part 1 – formal meeting in public · 2019-10-04 · page 1 . agenda for . council of governors...

AGENDA FOR Council of Governors Meeting

Date: Thursday, 17 October 2019 Time: 3.30pm – 5.35pm

Venue: LACE Conference Centre, Hall 2. Croxteth Drive, Sefton Park, Liverpool L17 1AA

NOTE: There will be a pre-meet for Governors at 2.30 pm

No. Item Lead Details Timings

PART 1 – FORMAL MEETING IN PUBLIC

A Council Business

A1 Welcome B Fraenkel Verbal to note 3.30pm

A2 Apologies – Governors: Attendees: J Rafferty;

B Fraenkel Verbal to note

A3 Declarations of Interest B Fraenkel Verbal to note

A4 Minutes of the Previous Meeting: 7 August 2019 Minutes & Action Log

B Fraenkel Paper for decision

A5 Update from the Chairman B Fraenkel Verbal to note 3.35pm

B Our Services

B1 Performance Report P Williams Paper for assurance 3.40pm

C Our Future

C1 Future Strategy and Developments: a) Strategy and Operational Plan Updateb) Development of the Clinical Strategyc) Developments with North West Boroughs

L Edwards

T Bennett

L Edwards

Presentation Paper for information & Presentation Presentation

4.00pm

4.10pm

4.30pm

D Our People

D1 Your Voice Your Change J Toole Presentation 4.55pm

BREAK 5.05pm

E Governance

E1 Lead Governor Election Result S Jennings Verbal to note 5.10pm

E2 Council of Governors - Governance Update S Jennings Paper for decision 5.15pm

F Information Items Papers to Note / For Information Note – these items are provided for noting by / or for information to the Council of Governors, they do not require approval or for a decision to be made. Governors are asked to read the papers prior to the meeting and may raise any questions in the Council of Governors meeting but these items will not formally be presented.

F1 Specialist Learning Disabilities Division Retraction Plan Update

S Wrathall Paper for information 5.20pm

F2 Update on Community Services Improvement Programme

T Bennett Paper for information

F3 Winter Plan 2019/20 T Bennett Paper for assurance

PART 2 – TO BE HELD IN PRIVATE

G1 Minutes of the Previous Private Meeting: 7 August 2019

B Fraenkel Paper for decision

5:25pm

H Any Other Business

H1 Any Other Business a) Governor Feedback from Visits b) Any Other Business

Governors Verbal 5.30pm

Close 5.35pm

Future Council of Governor Meeting Dates, all will begin at 3:30pm – 5:30pm

with a Governor only pre-meet at 2:30pm:

Wednesday 22 January 2020

Thursday 23 April 2020

Wednesday 22 July 2020

Thursday 22 October 2020

COUNCIL OF GOVERNORS WORK PLAN 2019/20

25 April 2019

7 Aug 2019

17 Oct 2019

Jan 2020

OPENING BUSINESS Welcome & Apologies Declarations of Interest Minutes of previous meeting

Action Log Review

Matters Arising

Chairman’s Update

STANDING ITEMS Chief Executives Report

Performance Report

Whalley Retraction Plan Update

Community Services Improvement Plan

ADDITIONAL REPORTS FOR DISCUSSION CQC Inspection Update

Strategy & Operational Plan (Update & Draft)

Quality Account – Indicator Selection

Quality Account (Draft)

Mersey Care NHS FT Annual Report

Annual Accounts

External Audit Report

Staff Survey Findings

Patient Survey Findings

ADDITIONAL REPORTS FOR INFORMATION Strategy & Operational Plan (Final)

Quality Account (Final)

PROSPECT Partnership Update

X

Winter Plan 2018/19 Review

Winter Plan 2019/20

Board Assurance Framework

COUNCIL OF GOVERNORS - GOVERNANCE Council of Governors Annual Work Plan*

Council of Governors Annual Report*

Council of Governors Development Plan*

Membership Strategy

Deferred pending input from M&E Cttee

Governor Involvement Strategy

Deferred pending input from M&E Cttee

Membership Update (Including M&E Cttee)*

X

Lead Governor Election Process*

Lead Governor Election & Declaration of Result*

Chairman / Ned Appraisal Process

Chairman / NED Appraisal Outcomes

Non Executive Directors Re-Appointments

Chairman / NED Remuneration (plan & outcomes)

Deferred following publication of new Guidance

Review of Governor Handbook*

Deferred pending approval of creation of Deputy Lead Governor

Governor Elections Update*

CLOSING BUSINESS Feedback on Events/ Visits

Review of Annual Work Plan

Any Other Business

Note: items relating to governance marked with * will be combined in one report namely, Council of Governors Governance Update.

Key:

Item scheduled to be presented to Council of Governors

X

Item scheduled but no update to report.

Item scheduled and received by Council of Governors

Item scheduled but deferred

Agenda Item No: A4

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C Status of these minutes (check one box):

Report to:

Council of Governors Draft for Approval: ☒

Formally Approved: ☐ Meeting Date: 17 October 2019

MINUTES OF THE MEETING OF THE

Council of Governors Date: Wednesday 7 August 2019 Time: 3:30pm-5:30pm

Venue: Quaker Meeting House, 22 School Lane, Liverpool L1 3BT

Name Job Title (Division/ Organisation*) *if not Mersey Care

Present: Beatrice Fraenkel Sayed Ahmed Helen Casstles Gillian Davies Julie Dickinson Karen Elliot Dean Hegarty Susan Martin Mark McCarthy Andrew Naylor Garrick Prayogg Debbie Riozzie Paul Smith Hilary Tetlow Alex Till

Chairman (Meeting Chair); Staff, Medical Public, Liverpool, Sefton and Knowsley Staff Nursing Service Users & Carers Staff, Non Clinical Staff, Other Clinical and Clinical Support Staff Public, Liverpool, Sefton and Knowsley Service Users & Carers (via teleconference) Service Users & Carers Public, Rest of England and Wales Service Users & Carers Public, Liverpool, Sefton and Knowsley Service Users & Carers Public, Rest of England

In Attendance: Murray Freeman Pam Williams Trish Bennett Louise Edwards Neil Smith Michael Green Stuart Richards Lois Newitt Andy Meadows Sarah Jennings Paula Murphy Alison Bacon Debbie Richardson

Non-Executive Director; Non-Executive Director; Executive Director of Nursing & Operations; Director of Strategy; Executive Director of Finance / Deputy Chief Executive Grant Thornton Grant Thornton Human Resources Business Partner Trust Secretary; Deputy Trust Secretary; Corporate Governance Compliance Manager; Membership & Engagement Manager Corporate Governance Assistant

