board of directors - lancashire and south cumbria nhs … board/trust board... · 2017. 11. 15. ·...

Board of Directors Thursday 02 November 2017

08:30am

Training Room 1 & 2, The Harbour, Windmill Rise, off Preston New Road,

Blackpool, FY4 4FE

(Sat Nav postcode FY4 4XQ)

Board of

Directors

Quality Committee

Finance & Performance Committee

Nomination / Remuneration

Committee

Audit Committee

Board of Directors

Meeting Board of Directors Meeting

Location Training Room 1 & 2, The Harbour, Windmill Rise, off Preston New Road,

Blackpool, FY4 4FE (Sat Nav postcode FY4 4XQ)

Date Thursday, 02 November 2017

Time 08:30am

Reference Item Lead Action Enc. FOIA

PART ONE (PUBLIC MEETING)

TB 154/17 Welcome and opening comments Chair Verbal

TB 155/17 Apologies for absence and confirmation of quoracy

Chair Verbal

TB 156/17 Declarations of Interest Chair Verbal

TB 157/17 Minutes of the previous meetings Chair Decision Paper

TB 158/17 Action Tracker Chair Decision Paper

SCRUTINY & ASSURANCE

TB 159/17 Patient Story Director of Nursing &

Quality Noting Verbal

TB 160/17 Trust Chair’s Report Chair Noting Paper

TB 161/17 Chief Executive’s Report Chief Executive Discussion Paper

TB 162/17 Audit Committee Chair’s Report Committee Chair Noting Paper

TB 163/17 Quality Committee Chair’s Report Committee Chair Noting Paper

TB 164/17 Finance & Performance Committee Chair’s Report

Committee Chair Noting Paper

TB 165/17 Quality & Performance Report Chief Operating Officer Noting Paper

TB 166/17 Finance Report Chief Finance Officer Noting Paper

TB 167/17 Quarterly Workforce Report Director of Human

Resources Noting Paper

TB 168/17 Board Assurance Framework Director of Nursing &

Quality Decision Paper

TB 169/17 Mental Health Act Managers Director of Nursing &

Quality Noting Paper

TB 170/17 Learning from Deaths Director of Nursing &

Quality Noting Paper

PART TWO (PRIVATE MEETING)

TB 171/17 Minutes of the last meeting Chair Decision Paper

TB 172/17 Chief Executive Report Chief Executive Noting Paper

TB 173/17 Draft Quality Report Director of Nursing & Quality/ Medical Director

Noting Paper

TB 174/17 Winter Planning Chief Operating Officer Noting Presentation

TB 175/17 RRCS Transition Chief Finance Officer Decision/

Discussion Paper

TB 176/17 Universal Services Chief Operating Officer Discussion Paper

TB 177/17 Any Other Business Chair Verbal

TB 178/17 Date & Time of the Next Meeting

07 December 2017, 8.30am

Chair Verbal

Declaration of Interest – Board of Directors

Date of Declaration

Surname First Name

Job Title Nature of Interest

Do you envisage a conflict of interest between outside employment and

your NHS employment?

Nil Declaration

21/02/2017 Eva David Trust Chair Employed by Union Learn as National Manager

Yes TUC funds learning in relation to apprenticeship and Trade Union representation.

06/02/2017 Tierney-Moore

Heather Chief Executive

1. Director of Lancashire Sport Partnership2. Trustee of Community Integrated Care3. Macmillan Allumni Patron4. Retained Consultant Glenview5. Patron Breakthrough Mental Health Charity

Yes Potential risk of CIC bidding to provide services in Lancashire that are also of interest to LCFT

06/09/2017 Furlong Gwynne Non-Executive Director &

SID

1. 1. Non-Executive Director of Together HousingGroup

2. 2. CEO of Regain Sports Charity3. 3. Trustee of Chorley Youth Zone4. 4. Non-Executive Director of subsidiary of

Progress Housing Group called Concert LivingLimited

No

13/02/2017 Ballard Peter Deputy Chair & Non-Executive Director

Chief Executive DSE Service No

29/03/2017 Dickinson Louise Non-Executive Director

1. Director at Talegar Limited2. Consultancy Services at Talegar Limited3. Foundation Governor and Finance Chair at

St.Vincents Primary School

No

03/02/2017 Wilson Isla Non-Executive Director

1. NED - Progress Housing Group2. Shareholder – FSquared Ltd3. Shareholder - Ruby Star Associates Ltd4. Consultancy/Advisory Work – Ruby Star

Associates

No

1 of 264

Declaration of Interest – Board of Directors

03/02/2017 Curtis David Non-Executive Director 1. Director at Clinical and Corporate Governance

Limited2. Clinical Associate at MIAA (Advisory Section)

No

07/02/2017 Gregory Bill Chief Finance Officer

1. Trustee of Healthcare Financial ManagementAssociation

2. Governor of Stockport College3. Co-opted member of Lancaster University

Financial and General Purpose Committee.4. Director of Red Rose Corporate Services

No

02/10/2017 Possener Julia Non-Executive Director

1. Lay member of the Lancaster UniversityManagement School and Faculty of Arts andSocial Science Ethics Committee. Although theTrust and LU have a working relationship andcollaborate such matters do not fall usuallywithin these Faculties.

2. My partner's sister is the owner of a domiciliarycare business which does have contracts withThe Trust. I am including this for the sake ofcompleteness. Bluebird Lancaster and SouthLakeland Ltd. I have no formal nor informalinvolvement in that business.

No No business with the Trust or other

organisations providing

services to NHS No unrelated faculties or formal or informal business.

13/02/2017 Roach Dee Executive Director of

Nursing & Quality

06/02/2017 Marshall Max Medical Director

06/02/2017 Moore Sue Chief Operating Officer

07/02/2017 Gallagher Damian Director of HR

2 of 264

BOARD OF DIRECTORS

Minutes of the Part One Board of Directors Meeting held on 05 October 2017 Training Rooms 1 & 2, the Harbour, Blackpool

PRESENT: David Eva, Trust Chair (Chair) Heather Tierney Moore, Chief Executive Max Marshall, Medical Director Peter Ballard, Deputy Chair Bill Gregory, Chief Finance Officer Sue Moore, Chief Operating Officer Dee Roach, Director of Nursing Damian Gallagher, Director of HR Louise Dickinson, Non-Executive Director Isla Wilson, Non-Executive Director Julia Possener, Non-Executive Director Gwynne Furlong, Non-Executive Director David Curtis, Non-Executive Director Jo Alker, Company Secretary

IN ATTENDANCE: Bev Howard, Head of Communications Andrew Pennington, Associate Director of Research and Development (Agenda Item TB 143/17 & TB 144/17) Viv Prentice, Deputy Company Secretary (minutes)

OBSERVERS: Lisa Knight, Insight NED Development Programme

TB 138/17 WELCOME & OPENING COMMENTS The Chair welcomed everyone to the meeting and thanked Board members for their contributions to the development session which had taken place prior to the Board meeting.

TB 139/17 APOLOGIES FOR ABSENCE & CONFIRMATION OF QUORACY There were no apologies for absence and confirmation of quoracy was provided.

TB 140/17 DECLARATIONS OF INTEREST Gwynne Furlong, Non-Executive Director and Bill Gregory, Chief Finance Officer declared an interest as both sit on the Red Rose Corporate Services Board. Heather Tierney-Moore, Chief Executive declared an interest as an AHSN Board member.

TB 141/17 MINUTES OF THE PREVIOUS MEETING The minutes of the previous meeting held on 06 September 2017 were approved as a true and accurate record.

TB 142/17 ACTION TRACKER The action tracker was reviewed and actions and updates provided.

TB 143/17 PATIENT STORY The Board observed a short video which followed a participant’s journey as they took part in a clinical research programme.

TB 144/17 RESEARCH AND DEVELOPMENT PLAN The Associate Director of Research & Development provided Board members with an update on the delivery of the Research & Development plan. He

UNCONFIRMED

3 of 264

reminded Board members of the key objectives and KPIs; this included a KPI for participant recruitment. This had initially been below target in 2016/17, however the department had successfully achieved target by the end of the financial year. Furthermore, it was anticipated that for 2017/18 this target would be exceeded. The Board noted that the Trust had been ranked number one in the National Care Trusts League Table for the ‘Volume of Research’. The Associate Director of Research & Development confirmed that income and grant funding had increased and although funding for clinical research had remained the same, in view of current cuts this was considered an achievement. Training and team development were outlined for the Board, which included information in relation to the recent communications project to engage staff in research throughout the Trust. Recent and ongoing study examples were presented to the Board, in particular a study into slip resistant footwear to reduce slips among healthcare workers. Following a question in relation to how research fits within the STP programme, the Medical Director confirmed that research would be added to the STP agenda when appropriate. The Board noted the update provided.

The Associate Director of Research and Development left the meeting TB 145/17 TRUST CHAIRS REPORT

The Chair presented his report which included an overview of both Non-Executive and Governor activity. Non-Executive Director, Julia Possener, took the opportunity to update the Board on the discussions she had led around Mental Health Act compliance. The Board noted that a future Board Development Session would be scheduled to discuss how the Trust discharges its responsibilities. In addition, Governors will be updated in respect of the assurance the Board receives around the Mental Health Act at the Council of Governors meeting in February 2018. Non-Executive Director, Julia Possener, advised that she would be attending the Hospital Managers Forum in November and would also be observing a forthcoming tribunal.

Following a number of concerns raised at the Scarisbrick Centre via Dear David, the Director of Nursing updated the Board on the immediate actions taken, which included involving nursing staff on clinical decisions and enhancing communication. The Trust Chair would also be visiting the service. The Director of Nursing will continue to update the Board via the Trust Chair’s Report. ACTION The Board noted the content of the Chair’s Report.

TB 146/17 CHIEF EXECUTIVE REPORT The Chief Executive introduced her report and noted the recent CQC inspection at HMP Liverpool. Initial feedback had been received which was positive and highlighted a strong focus on sustaining quality within the prison. The Trust awaits the final report. The Board noted that the Trust’s shared objectives had been developed and the business planning process had commenced for 2018/19.

4 of 264

The Chief Executive confirmed that the Innovation Agency re-licensing process had been deferred until March 2018. However, the Trust had signed a lease for their premises and noted the limited risk associated with this.

The Board’s attention was drawn to A&E performance and the importance of ensuring the Board was sighted both on winter planning and the Trust’s role in the system as a whole. The Chief Executive confirmed that the target for four hour waiting times remained at 95%. There was a concern that flu would impact significantly this year. A more detailed session on winter preparedness would be held at the November Board meeting. Following a question in relation to the Trust’s flu target, the Director of Nursing confirmed that the Trust’s target was 70% with a CQUIN of £600K. The Board were pleased to note that three weeks into the flu campaign the Trust had achieved 20%.

The Chief Executive drew attention to the Prime Minister’s recent announcement to undertake an independent review into the Mental Health Act, emphasising the importance of this for the Trust.

The Chief Executive informed the Board of her appointment as the Central Lancashire lead for the STP Board. In addition, Isla Wilson, Non-Executive Director had been appointed onto the STP Board and Gwynne Furlong, Non-Executive Director had been asked to support work around property and estates for the STP.

The Board noted that the Accountable Officer at Chorley & South Ribble CCG, Jan Ledward, had stepped down and that her replacement would be announced imminently. The interim CEO of Lancashire County Council would also be announced in the near future.

TB 147/17 QUALITY AND PERFORMANCE REPORT The Chief Operating Officer presented the Quality & Performance Report for month five and confirmed that the Trust was compliant with all NHS Improvement indicators. The Board noted the inclusion of the Southport & Formby Quality & Performance Report, which would be further developed over the coming months.

Key highlights of the Quality & Performance Report were outlined, which included the small reduction in length of stay across mental health beds, the data being reported around A&E wait targets and the increase in presentations.

The Chief Operating Officer confirmed that the Trust had received the outcome of Core 24 funding and whilst the Trust had not successful in receiving funding for unscheduled care, Core 24 funding would be released in-year and therefore confirmation was awaited from Commissioners.

The Board’s attention was drawn to the EIS two week wait target. Whilst performance was good, checks were being undertaken in relation to the reporting of this target. The Chief Operating Officer agreed to report back to the Board if there were any issues. ACTION

The Director of Nursing drew the Board’s attention to the increase in violence and aggression towards staff and reassured the Board that a detailed piece of work to review themes and hotspots had been undertaken to provide a baseline analysis.

5 of 264

TB 148/17 FINANCE REPORT The Chief Finance Officer presented the finance report which highlighted a significant deterioration from month four (£2m) with a pressure of £8.3m until the end of the year. The Trust had been working on recovery plans and assurance had been sought to bridge a gap of £6.5m.

The Chief Finance Officer confirmed that a meeting had been held with NHS Improvement. This was very constructive and provided an opportunity to share the risks and pressures.

In terms of CIP, this is currently behind plan and links with the run-rate on staffing. However, the majority of the schemes to reduce cost in year were delivering. In relation to cash, the Trust was still reporting a positive position, although this had fallen back this month due to a Local Authority contract.

The Chief Finance Officer confirmed that the issue with CQUIN was a national issue and potentially adds 0.5% on the total provider budget.

In relation to capital, the Trust was behind where it wanted to be at this point in the year. The Chief Finance Officer outlined the difficulties in gaining access to sites at hospital for perinatal and inpatient schemes. Whilst this had been escalated it remained unresolved.

TB 149/17 MEDICINES MANAGEMENT ANNUAL REPORT The Medical Director presented the Medicines Management Annual Report, the key highlights of which included the roll-out of EMPA and the business case for the roll-out of pharmacist technicians into community teams. In addition, the Lord Carter review had highlighted some promising data and reflected the work of both the recently retired and newly appointed Chief Pharmacist.

The Medical Director confirmed that there were no areas of fundamental concern.

The Board noted the content of the Medicines Management Annual Report.

DATE AND TIME OF NEXT MEETING 02 November 2017 @ 08:30a.m. Training Room 1 & 2, The Harbour

6 of 264

Board of Directors

Agenda Item TB 160/17 Date: 02/11/2017

Report Title Trust Chairs Report

FOIA Exemption No Exemption

Prepared by Umme Batan, Corporate Governance Support

Presented by David Eva, Trust Chair

Action required Noting

Supporting Executive Director Chief Executive

PURPOSE OF THE REPORT:

Report purpose The purpose of the report is to provide the Board with an overview of the activity undertaken by the Board and Non-Executive Directors in addition to the Board of Director meetings and Council of Governor meetings.

Strategic Objective(s) this work supports

To become recognised for excellence

Board Assurance Framework risk 1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as a care provider.

CQC domain Well-led

1.0 NON-EXECUTIVE DIRECTOR ACTIVITY The Non-Executive Directors have been attending the Board Committee meetings of which they are a member (including the Financial Recovery Group) and apologies have been given where they were unable to attend.

In addition to the usual Board business, Non-Executive Directors (NEDs) have been involved in their areas of special interest during the period of October 2017 – November 2017:

Gwynne Furlong

Attended the Land Committee meeting in October Met with the Company Secretary and the Deputy Company Secretary to discuss the

Quality and Assurance Committee agenda for the November meeting Attended the RRCS Board Meeting and a RRCS Shareholders meeting Met with the Property Services Director Met with the Chief Finance Officer

Peter Ballard

Visited the My Place project with the Chief Executive

Louise Dickinson

Attended the Good Practice Visit in October to the 0-19 Services at Sandy Lane HealthCentre

Met with the internal Auditors

7 of 264

Met with the Associate Director of Risk and Assurance to discuss an Audit Committee Report

Had an introductory meeting with Richard Tyler from KPMG and also met with Rob Jones the Senior Manager from KPMG

Had a tele-call with the Medical Director to discuss an Audit Committee report Attended monthly meeting with the Chief Executive

Julia Possener

Attended the HFMA Lay members event

David Curtis

Attended a Cooking Group organised by a Service User in Lancaster Attended the Schwartz Round in October Carried out a visit to the Cove in Heysham

Isla Wilson

Had a tele-call with the Marketing Manager from the TAS team to discuss LCC universal tender and social value

Had an introductory meeting with Steve Tingle the Head of Operations, Children and Young People Wellbeing Network

In addition to the above:

Louise Dickinson, Peter Ballard and Isla Wilson had a catch up meeting to discuss the Financial Recovery Group meeting papers

David Curtis, Julia Possener and Isla Wilson attended the Positive Practice Awards Event

Gwynne Furlong and Louise Dickinson attended the World Mental Health Day event at The Harbour

Peter Ballard and Isla Wilson met with the Company Secretary and the Governance Manager to discuss agenda setting for the October Finance & Performance Committee

Non-Executive Directors Peter Ballard, David Curtis, Julia Possener, Gwynne Furlong and Isla Wilson attended the Annual Members Meeting and the Annual Membership Conference on 25 October 2017

2.0 CHAIR’S ACTIVITY

The Chair attended the Board meetings and Council of Governors meeting including the CoG Nomination Remuneration Committee

The Chair had weekly catch up meetings with the Chief Executive The Chair attended external meetings including the System Leaders meeting The Chair and Deputy Company Secretary met with the Lead and Deputy Governor to

discuss the CoG forward plan and agenda setting. The Chair continues to meet with MPs and local authority members The Chair carried out a visit to Scarisbrick Inpatients Unit at Ormskirk Hospital The Chair attended and opened the Leyland Health Mela and the Positive Practice

Awards in October The Chair opened the Annual Members Meeting and the Annual Membership

Conference

3.0 COUNCIL OF GOVERNORS UPDATE This section has been added to the Chair’s Report in order to keep the Board updated on Council of Governor activity, recognising that since 1 April 2017, Board members have been attending meetings on an invitation basis.

8 of 264

Since the last Chair’s Report received on 5 October 2017, the following items have been considered by the Council of Governors:

17 October 2017 The Council of Governors approved the change to the number of governors on the

Council of Governors:

- Nominated Governors from 5 to 6

- Public Governors from 12 to 16

- Staff Governors from 6 to 7

These changes were presented and approved at the Annual Members Meeting on the

25th October.

The Chair took the opportunity to inform Governors on the Trust’s engagement with the

STP Board. Non-Executive Director Isla Wilson has been appointed as NED

representative and Non-Executive Director Gwynne Furlong has been asked to support

work around property and estates. In addition, Heather Tierney-Moore has been

appointed as the Central Lancashire lead for the STP Board

Andrew Pennington the Associate Director of R&D provided a presentation on theresearch carried out within the organisation

Matt Joyes the Associate Director of Safety and Quality Governance provided apresentation on the process for Raising Concerns within the Trust

4.0 USE OF THE COMMON SEAL To inform the Board that the Common Seal has been used as follows since the Board of Directors meeting on 05 October 2016:

18/10/2017 – Lease of Lingmell House, Chorley (Water Street) from Stonewell PropertyCompany Ltd. Lease of administrative offices set across 3 floors totalling 11,409 sqft

18/10/2017 - Lease of Chorley Centre Centre between LCFT and NHS PropertyServices

18/10/2017 - Lease of Coppull Clinic between LCFT and NHS Property Services

5.0 RAISING CONCERNS As Trust Chair I continue to oversee the Dear David process for staff to raise concerns. This process compliments other mechanisms for staff to raise concerns such as the Raising Concerns Guardian. During August, the following concerns were raised with me through Dear David:

Concerns over a potentially unnecessary and delaying stage in a care pathway;

Attitude of staff in a specific team;

Concerns over the Network Redesign and the capacity and the stress on managers

Concerns over a specific named manager;

Concerns over the level of violence on a specific ward at Guild Lodge.

The Executive Director of Nursing and Quality (as Executive Lead for Raising Concerns) and Associate Director of Safety and Quality Governance (as Raising Concerns Guardian) continue to administer the Dear David process on my behalf. They have ensured that all concerns are being reviewed with feedback provided to those raising concerns directly, where possible, and also included in the Quality Matters electronic bulletin to staff.

