Trust Board Meeting 28 March 2018 Agenda - Public Meeting papers... · Trust Board Meeting 28 March 2018 Agenda - Public Meeting ... Guardian of Safe W orking Report JB To receive

Caring, Learning and Growing

Trust Board Meeting 28 March 2018

Agenda - Public Meeting For a meeting to be held at 9.30am Wednesday 28 March 2018, The Waterfront Suite, East Riding Leisure Goole,

North Street, Goole, East Riding of Yorkshire DN14 5QX

Lead Action Report Format

Standing Items

1. Apologies for Absence

SM To note verbal

2. Declarations of Interest

SM To receive & note √

3. Minutes of the Meeting held on 28 February 2018

SM To receive & approve √

4. Action Log and Matters Arising

SM To receive & discuss √

5. Self Help and Social Meditation (SMASH) Presentation – Emma train Sullivan, Early Intervention Lead attending at 9.30am

JB To receive & note √

6. Chairman’s Report

SM To note verbal

7. Chief Executives Report

MM To receive & note √

8. Publications and Highlights Report

MM To receive & note √

Strategy 9. Operational Plan 2018/19 – Alison Flack, transformation

Programme Director attending

MM To discuss √

10. Digital Plan Update PBec To receive & note

√

Quality and Clinical Governance

11. Guardian of Safe Working Report JB To receive & note √

12. Healthy Food for NHS Staff, Visitors and Patients;

Commissioning for Quality and Innovation (CQUIN) Progress Report

PBec To receive & note

√

Performance & Delivery

13. Integrated Quality and Performance Report

PBec To receive & note

√

14. Finance Report

PBec

To receive & note

√

Corporate

15. Risk Register Update – Oliver Sims, Corporate Risk Manager attending

HG To receive & note

√

16. Gender Pay Gap Report ET To receive & note

√

17. Collaborative Commissioning PBec To receive & note

√

Board Committees 18. Finance Committee Assurance Report

FP To receive & note √

19. Charitable Funds Minutes 17 January 2018 PBee To receive & note

√


20. Report from the Mental Health Legislation Committee (MHLC) following meeting of 8 February 2018

MS To receive & note √

21. Any Other Business

22. Exclusion of Members of the Public from the Part II Meeting

23. Date, Time and Venue of Next Meeting Wednesday 25 April 2018, 9.30am, East Riding Leisure Beverley, Flemingate, Beverley, East Riding of Yorkshire, HU17 0LT

Caring, Learning and Growing Page 1 of 3

Agenda Item: 2

Title & Date of Meeting: Trust Board Public Meeting – 28 March 2018

Title of Report: Declarations of Interest

Author:

Name: Sharon Mays Title: Chairman

Recommendation:

To approve To note

To discuss To ratify

For information To endorse

Purpose of Paper:

The report provides the Board with a list of current Executive Directors and Non Executive Directors interests.

Key Issues within the report:

Updates to declarations for Mrs Lynn Parkinson, Interim Chief Operating Officer and Dr John Byrne

Monitoring and assurance framework summary:

Links to Strategic Goals

√ Innovating Quality and Patient Safety

√ Enhancing prevention, wellbeing and recovery

√ Fostering integration, partnership and alliances

√ Developing an effective and empowered workforce

√ Maximising an efficient and sustainable organisation

√ Promoting people, communities and social values

Have all implications been considered?

Yes Yes Detail in report

N/A Comment

Any Action Required?

Risk √

Legal √

Compliance √

Communication √

Financial √

Human Resources √

IM&T √

Users and Carers √

Equality and Diversity √

Report Exempt from Public Disclosure?

No

___________________________________________________________________________________________ Trust Board Page 2 of 3 Date: 28.2.18

Directors’ Interests

Name Declaration of Interest

Executive / Directors Ms Michele Moran Chief Executive (Voting Member)

Non Executive Director, The National Skills Academy for Health

Appointed as a Trustee for the RSPCA Leeds and Wakefield branch

Mr Peter Beckwith, Director of Finance, Infrastructure and Informatics (Voting Member)

No interests declared

Mrs Hilary Gledhill, Director of Nursing, Quality and Patient Experience (Voting Member)

Son works as a volunteer at Humber NHS Foundation Trust

Dr John Byrne, Medical Director (Voting Member)

Executive lead for Research and Development in the Trust. Funding comes into the Trust and is governed through the Trust’s Standing Instructions

Mrs Elizabeth Thomas - Director of Human Resources and Diversity (Non-voting Member)

Sister in Law HR Director of Human Resources, City Health Care Partnership (CHCP)

Mrs Lynn Parkinson, Interim Chief Operating Officer (Voting Member)

Currently seconded from Leeds and York Partnership NHS Trust – substantive post Deputy Chief Operating Officer

Non Executive Directors

Mrs Sharon Mays – Chairman (Voting Member)

Trustee of Ready Steady Read

Sister is Head of Compliance Standards and Information at Tees Esk and Wear Valley NHS Foundation Trust

Mr Peter Baren, Non Executive Director (Voting Member)

Non Executive Director Coast and Country

Housing Ltd

Government appointed independent Director –

British Wool Marketing Board

Son is a doctor in Leeds hospitals

Ms Paula Bee, Non Executive Director (Voting Member)

Chief Executive Age UK Wakefield District

Vice Chair Age England Association

Trustee – Nova Wakefield

Wakefield Provider Alliance

Director of Age UK, Yorkshire and Humber Support Services

Dr David Crick, Non Executive Director (Voting Member)

Trustee, Hull Crisis Pregnancy Centre

Wife was an employee of the Trust from 1994 – 2009 and has been an Associate Manager for the Trust since 2009.

Wife is Chair of Trustees Hull Churches Home from Hospital

Mr Mike Cooke, Non Executive Director (Voting Member)

Trustee, Yorkshire Wildlife Trust

Deputy Chair of Yorkshire Wildlife Trust

Consultant Advisor, University of York

Advisor , National Institute for Health Research


Independent Executive Mentoring Coach

Chair of NIHR International Collaboration Panel Steering Group to embed Applied Research in Health Care Settings

Mr Mike Smith, Non Executive Director (Voting Member)

Director MJS Business Consultancy Ltd

Trustee Magna Science Adventure Centre

Director, Magna Enterprises Ltd

Part Owner MJS Business Consultancy Ltd

Associate Hospital Manager RDaSH

Associate Hospital Manager John Munroe Group, Leek

Lord- Lieutenant's Officer for South Yorkshire

Council Member Barnsley and Rotherham Chamber of Commerce

Mr Francis Patton, Non Executive Director (Voting Member)

Chairman, The Cask Marque Trust

Treasurer, All Party Parliamentary Beer Group

Industry Advisor The BII (British Institute of Innkeeping)

Managing Director, Patton Consultancy

Non Executive Director and Chairman, SIBA, The Society of Independent Brewers

Director, Fleet Street Communications

Chairman, Barnsley Facilities Services Limited

Director, Cyclops Limited (charitable organisation)

Director, Walrus & Carpenter Limited

Non Executive Director Barnsley NHS Foundation Trust


Trust Board Meeting – Public Meeting Minutes of the Trust Board Meeting held on Wednesday 28 February 2018 in

the Conference Rooms, Trust Headquarters

Present: Mrs Sharon Mays, Chairman Ms Michele Moran, Chief Executive Mr Peter Baren, Non-Executive Director Ms Paula Bee, Non-Executive Director (by phone) Prof Mike Cooke, Non Executive Director Dr David Crick, Non-Executive Director Mr Francis Patton, Non Executive Director Mr Mike Smith, Non Executive Director Mr Peter Beckwith, Director of Finance Dr John Byrne, Medical Director Mrs Hilary Gledhill, Director of Nursing, Quality & Patient Experience Mrs Lynn Parkinson, Interim Chief Operating Officer

In Attendance: Mrs Elizabeth Thomas, Director Human Resources & Diversity Mrs Michelle Hughes, Interim Head of Corporate Affairs Mrs Jenny Jones, Trust Secretary Mr Adrian Jenkins, Communications Manager Ms Ruth Edwards, Speech and Language Therapist (for item 31/18) Ms Siobhan Ward, Speech and Language Therapist (for item 31/18) Dr Caroline Johnson Assistant Director of Quality Governance and Patient Safety (for items 38/18 & 39/17) Mr Oliver Sims, Corporate Risk Manager (for item 43/18) Mr Alex Fowler, Environment Manager (for item 45/18) Mrs Sarah Todd, Human Resources Service Manager (for items 46/18 & 47/18) Mr Mike Oxtoby, Public Governor A member of the public

Apologies: None 28/18 Declarations of Interest

The declarations were noted. Any further changes to declarations should be notified to the Trust Secretary. The Chairman requested that if any other items on the agenda presented anyone with a potential conflict of interest, they excuse themselves from the meeting for that item. It was noted that the declaration for Mrs Parkinson needed to reflect her secondment from Leeds Partnerships.

29/18 Minutes of the Meeting held on 31 January 2018 The minutes of the meeting held on 31 January 2018 were agreed as a correct record.

30/18 Matters Arising and Actions Log The actions list was discussed and the following noted:- 42.4/17 Hull City of Sanctuary Proclamation The Board noted that this action is being progressed 151/17 Digital Plan Mr Beckwith informed the Board that the Assisted Technology update will be shared with the

Item 3

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Executive Management Team (EMT) in March and an update included in the next quarterly report to the Board.

31/18 Hear in Hull Speech and Language therapists Ruth Edwards and Siobhan Ward delivered a presentation about the Hull 2017 City of Culture creative communities project ‘Hear in Hull’. They also shared a video presentation from VIPs involved with the project, showed an animation and shared a copy of a parent’s written story of her child’s involvement with the project. Professor Cooke asked if there was anything that the organisation can do to help to allow the service to become more creative. It was stated that venues for intensive therapy courses are a problem as there are very few Trust locations that have suitable rooms. Mr Beckwith will ask the Estates team to review this. Mr Smith asked if there were any problems with demand and resources. Ms Edwards explained that the team was now managing referrals well and the demand had plateaued. Although therapy treatment is taking up to six months, assessments are nearly within the 18 week time frame. More promotion of the stories and film is required so that it reaches wider audiences. Any ideas for wider promotion are very welcome. The Chief Executive thanked Ruth and Siobhan for taking the project forward.

32/18 Chairman’s Report The Chairman provided an update in relation to the work she has undertaken since the last meeting. This included:-

Visits to teams and services including a good knowledge and engagement visit to the Project Management Office (PMO). It was good to see how the lessons learned from the Whitby mobilisation are being used for the Scarborough and Ryedale contract.

The quarterly staff awards event where the Chief Executive was presented with a certificate for long service.

Attendance at the first Social Workers Forum where current, local and national issues were raised.

The Northern Chairs Network event where opportunities to work with other Trusts on a membership engagement event were included as part of the discussions.

Newly elected and re-elected Governors had their induction session in February. A regular meeting with public Governors also took place.

Resolved: The verbal report was noted.

33/18 Chief Executive’s Report The report provided a summary of activities and meetings undertaken by the Chief Executive. These included:- University

Work with the University continues to develop, with honorary titles and possible PhD (Doctor of Philosophy degree) initiatives being discussed. Trust Name The new name, Humber Teaching NHS Foundation Trust, will formally come into effect on 1st April 2018. Costs are being kept to a minimum by replacing the new brand only when absolutely necessary. NHS 70th Birthday The Communications Team is developing a plan to celebrate the NHS 70th Birthday which includes nominations for a NHS 70 star. A draft programme will be circulated to Board members. Professor Cooke suggested this needed to be linked to World Mental Health Day so there is a programme of events in the system.

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Research Conference Professor Alistair Burns, National Director for Older Peoples Mental Health (OPMH) will be the key note speaker at our Research Conference on 16th May. Sustainable Transformation Plan (STP) Local plan for Hull and East Riding are in development and will be shared with the Board when available. Chief Executives’ Meeting Smoke Free from October 2018 and finances were the key issues discussed at the meeting. Board Time Out The agenda has been circulated for this event which will be facilitated by the Organisational Development Manager. Professor Cooke referred to the Quality Improvement session that is taking place at the end of the week and thanked Mrs Gledhill and Dr Byrne for putting the agenda together for the session. Severe Weather Conditions On behalf of the Board, the Chief Executive thanked all staff for making the effort to get into work and ensuring patients are safe during the current adverse weather conditions. Impact Appeal Launch The launch of the Impact Appeal for Child and Adolescent Mental Health Services will take place soon. Resolved: The report was noted.

33/18 Publications and Highlights Report The report provided an update on the national, regional and local publications that have been published recently along with the name of the lead who can provide more information if required. Discussion will take place at the Board Time Out on the best way to use the information provided in this report. Dr Crick referred to the Healthcare Education publication noting that the loss of a bursary has already affected recruitment to nursing and would likely affect the number of applications for these other healthcare posts as well. Resolved: The Board noted the report and verbal updates provided.

34/18 Multi- Agency Public Protection Arrangements (MAPPA) Strategic Management Board Update The paper provided an update on the Trust’s responsibilities in line with Multi-Agency Public Protection Arrangements (MAPPA). Multi-Agency Public Protection Arrangements (MAPPA) are the statutory arrangements for managing sexual and violent offenders. Responsible Authorities (including Police, National Probation Service and Prisons) have a duty to ensure that the risks posed by these offenders are assessed and managed appropriately. The Humberside Area Multi-Agency Public Protection Arrangements (MAPPA) Annual Report 2016 – 17 was also provided. Mrs Parkinson reported that the Trust continues to meet the requirements of MAPPA and work with partners to achieve this. The Chairman has had positive feedback about the new training from staff who has stated it is more effective. Resolved: The update was noted

35/18 Suicide Prevention and Self Harm Mitigation Update 2017/18 Dr Byrne presented the report which has been through the Quality Committee. He explained

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that a suicide strategy workshop was held recently and the approach taken was one of using personal experiences of the attendees to facilitate discussion on the impact of suicide. The language when people respond when suicide occurs, looking after patients, carers and staff was also debated. Mr Baren asked if more bench marking data could be included in the report around training including what percentage of staff are trained and how this compares to other trusts. Dr Byrne felt this was operational detail rather than a strategic view, but will raise with the author. He also felt that discussion at the Quality Improvement event may help to focus discussions on what data is required. Professor Cooke liked the links to the development of the pathway and the ligature identification and mitigation included in the report. He suggested that system work that is taking pace should also be included. The Chairman agreed and asked that future reports include this and what the plan is to progress this. The Chief Executive suggested that East Riding and Hull need to progress their agendas as there is not a robust strategy in either East Riding or Hull. It would be helpful to increase this information in the next report. She also referred to the Zero Suicide Alliance which the trust has signed up to which needed to be referenced in future reports. Resolved: The Board noted the report Future reports to include benchmarking data around training compliance and other key areas Action LP System wide strategic work that is taking place to be included in the next report Action LP Reference to the Zero Suicide Alliance that the Trust has signed up for to be included in the next report Action LP

36/18 Director of Nursing Report Mrs Gledhill presented the report which provided the Board with an update on the work of the Nursing and Quality Directorate, working with Care Groups and external partners to drive quality improvements for our patients. Key issues described in the report included:

Forthcoming changes to the Data Protection Act and the implications for the Trust.

Establishment of a Professional Forum

Feedback from pre-registration students on their experience of working on placement in the Trust

Update on quality improvement initiatives in specialist services

‘Safe Wards’ roll out. Mr Baren referred to the General Data Protection Regulation (GDPR) which comes into force in May 2018 asking if the Data Protection Officer post has been progressed. Mrs Gledhill explained that the grading of this post is higher than was originally expected and discussions with the Director of Finance are taking place to facilitate this change. Mr Baren explained that this issue was raised at the last Audit Committee meeting and as a consequence a report will be coming to the Board and the next Audit Committee meeting. Resolved: The Board noted the content of the report. Update on the Data Protection post to be provided to the Board Action HG

37/18 Medical Director Report The report presented by Dr Byrne informed the Board regarding professional matters related to the Doctors employed by the Trust across all the services, pharmacy, medical education and GP engagement

Dr Byrne reported that some changes have been made to the junior doctor’s rotas so work is taking place to support them. There has been a slight reduction in the data that is received and the welfare of junior doctors is an important piece of work which is ongoing.

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The report provided a focus on the work of the Department of Psychological Medicine led by Dr Stella Morris. The Chairman found this piece helpful and will discuss outside the meeting ways in which this can be enhanced for her to use with external colleagues. Professor Cooke noted the recognition of the team in three publications commenting that it is a very fast moving service area in mental health and contributes to how the acute system works. Mr Smith asked where the liaison and diversion services fell in the structure. This will be responded to outside the meeting. Resolved: The report was noted Clarification on where the Liaison and Diversion service sits within the Trust structure to be provided outside of the meeting to Mr Smith Action LP

38/18 Quality Accounts 2017/18 Dr Johnson attended to present the report that provided the Board with an update and outlined the changes in the guidance for the 2017/18 Account. An event was held recently to discuss the Quality Account indicators. The report provided the Board with the detail necessary to:

a. ratify the mandated and local indicators b. agree three quality priorities for 2018/19

The timetable for the development and submission of the Quality Account was also provided. Two mandated indicators were presented for ratification

1. Early intervention in psychosis (EIP) people experiencing first episode of psychosis treated with a National Institute for Health and Care excellence approved care package within two weeks of referral.

2. Inappropriate out-of-area placements for adult mental health services The Board approved these indicators. Consultation with Governors that as the mandated indicators are mental health orientated; the local indicator should cover the broader range of the Trust’s services. Therefore, the following indicators were proposed:

Medicines errors

Pressure ulcers The Board discussed the Governors selections supporting that the Medicines errors indicator be the indicator of choice. It was noted that monitoring of grade 3 pressure ulcers should still remain an area of focus. The four Quality Priorities proposed were:- 1 Ensure we have meaningful conversations with patients/carers to develop therapeutic

relationships and engagement in service delivery 2 Ensure that quality improvement is part of every staff member’s role 3 Maximise patient safety across all of our services 4 Embed best available evidence in practice utilising patient reported and clinical reported outcome measures (PROMS, CROMS) The Board discussed all of the quality indicators and agreed that priorities two and three should be combined. Therefore all of the four quality priorities suggested would be adopted. The Board approved the two mandated indicators proposed, the local indicator for Medicine errors and all of the Quality Priorities subject to two and three being combined. Resolved: The Board approved the two mandated indicators proposed, the local indicator

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for Medicine Errors and all of the Quality Priorities subject to two and three being combined.

39/18 Care Quality Commission Action Plan To provide the Board with assurance that a comprehensive action plan has been developed in response to the regulation breaches identified during their October 2017 inspection. Professor Cooke explained that the Quality Committee has asked for the action plan to be discussed at the April meeting. He suggested that more actions could be devolved into care groups to help with the implementation and progression of actions. The Chief Executive emphasised that the same approach will be taken with this action plan which will be led by Operations who will own the plan. Mr Patton asked if internal audit will review the plan at some stage. It was confirmed this would take place. The Chief Executive said that there is a section on embedding actions, some are transactional and we have to look at how we demonstrate that previous actions are still embedded and what is being done for the next inspection which will have a patient safety focus. Dr Byrne explained that the Care Quality Commission (CQC) do respond to incidents. He gave an example of when an incident in secure services happened, the CQC visited to check on blanket restrictions. He felt that staff attitudes have changed as there was no immediate reactive response which may have meant that blanket restrictions were imposed. This demonstrates a culture change and staff are aware of the changes since the original CQC issues raised two years ago. Professor Cooke said changes are being seen between quality assurance and quality improvement. Both are needed and there is sufficient evidence to support this. Mrs Parkinson confirmed that ownership of the action plan will be through the care groups. Mr Baren referred to Regulation 17 where staff should be aware of who the freedom to Speak Up Guardian is. He explained there is going to be a change in who this is and a change to the structure which needs refreshing to ensure it is up to date. Resolved: The Board endorsed the action plan (taking into account the comments made)

40/18 Integrated Quality Performance Tracker (IQPT) – January 2018 The report provided the Board with a Quality and Performance Update as at the end of January 2018 and particularly:-

Bed occupancy rates have maintained in Mental Health and there continues to be low occupancy rates in Learning Disability units during Transformation

There are 10 patients waiting over 52 weeks which is an increase of one based on the previous month.

Clinical Supervision is newly reported for January

IG training has improved and now rated Amber Compliance with Performance Appraisal Development Reviews continue to improve, MAPA, Information Governance, Immediate Life Support and Basic Life Support are below target. Dr Crick asked if the Information Governance training target will be met. Mr Beckwith reported that all actions that can be taken are and individuals have been contacted. Managers are also closely monitoring the situation as 420 people need to complete the training to meet the target. It was clarified that if someone is off sick or on maternity leave they are still included in the figures which is why the target is 95% rather than 100%. Professor Cooke asked if progress has been made with the Executive Management Team reviewing the sickness target. It was confirmed this is yet to be discussed Mrs Gledhill commented on the improvement in clinical supervision since Spring 2017. By including this in the report it enables it to be monitored better. The Chairman asked Mr

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Beckwith to check the narrative on the front sheet around 52 week waiters as she felt this was incorrect. In relation to Child and Adolescent Mental Health Services the Chairman noted an increase in children waiting to be seen. Mr Beckwith reported that funding has been provided for SMASH and MIND initiatives and a request for recurrent funding has been made. This will have an impact on the waiting list and is considered as part of the capacity and demand work. The Chief Executive explained that as long as the organisation can demonstrate effective and efficient service there should be no issues with the funding. She recognised there will, be waiting lists due to the demand, but these are commissioner issues and they have to take responsibility for this. The pathway works as children are being moved through the system. Resolved: The Board noted the content of the report. The Executive Management Team to review the sickness target Action MM

41/18 Finance Report Mr Beckwith presented the report which provided the Board with an update of the financial position of the Trust at month ten. Key issues included:-

A surplus position of £0.459m was recorded to the 31st January 2018, this is consistent with the financial plan submitted to NHS Improvement (NHSI) and is inclusive of £1.097m Sustainability and Transformation funding (STF) income.

The year to date Trust Capital expenditure is £1.915m. The Trust has revised the forecast capital expenditure to £5.685m for the year, reducing the CAMHS project to £1.650m due to the funding delay

The planned level of Cost Improvement Programme (CIP) for 2017-18 is £5.200m. £2.830m of savings has been achieved year to date, this is below the planned level of savings (£3.419m)

The cash balance increased in the period to £7.5m due to lower creditor payments in month.

On the NHS Improvement (NHSI) return the use of resources metric is 2.

Agency costs are below the NHS Improvement ceiling Dr Crick referred to section 2.4.3 and the vacancies in the Community Mental Health Teams. Mrs Parkinson clarified that it was for the community mental health teams which are an area of focus currently. A piece of work has started around reviewing services to ensure it is robust and that teams are working in the right way with the right cases with the right level of acuity. Dr Crick also commented on the focus on agency pay; he asked if we record the excess of agency spend when compared to the substantive person being in post as that is the true excess cost to the Trust? Mr Beckwith explained that the new SBS system will allow this type of report to be provided to demonstrate the differences. Each year there is a spike in agency costs in March, probably connected to using up annual leave. Mr Baren asked if work has taken place to prevent this occurring this year. The Chief Executive reported that staff have been asked since September to ensure that there leave is booked and assurance has been provided that this has been done. The report indicated that care groups are over established and Mr Smith asked what the plan is to reduce this. Mrs Parkinson explained that a temporary contract is due to finish in March and this will be an opportunity to review the structure and associated costs. Resolved: The Board noted the report.

42/18 Interim Chief Operating Officer Report Mrs Parkinson presented her report providing an update on the work of the Operations Directorate, including the Operational Care groups, Emergency Preparedness Resilience and

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Response, Primary Care Services and Service Transformation. Of particular note were:-

An update on the work of the Hull and East Riding Mental health crisis care concordat strategy group. Significant progress has been made against some of the key priorities, other areas need further work including housing, urgent, acute mental health and substance misuse pathways

The mobilisation of the Scarborough and Ryedale community services contract is progressing well. Go live date is 1 May 2018

The Trust ceased providing Mental Health Services to the Pocklington locality on 31st January 2018 with services being provided by Tees Esk and Wear NHS Foundation Trust (TEWV) from 1st February 2018.

The work being undertaken with NHS Hull CCG to reduce the use of acute out of area beds

The opening of the new safe space for young people between the ages of 14 and 18

years as an alternative to the emergency department at times of crisis.

Professor Cooke referred to the exit of Pocklington services asking if there were any stranded costs and if so what was being done about them. Mrs Parkinson confirmed there are some costs which the Budget Reduction Strategy will address. Professor Cooke urged caution around the out of area treatment policy as there had been some patients returned to the same unit simultaneously without any assessment of whether additional staffing was required. Discussion will take place outside of the meeting to progress this matter and an update circulated to the Board. Mr Smith welcomed the update on the Mental Health Crisis Concordat asking whether the funding bid outcome is yet known. He was informed this has been put back until April 2018

Resolved: The content of the report was noted. Discussion to take place outside of the meeting regarding the repatriated patients and an update circulated to the Board. Action LP/MC

43/18 Director of Human Resources and Diversity Report Mrs Thomas presented her report which provided an update of relevant national and local events and publications as well as any key updates on Human Resources, Training and Education, Payroll and Occupational Health services. The key areas noted were:-

STP Workforce Strategy for Mental Health

Recruitment Update

Staff Profiles Mr Baren referred to the starters and leavers data which was a couple of months old. Mrs Thomas apologised that the up to date data was not included. Dr Crick suggested the wording “to plug the gap” in section 2.5 could be changed to “service redesign and skill mix”. The Chairman congratulated the team in reducing the time taken to recruit people into post.

Resolved: The report was noted.

44/18 Board Assurance Framework Quarter 3 Report The report provides the Board with the Quarter 3 2017/18 version of the Board Assurance Framework (BAF) allowing for the monitoring of progress against the Trust’s six strategic goals. Mr Sims explained that changes were made to the Board Assurance Framework between Quarter 2 to Quarter 3 2017-18 to Strategic Goal 1 (Innovating Quality and Patient Safety) and Strategic Goal 5 (Maximising and efficient and sustainable organisation). Dr Crick asked why there was no narrative in NQPE37 in strategic goal one. Mr Sims

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explained there are a large number of actions identified for this risk some of which will be included in the BAF risk. Key controls and actions are updated for individual risks and changes will be made for the next report. Professor Cooke said the Quality Committee considered if enough action is being taken to result in a change in the overall staffing level risk rating. After discussion and challenge it was felt this should remain the same for the present time. The Quality Committee also agreed to accept strategic goal six which had been reassigned to the Committee. Resolved: The report was noted

45/18 Policies For Ratification The report provided an update on Trust policies and 7 policies were presented for ratification:-

Policy for Supporting Transgender Patients

Safeguarding Allegations Against Staff Policy

Supportive Engagement Policy

Transfusion of Blood and Blood products

Information Governance Policy

Volunteer Policy

Waiting Times Policy Professor Cooke queried the number of policies the Board was being asked to ratify as a number of policies have been through the Quality Committee and noted a number of policies are also going through the Quality and Patient Safety Group (QPaS). Mrs Hughes, explained that the Document Control Policy introduced last year does have provision for minor changes to policies to be approved at Executive Director level and that this may not be being used as effectively as it could and will ensure policy changes are checked to ensure any that can be approved through executive directors are being. The Chief Executive clarified that the policies coming to the Board were in relation to the organisation and it is important the Board is aware of these. Mrs Gledhill said there was not an issue for QPaS and four policies were on the agenda for the last meeting. Professor Cooke felt there was an audit role as well as a Board role. In terms of the number of policies being presented to Board over recent months, Mrs Hughes explained that this was in part due to stocktake of policies undertaken in 2017 as many were out of date, but this should reduce in time. Mr Baren asked if the Information Governance policy presented for ratification, took into account the new GDPR requirements. Mrs Gledhill confirmed this is work that is currently being undertaken and is not included in the policy. It was queried whether the Board should be approving this policy given the requirement was not included. Mrs Gledhill emphasised that the policy approval is necessary for the Information Governance Toolkit requirement for this year. The policy is under review to ensure the new requirements are included and will come back for approval. Resolved: The Board ratified the policies presented The Information Governance Policy will be reviewed to take into account the GDPR requirements Action HG

46/18 Sustainable Development Management Plan (SDMP) Update The paper provided an update on progress against the Sustainable Development Management Plan (SDMP) approved by the Board in February 2017. The report will highlighted and gave recommendations against the four key areas of focus for the Trust in

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relation to carbon emissions, which are:-

Energy

Travel and Transport

Waste

Procurement Mr Fowler, Environment Manager explained that for energy emissions electricity is steadily reducing, but gas has increased due to the cold weather. Ways of reducing both electricity and gas emissions continue. The Chairman was pleased to see the case study and the use of WARP-IT in the report and suggested that discussion take place with the Communications team to help promote these more. Resolved: The report was noted

47/18 NHS Workforce Race Equality Standard Trust Benchmarking Report The report informed the Board of the Trust’s performance against the nine Workforce Race Equality Standard (WRES) indicators based on National Benchmarking Data. The Trust’s data is benchmarked against the most appropriate National data by Sector which is Mental Health as unfortunately there is no national data by Multi Speciality Organisation. Mrs Todd explained that the team was interviewed as part of the CQC visit and feedback received was positive. The Trust is performing against four of the indicators:-

Relative likelihood of staff accessing non mandatory training and career progression development

Percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months

Percentage believing that the Trust provides equal opportunities for career progression or promotion

Percentage of staff personally experiencing discrimination at work from manager, team or other colleagues

Underperformance was reported against three of the indicators:-

Percentage of staff in each of the Agenda for Change bands 1-9 or medical and dental subgroups and Very Senior Manager contracts compared with the percentage of staff in the overall workforce.

Relative likelihood of white staff being appointed from shortlisting compared to BME staff – 2016 and 2017

Relative likelihood of BME staff entering the formal disciplinary process compared to white staff

Mrs Gledhill commented on the next steps section of the report stating that more actions are required around what could be included in the training. Positive feedback and also training for staff for interviews around the quality impact assessment needs including as there is indication that staff have little confidence in completing these assessments as there is not a systematic approach for this. Mrs Todd confirmed these areas are being worked through. In terms of the Equality Impact Assessment work is taking place with the training team to provide a robust process. Recruitment and selection training is very robust and includes equality and diversity. An annual report on equality and diversity is on the Board workplan for May and will also go to the Quality Committee for review. Professor Cooke asked if consideration has been given to BME groups or a mentoring scheme. Mrs Todd confirmed that work is progressing to set up a network which is

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meaningful and helpful. A mentoring scheme has not been raised but will be considered as part of the future plans. Resolved: The Board noted the report

48/18 Gender Pay Gap Report All Trusts are required to publish their gender pay gap data and the gap in any bonuses paid which includes Clinical Excellence awards and retention payments by 31.03.18 using data taken on Snapshot date 31.03.17. Mrs Todd reported that the Trust’s current gender pay gap currently stands at 11% which is lower than the national figure of 18%. The Trust’s bonus figure is -49.32%, which shows that female staff are paid higher amounts of bonus pay. The only people reported to have received bonus pay are Medical Staff who have received Clinical Excellence Awards. There are 14 people who received bonus pay (9 Males and 5 Females). Despite being less in number due to their seniority, longevity of service and experience the female’s awards were higher than the males. Mr Patton suggested that when it is published an action plan is also provided to show what will be done. Mrs Thomas confirmed that a plan is being developed. The Chief Executive thought this was a good suggestion and an opportunity to highlight the work that is being undertaken. Professor Cooke proposed that a joint statement from the Chairman and Chief Executive at the beginning of the report might be helpful. It was agreed that the revised report, action plan and proposed statement come back to the March Board as it is an important issue and needs serious consideration. Resolved: The revised report, action plan and proposed statement come back to the March Board Action ET

49/18 Report from the Audit Committee The report provides the Board with an update of recent discussions at the Audit Committee. Mr Baren explained that the discussions included the GDPR requirements and also around the limited assurance medical equipment internal audit report. Further details on the discussion were provided to Dr Byrne including the queries relating to resuscitation and other specialised equipment that may not be regularly used. A copy of the report will be shared with Dr Byrne. Professor Cooke thanked Mr Baren for his leadership of the Audit Committee and for the effective relationship there is with internal audit. Resolved: The report and verbal update was noted.

50/18 Charitable Funds Committee Minutes 14 November 2017 Ms Bee presented the minutes from the November meeting. Bi annual reporting to the Board was noted and has been included in the Board workplan. Resolved: The minutes were noted

51/18 Charitable Funds Capital Appeal A logo has been developed following consultation and feedback, to support the charitable funds appeal for the new build Children and Adolescent Mental Health Service (CAMHS) Tier 4 unit. Resolved: The Board noted the report.

52/18 Any Other Business Reappointment of Associate Hospital Managers

Reappointment of Associate Hospital Managers Under Section 23 of the Mental Health Act 1983 the Board delegates authority to review and

12

potentially discharge detained patients to panels of three Associate Hospital Managers. These managers are appointed on three year honorary contracts, three of which are due to expire in March 2018. The Board was asked to approve the reappointment of the following managers:-

· Mike Hood · David Nurse · Lynn Hood (subject to final appraisal)

All of the above have been observed and two of them fully appraised. All three are recommended for reappointment for three years. Resolved:- The Board approved the reappointment of the three managers (above) for three years, subject to continuing suitability, to carry out the delegated power on its behalf. The next report from the Mental Health Legislation Committee to include an update on the delegated powers of Associate Hospital Managers Action JB/MS

53/18 Exclusion of Members of the Public from the Part II Meeting It was resolved that members of the public would be excluded from the second part of the meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest.

54/18 Date and Time of Next Meeting Wednesday 28 March 2018, 9.30am in the Waterfront Suite, Goole Leisure Centre, North Street, Goole DN14 5QX

Signed ……………………………………………………………… Date ………………. Chairman

Caring, Learning and Growing 1

Agenda Item 4 Action Log: Actions Arising from Public Trust Board Meetings

Summary of actions from February 2018 Board meeting and update report on earlier actions due for delivery in March 2018

Rows greyed out indicate action closed and update provided here

Date of Board

Minute No

Agenda Item Action Lead Timescale Update Report

28.2.18

28/18 Declarations of Interest

Declaration for Interim Chief Operating Officer to be updated to include working for Leeds Partnership

Interim Chief Operating Officer

March 2018 Completed

28.2.18

33/18 Chief Executive’s report

NHS 70th Birthday – draft programme of events to be circulated

Chief Executive March 2018 Part of Chief Executive’s Report

28.2.18

35/18 Suicide Prevention and Self Harm Mitigation Update 2017/18

Future reports to include benchmarking data around training compliance and other key areas


May 2018 Item not yet due

28.2.18


System wide strategic work that is taking place to be included in the next report



28.2.18


Reference to the Zero Suicide Alliance that the Trust has signed up for to be included in the next report



2

28.2.18 36/18 Director of Nursing Report

Update on the Data Protection post to be provided to the Board

HG March 2018 Head of Legal Services and Information Governance to take up the duties as the duties required are already in their job description.

28.2.18

37/18 Medical Director Report

Clarification on where the Liaison and Diversion service sits within the Trust structure to be provided outside of the meeting to Mr Smith


March 2018 Confirmation this sits in the Specialist Care Group

28.2.18 40/18 Integrated Quality Performance Tracker (IQPT) – January 2018

The Executive Management Team to review the sickness target

Chief Executive March 2018 Update to be provided at the meeting

28.2.18 42/18 Interim Chief Operating Officer Report

Discussion to take place outside of the meeting regarding the repatriated patients and an update circulated to the Board.

Interim Chief Operating Officer/Professor Cooke

March 2018 Discussion arranged

28.2.18 45/18 Policies For Ratification

The Information Governance Policy will be reviewed to take into account the GDPR requirements

Director of Nursing

June 2018 Item not yet due

28.2.18 48/18 Gender Pay Gap Report

The revised report, action plan and proposed statement come back to the March Board

Director of Human Resources & Diversity

March 2018 Item on agenda

28.2.18 49/18 Report from the Audit Committee

Medical equipment management audit report to be sent to Dr Byrne

Director of Finance

March 2018 Report provided

28.2.18 52/18 Any Other Business/ Reappointment of Associate Hospital Managers

The next report from the Mental Health Legislation Committee to include an update on the delegated powers of Associate Hospital Managers

Medical Director/Mr Smith

April 2018 Item not yet due

31.1.18 08/18 Digital Plan Quarterly Report

The Executive Management Team will review the priorities on the plan to ensure they meet requirements

Director of Finance

March 2018 Update included in Board Paper on Agenda

3

31.1.18 13/18 Integrated Quality Performance Tracker (IQPT) – December 2017

Executive Management Team review the key performance indicators for mandatory training and come back to the Board with a recommendation

Chief Executive March 2018 Work ongoing with a task and finish group of the Care Quality Commission (CQC) action plan which is progressing this work

31.1.18 23/18 Charitable Funds Committee Terms of Reference

Terms of Reference to be amended to reflect that the Chairman can be a member of the Committee

Director of Finance

March 2018 Updated Terms of Reference taken to 13 March Committee

Outstanding Actions arising from previous Board meetings for feedback to a later meeting

Date of Board

Minute No

Agenda Item Action Lead Timescale Update Report

29.3.17 42.4/17 Hull City of Sanctuary Proclamation

An update on what this has meant to the organisation to be provided in the future

Chief Executive November 2017

Regular contact with Local Authority being maintained

31/5/17 78/17 Equality Public Sector Duties Annual Report

The outcomes from the annual MHLC Equality and Diversity report to be included in this report in future.

Director of Human Resources & Diversity


28/6/17 113/17 Finance Committee Terms of Reference

A review of the duties within the Terms of Reference to be undertaken in 6 months by the Committee

Director of Finance

February 2018 Updated Terms of Reference included in Finance Committee Chair update.

27.9.17 151/17 Digital Plan Update on Assisted Technology to be produced for EMT prior to coming to the Board

Director of Finance

November 2017

Executive Management Team (EMT) paper included as appendix to report

25.10.17 193/17 Medical Director Report

Medical Staffing Strategy to be developed

Medical Director November 2017

A paper will be going to EMT in March outlining our approach to recruitment and retention of the medical workforce for the year

4

2018/19T

25.10.17 197/17 Policy Update

Annually a list of policies to be shared with the Committees

Interim Head of Corporate Affairs

January 2018 (revised to April 2018 in agreement with Chair/Chief Executive)

January Update: To be added to 2018/19 Committee workplans. Proformas distributed to Committee leads on 8/1/18 for populating and Committee discussion pre 31/3/18. Assurance to be provided to the April Board

29.11.17 212/17 Procurement Strategy Update

Pharmacy contract to come to the Board in February 2018

Director of Finance

February 2018 Contract has been extended for 1 year, this was reported to the Audit Committee. An updated from the Medical and Finance Director will be taken to Board later in the year. Update not yet due

29.11.17 213/17 Estates Strategy

A quarterly update will be provided to the Board that includes an update on the disposal programme

Director of Finance

April 2018 Item not yet due

29.11.17 213/17 Estates Strategy Document to be amended to clarify the situation around statutory compliance

Director of Finance

January 2018 Document updated and on website

29.11.17 214/17 Trust Strategy Update

The Chairman will discuss the Non Executive Directors involvement with Mrs Flack

Chairman/ Transformation Programme Director/Strategy Lead

February 2018 Meeting held


Sessions with stakeholders will be arranged; Board involvement to be considered

Chief Executive/ Transformation Programme Director/Strategy Lead

January 2018 Being planned as part of the Board update sessions


To ensure any corporate plans link with the overall Trust strategy and where necessary link with the

Transformation Programme Director/Strategy

January 2018 Strategy review against planning. Continuous process

5

Interim Head of Corporate Affairs Lead


Further update to the Board; timescale to be agreed

Chief Executive / Transformation Programme Director/Strategy Lead

March 2018 Strategy update at April meeting

29.11.17 216/17 Director of Nursing Report

The reviewed Patient Experience and Engagement Strategy to come to the Board in May 2018

Medical Director (previously Director of Nursing, Quality and Patient Experience)


29.11.17 222/17 Finance Report

The table for the Cost Improvement Plan to include costings in future.

Director of Finance

January 2018 Included in Finance Report

31.1.18 06/18 Chief Executive’s Report

Update on the plans to maximise the branding of “teaching” within the accountable care system for the name change to be provided in the next report

Chief Executive February 2018 Agreed with NHS Improvement for 1/4/18. Task and Finish Group in place

31.1.18 07/18 Publications and Highlights Report

Discussion to take place at a future Board Development session regarding the use of the publications reports

Chief Executive March 2018 Discussed at the Board Time Out session


Update on the inter operability

Director of Finance

May 2018 To be presented to the Trust Board in May 2018.


Update on sharing of information issues

Director of Finance

May 2018 To be presented to the Trust Board in May 2018.

31.1.18 13/18 Integrated Quality Performance Tracker (IQPT) – December 2017

Title of the mortality dashboard to be reviewed

Medical Director April 2018 Will be actioned for the April report

31.1.18 21/18 Annual Declaration Report

The evidence to be updated to include reference to the Quality Committee and the Well Led Review

Director of Finance

May 2018 List of evidence will be updated and included to support sign off of annual declarations in May

31.1.18 22/18 Sustainable A post meeting note will be included Chief Executive February 2018 Confirmation received that

6

Transformation Programme – Memorandum of Understanding

in the minute to confirm any legal advice

no issue with signing the contract.

A copy of the full action log recording actions reported back to Board and confirmed as completed/closed is available from the Trust Secretary

Page 1 of 3


Agenda Item: 5

Title & Date of Meeting:

Trust Board Public Meeting - 28 March 2018

Title of Report: SMASH – Self-help and Social Mediation

Author:

Name: Mandy Dawley Title: Head of Patient and Carer Experience and Engagement

Recommendation:

To approve To note √



Purpose of Paper:

To provide the Board with a presentation on the SMASH programme including a young person’s experience of the support it has offered.


The key messages of the presentation are:

To provide a young person’s experience of the support offered through the SMASH programme.

To highlight how early intervention in schools can support young people to develop the skills they need to thrive and avoid the needs for CAMHS intervention.

Emma Train Sullivan (SMASH Programme Manager), Rachel Witty (Practitioner) and Beckki Blakeston (Young Person) will be attending the Board meeting. They will deliver a presentation on the SMASH programme and this will include Beckki’s view point.






Developing an effective and empowered workforce

Maximising an efficient and sustainable organisation




N/A Comment


Risk √ To be advised of any Legal √


Page 2 of 3

Compliance √ future implications as and when required by the author

Communication √

Financial √

Human Resources √

IM&T √




No


Page 3 of 3

SMASH Programme

1. Introduction SMASH is a targeted emotional resilience and mental health programme. It has made a significant impact on over 250 secondary school pupils since September 2017 alone. The programme has been delivering early intervention and prevention programmes for over 10 years across Hull and East Riding.

2. The Model The SMASH programme provides bespoke support and interventions to meet the needs of individuals who are experiencing low resilience and mild to moderate mental health difficulties. The programme has successfully taken young people from the waiting list and direct from contact point to prevent issues from escalating.

3. The results Feedback from young people, their families and education is excellent. Young people are self-reporting back to the service that things are much better and that they are better equipped to manage testing times and bounce back. The results speak volumes and most groups’ attendance average at 96% to 98%. The Outcome Star data confirms significant improvements in; feelings and behaviours, relationships, confidence and self-esteem and education. These outcomes are directly aligned with the reasons for the referrals. SMASH has been so valuable that it has now secured two independent contracts with primary schools in the East Riding.


Agenda Item: 7


Title of Report: Chief Executive’s Report

Author:

Name: Michele Moran Title: Chief Executive

Recommendation:

To approve To note



Purpose of Paper:

To provide the Board with an update on local, regional and national issues.


The report provides a summary of key issues for information and discussion:-

Chief Executive Local, Regional and National Updates

Director updates o Director of Nursing o Medical Director o Interim Chief Operating Officer

Trust Policies update

Communications Report

Health Stars update

To approve the Zero Events on page 7











N/A Comment


Risk √ To be advised of any future implications reports as and when future implications by Lead Directors through Board required

Legal √

Compliance √

Communication √

Financial √

Human Resources √

IM&T √





No


Chief Executive’s Report

1. Around the Trust 1.1 Social Workers Conference I attended the inaugural Social workers conference during the month, which was a good event and a great way for our social workers to network. Both local and national speakers attended to share best practice. More dates are being planned.