Apologies Received: Veronica Webster Cheryl Barber Matthew Copple Mandi Gregory Vicky Keeley Jayne Moore Paul Taylor Mary Sutton Tashi Thornley

Appointed, Local Authority; Staff, Nursing Service Users & Carers Appointed, Unions and Other Staff Representative Bodies Appointed, Local Voluntary Public, Liverpool, Sefton and Knowsley Service Users & Carers Public, Liverpool, Sefton and Knowsley Service Users & Carers

Agenda Item No: A4

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Gie Peneche Paul Allen Tracey Cummins

Staff, Other Clinical and Clinical Support Staff Staff, Other Clinical and Clinical Support Staff, Nursing

ISSUES CONSIDERED 2019

A1 WELCOME

1. Mrs Fraenkel welcomed all Governors to this meeting and introductions were made around the table.

2. Mrs Fraenkel noted that Governors had previously requested short introductions to agenda items on the assumption that all Governors had read the papers ahead of the meeting to allow more time for questions to be raised. Mrs Fraenkel welcomed this approach and confirmed that the meeting would proceed on this premise.

A2 APOLOGIES

3. The apologies for absence received for the meeting were noted, as detailed above.

A3 DECLARATIONS OF INTEREST

4. There were no interests declared.

A4 MINUTES OF THE PREVIOUS MEETING HELD ON 25 April 2019 (including Action Log)

5. The minutes of the meeting held on 25 April 2019 were accepted as an accurate record.

6.

Action Lead Timescale Status

Recommendations approved by the Council of Governors, namely: • Approve minutes from 25 April 2019.

Further actions required: • None identified.

A5 UPDATE FROM THE CHAIRMAN

7. Mrs Fraenkel provided a verbal update in relation to recent activities, highlighting the following:

a) The resignation of Dr David Fearnley, Medical Director who had left the Trust at the end of July to take up a new post in Betsi Cadwaladr University Health Board in Wales. A farewell lunch was held at the recent Board meeting which several Governors had attended. The process was underway to seek a replacement and meanwhile, Dr Arun Chidambaram was stepping in as Interim Medical Director;

b) A welcome to new Governors who were formally appointed on 1 May 2019 for a three year term and participating in their first meeting today;

Agenda Item No: A4

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c) The good attendance at the Trust’s Annual General Meeting held at Aintree recently. Mrs Fraenkel stated that the high attendance was a good indication of Mersey Care’s support and inclusion of service users and carers;

d) Following the success of the last Members’ event in February, another event had been arranged for 15 October 2019 which will focus on progress in delivering our quality priorities and include a Q&A session. Details will shortly be circulated to Governors.

8.


Recommendations approved by the Council of Governors, namely: • Note the verbal update.


A6 UPDATE FROM THE DEPUTY CHIEF EXECUTIVE

9. Mr N Smith provided Governors with a verbal update on key issues arising since the last meeting and agreed to share a copy of the update with Governors after the meeting: National Issues a) Boris Johnson had been appointed as the new Prime Minister in July 2019 and

had concluded ministerial appointments to government. Matt Hancock remained as Secretary of State for health and Social Care with Chris Skidmore appointed as Minister of State. Nadine Dorries joined the department of Health and Social Care as a parliamentary under-secretary of state. Nadine is originally from Liverpool and trained as a nurse. New developments focusing on health services were anticipated and regular updates will be provided to the Council of Governors.

b) Following constraints on capital funding over recent years, new capital funding had been made available. An announcement had been made in respect of 20 different capital programmes amounting to £1.8 billion and Mersey Care had seen £33m of this for the provision of the Specialist Learning Disabilities Low Secure Unit development in Maghull which allowed the Trust to continue with the work of relocating service users at Whalley to Maghull;

c) The NHS Long Term Plan was a 10 year plan published in January 2019 and the

expectation was that local partners should increasingly work and plan together within Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs). The Trust was part of Cheshire and Merseyside Health and Care Partnership (STP) and also worked more locally, particularly with our partners in Liverpool and Sefton. Each area was to produce a strategy plan by the end of the year and again, Governors will be kept informed of progress over the coming months;

Agenda Item No: A4

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Local Issues d) A request for assistance from NHS England had been received by all mental

health trusts across the north of England following the identification of a small private hospital of 16 beds which accommodated autistic patients and was being de-registered by the Care Quality Commission. Mersey Care was the only organisation who offered to help and subsequently had put together a small team lead by Mrs T Bennett, who will assist in stabilising the service pending its re-registering. This had enabled the Trust to protect vulnerable patients and avoided the need for an emergency transfer. This support has been offered for a 3 month period;

e) Governors had previously identified concerns around performance indicators in relation to the percentage of service users in employment/settled accommodation. This would be addressed within the performance report on today’s agenda. At the request of Governors, the Chief Executive had arranged a meeting with the Metro Mayor, Steve Rotheram to explore how we can work together to improve this, however the meeting planned for 5 August was cancelled and was currently being re-arranged;

10. Mr P Smith referred to the £33m funding for the Low Secure Unit, stating that Governors were keen to understand the timeline and workforce planning around this. Mr N Smith stated that it was anticipated that the building would be complete and operational in 2023 subject to any delays in the plans and work would commence imminently to ensure robust workforce plans were in place.

11.


Recommendations approved by the Council of Governors, namely: • Note the verbal update.

Further actions required: • Circulate the written Deputy CEO update to all

Governors;

S Jennings

Aug-19

Completed

B1 PERFORMANCE REPORT

12. Mrs Williams provided a summary of Trust performance to 31 May 2019 against Regulatory and Operational Plan key performance metrics. Mrs Williams stated that the report was in the usual format; however the Operational Plan section now had measures split into long term improvement metrics and continuous improvement metrics in order to provide more clarity. New indicators were identified in the appendices and statistical control charts had been introduced as a quality improvement tool.

13. In relation to the Care Quality Commission section of the report, Mrs Williams confirmed that the Trust had improved in the Safe and Well Led domains. The Single Oversight Framework reflected that a total of 75.86% of metrics (29) had been achieved and this was consistent with April 2019. In relation to Our People, 57% of

Agenda Item No: A4

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metrics had been achieved (14). Full details were available within the report.