6.0 6.0 NIHR Lancashire Clinical Research Facility (CRF) Grand Opening The Lancashire CRF would like to invite Board members of all partner organisations to its

official grand opening on 21st November 2017, 12.45pm-2pm. Max Marshall and Karen

Partington will speak before patient representatives officially open the unit. A tour of the facility

9 of 264

will then be conducted for all guests. The event will be held at

Lancashire Clinical Research Facility, Avondale Unit, Royal Preston

Hospital, Sharoe Green Lane, Fulwood, PR2 9H

7.0 BOARD ACTION The Board is asked to note the updates provided for information.

10 of 264

Board of Directors


Report Title Chief Executive’s Report – Part One


Prepared by Heather Tierney-Moore, Chief Executive

Presented by Heather Tierney-Moore, Chief Executive

Action required Discussion/Decision



Report purpose The purpose of this report is to provide Board members with an overall summary of the Trust position and highlight areas for further discussion.


To provide high quality services

Board Assurance Framework risk 2.1 – The Trust does not receive assurance of the accuracy, timeliness and consistency of data and reporting with the potential to compromise decision making and service quality

CQC domain Well-led

Introduction This report aims to give Board members an overview of the activity undertaken since the last Board meeting, both within the Trust and externally.

QUALITY AND SAFETY

Serious Incidents During September 2017, ten serious incidents were reported: (brief information is provided to protect confidentiality; the term suicide is only used once a Coroner’s Inquest has returned a verdict of suicide)

Death (suspected suicide) of a patient under the care of the Assessment and TreatmentTeam in Hyndburn, Ross and Ribble Valley;

Death (suspected suicide) of a patient under the care of the Rapid Intervention andTreatment Team in Lancaster and Morecombe;

Concerns around the care and treatment of a deteriorating patient in the inpatient mentalhealth service at the Harbour;

Serious self-harm (suspected attempted suicide) of a patient under the care of OlderAdult Community Mental Health Team in Central Lancashire;

Death (suspected suicide) of a patient on leave from the inpatient mental health serviceat the Harbour;

Death of a prisoner at HMP Liverpool;

Serious violence incident at Guild Lodge involving self-harm and an improvised weapon.

In all cases, a formal investigation is now underway and the incidents have been reported to Commissioners, NHS England and regulators as required under the NHS Serious Incident Framework.

11 of 264

CQC State of Care Report The Care Quality Commission (CQC) annual State of Care Report was published in October 2017 and shows that the quality of health and social care has been maintained despite very real challenges and the majority of people are receiving good, safe care. However, it also warns that the health and social care system is at full stretch and struggling to meet the more complex needs of today’s population, meaning that maintaining quality in the future is uncertain.

The report sets out the CQC analysis of the quality of health and social care across the country based on the first full round of rated inspections covering almost 29,000 services. It shows that as of 31 July 2017, 78% of adult social care services were rated good as were 55% of NHS acute hospital core services, 68% of NHS mental health core services and 89% of GP practices and that many services originally rated as inadequate have used the findings of CQC inspections to make changes and improve their rating.

However, CQC noted there are also clear warnings from the changing nature of demand – increasing numbers of older people who are physically frail, many with dementia, more people with long term complex conditions – all of which is placing unprecedented pressure on the system.

Significant Health and Safety Incidents During September 2017, five incidents were reported to the Health and Safety Executive and Care Quality Commission under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR): (brief information is provided to protect confidentiality)

Two incidents of patient on staff violence in East Lancashire mental health inpatient servicescausing absence of more than 7 days from work;

Patient on patient violence in mental health inpatient services at the Harbour resulting in harmto a member of staff causing absence of more than 7 days from work;

Two incidents of patient on staff violence in mental health inpatient services at the Harbourresulting in harm to a member of staff causing absence of more than 7 days from work.

Raising Concerns During September 2017, seven concerns were reported through the various mechanisms including the Raising Concerns Guardian and through Dear David:

Concerns over a potentially unnecessary and delaying stage in a care pathway;

Attitude of staff in a specific team;

Concerns over the Network Redesign and the capacity and stress on managers;

Concerns over a specific named manager;

Concerns over the level of violence on a specific ward at Guild Lodge.

In all cases a review of proportionate scale has been commissioned. The findings from each review are individually fed back to the person raising the concern if they have provided their name. The findings from every concern is summarised in the Quality Matters bulletin.

Joanne Smith, Health & Wellbeing Project Manager and Dr Gita Bhutani, Associate Director for Psychological Professions presented at the 2nd Positive Practice in Mental Health Staff Wellbeing Special Interest Group meeting in London in early October. Dr Bhutani is Joint National Staff Wellbeing Lead for Positive Practice for Mental Health and the event was organised by the two Leads. Joanne Smith presented the work by Lancashire Care showcasing the approaches taken to staff health and wellbeing as well as the Schwartz Rounds developments in the Trust. The range of presentations included organisations from East, West, North and South of England as well as Fire Services and other Community and Mental Health Trusts.

12 of 264

Shout About Success Recognising successes, however big or small, sharing them across the Trust and empowering people to celebrate achievement can create an energy of positivity within the organisation. A new initiative is being launched in November 2017 that will provide opportunity for staff across the organisation to share stories about success. A new page has been developed on the Trust’s website where stories will then be shared. Providing this platform through which staff can share their successes will enable a systematic approach to sharing quality improvements and other achievements, as well as supporting the collation of evidence against the delivery of the Quality Priorities.

Staff Flu Vaccination Campaign 2017-18 In 2017/18 the target for the staff flu campaign that has been set nationally and agreed locally is to achieve 70% compliance for frontline healthcare workers by the end of February 2018. For this year the CQUIN is worth £206,351. Although this is less than last year and a longer timeframe has been set, it is still recognised as challenging and a considerable and sustained effort is being implemented to achieve the 70% target. This year’s staff flu campaign is well underway with current uptake for frontline staff at approximately 25%. Occupational Health have been running staff drop in clinics around the whole of the LCFT footprint, there are 70 in total, more staff have been trained this year to carry out peer to peer vaccinations and vaccinators have been provided with equipment to carry this out. A number of flu vouchers have been purchased this year, this was very successful in last year’s campaign and allowed staff the flexibility to have their vaccine at a time that suited them. Staff can also report, via SharePoint, if they have had their vaccines elsewhere. A communications campaign has been up and running over the last couple of months to promote awareness, posters have been developed that feature a range of staff from LCFT and these are displayed throughout the Trust. Weekly messages have been published in the Pulse and Twitter is being used to promote clinics. Screensavers have also been produced for computer screens across LCFT to remind all staff of the importance of this campaign. World Mental Health Day – The Harbour 10th October 2017

Lancashire Care NHS Foundation Trust worked in collaboration with the people who use our services, their families, unpaid carers, partner agencies, local charities and volunteer groups to celebrate World Mental Health Day raising awareness of the importance of mental health in the workplace. The event was held at the Harbour in Blackpool and was open to the people who use our services, members of the community, their families, unpaid carers and health professionals working in the field of mental health. The day provided the opportunity for people to network and access a

market place of information about services and local organisations providing mental health and carer support.

Members of the Quality Improvement

and Experience Team

13 of 264

The event was officially opened with an insightful speech given by the Mayor of Blackpool, Councillor Ian Coleman and included a number of fun activities aimed to boost mental health and wellbeing including, mindfulness, salsa dancing, physical activities, arts and crafts, health checks and carer awareness sessions. The day provided the opportunity to purchase produce and plants grown by the Grow Your Own Project based at Guild Lodge together with homemade arts and crafts made by the people who are currently at the Harbour. A special thanks was given to all those who donated fruit, cakes, refreshments and prizes, and to everyone who attended for helping make this such a successful afternoon. Positive Practice Awards On 12 October, the Trust was the proud host of the national Positive Practice in Mental Health

Awards, attended by almost 400 people from mental health trusts and partners from across the

country who are members of the collaborative led by Angie and Tony Russell. This year, the awards

were bigger than ever with 21 categories and entries of a very high calibre. Two of the Trust’s teams

made the shortlist in the category ‘Psychological Therapies in Secondary Care.’ The Acute Therapy

Service, who have also been shortlisted for a HSJ Award, were highly commended and the Psychosis

and Bipolar Psychological Care Network: Mood on Track Programme won.

Both teams went on to deliver a presentation about their service offer at the Lancashire launch event

of the Positive Practice service directory, also hosted by the Trust and were joined by colleagues from

the MyPlace project for Young People that the Trust runs in Partnership with the Wildlife Trust. The

event brought together colleagues from NHS England, local stakeholder organisations and NHS

colleagues to find out more about the online guide which comprises many examples of good practice

from within our Trust and from other parts of the country. The directory was developed by Angie and

Tony Russell based on the 20 years of experience they have of mental health services and with the

ethos that ‘there is a perfect mental health service out there, it’s just not all in one place’; the directory

serves to demonstrate this theory.

The directory can be found at http://positivepracticemhdirectory.org/ NHS England Visit to CAMHs and Children’s Psychological Services Two teams from NHS England visited the Harbour as well as Fylde Coast Children’s Psychological

Services and Blackpool CAMHS Tier 2 & 3 Community Services on 12 October, prior to attending the

Positive Practice in Mental Health awards.

Members of the NHSE Children and Young People’s Mental Health Team visited Whitegate Drive and

were very complimentary about the services, commenting “It was great to hear about all the work

underway to develop local services and there was clearly lots of enthusiasm and drive to work with

other agencies and services to improve outcomes for children and young people.”

Members of the NHSE Adult Mental Health Team visited The Harbour and spent time in the Hub and

hearing about the inpatient and community services the Trust provides and the way we work in

partnership with other organisations. The team commented that whilst they had seen many of the

ideas before in other Trusts they had never seen them all in one place before. The team also

undertook a tour of the unit including wards and reported back on how impressed they were with the

facilities.

Winter Preparedness & A&E Performance The organisation has activated its internal winter preparedness-plans and a presentation will be

provided to the Board on the detail of this under item TB 175/17.

14 of 264

http://positivepracticemhdirectory.org/

Quality Improvement Visit A small number of Trust staff will be visiting Northumberland Tyne and Wear Trust NHS Foundation

Trust on 30 October as part of work to share best practice across FTs. In particular we are keen to

learn from NTWs expertise around quality improvement. Amongst the visit team will be the Chief

Executive, Director of Nursing & Quality and Medical Director.

PEOPLE & LEADERSHIP

Medical Education

Training remains a vital area for the Trust helping with quality improvement, reputation and

recruitment. In line with this the Medical Educators in the Trust have been busy running two, two day

events, a Summer School and also a Training the Trainers event. The Summer School is offered to

Medical Students and FY doctors to give them a window into psychiatry as a career and hopefully

encourage some to pursue this. The Train the Trainers event refreshes core skills for old hands and

ensures that all new medical supervisors of junior doctors are up to speed with current developments

as required by the GMC. This event was led by LCFT but was a collaborative piece of work with

Pennine Care and Cumbria helping foster good relations with our neighbours. Both events were very

well attended, interesting and well received and will be reviewed before running again next year.

FINANCE AND PERFORMANCE

Finance Report The position at Month 6 sees a year to date operating deficit of -£2.3m, excluding planned Sustainability and Transformation funding of £0.7m, against a planned surplus to date of £0.3m. Though the run rate would appear to be consistent with previous months, but with several components of the recovery plan being transacted in month 6, this indicates the position has deteriorated further in month. The position remains driven by staffing pressures in ward and prison areas and consequential impact on cost improvement programmes (rising agency costs will also impact Use of Resources targets). Additionally, OAPs expenditure continues to exceed funding - see Out of Area Activity for more details. The forecast assumes current pressures and risks are addressed or mitigated in line with the recovery plan (see forecasting) and financial performance achieves (or exceeds) plan but the unmitigated projection indicates a gap of c£6.2m, c£8.3m without STF monies. This is broadly consistent with month 5 (£6.0m), and is again driven by excess OAPs of c£1.8m, prisons (see also Bank and Agency section) and additional mental health pressures. Delivery of the recovery plan and financial targets will require a significant and coordinated response with robust management and oversight. After taking in to account £1.7m of disposals, which are accounted for after EBITDA, EBITDA is broadly in line with I&E Margin. The new Use of Resources (UoR) metric is rated at 3, but will rise to a 2 should the Trust meet its financial plans and targets.

Quality & Performance Report The Quality & Performance Report can be viewed under item TB 165/17.

Communications & Engagement KPI Q2 The Quarter Two KPI report for Communications and Engagement is provided here.

Royal Visit to MyPlace

Lancashire Care and the Lancashire Wildlife Trust were thrilled to welcome HRH Prince Harry for a

tour of the MyPlace project at Brockholes Nature Reserve on 23 October. The MyPlace project is a

partnership supported by Big Lottery Funding and is one of 31 UK projects co-ordinated through Our

Bright Futures. The project itself focusses on ecotherapy-based prevention and early intervention

activity and works with young people in Central and East Lancashire. The Deputy Chair, Chief

Executive and Chief Operating Officer were present at the visit which was a fantastic opportunity to

showcase the project, with Prince Harry taking time out to speak to the young people involved with

the project and take part in bush craft activities.

15 of 264

CoG Governor Constituency Changes After careful deliberation by the Council of Governors over the course of the year, proposed changes

to the governor constituencies including nominated governor categories have now been approved by

CoG at its October meeting. In line with the Trust Constitution, the changes were also presented for

ratification by members at the Trust’s 2017 Annual Members Meeting on 25 October.

The changes are; increase in Nominated Governors from 4 to 6 covering public health and wellbeing

and higher education organisations, with the 4 remaining seats representing other partnership

organisations; increase in public governors from 12 to 16 representing STP areas rather than CCG

footprints; and increase in staff governors from 6 to 7 to include colleagues working in administrative

and clerical positions in Bands 4 or below.

BUSINESS DEVELOPMENT

Health Melas The Trust is a key supporter of the health mela events organised through the National Forum for

Health & Wellbeing. Following the success of the Preston Health Mela, the Trust has helped to

support a further two melas in Chorley and Leyland. The Chair and Chief Executive attended the

Leyland Health Mela on 14 October which focussed on the challenge of childhood obesity. The event

was well attended and in particular made efforts to engage with parents and children from local

primary and secondary schools. The Chorley Mela focussed on integrating services in Chorley and

was attended by Gwynne Furlong on behalf of the Trust Chair.

CCG Leadership Changes There have been two senior leadership changes within the Clinical Commissioning Groups in

Lancashire. Dennis Gizzy has replaced Jan Ledward as Accountable Officer at Chorley & South

Ribble CCG and Greater Preston CCG. Penny Morris has taken up the Interim Accountable Officer

role at Blackburn with Darwen CCG, in addition to her role as GP Clinical Lead.

16 of 264

Media relations Digital media activity Devices used Top 5 landing pages

Key themes and hot topics

Response from stakeholders to the delivery of the Inpatient Reconfiguration Communication & Engagement Plan has been positive. This has included a range of activity from email briefings through to face to face meetings and attendance at Health Scrutiny.

The Trust was represented at all the recent provider and commissioner AGMs. The key theme running through was partnership working, and LCFT’s contribution was more fully recognised than in previous years.

The Consultant Recruitment campaign (including video) was launched and promoted over social media. A similar campaign was also launched over the summer focussing on nurse recruitment.

Media and MP interest in the Liverpool Prisons contract was ongoing over the quarter. This interest continues into Q3.

Positive feedback has been received about the joint engagement activity the Trust has been conducting in partnership with Healthwatch Sefton. Attendance has been good at locations including flu clinics, Older People’s Forums and Memory Cafes.

Positive media coverage was generated following PR around the announcement of the new perinatal units. This will be focussed on again in the New Year, with people with lived experience.

A larger than usual amount of ‘Trust wide’ media coverage was generated by PR around the flu campaign

Engagement appointments GP and commissioner meetings made up the bulk of activity in Q2. Commissioner meetings included GP forums, Practice Manager forums and GP locality meetings, which provided opportunities to engage with a variety of stakeholders from Primary Care. Queries or issues raised at these meeting were fed back to the Networks via the relevant Relationship Manager, who retains responsibility for closing the loop once resolved. Third Sector included the Health Melas where Trust services were able to engage with multiple stakeholders including the public.

The number of appointments was in line with the previous quarter. Engagement activity was focussed on promoting CASH, the Quit Squad, engaging with stakeholders around the Inpatient Reconfiguration and Southport & Formby. Geographical focus in Q3 will be on Burnley, with concentrated proactive communication with stakeholders to explain the case for change in Burnley and promote the new services for the town. In addition, partnership work in South Ribble will require a focus in that geography.

Forward view for Quarter 3 2017/18

Quarter 2 2017/18 KPI Communications & Engagement Report

Twitter: On 30 September we had 9,337 followers.

Positive themes included:

The Trust has been selected to run one of four new specialist perinatal units.

Young people in Lancashire can get involved in the Myplace project which will boost their health.

Using tablet technology can be beneficial to both dementia and mental health patients.

Further improvements to mental health services in Lancashire have been agreed following a decision to conclude a long term programme of work.

The Contraception and Sexual Health service is calling on people to practice safe sex to avoid STIs and unplanned pregnancies during summer.

The Chorley Wellbeing Service has launched to support community wellbeing in the borough.

The Trust has topped the volume of research category in the Research Activity League Table for 2016/17.

The launch of a new efficient and safe Electronic Patient Record (ePR) System will improve patient care.

The Wellbeing and Mental Health Helpline is looking for volunteers to help make a difference to others.

Negative themes included:

Mental health worker from the Trust has been given a suspended jail term sentence after pleading guilty to stalking a colleague.

Member of staff given suspended prison sentence after being caught prescribing herself painkillers.

Web statistics

Number of visitors: 108,897 Page views: 421,175

Sentiment analysis (Sentiment is the measure used to determine how people are reacting by the use of positive or negative lan-guage)

Social media activity

Facebook: On 30 September we had 2,052 likes.

Our posts reached 375,693 people.

Top Posts

*This is the top 5 landing pages for

the main Trust website and does

not incorporate data from

Contraception and Sexual Health

(CaSH) and the Quit Squad

websites

572k impressions (The number of times content is

displayed i.e. potential number of opportunities to interact)

1,895 mentions (The number of times the Trust has been

mentioned)

Proactive press releases issued During Q2 we issued 60 proactive press releases. Reactive media statements During Q2 we responded to 20 requests.

Media Interviews During Q2 we took part in 5 media interviews including an interview with That’s Lancashire TV at the opening of Waterview in Lancaster and an interview with BBC Radio Lancashire about the findings of the CQC’s comprehensive inspection programme of all specialist mental health services.

21,308 – Nurse recruitment

8,308 – Consultant Recruitment

Videos

8,300 – Health Visitor Week

Annual Members meeting and membership conference Public and staff governor elections

Continued work in Southport and Formby Perinatal mobilisation

0-19 tender

100% positive

0% negative

17 of 264

Board of Directors


Report Title Audit Committee Chairs Report


Prepared by Shannon Higginbotham, Corporate Governance Manager

Presented by Louise Dickinson, Chair of Audit Committee




Report purpose To provide an outline of the activity undertaken by the Audit Committee, highlight assurance received and risks identified.



Board Assurance Framework risk N/A

CQC domain Well-led

1.0 INTRODUCTION This Chairs Report outlines the activity undertaken by the Board level Audit Committee on 24 October 2017.

2.0 BOARD ACTION

The Board of Directors is asked to note the content of the Chair’s Report for assurance.

18 of 264

CHAIRS REPORT

CHAIRS REPORT OF: Audit Committee

DATE OF MEETING: 24 October 2017

AGENDA ITEMS DISCUSSION, ASSURANCE, RISK OR FURTHER ACTION

Corporate Governance + Compliance Chairs Report

Discussion & Assurance Assurance was provided by the Chief Executive that work was progressing around the two key areas; Cyber Security Care Certs completion and the GDPR implementation. The committee received clarification that the quarterly meetings of the sub-committee were sufficient, largely due to the quality of reports received by the sub-committee. The Chair requested that further clarification and understanding was to be provided at the next committee meeting through the Chair’s report around the gaps in data available for the NHS Benchmarking Network programme.