1.2 Freedom to Speak up Guardian (FTSU) Appointments The Freedom to Speak up Guardian acts as an independent and impartial source of advice to staff at any stage of raising a concern. The Guardian has been trained in receiving concerns and has access to anyone inside or, if necessary, outside the organisation. Alison Flack has been appointed to the role after an internal process. Alison will work with myself and Non-Executive Director Peter Baren who is the organisation’s Senior Independent Director. A deputy to Alison has also been appointed, Helen Young. 1.3 Safe Space Humber’s story about the ‘safe space’ for young people that was posted on Facebook has now reached an 41,886 people. It has been shared 445 times and liked 218 times. The post showing the pictures of the facility has reached 4,478 people. It has been shared 38 times and liked 73 times. This is impressive social media and it demonstrates the importance of these services. 1.4 Patient Wi-fi To confirm to the Board that we have provided patient wi-fi access to all our inpatient units. A communication on patients having access to wi-fi which includes information about our Trust being a NHS Wi-fi fast follower has been sent out. 1.5 Partnership Humber has two joint partnership bids between the Trust and NAVIGO. One regarding management trainees and the other for social worker training. This is a positive step as it is good to work with NAVIGO on such projects. 1.6 Humber Teaching NHS Foundation Trust The Trust name will change on 1st April 2018 to Humber Teaching NHS Foundation Trust following approval by the Council of Governors and Trust Board. The advantages of becoming a teaching trust have been outlined by each our directorates below and will be maximised not only at the launch but on an ongoing basis. The Strategic Communications Manager will oversee delivery of the initial launch which will focus on all of the elements that have been identified at directorate level. A coordinated launch, which will include promoting and engaging with a large, diverse group of internal and external stakeholders and staff is planned. In addition to the initial launch, which will take place before the 1st April bank holiday, ongoing engagement, reinforcement and strengthening of the new brand will be taken both at a strategic communications level and at an Executive Management Team (EMT) level through individual conversations, promotion and dialogue with individual Executives through stakeholder discussions. The importance of continuous dialogue and promotion will monitored via EMT discussions and tracked through a clear communications plan for review after 3 months. The advantages of becoming a teaching trust have been identified at a directorate level


below and will be used on an ongoing basis to maximise the teaching brand: Nursing Directorate: Be a system leader with a national reputation for underpinning practice based on research and evidence based practice and training and development of the NHS workforce working with education providers to play a leading role in health and social care research, education and training. Offering a range of development opportunities for staff to increase their knowledge and skills and gain recognised academic qualifications. Work with colleges and universities to inform the content of academic modules to ensure staff are equipped with the knowledge and skills required and to offer opportunities for work based learning and development for re graduation students and post graduates.

Human Resources and Diversity Directorate ‘Teaching’ will evidence and promote what we already do in relation to teaching medical and clinical students in our joint working with education providers. It will promote the Trust as an employer who develops and grows its’ staff, which fits with our values of Caring, Learning and Growing. It will help us attract more interest in our vacancies as we will be more appealing to candidates who have personal aspirations to develop further.

Medical Directorate From a directorate perspective the role of ‘teaching’ is a fundamental aspect of what we do in terms of service delivery. This applies not just to our undergraduate and post graduate medics but also other health professionals such as psychologists. We see the quality of the ‘teaching or training‘ experience as fundamental to improving the quality of care as well as a key driver in maintaining ‘engagement’ with our staff and student body. Many of those who ‘do’ the teaching see it as an opportunity to ‘give’ something back, create a legacy. They see it as key part of their ‘professional’ being. This emotion is something which we endeavour to capture and nurture as its tangible evidence of ‘investing’ in our future. Finance Directorate Teaching allows the Trust to enhance its reputation as a provider of first class healthcare services, and allows us to use this to support our ambition to grow our business. Operations Directorate Care Services are delighted that Humber will have a new teaching status as this provides a range of opportunities and benefits that will support the delivery of high quality clinical services and improve outcomes for patients and service users. We see the key opportunity is to support the journey of the organisation to have learning, teaching, research and quality improvement at the heart of everything we do. By doing this we will be able to enhance the opportunities for our staff from a range of clinical professions to participate in teaching and research, this will make Humber a very attractive organisation to work for and will provide opportunity for us to attract students to the professions we need in order to make our services sustainable for the future. We see this as another very important way to work in collaboration and building on other partnerships we have already to become a recognised

leader in providing innovative, evidence based sustainable services. Associate Director of Research & Development, Cathryn Hart Being a teaching trust raises our profile and lets people know that we place great importance on learning and growing, something which is likely to attract more national and international experts to work with the Trust on new research studies, hence increasing the opportunities for our community to be offered new treatments and to help inform healthcare


of the future. A teaching trust is also likely to be viewed as a more attractive place to come and work. Details on the launch will be circulated outside the meeting. 1.7 Management Trainee Bids Humber has submitted the following bids for management trainees:-

1 (first placement) general management – November 2018 – July 2019

1 trainee (second placement) strategy and Policy – not available until March 2019 until September 2019

1 trainee (second placement) – general management (Human Resources) - September 2018 until May 2019 more likely September 2019 start.

These are always very over subscribed so we await the outcome later in the year. 1.8 Health Stars New Office Health stars have a new office in the old IT server room at Headquarters. 1.9 Mobilisation Planning continues for the mobilisation of the Scarborough contract, Whitby redevelopment and Child and Adolescent Mental Health Services (CAMHS) build. 1.10 Public Meeting A public meeting was held in Whitby during the month regarding the redevelopment. The Trust was represented and questions were posed to the Clinical Commissioning Groups (CCGs) mainly regarding the size of the site and York Foundation Trust contract. 2. Around the Region 2.1 Hull Place The Hull Place Board discussed the following at its February meeting:-

Eskimo Soup’s proposal to target prevention to children and young people was agreed to be taken forward.

How funding mechanisms for such projects will work will be developed.

There may be a possible launch at Expo of the PLACE work to date from Hull 2.2 East Riding Place The System leaders continue to meet and develop the East Riding Place plan. This is still in draft but a collaborative and partnership approach is being taken and supported across the patch. This is a positive way forward. Lee Thompson has been appointed to succeed Rosy Pope, as Head of Adult Services. Lee will be joining the Council in the Spring (date to be advised). The Health and Wellbeing Board (HWB) annual work-plan meeting took place, partners discussed the links to the developing place based plans the key there being that we all working towards “the East Riding being a great and healthy place to live”. 3. National News 3.1 Spring Statement The Chancellor announced in 2016 that major tax or spending changes will now be made


once a year at the Budget in the autumn. In line with this month’s Spring Statement, it contained no new policy announcements, but gave an update on the overall health of the economy

3.2 NHSI Operations Update

In the last 12 months there has been a 1.8% growth in the number of people attending A&E and a 3.7% growth in the number of people admitted to hospital as an emergency.

In February 2018, 85.0% of patients were seen within 4 hours (1.55m), the lowest performance figures since collection began. This is compared with 87.5% in February 2017. However this is a 1.9% increase on the equivalent figure for February 2017 (1.52m seen within 4 hours).

The number of patients seen in over 4 hours was 272,343 compared to 216,416 in February 2017, an increase of 25.8%.

There were 476,792 emergency admissions in February 2018, 6.5% more than in February 2017. Admissions in the last 12 months period were up 3.7% on the preceding 12 month period.

There were 68,707 patients waiting more than 4 hours from decision to admit to admission (26.1% higher than February 2017). Of these, 371 patients waited more than 12 hours (9.8% more than in February 2017).

In January 2018 patients spent a total of 152,300 extra days in hospital beds waiting to be discharged, compared to 197,500 in January 2017. This is a decrease of 22.9%. The proportion of delays attributable to NHS in January 2018 was 59.9%, up from 56.6% in January 2017.

On Return to Treatment (RTT) performance almost 16 million patients started treatment in the last 12 months. This represents a 3.9% increase on the previous year.

At the end of January 2018, there were 3.7m people on the waiting list for treatment. The waiting list has increased by 5.0% when compared to a year earlier. At the end of January 2018, of those waiting, 88.2% had been waiting for 18 weeks or less, a fall from 90.0% in January 2017.

3.3 Good Governance Institute - Board Member Development – System

Leadership Events This event is part of the 2018 Board Member Development Programme for NHS Trusts and NHS Foundation Trusts. This is an interactive and collaborative programme running throughout 2018. The events are taking place on 29 March in Birmingham and 8 May in Leeds. The purpose of the day is to engage attendees in developing the key themes for NHS Boards, providing opportunities to network and share learning from across the system, as well as drawing on lessons from other sectors. 4. Director’s Updates 4.1 Director of Nursing 4.1.1 Never Events fieldwork to begin in April The Care Quality Commission (CQC) has been asked by the Department of Health and Social Care to examine the underlying issues in organisations that contribute to the occurrence of never events. Never Events are serious incidents that are wholly preventable because guidance or safety


recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. The CQC have indicated that they will be considering how organisations receive and review national safety requirements to review how the proposed barriers for never events are implemented. They will also look at how patients and their families and carers are involved in the processes. The CQC will be carrying out fieldwork to inform this review from April-June 2018 and are currently scoping which organisations will be included in the field work. This activity may be linked into part of an inspection, or be a standalone visit. 4.1.2 Zero Events The Quality and Patient Safety Group and the Executive Management Team have refreshed the suite of zero events for 2018/19 to ensure the focus on patient safety remains aligned to the Trust patient safety priority areas. The following areas have been agreed as the areas where there will be additional reporting and scrutiny to drive occurrence to zero in the forthcoming year.

1. No Grade 3 pressure ulcers acquired in our care. Rationale: drive continuous improvement in pressure ulcer detection and management

2. No unlawful MHA detentions. Rationale: increased focus on compliance with the Act required due to a number of recent reported administrative errors.

3. No failure to recognise and escalate the deteriorating patient in line with trust policy. Rationale: A number of clinical incidences in our physical care setting where failure to escalate has been identified. With the launch of NEWS2, the Trust Physical Health policy and Sepsis training this increased focus will support embedding policy in practice.

4. No patient harmed by an avoidable infection. Rationale- this is a goal in the recently revised Infection Control Strategy aligned to national healthcare acquired infection policy.

5. No prone restraint not in line with trust policy.

Rationale: retained from 2017/18 suite of zero events but it is expected that we start a planned approach to zero during the year as we roll out the safe wards methodology.

6. No in patient suicides. Rationale: retained form last year in line with our Suicide and Self harm strategic plan.

7. No patient discharged from MH in patient services without a 7 day follow up. Rationale: commence reporting where this is not met to undertake actions to drive improvement towards a 3 day target.

These will be presented to the Quality Committee but have been approved by the Quality Committee chair to present to the Board. These will be reported against in the monthly quality dashboard with annual progress


reported in the annual Clinical Risk report. 4.2 Medical Director 4.2.1 Health Education England In response to our recent Annual Trainee feedback from Health Education England, Dr Doug Ma the College Tutor has held a workshop and a series of 1:1s to explore and build upon what’s been going well, but just importantly support out junior doctors with regard to some of the challenges that they face. This includes national context issues such as contracts, but just as importantly their experiences of training and supervision. 4.2.2 Medical Students Event The Medical Directorate will be hosting up to 24 potential medical students of the future (6th formers) on April the 26th, The day will have a focus on the opportunities’ that a medical career in mental health will offer. We are using a combination of current medical students, core trainees and consultants to deliver the day’s events. 4.2.3 Annual Research Conference 16 May 2018 The Preparations for our second Annual research conference are well in hand with the final speaker and delegate list being confirmed. 4.2.4 Conference The Medical Directorate will be attending The Royal College of Psychiatrists Spring Conference on March 23. We will be supporting the event as part of our recruitment approach for 2018/9 where will be using our current consultants as ambassadors for the Trust and the work that we do. We will be using a similar approach in the primary care events in the forthcoming year. 4.2.5 NHS Providers Event The Medical Director recently participated in a meeting with Keith Conradi, The Chief Investigator of the Health Care Safety Organisation Branch (HSIB). The event, hosted by NHS Providers was helpful in terms of understanding the direction of travel for HSIB and understanding their approach will draw on the work and experiences of the Air Accident Investigation Branch. Humber NHS Foundation Trust will be seeking to actively collaborate with HSIB in supporting the safety agenda in Healthcare. 4.2.6 Responsible Officer The Medical Director has recently completed the designated Responsible Officer training course and will take over the role from the end of March from Dr Michael Dasari. 4.3 Operations Update

4.1 Community Services

The Trust has now signed a contract with NHS Scarborough and Ryedale Clinical Commissioning Group (CCG) to deliver some community-based health services. A rigorous mobilisation plan is in place in order that a safe transfer of services can take place on the go live date of 1st May 2018.

4.2 Learning Disability Services

The development to the Enhanced Intensive Service continues with the new service go-live commencing from April 2018. The new service will facilitate the closure of learning disability assessment and treatment beds in line with the bed reduction plan agreed by the


Transforming Care Partnership Board. This partnership plan continues to be reviewed by NHS England and recent feedback about the Humber plans and progress has been positive. The new service specification has been based on national requirements that have been localised and agreed, it will operate flexibly over extended hours seven days per week. 4.3 Mental Health Liaison Service The Trust currently provides a mental health liaison service into HEY within the A&E department and acute wards across 2 hospital sites on a 24/7 basis but this does not fully meet the requirements of Core 24 (national liaison standards). We submitted a successful bid supported by Commissioners, the A&E delivery board and HEY under wave 1 of NHS England’s transformation fund for urgent care mental health liaison services in acute hospitals in early 2017. The Trust has been awarded £699k to expand the service from April 2018. Key elements of the programme are:

Improve the interface between health & social care and have a more preventative focus to support reducing the number of people using A&E and other emergency services when alternatives would be more appropriate

Improve the mental health service provision in A&E and throughout the general hospital

Provide mental health training to staff within the acute trust and other emergency service partners

Achieve measurable improvements for service users and their families when they present at the acute hospital, including reduced waiting times and length of stay in A&E and in the acute hospital.

Improved pathways of care internally within HFT and externally with partners.

5. Trust Policies No policies have been presented to sub committees of the Board for approval since the last report to Board in February 2018. Going forward, any policies presented for ratification will be included in the CEO Directors report. Document control sheets will continue to be scrutinised at the approving committee to provide assurance that the correct procedure has been followed and that the policy conforms to the required expectations and standards. The approval via committees will provide the necessary assurance to Board and the document control sheets will no longer be presented to Board.

6 Communications Update A summary of the Communications team’s key activities between 13 February and 9 March 2018 is provided below: Internal

Prepared and issued the seventh edition of Humber Voice, the twelfth edition of Board Talk and ninth edition of Team Talk;

Supported work for the young people’s mental health inpatient unit/children’s centre project; Trust Health and Wellbeing Steering Group; and the Scarborough and Ryedale Community Services contract mobilisation;


Wrote and issued communications regarding the departure of Chief Operating Officer Teresa Cope and the forthcoming retirement of Director of Human Resources and Diversity, Elizabeth Thomas;

Supported preparatory work for the Trust’s name change (to Humber Teaching NHS Foundation Trust) on 1 April;

Supported initial work on the Trust’s Agile Working project and Estate Strategy project;

Assisted with the preparation and publication of the Chief Executive’s latest video blog;

Provided text for, and supported the completion of, the Trust’s 2017-18 Annual Report and Quality Accounts;

Promoted the work of the Senior Management Team;

Supported efforts to improve the co-ordination of communications among healthcare providers and partners in the East Riding;

Supported the work of a Dementia Awareness and Dementia-Friendly group convened by East Riding of Yorkshire Council;

Published the Winter 2018 edition of Humber People;

Supported the Trust’s Employee of the Month competition;

Prepared Friends and Family test forms for the internet;

Prepared numerous patient information leaflets;

Welcomed Amy Smith to the Communications team. Amy is on a three-month secondment as a Communications Officer from the Goole ISPHNS team.

External

Six stories were posted on the Trust’s website between 13 February and 9 March, 2018. They included: ‘Trust wins contract to continue running GP practice after transforming its rating from requires improvement to good in less than a year’; ‘East Riding health visitors and school nurses launch new Facebook page’; ‘Trust nurse shortlisted for regional award’; ‘Trust offers 16 and 17-year-olds a taste of psychiatry; ‘Trust nurse hitches life on hubby’s tractor to beat ‘Beast from the East’ and open town’s minor injuries unit’; ‘Thank you for your extraordinary dedication to our patients’;

Between 13 February and 9 March 2018, the Communications team dealt with three enquiries from local and national media;

Drafted plans regarding the Trust’s participation in the NHS@70 celebrations, including Health Expo 2018;

Supported the forthcoming launch of Humber Recovery College’s summer prospectus;

On Facebook, between approximately 9 February and 7 March 2018, the Trust’s page gained 7,759 engagements (likes, comments and shares), down 31% on the previous 28 days, and 74 new followers, down 33% on the previous 28 days. We now have 1,202 followers on Facebook, up 45 on the previous month, and up 189 from 1,013 on 30 December 2018. The Trust has doubled its number of Facebook followers in little more than 14 months;

At the time of writing, the team’s Tweets earned 104,500 impressions over the preceding 28 days, or 3,700 per day. The Trust’s Twitter handle - @HumberNHSFT - now has 3,697 followers, an increase of 52 since mid-February 2018 and a rise of 168 from 3,529 on 2 January 2018. The Trust is now six followers short of adding 1,000 followers in little more than 14 months.


7. Health Stars Update

The Health Stars office has moved! They are now in a self-contained office on the ground floor of Trust HQ. Sincere thanks to Pete Beckwith and his IT and Estates team who have transformed the IT server room into the Health Stars Hub! The Health Stars Charity has welcomed Georgi Johnson as a volunteer to Health Stars. Georgi is a sixth form student at Beverley High School, and will be working with us one afternoon a week. Georgi will help us develop our youth voice for the Impact Appeal. We are working with the Communications Department to maximise the potential of the 70th birthday of the NHS. Work continues with RESQ, a Hull based call centre, who have confirmed that the Child and Adolescent Mental Health Services (CAMHS) project will be their charity for the next two years, and are pulling together a Communication and events plan. A meeting was held with new Whitby Governor Doff Pollard, regarding the building work and local fundraising opportunities. We are still waiting to hear from the project as to the scope for Health Stars. Health Stars has been asked to support the Maister Lodge project with external and internal enhancements in advance of the completion of the project in June 2018.

Michele Moran, Chief Executive March 2018


Agenda Item: 8


Title of Report: Publications and Policy Highlights Report

Author:

Name: Michele Moran Title: Chief Executive

Recommendation:




Purpose of Paper:

To update the Trust Board on recent publications and policy. Updates from Directors are included in bold/italics at the end of the reports.


3. Monitoring the Mental Health Act Report Care Quality Commission | 27 February 2018 4. Are we listening? A review of children and young

people’s mental health services Care Quality Commission |

9 March 2018

7. National NHS Staff Survey 2017 NHS England | 6 March

2018

10. Long-term sustainability of the NHS and adult social care: government response Department of Health and Social Care | 20 February 2018











N/A Comment


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Legal √

Compliance √

Communication √

Financial √

Human Resources √

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No

___________________________________________________________________________________________ Trust Board Page 2 of 14 Date: 28 March 2018

Publications and Policy Highlights PRIORITY REPORTS TO REVIEW: 3. Monitoring the Mental Health Act Report Care Quality Commission | 27 February 2018 4. Are we listening? A review of children and young people’s mental health services

Care Quality Commission | 9 March 2018

National NHS Staff Survey 2017 NHS England | 6 March 2018

7. National NHS Staff Survey 2017 NHS England | 6 March 2018

10. Long-term sustainability of the NHS and adult social care: government response Department of Health and Social Care | 20 February 2018

1. Chronic Neurodisability: Each and Every Need National Confidential Enquiry into Patient Outcome and Death | 8 March 2018

REPORT: This report focuses on the quality provided to children and young people with chronic disabling conditions, focusing in particular on cerebral palsies. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have also been identified in the clinical and the organisational care of these patients. The Primary Care, Community, Children’s and Learning Disability Care Group will consider this report in their governance meeting and feedback recommendations to the Quality Patient and Safety Group (QPAS). Lead: Lynn Parkinson, Interim Chief Operating Officer Secondary: Hilary Gledhill, Director of Nursing, Quality and Patient Experience

2. Self-care techniques for women impacted by exposure to sexual violence media coverage

Mental Health Foundation | 6 March 2018

GUIDANCE: Sexual harassment, violence and abuse is everywhere in the media. In today’s hyperconnected world, it can be difficult to take a healthy ‘time out’ when we need to. Overhearing or being included in casual conversations initiated by media coverage can be equally difficult to navigate. It’s not uncommon for abuse to feel remote to people reading about it who have not experienced it themselves. People can often forget that there are survivors all around us still living with the life-changing impact of what has happened. If you are a survivor of sexual harassment, violence and abuse, all of this can have a negative impact on your mental health. To help minimise this impact there are a number of things you can try to put your wellbeing first. Give yourself permission to take time out and focus on your own self-care, with our eight simple tips. They’re holistic, practical and open to all: Get Grounded Focus on your feet - do they feel hot or cold? How does the ground feel beneath them? Hard or spongy? Describe this to yourself in your head.


This can help to divert your thoughts and relax your brain. Take a breath Take a deep breath in, then breathe out slowly, making the out breath last a little longer than the 'in'. This can help to refocus your mind while also relaxing your body. Say what you see Take in the things around you and name them in your mind - table, lamp, chair, shoes, pen etc. Be as descriptive as you like. This can help you focus your brain on other things. Set your anger free Write down your thoughts and feelings on a piece of paper, and then rip the paper into small pieces. This can help regulate feelings of anger and rage that may understandably come up for you. Affirm your worth At times when you're feeling happy and positive about yourself and your life, try writing a couple of sentences of positive 'affirmation' on a piece of paper and keeping this on you. For ideas of the kind of things you might write down, try thinking about what a good friend might say about you, or the kinds of things you might say to a good friend who's been through something similar. This can help you regulate feelings when you are low. Educate and empower Reminding ourselves of the myths that exist in our society around rape and sexual violence and abuse, and how to challenge them, can feel empowering and positive. RapeCrisis Myths Vs Realities This can help you to feel empowered and challenge victim-blaming myths. Sort your social media Regularly assess your social media activity like Facebook, Twitter, and Instagram. Tune in with yourself and ask if they need to be adjusted. Are there particular accounts or people that trigger certain unpleasant emotions or feelings for you, and would it be worth unfollowing them for a while? This can help to give you some headspace and control over the content you see online. Talk and share When you're ready and feel safe to, talking to someone you trust about what's happened/ing to you and the way you're feeling can really help. It might be a friend or family member, or a specialist, confidential service like a Rape Crisis helpline (see details below). If nothing else, this can help to remind you that you're not alone. The Trust will take this through our Staff Engagement and Wellbeing Group for agreement on how best to publicise and support staff within the Trust.


Lead: Elizabeth Thomas, Director of Human Resources and Diversity

3. Monitoring the Mental Health Act report

Care Quality Commission | 27 February 2018

REPORT: Monitoring the Mental Health Act in 2016/17, our annual report on the use of the Mental Health Act (MHA), looks at how providers are caring for patients, and whether patient’s rights are being protected. Overview During 2016/17, we carried out 1,368 monitoring visits, met with 4,114 patients and required 6,475 actions from providers. Our Second Opinion Appointed Doctor service carried out 14,594 visits to review patient treatment plans, and changed treatment plans in 26% of their visits. We received 2,353 complaints and enquiries about the way the MHA was applied to patients. We were notified of 186 deaths of detained patients by natural causes, 54 deaths by unnatural causes and 7 yet to be determined verdicts. We were notified of 642 absences without leave from secure hospitals. Our findings We have seen limited or no improvement in the key concerns we have raised in previous years. We found:

32% (1,034 of 3,253) of care plans reviewed showed no evidence of patient involvement. This was 29% last year.

17% (594 of 3,434) showed no evidence of consideration of the patient’s particular needs. This was 10% last year.

31% (550 of 1,788) showed no evidence of the patient’s views. In 2015/16, 26% had not been recorded.

17% (588 of 3,372) showed no evidence of consideration of the least restrictive options for care. This compares to 10% of records last year.

24% (570 of 2,403) showed no evidence of discharge planning, compared with 32% last year.

This report is a helpful overview of what they found over the past year. We have been inspected ourselves as part of the process and areas for improvement are being worked through as part of our CQC work stream. The commission did note in their last inspection the significant improvements that have taken place within Humber since the previous inspection. I will review the report with the Mental Health Legislation team and bring our conclusions to the Mental Health Legislation Committee for discussion and assurance. Lead: Dr John Byrne, Medical Director


4. Are we listening? A review of children and young people’s mental health

services


REPORT: This report describes the findings of our independent review of the system of services that support children and young people’s mental health. The Prime Minister asked us to conduct a review of quality and access across the system of mental health services for children and young people. This report marks the second phase of that review. Read the report from phase one. The report draws on evidence gathered from fieldwork in 10 health and wellbeing board areas in England. What we did We spoke with staff working across these different parts of the system, and to children, young people, parents, families and carers who use their services. We reviewed policies and procedures. We visited schools, hospitals, voluntary organisations and other services. And we used ‘case-tracking’ to examine in detail how individual children and young people with mental health problems moved through the system. In total, across phase two of our work, we spoke with more than 1,300 people through focus groups and one-to-one interviews. We looked at three main aspects of the mental health system for children and young people:

1. People’s experience of and involvement in care 2. How partners plan and deliver services that offer high quality care that can be

accessed in a timely fashion 3. How partners in the local area identify mental health needs and what they do to start

the process of getting the right support for children and young people What we found We found that many children and young people experiencing mental health problems don’t get the kind of care they deserve. The system is complicated, with no easy or clear way to get help or support. We saw examples of services with caring and dedicated individuals who put children and young people at the centre of what they do. But these people are often working long hours, with limited money and an increasing demand for their services to overcome barriers to providing high-quality care. This cannot be maintained in the long run. Things need to change at the top, so those working with children and young people have the support they need to be able to provide the best care. Our recommendations and next steps We have made some recommendations to organisations responsible for making sure that the problems with mental health services are dealt with, including:

The Secretary of State for Health and Social Care should make sure there is joint action across government to make children and young people’s mental health a


national priority, working with ministers in health, social care, education, housing and local government

Local organisations must work together to deliver a clear ‘local offer’ of the care and support available to children and young people

Government, employers and schools should make sure that everyone that works, volunteers or cares for children and young people are trained to encourage good mental health and offer basic mental health support

Ofsted should look at what schools are doing to support children and young people’s mental health when they inspect

In 2019/2020, we will report on the progress the different organisations have made to act on the recommendations in the report. We will take these recommendations forward in our ongoing discussions with commissioners about improving access (especially timelines) for children and young people’s services. Lead: Lynn Parkinson, Interim Chief Operating Officer Secondary: Hilary Gledhill, Director of Nursing

5. Briefing – Mental health rehabilitation inpatient services


BRIEFING: This briefing looks at mental health rehabilitation inpatient services, including ward types, bed numbers and use by clinical commissioning groups and NHS trusts. Mental health rehabilitation inpatient services are an essential element of our mental health care system, but we are concerned about the high number of beds situated a long way from the patient’s home. This could result in people becoming isolated from their friends and families and cut off from the local services that will provide care following discharge. To find out more, we asked providers about the mental health rehabilitation inpatient services that they manage. We did this work in collaboration with NHS England and NHS Improvement. This report presents our findings. What we did We sent a request for information to all 54 NHS and 87 independent healthcare providers that manage mental health rehabilitation inpatient services. The information request asked about:

the number of locations and wards providing mental health rehabilitation services and the average daily cost of a bed on those wards

the type, size and ‘locked’ status of the wards

each patient’s length of stay, funding authority and the mental healthcare provider that would be responsible for aftercare

We excluded wards that provided longer-stay treatment and care for people with learning disability or for older people (most of whom had dementia) and units that specialised in the care of people with acquired brain injury.


What we found

Nearly two thirds (63%) of placements in residential-based mental health rehabilitation services are ‘out of area’, which means they are in different regions to the clinical commissioning groups (CCGs) that arranged them

There is very wide variation between CCG areas in the use of rehabilitation beds, and in the use of beds that are out of area

This is a costly element of provision. We estimate that the annual expenditure on mental health rehabilitation beds is about £535 million. Out of area placements account for about two-thirds of this expenditure

Our recommendations In response to these findings, we recommend that the Department of Health and Social Care, NHS England and NHS Improvement agree a plan to engage local health and care systems in a programme of work to reduce the number of patients placed in mental health rehabilitation wards that are out of area. The issue of ‘locked rehabilitation’ as described in this report is now firmly on the national agenda. A recent NHS North of England Mental Health CEO event did explore the topic further where there was a focus on possible solutions. Humber will be seeking to work on this area, in collaboration with our system partners as there will be real opportunities to improve patient care, experience as well as reducing costs. Lead: Dr John Byrne, Medical Director

6. Specialised health services recommendations

Department of Health and Social Care | Updated 5 March 2018

INDEPENDENT REPORT: This sets out recommendations by the Prescribed Specialised Services Advisory Group to ministers on services that NHS England should commission. The Prescribed Specialised Services Advisory Group (PSSAG) annually provides recommendations to ministers on which health services should be considered to be specialised and be nationally commissioned by NHS England, rather than locally commissioned by clinical commissioning groups. The 2017 report sets out the proposals considered by PSSAG at its May and October 2016 meetings, and outlines its recommendations for each of these proposals. This paper will be taken to the Operational Performance and Risk Group for consideration. The most significant area to be considered is in relation to Psychological medicine inpatient services for severe and complex presentations of medically unexplained physical symptoms which is to be commissioned by NHS England from 1st April 2020 Lead: Peter Beckwith, Director of Finance

7. National NHS Staff Survey 2017 NHS England | 6 March 2018

OFFICIAL STATISTICS: This presents results from an annual survey to collect staff views about working in their NHS organisation.


The survey collects staff views and experiences of working in their NHS organisation. Results are presented for individual NHS organisations and national level results are presented with a breakdown by organisation type, staff group and demographic characteristics. Official statistics are produced impartially and free from any political influence.

The numbers of staff in the Trust recommending the organisation as a place to work or receive treatment and the overall indicator of staff engagement remained similar to the 2016 staff survey and were slightly lower than the national average for a similar Trust. Our top five ranking scores were:

Percentage of staff / colleagues reporting most recent experience of harassment, bullying or abuse Percentage of staff reporting errors, near misses or incidents witnessed in the last month Percentage of staff believing that the organisation provides equal opportunities for career progression or promotion Percentage of staff experiencing discrimination at work in the last 12 months Percentage of staff witnessing potentially harmful errors, near misses or incidents in last month

Our bottom five ranking scores were:

Staff confidence and security in reporting unsafe clinical practice Effective team working Effective use of patient/service user feedback Percentage of staff able to contribute towards improvements at work Percentage of staff agreeing that their role makes a difference to patients/service users

The Trust has held focussed sessions on staff engagement at the Leadership Forum, has merged the established staff health and wellbeing group with staff engagement and has developed a staff engagement and wellbeing improvement plan. Lead: Elizabeth Thomas, Director of Human Resources and Diversity

8. Healthy child programme 0 to 19: health visitor and school nurse commissioning

Public Health England | Updated 9 March 2018 GUIDANCE: This service specification is for local authorities commissioning health visitors and school nurses, for public health services for children aged 0 to 19. The guidance has been republished to reflect new evidence and guidance to support local authorities commissioning ‘public health services for children and young people’ and in particular delivering the healthy child programme 0 to 5 and 5 to 19. It focuses on the contribution of health visiting and school nursing services leading and co-ordinating the delivery of public health for children aged 0 to 19.


The healthy child programme aims to bring together health, education and other main partners to deliver an effective programme for prevention and support. We will take these recommendations forward as part of our ongoing commissioner discussions to improve children’s services. Lead: Lynn Parkinson, Interim Chief Operating Officer

9. Medication errors: Short Life Working Group report Department of Health and Social Care | 23 February 2018

INDEPENDENT REPORT: Recommendations to reduce mediation-related harm in England. The Short Life Working Group report makes recommendations for a programme of work to tackle medication error and improve medicine safety. The Department of Health and Social Care also asked the Policy Research Unit in Economic Evaluation of Health and Care Interventions (EEPRU) to review the evidence on medication errors in England. You can find out more on the EEPRU website. This report has been one part of a broader piece of work which has focussed on raising awareness with regard to the role of medications and patient safety. Our Chief Pharmacist has produced a response which highlights what Humber NHS FT is currently doing in this field. This work is monitored through our drug and therapeutics committee. Lead: Dr John Byrne, Medical Director

10. Long-term sustainability of the NHS and adult social care: government

response Department of Health and Social Care | 20 February 2018

POLICY PAPER: Command paper responding to the Lords’ Select Committee report on long-term sustainability of the NHS and adult social care. The Lords Select Committee report on the long-term sustainability of the NHS and adult social care made 34 recommendations in the areas of:

service transformation

funding the NHS and adult social care

innovation technology and productivity

public health, prevention and patient responsibility

lasting political consensus

The government’s response states that significant efficiencies will be needed to make the NHS and social care system sustainable for the long term. Lead: Michele Moran, Chief Executive

11. Approaches to social care funding Lillie Wenzel, Laura Bennett, Simon Bottery, Richard Murray and Bilal Sahib - The Health Foundation | February 2018

http://www.eepru.org.uk/article/prevalence-and-economic-burden-of-medication-errors-in-the-nhs-in-england/

https://www.parliament.uk/business/committees/committees-a-z/lords-select/nhs-sustainability-committee/news-parliament-2015/nhs-sustainability-under-threat/

https://www.parliament.uk/business/committees/committees-a-z/lords-select/nhs-sustainability-committee/news-parliament-2015/nhs-sustainability-under-threat/


WORKING PAPER: This working paper from the Health Foundation and The King's Fund considers five approaches to funding social care for older people in England. The chosen models reflect the solutions most commonly raised in the debate around social care funding, and are not a comprehensive list of possible models. The objective of this paper is not to put forward a single recommendation, but to set out the implications of each of the models. The five models

Improving the current system.

The Conservative Party’s proposals at the time of the 2017 general election (a revised means test and a cap on care costs).

A single budget for health and social care.

Free personal care.

A hypothecated tax for social care.

Key conclusions

There is scope for making small improvements within the current system, and this approach would recognise the great difficulty successive governments have faced in achieving major reform. However, it would not address many of the fundamental problems with the current system, including the downward trend in the numbers receiving publicly funded care. Nor would it protect people against ‘catastrophic’ care costs.

The Conservative Party’s proposals would have, for some, resulted in a more generous system than the one currently in place. However, there are real concerns around implementing and operating such a complex system. There is also a question as to whether this would be the best use of additional funding for social care.

While a joint health and social care budget might support progress towards more integrated care, it will not in itself address the differences in eligibility between the two systems, or generate additional revenue for health or care.

Free personal care would mean increasing the government’s ‘offer’ on social care. However, given this would require an increase in public spending, there is a question as to whether this would be the best use of additional funding for social care.

A hypothecated tax may help gain public support for raising additional funding for social care. However, this would represent a significant shift from the existing system, and could exacerbate the lack of alignment between the health and social care.

Lead: Peter Beckwith, Director of Finance

12. Public satisfaction with the NHS and social care in 2017: Results and trends from the British Social Attitudes survey Ruth Robertson, John Appleby and Harry Evans – Nuffield Trust | 28 February 2018

REPORT: Nuffield Trust and The King's Fund present results and analysis from the annual British Social Attitudes survey. This year's results show a sharp, alarming drop in public satisfaction with the NHS. Key findings Satisfaction with the NHS overall


Public satisfaction with the NHS overall was 57% in 2017 – a 6 percentage point drop from the previous year. At the same time, dissatisfaction with the NHS overall increased by 7 percentage points to 29% – its highest level since 2007.

Older people were more satisfied than younger people: 64% of those aged 65 and over were satisfied with the NHS in 2017 compared to 55% of those aged 18 to 64. Between 2016 and 2017, satisfaction fell among all age groups.

The four main reasons people gave for being satisfied with the NHS overall were: the quality of care, the fact that the NHS is free at the point of use, the attitudes and behaviour of NHS staff, and the range of services and treatments available.

The four main reasons that people gave for being dissatisfied with the NHS overall were: staff shortages, long waiting times, lack of funding, and government reforms.

Satisfaction with NHS and social care services

Satisfaction with GP services fell to 65% in 2017 – a 7 percentage point drop from the previous year. This is the lowest level of satisfaction with GP services since the survey began in 1983 and the first time that general practice has not been the highest rated service.

Satisfaction with outpatient services was also 65% in 2017. The change from the previous year was not statistically significant.

Satisfaction with inpatient services was 55% in 2017, down by 5 percentage points from 2016.

Satisfaction with accident and emergency (A&E) services was 52% in 2017. The change in satisfaction from 2016 was not statistically significant.

Satisfaction with NHS dentistry services was 57% in 2017. The change from the previous year was not statistically significant.

Satisfaction with social care services was 23% in 2017. The change from the previous year was not statistically significant. At the same time, dissatisfaction with social care services increased by 6 percentage points in 2017 to 41%.

Lead: Michele Moran, Chief Executive

13. Commissioner perspectives on working with the voluntary, community and social enterprise sector Beccy Baird, Julia Cream and Lisa Weaks – The King’s Fund | 22 February 2018

REPORT: About this report The King’s Fund was commissioned by the Department of Health to conduct research that would explore how and why clinical commissioning groups (CCGs) and local authorities chose to engage with the voluntary, community and social enterprise (VCSE) sector. This report first sets out the methodology we used and then presents our findings on the factors that underpin the adoption of different approaches. We discuss how commissioners’ perceptions of their own strategic role, as well as their views on what role the VCSE sector plays in the local area, appear to exert a strong influence on commissioning decisions. This is a small-scale piece of research that we hope will make a helpful contribution to the debate initiated by the Joint VCSE Review (Department of Health et al 2016) and other initiatives such as the work of the Health and Wellbeing Alliance, the Office for Civil Society’s Public Service Programme and the report of the House of Lords Select Committee on Charities. Key messages

There is wide variation in the way commissioners engage with the voluntary, community and social enterprise (VCSE) sector. Some commissioners saw their role solely as stimulating a market of providers, with no particular interest in creating


a strong VCSE sector. Others had made a clear choice about the value of the VCSE sector as a critical player in developing asset-based approaches to care, engaging VCSE organisations as key partners in co-production of health and care outcomes.

The primary drivers for choosing a commissioning approach are local, not national. Strong local leadership, often political, and relationships with the sector are important to creating a partnership-based approach in the face of sometimes seemingly conflicting national priorities.

Most, if not all, of the commissioners we spoke to had heard of the Social Value Act and the Care Act, but their knowledge and use of these national legislative powers varied widely, from those that actively used them to support their commissioning intentions to those who were only minimally aware of them.

Co-production – sitting down with VCSE organisations as partners and equals – requires strong and mature relationships both within the sector and between the sector and commissioners. These relationships require time and attention to develop and maintain, and leaders of commissioning organisations need to be clearer about the need to invest in relationship-building.

While the NHS five year forward view outlines a commitment to developing stronger partnerships with VCSE organisations as part of a ‘new relationship with patients and communities’, in many areas commissioners are not prioritising these relationships.

Changes to commissioning may raise more challenges for successful co-production. As integrated care organisations develop, it is unclear who bears responsibility for supporting and developing community assets. There is a risk that more transactional approaches could develop in the absence of clear incentives to involve VCSE organisations in co-producing commissioning intentions.

Commissioners reported that they face intense pressure to deliver improved value for money and better outcomes. They were not convinced that grants were inherently better than contracts, rather they emphasised the importance of appropriate and proportionate use of whichever mechanism was chosen.

Information governance emerged as one of the most challenging issues around commissioning health and care services from VCSE organisations. For some, this was a serious barrier that prevented VCSE organisations from entering the marketplace.

The VCSE sector has a role in coming together to provide a strong and unified voice as it engages with commissioners. This requires leadership from within the sector to manage competition between different organisations. Strong leadership is essential to build collaboration and partnerships within the sector and with commissioners.

This paper will be taken to the Operational Performance and Risk Group to discuss.

Lead: Peter Beckwith, Director of Finance

14. Tackling multiple unhealthy risk factors: emerging lessons from practice Harry Evans and David Buck – The King’s Fund | 1 March 2018

REPORT: Overview

Previous research by The King’s Fund has shown that unhealthy behaviours cluster in the population. Around seven in ten adults do not follow guidelines on tobacco use, alcohol consumption, healthy diet or physical activity, yet most behaviour change services address these behaviours separately, not reflecting the reality of people’s lives.


This report shares learning and insight from services that are using innovative ways to address the problem of multiple unhealthy risk factors in their populations. It draws on interviews and information from eight case studies in local authorities and the NHS and updates the evidence base on tackling multiple unhealthy risk factors.

Most services included in the report are local authority led and are integrated health and wellbeing services. These provide behavioural advice and support to people across a range of different behaviours, including smoking, weight management and physical activity.

The NHS is also addressing multiple unhealthy behaviours. We set out learning from two hospitals supporting individuals with multiple risk factors.

The evidence for these behaviour change services to draw on, in the context of multiple unhealthy risk factors, remains limited. These services are in a position to develop the evidence base on how best to address multiple unhealthy behaviours.

The report makes recommendations on how services can develop and share evidence, and for how the Department of Health and Social Care and Public Health England can support further innovation in such services.

Lead: Dr John Byrne, Medical Director

15. How is the NHS performing? March 2018 quarterly monitoring report Richard Murray, Joni Jabbal, David Maguire and Deborah Ward | 8 March 2018

REPORT: The King’s Fund published its first quarterly monitoring report in April 2011 as part of our work to track, analyse and comment on the changes and challenges the health and care system is facing. This is the 25th report and aims to take stock of what has happened over the past quarter. We find that more patients are facing long waits for hospital treatment, with those experiencing the longest waits often most in need of treatment. With demand for services continuing to rise it's very unlikely that meeting waiting time targets will become more achievable, with implications for how the NHS protects patients waiting the longest. Highlights from this report will be included in the insight report to the Finance Committee in April Lead: Peter Beckwith, Director of Finance

16. Links between NHS staff experience and patient satisfaction: Analysis of surveys from 2014 and 2015 NHS England | 22 February 2018

REPORT: Using NHS staff and inpatient survey data, this report identifies the most important aspects of staff experience in predicting inpatient satisfaction. Summary The report also examines the experiences of staff (and patients) from a black and minority ethnic background, examining the extent to which treatment of these staff are linked with patient experience. Lead: Elizabeth Thomas, Director of Human Resources and Diversity


17. NHS workforce race equality – a case for a diverse board

NHS England | 7 March 2018 REPORT: This report, commissioned by NHS England and produced by The King’s Fund, describes an analysis of the links between employee engagement, sickness absence and spend on agency staff in NHS trusts in England in 2016-17. Lead: Elizabeth Thomas, Director of Human Resources and Diversity

18. Employee engagement, sickness absence and agency spend in NHS trusts NHS England | 7 March 2018

REPORT: This report, commissioned by NHS England and produced by The King’s Fund, describes an analysis of the links between employee engagement, sickness absence and spend on agency staff in NHS trusts in England in 2016/17. The Staff Engagement and Wellbeing Group will consider the above three reports to identify whether any further actions need to be added to our current plans. Lead: Elizabeth Thomas, Director of Human Resources and Diversity


Agenda Item 9

Title & Date of Meeting: Trust Board Public Meeting – 28th March 2018

Title of Report: Humber NHS Foundation Trust Operational Plan – 2018/19

Author:

Name: Alison Flack Title: Transformation Programme Director (Mental Health) and Name: Jezz Newton Title: Strategy Manager

Action Recommended:

To approve To note To discuss √ To ratify For information To endorse

Purpose of Paper:

To present the draft Operational Plan for 2018/19 for discussion with the Board.


In line with the NHS/NHSI Joint planning guidance for 2018/19, organisations have been requested to submit a refreshed operational plan building on the submissions made in 2017/18 together with a revised financial and workforce plan submission. A draft operational plan with the supporting detailed financial and workforce plans has been submitted to NHSI in line with the national timetable. The operational plan identifies the key priorities for 2018/19 and how they link with the Trust’s strategic goals. It also provides detail on the Trust’s financial and workforce plans for 2018/19. The draft is currently subject to discussion and consultation and will be shared with the Governors in early April. It will also be discussed at the Finance Committee and Quality Committee during April. The final version will be presented to the April Trust Board for final approval prior to the submission to NHSI/NHSE at the end of April 2018.