14. Dr Till referred to page 8 of the report pertaining to Cardio-Metabolic assessment and treatment for people with psychosis (Inpatients) and noted that the 2018 National Schizophrenia Audit, from which performance was sourced, now excluded Learning Disability and Secure Services. Dr Till queried how Non Executive Directors were seeking assurance in respect of these services. Mr N Smith highlighted that the report provided was from May 2019 and acknowledged that there was a more up to date report now available as per the Board of Directors meeting held on 31 July 2019. This was due to the timing of papers being circulated and this will be reviewed going forward. Mr Smith responded to Dr Till’s question, stating that across Cardio Metabolic issues, a significant improvement had been achieved in a number of areas and the Trust was now meeting a number of the associated national targets. In relation to the excluded data, Mr N Smith confirmed that this was at the decision of NHS England, but was still monitored by Division and work was on-going to ensure improved data quality. Dr Till stated that it would be useful to have data for other divisions presented, even if not included within the national audit. Mr N Smith agreed to highlight this for the next meeting to ensure clarity for Governors.

15. Mrs Williams confirmed that Non Executive Directors undertook detailed scrutiny of the Performance Report within the Quality Assurance Committee and the Performance, Investment and Finance Committee as well as the Board of Directors. Dr Murray concurred, adding that Non Executives reviewed a whole range of indicators to ensure focus and oversight.

16. Mrs Martin referred to ligature incidents reported on page 29 which provided out of

date information (from 2017) and queried what assurance had been provided to the Non Executive Directors in respect of this. Mrs Wrathall confirmed that care plans were in place for every service user with specific plans in place for those individuals with a risk in relation to ligatures. Mr N Smith confirmed that quarterly reviews were undertaken and each division’s performance assessment was challenged and reviewed. It was probable that the number of incidents reported were limited to a few service users who may have had a number of incidents and this detail was reported via the Executive Committee and relevant committees of the Board.

17. Mrs Fraenkel acknowledged Mrs Martin’s comment regarding 2017 data being

included in the report and confirmed that this would be addressed going forward, stating that the quality of data was continuously improving.

18. Mr Prayogg referred to the mention of action plans in the report and requested a

improved narrative was provided in relation to these.

19. Mrs T Bennett stated that divisions were taking ownership of targets and there had been a significant improvement in reporting. Constructive relationships between teams was aiding this work and should there be an area of concern, the Trust had a deep-dive process to identify issues and provide an improvement plan.

Agenda Item No: A4

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20.


Recommendations approved by the Council of Governors, namely: • Note the assessment of performance against

Regulatory and Operational Plan targets. • Note that Performance Improvement Plans have

been presented at the quarterly review meetings to provide assurance that improvement plans are in place for areas of underperformance.

Further actions required: • Review report with regard to readability and timely

data; • Data for all divisions to be included in report going

forward in respect of Cardio-metabolic indictors for inpatients;

A Patel / S Jennings N Smith / A Patel (J Billingsley)

Oct-19 Oct-19

Oct-19 CoGs Included in Oct-19 Reports and onwards.

B2 INTEGRATION UPDATE

21. Mrs T Bennett provided an update on the work the Trust has commenced around integration both from an internal Trust and an external system perspective following a request for an update at the previous meeting of the Council of Governors. Mersey Care were currently taking a leading role in the development and implementation of Integrated Care Teams across Liverpool and Sefton in order to improve care for people and reduce duplication.

22. Mrs Edwards confirmed that she was working with Mrs T Bennett in leading on this piece of work, stating that there was a need to focus on integration within Mersey Care’s own services and the quick improvements that could be achieved prior to the long term benefits of integration. Mrs Edwards added that there were many opportunities for integration with the Trust and between providers but there was a need to implement these effectively and carefully.

23. Mrs T Bennett stated that as integration was a complex area, a separate development session for Governors could be arranged if required. Following discussion it was agreed that Governors would like a development session to be arranged and requested that regular updates were provided to each Council of Governors meeting in relation to the integration of services.

24. Mrs Tetlow stated that Governors had discussed their concerns that the Liverpool Community Services Transition Sub-Committee would cease at the end of 2019 and proposed that this meeting should continue until integration was completed. Dr Freeman confirmed that he was a member of this Sub-Committee which focussed on the 44 key issues identified through the Kirkup Report. The Trust were now almost at a point where all the issues had been adequately addressed and the Sub-Committee was more assured regarding the level of care provided. Mrs Tetlow noted the comments, however stated that the Trust must ensure continued safety. Mrs Fraenkel confirmed that the Chairs of the Sub-Committee and of the Quality Assurance Committee were scheduled to meet and discuss the way forward along with Mrs T Bennett. Consideration will be given to forming a new Committee, as the Trust becomes integrated in both physical and mental health, to address the changing needs

Agenda Item No: A4

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or the organisation. Mrs T Bennett concurred and advised that this would be reflected upon in the planned development session. Miss Jennings agreed to make the necessary arrangements for a development session for Governors.

25.


Recommendations approved by the Council of Governors, namely: • Note the contents of this report

Further actions required: • Development session for Governors around

integration;

T Bennett / L Edwards (S Jennings)

Sept-19

By end Sep-19

C1 ANNUAL ACCOUNTS / ANNUAL REPORT

26. Miss Jennings confirmed that for completeness, the Council of Governors should receive the complete Annual Report 2018/19 which included the Annual Accounts and the Quality Account.

27. Mrs Fraenkel highlighted an error in relation to her qualifications on page 46 of the

Annual Report. Mr Meadows agreed to make the necessary amendments.

28. Mr N Smith stated that a presentation had been provided at the April 2019 meeting around the Trust’s financial position at year end and this position remained unchanged.

29.


Recommendations approved by the Council of Governors, namely: • Note the report

Further actions required: • Amend error in relation to Chairman’s

qualifications;

A Meadows

Aug-19

Aug-19

C2 EXTERNAL AUDIT FINDINGS

30. Mr Green and Mr Richardson (Grant Thornton) attended the meeting on behalf of Mr Patterson who was the Trust’s Audit Engagement Lead.

31. Mr Green presented Grant Thornton’s findings of a review of the Trust’s Quality Report against the requirements, stating that no issues were identified.

32. Mr Richardson stated that as part of their work, Grant Thornton had reviewed 3 indicators:

a) Inappropriate out of area placements – 2 cases in 18 days and Auditors satisfied data was accurate and complete. Able to reconcile this to national report figures;

Agenda Item No: A4

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b) Early intervention in psychosis (EIP) – issues identified with data set, therefore unable to reconcile data. Data for August 2018 not located and on this basis, this resulted in a qualified opinion. A recommendation to improve the Trust’s arrangements for compiling this indicator was provided;

c) Community acquired pressure ulcers – no material issues identified in relation to calculation of this indicator or the six dimensions of data quality;

33. Mrs Elliott referred to EIP data and queried what assurances Non Executive Directors had requested in relation to this. Mrs Williams (Audit Committee Chair) confirmed that external auditors findings were reported to the Audit Committee and as full assurance was not provided, the Committee had requested a follow up report which would be provided to the Audit Committee at their meeting on 14 August 2019, which was to include an action plan along with the full detail of the circumstances around this issue. Mrs Williams assured Governors that this was an unusual situation with regard to the transitional work and was an isolated IT issue rather than a trend, however assurance had been requested and follow up around the action plans would be monitored.