Financial Matters and Related Reporting

Discussion & Assurance Breaches and Waivers Q2 The Committee received the report for noting purposes. Losses and Special Payments Q2 The Committee received the report for noting purposes. The Finance Team is to report back to the January committee meeting with benchmarking data and comparison data between last year and this year. Value for Money Plan This report was provided to the Committee for oversight following its provision to the Finance and Performance Committee. An issue was identified in relation to the timing of the report being presented to each Committee within the Cycle of Business; which was to be addressed by the Company Secretary.

Internal Audit Reporting

Discussion, Assurance & Further Action Internal Audit Follow-up and Progress report The Committee noted both the internal audit follow-up and progress report, including two completed reviews (IT Asset Management and Fee Paying Medico Legal Work) providing significant assurance.

19 of 264

The Chair requested additional clarification on themes identified in the IT Asset Management Report, which MIAA confirmed to action. The Committee noted that progress on the Audit Plan is currently amber rated. MIAA confirmed there was no concerns with their access to the Trust and noted the amber-rating was a result of delays due to annual leave; which was has had an impact on timescales. This delay will be mitigated in Q3. Internal Audit Anti-fraud update Two cases were highlighted to the Committee; an occurrence of self-prescribing of controlled medication, and the successful prosecution of timesheet fraud. The Committee was informed that the self-prescribing breach related to a Nurse transferred with the new community service contract. A discussion was raised by the Chair around MIAA’s self-assessed amber performance for maintaining NHS Protects FIRST. The Chief Finance Officer will have a discussion with the Anti-Fraud team to consider whether any mitigation is possible and feedback to the January 2018 Audit Committee.

External Audit Reporting

Discussion & Assurance The Director of Nursing confirmed the Learning from Deaths policy had been published within the Trust. The Chair raised a discussion regarding ‘retire and returns’; the process element behind this and the impact on the Trust. The Chief Executive noted that this was relevant to the Trust and being addressed by HR.

External Audit Non-Audit Performance Update

Discussion & Assurance The Auditors provided an update on the piece of non-audit work that the Trust had asked them to conduct; which was not an assurance or advice assignment. The Committee noted this information has been shared with the Trust Board.

Clinical Audit Reporting

Discussion & Assurance

The Committee received the Clinical Audit Progress Report.

The Committee received assurance that progress against action plans was good, with only two outstanding actions which would be resolved in the short term.

The Medical Director drew attention to some low levels of compliance on the 2016/17 re-audits and noted this was being monitored by the Quality Committee.

The Medical Director also noted the poor performance in the POMH-UK audit on Rapid Tranquilisation

20 of 264

programme.

The Committee noted that the Trust was on-track the Clinical Audit Plan.

Corporate Governance & Risk Management Health Checks Report

Discussion, Assurance & Further Action

The Committee noted that this would be an on-going piece of work over the next two years. Assurance was received that the Company Secretary team and the Risk and Assurance team were working collaboratively together to undertake a robust review of the networks and directorates governance arrangements and to support the implementation of effective action plans where necessary.

It was noted that the report focused on the health checks undertaken within the Children and Young People’s Network and Human Resource directorate. The Committee received a summary of findings from both the Network and directorate to highlight the need for consistency and enhancement around structure, reporting requirements and meeting standards and the need for a consistent way of reporting risks through all meetings. A challenge was identified around the Trusts need to frame risks in a way that can be understood throughout the structure; a discussion was raised around the need for a training deliverance to support this.

The Committee noted that there were discussions of a risk champion within each of the networks to support the strengthening of the process; which had seen individuals identified within the senior teams.

The Chair requested further assurance through receipt of the detailed scoring matrix to understand the conclusions drawn.

Assurance Programme Update

Discussions & Assurance

The key pieces of work that had been undertaken within the last 12 months relating to Risk Assurance was presented to the committee. The work undertaken had reflected feedback from colleagues to make the processes able to be embedded effectively across the Trust.

Future planned developments was provided to the committee; with confirmation of additional objectives for Q3 and Q4, and a plan developed for 2018/19 to strengthen the systems and processes through further feedback from the networks. The committee noted that substantial work had been completed throughout the year and were satisfied with the content of the work being undertaken.

Raising Concerns Process

Discussion, Assurance & Further Action

The Committee noted the report confirming the processes in place for raising concerns through various mechanisms; it was clarified that the most well-utilised mechanism was the ‘Dear David’ tool.

Assurance was received by the Committee in relation to the Trust’s indicators in comparison to the national 21 of 264

average, and additional assurance was noted that the Trust’s internal mechanisms to raise concerns provided staffs with a sufficient range of tools, and the use of an external systems would unlikely present a benefit.

It was confirmed that alongside the Chief Executives report and the Quality Committee Chair’s report to board; the new Quality Report will provide an overall view of key themes and hot spots to Board.

The Chair requested benchmarking against upper quartile data for the staff survey to be reported at the next Committee meeting.

Overall, the Committee received good assurance that sufficient systems were in place for staffs to raise concerns; however there was a need to understand the information that is sighted at Trust Board and a requirement for a further review of benchmarking data.

Proposed Reporting Arrangements for Clinical Audit


The Medical Director highlighted three key proposals. The approval of the proposals would result in a reduction in the number of local clinical audits undertaken by 25% to redirect resources into national clinical audits.

These were confirmed to the Committee as:

Proposal 1: The Trust no longer allocates a specific number of Audits to each Network but ratherundertakes a risk assessment in Audit procedure to allow the allocation as appropriate to release thecapacity for national audits.

Proposal 2: The Trust to consider participation in accreditation schemes which also form part of nationalbenchmarking.

Proposal 3: The Medical Director proposed that the Audit Committee receive a Clinical Audit report on a 6monthly basis to provide assurance on the progression of the plan.

The Chair confirmed that the Committee was satisfied for these proposals to be made to Board.

Committee Discussion Without Auditors Present


A discussion took place regarding the extension of the Internal Auditors contract, and the requirement of the Audit Committee to make a recommendation to the Council of Governors on the extension of the External Auditor’s contract.

It was concluded that in regards to External Audit; a recommendation would be put forward to the Council of Governors for External Auditor’s contract to be extended for a further 2 years.

The Committee agreed it would be taking the opportunity to review stakeholder feedback on the Internal Auditors prior to approving a contract extension.

22 of 264

Board of Directors


Report Title Quality Committee Chair Report


Prepared by Viv Prentice, Deputy Company Secretary

Presented by David Curtis, Chair of Quality Committee


Supporting Executive Director Executive Director of Nursing and Quality


Report purpose To provide an outline of the activity undertaken by the Quality Committee.



Board Assurance Framework risk 1.1 The Trust does not protect services users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services

1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services

3.1 The Trust fails to deliver the benefits of being a Health and Wellbeing provider.

4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs

4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care

7.3 The Trust does not comply with Mental Health Legislation

CQC domain Well-led

1.0 INTRODUCTION This Chair Report outlines the activity undertaken by the Quality Committee held on the 28th September 2017.

2.0 COMMITTEE ACTION

The Trust Board is asked to note the content of the Chair Report for assurance.

23 of 264

CHAIR’S REPORT

CHAIRS REPORT OF: Quality Committee

DATE OF MEETING: 28 September 2017

BOARD ASSURANCE FRAMEWORK RISKS ALIGNED TO COMMITTEE:

1.1 The Trust does not protect services users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services

1.2 The Trust does not deliver safe, appropriate and therapeutic environments to deliver high quality services

3.1 The Trust fails to deliver holistic whole person care (Physical and Mental Health)

4.1 The Trust is unable to attract, recruit and retain high quality staff impacting on a continued dependency on temporary staffing levels, affecting quality of care and financial costs

4.2 The Trust does not deliver effective education, training and leadership opportunities resulting in a workforce who are unable to deliver high quality, safe care

7.3 The Trust does not comply with Mental Health Legislation

AGENDA ITEMS BAF RISK DISCUSSION, ASSURANCE, RISK OR FURTHER ACTION

Emerging Issues 1.1, 1.2, 3.1, 4.1, 4.2, 7.3

As a result of the fact finding process into the whistleblowing at HMP Liverpool, a number of concerns have now moved to formal HR investigations. In addition, assurance was provided that the Trust had responded appropriately following the recent concerns raised by a local MP.

Following the joint HMIP/CQC inspection in September 2017, initial feedback was positive and highlighted a strong focus on sustaining quality within the prison. However, the prison regime had been heavily criticised resulting in a rating of inadequate and the stepping down of the prison governor. The Trust has since conducted its own internal quality assurance visit which has resulted in a number of improvement actions.

Following a suicide on the inpatient wing in September 2017 the outcome from the management review is currently awaited.

Whilst the Trust has signalled its intention to withdraw from providing the healthcare contract at HMP Liverpool, a commitment to review the contract has been upheld by NHS England’s Regional Director of Nursing.

24 of 264


Board Assurance Framework Report

1.1, 1.2, 1.3, 3.1, 4.1, 4.2

Consideration was given to each of the assurance reports during the meeting and the Committee received assurance that there had been no significant changes to the risks in the last quarter.

Whilst the importance of highlighting how the Trust was responding to emerging risks was discussed, the Chair raised concern that risks in respect of quality were not being identified soon enough. The Chair therefore requested that for future meetings the paper accompanying the Quality Surveillance Report reflected not only concerns but the action being taken to address those concerns.

Quality and Safety Surveillance Reports

1.1 Work is currently underway to realign the data to the new network structures and from Q3 onwards would be realigned to the five CQC domains of safe, caring, effective, responsive and well-led. In addition, network specific indicators were being considered to provide a greater indication of quality, ie A&E breaches.

Key priorities for the Trust include the marginal increase in serious incidents and the increase in violence. In addition, incidents of self-harm had dropped in the month. A significant piece of analysis is therefore being undertaken and will be brought back to a future Quality & Safety Subcommittee.

Assurance was provided that the increasing number of complaints reflected the work that had been undertaken in the harder to reach areas and was therefore not considered a risk at this time.

Whilst overall compliance with core skills was above target, compliance with safety critical subjects remained a concern. Of particular concern was the number of overdue incident reviews, particularly within the mental health network.

With regards to the increase in pressure ulcers, the Committee noted that a rigorous review of pressure ulcers had been undertaken within the Adult Community Network.

A quality surveillance report had been produced for mental health law, allowing the Trust to monitor legal compliance in granular detail. It was agreed that this report would be tabled at the next Quality & Safety meeting alongside the current quality surveillance reports.

It had been agreed with the commissioners that future quality visits would be undertaken jointly with the Trust in an attempt to streamline the overall number of quality visits conducted throughout the Trust.

The Deputy Director of Nursing confirmed that risk ID 8444 relating to the delay in new-born screening results had been reviewed and would subsequently be reduced as a result of the mitigating actions that had been put in place. In addition, risk ID 8554 relating to withdrawal of the resuscitation service would be removed due to the withdrawal of the resus team across the whole site.

Quality Plan Bi-Annual Report

1.1 An update on the Quality Plan priority areas for 2017/18 was received that identified a number of areas behind schedule together with the work being undertaken to address these areas.

25 of 264


Staffing for Safety & Quality Bi-Annual Report

1.2 The staffing for safety and quality bi-annual report was received. The Trust’s involvement in both the Carter 2 initiative and the Community Productivity Pilot was noted. The mental health wards had also commenced a 90 day rapid improvement programme to look at improvements in rostering. A full establishment review was in progress, with the deadline brought forward to October. Quality audits were also being carried out for each ward and team in line with the original Hurst process. Whilst there remained some areas where sickness absence was above the Trust’s target of less than 5%, the Committee noted that work was being undertaken to address this.

Annual Medical Appraisal and Revalidation Report

1.1 The Committee received assurance in relation to the Trust’s appraisal and revalidation process and that the Statement of Compliance had been submitted to NHS England within the required timescale.

Quality and Safety Sub-Committee Chair Reports

1.1, 1.2, 3.1 The Committee received the Quality and Safety Sub-Committee Chair’s Reports following the April, May and July meetings. The Committee noted that a piece of remedial work was being undertaken to ensure complaint deadlines were adhered to in the mental health network.

The Trust’s ability to meet the national safety alert in respect of prescribing Sodium Valproate had been raised as a risk by the Chief Pharmacist. Although a number of mitigating actions had been put in place, the Trust would be unable to declare compliance by the 6 October.

The Committee noted the Trust’s achievement of 100% compliance with PREVENT training.

The baseline assessment of Southport & Formby Community Services in terms of quality due diligence had been undertaken and there was now a clear understanding in respect of the quality and safety challenges. Attention will now be focussed on the data contained within the monthly Clinical Director reports.

The report for Physical Health CQUIN in the mental health network had been completed and it was noted that the Network had not achieved the target. Discussions are currently underway with the Contracts Team to agree a way forward with commissioners.

The Committee noted that discussions had been held in respect of implementing a systematic approach to collecting data for supervision and that a piece of work would be undertaken to implement a central system to capture supervision data.

The Executive Director of Nursing expressed concern that the Quality & Safety Sub-Committee were not sighted on A&E mental health breaches and had therefore specifically requested that this be addressed through the Clinical Director reports. This would therefore feature in the quality surveillance reports.

The Committee were assured that the Trust was compliant with NHSI mortality review data and a description of the process had been uploaded to the Trust’s website. A formal report on learning from deaths would be tabled at the Board meeting in November.

26 of 264


Mental Health Law Sub-Committee Chair Report

1.1 The Committee received the Mental Health Law Sub-Committee Chair’s Reports following the June and September meetings. Following the lack of compliance with Mental Health Act training, the Committee noted that a review was being undertaken with a view to moving to competency based training.

It was noted that the sub-committee had commissioned further work to ensure clear guidance for staff and

managers prior to the forthcoming changes to the Mental Health Act. In addition, the Children and Families network group had been re-formed and were now looking beyond the CAMHS services and were reviewing mental health law across all of their services

People Sub-Committee Chairs Report

4.1, 4.2 The Committee received the People Sub-Committee Chair Report following the September meeting.

The ongoing work with the People Plan and the lack of compliance with core skills and the associated recovery plans in place for each network were noted. The work to increase compliance with core skills was discussed which included linking core skills to PDRs.

Limited assurance had been received in respect of the effectiveness of the employer relations activity due to the inaccuracy of the manually collected data. However, the networks had assured the sub-committee that there were no issues with employee relations in the Trust.

Risk Assurance 1.1, 1.2, 3.1, 4.1, 4.2, 7.3

It was agreed that following discussions throughout the meeting adequate assurance had been received and there had been no impact on the risk scores relevant to the Committee.

27 of 264

Board of Directors


Report Title Finance and Performance Committee Chairs Report

FOIA Exemption Part Exemption Section 43: Commercial Interests

Prepared by Shannon Higginbotham, Corporate Governance Manager

Presented by Peter Ballard, Trust Deputy Chair & Chair of Finance & Performance Committee


Supporting Executive Director Chief Finance Officer


Report purpose To provide an outline of the activity undertaken by the Finance & Performance Committee.



Board Assurance Framework risk 2.1 The Trust does not receive assurance of the accuracy, timeliness and consistency of data andreporting with the potential to compromise decision making and service quality

2.2 The Trust's ability to address and meet service demands is affected by uncertainty and inconsistency of commissioning arrangements.

5.1 The Trust does not have in place effective financial controls which could affect long term financial viability and sustainability

6.1 The Trust is unable to reposition in the marketplace to become established as a provider of choice achieving excellence

6.2 The Trust does not implement a transformational IT programme that ensures transition to a new intuitive clinical system across all services

CQC domain Well-led

1.0 INTRODUCTION

This Chairs Report outlines the activity undertaken by the Board level, Finance & Performance

Committee held on 19 October 2017.

2.0 BOARD ACTION The Board of Directors is asked to note the content of the Chair’s Report for assurance.

28 of 264

CHAIRS REPORT

CHAIRS REPORT OF: Finance & Performance Committee

DATE OF MEETING: 19 October 2017

BOARD ASSURANCE FRAMEWORK RISKS ALIGNED TO SUB-COMMITTEE:

2.1 If we do not work collaboratively with partners we will not be able to influence system wide transformation

2.2 If we do not deliver new models of care we will cease to be a creditable lead provider

3.2 If we fail to project our achievements then our reputation will not improve

5.1 If we do not meet our financial objectives we will not be able to provide sustainable services

5.2 If we do not work with partners to deliver system wide efficiencies this will undermine our own financial position and that of the STP

6.1 If we do not develop and maintain infrastructure, we will not be able to deliver safe , responsive and efficient care

6.2 If we not exploit the full capabilities of the new EPR system and wider technology to redesign services we will miss important opportunities to improve care

AGENDA ITEMS BAF RISK

DISCUSSION, ASSURANCE, RISK OR FURTHER ACTION

Board Assurance Framework

2.1

2.2

3.2

5.1

5.2

6.1

6.2

Positive assurance was identified in the below areas: - Progress of the Nerve Centre; confirmation of the digital innovation group and the recruitment procedures

being (BAF risk 6.1) - EPR Recovery Plans are enabling the programme overall to regain compliance with the key milestones (BAF

Risk 6.2) - The upgrade to RIO Version 7.7 - full appraisal undertaken of the benefits (BAF risk 6.2)

The key risks and gaps in assurances identified from the discussions and papers presented were agreed by the committee as below:

- Updated SFIs following the organisation restructure to ensure they reflect the changes (BAF risk 5.1) - Lack of commonality regarding the national collection of the national benchmarking data (BAF risk 5.1) - Risks around delivering against the savings realised as part of the organisational reset (BAF risk 5.1)

29 of 264

- Prevention of overpayments made to staff due mainly to late notifications to payroll being made by managersacross the Trust. Controls put in place are not having the required impact. Need to consider for the AGS interms of whether this is a material concern (BAF risk 5.1)

- Ligature risk assessments and ensuring compliance with the process (BAF risk 6.1)- Transition of the soft FM contract to the new providers and the potential impact on continuity of a quality

service (BAF risk 6.1)- Completion of the capital programme in relation to the Perinatal unit and the release of the estate by LTHTR

(BAF risk 6.1)- Requirement of the clear confirmation of the key contractual project milestones with associated finances (BAF

risk 6.2).- Financial assurances in relation to the EPR programme (BAF risk 6.2).

Trust Financial Position FOIA Exempt under Section 43: Commercial Interests

30 of 264

Infrastructure Sub-Committee Chairs Report

6.1

6.2

The committee considered the potential issues around the EPR programme and its delivery; relating to a financial penalty to the Trust that may occur if the work was not delivered within the agreed timescale. An additional concern was drawn attention to relating to the commencement of work on the LTH site. Concerns around the delay of ligature risk assessments being received from certain units was highlighted; it was agreed that this would require escalation to SLT if the issue persisted.

The committee noted the positive assurance relating to the Trusts consideration of IAO data security, in particular the discussion around the Southport & Formby EMIS contracts. An options paper would be brought to the next committee meeting for consideration.

The committee received assurance that KPI’s continued to be monitored to ensure performance was efficient and consideration of KPI’s being developed for the Hard FM contract was noted.

It was affirmed that an interim had been appointed to oversee the RRCS contract with additional management from the Chief Finance Officer; a paper would be brought to November Trust Board regarding this.

Finance Sub-Committee Chair Report

5.1 The potential for transacting services in Cumbria was discussed; it was noted by the committee that the process and its timescales would be altered slightly if this went ahead and the strategic appraisals of options would require consideration.

Ongoing work with Carter was drawn attention to and it was noted that a ‘model hospital’ would be designed for non-acute services similarly to the design for the acute sector. The committee noted that a draft model of this would be tested in December with the intention of launch in early 2018. Assurance was provided to the committee that the Trust had a good baseline of information to commence development.

Confirmation was received that Harvey House had now reached agreement with all necessary persons and this was now closed and under exception reporting. The committee noted that £650,000 would be repaid to the Trust, and the two key losses were defined as the amounts owed by the four guarantors and from the Harvey House Social Enterprise. Assurance was however received that the government department for the Trust was sighted and satisfied with this agreement.

