final care pathways, service delivery models and implementation and transition plan. Establishment of the Journeys Implementation , Transition Steering Group (JITSG) to drive the project plan (meets fortnightly). Additional information on how new clinical and leadership models will be developed and operationalised using a Policy Implementation Guide (PIG). This will ensure that a consistent approach is adopted across the organisation. Regular discussion and feedback re. criticality of filling posts held and decisions made on patient safety need.

The transition to the new system of working is complete. The new teams have been formed and caseloads have been transferred. A formal Post Implementation Review is now underway which is to be considered by the Board in Private session.

Cost Improvement Programme & Cost per Case Income

Requirement to deliver £3.2million (3%) recurrent CIP in 2015/16 without detrimental effect on quality/safety; Achieve cost per case income targets.

Implementation of CIPs monitored via finance managers and Area Directors, with escalation via Performance EMT in cases of non-delivery. Final reconciliation of Journey’s CIP savings underway. Weekly finance monitoring of cost per case activity.

£3.1m of CIPs actioned to date. Of the remaining £0.8m balance: £0.6m relates to Journeys, which has not yet been actioned in budgets, pending identification of additional posts that could be released after final reconciliation of old posts in scope and new appointments, and £0.2m relates to 2014/15 schemes brought forward that are no longer implementable and will need to be replaced in the 2016/17 programme, together with a replacement for the un-actioned Journey CIP.

CQUIN Failure to achieve the milestones and targets in the CQUIN schemes, now worth 2.5% of contract value (£2.0m)

Full payment for performance against CQUIN targets in Q3 2015/16 has been received. National CQUIN Schemes (1% of contract value) were announced on 9 March; 2 apply to NEP: NHS Staff health and wellbeing and Improving PH to reduce premature mortality in people with SMI. 4 local CQUIN schemes (1.5% of contract value) are progressing; L1. Physical Healthcare & Smoking Cessation; L2 Outcome Measures; L3 Education & Training; L4 Workforce Development.

Chief Executive’s Report (June 2013)

Chief Executive’s Report (March 2016)

4. Positive engagement with Commissioners and Partners in the integration agenda can be demonstrated

The Essex-wide Mental Health Strategic Review, conducted by the Boston Consulting Group, recommended that commissioners strengthen their leadership and commissioning structures with a single lead commissioner for mental health in Essex. Also recommended was a strengthening of specialist mental health service provision. CCGs are identifying a lead mental health commissioner across Essex, though how this will be operationalised is yet to be determined. On strengthening service provision, we are continuing to work with SEPT as part of our merger plans.

Strategic Objective 1 ‘NEP will be recognised as a leading provider of specialist mental health care’

3. NEP continues to provide community services across North Essex

Engagement with CCG thinking around individual programmes continues. NEP is actively involved with West Essex’s plans for an Integrated Care Organisation, is committed to “Care Closer to Home” in North East and continues discussions with the selected community services provider, ACE. Activity in West Essex is most advanced with alignment of services being considered around GP groupings.

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 5 Date: 23 March 2016 Title of Report: CQC Quality Summit Leads: Christopher Butler (Interim Chief Executive) and Natalie Hammond (Director of Quality & Nursing) Subject, Purpose and Recommendation: The Board of Directors is asked to receive a verbal report from Christopher Butler (Chief Executive) and Natalie Hammond (Director of Nursing and Quality) re the CQC Quality Summit held on 04 February 2016 (slides attached). Finance Implications: N/A Clinical Implications: N/A HR Implications: N/A Legal and/or Regulatory Implications: Part of the CQC inspection process; see http://www.cqc.org.uk/content/what-we-do-inspection Equality Implications: N/A Risks: N/A

23

http://www.cqc.org.uk/content/what-we-do-inspection

Safety and quality – at the heart of services

……our response to the CQC report

Andrew Geldard – Chief Executive Natalie Hammond – Director of Nursing and Quality


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A report that…….

• Demonstrates the value of opening our services to external, expert scrutiny

• Is a call to action for our adult in-patient wards

• Is a catalyst to drive our ‘Quality Conversation’

• Is a validation of our ‘Journeys’ community services

• Is our focus for action going forward

A report that…….

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Taking action…….

• Initial feedback and Notice set clear directions

• Began work immediately on • Quality Governance Framework • Estates issues • Care Planning issues • Systems issues

• Building robust quality assurance framework from ‘Board to Ward’

26

Action on safety……… • We have already:-

• Joined the national ‘Sign up to Safety’ Campaign • Begun our c£1.6m – 10 month capital programme

to reduce ligature risk and enhance ward environment – costed, funded and monitored weekly.

• Enabling risk management, patient centred & responsive

• Eliminated mixed sex accommodation where feasible & compliance achieved.

• Recruitment and retention strategies to reduce vacancies

• Re-design of ‘Places of Safety’ in development 27

Anti-ligature doors, windows and sanitary-ware already installed

28

Key to RAG Rating

Works Completed Action not yet started/due Work on programme Work in progress but subject to some delay or further

decision point Work substantially delayed or at risk of not completing

Version 1.1 - 29-01-16

Work programme – monitored weekly and on track 29

Action to improve outcomes…

• We are already:- • Monitoring quality care delivery with teams

reviewing a quality dashboard and driving progress

• Have established a new programme of activities/therapies 7 days a week and some evenings

• Emergency responsiveness and supporting systems reviewed by Nurse Consultant for Physical Health, including enhanced training

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Providing the best care ……..

• We are already:- • Reviewing the patient experience agenda • Launching the ‘Hello, my name is’ campaign • Launched the ‘My Care My Recovery’ initiative

in adult wards – rolling out across Trust • Focusing on collaborative and coproduced care • Ensuring recovery at the heart of what we do • Identifying service user strengths and defining

their preferred outcomes – the patient’s voice at the centre

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My Care – My Recovery plans printed and circulated in early October; orders for 1,000 more now in from units

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More responsive…….

• Action plans are in place from the ‘you said we did’ leaflets

• Duty of Candour established • Increasing contact with service users families

and carers with concerns / complaints • Waiting times reducing and being monitored • Immediate safety alert system in place • Shared Organisational Learning

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Shared Learning and Alert pages on Trust intra-net

34

Moving forward…….

• Imbedding a system of continual improvement - our ‘Quality Star’ approach

• A tool for constant review and a focus for on-going ‘Quality Conversation’ at team, ward and Trust level

• ‘Quality Star’ charts use CQC five line of enquiry

• What is positive – what needs improvement – actions - review

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Our Quality ‘Star-Charts’ and folders

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Strength of the assurance framework…….

• Quality Improvement Panels from board to ward to drive quality improvements.

• Executive and Non- executive visits to services ‘holding a quality conversation’

• Quality meetings with Matrons and clinical Services Managers

• Ward Manager development days • Development agreement with SEPT (MOU) • A review of Governance processes

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Quality Improvement

Quality Assurance

Quality improvement

Framework

Risk Management

•Board Level Assurance

Executive Quality Improvement Panel

•Area Level Assurance

Area Quality Improvement Panel

•Ward / Team level Assurance

Ward / Team Quality Improvement Panel

Quality Assurance Framework How the sections fit together

Assurance from Board to Ward

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Happy to take questions

Thank you 39

North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 6 Date: 23 March 2016 Title of Report: CQC Action Plan Update Lead: Natalie Hammond Director of Nursing & Quality Subject, Purpose and Recommendation: The Board of Directors is asked to receive and discuss an update regarding the CQC Action Plan (copy attached). This High Level Action Plan will be monitored on a weekly basis and will be scrutinised for progress at the Sub-Board Quality and Risk Committee. Monitoring of the implementation of the actions will be discussed in detail at the monthly Quality Improvement Panels with the Clinical Leads of the services and Executive Leads. Services will be subjected to peer review process assessing the implementation of the improvements against the Action Plan. Each action within the plan:

• Has an Executive Lead • Is rated:

o Green actions complete o Grey actions not due o Amber actions due o Red actions past timescale/risk identified

Progress is good with 3 actions remaining at red - review the leadership for health based places of safety (nursing and medical) – heading no 19. Finance Implications: Finance has been allocated. Clinical Implications: As per the report. HR Implications: N/A Legal and/or Regulatory Implications: A key response to the CQC inspection process.

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Equality Implications: N/A Risks: As per the report.

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NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST CHIEF INSPECTOR OF HOSPITALS CQC INSPECTION – HIGH LEVEL ACTION PLAN JANUARY 2016

Accompanied by Remedial Works Plan and Progress Spreadsheet Legend: Green actions complete Grey actions not due Amber actions due Red actions past timescale / risk identified Part 1 Trust Must Do actions from Provider Report

Action Action Detail Lead Director Timescale Progress Key metric/ benefit Sustainability RAG

1.0 The Trust must have effective systems in place for the safe prescribing and administration of medication

Review prescribing and administration of medication systems

Supporting Safe Prescribing and Administration of Medicines

Dr Malte Flechtner Medical Director

January 2016

Supporting Safe Prescribing and Administration of Medicines: Medicines management training for nurses, training for doctors focussing on prescribing errors, Mental Health training for Pharmacy staff, involvement in POMH UK audits, clinical audits covering medicines including controlled drugs and antimicrobial drugs, analysing, reporting and learning from drug errors via medicines management groups, prescribing quality group, RGE, publishing result on website, newsletters; regular visits to all inpatient units by pharmacists to monitor, give advice and check on prescribing, ordering, administering of medicines. Pharmacy interventions are regularly monitored.

Improve incident reporting (medication incidents) by 5% (set baseline) Training compliance (set target) Participation in clinical audit by pharmacy (in addition to POMH Audits)

Pharmacy interventions Prescribing quality group Peer reviews for assurance and learning

Staff to be reminded/trained in proper completion of prescribing charts to ensure information is complete and medicines used as prescriber intended 2015

Medicine Competency Framework (MCF) in place for all preceptors and new nurses starting in the Trust. Requires an 80% pass and calculations requiring 100%. Nurses involved in drug errors will be required to do all or part of the MCF and

Improve incident reporting (medication incidents) by 5% (set baseline) Training compliance (set target) 100% compliance by preceptors

Prescribing quality group Training and development group Practice Based Educational Facilitator Monitoring Monitoring of MCF compliance

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be supervised in practice. Monthly training day for nurses with 18 places. Joint training with pharmacy. To NMC standards. Bespoke support to ward managers with the MCF, investigating and learning from Datix errors.

100% compliance by new starters

figures

Improve pharmacy recruitment and retention August 2015 Completed Full establishment of

pharmacy department Monitor turnover

Improve prescribing of PRN medication in relation to reviews TBA TBA 10% reduction in PRN

medication prescribing Pharmacy audits (not POMH) on PRN prescribing

2.0 The Trust must ensure that medical equipment is working effectively and stored

Review the required medical equipment, both standard and emergency, and accessibility of this

Emergency responsiveness and supporting systems are being reviewed by the Nurse Consultant Physical Health

Natalie Hammond Director of Nursing

and Quality

2015

All wards visited by Nurse Consultant and all systems and equipment reviewed

Systems and processes reviewed

Regular review and monitoring by Medical Devices Group

All emergency bags are being assessed and a seal-tag approach introduced 2015

Completed on all 20 wards 100% sealed emergency bags in situ on all in-patient wards

Regular (weekly) auditing of medical equipment Peer review for assurance/learning

Ligature cutters will be assessed for their availability and storage requirement in the wards 2015

Completed on all 20 wards Uniform attached ligature cutters being piloted on 1 ward

100% ligature cutters in situ on all in-patient wards

Regular (weekly) auditing of medical equipment Peer review for assurance/learning

A ratified policy on the safe use of ligature cutters August 2015 Completed Policy approved by R&GE Regular review by Policy

Advisory Group

Wards to receive simulation training ‘in the event of emergency’ to test level of awareness and competence

March 2016

Current Basic Life Support training to be enhanced with the roll out of Intermediate Life Support training for inpatient band 6 and above staff beginning February 16 Emergency simulation training to begin by 30 March 16

Training records for ‘in the event of emergency’ ILS training to be 60% compliance by 2016 (produce training trajectory) 1 emergency simulation training session per month with review report and learning

Training and development group review on-going need for this training TASI trainers to support the intermediate LS training at ward level Peer review for assurance and learning

Report to the Board on how NEP will ensure that all emergency equipment is fit for purpose and stored appropriately so that in the event that it is required there is no

November 2015

Progress presented to November Board Completed

Trust Board informed

Monitoring by Physical Healthcare/Medical Devices Group

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unnecessary delay in it being made available

3.0 The Trust must ensure that action is taken to remove identified ligature risks and to mitigate where are poor lines of sight

Undertake a review of the current ligature policy examining the management of ligature anchor points and clinical responses expected

All in-patient areas to be re-assessed for ligature anchor points.


and Quality


and Quality

November 2015

Completed on all 20 wards Reduction in ligature anchor point incidents in adult in-patient settings Reduction in physical harm Patient Safety Assessments completed (incorporating ligature risk assessment) Patient Safety Assessment Action Plans

Annual patient safety assessments Monitored by Risk and Governance Executive Monitored by Clinical Boards Sign up to Safety campaign – thematic analysis

A new ligature risk tool is being utilised across the in-patient pathway to provide a more detailed description of ligature risks present and the level of required management and residual clinical risk

September 2015

Completed – launched on all 20 wards

100% Patient Safety Assessments completed (incorporating ligature risk assessment) with reports 100% Patient Safety Assessment Action Plans completed and implemented

Annual patient safety assessments Monitored by Risk and Governance Executive Monitored by Clinical Boards

A picture guide is being developed for each ward on their ligature risk and used to induct staff to the risk present

December 2015

Completed and displayed on all 20 wards and hand-outs to all relevant staff including bank staff

Picture guide in place 100% 100% relevant staff have hand-outs

Annual patient safety assessments Regular review

Clinical guidance on what constitutes a ligature anchor point risk and how to manage risk is part of this process

December 2015

Completed as part of above Clear clinical guidance 100% Staff awareness

Regular review of clinical guidance – Policy Advisory Group

A strategy on ligature risk and a ligature removal programme will be presented to the Board November

2015

Completed – Ligature point management and remedial works programme presented to November Board

Strategy in place Ligature removal programme

Annual review of strategy Monitoring of programme by Strategic Capital Group and Risk and Governance Executive

A ratified policy relating to the management of ligature anchor points

August 2015 Completed and approved by R&GE in August 2015

Policy in place

Regular review of policy by Policy Advisory Group

Clinical review of policy to ensure robustness August 2016 More robust policy in place Regular review of policy by

PAG

Review top 10 clinical policies and structured summaries to include management of ligature points

August 2016 Structured summary in place

Raise staff awareness

Policy Advisory Group – regular reviews

Launch new robust management of September Clinical staff aware of Patient safety audits

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ligature anchor points policy 2016 management of ligature anchor points policy

All relevant staff to be sent all top 10 clinical inpatient and community policy structured summaries

September 2016

Staff awareness of top 10 inpatient/community policies/structured summaries

Policy Advisory Group

A programme of audit in place and shared with staff to ensure actions taken to mediate risk in terms of practice

August 2015

Completed – ongoing programme on all 20 wards throughout the Trust with follow up

Audit tools in place All audits have reports and action plans Action plans implemented within agreed time frames Reduction in ligature anchor point incidents in adult in-patient settings

Monitoring by quality improvement panels Monitoring by R&GE

Ensure staff are aware of how they clinically manage the risk of ligature points

Leadership weekly safety walk rounds to consider ligature risk management


and Quality

September 2015

Completed – weekly ongoing

100% all tier management walk rounds taking place and recorded

Rolling programme in place

Safety alerts to highlight staff vigilance in clinical practice and how to manage ligature risk

July 2015

Completed and ongoing with internal and national safety alerts. IntraNEP page and Core Briefing

Publication and sharing of all safety alerts Reduction in ligature anchor point incidents in adult in-patient settings and reduction in harm

Monitoring by Quality Improvement Panels and Risk and Governance Executive

Themed review in shared organisation learning webpage on clinical management of ligature risk July 2015

Completed and on-going Shared organisation learning webpage live 100% cascading to all relevant staff

Monitoring by QIP and RGE

Examples of changes to practice to manage line of sight observation

February 2016

Convex mirrors installed on all 20 inpatient wards Observation e-learning ready for launch in Feb 16 Heat map and ligature booklet identifying high risk areas that informs staff

Reduction of risk due to lines of sight Reduction in incidents and harm to patients 100% shared learning of positive changes to practice


STORM training – improvement trajectory set for 60% of all registered in-patient clinical staff by 2016

December 2016

22% of clinical registered staff on inpatient units trained. Some units e.g. Finchingfield have exceeded target

60% of all inpatient qualified staff trained by end 2016


Health and Safety training to May 2016 Ligature Awareness Module Updated health and safety Regularly reviewed by training

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include updated ligature management

developed to be rolled out to staff by end February 2016 Additional section on ligature management to be added to current Health and Safety for Line Managers training from February 2016 Ligature Management - Health and Safety Awareness week in May 16

training Set improvement targets for H&S training compliance Year on year improvement in staff survey results 3 non-attendance = management meeting

and development group Revalidation

Review of effectiveness of modified ligature risks following action e.g. door top alarms

November 2015

Evaluation of door top alarm system report submitted to EMT November 2015

Evaluation of effectiveness

Planned preventative maintenance

4.0 The Trust must ensure that it complies with Department of Health guidance in relation to mixed sex accommodation

Review NEP delivering single sex accommodation processes to confirm changes required as identified in CQC report

Service users are accommodated in same sex wards where the whole ward is occupied by males or females only; or sleeping accommodation is in single rooms within mixed wards with toilet and washing facilities ensuite or very close by and are clearly designated male or female; or sleeping accommodation within mixed wards is in shared rooms used solely by male or female users.


and Quality

2016

Guidance has been issued and 6 of 7 adult acute wards are now single sex Building work in progress in PICU to allow gender separation Estate planning in place to move Peter Bruff Ward to more suitable accommodation

100% patient accommodation is appropriately segregated as per DoH guidelines Any breaches are agreed at appropriate levels and to agreed set of criteria, followed by root cause analysis

Daily bed management meetings with correct identification of service for admitted patients Monitor Datix reports

On mixed wards with single or shared bedrooms giving out onto one corridor, single bedrooms, toilet and bathing facilities are grouped to achieve as much gender separation as possible.

2015

Completed Mixed sex wards include clear gender separation

Daily bed management meetings

5.0 The Trust must proactively address any practices that could be considered restrictive, for example, the use of the Hub, access to toilets, access to the gardens, and access to snacks and beverages

Undertake scoping exercise to understand extent of blanket restrictions in NEP

Undertake scoping exercise

Vince McCabe Director of Operations

2015

Completed on all 20 wards Scoping exercise complete Eliminate blanket restrictions unless approved at appropriate levels, followed by root cause analysis

Monitor through walk rounds – tiered level of seniority from Matrons, Area Directors to Executive/Non-Executive Directors Thematic analysis of MHA reports

Ensure toilets are accessible to patients at all times 2015 Completed Sufficient toilet facilities

available at all times Monitor through walk rounds, Datix and patient feedback

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Peer review for assurance and learning

Ensure garden areas are accessible to patients 2015

Completed and any patient requiring to enter the garden at night is risk assessed and supervised

Patients are able to use the garden areas

Monitor through walk rounds, Datix and patient feedback Peer review for assurance and learning

Ensure food and drink is available when patients require it 2015

Completed Zero complaints about accessibility to food/drink

Monitor through patient feedback Peer review for assurance and learning

6.0 The Trust must ensure that there are sufficiently experienced staff on duty at all times to provide skilled care to meet patients’ needs

Develop a systematic approach to determining the number and range of skills of staff required

Undertake review of skill mix and staffing complement of in-patient areas


and Quality

January 2016

January 2016

Completed with report to the Board January 2016 with 3 approaches: (1) Qualitative survey from all Ward Managers (2) Use of evidence based acuity tool (NHS England) (3) Detailed shift by shift analysis for one week for benchmarking data and current guidance Now undergoing financial analysis and to seek funding from Commissioners

Skills mix and staffing at appropriate levels throughout in-patient areas Reduction in use of bank and agency staff

Monitoring through local and Trust Quality Improvement Panel and Safe Staffing Contract negotiations

Undertake specific ‘Hub’ staff analysis inclusive of AHPs

December 2015

Independent review conducted on Hub model and presented to November Board with a way forward to ensure no blanket restrictions on use of Hub

Skills mix and staffing at appropriate levels to meet the needs of the ‘Hub’ Reduction in use of bank and agency staff Reduction in staff turnover

Monitoring through local and Trust Quality Improvement Panel and Safe Staffing

Implement NHS England Patient Acuity Tool for Mental Health June 2015 Completed across all wards Appropriate staffing levels to

manage patient acuity Safe staffing monitoring

Establish leadership development days and ward manager leadership programme

November 2015

Genesis training programme for new managers implemented in November 2015 to be run quarterly Ward Manager Development Programme implemented in November 2015 to be run 6 monthly Further Leadership

Programme schedule Continuous programme reviewed regularly

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Development Programmes to be rolled out in 2016 Ward Managers Development Days in place

DoNQ to hold quarterly ward manager and clinical service manager events as a network of improvement


and Quality

2015 Completed and ongoing Programme schedule

Continuous programme reviewed regularly

7.0 The Trust must carry out assessments of each patient’s mental capacity where concerns have been identified and record these in the care records

Review systems and processes for the assessment of patient’s mental capacity where identified

Review Mental Capacity Act and Deprivation of Liberties Policy


and Quality April 2016

Head of Safeguarding leading revision of SET MCA & DoLS Policy. Policy drafted. To be approved by ESAB/ESCB for adoption in the new financial year. This proposes some radical changes such as replacing MCA1 & MCA2 forms with a single document for recording MCA assessments. Revision of NEP MCA & DoLS Policy will follow on.

Revised SET MCA and DoLS Policy Revised NEP MCA and DoLS Policy

Policy Advisory Group

Make assessment of capacity a mandatory field on Remedy

David Griffiths Director of Resources

June 2016 Agreed by EMT at away day in January 2016

Mandatory field in Remedy

Regular auditing and monitoring via Quality Improvement Panels

Revise ward review paperwork to outline and evidence how consent to treatment and capacity is considered and recorded

Dr Malte Flechtner Medical Director July 2015

Completed Consent to treatment and capacity is recorded

Auditing of ward review paperwork

8.0 The Trust must improve their governance and assurance systems relating to the assessment and management of ligature risks, the quality of care plans and the assessment of the quality of the ward activities programme provided

Review governance and assurance systems around assessment and management of ligature risks, the quality of care plans and the assessment of the quality of the ward activities programme provided

Develop Quality Improvement Panels at a local and Trust wide level – a forum for looking at the quality star tool, review of ward level quality indicators, local risk registers and workforce indicators Natalie Hammond

Director of Nursing and Quality

September 2015

Completed at all levels of the Trust

Improve quality indicators and progress risk management Quality dashboard Terms of reference

Quality and Risk Committee

Develop and implement Quality Governance Framework

September 2015

Completed – presented to Board September 2015 and implemented – outlines Quality Improvement Panels

Quality Governance Framework

Reviewed regularly

Review operational management April 2016 Discussed and agreed in Parity across NEP EMT

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structures and associated corporate functions to streamline delivery of services with a consistent approach, parity and learning

EMT; developing consultation documents

Shared learning Improved delivery of service

Map governance arrangements and hold governance meetings in each area

2015 Completed and regular governance meetings in place

Always start with patient story

Ongoing programme and regular review

Review delivery (and governance) of therapeutic interventions and group programmes across all acute inpatient wards with a focus on gender specificity, recovery, engagement and 7 days per week

September 2015

In progress in all 7 acute inpatient wards Completed

7 day a week inclusive of some weekends programme

Designated inpatient OT Consultant Lead

Review care plans in the Trust to ensure staff provide person centred care and treatment that is appropriate to meet their needs and reflects their personal preferences and is holistic in approach.

September 2015

Completed across all adult acute wards

My Care My Recovery plans developed

Quality improvement panels

Implement ‘My Care My Recovery’ initiative in acute in-patient wards

October 2015

Completed across all acute inpatient wards. Adaptation in development for all older adult inpatient wards “My Care My Support Plan”. Considering adaptation for CAMHS inpatient wards. Training completed by Practice Education Facilitators across the Trust. Qualitative audit against care plans carried out.

Holistic and inclusive care planning Improvement in engagement with patients and signing/ sharing of care plans

Regular audit

Review CPA training in line with recovery orientated care 2015

Completed – syllabus incorporates focus on recovery and My Care My Recovery now embedded

Improved CPA training

Evaluation of training

Revise ward review paperwork to outline and evidence how consent to treatment and capacity is considered and recorded

July 2015

Completed Consent to treatment and capacity is recorded

Auditing of ward review paperwork

9.0 The Trust must address the identified safety concerns in the health-based places of safety Ensure that seclusion and health based places of safety are compliant with the Mental

Review the design and fabric/ furnishings of seclusion and place of safety suites


and Quality February 2016

Redesign of the areas has been drawn up and the plans are out for

Revised design of seclusion and place of safety suites

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Page | 9


Health Act Code of Practice 1983

consultation Develop and implement a programme of works as a result of the review

David Griffiths, Director of Resources March 2016

Programme of works to be scheduled to maximise the availability of S136 suites in the Trust

Upgraded seclusion and HBOS suites Compliance with MHA Code of Practice 1983

Evaluation of upgraded facilities and monitoring of seclusion and S136

Complete works David Griffiths, Director of Resources

July 2016

10.0 The Trust must address the security of the doors within the forensic (low secure) core service

Identify and rectify the problems with the door security on Edward House

Repair or replace the defective doors within Edward House


October 2015

Completed – all interior doors with identified weakness have been reinforced to prevent opening with credit card or similar. Airlock and absconsion issue resolved

Zero absconsion due to defective doors

Planned preventative maintenance

Part 2 Trust Should Do actions from Provider Report


11.0 The Trust should ensure that systems are in place for the effective recruitment and retention of staff

Review recruitment and retention processes

Recruitment strategy

Lisa Anastasiou Director of

Workforce and Development

2015

Recruitment strategy in place to address recruitment challenges Board meeting February 16

Reduce vacancies Reduce agency levels

Executive Management Team monitoring

Undertake an evaluation of the timeliness of current recruitment processes End April 2016

In progress Improved timelines for recruitment to vacancies (define average time and agree on target reduction)

Regular audit

Review ways of retaining staff 2016

Working towards reducing turnover in line with Trust agreed threshold

Reduction in turnover of staff to Trust threshold of 10%

EMT monitoring

12.0 The Trust should ensure that care and treatment records, including risk assessments, are sufficiently detailed, personalised and kept up to date

Demonstrate that service users receive person centred care and treatment that is appropriate, meets their needs and reflects their personal preferences

Undertake regularly audits of the quality of care plans and risk assessments


and Quality

2016

A number of care plan reviews have taken place. Practice Education Facilitators involved in mentoring and coaching

Improved quality of care plans and risk assessments Mitigation of risk

Quality improvement panels Regular audit

Ensure appropriate referrals and access to, and use of, IMHA/IMCA (advocacy) Advertise comprehensively throughout services Communications campaign jointly with ECC

2016

(Speak to Lynn Prendergast re S75)

Improved use of advocacy by service users

Patient feedback Monitor referral activity with ECC Regularly audit/monitoring

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Page | 10


CPA training to be reviewed in line with recovery orientated care 2015

Syllabus incorporates focus on recovery and My Care My Recovery now embedded

Revised training in place Improved quality of care plans and risk assessments

Regular evaluation of training

Review documentation for consent to treatment July 2015

March 2016

Ward round review paperwork implemented in July 2015 Consent to admission/ treatment form designed summer 2015 to be part of admission packs – going to Policy Advisory Group

Improved recording of consent to treatment in line with Montgomery v Lanarkshire (2015) UKSC 11

Evaluate documentation templates

MHA Administrators to audit documentation to ensure capacity and consent to treatment April 2016

MHA Administrators will audit presence of consent form attached to T2 in notes

Improved recording of consent to treatment and appropriate use of MCA

Regular audit

Review patient information around treatment choices

Dr Malte Flechtner Medical Director 2016

Informative patient leaflets Improved patient awareness of treatment choices on admission

Patient feedback

13.0 The Trust should review the efficacy of the electronic record system in community bases and ensure accurate inputting of data

Review Remedy use in all community teams

Review current processes within Remedy, changing as appropriate and training available to community staff to ensure accurate and time inputting of data


June 2016 Business case to EMT April and reinstate Journeys Implementation Steering Group

Improved recording in Journeys pathways Improved accuracy of data

Quality improvement panels

Review of Remedy training capacity

June 2016

14.0 The Trust should ensure all MHA documentation is readily available and in good order

Review systems and processes for MHA documentation

Centralise the MHA administration function


and Quality

April 2016 Business case submitted to EMT January 2016

Sharing of resources Economies of scale Central management

Review administration of MHA Clear communication of where documentation should be kept in physical and electronic locations

To be scoped with above Policy/protocols updated Improved availability of documentation

Documentation audits

Implement accountability at ward level for local availability and correct filing of MHA documentation Vince McCabe

Director of Operations

2016 Follow on from above Improving filing and availability of MHA documentation at ward level

Management supervision Documentation audits

Ensure patients receive a copy of their Section 17 leave authority and that it is clear what type of leave is being authorised, together with the

2016 Audit checklist Compliance with Section 17 Feedback loop

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Page | 11


numbers of escorts specified 15.0 The Trust should ensure that all informal complaints are logged and reported centrally

Review complaints systems and processes

Centralise the reporting and logging of informal/low level complaints Natalie Hammond

Director of Nursing and Quality

2016

NEP is in the process of centralising all low level complaints into the Patient Safety and Complaints Team Reporting already centralised

Comprehensive recording/logging on Datix complaints module Improved management and monitoring of complaints

Regular reporting to Risk and Governance Executive Quality Improvement Panel

16.0 The Trust should formally review each restraint involving the prone position

Review therapeutic and safe intervention training (formerly control and restraint)

Implement revised Therapeutic and Safe Interventions Natalie Hammond

Director of Nursing and Operations

2015

Completed Action plan to reduce restrictive interventions

Revised TASI training in place Reduced prone interventions

Evaluation of training Training and development group TASI Governance Group

17.0 The Trust should ensure that patients who are detained under the MHA 1983 have information on how to contact the CQC

Publicise information on how to contact the CQC

Display posters/leaflets on wards Natalie Hammond Director of Nursing

and Operations

March 2016 Re-audit posters and leaflets (communications)

Improved awareness

Patient feedback

Inform patients of their rights and how to contact the CQC 2015 Auditing Improved awareness

Patient feedback

18.0 The Trust should review its staffing arrangements for the health based place of safety to ensure sufficient staff are available promptly without impacting on other services

Review health based places of safety

As part of the review of S136 suites consider the staffing arrangements to ensure prompt availability of staff without impact on inpatient wards


and Quality TBA

Review of seclusion and S136 suites in progress and linked to safer staffing work Financial analysis underway

Improved response to S136 suite admissions Staffing levels increased appropriately through agreement and agreed criteria

Safe staffing reports Monitoring S136 data

Implement recommendations from the review Vince McCabe To follow on

from above To follow on from above

19.0 The Trust should identify a lead for the health based place of safety at The St Aubyn Centre and The Christopher Unit

Review the leadership for health based places of safety (nursing and medical)

Ward Managers to take joint leadership for all S136 suites


and Quality Jan 2016

Ward Managers jointly manage S136 suites with medical counterpart

Joint leadership in place Quality Improvement Panel

Identify a lead Consultant for joint leadership of S136 suite at the St Aubyn Centre

Dr Malte Flechtner Medical Director

TBA To be discussed Lead Consultant identified

Clear leadership Quality Improvement Panel

Identify a lead Consultant for joint leadership of the S136 suite at The Christopher Unit

TBA To be discussed Lead Consultant Identified

Clear leadership Quality Improvement Panel

Identify a lead Consultant for joint leadership of the S136 suite at The Lakes

TBA To be discussed Lead Consultant identified

Clear leadership

Quality Improvement Panel

20.0 The Trust should ensure learning from some serious incidents is shared across the three access, assessment and brief intervention teams Review the way learning is shared across the Access, Assessment and Brief

Review the operational structure Natalie Hammond Director of Nursing

and Quality

2016 In progress Improved working relationships Improved sharing of learning

Quality Improvement Panel

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Intervention Teams of SI’s Reduction in SI’s

21.0 The Trust should agree target times for assessment for all access and brief intervention teams

Review assessment times

Develop target times for assessment for all access and brief intervention teams

Vince McCabe Director of Operations

2015 Journeys evaluation has demonstrated waiting times halved. Target times in place

KPI in place for assessment times (add contractual figure in here) Improved assessment times for patients

EMT performance

Legend: Green actions complete Grey actions not due Amber actions due Red actions past timescale / risk identified

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 7 Date: 23 March 2016 Title of Report: Monitor Investigation - Feedback Lead: Christopher Butler Interim Chief Executive and David Griffiths Director of Resources Subject, Purpose and Recommendation: The Council of Governors is asked to receive an update re Monitor’s Regulatory Approach to NEP. This report was presented to the Council of Governors on 08 March 2016. Finance Implications: As pre the report (Section 4). Clinical Implications: N/A HR Implications: N/A Legal and/or Regulatory Implications: As pre the report (Section 4). Equality Implications: N/A Risks: As pre the report (Section 4).

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1) Purpose of Report The purpose of this brief report is to update the Board of Directors on Monitor’s Regulatory Approach to the Trust, as set out in the attached letter (Appendix 1) 2) Monitor’s Action Monitor is seeking to better understand the Trust’s current financial and operational challenges and whether there is therefore a need for further regulatory action by Monitor. Their key lines of enquiry are:

• What the key drivers of the deterioration in the trust’s financial position were during 14/15 and 15/16;

• What the reforecast outturn deficit of £3.3m means for the trust’s plans for 2016/17 and beyond, including its cash position;

• How the trust plans to address the financial deterioration through operational improvements or strategic developments;

• Whether the Trust is appropriately addressing the underlying key themes from the CQC inspection undertaken in August 2015, the external governance review conducted in 2014 and any other relevant governance reviews.

Ultimately the purpose of this investigation is to identify whether, in Monitor’s judgement, the Trust is, or is at risk of, failing to comply with either a Condition of Service or Governance Licence conditions. 3) Investigation In January and early February the Trust provided a range of additional financial, governance and quality information requested by Monitor. A specific meeting to discuss the Trust’s draft response to the CQC Full Inspection report was also held with the Director of Nursing and Quality, Director of Operations and the Medical Director. This meeting also provided the opportunity for Monitor to offer helpful advice and suggestions to support the Trust’s preparation for the Quality Risk Summit on 4th February. Monitor subsequently conducted a 2 day site visit at the Trust on 9th and 10th February. During this time interviews were held with all Executive Directors, the Chairman and the Chairs of the Audit and Quality and Risk Committees. Monitor also met with the three Area Directors and their senior teams, and with HR/Workforce Managers. 4) Possible next steps Monitor’s Risk Assessment Framework and Enforcement Guidance sets out potential next steps that Monitor may take following their investigation. These include:

• no further action, • informal action and support to the Trust; or • formal enforcement actions – the initial options available to Monitor are set out

in the diagram (overleaf)

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5) Conclusion At the point this report was drafted (09 March) we were awaiting draft feedback from Monitor about the conclusions they have drawn following the visit and their proposed next steps. A verbal update will be provided at the meeting.

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01 February 2016

Chris Paveley Chair North Essex Partnership University NHS Foundation Trust 439 Ipswich Rd Colchester CO4 0HF

Dear Chris

North Essex Partnership University NHS Foundation Trust (“the Trust’): Notification of Decision to Open a Formal Investigation into the Trust’s Compliance with its Licence

1. I am writing to inform you of Monitor’s decision to open a formal investigation intothe Trust’s compliance with its licence. This investigation has been opened dueto concerns raised by a CQC inspection and deterioration in the Trust’s financialposition.

2. The purpose of this letter is to:

2.1 Set out Monitor’s concerns in relation to the Trust’s performance; and

2.2 Confirm the process that Monitor will adopt in assessing the extent of these concerns, whether they amount to a breach of the Trust’s licence and any regulatory action that may be appropriate as a consequence.

3. I would be grateful if you would ensure that this letter is shared with your Boardof Directors and Council of Governors.

4. Monitor’s Concerns

4.1 Care Quality Commission (CQC) quality concerns: Following a focused inspection undertaken by the CQC on 20 February 2015, the Linden Centre Mental Health Wards overall have been rated as “requires improvement”;

4.2 The Trust received a section 29A Warning Notice from the CQC on 21 September 2015;

4.3 The final CQC report published on 26 January 2016, gave an overall rating of the services provided by the Trust as ‘Requires improvement’, including an ‘Inadequate’ rating for the safety of services provided;

Wellington House 133-155 Waterloo Road London SE1 8UG

T: 020 3747 0000 E: [email protected] W: www.monitor.gov.uk

Appendix 1

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4.4 Our meeting with the Trust on 19 January 2016 highlighted that whilst the Trust could describe progress towards addressing the CQC’s concerns, at that stage the Trust was working through the factual accuracy checking process and had not yet evidenced that progress through a single, coherent, robust action plan in response to the CQC findings. At that date, the Board also had additional preparations to make for the CQC Summit scheduled for 4 February 2016 and we noted that they should make contact with the CQC ahead of the Summit;

4.5 Decline in financial performance: The Trust has reforecast its 2015/16 year

end position from a breakeven normalised position (adjusted for one-off asset sale income) to a £3.3m normalised deficit, and we have concerns over the Trust’s pace in demonstrating grip and control over the deteriorating financial position;

4.6 In Q2 2015/16, the Trust reported a Financial Sustainability Risk Rating (FSRR) ‘2.’ An FSRR ‘2’ or below suggests a material level of financial risk and is a trigger for regulatory action under Monitor’s Risk Assurance Framework (RAF);

4.7 NHS Staff Survey score 2014: The Trust scored in the lowest quartile for 11 out of 28 survey questions, ranking the trust in the lowest quartile overall for Foundation Trusts.

4.8 NHS Staff Survey score movement: The year on year change in the Trust’s staff survey scores showed a decline in results.

4.9 Organisational health indicators: Staff turnover rates at the Trust had deteriorated over the previous 12 months.

5. Monitor’s Process to Determine what, if any, Regulatory Action is Appropriate

5.1 Monitor considers all relevant factors in assessing what, if any, regulatory

action is appropriate in relation to its concerns, including:

Information gathered from the Trust and relevant third parties; Any Trust Board assurance that the Trust is able to continue to meet

the requirements of its licence;

Monitor’s published guidance relating to the requirements of the licence; and

The factors set out in Monitor’s Enforcement Guidance.

5.2 We may also seek further information from the Trust and will consider any relevant information from third parties, such as the Care Quality Commission and the Trust’s commissioners.

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6. Investigation Process 6.1 As part of Monitor’s investigation into the concerns outlined in section 4, we

will consider whether there is evidence of a potential breach of the Trust’s licence.

6.2 We have already requested relevant information from you as set out in our letter dated 22 December 2015 and subsequent emails. As previously arranged with you we intend to hold a two day site visit on 9 and 10 February 2015 at your offices. Attendees for this site visit have been agreed in correspondence with Elizabeth Mabbutt at the Trust. This will provide an opportunity for the Trust Board to explain and provide evidence as to the nature and strength of its governance arrangements and its consideration of the concerns set out in section 4 of this letter.

6.3 Any meetings with members of the Trust Board that take place will form part of the evidence Monitor will take into account in determining what, if any, regulatory action is appropriate. They will also form part of the evidence for any formal enforcement action that may be considered appropriate, in line with our Enforcement Guidance.

6.4 Meetings will be chaired by Monitor and attended by members of our central investigations team.

6.5 Following the initial site visit, Monitor’s review of all the information

provided by the Trust and consideration of any further relevant information obtained during our investigation, we will be able to confirm next steps and associated timings. Should formal enforcement action be considered as a result of our investigation, the Trust will be afforded an opportunity for engagement, in line with our Enforcement Guidance.

7. Next Steps

7.1 The Trust’s governance rating will be replaced until further notice with a description of the issues and the steps we are taking to address it. Further guidance on how Monitor assigns a governance rating to Trusts is set out in paragraph 4.2 of the Risk Assessment Framework.

7.2 Monitor will be issuing a press release on 29 January 2016 announcing that we have opened a formal investigation into the Trust’s compliance with its licence.

7.3 If you have any questions in relation to the matters set out in this letter, please contact your relationship manager, Ruth Forbes on 020 3747 0582 or by email at ([email protected]).