34. Mr N Smith confirmed that mitigation plans were in place to ensure the loss of data did not reoccur going forward.

35.


Recommendations approved by the Council of Governors, namely: • Note the report


D1 RESPECT AND CIVILITY INITIATIVE

36. Mrs Newitt provided an update to Governors in relation to the Trust’s Just and Learning Culture, Respect and Civility work stream and highlights included the following:

a) 2018 achievements; b) The facts around incivility; c) The Negative Acts Questionnaire; d) The plans for 2019; e) The aim of ‘Making the NHS the best place to work’; f) The Trust sign up to the Social Partnership Forum; g) The Respect and Civility Jigsaw (copies handed out to Governors); h) Supporting the Just and learning Culture Pilot; i) Board level support;

37. Mrs Fraenkel thanked Mrs Newitt for the informative presentation and stated that the

next stage would be reporting progress/improvement evidence to Governors and the Board. Mr N Smith concurred and stated that updates on progress to all Committees and the Board would provide learning opportunities throughout the Trust.

Agenda Item No: A4

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38. Mrs Newitt stated that a review of responses to the Negative Acts Questionnaire thus far was balanced, however a full review of responses would be undertaken in September 2019.

39. Mr Prayogg welcomed the presentation and queried whether protected characteristics would be captured in the returns of the questionnaire. Mrs Newitt confirmed that the BME Network had requested this and therefore results would be broken down accordingly.

40. Mr Prayogg stated that this initiative would benefit the Trust in relation to staff sickness as staff who were happy at work were less likely to be absent with sickness/stress. Staff with a mental health issue did not always feel able to disclose this to their employers and Mr Prayogg queried how this could be captured and support offered to staff. Mrs Newitt confirmed that the data set would be triangulated, stating that stress was the top cause of staff sickness in Mersey Care.

41. Mrs Tetlow queried how the impact of respect and civility in the workforce would impact service users and how this would be measured. Mrs Newitt welcomed this question and agreed to review this further.

42. Mr Hegarty stated that gaining a response from people who had experience of being bullied could be problematic due to the likelihood of a fearful culture and queried how people in such circumstances would be encouraged to come forward. Mrs Newitt highlighted the work being undertaken across the organisation to encourage staff to speak up and challenge inappropriate behaviour, adding that it was critical for people who were being challenged to listen and understand as they may not be aware that they were perceived as a bully. Work was on-going to influence this within the Trust.

43. In response to Mr Hegarty, Mrs Newitt confirmed that the Trust provided several avenues for help for staff and details of these pathways were included in the booklet that would shortly be provided.

44. Mrs Fraenkel noted that the initiative was still in its infancy and staff were to be trained and supported going forward around this topic.

45. Following discussion, Mrs Fraenkel proposed a development session be arranged for Board members in relation to the respect and civility initiative.

46. In response to Mr Prayogg, Mrs Newitt agreed to circulate the proposed booklet to Governors for comments ahead of publication.

47.


Recommendations approved by the Council of Governors, namely: • Note the presentation.

Further actions required: • Arrange Development Session for the Board in

relation to Respect and Civility; • Review how the impact of respect and civility in

the workforce would impact service users and how this will be measured;

A Meadows

L Newitt

Nov-19

Nov-19

By end Nov-19

By end Nov-19

Agenda Item No: A4

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• Circulate proposed Respect and Civility booklet to Governors for comments ahead of publication;

L Newitt (P Murphy)

TBC Prior to publication (date tbc)

E1 COUNCIL OF GOVERNORS – GOVERNANCE UPDATE (INCLUDING LEAD GOVERNOR ELECTION PROCESS)

48. Miss Jennings provided an update in relation to Governance advising that the report:

a) outlined the revised membership for the Governors Membership and Engagement Group for approval;

b) outlined the revised membership for the Governors Nominations and Remuneration Committee for approval;

c) advised Governors of the scheduled remuneration (pay) review of the Chairman and Non-Executive Directors;

d) outlined the process for the election of a Lead Governor in October 2019;

49. Miss Jennings stated that 3 years previously, the Governors Nomination and Remuneration Committee, supported by the Director of Workforce, had undertaken a pay review for the Chairman and Non Executive Directors and had requested a further review in three years. It would shortly be time to undertake this process again and Miss Jennings stated that she would contact members of the Committee in due course to schedule a meeting to review and consider the latest remuneration benchmarking information.

50. With regard to the Lead Governor role, Paul Taylor would end his term as Lead Governor in October 2019 and in light of this, an election would be held at the next meeting of the Council of Governors via an internal ballot, the full process for which was outlined in the paper. Miss Jennings added that should a person who is elected as Lead Governor step down in advance of the end of their term, the election process would commence sooner.

51. In response to Mr P Smith, Miss Jennings confirmed that following two rounds of Governor elections in quick succession it had been necessary to revise the membership of the Council of Governors Membership and Engagement Group as the majority of members’ terms of office had ended. Miss Jennings confirmed that she had since written to all those who had indicated they were interested in joining the Group to seek preferred options for meeting arrangements and a meeting schedule would shortly be prepared for circulation.

52.


Recommendations approved by the Council of Governors, namely: • Note the revised membership of the Membership

and Engagement Committee and associated (unchanged) Terms of Reference (Appendix A);

• Note the revised membership of the Nominations and Remuneration Committee and associated (unchanged) Terms of Reference (Appendix B);

• Note the intention to commence the next review of Chairman and Non-Executive Director

Agenda Item No: A4

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remuneration, the outcomes of which will be presented to the Council of Governors in October 2019 for approval;

• Note the Lead Governor election process and associated timescales.

Further actions required: • Develop meeting schedule for Membership &

Engagement Group;

S Jennings / A Bacon

Aug-19

Aug-19

E2 CHAIRMAN AND NON-EXECUTIVE DIRECTOR APPRAISAL OUTCOMES

53. Miss Jennings confirmed that the previous meeting of the Council of Governors had approved the proposed process for appraisals of the Chairman and Non Executive Directors. All appraisals had now been completed and a summary of performance for the Chairman and Non Executives was included in the report, including the details of the various commitments of each Non Executive.

54.


Recommendations approved by the Council of Governors, namely: • Note the outcomes of the process for the appraisal of

the Chairman; • Note the outcomes of the process for the appraisal of

the Non-Executive Directors (NEDs); • Note that the appraisal process will be reviewed in

2020 by the Nomination and Remuneration Committee.