The committee noted that the Finance sub-committee was considering the productivity improvement plans; which outcomes of work would be presented to the Trusts Executives.

Business Development And Delivery Sub-Committee Chairs

2.1

2.2

3.2

A discussion was raised regarding an update on the EIS measure; the committee noted that although further understanding is required to inform this piece of work, the Trust was intending to commence into a deep dive into the data quality for EIS due to the outcomes of the Q1 EIS 2 week standard.

31 of 264

Report It was confirmed that the failure of this was due to incorrect data submission by staff which corrective action plans were to be executed to mitigate the inaccuracy. Assurance was provided to the committee that a paper would be provided to SLT to consider the corrective action required to make the necessary impact and an update would be provided to the Finance and Performance Committee via the Chairs report. It was highlighted that the outcome of Q2 was pending and yet to be confirmed.

Further assurance was noted that the failure of a single quarter would not result in regulatory action by NHSi and the Trust would be focussing on ensuring that data input is accurate across the organisation.

Perinatal Business Case Update

5.1 Assurance was provided of the progression and developments of the Perinatal Mother and Baby Unit to the committee.

A potential risk of delay was raised in relation to the on-going challenges with commencement of work on the LTH site; these issues were confirmed to be being considered and managed as appropriate. A further potential risk was identified associated with the likelihood of commissioners withholding some monies required for the Perinatal unit if delays in the commencement of on-site work did occur.

A discussion was raised regarding the Trusts intention to bid for the Community Perinatal Mental Health Unit which was to be put out to tender within the near future; assurance was noted that through the experience gained through the Perinatal Mental Health Services and the extensive mentoring programmes with Wythenshawe; the Trust was in a beneficial position to submit the tender. A paper would be going to Board clarifying the context of the tender.

Delivering The Strategy (DTS)

5.2 Assurance was provided to the committee around the progress made against what was set-out to be completed at the beginning of the year. It was noted that the main financial shortfall causing a major gap in the CIP relates to staffing pressures in the Mental Health Network.

The Committee identified that against that 15.1million target; the current schemes identified totalled £12.6million, amounting to a shortfall of £2.5million.

The Committee received assurance around works being undertaken for next year’s DTS and its link to the CIP programme and opportunities from Carter. Further works commencing was discussed relating to benefits realisation from the DTS programmes to receive more clarity on both financial and non-financial benefits.

E-PR ProgrammeUpdate

6.2 The committee noted that the overall status of the programme was RAG rated as amber. Assurance was provided to the committee that although during the time the report was prepared, two work streams were rated as red, recovery plans were being implemented to be on-track.

In particular, the work streams categorised at red at time of reporting was; the data cleansing and migration, which 32 of 264

was then confirmed as on track to achieve the 24 October contract milestone, and the MIG; which the committee received additional assurance was not a financial milestone with any material impact on the critical path for go live. Assurance was provided to the Committee that all work streams would be categorised as RAG rating green following discussions at PMG.

It was noted that the Trust was proposing for E-PR to be implemented within Secure Services and a presentation would be prepared for Board in December. The committee was informed that the target date of the combination of RIO and Nerve Centre to be completed by Summer 2018, with RIO intending to go live in June 2018.

The overall summary of assurance received by the committee was that the programme was on schedule, resources was sufficient to support the process, and additional assurance that for those work streams categorised as not on track had the appropriate recovery plans in place to adhere to schedule.

The committee made a recommendation for further reports to include a financial summary to ensure the full remit of the committee is met through the reporting arrangements. The next update would be provided in April 2018 following Go Live.

Social Value Update 3.1 The committee noted the ongoing plans to demonstrate social value in a more robust way moving forward. It was

highlighted to the committee that the intentions of the reporting were to split the aspects of the report between Finance

+ Performance Committee and Audit Committee within their remit.

The committee received assurance around the developments underway and under discussion to form a strategic

approach to the recording and reporting of social value; with a clear definition of social value across.

A discussion was raised around the growing importance of social value within tendering and contracts; in particular

within the universal services contract. Assurance was noted that the ongoing work on Social Value across the Trust

will prove valuable for the Trusts position within future tenders.

The committee noted that the impact of this work would see improvements and a more robust approach within

2017/18; highlighting the Trusts ability to measure and recognising that there would be some gaps. It was emphasised

that moving forward; the impact would be seen much more significantly in 2018/19 with robust recording and reporting

arrangements in place.

WorkforcePerformance Reporting

4.1 The Director of HR highlighted the context of this report relating to overpayments within the Trust; which had been an ongoing issue addressed and monitored by the Audit Committee previously. The committee were drawn attention to

33 of 264

the major issue around this item as an on-going compliance issue, as a result of late notification to ESR; which covered 87% of overpayments.

The committee received assurance that in addition to current ongoing action plans in place; compliance is continuing to be enforced at a local level; whereby a detailed report is provided to the networks within each of the People and Leadership groups across the networks to ensure corrective action is taken at the appropriate level.

Further assurance was noted that the report does not reflect the improvements made in September 2017 due to the timings of report preparation.

Overall the committee noted that assurance was received that work was on-going with the intention of improving compliance, which was reflected in the improvements made in September 2017, however further understanding was required to be considered around defining what an acceptable level of non-compliance that the Trust can accept.

Risk Assurance All It was agreed that there had been no material impact on the risk scores relevant to the Committee. All additional risks

relating to the Committees associated BAF risks, and positive assurances drawn from the discussions was clarified

and agreed by the committee.

34 of 264

Board of Directors


Report Title Quality and Performance Report (QPR)

FOIA Exemption No Exemption Not Applicable

Prepared by Louise Corlett, Head of Business Intelligence

Presented by Sue Moore, Chief Operating Officer


Supporting Executive Director Chief Operating Officer


Report purpose To appraise the Board of Directors of key elements and themes from the Month 6 QPR



Board Assurance Framework risk 2.1 The Trust is unable to reposition in the marketplace to become established as a provider of choice achieving excellence

CQC domain Well-led

The Board are asked to note the QPR for month 6 with following comments below:

All NHS I metrics are compliant with the exception of performance against the Early Intervention

in Psychosis 2-week target.

An issue has been identified regarding how Early Intervention in Psychosis referrals are

recorded. The root causes and correct position against the target are being investigated and

therefore the current year to date position has been refreshed and is indicative only at this

stage. The correct position will be reported next month and it expected to confirm that we have

not met the target year to date. A remedial plan is being developed and a full report will be

presented to Senior Leadership Team meeting in November. The remedial action plan will be

monitored through the fortnightly task group that has been established and a formal report on

progress will be submitted to Corporate Governance and Compliance sub-committee by the

Head of Business Intelligence.

The measures within the Board Balanced Scorecard have been refreshed and aligned to

demonstrate our progress in achieving our strategic priorities. Whilst the measures are still

developing, the picture created by the current measures show the challenges faced by the

organisation currently in relation to our financial position and attracting the best people.

35 of 264

Are we SAFE?

Current CQC rating is ‘requires improvement’

Progress on the 16 key priorities in the Quality plan are being monitored through the designated sub-

committee and as shown in the BBSC the current status is that we are on track with 14 priorities and 2

are off track. The detailed position will be presented to Board through the Q2 update report.

In month 6, we reported zero incidents of potentially avoidable pressure ulcers (grade 3 and 4)

following the increase seen in Q1. This is a positive signal that the renewed focus on pressure ulcers,

which is being achieved through the quality priority work, is having an impact.

Physical violence towards staff is still tracking at higher than average in month 6, but is static at 220

incidents as also reported in month 5. There are no new areas of concern and the work into the

hotspots (PICU and OAMH) continues: The report on a deep dive review conducted on PICUs is due to

be presented to the next meeting of the Quality and Safety sub-committee and further

recommendations made. In addition, the review of personal care activities on Older Adult wards will be

ongoing over the next few months to provide specific training and identify if there are any changes in

clinical practice required. As reported last month, the impact of this work on incidence of violence is

unlikely to deliver a reduction in the short term although it is positive that incidence is not increasing.

The incidence of physical violence towards staff impacts upon a number of other metrics, therefore an

improvement in physical violence will also bring about an improvement in restraint, RIDDOR and the

mental health harm free care metric, which are all variable each month, with harm free care below the

required standard.

The number of serious incidents has reduced this month and is below the rolling 12-month average of

8.1 at 7. The serious Incidents reported are related to the physical violence against staff.

Currently, the Quality dashboard shows zero Never events, however, in October it has come to light

that an incident occurred in May which involved a patient receiving a higher dose than prescribed of

methotrexate. Fortunately, there was no patient harm however the incident meets the threshold for

reporting as a Never Event and will be investigated in accordance as a serious incident.

Are we CARING?

Current CQC rating is ‘Good’.

We maintain 100% compliance against mixed sex accommodation breaches.

Feedback received through the Friends and Family test is again stable in month 6 at 97% which

remains positive. The number of compliments has fallen in month to 537, well below the rolling 12-

month average, and is the second lowest received over the last 12 months. There is a lag in

submission of compliments in some areas therefore this number may increase slightly.

Are we EFFECTIVE?


Readmission rate for both 30 and 90 days, across both adult and older adult services has improved for

the third consecutive month in month 6, with both achieving the standards set of 8.7% and 15%

36 of 264

respectively. The improved performance shows the positive impact of the

team leader reviews at CMHT/CRHTT clinical discussion meetings and the visibility of this data at

locality governance groups. The processes will be kept in place, as will mechanisms to spread the

learning achieved so far as a means to reduce future readmissions.

Average Length of stay has deteriorated this month to 33 days, just above the 31-day standard. The

length of stay on adult wards includes PICU patients and it is noted that PICU length of stay has also

increased this month and is probably driving the increase overall. Over the last 4 months, the positive

impact of the Joint Advisory Group has been evident and whilst the focus has been maintained on the

patients with a length of stay of greater than 180 days it is inevitable that the LOS will be variable as

patients are discharged.

Are we RESPONSIVE?


The Trust continues to perform well against NHS I indicators, however, an issue has been identified

regarding performance in the Early Intervention in Psychosis service against the 2-week target. The

service had been reporting a compliant position against the 50% target this year and following a review

of processes within the service an issue has been identified with the logging of referrals which affects

the point at which the patient pathway is initiated and closed down for the purpose of waiting times

measurement. Therefore, the number of patients that meet the threshold for referral to treatment within

2 weeks is much lower than previously reported. The QPR shows the indicative performance which

shows a Q2 position of 8.6% and a year to date position of 6.7%. This is still being validated but it is

expected that the confirmed position will be confirmed as significant under-performance against the

measure. A remedial action plan to address the under-performance is being developed and will be

monitored through a fortnightly task group. A full report will be submitted to SLT in November and

progress against the action plan reported to Corporate Governance and Compliance sub-committee.

As expected, following the dip in performance in month 4, the Trust has recovered the position for 7

day CPA follow ups and has secured a compliant Q2 performance.

Responsiveness is also demonstrated through our achievement of the 18-week referral to treatment

(RTT) standard for AHPs and for dental waiting times. In the Community Wellbeing Network, dental

service RTT in Liverpool prison has fallen short of the 95% target, the position is a consequence of 2

routine patient cancellations in order to accommodate 2 urgent patients, which resulted in the 2 routine

patients being treated at greater than 18 weeks. The service has reviewed their processes accordingly.

The Community Well Being Network are compliant against all other contractual RTT measures.

In the Children and Young People’s Wellbeing Network, 3 out of 5 services across which we report in

month 6 against the 18 week RTT pathways are compliant, which maintains the improvement seen in

month 5.

The Children’s Speech and Language Therapy service have achieved the RTT measure of 92% of

patients on the waiting list having waited less than 18 weeks for the second consecutive month,

reporting 96%. As reported last month, the Chorley & South Ribble team have experienced delays

achieving the required capacity to deliver recovery and 28 of the 31 patients on the waiting list are in

the Chorley South Ribble team, although all of these patients are booked for appointments which will

37 of 264

have a positive impact on this team’s position. The Network are reporting

all teams are expected to be compliant by the end of October.

The 2 areas of performance which remain challenged are Child Psychology and CAMHs Tier 3.

Performance in Child Psychology for month 6 has improved to 84%, a further increase on the 77.7%

reported in month 5 against the 95% RTT standard for patients starting treatment. In addition, the

number of children on the waiting list who have waited >18 weeks continues to reduce (from 78 in

month 5 to 49 in month 6) which is a positive indicator of the impact that the recovery plan is having

and moves the service closer to being able to achieve the 95% target once the backlog is cleared.

Conversely, performance in the CAMHS Tier 3 service has deteriorated further and the service are

reporting 59% against the 95% RTT standard for completed pathways (compared to 64% in month 5).

The Chorley and South Ribble team continue to be the main contributor to the under-performance with

217 of the 235 service users who are on the waiting list having waited greater than 18 weeks. This is a

result of capacity shortfalls caused by sickness and vacancies, an issue that is being addressed by the

appointment of a new team leader and further appointments are expected in Q3. Currently, waiting list

validation is progressing on the longest waiting patients with appointments organised for those patients

contacted as part of the validation process. Additional management oversight is also now in place to

support the team and an improvement is expected from November.

Memory assessment services continue to perform well against the 70% target for the 6-week referral to

assessment standard and are compliant for the fourth month. All teams are performing well with the

exception of the Central Lancashire MAS team where underperformance will continue whilst a way

forward is sought on the establishment of a shared care agreement.

In Mindsmatter, a number of measures are monitored that indicate our overall responsiveness. The

service continues to perform well against the NHS I indicators for referral to treatment in 6 and 18 RTT

weeks however, the number of patients on the waiting list who have waited longer than 26 weeks has

increased this month to 26 following the reduction seen last month. This is being closely monitored and

patients offered alternatives where appropriate. Performance against the recovery metric remains

positive, however performance against prevalence continues to be challenging at team level. Whilst

IAPT overall have met the current contractual prevalence for Q2, the QPR tracks performance against

our internal trajectory which is phased to support the achievement of the increase in prevalence by Q4.

Following a substantial amount of work, 5 out of 8 teams have met the internal trajectory for prevalence

levels at the end of Q2. The 3 teams not meeting prevalence targets for Q2 will be required to redress

the gap during Q3. Actions are in place with regular monitoring to improve the position.

The high demand for inpatient beds continues, with occupancy levels exceeding 100% and increased

from last month at 116%. Consequently, the number of out of area placements (OAPs) has increased

in month to 26. As reported last month, there is evidence that the implementation of intensive support

schemes has impacted on the number of admissions yet this has not avoided the use of OAPS. Work

on reducing the number of patients who have a length of stay of greater than 180 days continues, as

identification of alternative provision would potentially enable the resolution of the OAPs position. STP

leads have supported the view that the financial impact of this cohort of patients is separate to the

OAPs spend and on this basis the Network has formally written to commissioners to take forward

options for onwards placements for these patients in a more appropriate setting for their needs.

38 of 264

Mental health liaison teams (MHLT) are reporting an improved position in

relation to the 12-hour breach numbers with a reduction from 17 to 6 in month 6. This demonstrates the

impact of the significant operational management oversight on patient flow and ensuring patients

access care in a timely manner. Demand for the teams continues to be challenging and performance

against the 1h and 4h metrics remains below target. We await formal feedback on the bid for monies

to mitigate the gaps in service provision pending the Core 24 funding available from 18/19. Formal

notification on our in-year bid is expected on the 30th October 2017.

This month the number of complaints has reduced again to 149 compared to 173 in month 5, although

is still above the rolling average of 133 per month. The number of upheld complaints is below the

average of 24, with 21 upheld in month which is extremely positive, as is the number of re-opened

complaints and those escalated to the ombudsman. This demonstrates the satisfaction of complainants

with the outcome of their complaints, most of which are related to communication and access to

treatment.

Are we WELL-LED?


The Staff engagement score for the Q2 position shows a static position with only a decimal point

increase on the Q1 position.

The decrease seen in Sickness rates last month have not been maintained and have risen slightly to

6.35%. The increase is driven by increases in the Mental Health Network and Support Services that

have both seen increases this month. Work continues on absence management across all areas in

accordance with Trust policy and the ‘back to basics’ approach.

Summary and Recommendations

The information in the QPR provides evidence of our performance against key metrics aligned to each

CQC domains. From this, and the exception reporting against each measure, we are able to

provide information that supports the assessment of our position against each domain.

The full QPR can be seen here.

39 of 264

https://www.lancashirecare.nhs.uk/media/Trust%20Board/Trust%20Board%20Documents/02%20November%202017/TB%20165%2017_QPR%20M6%20CONFIRMED%20v3.pdf

Board of Directors

Agenda Item TB 166 /17 Date: 02/11/2017

Report Title Finance Report

FOIA Exemption Part Exemption

Prepared by Shannon Carroll, Financial Services Director

Presented by Bill Gregory, Chief Finance Officer


Supporting Executive Director Chief Finance Officer


Report purpose To summarise and analyse actual and forecast financial performance and standing of the Trust, the implications and any proposed management action.


To provide excellent value for money in a financially sustainable way

Board Assurance Framework risk 5.1 The Trust does not achieve financial performance sufficient to maintain resilience and sustainability

CQC domain Effective

192 of 264

Summary

Actual Plan Var Forecast Plan VarSustainability

EBITDA 5,353 8,109 -2,756 15,641 17,745 -2,104Operational Deficit -2,291 321 -2,612 2,188 2,167 21

CIPs (against Trust Plan) 6,128 7,110 -982 15,100 15,100 0Cash and Liquidity 11,944 11,604 340 23,499 10,989 12,510Capex 1,525 5,335 -3,810 13,661 9,591 4,070UOR

Capital Service 4 3 3 2Liquidity 1 2 1 2I&E Margin 4 2 2 2I&E Variance 3 1 2 1Agency 2 1 2 1Overall 3 2 2 2

Sustainability

CIPs

Liquidity

Summary continued overleaf

Cash shows a favourable variance from plan of £0.3m. The capital position continues to offset the I&E position and pressures on working capital have been reduced. Forecast cash is currently expected to exceed plan, primarily as a result of assumptions around external capital funding for the Inpatient Scheme and the disposals of Westfields, Ribbleton and Ridge Lea - see Cash and Liquidity for more details.

Current Out-Turn

At month 6 with CIPs of £6.1m against a plan of £7.1m the Trust is c£1m behind plan, a deterioration of £0.2m on month 5 (£0.8m behind plan). The adverse variance is mainly due to a lack of performance on Run Rate Reduction Programmes on staffing pressures. Compensating schemes have, and continue to be, developed and network management team are being supported by to implement measures aimed at improving the position.

Month 6 sees a year to date operating deficit of -£2.3m, excluding planned Sustainability and Transformation funding of £0.7m, against a planned surplus to date of £0.3m. Though the run rate would appear to be consistent with previous months, but with several components of the recovery plan being transacted in month 6, this indicates the position has deteriorated further in month. The position remains driven by staffing pressures in ward and prison areas and consequential impact on cost improvement programmes (rising agency costs will also impact Use of Resources targets). Additionally OAPs expenditure continues to exceed funding - see Out Of Area Activity for more details. The forecast assumes current pressures and risks are addressed or mitigated in line with the recovery plan (see forecasting) and financial performance achieves (or exceeds) plan but the unmitigated projection indicates a gap of c£6.2m, c£8.3m without STF monies. This is broadly consistent with month 5 (£6.0m), and is again driven by excess OAPs of c£1.8m, prisons (see also Bank and Agency section) and additional mental health pressures. Delivery of the recovery plan and financial targets will required a significant and coordinated response with robust management and oversight. After taking in to account £1.7m of disposals, which are accounted for after EBITDA, EBITDA is broadly in line with I&E Margin. The new Use of Resources (UoR) metric is rated at 3, but will rise to a 2 should the Trust meet its financial plans and targets, see below.