Page 2 of 2





N/A Comment


Risk √ To be advised of any future implications as and when required by the author

Legal √

Compliance √

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Financial √

Human Resources √

IM&T √




No

‘Caring, Learning, and Growing’

Enhancing Prevention,

Wellbeing and

Recovery

Innovating

Quality and

Patient Safety

Fostering Integration,

Partnerships

and Alliances

Operational Plan 2018/19

Draft V16

Goals

Strategic

Developing an Effective and Empowered Workforce

Maximising an Efficient and Sustainable

Organisation

Promoting People,

Communities and Social

Values

2018/19

Operational Plan - 2018/19

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CARING LEARNING GROWING

Executive Summary This operational plan sets out the key priorities identified by the Trust Board for delivery during 2018/19. Our plan and vision at Humber is ambitious, and builds on the significant work that was achieved during 2017. We have continued to move forward at pace and our recent CQC inspection and overall rating of Good is testament to the hard work and collective effort of all our staff and partners. We know there is more work to do and we want to continue on our journey to improve our reputation to be a leading provider of multi-speciality health care provision. Our plan supports the national policy for delivery of mental health, community and primary care services and we will continue to be a valued and leading partner in the developing sustainable transformation partnership systems of health and social care. We are facing one of our most challenging years financially and we need to sustain this position whilst continuing to build on improving the quality and safety of our services. During May 2018 we will welcome new staff to Humber who will have transferred following the successful award of the Scarborough and Ryedale contract. We want to continue with our transformation programme for mental health services. We will continue to develop our plans to provide mental health inpatient services for children and young people, following the successful award of a contract by NHSE Specialist Commissioners. We have a challenging year ahead but with the ongoing commitment and dedication of our staff we will continue on our journey to providing outstanding care to our patients and their families. Michele Moran Chief Executive


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Index

1.0 Introduction ...................................................................................................... 4

2.0 Operating Environment .................................................................................... 6

3.0 Our Vision and Values .................................................................................... 9

4.0 Our Strategic Goals and Operational Plan Priorities for 2018/19 ................... 11

5.0 Quality ........................................................................................................... 20

6.0 Our Workforce ............................................................................................... 23

7.0 Financial Plan ................................................................................................ 26

8.0 Membership ................................................................................................... 31

9.0 Risks .............................................................................................................. 32

10.0 Performance Management of the Operating Plan.......................................... 32

11.0 Appendices .................................................................................................... 33


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1.0 Introduction Our Operational Plan sets out the key priorities for Humber NHS Foundation Trust for 2018/19. The plan will provide a reference for our staff and other stakeholders and also forms part of a suite of documents that have been submitted to NHS Improvement in order to provide assurance to our regulators. 1.1 About our Trust – Humber NHS Foundation Trust (Humber) Humber NHS Foundation Trust (Humber) provides a broad range of community and therapy services, primary care, community and inpatient mental health services, learning disability services, healthy lifestyle support and addictions services. We also provide specialist services for children including physiotherapy, speech and language therapy and support for children and their families who are experiencing emotional or mental health difficulties. Our specialist services such as forensic support and offender health, support patients from the wider Yorkshire and Humber area and further afield. We deliver a range of our services across a large geographical area which covers Hull, the East Riding of Yorkshire and the Whitby area of North Yorkshire. During 2018/19 this will be expanded to include our recent success to provide integrated prevention, community care and support services for adults living in Scarborough and Ryedale. We employ approximately 2,500 staff who work from over 70 sites covering a large geographical area encompassing the East Riding of Yorkshire, Hull, Malton, Ryedale, Scarborough and Whitby. We expect this to increase by approximately 180 additional staff as part of our successful tender award to provide an integrated community care and support service for patients living in Scarborough and Ryedale. We have approximately 16,000 members who we encourage to get involved, have their say and make a difference to how local healthcare services are provided. We have more than 120 volunteers who are passionate about working in our services and are available to help patients, staff and visitors. Our volunteers are dedicated and caring members of the community who give their time and skills freely to support us. Their work can make a huge difference to our patients’ experience while improving their own health and wellbeing. Our volunteers complement the work of our staff and provide practical support to our patients, their families and carers. 1.2 Continuing to build on our foundations

During 2017 we continued to build on our work to improve the services we provide and as a result of the commitment and hard work of all of our staff, volunteers and partners we achieved a rating of ‘Good’ by the Care Quality Commission (CQC). Although there is more work to do, we are on the right track, with thirteen of our services rated ‘good’ and three ‘requiring improvement’. Two aspects of our services for people with learning disability and autism – care and responsiveness – are rated ‘outstanding’. This is the standard we aspire to achieve across all of our services.

1.0 Introduction


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During 2017 we have worked hard to continue to grow and develop our organisation and we will continue on our journey throughout 2018/19. We have had a number of successes including:-

The acquisition of the integrated prevention, community care and support service for adults in Scarborough and Ryedale.

The successful award to provide a Child and Adolescent Mental Health Service (CAMHS) inpatient service to treat illnesses such as depression, psychosis, eating disorders, anxiety and emerging personality disorder.

An expanded research and development portfolio.

Significant work has taken place with a main focus on patient safety and reviewing clinical protocols. For example rapid tranquilisation and seclusion.

A developing commitment to our staff to improve their health and wellbeing by introducing a Staff Charter and personal responsibility framework.

A major partner of the Humber Coast and Vale Sustainable Transformation Partnership Mental Health Work Stream.

The ongoing transformation of our Adult Mental Health Services which includes development of a crisis pad for adults and also a Safe Space for young people which is delivered in partnership with Humbercare.

The continued expansion of our Primary Care Services.

The establishment of Humber Primary Care Ltd. 1.3 Humber Teaching NHS Foundation Trust In April 2018 we will become ‘Humber Teaching NHS Foundation Trust’. This will emphasise our commitment to delivering excellent services to our patients and carers, and reinforce our close working relationships with Hull York Medical School, The University of Hull and other educational establishments. This close working relationship will enable us to continue to work with our academic partners to nurture the future generation of doctors, nurses and other health care professionals. It will also mark a new chapter in Humber’s life.


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2.0 Operating Environment The NHS faces unprecedented financial and associated operational challenges. National leaders of the NHS have been clear that stabilising provider sector finances is critical to ensure overall NHS financial sustainability. One third of NHS Foundation Trusts were in deficit at the end of 2016/17, suggesting systemic issues were impacting performance. NHS Trusts continue to face rising and material increases in demand for their services as a result of demographic factors, pressures on primary and social care and increasing patient expectations. At the same time, patients have higher and more complex needs. Humber NHS Foundation Trust and the wider health care system face increasing pressure from meeting the demands of a growing population in the face of public sector funding constraints. This is recognised nationally in the ‘triple aims’ that the NHS has been tasked to achieve:-

Implement the vision in the ‘Five Year Forward View’ to improve health and care.

Deliver core access and quality standards.

Restore and maintain financial balance. These challenges mean health and social care systems must change from the traditional ‘see, treat and discharge’ model to one which ‘identifies problems at an early stage and works with patients to tackle them via integrated services supported by shared technology and information’. We will continue to work with Clinical Care Commissioning Groups (CCGs) and the HCVSTP to implement the 5 Year Forward View for Mental Health and we will work towards achieving the national Mental Health Delivery Plan for 2018/19. We are a key partner in the Humber Coast and Vale (HCV) Sustainability and Transformation Partnership (STP) and we will continue to work closely with all the partner organisations to deliver a more integrated health and social care system of provision. Within the HCV STP there are significant financial challenges as two of the partner organisations are currently working within a capped expenditure regime. The fundamental aims of the HCV STP is to ensure the local population is enabled to ‘Start, Live and Age Well’ whilst the health and social care systems focus on the triple aim of achieving desired health outcomes, maintaining quality services and closing the financial gap through efficiency. To excel these ambitions there is a genuine need for strong collaborative partnerships arrangements to help the public sector make the appropriate reforms. There are six ‘Place’ systems within the HCV STP and each of them is continuing to develop their local Place Based Plans. These will focus on the needs of the local population within each ‘Place’. We are a significant partner in contributing to the Hull and East Riding ‘Place’ plans. We also provide services within the Durham, Darlington, Tees, Hambleton, Richmondshire and Whitby (DDTHRW) STP. Humber NHS Foundation Trust’s Chief Executive Officer is our executive lead ensuring that we have proactive input to the local HCV STP and that the STP priorities are also reflected in our strategic and operational plans.

2.0 Operating Environment


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The HCV STP is made up of the following:-

HCV STP Partners Place Hull

East Riding of Yorkshire Vale of York

Scarborough & Ryedale North Lincolnshire

North East Lincolnshire

6 Clinical Commissioning Groups

3 Acute Trusts

3 Mental Health Trusts

6 Local Authorities

2 Ambulance Trusts

Humber NHS Foundation Trust is a multi-specialty healthcare and teaching provider committed to care, learn and grow, therefore is keen to be a local system leader whilst also providing appropriate support to other agencies leading system changes. Through strengthening the HCV STP governance and programme structures this will enable us to field more representatives to the key programme/project groups who are empowered to offer support and influence approaches. The Chief Executive Officer is a member of the Strategic Partnership Board and senior managers are in attendance at the respective programme work streams. There are synergies in terms of the HCV STP priorities and those of our own strategic goals for 2017-22, namely:-

Humber NHS Foundation Trust Goals Humber Coast and Vale STP Priorities

Goal 1 Innovating quality and patient

safety

Better ‘In-Hospital’ Care

Goal 2 Enhancing prevention, wellbeing

and recovery

Better ‘Out-of-Hospital’ Care

Goal 3 Fostering integration, partnership

and alliances

Better Mental Health Care

Goal 4 Developing an effective and

empowered workforce

Better Cancer Care

Goal 5 Maximising an efficient and

sustainable organisation

Balancing the Books

Goal 6 Promoting people, communities

and social values

Healthier People

The key focus will be on prevention, supporting people in terms of tobacco control, identifying and acting early on cancer, preventing cardiovascular disease and diabetes changing how people access primary and community care through integration; improving the quality of hospital services, high quality, networked and sustainable specialist services; shared support services; improving diagnostics and recovery packages. 2.1 HCV STP Mental Health Programme We continue to invest significantly across the mental health work stream. The Chief Executive is the Senior Responsible Office (SRO) and our senior staff provide the leadership and programme management support. The Mental Health Delivery Board continues to improve collaborative and partnership working, not only at STP level but also at a regional and national level. The priorities agreed in 2017/18 will continue to be developed in 2018/19


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with a key focus on partnership working with patients, carers and other stakeholders and improved clinical engagement. The Mental Health Programme Board has agreed in principle a Memorandum of Understanding across all the partners and this is continuing to be developed. The Mental Health Programme Board will continue to focus on the 5 Year Forward View for Mental Health and have aligned its priorities with the national Mental Health Delivery Plan for 2018/19. One of its key focusses will be in relation to the Mental Health Investment Standard (MHIS) and ensuring greater transparency regarding financial investment into the mental health priorities. There are six priority work streams for the Mental Health programme that are aligned to the national mental health operating plan (2018/19) and 5 Year Forward View for Mental Health:-

Eliminating out of area placements for acute adult patients

Crisis Care and Liaison Services

Community Mental Health Teams

Specialist Perinatal Community Services

Secure Care transformation and Forensic Outreach liaison Services

Dementia

The Mental Health Delivery Board priorities are all congruent with our operational service priorities. Whilst we face our most challenging period financially, we are strongly placed locally to deliver joined up care and have already introduced a number of new ‘exemplar’ services that are being rolled out nationally, for example the Perinatal Specialist Mental Health Service. We aim to be recognised as an outstanding organisation delivering outstanding care and will progress innovative service-led delivery. We have a key role in working with partner organisations, for example providing support to acute services, exploring innovative social models for self-care and prevention to provide community based health and social care that reduce service demand. 2.2 Transforming Care National Programme for Learning Disability Services We will continue to work with our partners to deliver the Transforming Care National Programme for Learning Disability Services. 2.3 Five Year Forward for Primary Care We will continue to implement our Primary Care Strategy to facilitate integration across health and social care. The General Practice Forward View (2016) also supports this.


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3.0 Our Vision and Values Our Vision:- We aim to be a leading provider of integrated health services, recognised for the care, compassion and commitment of our staff and known as a great employer and a valued partner. Our Values:-

These values shape the behaviour of our staff and are the foundation of our determination to:-

Foster a culture in which safe, high-quality care is tailored to each person’s needs and which guarantees their dignity and respect.

Achieve excellent results for people and communities.

Improve expertise while stimulating innovation, raising morale and supporting good decision-making.

Unify and focus our services on early intervention, recovery and rehabilitation.

Engage with and listen to our patients, carers, families and partners so they can help shape the development and delivery of our healthcare.

Work with accountability, integrity and honesty; nurture close and productive working relationships with other providers and our partners.

3.1 Involving Our Patients and Carers Putting patients and carers first is our main priority. We want to continue to build on the work we have started in working closely with our patients and carers to develop services across the Trust. Our Trust Board will continue to hear real patient stories on a monthly basis. We are committed to delivering high quality services across all areas in which we operate, this is demonstrated through delivery of our key values and always putting the needs of others first. We will demonstrate this by engaging with people, listening and responding to their experience so we can:-

Improve patient experience and satisfaction with our services.

Ensure services are more responsive to individual needs.

Help develop services that support patient’s dignity and independence.

Encourage our staff to find new ways to deliver healthcare.

CARING

LEARNING

GROWING

Caring for people while ensuring

they are always at the heart of

everything we do

Learning and using proven research as a basis for delivering

safe, effective, integrated care

Growing our reputation for being a provider of high-quality services

and a great place to work

3.0 Our Vision and Values


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Improve accountability to our patients, their families, carers and the public.

Provide a customer focused service and improve quality.

We know that patient experience is more than just meeting our patient’s physical needs. It is also about treating each patient and their carer(s) with the dignity, compassion and respect that they deserve as an individual. We don’t want to just meet expectations, we want to exceed them.

3.2 Continuing to work with our partners

We will continue to be an active partner and continue to develop services in conjunction with other partners. We have established close working relationships with Humbercare and MIND in developing our mental health services as part of its transformation programme. We will continue to play a key role in delivering the work of the crisis care concordat and ensuring we continue to prioritise the development of our crisis services for adults and young people. We are a key partner in the Hull and East Riding Place Based systems and are leading the work of the HCV STP mental health work stream.


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4.0 Our Strategic Goals and Operational Plan Priorities for 2018/19 As part of our Trust Strategy (2017-2022) we have identified six strategic goals, key objectives and supporting measures to achieve our ambitions and deliver key improvements. They are linked to government initiatives, regulatory findings and local health needs assessments based on discussions with Sustainability and Transformation Partnership (STP) representatives, patients, carers and families, staff, governors and partners. Our six strategic goals, key objectives and outcomes for 2018/19 are detailed below:-

4.0 Our Strategic Goals and Operational Plan Priorities for 2018/19


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4.1 Supporting Strategies During 2017 the Board have approved the following strategies that will support the achievement of our priorities:-

Research and Development Strategy (2017-19)

Recovery College Strategy (2017-20)

Health Stars Strategy (2017-22)

Primary Care Strategy (2017-19)

Suicide Prevention and Self Harm Strategy (2017-19)

Patient Safety Strategy (2017-19)

Digital Strategy (2017-19)

Estates Strategy (2017-19)

Workforce and Organisational Development Strategy (2017-19) 4.2 Expanding Our Research and Development Portfolio We view research as a core part of our service offering, as the main aim of research is to make a positive difference to the quality of healthcare the NHS provides now and in the future. Objectives identified in our current Research Strategy seek to build upon our existing strengths, to continue what we are doing well but also to be ambitious and innovative in our approach, to proactively seek and encourage new research partnerships and opportunities and to ensure we involve more of our community in good quality research. Our Research Strategy (2017-2019) was launched in May 2017 at our first major research conference which celebrated previous successes, showcased the research we were involved in and gave us another opportunity to engage with our stakeholders. We were also fortunate to welcome Professor Kapur and Professor Appleby who are national experts on suicide prevention. The inaugural ‘Developing a City of Research’ conference was well received throughout the local health and social care system and we are hoping to echo that success in the second conference in May 2018 where we aim to showcase even more local, national and international research that we are involved in. We are delighted to have a number of speakers from across the region with expertise in a wide variety of areas, including


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Professor Alistair Burns the National Clinical Director for Dementia and the National Clinical Director for Mental Health in Older People for NHS England. The objectives are identified in our Research Strategy (2017-2019) as follows:- 1) Embed research as core business. 2) Increase participation in research. 3) Maximise research income. 4) New partnerships for applied research. 5) Increase capacity and capability for research. 6) Excellence in the quality, safety and governance of research. 7) Translate research into practice. 4.3 Humber’s Recovery College The Recovery College believes in an educational approach to mental wellbeing, supporting individuals to recognise their own resourcefulness, talents and abilities, and arming them with knowledge and helpful tools in order to become experts in their own self-care. The College uses the Recovery Approach, which is about delivering person-centred care to achieve goals set by the individual; the emphasis is on ‘life worth living’ as opposed to ‘getting better’. The Recovery Approach was born as a user-led peer support service in the 1990s, but is now championed by progressive mental health services as a quality, holistic approach to good mental health care. The objectives are identified in our Recovery College Strategy (2017-20) as follows:- 1) Create a sustainable and efficient recovery college. 2) Develop and grow employment support within the Trust. 3) Support the continue development of peer support workers. 4) Continue to develop alliances and partnerships to support the Recovery College model. 4.4 Health Stars Charity Health Stars is our charity with a mission to promote the development of exceptional healthcare which goes above and beyond NHS core services, through investment in people, environments, resources, training and research. By making these investments they work to enhance the experience of our teams, patients and the community we serve. Through the Circle of Wishes process, everyone can access charitable funds to make a difference. We have enlisted the support of The HEY Smile Foundation, a local leader in the development and sustainability of charities, with experience of working within the NHS. HEY Smile Foundation’s work to-date for us has been to reposition our charitable funds, Health Stars, into a charity that is open for business, celebrates what’s great about our NHS teams and distributes the funds effectively. During 2018/19 Health Stars will continue to build on their work as an independent charity that works alongside Humber to enhance its ability to plan and react to the growing needs of its people and patients. It will continue to develop a joined up approach for both funding and resources which will provide additional support to Humber’s services.


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4.5 Operational Delivery Priorities Our frontline operational services are currently organised into three Care Groups:-

Adult and Older People’s Mental Health

Primary Care, Community, Learning Disabilities and Children’s Services

Specialist Services Each Care Group is working hard to respond to the health needs identified by commissioners and local people through redesigning services, providing more joined up care and increasing opportunities for partnership working. We have major transformation plans in place for a number of our clinical services. Our corporate services are equally important in delivering our vision, providing a high quality environment, a framework of support and a culture that allows our staff to flourish and develop. The operational service priorities highlighted below have a clear rationale based on the health needs of the local population, market assessment, stakeholder needs, external imperatives, policy drivers, NHS Mandate and contract requirements, commissioning intentions, capacity and capability, internal performance issues and service and cost pressures. The delivery of these priorities will be overseen by the Chief Operating Officer. The priorities are not exhaustive but spotlight key priorities for us in 2018/19, including actions to ensure we are well positioned to meet the needs of local communities, commissioners and public sector challenges in years to come. We are working with Clinical Commissioning Groups, Local Authorities and other partners to develop services and pathways. During mid 2018 it is proposed that there will be a review of the existing Care Group structures which will be led by the Interim Chief Operating Officer. The following tables list the High Level Objectives from each of the Care Group’s service plans and demonstrate how they align to our strategic goals and to the priorities of the Humber Coast and Vale Strategic Transformation Partnership (HCV STP) and the Transforming Care Partnership (TCP).


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Adult and Older People’s Mental Health Care Group (Care Group Director – Jan Smith)

HFT Strategic Goals HCVSTP / TCP

Priority

Innovatin

g

Qualit

y

Enh

ancin

g

Pre

vention

Foste

ring

Inte

gra

tio

n

Develo

pin

g

work

forc

e

Maxim

isin

g

Org

nais

atio

n

Pro

mo

tin

g

Peo

ple

Implementation of responsive community mental health services model

Implement new model of treatment for complex personality disorder

Establish a core 24 compliant mental health liaison service

Redesign the rehabilitation and recovery pathway

Develop a clear estates strategy for re-provision of inpatient service

Redesign of dementia services including a new primary care diagnosis model

Develop a revised pathway for older people with long term needs

Complete the refurbishment of Maister Lodge

Eliminate acute out of area AMH admissions through the development of additional local capacity and new

models of crisis care

Primary Care, Community, Learning Disabilities and Children’s Services Care Group (Care Group Director – Julia Harrison-Mizon)


Priority

Innovatin

g

Qualit

y

Enh

ancin

g

Pre

vention

Foste

ring

Inte

gra

tio

n

Develo

pin

g

work

forc

e

Maxim

isin

g

Org

nais

atio

n

Pro

mo

tin

g

Peo

ple

Continued roll out of 0-19 service

Implementation of Enhanced Intensive Service in Learning Disability (LD) services

Opening of new CAMHS inpatient unit

Continued transformation of community CAMHS and crisis service review

Further growth of the primary care portfolio

Redesign of Whitby hospital

Redesign of Pocklington and Whitby NCS

Achieve waiting times KPI’s

Specialist Services Care Group (Care Group Director – Tracy Flanagan)


Priority

Innovatin

g

Qualit

y

Enh

ancin

g

Pre

vention

Foste

ring

Inte

gra

tio

n

Develo

pin

g

work

forc

e

Maxim

isin

g

Org

nais

atio

n

Pro

mo

tin

g

Peo

ple

Capital programme to provide modern secure inpatient service

Redesign community and inpatient forensic pathways

Further develop the forensic facility of Recovery College

Support further growth of addiction service across STP

Continue the culture shift across whole Care Group to


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recovery focused pathways and practice

4.6 Key Operational Priorities Expanding our Primary Care Services Peeler House Surgery, in Hessle, became the sixth practice run by us and our fifth in the East Riding of Yorkshire. Its acquisition strengthens our position in the provision of primary care and will enable us to continue to bring together and improve our physical and mental health services. We also run Field House Surgery in Bridlington, the Chestnuts and Hallgate practices in Cottingham, Market Weighton Group Practice, and Northpoint Medical Practice in Bransholme, Hull. All six of our practices are now rated ‘good’ by the CQC. In October 2017, Humber NHS FT established Humber Primary Care Ltd (a private limited company) to enable Humber to hold General Medical Services (GMS) contracts with the practices we run. We will continue to deliver the objectives outlined in the Primary Care Strategy (2017-19). Scarborough and Ryedale Community Services We have secured a contract to provide an integrated prevention, community care and support service for adults in Scarborough and Ryedale. Supported by a comprehensive Mobilisation Plan that aligns strongly with Scarborough and Ryedale CCG’s vision to deliver a new, transformed service, our service is due to commence in May 2018. We will provide services targeted predominantly at older adults, those living with one or more long-term condition, and people who are frail due to age or disability. The aim will be to ensure patients are supported in their own homes, or as close to them as possible, and to prevent inappropriate admissions to hospital. Child and Adolescent Mental Health Services (CAMHS) Inpatient Unit Planning has been approved for us to create a ‘Children’s Campus’ off Walker Street, Hull, by linking the planned 11-bed unit to our existing Children’s Centre, refurbished to provide Child and Adolescent Mental Health (CAMHS) community and therapy services. We submitted our planning application after securing a 10-year contract from NHS England to develop a CAMHS inpatient service to treat illnesses such as depression, psychosis, eating disorders, anxiety and emerging personality disorder. The proposal is to deliver this service from a building which will include nine general CAMHS and two Psychiatric Intensive Care (PICU) en-suite bedrooms, a lounge, dining area, treatment and dispensing room, and quiet room. The new centre will also house multi-purpose activity, gaming and sensory rooms, an extra-care area, school, meeting room, gym, multi-faith room, family visit room and reception area. Adult Mental Health Services Transformation We want to continue the work we have started in transforming our adult mental health services. Our ambitious transformation programme will include the implementation of our Rehabilitation Strategy; expansion of our specialist perinatal services and the significant investment programme in our A&E Liaison Services.


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Understanding Capacity and Demand for our Mental Health Services In order to better understand the current capacity and demand placed upon our mental health services, and to review investment received from our local Clinical Commissioning Groups and the outcomes for our patients, we have commissioned Mental Health Strategies Ltd to work with our Care Groups to do this. Secure Services – New Models of Care As part of the New Models of Care, our secure services have been working closely with partner providers to look at how the current provision of low and medium secure services can be provided. It is expected that this will be implemented during 2018/19 and will include the provision of a forensic outreach liaison service. 4.7 Corporate Services Delivery of the operational service plans is supported by our corporate functions. The areas below represent the key projects during 2018/19 that will support us in achieving our aims and strategic objectives. The tables demonstrate how they align to our strategic goals:-

Workforce and Organisational Development (Director of Human Resources – Elizabeth Thomas)

HFT Strategic Goals*

Innovatin

g

Qualit

y

Enh

ancin

g

Pre

vention

Foste

ring

Inte

gra

tio

n

Develo

pin

g

work

forc

e

Maxim

isin

g

Org

nais

atio

n

Pro

mo

tin

g

Peo

ple

Staff Engagement

Health and Wellbeing

Human Resources and Organisational Development Transformation

Resourcing – Including reducing reliance and agency staff

Learning and development

Leadership and Management Capability

Infrastructure and Informatics (Director of Finance – Peter Beckwith)

HFT Strategic Goals*

Innovatin

g

Qualit

y

Enh

ancin

g

Pre

ve

ntion

Foste

ring

Inte

gra

tio

n

Develo

pin

g

work

forc

e

Maxim

isin

g

Org

nais

atio

n

Pro

mo

tin

g

Peo

ple

Implement the new Health and Social Care Network framework to replace N3

Implement a mobile working system for Lorenzo

Implementation of electronic prescribing across the organisation

Interoperability with NHS organisations’ systems

Implementation of order communications across the organisation

*Whilst each of the priorities will deliver against all of the strategic goals in varying degrees, the tables above demonstrate their closest alignment.


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4.8 Corporate Benchmarking In 2017/18 we took part in a national exercise to compare the costs and efficiencies of our corporate services with those of other NHS Trusts. The outcome of this ‘benchmarking’ exercise was that whilst a number of areas were very efficient compared to other NHS Trusts, some were identified as possibly offering an opportunity to improve. An action plan has been developed to greater understand the comparison and to address any areas that could be improved. We will focus on the areas that currently have the highest expenditure when benchmarked nationally. This will include Human Resources and Information Technology.


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5.0 Quality Through our care, we want people to feel better and get the most out of life. Providing high quality services is central to this and ensures we continue to be a successful and innovative provider. 5.1 Approach to Quality Governance The key systems and processes for ensuring effective quality governance and improvement sit within the remit of the medical and nursing directorates and include processes in relation to:-

Corporate risk management and clinical risk management.

Clinical audit and effectiveness.

Research and evidence based practice.

Patient and carer experience including patient complaints.

Quality performance monitoring and assurance. An established clinical and quality governance framework is in place with reporting from the Care Group clinical governance reporting structures via their clinical networks. The vehicle for quality improvement in the care group is via their Quality improvement Plans with reports to the Quality and Patient Safety Group for progress monitoring and organisational learning purposes and reports to the Quality Committee which is a sub-committee of the Trust Board for assurance purposes. Each care group has a Quality and Safety Group with responsibility to ensure that robust quality governance arrangements address the key elements of quality and safety in line with our Trust Framework. This framework includes the CQC questions to ensure routine consideration. A quarterly committee dashboard includes indicators set beneath each of the quality priorities to allow measurement of specific quality and safety issues. The Quality Committee is accountable to the Board escalating quality or safety concerns through routine reporting. We have a number of quality indicators that allow us to monitor the safety of the service we deliver. Some of our key indicators are listed in Appendix 1. 5.2 Approach to Quality Improvement Our executive lead for quality improvement is the Medical Director. Over the coming year we will focus on developing the capacity, capability and culture of continuous quality improvement. Capacity for quality improvement activities will be realised from within existing teams in addition to ensuring that all individuals have sufficient time to undertake annual appraisal, mandatory and required training and team quality and safety meetings. We see these activities as being a fundamental part of our collective day to day work both in clinical and corporate support services. We acknowledge that ‘freeing up time’ will be a challenge; however we are certain that it the long run it will benefit both patients and staff. We will seek to develop our capability to support Quality Improvement by working with Quality Improvement bodies to support individual and staff training in acquiring the required technical skills. We will seek to identify and subsequently support staff who currently have the technical skills but as yet have not been harnessed as part of a program. We

5.0 Quality


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demonstrated through our Reducing Restrictive intervention and Suicide and Self harm work that it has the capability to deliver improvement and we will seek to scale up this work and encourage local initiatives right across the breadth of our services. We have concluded that we are not going to be prescriptive on the methodology used as many of them have similar underlying philosophies, and to focus on one form may inadvertently result in us realising the diversified skills already present in our workforce. We will develop a ‘culture’ of continuous quality improvement (QI) at all levels. The Board has recently started to develop its own capabilities in terms of QI and will seek to develop a pledge to support others to also participate in similar initiatives. We will seek to encourage an approach where service user involvement is considered a central part of our work, and that over time, co-production will become a cultural norm. We understand developing the culture of continuous Quality Improvement will take time, effort and persistence. Quality improvement capacity and capability will be supported and monitored through the Quality Committee with every care group required to provide updates on a regular basis on the improvement and innovation that is taking place in their service. In developing the quality improvement plan we have taken into account:-

National and local commissioning priorities.

Trust quality goals.

Existing quality concerns and plans to address them.

Key risks to quality and how these will be managed.

The content of the Sustainable Transformation Partnership Plans. The Quality Improvement Plan supports our quality priorities which will be further developed during 2018/19. 5.3 Quality Priorities 2018/19 The Trust is committed to continuous quality improvement and uses a range of initiatives to drive improvement in all of the services it provides. Throughout 2018/19 the Trust will continue to drive forward the priorities identified in 2017/18 whilst focussing on three key priority areas informed by our staff in consultation with patients, carers and our partners. Quality Priority 1 Ensure we have meaningful conversations with patients/carers to develop therapeutic relationships and engagement in service delivery. Meaningful conversations are fundamental to the delivery of excellence in health care. In 2018/19 we will:-

Always ask patients/carers who they want us to share their information with.

Ensure our staff are empowered to involve our patients/carers.

Ensure that our methods of engagement are accessible and adapted to meet the needs of our community, using a range of communication methods.

Always involve patients/carers in the planning of their care. Quality Priority 2 Ensure that quality improvement is a part of every staff member’s role to maximise patient safety across all of our services.


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Quality improvement is about making health care safe, effective, timely, patient centred, efficient and equitable. We continually strive to improve and learn. In 2018/19 we will:-

Develop a leadership style that encourages new ideas and develops a culture of continual quality improvement underpinned by developing our approach to quality improvement.

Develop the skills of our staff in relation to quality improvement and the use of technology.

Embed a culture of asking ourselves “what have we done that has made a difference to our patients and carers?” by utilising feedback from our patients and carers in our clinical staff appraisal process.

Develop a meaningful and effective approach to learning from incidents, compliments, complaints and feedback with our staff, patients and carers.

Reduce harm to our patients through taking action to reduce the incidence of pressure ulcers acquired in our care.

Enhance our focus on patient safety incidents by supporting our staff to identify, report and learn from patient safety incidents specifically we will:- - Implement the ‘Safewards’ initiative in our Mental Health Units to improve patient,

carer and staff experience and reduce patient safety incidents. - Refresh and implement our suite of ‘Zero Events’ which aim to maximise safety in our

services.

Quality Priority 3 Embed best available evidence in practice utilising patient reported and clinical reported outcome measures (PROMS*, CROMS**). It is important that we measure outcomes to determine whether the care we deliver is effective. In 2018/19 we will:-

Implement the National Institute for Clinical Excellence (NICE) Guidance informed depression pathway across our Adult Mental Health Services.

Roll out PROMS* and CROMS** across identified services within Adult Mental Health.

Evaluate the effectiveness of our services using the agreed outcome measures. *PROMS = Patient Related Outcome Measures **CROMS = Clinician Related Outcome Measures


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6.0 Our Workforce The Workforce and Organisational Development Strategy and the Trust’s associated plans give consideration to Health Education England’s Workforce report, Facing the Facts, Shaping the Future – a draft health and care workforce strategy for England to 2027 and also align to the delivery of the NHS Five Year Forward View. The focus of the Workforce and Organisational Development Strategy is built around 4 key strategic priorities:-

Healthy Organisational Culture

Capable and Sustainable Workforce

Effective Leadership and Management

Enabling Transformation and Organisational Development These priorities will ensure that we have the right number of staff with the right skills available to deliver high quality patient care through direct clinical and medical care or in a supportive capacity, ensuring the alignment against new models of care. We face a number of challenges, many at a national level, in terms of the ability to recruit to medical, clinical and allied professional roles; this is further compounded by the financial pressures facing NHS organisations. At a local level there are challenges in terms of geographical location and an aging workforce. One of the key challenges for us is the recruitment, retention and availability of nurses, especially challenging with an ageing workforce, with retirement accounting for the highest reason for employees leaving the profession. We encourage staff to retire and return and about a third of our staff currently retiring stay with the Trust in either a substantive, temporary or bank role. There is the potential for us to lose 248 of our qualified nursing workforce over the next five years due to retirement. To address this, we work closely with the universities offering placement opportunities to support and encourage newly qualified nurses into the organisation. We intend to fund, through the apprenticeship levy, opportunities for career development for existing non-qualified staff to gain a degree in nursing to become registered nurses. Work is underway to increase the number of careers events that we attend at universities, with a view of encouraging newly qualified staff to join our organisation. It should be noted however that due to the supply of nursing staff, we are not alone in trying to attract staff into our organisation. In addition to registered nurses, we will commence a programme over the next five years to introduce Nursing Associate roles and have already piloted a programme and will be expanding this in 2018. We are looking at opportunities to retain our workforce in particular those eligible to retire and are offering flexible and part-time opportunities and exploring alternative roles to retain knowledge and experience. We recognise there are opportunities to promote roles within the Humber region and the wider NHS through careers events at local schools and colleges and there are already strong links in place with local schools and throughout 2018/19, we will expand on this to work with schools across the geographical area. We will be working with our partners to offer opportunities for work experience across many areas. There is already a successful Medical Work Experience Scheme and it would be the intention to formalise this scheme. Over the next year, a revised apprenticeship scheme will be introduced with opportunities for career development starting with an entry level scheme for those new to the organisation

6.0 Our Workforce


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and will include nursing apprenticeships and development opportunities linked to formal qualifications. As part of the future workforce plan, there will be new roles at Band 4 level for Associate Practitioners across the organisation to support our qualified workforce and there will be opportunities for development to Advanced Clinical Practitioner level. We have secured funding through Health Education for the Advanced Clinical Practitioner role for training due to commence in September 2018. Over 2018/19 we will commence recruitment to the CAMHS inpatient unit which will include a variety of clinical and non-clinical roles and the number of roles is expected to be between 55 and 60. There will continue to be a focus on staff health and wellbeing, identifying new initiatives to support staff, to manage sickness absence, with the aim of reducing sickness absence. All staff will be encouraged and supported to undertake the required statutory mandatory training and have the necessary training to undertake their roles. Our leadership programme launched in 2017, the second cohort will continue with a review of future delivery models working with the NHS Leadership Academy. A Management Development Programme will be developed and introduced to ensure managers have the necessary skills and training to manage their teams and to improve staff engagement. We have been successful in a bid to the NHS Leadership Academy to develop our Senior Management Team (SMT). The SMT has recently been established to support the Executive Management Team (EMT) and to improve working across operational and corporate directorates. This initiative will provide expert resource to support the SMT to operate as a shadow EMT. It is envisaged that this will support the personal development of those individuals and contribute to the succession planning for our organisation. The workforce plan will be adapted and modified to meet the budget challenges facing our organisation and it is expected there will be a re-alignment of roles, redeployment opportunities, new skills mix and new roles. We have a number of strategies to reduce agency expenditure and avoid unnecessary expenditure. This includes the recent in-sourcing of the staff bank; the establishment of a relief team of healthcare support workers and introduction of limited overtime in inpatient services. The recent roll out of a new eRostering system, supported by an externally resourced project is reviewing and managing progress to ensure that rosters are fair, effective and efficient and that staff can be utilised flexibly to respond to changes in acuity and demand. In response to the Lord Carter review we are implementing a patient acuity model within eRostering which will allow real time deployment of staff across inpatient pools to areas of escalating and/or greatest patient acuity. We have robust processes to improve compliance with agency price and wage caps and the new requirements set out by NHS Improvement to eliminate the sub-optimal use of agency staff. We are also exploring ways of reducing medical locum expenditure and a possibility of collaborating on a staff bank for medical locums. As new models of care emerge, workforce transformation will be critical to ensuring increased productivity and improved health outcomes. Clear and consistent staff engagement will help ensure that staff understand what is required of them in terms of mind set, values and behaviours, supporting them to work confidently across organisational boundaries and work to the full limits of their competence/professional registration.


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Development activities will be aligned with emerging new models of care to equip staff with the right skills and competencies.

6.1 Improving Our Staff Health and Well Being Our staff are our most important asset in providing high quality safe patient care to our patients. We want to build on the work that we have developed during the last 12 months in supporting our staff’s health and wellbeing. We have introduced a Staff Charter and are continuing to develop new ways of being able to demonstrate how we truly value our staff’s dedication and commitment. We will continue to hold staff awards events locally but also look to how we can support our staff to share their innovative work on a more regional and national basis. We want to continue to demonstrate how we are working within the Trust values of caring, learning and growing. Our staff health and wellbeing forum is becoming more established and we are looking at different initiatives to improve staff’s working lives. We need to continue to develop ways to improve staff engagement and to ensure that staff’s views are heard in developing services.


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7.0 Financial Plan The Director of Finance is the executive lead ensuring we have established robust financial and management accounting systems. The 2018/19 financial plan is based on current financial performance, national planning guidance, NHS Improvement Control Total and ongoing contract negotiations with commissioners. A summary of the key financial headlines for the plan are detailed in the table below. 7.1 Financial Summary 2017/18

Forecast (£m) 2018/19 Plan (£m)

Income and Expenditure

Income 113.449 125.384

Operating expenditure 110.482 122.371

Earnings Before Interest, Taxes, Depreciation and Amortization (EBITDA)

2.967 3.013

EBITDA % 2.620% 2.400%

Net Surplus/(Deficit) 0.233 1.151

Net Income and Expenditure Margin % 0.210% 0.920%

Other Key Financial Information

STF Funding 1.431 2.012

Year-end Cash Balance 5.622 8.020

Use of Resource Assessments 2.000 2.000

Agency Ceilings 3.072 2.828

Our income is expected to increase to £125.384m in 2018/19, significant items to note include:-

Successful award of an integrated prevention, community care and support service for adults in Scarborough and Ryedale.

The successful award to provide a Child and Adolescent Mental Health Services (CAMHS) inpatient service to treat illnesses such as depression, psychoses, eating disorders, anxiety and emerging personality disorder.

Further growth in Primary Care Practice; we now operate 6 primary care practices. We operate in an environment of rising costs, increased expectations and increasing demand, all of which present financial challenges for us. 7.2 Planning Assumptions The most significant cost to us is pay, and assumptions which underpin the plan are in the table below. 2018/19 % £000

Income Inflator 2.1% 84.3

Income Deflator (2.0%)

Pay Award 1% 917.4

Incremental Drift 0.3% 282.8

Non Pay Inflation - -

7.0 Financial Plan


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7.3 Control Total And Sustainability Transformation Funding The Draft Operational Financial Plan submitted meets our NHS Improvement Control Total of a £1.151m surplus, after the receipt of Sustainability and Transformation Funding of £2.012m. The reality is therefore an underlying deficit plan of £0.861m

2017/18 Plan (£m)

2018/19 Plan (£m)

Control Total – Surplus/(Deficit) 0.233 1.151

STF Funding 1.431 2.012

7.4 Current Contract Situation We are currently negotiating contract values with our main commissioners, contract type and length for the main contracts we hold are summarised in the table below:

Contract Name Contract Type 2018/19 Phase NHS Hull and East Riding CCG (Mental Health, Learning Disability and Community Services)

NHS Standard Contract + Collaborative Commissioning Governance Arrangements

Year 2 of 2

NHS England Specialist Commissioning

NHS Standard Contract Year 2 of 2

NHS Hambleton, Richmondshire and Whitby CCG (Community Services)

NHS Standard Contract Year 3 of 5(7)

NHS Scarborough and Ryedale CCG (Community Services) (Due to commence on 01/05/2018)

NHS Standard Contract Year 1 of 5(7)

7.5 New Contracting Arrangements For the NHS Hull and East Riding CCG contract in 2018/19, we will maintain our standard NHS contract but enhance its delivery with Collaborative Commissioning Arrangements with the commissioners. This will mean that key system partners are committed to work together to not only deliver the agreed contract, but to closely monitor it and adapt to any unexpected variations. 7.6 Procurement Procurement will continue to move forward with the key objectives outlined in our Procurement Strategy. We intend to develop further work on key spend areas, where appropriate reducing the range and variety of goods and working with other public sector stakeholders to develop economies of scale and improved terms for us and for the NHS. We continue to work with our colleagues to deliver significant projects on time and within budget integrating new services to our procurement model to ensure earliest transition and benefits are accrued at the earliest possible opportunity.


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7.7 Budget Reduction Strategy 2018/19 to 2020/21 Given the current economic climate that we operate in, a challenging Budget Reduction Strategy (BRS) of £6.1m is required to achieve our control total. We have a strong track record in the historic delivery of BRS (formerly Cost Improvement Programme CIP) savings, however the delivery of recurrent plans at the required level is becoming increasingly challenging. All BRS proposals go through a robust internal assessment process providing a high level of transparency with our main commissioners, governors, members and the public whilst ensuring any budget reductions will not impact adversely on the quality of our services. Monitoring and tracking of progress of the delivery of BRS schemes is undertaken by the Programme Management Office, with reporting of savings undertaken at Care Group Business Meetings and at the organisation-wide Operational Performance and Risk Group, which are formal sub groups of the Operational Management Group. The level of anticipated budget reduction required is as follows:

Care Group Net Base Budget (£m)

2018-19 Target Saving (£m)



PCCCLD 24.339 2.013 1.089 1.089

Mental Health 30.999 1.464 0.792 0.792

Specialist 8.292 0.732 0.396 0.396

Corporate Services 22.423 1.891 1.023 1.023

Totals 86.053 6.100 3.300 3.300

Budget Reduction Strategies (BRSs) in the table above relate to:- 1. Children’s Service re-design. 2. Workforce productivity, travel and estate savings. 3. Optimise use of eRostering to reduce use of agency staff on Inpatient Wards. 4. Implement a 2-shift Inpatient roster part way through. 5. Reduce length of stay and occupancy to increase ward efficiency. 6. Sustained overhead efficiency via targeted corporate efficiencies. 7. Further Estates rationalisation, procurement and central NHS Supply Chain product line

efficiencies.


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7.8 Summary Chart The Waterfall diagram below demonstrates how we have moved from a £0.233m planned surplus in 2017-18 to a planned surplus of £1.151m in 2018/19. Planning assumptions included the removal of any underachieved CIP, allowance made for Pay Award and incremental Drift, net effect of the Budget Reduction Strategy (Pressures and Savings), and the current BRS shortfall which is continually being reviewed to close the current gap.


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7.9 Capital Plan 2018/17 All routine planned capital expenditure will be funded from depreciation with schemes prioritised to support our strategic direction. The most significant schemes for 2018/19 include, but are not limited to the table below. The table includes £8.2m to provide a CAMHS inpatient unit, this was part of 2017/18 plans but has been deferred due to slippage in the NHS England procurement timeline.