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mailto:[email protected]

Yours sincerely,

Marianne Loynes Regional Director cc: Andrew Geldard - Chief Executive

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 8 Date: 23 March 2016 Title of Report: Staff Survey 2015 Lead: Lisa Anastasiou, Director of Workforce & Development Subject, Purpose and Recommendation: The Board of Directors is asked to receive and note the attached report on the results of the 2015 Staff Survey and the priorities identified in response Finance Implications: N/A Clinical Implications: N/A HR Implications: The staff survey is an indicator of staff satisfaction and morale and informs the trust’s overall approach to staff engagement as part of the overarching People Strategy. Legal and/or Regulatory Implications: N/A Equality Implications: Actions taken in response to the survey will be implemented with due regard for their impact on equality. Risks: N/A

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Staff Survey Results 2015 1. Introduction The annual staff survey is one method of ensuring that the Board understands the views of our workforce, the things we do well as an organisation and the areas for improvement. It is essential that as well as listening, we respond and therefore this paper is focused on the actions that will be taken in response to the 2015 survey. The survey was conducted between October and December 2015 and the results were published last month. In addition to the “core survey”, (with a mandated random sample size of 750 staff), surveys were also issued to the rest of the workforce resulting in an overall response rate of 41%. It is worth noting that 2015 was a particularly turbulent year for our workforce with the implementation of Journeys affecting the roles and working practices of 650 staff working in our community services and significant recruitment challenges. These factors have clearly had an impact on many staff and this is evidenced in both the survey report and supporting narrative. 2. Results In 2014 our staff engagement score result of 3.73 was higher than the national average and the motivation levels of our workforce were amongst the highest 20% in the country when compared with similar organisations. One year on in 2015 this score dropped to 3.61 against a national average of 3.75. Of the 32 key findings in the survey there are 16 areas where results have not changed since 2014, 6 which demonstrate deterioration (see page 2) and the remainder cannot be compared due to changes to the question format. The table below sets out our top 5 ranking scores and lowest 5 ranking scores as they compare with the national picture: Top 5 Scores Lowest 5 Scores Percentage of staff experiencing physical violence from service users, relatives or members of the public

Support from immediate managers

Percentage of staff experiencing violence from other staff

Demonstration of recognition and value by managers and the organisation

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Percentage of staff reporting incidents of violence against them

Work related stress

Quality of training (non-mandatory), learning or development

Harassment, bullying or abuse from other staff

Percentage of staff working extra hours

Satisfaction with the level of responsibility and involvement

The 6 key findings which show deterioration when compared with our 2014 results are as follows:

• Staff motivation at work • Staff satisfaction with their level of responsibility and involvement • Support from immediate managers • Percentage of staff suffering work related stress in the last 12 months • Percentage of staff who feel able to contribute towards improvements at

work • Staff confidence and security in reporting unsafe clinical practice

Detailed analysis of the results by area, team and professional group has highlighted that there are some staff groups who are expressing greater levels of dissatisfaction than others. This information is useful as a starting point for further discussions with staff to gain a full understanding of the views expressed and to develop an appropriate response. 3. Initial Response On publication of the results an immediate response was issued to all staff acknowledging the challenges of the past 12 months, confirming our commitment to acting on the views expressed in the survey and citing specific actions that will be taken, namely to: 1. Improve our staffing position to relieve the pressure on services Recruitment to key posts is a significant challenge at this time in the context of a national shortage of health professionals. The trust has a clear recruitment plan in place and progress against the plan is communicated to all staff at regular intervals. Improved staffing levels is an imperative factor if we are to increase staff morale. 2. Work together to act on the evaluation of the Journeys programme It is essential that all community staff feel involved in the evaluation of the Journeys programme and equally feel able to influence any changes to future

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ways of working. Workshops have been established to commence this, recognising that this will be an ongoing process of improvement.

3. To appoint a Freedom to Speak Up Guardian (in line with national direction) to ensure an additional method for staff to raise concerns, safely and with complete confidence

It is critical that all staff feel the trust is an environment where concerns can be raised in a safe way. A Guardian will be appointed and the role developed to support the achievement of this aim. 4. Re-launch our Respect and Dignity Campaign to ensure that all staff

feel valued and respected In partnership with trade union colleagues we will relaunch and boost efforts to encourage staff who feel they have not been treated with respect and dignity, to come forward and share their concerns in confidence and in the knowledge that they will be supported appropriately. 5. Improve the appraisal experience to ensure that training and

development needs are fully identified Our focus on appraisals will continue this year, not only in terms of the numbers undertaken, but on improving the quality of the experience through regular training and briefings for those appraising staff and appraisees. The aim, to ensure that staff leave their appraisal conversation feeling valued and clear on their objectives for the coming year. 6. Recognise and reward staff for outstanding contributions that improve

the quality of patient care and experience There are clear messages in the survey that more attention needs to be paid to the way that staff are recognised and rewarded for their contribution; both at a local managerial level and by the trust. This will be an area of priority for the Staff Engagement Group who will develop clear approaches to the issue over the coming weeks. 7. Introduce an initiative that supports the swift resolution of the small

things that frustrate staff on a daily basis Whilst this is not an action arising from the results of the survey directly, it is clear from the views of staff expressed in different forums, that a mechanism for ensuring a swift response to issues that hinder them in their work, will have a positive impact on morale. Again the approach to this initiative will be developed and overseen by the Staff Engagement Group.

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8. Ensure that the voice of staff is heard when suggestions are made that can improve the patient experience

Through local management teams we will ensure that the views of staff are harnessed and where improvements are made as a result we will ensure that this is communicated positively across the organisation. 4. Next steps A full plan setting out the detail, timelines and accountability for actions will be developed by the Staff Engagement Group. Progress will be monitored by the group and the Board will receive updates in the context of the wider People Strategy.

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 9 Date: 23 March 2016 Title of Report: Duty of Candour Update Lead: Natalie Hammond, Director of Nursing and Quality Subject, Purpose and Recommendation: The Board of Directors is asked to note the contents of this report:

• The Trust has a ‘being open’ policy which will be reviewed and approved in April 2016 • A number of key processes have been changed in recent months to ensure the Trust

discharges its Duty of Candour requirements • A Trust Serious Incident Panel is in operation to monitor Duty of Candour, and this

also covers any Trust Inquests • Route Cause Analysis Training provides training on Duty of Candour for our staff • A staff information leaflet from the NHS Litigation Authority is now available to all staff • A patient information leaflet has also been developed and is available to our patients

to explain Duty of Candour Finance Implications: Potential implications if the requirements identified within the legislation are not met. The Trust, as identified within the report, has a number of monitoring mechanisms in place to ensure the legislative requirements are met. Clinical Implications: The Trust not working with patients, families when an incident occurs and ensuring that their concerns are looked into as part of any Trust investigation. HR Implications: N/A Legal and/or Regulatory Implications: Not fulfilling our responsibilities and coming to the attention of the Care Quality Commission Equality Implications: N/A Risks: N/A

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Board of Directors’ Briefing - Duty of Candour

1) Introduction

The Duty of Candour regulation came into being formally in April 2015; the standard came from various high profile NHS inquiries but most notably the Francis Inquiry into the standards of care at Stafford Hospital. The Trust is required to comply with the legislation as set down within the Act. The Duty of Candour has also been included in NHS contracts to ensure provider organisations are able to comply with the standards that have been set down. The key requirement under the legislation for Duty of Candour is that all NHS organisations establish clear processes and mechanisms that if an incident occurs, that we communicate with those patients involved in an open and honest way. The Duty of Candour is a legal requirement placed on NHS organisations and if this statutory duty is breached then the Care Quality Commission (CQC) can take enforcement action against the organisation.

This paper aims to update the Board of North Essex Partnership University NHS Foundation Trust on the implementation of these standards and our current position.

2) Background

Following the publication of the Francis Report, it identified that there should be a duty to release information to those who may have been adversely affected by the provision of NHS services, and that this should not be dependent on a request for information but this should be voluntarily disclosed.

There is a duty now placed on NHS organisations to disclose this information to users of NHS services if it believes that somebody may have died, been seriously harmed and that this information should be routinely available.

3) Legal Responsibilities

To ensure that an NHS organisation is able to comply with the duties under the legislation they must:

• Notify the patient or individual that has been affected by the incident• The Trust must give the patient or individual a nominated name for further contact• Update the individual on any information that is currently available regarding the

incident• Advise the individual what process will be undertaken to investigate what has

happened• Include an apology to the individual on what has happened - at this point you are not

admitting any liability but apologising to the individual for what has happened• Provide a written apology and written contact with the individual concerned• If this incident is going to be investigated under the serious incident process, explain

the investigation process and provide written information if available

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• Within the legislation and the fact that the CQC has power to issue enforcementnotices if a trust fails to comply with the legislation, the CQC will look at individualcases where a serious incident has occurred and will investigate if it feels we havenot met this area.

4) How does the Trust comply with the Legislation?

Below identifies the measures that have been implemented to ensure the Trust has fully implemented the legislation:

• Once an incident/serious incident has been identified it is reported on the Trustincident reporting system, DATIX

• There is a governance process implemented regarding the oversight of incidents andnow has an established incident triage process to ensure all incidents of moderateharm and above are analysed to ensure none of these meet the serious incidentcriteria as laid out by NHS England in April 2015

• The Trust is currently updating the DATIX system to version 14 which has a clear setof questions for staff around the requirements for ensuring Duty of Candourrequirements have been met. This will be able to be audited as part of the audit cycleand ensure compliance

• All serious incident investigations have a focus on Duty of Candour to ensure that allrequirements have been implemented and documented

• The new Incident Reporting Policy which includes the serious incident investigationprocess, has a clear section on Duty of Candour so staff are aware of theirresponsibilities

• The Route Cause Analysis (RCA) training includes Duty of Candour and as aninvestigating officer what you legally need to perform to ensure the Trust meets itsrequirements

• A training session has been held between the Trust and Clinical CommissioningGroup (CCG) for staff on how to perform the Duty of Candour responsibilities and thiswill now be held twice yearly to ensure we have staff trained in this critical area ofpractice

• The Trust holds a weekly SI Panel which includes reviewing all serious incidents andensuring that Duty of Candour has been implemented

• The Trust’s Being Open Policy is going to be reviewed and approved in April• The Trust has standard templates for the apology that comes from the Chief

Executive in line with the requirements of this legislation• As part of the Trust Induction process, being open and honest is part of the Making

Patient Experiences Count training which re-enforces the legislation requirements• A staff booklet produced by the NHS Litigation Authority on saying sorry has been

used for staff within the Trust, and in the future, will be provided to staff involved inserious incidents to ensure staff are clear on what their responsibilities are (Appendix2)

• A booklet has now also been produced for patients and carers on what Duty ofCandour is and what they should expect from the Trust (Appendix 3)

• The Associate Director of Quality holds SI investigator update sessions quarterly andthis also includes updates on Duty of Candour

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5) How will the Trust monitor its compliance with Legislation?

The duty placed on NHS organisations in line with the Duty of Candour legislation is complex and requires us to have a systematic monitoring process in place:

• Monitored via the formal Trust Serious Incident Panel• Monitored via the governance forums in each of the areas within the Trust• Monitored via the serious incident scrutiny process as no final report will be approved

unless full Duty of Candour requirements have been fully implemented• Via DATIX reporting we will now be able to formally audit the compliance rate with

Duty of Candour

6) How does the Trust practically apply the Legislation?

Under the implementation of the legislation, the responsibilities for ensuring it is fully implemented rests with the Patient Safety and Complaints Team (PSCT). To ensure we meet the expectations the list below identifies what the Trust requires of those investigating serious incidents:

• The PSCT send a letter of apology from the Chief Executive• Information leaflet on Duty of Candour is also sent, and if a death is involved, a

bereavement information leaflet is also sent• The Investigating Officer is appointed and makes contact with the relative or patient

involved in the serious incident and identifying that they are now the point of contactfrom that point on if they require further information

• If the patient/relative has concerns around what has happened, the InvestigatingOfficer should meet to document their concerns so that these can be incorporatedinto the investigation, so that these questions can be answered and clear answersgiven to the patient or relative when the investigation report is handed over to therelatives

• If required, to keep the relatives updated as the investigation progresses• A meeting will be established with the patient/relative when the report is available so

that the Investigating Officer can discuss the findings of the investigation with them• If they have comments with the report this can be included as an addendum to the

final report

7) Continued Developments

The following developments need to continue to ensure Duty of Candour continues to be fully implemented:

• Two training days per year on Duty of Candour and this should be held jointlybetween the Trust and the CCG

• Specifically designed update sessions for Investigating Officers, and as part of this, itidentifies what the requirements under Duty of Candour are for staff

• Continued development of the organisational culture around the fact that it is ok forTrust staff to apologise, and if they do, they are saying sorry for the experience thatthey have had and not an admission of any liability

• Continue with the quarterly update sessions for serious incident investigators toencompass Duty of Candour

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8) Conclusion

This report has identified the key requirements that the Trust needs to perform under the Duty of Candour requirements. It has demonstrated that the Trust currently has an effective governance process in place for the continued implementation and monitoring of the Duty of Candour process. There are next steps that the Trust now needs to take forward, specifically regarding the training and development of its staff to ensure all requirements are undertaken and met.

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Appendix 1

These are the questions that will now be on DATIX to ensure we meet the requirements of Duty of Candour:

• Was the patient/appropriate person informed that an incident occurred?

• When was the patient/appropriate person informed?

• Were the members of staff involved in the incident involved in informing thepatient/appropriate person?

• Please provide details of staff members who informed the patient/appropriate person.

• Please provide details of the patient/appropriate person who was informed.

• Was an apology provided to the patient/appropriate person?

• Was a truthful account of the facts known at the time shared with thepatient/appropriate person?

• Was the patient/appropriate person advised about next investigative steps to beundertaken?

• Was a written memo of the initial disclosure securely recorded?

• Was a copy of this memo provided to the patient/appropriate person?

• When was this memo provided to the patient/appropriate person?

• Following a thorough investigation, were details related to personnel or systeminsufficiencies/failures discussed?

• Were details of personnel or system insufficiencies/failures and/or errors included in areport?

• Following investigation was a detailed written investigation report securely recorded?

• Was a copy of this detailed report provided in full to the patient/appropriate person?

• Were unsuccessful attempts to contact the patient/appropriate person recorded?

• Were support services offered to the patient/appropriate person affected by theincident?

• Did the patient/appropriate person accept the support services offered?

• What was the nature of support services provided?

• Were follow-up discussions offered to the patient/appropriate person?

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Saying sorry when things go wrong is vital for the patient, their

family and carers, as well as to support learning and improve safety.

Of those that have suffered harm as a result of their healthcare, fifty

percent wanted an apology and explanation. Patients, their families

and carers should receive a meaningful apology – one that is a

sincere expression of sorrow or regret for the harm that has

occurred.

Saying Sorry

Appendix 2 - Staff Leaflet

72

How should this happen?

Verbal apologies are essential

because they allow face-to-face

contact between the patient, their

family and carers and the healthcare

team. This should be given as soon

as staff are aware an incident has

occurred. A written apology, which

clearly states the healthcare

organisation is sorry for the suffering

and distress resulting from the

incident, must also be given.

Who should say sorry?

Information about a patient safety

incident must be given to patients

and their families in a truthful and

open manner by an appropriately

nominated person. Staff may be

unclear about who should talk to

patients when things go wrong and

what they should say; there is the

fear that they might upset the patient,

say the wrong things, make the

situation worse and admit liability.

Having a local policy that sets out the

process of communication with

patients and raising awareness

about this will provide staff with the

confidence to communicate

effectively. The local policy should

state who is the most appropriate

member of staff to give both verbal

and written apologies to patients and

their families; the decision should

consider seniority, relationship to the

patient, experience and expertise.

Most healthcare provision is through

multidisciplinary teams so any local

policy on openness should apply to

all staff that have key roles in the

patient’s care.

What if there is a formal

complaint or claim?

Poor communication may make it

more likely that the patient will

pursue a complaint or claim. It is

important not to delay giving a

meaningful apology for any reason,

including where there is a formal

complaint or claim. It is also

essential that any information given

is based solely on the facts known at

the time. Healthcare professionals

should explain that new information

may emerge as an investigation is

undertaken, and that patients, their

families and carers will be kept up-to-

date with the progress of an

investigation.

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Is an apology the same as

an admission of liability?

Saying sorry is not an admission of

legal liability; it is the right thing to

do. The NHS LA is not an insurer

and we will never withhold cover for

a claim because an apology or

explanation has been given. The

NHS LA claims teams are always

happy to provide support and advice

where there is a potential claim.

What about the staff

involved?

Healthcare organisations must

create an environment in which all

staff, whether directly employed or

independent contractors of NHS

care, are encouraged to report

patient safety incidents. Staff should

feel supported throughout the

investigation process because they

too may have been traumatised by

being involved. Sometimes patients

can suffer significant harm. In these

circumstances, the member(s) of

staff involved may find it hard to

participate in the discussion with the

patient and their family. Every case

needs to be considered individually,

balancing the needs of the patient

and their family with those of the

healthcare professional concerned.

In cases where the healthcare

professional responsible wishes to

attend the discussion to apologise

personally, they should feel

supported by their colleagues

throughout the meeting. In cases

where the patient and their family

express a preference for the

healthcare professional not to be

present, it is advised that a personal

written apology is handed to the

patient, their family and carers during

the initial Being Open discussion.

For more information

Being Open Guidance (National

Patient Safety Agency)

www.nrls.npsa.nhs.uk

Reports and Consultations on

complaint handling (Parliamentary

and Health Service Ombudsman)

www.ombudsman.org.uk

Review of the NHS Hospitals

Complaints System Putting

Patients Back in the Picture

(Clwyd and Hart)

www.gov.uk

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http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=65172&type=full&servicetype=Attachment

http://www.ombudsman.org.uk/reports-and-consultations

http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/255615/NHS_complaints_accessible.pdf

Key messages

Timeliness: The initial discussion with the patient and their family

should occur as soon as possible after recognition that something has gone

wrong.

Explanation: Patients and their families should be provided with a step

-by-step explanation of what happened, that considers their individual

needs and is delivered openly.

Information: Patients and their families should receive clear,

unambiguous information. They should not receive conflicting information

from different members of staff. The use of medical jargon and acronyms,

which they may not understand, should be avoided.

On-going support: Patients and their families should be given a

single point of contact for any questions or requests they may have. They

should also be provided with support in a manner appropriate to their

needs. This involves consideration of special circumstances that can

include a patient requiring additional support, such as an independent

patient advocate or a translator.

Confidentiality: Policies and procedures should give full consideration

of, and respect for privacy and confidentiality for the patient, their family and

staff.

Continuity of care: Patients are entitled to expect that they will

continue to receive all usual treatment and continue to be treated with

dignity, respect and compassion. If a patient expresses a preference for

their healthcare needs to be taken over by another team, the appropriate

arrangements should be made for them to receive treatment elsewhere.

“Achieving timely and fair resolution, enhancing learning

and improving safety.”

www.nhsla.com 75

Title

Duty ofCandour

Communicating when things go wrong

A guide for patients, families and Carers.This leaflet provides information on the Duty

of Candour process and what to expect.

Appendix 3 - Patient Leaflet

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32

What is the Duty of Candour?

Healthcare is very complex and things can change rapidly and unexpectedly. Occasionally things do not go to plan and a patient can be harmed despite our best intentions.

We regret every case of harm to our patients but we make sure we use the opportunity to learn and stop similar things happening again.

Why do things go wrong?

Healthcare staff should talk with you openly throughout your care.

The Duty of Candour is a formal requirement to be open and honest with patients if they have suffered harm. This means that if you suffer any unexpected or unintended harm during your care we will:

• Tell you about it• Apologise• Investigate• Give an open

explanation of whathappened.

Candour

Staff will speak to you honestly and openly as soon as possible.

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Duty of

4

What can I expect?

You will be treated with dignity and respect and you will receive an apology.

Candour

It is recommended that you do choose someone to support you during the discussion. This should be somebody that you are comfortable with, can talk to easily and who you do not mind hearing personal information.

Please let us know if you wish somebody to be with you for the discussion. An advocate can be arranged for you if required.

Please remember that when something goes wrong it is distressing for everyone involved including our members of staff.

5

An advocate can be arranged for you if required.

Should I have someone with me when staff are talking to me about what happened?

• A member of staff will speak to you honestly andopenly as soon as possible after the event todiscuss what happened, your condition and yourongoing care plan.

• All of the facts may not be clear at this time so staffmay not be able to answer all of your questions untilwe have investigated.

• If you are not in a condition to receive theinformation, for example if you are too ill orrecovering from anaesthetic, staff will inform yournext of kin or the person named by you in yourhealthcare record.

• You can involve family members or carers in thesediscussions.

• You will be treated with dignity and respect and youwill receive an apology.

• You can expect to be involved in and contribute todecisions made about your care.

• You will normally be given a named person to speakto about any further queries or concerns.

• We will investigate what went wrong and will beinformed about the findings.

• You can expect confidentiality.

78

CandourDuty of

6

• One or more staff may talk to you, depending on what happened.

• Usually the person leading the conversation will be someone fromyour healthcare team who knows the most about what happenedand will be able to answer any questions you may have.

7

What happens next?

• Further meetings may be necessary if all of theinformation you need is not available.

• We will tell you our findings and offer you a copy ofany report.

• If you are not satisfied with your care or yourconcerns have not been addressed you have theright to make a complaint. In the first instanceplease contact the Patient Advice Liaison Service(PALS):

Telephone: 01245 546400 Email: [email protected]

Further information on the Duty of Candour is available from the service you are attending or from PALS.

We will tell you our findings and offer you a copy of any report.

Who will speak to me about what happened?

How should I prepare for a duty of candour conversation?

Before the conversation you may find the following advicehelpful:

Think about what questions and concerns you have in relation to:

• What has happened• Your condition and your ongoing care• Write down any questions or concerns you have• Think about who you would like to have with you to support you• Think of what things may assist you moving forward.

Other formats and languages

If you need this information in other formats and languages please email a request to [email protected]

Visit our website: www.nep.nhs.ukFollow us on Twitter: @NEPNHSFind us on Facebook

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© North Essex Partnership University NHS Foundation Trust 2015. All rights reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. FOI Ref: 021602

Further sources of supportNorth Essex Partnership University NHS Foundation Trust The Chaplaincy is a confidential service available 24 hours a day to all patients, families and carers. They offer help on all aspects of pastoral care members of all faiths or those of no particular religious belief. Sacred spaces are also available at both of the main hospital sites. Telephone: Email:

HealthwatchHealthwatch England is the national consumer champion in health care and works to share information, expertise and learning in order to improve health and social care services. Website: www.healthwatch.co.uk

Support, Empower, Advocate, Promote (SEAP)Independent advocacy services to help resolve issues or concerns you may have about your health or healthcare services. Website: www.seap.org.ukEmail: [email protected]

Carers UK Provide free expert advice, information and support on issues including financial and practical matters related to caring. Website: www.caresuk.orgTelephone: 08088087777

Cruse Bereavement Care Provides support to those having experienced the death of a close friend or relative. Website: www.cruse.org.ukTelephone: 08444779400Email:[email protected]

NHS ChoicesProvides online information and guidance on all aspects pf Health and healthcare, to help you make choices about your health. Website: www.nhs.uk

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 10 Date: 23 March 2016 Title of Report: Operational Plan 2016/17- Update Lead: Mike Chapman, Director of Strategy Subject, Purpose and Recommendation: This paper provides the Board with an update on NHS Improvement process and expectation in relation to the development and submission of the final operational plan for 2016/17. Whilst the plan is in the process of being finalised, this paper outlines some of the key changes that have been made since submission of the draft plan. The Board of Directors is asked to consider and note;

i. The expectation and requirements related to submission of the final operational plan,

ii. That work is in progress to update and finalise the plan, iii. That a number of self-declarations are required from the Board;

and

iv. The Board is asked to delegate responsibility to the Director of

resources, the Chairman and the Chief Executive Officer to authorise and submit the final operational plan on behalf of the Board on 11 April 2016.

Finance Implications: The financial risks and implications have been outlined in the operational plan narrative document Clinical Implications: Quality and safety implications of Cost improvement initiatives will be assessed prior to submission HR Implications: N/A Legal and/or Regulatory Implications: Failure to submit an operational plan may trigger an investigation from our regulator. Equality Implications: There are no equality implications identified at this point. Risks: Reputational risk related to failure in submitting an operational plan to our regulator.

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1 Purpose

1.1 This paper provides the Board with an update on NHS Improvement process and expectation in relation to the development and submission of the final operational plan for 2016/17. Whilst the plan is in the process of being finalised, this paper outlines some of the key changes that have been made since submission of the draft plan.

2 Background

2.1 A paper presented to the Board, in January 2016 outlined NHS Improvement, process and time table for submission of a one year operational plan for 2016/17.

2.2 A draft operational plan narrative and the Annual Plan Review (APR) template was submitted to NHS Improvement on 8 Feb 2016. Work is in progress to update both the draft narrative plan and the APR template in readiness for submission by the required date.

2.3 Since submission of the draft operational plan in February 2016, the trust has complied with NHS Improvement requirement to complete and submit the weekly “contract tracker returns”. An update on the contract negotiation and position is being provided to the board as part of the finance update.

3 Final operational plan

3.1 The trust is required to submit a final operational plan to NHS Improvement by midday on Monday 11 April 2016. This will include,

• an updated final version of the operational plan narrative • a one page cover sheet drawing attention to any material changes from the draft

version. • a separate version of the final plan in a format suitable for external publication. • updated final version of the finance, activity and workforce data return

3.2 NHS Improvement also requires the trust board to make a series of declarations within the

Annual Plan Review template as part of its final operational plan for 2016/17. These self-certification declarations are also covered in the finance update paper.

3.3 This year, NHS Improvement is not asking NHS trust boards to refresh the declaration of sustainability (made in the 2014/15 strategic plans and 2015/16 operational plan). This requirement will instead be addressed in the scope of the local Sustainability and Transformation Plan (TSP).

4 Material changes

The board is asked to note that the following changes will be included in the final operational submission;

4.1 Key performance indicators.

4.2 We are required to formally agree the set of Key Performance Indicators (KPIs) to be

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reported in the APR; this should include KPIs that are reported internally and have a measurable threshold. The Executive Management Team has proposed that the following KPIs are included:

Description Threshold 1 Percentage of patients who have a care plan that has been shared with them 95%

2 Percentage of patients on Section 117 aftercare who have received an annual review of their care plan

95%

3 Proportion of patients with a crisis plan in place, limited to those on CPA 95%

4 Percentage of patients seen by psychiatric liaison service within 4 hours of referral

95%

5 Percentage of carers who have been offered an assessment and have subsequently accepted

75%

6 Duty of Candour No breach

7 Percentage of staff who have attended Safeguarding Training relevant to their level of expertise and in line with ESAB guidance

95%

8 Percentage of staff Sickness 4.5% 9 The total Vacancy rates TBC

10 Percentage of Extremely likely/likely responses from patients Family and Friends Test

4.3 Commissioning for Quality and Innovation (CQUINs)

4.4 Whilst the list of indicators is yet to be finalised as part of contract negotiations, the national CQUINS have been recently released and the CQUIN table will be updated accordingly.

Contract 2016/17 £ Goals

Adult and Older Adult Main Block tbc

1 L1: Physical Healthcare & Smoking Cessation

2 L2: Outcome Measures – Patient Reported Outcome Measure 3 L3: Shared Education and Training Programme 4 L4: Workforce- strategy and leadership N1: NHS Staff health and Wellbeing N2: Improving physical healthcare to reduce premature mortality in people with severe

mental illness Children & Young People (Tier 4) tbc 1 Improving CAMHS care pathways Journeys by enhancing the experience of family carer.

Specialised Commissioning Group

tbc

1 Implement “Sense of community “ in high secure wards 2 Recovery colleges- low secure 3 Reducing restrictive Practices within Adult secure services 4 Perinatal Involvement and support for partners/ significant others

MVA 1 TBC

Total

4.5 Cost improvement plan.

The cost improvement initiatives will be “Quality Impact” assessed and rated as part of the final submission.

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5 Governance and sign off of final plan

5.1 The board is asked to note that the operational plan will be updated if required when progress and/ or an agreement is secured in terms of our main contract. Any further material changes made to the plan will be communicated to the board via a briefing update ahead of final submission. In the meantime, the board is asked to delegate responsibility to the Director of resources, the Chairman and the Chief Executive Officer to authorise and submit the final operational plan on behalf of the board on 11 April 2016.

Mike Chapman

Director of Strategy

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 11a Date: 15 March 2016 Title of Report: Delivery of ‘All Together Better’ Strategy Update Lead: Mike Chapman, Director of Strategy Subject, Purpose and Recommendation: This paper provides an update on delivery of the Trust Strategy “All together better” within the last year. It outlines progress against key initiatives delivered in year and sets out the initiatives that will be driven in the next twelve months which will further support delivery of our strategy and strategic objectives. The Board of Directors is asked to note:

i. The progress made in delivery of the four strategic aims against the key success measures.

ii. The specific initiatives that has been delivered fully or partly in year against the planed activity.

iii. The development of a strategy dashboard. iv. The key initiatives that will be delivered in 2016/17 to support delivery of our

strategy. Finance Implications: N/A Clinical Implications: N/A HR Implications: N/A Legal and/or Regulatory Implications: Failure to deliver the strategy may trigger regulatory investigation and a request to resubmit a refreshed strategy Equality Implications: N/A Risks: N/A

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1 Purpose

1.1 This paper provides an update on delivery of the trust Strategy “All together better” within the last year. It outlines progress against key initiatives delivered in year and sets out the initiatives that will be driven in the next twelve months which will further support delivery of our strategy and strategic objectives.

2 Context

2.1 NEP launched its new five year strategy “All together better “ in April 2015 and outlined its four key new strategic objectives.

• NEP will be a leading provider of specialist mental health care • NEP will be a system leader and a partner in the development and delivery of

integrated community services. • NEP will continue to improve patient outcomes • NEP will continue to improve patient experience.

2.2 Within the last year, a number of significant events within the trust have directly and indirectly impacted on the pace and ability to deliver our strategy, namely:

• The Implementation of the community services transformation programme “Journeys”.

• Changes within the senior leadership team and redistribution of responsibilities for e.g. the creation of a standalone Nursing and Quality directorate.

• A Trust-wide CQC inspection and implementation of an improvement plan. • The transfer of CAMHS Tier 3 services to North East London NHS FT.

2.3 The external environment has been very challenging for a number of years. The Essex health

economy has and continues to experience a number of quality, a financial and operational challenge which is putting the sustainability of health and care services at risk. Following initial diagnostic work, NHS England decided to provide extensive support within the “Success regime framework” to Mid Essex and South Essex CCG’s to address these systemic issues.

2.4 An Essex wide review of mental health services was also commissioned from the Boston Consultancy by all the CCG’s, local authorities and two mental health trusts. The report made a number of recommendations which have been considered by the boards of all the sponsoring organisations. The boards of NEP and SEPT decided to explore the option of a merger which is now being pursued following Monitor established process for merger.

3 Delivering the strategy through the development and delivery of Business plan

3.1 Within NEP, delivery of the strategy is supported through the development and approval of directorate/ team business plans. The trust has established a process for developing, reviewing and approving business plans which consists of the following stages:

• Development and circulation of Business plan template and guidance. (Oct) • Provide support to team as required (Oct-Dec)

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• Submission of business plans and review (Early January) • Presentation of Business plans and feedback (Late January) • Development of NEP Operational plan and submission to Monitor (Jan/Feb)

3.2 An independent audit was commissioned in Aug/ Sep 2015 to determine the strength of the processes in place within the Trust for the development, implementation and delivery of the “All Together, Better Strategy”. Following the review, Baker Tilley concluded that the Board can take reasonable assurance that the controls in place to manage this risk are suitably designed and consistently applied, therefore assigned an overall amber/green rating.

3.3 They also noted that further improvement could be made to standardise the structure of business plans and tracking delivery of the strategy. The report made three recommendations for improvement which were included within the last business plan guidance issued to corporate teams in October 2015.

3.4 The last strategy update provided to the Board in July 2015, outlined the key initiatives that would be implemented in year to support delivery of the strategy. In February 2016, the Board received a further presentation “On evidencing the improvement in patient outcomes and experience”. It is against this backdrop that a further update is now provided.

4 High level -Key measure of success The tables below provide an update against the key measures of success which were outlined within our strategy.

4.1 Strategic aim 1: NEP will be a leading provider of specialist mental health care 1) Income from specialist mental health services will rise year-on-year • The opportunity to bid for specialist mental health care of medium/high value has been very

limited in year. Most of the opportunities have come from out of county and the trust is in the final stage of procurement for a large mental well-being service in Suffolk. The trust has also this year won two specialist services contract for Offenders with Complex Needs (OCAN) and Psychological therapy for Veterans services worth around £500k.

2) The increase in national profile of NEP can be demonstrated though its media and clinical / research profile

• The Trust is proactive and has issued a total of 49 press releases from April 2015 to March 2016, however the uptake and reporting has been rather mixed.

• A journalist from the Essex Chronicle came along to an open day about dementia where people had the opportunity to try on the Gert Suit and experience a Virtual Dementia Tour. This resulted in a full page feature on dementia in the Chronicle. Sir Simon Burns MP wrote positive comments about staff at the Linden Centre in the Essex Chronicle in June 2015. The Board decision to pursue a merger with SEPT was reported in the Health Service Journal and the event “Walk in the park” received positive coverage on the trust Dementia Day

• However, the trust received negative publicity on Channel 5 News in the summer, when footage filmed from a patient mobile phone at Linden centre was broadcasted. Further negative publicity of the Linden centre continued in the local press following a number of high profile coroner’s inquests. The trust also received adverse coverage on BBC Look East after the CQC published its

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inspection report in January. The trust agency spend, Monitor’s investigation and CQC rating were covered in an article published in the Gazette in February 2016.

4.2 Strategic aim 2: NEP will be a system leader and a partner in the development and delivery

of integrated community services 1) NEP continues to provide community services across north Essex • Most (80%) of the trust clinical activities takes place in the community within our specialist

Community Mental Health Services. We are the sole provider of secondary mental health services and have been successful in launching new services such as STaRS (Substance misuse services), Extended Veterans services, Street Triage and Supported Employment services in year. Following a procurement process, the trust lost and subsequently transferred the Child Adolescent Mental Health services (Tier 3) to NELFT in November 2015.

• Currently, NEP does not provide physical healthcare community service and/or Improving Access to Psychological Therapy services across CCG’s within Essex.

2) Positive engagement with commissioners and partners in the integration agenda can be demonstrated

• The three CCGs are at different places in developing their integrated community services and the trust is represented on their respective programme boards. West Essex CCG is more advanced in developing and implementing an “Integrated Care Organisation” and the trust Director of strategy has been heavily involved in pursuing this agenda. ACE has been awarded the contract to deliver “care closer to home” in north Essex and local senior managers are exploring the option for more partnership working. Mid Essex locality proposal is still in development and likely to be progressed through the success regime.

• The trust has worked with a number of partners including Anglia care Trust, Suffolk G.P. Federation, Suffolk Mind to develop some innovative proposal in service provision.

4.3 Strategic aim 3: NEP will continue to improve patient outcomes/experience 1) The proportion of service users saying they would be extremely likely or likely to recommend

our services continually increase Within the last year, the Patient Experience Board was re-launched with revised terms of reference, development of a Patient Experience dashboard and a comprehensive action plan. Delivery of the action plan is monitored at every meeting with in depth discussion and timely actions taken to address emerging issues. Friends and Family Test The Friends and Family test remain the nationally recommended survey to measure patient experience at regular interval. Within the trust, the FFT score has been collected within inpatient services for a number of months and has more recently been extended to community teams. The percentage of extremely likely/likely responses has consistently been above 70% and the FFT score has been mainly positive throughout the year as shown below.

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FFT score Questionnaires completed

% Extremely

Likely / Likely

responses Feb-15 -9.1 77 52% Mar-15 10.4 98 70% Apr-15 24.6 64 67% May-15 21.4 86 73% Jun-15 13.6 86 73% Jul-15 12.9 85 76%

Aug-15 35.1 115 77% Sep-15 16.7 60 72% Oct-15 15.5 68 81% Nov-15 23.9 46.0 78% Dec-15 45.7 70 81% Jan-16 37.2 129 82%

CQC Community teams Patient survey- • The trust did not perform very well in the last CQC Community mental health patient survey and

was rated among the five worst mental health trusts in the country. As a result of the outcome of this survey, all the initiatives supporting improving patient experience have been brought together and are now receiving focused attention through the “Patient Experience Board”.

52%

70% 67% 73% 73%

76%

77% 72%

81% 78% 81%

82%

40%

50%

60%

70%

80%

90%

100%

Feb- 15 M

ar-

15 Apr-

15

May

-15 Ju

n- 15 Jul-

15

Aug-

15 Sep- 15 O

ct-

15 Nov

-15 De

c-15 Ja

n- 16

% Extremely Likely & Likely responses (inc 3 month rolling average)

-9.1 10.4

24.6 21.4

13.6

12.9 35.1

16.7 15.5

23.9 45.7 37.2

-20.0-10.0

0.010.020.030.040.050.060.0

Feb- 15 M

ar-

15 Apr-

15

May

-15 Ju

n- 15 Jul-

15

Aug-

15 Sep- 15 O

ct-

15 Nov

-15 De

c-15 Ja

n- 16

FFT actual (inc 3 month rolling average)

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Other • Improvement to inpatient wards have been completed following the initial CQC findings and in

preparation for the next PLACE assessment. • A review of the Journeys programme identified that the waiting time for assessment has

reduced by a week and the average time for start of treatment has reduced by 5 weeks within a year.

2) The proportion of our staff saying that they would be extremely likely or likely to recommend our services continually increases

• The proportion of staff saying that they would be extremely likely or likely to recommend our services increased from 60.51% to 70.42% from quarter 1 to quarter 2 in year.

4.4 Strategic aim 4: NEP will continue to improve patient outcomes 1) A clear outcome measurement framework has been agreed and a baseline set for continuous

improvement • Clinicians continue to use a range of outcome tools to measure the effectiveness of the care and

treatment provided. It is widely accepted that there is not a single tool that can capture the improvement in outcomes for all mental health conditions, however it is considered that irrespective of the mental health conditions an assessment of mental well -being or quality of life (for dementia patients) before, during and at the end of treatment is a good indicator to track effectiveness of care /treatment provided.

• The Short Warwick and Edinburgh Well-being tool (SWEMWEB) and the Quality of Life tool (QOL AD) have been implemented and were included into our clinical system in Quarter 1 last year. We now have two quarters data that shows “significant improvement” in mental well-being scores for adult managed by our specialist teams. Similarly more the 50% of patients who have been diagnosed with dementia reported maintaining a good quality of life post diagnosis.

5 Progress against specific planned activity in 2015/16 towards achieving our strategic aims

5.1 Further to the key success measures reported above, a number of other initiatives were planned and delivered in year from other teams/directorate to support delivery of our strategic aims, a summary of those are outlined below.

5.2 Strategic aim 1: NEP will be a leading provider of specialist mental health care.

• Monitor and report on Research activity: 19 new research projects were approved within the last year which brings the total number of ongoing research to 62. The majority of these projects are around Mental Health (50%) and Dementias and Neurodegenerative Diseases topics (42%). Research themes include depression, schizophrenia, Alzheimer’s disease, fronto-temporal lobe dementia, health services research and eating disorders. NEP has been among the highest recruiters in the East of England (CRN Eastern) region for mental health research studies

• Provide training to Primary care staff/organisations: NEP delivered at least 24 training sessions /talks on a range of mental health to G.P’ s and other primary care organisations within the last year across the three CCG’s localities.

• Implement ‘Total Mobile’ solution and other relevant system developments. Within

90

the last year, 100 iPads and c400 iPhones have been rolled out across a number of key clinical teams. Remedy version 5.1 was released offering improved functionality.

• Review Journeys implementation: A review was completed in December 2015 and the recommendations are being taken forward through an action plan in 2016.

5.3 Strategic aim 2: NEP will be a system leader and a partner in the development and delivery of integrated community services

• Remain engaged in Frailty programmes: The locality teams/clinicians have continued to support and influenced other partners in the development of Frailty pathways.

• Develop easier access to medicine information through electronic medicines management: Due to other competing priorities within the ICT department this was not delivered in 2015, but has been prioritised for 2016.

5.4 Strategic aim 3: NEP will continue to improve patient experience

• Redevelop Trustline. A replacement to Trustline is being piloted by SEPT with access to Remedy- callers are kept updated until call is put through. New Contact card is being issued to service users.

• Respond the CQC inspection report: An action plan was presented at the Quality Summit in February 2016, this work will be monitored through the Quality Improvement Panel (QIP) in year.

6 Development of Strategy Dashboard.

6.1 In order to provide a more comprehensive overview on delivery of the strategy and the four strategic aims, we have also developed a “Strategy Dashboard” which not only compliments but also provides us with greater insight of delivery of our strategy against a suite of meaningful indicators/ measures (see Appendix 2).

6.2 Strategy update has historically been covered as part of the CEO briefing at every board meeting. With the development of a “strategy dashboard”, we are proposing to bring regular updates to the board from the Director of Strategy. This will provide greater regular reassurance and provide evidence against a comprehensive set of meaningful indicators.

7 Delivery of “All together Better”- Year 2 -2016-17

7.1 Delivery of our strategy will continue in 2016/17, through all our business units that will drive the implementation and monitoring of a number of specific strategic initiatives outlined in appendix one.

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Appendix 1: Planned activity for 2016/17 to support delivery of our strategic aims Strategic Initiatives Strategic Goal Target Key performance

indicators Strategic aim 1: NEP will be recognised as a leading provider of specialist mental health care

Improve estate compliance

Update estate records and information management processes and implement robust policies and procedures

• Update existing estate records to accurately reflect asset base

• Complete full Premises Assurance review

• Address deficiencies identified by review of PAM

• Prepare information systems for implementation of Carter efficiency programme

• Comprehensive and accessible data set

• Board adopted

PAM • Action plan to

ensure all criteria achieve at least good rating

• Information available in ‘Carter’ format and complete and accurate data set

Improve assurance of internal governance

Review internal policies and procedures and implement actions to ensure robust procedures are in place across all areas of department

• Complete review of all extant policies

• Update all policies where necessary

• Update procedures to ensure compliance with SFI’s and SO’s

• Summary of review and schedule of policies

• Updates completed and adopted

• Rewritten procedures and approved processes

Embed Sustainability Strategy into Trust activities

Put in place governance processes to ensure that sustainability is embedded throughout the organisation

• Ensure Sustainable Development Management Plan is adopted by the Trust

• Embed SDMP into all business and assurance processes

• Create a Sustainable Development Committee

• Agree annual targets for energy reduction

Update Risk Register to include climate change and sustainable development

• Routine reporting on progress to Board

• SDMP embedded in

business plans, Board Assurance Framework and annual reporting

• TOR’s for committee established and membership from all areas of Trust

• Routine reporting of performance information

Annual Report to include SD performance

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Complete delivery of Maintenance Department restructuring

Complete the review process of the structures and operating procedures of the Maintenance Service. Complete the implementation of the staffing structure and mobile working to ensure efficient and cost effective service delivery

• Complete recruitment to staffing structure and conclusion of HR processes for transfers of existing staff to new T&C’s

• Conclude implementation of helpdesk software system and mobile device management

• Complete deployment of vehicle fleet and new ways of working

• Finish review of PPM and Possible software solution strategy for future helpdesk integration

Improved Clinical Information and Knowledge

Clinical System Exploitation

• Implement REMEDY clinician workflow improvements

• Establish CQUINS delivery Capability

• Remedy Adoption • Clinical satisfaction

and advocacy • CQUINS targets in

place early Optimisation of Mobile Workforce

Implement tablet based mobility and exploitation of associated workplace technologies (e.g. iPhones, SmartBoards, collaborative tools etc.)