193 of 264

Capital and Financing

Use of Resources (UoR) risk ratings

Forecasting

Recovery Plan

#

Whilst it would appear that the gap can be bridged through the plan, this is not without significant risk. Delivery will only be achieved with a considerable coordinated and sustained effort across the organisation. The plan will continue to be refined and presented in more detail to the Financial Recovery Group along with the actions required.

Progress against the capital programme has been slow to date with expenditure at £1.5m against the original profile of £5.3m. The scheduling profile of many schemes was dependent on a number of tendering exercises (the last of which, Perinatal, is due end of October), agreements with third parties (Chorley site arrangements with LTH have now been agreed, network connection issues preventing the decant required for the Perinatal development remain a risk to timescales) and final funding approval (Inpatient schemes approval now received from NHSI, awaiting final confirmation of funds and timing from DH). Schedules for these and related/dependant schemes will now be finalised through discussions with the incumbent contractors and the Trust can push forward with the work required to complete its capital programme in line with its control total and funding.

Revised year end control totals are being provided to networks in line with the recovery plan and will require:• Progress and delivery of ward staffing actions• Implementation of the recovery plan.• Agreement of OAPs mitigations with commissioners.• Progress on land sales.

The current I&E position gives a rating of 4 and delivers a Capital Service rating of 4 constraining the current overall UoR to a 3. Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though forecast would achieve the overall target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan is based on disposals (which are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The Trust is also forecast to exceed its liquidity and slip against it's planned Agency target. Should conditions persist and costs not be managed within the control total then the resulting deterioration might trigger a review of our segmentation.

194 of 264

Forecast ForecastYTD YTD Out-turn Out-turn

Sep 2017 Aug 2017 at Sep 2017 at Aug 20176 5 Note 12 12 Note

Plan 0.321 0.187 Plan 2.167 2.167

Major Variances Major VariancesCIP Slippage -0.982 -0.838 - See CIP section CIP Slippage 0.000 0.000 - See CIP sectionOAPs -0.773 -0.331 - See OAPs section OAPs -1.792 -1.871 - See OAPs sectionStaffing -5.000 -4.143 - See also Bank and Agency section Staffing -8.201 -8.648 - See also Bank and Agency sectionOther Bud Vars 1.791 1.306 - See Services section Other Bud Vars 0.601 1.469 - See Services sectionReserves 3.040 2.401 - See Reserves section Reserves 8.899 8.313 - See Reserves sectionIncome -0.688 -0.555 - See Reserves section Income 0.514 0.764 - See belowMinor Variances 0.000 0.000 Minor Variances 0.000 0.000

Variance -2.612 -2.161 Variance 0.021 0.027

Actual -2.291 -1.974 Actual Forecast 2.188 2.194

---

-

Surplus - YTD (£m) Surplus - Out-turn (£m)

This month sees an operating deficit of £2.3m, £2.6m behind plan, of which £0.7m relates to STF funding.

YTD income variance relates mainly to STF funds which are assumed in forecast along with additional funds re NCAs and R&D

Staffing variance has increased in part due to phasings of development funding in mental health, but more materially due to ward pressures.The full year projection is an operating surplus of £2.2m, accounting for the STF funding in the plan. The position models an upside of c£8.3m and includes profit on disposals of c£1.7m.

-10,000.0

-8,000.0

-6,000.0

-4,000.0

-2,000.0

0.0

2,000.0

4,000.0

Plan CIP Surplus OAPs Staffing Other BudVars

Reserves Addl Income MinorVariances

2,167.0 0.0 -1,792.0 -8,200.7 600.8 8,899.4 513.9 0.0

-7,000.0

-6,000.0

-5,000.0

-4,000.0

-3,000.0

-2,000.0

-1,000.0

0.0

1,000.0

Plan CIP Shortfall OAPs Staffing Other BudVars

Reserves Addl Income MinorVariances

321.0 -982.4 -773.0 -4,999.9 1,790.7 3,039.7 -687.50 0.0

195 of 264



Plan 166.144 138.436 Plan 332.908 332.908

Major Variances Major VariancesCommunity Services 0.659 0.349 - Note 1 Community Services 2.172 2.448 - Note 1Mental Health 2.380 1.430 - Note 2 Mental Health 2.598 2.141 - Note 2Specialist Services -0.196 -0.038 - Note 3 Specialist Services -1.145 -1.147 - Note 3Non NHS Healthcare Income-0.835 -0.612 - Note 4 Non NHS Healthcare Income-1.758 -1.771 - Note 4R&D 0.180 0.160 R&D 0.600 0.285ETR 0.167 0.131 - Student Income ETR 0.297 0.146 - Student IncomeMiscellaneous 0.209 0.216 - Note 5 Miscellaneous 1.529 1.079 - Note 5STF -0.730 -0.591 STF 0.000 0.000

Minor Variances -0.039 0.000 Minor Variances 0.015 0.014

Variance 1.794 1.045 Variance 4.308 3.194

Actual 167.938 139.481 Actual Forecast 337.216 336.102

12

345 Major increases in the latter part of the year generated by AHSN.

Monthly Income Variances (£m) Cumulative Income Variances (£m)

Major decrease due to Southport commencing in May and not April offset by minor gains in other services including Rheumatology and District Nursing.Major increases revolve around the phasing of the Out of Area Placements expenditure, in addition to Liaison & Diversion and Eating Disorders. Major decreases in Rehabilitation Services and Hospital Liaison.Income is in line with plan at this stage. Year end variances are driven by the anticipated cessation of the HIV contract.Major decrease in respect of lower than planned activity in Sexual Health services and forecasts for Sexual Health and Offender Health later in the year.

0.000

5.000

10.000

15.000

20.000

25.000

30.000

35.000

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

Actual/Forecast

Plan

0.000

50.000

100.000

150.000

200.000

250.000

300.000

350.000

400.000


Actual/Forecast

Plan

196 of 264



Budget 141.407 117.751 Budget 281.506 281.856

Major Variances Major VariancesMental Health -5.654 -4.462 - Note 1 Mental Health -9.961 -9.626 - Note 1Community & Wellbeing -0.274 -0.304 - Note 2 Community & Wellbeing -0.489 -0.498 - Note 2Children & Young People 0.705 0.614 - Note 3 Children & Young People 0.866 0.841 - Note 3Pharmacy 0.169 0.146 - Note 4 Pharmacy 0.265 0.284 - Note 4Property Services 0.000 0.000 - Note 5 Property Services 0.000 0.000 - Note 5Corporate 0.089 0.000 - Note 6 Corporate -0.073 -0.052 - Note 6

Variance -4.965 -4.006 -9.392 -9.050

Actual 146.372 121.757 Actual Forecast 290.898 290.906

1

23

456 Corporate services are slightly ahead of plan year to date, with overspends in IM&T currently met by underspends in Medical and Innovation.

Mental Health in year overspend is driven more acutely by excess staffing costs, primarily on wards, (£2.5m). Actions to review the patients in inpatients setting, their appropriateness for the ward and levels of staffing associated with acuity are advanced and should furnish us with the appropriate information to discuss necessary action to recover the position, though risk remains until this is enacted. There is also significant CIP slippage, as all CIPS have been withdrawn but some schemes are still in development (c£1.1m). The Network's position is diminished further by ward overspends in Secure Services wards (c£1.3m). OAPs are now manifesting as overspends (£0.3m year to date)

Community's position is impacted by undelivered CIPs to date (£0.3m). Underspends on community teams and non-pay continue to alleviate the current position.Children and Young People have similarly been impacted by a shortfall on CIP delivery(£0.2m) and Sexual Health activity shortfall (£0.2m) but is currently being compensated for by vacancies and non-pay underspends.

YTD Service Net Expenditure Variance (£m) Forecast Service Net Expenditure Variance (£m)

Pharmacy is performing broadly in line with plan, with some underspends on staffing.Property Services are performing in line with plan and are expected to remain so.

-£6,000

-£5,000

-£4,000

-£3,000

-£2,000

-£1,000

£0

£1,000

£2,000Mental Health

Community &Wellbeing

Children &Young People Pharmacy

PropertyServices Corporate Total

Service Forecast Variance

-£12,000

-£10,000

-£8,000

-£6,000

-£4,000

-£2,000

£0

£2,000Mental Health

Community &Wellbeing

Children &Young People Pharmacy

PropertyServices Corporate Total

Service Year to Date Variance

197 of 264

CIP Achievement (£)Notes

Year to Date PerformanceAt month 6 with CIPs of £6.1m against a plan of £7.1m the Trust is c£1m behind plan, a deterioration of £0.2m on month 5 (£0.8m behind plan). The adverse variance is mainly due to a lack of performance on Run Rate Reduction Programmes on staffing pressures. Compensating schemes have, and continue to be, developed and network management team are being supported by to implement measures aimed at improving the position.

Schemes to be Transacted£1m of schemes are yet to be transacted at month 6 leading to year to date slippage of c£0.49m. There is a good degree of confidence in the delivery of these schemes.

Schemes In Process£1.6m of additional schemes identified are not yet sufficiently detailed to transact and after allowing for slippage factored into plan this results in slippage of c£0.42m. There is some confidence in the delivery of these schemes.

Schemes to be IdentifiedIncluding pipeline schemes plan totals exceed target and forecast is broadly in line with plan to achieve its CIP (£0.4m shortfall at month 5), though this is not without risk.

ForecastThe programme is currently expected to achieve the Annual Plan however risk of slippage, particularly on mental health and community schemes, remains.

Plan Actual Variance Plan Forecast Variance

£'m £'m £'m £'m £'m £'m

Cost Improvement Programmes 5.51 5.53 0.02 11.10 13.10 2.00

Run Rate Reduction Programmes 1.61 0.60 -1.01 4.00 2.00 -2.00

Total 7.11 6.13 -0.98 15.10 15.10 0.00

Plan Actual Variance Plan Forecast Variance

£'m £'m £'m £'m £'m £'m

Monitored Schemes 6.20 6.13 -0.08 12.62 12.50 -0.12

Schemes to be transacted 0.49 -0.49 0.98 0.98 0.00

Schemes in Process 0.42 -0.42 2.17 1.56 -0.61

Slippage/Schemes to be identified 0.00 -0.67 0.05 0.73

Total 7.11 6.13 -0.98 15.10 15.10 0.00

Year to Date Annual

Year to Date Annual

198 of 264

Month Month Month MonthSep 2017 Aug 2017 Sep 2017 Aug 2017

6 5 Note 6 5 Note

Agency Spend 863 829 Note 1 Bank Spend 1,813 1,481

Network Analysis Network AnalysisMental Health 554 585 - Note 2 Mental Health 1484 1190 - Note 2Children & Young Peoples 64 46 - Note 3 Children & Young Peoples 80 75 - Note 3Community & Wellbeing 215 244 - Note 4 Community & Wellbeing 197 165 - Note 4Corporate Services 30 -46 - Note 5 Corporate Services 52 50 - Note 5

Actual 863 829 Actual 1,813 1,481

1

2

34

5

The Trust has been given a ceiling by NHS Improvement for agency spend. This target is£7.695m for the year. At the end of period 6, the Trust is -£617k, or 16% above it'strajectory. The new Use of Resources rating measures agency against target and containstrigger points. Key trigger points are a requirement for 50% and 25% or better for ratings of3 and 2 respectively. An individual rating of at least 3 is required to obtain an overall ratingof 2 (see also Use of Resources section).

Corporate Services is net of the charge levied for agency staff. Agency spend is negligible with the exceptions of Health Informatics.

Agency Costs Over Time (£'000) Bank Costs Over Time (£'000)

A high level of vacancies is supported by bank and agency, though increased levels of recruitment mean overall staffing costs remain high. Agency costs have increased from last month as well as bank costs.Mental Health Networks bank and agency costs are primarily due to the level of acuity on inpatient wards being beyond the level established although the in month increase in bank is almost entirely attributable to staffing on Adult and Secure wards.Children and Young Peoples temporary staffing remains relatively minor and consistent.Community and Wellbeing sees an increase in both Bank but fall in Agency, with the major agency change being the recovery of medical staffing in Rheumatology and Dietetics, and bank deteriorating in Integrated Teams and Southport.


2015/16 935 1108 932 1180 1119 1176 1139 1183 1170 1072 1289 1209

2016/17 1536 1521 1728 1390 1238 1570 1154 1219 1401 1289 1321 1613

2017/18 1312 1268 1625 1365 1481 1813

0200400600800

100012001400160018002000


2015/16 1030 988 1262 1242 909 1202 1149 939 1073 1077 978 1174

2016/17 1098 862 1250 1184 986 1133 781 827 825 738 661 1006

2017/18 647 691 711 704 825 863

0

200

400

600

800

1000

1200

1400

Agency Ceiling Apr May Jun Jul Aug Sep Total Projection

Actual 647 691 711 704 825 863 4,442 8,184Plan 639 639 639 636 636 636 3,825 7,695Variance -8 -52 -72 -68 -189 -227 -617 -489% of Plan -16% -6%

199 of 264

Month Month YTD ForecastSep 2017 Aug 2017 Sep 2017 Out-turn

6 5 Note 6 12 Note

Plan -3.6 0.5 Plan 11.6 11.0

Major Variances Major VariancesI&E -0.6 -0.8 - Note 2 I&E -2.8 -2.1 - Note 2Capital & financing 0.8 0.7 - Note 2 Capital & financing 3.8 11.8 - Note 2Contract Vars and Adjs -1.1 0.0 Note 3 Contract Vars and Adjs -2.9 Note 3Debtors 1.2 -1.2 - Note 4 Debtors -2.0 -0.2 - Note 4Timing of settlements to suppliers 2.9 -3.4 - Note 4

Timing of settlements to suppliers 0.3 0.1 - Note 4

Provisions and deferred income 0.0 0.4 - Note 5

Provisions and deferred income 0.9 -0.1 - Note 5

Opening cash 0.0 0.0 Opening adjustment 2.7 2.7

Minor Variances 0.3 0.0 Minor Variances 0.3 0.3

Variance 3.4 -4.3 Variance 0.3 12.5

Actual -0.2 -3.9 Note 1 Forecast Actual/Forecast 11.9 23.5 - Note 1

1

2

34

56 Provisions and Deferred Income are currently generating gains of c£0.9m over plan. Crystallisation of income and redundancy settlements are expected to reduce gains and this is

factored into forecasts.

Monthly Cash and Liquidity Variance (£m) Forecast Cash and Liquidity (£m)

Timing of settlements to suppliers are broadly in line with plan.

Reductions in capital expenditure are supporting cash more than compensating for the impact of the deficit. Forecasts assume planned revenue and capital forecasts are achieved, that PDC for the inpatients Programme is in line with expectations, and that the disposal of Westfields, Ridge Lea and Ribbleton take place in 2017/18.

Debtors shows some improvement as councils settle backlogs but remains behind plan. NHS Debtors remain at similar levels to last month, including c£2m of late payments against current block.

Forecast cash is ahead of plan by c12.5m partly due to the change in opening position c2.7m, but mainly due to assumptions around disposals (net improvement c£5.75m - Westfields, Ribbleton and Ridge Lea) and the assumed external cash funding of a substantial part of the Inpatient Scheme (net improvement £4.6m). The forecast assumes that proposed management action to bring financial performance back in to line is achieved (including profit on disposals) and also that the Trust, as a result, maintains eligibility for Sustainability Funding.

Cash shows a favourable variance from plan of £0.3m. The capital position continues to offset the I&E position and pressures on working capital have been reduced - see below.

Contract variations and phasing adjustments negatively impact on cash and are not included in plans.

-10.000

-5.000

0.000

5.000

10.000

15.000


Opening cash balance

Financing and Other

Capital and Investment Activities

Changes to WC

Non Cash Flows

Cash flows from operating activities

0.000

5.000

10.000

15.000

20.000

25.000

30.000


Forecast

Plan

200 of 264

YTD Plan YTD Act Annual ForecastSep 2017 Sep 2017 Variance Plan Out-turn Variance

£000 £000 £000 £000 £000 £000

IT Schemes 0.840 0.659 -0.181 1.900 1.900 0.000 - Note 1

Estate and infrastructure SchemesLarge Schemes

MH Inpatient Schemes 3.070 0.247 -2.823 4.580 5.700 1.120 - Note 2

Perinatal 0.000 0.113 0.113 0.000 2.470 2.470 - Note 3

Places of Safety 0.000 0.000 0.000 0.000 0.490 0.490 - Note 4

High Priority Schemes 0.360 0.147 -0.213 1.263 1.260 -0.003 - Note 5

Maintenance and Replacement 0.465 0.276 -0.189 0.930 0.930 0.000Other (inc. contingency) 0.600 0.083 -0.517 0.918 0.911 -0.007

Total 5.335 1.525 -3.810 9.591 13.661 4.070

12

3

4

56 Underspend relates to contingency and reserves, some delays as a result of dependencies/focus on large schemes and fire safety have resulted in slippage rather than

pressures on contingency. Transfers between revenue and capital transacted are as required.

Note 6-

External cash funding has been agreed for the Perinatal project with £2.5m being allocated to 2017/18 and £1.0m allocated to 2018/19. Tender expected by end of October and work is expected to start in December/January though some issues with third parties may cause delays with the required decant and slippage may result.

£0.5m of external cash funding has now been allocated for Places of Safety. Funding currently exceeds planned work and should spend not be required this year then funding will be retained by DoH.

Capital Expenditure

Progress against the capital programme has been slow to date with expenditure at £1.5m against the original profile of £5.3m. The scheduling profile of many schemes was dependent on a number of tendering exercises (the last of which, Perinatal, is due end of October), agreements with third parties (Chorley site arrangements with LTH have now been agreed, network connection issues preventing the decant required for the Perinatal development remain a risk to timescales) and final funding approval (Inpatient schemes approval now received from NHSI, awaiting final confirmation of funds and timing from DH). Schedules for these and related/dependant schemes will now be finalised through discussions with the incumbent contractors and the Trust can push forward with the work required to complete its capital programme in line with its control total and funding.

IT programme is expected to be delivered on forecast.External cash funding has been provisionally allocated through the STP to the Inpatient project and approved by NHSI in October. Final confirmation of funding is awaited from DH. Both Blackburn and Chorley tenders were received in October and the site agreements have now been agreed with LTH. Works have started on site though commencement of main works is not expected until December, slightly later than originally intended. Exact timings will be dependant on discussions with contractors who have been stood down a number of times. As a result of the delays some slippage now seems likely.

No planned expenditure in Q1. Schemes have now started though with some delays, partly as a result of inpatient development.

201 of 264

Use Of Resource Metric

unitsPlan

YTD ending 30-Sep-2017

Actual YTD ending 30-

Sep-2017

Variance YTD ending 31-May-17

Plan YTD ending 31-

Mar-2018

Forecast YTD ending 31-

Mar-2018

Forecast Variance

Year ending31-Mar-18

Threshold 1 2 3 4

\ Capital Service Cover 2.5 1.75 1.25 <1.25Capital Service Cover Liquidity 0 -7 -14 <-14

I&E Margin 1.00% 0.00% -1.00% <=-1%

Capital service metric 0.0x 1.747 1.130 (0.617) 1.909 1.647 (0.262) Variance from plan 0.00% -1.00% -2.00% <=-2%

Capital service rating Rating 3 4 2 3 Agency 0.00% 25.00% 50.00% >=50%

Liquidity Metric Weighting

Capital Service Cover rating 20.00%

Liquidity metric £m (1.300) 3.127 4.427 (0.433) 13.383 13.816 Liquidity rating 20.00%

Liquidity rating Rating 2 1 2 1 I&E Margin rating 20.00%

Variance From Plan rating 20.00%I&E Margin Agency Spend 20.00%

I&E Margin metric % 0.19% (1.36%) (1.56%) 0.65% 0.65% (0.00%)

I&E Margin rating Rating 2 4 2 2

I&E Variance From Plan

I&E Variance from plan metric % (1.56%) (0.00%)

I&E Variance from plan rating Rating 3 2

Agency

Agency metric % (0.55%) 15.49% 16.04% (0.95%) 7.13% 8.08%

Agency rating Rating 1 2 1 2

Use Of Resources Rating

Overall rating unrounded Rating 2.80 2.00 If unrounded score ends in 0.5 Rating - -Rounded score Rating 3 2

Use Of Resources Rating before overrides Rating 3 2

4 Rating Trigger for Use Of Resources Rating Text Trigger No trigger

Use Of Resources Rating after 4 rating override Rating 3 2

Control total override - Control total accepted Text YES YES

Is the provider in Financial Special Measures? Text No No

Use Of Resources Rating after overrides Rating 3 2

Finance and use of resources is one theme of 5 in the Single Oversight Framework. Segmentation and therefore autonomy and support is dependent on performance across all themes.