2018/19 £m

Schemes from Internal Generated Capital

Ligature Reduction 0.100

Backlog of Maintenance 0.200 IT/Mobile Working (Including S&R Mobilisation) 1.000

PLACE, Estates Strategy & Innovation 0.225

Schemes c/F from 2017/18 0.250

Professional Fees (Incl IT) 0.320

To be prioritised 0.905

Major Schemes

CAMHS Inpatient provision 8.2 Humber Centre redevelopment

Total 3.000

7.10 Activity Planning The activity plan developed in 2017/18 was for a 3 year period. There will be an increase in activity due to the new services that we have acquired. A 7 year activity plan has been developed for the Scarborough and Ryedale new service provision. The work that has been commissioned from Mental Health Strategies Ltd will inform the capacity and demand plans. 7.11 Significant Financial Risks Major risk to our financial sustainability and our ability to deliver the 2017-18 and 2018-19 financial control totals are summarised in the following table. Risk Details

Contract Negotiation Contract Values have not yet been secured with commissioners

Demographic Growth Failure to secure demographic growth in line with STP and Five Year Forward View planning assumptions

Agency Failure to maintain agency spend within capped levels

Budget Reduction Strategy Failure to deliver the budget reduction strategy or identify schemes to close the current gap


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8.0 Membership As an NHS Foundation Trust, we are accountable to our membership. Members have an opportunity to hold us to account through elected Governors who represent the views of the membership at the highest level within the organisation. The Board takes account of those views when planning strategy. In order to develop and deliver an effective strategy, it is important that the views are representative of the local population and based on knowledge or experience of a service, proposal or healthcare condition. We have approximately 13,500 public members and 2,500 staff members. Our membership ‘offer’ is now more inclusive, bringing together service users, carers, volunteers and local communities under one membership umbrella and offering greater opportunities for engagement through events planned across our whole organisation. Our Governors have an essential role to play in running our organisation. They hold our non-executive directors to account for the performance of our executive directors, who are in charge of our day-today running. Our Governors also represent the views of our thousands of members and the public, and do so – at least in part – by attending our quarterly Council of Governors’ meetings. Our Governors are encouraged to play an increasing role in engaging our members in recruitment and engagement, particularly those who use our community services. Our Membership Operational Policy outlines how we will continue to recruit a representative membership and provide opportunities for members to influence our plans and services. The new 2018 policy is due to be considered – and hopefully approved - by our Council of Governors following extensive consultation. We will be looking at how we can align Governor and membership activities with key service development changes to ensure local communities are signposted to new services and have an opportunity to produce feedback on existing ones.

8.0 Membership


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9.0 Risks There are currently 4 risks reflected on the Trust-wide risk register which will impact on our ability to deliver this operational plan. The current risk position was agreed by the Executive Management Team on 15th January 2018, and is reflected in the table below. Table 1 - Trust-wide Risk Register (current risk rating 15+)

Risk ID Description of Risk Initial Risk

Score

Current Risk

Score

Target Risk

Score

FII22 Failure to achieve the organisation’s Cost Improvement Programme, achieve control total, and achieve required NHS Improvement ‘Use of Resources’ score for 2017/18.

20 16 8

FII179 Failure to identify and agree a financial plan that returns the Trust to surplus, meet NHS Improvement control total and deliver its short, medium and long-term CIP and service transformation to ensure costs are contained within budget.

20 20 8

FII200 The Trust's cash position deteriorates adversely where day to day functioning is impacted and the organisation is no longer financially independent.

15 15 10

NQPE37 Failure to meet Regulation 18 HSCA (RA) Regulations 2014 regarding Safer Staffing.

20 16 8

10.0 Performance Management of the Operating Plan We want to ensure that our plan is realistic and achievable and delivers real improvements to patient care, whilst maintaining our financial position and addressing national policy and local priorities. We have set ourselves some stretching targets to achieve as part of our overall long term strategy and it is important that the work completed in 2018/19 contributes to this achievement. It is important that our Trust Board has an overview on how we are performing against the plan and will receive regular updates on the progress being made against our plan. This will be included in the Trust’s quarterly strategy update. The Board will also receive the Integrated Performance Tracker (IPT) to give an update on performance against the key performance indicators together with the finance report which will show the financial position on a monthly basis against the plan. These will also be robustly monitored by the sub-committees that serve the Board.

9.0 Risks

10.0 Performance Management of the Operating Plan

Operational Plan - 2018/19 Appendices

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11.0 Appendices Appendix 1 – Key Quality Indicators

Innovatin

g

Qualit

y

Enh

ancin

g

Pre

vention

Foste

ring

Inte

gra

tio

n

Develo

pin

g

Work

forc

e

Maxim

isin

g

Org

nais

atio

n

Pro

mo

tin

g

Peo

ple

a) Quality Goals Safe

i) Ensure a responsive service for those in need of urgent care

ii) Implement a suicide reduction strategy

iii) Ensure every patient is provided with care which addresses both their physical and mental health needs.

Effective i) Continue to engender a culture whereby staff feel able to

raise concerns about unsafe clinical practice.

ii) Work in partnership with health and care providers, the voluntary sector and commissioners, to improve services.

Personal

i) Ensure easy and timely access to services.

ii) Improve engagement with patients and carers.

b) National clinical audits

c) Safe staffing

d) Mental Health standards (Early Intervention in Psychosis and Improving Access to Psychological Therapies

e) Improving the quality of mortality review and Serious Incident investigations and subsequent learning and action

f) Anti-microbial resisitance

g) Infection prevention and control

h) Reducing Falls

i) Reducing Pressure Ulcers

11.0 Appendices

Operational Plan - 2018/19 Appendices

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b) National CQUINs Improving staff health and wellbeing

Improving physical healthcare to reduce premature mortality in people with serious mental illness (PSMI)

Improving services for people with mental health needs who present to A&E

Transitions out of children and young people’s mental health services

Development of a Contract Minimum Data Set for Community Services

Supporting proactive and safe discharge

Preventing ill health by risk behaviours – alcohol and tobacco

Improving the assessment of wounds

Personalised care and support planning


Agenda Item: 10

Title & Date of Meeting: Trust Board Public Meeting - 28th March 2018 Title of Report: Digital Plan Update

Author:

Name: Lee Rickles Title: Head of Digital Delivery and Health CIO

Recommendation

To approve To note


For information To endorse x

The Board endorse the proposed Digital Delivery Plan and continue to support the role out of assisted technology that has been approved at Digital Delivery Group.

Purpose of Paper:

This a report to provide the 2018/19 Digital Plan and update the Board on Humber NHS Foundation Trust use of Assistive Technologies


The Digital Delivery Group has reviewed and approved the Digital Delivery Plan for 2018/19. The main changes for projects to be delivered during 2018/19 are;

Improve the capability of business intelligence for making informed decisions, has moved its completion into 2018/19

Implement technology across our services in Scarborough and Ryedale, has been added as this is a new piece of work

Implement agile working, has been added and Lorenzo mobile working has been removed. Agile working includes using all our systems in an agile way

Interoperability with NHS organisations’ systems has moved to green and funding has been obtained to implement this during 2018/19.

Implementation of electronic prescribing across the Trust is still at risk due to the level of additional funding required. This scheme is at risk for delivery in 2018/19.

The Full Delivery Plan is attached to this report The Trust is currently using or implementing the following assistive technologies;

My Heath,

Health hub,

SilverCloud

QB- ADHD diagnostic software tool,

Moodbeam,

e-CONSULT and Skype for business. This is being implemented as part of the Digital Delivery Plan. More details on assistive technology are attached at appendix A.


___________________________________________________________________________________________ Page 2 of 19










N/A Comment


Risk √ To be advised of any

Legal √ To be advised of any

Compliance √ future implications

Communication √ reports as and when

Financial √ future implications

Human Resources √ by Lead Directors

IM&T √ through Board

Users and Carers √ required



No


Digital Delivery Plan 2018/19

___________________________________________________________________________________________ Page 4 of 19

Summary

The Digital plan for 2018/19 has been reviewed and approved by the Digital Delivery Group. The summary plan is shown below and the detailed project and capital requirements are shown later in this document. The projects have been rescheduled to support new and changing requirements. The main changes for projects to be delivered during 2018/19 are;

Improve the capability of business intelligence for making informed decisions, has moved its

completion into 2018/19

Implement technology across our services in Scarborough and Ryedale, has been added as this

is a new piece of work

Implement agile working, has been added and Lorenzo mobile working has been removed. Agile

working includes using all our systems in an agile way

Interoperability with NHS organisations’ systems has moved to green and funding has been

obtained to implement this during 2018/19.

Implementation of electronic prescribing across the Trust is still at risk due to the level of

additional funding required. This scheme is at risk for delivery in 2018/19.

Conclusion

The majority of the 2018/19 digital plan has been achieved. The plan for 2018/19 is challenging and has

financial risk, especially around e-prescribing, but it is the view of the Digital Delivery Group it is achievable.

The Digital Delivery Group also confirmed that the projects match the Trust Strategy and need. The Digital

Delivery Group will continue to review the plan to ensure it supports our organisation’s needs.

___________________________________________________________________________________________ Page 5 of 19

Detailed Report

Trust Goal: 01 Innovating quality and patient safety 03 Fostering Integration, partnership and alliances

Objectives: 1.1 Deliver a paper lite electronic record using Lorenzo and SystmOne for Whitby, 0-19 and Pocklington

Project Executive: Peter Beckwith

Status Update Current Previous

Status Update Log Key

Project Lead: Julie Crockett Not delivered on time R

Scheduled status B G At risk A

Risks and Issues B G On schedule G

Late Tasks B G Complete B

CG: Adult and Older Peoples Mental Health Services CGD: Jan Smith CCIO: Adrian Elsworth

Project No: Key Activities / Milestones Timescales RAG Top Risks and Issues

Resources and Dependencies

Risk Rating

PMOP-399

Adult Mental Health RRS, community and inpatients live with Lorenzo paperless record

May 2017 B

PMOP-399

Adult Mental Health specialist services live with Lorenzo practice

Sep 2017 B

PMOP-347

Older peoples Mental Health CITOP, community and inpatient going live with Lorenzo paperless

Nov 2017 B

PMOP-410

Primary Care Dementia Service has been created for Hull pilot

Dec 2017 B

CG: Primary Care, Community, Learning Disabilities and Children’s Services

CGD: Julia Harrison Mizon CCIO: Jon Duckles



Risk Rating

Whitby Community Hospital paperless practices and e-prescribing

Jun 2017 B

N/A Clean up of SystmOne units following ERY Community transfer to CHCP

Dec 2017 B

PMOP-309

CAMHS are going live with Lorenzo paperless practice

Nov 2017 B

CG: Cross Care Group CGD: N/A CCIO: N/A



Risk Rating

Increase to 500 views of the Summary Care Record per month

July 2017 B

___________________________________________________________________________________________ Page 6 of 19

Trust Goal:

01 Innovating quality and patient safety 04 Developing an effective and empowered workforce 05 Maximising an efficient and sustainable organisation

Objectives: 1.3 Upgrade the network and telephony




Project Lead: Paul Wright Not delivered on time R

Scheduled status G G At risk A

Risks and Issues G G On schedule G

Late Tasks G G Complete B


CGD: Julia Harrison Mizon CCIO: Karen Warwick



Risk Rating

PMOP-027

Implement SmartComms at Goole Health Centre, Withernsea Community Hospital and Hornsea Community Hospital

Nov 2017 B

Implement SmartComms in our Hub at Scarborough and Ryedale

Jul 2018 G




Risk Rating

PMOP-027

Willerby Hill campus has been audited for SmartComms

Aug 2017 B In-house capacity to progress the roll out

PMOP-027

Confirm the allocation of land lines Willerby Hill campus

Dec 2017 B

PMOP-027

Complete the roll out of SmartComms at Willerby Hill

May 2018 G

___________________________________________________________________________________________ Page 7 of 19

Trust Goal: 01 Innovating quality and patient safety

Objectives: 1.4 Implement electronic referral service (eRS)




Project Lead: Lee Rickles Not delivered on time R

Scheduled status G R At risk A

Risks and Issues G R On schedule G

Late Tasks G R Complete B





Risk Rating

Project code?

Outpatient services at Alfred Bean use the electronic referral service (eRS) for all new referrals

Plan Oct 2017 Complete Mar 2018

B 6




Risk Rating

Create a plan for the roll out of the electronic referral service across all Trust services in 2018/19.

Apr 2018 G

80% of our services are available on eRS for GP practices.

Dec 2018 G

eRS systems resources and business change resources to support the new way of working.

6

___________________________________________________________________________________________ Page 8 of 19

Trust Goal:


Objectives: 1.5 Improve the capability for business intelligence




Project Lead: Tony Greenlaw Not delivered on time R

Scheduled status G A At risk A

Risks and Issues G A On schedule G

Late Tasks G A Complete B

CG: Cross Org CGD: N/A CCIO: N/A



Risk Rating

Phase 1b: Identify Data Lineage Mapping source systems; Tracing the data transformations; Designing a target reporting data structure

Mar 2017 B

Phase 2: Data Platform Develop data layer for Finance & Ops requirements; Implement Data Quality over data layer; Test data layer results; Deploy data layer to production

Jul 2018

G

Phase 3: Finance and Performance Reporting Analyse content and data source of IQPT; Prepare format and delivery mechanism for data capture; Finalise data repository; Develop data views of data within repository; Commence automation of IQPT

Oct 2018 G

___________________________________________________________________________________________ Page 9 of 19

Trust Goal:


Objectives: 1.6 Implement the new health and social care network (HSCN) to replace N3




Project Lead: Richard Brumpton Not delivered on time R







Risk Rating

N/A Infrastructure to start being implemented for WAN contract

Feb 2018 B

The installation of the new WAN connections and

decommission of the N3 connections needs to be

completed by Jun 2018 to stop the Trust being charged additional

unbudgeted costs for the use of N3.

9

Complete roll out of the new WAN

Jun 2018 G

Procurement issued for LAN May 2018 G

N/A Implement new remote access solution

Aug 2018 G

N/A Infrastructure to start being implemented new LAN

Dec 2018 G

___________________________________________________________________________________________ Page 10 of 19

Trust Goal:

01 Innovating quality and patient safety 03 Fostering Integration, partnership and alliances 05 Maximising an efficient and sustainable organisation

Objectives: 1.7. Move all paper or MS Office processes to an integrated process within the Trust s primary system by using additional best of breed











Risk Rating

PMOP-344

Plan stage 2 roll out of ESR self-service for managers

March 2018 G Allocation of a Project Lead to plan and implement ESR

stage 2.

Stage 2 roll out of ESR March 2019 G

Medical e-job Go live on e-job planning

Nov 2018 R

PMOP-091

Create a plan and business case for the role out of NHSmail 2 Skype for business

Jul 2018 G

The business case saving has been accounted for as part of the BTmeetme CIP and this new scheme will not provide any savings. Mitigations – Build on the new ways of working using skype to replace BTmeetme.

6

Confirm the options for e-expense and e-rosters as both contacts end in 2018/19.

April 2018 G

___________________________________________________________________________________________ Page 11 of 19

Trust Goal: 01 Innovating quality and patient safety 02 Enhancing prevention, wellbeing and recovery 06 Promoting people, communities and social values

Objectives: 1.8. Patient leadership of the digital plan











Risk Rating

Create patient and care engagement and leadership based on the outputs from the Working Together to Enhance Health and Wellbeing event. This will be does in conjunction with the Head of Patient Experience.

Mar 2018 B

Review the output from the Working Together to Enhance Health and Wellbeing event to determine the most appropriate

May 2018 G

Launch patient and carer digital leadership group

Jul 2018 G

___________________________________________________________________________________________ Page 12 of 19

Trust Goal: 01 Innovation quality and patient safety 04 Developing an effective and empowered workforce 05 Maximising an efficient and sustainable organisation

Objectives: 1.10 Implement e-prescribing






Risks and Issues A A On schedule G





Risk Rating

Create a plan and business case for the role out of e-prescribing for Lorenzo

Jul 2018 A

Additional funding from NHS England, National

Information Board or Sustainable

Transformation Programme is required for the Trust to implement e-prescribing for Lorenzo.

The method of accessing additional funding is

expected to be communicated in Quarter 4

2017/18.

9

___________________________________________________________________________________________ Page 13 of 19

Trust Goal: 01 Innovation quality and patient safety 04 Developing an effective and empowered workforce 05 Maximising an efficient and sustainable organisation

Objectives: 1.11 Implement Interoperability






Risks and Issues A A On schedule G





Risk Rating

NHS Digital to confirm interoperability requirements for TPP SystmOne and DXC Lorenzo

Jan 2018 Jul 2018

R

NHS Digital have not complete the GP Connect first of type work to allow

us, TPP and DXC to create a solution. The delay has

impacted our ability to define the technical

solution, which would be the basis for the business

case.

We are dependent on NHS Digital and Global Digital

Exemplars (GDE) to completed the GP Connect first of type. Humber FTY is

a member of the NHS Interoperability board, so are

in a position to know what progress is being made.

6

DXC to provide a proposal to deliver interoperability between HEY Lorenzo, SystmOne GP and Community, NRLS and Liquid Logic Social Care system

Apr 2018

G This is being carried out as

part of the existing SBS clinical system contract.

6

Implement beta process for providing safety plan contact details within the national record locator service (NRLS) to be accessed by the Yorkshire Ambulance Service

Jun 2018 G

NHS Digital to provide a technical solution to load

data into the national record locator service (NRLS)

6

Implement DXC interoperability solution

Jul 2018

___________________________________________________________________________________________ Page 14 of 19

Trust Goal: 04 Developing an effective and empowered workforce 06 Promoting people, communities and social values

Objectives: 1.20 Cybersecurity




Project Lead: Richard Brumpton Not delivered on time R




Commentary:

The cyber essential plus action plan is being implemented to ensure the Trust is secure and is accredited by May 2018. The Trust support NHS Digital’s CAREcert process and has agreed to be assessed by NHS Digital. The NHS Digital Cyber audit has identified a number of new improvements which can only be completed with the new WAN and LAN infrastructure.




Risk Rating

Cyber essentials re-accreditation

July 2018 G

Cyber essential plus action plan implemented

Feb 2019 G

Cyber essentials plus accreditation

Jun 2019 G

Annual penetration testing completed

Oct 2018 G

___________________________________________________________________________________________ Page 15 of 19

Trust Goal: 01 Innovating quality and patient safety 03 Fostering Integration, partnership and alliances

Objectives: 1.21 Continue paper lite electronic record




Project Lead: Julie Crockett Not delivered on time R




CG: Adult and Older Peoples Mental Health Services CGD: Jan Smith CCIO: Adrian Elsworth



Risk Rating

CQC action plan completed for clinical charts, Structure Care Plans and Clinical Data Capture forms.

March 2018 G

CG: Specialist Services CGD: Tracy Flanagan CCIO: Gil Gilbert



Risk Rating


May 2018 G





Risk Rating

Implement Child Protection Information System (CP-IS) at Whitby MIU

March 2018 B

PMOP-385

Support the mobilisation of Scarborough and Ryedale Services

May 2018 G

PMOP-385

Implement all year one digital solutions for Scarborough and Ryedale Services

April 2019 G


July 2018 G




Risk Rating

N/A

Hull City Council implementation of Liquid Logic for Humber HT Social Care staff

December 2017 February 2018 March 2018

A

___________________________________________________________________________________________ Page 16 of 19

Trust Goal:

04 Developing an effective and empowered workforce 05 Maximising an efficient and sustainable organisation

Objectives: 1.22 Become an agile organisation











Risk Rating

Create the approach to implement Agile working

Mar 2018 G

The first tranche of services (4 teams) to implement Agile working.

Jun 2018

G

Review the implementation of the first tranche of services and revise the approach

Jul 2018

G

Confirm teams in the second tranche and plan the implementation

Jul 2018

G

Implement the second tranche Sept 2018

G

___________________________________________________________________________________________ Page 17 of 19

Capital allocation for 2018/19

Digital schemes 2017/18 2018/19 2019/20

Core network replacement

(Willerby) 180,000£ 372,000£ 60,000£

Site (WAN) network replacement 288,468£ 71,532£ 60,000£

Cabling/Cabinets to support

network and SmartComms 30,000£ -£ -£

Rolling Replacement Programme 171,000£ 170,403£ 288,000£

New remote access solution -£ 54,000£ -£

Software Asset Management -£ 30,000£ -£

Lorenzo Interoperability -£ 120,000£ -£

Clinical system assets 30,532£ 56,065£ 56,065£

Schemes approved by the DDG 700,000£ 874,000£ 464,065£

Annual Digital Capital Allocation 700,000£ 900,000£ 700,000£

Budget available from annual

Digital Capital Allocation -£ 26,001£ 235,936£

Scarborough and Ryedale Digital

Capital Allocation -£ 556,800£ 118,200£

Office 2010 upgrade -£ -£ 900,000£

Windows 7 to 10 Upgrade -£ -£ 900,000£

VMware Rolling Replacement

(Servers) -£ 18,000£ 180,000£

Anti-Virus and Encryption

infrastructure -£ -£ 78,000£

SharePoint -£ 120,000£ -£

Lorenzo e-prescribing -£ 150,000£ -£

Digital capital schemes which

require additional funding -£ 288,000£ 2,058,000£

Iden

tifi

ed s

chem

es f

rom

cap

ital

allo

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on

Iden

tifi

ed s

chem

es

wh

ich

req

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cap

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___________________________________________________________________________________________ Page 18 of 19

Appendix A

Humber NHS Foundation Trust use of Assistive Technologies

In 2015, 71% of all UK citizens had a smartphone and 88% of adults used the internet. But only 2% of the population report any digitally enabled transaction with the NHS. Our patients are generally connected to the internet and use technology every day, such as internet shopping, social media, reviewing services, on-line banking etc. Assistive Technology can also be called telehealth, telemedicine or e-health, which are now interchangeable terms for the use of technology that can enable clients to stay independent in their own homes for longer, helping to drive down the care costs that might be incurred if the individual otherwise had to go into residential care or required intensive local care. We are currently working on the following assistive technologies in our services; My Heath Guide is an electronic patient held record used by patients with learning disabilities. We were successful in receiving central funding to develop this system with the supplier. We have provided 100 tablets as gifts to the patients so they can used the app. The first 50 was funded as part of the central funding received and the second 50 have been funded from the Care Group budget. This systems is listed in the NHS apps library. Health hub is an internet telehealth system we are implementing with our cardiac nurses based in Whitby. This is to be expanded into Scarborough and Ryedale as part of the new services transformation plan. A cost of £244,800 was included as part of the Scarborough and Ryedale assistive technologies solution. SilverCloud is an online cognitive behavioural therapy (CBT) system used with our talking therapies patients. This is systems is listed in the NHS apps library. QB- ADHD diagnostic software tool is a tool for supporting the diagnosing ADHD. QbTest is designed to be added to the assessment process along with clinical interview and rating scales. Two devices are being used in our CAHMS services. Moodbeam is a simple mood tracker which is in the development stage with the developer. This device tracks happy and unhappy moods and only requires a smart device to send the results into the app. The app shows the information to the patient and (with consent) health care professional. This is to begin testing with 10 devices in CAHMS and 10 devices with recovery college students. The production devices are expected to be manufactured in the middle of 2018. e-CONSULT web sites are built in around a knowledge based for general practice services. It will apply logic to the questions asked by patients and then direct them to the most appropriate service. This has been implemented in our GP practices.

___________________________________________________________________________________________ Page 19 of 19

A community service version is to be developed as part of the Scarborough and Ryedale as part of the new services transformation plan. Skype for business is now available for video consultations. Video conferencing with patient has been used at other Trusts and has been found effective, if matched to the right patient and service. We are currently in the planning stage to implement skype for business for our veterans and IAPT services. The above assistive technologies are stand alone and do not integrate with our core clinical systems. This was not an issue with paper based records, but as we are now have electronic patient records in our clinical services integration will become more important. The integration will speed up communication and duplication in record keeping. We have implemented My Health Guide and Silver Cloud at scale. The Kingsfund has identified that on a practical level, a move from small-scale technology pilots to wide-scale implementation will need to overcome several barriers:

the evidence base on cost-effectiveness is relatively weak, deterring risk

averse investors

clinicians may not be convinced that the benefits outweigh the costs

service users could prove reluctant to accept and use assistive

technologies, if they feel they are used as a substitute for face-to-face

contact

politically, reducing hospital-based care in favour of remote care in the

community is also likely to be challenging.

Further investment in assistive technologies needs to consider the above barriers to ensure we successfully implement and embed assistive technologies. To ensure we have clear needs, ownership, resources and funding; the approval and management of future schemes would by the Digital Delivery Group. Recommendation EMT continue to support the role out of assisted technology that has been approved at Digital Delivery Group.


Agenda Item 11


Title of Report: Guardian of Safe Working Report in addition to Medical Director’s Report

Author:

Name: Dr Lucy Williamson Title: Consultant Forensic Psychiatrist & Guardian of Safe Working

Recommendation:

To approve To note To discuss To ratify For information To endorse

To reconcile the reporting frequency with the production of the survey data which will be one month after the end of each quarter.

Purpose of Paper:

To inform the Board regarding the safe working conditions of junior doctors for the three months to March 2018.


Adoption of new Junior Doctor rota



Innovating Quality and Patient Safety

Enhancing prevention, wellbeing and recovery

Fostering integration, partnership and alliances



Promoting people, communities and social values



N/A Comment



Legal √

Compliance √

Communication √

Financial √

Human Resources √

IM&T √




No

Page 2 of 2

Guardian of Safe Working Report Guardian of Safe Working Report The Guardian of Safe Working has now been in post since July 2016 to oversee the safe working conditions of junior doctors in the Trust as part of the new Junior Doctors Contract. Dr Lucy Williamson continues to meet with junior doctors at the forum on a monthly basis to review working pattern issues. Number of doctors / dentists in training (total): 23 (6 LTFT) (excluding Grimsby trainees) Number of doctors / dentists in training on 2016 TCS (total): 14 Amount of time available in job plan for guardian to do the role: 0.5 PA per week Exception reports (with regard to working hours) 27 Hours monitoring Repeat hours monitoring took place in January but returns were low preventing any reliable data analysis. However JCD chair and LNC rep for the junior doctors undertook a survey of the doctors’ views on the new rota and it was almost unanimously positive. Further minor changes to the rota are to be introduced from April at the request of the junior doctor body. The doctors have opted not to re-run the hours monitoring until the new rota pattern is embedded. Qualitative information This has been a period of settling into the new on-call patterns for the junior doctors but feedback has been positive with a few minor changes to take effect from April. The new rota pattern has also resulted in fewer requirements for locums (from 54 to 36). The monitoring period also gave opportunity to look at the type of tasks during on-call duty. Most were appropriate but there continues to be some inappropriate calls for drug card re-writing, unnecessary patient reviews and routine phlebotomy/ ECG taking which aligns with concerns raised in Guardian forum meetings. Agreement has been made with care group directors as part of the physical health strategy to upskill ward staff to undertake these tasks but there will be a period of training and culture change before this is embedded and junior doctors see the changes in their workload. Summary Currently there are increasing numbers on the new contract and we still need to embed junior and senior doctors consistently using the software system for exception reporting. Exception reports have reduced from 54 to 27 but feedback from some juniors is that they are still not reporting excessive hours for a variety of reasons. Post vacancies, including those with locum consultants as they cannot act as educational/clinical supervisors, are contributing to on-call workload. Recommendation The next report should come to the July Board as this will allow us to capture and review data for the first quarter of the year and then quarterly thereafter.


Agenda Item 12

Title & Date of Meeting: Trust Board Public Meeting - 28th March 2018

Title of Report: Healthy food for NHS staff, visitors and patients: Commissioning for Quality and Innovation (CQUIN) progress report

Author:

Name: Ginny Hemingway/Chris Rounce Title: Patient Services Manager/Information Development Manager

Recommendation:

To approve To note √ To discuss To ratify For information √ To endorse

The Trust Board is asked to note the positive progress towards achievement of the CQUIN Targets.

Purpose of Paper:

To publicly demonstrate the Trust’s commitment to meeting the CQUIN standards for healthy food.


The Trust is maintaining the standards set in the previous year’s CQUIN and is meeting all targets for stocking low sugar drinks and low calorie confectionery











N/A Comment



Legal √

Compliance √

Communication √

Financial √

Human Resources √

IM&T √




No


Healthy food for NHS staff, visitors and patients CQUIN progress report 1 Introduction and Purpose

The purpose of this paper is to update the Trust Board on the progress made against the 2017/18 Commissioning for Quality and Innovation (CQUIN) Indicator in relation to healthy food for NHS staff, visitors and patients. It is a requirement of this indicator that any changes or planned changes must have been discussed at a public board meeting.

2 National Context

Public Health England’s report “Sugar reduction – The evidence for action” published in October 2015 outlined the clear evidence behind focussing on improving the quality of food on offer across the country. Almost 25% of adults in England are obese, with significant numbers also being overweight. Treating obesity and its consequences alone currently costs the NHS £5.1bn every year. Sugar intakes of all population groups are above the recommendations, contributing between 12 to 15% of energy. Consumption of sugar and sugar sweetened drinks tending to be highest among the most disadvantaged who also experience a higher prevalence of tooth decay and obesity and its health consequences. It is important for the NHS to start leading the way on tackling some of these issues, starting with the food and drink that is provided & promoted in hospitals.

3 CQUIN Scheme

To achieve the stated aims the CQUIN framework has included successive schemes to incentivise trusts to improve their offering in terms of healthy food available to patients, staff and visitors. The Trust is committed to delivering improvements in healthy food through its participation in the CQUIN scheme.

To achieve the 2017/18 CQUIN the Trust must meet the following requirements: Firstly, maintain the four changes that were required in the 2016/17 CQUIN, those being :

a) The banning of price promotions on sugary drinks and foods high in fat,

sugar or salt.


b) The banning of advertisements on NHS premises of sugary drinks and

foods high in fat, sugar or salt.

c) The banning of sugary drinks and foods high in fat, sugar or salt from checkouts.

d) Ensuring that healthy options are available at any point including for those staff working night shifts. We will share best practice examples and will work nationally with food suppliers throughout the next year to help develop a set of solutions to tackle this issue.

Secondly, introduce three new changes to food and drink provision, specifically for 2017/18:

a) 70% of drinks lines stocked must have less than 5 grams of added sugar per 100ml. In addition to the usual definition of sugar sweetened beverages it also includes energy drinks, fruit juices (with added sugar content of over 5g) and milk based drinks (with sugar content of over 10grams per 100ml).

b) 60% of confectionery and sweets do not exceed 250 kcal.

c) At least 60% of pre-packed sandwiches and other savoury pre-packed

meals (wraps, salads, pasta salads) available contain 400kcal (1680 kJ) or less per serving and do not exceed 5.0g saturated fat per 100g.

Implementation of the objectives of the scheme is consistent with the Trust

strategy and values, specifically to create a positive and healthy workplace for

all staff and patients by implementing health and wellbeing initiatives.

4. Scope

This CQUIN applies to all Trust outlets where food or drink may be sold to

patients, staff and the public. The following are in scope:

TTs Café, Trust Headquarters

East Riding Community Hospital Café

Whitby Hospital Café

Trust stocked vending machines in public areas

The cafes all sell a range of freshly prepared food plus confectionery and

drinks. For the purposes of this CQUIN none of the food freshly prepared on

site is considered to be pre-packed.

Each provider must evidence to commissioners that they have maintained the changes in 2016/17 and introduced the 2017/18 changes by providing at least the following evidence:


A signed document between the NHS Trust and any external food supplier committing to keeping the changes

Evidence for improvements provided to a public facing board meeting

TTs café is the only external food supplier. All other outlets are run and stocked directly by Humber FT.

5. Data

Data used to calculate this CQUIN’s performance is based on stock orders rather than sales. This is because individual orders for most suppliers are itemised in the Trust’s purchasing system whereas the same data is not available for sales. As orders are directly influenced by sales the assumption has been made that when averaging over the course of a year the amount of stock purchased and sold will be essentially equivalent. Orders that were not itemised in the purchasing system (e.g. lower value, direct orders to a supermarket) or external to Humber FT (e.g. TTs) have been manually collated from receipts or other records.

6. Performance

Humber successfully achieved all requirements of the 2016/17 CQUIN and hereby restates its commitment to maintaining these standards in the future. As the only external supplier of food on Trust premises, TTs café have signed a commitment to also uphold these standards.

At the date of this report order data is available for the period April 2017 to

end December 2017, in this period

15,228 items of confectionery have been ordered of which 13,973

(91%) do not exceed 250 kcal, against a target of 60%.

6,069 drinks have been ordered, of which 4,857 (80%) have less than

5 grams of added sugar per 100ml, against a target of 70%.

7. Conclusion

Based on the analysis of data available it is anticipated the Trust will be able

to demonstrate it has met the requirements for the CQUIN targets for

2017/18.

8. Recommendation

The Trust Board is asked to note the positive progress towards achievement of the CQUIN Targets.


Agenda Item 13

Title & Date of Meeting: Trust Board Public Meeting – 28th March 2018 Title of Report: Integrated Quality and Performance Tracker - February 2018

Author:

Name: Debby Shaw Title: Performance Management Advisor Lead : Director of Finance

Action Required:


To discuss √ To ratify For information To endorse

The Trust Board are asked to note the contents and performance reported in the IQPT (Integrated Quality and Performance Tracker) for the period ending 28th February 2018.

Purpose of Paper:

The report provides the Trust Board with a Quality and Performance update as at the end of February 2018.


Bed occupancy rates have been maintained in Mental Health and there continues to be low occupancy rates in Learning Disability units during Transformation.

There are six patients waiting over 52 weeks which is an improvement of four based on the previous month.

MAPA (Management of Actual or Potential Aggression) training has increased and is now rated Amber whilst BLS (Basic Life Support) continues to improve.











N/A Comment



Legal √

Compliance √

Communication √

Financial √

Human Resources √

IM&T √




No

Page 2 of 8

Integrated Quality and Performance Tracker February 2018 1. Introduction and Purpose

This paper provides the Board with a summary on the progress being made against the key basket of NHS performance indicators together with local operational measures that underpins the delivery of the Trust Operational Plan. This is presented as the Trust’s Integrated Quality and Performance Tracker (IQPT).

2. Reporting Framework

The refreshed reporting framework has been aligned to the 5 themes in NHS Improvement's (NHSI) Single Oversight Framework (SOF), which sets out how NHSI will oversee and assess the performance of the trust.

Single Oversight Themes

PI (Performance Indicator) Return Forms will be appended as exception reports only for those indicators RAG rated Red, which denotes performance outside targets sets. Exception Reports will present performance, trajectories, reasons for adverse performance, mitigating circumstances and assign actions to address under performance.

Page 3 of 8

3. Quality Domain 3.1 Patient & Carer Experience

February 2018 has seen continued strong performance in all four categories; the FFT (Friends and Family) results have seen an increase of 1.8% when compared to January, now reporting at 90.8% for February. The Trust received a total of 12 compliments for the month of February, eight related to excellent care provision, one emotional support, one appropriate discharge and two related to leadership and learning. Nineteen formal complaints were received in February. The Trust responded to seven complaints in the month of February 2018, four complaints were not upheld (57%), three complaints were partly upheld (43%). The general themes from the three partly upheld complaints include:-

Communication;

Appointments;

Clinical Treatment – delay or failure to provide a diagnosis

3.2 Clinical Risk

During February 2018 there have been 461 incidents compared with 492 in January 2018; a decrease of 6.3%. Two Serious Incidents were declared during February 2018. Investigators have been identified and Duty of Candour has been undertaken. The percentage of harm free care remains consistent with the previous month at 98.8%, which is consistent with recent months. Safer Staffing – a full update is included in section 2.6 of the IQPT.

3.3 Clinical Effectiveness

NICE (National Institute for Health and Care Excellence) - During February 2018 there were 38 NICE guidelines published of which 19 were deemed as not applicable and 19 were considered as being potentially applicable to the organisation.

Page 4 of 8

4. Finance and Use of Resource's Domain

Performance at a glance highlights that the key measures stemming from the financial strategy to support the realisation of the Strategic Operational plan include:

4.1 Use of Resources Assessment

Use of the Resources Scoring for NHS Improvement's assurance requirements remains at a 2 at the end of February which is consistent with the Trust’s plan submission.

4.2 Cash

The cash balance at 28th February was £7,256m, a decrease from the previous month of £0.285m.

5. Operational Performance Domain

Performance at a glance highlights that of the 24 NHS Improvement (NHSI) indicators reported for the current period, 15 are RAG rated Green, four Amber and five rated Red.

5.1 Waiting Times

Waiting times continues to be an area of focus, which are reviewed monthly by the Operational Performance and Risk Group. There are six patients waiting over 52 weeks which is an improvement of four based on the previous month.

5.2 Occupied Bed Days (OBD)

There remains continuing under occupation within Learning Disability Services which is expected and anticipated in accordance with the Transforming Care Partnership (TCP) programme. One unit planned to close in April 2018. Mental Health maintains an overall occupancy of around 83.5%. The Trust is mandated to provide its performance activity for OBDs to NHSI based on a standard formula which excludes the use of leave beds however the IQPT dashboard also shows figures 'including leave' to give a more balanced viewpoint of patient activity.

Page 5 of 8

5.3 Mental Health Data Completeness

Currently still being provided for the remainder of 2017/18 but will be replaced by the new Data Quality Maturity Index (DQMI) from April 2018. Metrics from this date will only relate to accommodation, employment and ethnicity. These will be published by NHS Digital quarterly and two months in arrears.

6. Leadership and Improvement Domain 6.1 Mandatory Training

Performance against different Mandatory training courses has been aggregated for Board reporting. More detailed analysis across the different levels of training is reported to Executive Management Team and Care Groups. The Mandatory Training indicator does NOT include training for the GP primary care practices. This is shown separately due to a slight difference in reporting processes.

6.2 PADRs

Update - PADR completion has decreased marginally in February with the figure at 83.1% compared with the figure at 81.6% in January; we remain just 1.9% off plan.

6.3 Sickness

Based on initial figures, sickness results have improved markedly during February and are now reporting favourably against the 5.2% target at 5.1%.

7. Primary Care Domain - Training

Overall training compliance continues to improve and now stands at 83.9%. Of the 15 separate indicators, 13 are Green, one Red (BLS) and one Amber (IG).

Page 6 of 8

8. Overall Performance

Overall performance of targets across each of the domains is summarised in the table below:

Feb-18

Within Target Within Tolerance Outside Target

Quality

Finance 3 2 0

Operational 15 4 5

Strategic 1 0 1

Leadership 18 7 1

Primary Care

Training13 1 1

Monthly KPI Assurance Levels

Not currently RAG rated

9. National Health Strategy Sustainability and Transformation Plan

Refer to Appendix A for updates on the Trust’s National Health Strategy Sustainability and Transformation Plan. This is shown quarterly.

Page 7 of 8

10. Ongoing Developments

In November 2017, NHS Improvement updated the Single Oversight Framework.

Indicator Requirement by NHSI Action

CQC Community MH Survey (annual)

To add as a new indicator

BI to add to the Quality dashboard Mar 2018

% of clients in settled accommodation and employment

To add as new indicators in dashboard

Data to be available from Q1 2018/19 (Operational Dashboard)

Consultant Led (ABH) 18 weeks RTT pathway

To be removed To be removed from 2018/19 IQPT

Maximum 6 week wait for diagnostic procedures


BI to add to the Operational dashboard from Q1 2018/19

Cardio-metabolic assessment/treatment for people with psychosis is delivered routinely


BI to add to the Operational dashboard Mar 2018

Data Quality Maturity Index (DQMI).

Replace MHSDS previous standards for ‘priority’ and ‘identifier’

To be amended from Q1 2018/19

Inappropriate out of area placements for adult MH services (patients in out of area beds within qtr)


BI to add to the Strategic Change dashboard Mar 2018

NHS Staff Survey. Recommendation as a place to work or receive treatment

To be added annually BI to add to the Leadership dashboard following publication of the results (Mar 2018)

Proportion of Temporary staff

To be added in the form of Agency Staff costs as a proportion of total staff costs

To be included in Finance Report and IQPT from March 2018

E Coli and MSSA rates Addition of two new indicators

Already included in the Infection Control section of the Quality Dashboard

Patients requiring acute care who received a gatekeeping assessment as standard for MH providers

To be removed as NHSI no longer consider this indicator useful. New metric to be developed

To be removed from 2018/19 IQPT. New Metric to be included once available

Refer to Appendix B to identify the ongoing development of implementing and mapping the NHS England Key Performance Indicators into the IQPT for 2018/19. Further clarification required from NHS England with regard to some descriptors.

Page 8 of 8

12. New Developments

Clinical Supervision has now been added to the IQPT and will show all results from April 2017 to present month. This is split into two elements:

Percentage of staff who received clinical supervision within 4-6 weeks

Percentage of teams who responded who have a clinical structure in place

In February, the percentage of staff who received supervision fell from 81.2% to 75.5% and currently rates as Amber.

13. Future Considerations Further changes and updates to the IQPT in future months including:-

i) Continued use of benchmarking information where this is available

ii) Continued development of appropriate KPIs to measure across full pathways of care

iii) Review of indicator targets/thresholds iv) Inclusion of previous year’s comparative performance to

support trend analysis. v) Mapping of indicators to the Trust Strategic Goals

14. Recommendations

The Board are asked to:

1. Note the contents and performance reported in the IQPT for the period ending 28th February 2018.

2. Approve the proposed amendments to the IQPT in relation to the

updated Single Oversight Framework


INTEGRATED

QUALITY AND PERFORMANCE

TRACKER

This document provides a summary of the performance measures stemming from the NHS Constitution, NHS Mandate, NHS Outcomes Frameworks and the regulator requirements. These measures are tailored to provide assurance to the Trust Board on the performance relating to patient safety, patient experience together with resource capacity and capabilities to underpin the delivery of good governance and service provision. It serves to identify and quantify risks and mitigating actions to reduce potential breaches of performance activity in which contractual penalties will be incurred. Data is provided from a variety of sources (including Lorenzo, SystmOne, ESR and DATIX).

Prepared by: Business Intelligence Team

Reporting Period Ending: Chief Executive: Michele Moran

Feb 2018

Quality

Continuously improving care quality, helping to create the safest, highest

quality health and care service

Qu

ality

Page 2 of 53

Quality Report Section 1

** 2017/18 is in the process of been issued by Quality Health

Overall Experience Score for CMHT (Community

Mental Health Team)

Patient Survey - 16/1774%

Trust Result

73%National Benchmark (Upper Quartile)

Patie

nt / C

arer Exp

erie

nce

Domain

99.2%

98.8% 98.6%

91.0%

Friends and Family Year to Date Satisfaction Results

FFT - Friendly/Helpful

FFT - Information

FFT - Involved

FFT Score

95.6%

100.0%

86.2%

Friends and Family Satisfaction within the Care Groups

Mental HealthServices(Division)

Primary Care,Community,Children's andLD Services(Division)

SpecialistServices(Division)

Page 3 of 53

Quality Dashboard

Domain

Section 1.1 Patient / Carer Experience Friends and Family2 4 5 6

89.2% 91.7%

96.0%

89.9%

95.3% 95.8%

92.1%

88.2% 87.7% 89.0% 90.8%

80.0%

85.0%

90.0%

95.0%

100.0%

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Friends and Family Patient 89.2% 91.7% 96.0% 89.9% 95.3% 95.8% 92.1% 88.2% 87.7% 89.0% 90.8% 0.0%

Survey Responses 437 290 200 327 169 190 280 187 277 218 282 0

Positive Responses 390 266 192 294 161 182 258 165 243 194 256 0

Friends and Family Patient 16-17 92.5% 90.3% 91.0% 96.8% 96.4% 97.1% 94.8% 91.6% 90.7% 97.1% 95.3% 95.5%

Friends and Family - Patients Likely to Recommend

99.8% 99.6% 100.0% 99.7% 99.3% 98.6% 98.3% 98.1% 99.6% 98.4% 98.7%

80.0%

85.0%

90.0%

95.0%

100.0%


FFT - Friendly/Helpful 99.8% 99.6% 100.0% 99.7% 99.3% 98.6% 98.3% 98.1% 99.6% 98.4% 98.7% 0.0%



FFT - Friendly/Helpful 16-17 99.7% 99.6% 99.3% 99.3% 99.7% 99.8% 98.8% 99.5% 99.6% 99.6% 99.3% 99.2%

Friends and Family - Staff were friendly and helpful

99.8% 99.3% 99.0% 98.7% 96.8% 99.3% 99.2% 97.6% 98.9% 97.4% 98.8%

80.0%

85.0%

90.0%

95.0%

100.0%


FFT - Information 99.8% 99.3% 99.0% 98.7% 96.8% 99.3% 99.2% 97.6% 98.9% 97.4% 98.8% 0.0%



FFT - Information 16-17 98.8% 99.0% 98.6% 99.5% 100.0% 99.8% 98.5% 99.8% 100.0% 99.6% 99.7% 99.6%

Friends and Family - Received appropriate information regarding Care

99.5% 98.6% 98.9% 98.7% 97.4% 98.6% 98.8% 97.0% 98.9% 97.4% 98.4%

80.0%

85.0%

90.0%

95.0%

100.0%


FFT - Involved 99.5% 98.6% 98.9% 98.7% 97.4% 98.6% 98.8% 97.0% 98.9% 97.4% 98.4% 0.0%



FFT - Involved 16-17 98.5% 99.2% 98.1% 97.8% 98.6% 98.8% 98.5% 99.2% 98.7% 99.7% 99.5% 98.9%

Friends and Family - Felt involved in the decision making of my Care

Page 4 of 53

Quality Dashboard

Domain

Section 1.1 Patient / Carer Experience Friends and Family2 4 5 6

96.0% 100.0% 99.5% 98.6% 98.9% 98.7% 97.4% 98.6% 98.8% 97.0% 98.9% 97.4% 98.4% 100.0%Patient Feedback narrative

The Trust performed very well in the 2016/17 community mental health teams survey (scoring an overall 74%, compared with the national benchmark of 73%). It has made significant progress and improvements since the 2016 survey and has publicised the achievements. The Trust recognises the challenge to build on and maintain these improvements and the Mental Health care group is including any areas for improvement in the care group's Quality Improvement Plan.