E3 REAPPOINT OF NON-EXECUTIVE DIRECTORS

55. Miss Jennings stated that in line with the Council of Governors’ statutory duties, Governors were responsible for appointing and reappointing Non Executive Directors. In light of this, Governors were being asked to reappoint/agree terms of office of 3 years for three Non Executives, namely Gerry O’Keeffe, Gaynor Hales and Pam Williams. Miss Jennings stated that Governors decisions should be based on the recommendation of the Chairman and the appraisal outcomes (as per agenda item E2).

56.


Recommendations approved by the Council of Governors, namely: • consider and approve the proposed terms of office for

the three NEDs outlined in this paper


Agenda Item No: A4

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57. Miss Jennings advised that the following agenda items, F1 to F5, were provided as information items and as such these would not be subject to formal presentation to this meeting, however Governors were able to raise any questions.

F1 SPECIALIST LEARNING DISABILITIES DIVISION RETRACTION PLAN UPDATE (for information)

58.


Recommendations approved by the Council of Governors, namely: • To note progress to date • To note the content of the report


F2 UPDATE ON COMMUNITY SERVICES IMPROVEMENT PROGRAMME AND OVERSIGHT ARRANGEMENTS (for information)

59.


Recommendations approved by the Council of Governors, namely: • note the continued progress within the programme

based on this high level overview report.


F3 FINAL 2018/19 QUALITY ACCOUNT (for information)

60.


Recommendations approved by the Council of Governors, namely: • Note the report. • Note the areas of progress


F4 WINTER PLAN EFFECTIVENESS 2018/19 (for information)

61.


Recommendations approved by the Council of Governors, namely: • Note the contents of this paper; • Be assured of the progress being made by Mersey

Care in its response to winter across the wider health and social care system.


Agenda Item No: A4

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F5 BOARD ASSURANCE FRAMEWORK (for information)

62.


Recommendations approved by the Council of Governors, namely: • Note the report.


63. Representatives from Grant Thornton left the meeting at this point.

64. No further business was raised.

65. Part 1 of the meeting closed.

Agenda Item No: A4

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Council of Governors - Actions from meetingsPage Agenda Item Action Owner Status Due Date Comments

Jan-19 CoGs B2-Trust Performance Report

Outcomes of work with Edge Hill University (Staff sickness) to be included in next report

Executive Lead: A Oates Operational Led: Asim Patel

TBC

Currently an issue around funding of the work with the University which was resulting in a delay in commencement of this project and completion of this action.

Apr-19 CoGs A7-Update from the Chief Executive

Provide update in relation to meeting/discussions with the Metro Mayor around the number of our service users in employment/accommodation

Executive Lead: J Rafferty

Aug-19

The Chief Executive will contonue to update Governors through his Chief Executives Update at each Council of Governors Meeting.

Aug-19 CoGs D1-Respect and Civility Initiative

Arrange Development Session for the Board in relation to Respect and Civility

Executive Lead: A Oates Operational Lead: A Meadows

Not due Nov-19 By end Nov-19

Aug-19 CoGs D1-Respect and Civility Initiative

Review how the impact of respect and civility in the workforce would impact service users and how this will be measured

Executive Lead: A Oates Operational Lead: L Newitt

Not due Nov-19 By end Nov-19

Aug-19 CoGs

E1-Council of Governors - Governance Update (incl Lead Governor Election Process

Develop meeting schedule for Membership & Engagement Group

Executive Lead: E Darbyshire Operational Lead: S Jennings / A Bacon

Aug-19Next meeting arranged for 8 October 2018, further meeting dates to be discussed at this meeting.

Meeting held on 7 August 2019

Meeting held on 7 August 2019 - PRIVATE SESSION

Meeting held on 25 April 2019

Meeting held on 17 January 2019

Aug-19 PRIVATE CoGS

E1-AOB- Governor Feedback from Visits

Develop a formal feedback process following Governor service visits S Jennings Aug-19

To be progress through the Membership and Engagement Group

KEYTO BE ACTIONED

COMPLETEDONGOING

Agenda Item No: B1

COUNCIL OF GOVERNORS Report provided (check necessary boxes): Agenda Item No. B1

To Note: ☒ For Assurance: ☐ Report to: Council of Governors

For Decision: ☐ For Consent: ☐ Meeting Date: 17 October 2019

Performance Report

Accountable Director(s):

Neil Smith, Executive Director of Finance 0151 471 2205

Report Author(s): Asim Patel, Joint Chief Information Officer 0151 473 2982

Purpose of Report To provide a summary of Trust performance to 31 August 2019 against Regulatory and Operational Plan key performance metrics.

Summary of Key Issues for Consideration of Governors :

Care Quality Commission

The Care Quality Commission last inspected the Trust between October and December 2018, and the report from this inspection visit was published on 5 April 2019. The current overall CQC rating remains at Good, but the position has strengthened with the Trust attaining the rating of Good for the Safe, Effective, Caring and Responsive domains and Outstanding for the Well Led domain. This evidences an improvement in both the Safe and Well Led domains.

Single Oversight Framework

In August 2019, the Trust was advised that there is a new NHS Oversight Framework (NOF) which will replace the current Single Oversight Framework for 2019/20. The new approach to the Oversight Framework will set out how regional teams review performance and identify support needs across Sustainability Transformation Partnerships (STPs) and Integrated Care Systems (ICSs). An overview of the NHS Oversight Framework has been provided in Appendix 2, this high level summary shows the metrics relevant to the Trust and indicates where these differ from the metrics currently reported within the Single Oversight Framework. Engagement is underway with the NHS Improvement regional team with regards to mobilising the changes outlined in the NHS Oversight Framework from October 2019. As the changes predominantly impact ‘Our People’ metrics, the Performance and Intelligence Team are working closely with Workforce Colleagues to mobilise the NHS Oversight Framework and understand its impact.

The Trust performance within the Single Oversight Framework is

Agenda Item No: B1

“segment score 2” (targeted support).

The ‘use of resources’ risk rating is the metric which measures the financial performance of the Trust. At Month 5 this is rated as 2 in line with plan and is forecast to improve to 1 before March 2020.

75.86% of metrics (29) within the Single Oversight Framework have been achieved. This is an improvement when compared with July 2019 (72.41%). In August 2019, IAPT – Proportion of people completing treatment who move to recovery (Monthly) was achieved and CPA 7 Day Follow-Up was achieved.