• Community staff using tablet mobility by Dec ‘16

• adoption of workplace tools across clinical workforce

• Target users increased from 120 (2015/16 target) to 450 (of 650 community)

• Reduction in delay of community information available within the system

• clinical advocacy for workplace tools

Increase effectiveness of staff resources

Implement eRostering and effective deployment of new working practices

• Upgrade system from v9.5 (locally hosted) to version 10 (cloud hosted)

• Enable new modules: • HealthRoster v10 • Bank Staff v10 • Safe Care Ward, Live

(mobile), ESR Go, e-Portal

• Delivery to plan – assure continuity of service

• Evidence based support of Agency spend reduction, greater Bank use and increased staff adoption

Develop Dash boarding for Trust Decision Making and Benefit Realisation

• Transparency of Organisational Data - Improve Decision Making

• Establish leadership

• Implement prototype converged data warehouse

• Interface REMEDY, Datix & Pharmacy systems

• 60% of identified Dash board use cases in use

• Benefits realisation model in place and

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for organisational transformation agenda

• Dashboard reports for EMT, BSSG & CSSG

actively tracking outcomes

Reduce ICT asset waste increase Value for Money

• Printer rationalisation programme

• Centralise hard and soft asset management

• Baseline service models

• Centralised procurement process

• Centralisation of all ICT budgets

• Service management KPI’s and MI reports created

• 100% of new assets acquire, tracked and deployed via ICT portal

• Service management plan for all systems

• All ICT contracts appear in contracts database

• Forward plan of investment aligned to inflight systems

Hi-light specialist services in depth

Create series of micro-sites which can explore services in greater detail

3 services and 2 site based micro sites within the year

Sites up and running, Monitoring in place,

Greater presence in national media

Increased coverage in specialist publications

One story per month in national/medical/specialist publication

Achieve target

VIP visits One hi-profile visit by Minister or leading medical figure in year

As goal Achieve target

Win additional business

Increase income Dependent on opportunities available

Revenue and margin

Demonstrate compliance to Monitor

Maintain licence Achieve compliance Monitor rating

Support the Trust obtain and sustain improvements from its supply chain through transforming the transactional function to a strategic supply chain management function

Identify and quantify procurement and supply chain improvement potential and create a business case for realising this potential through restructuring the Procurement Department

• Delivery of supply chain improvements creating a platform for taking the function to the next level

• Procurement Business case submitted for approval

• Procurement strategy in place

• Implement a new structure within the Financial year 2016/2017 appointing appropriate skills and expertise required to deliver best practice procurement services

• Compliance to the Procurement SLA defined KPIs and set targets

• Non pay efficiency measures and procurement performance to be monitored and reported to the Board

Training other healthcare

Review our mandatory insulin

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professionals to manage medicines more effectively.

and anticoagulant training packages and the current highly successful Medicines Management for Nurses An online rapid tranquillisation training package will be considered. A common training package on prescribing and learning from previous errors will be worked on.

Strategic aim 2: NEP will be a system leader and a partner in the development and delivery of integrated community services

Successfully conclude merger of Estate & Facilities services as part of Trust merger

Develop plans to successfully bring Estate & Facilities services together with SEPT services to ensure successful merger of Trusts

• Develop merger plans jointly with SEPT staff

• Agree objectives for mutual development of services

• Agree delivery of merger business case benefits

• Deliver merger implementation plan

• Agreed service delivery structure

• Benefits realisation plan

• Merger implementation plan

• Assurance of implementation to Merger Board

Full engagement in CCG led Local Estates Forums

Play an active role in the development of Strategic Estates Plans for all CCG areas to ensure efficient use of all public sector estate

• Routine and active membership of all LEF’s

• Trust estate strategy informed by LEF strategy

• Greater collaboration with health partners in estate usage

More efficient use of estate

• Full engagement in planning process

• Open sharing of key estate information

• Joint ventures and service integration on health sites

Lower cost of estate operations

Enable integrated clinical information sharing

• Implementation of HiE

• REMEDY integrated with PDS (Personal

• Demographics Service)

• Datix client cases viewable alongside patient summary

• Summary care information shared between NEP and SEPT

• EssexStars using joint portal for care information

• NHS number used as primary identifier across compatible systems

Enabling Partnership Working

ICT & CSM become an enabler

Removing barriers to integration

Practicable information sharing (IG) standards & practice

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Focus on Trust integrates social work and mental health

Social work promotion through ‘Thinking ahead’

Focus on Trust integrates social work and mental health

Social work promotion through ‘Thinking ahead’

Support where appropriate to West Essex ICO and other integration initiatives

Support publicly and facilitate internal coms

Dependant on external developments

Dependant on external developments

Participate in nation public health campaigns

Continue to support national campaigns: e.g. stay well this winter

Always have public health messages on front of web site

As target

Complete merger process with SEPT

Complete merger April 2017 Milestones hit in plan

Continue to develop collaborative offerings for commissioners

Effective market participant

Ongoing Potential partners continue to want to join forces

Increase collaboration with other public bodies

Lead collaborative procurements that maximise the opportunity to achieve economies of scale

• Award collaborative contracts

• Achieve economies of scale and support customers implement best practice operational processes and procedures working in partnership with their key providers

Compliance to the Procurement SLA

To fully engage in the development of IT solutions to better manage medication use.

Prescription Tracking System (PTS) (software and hardware) Electronic Medicines Management (eMM) (New software)

By April 2017 New system in place

Strategic aim 3: NEP will continue to improve patient experience Continued improvement of the patient environment

Continue to improve the quality of patient areas in terms of estates and facilities support functions

• Ensure continued ‘above average’ scores in PLACE assessment

• Improve responsiveness to helpdesk requests for clinical areas

• Focus on contract management to ensure full delivery of specified services

• Standardise working practices for all E&F services across Trust

• Submitted PLACE scores

• Carter Efficiency data

• ERIC data • Helpdesk statistics • Contractor

performance reports

• Updated service specifications

Technology • Leverage mobility • Survey available at • 25% increase in

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supporting care and experience

to provide accessible friends and family surveys

• Provide internet access for patients in all Trust buildings

point of care / discharge

• Inpatient areas able to acquire pc’s and tablets for client usage

survey information • 75% of inpatient

utilising client access services

Increase effectiveness of staff resources

Benefits adoption of eRostering

Alignment of resources against operational / clinical need and budget

No deviation from Trust plans for delivery of organisational clinical services & budgets across Trust

Implementation of FFT

All services regularly feeding back FFT data

Set targets for all service in terms of numbers

Implementation of FFT

Integrated analysis of different data strands

Develop system for integration of data including free text analysis

Investigation of systems, choice of system and development of reports

Set targets for breadth, timeliness and depth of reports

Support front line in developing feedback

Hold internal training session on survey construction, delivery and analysis

One session in the year As target

Support the development of the Patient Experience Work stream

Patient experience becomes embedded

Measurable improvements Dashboard is developed and shows improvements

Support supplier and product/service developments ensuring that the products and services procured by the Trust adhere to the required standards and mitigate/eliminate risk.

Understanding the current markets and market forces, technological advancements and service developments.

• Maximise competition amongst providers

• Use of fully compliant and risk adverse products and services

• Undisrupted supply

To improve patient adherence To prescribed medication

Subscribe to the Choice and Medication website To improve the utilisation of the Choice and Medication resource Developing a two-hour online training programme on adherence

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Strategic aim 4: NEP will continue to improve patient outcomes Ensure patient safety in clinical environments becomes exemplary

Aggressively address deficiencies in standards of patient environment with regard to patient safety and ensure consistency of all standards and components throughout properties

• Complete all remedial works to address CQC criticisms

• Review and update standard components policy

• Develop design standards for minor works and major capital projects

• Ensure clear approval processes for project management

• Improve staff training and contractor management with regard to standards of maintenance and minor works

• Board assurance process

• Updated and approved standard components catalogue

• Staff training records and PDP’s

• Standard design briefs

• Clear Trust governance structures

• Improved management procedures

Satisfactorily complete the Derwent Centre major capital project

Complete programme of works to deliver the fully upgraded ward environments at the Derwent Centre within the agreed programme and budget

• Ensure progress of contractor and consultant team continue in line with current programme

• Action changes in layout and specification to address service model requirements and developments

• Ensure project governance is robustly adhered to

• Standards of clinical environment to be class leading in performance and safety

• Project Board reporting

• Consultant project team reporting

• Project QS reports • Change logs • Board of Directors

routine progress reports

Effective and Efficient Medicines management

• Implementation of (EMM) Electronic Medicines Management solution

• Investigation of ePrescribing benefits

• Support Pharmacy in the implementation of EMM

• Enable transformation case for ePrescribing

TBC - Business case submission Q3 2016/17 for ePrescribing

Digital at point of Care 2020

Implementation of eDRMS

• Centralisation of Medical records

• Lean process reviews to > efficiency and < cost to serve

• Medical records centralised Q3 2016/17

• Business case supporting eDRMS

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• eDRMS benefits review procurement Q3 2016/17

Improve internal communications with focus on quality and spread of best practice

Revised format to IntraNET Revised internal coms policy and delivery

Revised policy and delivery system in place by summer

As target

Ensure fast response to any new clinical issue

Integrate alerts into new systems

As Goal As target

Develop clinical resources section of IntraNEP

Link with clinical boards to develop and respond to their ideas

TBA after consultation As target

Further develop the SWEMWBS work

Demonstrates patients outcomes

Shows improvement CQUIN achieved

Achieve CQUIN targets

Improve quality, gain income

By CQUIN By CQUIN

Develop a “best practice” supplier base in terms of direct price, value-added benefits and supply chain efficiency through on-going monitoring and continuous development of process and service design.

Key suppliers delivering value for money throughout the contract period

Strategic Critical contracts are managed effectively measuring the supplier performance

Supplier performance reviews and meeting targets against agreed KPIs

To achieve medicines optimisation

• Understand the patient experience

• Ensure choice of medicines is evidence based

• Ensure medicine use is as safe as possible

• Make medicines optimisation part of routine practice

By April 2017 iIprovement in patient experience and outcomes- monitored through dashboard

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Objective 1: NEP will be recognised as a leading provider of specialist mental health

2014-15 Q1-15-16 Q2-15-16 Q3-15-16 Q4-15-16Monitor GRSO Green Green under review under review TBCMonitor FRR 3 3 2 2 TBCNHS Protect Amber Amber Amber AmberCQC rating No Concerns No Concerns No concerns No Concerns Requires improvement

Q1 Q2 Q3 Q4 2015/16

Number of positive stories in local/ national papers 10 15 7 n/a 32

Numbers of Visitors to NEP site 15718 15835 15175 n/a 46,728

Numbers of Awards/ National recognition 0 1 2 n/a 3

Number of Research being undertaken 44 55 62 n/a 62

• Following a recent investigation by Monitor the trust is waiting for confirmation of its revised GRSO rating. • The trust was rated as “Requires improvement” be CQC following a trust wide inspection in 2015- the issues

raised are being addressed as part of an improvement plan which is overseen by the Quality Improvement Panel.

• Within the early part of 2015, media coverage was dominated inquest, death and follow up. Positive stories Mid-year around dementia care, quarter 4 focused on CQC report.

• The number of research continues to expand with a high number of participants recruited.

Objective 3: NEP will continue to improve patient experience

Patient Experience metrics July 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan-16 Feb-16 Mar

Percentage of admission to inpatients services who has access to CRHT

94.8 94.8 96 98.9 98.4 94.9 95.1 93.8

No of complaints 9 9 11 7 10 8 6 15 No of compliments 6 3 13 14 10 13 6 12 No of PALS Queries 20 24 28 30 38 29 26 18 Family and Friend test score 12.9 37.5 17.2 15.5 23.9 45.7 37.2 tbc

Patient survey metrics 2014 2015 Best Trust

7. Have you been told who is in charge of organising your care?

8.8 6.8 8.9

19. Did you know who was in charge of organising your care while this change was taking place?

6.5 4.5 6.8

42. Overall in the last 12 months, did you feel that you were treated with respect and dignity?

8.6 7.8 8.8

12. Were you involved as much as you wanted to be agreeing what care you will receive?

7.3 6.5 8.2

40. Do the people you see through NHS mental health services help you feel hopeful about the things that are important to you?

6.2 4.9 6.5

3. In the last twelve months, do you feel you have seen NHS mental health services often enough for your needs?

6.7 5.3 7.0

41. Overall patient satisfaction score 7.2 6.3 7.4

Objective 2: NEP will be a system leader and a partner in the development and delivery of integrated community services

• The trust continues to engage with health and social care commissioners with a view to develop integrated community services. West Essex CCG is more advanced in developing and progressing its proposal, the trust is represented on the ICO programme Board by the Director of Strategy. The locality operational management team have also been involved in the discussion and development of the model. North Essex CCG has chosen ACE as preferred provider for their “Care closer to Home” programme, this currently does not include mental health services, but local clinicians are fully engaged with ACE to explore partnership working. Mid Essex CCG a plan are not fully developed and is likely to emerge from the success regime work.

• In collaboration with our partners, the trust has developed an innovative proposal to provide Primary care mental health services for out of County - the trust is one of the two providers to have reached the final stage of this procurement. Preferred provider will be notified by end of March 2016

• Following the Boston consultancy review of mental health services across Essex, the trust is pursuing the option of a merger with SEPT- the trust is complying with Monitor process for merger and recently submitted an outline Business case for review.

Objective 3: NEP will continue to improve patient outcome

Patient Outcome metrics Aug Sep Oct Nov Dec Jan Feb March Benchmark where applicable

Number of Serious Incident reported in month 6 4 6 5 6 9 9 n/a % CPA patients receiving a formal review within 12 months

97 96.6 97 96.5 96.2 96 95.4 95%

% CPA patients receiving follow up contact within 7 days of discharge

95.7 98.3 97 100 99.3 100 97.3 95%

Meeting commitment to serve new psychosis cases by EIP teams

139.8 116.5 139.5 116.5 139.8 104.9 139.3 95% (9 monthly)

Average length of stay inpatients (adult of working age) adjusted

20 20 20 16 18 20 18 tbc

Average length of stay inpatients (Older Adult) adjusted

28 33 41 36 32 28 22 tbc

Number of points improvement in SWEMWEB score 4 4 1.7 1.7 1.7 TBC TBC 1.5- 4 Number of patient supported into paid employment 24 26 20 32 22 22 26 n/a Number of patient supported into retaining employment

9 8 10 12 8 17 14 n/a

Number of patient supported to take up mainstream education/ training

4 16 11 12 1 10 4 n/a

Number of patient supported into volunteering and work placement.

8 11 14 22 5 6 10 n/a

The above data provides useful information on a range of metrics demonstrating improvement in patient outcomes- While the number of serious incident is decreasing the trust remains an outlier- The trust has continued to meet and exceed its target for follow up of patient following discharge within seven days and patients receiving a formal review within 12 months. Significant Improvement in well-being score has been noted in two quarters for people receiving community support/treatment. Finally, our supported employment services continues to deliver employment, education/ training and volunteering outcomes

Cleanliness Food Privacy Dignity

Condition, appearance

Dementia

2014 98.42% 86.20% 78.56% 92.27% # National 97.16% 89.84% 89.61% 92.50% # 2015 98.97% 86.30% 79.53% 88.32% 85.98% National 97.52% 88.49% 86.03% 90.11% 74.04%

1. The 2016 CQC Community patient survey is underway, with the first batch of questionnaire being sent out in first week of March 2016.

2. Complaints, compliments and PALS queries are being analysed to identify themes

3. The Patient Experience Board is now responsible for driving through a range of initiative to improve patient experience.

4. PLACE improvement plan in place.

PLACE Assessment scores 2015 CQC community patient survey score

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 11b Date: 23 March 2016 Title of Report: The Success Regime Lead: Mike Chapman, Director of Strategy Subject, Purpose and Recommendation: The attached report has been drafted by the Communications Lead, Mid and South Essex Success Regime for the Boards of Essex trusts and CCGs. The Board of Directors is asked to:

i) support senior staff and communications leads in facilitating wider

discussions with staff and local stakeholders;

ii) consider and comment on the operational briefing for the Success Regime attached at appendix 1;

iii) make arrangements to submit feedback by 2 May 2016 to:

[email protected] Finance Implications: N/A Clinical Implications: N/A HR Implications: N/A Legal and/or Regulatory Implications: N/A Equality Implications: N/A Risks: N/A

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Mid and South Essex Success Regime A programme to sustain services and improve care 14 March 2016 Purpose 1. During March and April, partners in the Mid and South Essex Success Regime

are asked to hold discussions with their boards and governing bodies, ideally in public, and to respond to the programme office with feedback. The programme will benefit from the overall views of each board and any specific views and comments on aspects of the plan.

2. This paper provides a summary of the Success Regime operational briefing that

was published on 1 March and invites views. The full briefing is attached at appendix 1.

Headline summary 3. The plan

3.1. The Success Regime gives us the opportunity to realise the full potential of our workforce, achieve financial balance by 2018/19 and provide the best of modern health and care for local people.

3.2. We have identified six priority areas in which to accelerate change to sustain

local services and improve care. These are summarised below:

1. Address clinical and financial sustainability of local hospitals by:

o Increasing collaboration and service redesign across three sites o Sharing back office and clinical support services.

2. Accelerate plans for changes in urgent and emergency care, in line

with national recommendations e.g.:

o Doing more to help people avoid problems and get the right help o Developing same day services and urgent care in communities,

to reduce unnecessary visits and admissions to hospital o Designating hospital sites for specialist emergency care.

3. Join up community-based services – GPs, primary, community,

mental health and social care – around defined localities or hubs.

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4. Simplify commissioning, reduce workload and bureaucracy e.g.:

o Reduce the number of contracts from around 300 to around 50 o Commission services on a wider scale e.g. with one lead

provider where several may be involved o Agree a consistent and common offer to focus on priorities and

identify limits of NHS funding.

5. Develop a flexible workforce that can work across organisations and geographical boundaries.

6. Improve information, IT and shared access to care records.

4. Why we are doing this

4.1. We need to keep up with increasing demands and the pace of change of modern health and care so that we can do more for people now and in the future.

4.2. If we did not accelerate change, the current £94 million NHS deficit in mid

and south Essex could rise to over £216 million by 2018/19. We would not be able to meet year on year growing demands.

4.3. Our aim is to get the system back into balance by 2018/19 and deliver the

best joined up and personalised care for patients. 5. The approach

5.1. Change will be led by clinicians, with the involvement of service users, staff and local people.

5.2. The Success Regime provides programme structure, rigour and support,

including a financial bridge during the transition to a balanced position in 2018/19.

5.3. We are keen to involve people at this early stage. There will be more

opportunities to help shape options over the summer, and further public consultation on options in the autumn.

Background 6. Areas and services involved

6.1. All health and social care services in mid and south Essex are involved in the programme, including some 183 GP practices, community services, mental health, social care and hospital services.

6.2. The Success Regime area will be the footprint for the Sustainability and Transformation Plan that health and care organisations are required to agree by June 2016, as part of implementing the NHS Five Year Forward View.

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6.3. The main partner organisations are as follows: Clinical commissioning groups (CCGs): Basildon and Brentwood Castle Point and Rochford Mid Essex Southend Thurrock

Local authorities: Essex County Council Southend-on-sea Borough Council Thurrock Council

Service providers: Basildon and Thurrock University Hospitals NHS Foundation Trust (BTUH) East of England Ambulance Service NHS Trust Mid Essex Hospital Services NHS Trust NELFT NHS Foundation Trust North Essex Partnership University NHS Foundation Trust Provide Southend University Hospital NHS Foundation Trust South Essex Partnership University NHS Foundation Trust

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7. Success Regime governance 7.1. Each partner organisation in the Success Regime has clinical and leadership

representation at a System Leaders Group (SLG) and a Clinical and Professional Leaders Group (CPLG).

7.2. These representatives have the responsibility for steering the overall

programme and keeping their organisations and local networks updated. 7.3. The SLG is chaired by an independent clinical chair, Dr Anita Donley, a

consultant from Plymouth Hospitals NHS Trust and clinical vice-president of the Royal College of Physicians.

7.4. The Mid and South Essex Success Regime is accountable to the Regional

Directors of three national organisations - NHS England, NHS Trust Development Authority and Monitor.

Examples of potential changes for patients 8. Local health and care

8.1. The range of services provided locally could expand over the next three to five years, with joined up services based in primary care, multidisciplinary teams and close links with voluntary sector and other public services.

8.2. There would be a greater emphasis on supporting people to stay healthy and encouraging individuals to take responsibility for their own health and wellbeing. Greater use of technology would give people online and practical tools to self-manage where possible.

8.3. Vulnerable people, frail people and those identified as at higher risk would

have the benefit of a personalised plan and joined up services that can monitor and intervene at an early stage to avoid escalating problems.

8.4. There could be more consultations available locally by involving a wider

range of professionals.

8.5. Some routine hospital outpatient services could be available from local health facilities.

9. Care in hospital

9.1. There would continue to be three sites providing core hospital services at Basildon, Chelmsford and Southend.

9.2. Some specialist services could be provided by a designated hospital and, for

these services, some patients may have to travel further than their local hospital, as is the case now with cardiothoracic services at Basildon, radiotherapy services at Southend and burns and plastics at Broomfield.

9.3. Such changes would lead to improved clinical staffing levels, potentially

shorter waiting times, better quality of care and patient experience and better clinical outcomes for recovery.

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10. Urgent and emergency care

10.1. Vulnerable and high-risk patients would have the benefit of joined-up and personalised health and social care and early intervention to avoid emergencies.

10.2. Service developments in localities could offer more urgent care in the

community e.g. frailty assessment units, 24/7 mental health crisis support.

10.3. Developments in 111 and ambulance services could offer more online and telephone access to high quality urgent care.

10.4. Most people in need of urgent care could be seen at home, in a local

health facility or at the nearest local hospital.

10.5. Under options to be developed by local clinicians, some very serious emergencies could be taken by ambulance to a designated hospital, as is the case now for complex heart problems (e.g. to specialised services in Basildon) and for multiple serious injuries (e.g. to major trauma centres at the Royal London or Addenbrooke’s in Cambridge).

Governance to support collaboration 11. The five CCGs are working together to simplify commissioning and agree “a

consistent and common offer”. It has been agreed in principle that a single committee could be the best approach to achieve joint commissioning. CCGs are currently determining terms of reference and operational details.

12. The three acute trusts are developing a group model to extend their current

collaboration in both clinical and non-clinical functions across the three sites. This could include building single teams in some specialties, clinical support and back office functions.

13. To support the proposed service improvements, commissioners and acute

providers are negotiating block contracts for 2016/17. Current progress 14. Clare Panniker, chief executive of BTUH, is coordinating workstreams for the

acute care changes. Caroline Rassell, accountable officer of Mid Essex CCG is coordinating primary and community workstreams.

15. Leaders are currently being assigned to each workstream and developing the

details of project initiation. 16. Next steps and milestones:

1 March Start of discussions and feedback April Launch of workstreams and detailed planning End May Wider engagement in potential service changes Sep-Dec Refine options and consult

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17. The high level summary of the Success Regime has been widely published with

local community groups, representative organisations and in the local press and media. Information is available from web pages hosted by Castle Point and Rochford CCG on behalf of all partners. Please visit: http://castlepointandrochfordccg.nhs.uk/success-regime

Conclusion 18. From 1 March until end of April, we are promoting local discussions and listening

to views on the overall plan, whilst putting in place the arrangements for developing options for change.

19. Feedback from discussions in these early stages will inform both the developing

options and the working arrangements to speed up the pace of change. 20. Boards and other local groups are invited to send their feedback by 2 May to the

Success Regime programme office at [email protected] Recommendation 21. The Board is asked to

21.1. support senior staff and communications leads in facilitating wider

discussions with staff and local stakeholders; 21.2. consider and comment on the operational briefing for the Success Regime

attached at appendix 1; 21.3. make arrangements to submit feedback by 2 May 2016

to: [email protected]

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Mid and South Essex Success Regime A programme to sustain services and improve care

Operational Briefing

Tuesday 1 March, 2016

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http://en.wikipedia.org/wiki/File:NHS-Logo.svg

2

Overview: Success Regime (SR)

SR and diagnosis

SR launched in June 2015

Diagnostic phase ran October to November 2015

Two core recommendations: • Mid and South Essex as the

geographic scope of SR • Six core areas to address

Implementation planning

Ran end November 2015 – mid February 2016

Goal to create an integrated, internally consistent whole system plan for Mid and South Essex...

...which will put the system back into balance in 18/19...

....and enable local organisations to deliver high quality care and address local inequalities

Moving forward

Period for discussion and feedback

Align SR plans with 16/17 operational plans

Align clinical priorities between CCGs and providers on service redesign

Identify and 'formally' kick off appropriately resourced workstreams…

...working to clear objectives, scope and milestones, with aim of delivering significant changes in 16/17

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3

Who has been involved: broad engagement across multiple settings

Regional Directors: 6 meetings

CCG Accountable Officers: 8 meetings Acute Trust CEOs: 6 meetings

Senior Leadership Group: 4 meetings

Medical Directors: 10 meetings

Acute Chairs: 4 meetings CCG chairs: 4 meetings

CPLG: 2 meetings Directors of Finance: 10 meetings

SR workstreams: ~50 meetings

Plus hundreds of 1:1 discussions across the patch 110

4

Key facts about Mid and South Essex

Mid Essex

CCG Population: 373k

Health and care income : £693m

Basildon &

Brentwood CCG Population: 269k

Health and care income : £513m

Southend CCG Population: 184k

Health and care income: £363m

Castle Point &

Rochford CCG Population: 179k

Health and care income: £347m Thurrock CCG

Population: 169k Health and care income: £317m

SUHFT

BTUHFT

MEHT

Population: 1,175k1

3 local authorities: • Essex; Southend; Thurrock

5 CCGs, 3 Acute trusts

• 85% of acute activity from 5 CCGs remains in Essex NHS trusts

• 93% of local trust activity is from Mid and South Essex patients

System health and care income 15/163: £2,233m System health and care exp. 15/163: £2,327m System health deficit 15/164: £94m

Note: all financials are 2015/16 estimates: Version 13,12th Feb modelling assumptions 1. Population based on 14/15 2. Travel times without traffic from google (Jan 16) 3. Includes estimate of social care expenditure (based on 14/15 report) related to health and CCG mental health expenditure 4. Deficit relates to health only

36 mins (2)

33 mins (2)

23 mins (2)

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5

Recap: challenges and root causes

Urban social geography of Essex

Population health inequalities

Rising demand in health and social care

National and local trends

Clinically and economically disadvantaged acute footprint

Workforce and talent gaps

• Rota gaps (e.g. A&E); GP capacity

Complicated commissioning landscape

• 5 CCGs; 3 LAs; >300 contracts

Limited data usage and data sharing

Time and effort spent on decision-making can be protracted, with decisions often re-opened

Senior managerial and clinical leader capacity focused on operational imperatives

1

2

3

4

5

6

Key challenges

Few co-terminous boundaries

Distance between actual and target funding

for Essex

No overall Essex plan and few 'givens'

around acute footprint

Root causes

112

6

Overview: diagnostic recommended six areas of focus

Correct the clinical and financial disadvantage of the acutes

Create / accelerate UEC plan based on national recommendations

Accelerate existing strategies for primary, community and social care integration

Simplify commissioning and reduce workload and duplication

Enable greater flexibility of workforce across organisations

Raise level of data availability and data sharing

1

2

3

4

5

6 Enablers

113

7

SR goals

Create and support the development of a transparent, internally consistent, whole system plan to:

• Enable organisations to deliver high quality care for patients and reduce local health inequalities • Put the system into financial balance in 18/19; secure sustainable services for the future • Address root causes identified in the diagnostic • Provide directional clarity to enable organisations to plan over next 2-3 years

Establish a locally led and nationally supported programme to deliver the plan

• Build and extend existing strategies and collaborations which are consistent with 5YFV • Foster greater balance between system view and organisational view • Incorporate building change and other capabilities in leaders and workforce

Use tripartite oversight to unblock barriers to enable delivery at pace

• Apply flexibility to business rules; give 'permissions' • Encourage a system approach, collaboration, and focus on 5YFV • Bring national expertise and other forms of support to bear • Enable headroom for change from national operational requirements

1

2

3

114

8

Proposed model of care

1

2

3

Models of care described in this plan are consistent with the 5YFV...

...and are largely an acceleration of many of the existing provider and commissioner strategies

Deliver more services or parts of pathways out of hospital where appropriate, and closer to home

Drive greater integration at locality level of primary care, community care, mental health, social care, public health and the voluntary sector to deliver services better aligned to local need

Reconfigure the acute hospitals to ensure delivery of core acute services at each site, yet greater concentration of more specialist care, and greater separation of non-elective and elective care to improve operations

115

9

Key components: 'at a glance'

1

Group model with single clinical and support teams; service reconfiguration to support improved quality and clinical staffing levels

Correct the clinical and financial disadvantage of the acutes

4a Create a consistent and common offer, agree ‘committee in common' approach

Simplify commissioning

2

Whole pathway plan including proactive management for complex cohorts, stronger clinical triage in 111-OoH-999

Create / accelerate UEC plan based on national recommendations

3

Build strong localities able to deliver greater number of integrated services, closer to patients, with general practice at the core

Accelerate existing strategies for primary, community and social care integration

4b

Reduce duplication, the number of contracts, clarify commissioning teams and look for ways to reduce 'bureaucracy'

Create management and clinical capacity by reducing workload and duplication

Recommendations from the diagnostic Key components of the plan

116

10

Enablers: high level objectives

IT Create a shared care record across the SR patch which provides real-time cross-sector access – for example, NHS 111 able access to primary care GP records • In line with Five Year Forward View requirements

Data Create a system-wide patient and service user dataset to track SR targets and revised QoF requirements, and enable deeper insights to support delivery of care • For example, locality-level dashboards with baseline, outcomes and targets

Estates Explore the potential to take a different approach to estates, including enhanced utilisation of core estate to support new models of care, and value released out of non-core sites through sale, remodelling, innovative financing

Workforce

Support to workstream initiatives to realise plans, e.g. • Development of an Improvement Academy for the acutes at Group level to empower and

equip clinicians around pathway redesign • Enabling primary care to create new roles for other professionals to free GP capacity

117

11

The 2015/16 position for the system is currently an in-year deficit of £94m1

• £92m of which sits in the acute trusts: £43m MEHT; £32m BTUFT; £18m SUHFT2

Each year, the in-year system deficit increases by between £35-44m

• Annual system income driven predominantly by CCG allocations of between 2-5%... • ...which do not compensate for the effect of demand growth and inflation

– acute demand growth ~3%3 – other demand growth (e.g. primary care, mental health, prescribing) between 2-7% – inflation 2-3%

System needs to make recurrent savings of ~£70-£80m a year to be in balance in 18/19

• Requires a total saving of ~£94m (i.e. ~£30-£35m each year) to correct current in-year deficit • Plus a further £35-44m saving each year to meet new growth in demand and rising costs

Size of the challenge

1. Version 13 of modelling, February 12th 2. Individual acute trust deficits do not sum to the total acute trust deficit due rounding 3. Acute demand growth of 3% based on weighted average of 2.3% for non -elective and 3.3% for elective demand - based on January 2016 NHSE guidance

118

12

Size of the challenge: Momentum case income vs expenditure by year

15/16 Change in

16/17 Change in

17/18 Change in

18/19 18/19 momentum

case

Income £1,837m £76m £57m £61m £2,031m

Expenditure (£1,931m) (£112m) (£99m) (£105m) (£2,247m)

Net deficit change each year

(£94m) (£35m) (£42m) (£44m) (£216m)

Total in-year deficit

(£94m) (£130m) (£172m) (£216m)

Source: Financial model

Version 13, February 12th

119

13

Potential savings identified to date

Cost reduction Shift activity to lower cost settings Demand management

Clinical services

• Reconfigure around hub and spoke, reduce agency spend

Clinical support and back office

• Drive efficiency through better resource management

CIPs

• Acute CIPs

Source: Financial model, SR workstreams

Unplanned

• Improve out of hospital triage to reduce A&E attendances

Planned

• Shift follow-up outpatients into community to reduce volume

Complex care management

• Increase active mgmt. of complex cohorts to reduce non-elective admissions

Common offer

• Create consistent service offering across SR

QIPP

• Joined-up CCG QIPP plan, e.g. prescribing; CHC

£17m

£10m

£64m

£9m

£9m

£25m

£19m

£61m

£27m £18m £44m


£125m

120

14

System bridge 2015/16 to in-year position 2018/19

56

-300

-200

-100

0

100

200

151

SR deficit breakdown in 2018/19, £m

Unified, single-CCG led QIPP

Momentum deficit 18/19

Hospital clinical services

Acute CIPs In-year position 18/19

Acute back office and CSS

Planned / "Ologies", e.g. pain,

rheumatology, dermatology

(216)

PC, community, CHC, other

(151)

Unplanned / UEC

(164)

Income uplift

194

125

Inflation and demand

15/16 position

(94)

Complex, incl. Frailty, LTC, EOL

Common offer

13

NHSE Private Net uplift

CCG Baseline impact

Forecast deficit to breakeven + 1%2 transformation:

£(39)m-£4m2

Redesign of clinical serv ices (£60.3m):

reconfiguration of the acutes; movement of selected pathways out of hospital ("ologies");

UEC channel optimisation; and complex patient demand management

Includes net expenditure out of Essex

Acute demand 3.3% elective,

2.3% NEL based on Jan

16 NHSE

CCG allocations

corrected for GP IT, ETO,

CAMHS

Acute deficit £92m ((BTUFT: £32m, MEHT: £43m, SUFT: £18m); CCG deficit £2m


Simplification of

commissioning

(£79.2m): "common Offer", unified single-CCG led QIPP plan

Remov al of fixed

costs (£74.2m): acute back-office

and clinical support savings; acute CIPs

Stretch of existing initiatives; estates; redesign with top down view; and

review of areas not yet assessed

9.0 25.1 18.6

60.6

17.0 9.2

10.4 63.8

Total sav ings identified: £213.7m

121

15

Discussion and feedback from boards, governing bodies and local partner organisations

Engage with and gather inputs from national experts, local clinicians, service users and

local communities

Align SR plans with 16/17 operational plans

Align clinical priorities between CCGs and providers on service redesign sequence

Adjust the programme governance to the implementation phase

Start mobilisation and create implementation teams

Moving forward: next two months

122

16

Draft key milestones (I)

Key Milestone

SR operational briefing circulated Align SR plan for 16/17 with operational targets Programme governance in place for next phase Refine SR plan to include Board feedback Proposed options for key services changes identified

Date

1st March Early April April Mid May End May

Following actions

Start of discussions with Boards and Governing Bodies which runs to 2nd May Align plans and targets (e.g. for QIPP / CIP) based on agreed contracts Formal 'launch' of work streams with agreed deliverables, milestones, dates and teams Confirm full clinical redesign programme for hospital, out of hospital and urgent care services Start of patient, clinical and staff engagement on potential service changes and implications

123

17

Draft key milestones (II)

Key Milestone

Acute Boards agree 'Committee in Common' CCG Governing bodies agree 'Committee in Common' End of engagement on development of options Start of public consultation End of public consultation

Date

End May End June Early Sept Late Sept Late Dec

Following actions

Programme governance adjusted to account for Committees in Common • SROs to lead joint working

Refinement of options based on input from patient, clinical and staff engagement Formal public consultation around key services changes Finalisation of clinical service changes and implementation timelines

124

18

Local health and care overview: three goals

Build strong localities: that can deliver more integrated services

• Build on and extend existing CCG plans, bring more care closer to home, including shared care with acute, community, social care and specialist providers

1

Better management of whole non-elective care pathway based on national

guidelines / Willetts recommendations

• From focus on those at risk of admission, to better triage, to consistent approach to assessment of frail elderly and if they are admitted, to getting them home quickly

2

Simplify commissioning and create a consistent and common offer

• Reduce duplication – 'do once not five times where possible' - and provide a consistent service offer

3

125

19

CCG Neighbourhood Pop'n (k) # GP practices

Mid

Ess

ex

Braintree 64 5 Witham 29 5 Chelmsford 1 45 7 Chelmsford 2 49 4 Colne Valley 45 8 Dengie 23 5 Prosper 63 6 Maldon 32 3 South Woodham 22 5

B&

B

Billericay 40 7 Brentwood 77 8 East Basildon 60 14 Wickford 34 5 West Basildon 57 9

Th

urr

ock Grays 70 12

South Ockendon 35 6 Tilbury 38 9 Corringham 26 6

CP

&R

Rochford 58 7 Rayleigh 34 4 Benfleet & Hadleigh 46 7 Canvey Island 42 8

SE

Southend 185 35

Potential localities

1

2

3

5

7

4

6

8

9

10

11

12

13

15

17

14

16

18

19

20

21

22

Note: Clusters have been identified for i llustrative purposes and do not represent real or intended neighbourhoods. Source: BCG analysis of GP patient l ist size data (HSCIC October 2015)

CP&R

Southend

B&B

Thurrock

23

1

2

3

5

7

4

6

8

10

11

14

13

15

17

19

16

18

20

21

22

23

9

12

Mid Essex

126

20

Build strong localities: levels

Level 1: Increase capacity of primary care to meet rising demand by

• GPs focusing on complex cohorts with extended consultations • Increase number of consultations offered including use of other allied primary care clinicians • Work to meet national access requirements

Level 2: Accelerate implementing MDT1 approach and supporting services in primary care

• Reduce non-elective admissions for complex patients (EoL, frailty) and those at high risk

Level 3: Expand services in primary care setting to meet needs of complex conditions

• Outpatient services for specific specialities2 out of the acutes ("ologies") • Mental Health for selected service users out of specialist trusts3

Level 4: Each locality to become accountable for wider determinants of health and wellbeing

• Integrated physical, mental health, primary care, social care, community care, and public health

• Outcomes-based contracts delivered through MSCPs4 with leader provider model • Build out to encompass wider services: VCS, housing, employment, social prescribing

1. Multi-disciplinary team 2. Initial priorities specialities are dermatology, rheumatology, neurology, ophthalmology and pain 3. A per 2015 Strategic Review, e.g. 95% of service users in Clusters 1-3; up to 40% in Cluster 4 4. Multi -speciality community providers

127

21

Integrate key components of the national recommendations including:

• A&E designation

• Active management of those at risk of admissions

• Develop frailty assessment units

• Improve clinical triage: 111-OoH; 999

• Consistent health and social care support for frail elderly leaving hospital

• Consider 24/7 mental health crisis service

Better management of whole unplanned care pathway

128

22

Commission at SR level or above where appropriate

• Acutes, 999, specialised MH, ...

Move to lead provider and outcomes focused contracts • eg EOL

Reduce complexity

• e.g. simplified contractual arrangements

Common offer • Consistent access, reduce variation (eg elective referrals) • Common (aligned) service offers

Agree 'committee in common' for CCGs • Enable change at pace

Simplify commissioning and create a consistent, common offer

Simplify commissioning

Consistent and common offer

'Committee in Common'

129

23

All acutes realise the need for close 'working together'

• Part of solving for the clinical and financial disadvantages of the footprint... • ...and builds off existing collaborative activities

As part of the Success Regime, plan is to take a significant step

• Progressively move towards single teams, common processes, shared platforms – clinical teams, in clinical support and back office functions

Benefits of this closer working will be to enable:

• Evidence-based clinical operating processes to improve outcomes and reduce costs • Optimal service arrangements across sites and service planning over a larger portfolio • Sharing of expertise and development of sub-specialisation (eg radiology and pathology) • Scale advantages and reduction of duplication in back office

The three acute boards are considering proposal for a 'group model' that leverages a

'committee in common' in the first instance

• To move at pace, and to balance any financial asymmetry as change is implemented

Acutes: working together

130

24

Services in the acutes to be redesigned to address both clinical and financial challenges

• Improving safety and quality by consolidating rotas • Meeting national guidelines, e.g. separation of elective and non elective care • Addressing high fixed costs

Clinical services will be more joined up, with joint teams, single platforms, common

platforms

• Better opportunities for career progression, training and development, and potentially new roles

This thinking builds upon and extends existing collaborations including:

• Acute Care Collaboration • Joint ventures on pathology, pharmacy

Acute clinical redesign: update on emerging thinking

131

25

Principles for redesign

Start from a patient and service user perspective

Avoid moving or replicating high fixed cost services • Maintain some "givens"

Ensure deliverability by 2017

• No major new builds, use of existing infrastructure with refits Ensure clear rationale for any service redesign

• If no clear rationale, then no change Design along pathways

• Move care between hospital and community, and increase integrated working

1

2

3

4

5

Work led by clinicians, with continuous feedback from staff,

patients and service users, and the public

132

26

Identify potential for change, frame opportunity and set initial targets

Refine high level options

• Core group of 3-5 frontline clinical staff • Facts and data, clinical perspective, path forward • Start wider discussions with staff and local people

Core clinical group to test proposal (+/- options) with frontline working groups

• Broader set of clinical leaders related to pathway being redesigned • Core group working up weekly: further facts and data • Service user involvement with working groups

Test proposals

• Broad set of multidisciplinary staff across acutes, PC, SC, MH, public health

• Feedback to staff and local people • Further patients and public engagement to develop options for consultation

Undertake formal public consultation

Translate refined proposal into implementation plan

Recap: key steps for clinical service redesign

1

2

3

4

5

6

7

Initial ideas

Refine options and

phasing

Pre consultation engagement

Consultation

Implement-ation plan

PEx sign off proposal & target

Narrative to governing bodies

Sign off by governing bodies

Currently at Step 2

133

North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 12 Date: 23 March 2016 Title of Report: Merger with South Essex Partnership University NHS Foundation Trust (SEPT): Progress Report Lead: Christopher Butler, Interim Chief Executive Subject, Purpose and Recommendation: This paper updates the Board on the work to pursue a merger with South Essex Partnership University NHS Foundation Trust (SEPT) following the review of the Outline Business Case by Monitor in February 2016. The Board of Directors is asked to:

i. Note the initial feedback from Monitor’s Provider Appraisal Directorate on the Outline Business Case.

ii. Note that a Heads of Agreement document will be discussed and agreed at Part

II of the Board to detail the creation of a Project Board with formal delegated authority to progress the merger work.

iii. Agree the recommendation that a notification to the Competition & Market

Authority is disproportionate given the review of competition undertaken by both Trusts’ and Monitor’s Competition & Cooperation Division.