On comparing February 2018 to the previous three months there is an improvement in the FFT survey results for patients likely to recommend our services to their friends and family. It must be noted that the Primary Care, Community, Children's and Learning Disabilities care group received a 100% satisfaction score and all FFT scores (highlighted in the graphs above) have improved since the previous month (January 2018).It is recognised that further improvement is required to improve a) the number of FFT returns and b) the number of patients likely to recommend our services to their friends and family. A task and finish group has been established including members from the Staff Champions of Patient Experience (SCoPE) forum to develop a pathway to highlight; when to hand out an FFT survey form, the process for sharing the information with teams and subsequently how the teams must act upon the feedback for lessons learned and closing the loop. It is anticipated that by standardising the FFT process across the Trust will improve the response rate and encourage a more robust system across teams for sharing best practice. Also it will help to facilitate a process at team level to develop affective action plans to support with the learning from negative responses.

A real time patient and carer experience dashboard is in development. The dashboard will go live in April 2018 and phase one will include qualitative and quantitative FFT data and future phases will include information such as complaints, compliments, staff sickness. This is not an exhaustive list and will evolve.

FFT survey comments for February 2018 include:Secondary Mental Health Services: "Think it's important people can find help and support in services rather than just a GP".Swale Ward, The Humber Centre: "Lack of therapy options".Mental Health Response Service: "I have had previous episodes with home treatment, this has been (again) a period in which I cannot fault the team. They are always professional, caring, keep me informed and just a really useful good service!".

Page 5 of 53

Domain

Section 1.2 Patient / Carer Experience Overall Trust Position2 3 4 5 6

Patient Experience Indicators Dec-17 Jan-18 Feb-18

Eliminating Mixed Sex Accommodation 0 0 0Duty of Candour Compliance 100% 100% 100%

Key Messages - Compliments

Quality Dashboard

The Trust received a total of 12 compliments for the month of February 18. Of the 12 compliments received, 8 relate to excellent care provision, 1 emotional support, 1 appropriate discharge and 2 great leadership and learning.

During the last 11 months the Trust has received 261 compliments. The key theme for compliments is excellent care provision which represents 228 compliments received (87%).

The February 2018 compliments communication celebrated the excellent feedback received on the Addictions service. Compliments included: "“Many thanks for helping me recover after my illness”."I sat in my first family support session……..One simple question of “what could I do to change feeling like that” opened the door to realising I had a choice in deciding my own future and although some choices are difficult they mean I have my life back""I am so grateful for what the service has done for us over the last six months…….Alcohol addiction is the elephant in the room, a socially acceptable drug for so many, yet for a few it becomes an illness which wreaks havoc on people's lives - not just the person with the problem but also their whole family and on occasions, wider society too. This service's responsive, no blame, integrated response has worked for us, thank you!"

0

20

40

60


Compliments Received

0

5

10

15

20

25

30

35

40

45

Dec-17 Jan-18 Feb-18

Compliments by Theme

Great Leadership andLearning

Effective EquipmentProvision

Emotional Support

Appropriate Discharge

Excellent Care Provision

Page 6 of 53

Domain

Section 1.3 Patient / Carer Experience Overall Trust Position2 3 4 5 6

Key Messages - Complaints

Quality Dashboard

The Trust received 19 complaints during the month of February 2018. Over the past 11 months (April 2017 to February 2018) the average number of complaints received each month was 16 and the total number of complaints received for this period is 176.

The Trust responded to 7 complaints in the month of February 2018. There is a difference between the number of complaints received and number of complaints responded to due to the length of time it takes to investigate a complaint. Therefore the number of complaints responded to in February 2018 will relate to complaints received in previous months.

During February 2018, 4 complaints were not upheld (57%) and 3 complaints were partly upheld (43%). There were no fully upheld responses in February 2018. Of the 7 complaints responded to, 4 related to the Mental Health Services Care Group, 2 related to the Primary Care Community Children's and Learning Disabilities Care Group and 1 related to the Specialist Services Care Group.

The general themes from the 3 partly upheld themes include; communications (1), appointments (1) and clinical treatment; delay or failure to diagnose (1). Action plans are in place with the teams to address the issues and reporting against actions will be highlighted in the quarterly quality dashboard.

0

5

10

15

20


Complaints Responded To - Upheld Split

Complaints Upheld Fully/Partially Complaints Not Upheld

0

5

10

15

20

25

30


Complaints Responded To - Care Group Split

PC, Comm, Child & LD CG Corporate CG Mental Health CG Specialist CG

13 18

23 14 14 18 16 15 16

10 19

0

10

20

30


Complaints Received

Complaints received

Page 7 of 53


Zero Events Improvement Trajectory Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

In-Patient Suicide 0 0 0 0 0 0 0 0 0 0 0AWOL from Secure Unit 0 0 0 0 0 1 0 1 0 0 0Prone Restraints 4 6 2 5 3 2 1 17 12 4 4Avoidable Grade 4 Pressure Ulcers acquired in Humber 0 0 0 0 0 0 0 0 0 0 0Blanket Restriction 2 2 2 2 2 2 1 1 1 1 0

Admin Agency Shifts 15 3 34 34 31 41 44 44 0 0 0HCA Agency Shifts 152 165 253 257 277 178 186 142 48 43 79Total Shifts Covered by Agency 167 168 287 291 308 219 230 186 48 43 79

Narrative Update

Prone Restraint

There were 4 prone restraints in February. No prone restraints outside of Trust policy guidance.

Please note, the mortality report will be produced in next month's report (Apr-18).

Clin

ical Risk

Domain

Mental HealthServices CG

Primary Care,Community,

Children's and LDServices CG

Specialist Services CG Corporate Services

Year to Date 2930 1983 668 55

0

500

1000

1500

2000

2500

3000

3500

Incidents by Care Group - Year to Date

No Harm Low Harm Mod Harm Severe Harm Death

Numbers 4200 1147 213 10 42

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Category of Harms Severity - Year to Date

Page 8 of 53

Domain

Section 2.1 Clinical Risk Overall Trust Position2 3 4 5 6

Incident Categories

Page

Narrative Update Incident Analysis Incident Exceptions

Jan-18 Feb-18% of Harm Free Care 98.9% 98.8%% of incidents that reported in Severe Harm or Death 1.8% 1.8%

National Safety Alerts : Central Alert System (CAS)

CAS Alerts within timescale 7 9CAS Alerts reported in month 7 9CAS Compliance within timescale 100.00% 100.00%

Quality Dashboard

During February 2018 there have been 441 reported incidents

compared with 490 in January 2018; a decrease of 10.0%.

Incidents categorised as no harm fell by 3.71% and low harm rose by

4.6% between January 2018 and February 2018. Reporting in the

other severity categories each showed a variance of less than 1%.

Two serious Incidents were declared during February 2018.

Investigators have been identified and Duty of Candour undertaken.

One serious incident related to a patient on leave prior to discharge

who was found at home having fallen out of bed. The second SI

relates to the care of a deteriorating patient in the community. The

learning from the serious incidents will be reported in the quarterly

learning from incidents section of the integrated performance report.

During February 2018 the categories in the top 10 reported incidents

which saw an increase compared to January 2018's incidents were:

Self-Harm - Incidents in this category increased by 3.7% ( n=2). The units

reporting the greatest changes in reporting were Avondale which

increased from 0 incidents in January to 11, Westlands which increased

from 11 incidents in January to 22 and PICU which saw a reduction in

reported incidents between January and February (reduced from 31 in

January to 21). The 56 incidents of self-harm reported during February

2018 resulted in no harm or low harm, there were no moderate harm

incidents compared to 3 reported in January 2018. The Avondale and

Westlands incidents attributed to 4 patients.

Violence & Aggression - Physical - The overall number of incidents in this

category has increased by 25% (n=7) between January 2018 and February

2018, the main area's with an increase were Lilac Unit and Ouse Ward.

The incidents resulted in a severity of no harm or low harm.

Harm Free Care Update:-

Following a request from the Trust Board to review harm free care indicator,

the BI (Business Intelligence)Team in association with the Director of Nursing

have agreed a new methodology to calculate Harm Free Care, which is listed

below:-

Denominator – Total number of clinical contacts including OBD’s during the

reporting period

Numerator – No of incidents logged in the reporting period resulting in some

level of harm

Compliance – Denominator minus numerator / Denominator

0 100 200 300 400 500 600 700

Self Harm

Violence & Aggression - Physical

Violence & Aggression - Non-Physical

Medication Error (Prescribing, Dispensing,Administration and Adverse Drug…

Patient Care Problem

Death Of Patient

Concern for Person(s) (inc. Neglect /Emotional Harm)

Slips / Trips / Falls

Security Incident

Problems with Admission / Discharge /Transfer

Top 10 Categories Year to Date

0

100

200

300

400

500

600

700

Axi

s Ti

tle

Apr-17

May-17

Jun-17

Jul-17

Aug-17

Sep-17

Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Death 6 4 4 6 1 2 2 1 3 6 7 0

Severe Harm 0 1 0 2 1 0 2 0 0 3 1 0

Mod Harm 19 22 13 21 25 24 12 22 17 22 16 0

Low Harm 109 106 114 145 91 104 105 99 96 83 95 0

No Harm 344 421 388 415 374 466 389 322 383 376 322 0

Average 16-17 582 582 582 582 582 582 582 582 582 582 582 582

Adverse Incidents - Datix Incidents - Trust

0

20

40

60

80

100

120

140

Near Misses and Never Events

Never Events

Near Misses

Page 9 of 53

Domain

Section 2.4 Clinical Risk - Infection Control Quality Dashboard4 5 6 7 8 9 10 11 12 13 14 15 4 5 6 7 8 9 10 11 12 13 14 15

East Riding Indicators Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Whitby Indicators Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18Page

Infect_1

Number of Methicillin Sensitive Staphylococcus

Aureus (MSSA) cases0 0 0 0 0 0 0 0 0 0 0

Infect_14

Zero tolerance methicillin-resistant Staphylococcus aureus*

0 0 0 0 0 0 0 0 0 0 0

Infect_2

Minimise rates of Clostridium.difficile 0 0 0 0 0 0 0 0 0 0 0

Infect_15

Minimise rates of Clostridium difficile* 0 0 1 0 0 0 0 0 1 0 0

Infect_3

Notification of Clostridium.difficile toxin positive cases

within 24 hoursN/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Infect_16

Notification of Clostridium difficile toxin positive cases by next working day

N/A N/A Yes N/A N/A N/A N/A N/A Yes N/A N/A

Infect_4

Zero tolerance MRSA 0 0 0 0 0 0 0 0 0 0 0

Infect_17

Notification to commissioner of cases of MRSA Bacteraemia within one working day

N/A N/A N/A N/A N/A N/A N/A N/A No N/A N/A

Infect_5

Notification of MRSA Bacteraemia to be notified to

commissioner within 2 working daysN/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Infect_6 0 Narrative

#N/A

Infect_7

Patients who meet the criteria for MRSA screening are

managed as per locally agreed protocols and all

positive results are acted upon

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Infect_8

Patients with MRSA are on MRSA Care Pathway ( i.e.

managed in accordance with Infection Control

Guidance)


Infect_9

Post Infection Review (PIR) of MRSA bacteraemia/SI

report to be provided to the commissioner within 14

working days of the case being identified


Infect_10

Number of E-Coli cases 0 0 0 0 0 0 0 0 0 0 0

Infect_11

Copies of all reports and associated action plans in

response to any external IPC focus visits/inspections are

made available to the CCG within 5 working days


Infect_12

Root cause analysis are undertaken for all

Clostridium.difficile cases with key issues and lessons

learned are submitted to the CCG.

0 0 0

No Trust apportioned cases of either MRSA, MSSA, E.coli or C. difficile have been reported during February, therefore the Trust remains on trajectory to achieve the contractual agreed trajectories.

Lessons learned for the Trust apportioned case reported in December:• Importance of commencing a bowel chart when a patient starts with diarrhoea • Prompt faecal specimen collection • Prudent antibiotic prescribing and administration to be adhered to

The completed report has been shared with the Clinical Network Group on the 9th of March. An action plan has been developed which includes the delivery of a bespoke educational programme for all clinical staff on the inpatient unit at Whitby.

Infe

ctio

n C

ontro

l

Quality Dashboard

Infe

ctio

n C

ontro

l

MRSA screening is completed for all inpatient

admissions who meet the eligibility criteria as defined

within the locally agreed protocol

63 100 67

Page 10 of 53

Domain

Section 2.5 Safeguarding Alerts2 3 4 5 6

Narrative

Quality Dashboard

Clinical Risk

Nationally, the number of safeguarding children referrals to the local authority in 2017 has increased by 3.96%.

Referrals for children remain below average but are on a par in relation to last month. They have maintained a fairly consistent level for the past few months with a spike in October 2017. Neglect continues to remain the highest type of abuse reported in the last month, which is in line with national trends. There has been an increase in the referrals for emotional abuse and physical abuse so these areas are almost on a par with the areas of neglect. This is not so reflective of national trends as there has been a general downward trend in the proportion of children subject to a Child Protection Plan due to physical abuse (NSPCC accessed online 2017). The safeguarding service continues to promote safeguarding development for staff in monthly session and is working on the recording of safeguarding children supervision trust wide.

The adult referrals are remaining within the below average figures we have observed throughout the year. The call rate to the team remains high and the call rates continues to create significant activity on the duty system for the team. Neglect continues to be the largest type of abuse reported, this is reflective of national trends. Mental health services are the highest referral area for the trust although there has been a slight reduction within the last 6 months. Primary care, community and LD and children’s services are the second highest referral area by Care Group with Specialist services the lowest currently for referral rates trust wide. The safeguarding team are preparing to deliver integrated children and adult training level three from May 2018 which will further reflect and embed the integrated process for safeguarding and the Think family approach we are supporting .Adult training compliance remains robust apart from the GP practices which is being addressed and Prevent training is now on line which should help compliance rates trust wide. Monthly development sessions for staff are improving understanding and creating empowerment for staff and managers development sessions are also well received regarding the complex coordination and management of safeguarding concerns.

0

10

20

30

40

50

60

70

80


Safeguarding Referrals Rate to Local Authority

Adult Refs Child Refs Adult Ave 2016-17 Child Ave 2016-17

0 50 100 150 200 250 300

Neglect

Physical

Emotional

Sexual

Psychological

Domestic

Organisational

Financial

Self neglect

Internal Organisational

Neglect

Physical

Emotional

SexualPsychological

Domestic

Organisationa

l

Financial

Selfneglec

t

Internal

Organisationa

l

Adult 1103402632212020144

Child 14710812334030000

Referral Reasons (Top 10) Year to Date

Page 11 of 53

Domain

Section 2.6 Clinical Risk Safer Staffing Dashboard is produced one month in arrears. Safer Staffing2 4 5 6

6 7 9 10 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 29 30 31 32 33 34

Car

e G

rou

p

Ward SpecialityStaffing Levels

affecting patient

care

Incidents of

Physical Violence

/ Aggression

Complaints

Upheld

(and partly

upheld)

Drug Errors

Slips

Trips

Falls

Mandatory

Training (ALL)PADRs

Sickness Levels

(clinical)

WTE Vacancies

(RNs only)

Quality

Indicator Total

Improvement

Trajectory (prev

month)

Avondale Adult MH Assessment 69% 25.3% 1.9% 96% 93% 92% 126% 2 13 0 0 1 89.8% 84.0% 1.6% 1.0 0

New Bridges Adult MH Treatment (M) 96% 17.0% 7.8% 95% 99% 100% 102% 2 41 0 0 2 93.8% 82.5% 7.3% 3.0 2

Westlands Adult MH Treatment (F) 94% 27.9% 7.0% 78% 107% 83% 118% 10 47 0 0 6 86.0% 65.1% 12.6% 3.0 3

Mill View Court Adult MH Treatment 102% 16.7% 2.5% 87% 107% 100% 100% 2 20 0 0 12 87.3% 81.3% 13.1% 2.0 2

Hawthorne Court Adult MH Rehabilitation 92% 21.4% 0.4% 75% 94% 100% 106% 2 31 0 0 3 81.4% 71.0% 5.8% 3.0 2

PICU Adult MH Acute Intensive 84% 31.5% 8.7% 65% 137% 89% 134% 7 51 0 0 0 82.8% 100.0% 3.4% 3.8 1

Maister Lodge Dementia Treatment 53% 21.8% 0.7% 83% 117% 97% 120% 0 0 0 0 0 81.2% 97.5% 5.7% 2.4 0

Mill View Lodge Older Adult Treatment 108% 27.9% 0.0% 72% 110% 100% 100% 0 16 0 0 18 88.9% 76.0% 12.0% 0.6 3

Whitby Hospital Physical Health Ward 86% 1.9% 0.0% 81% 81% 102% 97% 31 1 0 0 59 69.4% 73.8% 12.3% 2.0 2

Greentrees Forensic Medium Secure 70% 8.8% 0.0% 99% 80% 100% 101% 1 0 0 1 18 76.7% 83.3% 13.5% 2.4 1

Darley Forensic Low Secure 72% 33.2% 0.0% 87% 67% 97% 100% 0 6 0 0 0 90.8% 95.0% 11.1% 2.0 2

Bridges Forensic Medium Secure 76% 24.0% 0.0% 81% 76% 75% 108% 1 0 0 0 0 81.2% 86.7% 9.7% 3.4 1

SwalePersonality Disorder Medium

Secure80% 32.6% 3.4% 116% 108% 103% 137% 3 7 0 0 2 89.8% 96.0% 2.8% 0.0 1

Ullswater Learning Disability Medium Secure 60% 41.3% 0.0% 100% 116% 100% 152% 1 9 0 0 3 91.1% 95.5% 4.0% 2.0 1

Townend Court LD Assessment/Treatment 77% 26.8% 0.0% 67% 100% 100% 102% 0 69 0 0 3 86.1% 93.0% 4.8% 5.5 1

Granville Court LD Treatment 33.0% 4.1% 111% 86% 100% 89% 1 3 0 0 4 35.1% 70.9% 10.0% -0.1 3

Deteriorated

Improvement Trajectory based on

previous month

Improved

AmberNo Change

Whitby Green 90-95%

Green

>92%

88-92%

< 87%

Red

Night

OBD (Bed Occupancy)

Threshold

OBDs (inc leave)

Ad

ult

Me

nta

l He

alth

Co

mm

un

ity

Ho

spit

als

and

Old

er

Pe

op

le M

HSp

eci

alis

tC

HLD

Agency %

Filled

Traj

ect

ory

Day

Registered RegisteredUn Registered

High Level Indicators

STAFF QUALITY INDICATORSPATIENT QUALITY INDICATORS (ACCUMULATED 2017-18)

Un Registered

Units

Bank %

Filled

Trje

cto

ry

Safer Staffing Dashboard

Bank/Agency Hours Average Safer Staffing Fill RatesReport Month: January 2018

Page 12 of 53

Domain

Section 2.6 Clinical Risk Safer Staffing Dashboard is produced one month in arrears. Safer Staffing

Safer Staffing Dashboard

Narrative

Registered Nurses Fill Rates

During January 10 units across the Trust had a fill rate below 90%. This is a slight improvement when compared to December when 11 units had registered nurse fill rates below 90%. Work has commenced in PICU to check establishment against a validated safer staffing tool.

Sickness

During this reporting period 9 units reported sickness above 6% compared to 10 units in December. Westlands, Mill View Court, Hawthorne Court and Bridges are all reporting an increase in sickness compared to the previous month. Charge Nurses are meeting with HR monthly and are working to the new Trust Policy around managing attendance. They receive regular updates from HR so can identify any concerns earlier and put in appropriate support as required. Active recruitment continues. Skill mix is being reviewed in order to address challenges recruiting to specific Bands. Mandatory Training

Mandatory training compliance has improved on all units when compared to December. Granville Court is improving however, the compliance rate remains low at 35.1%. There are specific actions in place to address this. Two members of staff have been identified to do one to one sessions, protected supportive learning time is in place, and there is a monthly mandatory training focus which is driving up compliance (March’s focus is IG and April will be ILS) and training is a standard agenda item in all team meetings.

Staffing levels affecting patient care

During January there was total of 20 incidents reported relating to staffing concerns all of which resulted in no harm. 5 incidents were reported as having affected patient care as follows: 2 incidents resulted in patients’ leave being cancelled; there was a delay in the transfer of patients from the acute hospital to Whitby Community Ward; community visits were cancelled as a result of staff covering the inpatient ward and the Mental Health Response team reported service delivery as having been affected. All incidents were reported to management for appropriate actions to be taken at the time.

Page 13 of 53


Clin

ical Effective

ne

ss

Domain

51% 46%

3% 0%

Pressure Ulcers Year to Date (2017-18)

Grade 3 and 3+ above PU not acquired in Trust

Grade 3 and 3+ above PU acquired in Trust

Grade 4 PU not acquired in Trust

Grade 4 PU acquired in Trust

The Pie chart demonstrates that there are 5% more Pressure ulcers of Grade 3/3+ developed in our care as opposed to inherited. What that does not demonstrate is the avoidability to Humber NHS Foundation Trust due to non - compliance, terminal ulcers and or critical ischeamia etc.

Page 14 of 53

Domain

Section 3.1 Clinical Effectiveness Quality Dashboard2 3 4 5 6

Pressure Ulcer Analysis - Pocklington Only

Pressure Ulcer Analysis - Whitby Only

Quality Dashboard

Key Messages - Pressure Ulcers

Pocklington Grade 3/3+. The total number for the month was four of which three developed in our

care. Initial investigation and presentation to the PU forum identified that all where unavoidable to

Humber NHS Foundation Trust and did not require RCA (Root Cause Analysis). The reason for the

ulcer development was patient non -compliance with equipment, treatment plans and sleeping

arrangement

Pocklington Grade 1/2. The total number reported for the month was seven of which two

developed in our care.

Whitby Grade 3/3+. The total number reported in the month was three of which one developed in

our care. This was an end of life patient with terminal ulceration. RCA (Root Cause Analysis) was not

required. The other two cases was not acquired in the Trusts care.

Whitby Grade 1/2. Total number reported during the month was five of which two developed in our

care.

All patients with the ulceration to the skin integrity are been monitored by the team leaders with a

view to escalation to Tissue Viability as required.

0

1

2

3

4

5


Grade 3 and 3+ - PressureUlcers in month

Acquired Grade 3 and 3+ inour care

Grade 4 - Pressure Ulcers inmonth

Acquired Grade 4 in our care

0

2

4

6

8

10


Grades 1 and 2 in month

Grades 1 and 2 Acquired

0

2

4

6

8

10


Grade 3 and 3+ - PressureUlcers in month

Acquired Grade 3 and 3+ inour care

Grade 4 - Pressure Ulcers inmonth

Acquired Grade 4 in our care

0

1

2

3

4

5

6

7


Grades 1 and 2 in month

Grades 1 and 2 Acquired

0

2

4

6

8

10

Avoidability Score

Pressure Ulcers Quality & Safety Reviews (QSR) Avoidability Score (YTD)

1 - Definitely avoidable 2 - Strong evidence of avoidability

3 - Probably avoidable, more than 50-50 4 - Possibly avoidable, less than 50-50

5 - Slight evidence of avoidability 6 - Definitely unavoidable

Page 15 of 53


Clin

ical Effective

ne

ss

Domain

Page 16 of 53

Domain


Clinical Audits

Quality Dashboard

February 2018

12 audits were planned to start in February and of these 5 started as planned:Driving risk assessment amongst inpatients with psychiatric disorders (Newbridges), NICE NG19 Diabetic Foot Care, Weight Monitoring in Psychiatric Inpatients (Westlands), Does prevalence of prescribed medications with abuse or dependence potential change after a new clinical alert system adopted? (Service Evaluation), Family Therapy service at Townend Court (Service Evaluation).

The audits that did not start as planned are as follows:

NICE CG128 Autism in Under 19s, CG78 Borderline Personality Disorder (PICU), NICE QS88 Borderline/Antisocial Personality Disorder, NICE CG91 Depression in Adults with a Chronic Physical health problem, NICE CG120 Psychosis with substance misuse, NICE CG142 Autism in Adults, NICE CG51 Drug Misuse in over 16's, NICE NG51 Sepsis, Chaperone Policy, NICE CG174 IV.Fluids (Community), Re-audit of Risk Assessment Prior to Leave (via Perfect Ward), NICE NG69 Eating Disorders, CG146 Osteoporosis, NICE CG162 Stroke rehabilitation. These audits have been rescheduled and added to the 2018-19 audit plan.

Audit Activity in February

The following audits are ongoing with data collection and analysis during this month: CG189 Obesity: Clinical Assessment and Management, Patient experiences of initial consultation in Primary Care when presenting with low back pain, SEA 2017 - 08 Records Audit, CG137 Epilepsies, PREVENT referrals, (All covered by the Trust peer review programme), MHA Inspection Audits (All being covered by Perfect Ward), Audit of in-patient experience in Learning Disability service, NG15 Antimicrobial Stewardship, NG10 Violence & Aggression, QS134 Coeliac Disease, Service Evaluation of Holderness Care Navigator Project, Service Evaluation of Older People's Fellowship programme, National Baby Feeding Initiative, NICE CG191 Pneumonia, Occupational & Educational Needs in Psypher, CQUIN Audit of Lorenzo Records , Audit of Supervision Process in ER Psychiatric Training Scheme, Understanding the needs of Patients with Profound & Multiple Learning Disabilities, Clozapine prescribing, Prescription medication and opoid substitution treatment , Investigating routine use of Patient Outcome Measures in a Community Mental Health Team (Service Evaluation), Audit of Care Records in HFT.

Audit Reports completed in February

There were 5 audit reports completed in February:Driving Risk Assessment at New BridgesNICE CG53 Chronic FatigueSafeguarding - Children's Records in Whitby MIUSafeguarding - Think child, think parent, think family (Holderness CMHT)Safeguarding - Think child, think parent, think family (Westlands)Safeguarding - Think child, think parent, think family (Rapid Response Service).

Clinical Audits Narrative

0

5

10

15

20

25


Clinical Audits

Audits planned to start in month Audits started in month Audits completed in month

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%


Clinical Audits - Audits Started in month percentage split

PC, Comm, Child & LD CG Mental Health CG Specialist CG

Page 17 of 53

Domain


NICE Guidelines NICE Guidelines Narrative

Quality Dashboard

During February 2018 there were 19 NICE guidelines published applicable :

MIB140 Coban 2 for venous leg ulcers - Applicable to Community care group. Sent to Lead Tissue

Viability Nurse for review. QS163 Mental health of adults in contact with the criminal justice system -

Applicable to Specialist services. Sent to Team Leader in Addictions for review. QS164 Parkinson's

disease - Applicable to Primary Care. Sent to Deputy Medical Director Primary Care to review and 2

audits added to the audit plan 2018-19. QS93 Atrial Fibrillation - Applicable to Primary Care. Sent to

Deputy Medical Director Primary Care to review. Audit added to the audit plan 2018-19. CG147

Peripheral arterial disease: diagnosis and management - Applicable to Primary Care. Sent to Deputy

Medical Director Primary Care to review: The sections which are relevant to GP services has not

changed and it is also picked up in regular QoF audits.

The Key Therapeutic Topics published in February were sent to the Chief Pharmacist for review.

Confirmation of Applicability for January's NICE Guidance:

MIB139 EpiFix for chronic wounds - Applicable to Community care group. Reviewed by Lead Tissue

Viability Nurse: Not implemented as there is no cost effective data available and no clinical evaluations

provided at this time in the UK to compare against current UK best practice. NG82 Age-related macular

degeneration - Applicable to Primary Care. Sent to Primary Care lead for review. NG84 Sore throat

(acute): antimicrobial prescribing - Applicable to all care groups, Pharmacy and Infection Control for

information only.

Reports due back from October 2017 meeting - reporting in February 2018

QS162 Cerebral palsy in children and young people: Outstanding. Awaiting response from Children's

and LD leads. NG79 Sinusitis (acute): antimicrobial prescribing: Partially implemented. Current guidance

is in keeping with current management of this condition in Primary Care. Sent to Drugs & Therapeutics

Group for review. NG076 Child abuse and neglect: Outstanding. Awaiting response from Safeguarding

lead. Sent to CAMHS and Children's Therapies leads for review. CG089 (Updated) Child maltreatment:

when to suspect maltreatment in under 18s: Outstanding. Awaiting response from Safeguarding lead.

Sent to CAMHS and Children's Therapies leads for review.

0

5

10

15

20

25

30

35

40

May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Nope

NICE Guidelines

NICE Guidelinesreleased inmonth

NICE Guidelinesapplicable

PC, Comm, Child & LD CG Mental Health CG Specialist CG Corporate

Number of NICE Guidelines Reviewed in Oct 2017 and due for Reporting in February 2018

4 0 0 0


Number of NICE Guidelines in October 2017 circulated for information only

0 0 0 0


Overdue Reviews for February 2018

1 0 0 0

3 0 0 0


Reviews Completed for February 2018

Page 18 of 53

Finance and Use of Resources

Balancing provider finances and improving productivity

Finan

ce

Page 19 of 53

Feb 2018SCORECARD

Summary Period Ending:

Finance and Use of Resources

Balancing provider finances and improving productivity

Finance

Cash in Bank

(Direction of Travel)

Clusters

Use of

Finance Score

Income/Expenditure

Use of Bank and Agency

Page 20 of 53

Indicators

3 2 0 1

Apr-17 May-17 Jun-17 Q1 Jul-17 Aug-17 Sep-17 Q2 Oct-17 Nov-17 Dec-17 Q3 Jan-18 Feb-18 Mar-18 Q4

F 1 5

Bank, Agency and Overtime

- Trustwide (£'000s)Lo

w S

pen

dFair

Mth

ly

£819 £940 £855 £2,614 £866 £787 £668 £2,320 £718 £707 £701 £2,126 £476 £695 £8,232

F 2a 5 Cash in the Bank (£'000K)

No

ne

set

Not Rated

Mth

ly

£8,575 £8,650 £8,902As at

Jun 17£11,486 £10,411 £9,261

As at

Sep 17£7,772 £7,107 £6,875

As at

Dec 17£7,540 £7,256

F 2b 5 Use of Resources Score <2 Good

Mth

ly

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

F 3 5

Income/Expenditure against

Plan (£'000K) - Cumulative

Surp

lus

Good

Mth

ly

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

F 4 5

PbR Clustering (Patients

Clustered) 95

.0%

Fair

Mth

ly

94.7% 95.1% 95.8% 95.2% 95.8% 95.1% 95.5% 95.5% 95.5% 94.8% 93.4% 94.5% 93.6% 93.0% 93.0%

F 5 5

PbR Clustering (Patients

Clustered with a Review) 95

.0%

Good

Mth

ly

96.2% 96.7% 95.4% 96.1% 95.3% 95.6% 95.1% 95.3% 95.6% 93.7% 94.6% 94.6% 95.1% 94.0% 94.0%

SOF Domains Strategic Goals

Quality 1 Innovating quality and patient safetyFinance 2 Enhancing prevention, wellbeing and recoveryPerformance 3 Fostering integration, partnership and alliancesStrategy 4 Developing an effective and empowered workforceLeadership 5 Maximising an efficient and sustainable organisation

6 Promoting people, communities and social values

As at March 2018

YTD

Freq

uenc

y Quarter 1

En

try

Stra

tegi

c G

oal

Indicator Definition

Thre

sho

ld /

Targ

et Current month RAG

Definition

Feb-18

Quarter 2 Quarter 3

Regulator

Provider Lead

Contract Period 2017-18

Issue Date 21 March 2018

NHS Improvement

Humber NHS Foundation Trust

Quarter 4

Monthly KPI Assurance Levels : Finance

DASHBOARD 2017-18Total Entries

(RAG only)Within Target Within Tolerance Outside Target

Under Review/ Not

Rated

Quarter Ending: Q3

Financial Indicators and CQUiNS

5Period Ending:

Page 21 of 53

Operational Performance

Maintaining and improving against core standards

Op

eratio

nal

Page 22 of 53

Feb 2018SCORECARD



Maintaining and improving against core standards

Operational

Gatekeeping Delayed Transfers

of Care

CPA Reviews (12 months)

CPA 7 day

follow ups (quarterly)

Readmissions Performance

Occupied Bed Days

MHSDS - Metrics

Waiting Times (seen)

IAPT Waits

EIP Waits

Waiting Lists (unseen)

Page 23 of 53

Indicators

0

OP

2

1Occupied Bed Days - Specialist

Including Leave ONLY 90

.0%

Weak

Mth

ly

94.7% 93.7% 90.7% 93.0% 88.4% 80.1% 78.8% 82.4% 77.8% 75.6% 70.1% 74.5% 71.6% 71.9% 71.9%

OP

3 M

H

1Occupied Bed Days - Mental Health

Excluding Leave 85

.0%

Good

Mth

ly

92.1% 91.6% 86.1% 89.9% 90.1% 91.2% 91.4% 90.9% 82.9% 82.1% 80.3% 81.8% 79.5% 83.5% 83.5%

OP

3 M

H in

c

1Occupied Bed Days - Mental Health

Including Leave 85

.0%

Fair

Mth

ly

98.3% 98.4% 94.1% 96.9% 98.3% 98.5% 98.7% 98.5% 90.1% 87.2% 86.5% 88.0% 86.6% 89.7% 89.7%

OP

4

1Occupied Bed Days - Children's and LD

Excluding Leave 85

.0%

WeakM

thly

70.5% 69.2% 61.7% 67.1% 62.6% 62.3% 61.0% 62.0% 54.8% 63.7% 69.2% 62.6% 76.5% 76.4% 76.4%

OP

4 in

c

1Occupied Bed Days - Children's and LD

Including Leave 85

.0%

Fair

Mth

ly

77.0% 69.2% 63.3% 69.8% 67.6% 65.2% 63.7% 65.5% 57.6% 63.7% 73.9% 65.1% 76.9% 81.4% 81.4%

OP

6

1Occupied Bed Days - Whitby

Excluding Leave 90

.0%

Good

Mth

ly

87.5% 94.0% 91.8% 91.1% 91.9% 85.6% 78.9% 85.6% 79.6% 76.9% 88.2% 81.6% 85.6% 92.0% 92.0%

OP

6 in

c

1Occupied Bed Days - Whitby

Including Leave 90

.0%

Good

Mth

ly

87.5% 94.0% 91.8% 91.1% 91.9% 85.6% 78.9% 85.6% 79.6% 76.9% 88.2% 81.6% 85.6% 92.0% 92.0%

OP

7

1Care Programme Approach (CPA)

Formal Review within 12 months 95.0

%

Fair

Mth

ly

95.6% 95.2% 92.3% 94.4% 94.3% 95.5% 95.3% 95.1% 96.3% 95.3% 94.8% 95.5% 94.7% 93.7% 93.7%

OP

8

1Admissions to inpatients services

- Access via Crisis (gate-keeping) 95.0

%

Good

Mth

ly

100.0% 100.0% 98.8% 99.6% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.9%

OP

9

1Early Intervention in Psychosis (EIP)

- First episode treated within 2 weeks 50.0

%

Good

Mth

ly

77.8% 55.0% 86.7% 71.7% 30.8% 28.6% 53.8% 36.2% 83.3% 100.0% 93.8% 91.2% 95.0% 100.0% 91.2%

OP

10a

1 IAPT - Treated in 6 weeks of referral

75.0

%

Good

Mth

ly

96.8% 96.7% 98.1% 97.2% 96.2% 97.5% 97.4% 97.1% 98.7% 98.1% 98.8% 98.5% 97.2% 100.0% 97.8%

OP

10b

1 IAPT - Treated in 18 weeks of referral

95.0

%

Good

Mth

ly

100.0% 99.6% 100.0% 99.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.5% 100.0% 99.9%

OP

11

1 ER IAPT - Moving to Recovery

50

.0%

Good

Mth

ly

55.2% 50.6% 49.7% 51.7% 58.0% 57.7% 59.4% 58.3% 58.7% 53.8% 55.2% 55.9% 58.5% 57.5% 55.8%

OP

12

2Care Programme Approach (CPA)

Follow Up within 7 days of discharge 95.0

%

Good

Mth

ly

95.9% 98.0% 97.4% 97.2% 96.5% 98.6% 93.6% 96.2% 99.0% 98.6% 100.0% 99.2% 97.3% 97.5% 97.5%

Freq

uenc

y

2415 4

Quarter 1 Quarter 2

En

try

Stra

tegi

c G

oal


Thre

sho

ld /

Targ


Definition

Monthly KPI Assurance Levels : Monitor

PI RETURN FORM 2017-18Total Entries

(RAG only)Under Review/

Not Rated

Q3


Feb-18Period Ending:

Quarter Ending:

Within Target Within Tolerance

Quarter 3 Quarter 4

21 March 2018

YTD/QTD

Month EndQ3 Feb-18 Mar-18 Q4Apr-17 May-17 Jun-17 Q1 Jul-17 Dec-17

Regulator

Provider Lead

Contract Period

Issue Date

Outside Target

5

NHS Improvement


2017-18

Aug-17 Sep-17 Q2 Oct-17 Nov-17 Jan-18

Page 24 of 53

Indicators

0

Freq

uenc

y

2415 4

Quarter 1 Quarter 2

En

try

Stra

tegi

c G

oal


Thre

sho

ld /

Targ


Definition

Monthly KPI Assurance Levels : Monitor

PI RETURN FORM 2017-18Total Entries

(RAG only)Under Review/

Not Rated

Q3


Feb-18Period Ending:

Quarter Ending:

Within Target Within Tolerance

Quarter 3 Quarter 4

21 March 2018

YTD/QTD

Month EndQ3 Feb-18 Mar-18 Q4Apr-17 May-17 Jun-17 Q1 Jul-17 Dec-17

Regulator

Provider Lead

Contract Period

Issue Date

Outside Target

5

NHS Improvement


2017-18

Aug-17 Sep-17 Q2 Oct-17 Nov-17 Jan-18

OP

13a

1Referral to Treatment

- Non Admitted 18 weeks (Alfred Bean) 90.0

%

Good

Mth

ly

100.0% 99.2% 99.3% 99.5% 99.3% 96.2% 97.5% 97.7% 96.6% 97.0% 97.9% 97.1% 91.1% 98.4% 97.6%

OP

13b

1Referral to Treatment

- Incomplete 18 Weeks (Alfred Bean) 92.0

%Good

Mth

ly

98.0% 100.0% 99.6% 99.5% 97.2% 99.1% 97.0% 97.8% 96.6% 96.2% 95.0% 96.0% 99.4% 97.0% 97.9%

OP

13c

1Total Time in A&E (Whitby)

- spent waiting less than 4 hours 95.0

%

Good

Mth

ly

100.0% 100.0% 100.0% 99.9% 99.8% 99.7% 99.6% 99.7% 100.0% 100.0% 99.7% 99.9% 100.0% 99.8% 99.9%

OP

14

2Minimising Mental Health Delayed Transfers of

Care - As at Month End 7.5% Good

Mth

ly

7.9% 6.9% 6.9% 7.3% 5.9% 7.0% 7.2% 6.7% 5.9% 3.8% 4.8% 4.8% 5.2% 5.1% 6.1%

OP

15

3Mental Health Data Completeness

- Identifiers (as at month end) 95

.0%

Good

Mth

ly

99.8% 99.8% 99.8% 99.8% 99.8% 99.8% 99.8% 99.8% 99.7% 99.7% 99.7% 99.7% 99.8% 99.8% 99.8%

OP

16

3Mental Health Data Completeness

- Priorities (as at month end) 85

.0%

Weak

Mth

ly

53.5% 54.1% 54.6% 54.3% 55.0% 55.9% 56.5% 55.8% 56.6% 56.6% 56.8% 56.7% 56.7% 56.5% 56.5%

Mar-17 Apr-17 May-17Rolling 3

monthsJun-17 Jul-17 Aug-17

Rolling 3

monthsSep-17 Oct-17 Nov-17

Rolling 3

monthsDec-17 Jan-18 Feb-18

Rolling 3

months

12 month

average

OP

20

1RTT - within 18 weeks of Referral

- Seen / Experienced Waits 95

.0%

Fair

Mth

ly

94.3% 90.9% 90.1% 92.5% 85.7% 87.9% 86.9% 86.8% 85.1% 83.1% 90.4% 86.0% 91.2% 90.6% 91.4% 91.0% 89.2%

OP

21

1RTT - within 18 weeks of Referral

- Unseen / Waiting List 92

.0%

Weak

Mth

ly

88.4% 83.0% 85.1%

as at

month

end

84.8% 83.6% 81.6%

as at

month

end

81.4% 84.1% 84.9%

as at

month

end

84.6% 85.4% 85.5%

as at

month

end

85.5%

OP

22a

1RTT > 52 weeks of Referral

- Unseen / Waiting List

0 Weak

Mth

ly

43 10 9

as at

month

end

13 12 12

as at

month

end

13 18 14

as at

month

end

15 10 6

as at

month

end

6

Mar-17 Apr-17 May-17Rolling 3

monthsJun-17 Jul-17 Aug-17

Rolling 3

monthsSep-17 Oct-17 Nov-17

Rolling 3

monthsDec-17 Jan-18 Feb-18

Rolling 3

monthsMonth End

OP

1

1

Emergency Readmissions

- Mental Health

(Reported one month in arrears) 10

.0%

Good Mth

ly

0.7% 0.0% 2.4% 1.1% 2.1% 3.1% 0.0% 1.7% 2.1% 2.5% 6.3% 3.6% 3.4% 1.0% 1.0%

KEY: SOF Domains Strategic Goals KEY to abreviations:

Quality 1Finance 2Performance 3Strategy 4Leadership 5

6 Promoting people, communities and social values

12 month rolling figure

RTT - Referral to TreatmentIAPT - Improved Access to Psychological Therapies

Patients Discharged in the month of:

Innovating quality and patient safetyEnhancing prevention, wellbeing and recoveryFostering integration, partnership and alliancesDeveloping an effective and empowered workforceMaximising an efficient and sustainable organisation

Page 25 of 53

KPI Type

OP 4

5 6 7 8 9 10 11 12 13 14 15 16 23As at

Excluding Leave Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 mth end

Activity 70.5% 69.2% 61.7% 62.6% 62.3% 61.0% 54.8% 63.7% 69.2% 76.5% 76.4%Target/Plan 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%

Variance to plan -14.5% -15.8% -23.3% -22.4% -22.7% -24.0% -30.2% -21.3% -15.8% -8.5% -8.6%

As at month end Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 mth end

Lilac8 beds) 63.3% 81.0% 58.3% 73.8% 62.5% 51.7% 37.5% 43.8% 64.5% 74.2% 63.4% 63.4%

Willow(6 beds) 84.4% 83.3% 66.7% 66.7% 67.2% 66.7% 66.7% 75.0% 69.4% 79.0% 79.2% 79.2%

Beech(6 beds) 66.1% 39.2% 61.1% 43.5% 57.0% 67.8% 66.1% 78.9% 75.3% 76.9% 91.1% 91.1%

5 6 7 8 9 10 11 12 13 14 15 16 21

Including Leave Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Activity 77.0% 69.2% 63.3% 67.6% 65.2% 63.7% 57.6% 63.7% 73.9% 76.9% 81.4%Target/Plan 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% Optimum

Variance to plan -8.0% -15.8% -21.7% -17.4% -19.8% -21.3% -27.4% -21.3% -11.1% -8.1% -3.6%


Lilac8 beds) 67.9% 81.0% 59.6% 81.5% 62.5% 52.1% 42.7% 43.8% 67.7% 75.0% 72.3%

Willow(6 beds) 89.4% 83.3% 66.7% 66.7% 68.3% 66.7% 66.7% 75.0% 69.4% 79.0% 80.4%

Beech( expected to be 6 beds) 76.7% 39.2% 65.0% 50.0% 65.6% 76.1% 68.3% 78.9% 86.6% 77.4% 94.6%

Financial Penalties

£

£

76.4%

Good

Performance

Improve-ment

trajectory

PI RETURN FORM 2017-18For the period ending: Feb 2018 BY EXCEPTION

Indicator Title Description/Rationale

Occupied Bed Days - Learning DisabilitiesTotal of all occupied bed day percentages for all inpatient units within the Learning Disability Service

Occupied Bed Days are based on EXCLUDING LEAVE on this PI Return. A comparison with INCLUDING leave is shown on the chart below.