The seven metrics which are underperforming are:

Metrics Trend compared with Previous Position

Clients in Settled Accommodation % (Monthly) Staff Sickness (Monthly) Staff Turnover (Monthly) Data Quality Maturity Index (DQMI) – MHSDS Dataset Score IAPT - Proportion of people completing treatment who move to recovery (Quarterly) Cardio-Metabolic Assessment and Treatment – Inpatient Wards (Annual) Annual Metric

Cardio Metabolic Assessment and Treatment – Community Mental Health Services (Annual) Annual Metric

Operational Plan 2019/20

63% of the Long-Term Quality Improvement Metrics (32) within Our Services have been achieved. This is consistent when compared with July 2019 (63%). Metrics which have moved from Green to Red in August 2019 are:

• Physiotherapy Waiting Times (Liverpool)

70% of the Continuous Improvement Metrics (46) have been achieved. This is an improvement when compared with July 2019 (64%). Metrics which have moved from Green to Red in August 2019 are:

• 95% of Inpatients to be assigned a Specialist SupportTeam Link by March 2020.

• Reduction in the number of service users nursed in longterm segregation (using baseline of March 2019) by 20%by March 2020

25% of the Operational Plan Metrics (16) within Our People have

Agenda Item No: B1

been achieved. This is a deterioration when compared with July 2019 (56%). Metrics which have moved from Green to Red in August 2019 are:

• Recruitment Time to Hire• Personal Achievement and Contribution Evaluation

(PACE) Compliance 2019/20 (Attainment within Window)- Compliance against Bands and Target DatesBand 6 and above 95% by 1 September 2019

• Clinical Supervision – All Clinical Staff / All ClinicalProfessional Staff – Local/Secure/ SpLD Division Only

• Clinical Supervision – All Clinical Staff / All ClinicalProfessional Staff – Community Division

Statistical Process Charts have been provided in Appendix 1 for the metrics highlighted within the Executive Performance Report.

The breakdown of performance for the DQMI Data fields is provided in Appendix 2.

As stated above, the 2019/20 NHS Oversight Framework has been provided in Appendix 3.

Recommendation: The Council of Governors is asked to:

1) Note the assessment of performance against Regulatory andOperational Plan targets.

2) Note that Performance Improvement Plans have beenpresented at the quarterly review meetings to provideassurance that improvement plans are in place for areas ofunderperformance.

Previously Presented to:

Committee Name Date (Ref) Title of Report Outcome / Action

Executive Committee 19.09.2019 Executive Performance Report – Month 5 2019/20

Board of Directors 25.09.2019 Executive Performance Report – Month 5 2019/20

......Trust Performance Overview - August 2019

20 4On track On track15 (75%) 2 (50%)

32 16On track On track20 (63%) 4 (25%)

46On track32 (70%)

5 6On track On track 5 (100%)

5On track2 (40%)

2014/1 2015/16 2016/17 2017/12018/19### £213 £248 ### ###

Key Improved compared with previous month Deteriorated compared with previous month Remained the same compared with previous month

The new Care Model was approved on the 1 July 2019 by all partnerships. Data flows and reporting

are currently being identfied and confirmed.

Operational Plan2019/20 Metrics Trend

Off track

Long-Term Quality Improvement2019/20 Metrics Trend

Off track12 (37%)

3 (60%)

Our Resources

Continuous Improvement2019/20 Metrics Trend

Off track 14 (30%)

Our Future

Please Note: Metrics for which a judgement of performance is not appropriate or are not currently reported on within the report have been excluded.

Off track

Single Oversight Framework 2019/20 Metrics Trend

Off track 0 (0%)


TrendOff track Off track 5 (25%) 2 (50%)

2019/20 Metrics Trend 2019/20 Metrics


Off track 7 (75%)


CaringResponsive

Well-led

GoodGood

Outstanding

Our PeopleOur Services


Effective

Care Quality Commission Rating:Safe

Overall GoodGoodGood

Single Oversight Framework Segment Score: 21234

Maximum AutonomyTargeted SupportMandated SupportSpecial Measures

6.60% 6.38% 6.47% 6.80% 7.07% 6.86%

Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19

Staff Sickness - Single Oversight Framework

1.25%0.63% 0.67% 0.64% 0.92% 0.91%

Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19

Staff Turnover (In-Month) - Single Oversight Framework

2019/20 Metrics

Metric Rating Metric RatingOccurrence of any Never Event G Written Complaints GPatient Safety Alerts not completed by deadline G Staff Friends and Family Test 90.11%Under-Reporting of Patient Safety Incidents 32.77 Community Friends and Family Test 95.90%

Mental Health Friends and Family Test 90.89%Under 16 Admissions G

Metric Rating Inappropriate Out of Area Placements GCare Programme Approach 7 day Follow Up G Care Quality Commission - Community Mental Health Survey G% Clients in Settled Accommodation G% Clients in Employment RData Quality Maturity Index (DQMI) - MHSDS Dataset Score R Metric Rating

Early Intervention Treatment start within 2 weeks of referral - Unify GEarly Intervention Treatment start within 2 weeks of referral - MHSDS G

Metric Rating Cardio Metabolic Assessment and Treatment - Inpatient Ward RStaff Sickness R Cardio Metabolic Assessment and Treatment - EIP Services GStaff Turnover R Cardio Metabolic Assessment and Treatment - Community MH Services RProportion of Temporary Staff G IAPT - Waiting time to begin treatment within 6 weeks GStaff Survey G IAPT - Waiting time to begin treatment within 18 weeks GAgency Spend Y IAPT - Proportion of people completing treatment who move to recovery - M GLiquidity Days G IAPT - Proportion of people completing treatment who move to recovery - Q RCapital Services Capacity Y A&E Max waiting time of 4 hours from arrival to admission/transfer/discharge GIncome and Expenditure Margin YIncome and Expenditure Margin Variance (based on original plan) G

% Metrics Not Achieved/ Performance worse than National Median/ Benchmark 24.14%

Metrics for which a judgement of Performance is not appropriate have not been included in the above calculations.

WELL LED

% Metrics Achieved/ Performance better than National Median/ Benchmark (includes Finance Metrics reported on Plan as per NHSi Reporting) 75.86%

Single Oversight Framework 2019/20

RESPONSIVE

CARING

EFFECTIVE

SAFE

Overall GoodGoodGoodGoodGood

Outstanding

Trust Self-Assessment

Complete

Complete

Complete

Further detail can be found at:

Regulation 17 HSCA (RA) Regulations 2014: Good governance in end of life care, and walk-in centres.