Finance Implications: The Board should note that the Heads of Agreement confirm the finances for the transaction outlined in the Long Term Financial Model of the OBC and further commit NEP to meeting half of these costs until such time as the merger is completed or formally stopped. The details of the Heads of Agreement are commercially sensitive and so will be considered in full at Part II of the Board meeting. Clinical Implications: There are no direct clinical implications of this paper but the merger of itself proposes a number of changes to clinical practice that were outlined in the Benefits Realisation section of the OBC. These will be further developed for the Full Business Case to be submitted in September 2016. HR Implications: There are no direct HR implications of this paper but the Heads of Agreement place certain restrictions on substantive recruitment to senior posts in the transition period to a new merged organisation.

134

Legal and/or Regulatory Implications: There are two regulatory implications the Board should note. i. the recommendation not to notify the Competition & Markets Authority of the proposed

merger ii. the progression through Stage 2 of Monitor’s transaction guidance with the completion of the review of the Outline Business Case Equality Implications: The Board should note that a formal Equality Impact Assessment (EIA) of the merger will be commenced in late April/May with stakeholder groups identified across both Trusts. The EIA will form an important part of the FBC scheduled to be presented to each Trust Board for approval in September 2016. Risks: A full risk register is maintained for the project.

135

Merger with South Essex Partnership University NHS FoundationTrust

Outline Business Case Review 1. The Outline Business Case (OBC) for the merger was submitted to Monitor on 8th January 2016 as

was reported to the January Board. The formal review of the OBC by Monitor’s Provider Appraisal Division began in February and finished with an Executive Challenge Session on 11 March 2016.

2. The review process with Monitor has been very helpful in offering advice to the Project Team in a number of areas. The review covers four broad areas: a. Strategic rationale – the focus is to ensure that any changes since the Strategic Options Case

recommended merger in September 2015 have been captured. The review considered the fact that the Strategic Review of Mental Health Services had formally reported in November 2015 and received the full support of the commissioners and providers. The review included discussions with the lead Essex CCGs who commission mental health services to ensure that the merger itself had their support. Changes to the NHS planning guidance and developments in the Essex success regime were also considered. The conclusion of the review was that the strategic rationale for a merger remains valid.

b. Finances – Monitor’s review team thoroughly tested the Long Term Financial Model (LTFM) submitted with the OBC and sought to understand in more detail a number of the financial assumptions that had been made and to consider “downside risk” – that is to model what would happen if the financial position of either NEP or South Essex Partnership Trust (SEPT) were to deteriorate before the merger or if some of the positive savings assumptions of the merger did not happen. Areas for review and consideration by the Project Team will be contained in Monitor’s formal feedback but no significant issues were raised as part of the Executive Challenge Session.

c. Quality – at the OBC stage the plans for quality improvements are less formalised: this is essential to the FBC and is where the external review of the business case and Medical Director sign off are important. Nonetheless the review did consider how the position of the merger project had changed since the publication of NEP’s Care Quality Commission (CQC) report in January 2016. As the OBC suggested if anything the rating of “requires improvement” actually strengthens the case for merger: irrespective of merger SEPT are and would have been asked to support NEP’s CQC action plan and a formal merger will serve only to strengthen and increase the pace of such co-operation.

d. Transaction execution: the review considered the capacity and capability of both organisations to undertake such a significant transaction. The Project Team felt, during the review process, that the level of resources devoted to the merger work needed to take a step forward and that some additional governance of the transaction was required. This is discussed at the Heads of Agreement section below. The review process also highlighted the need to undertake a rigorous process of due diligence and the significant work that needs to be contained in the merger organisational development plan. All involved agree that the

136

greatest risk to the merger is not the actual regulatory transaction but a failure to fully address organisational and cultural differences meaning the benefits of merger are not fully realised. The detail of Monitor’s feedback will be considered in Part II of the Board initially.

3. Monitor’s formal written feedback will be received after this Board paper has been written andadditional relevant feedback will be reported to the Board verbally. Full consideration ofMonitor’s review will be made in the Board’s Part II private session.

4. The Challenge Session did not however highlight any problems that stop the work progressing toStage 3 Full Business Case (FBC). It is intended that this business case will be received at theSeptember 2016 Board meeting.

5. Two further clinical workshops were held in early March to refine the approach to benefits realisation and this helped start the formal process of clinical due diligence. A procurement process will commence shortly to select the necessary external support for the merger transaction – legal, audit and advisory. This is being run under SEPT’s procurement processes but with equal decision making with NEP teams. All appointments are expected to be confirmed by the end of April.

Heads of Agreement

6. During the review process the Project Team were prompted to consider the proposedgovernance of the merger and a number of other areas for consideration such as balancing such asignificant transaction with daily operational requirements. A number of guiding principles havebeen established and set down formally in a non-legally binding Heads of Agreement documentthat each Trust will sign following approval from their Board and legal drafting of the document.

7. A revised governance proposal for the project will be considered in full at Part II of the meetingbut the key point to note is that a Project Board will be created to progress the merger. TheProject Board will be a committee of both NEP and SEPT’s Trust Boards and will work within aclear scheme of delegation. It is important to stress that the Project Board cannot take decisions– these will still be the preserve of the Trust Boards. The Full Business Case for merger, forexample, will be presented to each Trust Board for approval before it is submitted to Monitor for a risk rating. The Project Board will ensure the work is progressed and will make a recommendation to the Trust Board. The creation of the Project Board does not pre-determine the merger as the FBC can still be rejected by either Trust Board, or by a vote of Governors as a result of Monitor’s risk rating.

8. The Heads of Agreement propose the Terms of Reference of the Project Board and also a revisedterms of reference for the Strategic Alliance Working Group (SAWG). The SAWG has previouslybeen the forum where cooperation and collaboration between the two Trusts could be discussedbut was not structured properly to take on the governance required by such a significanttransaction as merger. The SAWG remains in place to allow for a forum where collaborativeefforts outside the merger can be discussed for the next 12 months.

137

9. As part of the FBC review process Monitor requests a Board to Board meeting and this will be held with the Project Board representing both organisations rather than with both Trust Boards. However, it is a guiding principle that membership of the Project Board does not pre-determine membership of the merged organisation’s Board for either Executive or Non-Executive roles. Substantive Executive Director Board appointments will be made in line with good HR practice and organisational change policies; Non-Executive Director Board appointments will need to be made in line with the new organisation’s constitution and Governor Nominations Committee.

10. In addition the Heads of Agreement confirm both organisation’s commitment to sharing the costs of the transaction equally and to ensuring that material operational and investment decisions taken in the phase leading to merger will only be made after consultation with the other party.

Competition Considerations 11. As well as the OBC a revised Competition Analysis was submitted to Monitor’s Co-Operation &

Competition Directorate on 8th January 2016. This was reviewed jointly with the Monitor team during January and February, including discussions with commissioners and other stakeholders. Monitor has advised that on the basis of the information they asked for and received, and in discussion with commissioners, that they do not perceive there to be significant competition concerns with the merger.

12. It is important to note that the Monitor team do not use the same methodology as a team from the Competition & Markets Authority (CMA) would. The CMA take advice from Monitor and its review but is not bound by this advice.

13. It is important that in public discussions about the merger there is a very clear distinction maintained between a decision not to notify and the transaction receiving regulatory clearance from the CMA: as no notification has been made the merger does not have regulatory clearance and there remains a residual risk that the CMA may choose to review the transaction of its own accord for instance following a formal complaint being received from a third party. The project team believe this risk to be small and remain confident that any review would complete at Phase I. Such a review would not throw out the timetable for merger by April 2017 but would incur a £120,000 fee and of course the opportunity cost of time and resource required in cooperating with the CMA review.

14. The Project Team have reviewed Monitor’s advice and, considering the fact that the CMA still have the ability to review the transaction if they wish, believe that it would be disproportionate to notify the transaction to the CMA and incur the £120,000 fee. The Boards is therefore recommended to approve the decision not to notify the CMA with regard to the merger.

138

North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 13 Date: 23 March 2016 Title of Report: Finance Report for the Eleven Months Ending 29 February 2016 Lead: David Griffiths, Director of Resources Subject, Purpose and Recommendation: The Board of Directors is asked to note the report. Financial Performance The detailed Financial Performance pack is attached to this report. The summary reports that the Trust has achieved EBITDA of £2.82 million before account is taken of interest, depreciation and PDC dividends. After account is taken of depreciation, dividends and interest, the Trust is reporting an underlying deficit of £(3.00) million year to date. This performance is £(2.4) million lower than the plan at Month 11. The variation to Monitor plan1 reflects:

• Lower income than planned, (£1.0)m; • Significantly higher pay costs, £(1.9)m, caused by non-delivery of CIPs (£0.7m) and

high agency spend; and • A small underspend on non-pay and other technical adjustments of £0.5m.

Once account is taken of profits received from the sale of a number of surplus properties the Trust’s final reported position as at Month 11 is a surplus of £10.70 million. The year-end forecast has been updated for Month 11. This suggests an underlying deficit of circa £(3.5m), and a final accounts surplus of £11.9m after profits on disposal are taken into account. This is a marginal deterioration of £78k compared to the month 10 forecast. The M11 forecast outturn includes the positive impact of the settlement of the 2015/16 contract position with the CCGs although this was offset by further operational financial pressures, particularly in Mid and West. The Trust’s overall Cash position remains strong, with balances of £13.9m at the end of Month 11. This was £4m above plan, primarily as a consequence of VAT receipts from the sale of Severalls due to be paid over in March and slippage on the Capital programme, particularly in the profile of claims from the Derwent Centre contractor. This latter issue will

1 For consistency with Monitor submissions, all variances are now recorded against Monitor Plan figures.

139

also impact on the year-end cash forecast which is now forecast to be in line with the Monitor plan at £8.9m. Monitor introduced a new Financial Sustainability Risk Rating (FSRR) from August, which includes two additional metrics (actual I&E surplus, and I&E surplus variance compared to plan) to those included in the old Continuity of Service Risk Rating (CoSRR). Under the new FSRR the Trust’s rating was “2” at end of February. The year-end forecast FSRR remains at “2”, the same as Q2. Finance Implications: After consideration of identified risks the Trust is considered to be a going concern able to implement its approved strategic plans, although there are significant risks in maintaining a strong FSRR rating. Clinical Implications: The financial performance of the Trust should not, of itself, constrain planned clinical performance. HR Implications: The Trust’s reward strategy is affordable and within budget. Legal and/or Regulatory Implications: The Trust has not been advised of legal action, or the risk of legal action, which may materially impact upon the Trust’s financial performance. Equality Implications: N/A Risks: At this point in the financial year the majority of the key financial risks are incorporated within the year-end forecast. Key issues moving forward into 2016/17 are:

• Development and delivery of the CIP plan in safe and timely fashion • Agreement of a contract value for 2016/17 with CCG commissioners

140

Board Financial Performance Pack

Month 11: 29th February 2016

Contact: David Lambert Associate Director of Finance [email protected] 01245 (2082) 546459

@NEPNHS

NorthEssexPartnership

Page 1141

Main Report: Page Page

Financial Report Summary 3 Agency Expenditure 9

Key Performance Indicators 4 High Level Forecasts 10

Income & Expenditure 5 Capital Programme 11

Balance Sheet 6 Cost Improvement Programmes (CIPs) 12

Cash Flow 7 Debtors & Creditors 13

Subjective Analysis 8

Index

Page 2142

2014/15

Monitor

Plan YE

2015/16

Forecast YE

2015/16Variance

£000 £000 £000 £000

Introduction Income (109,702) (106,634) (105,760) 874

Pay 85,508 81,633 84,024 2,391

Non-Pay 19,290 19,375 19,016 (359)

Financing Costs 6,117 5,624 6,194 570

Financial Overview Net (surplus)/deficit 1,213 (2) 3,473 3,475

Impairments & Profit on Disposals 16,067 (14,475) (15,340) (865)

Net (surplus)/deficit 17,280 (14,477) (11,867) (2,610)

Balance at

31/03/15

Monitor

Plan YE

2015/16

Forecast YE

2015/16Variance

£000 £000 £000 £000

Cash Balance 10,353 8,680 8,995 315

Ann Bud YTD Act YE Forecast Variance

£000 £000 £000 £000

Capital Expenditure and Loans 15,627 10,687 13,478 2,149Cash Property Disposals (General) (4,650) (4,832) (4,273) (377)

Property Disposals (Severalls) (6,964) (6,672) (6,672) (292)

Cost Improvement Programme (CIPs)

Capital

Financial Risks

Governance declaration

There are a further 2 properties under offer for financial year 15/16 - being Old Ivy Chimneys,and New Ivy Chimneys. We expect that they will complete in March.

Capital Summary

Spend to date is £8.0m, with a further £0.5m of orders pending delivery, against a forecast spend of £13.2m.

The value of the Trust's cost improvement programme is £3.19m, excluding £1m of budgetary adjustments made in Month 1. Of these £2.43m has been delivered or actioned from budgets at Month 11 in line with plans agreed with managers. £0.76m remains to be found. The focus is now on reducing agency spend for the current year, and working towards achieving next year's CIPs.

EMT continues to monitor financial risks and delivering CIP opportunities for 2015/16 and beyond- Delivering the CIP- Agreeing 16/17 contracts- Achieving cost per case occupancy targets- Managing agency spend, sickness and other HR issues- Risk Share agreements for inpatient beds- Managing cash & working capital- Planned property disposals - NHS Property Services VAT risk

The expected deficit in the year-end forecast is primarily as a consequence of a greater than expected reduction in income and escalating agency costs, with £9.3m spent on agency so far this year, and a forecast agency spend for the full year of £10.2m. Another contributing factor is the lower than planned delivery of CIPs.

The cash receipt from the sale of Severalls has improved the cash position and we will receive 3 further cash installments of £6m over the coming 3 years. However, the cash position is still tight and for 2016/17 we are applying for a bridging loan of £6m using the security of the furture cash receipts mentioned above.

The Severalls non-operational site was sold in M10, and the forecast assumes that New and Old Ivy Chimneys will be sold before the end of the financial year.

Agreement has now been reached with commissioners regarding the value of 15/16 contract payments, and the M11 position reflects this. Whilst this improved the forecast outturn for this main contract this was offset by additional operational pressures, particularly in mid and west areas and the forecast outturn is therefore consistent with last month at £11.9m

Assuming all property sales proceed as planned, the cash balance at the end of the year will be £9m. This is approximately 27 day's working capital (excluding income).This is an improvement compared to the forecast last month, caused by lower than expected Capital spend payments

Finance Report for the Period Ended 29th February 2016 *

The Board anticipates that the Trust will not be able to maintain a Financial Sustainability Risk Rating of at least 3 over the next 12 months. This is based on the Month 11 return to Monitor showing a FSRR of 2 and a forecast at year end of 2.

The forecast year end cash position of £9m assumes property sales income in line with Monitor Plan and no further income penalties.

I&E Summary

Cashflow Summary

This report presents the detailed financial performance for the month ended 29th February 2016 focusing on key indicators within the Monitor financial regime. It shows that to 29th February the Trust has earned EBITDA of £2.82m. The Trust's Balance Sheet shows Net Assets of £74.91m.

The Trust is forecasting a surplus of circa £11.9m at year-end compared to the Monitor Plan of £14.5m surplus. However, excluding exceptional items (impairments and profits on disposal) the Trust is forecasting an underlying deficit of £3.5m which is a slight improvement from the forecast at Month 10.

Financial Report Summary

0

1

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Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

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h -

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w

Financial Sustainability Risk Rating

Monitor Plan

FSRR

Page 3

143

Key Performance Indicators

(100)

400

900

1,400

1,900

2,400

2,900

3,400

M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

(£'0

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YTD (Surplus) / Deficit against plan (Excluding Profits on Disposals)

Actuals Monitor Plan

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6

8

10

12

14

16

Y/E Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

£m Cash Flow Forecast

Actuals / Forecast Monitor Plan

Key Performance Indicators

0

500

1,000

1,500

2,000

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3,000

3,500

M1

M2

M3

M4

M5

M6

M7

M8

M9

M10

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CIPs To Be Actioned

0

2000000

4000000

6000000

8000000

10000000

12000000

14000000

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Capital Expenditure

Orders

YTD Actuals

Monitor Forecast

YE Forecast

Page 4144

Overview

Income

The Trust has had a shortfall of £988k of total income against Monitor Plan.

Full year YTD YTD Plan & Actuals

Monitor Plan Plan Actuals Variance

£000 £000 £000 £000

Block Contract: Adult & Older Adult (70,906) (64,989) (64,937) 52Block Contract: CAMHS (4,246) (4,246) (4,314) (68)Block Contract: Specialist Services (6,373) (5,842) (5,817) 25Block Contract : Other (2,061) (1,889) (2,253) (364)Clinical Partnerships mandatory services (9,030) (8,278) (8,747) (469)Other - Cost and Volume Contract Income (4,390) (4,024) (4,069) (44)Other non-protected clinical income (1,616) (1,481) (526) 956Total Clinical Income (98,622) (90,749) (90,662) 87

Education and Training (5,328) (4,884) (4,324) 560Other Income (2,382) (2,184) (1,690) 494Research and Development (302) (277) (430) (153)Total Other Income (8,012) (7,345) (6,443) 902

Total Income (106,634) (98,094) (97,105) 988

Pay 81,633 75,065 76,980 1,915

Drug costs 1,870 1,714 1,893 179Clinical Supplies & Services 412 378 422 44Secondary Commissioning Costs 1,094 1,003 348 (655)Non Pay - Other 15,999 14,697 16,195 1,498Release of Provisions 0 0 (1,555) (1,555)Non-pay costs 19,375 17,791 17,302 (489)

Total costs 101,008 92,856 94,283 1,427

EBITDA (5,626) (5,238) (2,823) 2,415

Total Depreciation 3,579 3,280 3,719 439Total Interest Receivable (31) (28) (44) (16)Total Interest Payable - inc WC facility 467 428 428Unwinding Discount Provisions 0 0 115 115PDC Dividend 1,609 1,475 1,606 131Net (surplus)/deficit before impairments (2) (83) 3,002 3,084

Impairments & Profit on Disposals (14,475) (14,190) (13,742) 448

Net (surplus)/deficit (14,477) (14,272) (10,740) 3,532

Bad debts are higher than planned (£1,102k YTD spend), largely due to unpaid invoices from other NHS organisations. Spend on premises remains higher than planned (£4,820k YTD spend), due to buildings not being vacated in accordance with plans, spend on telephones and ICT remaining high, and unplanned costs for team relocations and unit closures; the higher than planned spend on premises is not expected to continue into 2016/17..

I&E Statement Month 11

The Income and Expenditure account gives an overview of the performance of the Trust by main Income and

Expenditure headings. Income is subdivided, separating Clinical Income from Other Income. Costs are

analysed by main budget headings.

The table contains the current annual budget which may be adjusted in year and vary from the original plan.

In addition to EBITDA and net (surplus)/deficit, the table also shows the year-to-date variance against the

phased annual budget. EBITDA and net (surplus)/deficit demonstrate the current trading position of the Trust

whereas the variance gives an indication of performance against plan.

Total expenditure as at M11 was overspent by £1,427k compared to Monitor Plan; comprising a £1,915k overspend on Pay and £489k underspend on Non-pay.

£574k of the Journeys CIP remains. This will now be consolidated into the 2016/17 CIP plans. The rate of spend on agency remains consistently high, with £9.3m spent so far ths year (£8.5m at M10). On-going work to bring agency spend in line with Monitor guidance, and the Trust recruitment drive, have had no impact on reducing agency spend to date.

- The Block Contract for Adults and Older Adults is reporting a small shortfall in income YTD against the Monitor

Plan. This reporting line includes the adult block contract and the associate commissioner block contracts. The variance to plan is a result the original plan being based on activity levels of 2014-15. Block Contract Other includes MVA and GP Services, the MVA income is in line with plan.

- Clinical Partnerships , which include the Essex County Council services and Herts County Council services are reporting a surplus to the Monitor Plan YTD (£513K). This is a result of additional funding for the ECC S75 agreement part way through this year, the ECC Supported Employment Service Contract income moving to Central Income, and Herts CC funding being agreed at £44K less than planned for the full year. - Other Cost and Volume Contract Income includes Non Contracted Activity (including risk share), Rainbow Unit, Larkwood, PICU & Brian Roycroft Unit. The surplus income to plan YTD of £38K is a mixture of additional income from the PICU risk share for the first six months, due to high occupancy on these two units, and high volume of adult risk share beds (which we charge on to commissioners). On the negative side, occupancy in the mother and baby unit is consistently lower than expected, as is the PICU cost per case income, with an occupancy of one inpatient for this year.

- Other non protected clinical income includes the Criminal Justice Mental Health Team (CJMHT) contract. The original contract was believed to be in line with 14/15, however the service NEPFT provides was reduced resulting in a much smaller value contract for 2015-16. This has resulted in the large underachievement YTD to plan.

Expenditure

Income & Expenditure

(100)

400

900

1,400

1,900

2,400

2,900

3,400

M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

(£'0

00

)

YTD Actual against plan (Excluding Profits on Disposals)

Actuals Monitor Plan

Income & Expenditure

Other Clinical

14%

Block Income

78%

Ed & Train 5%

Other 3%

Income

Pay 82%

Drugs 3%

Other 16%

Expenditure

Page 5

145

Overview

2014/15 YTD Act

£000 £000

Assets, Non-Current

Property, plant and equipment 79,370 82,985 88,166 86,147Non NHS Trade Receivables - Non Current 0 12,226 18,341 12,227NHS Trade Receivables - Non Current 24 11 24 11Total Assets, Non-Current 79,394 95,221 106,531 98,385 Due <1 Year Due >1 Year Total Due Due <1 Year Due >1 Year Total DueAssets Current Severalls Disposal 10,067 10,067 - 10,074 10,074Inventories 57 63 57 69NHS Trade Receivables - Current 4,129 6,676 9,720 6,676 Early Retirement 184 2,066 2,250 185 1,945 2,130Impairment of Receivables (147) (1,115) 0 (1,460) Injury Benefit 57 831 888 57 779 836Other Receivables - Current 832 337 834 202 Serco Contract Delays - - - - - -Accrued Income 941 7,455 941 2,590 Property Costs 1,210 1,210 186 - 186Prepayments - Current non-PFI 467 804 1,109 482 Income 406 406 683 - 683Non Current Assets Held For Sale 15,117 711 0 0 Other 2,544 2,544 1,003 - 1,003Cash (Government Banking Serv) 10,327 13,937 8,680 8,607 Total 4,401 12,964 17,366 2,114 12,798 14,912Cash (Commercial Bank) 26 22 0

Total Assets - Current 31,748 28,890 21,341 17,166Total Assets 111,142 124,112 127,872 115,551Liabilities Current Annual Leave for Staff 665Bank Loan less then one Year (2,615) (2,615) (2,615) (2,615) Property and Associated Costs 319Deferred Income - Current (601) (6,062) (6,367) (523) Staff payments 500Provisions for liabilities and charges - Current (4,401) (2,114) (2,901) (1,587) STARS 220Tax Payables, Current (1,543) (2,751) (1,543) (1,402) Loan Interest 156Trade Payables Current (1,889) (1,006) (1,556) (1,172) Invoice accruals 949Invoice Accruals (2,438) (949) 0 (1,106) Other 302Other Trade Payables Current (486) (886) (3,901) (1,033) Total 3,111

Capital Creditors (647) (512) (647) (597) NotesAccruals, Current (1,484) (2,006) (1,443) (2,338)PDC dividend creditor 0 (730) 0 0Interest Payable on interest bearing borrowings 0 (156) 0 0Total Liabilities, Current (16,103) (19,786) (20,973) (12,372)Net Current Assets/(Liabilities) 95,039 104,326 106,899 103,179Liabilities, Non-Current

Loans Non Current (15,096) (13,589) (12,481) (12,481)Pension Liability - ECC (3,032) (3,032) (2,156) (3,032)Provisions for liabilities and charges - Non Current (12,964) (12,798) (12,964) (12,887)Other Liabilities, Non-Current (31,092) (29,420) (27,601) (28,400)Total Assets Employed 63,947 74,906 79,298 74,779Taxpayers' and Others' Equity

Public Dividend Capital (29,087) (29,087) (29,087) (29,087)Income and Expenditure Reserves 11,196 (24,366) (3,278) (24,238)Revaluation Reserve (49,088) (24,486) (49,088) (24,486)Pension Reserve 3,032 3,032 2,155 3,032

Total Taxpayers Equity (63,947) (74,906) (79,298) (74,779)

304-

41

Balance Sheet as at Month 11 The balance sheet is a snapshot of the Trust's financial position at a point in time.

It identifies: Fixed Assets, Liquid Assets, Liabilities, Taxpayers' Equity.

The Continuity of Services risk rating uses the Trust's liquidity ratio (broadly current assets less current

liabilities) to assess the financial strength of the Trust.

ProvisionsYE 2014/15 Month 11

YTD

Monitor

Plan

F'cast Y'end

1516

YE 2014/15 Month 11Accruals

66553

The percentage of invoices paid within 30 days for month ended February 2016 is 75%. This is a slight increase on last month (71%) We continue to work with Serco to drive further improvements including a drive to reduce the number of old outstanding invoices. We have now recruited a 3 month position in Finance to help HR clear these outstanding invoices.

Deferred income includes £5,539,000 of contract income for CCGs which has been invoiced early.

Impairment of receivables has increased significantly due to lower than expected Cluster 1-4 activity resulting in disputed invoices with the CCGs (£511,000). Prepayments include £291,000 of IT costs, £60,000 of insurance costs and £252,000 of rental costs. Accrued income includes £6m for the sale of Severalls (due in installments), £397,000 NHSE income, £120,000 Enable East income, and £132,000 of CQUIN income.

2,438

3,922421

Balance Sheet

Page 6146

YTD Monitor Overview

Actuals Plan

£000 £000

Surplus/(Deficit) from Operations (3,002) 175

Finance income/charges 499 36Depreciation and amortisation, total 3,719 298Impairment losses/(reversals) 0 0Gain/(loss) on disposal of property plant equipment 0 (8,262) NotesPDC dividend expense 1,606 0 The EBITDA position contributes to the positive operating cash flows of £2,823k.Non-cash flows in operating surplus/(deficit), Total 5,824 (7,927) YTD cash flows from operating activities are a net outflow of £(2,187)k.Operating Cash flows before movements in working capital 2,823 (7,752)

(Increase)/decrease in Inventories (6) 0(Increase)/decrease in NHS Trade Receivables (1,579) 0 Cashflow forecast commentary(Increase)/decrease in Non NHS Trade Receivables 495 0 Cashflow is based on the submitted Monitor plan for income and expenditure.(Increase)/decrease in accrued income (6,514) 0 Property sales assumed - Old and New Ivy Chimneys due in Q4 15/16(Increase)/decrease in prepayments (337) 0 Final cash position pending all assumptions above is £9 million Increase/(decrease) in Deferred Income (ex donated assets) 5,461 0Increase/(decrease) in provisions (2,287) (125)Increase/(decrease) in tax payable 1,208 Interest RepaymentIncrease/(decrease) in Trade Creditors (2,372) 0 Rate Date Due <1 Year Due >1 Year Total DueIncrease/(decrease) in Other Creditors 400 0Increase/(decrease) in accruals 522 0 Crystal Centre Loan 5.33% Sep-18 978 1,953 2,931Increase/(decrease) in other Financial Liabilities 0 (43) St Aubyn Centre Loan 2.65% Sep-21 736 3,686 4,423

Total Increase/(Decrease) in working capital (5,010) (168) Derwent Centre Loan 1.42% Mar-22 500 2,750 3,250

Net cash inflow/(outflow) from operating activities (2,187) (7,920) Derwent Centre Loan 2 2.17% Dec-29 400 5,201 5,600

Capital expenditure, total (9,314) (899) Total 2,614 13,590 16,204Proceeds on disposal of property, plant and equipment 17,618 8,771

Interest received on cash and cash equivalents 44 3

Total Net cash inflow/(outflow) from investing activities 8,348 7,875

Net cash inflow/(outflow) before financing 6,161 (45)Repayment of commercial loans (1,507) 0Repayment of non-commercial loans 0 (436)Interest (paid) on non-commercial loans 0 (87)Interest (paid) on commercial loans (272) 0Interest (paid) on bank overdrafts 0 0PDC Dividends paid (876) (259)Public Dividend Capital received 0 0Drawdown of non-commercial loans 0 0Drawdown of commercial loans 0 0(Increase)/decrease in non-current receivables 13 0

Increase/(decrease) in non-current payables (141) 0

Other cash flows from financing activities (115) 0

Total Net cash inflow/(outflow) from financing activities (2,897) (782)

Net increase/(decrease) in cash and cash equivalents 3,263 (828)

Cash Flow Statement Month 11 The detailed Cash-flow statement shows how liquid resources are generated within the organisation,

and how they are used. Funds are generated from operations combining EBITDA with movements in

working capital. Funds are expended on capital expenditure or exceptional items. The net cash flow is

determined when loans, interest, dividends and changes in shareholders' equity are taken into account.

YTD total cash balances have increased by £3,263k and the Trust's cash balance stands at £13,959k as at 29th February 2016.

LoansMonth 11

Cash Flow Statement

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Y/E Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

£m Cash Flow Forecast

Actuals / Forecast Monitor Plan

Page 7147

Annual

Budget

YTD

Budget

YTD

Actual

YTD

Variance

£000 £000 £000 £000

Admin and Clerical 9,913 9,102 7,856 (1,246) 349.9 313.0 (36.9)Admin and Clerical Agency 86 78 1,506 1,428 0.0 0.0 0.0CIPS - Pay (746) (685) 0 685 0.0 0.0 0.0AHPs 10,513 9,709 8,170 (1,539) 232.8 196.6 (36.3)AHPs Agency 15 14 128 115 0.0 0.0 0.0AHPs-ECC Partnership 3,715 3,415 2,236 (1,179) 95.2 56.7 (38.4)Ancillary/Maintenance 3,268 2,996 2,396 (600) 139.6 103.7 (35.9)Ancillary/Maintenance Agency 15 13 187 174 0.0 0.0 0.0Medical Agency (3) (6) 1,944 1,950 0.0 0.0 0.0Medical -NHS 12,510 11,523 10,311 (1,211) 128.5 93.9 (34.6)Nursing Agency 26 26 1,849 1,823 0.0 0.0 0.0Nursing Agency Qualified 49 49 2,761 2,712 0.0 0.0 0.0Nursing Agency Unqualified 0 0 359 359 0.0 0.0 0.0Nursing -Bank Qualified 1,175 1,075 1,792 717 37.6 66.3 28.7Nursing -Bank Unqualified 1,056 960 4,027 3,067 37.1 125.1 88.1Nursing -NHS Qualified 26,886 24,734 19,861 (4,872) 603.7 479.5 (124.2)Nursing -NHS Unqualified 9,199 8,426 6,144 (2,282) 338.3 271.1 (67.2) Key

Other Payroll Costs 0 0 0 0 0.0 0.0 0.0Redundancy Payments 0 0 0 0 0.0 0.0 0.0 = On Plan

Reserves (284) (517) 0 517 0.0 0.0 0.0 = Low Risk of under-achieving

Senior Manager 5,562 5,100 4,844 (256) 83.7 71.4 (12.3) = High Risk of under-achieving

Total Pay 83,607 76,604 76,980 376 2,046.2 1,777.2 (269.0)

Notes

Enable East agency spend of £71k shown left does not include the costs of consultants which would bring the total agency spend (as per the Monitor definition) to £681k

Overview

Pay budgets represent approximately 80% of the Trust's total

costs. The management of pay costs are fundamental to the

financial success of the organisation.

On the whole, pay costs tend to be "fixed" costs within the Trust

with most staff being paid via fixed salaries. In ward areas and

other 24/7 services, enhancements are paid to recognise un-social

hours, but again these areas tend to have relatively fixed

establishments and pay costs.

When pay costs vary, this tends to be a consequence of vacancies

and the use of supplementary hours to cover staffing shortages or

higher level patient observations.

Month 11 RAG TrendWTE

Budgeted

WTE

Worked

WTE

Variance

West agency spend includes £404k of medical, £2.72m of nursing, and £365k of other.NE agency spend includes £701k of medical, £308k of nursing, and £162k of other.Mid agency includes £279k of medical agency, £1.68m of nursing, and £255k of other.Corporate agency spend includes £417k on medical locums, £119k on nursing, and £738k of other.

CIPS - Pay includes £527k of Journeys CIPS which remain to be achieved.

CYP agency spend includes £194k of medical, £154k of nursing, and £161k of admin and clerical agency.

BIS agency spend includes £75k of other.

Subjective Analysis - Pay

5.7%

8.5%

12.1%

6.4%

11.7%

5.9%

18.1%

BIS (1.7m)

CYP (6.6m)

Corp (11.9m)

EE (1.2m)

Mid (20.9m)

NE (21.7m)

West (19.9m)

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% 20.0%

A

r

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a

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a

y

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Total Agency Spend as % of Total Pay

Agency %

Page 8

148

Week 1 55 Week 8 53 Week 15 33 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Total

Week 2 78 Week 9 29 Week 16 - Planned Agency Spend 345 214 170 128 117 107 1,081

Week 3 134 Week 10 54 Week 17 - Planned Total Spend 2876 2135 2135 2135 2135 2139 13,555

Week 4 116 Week 11 45 Week 18 - Agency spend as % of total 12% 10% 8% 6% 5% 5% 8%

Week 5 62 Week 12 43 Week 19 - Actual Agency Spend 405 473 451 453 511 0 2,293

Week 6 16 Week 13 33 Actual Total Spend 2,391 2,430 2,340 2,298 2,392 0 11,851

Week 7 54 Week 14 33 Agency spend as % of total 17% 19% 19% 20% 21% 0 19%

Number of shifts exceeding cap (from 22/11/2015) Agency spend ceiling for Qualified Nurses (£k)

Agency Expenditure

0

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Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12

Agency Spend (£k)

Nursing

Nursing Qualified

Medical Admin & Clerical

Nursing Unqualified

Page 9149

2014/15 Overview

ActualM10

Actuals

M11

Actuals

Spend

trendRAG Trend M10 Forecast M11 Forecast

Movt on

forecastRAG

£000 £000 £000 £000 £000 £000 £000

Income (100,987) (7,117) (7,843) (726) (97,900) (98,096) (195)

Business Infrastructure Services 11,572 540 403 (137) 6,813 6,605 (208)

Children & Young People Services 9,865 310 249 (61) 6,489 6,440 (49)

Corporate 10,390 1,420 1,287 (134) 15,175 15,257 82 Key

Mid Essex 22,855 1,904 1,923 19 22,136 22,281 145 = On Plan

North East Essex 20,850 1,984 1,959 (25) 23,458 23,303 (155) = Low Risk of under-achieving

West Essex 21,027 1,952 2,124 172 23,498 23,783 285 = High Risk of under-achieving

Reserves 60 0 0 0 28 28 0

Total EBITDA (4,367) 993 101 (893) (303) (399) (96) = Improved from last month

Overheads 5,598 15 500 484 3,697 3,871 174 = Same as last month

Impairments & Profit on Disposals 53 (11,962) (50) 11,912 (15,340) (15,340) 0 = Worse than last month

Net (Surplus)/Deficit 1,284 (10,954) 550 11,504 (11,946) (11,867) 78

Notes

The forecast in service lines is an assessment of the expected year-end position. These forecasts will be refined as we move forward to more accurately reflect the expected out-turn position.

Income

Business Infrastructure Services

Children & Young People Services

Corporate

Mid Essex

North East Essex

West Essex

The forecast spend has increased in month due to property costs and an increase in drugs spend for Essex STaRS, and a backlog of agency costs for the Access and Assessment team

Overheads

The forecast spend has increased in month due to a reduction in the out of hours A&E CAMHS income, and an increase in forecast costs for running the Marginalised and Vulnerable Adults contract.

The forecast spend has fallen slightly, due to unfilled medical vacancies.

The forecast spend has increased in month due to expected back pay of working time directive payments to bank staff, which were unpaid because of a payroll error.

The forecast has fallen slightly, due to additional income for CAMHS property rentals, and income for an expected rates refund on Derwent Centre.

Reserves have now been exhausted for 2015/16. Detailed work is required to address the 2015/16 income reductions for future years (Reserves have funded these non-recurrently for 2015/16), and to address any additional expected reductions in income for 2016/17.

The forecast spend remains largely unchanged in month.

The forecast spend remains largely unchanged in month.

Summary Income and Expenditure

Month 11 Actuals YE 2015/16 Movement on Forecast

This page shows the actual change in

spend compared to prior month, and the

change in year end forecast since last

month.

The forecast has increased slightly as the contract value has now been finalised, and agreement has been reached for CQUIN and other payments in year with the CCGs.

High Level Forecasts

Page 10

150

Overview

YTD Actuals YTD Variance

£000 £000 £000 £000

1. Strategic SchemesBusiness Systems Development 737 757 (20) 757Derwent Centre, Harlow 2-5 8,800 6,210 2,590 6,194Severalls Reprovision 300 134 166 300Mobility Workflow 534 74 460 534Extension to Rainbow Unit 70 86 (16) 86Microsoft Licensing 53 44 9 53ECT Services 50 0 50 50Extension to Christopher Unit 535 521 14 535CQC Compliance 0 295 (295) 720Derwent Centre Capping Off 450 191 259 407

1. Strategic Schemes Total 11,529 8,313 3,216 9,636 Expenditure

2. Replacement & Refurbishment 370 282 88 3523. Infrastructure, H&S, PLACE 1,106 573 533 8524. Capital Development 10 8 2 105. Contingency 12 2 10 12Total Capital Expenditure 13,027 9,179 3,848 10,862

7. Loan Repayment 2,600 1,508 1,092 2,616Property Disposals (General) (4,650) (4,832) 182 (4,273)Property Disposals (Severalls) (6,964) (6,672) (292) (6,672)

Capital Monitor Forecast

Disposals

Assets

We received the updated Castons cash forecast for the Derwent Centre project on 10th March. This shows a considerable underspend forecast for the year. The cashflow we received in January forecast total spend to date of £10.3mil by March 31st. The revised cashflow in March now states £8.9m by end March.

The closing Trust asset cost and net book value for Month 11 is £106,315,368 and £81,889,644 respectively. As at Month 11 depreciation incurred (excluding disposals) totals £3,295,000 against a YTD budget of £3,029,000. Further asset detail can be found on the Asset page 6 of the Capital Report.The Trust is also in the process of a full property valuation, which will be ready for year end.

As part of the Trust's reporting requirements, a monthly capital expenditure forecast is to be submitted each financial year to Monitor. As at Month 11 the Trust has expenditure of £8,863,364 against a Monitor forecast of 11,849,030 this being 75% of the monthly forecast.

Capital ProgrammeMonth 11 Current YE

Forecast

Annual

Budget A brief overview of capital expenditure only is included in this report. More detailed reports on

the progress of the capital programme are made to the Strategic Capital Group and Trust

Board throughout the year.

The Board approved a capital programme at the beginning of the year totalling £13,027,000

plus £2,614,000 for loan repayments.

The source of funds for the capital programme are internally generated funds (EBITDA),

accumulated cash balance, and long term loans.

The property disposal budget is based on the planned proceeds for the financial year.

The Trust planned to dispose of eight properties (one of which was unsold last year) in 2015/16 financial year with Monitor forecast receipts of £5,850,000 excluding Severalls. This has been revised to YE Forecast £4,272,787 based on proceeds received and offers accepted. As at Month 11, seven properties have been disposed being High Beech, Glen Avenue, 7 Oxford Road, 2-4 Pitfields, Creffield Road, Severalls and 9 Oxford Road. Old Ivy and New Ivy Chimneys are both due to complete by the end of the financial year.

Financial Overview

As at 29th February 2016 the Trust has approved a capital budget of £13,027,000 (excluding loans & disposals) of which expenditure of £9,179,058 has been incurred with a further £298,471 of orders raised pending deliver of goods or services. Expenditure as at Month 11 is 70% of the budget.

Capital Investment Programme

0

2000000

4000000

6000000

8000000

10000000

12000000

14000000

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Capital Expenditure

Orders

YTD Actuals

Monitor Forecast

YE Forecast

Page 11151

Committed ActionedUnder/(Over)

- achieved£000 £000 £000

HR & Workforce 20 20 0Medical Services 214 214 0Strategy 13 11 1Finance, Contract & Performance 156 156 0Director of Operations 130 130 0Total Corporate 532 531 1Business Infrastructure Services 172 163 9 KeyMid Essex 350 285 65 = On Plan = Improved from last monthNorth East Essex 1,301 1,165 135 = Low Risk of under-achieving = Same as last monthWest Essex 715 170 545 = High Risk of under-achieving = Worse than last monthOverheads 120 120 0CIPS Total 3,189 2,433 756

Income 14 14 0Pay 923 751 172Journeys 1,550 976 574Non Pay 702 693 10CIPS Total 3,189 2,433 756

CIPs £000

Monitor Plan 4,190 Actioned M1 (planning assumptions) 1,001

3,189

Unachieved CIPS 14/15 835 2,354

BIS

£9k remains for unidentified CIPS.Mid & Secure Services

£65k for undelivered Journeys CIPS. North East & Rehab

£135k for undelivered Journeys CIPS.West & Substance Misuse

£373k for undelivered Journeys CIPS; £172k other pay CIPS brought forward from prior years.