Executive Lead

Lynn Parkinson

69.2%

76.5% 76.4% 73.9%

76.9%

81.4%

25.0%

35.0%

45.0%

55.0%

65.0%

75.0%

85.0%

95.0%

105.0%


OBDs - Learning Disabilities

% Exc Leave % Inc Leave Target

Page 26 of 53

KPI Type

OP 4

Report Run Date: 06/03/2018

<80%80-83%83-87%87-90%>90%

Solution to correct/mitigate against the under-performance Date Status

Apr-18 Open

Upper Amber

Data Source: Lorenzo

Part of the transformation of care model will look to see a planned reduction in beds in 2017/18. This will

include the planned closure of the 6 bedded Beech Unit to commence in April 2018 as part of the

development of the Intensive Support Team to enhance community support as part of the Transforming

Care Agenda. Available bed days will remain and will therefore continue to result in under occupancy.

Please also see Clinical Director commentary to the right.

The performance on occupied bed days in Townend Court is entirely consistent with the national

policy in relation to Transforming Care for people with a learning disability with a reduction on the

reliance of inpatient beds. A revision of the occupied bed day target will need to be discussed and

agreed with the CCGs in support of the contract variation for the Intensive Service. This will include

the planned closure of the 6 bedded Beech Unit to commence in April 2018 as part of the

development if the Intensive Support Team to enhance community support as part of the

Transforming Care Agenda.

As part of the Transforming Care Programme, we continue to support people who have complex

needs within the unit; there are weekly calls and reviews of patients – with a number of discharges

forecast during March 2018 in line with the Humber-wide TCP trajectory. This will also support the

planned closure of Beech Unit.

Owner

Review of the transformation process required to work towards a revised optimum level for bed availability and occupancy Helen Wilkinson

Upper Red

Scoring ThresholdsLower Red

Lower AmberGreen

Occupied Bed Days - Learning Disabilities

(page 2)

Total of all occupied bed day percentages for all inpatient units within the Learning Disability Service

Occupied Bed Days are based on EXCLUDING LEAVE on this PI Return. A comparison with INCLUDING leave is shown on the chart on the previous

page.

Executive Lead

Lynn Parkinson

Business Intelligence Information Management Modern Matron Gary Green



Page 27 of 53

KPI Type

OP 16

5 6 7 8 9 10 11 12 13 14 15 16 23

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD

Activity 53.5% 54.1% 54.6% 55.0% 55.9% 56.5% 56.6% 56.6% 56.8% 56.7% 56.5%

Target/Plan 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%

Variance to plan -31.5% -30.9% -30.4% -30.0% -29.1% -28.5% -28.4% -28.4% -28.2% -28.3% -28.5%

High

Direction

£

Report Run 12/02/2018

Employment 84.6%Settled Accommodation 85.9%Ethnicity 84.7%Education (CYP only) 83.8%Diagnosis Recorded 3.8%



Additional commentary Business Intelligence Department

Owner

Diagnosis is provided on inpatient only which impacts dramatically on the overall compliance rate (3.0%). This is a potential

national issue and will remain until data collection of diagnosis on assessment is carried out but this is not mandated nationally.

Figures provided are refreshed and validated each month. The latest figures you see in the charts will be based on the refresh

from two months previous. This a a change to the previous dataset collected and therefore no previous comparison are available.

Split of percentage compliance for current month

Mental Health Minimum Data Set

56.5%

Business Intelligence Single Oversight FrameworkGood

Performance

The new Data Quality Maturity Index (DQMI) - Mental Health Services Data Set (MHSDS) Data score replaces previous standards

for submitting 'priority' and 'identifier' metrics to MHSDS. Changes to these perameters to only include metrics for

Accommodation, Employment and Ethnicity will be reported from April 2018. Work is currently underway within the Trust to

process the reporting tables in line with NHS Digital requirements. These are published quarterly and two months in arrears Financial

Penalties £

Complete and Valid submissions of metrics in the monthly Mental Health Services Data Set submissions to NHS Digital. Based on refreshed data two

months previous

Executive Lead

Lynn Parkinson



0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%


Data Completeness: Priorities

% result Target

Page 28 of 53

KPI Type

OP 20

5 6 7 8 9 10 11 12 13 14 15 16 23

Trustwide Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

No. Treated in

period3787 1314 1992 1966 1873 1833 1836 2050 1700 1084 1594 1428

No. Treated in 18

weeks3570 1195 1794 1685 1646 1593 1563 1704 1537 989 1444 1305

% Treated within

18 Weeks94.3% 90.9% 90.1% 85.7% 87.9% 86.9% 85.1% 83.1% 90.4% 91.2% 90.6% 91.4%

Target/Plan 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Hull CCG Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

No. Treated in

period411 398 539 503 421 379 338 501 499 341 446 453

No. Treated in 18

weeks331 327 430 373 352 310 267 393 407 295 365 384

% Treated within

18 Weeks80.5% 82.2% 79.8% 74.2% 83.6% 81.8% 79.0% 78.4% 81.6% 86.5% 81.8% 84.8%

Target/Plan 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

East Riding CCG Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

No. Treated in

period2820 346 459 445 414 374 323 410 511 338 511 438

No. Treated in 18

weeks2706 310 388 388 357 341 293 346 462 304 452 387

% Treated within

18 Weeks96.0% 89.6% 84.5% 87.2% 86.2% 91.2% 90.7% 84.4% 90.4% 89.9% 88.5% 88.4%

Target/Plan 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

All Other CCGs Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

No. Treated in

period556 570 994 1018 1038 1080 1175 1139 690 405 637 537

No. Treated in 18

weeks533 558 976 924 937 942 1003 965 668 390 627 534

% Treated within

18 Weeks95.9% 97.9% 98.2% 90.8% 90.3% 87.2% 85.4% 84.7% 96.8% 96.3% 98.4% 99.4%

Target/Plan 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

12 month

average


RTT Experienced Waiting Times (Completed

Pathways)Referral to Treatment Experienced Waiting Times (Completed Pathways) : Based on patients who have commenced treatment during the reporting period and

DO NOT include any patients who are yet to commence treatment

Executive Lead

Lynn Parkinson


89.2%

12 month

average

81.0%

12 month

average

91.1%

12 month

average

92.1%

Page 29 of 53

Business Intelligence CommentaryGood

Performance

HighAll patients waiting over 52 are reviewed by the Operations Risk and Performance

Group each month.

Please refer to OP23 Waiting Times summary for narrative by service area.

Richard Voakes




Financial

Penalties £

Chief Operating Officer Lynn Parkinson

Continued from page 1Executive Lead

Lynn Parkinson

Improve-ment

trajectory

The PI return presents the actual experienced waiting times for all Trust patients and the extent to which 95% are seen

within 18 weeks. The Trust's position as at Feb-18 is 91.4%, which is an increase of 0.8% of the previous month (Jan-18).

The subsequent data tables present the Trust's performance by the respective Clinical Commissioning Group (CCG) for Hull

and East Riding and a further table to represent the remaining CCGs.

The Hull CCG waiting times YTD figures shows red as falls below the 95% target.

RTT Experienced Waiting Times (Completed

Pathways)

88.0%

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%


Waiting Times Trustwide

% result

Target

Linear (% result)

Page 30 of 53

KPI Type

OP 21

5 6 7 8 9 10 11 12 13 14 15 16 23Trustwide Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

No. Waiting to

Commence10513 3927 4114 4007 4017 3881 3810 3922 3909 3690 3875 3662

No. Waiting less

than 18 weeks9289 3261 3501 3396 3358 3166 3102 3297 3318 3122 3309 3131

% Waiting less

than 18 Weeks88.4% 83.0% 85.1% 84.8% 83.6% 81.6% 81.4% 84.1% 84.9% 84.6% 85.4% 85.5%

Target/Plan 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92%

Hull CCG Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

No. Waiting to

Commence2020 1828 1822 1624 1681 1662 1698 1750 1877 1845 1952 1925

No. Waiting less

than 18 weeks1737 1522 1511 1319 1322 1284 1346 1438 1552 1522 1608 1578

% Waiting less

than 18 Weeks86.0% 83.3% 82.9% 81.2% 78.6% 77.3% 79.3% 82.2% 82.7% 82.5% 82.4% 82.0%

Target/Plan 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92%

East Riding CCG Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

No. Waiting to

Commence7721 1591 1589 1596 1448 1425 1322 1333 1338 1219 1239 1190

No. Waiting less

than 18 weeks6830 1268 1338 1369 1256 1209 1086 1110 1133 1030 1064 1034

% Waiting less

than 18 Weeks88.5% 79.7% 84.2% 85.8% 86.7% 84.8% 82.1% 83.3% 84.7% 84.5% 85.9% 86.9%

Target/Plan 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92%

Current

Month

86.9%

82.0%



RTT Unseen Waiting Times (Incomplete

Pathways)

Current

Month

85.5%

Current

Month

Referral to Treatment Unseen Waiting Times are based on patients who are yet to commence treatment but their care still remains open with the Trust. A

proportion of those patients may have already had an assessment of their need but are awaiting treatment to commence

Executive Lead

Lynn Parkinson

Page 31 of 53

Good

Performance

High

For the period ending: Feb 2018 BY EXCEPTION


Business Intelligence Commentary Richard Voakes

A full commentary on waiting times performance is included in this IPT.

RE9 provides detailed commentary on waiting times performance by Care Group.


Improvement

trajectory

Lynn ParkinsonChief Operating Officer

PI RETURN FORM 2017-18

This PI presents the unseen waiting times also called the 'incomplete pathway'. Information for this performance measure is taken at the end

of the month and indicates the number of patients who are waiting for assessment or for treatment to commence and how long they have

waited since they were referred into our services. The standard is 92%.

At the end of feb-18, the number of patients waiting for treatment was 3662, in which 85.5% have been waiting less than 18 weeks. This is

6.5% off plan, which is a slight upward trajectory/trend.


Pathways)Continued from page 1

Executive Lead

Lynn Parkinson

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%


Waiting Times less than 18 weeks

% result

Target

Linear (% result)

Page 32 of 53

KPI Type

OP 22

5 6 7 8 9 10 11 12 13 14 15 16 23Trustwide Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

No. Waiting to

Commence10513 3927 4114 4007 4017 3881 3810 3922 3909 3690 3875 3662

No. Waiting more

than 52 weeks43 10 9 13 12 12 13 18 14 15 10 6

% Waiting more

than 52 Weeks0.4% 0.3% 0.2% 0.3% 0.3% 0.3% 0.3% 0.5% 0.4% 0.4% 0.3% 0.2%

Target/Plan 0 0 0 0 0 0 0 0 0 0 0 0

2 3 4 5 6 7 8 9 10 11 12 13 14By Service Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18

Learning

Disabilities4 3 3 7 9 6 8 12 11 10 6 6

CAMHS 0 0 0 0 0 1 0 0 0 3 2 0

MH Specialist

Services0 1 1 0 0 1 2 3 3 2 2 0

Memory Services 1 2 1 0 0 0 2 1 0 0 0 0

Dept of

Psychological

Medicine

1 1 0 0 0 0 1 0 0 0 0 0

Adult MH 1 3 1 2 1 2 0 1 0 0 0 0

Vale of York

Community0 0 3 3 2 2 0 0 0 0 0 0

Paediatric

Therapy0 0 0 1 0 0 0 0 0 0 0 0

Health Trainers 0 0 0 0 0 0 0 0 0 0 0 0

Community

Hospitals0 0 0 0 0 0 0 0 0 0 0 0

OP CMHT 0 0 0 0 0 0 0 0 0 0 0 0

MH Assessment

Services0 0 0 0 0 0 0 0 0 0 0 0

Physiotherapy 0 0 0 0 0 0 0 0 0 0 0 0

Forensics 0 0 0 0 0 0 0 0 0 0 0 0

ASD 0 0 0 0 0 0 0 0 0 0 0 0

Lynn Parkinson

A full commentary on waiting times performance is included on this IPT.

OP23 provides detailed commentary on waiting times performance by Care Group.

Financial

Penalties £


Referral to Treatment Unseen Waiting Times are based on patients who are yet to commence treatment but their care still remains open with the Trust. A

proportion of those patients may have already had an assessment of their need but are awaiting treatment to commence

Executive Lead

Lynn Parkinson

Chief Operating Officer


Improve-ment

trajectory


Pathways) : 52 week waiters

Current

Month

0.2%

Page 33 of 53

No

KPI Type

OP 23

Adult Mental

Health

Community

Services

Specialist

Mental Health

Services

Department of

Psychological

Medicine

Older Peoples

Community

Services

East Riding

Memory

Services

Hull Memory

Service

Summary of the Chief Operating Officer's comments on each Care Group Executive Lead

Lynn Parkinson

As at 28th February 2018, 170 patients were on the waiting list for either assessment and/or treatment, of these 39 patients have been waiting for over 18 weeks from receipt of referral, which

is a reduction of 5 cases when compared to the Jan-18 position. Waiting list action plans are in place for both the Hull and East Riding Mental health teams, these plans are being monitored

regularly by the Care Group. No patients are waiting over 52 weeks.

As at 28th February 2018, 33 patients are currently on the waiting list for either assessment and/or treatment, of these 13 patients have been waiting for over 18 weeks from receipt of referral,

which is a reduction of 5 when compared to the Jan-18 position. Predominately the patients waiting more than 18 weeks are in Specialist Psychotherapy and the Trauma Service, the services

are currently under review by the Care Group. No patients are waiting over 52 weeks.

As at 28th February 2018, 222 patients are currently on the waiting list for either assessment and or treatment, of these 18 patients have been waiting for over 18 weeks from receipt of referral.

There are currently no patients waiting over 52 weeks at the end of Feb-18.

Mental Health Group (Care Group Director Jan Smith)

Waiting Times Context Summary



As at 28th February 2018, 236 patients are currently on the waiting list for either assessment and or treatment, of these 18 patients have been waiting for over 18 week from receipt of referral,

this is an increase of 9 when compared to Jan-18. There are currently no patients waiting over 52 weeks.

As at 28th February 2018, 86 patients are currently on the waiting list for assessment, of these 4 patients have been waiting for over 18 week from receipt of referral for an assessment. The

average wait for those patients currently awaiting assessment is 6.3 weeks, against the target of 8 weeks.

As at 28th February 2018, 92 patients are currently on the waiting list for assessment, with 4 patients waiting for over 18 week from receipt of referral. The average wait for those patients

currently awaiting assessment is 6.3 weeks, against the target of 8-12 weeks.

Page 34 of 53

No

KPI Type

OP 23Summary of the Chief Operating Officer's comments on each Care Group Executive Lead

Lynn ParkinsonWaiting Times Context Summary



As at 28th February 2018, 661 patients are currently on the waiting list for either assessment and or treatment, of these 144 patients have been waiting for over 18 weeks from receipt of

referral. There are currently no patients waiting over 52 weeks at the end of February 2018.

SPEECH & LANGUAGE THERAPY Waits over 18 weeks are reviewed by the Service Lead for Children’s Speech & Language Therapy in accordance with the Standard Operating Procedure as part

of the operational management arrangements; this includes the monitoring on a weekly basis through team meetings. Various strategies continue to be implemented to maximise capacity for

new referrals, e.g. triage clinics during school holidays to maximise capacity for school appointments in term time, caseload management meetings with all therapists termly in order to ensure

pathways are being followed, episodes of care implemented and group therapy opportunities maximised.

East Riding – currently there are 38 children waiting for an appointment who have waited over 18 weeks; 5 children have been offered an appointment and 33 children are still waiting for their

first face to face contact. The number of children waiting over 18 weeks has remained static over the last month. We have recently been successful in recruiting 1.0 WTE Band 5 who is

expected to be in post during March 2018.

Hull – there are currently 103 children waiting for an appointment over 18 weeks, which has remained static over the last month. Again, we have recently been successful in recruiting to 1.0

WTE Band 5 vacancy who we expect to be in post March 2018. In addition, there is 0.6 WTE maternity leave vacancy which is being partly covered by staff working additional hours.

We are delighted to have recruited to staff to these posts and have used social media and the recent Hear in Hull work as a platform.

Graduated response was launched at end of October 2017 in agreement with commissioners – parents, education and other professionals are being asked to complete a screening assessment

prior to referral. The referrer will indicate the results of the screening assessment as follows: green – no problem (referral rejected); amber – parents and other professionals sign-posted to

strategies, advice and training to help support the child or red – referral accepted. We will be reviewing and monitoring referrals received over the next 6 months to understand the impact on

referral rates and waiting times.

There was a meeting with Hull commissioners at the beginning of January 2018 following the recent Hull SEND inspection report. It has been recognised that there is insufficient capacity to

meet the demand for the SLT service. Hull CCG is liaising with Hull City Council to explore the possibility of some joint commissioning of the SLT service.

PHYSIOTHERAPY: Within Hull there are no children waiting beyond the 18 week wait.

Within East Riding there are currently 26 children on the waiting list. The referral for the child with the longest wait was received in August 2017 (20 weeks), the child was assessed in the triage

clinic in September 2017, has an appointment in January 2018, having been seen in orthotics and provided the relevant prescription following assessment.

Two further children in the Goole area have been offered an appointment in February 2018 (both of which have waited 19 weeks at December 2017); again, both have been seen in triage clinics

in September 2017 for initial assessment.

A further child is waiting for a one-off assessment to be seen in school (18 week wait currently) who will be offered an appointment in February 2018.

Due to internal recruitment the team currently have 1 WTE qualified post vacant and a senior member of the East Riding team who is on maternity, these are being covered by staff working

additional hours and/or bank staff in order to minimise the impact on waiting times.

Children's

Therapy

Services -

Speech and

Language

Therapy

Primary Care, Children, Learning Disabilities & Community Care Group (Care Group Director Julia Mizon)

Page 35 of 53

No

KPI Type





HULL CAMHS: As of the 28th February 2018 there are 63 young people over 18 weeks in Hull Core CAMHS service, which is an increase of 4 when compared to Jan-18. The deterioration in

waiting times relates to an increase of referrals to ADHD since CHCP ceased accepting referrals (June-17), and an increase in referrals to the Conduct pathway.

The Conduct pathway will be addressed by an increase in the Incredible Years Parenting Groups offered by CAMHS, and through integrated working with Hull City Council, who will also offer

Incredible Years groups. A replacement Senior Clinical Psychologist will be in post from January 2018 who will support the team to address the ADHD waiting list. We are in discussion with Hull

CCG to understand how we manage the increased demand for ADHD assessments within the CAMHS service.

The CCG recognises that the deterioration in waiting times is related to ADHD, and we are working closely with the commissioners.

ER CAMHS: The amended position is as follows, as at the 28th February 2018 there are 40 young people waiting over 18 weeks in East Riding Core CAMHS service, which is a reduction of 13

when compared to the reported position for Jan-18. The deterioration in waiting times continues to be related to the increase in referrals during the earlier part of the year; which was

highlighted at that time and in subsequent updates. The referral rates into ER CAMHS are exceeding 2016/17 levels.

The SMASH and MIND programmes are supporting the delivery of services against the current referral rates. A new SMASH programme started in January 2018, so the waiting times will improve

in a stepped manner through this service - the same applies to the conduct pathway with the Incredible Years parenting programme (18-week programme). The MIND counselling programme

will be available until 31 March 2018; an average of 11 young people (referrals) a week are being supported through this route.

All Conduct referrals are either under assessment or assessment is completed, which is an improvement on the reported position (data quality – see below). We are in discussion with ERoYC

with regard to them also supporting the Incredible Years programme.

Child and

Adolescent

Mental Health

(CAMHS)

Page 36 of 53

No

KPI Type





Learning

Disabilities

Whitby

Services

HULL: there are 79 patients on the waiting list for assessment and/or treatment, of these 42 patients have been waiting over 18 weeks from receipt of referral, which is an increase of 3 when compared to

January 2018.

EAST RIDING: there are 55 patients waiting for assessment and/or treatment, of which 18 patients have been waiting for over 18 weeks from receipt of referral, which is a reduction of six when compared to

January 2018.

During February a new Lorenzo activity recording glossary has been published to all clinical services which will aid/improve the quality of the data used to calculate accurate waiting times.

The Adult LD waiting lists reports are inflated due to inaccurate recording of contacts and closing down of referrals within the clinical system. The discrepancy is partly due to data accuracy issues that have

occurred in the transfer of information from SystmOne to Lorenzo. Though the majority of the discrepancy appears to be due to a lack of knowledge within the administrative and clinical team in the

Learning Disability Service as to how to mark their entries on Lorenzo so as to reflect the information that is needed to ensure they correctly show in the waiting list reports.

Work has begun with the Performance Team and the clerical and clinical team’s .A meeting was held on the 13/03/2018 to clarify what is required of the clinicians and administrators to ensure that access

plans data is captured accurately in the future.

The waiting list pressure for Learning Disability services has been raised with commissioners and piece of joint work between the commissioners and the service is currently underway to review capacity and

demand. The waiting list pressures are also reflected on the Care Group risk register.

A further analysis of the waiting times has been undertaken by Consultant Clinical psychologist Alex Hamlin who has reviewed the changing trends of LD referrals matched to the professional groups

In terms of the patients reported to be waiting over 52 weeks: There are none now waiting on the nursing case load. There are two service users who are waiting for Occupational Therapy interventions,

which have been deemed clinically necessary but not urgent. The Occupational Therapy team have made a significant turnaround in waiting times and have a clear prioritisation system in place. The same

applies to the two service users waiting for Psychology intervention in the East Riding.

WHITBY: There are 5 patients waiting over 18 weeks from referral. The number of people on the waiting list has remained largely static although there has been an increase in referrals – this is due to

improvements in the monitoring and management of waiting times using System1 in therapy services, daily review, triage and allocation by the integrated NCS team and the additional capacity provided by

the newly appointed continence specialist.

There continue to be vacancies and absence through long term sickness which impact on the overall capacity to manage the demand/need which is being addressed through recruitment, use of bank staff

where possible and the application of the revised absence policy.

Page 37 of 53

No

KPI Type





Vale of York

Services

Health Trainers

The Pocklington/Vale of York team is relatively small and consists of nursing and specialist therapy posts - there has been a significant impact of sickness absence since December 2017 arising

from emergency or urgent surgery. This has impacted detrimentally in terms of waiting times in such a small team. There continues to be on-going work to validate the waiting lists and prioritise

referred patients; the newly appointed team leader is spending more time working clinically whilst reviewing caseloads and supporting increased patient flow.

The increase of numbers of people on the waiting list is as a result of the newly commissioned North Yorkshire Weight Management service, received during December 2017 ahead of the

service mobilising for delivery from January 2018. The service is now active with all the referrals being placed in a group to commence treatment.

A process on continuing data validation and correction is on-going to ensure that the waiting times and lists are accurate.

Page 38 of 53

Strategic Change

Ensure every area has a clinically, operationally and financially sustainable pattern of care

Strategy

Page 39 of 53

Feb 2018

Strategic Change

Ensure every area has a clinically, operationally and financially sustainable pattern of care

SCORECARD


Strategic Change

Admissions of under 18s LD Greenlight

Toolkit

Access to Healthcare for people with a Learning Disability (quarterly)

Page 40 of 53

Indicators

1 0 1 0


ST 1

a Admission of patients under 18 to adult

wards

0 Weak

Mth

ly

1 2 2 5 1 0 1 2 0 2 1 3 2 1 1

ST 2 Best practice in Mental Health for people

with Learning Disability n/a Good

Mth

lyGreen Green Green Green Green Green Green Green Green Green Green Green Green Green Green

SOF Domains Strategic Goals Safer Staffing Thresholds have been revisedQuality 1 Red <75%Finance 2 Amber 75-90%

Performance 3 Green >90%Strategy 4Leadership 5

6

En

try


Thre

sho

ld /

Targ


Definition

Freq

uenc

y Quarter 1 Quarter 2 Quarter 3

Feb-18

Quarter 4As At

Month End

Strategic Change

2 Period Ending:

Contract Period 2017-18Issue Date 21 March 2018

Regulator NHS Improvement

Provider Lead Humber NHS Foundation Trust

Monthly KPI Assurance Levels : Safe


(RAG only)Within Target Within Tolerance Outside Target

Under Review/

Note Rated

Quarter Ending: Q3


Innovating quality and patient safetyEnhancing prevention, wellbeing and recovery

Fostering integration, partnership and alliancesDeveloping an effective and empowered workforceMaximising an efficient and sustainable organisation

Page 41 of 53

KPI Type

ST 1a

5 6 7 8 9 10 11 12 13 14 15 16 23Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Avg

Activity 1 2 2 1 0 1 0 2 1 2 1Target/Plan 0 0 0 0 0 0 0 0 0 0 0 0

Variance to plan 1 2 2 1 0 1 0 2 1 2 1

ST 1b

3 4 5 6 7 8 9 10 11 12 13 14 21Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD

Activity 0 0 1 0 0 0 0 0 0 0 0Target/Plan 0 0 0 0 0 0 0 0 0 0 0 0

Variance to plan 0 0 1 0 0 0 0 0 0 0 0

High

Run Date:

£

Admission Summary

0



Number of patients aged under 18 who were admitted to an adult ward

As a proportion of the numbers admitted above, how many patients were aged 16 or under at the time of admission

Executive Lead

Lynn Parkinson

Executive Lead

Lynn Parkinson

Admissions of under 18s to adult wards

1

Admissions of under 16s to adult wards

Business Intelligence Commentary Performance ManagementGood

Performance

Patient was admitted to the ward following an overdose and voicing concerns around being unable to keep themselves safe.

There were issues around an increase in risk should they not be admitted due to the patient continuing to express suicidal

thoughts and plans to end their life should they return to their home address. They were discharged two days later following an

out of area bed being sourced. Improvem

ent Trajectory

Data Source: Lorenzo 03/03/2018

Operational Service Commentary Lynn Parkinson Financial

Penalties £

As there is no Inpatient provision with Humber, patients aged under 18 are admitted to one of two wards within the Trust until

a suitable CAMHS In-patient placement is identified. Mill View Court is the designated admission unit for males and Westlands

is the designated admission unit for females. Appropriate placements are sought as a matter of urgency.

Service Lead

0

1

2

3


Admissions of Under 18s and Under 16s

Under 18 Under 16

Page 42 of 53

Building capability to deliver sustainable services

Leadership and Improvement Capability

Lead

ersh

ip

Page 43 of 53

Feb 2018SCORECARD


Leadership and Improvement Capability

Building capability to deliver sustainable services

Leadership and Improvement

Overall Training Sickness

Primary Care Training

Research and Development

PADRs

Turnover

Clinical Supervision

Page 44 of 53

Indicators

18 7 1 3


WL

1

Percentage of Sickness Absence

5.2

%

Good

Mth

ly

5.0% 4.8% 5.1% As at June 5.1% 4.8% 5.9% As at Sept 5.5% 5.1% 4.7%As at

Dec4.5% 5.1%

As at

Mar5.1%

WL

1 ro

lling

Sickness Absence Rolling 12 months5

.2%

Fair

Mth

ly

5.4% 5.3% 5.3% n/a 5.3% 5.4% 5.5% n/a 5.5% 5.5% 5.5% n/a 5.4% 5.4%

WL

3 TO

M

Staff Turnover as at month end

0.8

%

Good

Mth

ly

1.6% 1.4% 0.9% 0.9% 4.4% 1.3% 1.7% 1.7% 1.2% 0.7% 1.3% 1.3% 0.9% 0.6% 0.6%

WL

4 (i)

Percentage of Appraisals Completed

85

.0%

Fair

Mth

ly

78.8% 83.0% 80.6% 80.6% 79.9% 77.3% 78.4% 78.4% 80.8% 79.7% 81.1% 81.1% 83.6% 83.1% 83.1%

WL

4 (ii

) Percentage of Appraisals Completed for

staff whose employment exceeds 12

months 85

.0%

Fair

Mth

ly

no data 83.6% 82.8% 82.8% 82.8% 80.5% 80.5% 80.5% 84.2% 82.2% 83.5% 83.5% 85.5% 84.9% 84.9%

WL

9a Percentage of staff with appropriate Clinical

Supervision 80

.0%

Fair

Mth

ly

74.9% 73.2% 67.7% 67.7% 64.4% 69.8% 70.0% 70.0% 71.0% 72.8% 73.4% 73.4% 81.2% 75.5% 75.5%

WL

9b Percentage of teams with Clinical

Supervision Structure in place 80

.0%

Good

Mth

ly

95.7% 98.1% 96.8% 96.8% 98.4% 100.0% 97.6% 97.6% 97.5% 96.3% 98.7% 98.7% 100.0% 100.0% 100.0%

WL

5

Trust Overall Training Compliance

75

.0%

Good

Mth

ly

73.2% 74.1% 75.8% 75.8% 77.5% 79.4% 78.5% 78.5% 78.7% 80.8% 83.3% 83.3% 84.7% 85.7% 85.7%

WL

5a Control of Substances Hazardous to Health

(COSHH) 75

.0%

Good

Mth

ly

78.2% 79.6% 82.4% 82.4% 85.2% 86.4% 85.2% 85.2% 85.5% 86.0% 87.9% 87.9% 88.6% 89.2% 89.2%

WL

5b

Managing Conflict

75

.0%

Good

Mth

ly

75.1% 75.7% 76.9% 76.9% 79.5% 81.3% 75.3% 75.3% 76.7% 80.6% 84.7% 84.7% 84.3% 85.9% 85.9%

WL

5d (t

)

MAPA Overall

75

.0%

Fair

Mth

ly

50.3% 52.0% 55.9% 55.9% 54.5% 56.1% 56.5% 56.5% 59.3% 59.9% 59.6% 59.6% 63.5% 68.6% 68.6%

WL

5e

Display Screen Equipment (DSE)

75

.0%

Good

Mth

ly

70.8% 72.0% 73.6% 73.6% 76.9% 77.5% 76.4% 76.4% 75.0% 80.0% 84.0% 84.0% 85.9% 87.0% 87.0%

WL

5f

Equality & Diversity

75

.0%

Good

Mth

ly

71.1% 72.7% 75.5% 75.5% 78.4% 79.5% 80.8% 80.8% 81.5% 83.4% 85.2% 85.2% 85.9% 86.6% 86.6%

WL

5h (t

)

Fire

75

.0%

Good

Mth

ly

78.4% 79.1% 79.2% 79.2% 78.6% 79.0% 77.9% 77.9% 76.8% 77.4% 80.7% 80.7% 83.0% 83.5% 83.5%

WL

5i

Health & Safety

75

.0%

Good

Mth

ly

85.3% 85.5% 86.3% 86.3% 88.1% 88.9% 87.4% 87.4% 87.2% 88.7% 89.9% 89.9% 91.2% 91.2% 91.2%

WL

5k (t

)

Infection Control

75

.0%

Good

Mth

ly

72.9% 73.0% 73.9% 73.9% 77.6% 80.6% 78.8% 78.8% 79.4% 84.4% 87.3% 87.3% 89.1% 90.1% 90.1%

WL

5l

Information Governance (IG)

95

.0%

Fair

Mth

ly

63.6% 66.0% 73.4% 73.4% 78.1% 78.5% 75.8% 75.8% 77.5% 80.1% 85.4% 85.4% 88.0% 89.9% 89.9%

WL

5n (t

)

Mental Capacity Act (MCA)

75

.0%

Good

Mth

ly

84.4% 83.9% 84.0% 84.0% 84.5% 84.5% 82.9% 82.9% 82.7% 85.0% 87.0% 87.0% 88.1% 88.1% 88.1%

WL

5p (t

)

Moving & Handling

75

.0%

Good

Mth

ly

68.5% 72.3% 73.6% 73.6% 75.6% 78.5% 77.2% 77.2% 76.5% 78.8% 80.8% 80.8% 83.0% 83.5% 83.5%

WL

5r (t

)

Prevent

75

.0%

Good

Mth

ly

83.5% 83.4% 84.0% 84.0% 84.9% 94.1% 92.2% 92.2% 90.9% 91.9% 92.5% 92.5% 92.1% 92.1% 92.1%

Freq

uenc

y Quarter 1 Quarter 2 Quarter 3 Quarter 4As at

Month End




En

try


Leadership and Improvement (Training EXCLUDES Primary Care Practices)

Thre

sho

ld /

Targ

et

Monthly KPI Assurance Levels : Well Led


(RAG only) Within TargetWithin

ToleranceOutside Target

Under Review/

Not Rated

26Quarter Ending: Q3

Period Ending: Feb-18 Issue Date 21 March 2018

Current month RAG

Definition

n/a

Page 45 of 53

Indicators

18 7 1 3

Apr-17 May-17 Jun-17 Q1 Jul-17 Aug-17 Sep-17 Q2 Oct-17 Nov-17 Dec-17 Q3 Jan-18 Feb-18 Mar-18 Q4Freq

uenc

y Quarter 1 Quarter 2 Quarter 3 Quarter 4As at

Month End




En

try


Leadership and Improvement (Training EXCLUDES Primary Care Practices)

Thre

sho

ld /

Targ

et

Monthly KPI Assurance Levels : Well Led


(RAG only) Within TargetWithin


Under Review/

Not Rated

26Quarter Ending: Q3


Current month RAG

Definition

WL

5t (t

)

Basic Life Support (BLS)

75

.0%

Weak

Mth

ly

34.7% 36.1% 38.2% 38.2% 41.1% 42.6% 47.7% 47.7% 51.7% 56.5% 55.7% 55.7% 58.0% 61.0% 61.0%

WL

5u

Immediate Life Support (ILS)7

5.0

%

Fair

Mth

ly

66.1% 64.8% 61.0% 61.0% 50.6% 52.8% 67.9% 67.9% 68.5% 66.2% 69.5% 69.5% 71.0% 72.7% 72.7%

WL

5x (t

)

Adult Safeguarding

80

.0%

Good

Mth

ly

81.3% 83.8% 81.7% 81.7% 82.9% 85.9% 83.4% 83.4% 84.0% 85.6% 89.0% 89.0% 90.0% 90.7% 90.7%

WL

5aa

(t)

Children Safeguarding

80

.0%

Good

Mth

ly

73.3% 73.9% 74.6% 74.6% 76.7% 78.9% 77.8% 77.8% 76.7% 77.6% 81.7% 81.7% 82.9% 84.6% 84.6%

WL

5ab

Mental Health Act (MHA)

75

.0%

Good

Mth

ly

78.4% 80.3% 80.0% 80.0% 76.0% 76.9% 76.2% 76.2% 77.5% 77.0% 80.1% 80.1% 81.6% 84.7% 84.7%

WL

7

Staff Flu Vaccination Uptake (Trustwide) n/a ## Not Rated

Mth

ly

30.7% 40.8% 48.0% 48.0% 58.1% 60.9% 60.9%

Research and Development Target 55 110 165 As at June 220 275 330 As at Sept 385 440 495As at

Dec550 605 660

As at

Mar660

WL

8 Research and Development -

Recruitment of Patients on Studies 10

0.0

%

Good

Mth

ly

138.2% 145% 134% 134% 141% 121% 131% 131% 143% 154% 156% 156% 168% 159% 159%

WL

8b Research and Development - Total

Recruitment (within MTH/QTR)

66

0 /

yr

Not Rated

Mth

ly

76 83 62 62 90 23 99 99 116 127 96 96 151 40 40

WL

8a Research and Development - Recruitment

(YTD cummulative) n/a 76 159 221 221 311 334 433 433 549 676 772 772 923 963 963


Quality 1 Training : Amber RAG rating based on 10% leewayFinance 2Performance 3Strategy 4Leadership 5

6

Achievement

month to date

Data provided October to February. March shown to complete year


Innovating quality and patient safetyEnhancing prevention, wellbeing and recoveryFostering integration, partnership and alliancesDeveloping an effective and empowered workforceMaximising an efficient and sustainable organisation

Page 46 of 53

Indicators

13 1 1 7


GPW

L 5

Overall Training Compliance7

5.0% Good

Mth

ly

60.7% 60.3% 61.4% 61.4% 65.8% 74.0% 77.0% 77.0% 76.5% 75.7% 80.6% 80.6% 82.0% 83.9%See

Monthend

GPW

L 5a Control of Substances Hazardous to Health

(COSHH) 75.

0% Good

Mth

ly

48.2% 47.6% 50.6% 50.6% 59.6% 75.3% 75.9% 75.9% 73.9% 69.8% 79.6% 79.6% 78.5% 87.1%See

Monthend

GPW

L 5b

Managing Conflict

75.

0% Good

Mth

ly

61.5% 63.5% 66.7% 66.7% 70.7% 79.7% 81.6% 81.6% 81.8% 83.3% 88.2% 88.2% 86.0% 87.1%See

Monthend

GPW

L 5e

Display Screen Equipment (DSE)

75.

0% Good

Mth

ly

53.9% 53.3% 58.4% 58.4% 67.1% 72.3% 76.5% 76.5% 75.6% 75.8% 81.8% 81.8% 83.0% 85.2%See

Monthend

GPW

L 5f

Equality & Diversity

75.

0% Good

Mth

ly

61.0% 59.3% 60.5% 60.5% 65.2% 67.4% 72.4% 72.4% 71.6% 72.9% 79.6% 79.6% 82.8% 82.8%See

Monthend

GPW

L 5h

(t)

Fire

75.

0% Good

Mth

ly

58.5% 58.0% 57.1% 57.1% 61.4% 78.4% 81.4% 81.4% 79.3% 82.3% 82.8% 82.8% 84.9% 86.0%See

Monthend

GPW

L 5i

Health & Safety

75.

0% Good

Mth

ly

69.5% 69.1% 67.4% 67.4% 70.8% 71.9% 74.7% 74.7% 75.0% 78.1% 86.0% 86.0% 87.1% 86.0%See

Monthend

GPW

L 5k

(t)

Infection Control

75.

0% Good

Mth

ly

69.5% 70.4% 68.6% 68.6% 70.8% 78.7% 80.5% 80.5% 83.0% 84.4% 87.1% 87.1% 91.4% 90.3%See

Monthend

GPW

L 5l

Information Governance (IG)

95.

0% Fair

Mth

ly

67.1% 67.9% 72.1% 72.1% 77.5% 78.7% 79.3% 79.3% 75.0% 80.2% 89.2% 89.2% 84.9% 90.3%See

Monthend

GPW

L 5n

(t)

Mental Capacity Act (MCA)

75.

0% Good

Mth

ly

70.7% 71.6% 68.6% 68.6% 70.8% 74.2% 66.7% 66.7% 69.0% 73.3% 73.8% 73.8% 73.2% 83.3%See

Monthend

GPW

L 5p

(t)

Moving & Handling

75.

0% Good

Mth

ly

59.8% 59.3% 61.6% 61.6% 64.0% 67.4% 72.4% 72.4% 73.9% 76.0% 79.6% 79.6% 83.9% 84.9%See

Monthend

GPW

L 5r

(t)

Prevent

75.

0% Good

Mth

ly

58.5% 58.5% 57.5% 57.5% 61.8% 84.3% 88.5% 88.5% 85.2% 74.0% 78.5% 78.5% 78.5% 80.6%See

Monthend

GPW

L 5t

(t)

Basic Life Support (BLS)

75.

0% Weak

Mth

ly

33.3% 31.4% 37.8% 37.8% 42.5% 60.0% 59.2% 59.2% 61.4% 55.7% 63.0% 63.0% 64.8% 61.2%See

Monthend

GPW

L 5x

(t)

Adult Safeguarding

80.

0% Good

Mth

ly

70.7% 72.2% 69.8% 69.8% 76.4% 79.8% 82.8% 82.8% 81.8% 70.8% 72.0% 72.0% 76.3% 80.6%See

Monthend

GPW

L 5a

a (t)

Children Safeguarding

80.

0% Good

Mth

ly

51.2% 48.1% 51.2% 51.2% 51.7% 62.5% 77.9% 77.9% 77.3% 78.1% 79.6% 79.6% 83.9% 81.7%See

Monthend


Quality 1Finance 2Performance 3Strategy 4Leadership 5

6

Monthly Training Assurance Levels : GP Practices


(RAG only)Within Target

Within


Under Review/

Not Rated



15



Quarter Ending: Q3

En

try


Thre

sho

ld /

Targ


Definition

Quarter 3 Quarter 4

YTD

Leadership and Improvement - Training - Primary Care

Freq

uenc

y Quarter 1 Quarter 2


Innovating quality and patient safetyEnhancing prevention, wellbeing and recoveryFostering integration, partnership and alliancesDeveloping an effective and empowered workforceMaximising an efficient and sustainable organisation Page 47 of 53

KPI Type

WL 5t (t)

5 6 7 8 9 10 11 12 13 14 15 16 23As at

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Month end

Activity 34.7% 36.1% 38.2% 41.1% 42.6% 47.7% 51.7% 56.5% 55.7% 58.0% 61.0%

Target/Plan 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75%

Variance to plan -40.3% -38.9% -36.8% -33.9% -32.4% -27.3% -23.3% -18.5% -19.3% -17.0% -14.0%

Staff No. Completed ComplianceGood

Performance

574 335 58.4%2

High

36 29 80.6%3

599 358 59.8%4

122 90 73.8%5

Improvement Trajectory

6

1331 812 61.0%7

Run Date:

Solution to correct/mitigate against the under-performance Date StatusOwner

Deputy Director of Human Resources Julie Hall Business Intelligence Debby Shaw

BLS training has increased this month as training opportunities continue to be provided . The training team

continue to identify opportunities to increase attendance on the training sessions and to support this, the

Personal & Team Safety training refresher will include BLS training. A review is currently taking place into

where there are areas of non-compliance.

Data Source: ESR 09/03/2018

For February - Of the 328 inpatient staff, 221 were compliant compared to 591 staff compliant from the remaining 1003.

There are NO Paediatric BLS results for inpatient units.

Total

Mandatory Training - BLS A percentage compliance based on an overall target of 75% for all mandatory and statutory coursesExecutive Lead

Elizabeth Thomas

338 Corporate (Division)

338 Primary Care, Community, Children's and LD Services (Division)

338 Specialist Services (Division)

61.0%

338 Mental Health Services (Division)



55.7% 58.0% 61.0% 59.3%

62.4% 67.4%

54.5% 56.5% 58.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%


Mandatory Training - BLS overall

All Services Inpatient Only Others Target

Page 48 of 53

KPI Type

WL 7

5 6 7 8 9 10 11 12 13 14 15 16 23Table 1 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD

Activity no data no data no data no data no data no data 30.7% 40.8% 48.0% 58.1% 60.9%

Target/Plan no data no data no data no data no data no data n/a n/a n/a n/a 70%

Variance to plan 9.1%Current Month:

Feb-18 % Uptake

All doctors 69.0%

GPs only 53.3%

Nurses (exc GP practices) 46.0%

Nurses (inc GP practices) 20.0%

Other qualified 63.1%

Support to Clinical 80.4%

Support to GP 47.7%

High

£ 59,000


Feb-18 Open

Breakdown of Staff Groups targeted



Staff Uptake of Flu Vaccination Number of Front Line Health Care Workers in Post and Number Vaccinated by Occupational GroupExecutive Lead

Elizabeth Thomas

Collection Ended

All Doctors (excluding GPs)

GPs Only

60.9%

71 49

15 8

Staff in Post Vaccination Uptake

726 334

5 1

Qualified Nurses, midwives and health visitors (excluding GP Practice Nurses)

Qualified Nurses, midwives and health visitors (GP Practice Nurses only)

Support to GP staff

Number of HCWs NOT involved with Direct Patient Care

325 205

551 443

All other profesionally qualified clinical staff, which comprises of:-

* Qualified scientific, therapeutic & technical staff (ST&T),

* Qualified allied health professionals (AHPs),

* Other qualified ST&T,

* Qualified ambulance staff

Support to Clinical Staff, which comprises of:-

* Support to doctors (excluding GPs) & nurses

* Support to ST&T staff

* Support to ambulance staff

Good

Performance

Incentive

Payment

65 31

90

Business Intelligence LeadDebby Shaw

This years campaign are a significant improvement from previous years. The Trust did not manage to hit the highest threshold for CQUIN payment but will get 50% of the value (approx. £29500 out of £59000). Next year’s top threshold is increasing from 70% to 75% so there will need to be a further improvement again to reach this level. The Occupational Health Service have continually promoted opportunities for staff to have the vaccination, carried out a number of clinics and drop in session on the units. Following the success of this year, the flu vaccination group will reconvene to to plan the 2018/2019 campaign using peer vaccinators across the Trust.