Note that under the Single Oversight Framework a score of 1 is now the best rating and 4 the worst. A rating of 4 on any metric or an average rating of 3 triggers a concern and a potential support need.

The current I&E position gives a rating of 4 and delivers a Capital Service rating of 4 constraining the current overall UoR to a 3. Assuming current pressures and risks are addressed through the recovery plan and I&E performance achieves (or exceeds) forecast the Trust will achieve a UoR of 2 in line with the plan. However, though forecast would achieve the overall target rating, Capital Service is based on EBITDA and since part of the Trusts recovery plan is based on disposals (which are excluded from EBITDA) the Trust is not forecast to achieve planned Capital Service. The Trust is also forecast to exceed its liquidity and slip against it's planned Agency target. Should conditions persist and costs not be managed within the control total then the resulting deterioration might trigger a review of our segmentation.

• Capital Service is currently a 3 against a plan of 2, an increase in operating performance of c£0.8m would be required to increase the rating to 2.

• Liquidity is currently a 1 against a plan of 1, a deterioration in the liquidity metric of c£3.1m would be required to reduce the rating to 2.

• I&E Margin rating is currently 4 against a plan of 2, an increase in operating performance of c£0.6m would be required to increase the rating to 3 - Note that the deficit of -£2.3m is £2.6m behind the RCT (£1.9m exc STF)).

• I&E Variance from Plan is currently 3, an increase in operating performance of c£0.6m would be required to increase the rating to 2.

• Agency is currently 2 based on a metric of 16%, a decrease in agency costs of

202 of 264

Reserves

Reserve Budget Actual £ Annual Projected £

To Date To Date Variance Budget Actual Variance Narrative

£'000 £'000 £'000 £'000 £'000 £'000

Capital Charges £7,686 £7,662 £24 £15,546 £13,624 £1,922 Anticipated Profit on Disposals offset by var due to revaluation of estate

Pay Reserve £1,003 £485 £518 £1,529 £970 £559 Charge for Apprentice Levy and Junior Medic ContractPressures Reserve £252 £100 £152 £503 £200 £303 Funds to be applied to servicesCIP Reserve £967 -£40 £1,007 £1,834 -£80 £1,914 Gain on CIP to be applied to service pressuresEmerging Pressures -£270 £0 -£270 -£2,261 £0 -£2,261 Utilisation of Reserves to meet Emerging PressuresDevelopments £632 £270 £362 £961 £250 £711 Costs to be applied as incurredContracts £157 £0 £157 £227 £0 £227 Minor contract gains to be applied to servicesOrganisational Reset £883 £338 £545 £1,766 £676 £1,091 Funds to be returned to Networks, with some staffing chargesAgency & Direct Engagement -£300 -£281 -£19 -£600 -£612 £12 Premium for using non-contracted staffSavings to be Identified £0 -£2 £2 £0 -£3,830 £3,830 Additional savings required to deliver control total

Non Pay Inflation £547 £60 £487 £794 £121 £673 Funds to be applied for inflationary pressures

Total £11,556 £8,592 £2,964 £20,299 £11,318 £8,981

203 of 264

MATTERS

ID Meeting DatePaper Status

2017/01 Jul-17 VerbalPartial




2017/05 Jul-17 Verbal

Excluded

2017/06 Jul-17 VerbalExcluded



The Trust is actively exploring the potential for land sales. Gains may crystallise in 17/18 dependent on timing and profits willcontribute toward the control total.

On-going Claims: The process of reclaiming VAT in relation to older developments continues. Communications with HRMC progressthough timing and amounts remain uncertain. Treatment is being discussed with external audit but initial indications are positive. Thevalue may be up to £2m, though less than half this amount is included in plans and forecasts. Our advisors are actively engaged inbringing this to a final resolution.

SubjectA number of disputes require resolution and may result in arbitration. These concern NHSE, West Lancs, and Pennine CCGs. These arebeing escalated through NHSI.

NHSI is currently clarifying the position around elements of the national contingency reserve, £0.5m of which is now outstanding.

The forecast trajectory with regard to Out of Area Placements (OAPs) is currently projected to £1.8m. However there remains a risk tothis this position.

Provision for charges incurred as a result of the organisational reset have been made, the process is largely complete, but somechallenges remain and these may have financial consequences.

STF monies have been included in forecasts on the assumption that the Trust will achieve its revenue control total. Should this not bethe case £2.1m of funding would be lost.The Trust is monitoring national legal challenges around pay for sleepover in Learning Disabilities care placements, there is a potentialfinancial risk.

204 of 264

OUT OF AREA ACTIVITY

NetworkActual/ Forecast Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar TotalAcute OAPs (places) 15 11 14 13 10 11 16 16 10 10 10 10 146PICU OAPs (places) 9 13 9 12 12 11 10 9 8 8 8 8 117Total Beds 24 24 23 25 22 22 26 25 18 18 18 18 263Acute OAPs (£'000) 244 185 228 218 168 179 269 260 168 168 152 168 2407PICU OAPs (£'000) 206 308 206 284 284 252 237 206 189 189 171 189 2721Total £'000 450 493 434 502 452 431 506 466 357 357 323 357 5128

1

23

4

567

ForecastActuals

The Trust has written to commissioners about the pressure caused by patients awaiting alternative placements.The Trust has opened negotiations with commissioners about the financial impact of patients inappropriately occupying our beds in excess of 180 days.

The Trust is mobilising Acute Therapy Services in Pennine and Chorley, Crisis Support Units in Preston and Blackpool, and a Crisis House in Coppull. These services have an impact on the bed trajectory and variations in timing will alter the OAPs usage accordingly.

There is a fund of c£3m for OAPs, financed 50:50 by the Trust and Lancashire CCGs. Any underspend can be used to support inpatient staffing while occupancy is above 90%.

Current projection suggest there will be expenditure of £5.1m for OAPs in 2017/18., though slippage on developments takes the net impact to 4.8m as reported elsewhere.

Commissioners have asked for, and are receiving, monthly actual performance against the profile.

If the current trajectory persists this would present pressure in the order of £2.4m (net).

205 of 264

Board of Directors


Report Title Workforce Board Report Q2 2017/18


Prepared by Michelle Kaye, Head of Workforce Planning and Information

Presented by Damian Gallagher, Director of HR




Report purpose To support and inform the Board’s delivery of the LCFT Workforce Strategy


To employ the best people

Board Assurance Framework risk 4.1

CQC domain Well-led

Introduction: The LCFT Workforce Board Report has been designed to provide the Board with a quarterly update on the organisations performance against ten agreed workforce Key Performance Indicators (KPI’s). The data presented is supported with narrative that highlights the current workforce management challenges being experienced by the Business. The structure of the narrative is designed to provide high level information about the remedial and supportive activities and actions being taken to manage performance improvement and provide assurance to the Board that the organisation is committed to effectively managing and mitigating the identified workforce management risks. This report provides performance against the workforce indicators for the Quarter 2 period, 01 July 2017 to 30 September 2017. The data presented in this report is sourced from the following LCFT Directorates:

Human Resources

Human Resources Quality Academy

Finance Information to support the preparation of narrative is provided by HR Business Partners in conjunction with Network Management. Members of the Board are invited to note the content of the report and are encouraged to ask any questions and make requests for further information with the Director of Human Resources.

Workforce KPI Performance Headlines: The workforce indicators set out on page 3 of the Workforce Board Report present LCFT’s overall performance against the ten workforce KPI’s in the Quarter 2 period.

206 of 264

Performance is rated against the Trusts defined targets, using the Red and Green indicators adopted by LCFT. These are supplemented with an indicative performance trend arrow. The trend is set against performance reported in the previous quarter. 1. Peripheral Workforce Reliance LCFT’s use of a Bank and Agency workforce has increased through the Q2 period, closing the

quarter at 12.33%. The first two months of the quarter delivered a slight reduction against the Q1 closing position of 10.77% and the final month of the quarter a slightly worsened position when compared to the Q1 closing figure. The LCFT Bank Workforce continues to be the primary source of flexible labour for the Trust.

2. Operational Gap The Trust operating gap has remained below the Trust target of 5% throughout the quarter and

LCFT reports a stable Q2 closing rate of 2.96%. The total operating gap (including Sickness Absence and Annual Leave absences) is 11.46% at

the close of Q2. This is a decrease on the Q1 closing percentage of 17.54%. 3. Sickness Absence

Sickness Absence has fluctuated through Q2 and closes the quarter at 6.35%, a slightly improved position from the start of the quarter. The Community & Wellbeing and Children & Young Persons Wellbeing Networks have delivered a relatively stable performance across Q2 with a slightly reduced position when compared with their starting rate for the period. The Mental Health Network and Support Services have both seen increases in sickness absence through the quarter. All Networks continue to focus on Sickness Absence Management and have undertaken internal reviews on how they are managing and tracking the management of sickness in their networks to ensure that they are adopting the best and most effective approach for their particular services and system needs.

Long term and short term sickness absence report a closer, even split at the close of the quarter

with 50.69% of absences being attributable to Long Term Sickness (Absences lasting 28 days or more in one episode).

4. Vacancy Rate The Board Report provides two rates to support the assessment of vacancies.

Establishment Vacancy Rate: The number of vacancies the business runs with against its Budgeted Establishment

Active Vacancy Rate: The number of vacancies being actively recruited to (this is a count of any vacancy that is within the recruitment process from recruitment authorisation through to starting with the trust). The budgeted establishment vacancy rate has continued its upward trend through the Q2 period

and reports a closing rate of 12.07% (compared with 9.52% at the close of Q2). The number of these in active recruitment has slightly reduced through the period (and against the

Q1 position), closing at 55.63%. This equates to 643 ‘live’ recruitment events totalling 435.78FTE across the Trust. 81 of these vacancies are at either being held for organisational change or are active at the internal redeployment recruitment stage (44.71FTE) and 562 vacancies are in Open Recruitment (391.07FTE).

5. Safer Employment Compliance

Core Workforce

207 of 264

Compliance in recruiting and employment practice standards across the Core Workforce, continues to perform well. This period reports an overall compliance of 82.97%. This is below the Trust target of 85% but is not a true reflection of the compliance performance, which has skewed results due to a non-compliance of one individual under the Safer Employment Practice Compliance measures. Please see the Board Assurance narrative on slide 23 of the report for further information**.

The breakdown position for compliance under the Safer Employment category reports 100%

compliance for Safer Recruitment Practice and 66% compliance for Safer Employment Practice**.

Bank Workers Compliance in recruitment and active engagement practice standards across the Bank Only

Worker population continues to perform well and reports an overall compliance rate of 96.58% in Q2. Bank Worker Safer Recruitment Practice Compliance reports 100% for the quarter and Safer Engagement Practice reports 93%.

6. Turnover Rate

Quarter 2 has seen a slight increase in the Trust Turnover rate, reporting 13.95% at the close of the quarter.

7. Appraisal Performance Quarter 2 of the 2017/18 performance year is the second cycle of PDR management and includes PDR quarterly review activity in the compliance measure. The Quarter 2 Appraisal report uses four categories to measure PDR activity and performance against the Trust target:

The proportion of employees who have either: 1. The proportion of employees who have initiated their 2017/18 PDR in the ePDR system have objectives

in place and have review activity recorded. 2. Have completed the Medical Workforce Appraisal process.

1. New Starters, within the 60 day grace period, who have registered with the ePDR system but do not yet

have personal objectives in place. 2. Members of the Medical Workforce who have arrangements in place to complete their Medical Appraisal

and are inside the approved timescales for completion.

The proportion of existing employees who have either: 1. Have not initiated the 2017/18 PDR in the ePDR system. 2. Have not registered with the ePDR system and for whom we have no information. 3. Members of the Medical Workforce who have not completed the Medical Appraisal process and are

outside of their ‘Appraisal birthday’. 4. Have initiated their 2017/18 PDR but who do not have objectives in place 5. Have objectives in place but have not completed a review

The proportion of New Starters, within the 60 day grace period, who have not registered with the ePDR system.

The overall Trust Appraisal compliance rate for Q2 (inclusive of the Medical Workforce) is 37.66%. This represents the number of employees who are either rated Green or Amber, according to the categories above. Compliance is below the Trust target of 85%.

3. Mandatory & Statutory Training Compliance Overall mandatory and statutory training compliance continues to improve and has achieved the

Trust Target, reporting an overall compliance of 89% at the close of Q2.

208 of 264

Mandatory Training Compliance is high on the Trust agenda. Networks are currently agreeing new trajectories, to support their achievement of the Trust Target by December, for those individual subjects that remain non-compliant. The People sub-committee continues to monitor this target closely and each Network reports improvements in compliance and accuracy of centrally held compliance data.

4. InductionThe Induction completion rate has fallen slightly below the Trust Target of 95% and reports 88.24%compliance at the close of the quarter.

Damian Gallagher HR Director

209 of 264

The full report can be seen here.

https://www.lancashirecare.nhs.uk/media/Trust%20Board/Trust%20Board%20Documents/02%20November%202017/TB%20167%2017_LCFT%20Q2%20Workforce%20Board%20Report%202017_18%20FINAL.pdf

Board of Directors


Report Title Board Assurance Framework (BAF) Quarter 2 Review

FOIA Exemption Part Exemption Appendix 1 – BAF Risks

Prepared by Andrew Mawdsley, Compliance and Risk Assurance Business Partner

Presented by Julie-Ann Bowden, Associate Director of Compliance and Business Assurance

Action required Decision

Supporting Executive Director Executive Director of Nursing & Quality


Report purpose To provide assurance in relation to the Q2 review of the BAF risks and request Board of Director’s decision on the end of quarter position.



Board Assurance Framework risk This report contains an update relating to all BAF risks

CQC domain Well-led

ASSURANCE:

Does this report provide assurance for systems and controls?

Yes

Assurance Level *** Significant- High confidence in the level of assurance evidence provided.

There is a reasonable level of assurance that processes and procedures are in place and are delivering compliance. There is some scope for improvement in existing arrangements to reduce the risk of non-compliance.

Does this report provide assurance for compliance?

Yes

Assurance Level *** Significant- High confidence in the level of assurance evidence provided.

Assurance evidence is that there are some weaknesses in the design and/or operation of controls that could affect achievement of the objectives of the system, function or process, impacting on compliance. This impact would be minimal or they would be unlikely.

PAPER DEVELOPMENT PROCESS:

Meeting Presented Action Date

All sub-committees within the governance framework over the course of Q2 have reviewed BAF risks and 15 and above risks

NA NA NA

237 of 264

Senior Leadership Team – Monthly Risk Update Andrew Mawdsley, Risk & Assurance Business Partner

Discussion 11.09.17

Senior Leadership Team – Q2 BAF Review Julie-Ann Bowden, Associate Director Risk & Assurance

Discussion 23.10.17

1.0 INTRODUCTION 1.1 The Board of Directors has overall responsibility for ensuring that systems and controls are in

place that are adequate to mitigate any significant strategic risks which threaten the achievement

of the strategic objectives.

1.2 The strengthened management processes around the analysis and evaluation of risk which

compliments the governance arrangements, continues to support more detailed analysis, which

has provided Senior Leadership Team with an opportunity to look at the aggregation of risk from

a management perspective and examine the impact on the strategic priorities of the organisation.

1.3 As part of the Q2 process the Board Assurance Framework (BAF) has been reviewed in detail

with each risk owner. The review has considered:

The need to consider the re-scoring of the BAF risks taking account of an assessment of the

assurances and controls and any gaps identified during Q2. This takes particular account of

assurances delivered through the governance meetings and information in the Chairs’

Reports.

Work to strengthen the analysis of mitigating actions required to close the gap between the

current risk score and the target risk score.

Ensuring that systems and controls are in place that are adequate to mitigate any significant

strategic risks which threaten the achievement of the strategic objectives.

1.4 The report provides an opportunity for the Board to review the Q2 BAF risk position along with the

operational plan objectives aligned with the BAF. In addition, themes and gaps that the Risk and

Assurance team have identified as part of the risk profiling and assurance mapping are included

which has also been informed through discussions with Executive Directors and reporting through

to the corporate governance meetings.

2.0 RISK MANAGEMENT 2.1 Review of the Board Assurance Framework (BAF) is carried out at each committee and sub-

committee for the BAF risks, providing an opportunity to consider the information relating to the

BAF risks, commission additional assurances and identify any associated risks that need

escalating or de-escalating. Operational objectives that are mapped to the BAF risks are included

within the BAF risk reports, providing the position in terms of the achievement of each objective.

This supports the identification of any additional assurances that may need to be commissioned

by the Chair as well as recognising where the achievement of objectives may support the

mitigation and control of the BAF risks

2.2 The 15 and above risks are scored using the Trust’s standard risk scoring matrix and are aligned

against the relevant BAF risk so that Executive Directors have the opportunity to review

significant operational risks as reported on Datix. These risks may also collectively impact on the

strategic risks contained within the BAF. The review of 15 and above risks takes place in

238 of 264

management meetings across the organisation as well as at sub-

committee level in the organisation.

2.3 To support the Q2 review of the BAF risks, the Risk and Assurance team has collated assurance

information throughout the quarter onto the Assurance Map. The information has been identified

through attendance at sub-committee meetings and review of chairs reports from all sub-

committees. The assurance mapping has been used to support discussions with Executive

Directors and assist with updating of the BAF risks. During Q3 an automated IT solution is being

developed to systemize the assurance mapping approach to make it more efficient but also to

increase reporting capability.

2.4 The Risk Surveillance activity that the Risk and Assurance Team have introduced during Q2

includes a process of quality review of risks that are added to the Datix system. The initial focus

for Q2 has been ensuring that any risks scored 12 and above are linked to a relevant BAF risk(s),

ensuring review dates are in accordance with policy and supporting the journey of risk through

the system, in particular those risks that may have been in the holding area for some time.

Through adopting this proactive approach, the team have also been able to support colleagues

from across the organisation in their understanding of the risk management process. The focus

for Q3 will be including a review of the risk titles to ensure that they are framed appropriately.

3.0 REVIEW OF THE BOARD ASSURANCE FRAMEWORK (BAF) STRATEGIC RISK REGISTER

Q2

3.1 The quarterly review process provides an opportunity for Executive Director leads to meet with

the Associate Director of Risk and Assurance to discuss the update of their relevant risks. All

these meetings have taken place and adjustment to the BAF risks has subsequently been

undertaken prior to review by Senior Leadership Team on 23.10.17. The proposed end of Q2

position for the BAF risks with associated operational plan objectives can be viewed in Appendix

1.

3.2 The Heat Maps for the year to date can be reviewed in Appendix 2. There has been an increase

in the scoring of risks during Q2 as follows:-

BAF risk 1.1 – If we do not meet regulatory standards for quality and safety we will not be fit for

purpose as a care provider.

This risk has increased in score during Q2 due a number of specific areas of concern in relation

to quality such as safer staffing and violence and aggression. In addition, the outcome of a CQC

inspection of offender healthcare services at HMP Liverpool in September 2017 identified areas

for improvement and has also contributed to the increase in the risk.

Original Score

01.04.17

Score at

Q1 Score at Q2

2017/18 Risk

Target

12 12 16 8

3x4 3x4 4x4 2x4

239 of 264

BAF risk 4.2 – If staff are not provided with extensive education,

training and leadership development we will not have an organisational

culture that supports high performance.