Budget CIPS 2015/16

Efficiency Programme Month 11 RAGOverviewThe Trust's longer term financial model plans for significant year-on-year savings generated by an internal

efficiency programme. These savings allow the Trust to respond to inflationary pressure and also to steadily

improve its financial performance. The target relates to the initial list of initiatives compiled by the areas whilst

the agreed CIPs were limited to initiatives with a status of 'green' or 'amber' i.e. those considered deliverable

within FY14/15. Actioned CIPs are where specific budget lines have been adjusted and delivery is underway

whereas those "to be actioned" are where the budget lines to be altered are yet to be confirmed.

Work has begun to identify CIPS for the 2016/17 and 2017/18 financial years. It has been agreed that any

remaining CIPS for 2015/16 will be consolidated into the 2016/17 CIPs targets.

Cost Improvement Programmes (CIPs)

0500

1,0001,5002,0002,5003,0003,500

M1

M2

M3

M4

M5

M6

M7

M8

M9

M10

M11

M12

(£'0

00

) CIPs To Be Actioned

Income Pay Journeys Non Pay

Committed 14 923 1,550 702

Actioned 14 751 976 693

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

(£0

00

)

CIPs Achievement YTD

Page 12152

Debtors Overview

Notes

Receivables Balances Month 11

NHS Receivables 6,102Staff Receivables 57VAT Due from HMRC -Other Receivables 527Total Trade Rec 6,686 468690

Trade Rec >90 days 652 368742

Creditors

Impairment of receivables has increased significantly due to loss of CQUIN income. Prepayments include £187,000 of IT costs, £185,000 of insurance costs and £96,000 of lease car costs. Accrued income includes £375,000 cost per case income, £144,000 ECC income, and £149,000 of CQUIN income.

Payables

NHS - 30 Days No. £000 No. £000

Deferred income includes £5,539,000 of contract income for CCGs and £414,000 for STARS- which has been invoiced early. Paid Over 30 Days 9 67 10 256Paid Within 30 Days 42 398 67 417NHS Total 51 465 77 673

Non NHS - 30 Days No. £000 No. £000

Paid Over 30 Days 375 449 520 546Paid Within 30 Days 1,670 2,162 1,517 2,419Non NHS Total 2,045 2,611 2,037 2,965

Overall Paid 2,096 3,076 2,114 3,638

Paid Within 30 Days 81% 84% 75% 78%

14/15 Average Month 11

Creditor 30-day payment performance has improved slightly to 75% (from 71% in M10 and and average of 81% in 1415). The finance resource to process NETSS invoices is now in place and is making steady progress.

Debts have reduced in M11. Of the 90 days + invoices outstanding, £355k relate to risk share invoices with NEECCG currently being discussed at executive level.

A change to the way that Commissioners pay

the Trust (in Summer 2014) has led to a one

off increase in NHS debtors at the end of

each month. This is due to invoices being

raised at the end of the month for payment

early next month (previously invoices were

raised and paid in the same month). This

leads to an improvement in cash flow as

invoices are paid approximately two weeks

earlier than last year.

7,933

390

14/15 Average

6,8935488

898

1000 2000 3000 4000 5000 6000

M1

M2

M3

M4

M5

M6

M7

M8

M9

M10

M11

M12

£'000

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

30-60 2142 1356 597 2901 563 300 2620 189 765 1939 560 -

60-90 1851 1934 476 372 198 131 141 369 103 187 333 -

>90 1410 2184 1407 1235 433 606 423 527 677 582 652 -

Total Overdue Debt

Debtors & Creditors

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

£'0

00

Total Receivables

Total Trade Receivables Trade Receivables >90 days

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

% Invoices Processed within 30 Days (Volume)

NHS Non NHS Overall

Page 13153

North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 14 Date: 23 March 2016 Title of Report: Operational Performance Summary to 29th February 2016 Lead: David Griffiths, Director of Resources and Vince McCabe, Director of Operations Subject, Purpose and Recommendation: The Board is asked to receive and note the Trust’s Operational Performance at Month 11. The format of the Operational Performance Summary has been amended for 2015/16. There are now three distinct sections:

• Monitor’s Access and Outcomes Measures as defined in the Risk Assessment Framework;

• Other KPIs; and • Contractual Targets where performance concerns have been raised by

Commissioners. Monitor Access and Outcome Measures For the month of February, the Trust has recorded that it met 6 of the 7 access and outcome measures contained within Monitor’s Risk Assessment Framework. Although one indicator (KPI 4 – % admissions Gatekept) was marginally below the threshold (93.8% v 95%) this indicator was met for quarter four year to date, and performance will also increase once final data validation checks have been competed. Performance on KPI 2 (CPA – 12 month formal review) was also maintained across the Trust as a whole, although performance in Mid Area continues to marginally lag below the other Areas. There are no areas of concerns with any other Monitor Access and Outcomes Measures Other KPIs The number of other KPIs routinely reported to the Board has been expanded to include elements of all main contracts, including S75, Suffolk Health Outreach and GP Services. KPIs 8-12 relate to the Trust’s main contract, and where a threshold has been set (KPI 8 and 11) improvements continue to be made. In respect of KPI 8 – Carers Assessments Accepted the Trust is now exceeding the threshold with very strong performance in North East and West, and improved performance from Mid. In respect of KPI 11 (ICD Diagnosis on

154

Discharge) the threshold was marginally missed in February (94.9% v 95%), and further continues in Mid to bring their level of performance upto the same level as the rest of the Trust. KPIs 13-15 cover the Section 75 agreement with Essex County Council, Services for Vulnerable and Marginalised Adults in Suffolk and GP services respectively and trend data will be developed over the coming months. There are no specific areas of concern. Contractual Targets with concerns This section of the report summarises those contractual KPIs where commissioners had previously raised formal Contract Queries and/or Notices and which had the potential for a financial consequence if performance is not improved. All of the formal Contract Queries and/or Notices have now been closed by commissioners following improvement in performance by the Trust over the Summer/Autumn period. Overall this performance has been maintained albeit with some marginal dips in performance on some indicators each month (for example KPI 19 performance was 94.5% in February), although these are proactively managed by the Area Performance Managers and there have been no sustained under-performance on any indicator. Now that performance on these contractual KPIs has been stablilsed, the focus of the Performance Team is now on supporting Areas in meeting thresholds associated with 2015/16 CQUIN schemes, particularly around smoking and physical healthcare checks. Finance Implications: Financial plan – ensure costs contained despite rising activity. Potential loss of Commissioners’ reward monies if CQUIN quality / innovation targets not met or KPI with contractual penalties are not met. Clinical Implications: Actions are being taken to achieve improved standards in recording; this should deliver positive change to patient experience and access to services. HR Implications: N/A Legal Implications: Failure to meet the access and outcome targets in the RAF may trigger a “governance concern” by Monitor; which could potentially lead to an initial investigation and/or enforcement action re Trust’s Licence. Legal and/or Regulatory Implications: N/A Risks: N/A

155

NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST down = i same = 1 colours will change automatically

BOARD REPORT DASHBOARD up = #down = i

Indicator Target Mid North East West C&YP Feb-16 Quarterly to Date Performance Trend/Commentary

1

Care Programme Approach

(CPA) patients receiving

follow-up contact within 7

days of discharge

95% % Followed-up within 7 Days 96.9% 96.3% 100.0% 100.0% 97.3% 98.6%

i

2

Care Programme Approach

(CPA) patients receiving a

formal review within 12

months

95% % Reviewed within 12 months 94.7% 96.6% 94.5% 95.4% 95.4%

i

3Minimising delayed transfers

of care

Less than or

equal to 7.5%0.0% 0.0% 5.1% 0.0% 1.4% 1.6%

#

4

Admissions to inpatients

services had access to crisis

resolution home treatment

Teams

95% % Gatekept 83.3% 94.5% 100.0% 93.8% 98.2%

i

5

Meeting commitment to

serve new psychosis cases

by early intervention teams

95% 66.7% 333.3% 0.0% 139.8% 122.3%

#Overall 99.5% 99.6% 99.5% 99.5% 99.5%

NHS Number 98.9% 99.3% 98.4% 98.9% 98.9%

Date of Birth 100.0% 100.0% 100.0% 100.0% 100.0%

Postcode 99.1% 99.1% 99.5% 99.2% 99.2%

Gender 100.0% 100.0% 100.0% 100.0% 100.0%

GP Practice 99.4% 99.3% 99.7% 99.5% 99.5%

Overall 82.3% 86.7% 86.6% 85.0% 85.0%

Accommodation 81.5% 85.9% 91.7% 86.0% 86.0%

Employment 77.2% 76.8% 84.6% 79.3% 79.3%

HoNOS in past 12 Months 85.4% 91.7% 84.4% 87.5% 86.4%

#7

Data completeness –

outcomes (aggregate)50%

A.

Mo

nito

r C

om

plia

nce

Fra

me

wo

rk

6Data completeness –

identifiers (aggregate)97%

#

90%

95%

100%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2014/15 % 2015/16 % Target

0

10

20

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

EIP 2014/15 EIP 2015/16 EIP Target

95%

96%

97%

98%

99%

100%


2014/15 % 2015/16 % Target

40%

60%

80%

100%


2014/15 % 2015/16 % Target

0%

5%

10%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar% 2014-15 % 2015-16 DToC Target

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2014/15 Valid 2015/16 Valid Target

50.0%60.0%70.0%80.0%90.0%

100.0%


2014/15 Gatekeeping 2015/16 Gatekeeping Target

156




A.

Mo

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Fra

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100%

8Carers Assessments

Completed75%

Percentage of carers who have been

offered an assessments and

subsequently accepted

68.8% 100.0% 86.1% 82.0% 79.9%

#Adults of working age 79.2% 110.4% 103.9% 98.7% 98.7%

Older Adults 104.3% 95.6% 102.5% 100.5% 99.8%

PICU 83.2% 83.2% 82.1%

Low Secure 99.0% 99.0% 97.6%

Adults of working age 85.3% 111.7% 104.4% 101.4% 101.2%

Older Adults 104.4% 97.0% 102.5% 101.0% 100.6%

PICU 84.5% 84.5% 83.1%

Low Secure 105.0% 105.0% 104.6%

10

Emergency Re-admissions

within 28 days of previous

discharge (Governor

selected KPI)

% Readmissions 3.0% 8.6% 6.1% 0.0% 6.4% 8.9%

11 ICD Diagnosis 95% At Inpatient Discharge 84.8% 97.5% 97.1% 100.0% 94.9% 95.7%

#

Active Clients in Month 4,567 4,974 3,348 14,404 14,404

MH Cluster Assigned 4,178 4,780 3,053 12,508 12,508

Valid Cluster Assigned 3,134 4,032 2,138 9,304 9,304

% Valid 75.0% 84.4% 70.0% 74.4% 74.4%

9iiInpatient Occupancy Rate,

incl Leave

9iInpatient Occupancy Rate,

excl Leave90%

B.

Oth

er

KP

Is

12 MH Clusters

#

TBA

40%

60%

80%

100%

120%


% 2014/15 % 2015/16 OBDS Target (excl Leave)

4%

10%

16%

22%


0%

20%

40%

60%

80%

100%


0%

20%

40%

60%

80%

100%


2014-15 2015-16 Target

157




A.

Mo

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100%

93% 18+ years assessment in 4 wks 7.7% 41.9% 78.3% 46.8% 54.9%

80%% Social Care Service Users in

receipt of a personal budget41.1% 27.5% 37.3% 32.6%

95% Review of Secion 117 93.2% 95.8% 97.5% 95.3%

111 per month Carers Assessments Completed 147.8% 131.7% 118.4% 133.9% 152.3%

90% Registered with GP and/or Dentist 91.0%

90% Ethnicity Recorded 97.2%

90% Accommodation Status 98.3%

95%Percentage of Service Users with a Care Plan 95.1%

Acorns 92.8%

Dilip Sabnis 93.9%

St Clements 92.8%

Note: KPI 8 (CCG set) measures the proportion of Carers who have been offered an assessment; KPI 13 (Essex CC set) measures the number of Carers who have accepted an Assessment

Little variance between months on these indicators, care

plan performance is now above target

Performance improved

Oth

er

KP

Is

% of maximum QOF points achieved

14 Health Outreach

13 Essex County Council

15 95%

158




A.

Mo

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Fra

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100%

Number of Assessments at

A&E or Hospital99 69 80 248 507

% Assessed within 4 hours 99.0% 100.0% 98.8% 99.2% 99.2%

17 Physical Healthcheck 35% % with healthcheck 45.2% 55.4% 57.8% 51.8% 51.8%

#

18 Care Plan Shared 95% % with a care plan shared 95.3% 96.6% 96.6% 96.1% 96.1%

#

19 Crisis Plan in Place 95%Number of patients with a

crisis plan91.4% 97.0% 95.9% 94.5% 94.5%

i

20 Ethnicity 90% % Valid Ethnicity Recorded 97.2% 97.2% 98.7% 93.4% 97.5% 97.5%

#

21 Section 117 Reviews 95%% with a formal review in 12

months93.2% 95.8% 97.5% 95.3% 95.3%

#22 DQUIP (Quarterly) Amber

23 SDIP (Quarterly) Green

C.

He

alth

Co

mm

issio

ne

rs K

PI's

16 Psychiatric Liaison 95%

10%

30%

50%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2014/15 Valid 2015/16 Valid Target

20%

40%

60%

80%

100%


2014/15 Valid 2015/16 Valid Target

25%

50%

75%

100%


Ethnicity 2014/15 Ethnicity 2015/16 Target

0%

20%

40%

60%

80%

100%



20%

40%

60%

80%

100%



159

North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 14b Date: 23 March 2016 Title of Report: Workforce Report Lead: Lisa Anastasiou, Director of Workforce & Development Subject, Purpose and Recommendation: The Board of Directors is asked to receive and note the attached workforce report which details key workforce indicators at 29 February 2016. Key points for noting are as follows: Staff Turnover Turnover has remained the same as last month at 12.7 % (9.5% excluding retirements). There are no notable changes in the trends from last month. Sickness Absence There has been an increase in sickness absence from 3.9% in Dec to 4.4% in January. However, the current rate is below the trust’s threshold of 4.5% and the year to date position of 4% is also below the threshold. This report includes details of long term absence as a percentage of overall absence by locality. Mandatory Training The overall compliance level for mandatory training is 82.6% an improvement on the January position and the highest compliance rate since July 2015. Work is currently underway to further streamline the training matrix, improve quality and accountability for compliance at all levels of the trust. Recommendations, including a requirement for exception reporting by managers if their team’s compliance falls below expected levels, have been presented to the Quality and Risk Committee for consideration. Courses with significantly lower than expected compliance levels are being targeted throughout March with direct emails to non-compliant staff, additional courses for face/face training – delivered on wards where viable and a screen saver campaign to remind staff. Appraisals The number of recorded appraisals is 80.1%. This is the highest level since February 2015 and a continuation of the incremental improvement evident since last August. The incremental improvements have coincided with the introduction of the IntraNep based managers portal, which provides comparative data across teams. The improvement this

160

month could also be attributed to a ‘February is Appraisal Month’ campaign that has been led by the workforce team. Vacancies and Recruitment The vacancy factor in February was 18.85% of full time equivalent posts (FTE’s), a slight improvement on last month’s overall position. The trust continues to face significant challenges in filling nursing roles particularly in the west and mid areas of the Trust. There are currently 114 FTE nursing vacancies across the Trust (19.05%). Given the pressures that vacancies inevitably place on our services, there are a number of key actions that have been implemented and are being implemented to improve our position. They include

- Earlier engagement with student nurses, namely recruiting newly qualified students to Band 5 nursing posts through with an offer of employment at the start of their course

- Greater efficiencies in interviewing through centralized recruitment led by senior nursing teams

- Dedicated manager overseeing recruitment with a focus on enhancing our recruitment campaigns e.g. job fairs presence as well as our online profile

- Review of international recruitment options - Review of incentive options

Bank and Agency Staff There has been an overall increase in the number of nursing shifts requested for both registered and unregistered cover, 4.8% more than in January. The biggest increase was in requests for unregistered shifts for which there were 412 more requests than last month. 96.4% of registered 95.4% of unregistered shifts requested were filled. Finance Implications: Sickness absence and vacancies has a direct impact on bank and agency staffing expenditure. Clinical Implications: N/A HR Implications: The workforce report provides an insight into the health and satisfaction of the workforce Legal and/or Regulatory Implications: Not applicable Equality Implications: N/A Risks: N/A

161

Board of Directors - Workforce

Reports

Summary Data - February 2016

162

2. Sickness v Long Term Sickness2i. Sickness v Long Term Sickness - By Area

5. PDR's (i)(ii) (iii)

7i. Course Training Compliance7ii. Course Training Compliance7iii. Course Compliance - Time Line8. Bank and Agency Fill Rates9. Employee Relations10. Vacancies

6. Trust Training Compliance

4i. Turnover


Workforce Performance Report 29th February 2016

3. Sickness Comparision

1. Sickness Absence (i)(ii)(iii)

4ii. Turnover - Rolling Year

163

Target Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

Sickness Absence * 4.5% 4.8% 4.2% 4.2% 4.0% 3.9% 3.5% 3.8% 4.3% 3.9% 4.3% 3.8% 3.9% 4.4% -

Turnover 10% 13.0% 13.3% 13.6% 14.4% 14.1% 13.7% 13.5% 13.3% 14.5% 13.4% 12.9% 12.7% 12.6% 12.6%

PDR's 90% 80.6% 80.4% 78.5% 77.9% 76.3% 73.8% 72.6% 70.5% 70.7% 71.7% 72.6% 74.2% 77.3% 80.1%

Training Compliance 90% 84.6% 84.5% 81.5% 81.9% 79.5% 81.8% 82.7% 82.3% 80.7% 81.0% 81.5% 82.0% 81.9% 82.6%

Bank and Agency Fill Rates

Registered - 94.00% 95.80% 97.25% 97.67% 98.04% 97.45% 96.98% 96.97% 98.24% 97.36% 96.71% 96.61% 98.02% 96.39%

Unregistered - 93.30% 92.60% 96.51% 96.16% 96.89% 97.04% 96.92% 96.62% 97.02% 95.31% 95.98% 95.31% 96.41% 95.39%

Workforce Performance Report 29th February 2016

Summary of Performance

Monthly Position

164

Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

Mid Essex Directorate 4.1% 3.4% 2.7% 3.0% 3.2% 2.6% 3.5% 4.9% 4.0% 4.0% 3.5% 3.7% 3.8% 3.6%

North East Essex Directorate 4.1% 3.6% 4.0% 3.4% 3.1% 3.5% 3.8% 4.0% 3.8% 3.9% 2.8% 2.9% 4.0% 3.6%

West Essex Directorate 5.8% 4.3% 4.8% 4.6% 5.0% 3.3% 3.6% 4.0% 4.0% 4.9% 5.3% 5.9% 6.4% 4.7%

Children & Young People Directorate 6.7% 6.6% 5.0% 4.1% 3.8% 4.1% 3.0% 3.2% 4.7% 6.1% 8.5% 6.6% 4.9% 4.6%

Corporate Directorate 4.0% 4.3% 4.2% 6.0% 5.8% 5.4% 4.6% 4.6% 3.2% 3.2% 2.4% 2.1% 2.6% 4.0%

Director of Operations & Nursing Directorate 8.1% 5.7% 11.4% 6.9% 8.0% 8.7% 8.1% 8.1% 6.2% 5.3% 4.7% 5.2% 6.9% 6.8%

BIS Directorate 2.8% 5.5% 5.5% 3.7% 3.5% 2.8% 4.7% 4.0% 4.3% 3.8% 4.0% 2.0% 3.6% 3.7%

Enable East Directorate 0.7% 0.0% 0.0% 0.0% 0.3% 0.0% 0.0% 0.3% 0.3% 0.4% 0.0% 10.5% 0.0% 1.0%

NEPFT Total 4.8% 4.2% 4.2% 4.0% 3.9% 3.5% 3.8% 4.3% 3.9% 4.3% 3.8% 3.9% 4.4% 4.0%

Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

Add Prof Scientific and Technic 4.9% 3.6% 4.0% 4.8% 5.1% 5.1% 3.6% 3.8% 2.7% 3.1% 2.4% 3.9% 4.6%Additional Clinical Services 6.4% 5.0% 5.1% 5.0% 3.8% 3.7% 4.0% 4.3% 4.8% 4.5% 3.8% 4.0% 4.5%Administrative and Clerical 4.9% 3.8% 4.7% 3.9% 4.0% 3.7% 4.7% 5.5% 4.4% 4.5% 4.2% 4.3% 5.2%Allied Health Professionals 1.5% 3.2% 4.3% 6.2% 4.4% 4.4% 2.0% 0.8% 2.5% 4.1% 2.2% 5.6% 7.0%Estates and Ancillary 5.2% 5.8% 6.2% 5.6% 4.7% 3.5% 4.6% 4.2% 4.0% 4.2% 3.9% 3.0% 3.0%Medical and Dental 1.4% 1.5% 0.3% 0.0% 1.3% 0.4% 0.0% 0.0% 0.5% 0.8% 0.9% 0.9% 0.9%Nursing and Midwifery Registered 4.6% 4.5% 3.7% 3.5% 4.0% 3.5% 3.9% 4.9% 4.4% 5.1% 4.8% 4.2% 4.6%NEPFT Total 4.8% 4.2% 4.2% 4.0% 3.9% 3.5% 3.8% 4.3% 3.9% 4.3% 3.8% 3.9% 4.4%

*Psychology Teams have now been moved into their individual areas

S98 Other known causes - not elsewhere classifiedS11 Back ProblemsS13 Cold, Cough, Flu - Influenza

Data Source: ESRExtract Date: 09/03/2016Contact: Lisa Fricker (01245 54) 3134 6474

1(i). Sickness Absence - Performance Threshold 4.5%

S10 Anxiety/stress/depression/other psychiatric illnesses

1(i). Sickness Absence by Directorate

1(iii). Top Five Sickness Absence Reasons

40.6%Percentage Lost

S99 Unknown causes / Not specified

Staff Group

Sickness Reason

YTD

5.8%

1(ii). Sickness Absence by Staff Group

15.5%

Directorate

5.2%

% FTE Days lost Feb-15 to Jan-16

6.5%

% FTE Days Lost in Month


165

NEPFT Total Long Term Sickness = One month or longer

Produced by: Lisa FrickerExtract Date: 09/03/2016Source: ESR

2. Sickness Days Lost in Month Compared to Long Term Sick days Lost in Month

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

Trust Wide

Long Term Sickness All Sickness Threshold

166

NEPFT Total Long Term Sickness = One month or longer

Produced by: Lisa FrickerExtract Date: 09/03/2016Source: ESR

2i. Sickness Days Lost in Month Compared to Long Term Sick days Lost in Month - By Area

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

Mid


0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%West


0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%C&Y People


0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%North East

Long Term Sickness All Sickness Target

167

Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

North Essex Partnership Foundation Trust 4.2% 4.2% 4.0% 3.9% 3.5% 3.8% 4.3% 3.9% 4.3% 3.8% 3.9% 2.9%

Cambridgeshire and Peterborough NHS Foundation Trust* 4.9% 4.6% 4.6% 4.7% 4.6% 4.6% 4.8% 4.7% 5.1% - - -

Norfolk and Suffolk NHS Foundation Trust* 5.4% 5.0% 4.8% 4.5% 4.4% 4.5% 4.9% 4.8% 5.0% - - -

Hertfordshire Partnership NHS Foundation Trust 4.7% 4.8% 4.1% 4.2% 4.8% 4.9% 4.5% 4.5% 4.8% - - -

South Essex Partnership University NHS Foundation Trust* 5.2% 5.3% 5.3% 4.8% 5.0% 4.8% 4.2% 4.6% 4.8% - - -

Mental Health and Learning Disability (England) 5.0% 5.0% 4.6% 4.5% 4.6% 4.6% 4.6% 4.7% 4.9% - - -

NHS England (Average all Trusts) 4.4% 4.2% 4.0% 3.9% 3.9% 4.0% 3.9% 4.0% 4.2% - - -

NHS England 2014-15 (All Trusts) 4.3%

Mental Health 2014-15 4.9%

*Source - Heath and Social Care Information Centre, last available data is October 2015

Please note: Sickness absence data is for the period 1st to 30th March due to the implementation of Journeys on the 31st March.



3. Sickness Comparision to Foundation Trusts in the Region

Staff Group

168

Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

Add Prof Scientific and Technic 2.6% 3.0% 1.7% 0.7% 2.4% 0.7% 1.7% 0.5% 1.2% 0.9% 0.5% 0.6% 16.7%Additional Clinical Services 1.3% 0.7% 0.9% 1.2% 1.1% 1.6% 1.2% 1.9% 0.3% 1.0% 0.2% 0.5% 10.4%Administrative and Clerical 2.7% 1.6% 1.0% 1.3% 1.2% 1.2% 1.1% 0.6% 0.5% 0.5% 0.9% 1.6% 12.7%Allied Health Professionals 3.5% - 1.3% - 1.5% - 1.7% 1.7% - - 2.4% - 10.2%Estates and Ancillary 1.3% - 1.6% - - - 0.6% 0.8% - 1.4% - 1.0% 6.5%Medical and Dental * 0.8% 2.3% - 1.5% 0.7% - 1.5% - - 2.1% - - 9.9%Nursing and Midwifery Registered 3.4% 1.6% 0.6% 0.7% 1.1% 0.6% 1.0% 2.2% 0.6% 0.9% 1.7% 0.8% 14.7%Total 2.6% 1.4% 0.9% 0.9% 1.2% 0.9% 1.2% 1.4% 0.5% 0.9% 1.0% 0.9% 12.6%

Rolling 12 months 13.6% 14.4% 14.1% 13.7% 13.5% 13.3% 14.5% 13.4% 12.9% 12.7% 12.6% 12.6%

Threshold 10.0%

Distance from threshold -2.6%

October turnover excludes employees TUPE'd to NELFT

Excludes medical rotation grades, trainee Psychologists

In Month % Calculation

Numerator : FTE of leavers in current monthDenominator : FTE of staff in post as at the end of the reporting month, plus number of leavers in month

Rolling 12 Month % Calculation

Numerator : FTE of leavers in previous 12 month periodDenominator : FTE of staff in post as at the end of the reporting month, plus number of leavers previous 12 month period


4i. Staff Turnover - Performance Threshold 10%

% Turnover Including retirements Rolling

YearStaff Group

169

Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

300 Mid Essex Directorate 10.2% 10.7% 12.7% 12.7% 12.1% 12.1% 11.3% 10.2% 10.2% 10.1% 10.4% 11.6% 11.9%300 North East Essex Directorate 15.0% 11.9% 12.2% 11.3% 10.5% 10.9% 8.9% 12.0% 10.8% 10.6% 9.7% 9.5% 8.8%300 West Essex Directorate 15.3% 17.6% 18.0% 18.0% 17.7% 16.0% 17.3% 20.3% 16.5% 15.1% 15.2% 15.5% 15.6%300 Children & Young People Directorate 13.7% 15.0% 16.1% 15.7% 16.5% 16.8% 17.4% 20.0% 26.7% 28.2% 28.0% 25.1% 25.3%300 Corporate Directorate 16.3% 15.3% 15.7% 15.0% 14.1% 14.7% 14.9% 12.8% 11.9% 10.6% 10.9% 9.9% 10.2%300 Director of Operations & Nursing Directorate 4.7% 11.4% 14.0% 16.4% 18.9% 19.4% 18.7% 18.7% 17.7% 17.5% 17.9% 17.7% 19.2%300 Business Information Systems Directorate 9.2% 10.2% 10.9% 10.3% 10.5% 11.7% 11.7% 11.8% 10.6% 9.6% 9.6% 6.5% 7.8%300 Enable East Directorate 7.1% 18.8% 21.4% 15.4% 15.4% 15.4% 23.1% 23.1% 33.3% 33.3% 33.3% 33.3% 41.7%Trust Total 13.3% 13.6% 14.4% 14.1% 13.7% 13.5% 13.3% 14.5% 13.4% 12.9% 12.7% 12.6% 12.6%

Trust Total Excluding Retirements 9.9% 10.7% 13.5% 10.8% 10.3% 9.9% 9.6% 11.2% 9.8% 9.5% 9.5% 9.7% 9.7%

October turnover excludes employees TUPE'd to NELFT


4ii. Staff Turnover - Rolling Year

Performance Threshold 10%

Directorate% Turnover Including Retirements

170


Add Prof Scientific and Technic 73.2% 70.3% 69.0% 69.7% 68.2% 67.3% 67.6% 64.8% 69.7% 69.7% 70.8% 73.2%Additional Clinical Services 79.5% 78.5% 76.4% 75.5% 70.8% 70.3% 70.9% 73.7% 73.2% 76.5% 77.0% 79.6%Administrative and Clerical 79.0% 79.0% 80.2% 81.2% 78.5% 74.1% 75.3% 73.7% 73.7% 76.3% 81.9% 83.4%Allied Health Professionals 71.4% 69.4% 70.5% 70.5% 65.6% 65.6% 61.3% 65.1% 65.6% 64.1% 63.5% 66.1%Estates and Ancillary 91.8% 92.9% 91.8% 88.9% 86.5% 80.0% 81.0% 72.0% 79.5% 83.7% 84.0% 84.6%Medical and Dental 81.8% 80.4% 70.1% 30.9% 77.9% 80.6% 80.6% 94.1% 94.2% 94.1% 94.0% 94.2%Nursing and Midwifery Registered 77.0% 76.7% 74.5% 73.8% 67.8% 66.0% 65.4% 67.7% 67.3% 67.7% 72.7% 77.7%NEPFT Total 78.5% 77.9% 76.3% 73.8% 72.6% 70.5% 70.7% 71.7% 72.6% 74.2% 77.3% 80.1%


Mid Essex Directorate 77.1% 75.8% 73.4% 71.5% 72.3% 69.1% 68.0% 71.1% 72.2% 73.7% 79.0% 82.9%North East Essex Directorate 80.7% 80.7% 78.6% 75.1% 69.3% 65.4% 65.8% 65.5% 68.8% 71.7% 73.0% 77.6%West Essex Directorate 77.7% 75.9% 75.2% 70.6% 70.7% 71.5% 70.5% 70.6% 71.7% 73.3% 78.1% 79.9%Children & Young People Directorate 75.3% 74.1% 74.1% 72.2% 75.5% 75.8% 76.0% 85.7% 74.7% 76.0% 73.6% 67.6%Corporate Directorate 80.4% 82.4% 79.1% 81.7% 80.1% 76.4% 81.3% 85.5% 86.3% 84.4% 85.4% 86.5%Director of Operations & Nursing Directorate 61.5% 61.5% 52.8% 62.9% 70.6% 78.8% 78.1% 68.8% 71.9% 69.7% 80.6% 84.4%BIS Directorate 86.3% 87.7% 90.4% 84.0% 80.5% 79.2% 77.6% 76.3% 71.1% 77.6% 77.0% 75.7%Enable East Directorate 100.0% 90.9% 100.0% 81.8% 81.8% 70.0% 88.9% 75.0% 75.0% 62.5% 62.5% 85.7%NEPFT Total 78.5% 77.9% 76.3% 73.8% 72.6% 70.5% 70.7% 71.7% 72.6% 74.2% 77.3% 80.1%

*Psychology Teams have now been moved into their individual areas

Headcount

PDR's Due

Headcount

Invalid

Invalid 0-1

month

Invalid 2-6

months

Invalid 6-12

months

Invalid over

12 months

No PDR

recorded

% PDR's

Invalid

123 33 1 15 7 1 9 26.8%

324 66 10 25 9 6 16 20.4%

362 60 8 30 14 2 6 16.6%

62 21 3 8 5 3 2 33.9%

123 19 - 13 3 - 3 15.4%

86 5 - - 2 1 2 5.8%

479 107 15 50 25 5 12 22.3%

1,559 311 37 141 65 18 50 19.9%

Headcount

PDR's Due

Headcount

Invalid

Invalid 0-1

month

Invalid 2-6

months

Invalid 6-12

months

Invalid over

12 months

No PDR

recorded

% PDR's

Invalid

665 165 15 75 35 13 27 24.8%469 88 18 41 11 4 14 18.8%

Data Source: ESRExtract Date: 08/03/2016Compiled by: Lisa Fricker, Information AnalystContact: 01245 546 474, Email: [email protected]

Note: Staff with less than 12 months service are not included. Training Grade Doctors are now included.

5iii. PDRs not compliant

DirectoratePercentage Compliant

Staff Group

Estates and Ancillary

Add Prof Scientific and TechnicAdditional Clinical Services

Nursing and Midwifery Registered

Administrative and ClericalAllied Health Professionals

Medical and Dental

Feb-16

Community TeamsInpatient Teams

Team Type

Feb-16

5i. PDRs Compliant

5ii. PDRs by Directorate

Staff GroupPercentage Compliant

Trust Total

171

Required Achieved

Compliance

%

44,183 36,487 82.58%

Staff Group

Assignment

Count Required Achieved

Compliance

%

Add Prof Scientific and Technic 129 3,139 2,673 85.15%

Additional Clinical Services 382 10,860 8,999 82.86%

Administrative and Clerical 430 7,927 6,719 84.76%

Allied Health Professionals 73 2,030 1,760 86.70%

Estates and Ancillary 139 2,577 2,018 78.31%

Medical and Dental 118 3,153 2,150 68.19%

Nursing and Midwifery Registered 516 14,497 12,168 83.93%

The above table includes Prevent and excludes Safeguarding Supervision

Excludes employees on a career break, external secondment, maternity leave and long term sickness greater than one year

Data Source: ESRExtract Date: 09/10/2016Contact: Lisa Fricker (01245 54) 3134 6474)

6. Overall Trust Training Compliance - Performance Threshold 90%

Assignment Count

1,787

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Add Prof Scientificand Technic

Additional ClinicalServices

Administrative andClerical

Allied HealthProfessionals

Estates andAncillary

Medical andDental

Nursing andMidwiferyRegistered

Co

mp

lia

nce

Staff Group

172

Display Screen Equipment (DSE) (e-Learning) 385 90.59% 40 9.41% 385 90.59% 40 9.41%

Equality and Diversity eLearning, including Harassment & Bullying (e-Learning) 1,586 88.80% 200 11.20% 1,501 88.55% 194 11.45%

Fire Safety Awareness (Classroom) 1,386 78.75% 374 21.25% 1,318 78.97% 351 21.03%

Food Safety - CIEHH approved (e-Learning) 370 71.15% 150 28.85% 370 71.15% 150 28.85%

Health and Safety Training for Managers - Risk Assessment including Slips, Trips and Falls Prevention (staff and others) and Major Incident Training (Classroom) 116 78.91% 31 21.09% 116 78.91% 31 21.09%

Manual Handling Awareness (e-Learning) 880 73.76% 313 26.24% 858 75.59% 277 24.41%

Manual Handling including Falls Prevention - Patient Handlers only (Classroom) 311 71.17% 126 28.83% 311 71.17% 126 28.83%

Prevent (Classroom & e-Learning) 1,098 61.72% 681 38.28% 1,060 62.80% 628 37.20%

Basic Life Support 815 45.79% 965 54.21% 769 45.53% 920 54.47%

Care and Clinical Risk, including Dual Diagnosis and Mental Health Care Clustering (Classroom) 961 80.42% 234 19.58% 922 83.51% 182 16.49%

Personal Safety (Face to Face) 166 9.29% 1,620 90.71% 144 8.50% 1,551 91.50%

Including Ethical Care - Breakaway includes Basic Life Support (Classroom) - 83.93% - 16.07% - 83.78% - 16.22%

Therapeutic and Safe Interventions (TASI) Classroom 70 17.07% 340 82.93% 70 17.07% 340 82.93%

Including Ethical Care - Control and Restraint, including Basic Life Support, Rapid Tranquilisation, and Inpatient Observation (Classroom) - 90.98% - 9.02% - 90.98% - 9.02%

Infection Control: Infection Prevention and You (e-Learning) 421 74.51% 144 25.49% 421 74.51% 144 25.49%

Infection Control: Principles of Infection Prevention (e-Learning) 586 48.27% 628 51.73% 551 49.07% 572 50.93%

Infection Prevention & Control - Hand Hygiene, including Inoculation Incident Training (Classroom & e-Learning) 1,396 78.60% 380 21.40% 1,325 78.64% 360 21.36%

Introduction to Information Governance (Classroom) 1,628 91.15% 158 8.85% 1,556 91.80% 139 8.20%

Information Governance: The Refresher Module (e-Learning) 1,288 72.12% 498 27.88% 1,242 73.27% 453 26.73%

Making Experiences Count, including Incident Reporting, Complaints and Claims and Record Keeping Standards (e-Learning) 918 79.83% 232 20.17% 884 83.47% 175 16.53%

Mental Health Act 1983 Practical Application (e-Learning) 574 89.13% 70 10.87% 574 89.27% 69 10.73%

Rapid Tranquilisation (Classroom) 412 85.48% 70 14.52% 380 89.62% 44 10.38%

Remedy (Classroom) 1,148 91.33% 109 8.67% 1,069 91.68% 97 8.32%

Risk Awareness (Classroom) 4 66.67% 2 33.33% 4 66.67% 2 33.33%

Safeguarding Adults and Children Level 1 including Learning Disability and Autism (e-Learning) 1,684 94.29% 102 5.71% 1,610 94.99% 85 5.01%

Safeguarding Adults and Children Level 2 (e-Learning) 1,031 86.20% 165 13.80% 983 88.96% 122 11.04%

Safeguarding Adults and Children Level 3 including Learning Disability and Autism (Classroom) 867 72.55% 328 27.45% 832 75.36% 272 24.64%

Safeguarding Children Level 4 including Learning Disability and Autism (Classroom) 66 81.48% 15 18.52% 65 81.25% 15 18.75%

**Excludes Trainees - Excludes the Junior Doctors and Trainee Psychologists

Excludes employees on a career break, external secondment, maternity leave and long term sickness greater than one year


Infection Control: The lower than average compliance can be explained through the removal of the Principles of Infection Prevention (e-Learning) course following changes in Skills for Health. The Infection Control team developed a

new course also know as Principles of Infection Prevention (e-Learning), this has now been rolled out and significant improvement is expected over the next few months.

The roll out of the new TASI and Personal Safety training (which replaced the old style ECCR Breakaway and Control and Restraint) began in December 2015 with new starters/bank staff and in February 2016 for substantive staff. Given

that the roll out is in its infancy, to date, just under 10% of staff have trained in the new style Personal Safety course. The above and total compliance figure reported, reflects the current compliance for both courses with the new

refresher period of within 2 years applied. Whilst the whole inpatient workforce will be retrained in the new TASI programme, a RAG rating has been applied and staff currently non-compliant in the old style training have been prioritised.