Data is collected September to February with reporting beginning at the end of October. It is accumulated until collection period ends in February with a national target of 70%.

The February data based on national returns will be available early April.

Julie Hall/Chris Rounce

Improve-ment

10/03/2018Entry Date Operational Commentary

Ensure all completed vaccincations within GP practices have been communicated to Occupational Health for data collection Jon Duckles

Owner

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

All

do

cto

rs

GP

s o

nly

Nu

rse

s (e

xc G

Pp

ract

ice

s)

Nu

rse

s (i

nc

GP

pra

ctic

es)

Oth

er q

ual

ifie

d

Sup

po

rt t

o C

linic

al

Sup

po

rt t

o G

P

% Uptake - Oct 17 to Feb 18

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

How We Compare (previous month end)

England Regional Yorks/Humber HFTFlu Vaccination Update across the UK 2016/17

(Humber shown as the red bar)

As at Jan 2016-17

As at Jan 2017-18

Page 33

Page 49 of 53

updated Oct-17

Target Set By Target Threshold Amber RAG Red RAG Frequency

QU 1 Patient Carer Experience - Patient Friends and Family Test NHSI >=90% <90% <85% Mthly

QU 2 Patient Carer Experience - Core Question Satisfaction NHSI >=90% <90% <85% Mthly

QU 3 Patient Carer Experience - Compliments received Local Mthly

QU 4 Patient Carer Experience - Complaints responded to (upheld) NHSI <25% undefined >25% Mthly

QU 5 Clinical Risk - Incidents and Harm n/a n/a n/a n/a Mthly

QU 6 Clinical Risk - Patient Mortality n/a n/a n/a n/a Mthly

QU 7 Clinical Risk - Infection Control National variable variable variable Mthly

QU 8 Clinical Risk - Safer Staffing Dashboard (Collective of indicators for inpatients) National variable variable variable Mthly

QU 9 Clinical Effectiveness - Audit narrative n/a n/a n/a n/a Mthly

QU 10 Learning - Quarterly briefing paper n/a n/a n/a n/a Quarterly

F 1 Finance : Bank, agency and overtime spend Local reduced spend undefined > spend Mthly

F 2 Scoring Local <=2 >2 >2 Mthly

F 3 Finance : Budget position against plan Local on plan off plan off plan Mthly

F 4 PbR : Clustering of Patients NHSE (Quality Standards) >=95% <95% <85% Mthly

F 5 PbR : Cluster Reviews NHSE (Quality Standards) >=95% <95% <85% Mthly

CQUIN 1 Hull & East Riding Mental Health and Community Services basket n/a 81% n/a n/a Quarterly

CQUIN 2 Secured Services basket n/a 81% n/a n/a Quarterly

CQUIN 3 Hambelton, Richmondshire, Whitby n/a 81% n/a n/a Quarterly

OP 1 Emergency readmissions - Mental Health NHSI <=10% undefined >10% Mthly

OP 2 Bed Occupancy : Specialist Commissioning >=90% undefined <90% Mthly

OP 3 Bed Occupancy : Mental Health RCP benchmark 83-87%87-90%

80%-83%

<80%

>90%Mthly

OP 4 Bed Occupancy : Children's and Learning Disability Services RCP benchmark 83-87%87-90%

80%-83%

<80%

>90%Mthly

OP 5 Bed Occupancy : Older People's Services RCP benchmark 83-87%87-90%

80%-83%

<80%

>90%Mthly

OP 6 Bed Occupancy : Whitby Hospital Local 83-87%87-90%

80%-83%

<80%

>90%Mthly

Fin

an

ace

GLOSSARY Integrated Quality and Performance Tracker

Indicator Title

Qu

alit

y

The index below lists the current indicator code, indicator title, the RAG thresholds and the frequency of reporting.

The Glossary will be updated regularly and 'retired' indicators listed at the end.

Op

era

tio

na

l Per

form

ance

DO

MA

IN

Indicator

Page 50 of 53

Target Set By Target Threshold Amber RAG Red RAG Frequency

OP 7 CPA Reviews NHSI >=95% undefined <95% Mthly

OP 8 Patients having had access to Crisis service on admission (Gate-keeping) NHSI >=95% undefined <95% Mthly

OP 9 Early Intervention in Psychosis - First treatment within two weeks NHSI >=50% <50% <45% Mthly

OP 10a Improving Access to Psychological Therapies (IAPT) - 6 weeks NHSI >=75% <75% <70% Mthly

OP 10b Improving Access to Psychological Therapies (IAPT) - 18 weeks NHSI >=95% <95% <90% Mthly

OP 11 IAPT - Moving to Recovery NHSI >=50% undefined <50% Mthly

OP 12 Patients on CPA receiving 7 day follow up after discharge NHSI >=95% undefined <95% Mthly

OP 13a Community Hospitals Referral to Treatment - non admitted NHSI >=90% undefined <90% Mthly

OP 13b Community Hospitals Referral to Treatment - incomplete pathways NHSI >=92% undefined <92% Mthly

OP 13c Total time in A&E NHSI >=95% undefined <95% Mthly

OP 14 Delayed Transfers of Care (Patients whose transfer has been delayed) NHSI <=7.5% undefined >7.5% Mthly

OP 15 Mental Health Data Completeness : Patient Identifiers NHSI >=95% undefined <95% Mthly

OP 16 Mental Health Data Completeness : Patient Priorities NHSI >=85% undefined <85% Mthly

OP17 Diagnostics Suspended 99% undefined <99% Mthly

OP 18 Attrition rates for breastfeeding at 6-8 weeks Variable <=11.5% undefined >11.5% Yearly

OP 19a Human Papillomavirus (HPV) immunisation : Dose 1 (March to July only) Local Authority variable/mth < aprox 10% > 10% Yearly

OP 19b Human Papillomavirus Immunisation (HPV) : Dose 2 (March to July only) Local Authority variable/mth < aprox 10% > 10% Yearly

OP 20 Waiting List Variable Low n/a n/a Mthly

OP 21 Waiting Times <18 weeks Variable <18 weeks n/a n/a Mthly

OP 22 Waiting Times <52 weeks Variable <52 weeks n/a n/a Mthly

OP 23 Waiting Times Summary n/a n/a n/a n/a Mthly

ST 1 Admissions of Patients under 18 to adult units n/a n/a n/a n/a Mthly

ST 2 Best practice in Mental Health for People with Learning Disabilities NHSI Met undefined Not Met Mthly

ST 3 Access to Healthcare for people with a Learning Disability NHSI Met undefined Not Met Quarterly

Indicator TitleO

pe

rati

on

al P

erfo

rman

ceSt

rate

gyIndicator

Page 51 of 53

Indicator Name Threshold Amber RAG Red RAG Frequency

WL 1 Sickness absence Local <=5.2% <6.0% >6.0% Mthly

WL 2 Staffing Establishment and Vacancies undefined undefined undefined undefined Mthly

WL 3 Staff Turnover - per month and rolling 12 months undefined 10% per 12m undefined undefined Mthly

WL 4 PADR completion Local >=85% <85% <80% Mthly

WL 5a Mandatory Training : Control of Substances Hazardous to Health (COSHH) Local >=75% <75% <65% Mthly

WL 5b Mandatory Training : Managing Conflict Local >=75% <75% <65% Mthly

WL 5cd Mandatory Training : MAPA - Level 1 and 2 Local >=75% <75% <65% Mthly

WL 5i Mandatory Training : Health and Safety Local >=75% <75% <65% Mthly

WL5 jk Mandatory Training : Infection Control - Level 1 and 2 Local >=75% <75% <65% Mthly

WL 5op Mandatory Training : Moving and Handling - Level 1 and 2 Local >=75% <75% <65% Mthly

WL 5vw Mandatory Training : Safeguarding Adults (POVA) - Level 1 and 2 CQC >=80% <80% <70% Mthly

WL 5yz aa Mandatory Training : Safeguarding Children (POVC) - Level 1, 2 and 3 CQC >=80% <80% <70% Mthly

WL 5 gh Mandatory Training : Fire - Level 1 and 2 Local >=75% <75% <65% Mthly

WL 5i Mandatory Training : Information Governance NHSI >=95% <95% <85% Mthly

WL 5mn Mandatory Training : Mental Capacity Act (MCA) - Level 1 and 2 Local >=75% <75% <65% Mthly

WL 5qr Mandatory Training : PREVENT - Awareness and Level 3 Local >=80% <80% <70% Mthly

WL 5st Mandatory Training : Basic Life Support - Adult and Paediatrics Local >=75% <75% <65% Mthly

WL 5u Mandatory Training : Immediate Life Support Local >=75% <75% <65% Mthly

WL 5e Mandatory Training : Display Screen Equipment (DSE) Local >=75% <75% <65% Mthly

WL 5f Mandatory Training : Equality & Diversity Local >=75% <75% <65% Mthly

WL 5ab Mandatory Training : Mental Health Act Local >=75% <75% <65% Mthly

GP WL 5 Mandatory Training : All Primary Care GP Practices Local >=75% <75% <65% Mthly

WL 6 Friends and Family Test - Staff Local >=90% <90% <85% Quarterly

WL 7 Uptake of Staff Flu Vaccination Programme - Trustwide (Sept to February Only) National 0 0 0 Mthly

WL 8 Research and Development - Recruitment to Studies NIHR CRN >=100% none set none set Mthly

WL 9a Clinical Supervision - Percentage of Staff receiving supervision within 4-6 weeks Local >=80% <80% <75% Mthly

WL 9b Clinical Supervision - Percentage of teams with clinical structure in place Local >=80% <80% <75% Mthly

Wo

rkfo

rce

and

Le

ade

rsh

ipIndicator

Page 52 of 53

Issue Date: 21/03/2018

Julia Harrison-MizonJan Smith

Tracy FlanaganMental Health Services:

Specialist Services:

Primary Care, Community, Children's and Learning Disability Services:

Page 1 Caring, Learning and Growing

Agenda Item: 14


Title of Report: Finance Report 2017/18: Month 11 (February)

Author:

Name: Peter Beckwith Title: Director of Finance

Recommendation:

To approve To note X



Purpose of Paper:

The report provides the Board with an update of the financial position of the Trust at Month 11


A surplus position of £0.582m was recorded to the 28th February

2018, this is consistent with the financial plan submitted to NHS Improvement (NHSI) and is inclusive of £1.264m Sustainability and Transformation funding (STF) income.

Expenditure for clinical services was higher than plan by £3.611m year to date which is mainly due to higher staff costs.

The year to date Trust Capital expenditure is £2.597m. The Trust has revised the forecast capital expenditure to £4.539m for the year, reducing the CAMHS project due to the funding delay.

The planned level of Cost Improvement Programme (CIP) for 2017-18 is £5.200m. £3.010m of savings has been achieved year to date, this is below the planned level of savings (£4.462m),

The cash balance decreased slightly in the period to £7.25m.

On the NHS Improvement (NHSI) return the use of resources metric is 2.











N/A Comment


Risk √ To be advised of any

Legal √ To be advised of any


Compliance √ future implications

Communication √ reports as and when

Financial √ future implications

Human Resources √ by Lead Directors

IM&T √ through Board

Users and Carers √ required



No


FINANCE REPORT – February 2018 1. Introduction

This report summarises the financial position for the Trust as at the 28th February 2018

2. Income and Expenditure

The Trust reported a surplus position of £0.089m for the month of February and a year to date surplus of £0.582m, which is consistent with the NHS Improvement (NHSI) control total. The reported position is inclusive of 11 months Sustainability and Transformation Funding (STF) of £1.264m.

The income and expenditure position at 28th February 2018 is shown in the summarised table below:

Table 1: 2017/18 Income and Expenditure Summary

Budget

£000s

Actual

£000s

Variance

£000s

Budget

£000s

Actual

£000s

Variance

£000s

Income (112,385) (9,241) (9,923) (682) (103,068) (104,922) (1,854)

(112,385) (9,241) (9,923) (682) (103,068) (104,922) (1,854)

Expenditure

Clinical Services

Childrens, Learning Disability & Primary Care 32,542 2,571 2,840 269 30,012 32,089 2,077

Specialist Services 11,186 962 966 4 10,334 10,459 125

Adult Mental Health Services 35,843 2,964 3,242 278 32,857 34,266 1,409

79,571 6,497 7,047 551 73,203 76,813 3,611

Corporate Services

Chief Executive 1,931 136 182 47 1,796 1,696 (100)

Chief Operating Officer 4,678 407 431 24 4,266 4,206 (60)

Finance 14,684 1,197 1,575 378 13,492 14,015 522

HR 3,196 280 244 (35) 2,917 2,945 28

Director of Nursing 3,376 278 302 23 3,098 3,444 346

Finance Technical items 619 44 6 (38) 485 (1,004) (1,490)

Reserves / CIPs not yet allocated (108) (23) (35) (12) (683) (877) (194)

28,377 2,318 2,705 387 25,371 24,425 (946)

Total Expenditure 107,948 8,814 9,752 938 98,574 101,239 2,665

EBITDA (4,437) (426) (170) 256 (4,494) (3,684) 811

Depreciation 2,732 231 233 1 2,546 2,699 154

Interest 198 17 17 - 182 162 (20)

PDC Dividends Payable 2,000 167 - (167) 1,833 1,667 (167)

Exceptional Items (1,431) (167) (167) - (1,264) (1,264) -

Net Surplus before Transformation (938) (179) (88) 90 (1,198) (420) 778

Contingency 750 93 - (93) 657 - (657)

NHS Improvement Control Total (188) (86) (88) (2) (541) (420) 121

Excluded from NHS I Control Total

Donated Depreciation ** (45) (4) (1) 3 (41) (162) (121)

Adjusted NHS Improvement Control Total (233) (90) (89) 1 (582) (582) (0)

EBITDA % 3.9% 4.6% 1.7% 4.4% 3.5%

Surplus % 0.2% 0.9% 0.9% 0.6% 0.6%

(Negative Variance (Brackets) represents a Favourable variance)

17/18

Annual

Budget

£000s

In Month Year to Date


2.1 Income

Income year to date was higher than plan by £1.854m. This is due to the inclusion of additional income relating to the transfer of community services, which is offsetting the reduction of income due to the defund reduction by ERCCG for cluster 1 -4, lower than planned sessional space, lower than planned direct access imaging and reduced NCA income

2.2 Expenditure

Expenditure for clinical services was higher than plan by £3.611m year to date which is mainly due to higher staff costs.

2.3 Staff costs

The table below shoes the year to date staff costs, split by staff type.

Table 2: Staff Costs

Budget Substantive Bank Locum Agency Total Budget Variance

£000's £000's £000's £000's £000's £000's £000's

Consultant 9,508 7,456 - 1,841 1,272 10,570 (1,062)

Nursing 29,378 25,670 3,837 - 476 29,983 (605)

AHPs 18,364 16,712 87 - 224 17,023 1,341

Clinical Support Staff 10,145 8,608 168 - 307 9,083 1,061

Senior Manager - - - - - - -

Administration & Clerical 18,380 17,133 449 - 377 17,959 422

Chairman & Non Execs 107 114 - - - 114 (7)

Executive Board 812 794 - - - 794 18

Vacancy Factor & CIP Target (4,936) 80 - - - 80 (5,016)

Grand Total 81,758 76,567 4,542 1,841 2,656 85,606 (3,848)

Year To DateStaff Group

2.3.1 Agency costs

For 2017/18, NHSI have set an agency ceiling for the Trust of £3.072m (unchanged from last year) plus a new target for reduction in spend on agency medical locums of £0.128m for the year. Actual agency expenditure for February was £0.224m, which is below the ceiling of £0.256m for the month and £2.656m year to date. Work is ongoing to recruit permanent staff and reduce agency spend, particularly for consultants. A breakdown of agency spend by Care Group and staff type is shown below:


Table 3: Agency Spend analysis

STAFF TYPE

PRIMARY CARE,

COMMUNITY,

CHILDRENS AND

LD SERVICES

MENTAL HEALTH

SERVICES

CAREGROUP

SPECIALIST

SERVICES

CAREGROUP

CORPORATEGrand

Total

£000 £000 £000 £000 £000

Consultant 139 909 192 33 1,272

Medical Staff - - - - -

AHPs 151 73 - - 224

Nursing 101 286 88 - 476

Clinical Support Staff 17 290 1 0 307

Senior Manager - - - - -

Administration & Clerical 0 68 - 308 377

TOTAL 408 1,627 280 341 2,656

Agency spend compared to the NHSI ceiling is monitored each month, performance against the Trust local target is summarised in the graph below:

Table 4: Agency Spend compared to Local Agency Ceiling

Table 5: Agency Spend compared prior year


The most significant area of Agency expenditure remains Medical Locums, spend to the end of February was £1.272m or 40% above the NHS ceiling. The spend in month is £0.101m, £0.010m higher than the NHS I Ceiling.

Table 6: Agency Locum Spend

Agency Medical Locums

Month £000’s

YTD £000’s

NHS I Ceiling 91 905 Spend 101 1,272

Difference (10) (367)

The table below shows the weekly breaches reported to NHS Improvement in February.

Table 7: Breaches Reported

Date Wage Breach Price Breach Both Breach

Week ending 04/02 14 0 21




Grand Total 55 0 90

Table 8: Agency, Bank and Overtime Costs


2.4 Clinical Services Expenditure

2.4.1 Children’s, Learning Disabilities, Community Services and Primary Care

Year to date expenditure of £32.089m represents an overspend against budget of £2.077m.

Expenditure on agency consultants for ER CAMHS & Hull LD patients residing in The Priory unit are the main reasons for overspending on Children & LD.

Overspends on pay expenditure in Pocklington & Whitby have created a pressure in Community Services.

Use of Locums in Primary Care has resulted in a cost pressure in this area.

2.4.2 Specialist

An overspend of £0.125m was recorded YTD for Specialist Services. Additional income has been received from NHS England for the Addictions and Diversion services to offset this overspend.

2.4.3 Mental Health

An overspend of £1.409m was recorded year to date for Mental Health.

The overspend relates to four particular areas;

Within inpatient units, due to the need to maintain safer staffing levels and cover the rota requirements and an increase in the cover for sickness and training,

From the use of Agency staff within the Consultants,

Within the Care Group Management team due to over establishment

Year to date unachieved CIP.

These are offset by vacant posts within the Community Mental Health Teams, a reduction in the East Riding Partnerships expenditure and other minor variances.

2.5 Corporate Services Expenditure

The overall Corporate Services expenditure was £1.676m underspent year to date, due to non pay expenditure being lower than budget.

The Chief Executive directorate has a year to date underspend of £0.100m, relating to vacancies and non recurrent income.


The Chief Operating Officer directorate has a small year to date underspend of £0.060m, relating to vacancies within the Programme Management Office.

The Finance directorate reported an overspend of £0.522m, due to higher than planned staff costs and Whitby market rent charges, which have been offset by additional income.

The Human Resources directorate is showing an overspend of £0.028m, due to higher than budgeted pay costs year to date.

Finance Technical items includes non recurrent items relating to the Westwood overage and capitalisation of medical equipment.

The Director of Nursing directorate is showing an overspend due to the CQC subscription budget which was reduced prematurely following the transfer of the East Riding Community Services contract. The charge will be reduced in 2018/19 to match the budget.

3. Balance Sheet

The balance sheet shows the Trust’s assets and liabilities as at 28th February 2018. In month, the net current asset position decreased to £7.541m, due to an increase in fixed assets, as well as a decrease in trade creditors and a decrease in cash.

4. Cash

The cash balance at 28th February was £7.256m, a small decrease from the previous month of £0.284m.

5. Capital

The year to date capital expenditure of £2.597m comprises expenditure for IT (£0.872m) and Property Maintenance/Acquisitions (£1.725m). The capital spend forecast has been revised to take account of the delay in the CAMHS project, due to the delay in receiving funding, it is now forecast to be £4.539m, including year to date £0.477m of expenditure has been spent on this project.

Table 9: Capital programme


6. CIP Performance

The Trust has a full year cost improvement target of £5.2m, with identified schemes for £4.591m. Year to date savings of £3.005m have been achieved against the year to date planned savings of £4.462m, as included in the plan submitted to NSH Improvement. These year to date savings are £2.515m lower for identified schemes and £1.457m lower overall, following the inclusion of non recurrent savings. The current CIP delivery forecast is £3.011m Delivery of CIP continues to be one of the biggest risks in terms of the Trust delivering its overall financial control total, work to develop new schemes has continued since the last month’s report. The forecast savings compared to NHS Improvement target are shown in the graph and table below.

Table 10: Cost Improvement programme

Care Group RecurrentNon

RecurrentTOTAL Recurrent Non Recurrent TOTAL

Adult Mental Health 516,671 313,543 830,214 516,671 313,543 830,214

Primary Care, Community, Learning Disabilities & Children's Services491,907 - 491,907 491,907 - 491,907

Specialist Services 48,066 603,074 651,140 115,566 541,074 656,640

Corporate - 1,031,919 1,031,919 - 1,031,919 1,031,919

Total 1,056,644 1,948,536 3,005,180 1,124,144 1,886,536 3,010,680

Forecast (£)Actual to date (£)


An analysis by Maturity (Volume and Value is summarised in the table below)

Area 0 25% 50% 75% 100% Total (No)

Mental Health 3 5 8

Corporate 2 13 4 6 5 30

PCCLD 5 6 4 5 20

Specialist 1 2 3

Total (No) 2 22 10 10 17 61

Area 0 25% 50% 75% 100% Total (£000)

Mental Health 127 703 830

Corporate 407 603 - - 22 1,032

PCCLD 406 26 - 60 492

Specialist 116 541 657

Total (£000) 407 1,251 26 - 1,326 3,011

7. NHSI Use of Resources Assessment Performance against the NHSI Single Oversight Framework (SOF) is summarised in the table below. The SOF assesses the Trust’s financial performance across different metrics, the Trust can score between 1 (best) and 4 (worst) against each metric, with an average score across all metrics used to derive a use of resources score for the Trust. Should the Trust score a 4 or 3 in any of the areas under the use of resources assessment, this would identify a potential support need. For February the overall use of resources rating for the Trust is a 2, which is lower than the planned rating on the NHSI Plan of 1.

Table 11: Use of Resources


Use of Resources Metrics Actual Weight

Debt Service Cover 1.91 20%

Liquidity 23.85 20%

I & E Margin 0.54 20%

I & E Margin Variance from Plan -0.02 20%

Agency 9.20 20%

Weighted Average Risk Rating 1.0

2.0

1.0

2.0

2.0

1.0

2.0

2.0

1.0

3.0

1.0

1.0

Planned Rating Actual Rating

8. Risk and Mitigations

The following table summarises the current risks to the delivery of the financial plan and mitigating actions that are taking place.

Table 12: Risk and Mitigations

Risks Mitigations

Failure to achieve CIPs Care Groups overspending Capital Plan - slippage/overspends - CDEL limit exceeded Cash balances ER Community Services decommissioning (& the correlation generally between lost contracts and costs) NHSI Risk Rating decline (STF & capital access)

Monthly CIP Deep Dive meetings Monthly Confirm & Challenge Performance reviews Monthly Management Accounts reviews Staff recruitment & retention Budget holder accountability improvements Estates management & scheme contingencies Capital Programme Board control Weekly cash management reviews Weekly cashflow forecasting Cash-releasing CIPs development Liaison with CCG & CHCP Maximise recharge opportunities Remove costs as planned Tight control of cash Maintain agency spend within limits Achieve control total 2017/18

9. Recommendations

The Board is asked to note the Finance report for February and comment accordingly.

____________________________________________________________________________________________


Agenda Item: 15


Title of Report: Risk Register Update

Author:

Oliver Sims Corporate Risk Manager

Recommendation:

To approve To note



Purpose of Paper:

The report provides the Board with an update of Trust-wide risk register (15+ risks) including the detail of any additional or closed risks since last reported to Trust Board in January 2018.


The Trust-wide risk register details the risks facing the organisation scored at a current rating of 15 or higher (significant risks).

There are currently 5 risks held on the Trust-wide Risk Register which was last reviewed by the Executive Management Team on 12th March 2018.

There have been no risks removed from the Trust-wide risk

register since last reviewed at the January Board Meeting.

There has been 1 risk added to the Trust-wide risk register since last reviewed at the January Board Meeting. The additional risk has been approved by the Executive Management Team and is summarised below:

Risk

ID Risk Description Current Rating

HR28

Failure to meet Regulation 12 HSCA (RA) AND 18 HSC (RA) Regulations 2014 regarding mandatory training, clinical supervision and completion of appraisals.

15

The full Trust-wide risk register extract is appended to this

report to allow the Board to fully consider the Trust’s highest rated risks.

___________________________________________________________________________________________ Trust Board Page 2 of 5 Date: 28

th March 2018


Links to Strategic Goals Innovating Quality and Patient Safety Enhancing prevention, wellbeing and recovery Fostering integration, partnership and alliances Developing an effective and empowered workforce Maximising an efficient and sustainable organisation Promoting people, communities and social values



N/A Comment


Risk To be advised of any

Legal To be advised of any

Compliance future implications

Communication reports as and when

Financial future implications

Human Resources by Lead Directors

IM&T through Board

Users and Carers required

Equality and Diversity


No


th March 2018

Trust-wide Risk Register There are currently 5 risks reflected on the Trust-wide risk register which records all risks currently scored at a rating of 15 or above. The current risk position was agreed by Executive Management Committee on 12th March 2018, and is reflected in Table 1 below:

Table 1 - Trust-wide Risk Register (current risk rating 15+)

Risk ID Description of Risk Initial Risk

Score

Current Risk

Score

Target Risk

Score

FII22

Failure to achieve the organisation’s Cost Improvement Programme, achieve control total, and achieve required NHS Improvement ‘Use of Resources’ score for 2017/18.

20 20 8

FII179

Failure to identify and agree a financial plan that returns the Trust to surplus, meet NHS Improvement control total and deliver its short, medium and long-term CIP and service transformation to ensure costs are contained within budget.

20 20 8

FII200

The Trust's cash position deteriorates adversely where day to day functioning is impacted and the organisation is no longer financially independent.

15 15 10

NQPE37

Failure to meet Regulation 18 HSCA (RA) Regulations 2014 regarding Safer Staffing. 20 16 8

HR28

Failure to meet Regulation 12 HSCA (RA) AND 18 HSC (RA) Regulations 2014 regarding mandatory training, clinical supervision and completion of appraisals.

20 16 8

Closed/ De-escalated Trust-wide Risks

No risks have been downgraded from the Trust-wide risk register since last reported to the Trust Board in January 2018. There have been no risks closed from the Trust-wide risk register since last reported to the Trust Board.

Wider Risk Register

There are currently 189 risks held across the Trust’s risk registers. This is a decrease of 5 risks from the 194 reported to Trust Board in January. The table below shows the number of risks at each current risk rating in comparison to that presented to the January 2018 Board.

Table 4 - Total Risks by Current Risk level

Current Risk Level Number of Risks –

January 2018 Number of Risks –

March 2018

20 1 2

16 2 2

15 1 1

12 36 35

10 2 2

9 75 73

8 28 27

6 38 38

4 10 8


th March 2018

Current Risk Level Number of Risks –

January 2018 Number of Risks –

March 2018 3 0 0

2 1 1

1 0 0

Total Risks 194 189

The chart below highlights the number and percentage of risks by Directorate/ Care Group. Chart 1 – Care Groups/ Directorates Risk Composition

The risk profile across each area of the Trust is shown in the Figures 1 and 2 below.

Key: NQPE – Nursing, Quality & Patient Experience MD – Medical Directorate HR – Human Resources FII – Finance, Infrastructure & Informatics CA – Corporate Affairs

Key: OPS – Operations NQPE – Nursing, Quality &

Patient Experience FII – Finance, Infrastructure &

Informatics HR – Human Resources CA – Corporate Affairs MD – Medical Directorate EP - Emergency

Preparedness, Resilience & Response PC – Primary Care CLD – Children’s and

Learning Disability CS – Community Services SS – Specialist Services MH - Mental Health Care

Group


th March 2018

Key: EP – Emergency Preparedness OPS – Operations PC – Primary Care SS – Specialist Services CLD – Children’s and Learning Disability CS – Community Services MH –Mental Health

Trust-wide Risk Register Trust Board- 28 March 2018

Ris

k id Description of Risk

Imp

act/

Co

nse

qu

ence

Typ

e

Like

liho

od

(In

itia

l)

Imp

act

(in

itia

l)

Init

ial R

isk

Sco

re

Init

ial R

isk

Rat

ing

Key Controls Sources of Assurance Gaps in Controls/ Controls currently failing Gaps in Assurance

Like

liho

od

(C

urr

ent)

Imp

act

(Cu

rren

t)

Cu

rren

t R

isk

Sco

re

Cu

rren

t ri

sk

What additional actions need to be completed?

Lead

Man

ager

Lead

Dir

ecto

r

Ris

k M

on

ito

rin

g G

rou

p

Ris

k O

vers

igh

t G

rou

p

Like

liho

od

(Ta

rget

)

Imp

act

(Tar

get)

Targ

et r

isk

sco

re

Targ

et r

isk

1

FII2

00

The Trust's cash position deteriorates adversely

where day to day functioning is impacted and the

organisation is no longer financially independent.

Fin

ance

/Cla

ims

Po

ssib

le

Cat

astr

op

hic

15

Sign

ific

ant

1. Daily monitoring of the cash position and

weekly update to CE.

2. Forecasts made on a monthly basis.

3. Weekly reviews of outstanding debtors with

contact made to recover debt.

4. Creditor payments made on a weekly basis

5. Cash position reported as a standing item to

the Board and Finance Committee.

6.Trust within its revenue and capital budgets

which are dependent on resource provided.

7. Monthly budget reports / budegt reduction

strategy & recovery plan

1. Monthly reporting of financial

position to Board.

2. Monthly reports and Quarterly

Accounts Returns to NHS I & quarterly

feedback.

3. EMT report.

4. Finance Committee report.

5. OPRG Sub-group report.

1.Trust remaining within its Revenue and

Capital budgets.

2. Accountability Framework

None Identified.

Po

ssib

le

Cat

astr

op

hic

15

Sign

ific

ant

1. Budget Reduction Strategy and MTFP which

integrates the Cash Flow projections.

2. Capacity and demand modelling.

Iain

Om

on

d

Pet

er B

eckw

ith

FII B

usi

nes

s M

eeti

ng/

EM

T

Bo

ard

Un

likel

y

Cat

astr

op

hic

10

Hig

h

2

FII1

79

Failure to identify, agree and implement a financial

plan that returns the Trust to surplus, meets NHS

Improvement control total and deliver its short,

medium and long term CIP and service

transformation to ensure costs are contained

within budget. This also reflects the risk that

income declines through implementation of tariff,

or national and local commissioner targets.

Ob

ject

ives

Alm

ost

Cer

tain

Seve

re

20

Sign

ific

ant

1. Budgets agreed

2. Monthly reporting & monitoring and

discussion with budget holders

3. Small contingency / risk cover provided in

plan.

4. CIP programme - Project management

approach to delivery of CIP (standardised

templates).

5. Bi-weekly Deputies meeting tasked with CIP

delivery.

6. MTFP developed to inform plans.

7. Service plans.

8. Finance Committee established.

9. Budget recovery plan agreed by EMT.

10. Budget Reduction Strategy 2018-19 to 2020-

21 established which will produce a MTFP,

incorporating the CIP process.

10. Non-recurrent savings.

1. Monthly reporting to Board

2. Monthly & Quarterly reporting to

NHS I and NHS I feedback

3. Deputies Forum monitoring

progress of CIP plans.

4. Standing item on EMT agenda.

5. Budget Reduction Strategy, policy

and procedure agreed.

1. Insufficient contingency identified.

2. CIP slippage (et end of Q1) in 2017/18.

3. Accountability Framework

1. MTFP Reporting once

plan in place would provide

assurance over medium to

longer term planning.

2. Risks inherent in 2017/18

CIP plans.

3. Accountability framework

- '

Alm

ost

Cer

tain

Seve

re

20

Sign

ific

ant

1. Development of MTFP reporting to Board on

a quarterly basis.

2. Budget Recovery Plan implementation.

3. Draft version MTFP.

4. Budget Reduction Strategy implemented

with agreement from CCGs regarding capacity

and demand.

Iain

Om

on

d

Pet

er B

eckw

ith

FII B

usi

nes

s M

eeti

ng/

EM

T

Bo

ard

Un

likel

y

Seve

re

8

Hig

h

Humber NHS Foundation Trust - Trust-wide Risk Register 1


Ris


Imp

act/

Co

nse

qu

ence

Typ

e

Like

liho

od

(In

itia

l)

Imp

act

(in

itia

l)

Init

ial R

isk

Sco

re

Init

ial R

isk

Rat

ing


Like

liho

od

(C

urr

ent)

Imp

act

(Cu

rren

t)

Cu

rren

t R

isk

Sco

re

Cu

rren

t ri

sk


Lead

Man

ager

Lead

Dir

ecto

r

Ris

k M

on

ito

rin

g G

rou

p

Ris

k O

vers

igh

t G

rou

p

Like

liho

od

(Ta

rget

)

Imp

act

(Tar

get)

Targ

et r

isk

sco

re

Targ

et r

isk

3

FII2

2

Failure to achieve the organisations Cost

Improvement Programme, achieve control total,

and achieve required NHS Improvement Use of

Resources Score for 2017/18.

Fin

ance

/Cla

ims

Alm

ost

Cer

tain

Seve

re

20

Sign

ific

ant

1. Monthly Monitoring of Financial Position

discussed with budget holders (regular confirm

and challenge)

2. CIP programme - Project management

approach to delivery of CIP (standardised

templates)

3. OPRG Sub-Group monitors performance

against plans.

4. Small amount of contingency/Risk cover

provided for in plan.

5. Contractual discussions with commissioners.

6. Standing item on EMT agenda.

7. Standing item on Finance Committee

agenda.

8. Non-recurrent savings identified and agreed

at EMT/ Finance Committee.

1. Monthly reporting of financial

position to Board.

2. Monthly reports and Quarterly

Accounts Returns to NHS I & quarterly

feedback.

3. EMT report.

4. Finance Committee report.

5. OPRG Sub-group report.

1. Insufficient contingency identified.

2 Non Delivery of the CIP project and

recurrent budget targets

3. Demand too high for the level of

resources available

1. Risks in 17/18 CIP plans.

2. Shortfall as current plans

do not meet CIP target.

Alm

ost

Cer

tain

Seve

re

20

Sign

ific

ant

1. Improve Communications sections of Service

Plans to ensure opportunities are exploited to

showcase/market our services.

2. Engage NHSI for sight of other Trust CIPs.

3. Non-recurrent savings to be removed from

budget.

4. 3 year Budget Reduction Strategy introduced

2018-19 to 2020-21.

Iain

Om

on

d

Pet

er B

eckw

ith

FII B

usi

nes

s M

eeti

ng/

EM

T

Bo

ard

Un

likel

y

Seve

re

8

Hig

h

Activities and leave is sometimes cancelled

due to short staffing and annual leave.

There is not always enough suitably

qualified staff on duty.

4

NQ

PE3

7

Failure to meet Regulation 18 HSCA (RA)

Regulations 2014 regarding Safer Staffing.

1. 6-month safer staffing report.

2. CQC well-led report (January 2018).

3. Staffing establishments across

most units are in line with the

national average. ( Benchmarking

data)

4. Older Adult units are in the upper

quartile nationally for their RN levels.

1. Routine performance monitoring of staffing

establishments and daily staffing levels review

by care groups.

2. Health roster system.

3. Management of attendance.

4. Support from other professional groups and

nursing leadership to deliver safe staffing

levels.

6. Daily checks on following days roster

requirements to ensure staff cover is arranged

in some clinical areas.

7. Continued recruitment drive, looking at

different incentive schemes, use of overtime,

bank and agency

8. Daily rota management in some clinical

areas.

9. Use of flexible workforce solutions where

available in some clinical areas.

10. Validated tool used to agree

establishments.

11. DATIX incident reports.

12. Bed Escalation Policy.

13. Monthly performance report- Quality

dashboard to identify risks

Safe

ty

Alm

ost

Cer

tain

Seve

re

20

Sign

ific

ant

1. Negative assurance from

report and findings

following recent CQC well

led inspection. Requirement

notice in regard to

Regulation 18 HSCA (RA)

Regulations 2014, Staffing.

1. Ensure a 12 monthly review of inpatient

establishments is undertaken with priority

given to PICU.

2. Work with commissioners to develop new

models of care/delivery options utilising the

whole workforce.

3. Consider the purchase of the Safe Care

module for e-Roster to inform real time

decision making to reflect changes in patient

acuity.

4. Continue to actively recruit to vacancies and

consider creative ways of doing so, working

with partners across the health economy.

5. Consideration of nursing apprenticeships and

nursing associate roles and greater use of the

wider multi-disciplinary team in providing

clinical leadership to units.

6. Focus on safer staffing from a

multidisciplinary team approach to be

strengthened to oversee and develop a work

plan to ensure the Trust has robust systems

and processes in place in relation to safer

staffing.

7. Ensure patient experience is captured across

all units to provide patient insight in relation to

quality of care delivery.

Like

ly

Seve

re

16

Sign

ific

ant

Car

olin

e Jo

hn

son

8

Hig

h

Hila

ry G

led

hill

EMT

Bo

ard

Un

likel

y

Seve

re



Ris


Imp

act/

Co

nse

qu

ence

Typ

e

Like

liho

od

(In

itia

l)

Imp

act

(in

itia

l)

Init

ial R

isk

Sco

re

Init

ial R

isk

Rat

ing


Like

liho

od

(C

urr

ent)

Imp

act

(Cu

rren

t)

Cu

rren

t R

isk

Sco

re

Cu

rren

t ri

sk


Lead

Man

ager

Lead

Dir

ecto

r

Ris

k M

on

ito

rin

g G

rou

p

Ris

k O

vers

igh

t G

rou

p

Like

liho

od

(Ta

rget

)

Imp

act

(Tar

get)

Targ

et r

isk

sco

re

Targ

et r

isk

5

HR

28

Failure to meet Regulation 12 HSCA (RA) AND 18

HSC (RA) Regulations 2014 regarding mandatory

training, clinical supervision and completion of

appraisals.

Safe

ty

Alm

ost

Cer

tain

Seve

re

20Si

gnif

ican

t

1. Routine performance monitoring of

statutory/ mandatory training compliance.

2. Monthly appraisal compliance reports.

3. Development and implementation of staff

incentive scheme linked to appraisal

completion and statutory/mandatory training.

4. Individual emails to staff and managers with

training renewal reminder

5. MAPA training review undertaken.

6. Training department produces two weekly

compliance report monitored at weekly Senior

Operations meeting

7. Statutory/ mandatory matrix reviewed and

agreed by EMT.

8. Trust clinical supervision policy refreshed to

include reporting requirements.

9. Supervision compliance reported monthly

against the agreed Trust compliance rate in the

Integrated Quality & performance Tracker.

1. CQC well-led report (January 2018).

2. Trust Board

3. Executive Management team

4. Weekly Senior Operations meeting

4. Increasing trajectory in year against

overall compliance rates

• Review of appraisal policy.

• Optimised e-roster system

• Maintenance of safer staffing whilst

training skills

• Refresh of Trust appraisal policy to

simplify the process, proportionate to the

roles/responsibilities and ensure there is

alignment with the Trust vision and values.

• Review of the delivery of statutory and

mandatory training to ensure it remains

flexible and accessible to meet the needs of

staff.

1. Negative assurance from

report and findings

following recent CQC well

led inspection. Requirement

notice in regards to

Regulation 12 HSCA (RA)

AND 18 HSC (RA)

Regulations 2014 - training

has improved - ILS/BLS/

MAPPA/IG four areas

struggling

Like

ly

Seve

re

16

Sign

ific

ant

1. Appraisal policy review to be undertaken.

2. Optimal e-roster system to ensure that

mandatory training requirements are built into

the roster to ensure sustainability.

3. Matrons to ensure Team Meetings are

scheduled for all units for 2018/19 and monitor

attendance via team meeting minutes taking

appropriate action as required where

attendance is low/meetings are cancelled.

4. Review of the delivery of statutory and

mandatory training to ensure it remains flexible

and accessible to meet the needs of staff.

Eliz

abet

h T

ho

mas

Eliz

abet

h T

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1 Caring, Learning and Growing

Agenda Item 16

Title & Date of Meeting: Trust Board Public Meeting - 28.02.18

Title of Report: Gender Pay Gap Report

Author:

Name: Sarah Todd Title: HR Services Manager (Equality and Diversity Lead for Staff)

Recommendation:

To approve √ To note To discuss √ To ratify √


Purpose of Paper:

To provide the Board with a revised report that includes a joint statement from the Chairman and Chief Executive and the actions we are taking to improve the gender gap prior to its compulsory publication before 31.03.18


All Trusts are required to report on the gender pay gap and the gap in any bonuses paid which includes Clinical Excellence awards and retention payments. The Trust’s current gender pay gap currently stands at 11% which is lower than the national figure of 18%. The Trust’s bonus figure is -49.32%, which shows that female staff are paid higher amounts of bonus pay. The only people reported to have received bonus pay are Medical Staff who have received Clinical Excellence Awards. There are 14 people who received bonus pay (9 Males and 5 Females). Despite being less in number due to their seniority, longevity of service and experience the female’s awards were higher than the males.











N/A Comment



Legal √

Compliance √

Communication √

Financial √

Human Resources √

IM&T √




No

Caring Learning Growing

GENDER PAY GAP REPORT

January 2018

Last year we refreshed our Trust’s values which are Caring, Learning and Growing. We have a Workforce and Organisational Development Strategy which has 4 strategic priorities:

Healthy Organisational Culture

Capable & Sustainable Workforce

Effective Leadership & Management

Enabling Transformation & OD Our first priority: Healthy Organisational Culture, includes promoting equality & valuing diversity. As an organisation we score higher than the national average in the staff survey for the percentage of staff believing that the organisation provides equal opportunities for career progression or promotion and lower than the national average for the percentage of staff experiencing discrimination at work. Although we have achieved much in creating an environment where people feel we provide equal opportunities and take action against any discrimination we are not complacent and set annual priorities around our Public Sector Equality Duties. In producing this report we recognise that we have more to do to reduce the gender pay gap and we remain committed to a workplace that respects and harnesses equality and diversity. We will work to improve the gender pay gap by undertaking the actions set out at the end of this report.

Sharon Mays Michele Moran Trust Chair Chief Executive


What is the Gender Pay Gap? “The gender pay gap shows the difference between the average (mean or median) earnings of men and women. This is expressed as a percentage of men’s earnings e.g. women earn 15% less than men. Used to its full potential, gender pay gap reporting is a valuable tool for assessing levels of equality in the workplace, female and male participation, and how effectively talent is being maximised.” What is the difference between the gender pay gap and equal pay? “The gender pay gap differs from equal pay. Equal pay deals with the pay differences between men and women who carry out the same jobs, similar jobs or work of equal value. It is unlawful to pay people unequally because they are a man or a woman. The gender pay gap shows the differences in the average pay between men and women. If a workplace has a particularly high gender pay gap, this can indicate there may a number of issues to deal with, and the individual calculations may help to identify what those issues are. In some cases, the gender pay gap may include unlawful inequality in pay but this is not necessarily the case.” Guidance: Managing Gender Pay Reporting. ACAS It is a legal requirement for all relevant employers to publish their gender pay report within one year of the ‘snapshot’ date: this year’s date being 31st March 2017. All employers must comply with the reporting regulations for any year where they had a headcount of 250 or more employees on the ‘snapshot’ date. Relevant employers must follow the rules in the regulations to calculate the following information:

Their mean gender pay gap

Their median gender pay gap

Their mean bonus gender pay gap

Their median bonus gender pay gap

Their proportion of males receiving a bonus payment

Their proportion of females receiving a bonus payment

Their proportion of males and females in each quartile pay band

A written statement, authorised by an appropriate senior person, which confirms the accuracy of their calculations. However, this requirement only applies to employers subject to the Equality Act 2010 (gender Pay Gap Information) Regulations 2017.