Regulation 18 HSCA (RA) Regulations 2014 Staffing in community mental health services for adults of working age, community health services for adults, and walk-in centres

https://www.cqc.org.uk/sites/default/files/new_reports/AAAJ0888.pdf

The CQC have confirmed that they have accepted the Trust’s formal response, the ‘Hospital Report of Actions’ confirming the plans to address the regulatory breaches. There are detailed action plans in place to respond to

each action point and these are formally monitored via divisional governance groups, with oversight, updates and challenge being received and delivered by the Deputy Director of Nursing. The second bi-monthly update and

exception report was presented to the Quality Assurance Committee on 11 September 2019. There are meetings diaried to review the details of the evidence and RAG rating of Must Do’s and Should Do actions during September

and October to evidence embeddedness, and to develop the actions required from non-clinical service areas to support the Divisions. Whilst the Must Do’s are complete, it is critical to continue the oversight and monitoring to

ensure that the standard is maintained and embedded.

Regulation 12 HSCA (RA) Regulations 2014: Safe care and treatment in community mental health services for adults of working age, in community health services for adults,

in walk-in centres and end of life care.

Requirements Notices

EffectiveCaring

Care Quality Commission

ResponsiveWell-Led

Care Quality Commission Rating:Safe

https://www.cqc.org.uk/sites/default/files/new_reports/AAAJ0888.pdf

Mersey Care NHS Foundation Trust Executive Summary

A. CARE QUALITY COMMISSION

Accountable Director: Trish Bennett

The Care Quality Commission last inspected the Trust between October and December 2018, and the report from this inspection visit was published on 5 April 2019. The current overall CQC rating remains at Good, but the position has strengthened with the Trust attaining the rating of Good for the Safe, Effective, Caring and Responsive domains and Outstanding for the Well Led domain. This evidences an improvement in both the Safe and Well Led domains.

B. SINGLE OVERSIGHT FRAMEWORK

The Trust is achieving a Single Oversight Framework Segment Score of 2 (Targeted Support) and is achieving 75.86% of all Single Oversight Framework Metrics (29).

In August 2019, the Trust was advised that there is a new NHS Oversight Framework (NOF) which will replace the current Single Oversight Framework for 2019/20. The new approach to the Oversight Framework will set out how regional teams review performance and identify support needs across Sustainability Transformation Partnerships (STPs) and Integrated Care Systems (ICSs). An overview of the NHS Oversight Framework has been provided in Appendix 3, this high level summary shows the metrics relevant to the Trust and indicates where these differ from the metrics currently reported within the Single Oversight Framework. Engagement is underway with the NHS Improvement regional team with regards to mobilising the changes outlined in the NHS Oversight Framework from October 2019. As the changes predominantly impact ‘Our People’ metrics, the Performance and Intelligence Team are working closely with Workforce Colleagues to mobilise the NHS Oversight Framework and understand its impact.

All divisions have produced performance improvement plans for the single oversight framework indicators and other priority areas. These are discussed in detail within the divisional quarterly performance review meetings chaired by Neil Smith, Executive Director of Finance.

The 7 metrics which are underperforming are detailed below:

1. Cardio-Metabolic assessment and treatment for people with psychosis – Inpatients - Annual Metric Target 90% Actual 74% - Local Division Position

The above figure is from the Commissioning for Quality and Innovation Results (CQUIN) and is for the Local Division Only. The 2018 audit was completed and submitted on the 15 March 2019. The final results were received on the 30 June 2019 and reported a position of 74%. This is a significant improvement compared to the 27% Local Division achieved in 2017. Whilst the Local Division is under the national target required of 90%, they are above the national average (56.50%).

This will remain a focussed area for the division and will be monitored monthly through the inpatient physical health metric within the Operational Plan.

2. Cardio-Metabolic assessment and treatment for people with psychosis – Community MentalHealth Team – Annual Metric Target 65% Actual 20%

These are the results from the Commissioning for Quality and Innovation Results (CQUIN) for 2018. The 2018 audit was completed and submitted on the 15 March 2019. The final results were

received on the 30 June 2019 and reported a position of 20%. This shows no improvement compared with the audit from 2017. The national average for 2018 is 48.8%.

This will remain a focussed area for the division with key actions being undertaken and will be monitored monthly through the new community physical health metric within the Operational Plan.

In relation to the metrics above (point 1 and 2) these are no longer measured as part of the new 2019/20 NHS Oversight Framework.

3. Clients in Employment (%) Target 8% Actual 4.95% (internal Reporting)

The data for these metrics are derived from the published Mental Health Services Minimum Dataset which has a two month time lag. To allow the Trust to monitor the latest data available, internal reporting has been developed in line with the Mental Health Services Minimum Dataset methodology.

The % of Clients in Employment improved from December 2018 and currently remains at 5%. The improvement was attributable to the focus on data completeness, although deterioration in the data completeness has been observed over the last couple of months due to service user’s employment status not being reviewed within the 12 month period which is part of the underlying rules for this metric. The Local Division will prioritise this and potential solutions will be explored.

Nov 2018

Dec 2018

Jan 2019

Feb 2019

March 2019

April 2019

May 2019

June 2019

July 2019

Aug 2019

Clients in Employment

%* 3% 2% 3% 4% 5% 6% 6% 5% 5% 5%

*rounded to the nearest whole figure

4. Staff Sickness Target 5.06% Actual 6.86%

The Trust’s sickness absence rate for August 2019 is 6.86% which is a decrease of 0.21% on the refreshed data from the previous month. This is against a peer position of 6.17% and an internal target of 6.0%. Short term absence is 2.70% and long-term absence is 4.15%.

Currently, no Clinical Division is achieving the Trust target of 6%. The Community Division have had a slight increase in month to 6.84%. Local Division had a decrease of 1.16% to 7.90%, Secure Division had a slight decrease to 8.37% and Specialist Learning Disability Division a slight decrease to 7.39%.

Actions Taken to Improve Performance: • We continue to participation in national NHSI programme focussed on how health and

wellbeing interventions can impact positively on sickness absence. We are working with NHS England and NHSi regarding a further piece of potential research across Trusts within the Merseyside footprint which utilises population health data.

• The business case has been agreed to fund a new technological solution for an absencemanagement system which will allow real time reporting. The 12 month pilot in Secure/SpLD and some corporate functions will commence in November 2019.

5. Staff Turnover Target 0.89% Actual 0.91%

The Trust’s turnover rate for August 2019 is 0.91% which is a 0.01% improvement on the previous month (0.92%). This is against a national median of 0.89% and a peer position of 0.77%.

In August 2019, the main increases in staff turnover were within the Secure Division and Specialist Learning Disability Division which have increased in-month by 0.27% and 0.67% respectively and are reporting above the National Median. A small increase within Local Division can be seen when compared with July 2019 of 0.11%, however, they are reporting below the National Median.