7i. Course Training Compliance - Performance Threshold 90%

Meets

Requirement

Does not meet

requirement

Includes Trainees **Excludes TraineesCourse Name

Meets

Requirement

Does not meet

requirement

Statutory

Mandatory

173

Course Name Competence Name

Display Screen Equipment (DSE) (e-Learning) 300|LOCAL|Display Screen Equipment (DSE) - eLearning| 385 90.59% 40 9.41%

Equality and Diversity eLearning, including Harassment & Bullying (e-Learning) 300|LOCAL|Equality and Diversity eLearning| 1,586 88.80% 200 11.20%

Fire Safety Awareness (Classroom) 300|LOCAL|Fire Safety Awareness - 2 Yearly| 643 84.49% 118 15.51%

300|LOCAL|Fire Safety Awareness - Annually| 753 74.48% 258 25.52%

Food Safety - CIEHH approved (e-Learning) 300|LOCAL|CIEH Level 2 Award in Food Safety in Catering| 370 71.15% 150 28.85%

Health and Safety Training for Managers - Risk Assessment including Slips, Trips and Falls

Prevention (staff and others) and Major Incident Training (Classroom)

300|LOCAL|Health and Safety Training for Managers including risk assessment| 124 84.35% 23 15.65%

300|LOCAL|Major Incident Training| 117 79.59% 30 20.41%

Manual Handling Awareness (e-Learning) NHS|MAND|Moving & Handling for Inanimate Load Handlers - 2 Years| 68 48.92% 71 51.08%

NHS|MAND|Moving & Handling for Inanimate Load Handlers - 3 Years| 906 76.52% 278 23.48%

Manual Handling including Falls Prevention - Patient Handlers only (Classroom) NHS|MAND|Moving & Handling for People Handlers - 2 Years| 311 71.17% 126 28.83%

300|LOCAL|Prevent Classroom 3 Year| 750 61.68% 466 38.32%

300|LOCAL|Prevent eLearning 3 Year| 348 61.81% 215 38.19%

Basic Life Support (Classroom) 300|LOCAL|Basic Life Support| 815 45.79% 965 54.21%

Care and Clinical Risk, including Dual Diagnosis and Mental Health Care Clustering

(Classroom)

300|LOCAL|CPA and Clinical Risk Management| 981 82.09% 214 17.91%

300|LOCAL|Dual Diagnosis| 1,009 84.72% 182 15.28%

300|LOCAL|Mental Health Care Clustering| 624 79.29% 163 20.71%

Personal Safety (Classroom)* 300|LOCAL|Personal Safety - Practical| 166 9.29% 1,620 90.71%

300|LOCAL|Personal Safety - Theory| 166 9.29% 1,620 90.71%

Therapeutic and Safe Interventions (TASI) Classroom* 300|LOCAL|TASI - Full| 67 16.46% 340 83.54%

300|LOCAL|TASI - Refresher| 67 16.46% 340 83.54%

Infection Control: Infection Prevention and You (e-Learning) NHS|MAND|Infection Control - Level 1 - 3 Years| 421 74.51% 144 25.49%

Infection Control: Principles of Infection Prevention (e-Learning) NHS|MAND|Infection Control - Level 2 - 2 Years| 586 48.27% 628 51.73%

Infection Prevention & Control - Hand Hygiene, including Inoculation Incident Training

(Classroom & e-Learning)

300|LOCAL|Infection Prevention & Control - Hand Hygiene - Annually| 850 71.07% 346 28.93%

300|LOCAL|Infection Prevention & Control - Hand Hygiene - One Off| 555 94.07% 35 5.93%

Introduction to Information Governance: One Off (Classroom) 300|LOCAL|Information Governance elearning - One Off| 1,288 72.12% 498 27.88%

Information Governance: The Refresher Module (e-Learning) NHS|MAND|Information Governance - 1 Year| 1,628 91.15% 158 8.85%

Making Experiences Count, including Incident Reporting, Complaints and Claims and Record

Keeping Standards (e-Learning)

300|LOCAL|Making Experiences Count, including Incident Reporting, Complaints and Claims

and Record Keeping Standards|

918 79.83% 232 20.17%

Mental Health Act 1983 Practical Application (e-Learning) 300|LOCAL|Mental Health Act 1983 Practical Application - eLearning| 574 89.13% 70 10.87%

Rapid Tranquilisation (Classroom) 300|LOCAL|Rapid Tranquillisation - 3 Yearly| 412 85.48% 70 14.52%

Remedy (Classroom) 300|LOCAL|Remedy IT Training| 1,148 91.33% 109 8.67%

Meets Requirement Does not meet

requirement

7ii. Course Training Compliance - Performance Threshold 90%

Prevent (Classroom & e-Learning)

Mandatory

Statutory

174

Course Name Competence Name Meets Requirement Does not meet

requirement

7ii. Course Training Compliance - Performance Threshold 90%

Risk Awareness (Classroom) 300|LOCAL|Risk Awareness - Annual| 4 66.67% 2 33.33%

Safeguarding Adults and Children Level 1 including Learning Disability and Autism (e-

Learning)

300|LOCAL|Autism| 1,693 94.79% 93 5.21%

300|LOCAL|Learning Disabilities Foundation Level - eLearning/classroom| 1,728 96.75% 58 3.25%

NHS|MAND|Safeguarding Adults Level 1 - 3 Years| 1,728 96.75% 58 3.25%

NHS|MAND|Safeguarding Children Level 1 - 3 Years| 1,731 96.92% 55 3.08%

Safeguarding Adults and Children Level 2 (e-Learning) 300|LOCAL|Autism| 1,138 95.15% 58 4.85%






Safeguarding Adults and Children Level 3 including Learning Disability and Autism

(Classroom)

300|LOCAL|Autism| 1,137 95.15% 58 4.85%




NHS|MAND|Safeguarding Adults Level 3 - 3 Years| 953 79.75% 242 20.25%



NHS|MAND|Safeguarding Children Level 3 - 3 Years| 927 77.57% 268 22.43%

Safeguarding Children Level 4 including Learning Disability and Autism (Classroom) 300|LOCAL|Autism| 80 98.77% 1 1.23%

300|LOCAL|Learning Disabilities Foundation Level - eLearning/classroom| 80 98.77% 1 1.23%

300|LOCAL|Safeguarding Children Level 4 - 3 Year| 66 81.48% 15 18.52%




*Please see details re: old ECCR compliance on 7i. Course Training ComplianceExcludes employees on a career break, external secondment, maternity leave and long term sickness greater than one year


175

Course Name


Personal Safety (Face to Face) (Including Breakaway includes Basic Life Support (Classroom))* 68.23% 68.64% 68.48% 71.51% 70.52% 68.34% 65.09% 83.79% 85.26% 84.30% 83.89% 83.93%

Therapeutic and Safe Interventions (TASI) Classroom (Including ECCR)* 65.39% 69.32% 52.17% 70.85% 68.84% 68.76% 63.84% 67.08% 65.35% 61.81% 63.55% 90.98%

Fire Safety Awareness (Classroom) 70.94% 70.42% 71.65% 75.25% 80.41% 78.72% 78.47% 75.47% 75.79% 79.41% 79.05% 78.75%

Health and Safety Training for Managers - Risk Assessment including Slips, Trips and Falls Prevention (staff and others) and Major Incident Training (Classroom) 73.86% 68.28% 68.24% 68.24% 75.16% 74.83% 74.17% 72.85% 79.47% 78.67% 79.73% 78.91%

Information Governance elearning - One Off (Classroom) 89.98% 89.91% 90.30% 91.22% 91.99% 90.71% 89.24% 89.99% 91.15% 91.91% 91.86% 91.15%

Information Governance: The Refresher Module (e-Learning) 30.01% 40.93% 44.04% 50.00% 57.41% 59.32% 59.68% 65.27% 68.46% 71.54% 73.42% 72.12%

Safeguarding Adults and Children Level 1 including Learning Disability and Autism (e-Learning) 94.91% 94.49% 94.68% 95.80% 96.21% 95.98% 94.43% 94.91% 95.52% 96.43% 96.36% 94.29%

Safeguarding Adults and Children Level 2 (e-Learning) 89.57% 90.19% 89.92% 90.49% 90.97% 89.25% 87.32% 86.62% 87.33% 88.24% 88.81% 86.20%

Safeguarding Adults and Children Level 3 including Learning Disability and Autism (Classroom) 78.75% 79.23% 78.93% 81.31% 83.76% 81.51% 79.32% 75.95% 73.82% 74.79% 75.85% 72.55%

Safeguarding Children Level 4 including Learning Disability and Autism (Classroom) 73.81% 72.46% 81.16% 81.75% 81.62% 80.45% 82.48% 77.38% 75.90% 76.83% 73.17% 81.48%

*Please see details re: old ECCR compliance on 7i. Course Training ComplianceExcludes employees on a career break, external secondment, maternity leave and long term sickness greater than one year

Data Source: ESR09/03/2016Contact: Lisa Fricker (01245 54) 3134 6474)

7iii. Course Training Compliance - Performance Threshold 90%

Percentage Compliant

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%


Training Compliance Time Line Mar 15 - Feb 16

Safeguarding Adults and Children Level 1 including Learning Disability and Autism (e-Learning) Safeguarding Adults and Children Level 2 (e-Learning)

Safeguarding Adults and Children Level 3 including Learning Disability and Autism (Classroom) Safeguarding Children Level 4 including Learning Disability and Autism (Classroom)

176

Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 YTD

Shifts Requested 2,003 1,674 1,578 1,764 1,919 2,048 1,880 1,894 1,609 1,683 1,873 1,996 21,921

Shifts Not Filled 55 39 31 45 58 62 33 50 53 57 37 72 592

Filled by Bank 1,499 1,252 1,212 1,171 1,263 1,288 1,203 1,196 1,175 1,171 1,287 1,339 15,056

Filled by Agency 449 383 335 548 598 698 644 648 381 455 549 585 6,273

Total Filled 1,948 1,635 1,547 1,719 1,861 1,986 1,847 1,844 1,556 1,626 1,836 1,924 21,329

Filled by Bank % 74.8% 74.8% 76.8% 66.4% 65.8% 62.9% 64.0% 63.1% 73.0% 69.6% 68.7% 67.1% 68.7%

Filled by Agency % 22.4% 22.9% 21.2% 31.1% 31.2% 34.1% 34.3% 34.2% 23.7% 27.0% 29.3% 29.3% 28.6%

Total filled % 97.3% 97.7% 98.0% 97.4% 97.0% 97.0% 98.2% 97.4% 96.7% 96.6% 98.0% 96.4% 97.3%

Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 YTD

Shifts Requested 3,786 3,409 3,503 3,446 3,443 3,673 3,257 3,260 2,689 2,732 2,756 3,168 39,122

Shifts Not Filled 132 131 109 102 106 124 97 153 108 128 99 146 1,435

Filled by Bank 3,370 3,001 3,032 2,838 2,766 2,814 2,490 2,575 2,300 2,305 2,458 2,697 32,646

Filled by Agency 284 277 362 506 571 735 670 532 281 299 199 325 5,041

Total Filled 3,654 3,278 3,394 3,344 3,337 3,549 3,160 3,107 2,581 2,604 2,657 3,022 37,687

Filled by Bank % 89.0% 88.0% 86.6% 82.4% 80.3% 76.6% 76.5% 79.0% 85.5% 84.4% 89.2% 85.1% 83.4%

Filled by Agency % 7.5% 8.1% 10.3% 14.7% 16.6% 20.0% 20.6% 16.3% 10.4% 10.9% 7.2% 10.3% 12.9%

Total filled % 96.5% 96.2% 96.9% 97.0% 96.9% 96.6% 97.0% 95.3% 96.0% 95.3% 96.4% 95.4% 96.3%

Source: Manual (NETSS)Contact: Lisa Fricker (01245 546497)Report Date: 09/03/2016

8. Bank and Agency Usage

Month

Registered

Shifts

Month

Unregistered

Shifts

Kitwood Ward requested 315 shifts, 6.10% of total shiftsStort Ward requested 305 shifts, 5.91% of total shifts

During February 5,164 shifts were requested this is an increase of 4.8% compared to January. 78.2% of shifts requested were filled by bank staff (combined qualified and unqualified) and 17.6% of shifts requested were filled by preferred agency, this is a 1.4% increase in agency usage compared to the previous month. 218 shifts were unfilled a total of 4.2% in February the unfilled rate in January was also 4.2%.

Of the 5,164 shifts requested during February these are the top five wards with the highest number of requests:-

Brian Roycroft requested 461 shifts, 8.93% of total shiftsEdward House requested 435 shifts, 8.42% of total shiftsGalleywood requested 319 shifts, 6.18% of total shifts

177

Disciplinary Grievance

Gender Male 3 -

Female 1 -

No 1 -

Not Declared - -

Undefined 3 -

Atheism - -

Christianity - -

Other - -

I do not wish to disclose my religion/belief 1 -

Undefined 3 -

Heterosexual - -

I do not wish to disclose my sexual orientation - -

Undefined 3 -

Marital Status Divorced 1 -

Married 1 -

Single 2 -

Legally Separated - -

Age Band 41-45 1 -

51-55 2 -

56-60 - -

61-65 1 -

Ethnic Category A White - British - 3

N Black or Black British - African - 1

Assignment Status Maternity Leave - -

Total Open Cases 4 -

Jan-16 3 -

Note: Gender Re-assignment is not currently a recording option on ESR, we can confirm no current cases are protected under

this characteristic.

Source: ESRContact: Lisa Fricker (01245 546474)Report Date: 10/03/2016

Sexual Orientation

9. Employee Relations by Protected Characteristic

Open cases February 2016

Protected Characteristic

Disabled

Religious Belief

178

DirectorateFTE

Variance

Vacancy

Percentage

FTE

Variance

Vacancy

Percentage

FTE

Variance

Vacancy

Percentage

FTE

Variance

Vacancy

Percentage

FTE

Variance

Vacancy

Percentage

FTE

Variance

Vacancy

Percentage

FTE

Variance

Vacancy

Percentage

300 Mid Essex Directorate -118.45 -22.47% -110.54 -20.93% -112.34 -21.36% -110.64 -21.01% -112.94 -21.37% -118.44 -22.41% -116.15 -21.98%

300 North East Essex Directorate -60.58 -11.35% -60.58 -11.36% -61.15 -11.44% -56.53 -10.55% -55.83 -10.42% -60.87 -11.31% -62.18 -11.49%

300 West Essex Directorate -118.05 -24.85% -117.70 -24.99% -120.03 -25.21% -138.11 -27.91% -133.90 -27.06% -116.39 -24.58% -115.73 -24.55%

300 Children & Young People Directorate -40.25 -21.63% -38.95 -20.93% -6.84 -8.58% -11.31 -13.44% -10.76 -12.87% -13.76 -16.46% -13.83 -16.74%

300 Corporate Directorate -33.63 -17.49% -32.10 -16.71% -25.11 -13.07% -26.76 -13.74% -26.66 -13.57% -32.55 -16.30% -30.24 -15.32%

300 Director of Operations & Nursing Directorate -8.50 -20.27% -8.50 -19.80% -9.10 -20.91% -10.10 -22.68% -10.75 -23.80% -12.27 -26.57% -9.41 -21.31%

300 Business Information Systems Directorate -15.16 -17.04% -16.38 -18.40% -18.68 -20.38% -15.93 -18.00% -15.93 -18.00% -18.93 -20.92% -18.93 -21.15%

300 Enable East Directorate -3.00 -23.08% -4.00 -30.77% -5.00 -38.46% -5.00 -38.46% -5.00 -38.46% -5.00 -38.46% -4.00 -36.36%

NEPFT Total -397.62 -19.32% -388.75 -18.91% -358.24 -18.31% -374.38 -18.89% -371.77 -18.72% -378.21 -19.17% -370.48 -18.85%

Staff GroupFTE

Variance

Vacancy

Percentage

FTE

Variance

Vacancy

Percentage

FTE

Variance

Vacancy

Percentage

FTE

Variance

Vacancy

Percentage

FTE

Variance

Vacancy

Percentage

FTE

Variance

Vacancy

Percentage

FTE

Variance

Vacancy

Percentage

Add Prof Scientific and Technic -41.66 -23.68% -42.97 -24.35% -39.69 -25.98% -49.44 -30.52% -49.44 -30.33% -50.58 -30.67% -39.31 -25.49%

Additional Clinical Services -88.56 -21.12% -81.36 -19.40% -83.63 -20.29% -78.99 -18.96% -74.84 -17.83% -63.04 -15.33% -69.18 -16.65%

Administrative and Clerical -77.34 -17.10% -77.09 -17.01% -55.94 -13.04% -59.68 -13.75% -62.12 -14.25% -68.22 -15.44% -71.03 -16.08%

Allied Health Professionals -13.27 -17.67% -14.85 -19.78% -12.48 -16.99% -14.67 -19.39% -13.67 -18.07% -12.78 -16.98% -13.82 -18.18%

Estates and Ancillary -39.37 -28.45% -39.88 -28.82% -42.11 -30.46% -39.33 -28.46% -40.53 -29.32% -42.08 -30.44% -42.09 -30.45%

Medical and Dental -20.89 -14.12% -18.94 -13.06% -16.70 -12.31% -19.70 -14.21% -19.86 -14.20% -30.87 -22.08% -20.76 -14.85%

Nursing and Midwifery Registered -116.52 -17.96% -113.65 -17.54% -107.69 -17.51% -112.55 -18.24% -111.30 -18.15% -110.64 -18.39% -114.28 -19.05%

NEPFT Total -397.62 -19.32% -388.75 -18.91% -358.24 -18.31% -374.38 -18.89% -371.77 -18.72% -378.21 -19.17% -370.48 -18.85%

Leavers in month 13.97 19.12 21.56 7.40 10.96 12.92 13.47

Shannon House establishment of 23.33 FTE excluded from January 2016.

October onwards exclude the CAMHS staff TUPE'd to NELFT

Data Source: (ESR)Extract Date: 08/03/2016Contact: Lisa Fricker (01245 54) 3134 6474)

10. Vacancies by Directorate

Feb-16

Feb-16

Dec-15

Dec-15

Sep-15

Sep-15

Nov-15

Nov-15

Aug-15

Aug-15

Oct-15

Oct-15

Jan-16

Jan-16

-160.00 -140.00 -120.00 -100.00 -80.00 -60.00 -40.00 -20.00 0.00

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Vacant FTE

Dir

ect

ora

te

Vacancies by Directorate and Month

300 Enable East Directorate

300 Business Information Systems Directorate

300 Director of Operations & Nursing Directorate

300 Corporate Directorate

300 Children & Young People Directorate

300 West Essex Directorate

300 North East Essex Directorate

300 Mid Essex Directorate

179

Staff Group Appendix

Add Prof Scientific and Technic - Psychologist\Psychotherapist, Social Worker, Pharmacist, Technician

Additional Clinical Services - Assistant Psychologist\Psychotherapist, Associate Practitioners, Healthcare Assistants, STR, Technical Instructor, Trainee Practitioner

Nursing and Midwifery Registered - Director of Nursing, Inpatient\Community Nurses, Nurse Consultants, Nurse Practitioners, Modern Matron

Medical and Dental - Medical Director, Consultant, Associate Specialist, Staff Grade, Trust Grade, Specialty Registrar, Specialty Doctor, GP, other Community Health Service

Estates and Ancillary - Maintenance Craftsmen, Grounds person, Gardener, Domestic Support Workers

Allied Health Professionals - Art\Music\Multi\Occupational\Physio\Speech Therapists and Dieticians

Administrative and Clerical - Chief Ex, Chair, Senior Managers, Managers, Clerical Workers, Non Execs

180

North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 15 Date: 23 March 2016 Title of Report: Quality Report Lead: Natalie Hammond, Director of Nursing and Quality Subject, Purpose and Recommendation: The Board of Directors is asked to note the contents of this report:

• There have been 12 Serious Incidents in January • The number of community complaints has been lower in early part of 2016 compared

to the higher trends in 2015 • Themes from complaints continue to be centred around communication, access to

services and clinical treatment • The Audit Plan for 2016/17 will be approved at the Risk and Governance Executive in

April 2016 Finance Implications: Number of claims currently on-going - these are being managed within our Risk Department in close liaison with the NHS Litigation Authority. Clinical Implications: Themes emerging from Serious Incidents and Datix Incidents and complaints have been identified as key learning, and work-streams to be considered under the Sign-up to Safety Work Programme that will focus in on key organisational learning from incidents. HR Implications: N/A Legal and/or Regulatory Implications: Other than those identified within the claims section of this report, no other legal implications have been identified. The regulatory implications on the current performance of the Trust in respect of quality are identified within the Care Quality Commission (CQC) update.

• The Quality Summit has now been held with key stakeholders and CQC work updated to reflect the Summit outcome

• High Level Action Plan update has been submitted to the CQC Equality Implications: N/A Risks: N/a

181

Board Quality Report

March 2016

182

Patie

nt S

afet

y

Serious Incidents

There has been a higher number of serious incidents in January 2016 than previously. These can be explained via the graph below which identifies a higher number of cases where we are awaiting cause of death, this is usually due to the Trust awaiting toxicology results. The increase in our number indicates that we have now met the threshold for Serious Incidents (SI) as set by our commissioners. This will require close monitoring for the remainder of the year. There are a number that could be de-escalated once cause of death has been established so this may reduce our number below the threshold target of 60. The Trust is now strengthening the SI Panel to include clinical representation from the three areas of the Trust. This will ensure an additional level of scrutiny on those SI’s reported, how the investigations are progressing and monitoring of the action plans to ensure lessons learnt and any corrective actioning can be implemented and shared within the Trust. The first meeting of the new panel will be 11th March.

Serious Incident Themes

The themes across the serious incidents that have been reported are indicated in the graph. The Trust has a number of SI investigations that have been undertaken following patients deceased at home. The sign up to safety campaign that has recently commenced will have an identified target around suicide prevention and the data analysis for this work is currently being undertaken. The Trust also has a number of homicides that are currently on-going whilst the police investigation concludes, the Trust has recently met with NHS England to discuss these difficulties and some work is currently being undertaken to ensure communication on these cases is strengthened so that at an appropriate point the Trust investigation can commence.

02468

10121416

Serious incidents by theme Apr 15 - Jan 16

183

Patie

nt S

afet

y

Incidents

The incidents reported by the Trust remains fairly constant in terms of numbers. The Trust is lower than the threshold that has been set for the end of the year, this could indicate a lower reporting. On 4th April a pilot Datix awareness week will be launched in Mid area to work with staff on incident reporting, provide additional training and also to have the conversation with staff on what types of incidents should be reported. The aim of this event is to encourage incident reporting and gain feedback from staff on how the process works for them. We have a newly established incident triage system that has been implemented which involves all incidents that have been reported being triaged to identify if any additional information is required, a check to ensure that they have been correctly categorised and that there are no serious incidents within them. The Trust is shortly to complete a piece of work on how North Essex Trust compares nationally to others in its levels of incident reporting.

Incident Themes

The incident themes are identified on the graph opposite. The top incident category is violence and aggression. The other categories of incidents being reported are relatively low and the Datix awareness week will aim to increase reporting. One of the main aims of the week is to also increase the numbers of near miss categories so that we have some trends around this area so that leaning can occur within the category. On 23rd March a Trust wide webinar is being held as part of the sign up to safety campaign to identify the best methods of communicating with our staff on lessons learnt from incidents and serious incidents. This will enable us to develop a framework based on these strategies to increase the learning across the organisation.

0

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1000

1500

2000

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3000

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Apr 15 to Feb 16 Incidents

184

Patie

nt S

afet

y

Physical Interventions

There has been a continuing month on month increase in physical interventions since October. January data shows an increase in both type of incident. An analysis of these incidents for the months of November – January shows an increase in the older adult wards along with the sustained level in CAMHS services. There continues to be a Trust action plan in place to reduce the number of restrictive interventions in line with national guidance. New training has commenced in January 2016. 33% of the physical interventions In January occurred on Larkwood and 28% older adult wards . The use of physical interventions is also one of those mile stones identified within the sign up to safety campaign and the data collection on the number of interventions used is shortly to be analysed.

Violence

This graph covers all aspects of violence in the Trust. Patient to patient violence is currently showing an upward trend. This is predominantly in older adult services for the last two months. Physical assaults to staff is currently still higher than this time last year 40 physical assaults in December - 30 in older adult – mostly dementia care wards. Verbal aggression has reduced greatly in the last month. Risk and Governance Executive continue to monitor specific wards, particularly Topaz ward.

0

10

20

30

40

50

60

70

80

90

100

PhysicalInterventions

RapidTranquillisation

Physical Interventions and Rapid Tranquillisation Incidents 2015 -2016

0

10

20

30

40

50

60

70

80Patient toPatientincidents

Physicalassaults toStaff

Physicalaggressiontowardsproperty

Verbalaggression

Trust Violent incidents 2015-2016

185

Patie

nt S

afet

y

Falls

Patient falls trust wide is closely monitored on a month by month basis. The Trust has shown clear improvement in the incidence of falls year on year. Falls data is analysed both to highlight individual patient care issues - examining care plans and the use of assistive technology, review of footwear, physical health and medication. Falls are analysed to see if there are environmental factors or specific high risk times such as a specific location or time on a ward. No one ward is an outlier with this type of incident. There has been 18 RIDDOR reportable incidents for service users to the HSE since April 2015. This is a reduction on this type of incident in comparison to last year. There is currently a data analysis exercise being undertaken on falls over the last 2 years and identifying harm associated with these so that a sign up to safety harm reduction percentage can be calculated and included in our improvement plan.

Medication

Only 8 incidents reported in January and 13 in December. All are no harm / minor. Most of these incidents in December occurred in Mid and hot spot was identified as Topaz. There is an action plan in place to address the issues including changing where medication is administered and also additional support from Pharmacy. There is a detailed report submitted to each RGE meeting which includes analysis and learning and actions taken to address the specific issues raised. 186

Patie

nt S

afet

y

Training

There was a small but steady month on month increase in overall mandatory training compliance from October 15 to January 16. However following a number of changes to the training matrix and the mandatory requirements this increasing trajectory has slipped. The changes include a requirement for all Band 6 and above staff to complete the more advanced Immediate Life Support training (instead of Basic Life Support) in response to learning from SIs. One these changes are embedded an improvement in compliance is expected. There are a number of further measures that have been implemented to further improve mandatory training compliance Increasing eLearning Options for Mandatory Training Currently 46% of mandatory training courses are available by eLearning. The Workforce Development and Education Team recently completed a Subject Matter Expert Review on all mandatory topics to look at how we can improve access for staff. We have committed to the development of eLearning options for mandatory and statutory courses, with the exception of the physical competency based ones (i.e. BLS/ILS, Manual handling, TASI, Personal Safety) or those where guidelines have been set nationally or by commissioners/governing bodies (i.e. Safeguarding – intercollegiate guidance sets out that training should be face to face/Fire Safety – Fire Code). ELearning generally is a quicker option and can impact less on release time. ELearning Options will be development. It must be noted that the eLearning options are designed to increase accessibility not replace face to face training. For revalidation nursing staff require evidence of ‘participatory CPD’ hours. Reducing the number of days for face to face training courses where viable Work, as part of the above mention Subject Matter Expert Review, is already underway to reduce the number of days required for face to face training. Personal Safety has been reduced from 2 days to one day and we are working with the Safeguarding team to reduce Safeguarding refreshers from 2 to one day. A Review of the staff group required to undertake mandatory training is currently being undertaken.

0

10

20

30

40

50

60

70

80

90

100

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov

-15

Dec-

15

Jan-

16

Feb-

16

Com

plia

nce

Perc

enta

ge (%

)

Training Compliance by Directorate (Jan 15 - Feb 16)

300 Children & Young People Directorate

300 Mid Essex Directorate

300 North East Essex Directorate

300 West Essex Directorate

187

Patie

nt S

afet

y

Safety Thermom

eter

There are two thermometers undertaken on a monthly basis. One in older adult inpatient units (nationally agreed thermometer) covering falls, pressure ulcers, VTE and Catheter and UTI’s. Falls to date this year have been the highest but this continues to show a downward trend. Adult wards have developed their own thermometer covering falls, violence, self harm and medication errors. Violent behaviour represents the most harms representing 38 harm incidents of 52 incidents in total since April 2015.

CAS Alerts

The only open alert with on going work relates to self closing fire doors and the need to ensure staff are aware of the risk when doors close automatically – this is particularly an issue in older adult wards where mobility may be an issue. No new relevant alerts have been issued.

0

5

10

15

20

25 CAS Alerts April 2015 - Mar 2016

188

Patie

nt S

afet

y

CQC

The latest version of the high level CQC action plan was submitted to the Care Quality Commission on 3rd March 2016. The Quality Improvement Plan is the key work being undertaken following the CQC completing their inspection. The Trust has received four unit specific MHA reports as a result of the inspection only. Quality Improvement Panels being undertaken in all areas and these are being developed further. The Trust quality improvement panels are now held together with all three areas, this is to promote learning and sharing across the Trust. The Quality Improvement Plan includes significant work to improve environments, care-planning practice and building team risk registers. There are currently two action plans being implemented for the previous unannounced visits to the Lakes and the Linden Centre, and these are updated as actions are being achieved. The Linden Centre action plan is progressing well with the environmental improvements in relation to the doors and windows. The other main elements of the action plan relate to the use of an acuity tool and the improvements in relation to care-planning and risk assessments . 60% of inpatient staff in adult admissions to receive STORM training and weekly audit of care-plans and risk assessments. Both the Lakes and Linden Centre have now instigated gender separation on the wards. The Lakes action plan included the removal of the door closer and this has been done where possible and the introduction of mirrors to improve line of sight. The Lakes seclusion room has been re-designated to a de-escalation suite and there is a de- escalation pathway that we are evaluating. The CQC action plan is being continually updated and actions monitored via the governance process within the Trust.

Graphs show claims reported through 2014/15 into Quarter 4 of 2015/16. 18 x claims received to date in 2015/16. Orange line indicates how NEP compares against NHSLA average for mental health Trusts. Clinical graph - shows 8 x claims received in 2015/16. Claims experience generally comparative with other mental health Trusts but increasing Q2/3/4 2015/16 against the member average which has dropped slightly. Third party graph - shows steady rise through 2014/15, rising sharply in Q1 of 2015/16 to above average for mental health Trusts, levelling out in Q2/3/4 to 1 claims per month, with a general reduction in claims for mental health Trusts also showing. 10 x 3rd Party claims to date in 2015/16. All Portal claims (under £25K).. Joint work continues with Facilities Team to address issues arising from spate of claims from Support Services Staff. Causes Clinical - Top causes continue to be Suicide (inpatient & community)/Falls/ Quality of Care issues. Third Party - Top causes remain as falls/personal accidents. Claims closed/settled in Q4 Clinical 1 x settled, 1 x reported and rejected due to lack of specific allegations re NEP, 1 x closed due to limitation expiry. 3rd Party 3 x claims closed - successfully defended and limitation now expired. New claims received in Q4 Clinical – 1x suicide in community 2013 (under investigation) and 1x rejected due to lack of allegations re NEP (to be closed). Third Party 1 x support services assistant personal accident (repudiated). Key Learning points

Clinical claims

189

Patie

nt E

xper

ienc

e

Complaints

The complaints within the community continue to be higher than the in-patient areas. There are specific areas that are higher than others and this will continue to be monitored via the patient safety and complaints team. The in-patient complaints remain fairly static, there have been some peaks identified at some points during the year. Continued Developments • Complaints training for all staff to be commenced in April

2016. • New complaints toolkit published by NHS England • Complaints scrutiny panel meets in March to facilitate

the learning and corrective actioning from complaints. • All complaint letters are acknowledged within 3 working

days • Complaints policy will shortly be reviewed.

Complaint Themes

The compliant themes are identified on the graph are there are several categories that are higher: access to services, clinical treatment, staff attitude and behaviour and communication. The patient safety and complaints team are currently reviewing the content of the training on patient experience within Trust induction. The patient safety and complaints team are shortly to commence a piece of work on compliments and how we share these with clinical staff. The highest category on complaints which is access to services will require a deep dive into the issues contained within this category as we need to clearly identify is this is related to one aspect of accessing services or it is more widespread across the accessing of Trust services.

012345678

April Jun Aug Oct Dec Feb

West Community

Mid Community

CYPS

NE Community

GPS

Community Complaints

012345678

April

May Ju

nJu

lyAu

gSe

pt Oct

Nov De

cJa

nFe

bM

ar

West Inpatients

Mid Inpatients

NE Inpatients

Inpatient Complaints 2015-2016

05

1015202530354045

Number of complaints by theme Apr 15 - Jan 16

190

Patie

nt E

xper

ienc

e

Low Level concerns

Patient Advice and Liaison Services (PALS) identifies the themes from the contact it has with the Trust. Communication continues to be a key area within the PALS contacts with the Trust. It should also be noted at this point that communication is also a key area within the formal complaints category of the Trust. Standards of care and to raise Trust awareness are also key factors within this data that has been collected.

191

Clin

ical

Effe

ctiv

enes

s

Audit

There continues to be some key audit work undertaken within the Trust. Key Developments: • The audit policy is shortly to be reviewed. • The audit registration process has been reviewed to

ensure it is user friendly for clinical staff • The draft audit plan for the Trust will be approved in April

in time for the new financial year. • The audit plan centres on CQUIN audits and a number of

other core audits that will be on the programme of year for 1016/17.

• Audit best practise day planned for June/July this year to celebrate the achievements that have been undertaken over the last audit year and key audits will be presented and the changes in practise will be identified and shared.

GP discharge audit: This audit has now been completed within the last few days for quarter 2 and 3. • A focus moving forward to ensure GP’s receive their

summaries for patients within 24 hours of discharge. • Method of how the summaries get to GP colleagues

will also be developed to ensure secure email is used to avoid the issues of utilising fax machines as this decreases quality.

• Working with our Medical Director and Area Medical Directors in taking forward the action plan and this important work stream.

NICE Guidance

There is currently a piece of work being undertaken looking at NICE guidance and this covers the following: • Establishing a clear corporate lead for NICE guidance • Establishing a policy for the receiving, assessing and

implementation of NICE guidance within the Trust • Ensuring we have established a NICE database which will

evidence the implementation of NICE guidance • Provide a mechanism for horizon scanning of NICE

guidance

192

Risk

Esc

alat

ion

Repo

rt

Trust

There are 29 trust-wide operational risks identified on the current Risk Register. 2 of these risks are current in the extreme level and these are the non delivery of CIPS programme and recruitment to maintain safe staffing levels. 10 of the 29 relate to statutory compliance . Key areas are heighten risks around bed management issues, privacy and dignity standards compliance and single sex accommodation requirements. A risk around the non achievement of full CQUIN funding has also been added to the strategic risk register. Staffing risks mainly around staff sickness and recruitment challenges, particularly in older adult wards, with this leading to increase use of bank and agency staff. Health and safety risks relating to risk assessment and compliance with procedures, violence and aggression and falls prevention. Finally reputational risks around effective management and learning from serious incidents and patient feedback systems along with a risk relating to the effective demonstration of our duty of candour.

Mid

There are currently 6 risks on the Area Risk Register. High vacancy factor and low staff morale alongside CQC compliance are currently heighten risks which they are managing with a robust action plan. Also the ability to delivery on their full CIP plans.

West

There are still 15 risks on the Area Risk Register. Additional to high level of vacancies in older adult areas and staffing for the Hub, impact of the refurbishment on the environment and patient care is high risk on their register. Impact of integrated care organisation on specialist mental health provision. Patient safety environmental changes and CQC compliance are on the top of their working agenda. Also the ability to delivery on their full CIP plans.

North East

There are 7 risks on the Area Risk Register. Changing to the commissioning intentions for the Ne area. High volume of AMHP assessment and their unpredictable demand alongside S136 assessments. Overall compliance with patient environmental and privacy and dignity standards. Staffing / vacancy issues have been added and meeting the required targets for personalisation agenda.

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 16 Name of Meeting: Meeting of the Board of Directors in Public Date: 23 March 2016 Title of Report: Ward Staffing Levels – January 2016 Lead Director: Natalie Hammond, Director of Nursing & Quality Subject, Purpose and Recommendation: The Board of Directors is asked to discuss and note the report. A monthly report to the Board containing details and summary of planned and actual staffing on a shift-by-shift basis is part of the ‘Hard Truths’ commitments. The attached is the report as initiated by the Non-Executive Team summarising the position for each ward with the planned and actual staffing as reported via Unify (National Reporting System). The report identifies those wards which the Nursing and Quality Team have identified as ‘ hot spots’ requiring exception reporting - these are all wards rated as red or amber via RAG rating. These wards have been reviewed to ensure there have been no significant concerns in regards to the safety and quality of care on the individual wards identified. The exception commentary takes into account the responsibilities of the Board as specified by the CQC and NHS England, and noted in the section of this covering report that deals with ‘Legal Implications’ (a-e below). The CQC and NHS England also require ‘a Board Report describing the staffing capacity and capability, following an establishment review, using evidence based tools where possible is presented to the Board every six months’. The current report summarises and focuses on the information that is regularly uploaded to ‘NHS Choices’ using the UNIFY System. Finance Implications:

• Potential future financial costs associated with data solutions to record and track staff usage

• Reduction in reliance of temporary staff and reduction of cost associated with on-going usage of highest agency staff. 194

Clinical Implications: As described in Section 4 of the report - Exception reporting. HR Implications: Following the implementation of Journeys a number of wards continue to actively recruit to vacant posts. A number of new staff have started within the Trust in recent weeks or have start dates in the near future. Legal Implications: The CQC and NHS England’s requirements are laid out in a letter dated 31 March 2014 http://www.england.nhs.uk/2014/04/01/hard-truths/ and associated table of actions. For the Board this includes the following requirement: ‘A Board Report containing details of planned and actual staffing on a shift by shift basis at ward level for the previous month. To be presented to the Board every month. Boards must, at any point in time, be able to demonstrate to their commissioners that robust systems and processes are in place to assure themselves that the nursing, midwifery and care staffing capacity and capability in their organisation is sufficient to provide safe care.’ The associated ‘table of actions’ describes the expectations of the Board in further detail, asking that the Board:

a) Receives an update containing details and summary of planned and actual staffing on a shift-by-shift basis

b) Is advised about those wards where staffing falls short of what is required to provide quality care, the reasons for the gap, the impact and the actions being taken to address the gap

c) Evaluates risks associated with staffing issues d) Seeks assurances regarding contingency planning, mitigating actions and incident

reporting e) Ensures that the Executive Team is supported to take decisive action to protect patient

safety and experience.” Equality Implications: N/A Risks: N/A

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http://www.england.nhs.uk/2014/04/01/hard-truths/

NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST MONTHLY WARD STAFFING REPORT

January 2016

1) Background

The purpose of this report is to provide the Board of Directors with the monthly information required as part of the delivery of the Hard Truths commitments associated with publishing staffing data regarding nursing and care staff. It is a requirement for the Board to be updated on progress being made in respect to meeting the expectation in the guidance by the Chief Nursing Officer and the National Quality Board, How to ensure the Right People, with the Right Skills are in the Right Place at the Right Time; A Guide to Nursing, Midwifery and Care Staffing Capacity and Capability. It is acknowledged that staffing analysis alone does not give adequate assurance of patient safety, high quality care and positive patient experience. The triangulation of key measures, alongside staffing data will better inform the Board and Service Lines to identify key areas of concern, target measures to address such concerns, and enable clinicians and service management teams to have greater integrated intelligence to drive improvements in patient care. This analysis is therefore limited but will steer focus to areas of risk and allow wards and teams to share best practice in respects to how they may have achieved more positive outcomes.

2) Overview

The information returned to the central NHS collection (Unify) is reviewed to ensure the information collated is an accurate understanding of staffing needs and cover required for each shift. This takes place on a weekly basis with Area Chief Nurses and Executive Director/s to identify any exception reporting from the previous week, any mitigations and actions taken to ensure safe staffing as well as discuss any concerns for the following week. 3) Dashboard

This report has two months of dashboard data December 2015 and January 2016. As of the time of the report writing, February and March data had not been available nor placed on Unify. This data is then shown along with previous months as a trend analysis from February 2015 to January 2016.

This report will cover the January 2016 activity in detail.

196

Are

a

Ward Name No of Beds

Occupancyrate

(excl leave)

Occupancyrate

(incl leave)

StaffWTE

Fill rate Registered

Fill rate Unregistered Falls Pressure

Ulcers HCAI

Ardleigh Ward (Adult) 18 97.9% 113.5% 21.6 97.3% 146.5%

Gosfield Ward (Adult) 18 100.3% 113.5% 18.8 90.9% 131.0% 1 1

Peter Bruff Unit (Adult) 17 99.2% 103.9% 19.6 100.5% 109.7%

Bernard Ward (Older Adult) 14 100.7% 101.7% 17.8 77.4% 119.4%

Henneage Ward (Older Adult) 16 101.8% 106.8% 18.0 81.2% 126.5% 4

Tower Ward (Older Adult) 15 78.4% 80.6% 18.0 87.7% 113.4% 4

Ipswich Road (Adult) 11 100.0% 100.0% 20.0 114.0% 108.4%

Longview (CYPS) 15 97.1% 114.9% 19.4 114.8% 99.1%

Larkwood (CYPS) 10 87.1% 93.3% 22.8 115.5% 90.3%

Finchingfield Ward (Adult) 23 80.7% 85.3% 18.6 106.0% 132.9%

Galleywood Ward (Adult) 24 75.0% 81.0% 18.8 87.1% 142.6%

Ruby Ward (Older Adult) 17 93.6% 103.9% 14.1 81.7% 129.0%

Topaz Ward (Older Adult) 17 97.8% 98.6% 12.4 67.3% 198.7% 3

Edward House (Adult) 20 96.4% 100.0% 29.4 93.2% 102.4%

Christopher Unit (Adult) 5 98.0% 98.0% 14.1 76.9% 130.3%

Rainbow Unit (Adult) 8 96.2% 98.1% 15.4 103.2% 103.6%

Stort Ward (Adult) 16 97.5% 104.8% 18.8 100.5% 179.4%

Chelmer Ward (Adult) 16 103.9% 110.9% 18.0 107.0% 157.4%

Kitwood Ward (Older Adult) 16 83.9% 89.3% 16.2 91.9% 196.1% 2

Roding Ward (Older Adult) 14 87.3% 88.3% 18.1 107.7% 105.4%

Brian Roycroft (Older Adult) 16 82.1% 83.0% 19.1 60.0% 230.6% 1

326 93.09% 98.54% 18.5 93.43% 135.84% 15 0 1

Safe Staffing Dashboard - Dec 2015 data

Green = 85% or moreAmber 60% to < 85 %

Red < 60%

Nor

th E

ast /

CA

MH

SM

id

O

197

Are

a

Ward Name No of Beds

Occupancyrate

(excl leave)

Occupancyrate

(incl leave)

StaffWTE

Fill rate Registered

Fill rate Unregistered Falls Pressure

Ulcers HCAI

Ardleigh Ward (Adult) 18 100.0% 123.5% 102.2% 152.3%

Gosfield Ward (Adult) 18 100.6% 113.0% 105.9% 120.6%

Peter Bruff Unit (Adult) 17 99.0% 103.3% 22.2 103.2% 106.5% 2

Bernard Ward (Older Adult) 14 103.6% 103.6% 18.5 79.4% 123.1% 4

Henneage Ward (Older Adult) 16 93.1% 96.5% 19.1 91.9% 158.1% 3

Tower Ward (Older Adult) 15 94.8% 94.8% 15.0 88.4% 109.7% 4 1

Ipswich Road (Adult) 11 99.5% 99.5% 19.6 108.6% 98.1%

Longview (CYPS) 15 97.4% 104.1% 20.4 103.2% 112.9%

Larkwood (CYPS) 10 85.6% 90.0% 21.6 111.0% 91.4%

Finchingfield Ward (Adult) 23 78.3% 82.9% 20.6 107.4% 130.3%

Galleywood Ward (Adult) 24 74.8% 78.9% 19.4 96.8% 157.4% 1

Ruby Ward (Older Adult) 17 97.4% 108.8% 17.3 79.6% 141.9% 3 1

Topaz Ward (Older Adult) 17 99.3% 100.3% 18.6 68.7% 165.2% 4 3

Edward House (Adult) 20 98.3% 103.6% 27.0 95.2% 126.1%

Christopher Unit (Adult) 5 93.7% 93.7% 15.5 83.3% 133.5%

Rainbow Unit (Adult) 8 75.6% 75.6% 13.6 110.8% 91.9% 1

Stort Ward (Adult) 16 104.2% 110.5% 18.0 114.5% 181.9%

Chelmer Ward (Adult) 16 99.7% 103.6% 15.0 119.4% 158.1%

Kitwood Ward (Older Adult) 16 95.5% 96.5% 14.4 86.6% 184.5% 3

Roding Ward (Older Adult) 14 85.6% 90.7% 14.9 113.5% 111.3%

Brian Roycroft (Older Adult) 16 84.4% 84.4% 17.7 66.5% 250.5% 1

326 93.34% 97.98% 19.4 96.95% 138.35% 23 1 7

Safe Staffing Dashboard - Jan 2016 data

Green = 85% or moreAmber 60% to < 85 %

Red < 60%

Nor

th E

ast /

CA

MH

S

38.8

Mid

O

198

North East / CAMHS

50.0%

100.0%

150.0%

200.0%Ardleigh Registered Non Registered

50.0%

100.0%

150.0%

200.0%Gosfield Registered Non Registered

50.0%

100.0%

150.0%

200.0%Peter Bruff Registered Non Registered

50.0%

100.0%

150.0%

200.0%Bernard Registered Non Registered

50.0%

100.0%

150.0%

200.0%Henneage Registered Non Registered

50.0%

100.0%

150.0%

200.0%Tower Registered Non Registered

50.0%

100.0%

150.0%

200.0%Ipswich Road Registered Non Registered

50.0%

100.0%

150.0%

200.0%Longview Registered Non Registered

50.0%

100.0%

150.0%

200.0%Larkwood Registered Non Registered

Mid

50.0%

100.0%

150.0%

200.0%Finchingfield Registered Non Registered

50.0%

100.0%

150.0%

200.0%Galleywood Registered Non Registered

50.0%

100.0%

150.0%

200.0%Ruby Registered Non Registered

50.0%100.0%150.0%200.0%250.0%300.0%

Topaz Registered Non Registered

50.0%

100.0%

150.0%Rainbow Unit Registered Non Registered

50.0%

100.0%

150.0%Edward House Registered Non Registered

50.0%100.0%150.0%200.0%250.0%

Christopher Unit Registered Non Registered

199

4) Exception Reporting The Dashboard for January 2016 evidences that 17 out of 21 wards achieved over 85% safe staffing levels for registered nurses, meeting the staff establishment requirement. Below is a summary of the identified wards that require exception reporting. NORTH EAST

Tower Ward RAG rated Amber for registered staff - AM shifts (79%).