Most NHS trusts will fall into the above category and thus must comply. With this in mind, IBM suppliers of the ‘Electronic Staff Record’ have developed a report which uses the required calculations to produce the gender pay gap data.



Gender Pay Gap Report

Below are 4 tables outlining the Trust’s Gender pay Gap, in summary:

The Trust’s mean gender pay gap is 11.06%

The Trust’s median gender pay gap is 0.35%

The Trust’s mean bonus gender pay gap is -49.32%

The Trust’s median bonus gender pay gap is -80.14%

The proportion of males receiving a bonus payment is 1.26%

The proportion of females receiving a bonus payment is 0.18%

The proportion of males and females in each quartile pay band is:

o Quartile 1: 82.57% Female and 17.43% Male




Gender Pay Gap Data

Average & Median Hourly Rates

Number of employees | Q1 = Low, Q4 = High

Gender Avg. Hourly Rate

Median Hourly Rate

Quartile Female Male Female %

Male %

Male 16.7069 13.4990

1 635.00 134.00 82.57 17.43

Female 14.8585 13.4509

2 619.00 174.00 78.06 21.94

Difference 1.8484 0.0480

3 639.00 143.00 81.71 18.29

Pay Gap %

11.0637 0.3557

4 616.00 188.00 76.62 23.38

Gender Pay gap Bonus Data

Gender Avg. Pay Median Pay

Gender Employees Paid Bonus

Total Relevant Employees

%

Male 8,290.34 5,967.20

Female 5.00 2787.00 0.18

Female 12,379.32 10,749.60

Male 9.00 716.00 1.26

Difference -4,088.98 -4,782.40

Pay Gap %

-49.32 -80.14


Mean Gender Pay Gap: The calculation shows the difference between the mean average hourly rate of pay that male and female full-pay relevant employees receive. For all calculations full pay does not mean full time, it means that a person has received their full pay therefor people on maternity leave with half pay and those on sick leave with half pay are excluded. The calculation is undertaken by subtracting the mean average hourly rate of pay of all female full-pay employees from the mean average hourly rate of pay of all male full-pay employees and dividing the result by the mean average hourly rate of pay of all male full-pay employees and multiplying it by 100.

The Trust’s mean gender pay gap is 11.06%

Median Gender Pay Gap: The calculation shows the difference between the median hourly rate of pay that male and female full-pay relevant employees receive. The calculation is undertaken by subtracting the median hourly rate of pay of pay of all female full-pay employees from the median average hourly rate of pay of all male full-pay employees and dividing the result by the median average hourly rate of pay of all male full-pay employees and multiplying it by 100.

The Trust’s median gender pay gap is 0.35%

Mean Bonus Gender Pay Gap: The calculation shows the difference between the mean average bonus pay that male and female full-pay relevant employees receive. The calculation is undertaken by subtracting the mean average bonus pay of all female full-pay employees (who were paid bonus pay during the 12 month period ending with the snap shot date) from the mean average hourly rate of pay of all


male full-pay employees (who were paid bonus pay during the 12 month period ending with the snap shot date) and dividing the result by the mean average bonus pay of all male full-pay employees and multiplying it by 100.

The Trust’s mean bonus gender pay gap is -49.32%

The negative figure shows that females are paid a higher rate of bonus pay than males.

The only people reported to have received bonus pay are Medical Staff who have received Clinical Excellence Awards. There are 14 people who received bonus pay (9 Males and 5 Females). Despite being less in number due to their seniority, longevity of service and experience the female’s awards were higher than the males.

Median Bonus Gender Pay Gap: The calculation shows the difference between the median bonus pay that male and female full-pay relevant employees receive. The calculation is undertaken by subtracting the median bonus pay of pay of all female full-pay employees from the median average bonus pay of all male full-pay employees and dividing the result by the median average bonus pay of all male full-pay employees and multiplying it by 100.

The Trust’s median bonus gender pay gap is -80.14%

The proportion of males and females receiving a bonus payment:

These two calculations show the proportion of male employees who were paid bonus pay and the proportion of female employees who were paid bonus pay.

Male-This calculation is undertaken by dividing the number of males who were paid bonus pay in the qualifying period by the total number of male employees and multiplying by 100.

Female- This calculation is undertaken by dividing the number of females who were paid bonus pay in the qualifying period by the total number of female employees and multiplying by 100.

The proportion of males receiving a bonus payment is 1.26%

The proportion of females receiving a bonus payment is 0.18%

The difference in the figures can be explained by the high proportion of females in the organisation, however the numbers of staff receiving bonuses is still very low.


The proportion of males and females in each quartile pay band: This calculation shows the proportions of male and females in four quartile pay bands. The calculation is undertaken by dividing the workforce into four equal parts;

firstly, all relevant employees are ranked from lowest hourly rate of pay to the

highest hourly rate of pay

Secondly, the list is divided into four sections called quartiles with an equal

number of employees in each section

The proportion of males and females in each quartile pay band is:





The highest proportion of male employees per quartile is in the highest bracket whilst the lowest proportion is in the lowest bracket which results in the gender pay gap of 11.06% Conclusion Whilst the Trust has a Gender Pay Gap at 11.06%, it is lower than the National average of 18%. The Trust as a whole has a proportion of 74.54% Females and 25.46% Male but this proportion is different across the staff groups. The lowest proportion of males is in the staff Group Allied Health Professionals with 88% Female and 12% Male closely followed by Nursing at 82% Female and 18% Male. The highest proportion of Males within the Trust is in the Staff Group Medical and Dental with 54% Female and 46% male, followed by Estates and Ancillary 67% Female and 33% Male. There are proportionately more female staff than male staff working at lower bands and adversely proportionately more male staff working at higher bands however the numbers involved in the Trusts data are relatively small but make a significant difference to the percentages The number of staff being paid bonuses is very low with a total of 14 people receiving additional benefits and these are all Clinical Excellence Awards to Medical Staff. However the highest amounts are paid to female medics who have longevity of service and experience. The Trust has a high proportion of Female staff overall and this is generally in line with National NHS Figures (77%).


What we will do to reduce the gender gap We remain committed to a workplace that respects and harnesses equality and diversity. We will work to improve the gender pay gap by undertaking the actions below:

Continue to provide fair and equitable access to training and career

promotion.

Continue to identify and develop leaders and managers based on aspiration

and skills, taking account of gender uptake.

Review the Recruitment and Selection training package to include

interviewing by diverse panels to avoid unconscious bias.

Continue to make equality and diversity training mandatory for all staff.

Deliver unconscious bias training as part of our E&D training.

Review job titles to ensure that they are gender neutral and are not

traditionally stereotypical.

Work closer with schools as appropriate to encourage school leavers to take

up a career in the NHS, promoting all roles for all genders.

Better promote Flexible Working opportunities including shared parental

leave entitlements.

Include an annual review of gender split across all bands as part of the

annual Public Sector Equality Duty process, including it as a main priority for

2018/19 in our annual equality and diversity report to the Board.

Continue our commitment of encouraging an even gender split at Board

level.

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Agenda Item: 17


Title of Report: Collaborative Commissioning Contract Governance Arrangements (Hull/East Riding)

Author:

Name: Vicky Scarborough Title: Deputy Director of Business and Contracting

Recommendation

To approve To note



The attached report is for information and has been discussed and approved at both Senior Management team (SMT) and the Executive Management Team (EMT).

Purpose of Paper:

The purpose of this paper is to outline for the Board the revised changes to the contracting governance arrangements for the Hull and East Riding contract. .


Rationale for the proposed new arrangements and the new proposed governance structure are included in the body of the report. EMT and SMT have approved the approach.











N/A Comment


Risk

Legal To be advised of any

Compliance future implications

Communication reports as and when

Financial future implications

Human Resources by Lead Directors

IM&T through Board

Users and Carers required

Equality and Diversity


No


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Contracting Governance Arrangements (Hull and East Riding) Collaborative Working

1. Introduction and Purpose The purpose of this paper is to outline for the Trust Board the revised proposed changes to the contracting governance arrangements for the Hull and East Riding contract and to provide an update from EMT and SMT discussions.

2. Background and Context Both local CCGs signed an Aligned Incentive Contract with Hull and East Yorkshire Hospitals (HEYT) for their 17/18 contract. This was in the context of ‘no more money’ in the system, the HEYT tariff based system, and an overall requirement to refresh the approach to contracting in this system, in line with STP working. A paper on this subject has been to both SMT and EMT for discussion and a concern was expressed about avoiding this being the first stage of a ‘directly managed unit’. A meeting has been held with both CCGs to revisit the proposal, in light of Trust comments, and establish if a different way forward can be found. This paper outlines that proposal.

3. Proposal

Since the SMT meeting on the 19th January 2018, a meeting has been held between the CCG and the Trust, attendance included; Michele Moran, Jane Hawkard, Teresa Cope, Alex Seale and Pete Beckwith. The proposal was discussed in detail and the remainder of this paper outlines that revised proposal and provides answers to questions raised at the SMT on the 19th January 2018.

Appendix A outlines the revised proposed governance arrangements for the management of the Hull and East Riding contract.

The existing Contract Management Board (CMB) will be disbanded, however the existing NHS Standard contract documentation will continue to be used. The changes proposed surround the governance arrangements of the contract and the opportunities provided by the STP for a more collaborative approach to solving system issues. In line with Appendix A, it is proposed; The Executive Leadership includes the two Local Authority CEOs The Oversight Management Board (OMB) has 50:50 representation from the CCGs and the Trust. This will be achieved through each organisation being represented by their Chief Finance Officer or Finance Director and each supporting groups Chair. The OMB will be the forum for consolidating work programme delivery and unblocking any issues escalated from the groups. The Chair of the OMB will be the East Riding CCG CFO. The Children’s and LD Delivery Group is jointly chaired by a CCG and a Local Authority representative. The Group needs to keep representation to a minimum and include

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representatives from the Trust, CCGs and Local Authorities. A clear link needs to be created from this Group to the Children’s Trust Board. The Adult and Older People Mental Health Delivery Group is chaired by the Trust. This Group is also to include Local Authority representatives and be kept to a minimum number of attendees. Both these groups will develop joint priorities and create work plans and timelines for the work programme for the year based on agreed challenges and opportunities. The OMB would sign off plans. An initial idea for the workstreams that fit under the delivery groups is Adult Mental Health Rehabilitation and Out of Area placements. In response to a query posed at SMT the CCG has confirmed that ‘the proposed delivery groups won’t be able to do everything for everybody and the question remains the same under the current contract structure. Overall the revised governance structure aims to keep track on issues, priorities and resources so senior leaders can align plans and delivery. TCP for example is mandatory, multi-agency and extends beyond Hull & ERY and has its own specific agenda’.

The Technical and Information Group is chaired by the Trust. Given the Groups remit on performance, project management, finance business intelligence and capacity and demand, it is suggested that the Deputy Director of Finance and IT be the chair with support from the Head of Contracts and Performance. This group supports the ‘business intelligence requests’ of the other groups. The CCG have confirmed that would not wish this Groups title to change as the focus is not solely Finance (request from previous SMT). The provider CIP/Carter Group is chaired by the Deputy Director of Business and Contracting or the Trust. This will be a group that reviews provider opportunities for savings and efficiencies in line with Carter report proposals. The Quality Oversight Group is chaired by the Director of Nursing for East Riding CCG. The group will oversee the quality aspects of the contract and Quality Impact Assess the work programmes and plans from the Delivery groups. The proposals above results in 3 Trust chairs and 2 CCG chairs, thus equally balancing the representation on the OMB. All groups will have proportionate representation from both the CCGs and the Trust. A stock take of other Groups that are currently in operation would be undertaken in the first 2 months and any that can be ceased will be.

4. Timeline It is proposed that new arrangements and structure would run in shadow form from March 2018. The first meeting of the Executive Leadership team would be provisionally planned for May 2018 with a focus on signing off the work plans created by the Delivery groups. It should be noted that the existing arrangements of a CMB with supporting sub-groups can be reinstated should this new arrangement not work.

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5. Other Points Work will need to be completed to ensure there are clear links with the STP work programmes as we need demonstrate a coordinated and coherent plan. In terms of additional capacity required to facilitate this new way of working, this will need to be assessed over time. However the principle of a more co-ordinated approach should help get the most out of the capacity shared between all organisations. A review after 6 months is proposed. SMT discussed the changes at its meeting on the 2nd February 2018 and approved the amendments for final consideration by EMT.

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Agenda Item: 18


Title of Report: Finance Committee Assurance Report

Author:

Name: Francis Patton Title: Non-Executive Director and Chair of Finance Committee

Recommendation

To approve To note

To discuss √ To ratify

For information √ To endorse

Purpose of Paper:

The Finance Committee is one of the sub committees of the Trust Board This paper provides an executive summary of discussions held at the meeting held on 13th March 2018 and a summary of key issues for the Board to note.

Any Issues for Escalation to the Board:

The committee recommends that the Board:-

Agree and sign of the new Terms of Reference, standard agenda and cycle of business.

Note and discuss the committee’s concerns over achievement of the Business Reduction Strategy for 2018/19

Executive Summary - Assurance Report:

The aim of this report is to provide assurance to the Board on the financial performance of the Trust and raise any issues that it feels need escalating to the Board for further discussion. A summary of the key areas discussed is that financial performance for 2017/18 remains on plan and the forecast outturn is that the Trust will hit the control total, helped by the Westwood overage, which may result in extra bonus STF funding. In terms of next year’s Budget Reduction strategy there remains a gap between reductions identified and the Trust target and the committee was not fully assured that there is a plan to address this. The Terms of Reference were reviewed and are here today for ratification by the Trust Board along with a standard agenda and cycle of business. Finally the section of the BAF relating to Finance committee and no changes were made.

Key Issues:

The key areas of note arising from the Committee meeting held on 13th March are: Please highlight agenda items

The committee undertook a full review of the Terms of Reference of the committee, a standard agenda and the Annual Cycle of work. A number of amends were made to all 3 and they are presented here today for ratification by Trust Board. One of the key changes that will take place is that the Care Group Directors will attend every Finance committee

___________________________________________________________________________________________ Trust Board 28.3.2018 Page 2 of 2

meeting to talk through the finances within their Care Group. This will be trialled for 6 months to see what value it adds before a decision is taken as to whether they become full members of the committee.

The BAF for strategic goal 5, maximising an efficient and sustainable organisation, was reviewed and remains at red for March 2018. No new risks were added but risks FII122, FII179 and FII200 were reviewed and no changes were made.

In terms of financial performance the committee was too early after month end to receive a full written report. The FD summarised the position at Month 11 as being on plan with a £582k surplus and continues to have confidence that the Trust will achieve its forecast plan of the £233k control total. Agency control is good running at £224k versus the £256k target. Cash is £7.2m but an expected PDC payment in month 11 will drop year end cash to £6.45m therefore cash management and cash flow remain an area of risk for the Trust. CIP continues to be an issue with £3m delivered year to date versus a target of £5.2m and only £1m of this is recurrent. Achieving the control total will be difficult but has been helped by some non-recurrent income. If achieved there is an STF bonus pot available at year end plus pound for pound matching of any over delivery. This needs careful monitoring.

A detailed discussion was held around the 2018/19 Budget Reduction Strategy. At Month 11 the forecast for next year shows a gap between proposals and target of £1.53m. In addition of the savings identified £2.662m is red rated meaning that the Trust is entering 2018/19 with a potential gap of £4.192 from an overall target of £8.803m. In terms of the unidentified £1.53m then £1.141m sits against the Mental Health Care Group. The Care Group Director for Mental Health was at Finance committee and whilst quite positive about her ability to deliver the red rated savings of £1.027m in her directorate had no plans for the £1.141m and felt that it was not achievable. Overall Finance committee did not feel assured that the present plan was far enough developed nor gave enough assurance that the requisite amount could be achieved either at Trust level or individual directorate level. This will therefore be looked at in depth at the next committee meeting.

A review of the effectiveness of the committee in its first six months of existence was undertaken and is attached for review by the Board.

FINANCE COMMITTEE

Agenda

For a meeting to be held on 2018, 1pm – 3pm, Boardroom, Trust HQ

Lead Action Report Format

Standing Items

1. Apologies for Absence

Chair To note

2. Declaration of Interest

Chair To note

3. Minute of the last meeting held on 1

Chair To approve

4. Action List, Matters Arising & Cycle of Business

Chair To discuss

Meeting Items

5.

To receive and review the Trust’s Finance reports - Finance Insight Report - Trust Overarching Financial position - Cash report - Relevant sections of the IQPT

FD

6. To receive and review the Care Group’s financial performance

CG Directo

rs

7. To receive and review the Trust’s Budget Overarching Reduction Strategy report

FD

8. To receive and review the Care Group’s Budget Reduction Strategy reports

CG Directo

rs

9. To receive and review the relevant BAF risks

OS

To discuss

Minutes of any groups reporting to this Group

10. Digital Delivery Group

FD

11. Estates Delivery Group FD

12. Capital Programme Group FD

13. Carter Group FD

14. SPV Task and Finish Group FD

15. To sign off any policies Chair

16. To review the committees work plan Chair

17. To review the meeting Chair

18. Any Other Business

19. Date, Time and Venue of Next Meeting

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Terms of Reference

Finance Committee

Authority

The Finance Committee (the committee) is constituted as a standing committee of the Trust Board. Its terms of reference may only be amended with the approval of the Trust Board. The committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any director or member of staff, all of whom are directed to co-operate with any request made by the committee. The committee is authorised by the Board to obtain outside legal or other independent professional advice as it requires and to secure the attendance of those with relevant experience and expertise if it considers this necessary. The committee is delegated by the Board to exercise decision-making powers in discharging its duties, whilst recognising those matters reserved elsewhere.

The committee may form any working group, tasked for a specific purpose and for a fixed period of time, to support the delivery of any of its duties and responsibilities, or for relevant research.

Role / Purpose

The primary role of the committee is to monitor, review and support the Finance Directorate of the Trust, making recommendations to the board as appropriate and taking actions as required. It shall challenge the timeliness, accuracy and quality of financial and performance measures and reporting, and the systems underpinning them. It should ensure performance and relevant action plans are reviewed and managed in pursuit of Trust objectives. It shall review and challenge the Estates & Facilities work programme and delivery of the Trusts Estate Strategy, policies & procedures. It shall review and challenge the Digital Delivery work programme, policies and procedures It shall review and challenge delivery of the Trust’s Capital Investment Programme. It shall support the objectives of the Trust and its Board, and the provision of assurance to the Board and the Audit Committee. The committee shall maintain an annual work programme, ensuring that all matters for which it is responsible are addressed in a planned manner, with appropriate frequency, across the financial year.

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The work and effectiveness of the committee shall be subject to monitoring by the Audit Committee, which shall undertake at least one formal review annually of the effectiveness of the committee, as part of its assurance function.

Duties

The duties of the committee include the following:

Scrutinise all financial plans, including the Trust’s annual financial plan, prior to seeking Board approval

Monitor delivery of the Trust’s CIP and other financial savings programmes

Approve the processes and timetable for annual budget setting, and budget management arrangements

Approve the processes for managing the Trust’s capital programme

Monitor delivery of Trust capital programme

Review and endorse the Trust’s medium and long term financial models prior to Board approval

Monitor the detailed monthly income and expenditure position of the Trust, overall financial performance against plan, and projected final outturn

Receive assurance from the Care Group Directors in respect of performance against annual budgets, capital plans and the cost improvement programme, quality, innovation, productivity and prevention plans, commissioning for quality and innovation plans (CQUIN), activity and key performance indicators, corporate governance activities and responsibilities;

Monitor effective balance sheet management, including asset management and cash planning

Monitor financial performance indicators, including compliance with Public Sector Payment Policy

Monitor the development, application and delivery of financial recovery plans

Monitor the development and application of financial contingency plans

Review the robustness of the risk assessments underpinning financial forecasts

Review of the Finance Directorate risk register, including delivery of action plans

Approve financial policies & procedures, including standing financial instructions

Work with the Audit Committee and the Quality Committee advising on the non-clinical aspects of risk management.

Identify opportunities for improvement and encourage innovation

Monitor contract negotiation and performance noting the position of contracts and raising any concerns; receiving assurance from the Executive Directors in respect of the organisation meeting the contractual requirements and expectations of commissioners, meeting the legislative / regulatory requirements of regulators and other bodies contracts including those over £5m.

Have due regard to the public sector equality duty and the Trust’s equality objectives

Proper referral of issues arising to other Trust committees or groups

Comment on Estates strategy policies & procedures

Comment on Digital Plans policies & procedures

To Oversee the work of the Special Purpose Vehicle (SPV) Task and Finish Group

3

The committee shall be proactive in agreeing the most appropriate reporting format and style to suit the particular needs of the following users and stakeholders in accordance with best practice:

the Board (who may at any time request additional information, or information in a different format) and committees

commissioners, including CCGs and NHS England

public and patients

staff

budget holders

other stakeholders, e.g. other Trusts, local authorities Authority The committee may investigate, monitor and review any activity within its terms of reference. It is authorised to seek any information it requires from any committee, group, director or member of staff (including interim and temporary members of staff), who are directed to co-operate with any request made by it. The committee may secure the attendance at its meetings of any individual or group:

to represent an area of business under review, or

with experience or expertise pertinent to a particular topic or review

Membership

Membership of the committee shall be comprised of the following:

2 x Non-Executive Directors (1 of whom shall chair the committee)

Chief Executive

Chief Operating Officer

Director of Finance

Deputy Director of Finance/Financial Controller Non-Executive Directors are entitled to attend any Trust committee meeting. The Chair has the right to come to any committee at any time. The Chair of the Committee is the Non-Executive Director appointed by the Chair of Humber NHS Foundation Trust. If the Chair is not present, then the Deputy Chair (one of the other NED’s) shall chair the meeting Declarations of interest Members are required to state for the record any interest relating to any matter to be considered at each meeting, in accordance with the Trust’s Conflict of Interest policy. Members will be required to leave the meeting at the point a decision on such a matter is being made, after being allowed to comment at the chairman’s discretion. Declarations shall be recorded in the minutes.

Responsibilities of Members

Members of the Committee have a responsibility to: a) attend at least 10 out of 12 meetings, having read all papers beforehand; b) act as ‘champions’, disseminating information and good practice as appropriate, using systems such as available within the Trust. c) identify agenda items, for consideration by the Chair, to the Lead Director/ Secretary at least 10 working days before the meeting; d) prepare and submit papers for a meeting, at least 1 week before the meeting; e) if unable to attend, send their apologies to the Chair and Secretary prior to the

4

meeting and identify their deputy where applicable. f) when matters are discussed in confidence at the meeting, to maintain such confidences; g) declare any conflicts of interest / potential conflicts of interest in accordance with the Humber NHS Foundation Trust’s policies and procedures;

Quorum

A quorum shall be three of the above, comprising at least one Non-Executive Director. Decisions will normally be reached by consensus, but where voting is required, decisions will be made by a simple majority of the members present. For the avoidance of doubt, designated members of the committee shall be entitled to vote; other attendees are not. Members declaring an interest do not count towards a quorum for the relevant item(s), nor are they (nor their deputy) allowed to vote thereon.

Chair

The Committee shall be chaired by a Non-Executive Director

Frequency

Meetings shall be held every month; a schedule of meetings for the year shall be published in advance and circulated to members and interested parties. The chairman may at any time convene additional meetings of the committee to consider business that requires urgent attention.

Agenda and Papers

An agenda for each meeting, together with relevant papers, will be forwarded to committee members to arrive 1 week before the meeting. A schedule of business reflecting the annual work programme and other matters requiring attention shall be included in each meeting agenda. Unapproved minutes will be circulated to the membership.

Minutes and Reporting

The Committee will have the following reporting responsibilities:

a) to ensure that the minutes of its meetings are formally recorded and provided to the Board of Directors.

b) to present the Chair’s Log to the Board of Directors at the Board’s meetings regularly. The Log shall be prepared by the Chair of the Committee, outlining the key issues discussed at the meeting and those issues that need to be brought to the attention of the Board of Directors. Cover sheets are to be completed for the chairs log and action log outlining assurance escalation;

c) to produce those assurance and performance management reports listed in the Committee’s annual work programme which has been agreed with, and are required by, the Board of Directors; d) any items of specific concern, or which require the Board of Directors’ approval, will be subject to a separate report to accompany the Chair’s Log; e) to produce an annual report for the Board of Directors setting out: i. the role and the main responsibilities of the committee ii. membership of the committee iii. number of meetings and attendance iv. a description of the main activities during the year v. a completed annual self-assessment and the identification of any development needs for the Committee

Administrative Arrangements

The Lead Director - the Director of Finance - is a member of the Committee and has corporate responsibility for:

i liaising with the Chair on all aspects of the work of the Committee, including providing advice;

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ii ensuring the Committee acts in accordance with the Trust’s standing orders and the scheme of reservation and delegation;

iii identifying an officer to undertake the role of Secretary; iv overseeing the delivery of the Secretary’s duties. v minutes are to be written, produced and circulated in 7 working days to

members with 3 working days for changes. b) The Secretary of the Committee will be responsible for:

i attending the meeting; ii ensuring correct and formal minutes are taken in the format prescribed and once

agreed by the Chair, distributing minutes to the members. iii distribution of approved minutes to the Board of Directors iv keeping a record of matters arising and issues to be carried forward via an action

log; v producing an action log following each meeting and ensuring any outstanding

action is carried forward on the action list until complete; vi producing a schedule of meetings to be agreed for each calendar year and

making the necessary arrangements for confirming these dates and booking appropriate rooms and facilities;

vii providing appropriate support to the Chair, Lead Director and Committee members;

Monitoring and Review

It is the responsibility of the Chair to lead the review the effectiveness of the Finance Committee’s Terms of Reference. A review of attendance and effectiveness will be undertaken annually.

Approval Date 13th March 2018

Review Date March 2019

6

Finance Committee Organogram

* Not a formal Sub Group of the Finance Committee, but minutes and work feed into the Committee Workplan

Forward Plan for Finance Committee – March 2018-March 2019

Mar April May June July Aug Sept Oct * Nov Dec Jan Feb Mar

MINUTES OF PREVIOUS MEETING

CHAIRS LOG

ACTION LOG

ITEMS FOR SPECIAL MONITORING (items will change depending on priorities)

Finance – Insight Report

Finance report – Trust

Cash position

IPQT – Performance Section

Care Group financial reports

Year end forecast

Half Year Review

GENERAL ITEMS

Trust Budget Reduction strategy

Care Group Budget Reduction Strategy

BAF and CRR

Capital Plan

Digital Delivery Progress Report

Estates Strategy Delivery Report

SUBGROUP CHAIRS LOG

Capital Management Group

Digital Delivery Group

Estates Strategy Delivery Group

Carter Group

SPV Task and Finish Group

ANNUAL REPORTS from all sub-groups

ADDITIONAL REPORTS

Strategy Delivery for 2018/19 (Strategic Goal 5) (to Board following month)

NHSI annual plan - 2019/20

Benchmarking costs – as and when available

MARS Report (If considered)

NHSLA – CNST Risk Profile

Loans Review

Aged Debtors – Deep Dive

ANNUAL REPORTS

Annual report of F&P

Mar April May June July Aug Sept Oct * Nov Dec Jan Feb Mar

(for Board) (FP) Start

Sustainability

Financial implications of industrial tribunals & suspensions

ITEMS FOR INFORMATION

Internal Audit Reports (MW)

Agreed: ___________ To be updated monthly


Agenda Item: 19


Title of Report:

Charitable Funds Committee Meeting 19 January 2018 Minutes

Author:

Name: Paula Bee Title: Non Executive Director

Recommendation

To approve To note



Purpose of Paper:

The report provides the Board with an update of recent activity at the Committee


Any issues identified in the minutes











N/A Comment



Legal √

Compliance √

Communication √

Financial √

Human Resources √

IM&T √




No


Charitable Funds Committee

Minutes of the Charitable Funds Committee Meeting

held on Wednesday 17 January 2018, 1.00pm in the Conference Room A, Trust Headquarters

Present: Peter Baren, Non-Executive Director (Chair)

Paula Bee, Non-Executive Director (via conference call) In Attendance: Michele Moran, Chief Executive

Peter Beckwith, Director of Finance Mervyn Simpson, Financial Services Manager Andy Barber, Hey Smile Foundation Charity Director Jenny Preston, Charity Manager Sarah Sheperdson, HEY Smile Foundation Clare Woodard, Charity Champion (for item 11/18) Jenny Jones, Trust Secretary (minutes)

Apologies: None 01/18 Declarations of Engagement

None declared.

02/18 Minutes of the Meeting held on 14 November 2017 The minutes of the meeting held on 14 November 2017 were agreed as a correct record with the following amendments:- 67/17 Health Stars Operational Plan The funding levels within the fourth paragraph were incorrect and should read £543,570,00 It was noted that the Committee did not approve the Operations Plan as further amendments were required. It was agreed that the resolution for this item should be amended to read:- “The Committee reviewed the first draft of the Operations Plan”

03/18 Matters Arising and Actions List

The actions list was reviewed and the updates below noted:- 52/17 Circle of Wishes Update Mrs Preston reported that a clinical expert, Dr John Byrne, has been identified to validate the appropriateness of clinical items. The Committee work plan was tabled. Copy to be sent to Ms Bee. Additions made include review of the report to the Board on the Operations Plan and also the review of the full accounts every six months.

04/18 Health Stars Operations Plan Update The paper updated the Committee on the progress of the Plan for 2018/19. A full


review of the draft operations plan has been carried out including review of all the constructive feedback from the Committee. Meetings have been arranged with key Trust staff to ensure that processes are aligned to the Trust, its strategic objectives and goals. Resolved: The update was noted

05/18 Health Stars Update The report provided the Committee with an update on

Legacy received

Significant grant funds generated

Wish plans to be developed

Level of work to change the finance reporting Work has also taken place on prospect research and development of businesses, local and national funders. The work that S Shepherdson and the team have done with Xero has been excellent. Started to put in appointments to review individual funds including identifying the priorities for fund raising within each fund. This will be done in conjunction with fund guardians. It was queried if the amount of charitable fund in Scarborough is known. Mr Barber is led to believe this is a sizeable amount and is in the process of clarifying this with York. A proposal report will be available for the next meeting. An update on the legacies for Bridlington and CAMHS were provided. An events programme has been developed but not yet publicised. The Chief Executive suggested this was circulated to the Committee prior to the next meeting and also an agenda item at the next meeting. Mr Barber explained it is challenging to come up with events that can engage all Trust staff. He took the Committee through the various ideas identified in the report explaining that many were family orientated and others included work with other Trusts to celebrate the NHS 70 birthday. A favourable deal has been agreed with the new Hilton Hotel in Hull. Members suggested that a wider spread of venues should be reviewed to ensure that it covers the Trust area. There are some appropriate venues in Whitby for example. GDPR – Mr Barber explained that there is a policy in existence which needs aligning with the Trust’s. Mr Barber will liaise with Mr Beckwith and raise at the next Information Governance meeting. Resolved: The report and verbal updates were noted. Proposal re Scarborough Funds to be available at the next meeting Action AB/JP Events programme to be circulated to the Committee and on the agenda for the next meeting Action JP GDPR to be discussed at the next Information Governance Meeting Action PBec

06/18 Health Stars Financial Report Mr Barber introduced the new formatted report which included: -


Health Stars Financial Highlight Report

Health Stars P&L April to Nov 2017

Copy of Fund balance sheets

An overview of Fund Zones

The charity reported income for year to November of £179,472k.

Expenditure reported for the year to November is £21,363 on wishes, excluding gifts in kind.

Total net increase in funds for the year to November is £108,756, due mainly to a legacy received split across Bridlington and Alfred Bean and community services.

It was noted that under the Admin Fees lines on the profit and loss report, further work is still to be done to moves costs into the correct lines which will be completed by the next meeting. Ms Bee felt this was a helpful report showing the detail the Committee required. She asked if it was possible to align the information with the expectations as it was not possible to judge it alone. The Chief Executive said that Mrs Preston’s salary was agreed for a 6 month period and the governance around this needed to be tied up. The Board needed to be updated on the position about the salary and any contributions. It was agreed that a paper would be prepared for the March Board meeting which will be shared with the Committee prior to submission. Mrs Preston agreed with the suggestion given that the CHCP agreement was initially for 12 months so it would be an appropriate time to review. Discussion took place around the fund zones and whether these should be further reviewed. Mr Beckwith’s view was that where there are shared premises, the Trust would be the main holder. A bid through the Purse Foundation for £80k to look at voluntary manager costs to support the youth volunteers is being pursued. Mr Baren asked about Hornsea plans as the Trust does operate services from the area. He was informed that if the legacy is unrestricted it might be able to be used for the benefit of the people of Hornsea. It was confirmed that the legacy for Macmillan is restricted to the Macmillan Unit in Bridlington and was shown as part of the Bridlington zone in the report. The Chief Executive found the fund zones details interesting. She noted that there were huge amounts for CHCP and not as much for the Trust which may help with future discussions about the charity. She recognised the decision for CHCP was taken at a point in time and was right however there is more intelligence available now. Mrs Preston/Mr Barber and Mr Beckwith will be reviewing the Scarborough charitable funds. Following a query, It was confirmed that all charitable funds are held in a separate bank account and are not part of the Trust’s main account. It is hoped that a local auditor can be used to audit the charity accounts rather than using the external auditors which are more costly. A proposal paper was suggested for the next meeting outlining the plans. Mr Beckwith will also raise in his next discussion with the auditors.


Resolved: The report and verbal updates were noted Report to show figure against expectations to be included in future reports Action AB Report re future proposals around Charity Manager salary and CHCP to be prepared for the next meeting and subsequently the March Board meeting Action JP/PBec Proposal to change the auditor for the charity accounts to be prepared for the next meeting Action JP/PBec

07/18 Charitable Funds Management Fee Splits Mr Barber reported that the management fee splits have been agreed up to the end of the financial year and were discussed at the last meeting. Ms Bee clarified that for the appeal the potential funding to support the programme of work and fee for admin agreed that the levy included a percentage of admin fees and own fees. Resolved: The verbal update was noted and Committee support for the split reaffirmed.

08/18 Terms of Reference for Capital Appeals Group The Terms of Reference were presented to the Committee for discussion. Following discussion it was agreed that:-

The name of the group would be the CAMHS Tier 4 Task and Finish Group for the CAMHS project

The word “capital” would be removed from the document as there could in future be revenue

The inclusion of the Director of Finance in the group was raised. It was pointed out this would likely be a delegate who would attend.

As it is a task and finish group an effectiveness review is not required, however there would be an end of project report to the Committee.

Ms Bee was concerned about the membership as there was no reference to co-opting other members such as patients, carers or representative from other organisations who may be involved in the appeal. Mr Barber said it is appropriate to have both internal and external members on the group. Key members are the internal team and bring in co-opted. It was agreed that the changes discussed would be made and e mailed to members so they can be virtually approved and formally confirmed at the March meeting. Resolved: Changes to be made to the Terms of Reference and e mailed to members for virtual approval. Action JP Final version of the Terms of Reference to be submitted for formal approval at the March meeting Action JP

09/18 Proposed Targets for Capital Appeals Group The paper outlined the proposed Committee members for the Group. At the last CAMHS meeting the Terms of Reference were reviewed along with the recruitment of internal members and the proposed names for the campaign. Following a query around the role of the group, Mrs Preston clarified that this group is more of a wider community group of people who would work to help promote the appeal and bring in their expertise and hopefully support from their own contacts. The Chief Executive said this was not made clear in the paper, as it


read as if all the people named would be on the Task and Finish Group. She suggested the group name be amended to something different to make the distinction eg Community Engagement Group. The intention is for one person of this group to be invited to be a member of the Task and Finish Group and they would feedback on behalf of the group. It was suggested by Ms Bee that something needed to be included in the Capital Appeals Group Terms of Reference (ToR) previously discussed to show that the Community Engagement Group (if this was to be the name), to state that a member of the Group would have a seat on the Task and Finish Group. This group could then help support the appeal through its membership. It was suggested that the Patron of the appeal may be the best person to sit on the Task and Finish Group. Ms Bee suggested also including in the ToR, the duties of this person to provide clarity on the role and function. She felt there should also be this role be included in the ToR for both the Community Engagement Group and the Task and Finish Group to reflect the identified person being a conduit between the Task and Finish Group and the members of the Community Engagement Group. There should also be clarity in the ToR that the seat on the Task and Finish Group is a non voting role. It was suggested that the role and function could be scripted so members are clear about the appeal when discussing with their colleagues. The Senior Responsible Officer (SRO) has been identified as Iain Omand. However due to the nature of the role it was suggested that this perhaps should be Mrs Preston so there is alignment between the campaign and the Community Engagement Group. The Group also needed to have strong governance around it. The establishment of a Community Engagement Group with the people identified in the report with a co-opt arrangement for each person on the Community Engagement Group was supported. The Patron will be asked to sit on the Task and Finish Group. A welcome letter from the Chief Executive and Ms Bee to be drafted and checked with legal services around the establishment of the Community Engagement Group setting out the remit and covering all areas including potential suppliers and any conflicts of interest. The Chief Executive will also meet with Alan Johnson to thank him for being a Patron of the appeal. Ms Bee suggested drawing up a framework for the Community Engagement Group to consider which will be aligned to the appeal. She also proposed that the activity of the group should be recorded and consideration given as to how this would be fed back into the Task and Finish Group. Mrs Preston thought a verbal update would be sufficient. An induction event is also planned at which the expectations of the Group would be set out. It was agreed that the Task and Finish Group minutes will feed into this Committee. It was agreed to separate out the Terms of Reference to reflect the discussions at the meeting and revised copies to be e mailed to Committee members for virtual sign off rather than waiting for the March meeting.


Potential Funding Targets will be identified for the next meeting. The Committee considered the refurbishment of the Children’s Centre and whether this should be included as part of the appeal campaign. It was agreed that the Task and Finish Group will look at this as the Committee considered this to be part of the project. Resolved: The report was noted Capital Appeals Group Terms of Reference to state that a member of the Group will have a seat on the Task and Finish Group Action JP The role and non voting status of the identified person to be included in the ToR for both the Community Engagement Group and the Task and Finish Group Action JP Patron of the appeal to be asked to have a seat on the Task and Finish Group Action JP A welcome letter from the Chief Executive to members of the Community Engagement Group to be drafted which will include the remit of the Group. Action JP Chief Executive to meet with Mr Johnson to thank him for being the appeal patron Action MM Terms of Reference to be separated out to reflect discussions and for these to be e mailed to Committee members for virtual sign off Action JP Potential funding targets to be identified for the next meeting Action JP

10/18 Proposed Logo or the Children’s Campus Appeal of the Capital Appeals Group The Committee was shown proposed logos for the appeal for consideration. The reason for the use of the “Impact” name was explained and has been discussed within the project group. Mr Baren asked if the word “appeal” within the “t” could be made to stand out more. The Chief Executive suggested using black font which may improve it. The Health Stars star is used as the dot above the “I” as it is important that there is recognition of the Trust’s charity. Discussion also took place around the inclusion of the smiley face, but this was seen as acceptable. It was suggested that the amendments be made to the proposed logo and for them to be e mailed to the members for final review. The business proposal for Eskimo Soup will be circulated to Committee members. Discussion took place regarding a public launch and how this could be progressed. The Chief Executive advised caution given that the contract is yet to be agreed and signed and too much publicity could be detrimental if there are any problems with the funding for the project. Ms Bee suggested including in the Terms of Reference wording be amended further to cover the publicity aspect and state that all plans should have the approval of the Chief Executive before any wider appeal is published. The Committee supported this proposal. Resolved: The Committee noted the suggestions. Amendments to be made and logo to be recirculated to members for final review. Action JP Terms of Reference for the Task and Finish Group to be further amended to included that any publicity should have the agreement of the Chief Executive. Action JP


Eskimo Soup Proposal to be shared with the Committee Action JP

11/18 Circle of Wishes Update The report provided an update on the Circle of Wishes activity. Clare Woodard, Charity Champion joined the meeting for this item. The Chief Executive raised concern at some of the items put forward for funding which included butter and plastic spoons from the Bridlington fund zones. Mrs Preston explained that as these are below the limit they are authorised by the fund manager. The Chief Executive disagreed stating these are items that should be paid for out of core services not through charitable funds. Previously these items were purchased through petty cash. It was confirmed that these items have already been purchased due to the low authorisation value. It was queried whether the fund could be frozen until this issue has been resolved. Mr Baren suggested sending a letter from the Committee expressing its concerns over the use of the fund. Mr Barber said that as there is significant amount of funds in the account, a letter could be sent to the Charity Commission with a suggestion to use the funds in different areas of Bridlington that would be for the benefit of the people in Bridlington. The money is for local use in Bridlington, but due to changes with services it is difficult to spend the money where it was intended. It was agreed to send a letter to the fund manager in the first instance, and copied to Mr Beckwith for him to discuss with his opposite number. The Chief Executive suggested using some of the money she raised to help with the low stimulus room at Westlands. It was confirmed that £7k is already available. It was noted that the defibrillators and water cooler item have been removed as per discussions at previous meetings. Discussion took place around the kitchen for Westlands. Donations such as these are treated as gifts in kind, with invoices raised and then “nilled” off. It was also suggested that this should also apply to the use of office space at Trust HQ. It was noted that Health Stars is approaching its 200th wish. Resolved: The report was noted. Letter to be sent to the Fund Manager for Bridlington and copied to Mr Beckwith regarding the change of use of funds Action JP/AB

12/18 Items for Escalation or Inclusion on the Risk Register All items identified throughout the meeting. It was suggested that the Communication plan for the children and young people appeal come to the next meeting for consideration.

13/18 Any Other Business The Chief Executive thanked everyone for their work with the charity and in particularly the Impact appeal.

14/18 Date and Time of Next Meeting 13 March 2018, 10.30am in Conference Room B, Trust Headquarters

Signed: ………………………………………….Chairman: Peter Baren

Date: ……………………….


Agenda Item: 20

Title & Date of Meeting: Trust Board Public Meeting - 28 March 2018

Title of Report:

Report from the Mental Health Legislation Committee (MHLC) following meeting of 8 February 2018

Author:

Name: Michael Smith Title: Chair MHLC

Recommendation

To approve To note


For information √ To endorse

Purpose of Paper:

To update the Board on issues discussed, approved or escalated at MHLC on 8th February 2018


o The committee wanted a deeper understanding of issues around the use of Section 4 of the Mental Health Act

o There is a requirement for more informative and less time-consuming quarterly performance reporting

o There is no committee representative that covers Approved Mental Health Professionals (AMHPs) in Hull

o Excellent progress has been made in reducing restricted interventions resulting from a structured approach and a real transformation in culture and team working.











N/A Comment



Legal √

Compliance √

Communication √

Financial √

Human Resources √

IM&T √




No


Briefing report - Mental Health Legislation Committee (MHLC) 8 February 2018 Key issues

The meeting was quorate The quarterly performance and assurance report was analysed. The report

contains a large quantity of data and demonstrates a real desire to monitor and measure. In order to make best use of the data and specifically to avoid the misinterpretation of, for example data ‘blips’ or slow moving (unnoticed) trends, Dr Byrne has agreed to assist with establishing best practise in this area and to provide a report and suggestions to the next meeting

The Committee had previously noted and expressed concern about a shortage of Approved Mental Health Professionals (AMHPs) in Hull. This had been escalated and Dr Byrne was also to ask Hull City Council to provide representation at the meeting (East Riding Council already being represented).

The Committee noted the Trust’s compliance of Annex B of the Mental Health Act Code of Practice policy requirements. This had been as a result of hard work to audit and update policies.

Excellent progress had been made with reducing restrictive interventions and the Committee applauded the structured approach to this task and a real transformation in culture under the leadership of the Assistant Director of Nursing.

Risks to be brought to the Board’s attention

There is a mismatch between audits requested and the resource available to undertake them. A review of their necessity is to take place, in the context of overall improvements to auditing brought about by the use of the Perfect Ward ‘App’ (a tablet (computer) based method for monitoring compliance) which is proving to be effective and well-liked by staff.

There have been a cluster of ‘unlawful detentions’ which, although unconnected and rectified reinforce the need for regular reporting to the Committee for further investigation and escalation where necessary.

Documents

Trust Board Meeting 28 March 2018 Agenda - Public Meeting papers... · Trust Board Meeting 28 March 2018 Agenda - Public Meeting ... Guardian of Safe W orking Report JB To receive