This risk has increased in score during Q2 as a reflection of the overall Core Skills position that

currently has 5 out of the 14 key subjects below the Trust target of 85%.

4.0 REVIEW AND THEMING OF RISKS

The following themes have consistently been reported to Trust Board since Q1 2017/18. These

themes are still considered to be appropriate, with the relevant updated wording as below:

4.1.1 Financial Closing the financial gap has remained a challenge throughout the quarter. The gap reported for

the end of or Q2 is £2.6m with the unmitigated projection indicating an end of year gap of £8.3m.

The position continues to be driven by staffing pressures in ward and prison areas which have an

impact on inpatient ward overspend due to the use of bank and agency. Other contributors

include the slow start to delivery against planned CIPs where there remains a shortfall in

identifying recurrent savings. Out of Area Placement expenditure continues to exceed funding,

exacerbated by an increase in demand and length of stay. There is a continued focus on key

actions in the Financial Recovery Plan to minimise the impact of these pressures including

alternative support to reduce OAPs (eg CSU, CDU, Crisis House, ATT).

4.1.2 Workforce Clinical staffing shortages continue to be a key pressure during Q2 which have an impact on the

health and wellbeing of the people working in the organisation, as well as on the financial position

and ultimately the quality of services provided. There are also continued challenges with

recruitment, managing sickness absence and core skills/ PDR compliance. The People Plan

continues to be a key programme of work, engaging our workforce in the achievement of these

important deliverables. The Annual Staff Survey has now been launched, with 1200 people

across the organisation being asked to complete the questionnaire, the results of which will be

available in the new year.

4.1.3 Quality The strong operational risk profile across a number of BAF risks highlights the significant

challenge in providing quality services. There are continued challenges relating to restraint,

pressure ulcers and violence to staff as well as the impact that preparing for the CQC visit in

February 2017 may have on services. Clinical staff shortages continue to impact on the challenge

to achieve safer staffing across the Trust. A Task Force led by the Director of Nursing has been

established during Q2 which aims to address staffing issues and is monitored through the

Staffing for Safety and Quality Group. The delivery of the Quality Priorities supports the

Original Score

01.04.17

Score at

Q1 Score at Q2

2017/18 Risk

Target

9 9 12 6

3x3 3x3 4x3 2x3

240 of 264

mitigation of these risks and monitoring of this is done through the

Quality and Safety Sub-committee.

4.1.4 Collaboration and Partnerships The Trust continues to be an active partner in system-wide clinical and non-clinical work streams,

as well as Local Delivery Plans, leading and supporting the development of new models of care

in addition to efficiencies across a range of back office functions. This have been developments

through the quarter relating to Perinatal services and Central and Pennine inpatient MH services.

The Board recently took the opportunity to consider in more detail our place in the STP and the

outputs from this session will further sharpen our focus in a number of key areas. The Lancashire

and South Cumbria STP Board has now been established, with a non-executive director from the

Trust appointed as a member. The Chief Executive is also a Board member and has been

appointed as the LDP lead for central Lancashire. Winter resilience will be a significant challenge

for the health economy, with the 4 hour wait in A&E being an indicator of quality and safety

across the system. The collaboration between mental health services and acute services

continues to be a priority in supporting how the system responds to the winter pressures.

Challenges exist with the different approaches and pace to the STP/LDP development along with

the impact of continuing tendering services and challenges with measuring metrics at HMP

Liverpool. These all have the potential to impact on the Trust’s reputation.

6.0 OPERATIONAL RISK EXPOSURE

6.1 An in-depth review of the operational risks has been undertaken which has resulted in the

updating of the ‘operational risk exposure summary’ section for each BAF risk. These can be

viewed on the BAF document in Appendix 2. The analysis has also resulted in the production of a

thematic summary of the operational risks. This can be viewed along with a breakdown of new,

escalated, reduced and closed operational risks throughout Q2 at Appendix 3.

7.0 RECOMMENDATION

7.1 The Board of Directors is requested to approve the BAF 2016/17 Risk Register at Q2

241 of 264

APPENDIX 2

BAF Heat Maps 2017/18

Risk Key

HIGH

MEDIUM

LOW

Original Risk Score April 2017 Risk Score at Q1 Risk Score at Q2

Risk Score at Q3 Risk Target 17/18 Risk Score at Q4

242 of 264

Operational Risk Exposure Summary

Thematic Summary

A review of the risks rated 12 and above for each theme has been carried out to provide a thematic

summary of the operational risk exposure against each BAF risk. The thematic summary has identified

risks of a similar nature that are common across several risk themes. These common themes are

outlined below:

1. Resources, Capacity and Capability - This is common across several areas in particularly bid/

tender and mobilisation of new services. Risks relate to the capacity to mobile new services,

capacity in Hearing Feedback team and the challenges associated with the contacts under tender.

This risk area is considered in detail under the review a variety of BAF risks depending on the

content of the risks. Capability and capacity risks relating to collaboration and new models of care

are consider under BAF risks 2.1 and 2.2. Resources risk may also be reviewed under 5.1 and

Resources, Capacity and Capability risks relating specifically to people are reviewed under BAF

risks 4.1 and 4.2.

2. Staffing and Training – Risks as a consequence of recruitment, staff shortages, staff sickness

and compliance with core skills training risks are a common theme across all networks and these

risks have aggregated up to support level to ensure consideration of the risks occurs at appropriate

governance meetings to identify control measures and assurance. These risks are a key

consideration for the review of BAF risk 4.1 and 4.2 as well as 1.1 from a safety perspective.

3. Regulatory Compliance - There are a number of risks that make reference to the control of

regulatory and statutory requirements which are both clinical and non-clinical in nature. This

includes risks relating to data quality, Information Governance, mental health legislation and quality

& safety. The overall regulatory burden that the Trust experiences remains high with the risk

profile providing corporate awareness of associated risk in this area a well as compliance with

statutory legislative requirements. These risks are aligned to BAF risk 1.1 although they may be

aligned to all BAF risks depending on the nature of the regulations.

4. Finance - Finance risks run across the majority of themes and there are risks specific to each

network which are managed at Network level. There are also escalated risks such as the non-

achievement of the control target and CIP plans which are managed at support service/Executive

Director level. All finance related risks are considered through the review of BAF risks 5.1 and 5.2.

5. Reputation - There are several activities running across the risk theme that have the potential to

impact on the Trust's reputation. This includes communications and engagement risks such as

negative publicity from public comments as well as risks relating to performance at HMP Liverpool

and delivering the EPR programme. The review of BAF risk 3.2 specifically considers reputational

factors but risks that mention partnership and collaborative working also have an impact on

reputation. The organisation’s reputation impacts on our ability to recruit and retain staff and

therefore aligns to BAF risk 4.1 as well.

The Risk and Assurance team has been supporting the organisational approach to increasing the

maturity of operational risk reporting within the Trust following the organisational reset. This has

involved working closely with the Networks and support services to assess the reporting arrangements

and support with the production of risk reports. This approach supports the provision of assurance that

operational risks are being reported and managed effectively by local management arrangements to to

support the mitigation of controls and identification of actions required to manage risks. The network

APPENDIX 3

243 of 264

and corporate governance arrangements and escalation procedures support the escalation of risk to

appropriate groups/committees for review where appropriate.

Support has also been provided to a number of meetings within the corporate governance structure to

produce risk reports. However the implementation of the alignment of financial codes to the team

names in Datix risk module has presented a challenge to producing accurate risk reports.

Conversations are taking place with the relevant teams to address this issue and a risk has been

reported onto Datix by the Risk and Assurance Team.

The Risk and Assurance team has responsibility for providing risk management support and the

operational risk management systems and process will be further enhanced with the governance and

Risk Health Checks that commence in Q3 and the development of a risk training package. Following

the transfer of the team into the Directorate of Nursing and Quality, a new objective has been

developed to drive further development in this area and is due to be approved formally by SLT as part

of the Q2 operational objective review process. Details of the objective are provided below:

Objective: Review and strengthen the risk management systems, processes and culture within the

Trust

1. Undertake a review of the Risk Management Policy to strengthen in line with the established processes, procedures and regulatory requirements.

The Risk Management Policy is a document that provides staff with the absolute compliance requirements in relation to managing risk which then impacts improving the level of risk maturity in the organisation.

Q4

2. Work in collaboration with the Governance &

Compliance Team on developing and delivering

the Governance and Risk Health Checks

Ability to report increased assurance to

Corporate Governance & Compliance

Sub-committee and upwards to Audit

Committee

Q4

3. To develop an interim risk and assurance

training package that is then taken out to staff in

the organisation in a ‘train the trainer’ approach.

People in the organisation feel

supported in developing their risk and

assurance knowledge and capabilities.

Q3

4. The develop a sustainable risk and assurance training suite utilising an interactive IT platform.

People in the organisation will be engaged and motivated to develop their knowledge of risk and assurance.

Q4

18/19

5. Embed a risk surveillance model that supports the analysis and reporting of risk from team to board.

Strengthened assurances in relation to the risk management systems and processes.

Q4

In addition, MIAA are scheduled to carry out a Risk Management internal audit in Q3 to provide a level

of assurance on the current risk management processes in place.

244 of 264

Board of Directors


Report Title Mental Health Act Manager - Assurance Report (Responsibilities of Hospital Managers)


Prepared by Matthew Joyes, Associate Director of Safety and Quality Governance

Presented by Dee Roach, Executive Director of Nursing and Quality




Report purpose This paper provides the Trust Board with an assurance report on the effective discharge of the duties of Hospital Managers under the Mental Health Act



Board Assurance Framework risk 1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as a care provider

CQC domain Well-led

1.0 INTRODUCTION 1.1 This paper provides the Trust Board with an assurance report on the effective discharge of the

duties of Hospital Managers under the Mental Health Act.

2.0 BACKGROUND 2.1 The Mental Health Act 1983 (MHA) is the legislation that governs the formal detention,

treatment and care of mentally disordered people in hospitals. The MHA has been amended by the Mental Health Act 2007.

2.2 The Hospital Managers for the purpose of the Mental Health Act are the NHS Foundation Trust as a body. In practice, this means the Trust Board has overall responsibility and accountability. The term Hospital Manager therefore does not mean any individual or management team of the Trust or any individual hospital.

2.3 It is Hospital Managers who have the authority to detain patients under the Mental Health Act. The Hospital Managers have the responsibility for ensuring that the requirements of the Act are followed, including patients subject to a Community Treatment Order (CTO).

“It is the hospital managers who have the authority to detain patients under the Act. They have the primary responsibility for seeing that the requirements of the Act are followed. In particular, they must ensure that patients are detained only as the Act allows, that their treatment and care accord fully with its provisions, and that they are fully informed of, and are supported in exercising, their statutory rights.”

Mental Health Act Code of Practice

245 of 264

2.4 Hospital Managers have important statutory powers, responsibilities and

duties concerning detained and CTO patients. Excluding the function of discharging patients/renewing detention orders (see 1.5 below), Hospital Managers may delegate these statutory tasks to officers of the Trust – within Lancashire Care NHS Foundation Trust these are delegated to Executive Directors and their management teams. These duties include:-

Admission

Scrutiny and rectification of documents

Transfer

Giving of information

Duties in respect of victims of crime

Patient’s correspondence

Duty to refer cases to Tribunals

References by the Secretary of State for Health

Hospital Accommodation for children and young people 2.5 Under Section 23 of the Mental Health Act 1983 a patient may apply for a review of their

detention or Community Treatment Order. In addition to this the Hospital Managers must undertake a review following the renewal or extension of a detention or Community Treatment Order. The Hospital Managers for the purpose of discharging their functions under section 23 of the Mental Health Act are the Non-Executive Directors – within Lancashire Care NHS Foundation Trust the Non-Executive Directors appoint a committee of Associate Hospital Managers to undertake this duty. The term committee is used in the Act and is descriptive, it refers to the total cohort of Associate Hospital Managers rather than a formal committee meeting. These Associate Hospital Managers are not, and must not, be employed by the Trust.

3.0 APPOINTMENT AND OVERSIGHT OF ASSOCIATE HOSPITAL MANAGERS 3.1 Arrangements for the management and governance of mental health law changed in 2015 when

the function was centralised into the Safety and Quality Governance Department of the Nursing and Quality Directorate. Prior to this, the function was delivered by individual services. This section details the arrangements put in place since that transfer as the function has been fully restructured.

3.2 The management of Associate Hospital Managers is delegated to the Associate Director of

Safety and Quality Governance who overseas the Trust’s mental health law function. The Associate Director is assisted by the Mental Health Law Manager, Deputy Mental Health Law Manager and Mental Health Law Administrators operating in each locality.

3.3 There are currently 28 Associate Hospital Managers. 3.4 Associate Hospital Managers are recruited through open advertisement in line with all other

vacancies in the Trust. There has been two recruitment processes since 2015. The process follows standard Trust format of advert, shortlisting, interview and pre-commencement checks. These checks include references and a Disclosure and Barring Service (DBS) check.

3.5 It is acknowledged and recognised there is a need to increase the diversity of the cohort of

Associate Hospital Managers to truly reflect the patient’s served by the Trust. To this end, the Trust Equality and Diversity Manager was fully involved in the last recruitment process (and has since been involved in training and awareness for the existing cohort).

3.6 Associate Hospital Managers are given an honorary contract with the Trust. They are not employees and hold no contract of employment. They are given an honorary allowance of £55 per panel meeting, plus mileage expenses at standard rates. The allowance was last reviewed

246 of 264

in 2015 by the Associate Director of Safety and Quality Governance who holds the budget for mental health law.

3.7 An induction programme has been developed for all new appointees. A programme of mandatory training has been developed that sets out the expectation for all Associate Hospital Managers and includes safeguarding, equality and diversity and conflict resolution. Additionally, a rolling programme of Continuous Professional Development (CPD) training is arranged.

3.8 An Associate Hospital Managers Handbook has been developed setting out the requirements of the Act, the role and expectations of the Trust.

3.9 An appraisal programme has been developed for all Associate Hospital Managers. This includes a self-assessment and peer review. The process runs on a three-yearly cycle with an expectation that all mandatory training, the appraisal process and a minimum panel commitment of twelve per year are all compliant within that time period. Failure to do so will result in the termination of the honorary contract.

3.10 The Associate Director of Safety and Quality Governance chairs a six-monthly Associate Hospital Managers Forum, which in turn reports into the Trust Mental Health Law Sub-committee.

3.11 Performance of the Associate Hospital Managers is managed in accordance with Trust policies including the Disciplinary Policy and Performance Policy. Associate Hospital Managers have access to the Grievance Policy and Raising Concerns Policy.

3.12 During the current financial year (April 2017 to present) there are no performance or conduct concerns. Since 2015, there have been two conduct concerns. One concern was dealt with through informal performance management and one concern was dealt with through formal performance management however the individual resigned their honorary contract.

3.13 A representative of the Associate Hospital Managers is invited to attend the Trust Mental Health Law Sub-committee and has a standing item to raise any matters on behalf of their peers.

4 EFFECTIVE DISCHARGE OF HOSPITAL MANAGER DUTIES 4.1 The delegated duties of the Mental Health Act are monitored through the Trust Mental Health

Law Sub-committee. This sub-committee in turn reports into the Quality Committee. Each Network has a dedicated Mental Health Law Group which manages and monitors application of mental health law within their Network (a specific secure mental health services group also exists). The Safety and Quality Governance Department produces a Mental Health Law Surveillance Report which provides performance data on compliance to the Sub-committee.

4.2 The Trust is an active member of the Multi-Agency Oversight Group (MAOG) and provides administrative support to this group, which is chaired by Lancashire Police. The group brings together multi-agency partners to discuss and collaboratively address issues. The MAOG is supported by locality working groups led by Trust service managers and locality police inspectors. The Mental Health Law Manager provides a report to the Trust Mental Health Law Sub-committee as a standing item.

4.3 Associate Hospital Managers enact the non-delegated tasks of Hospital Managers as mentioned in 2.5 above. This is done through a panel of 3 Associate Hospital Managers. The Mental Health Law Manager and their Mental Health Law Administrators undertake administrative co-ordination and facilitation of each panel but take no part in the proceedings or decision making process.

247 of 264

4.4 There are, on average, 37 panels per month. There were 455 panels held in the last full financial year.

4.5 The Trust has a robust suite of policies and procedures to set-out the approach to compliance with mental health law. A programme of training is also in place.

4.6 At this time there are no performance or conduct concerns in relation to Associate Hospital Managers to specifically raise with the Trust Board, however the Mental Health Law Sub-committee is closely monitoring the following broader issues that impact on compliance with the Mental Health Act:

Lapses of Section 136 – there is an increasing trend of Section 136s lapsing before patients are onward moved and this is likely to increase significantly with impending legislation changes that will reduce the duration of a Section 136 from 72 hours to 24 hours;

Patients not seen by a Section 12 Doctor – on average only 22% of patients are seen by a Section 12 Doctor;

Patients not given their Section 132 Rights verbally within 24 hours of admission – on average only 35% of patients are given their Section 132 Rights within 24 hours of admission;

Section 5(2) Not Converted – on average 48% of Section 5(2) detentions are not converted.

5 CURRENT AND FUTURE REPORTING 5.1 As mentioned above, the Trust has in place a robust governance framework for mental health

law as shown in the chart below:

5.2 As mentioned above, each group reports into the Mental Health Law Sub-committee. The Sub-

committee also receives the above mentioned Mental Health Law Surveillance Report and a Clinical Audit Report specific to any relevant audits.

Trust Board

Quality Committee

Mental Health Law Sub-committee

Multi Agency Oversight Group

x4 Locality Multi-Agency Working

Group

Associate Managers Forum

Mental Health Network Mental

Health Law Group

Secure Services Mental Health Law

Group

Community & Wellbeing Network Mental Health Law

Group

Children and Young People's Network

Mental Health Law Group

248 of 264

5.3 It is recognised that reporting of assurance direct to Board has not been undertaken and it is proposed that a formal annual report on mental health law is provided each year. This proposal, if approved, will provide assurance to the Board on its duties and further enhance the scrutiny already in place through the Quality Committee and Mental Health Law Sub-committee.

5.4 It is planned to have mental health law as a topic for a future Board Development Session. 6 CONCLUSION 6.1 The Trust has significantly strengthened its approach to compliance with mental health law

since 2015, particularly in relation to the role of Associate Hospital Manager. The Trust Board is asked to receive this assurance. This paper proposes to strengthen that through a further annual report direct to the Trust Board.

7 RECOMMENDATIONS 7.1 The Trust Board is asked to note this report. 7.2 The Trust Board is asked to approve the recommendation that a formal annual report on mental

health law is provided each year direct to the Trust Board.

249 of 264

Board of Directors


Report Title Learning from Deaths – Assurance Report


Prepared by Matthew Joyes, Associate Director of Safety and Quality Governance

Presented by Dee Roach, Executive Director of Nursing and Quality




Report purpose This paper provides the Trust Board with an assurance report on how the Trust learns from death and how it complies with the new national guidance on deaths



Board Assurance Framework risk 1.1 If we do not meet regulatory standards for quality and safety we will not be fit for purpose as a care provider

CQC domain Well-led

1.0 INTRODUCTION 1.1 For many people, death under the care of the NHS is an inevitable outcome and they

experience excellent care from the NHS in the months or years leading up to their death. However some patients experience poor quality provision resulting from multiple contributory factors, and some deaths are avoidable arising from mistakes in care. When mistakes happen, the Trust is committed to investigating them thoroughly and will understand the causes. The purpose of reviews and investigations of deaths is to learn in order to prevent recurrence.

1.2 This paper includes one appendix – a baseline assessment against the national guidance and

the current position as of October 2017. In summary, the Trust is compliant with all deadlines and plans to achieve all upcoming deadlines.