Registered nurse establishment; 2 registered per AM/PM. This was not met

consistently in January; however one registered nurse on duty was achieved throughout the month.

A small number of shifts did not meet the agreed establishment as a result of NETTs/agency being unable to secure cover

Ward vacancy level during January are 2 WTE registered nurses and 3 WTE unregistered staff. All posts are recruited to with individuals due to take up post in February and March

Sickness, training, vacancies and high clinical activity (including various levels of observation used to manage patient risk) accounts for the use of bank and agency staff

To ensure continuity of care, regular bank/agency staff (have a working knowledge of the ward and service users) were used were possible

Additional staff available to supplement/support clinical care includes: o Ward Manager 9-5 available to support care delivery

West

50.0%100.0%150.0%200.0%250.0%

Kitwood Registered Non Registered

50.0%

100.0%

150.0%

200.0%Chelmer Registered Non Registered

50.0%

100.0%

150.0%

200.0%Stort Registered Non Registered

50.0%100.0%150.0%200.0%250.0%

Roding Registered Non Registered

50.0%100.0%150.0%200.0%250.0%300.0%350.0%

Brian Roycroft Registered Non Registered

200

Bernard Ward RAG rated Amber for registered nurses for PM shift (61%). Registered nurse establishment; 2 registered per AM/PM. This was not met

consistently in January; however one registered nurse on duty was achieved throughout January

Registered nurse establishment vacancies 2.8 WTE. Posts are actively being recruited into – one individual initially accepted the post but then withdrew

Sickness, training, vacancies and high clinical activity (including various level of observation used to manage patient risk) accounts for the use of bank and agency. One service user at Colchester General Hospital detained on a Section requiring 24 hour observation and support

Additional staff available to supplement/support clinical care includes: o Ward Manager o Twilight and Review Nurse o Adjacent ward available to provide support

Henneage Ward RAG rated Amber for registered nurses for night shift (68%). Registered nurse established safe staffing: 2 registered nurses per shift. This has not

been met consistently in January, however at least one registered nurse on duty was achieved throughout January

Acquiring two registered nurses at night remains difficult. Henneage Ward Manager has requested permission to change their night shift skill mix from 2 registered and 1 unregistered to 1 registered and 2 unregistered (due to vacancies, the ward has continually struggled to roster on 2 registered staff at night)

The introduction of a twilight shift (registered nurse) was proposed as this would mitigate against the potential reduction in available registered nurse time. This was piloted, evaluated and a formal decision agreed to change the 2014 skill mix

Sickness, training, vacancies and high clinical activity (including various level of observation used to manage patient risk) accounts for the use of bank and agency.

Additional staff available to supplement/support clinical care includes: o Ward Manager o Review Nurse two days a week o Adjacent ward available to provide support

Larkwood Ward RAG rate Amber for non-registered staff for both day shifts (76% & 77%) respectively. Whilst unregistered staff on the AM shift did not meet the planned establishment,

registered nurse fill rate for both shifts exceeded 100% Both Larkwood and Longview were supporting the care of a young person in the

acute sector (1:1). This redeployment of staff may account for the reduction in unregistered availability

201

Recruitment – One WTE registered nurse due to take up post in April Additional staff available to supplement/support clinical care includes:

o Ward Manager and other clinical staff (OT’s, Psychology) available to offer support

o Adjacent ward available to support if necessary WEST

Brian Roycroft Ward

Rag rated amber for registered staff (73.8%) and red for registered night staff (51.6%).

Ward qualified established safe staffing level – at least one registered nurse per shift is required and this has been met throughout the month. Staffing the unit with substantive registered staff remains a significant challenge. High levels of service users on Level 4 observations due to frailty and physical health care support

Interviews for the 5 WTE vacant Band 5 posts will be held on the 29th March Currently 6 HCA staff on short term contracts to mitigate the current staffing and

recruitment challenges. Their fixed term arrangements have been extended until the end of May 2016

Regular Band 5 bank staff have been used to ensure continuity of care and safety Kitwood Ward

Currently RAG rated as green with 86.6% average fill rate for registered staff but shows high levels for fill rates for non-registered

Ward qualified established safe staffing level – at least one registered nurse per shift is required and this has been met throughout the month

There have been several physically unwell service users that has led to additional staffing required to transfer and observe whilst in the local acute hospital

Four WTE vacancies for registered nurses were recruited to in mid-February with anticipated start dates for these staff in May

Some shifts have been covered using block booking of agency and bank to maintain continuity of care

MID

Ruby Ward RAG rated Red (50%) at night as number of shifts where unable to meet establishment for registered nurses. The majority of the shifts were covered by agency staff (32%) bank staff (13%) permanent staff on a bank shift (5%).

RAG rated Amber (81%) for late shifts where unable to meet establishment for

202

registered. Majority of shifts covered by permanent staff on bank (74%) and agency staff (6%).

Planned staffing: Early - 2 registered and 2 non-registered, Late - 2 registered and 2 non-registered and Nights - 2 registered and 1 non-registered

Ward continues to have high use of bank and agency staff due to regular enhanced observations

Vacancies (end of January) – registered 4 WTE and non-registered 4.8 WTE Staffing pressures are due to annual leave, sickness and study leave Night shifts have been supported by using regular bank staff for continuity of care

NB: Will continue to be RAG rated red at night as unable to achieve establishment of 3 registered nurses even with bank and agency. Topaz Ward RAG rated Red (32%) at night as number of shifts where unable to meet establishment for registered. Planned staffing: Early - 2 registered and 2 non-registered, Late - 2 registered and 2

non-registered and Nights - 3 registered and 1 non-registered Shifts mainly covered by agency staff (31%) and bank staff. Permanent staff on

bank also support the roster Ward continues to have high use of agency and bank staff due to regular

enhanced patient observations for falls risk and physical health care needs Staffing pressures are due to annual leave, sickness and study leave Night shifts have been supported by using regular bank staff for continuity of care

NB: Will continue to be RAG rated red at night as unable to achieve establishment of 3 registered nurses even with bank and agency. Christopher Unit RAG rated Red (58%) at night as number of shifts where unable to meet establishment. Registered nurse established safe staffing: 2 registered nurses per shift. This has not been met consistently in January, however a least one registered nurse on duty was achieved throughout January achieving minimum safety levels. Planned staffing: Early - 2 registered and 2 non-registered, Late - 2 registered and 2

non-registered and Nights - 2 registered and 1 non-registered Majority of shifts covered with agency registered staff (31%); bank staff (19%) and

permanent staff on bank (8%) Vacancies (end of January):

o 4 WTE x registered staff vacancies currently advertised

203

o 2 WTE x non registered staff vacancies currently advertised Additional staff available to supplement/support clinical care, include:

o Ward Manager 9-5; Ward Manager covered the ward all week due to vacancies

o Where possible, on Tuesday pm, Wednesday am and Friday am, a registered nurse supernumerary to cover care reviews

Galleywood Ward RAG rated Amber (85%) for late shifts where unable to meet establishment for registered. Planned staffing: Early - 2 registered and 2 non-registered, Late - 3 registered and 2

non-registered and Nights - 2 registered and 1 non-registered Majority of shifts covered by permanent staff working bank (47%); agency staff

(25%) and bank staff (13%) Vacancies/sickness absence:

o Staffing pressures are due to annual leave, sickness and supernumerary (pregnancy) requiring bank/agency support

5) Summary

Within all the wards highlighted as exception reports, there have been no significant concerns in regard to the safety and quality of care on the ward when reviewing clinical incidents and safeguarding reports associated with the staffing levels:

• No incident has been received on DATIX of reported patient harm caused by inadequate staffing resource

• No complaint has been received stating inadequate staffing resource as the cause Themes presenting in January’s analysis are vacancy levels, sickness absence, annual leave cover, agency fill rates and high levels of acuity.

Fill rates for vacant shifts continue to be problematic with NETSS being unable to fill a number of shifts with either bank or agency, or individuals cancelling shifts at short notice. This situation has been raised with the Head of NETSS on several occasions.

Vacancy levels vary across wards, and whilst there have been some recent improvement in recruitment, further significant progress is required to address current vacancy rates and turnover across the Trust.

Whilst overall the wards have met their planned number of hours worked for registered staff and care support staff, they continue to address current challenges in securing staff with the use of temporary staff, at times of an opposite grade. Sickness continues to require robust management to further strengthen a consistent workforce to meet all quality and patient experience indicators.

204

6) Action Plan

There is continuing action and response from the safe staffing data on a weekly basis. The Areas Chief Nurses review the data and the themes and report concerns to the Director of Nursing & Quality for response.

Current Actions:

• High level Steering Group to review recruitment strategy trust-wide • Area Chief Nurses to work locally with Matrons regularly regarding recruitment • Director of Nursing & Quality to meet graduating student nurses to encourage

local recruitment when appropriate • Two recruitment interview dates have been set in April and June for graduate

student nurses • Staff secondment proposals must be agreed by the Area Chief Nurse and

assessed for their impact on safe staffing levels • Ward areas that are, for more than 2 consecutive months of exception reporting,

in the red zone, will require a management action plan • Ward areas that present with a number of significant risks, incidents of patient

harm will be subject to immediate remedial action inclusive of staffing review • The Mental Health Staffing Framework, which focuses on inpatient care safe

staffing levels, was piloted in December 2015 – this will be repeated. Timescales yet to be agreed

• ACNs and local Matrons met with NETTS to discuss the problems faced around fill rates and quality of temporary staff, a series of action to improve this are under way and ongoing

• The new e-rostering steering committee project plan identifies how significant improvement can be made in delivering safe staffing levels such as on-line bank booking made remotely by bank staff, real-time safe staffing data to deploy resources as required

• The Quality Improvement Panels discuss and scrutinise staffing levels in order to be responsive to the safe staffing agenda

7) Future Considerations

The format and presentation of this report is still under review.

There is no further update to the requirement of the publication of nursing safer staffing indicators, which will provide an overall RAG rating for the Trust.

The Mental Health Staffing Framework, which focuses on inpatient care, was commissioned as part of the NHS England’s ‘Compassion in Practice Programme’. It was developed by an independent group of directors of nurses who undertook a rigorous review of the available evidence and drew on their extensive experience.

Amongst its objectives is to equip mental health leaders with the skills and knowledge to plan and deliver safe staffing. It will also provide a means of assessing their services against agreed best practice.

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Developed by nurses for mental health leaders, the framework aims to ensure that mental health inpatient wards have the right staffing level for their specific needs.

The outcome and findings from the pilot of the framework formed part of the capacity and capability presented to the Board in January. This data will continue to inform analysis of safe staffing levels and patient acuity. It aims to identify the dependency and staffing requirement for a unit once a month’s retrospective data is gathered. This work is on-going.

This is just one component of a significant on-going programme of work that the Trust is undertaking is undertaking to ensure the wards are safely staffed with the right people, with the right skills.

206

North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 17 Date: 23 March 2016 Title of Report: Nursing and Midwifery Council (NMC) Revalidation for Nurses Lead: Natalie Hammond, Director of Nursing & Quality Subject, Purpose and Recommendation: The Board of Directors is asked to discuss and note the update report dated March 2016. The Nursing & Midwifery Council (NMC) is proposing new requirements that Nurses and Midwives must meet when renewing their registration every three years. Revalidation replaces the post-registration education and practice (PREP). On the 8th October, 2015 the NMC made the decision to proceed with Nurses’ and Midwives Revalidation. Finance Implications:

• Non identified

Clinical Implications: • Potential implications for service delivery if registrants do not complete revalidation

requirements by their revalidation date.

HR Implications: • As above

Legal and/or Regulatory Implications:

• Potential legal costs through HR procedures if staff cannot revalidate or if any litigation issues arise from the revalidation processes

Equality Implications: N/A Risks:

• Ensuring all staff understand the Revalidation process • Additional time for Registered Nurses to complete the Revalidation process • Ensuring that managers are supplied with dates when their staff revalidate to prevent

lapses in registration process which may impact on service delivery • Impact on service if staff do not submit timely revalidation requirements

207

NMC Nursing Revalidation Project

Update Report to the Board of Directors (March 2016)

Introduction The Nursing and Midwifery Council (NMC) Revalidation process commences from 01 April 2016. All nurses and midwives have been informed by the NMC of the revalidation requirements and asked to familiarise themselves with and start to develop their portfolio, which is seen as a continuous process and not a point in time activity or assessment. Background An initial report detailing the requirements of NMC revalidation, NEP preparation to date, nursing profile of the number of registrants due to revalidate from April 2016, the means in place to support the process, and the potential risks was presented to the September 2015 Board and updated bi-monthly. This was accompanied by a detailed action plan. The key objectives were to:

• Set up a Revalidation Task and Finish Group reporting to the Nursing Council to identify and manage potential challenges

• Review of appraisal documentation to support the confirmation process required by NMC

• Develop the Intranep page to access current guidance and access to resources for professional portfolios

• Review Registration of Professional Staff Policy to include revalidation • Training for nurse and non-nurse managers who will act as confirmers • Guidance on using the electronic portfolio • An agreed process to support Bank nurses including clarification and guidance

around the role of confirmers • Develop the proposal on how to gather feedback from service users and patients

Governance The Task and Finish Group provides a robust governance system whose role is to review progress and identify any potential risks with agreed clear actions and responsibilities. The Group has high level membership including Revalidation Lead, Area Chief Nurses, Lead for NETSS, Associate Director Workforce Development, Associate Director HR, Education Facilitators along with Staff Side representation. This Group will meet quarterly to review progress towards the action plan. Any risks clinical, service or financial risks will be reported to Natalie Hammond, Executive Director of Nursing & Quality. Progress to date

• Revalidation Task and Finish Group are addressing all of the above objectives with key actions identified

• Further workshops and reflective sessions have been organised and are being well attended by registered nurses. To date over 170 nurses have attended one or both of these sessions. This is further supplemented by Team and individual support where required

• All registrants are being encouraged to register with NMC online and register with Nursing Times (NT) to access the electronic portfolio and online support. To date, 620 nurses have been registered to use the NT electronic portfolio, although the

208

number using the portfolio is significantly less. A review of the use of the electronic portfolio will be undertaken to assess whether NT is the most appropriate option

• A revalidation page on Intranep contains comprehensive information to support nurses with revalidation

• A staff Training and Education Brochure is being developed by Workforce that will identify all training programmes offered by NEP stating the number of CPD hours per programme and those that can be counted as participatory CPD for the purposes of revalidation

• The first group of 25 nurses are due to submit their applications for revalidation by 01 of April 2016; a number of these have already completed the requirements and submitted. The remainder are steadily working towards achieving this goal within the timeframe

Potential Risks and Mitigation

• Failure to revalidate within timescale The greatest risk to NEP is failure of nurses to complete revalidation process within their given timescale. The NMC issued this advance warning May 2015 “From 1 November 2015, a change to the Nursing and Midwifery Council (NMC) registration process means that if nurses or midwives fail to renew their registration before it expires, they will be removed from the register. The previous grace period will no longer apply. Readmission to the register can take between 2 and 6 weeks and, until they are readmitted, nurses and midwives will be unable to practise”. NEP nurses were made aware of this change some months ago and clear processes have been instigated to ensure requirements are met in a timely manner. To further mitigate this risk all registrants are emailed by me up to 6 months in advance of their revalidation date reminding them of their responsibility and the requirements they have to meet to successfully complete this process. This is followed through with regular contact to offer support whilst requesting an update on progress and the name of their confirmer; this has proved successful to date.

• Guidance for Confirmers Clear guidance has been written by the NMC for nurse and non-nurse managers who will act as confirmers to sign off that the nurse has met the requirements of revalidation. This is recommended to be part of the annual appraisal in the final 6 – 12 months prior to revalidation to allow sufficient time for additional information to be collected if required. The non-nurse managers within NEP have been sent information and offered personal support and guidance if required. For Bank nurses who work across a number of clinical areas at NEP, the role of the confirmer is currently being managed on an individual basis. Learning from this early process will inform future guidance. Further discussions are taking place with Clinical Managers and NETSS to resolve this issue.

Conclusion There is a comprehensive process in place to implement arrangements to enable registered nurses to complete the revalidation process. This is fully supported by the Area Chief Nurses and the Education Facilitators. Sue Champion Revalidation Project Lead 8th March 2016

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 18 Date: 23 March 2016 Title of Report: Medical and Non-Medical Education Update Lead: Dr Malte Flechtner , Medical Director Subject, Purpose and Recommendation: The Board of Directors is asked to receive and note the attached update which details preparation for the Quality Performance Review visit in May, an update on the Medical training initiatives and nursing student recruitment. Anglia Ruskin University’s proposal to develop a medical school and the Memorandum of Understanding are also attached. Finance Implications: N/A Clinical Implications: N/A HR Implications: N/A Legal and/or Regulatory Implications: N/A Equality Implications: N/A Risks: N/A

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1. Update on the Quality and Performance Review (QPR) visit to the Trust on Friday, 20 May 2016

Context

We have a LDA worth around £2.7 m with HEE

The purpose of the visit will be the review of our performance against the Learning and Development Agreement (LDA) including the GMC and Non-Medical Commissioned Programmes standards and domains, and the review and triangulation of the evidence gathered through HEEoE‟s quality management processes and any additional evidence provided by the Trust. It will explore key lines of enquiry and areas for improvement where further assurance is needed and it will celebrate good practice.

Last (Deanery) visit to NEP was about three years ago; we had a very positive report Dean’s Quality & Performance Review (July 2013)report is available at: https://heeoe.hee.nhs.uk/qpr_north_essex Visit schedule:

• Pre visit meeting : Friday 11 March 2016 • Full day visit: Friday 20 May 2016 ( Trust HQ) • Feedback visit: Friday 17 June 2016

Forthcoming visit was originally scheduled for September/October 2016. In view of our proposed merger, HEEoE wanted to visit both the Trusts around the same time – SEPT had their visit earlier this month. The visit on 20th May is expected to be fully multi-professional, reflecting the whole workforce and the clinical learning environments we provide within NEP

Recent CQC report & our action plan and National Trainee Survey & our action plan will be of interest to the visiting team. They will be keen to see evidence of ‘organisational learning’. In particular, how learning from SIs are communicated to our trainees across all professions and grades

The visitors would be interested in our proposed merger with SEPT and would like to be reassured that education and training will not be adversely affected

HEEoE will consider the overall governance of education and training within the Trust for all professions and specialties. This was an area we needed to improve following the last visit

As following any such visits the feedback meeting on the day of the visit will focus on highlights and any urgent matters, if applicable. If a concern arises during the visit which

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cannot be triangulated, this will be taken out with the report and the Trust will be asked to investigate.

Visiting Team

The multi-professional team led by the Postgraduate Dean and HEEoE‟s Senior Team usually include representation from the Essex Workforce Partnership and the HEIs ( Higher Education Institutions) as well as peer reviewers, trainee/student and Lay Representatives.

Trust Representation

High level representation from the Trust will be required (CEO, Medical Director, Director of Resources, Director of Nursing , HR Director, Medical Staffing Manager, Assos Director of Workforce Development, DME, Non-Medical Tutor etc)

Visiting team would like to meet separately with, a representative sample of Tutors, Supervisors from the specialties (including foundation, core, higher, general practice), Mentors, Education Leads from Pharmacy, AHPs, HCSs, from all areas of the Trust

Expected Presentations

Chief Executive covering

• Trust strategy and Trust vision including challenges • changes to services , proposed merger

Director of Resources, covering

• allocation of medical and non-medical (NMET) funding for education and training

Medical Director, covering:

• Governance of, and Board level engagement with, education and training within the Trust for all professions and specialties.

• Revalidation of junior doctors • Plans for revalidation of nurses • Management of SIs (reporting system) and dissemination of the learning from SIs to

trainees and students/learners including support provided by the Trust to trainees and learners if they are involved in an SI. Feedback from SIs will be explored as part of the afternoon meetings with the trainees and students

The Director of Medical Education and the Non-Medical Tutor may wish to do separate presentations or one person may cover both areas. The presentations should be brief and evidence-based and focus on the actions taken to address concerns

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Non-Medical Tutor’s presentation

Focus on opportunities/good practice and challenges in the delivery of non-medical education and training for all areas (Nursing, AHPs, HCSs, Pharmacy) comprising:

• induction • time for mentoring / recognition of mentors / mentor support / mentor register • student support / the “Student voice” • supervision • access to IT (student logins)

Director of Medical Education’s presentation

Focus on opportunities/good practice and challenges in the delivery of medical education and training including:

• DME’s 2015 QM3 report & Quality matrix • GMC survey results • Induction (trust and departmental) and processes in place for trainees starting out of

phase • Selection, training and appraisal of educational and named clinical supervisors (GP)

and SPA allocation • Faculty development and support • “Trainee voice” trainee engagement • Support for trainees in difficulty • Supervision including out of hours • SAS doctors

Corporate Documents

• Education and training should be discussed at every Board meeting. The last 3 sets of Board minutes will be required

• HEEoE will also require a list of the Trust’s SIs in advance of the visit and evidence of learning shared

• Corporate induction schedule

Summary of areas to be explored during the visit

• Governance of, and engagement with, non-medical and medical education and Training/education strategy

• Allocation of medical and non-medical (NMET) spending • KPIs for all non-medical groups (nursing, allied health professions, pharmacy,

HCSs): • Patient safety • Induction including departmental induction and induction for locums and trainees

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starting out of phase. • Clinical and educational supervision across the professions and learning

environments • Out of hours supervision • Electronic patient records - REMEDY • Handover • Rotas / gaps in rotas • Bullying and harassment/undermining • The trainee voice / student voice and engagement • SIs: dissemination of SIs and the learning from them / response to concerns • Support for trainees in difficulty / support for students Specialties, particularly those with concerns • Selection, training and appraisal of educational supervisors and named clinical

Supervisors / 0.25 PA allocations per trainee in job plans • Faculty of Educators / Faculty groups • Mentorship and support for mentors for all professions / mentor registers / trust

processes around mentorship • IT access and information governance including for locums • Confidentiality and dignity • E&D and safeguarding training. • Fairness: how does the Trust ensure that its processes are fair, for example is there

appropriate induction for overseas staff? How does the Trust support staff with cultural differences? Human factors training.

• NHS values How are we preparing for QPR? Pre meeting took place on 11th March 2016; there were no surprises. The points mentioned above were highlighted. HEE will send us the formal minutes of the meeting with agreed actions by us and HEE regarding preparation and arrangements for the visit. Nazir Shivji, Head of Professional Education and I are coordinating the preparation with help from HR (Medical Workforce/Education) Team. Regular meetings are being set up involving education/training leads of all professions and the Associate Director of Workforce Development and Education. Dionne Saxon and I have met Alan Hills ( Finance) to clarify matters related to our LDA with HEEoE and medical/non-medical tariff money allocation Nazir and I will keep the Exec Directors updated and will organise a meeting to brief and prepare the presentations for the day

2. Trainee Doctor Recruitment Trainee doctor recruitment situation remains very challenging nationally across all specialties. Psychiatry is one of the worst affected specialties. According to the F2 Career

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Destination Report (2015) only 52% of the doctors joined specialty or GP training after completing two years of mandatory Foundation training after graduation in 2014. What are we doing? There are various national initiatives to improve recruitment into psychiatry and to improve mental health awareness of all doctors

• Expansion of GP training opportunities We have increased our GP training capacity over the last 2-3 years in collaboration with local GP training programmes and HEEoE

• Expansion of Foundation Doctor placements in Psychiatry We have worked collaboratively with the 3 acute hospitals within NEP areas to increase psychiatry placements in line with national targets set by HEE

• MTI ( Medical Training Initiative) The Medical Training Initiative (MTI) is designed to enable a small number of International Medical and Dental Graduates to enter the UK to experience training in the NHS for up to two years before returning to their home country. Under the scheme, training capacity not required for planned UK/EEA training numbers is made available for overseas doctors and dentists who meet the required eligibility criteria. The RCPsych MTI Scheme is for psychiatrists who have qualified in their own country and who wish to further their expertise in psychiatry by acquiring additional skills in their own specialty or in a subspecialty We have been successful in attracting two such International Fellows at CT2/3 level under the RCPsych scheme to start from Aug 2016 subject to necessary checks and formalities. We are the first mental health Trust in East of England to attract trainees under the scheme.

• Offering Clinical attachments/observerships We are offering clinical attachment opportunities for local and overseas doctors to support and encourage them to apply for specialty training in psychiatry and to choose NEP as their training provider. As now psychiatry is considered as a shortage specialty, overseas doctors are also allowed to apply for training through national recruitment, subject to qualifications in round one itself We are expecting two such attachees from overseas soon Long term measures

• Work experience/Clinical Shadowing opportunities for A level students

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We have been offering such placements for A level students from local schools as part of ‘widening access’ initiatives with the aim of fighting stigma and promoting psychiatry as a career. Our consultants have also been involved in working with schools to help pupils with medical school application process

• Career fairs We have also taken part in multi-professional careers fairs promoting careers in mental healthcare delivery and also in Career fairs aimed at Foundation Year doctors

3. Medical Student Placements

• University of East Anglia From November 2016 we will be offering psychiatry placements for 4th year medical students from Norwich Medical School (University of East Anglia). To start with we have agreed to offer 4 weeks long placements for 24 students during the year in batches of 8 at a time. Depending on our performance and students’ feedback there is potential to expand the contract if we offer a valuable experience and training for the students Irrespective of the commercial benefits of such a contract; a formal link with a medical school and opportunities to be involved in medical student teaching would potentially make NEP more attractive for all grades of doctors and help with recruitment and retention.

• ARU Medical School We have signed a MoU (appendix 1) to collaborate with the Faculty of Medical Science, Anglia Ruskin University, in the development of an Undergraduate Medical School The project is at an early stage; currently going through GMC, HEE Government approval process and curriculum development. The proposal is for a smallish intake by 2018- about 60 - 70 students to begin with. In line with current priorities and changing healthcare needs and delivery models, Primary Care and Mental Health is expected to feature significantly in the curriculum Our senior clinicians across all professions and Trainees can expect a lot of opportunities to be involved ( appendix 2 ARU briefing paper)

4. Nursing Students – Recruitment We have committed to earlier engagement with student nurses in offering contracts of employment subject at the start of BSc courses, subject to completion. The aim is to gain the commitment of students to the Trust through our commitment to employing them. This will support our challenges in recruitment to Band 5 nursing roles.

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Abdul Raoof Director of Medical Education, March 2016

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Appendix 1

MEMORANDUM OF UNDERSTANDING This Memorandum of Understanding is made between North Essex Partnership University NHS Foundation Trust and the Faculty of Medical Science, Anglia Ruskin University of Rivermead Chelmsford, Essex CM1 1SQ, United Kingdom (together the Signatories) This Memorandum of Understanding signifies the wish of the North Essex Partnership University NHS Foundation Trust to collaborate with the Faculty of Medical Science, Anglia Ruskin University, in the development of an Undergraduate Medical School. This collaboration is for the purposes of promoting and developing:

the provision of undergraduate medical education in Essex by Anglia Ruskin University

the provision of clinical training placements for undergraduate medical students

the provision of high quality multi-professional learning environments for

undergraduate medical students

the development of a clinical academic faculty

medical research and innovation including clinical research and the development of technology for clinical work

the attraction of research funding from both public and private sector funding sources

the development and growth of regional, national and international centres of

excellence in clinical care

Partnership work with other national and international organisations to promote a multi-centre and multidisciplinary approach to healthcare problems informed by world-class practice.

This Memorandum establishes the commitment and intention of the Signatories to co-operate. It is not legally binding on any Signatory Signed: Signed: Dr Abdul Raoof,

Director of Medical Education For Faculty of Medical Science: For North Essex Partnership University

NHS Foundation Trust Date: Date: 09/03/2016

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APPENDIX 2

PROPOSAL TO DEVELOP AN UNDERGRADUATE MEDICAL

SCHOOL

Anglia Ruskin University

Faculty of Medical Science

Contents:

1. Introduction 2

1.1. Vision statement and objectives 2

2. Background 2

3. Justification 3

4. Link to Corporate objectives 4

5. High level requirements and engagement 4

5.1. General Medical Council 5

5.2. Department of Health 5

5.3. Health Education England 5

6. Stakeholder influences 5

6.1. Community 5

6.2. Local and regional healthcare providers 5

6.3. Anglia Ruskin University 5

6.4. Local Education and Training Board 6

6.5. Department of Health 6

7. Assumptions, risks, constraints and dependencies 6

7.1. HEFCE Funding 6

7.2. Local providers of clinical placements 6

7.3. Development timeline 6

8. Project scope and milestones 6

9. Financial business case (summarised) 7

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1. Introduction This paper summarises the proposal for a new Undergraduate Medical School situated at Anglia Ruskin University. It sets out the purpose, context, justification and conditions for developing a medical school. The detailed version of this paper was presented to, and was approved by, the ARU Board on 25th November 2015. 1.1. Vision statement and objectives for the Anglia Ruskin Medical School

Our vision is to educate and train doctors fit to deliver health care in the 21st century as set out in the Lancet Commission for health professional education1. To achieve this we aim to produce a dynamic, coherent and modern curriculum that addresses the competencies to deal with future patient and population needs, places graduates at the centre of health teams, embeds technical skills within a broader contextual understanding, emphasizes continuous care of persons rather than episodic patient encounters, puts emphasis on primary intervention rather than hospital care, and develops leaders to shape health systems. We set social accountability as our core value. To achieve this vision we will strive for the objectives of: Transformative learning

We aim to produce graduates who are able to find, analyse and synthesise information to make effective decisions, be key team workers within health systems, and respond to local priorities while understanding and mobilizing resources in the global context. We will enable doctors to become experts by acquiring the knowledge and skills to deal with disease (informative learning), to instill them with the values of professionals (formative learning), but to make them competent for the 21st century we will develop them into enlightened change agents through excellent leadership skills so that they can respond to the complexity and uncertainty of modern practice (transformative learning).

Interdependence

We aim to deliver medical education that mirrors the interdependencies of a complex health system by being part of that health system. We aim to educate and train doctors to deliver modern healthcare within education networks and alliances rather than in large, isolated ‘teaching’ institutions. We aim to provide a learning environment in an academic system rather than an academic centre, and to move from local ‘tribal’ preoccupations to

global social accountabilities. We also aim to have graduates who understand their role in a non-hierarchical, transprofessional context, and who are able to lead teams that are responsive to local and global community needs.

2. Background

2.1 Essex faces significant health workforce challenges that require innovative solutions. Primary care is a particular area of concern, with persistent under recruitment and poor retention of general practitioners in the region.

2.2 The government has made a commitment to maintain primary care as the foundation of NHS care, which means that the number of General Practitioners (GPs) in training needs to be increased as fast as possible, with new options to encourage retention.

1 Frenk J, Chen L, Bhutta Z, et al. (2010).Health professionals for a new century: transforming

education to strengthen health systems in an interdependent world. 376; 1923 – 1958.

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2.3 There is a national recognition that health systems need to work differently in order

to overcome the challenges they face2. Traditional boundaries between primary and hospital care, between physical and mental health, and between healthcare and social care represent barriers that need to be broken down2.

2.4 Undergraduate medical students enrolling now will still be practicing in 2050, which

requires education providers to understand and respond to future service delivery needs by training a resilient medical workforce. Not only will the healthcare needs of future decades be significantly different, but ways of working with patients and care providers will also be fundamentally different. The workforce will have to move from an emphasis on individual ability to collective competence, with the flexibility to tailor health care to individual patients’ needs.

2.5 There is a global recognition that undergraduate medical education will benefit from

diverse learning contexts, and that this will prepare physicians for the realities of practice in the settings that will benefit from their input. Traditionally, undergraduates have gained their clinical exposure in large tertiary centres, which serve a significantly different demographic from patients they are likely to face in the future. Educational experiences should ideally reflect societal needs so that doctors are adequately prepared for their future practice. The educational environment should be constructed as a ‘health-education system’ rather than an academic centre.

2.6 Doctors of the future should should not only be trained to be technical experts, but be

effective members of a ‘locally responsive but globally connected’ health care team, which reflects the realities of how healthcare is provided in the 21st century.

2.7 Our Postgradaute Medical Institute (PMI) has developed a rapidly expanding

postgraduate medical education capability, with a special expertise in the delivery of simulation-based medical education which enables learning in near-authentic environments whilst ensuring total patient safety. This technology-enhanced learning facilitates the acquisition of both technical skills as well as the essential non-technical skills that are vital to effective patient care.

2.8 We have developed a strong multi-professional approach to health education. Our

new Faculty of Medical Science has developed several programs in the allied health sciences, pre-hospital emergency care, and non-physician clinical care (Physician Associates and Surgical Care Practitioners). Along with nursing education these programmes will all contribute to the future NHS health workforce and are synergistic with undergraduate medical education.

3. Justification 3.1. There are both national and local shortages in those particular medical specialities which

make a significant contribution to the primary care workforce. The Centre for Workforce Intelligence (2014) makes it clear that the current level of GPs being trained is inadequate and the UK is likely to experience a significant workforce supply-demand imbalance by 2020. In addition, the psychiatry workforce per capita ratio will fall from 11.6 per 100,000 poulation (psychiatry FTE) in 2012 to 6.8 by 2033. A medical school at ARU will directly address these predicted shortages by recruiting and educating students with a propensity to work in these community-based specialisms after graduation.

2 The NHS Five Year Forward View

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3.2 The Centre for Workforce Intelligence Horizon 2035 paper (2014)3 highlights the fact that doctors tend to work in or close to the area where they trained, which supports our rationale for educating doctors locally to meet local workforce demands.

3.3 Teaching placements in Essex are currently used extensively by London-based medical schools and postgraduate specialty rotations. However, there is an intention by Health Education East of England to ‘repatriate’ these posts, which makes it opportune to develop an undergraduate training capability in Essex. This will then create the ‘pipeline’ for postgraduate recruitment with ultimate retention of community-focussed physicians upon qualification.

3.4 We are situated in an environment with a catchment population that reflects the disease burden with which future doctors will be faced. A new medical school in Essex presents an opportunity to align the training of future doctors with societal priorities. The burgeoning elderly population with its growing burden of dementia and comorbidities offers an ideal environment in which to deliver relevant medical training.

3.5 Through our PMI, we have forged close partnerships across a broad range of

organisations that are part of the regional health economy, which includes primary care, acute care, mental health, public health, hospice care and local authorities4

3.6 In keeping with NHS priorities, we are in a position to facilitate the transition of episodic

acute care to preventive care in community settings by structuring student placements within integrated pathways of care.

3.7 We have strong links with overseas medical education institutions with the opportunity to

influence global health priorities through our educational activities5. Even though the UK must produce a health care workforce capable of serving its own population, it is unavoidable that they will be called upon to deliver care in a global context. With the increasing ease of travel disease is no longer contained within narrow geographic boundaries, allowing rapid spread of infectious diseases such as SARS, H1N1 Influenza and Hemorrhagic Viral Disease, and the recrudescence of diseases such as tuberculosis and malaria. Through our links with overseas academic health care institutions, we will create opportunities for our medical students to participate in elective studies in global contexts as part of their self-directed development.

4. Link to Corporate Objectives The ambition to develop undergraduate medical training is set out in the ARU Corporate Plan 2015-17. Goal 4 expresses the intention to establish Chelmsford as a nationally and internationally recognised centre with an enhanced portfolio in health, including undergraduate medicine. 5. High level requirements and engagement 3 Horizon 2035 : international responses to big picture challenges : review of changing global models of care

and the workforce of the future. London : CfWI, 2014 4 Barking, Havering and Redbridge University Hospitals; Basildon and Thurrock University Hospitals NHS

Foundation Trust; Colchester Hospital University NHS Foundation Trust; Hinchingbrooke Health Care NHS Trust; Mid Essex Hospital Services NHS Trust; NHS South Essex; North Essex Partnership NHS Foundation Trust; Southend University Hospital NHS Foundation Trust; South Essex Partnership NHS Foundation Trust; The Princess Alexandra Hospital NHS Trust; Royal Society for Public Health; Nuffield Health; Springfield Hospital; Farleigh Hospice; Saint Francis Hospice; St Helena Hospice; St Luke's Hospice; Essex County Council 5 India, Malasia, Sri Lanka, and Zambia

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http://www.basildonandthurrock.nhs.uk/


http://www.colchesterhospital.nhs.uk/

http://www.hinchingbrooke.nhs.uk/

http://www.meht.nhs.uk/

http://southessex.nhs.uk/

http://www.nepft.nhs.uk/

http://www.southend.nhs.uk/

http://www.sept.nhs.uk/

http://www.pah.nhs.uk/


http://www.rsph.org.uk/

http://www.nuffieldhealth.com/

http://www.springfieldhospital.co.uk/

http://www.farleigh.org/

http://www.sfh.org.uk/

http://www.sthelenahospice.org.uk/

http://www.stlukeshospice.com/

http://www.essex.gov.uk/Pages/Default.aspx

5

5.1. General Medical Council We have already engaged with the GMC to begin the process of making an application to the General Medical Council (GMC) for recognition under the Medical Act (1983). The outcomes that we are required to achieve are defined in the document : Promoting excellence: standards for medical education and training (July 2015). A minimum of 30 months of development is required before the first intake of students can be considered, during and after which time there will be ongoing quality review. 5.2. Department of Health Two information sharing meetings have taken place with the Department of Health, where we made clear our intention to proceed with development of a medical school based on the justifications set out above. The Department indicated that our proposed model of education delivery was innovative and spoke to national and regional priorities. 5.3. Health Education England Formal discussions have taken place with Health Education East of England (HEEoE) to determine how a proposed medical school might align with workforce planning for the region. We reinforced our commitment to addressing issues of local workforce around community-foccused and primary care, and how our proposed model of situating a curriculum within regional contexts is likely to contribute to a solution. 6. Stakeholder influences 6.1. Community We will proactively enroll students from the region to affirm our social accountability to our population. We are committed to widening participation and will actively engage with regional high schools through a program that targets economically and educationally disadvantaged pupils. Furthermore, we will support such local students through a scholarship scheme. In the event of a fully independent financial model the medical school will also make a commitment to provide bursaries to a significant proportion of its intake. 6.2. Local and regional healthcare providers The envisaged undergraduate curriculum will deliver the outcomes required by the GMC, but will prepare doctors to serve local and regional healthcare needs and instill in them the relevant values needed for a modern NHS. It will emphasise generic acute care (rather than specialty-based care), have an appropriate mix of acute medicine, community care, psychiatry and general practice, and de-emphasises the tertiary care centre. Extended clinical placements will emphasise generalism within integrated care pathways. It will also train doctors to work effectively in teams and be comfortable with the complex environment in which they will be expected to practice. 6.3. Anglia Ruskin University We already deliver education for nursing, the allied health sciences, non-physician clinicians and postgraduate medical doctors, placing us in a position to respond to the needs of the future multi-professional workforce. Undergraduate medical education is a natural extension to this current activity. Through our Postgraduate Medical Institute, we have forged close partnerships across a broad range of organisations that are part of the regional health economy, which includes primary care, acute care, mental health, public health, hospice care

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and local authorities6. In keeping with NHS priorities, we are in a position to facilitate the transition of episodic acute care to preventive care in community settings by structuring student placements within integrated pathways of care. 6.4. Local Education and Training Board It is key that the development of a medical school brings added value to the region and aligns with the aims of Health Education East of England. 6.5. Department of Health and NHS England The case for a medical school in Essex is predicated on a ‘disruptive’ model that offers the NHS a potential solution to its medical workforce crisis. We have made clear to the DoH that we seek consciously not to emulate traditional medical schools and produce ‘more of the same’, but to produce doctors able to respond to future NHS needs. At a regional level we aim to make a positive contribution to the ‘Success Regime’, and help create the necessary conditions to achieve a sustainable healthcare workforce. 7. Assumptions, risks, constraints and dependencies 7.1. HEFCE funding Alternative business cases have been developed in the event of HEFCE not allocating any funding for student places. Early indications show that the government is unlikely to increase investment in medical education and therefore unlikely to expand nationally funded medical student numbers. 7.2. Local providers of clinical placements Medical education cannot be delivered without practicing in clinical environments. Essex benefits from having numerous healthcare providers in the region that cover the full range of acute care, primary care, mental health and community care. However, some of these providers already host students from neighbouring medical schools and we need to undertake a full evaluation of the current placement capacity to determine optimal distribution of future teaching placements. Where providers do not currently offer undergraduate training we need to support them to develop a teaching capability so that capacity (particularly in primary care) is actively expanded. 7.4. Development timeline In order to achieve an initial student intake for September 2018, the project will be initiated at the beginning January 2016. This will give approximately 20 months to develop a medical school sufficiently prepared for GMC to approve selection of students from September 2017. During this time all structures, processes, staff and clinical placements will need to be fully established to the satisfaction of the GMC. 8. Project scope and milestones There are 3 distinct phases in the development of a medical school, which are: 6 Barking, Havering and Redbridge University Hospitals; Basildon and Thurrock University Hospitals NHS

Foundation Trust; Colchester Hospital University NHS Foundation Trust; Hinchingbrooke Health Care NHS Trust; Mid Essex Hospital Services NHS Trust; NHS South Essex; North Essex Partnership NHS Foundation Trust; Southend University Hospital NHS Foundation Trust; South Essex Partnership NHS Foundation Trust; The Princess Alexandra Hospital NHS Trust; Royal Society for Public Health; Nuffield Health; Springfield Hospital; Farleigh Hospice; Saint Francis Hospice; St Helena Hospice; St Luke's Hospice; Essex County Council

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http://www.bhrhospitals.nhs.uk/



http://www.colchesterhospital.nhs.uk/

http://www.hinchingbrooke.nhs.uk/

http://www.meht.nhs.uk/

http://southessex.nhs.uk/

http://www.nepft.nhs.uk/

http://www.southend.nhs.uk/

http://www.sept.nhs.uk/



http://www.rsph.org.uk/

http://www.nuffieldhealth.com/

http://www.springfieldhospital.co.uk/

http://www.farleigh.org/

http://www.sfh.org.uk/

http://www.sthelenahospice.org.uk/

http://www.stlukeshospice.com/

http://www.essex.gov.uk/Pages/Default.aspx

7

Project initiation and proposal submission for GMC approval;

The focus of this stage is to meet the initial requirements set by the GMC for recognition to commence undergraduate medical training. The goal will be to put in place a robust plan to develop structures, systems, infrastructure and prospective curriculum. At this stage potential clinical placements will need to be identified and supported by Memoranda of Understanding with provider organisations.

Pre-operational constitution of the medical school, prior to the first intake of students;

During this phase all infrastructure build should be completed, core faculty identified, clinical placements confirmed by Service Level Agreements and a marketing strategy commenced. The GMC will require detailed documents confirming that appropriate progress is being made, culminating in a site visit at which they will make a decision about whether we are able to proceed with the proposal.

Operational phase, commencing with the first intake of students; After commencing operations the GMC will undertake annual performance and quality reviews over the first 5 years to assure itself that the outcomes it requires will be attained. During this phase there will be a progressive scale-up up faculty and systems to support a year-on-year increase in student number until the potential full capacity of 300 students is reached.

9. Financial business case (summarised) 9.1 Capital Expenditure

An investment of £18m has been factored in to develop physical accommodation for a new medical school, to include the costs of Fixtures Fittings and Equipment. There will also be an investment of £1.5m to develop a world class Anatomy teaching facility, which will include an imaging and skills laboratory. In addition, there will be a £500k investment in hospital hubs to support distributed training sites.

9.2 The primary business case is based on 60 student places per intake year, with an

attrition rate of 3%. This means that at year 5 we will have 283 FTE students on the programme.

9.3 Financial business cases have been costed for both options of nationally funded places

and self-funded students. The independent model describes the effect of scholarships aimed at widening participation, and of placement fees in lieu of SIFT.

9.4 Research and Third Stream Income

A modest research income is assumed in the early years starting at £100k, growing to £1.55m in the later years. This will be achieved through Clinical Academic staff and Professors bringing their research portfolios with them.

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 19 Date: 23 March 2016 Title of Report: Insurance Arrangements 2016/17 Leads: David Griffiths (Director of Resources) & Dermot McCarthy (Trust Secretary) Subject, Purpose and Recommendation: The Board of Directors is asked to note the purchase of ‘top-up’ insurance cover for 2016/17 Finance Implications: The cost of ‘top up’ insurance cover for 2016/17 is £38,925 (subject to final adjustment) compared to the last renewal premium of £42,692 including Insurance Premium Tax. Clinical Implications: N/A HR Implications: N/A Legal and/or Regulatory Implications: N/A Equality Implications: N/A Risks: The insurance provided under the NHS Litigation Authority (NHSLA) scheme does not meet the Trust’s needs as a Foundation Trust and mitigating action therefore needs to be taken, by taking out top-up cover via the commercial market.

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NEP Insurance Arrangements 2016/17 1) Background: Standing Financial Instructions (SFIs) item 21.3 state that: The Finance Director shall report to the Board of Directors at intervals of not more than fifteen months on the insurances in respect of its operations of which the Trust has the benefit, and shall make recommendations to the Board of Directors (consistent with any guidance issued by Monitor) as to whether the Trust should insure through the risk pooling schemes administered by the NHS Litigation Authority for some or all of the risks covered by the risk pooling schemes, or insure with commercial insurers. The last report was made to the Board in March 2015, and in accordance with the SFIs an update report is now brought to the Board. The Trust’s core insurance cover is provided via the National Health Service Litigation Authority (NHSLA), a Special Health Authority established in 1995 under Section 11 of the NHS Act 1977. The principal task of the Authority is to administer schemes set up under Section 21 of the National Health Service and Community Care Act 1990. This enables the Secretary of State to set up one or more schemes to help NHS bodies pool the costs of any “loss of or damage to property and liabilities to third parties for loss, damage or injury arising out of the carrying out of [their] functions”. There are four core NHSLA schemes: a) a scheme covering liabilities for alleged clinical negligence where the original incident occurred on or after 1 April 1995 (the “Clinical Negligence Scheme for Trusts” or CNST); b) a scheme covering liabilities for clinical negligence incidents which occurred before that date (the “Existing Liabilities Scheme” or ELS); c) a scheme relating to any liability to any third party where the original incident occurred on or after 1 April 1999 (the Liability to Third Party Scheme or LTPS); d) a scheme relating to any expenses incurred from any loss or damage to property where the original loss occurred on or after 1 April 1999 (the Property Expenses Scheme or PES). The insurance matters relating to a) to c) above are dealt with via the Risk Management Department under the direction of the Director of Nursing & Quality , reporting through the Risk and Governance Executive (RGE). A key issue for FTs in relation to the PES (Property Expenses Scheme PES) is summarised by the Healthcare Financial Management Association (HFMA) guidance (FT Finance Briefing - FT Insurance Cover, April 2009) which confirmed the need for FTs ‘to buy cover over and above the £1m threshold the NHSLA provides for its various property covers, plus additional cover for activities excluded by the NHSLA, such as non-NHS income generation.’ Following input from NHS Providers a selection process for insurance brokers was carried out and Trust secured the services of Willis to consider the scope of cover afforded by the NHSLA, advise on general insurance matters, and to secure any appropriate additional cover from the market. Willis has advised that the key area to address relates to property. This is consistent with the work of NHS Providers in this

227

area and HFMA guidance. This report therefore focuses on the cover afforded under item 1d) above, the NHSLA Property Expenses Scheme (PES). 2) Property a) Material Damage As previously reported to the Board (March 2014) the key issue relates to property insurance where the NHSLA limit of cover is low. The PES limit for each property claim is £1million, significantly less than the value of a number of Trust owned buildings and their contents [PES Scheme 7.1]. In a letter to the FT Network (NHS Providers’ predecessor organisation) [September 2007] the scheme lead gives the context: “The original intention was that the burden of a significant or catastrophic loss would not fall on the pool and instead Members would, in the event of a loss that exceeded the limit, approach the relevant NHS Executive Regional Office to explore future service plans and funding requirements, as opposed to automatically recreating the asset. With the advent of FTs and the absence of any form of alternative NHS funding, the issue of full-value property coverage assumes considerable importance.“ This indicated the need for the Trust to put in place additional cover in relation to buildings with a replacement value in excess of £1million. Following advice from Willis, the Trust put in place extended cover for the buildings which it owns which have a replacement value in excess of £1million. This list was been updated (February 2016): • The Linden Centre/Edward House • Derwent Centre • The Lakes • The Crystal Centre • The C&E Centre • The St Aubyn Centre • Kingswood • Landermere Centre • Herrick House b) Business Interruption Business interruption insurance addresses the issue of significant loss from interruption or interference with the business of the Trust resulting in a loss of income and increased costs of working. Under the NHSLA Property Expenses Scheme (PES) cover is in place in respect of business interruption of up to £1m for an indemnity period of 24 months. Due to the risk of a requirement in excess of £1m for this purpose in respect of the Trust’s larger properties (listed above), extended business interruption insurance has been purchased from the commercial sector. This is set at a level of £3m with an indemnity period of 24 months. Our brokers advise that this is an appropriate level of cover. In addition to the properties listed, this extended cover has been applied to all properties that are occupied by the Trust. c) Loss Recovery Following a major loss this service provides a range of expert support including: • Providing initial telephone assistance 24 hours a day, 7 days a week • Personal attendance by the claims handler as soon as practicable following

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notification of the loss to ascertain extent of any loss or damage and liaise with insurers in all matters concerning the loss. • Preparation of itemised schedule of valuation of all fixtures & fittings, plant, machinery and stock for submission to insurers. • Co-ordination of surveyors, engineers, architects and builders as required • Negotiating interim payments from insurers • Negotiating the best practicable settlement within the limitations of the relevant policyholder. 3) Fraud/Fidelity Guarantee The Board has also previously noted the issue of cases of fraud involving 3rd party payment services and the potential of fraud by staff. Contractual terms in place address the issue of fraud carried out by an employee of the provider of payment services (reported to the Board in March 2012 (under agenda item 16, Update - New Contract for Payroll and Financial Services) including that: “The contract provides £5million cover for negligent acts, errors or omissions by the contractor …” In respect of the issue of potential fraud by employees, there is limited Fidelity Guarantee cover under the PES (limited to £250k, with a £20k excess). The Trust holds top-up cover for a limit of indemnity of £5million, any one loss). It is recommended that this cover continue for 2016/17. 4) Income Generation and Fundraising Although the scope of the NHSLA scheme has been extended in terms of activities covered this year, our broker’s advice is that this may not cover the full scope of the activities of Enable East and top-up cover is therefore included in the proposal for 2015/16. The Trust also has in place cover for fundraising activities offsite. (Limit of indemnity £5million). 5) Premiums/Insurers Category of Cover £ Provider Property top up/business interruption 22,422 Liberty Mutual Insurance Co Loss Recovery 850 Lorega Public and Products (inc. off site events) 525 Travelers Insurance Co Crime 6,000 AIG Europe Ltd MVA trailer 500 Aviva Insurance Services UK Broker Fee 5,750 Willis Insurance Premium Tax 2,878 - Total 38,925 = Liberty, a major company with a Standard and Poor rating of ‘A- (Strong)’ (March 2016). 6) Other issues a) Directors and Officers – One area of potential concern for Non-Executive directors is the liabilities they may face in the event of any wrong decisions or negligence on their part. Cover is in place under the PES [Schedule 4] for NHS work. The indemnity for Non Executives reads ‘A chairman or non-Executive member or director who has acted honestly and in good faith will not have to meet out of his or her own personal resources any personal civil liability which

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is incurred in the execution of purported execution of his or her board function, save when the person has acted recklessly’. This does not cover private contracts and other non-NHS responsibilities. Charity work is not covered, so a claim resulting from an error or omission raising, handling or spending charitable funds would not be covered by the NHSLA, albeit the risk is negligible. b) Governors - The NHSLA lead has advised the FT Network that Directors and Officers cover (D&O) does extend to governors: “The only ‘Board’ in the mind of the creators of LTPS in 1999 would have been the Board of Directors, but I am happy to extend D&O cover to any member of a Foundation Trust Board of Governors, provided of course that any liability arises out of the ‘Relevant Function’. The indemnity would apply to any member of a properly constituted Board of Governors regardless of what name that Board might go under”. It is therefore recommended that separate cover is not taken out in respect of governors’ liability. 7) Recommendations: The Board of Directors is to note the purchase of ‘top-up’ insurance cover for 2016/17.

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North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 20 Date: 23 March 2016 Title of Report: Summary of Board Decisions Presented By: Dermot McCarthy, Trust Secretary Subject, Purpose and Recommendation: Attached for information is a summary table showing a ‘rolling year’ of Board decisions. The Board of Directors is asked to note the report. Finance Implications: N/A Clinical Implications: N/A HR Implications: N/A Legal Implications: N/A Equality Implications: N/A Risks: N/A

231

Date of Meeting

Type of Meeting

Minute Reference

Decision Item Received/Noted etc

26.03.14 Public 2014/026 Minutes of the Meeting Held In Public on 29 January 2014 The Minutes of the meeting held on 29 January 2014 were agreed at a correction record and signed by the Chairman.

2014/028

North East Area & CAMHS Business Plan - The Board of Directors received the North East Area and CAMHS Business Plan.

2014/029

Chief Executive’s Report The Board of Directors received the Chief Executiv Report.

2014/030 Suicide prevention: joint working initiative with The Samaritans The Board of Directors

a) received the Suicide Prevention: Joint Working Initiative with Samaritans and

b) agreed that the Memorandum of Understanding and Non-Disclosure Agreement be signed.

2014/031 Financial Plan/contract for 2014/15 The Board of Directors received and noted the Financial Plan/Contract for 2014/15 Report

North Essex Partnership University NHS Foundation Trust - Summary of Board Decisions

232

Date of Meeting

Type of Meeting

Minute Reference


2014/032

The Monitor Annual Planning Process - Two-Year Operational Plan Submission The Board of Directors noted the report re the Monitor Annual Planning Process – Two-Year Operational Plan Submission.

2014/033 Patient Experience The Board of Directors noted progress against the action plans; approved the terms of reference for the Patient Experience Group subject to the agreed amendments.

2014/034

Staff Survey The Board of Directors received the presentation from Lisa Anastasiou regarding the Staff Survey.

2014/035 Duty of Candour The Board of Directors:

a) noted the report on the proposed statutory Duty of Candour; and

b) approved the “Being Open and Duty of Candour” Policy for a period of one year, subject to the addition of a Statement of Intent noted above.

2014/036 Quality account priority improvements 2014/15 The Board of Directors accepted the recommendations made by the Risk and Governance Executive in respect of the Quality Account/Report.


233

Date of Meeting

Type of Meeting

Minute Reference


2014/037 Finance report for the month ended 28 February 2014 The Board of Directors noted the Finance Report as at 28 February 2014.

2014/038 Operational performance summary to 28 February 2014 The Board of Directors noted the Trust's performance against Monitor’s access and outcome indicators contained within the Risk Assessment Framework (RAF).

2014/039 Workforce Report The Board of Directors received and noted the Workforce Report.

2014/040 Quality and Risk report The Board of Directors noted the Quality and Risk Report.

2040/041

Journeys Programme The Board of Directors: a) Received the Journeys Highlight Report and approved the revised project timescales (July 2014). b) Noted the dissolution of the Journeys Programm Board and the ongoing direct oversight of the programme by the Executive Management Team (EMT)


234

Date of Meeting

Type of Meeting

Minute Reference


2014/042 Senior Independent Director (SID) The Board of Directors appointed Brian Johnson as Senior Independent Director with effect from 1 June 2014.

2014/043 Insurance Arrangements The Board of Directors noted the purchase of top up insurance cover for 2014/15 and agreed that this be extended for a further year.

2014/044 Council of Governors – Meeting held on 11 March 2014 The Board of Directors received feedback on the Council of Governors’ meeting held on 11 March 2014.

2014/045 Execution of Deeds The Board of Directors noted the Report.

26.03.2014 Private P2014/039 Financial Plan and Contracts For 2014/15 The Board of Directors agreed that

a) A break even budget be established for both years of the 2-year plan (2014/15 and 2015/16).

b) The Capital programme (excluding the Derwent Centre) be scaled down for 2014/15.

c) Subject to the above, the Board of Directors approved the Financial Plan for 2014/15.


235

Date of Meeting

Type of Meeting

Minute Reference


P2014/040 Outline Financial Plan – Progress The Board of Directors agreed that the Outline Capital Plan should be reviewed in the context of the previous item and a brief update circulated during the week commencing 31 March 2014.

P2014/041 The Monitor Annual Planning Process – Two Year Operational Plan Submission The Board of Directors

a) noted the report b) agreed to the submission of the Two Year

Operational Plan to Monitor c) recorded its thanks to Quentin Cornish for his

excellent contribution to the plan.

P2014/042 Commercial And Service Integration – Update The Board of Directors noted Commercial and Service Integration update.

P2014/043 Finance Report For The Year Ended 29 February 2014 The Board of Directors noted the finance report for the year ended 29 February 2014.

P2014/044 Severalls Verbal Update The Board of Directors noted the Severalls Verbal Update.


236

Date of Meeting

Type of Meeting

Minute Reference


P2014/045 Monitor’s Risk Assessment Framework Reporting requirements re. Disposal of Severalls The Board approved the following statement; “The Board of Directors is satisfied that the Trust has considered and followed the requirements for a material transaction as set out in Appendix C of the Risk Assessment Framework (RAF) and also in Monitor’s Risk Evaluation for Investment Decisions by NHS Foundation Trusts (REID)”.

P2014/046 REMEDY Update The Board of Directors noted the REMEDY update.

25.05.2014 Public 2014/54

Chief Executive’s Report The Board of Directors received the report.

2014/55 The Monitor Annual Planning Process For 2014/15 Beyond The Board of Directors: Noted the initial feedback from Monitor regarding the two year operational plan and progress and requirements of the 5 Year Strategic Plan. Confirmed its agreement to the self-certifications contained in the report “in principle”, subject to circulation of a documented rationale of the verbal assurances given, by 30 May 2014.


237

Date of Meeting

Type of Meeting

Minute Reference


2014/56 Annual Reports 2013/14 of the Board Committees a The Board of Directors approved the reports of the Audit Committee, Nominations Committee and Remuneration Committee for 2014/15.

2014/57 Annual Report, Quality Account And Financial Accounts For The Period End 31 March 2014 The Board of Directors: - Approved the Annual Report 2013/14 subject to

any non-material changes to be authorised by the Chief Executive.

- Agreed to postpone adoption of the Financial Accounts for the period 2013/14 until 28 May 2014.

- Agreed to present the Annual Report & Accounts 2013/14 to the Council of Governors at the Governors’ Annual Public Meeting on 22 September 2014.

-

2014/58 Annual Accounts 2013/14 – Directors’ Assessment of Going Concern The Board of Directors confirmed that there were no material uncertainties that may cast significant doubt about the Trust’s ability to continue as a going concern for at least 12 months beyond the date of the 2013/14 statement of accounts.


238

Date of Meeting

Type of Meeting

Minute Reference


2014/59 Patient-Led Assessment of the Care Environment (PLACE) 2013 – Action Plan Update The Board of Directors noted the PLACE action plan update.

2014/60 Serious Incidents (SIs) Annual Report 2013/14 The Board of Directors Received the Serious Incidents (SIs) Annual Report 2013/14.

2014/61 Finance Report For The Month Ended 30 April 2014 The Board of Directors approved the Month 1, 2014/15, Financial Report.

2014/62A) Operational Performance Summary To 30 April 2014 The Board of Directors noted the Trust's performance against Monitor’s access and outcome indicators contained within the Risk Assessment Framework (RAF).

2014/62 B) Workforce Report The Board of Directors received and noted the Workforce Report.


239

Date of Meeting

Type of Meeting

Minute Reference


2014/63

Quality and Risk Report The Board of Directors noted the Quality and Risk Report.

2014/64

Hard Truths – Ward Staffing Levels The Board of Directors received the Hard Truths Safe Staffing Initial Report.

2014/65

Monitor Compliance – Finance & Governance Report for Quarter 4 2013/14 The Board noted the Monitor compliance return for Finance and Governance for Quarter 4, 2013/14, including that the submission supports the following ratings: Continuity of Service Risk Rating (CoSRR) of 3 Governance Risk Rating (GRR) of Green.

2040/66 Journeys Programme Highlight Report The Board of Directors discussed the Journeys Highlight Report, noted the progress to date, the risks identified and the agreed extension of the public consultation.

2014/67 Quality Governance Framework Action Plans The Board noted the Quality Governance Framework Action Plans.

2014/68 Execution of Deeds The Board noted the report.


240

Date of Meeting

Type of Meeting

Minute Reference


2014/69 Non Executive Director (NED) Committee Responsibilities The Board approved schedule of Non Executive Director committee responsibilities.

2014/70

Summary of Board Decisions The Board noted the report.

2014/71 Any other notified business: a) Council of Governors – Lead Governor

Election Process The Board noted the report.

b) John Gilbert, Non Executive Director The Board of Directors recorded its thanks to John Gilbert for his significant contribution to the work of the Trust as a Non Executive Director.

21.05.2014 Private P2014/051

Audit Committee – Verbal Report On The Meeting Held on 21 May 2014

P2014/052 The Monitor Annual Planning Process For 2014/15 And Beyond The Board of Directors noted the report.

P2014/053 Commercial and Service Integration Update The Board of Directors noted Commercial and Service Integration update.


241

Date of Meeting

Type of Meeting

Minute Reference


P2014/54

Severalls Hospital Disposal Verbal Update The Board of Directors noted Severalls Hospital Disposal verbal update.

P2014/055 Finance Report for the Month Ending 30 April 2014, Month 01 The Board of Directors noted the Finance Report, verbal update, for Month 1.

28.05.14 Private P2014/060 The Monitor Annual Planning Process for 2014/ And Beyond The Board of Directors noted the update regarding the Annual Planning Process including that a set of positive declarations would be made to Monitor.

P2014/061 Annual Report, Quality Account and Financial Accounts For The Year Ended 31 March 2014 The Board of Directors: - Adopted the accounts for the period 2013/14; - Agreed the Letter of Representation; - Agreed to Present the Annual Report &

Accounts 2013/14 to the Council of Governors at the Governors’ Annual Public Meeting on 22 September 2014.

30.07.14 Public 2014/74 Presentation The Board of Directors received presentation by D Olive, Area Director West Essex and members of h management team.


242

Date of Meeting

Type of Meeting

Minute Reference


2014/80 Chief Executive’s Report The Board of Directors received the Chief Executive’s report

2014/83 “Our NEP” – Update On Progress Regarding Branding And Values The Board of Directors received the report

2014/84a Journeys a) Programme Highlight Report

The Board of Directors received the Journeys Programme Highlight report.

2014/84b b) Trust Response to Stakeholder Comments on the Journeys report

The Board of Directors received the report re the Trust Response to Stakeholder Comments on the Journeys.

2014/85 Carers’ Strategy 2014/17 The Board of Directors approved the implementation of the Carers’ Strategy 2014-17.

2014/86

Complaints And Compliments Annual Report The Board of Directors received the Complaints and Compliments report 2013/14.


243

Date of Meeting

Type of Meeting

Minute Reference


2014/87

General Medical Council (GMC) National Training Survey 2014 The Board of Directors received the GMC Training Survey 2014

2014/88 Finance Report For The Year Ended 30 June 2014 The Board of Directors received the Finance Report for the year ended 30 June 2014

2014/89 Performance Report The Board of Directors received and noted the Performance and the Workforce Report

2014/090 Monitor Compliance Finance & Governance Report For Quarter 1 2013/14 The Board of Directors approved the Monitor Compliance Finance & Governance Report for Quarter 1, 2014/15.

2014/091 Maintaining And Ensuring Safe Staffing Levels The Board of Directors received the Maintaining and Ensuring Safe Staff Levels report.

2014/092 Quality and Risk Report The Board of Directors received the Quality and Risk Report.


244

Date of Meeting

Type of Meeting

Minute Reference


2014/093 Annual Report On Medical Revalidation 2013/14 The Board of Directors:

a) received the report and; b) agreed that the Chairman sign a declaration

providing the Medical Director as the Responsible Officer a completed ‘statement of compliance’ confirming that the organisation, as a designated body, was in compliance with the regulations.

2014/094 Risk and Governance Executive Annual Report 2013/14 The Board of Directors received the Risk and Governance Annual report 2013/14.

2014/095 Research and Development Annual Report 2013/2014 The Board of Directors received the R&D Annual report.

2014/096 Reservation of Powers to the Board and Scheme of Delegation The Board of Directors approved the revised Reservation of Powers to the Board and Scheme of Delegation.

2014/097 Standing Financial Instructions: The Board of Directors approved the revised Standing Financial Instructions


245

Date of Meeting

Type of Meeting

Minute Reference


2014/098 Execution of Deeds The Board of Directors approved the Execution of Deeds.

30.07.14 Private P2014/060 Minutes of the meeting held in private on 21 May 2014 The minutes of the meeting held on 21 May 2014 were agreed as a correct record and signed by the Chairman.

P2014/61 Minutes of the meeting held in private on 28 May 2014 The minutes of the meeting held on 28 May 2014 were agreed as a correct record and signed by the Chairman.

P2014/62 Derwent Centre Update on Phases 2-5 The Board:

i) Approved (retrospectively) the decision by EMT to place an order with Vinci Construction for the concrete strengthening works

ii) Approved entering into the main contract with Vinci Construction

iii) Approved instruction to Vinci Construction to undertake a redesign and costing exercise for the removal of the Lower Ground Floor as a Contract Variation and subject to the potential cost saving for EMT to instruct the project team accordingly


246

Date of Meeting

Type of Meeting

Minute Reference


iv) Approved proceeding with a further Value Engineering exercise with Vinci

v) Agreed to transfer responsibility of structural design to Vinci Construction subject to discussions with Vinci and advice from Castons

vi) Acknowledged the revised programme and contract dates

vii) Approved the overall total project budget for phases 2 to 5.

P2014/063

Severalls Hospital Disposal Udpate The Board of Directors noted its support for the ongoing negotiations.

P2014/064 Capital Investment – revised funding Plan 2014/15 to 2018/19 The Board of Directors received the revised forward plan for capital investment 2014/15 to 2018/19.

P2014/065 Authority to Apply for Loan Finance The Board of Directors gave the Director of Resources authority to apply to the DH Independent Trust Finance Facility for;

i) loan finance for the Derwent Centre ii) bridging loan for the Severalls cashflow.


247

Date of Meeting

Type of Meeting

Minute Reference


P2014/066 Award of the Cook Chill Catering Contract The Board awarded the contract for the Provision of Cook Chill Food to Anglia Crown for 3 years, commencing 03 November 2014.

P2014/067 Audit Committee – Verbal Report Re the Meeting held on 17 July 2014 The Board received the report re the Audit Committee held on 17 July 2014.

P2014/068

Journeys Staff Consultation The Board received the presentation re the Journeys Staff Consultation.

P2014/069

Commercial and service integration Update The Board received the Commercial and Service Integration Update.

P2014/070 National NHS Community Mental Health Service Users Survey Results Summary (Embargoed) The Board received the presentation re the National NHS Community Mental Health service uses survey results.


248

Date of Meeting

Type of Meeting

Minute Reference


P2014/071 Anonymous Whistle Blowing Complaints Edward House The Board noted the report.

P2014/072 Finance Report For The Year Ended 30 June 2014, Month 03 The Board of Directors noted the Finance Report for Month 3.

P2014/073 Five Year Strategy The Board agreed that the Director of Strategy would offer feedback meetings to Non Executive Directors over the next 2 weeks.

24.09.2014 Public 2014/106 Minutes of The Meeting held on 30 July 2014 The minutes of the meeting held on 30 July 2014 were agreed as a correct record and signed by the Chairman.

2014/108 Chief Executive’s Report The Board of Directors received the Chief Executive’s Report.

2014/109 Initial Feedback from Monitor Regarding their Review of The Trust’s 5 Year Plan Submission The Board of Directors noted the report.


249

Date of Meeting

Type of Meeting

Minute Reference


2014/110 National NHS Community Health Service Users’ Survey The Board of Directors received and noted the results of the Community Mental Health Users’ Survey.

2014/111 Journeys – High Level Summary Progress Report The Board of Directors received and noted the Journeys Summary Progress Report, including the revised project timescales.

2014/112 Finance Report for the month ended 31 August 2014 The Board of Directors received the Finance Report for the month ended 31 August 2014.

2014/113 Performance Summary The Board of Directors received and noted the Performance and the Workforce Reports.

2014/114 Safe Staffing The Board of Directors received the Safe Staffing Report.

2014/115 Quality and Risk Report The Board of Directors received the Quality and Risk Report.


250

Date of Meeting

Type of Meeting

Minute Reference


2014/116 Constitution Review The Board of Directors approved the changes to the Trust’s Constitution prior to consideration by the Council of Governors on 07 October, 2014.

2014/117 Audit Committee Membership The Board of Directors approved the membership of the Audit Committee

2014/118 Nominations Committee Report The Board of Directors:

i) received the report regarding the meeting of the Nominations Committee held on 01 September 2014; and

ii) approved the Terms of Reference of the Nominations Committee.

2014/119 Summary of Board Decisions The Board of Directors received the summary of Board decisions.

26.11.2014 Public 2014/123 Mid Area and Secure Services Business Plan The Board of Directors received the presentation regarding the Mid Area and Secure Services Business Plan.

2014/127 Minutes of the Meeting held on 24 September 2014 - The Minutes of the meeting held on 24 September 2014 were agreed as a correct record and signed by the Chairman.


251

Date of Meeting

Type of Meeting

Minute Reference


2014/129 Chief Executive’s Report The Board of Directors received the Chief Executive’s Report.

2014/130 Update on the NEP Five Year Strategy ‘All Together Better’ – Following Stakeholder Consultation The Board of Directors noted:

a) the publicly circulated version of the NEP Five Year Strategy, “All Together, Better” and;

b) the guidance to areas and directorates for the completion of business plans, which will deliver the new Trust Strategy.

2014/131 Carers’ Strategy Action Plan Update

The Board of Directors noted the Carers’ Strategy Action Plan Update.

2014/132 Patient-Led Assessment of the Care Environment (PLACE) Inspection 2014 The Board of Directors noted the PLACE 2014 results and action plan.

2014/133 Finance Report as at 31 October 2014 The Board of Directors received the Finance Report as at 31 October 2014.


252

Date of Meeting

Type of Meeting

Minute Reference


2014/134 Losses and Special Payments Approval - The Board of Directors approved the write-off in respect of this debt for £54,570.

2014/135 Performance Summary - The Board of Directors received and noted the Performance and the Workforce Reports.

2014/136 Safe Staffing Levels - The Board of Directors received the Safe Staffing Monthly Update Report for each of the Trust’s Wards.

2014/137 Quality and Risk Report - The Board of Directors received the Quality and Risk Report.

2014/138 Risk Management Strategy - The Board of Directors approved the Risk Management Strategy on an interim basis, until 31 May 2015.

2014/139 Audit Committee Terms of Reference - The Board of Directors approved the revised Terms of Reference of the Audit Committee.


253

Date of Meeting

Type of Meeting

Minute Reference


2014/140 Revised Anti-Fraud & Bribery Policy The Board of Directors approved the revised Anti-fraud & Bribery Policy.

2014/141 ECC and NEP Annual Partnership Report - The Board of Directors received the report.

2014/142 Register of Directors’ Interests - The Board of Directors received the update to the Register of Directors’ Interests.

2014/143 Summary of Board Decisions The Board of Directors received the Summary of Board Decisions.

2014/144 Execution of Deeds - The Board of Directors noted the report re the Execution of Deeds.

26.11.2014 Private P2014/089 Minutes of The Meeting Held In Private on 24 September 2014 – The Minutes of the meeting were agreed as a correct record and signed by the Chairman.


254

Date of Meeting

Type of Meeting

Minute Reference


P2014/090 Commercial & Service Integration Report The Board of Directors received the

Commercial and Service Integration Report. P2014/091 Severalls Disposal Update

The Board of Directors agreed to the recommendations as presented

P2014/092 Journeys High Level Summary Progress Report

The Board of Directors: i) Noted the progress re Journeys to date

and the risks identified ii) Noted the establishment of the Journeys

Implementation and Transition Steering Group. (JITSG)

iii) Noted the detailed Implementation and transition plan and progress rating.

P2014/093 Serious Incident Panel Investigation Report

The Board of Directors received the Serious Incident Panel Investigation report including the findings and recommendations

P2014/094 Board Committee Reports/Minutes The Board of Directors noted the:

• Quality and Risk Committee Report • Audit Committee Draft Minutes (09

October 2014) • The Nominations Committee Draft

Minutes (22 October 2014).


255

Date of Meeting

Type of Meeting

Minute Reference


28.01.16 Public 2016/154 Chief Executive’s Report The Board of Directors noted the Chief Executive’s Report.

2016/155 Nominations Committee Report re the Appointment of an Interim Chief Executive The Board of Directors received the report on behalf of the Nominations Committee.

2016/156 Chief Inspector of Hospitals Care Quality Commission (CQC) Inspection August 2015: Publication of Final Report on 26 January 2016 The Board of Directors received the final report from the Chief Inspector of Hospitals Care Quality Commission (CQC) Inspection in August 2015 published on 26 January 2016.

2016/157 Mortality Review at Southern Healthcare FT and Implications for NEP The Board of Directors: Received the report outlining themes from the recent Southern Healthcare Report; ii) Noted and approved the actions that are now being taken with the Trust; and iii) Agreed to discuss this further at the Quality and Risk Committee (QARC).


256

Date of Meeting

Type of Meeting

Minute Reference


2016/158 Patient-Led Assessment of the Care Environment (PLACE) Inspection 2015 The Board of Directors noted the confirmed PLACE 2015 results and the Trust’s action plan update.

2016/159 NHS Benchmarking Network – Mental Health Benchmarking – 2015 Benchmarking of the 2014/15 Reference Cost Submission The Board of Directors noted the 2014 NHS Reference cost benchmarking report.

2016/160 Update on Merger The Board of Directors noted the update re the merger and confirmed the decision to proceed.

2015/161 Finance Report for the 9 Months Ending 31 December 2015 The Board of Directors noted the Finance report for the nine months ending 31 December 2015.

2015/162 Operational Performance Summary to 31 December 2015 The Board received and noted the Trust’s Operational Performance at Month 9.

2016/163 Workforce Report The Board of Directors received and noted the Workforce Report.


257

Date of Meeting

Type of Meeting

Minute Reference


2016/164 Monitor Compliance – Finance & Governance Return for Q3 2015/16 The Board of Directors approved the Monitor Compliance Return for Finance & Governance for Quarter 3 2015/16, including the associated Board Declarations.

2016/165 NHS Improvement Agency Rules The Board of Directors noted the update in relation to the use of agency staff and rules issued by Monitor and the Trust Development Agency (TDA) (now NHS Improvement) in respect of the use of agency nurses.

2016/166 Quality Report The Board of Directors received and noted the Quality Report.

2016/167 Ward Staffing Levels (November 2015) The Board of Directors received the Ward Staffing Level report.

2016/168 Capacity and Capability Skill Mix Review The Board of Directors:

• Noted the contents of the report and expectations for reporting staffing capability and capacity to the Trust Board

• Reviewed the methods used to address the capacity and capability of the Skill Mix Review

• Noted intended work on dependency/acuity,


258

Date of Meeting

Type of Meeting

Minute Reference


and to consider the outcome of this work at its July Board

• Agreed to receive for formal review on a six monthly basis staffing levels/skill mix report

• Agreed that a financial impact assessment of enhancing the skill mix is required for completeness

• Supported the recommendations in the report.

2016/169

Board Committee Verbal Reports The Board of Directors received the verbal report regarding the Quality and Risk Committee (23.12.15) The Board of Directors received the verbal report regarding the Remuneration Committee (12.01.16) The Board of Directors received the verbal report regarding the Remuneration Committee (14.01.16)

2016/170 Nursing and Midwifery Council (NMC) Revalidation for Nurses The Board of Directors noted the update report dated 08 January 2016.


259

Date of Meeting

Type of Meeting

Minute Reference


2016/171 Emergency Preparedness, Resilience and Response Assurance – Update on Action Plan The Board of Directors noted the report and confirmed that the 2 assurances described (information cascade testing and transport arrangements) were adequately managed via the Trust’s Emergency Plan.

2016/172 Medical and Non-Medical Education The Board of Directors received the verbal update on Medical and Non-Medical Education.

2016/173 Policy for the Approval and Management of Policy The Board of Directors approved the Policy for the Approval and Management of Policy.

2016/174 Summary of Board Decisions The Board of Directors noted the Summary of Board Decisions.

2016/175 Execution of Deeds The Board of Directors noted the Execution of Deeds.

28.01.16 Private P2015/093 Minutes of the Meeting held in private on 16 December 2015 The minutes were agreed as a correct record and signed by the Deputy Chairman.


260

Date of Meeting

Type of Meeting

Minute Reference


P2015/095 Monitor Annual Plan The Board of Directors noted the report re the Monitor Annual Plan.

P2015/096 Merger of NEP with SEPT The Board of Directors noted the report and discussion re the Merger NEP and SEPT.

P2016/097 Monitor Investigation The Board of Directors noted the report and discussion re the Monitor Investigation.

P2016/098 2016/17 Financial Planning Parameters The Board of Directors: i) Confirmed that further dicussion of the control total (£2.8M deficit for 2016/17) would take place at an additional meeting of the Board of Directors in Private. ii) Agreed the CIP programme for 2016/17 and the related assurance process.

P2016/099 Suffolk Primary Care MH Service Tender Update Briefing The Board of Directors: Received the report regarding the Suffolk Primary Mental Health Care Tender; and Delegated authority to the Chief Executive to submit the bid in advance of the deadline (15 February 2015) XXX.


261

Date of Meeting

Type of Meeting

Minute Reference


P2016/100 Staff Survey The Board of Directors received the Presentation re the Staff Survey.

P2016/101 Linden Centre The Board of Directors: i) Received the report re the Linden Centre; and ii) Approved the recommendation to proceed with the Developmental Plan.

P2016/102 Chief Inspector of Hospitals (Care Quality Commission) Inspection August 2015 – Publication of Final Report 26 January 2016 The Board of Directors noted the verbal update re the Chief Inspector of Hospitals (Care Quality Commission) Inspection August 2015.

P2016/103 Journeys Evaluation The Board of Directors received the report re Journeys’ Evaluation.

P2016/104 Derwent Centre i) The Board of Directors supported the decision to implement the hybrid model for the operation of the hub at the Derwent Centre. ii) Derwent Centre Project Progress Update The Board of Directors noted the report including the project risks.


262

Date of Meeting

Type of Meeting

Minute Reference


P2016/105 Report on Income Contract Performance The Board of Directors noted the report on income contract performance.

P2016/106 CCG Contract, Second 6 Months – Verbal Report The Board of Directors noted the report re CCG Contract, Second 6 Months

P2016/107 Board Committees a) Quality and Risk Committee (23 December

2015) The Board of Directors received the draft minutes of the meeting of the Quality and Risk Committee held on 23 December 2015.

b) Nominations Committee (12 January 2016) The Board of Directors received the draft minutes of the meeting of the Nominations Committee held on 12 January 2016.

c) Remuneration Committee (12 January 2016) The Board of Directors received the draft minutes of the meeting of the Quality and Risk Committee held on 23 December 2015.

P2016/108 Board Evaluation Next Steps The Board of Directors: i)Received copies (tabled) of the Board Development Plan


263

Date of Meeting

Type of Meeting

Minute Reference


ii) Noted that this was a topic for discussion at theFebruary 2016 Board Seminar.

P2016/109 Severalls Update – Verbal Report The Board of Directors noted the verbal update re Severalls.

03.02.16 Private P2015/116 Financial Planning Update 2016/17 The Board of Directors: i) Discussed and considered the latest update inrespect of the Draft 2016/17 Financial Plan; ii) Reviewed and accepted the risks associated withdeveloping a Financial Plan that meets the proposed Control Total set by NHS Improvement; iii) Confirmed the proposed level of deficit to beincluded in the Draft 2016/17 Financial Plan at £2.8m; and iv) Noted that the draft Financial Plan commentarywould set out that the Trust was not able to positively confirm acceptance of the proposed NHSI Control Total at this point in time, given the level of risks associated with the Trust’s main contract, but was committed to working towards it as far as was reasonable.

P2015/117 Co-location of Clinical Inpatient Services The Board of Directors approved the Full Business Case (FBC) for the relocation of Peter Bruff ward to Bernard Ward, and Bernard Ward to McIntyre Ward, at a total cost of £Xk (including VAT, fees, FFE etc).


264



Agenda item No: 21

Date: 23 March 2016

Title of Report: Execution of Deeds

Lead: Dermot McCarthy, Trust Secretary

Subject, Purpose and Recommendation:

The Board of Directors is asked to note the report. Since the last report to the Board the following deeds have been executed:

i. No. 186 (dated 29/01/2016) Severalls Hospital: Land transfer re part of SeverallsHospital between the Homes and Communities Agency (HCA) and NEP (transferor) and Bellway Homes, Bloor Homes and Taylor Wimpey UK Ltd (transferee)

ii. No 187 (dated 29/01/2016) Severalls Hospital: Lease of land at Severalls hospitalbetween the HCA, NEP and Bellway Homes, Bloor Homes and Taylor Wimpey UK Ltd

iii. No 188 (dated 29/01/2016) Severalls hospital: Lease of premises known as WillowHouse, The Laurels and Birchwood House forming part of Severalls Hospital, between NEP and Bellway Homes, Bloor Homes and Taylor Wimpey UK Ltd.

iv. No 189 (dated 02/03/16) New Ivy Chimneys: Agreement for sale of the New IcyChimney site between Nep and Framar Developments Ltd

v. No 190 (dated 02/03/2016) New Ivy Chimneys: Land transfer document re the NewIvy Chimneys site between NEP and Framar Developments Ltd

vi. No 191 (02/03/2016) Old Ivy Chimneys: Agreement for Sale for the Old Ivy Chimneysite between NEP and St Giles Property Developments Ltd

vii. No 192 (dated 02/03/2016) Old Ivy Chimneys: Land transfer document re the Old IvyChimneys site between Nep and St Giles Property Developments Ltd.






Risks: N/A

265



Agenda item No: 22

Date: 23 March 2016

Title of Report: Any Other Notified Business


Subject, Purpose and Recommendation: The Board is invited to discuss any items of urgent business notified in advance of the meeting to Chris Paveley, Chairman or Dermot McCarthy, Trust Secretary.






Risks: N/A

266



Agenda item No: 26

Date: 23 March 2016

Title of Report: Questions from members of the public relating to items on the agenda only


Subject, Purpose and Recommendation: The Board of Directors is invited to reply to any questions from members of the public relating to items on the agenda only.






Risks: N/A

267