2.0 BACKGROUND 2.1 Under the National Guidance on Learning from Deaths, published by the National Quality Board

in March 2017, all Trusts are required to:

Publish a updated policy on how their organisation responds to and learns from deaths of patients who die under their management and care, including:

o how their processes respond to the death of an individual with a learning

disability, severe mental illness, an infant or child death, a stillbirth or a maternal death

o their evidence-based approach to undertaking case record reviews o the categories and selection of deaths in scope for case record review (and how

the organisation will determine whether a full investigation is needed)

250 of 264

o how the Trust engages with bereaved families and carers, including how the Trust supports them and involves them in investigations

o how staff affected by the deaths of patients will be supported by the Trust.

Collect specific information every quarter on:

the total number of inpatient deaths in an organisation’s care

the number of deaths the Trust has subjected to case record review (desktop review of case notes using a structured method) (NB: information relating to deaths reviewed using different methodologies – eg inpatient adult deaths, child deaths, deaths of patient with learning disabilities – may be separated in the report to provide distinction/clarity where required)

the number of deaths investigated under the Serious Incident framework (and declared as Serious Incidents)

of those deaths subject to case record review or investigated, estimates of how many deaths were more likely than not to be due to problems in care

the themes and issues identified from review and investigation, including examples of good practice

how the findings from reviews and investigations have been used to inform and support quality improvement activity and any other actions taken, and progress in implementation.

Publish this information on a quarterly basis by taking a paper to public Board meetings. 2.2 There are three levels of scrutiny that can apply to the care provided to someone who dies; (i)

death certification; (ii) case record review; and (iii) investigation. They do not need to be initiated sequentially and an investigation may be initiated at any point, whether or not a case record review has been undertaken (though a case record review will inform the information gathering phase of an investigation together with interviews, observations and evidence from other sources).

2.3 The National Guidance on Learning from Deaths includes a number of terms. These are defined below. Death certification The process of certifying, recording and registering death, the causes of death and any concerns about the care provided. This process includes identifying deaths for referral to the coroner. Mortality review A systematic process to review a series of individual case records using a structured or semi-structured methodology to identify any problems in care and to draw learning or conclusions to inform any further action that is needed to improve care within a setting or for a particular group of patients. Case record review/structured case judgement review A structured desktop review of a case record/notes carried out by clinicians to determine whether there were any problems in the care provided to a patient. Case record review is undertaken routinely to learn and improve in the absence of any particular concerns about care. This is because it can help find problems where there is no initial suggestion anything has gone wrong. It can also be done where concerns exist, such as when bereaved families or staff raise concerns about care.

251 of 264

Investigation A systematic analysis of what happened, how it happened and why, usually following an adverse event when significant concerns exist about the care provided. Investigations draw on evidence, including physical evidence, witness accounts, organisational policies, procedures, guidance, good practice and observation, to identify problems in care or service delivery that preceded an incident and to understand how and why those problems occurred. The process aims to identify what may need to change in service provision or care delivery to reduce the risk of similar events in the future. Investigation can be triggered by, and follow, case record review, or may be initiated without a case record review happening first. Death due to a problem in care A death that has been clinically assessed using a recognised method of case record review, where the reviewers feel that the death is more likely than not to have resulted from problems in care delivery/service provision (note: this is not a legal term and is not the same as ‘cause of death’). The term ‘avoidable mortality’ should not be used, as this has a specific meaning in public health that is distinct from ‘death due to problems in care’.

2.4 The Executive Director of Nursing and Quality is the executive lead for patient safety. The

Executive Medical Director jointly leads this work. The Non-Executive Director lead for quality and safety is David Curtis, chair of the Board’s Quality Committee and chair of the Serious Incident Learning Panel.

3.0 LEARNING FROM DEATHS: SERIOUS INCIDENTS 3.1 The Trust has a robust system and process in place to report deaths as incidents and for them

to be reviewed to determine if a further investigation is needed. A comprehensive Incident Policy is in place.

3.2 The Trust reports deaths onto its quality governance system (Datix) as follows:

All deaths of mental health service patients, or those discharged in the previous six months. This includes all deaths in a mental health hospital. These will be STEIS reported as a Serious Incident if there is an actual or potential failure or omission in healthcare services.

All deaths of learning disability service patients, or those discharged in the previous six months. These will be STEIS reported as a Serious Incident if there is an actual or potential failure or omission in healthcare services.

Deaths of memory assessment service patients up to their first medication review and thereafter if there is an actual or potential failure or omission in healthcare services. These are STEIS reported as a Serious Incident if there is an actual or potential failure or omission in healthcare services.

All deaths of offender health service patients. These are all STEIS reported as a Serious Incident.

All child deaths in universal services. These will be STEIS reported as a Serious Incident if there is an actual or potential failure or omission in healthcare services.

Deaths of community health service patients if there is an actual or potential failure or omission in healthcare services or any death that occurs in a community health hospital. These are STEIS reported as a Serious Incident if there is an actual or potential failure or omission in healthcare services.

3.3 All deaths listed above have a 3 Day Review undertaken by the local team manager or service manager. They are reviewed daily on a Quality Governance Conference Call chaired by the Associate Director of Safety and Quality Governance. This review identifies any need for further investigation and any duty of candour requirements. There is also a weekly Serious Incident Review Panel chaired by the Executive Medical Director (deaths that are evidently of natural causes with no potential healthcare service contribution are filtered prior to the panel – but still recorded including the rationale for no further action and may be reviewed by the panel). The

252 of 264

decisions made by the daily call and panel are recorded on the quality governance system and a framework is used to justify decisions made, as developed from the Mazars Report into Southern Health NHS Trust.

3.4 A cause of death and source is recorded for all deaths. If this is unknown at the time, a process

ensures this is collated when known and this may prompt a further review (i.e. if a subsequent coroner’s inquest ruled a death as suicide).

3.5 A standardised framework is used to classify deaths and investigation decisions – developed

from the Mazars Report into Southern Health NHS Trust. This categorises deaths as:

Expected Natural

Expected Unnatural

Unexpected Natural

Unexpected Unnatural 3.6 A process is in place for both serious incident reporting (STEIS) and patient safety repprting

(NRLS). These processes ensure regulators and commissioners are aware of incidents in accordance with the NHS Serious Incident Framework. A separate process is in place for statutory notifications to the CQC under the Mental Health Act.

3.7 The Trust has created an Investigations and Learning Team to undertake all serious incident

investigations. This team is independent of clinical services to maintain objectivity and consists of full time senior and expert investigators, trained to post graduate level in investigations.

3.8 The definitions of predictable and preventable – used in serious incident investigations – have

been standardised and applied across serious incident investigations. 3.9 The Trust has established mechanisms for sharing learning across serious incidents. This

includes:

All staff involved in the serous incident process receive a copy of the anonymised report by the Investigations and Learning Team;

Debriefs are offered to teams by the Investigations and Learning Team;

A programme of Dare to Share, Time to Shine events are in place;

Each individual investigation report has a specific “Sharing the Learning” section. 3.10 The Trust established a Serious Incident Learning Panel in 2017 to oversee and challenge the

improvement plans post-investigation. This panel is led by a non-executive director and includes executive directors, senior managers and commissioners.

4.0 LEARNING FROM DEATHS: STRUCTURED CASE JUDGEMENT REVIEWS 4.1 The Trust does not currently undertake internal structured case judgment reviews. This

approach has been established in acute Trusts for some time however is a new approach for mental health and community health services.

4.2 Work is now underway and will be complete during quarter three of 2017/18 to implement this process. A standard tool has been developed and work is underway to identify reviewers. A Mortality Review Panel will be established to support and oversee this work. The panel will report to the Serious Incident Learning Panel.

4.3 The Trust is involved with the national Learning Disability Mortality Review (LeDeR) programme. The Trust lead for this involvement is the Deputy Director of Nursing.

253 of 264

4.4 The Trust is also engaged with local safeguarding authority led processes for reviews of child deaths (i.e. Child Death Overview Panel). The Safeguarding Team undertake regular thematic reviews through the Safeguarding Lessons Learned Portfolio Group.

5.0 FAMILY AND CARER INVOLVEMENT AND SUPPORT 5.1 Bereaved families and carers are considered equal partners in the serious incident process. 5.2 The Investigations and Learning Team engage with families and carers throughout the process

allowing people affected to set questions for the investigation and sharing of the final report. The team also seek the views of families and carers on how the report should describe the patient such as using a name.

5.3 A feedback mechanism is in place for anyone involved in an investigation to provide feedback

including families and carers. The feedback can be anonymous and is collated within the same system used for FFT allowing data analysis.

5.4 A Being Open and Duty of Candour Procedure is in place. Assurance reporting on this is

included in the monthly Quality Surveillance Report and to commissioners. 5.5 Further work is needed around family liaison and a new Family Liaison and Bereavement

Support Procedure will be developed during quarter four of 2017/18. The Trust is currently exploring regional and national best practice in relation to this.

6.0 REPORTING 6.1 The Trust has recently developed and implemented a Learning from Deaths Procedure which

meets the national requirements detailed above in section 2.1. 6.2 The Trust currently produces a six monthly Serious Incident and Mortality Report, which

includes a mortality review section. This is received by the Quality Committee. The Trust also reports all serious incidents to the Board through the monthly Chief Executive’s Report.

6.2 The six-monthly serious incident report will move to quarterly from quarter three of 2017/18.

After review by the Quality Committee it will be submitted to the Trust Board for discussion in the public section. This report will meet the national requirements detailed above in section 2.1.

6.3 A new Quality Report will be produced monthly for the Trust Board and will include serious

incident and mortality data. This report will be received in the public section of the Trust Board.

7.0 CONCLUSION 7.1 The Trust has robust systems and processes for the management of serious incidents. Equally,

the Trust is significantly ahead nationally in the implementation of a centralised Investigations and Learning Team. The key area of challenge in relation to serious incidents is on improvement planning post-investigation and in having assurance that learning has been embedding and practice has changed.

7.2 The Trust is establishing a structured case judgement review process and this will go-live during

quarter three of 2017/18. Structured case judgement reviews are new to mental health and community health services and the Trust is learning and sharing with other providers going through this implementation.

7.3 Mortality data is already included in the six-monthly Serious Incident and Mortality Report

received by the Quality Committee. This report will move to quarterly and will be submitted to the Trust Board for discussion in the public section. A new monthly Quality Report will be

254 of 264

produced which will include mortality data and this will be submitted to the Trust Board for consideration in the public part of the meeting.

7.4 Additional work is planned for quarter 4, in relation to family liaison and support. 8.0 RECOMMENDATIONS 8.1 The Trust Board is asked to note this report.

255 of 264

of 9

Baseline Assessment:

National Guidance on Learning from Deaths (National Quality Board, March 2017)

Standard

The Board should ensure that their organisation:

RAG Rating Current position (October 2017) Additional work planned

has an existing board-level leader acting as patient safety director to take responsibility for the learning from deaths agenda and an existing non-executive director to take oversight of progress;

The Executive Director of Nursing and Quality is the executive lead for patient safety. The Executive Medical Director jointly leads this work.

The Non-Executive Director lead for quality and safety is David Curtis, chair of the Board’s Quality Committee and chair of the Serious Incident Learning Panel.

N/A

pays particular attention to the care of patients with a learning disability or mental health needs;

As a provider of mental health, learning disability and community health services, the Trust is committed to high quality care for its patients. The Executive Medical Director chairs a Trust-wide group which oversees the delivery of quality improvement work and the integration of physical and mental health services.

N/A

256 of 264

of 9

has a systematic approach to identifying those deaths requiring review and selecting other patients whose care they will review;

The Trust reports deaths onto its quality governance system (Datix) as follows:

All deaths of mental health service patients, or those discharged in the previous six months. This includes all deaths in a mental health hospital. These will be STEIS reported as a Serious Incident if there is an actual or potential failure or omission in healthcare services.

All deaths of learning disability service patients, or those discharged in the previous six months. These will be STEIS reported as a Serious Incident if there is an actual or potential failure or omission in healthcare services.

Deaths of memory assessment service patients up to their first medication review and thereafter if there is an actual or potential failure or omission in healthcare services. These are STEIS reported as a Serious Incident if there is an actual or potential failure or omission in healthcare services.

All deaths of offender health service patients. These are all STEIS reported as a Serious Incident.

All child deaths in universal services. These will be STEIS reported as a Serious Incident if there is an actual or potential failure or omission in healthcare services.

Deaths of community health service patients if there is an actual or potential failure or omission

A cohort of structured case judgement reviewers will be recruited to complete reviews for allocated cases during Q3 of 2017/18. This will be an initial pilot running through Q4 of 2017/18.

A monthly Mortality Review Panel will review and scrutinise all completed mortality reviews and determine further action. This panel will report to the Serious Incident Learning Panel.

The triggers for a structured case judgement review review (which are separate to the triggers for a serious incident) will be:

all deaths where bereaved families and carers, or staff, have raised a significant concern about the quality of care provision;

all in-patient, out-patient and community patient deaths of those with learning disabilities (using the LeDeR review process) and/or with severe mental illness;

all deaths in a service specialty where an ‘alarm’ has been raised with the Trust (i.e. through audit or regulators);

all deaths in areas where people are not expected to die, for example in relevant elective procedures;

deaths where learning will inform the Trust’s existing or planned improvement work, for example if work is planned on improving sepsis care, relevant deaths should be reviewed (to maximise learning, such deaths could be reviewed thematically);

257 of 264

of 9

in healthcare services or any death that occurs in a community health hospital. These are STEIS reported as a Serious Incident if there is an actual or potential failure or omission in healthcare services.

All deaths listed above have a 3 Day Review undertaken and are reviewed daily on a Quality Governance Conference Call chaired by the Associate Director of Safety and Quality Governance and also by a weekly Serious Incident Review Panel chaired by the Executive Medical Director. Deaths that are evidently of natural causes with no potential healthcare service contribution are filtered prior to the panel – but still recorded including the rationale for no further action and may be reviewed by the panel.

A cause of death and source is recorded for all deaths. If this is unknown at the time, a process ensures this is collated when known and this may prompt a further review (i.e. if a subsequent coroner’s inquest ruled a death as suicide).

A standardised framework is used to classify deaths and investigation decisions – developed from the Mazars Report into Southern Health NHS Trust.

A process is in place for both STEIS and NRLS reporting. A separate process is in place for statutory notifications to the CQC under the Mental Health Act.

The daily call and weekly panel determine if further investigation is needed above the 3 Day Review

a further sample of other deaths that do not fit the identified categories so that the Trust can take an overview of where learning and improvement is needed most overall (this does not have to be a random sample, and could use practical sampling strategies such as taking a selection of deaths from each weekday);

following any linked inquest and issue of a Regulation 28 Report on Action to Prevent Future Deaths (if not already completed or new information comes to light).

258 of 264

of 9

Standard



completed by the service. The Trust has created an Investigations and Learning Team to undertake all serious incident investigations. This team is independent of clinical services to maintain objectivity and consists of full time senior and expert investigators, trained to post graduate level in investigations.

A new Learning from Deaths Procedure has been developed and implemented.

A standardised structured case judgement review tool and process has been developed.

At this time the Trust does not undertake structured case judgement reviews which results in the yellow rating.

259 of 264

of 9

Standard



adopts a robust and effective methodology for case record reviews of all selected deaths (including engagement with the LeDeR programme) to identify any concerns or lapses in care likely to have contributed to, or caused, a death and possible areas for improvement, with the outcome documented;

See section above.

The Trust is involved with the LeDeR programme. The Trust lead for this involvement is the Deputy Director of Nursing.

The Trust is engaged with local safeguarding authority led processes for reviews of child deaths (i.e. CDOP, Rapid Reviews, SUDI). The Safeguarding Team undertake regular thematic reviews through the Safeguarding Lessons Learned Portfolio Group.

The definitions of predictable and preventable – used in serious incident investigations – have been standardised and applied across serious incident investigations.

The Trust will use Datix as its electronic database to record structured case judgement review alongside serious incident investigations.

To ensure objectivity, case record reviews should wherever possible be conducted by clinicians other than those directly involved in the care of the deceased.

See section above.

The external LeDeR process will be integrated into the trust mortality governance process.

260 of 264

of 9

Standard



ensures case record reviews and investigations are carried out to a high quality, acknowledging the primary role of system factors within or beyond the organisation rather than individual errors in the problems that generally occur;

See section above.

See action above.

Training in completing mortality reviews will be commissioned and delivered during Q3 of 2017/18.

The Trust will establish a Mortality Review Group leading the work around governance and surveillance of structured case judgement reviews during Q3 of 2017/18.

ensures that mortality reporting in relation to deaths, reviews, investigations and learning is regularly provided to the board in order that the executives remain aware and non-executives can provide appropriate challenge. The reporting should be discussed at the public section of the board level with data suitably anonymised;

The Trust currently produces a six monthly Serious Incident and Mortality Report, which includes a mortality review section. This is received by the Quality Committee.

The Trust currently reports all serious incidents to the Board through the monthly Chief Executive’s Report.

The six-monthly serious incident report will move to quarterly from Q3 of 2017/18. After review by the Quality Committee it will be submitted to the Trust Board for discussion in the public section.

A new Quality Report will be produced monthly for the Trust Board and will include serious incident and mortality data. This report will be received in the public section of the Trust Board.

ensures that learning from reviews and investigations is acted on to sustainably change clinical and organisational practice and improve care, and reported in annual Quality Accounts;

The Trust publishes data on incidents and serious incidents in its Quality Account in accordance with national reporting guidance.

See below for details on learning.

N/A

261 of 264

of 9

Standard



shares relevant learning across the organisation and with other services where the insight gained could be useful;

The Trust has established mechanisms for sharing learning across serious incidents. This includes:

All staff involved in the serous incident process receive a copy of the anonymised report by the Investigations and Learning Team;

Debriefs are offered to teams by the Investigations and Learning Team;

A programme of Dare to Share, Time to Shine events are in place;

Each individual investigation report has a specific “Sharing the Learning” section.

A new Learning Bulletin will be launched during Q3 of 2017/18.

A new library of anonymised investigation reports and learning bulletins will be established during Q3 of 2017/18 (information is already available on the quality governance system but this requires a user account).

ensures sufficient numbers of nominated staff have appropriate skills through specialist training and protected time as part of their contracted hours to review and investigate deaths;

The Trust has created an Investigations and Learning Team to undertake all serious incident investigations. This team is independent of clinical services to maintain objectivity and consists of full time senior and expert investigators, trained to post graduate level in investigations.

See above for recruitment of mortality reviewers.

262 of 264

of 9

Standard



offers timely, compassionate and meaningful engagement with bereaved families and carers in relation to all stages of responding to a death;

Bereaved families and carers are considered equal partners in the serious incident process.

The Investigations and Learning Team engage with families and carers throughout the process allowing people affected to set questions for the investigation and sharing of the final report. The team also seek the views of families and carers on how the report should describe the patient such as using a name.

A feedback mechanism is in place for anyone involved in an investigation to provide feedback including families and carers. The feedback can be anonymous and is collated within the same system used for FFT allowing data analysis.

A Being Open and Duty of Candour Procedure is in place. Assurance reporting on this is included in the monthly Quality Surveillance Report and to commissioners.

Further work is needed around family liaison and a new Family Liaison and Bereavement Support Procedure will be developed during Q4 of 2017/18.

263 of 264

of 9

Standard



acknowledges that an independent investigation (commissioned and delivered entirely separately from the organisation(s) involved in caring for the patient) may in some circumstances be warranted, for example, in cases where it will be difficult for an organisation to conduct an objective investigation due to its size or the capacity and capability of the individuals involved; and,

The Trust Incident Procedure allows for independent investigations and the Trust has both engaged with and commissioned independent reviews.

N/A

works with commissioners to review and improve their respective local approaches following the death of people receiving care from their services. Commissioners should use information from providers from across all deaths, including serious incidents, mortality reviews and other monitoring, to inform their commissioning of services. This should include looking at approaches by providers to involving bereaved families and carers and using information from the actions identified following reviews and investigations to inform quality improvement and contracts etc.

The Trust actively engages with local commissioners directly and through the Joint Quality and Performance Committee. Commissioners are invited to attend the Trust’s SI Learning Panel.

N/A

264 of 264