The main reasons for staff leavers within the Secure and SpLD Divisions were due to voluntary resignation and staff becoming of retirement age.

All other Divisions had an improvement in relation to their staff turnover when compared with July 2019 and are all reporting under the National Median.

6. IAPT - Proportion of people completing treatment who move to recovery (Internal Reporting) -Quarterly Target 50% Actual 39.82%

In the May 2019 Executive Performance Report there was a detailed assessment of the reasons why performance had dropped which was linked to the introduction of new clinical models and waiting times. The service continues to have confidence in their plans for improvement and we have seen that the position has improved from 36.35% in May 2019 to 50.38% in August 2019. In order for the metric to be achieved for Q2 2019-20, the service will need to achieve a minimum of 53% in September 2019. The service is confident the target will be achieved in Q3 2019-20.

Further improvements are projected in line with the trajectory below:

Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target 46% 50% 50% 50% 50% 50% 50% 50% 50% Actual 47.29% 50.38%

7. Data Quality Maturity Index (DQMI) – Mental Health Services Data Set (MHSDS) DatasetScore Target 95% Actual 84.50%

The methodology for this indicator has been updated by NHS digital to include further additional field items. The August 2019 report relates to the May Mental Health Services Data Set 2019 submission which now includes all 36 data items.

The August 2019 position of 84.50% has improved when compared with 77.90% reported in June 2019. Although, we are reporting at below the national standard of 95%, the Trust is reporting above the national average of 71.53% and of our peers at 84.33%.

A working group has been developed to identify the reporting requirements for each of the new data fields to ensure the data is captured at the earliest opportunity within the MHSDS submissions. Work is continuing for each of the data fields with actions being taken within the divisions and clinical systems. This is a CQUIN for the Local Division for 2019/20 which the Secure and Specialist Learning Disability Divisions are supporting with.

Single Oversight Framework – Financial Performance

The ‘use of resources’ risk rating is the metric which measures the financial performance of the Trust. At Month 5 this is rated as 2 in line with plan and is forecast to improve to 1 before March 2020.

Capital Services Capacity The capital services capacity rating is currently 2. In order to achieve a level 1 we would need to increase our surplus by £2.065m at month 5.

Income and Expenditure Margin The income and expenditure margin is currently rated at 2. The Trust continues to forecast a full year surplus of £3.721m, this will result in a rating of 1 for this metric at the end of the financial year.

The most significant financial risks for 2019/20 continue to be:

a. Medical cost management - £2.800mb. Corporate CIP delivery - £3.100m

The Trust set aside a risk reserve of £5.900m in the 2019/20 financial plan. Full year cost pressures have been identified as part of the forecast at quarter 1 totalling £0.979m which will be supported by non-recurrent slippage in reserves during the year.

On-going financial management and recovery actions are planned in year and as part of the long term financial plan in relation to key financial risks. Focus during quarter 2 continues to be on safe financial recovery of in year pressures along with longer term recurrent solutions. This will be reported as part of the forecast at quarter 2 and development of the long term financial plan.

C. Long-Term Quality Improvement - Operational Plan 2019/20

The Trust Board approved the Operational Plan for 2019/20 and the Trust is achieving 66% of the Operational Plan Metrics (53). Further detail is provided below.

Our Services

Accountable Director: Trish Bennett

The Trust is currently achieving 63% of the Long-Term Quality Improvement metrics (32) within Our Services.

As part of the quarterly performance framework all identified underperforming operational plan metrics will have a full review which will include a deep dive and challenge of the recovery plan, improvement trajectory and assessment of risk.

Metrics which have moved from Green to Red in August 2019 are:

• Physiotherapy Waiting Times (Liverpool) Target 8 weeks Actual 9 weeks

As at the end of July 2019, the waiting time reported for the Physiotherapy Service in Liverpool has increased above the 8 week target to 9 weeks.

This is the first time waiting times have been above target since December 2017. This increase is attributed to short term capacity issues within the service and it is expected that they will be back within the 8 week target next month.

The total number of patients waiting increased along with the number waiting over 8 weeks during July 19. The longest wait also increased from 1 patient waiting 14 weeks to 1 patient waiting 18 weeks.

There is limited risk of patient harm as all referrals to the service are triaged and seen based on clinical need. There is a Duty Therapist available each day for queries and changes in a patient’s condition can be discussed and re-triaged. Advice can also be given over the telephone.

There have not been any incidents reported relating to patient harm.

Latest analysis points towards waiting times being within the 8 week target for September 2019.

It should be noted that waiting times for Allied Health Professional (AHP) services in Community Division is an improving picture. At the end of Month 4 2019/20, 9 out of 11 waiting times targets were achieved, this compares to 6 out of 11 targets being achieved at the end of quarter 3 2019/20. SALT (Speech and Language Therapy) in Liverpool are currently reporting waits above the 8 week target, but they are ahead of the improvement trajectory to be at target (8 weeks) by October 2019. Across AHP services combined numbers waiting, numbers waiting over 18 weeks and longest waits have reduced when compared to the same time period last year. Weekly reporting and pro-active monitoring of caseloads are two actions that have been put in place to drive improvement, capacity is also being reviewed on an on-going basis. Improvement plans are in place for areas that still require progress towards target, the continued aim for all services is to see all patients in a timely manner, ensuring no patients are waiting longer than necessary for appointments.

Continuous Improvement 2019/20 – Our Services

The Trust is currently achieving 64% of the Continuous Improvement metrics (44). Divisional Analysis can be found detailed within the report. Metrics which have moved from Green to Red in August 2019 are:

• 95% of Inpatients to be assigned a Specialist Support Team Link by March 2020Target 70% Actual 63.89%

This metric ensure that inpatients have a link to the Specialist Support Service which will help enable and achieve discharge into the community when appropriate and also ensures that the service user when discharged from the inpatient service will have a known contact to the SST which should help prevent re-admission into an inpatient service.

Specialist Support Teams (SST) work with all inpatients at Whalley, and work is ongoing to ensure that all inpatients have an SST representative indicated where appropriate on the system. SST Case Managers are getting assigned, however there is a delay in getting this information transferred onto the system. It is anticipated that this will be resolved in the next few weeks and for the indicator to be back on target for September 2019.

• Reduction in the number of service users nursed in long term segregation (using baseline ofMarch 2019) by 20% by March 2020 Target 25 Actual 31

In August 2019 the increase in the number of patients in long term segregation was due to newly admitted service users and deterioration in the mental state of a number of service users who have previously had their long term segregation terminated and it has had to re-commence. A number of Quality Improvement projects to reduce long term segregation is in place and increased opportunities for patients nursed in long term segregation to engage in extended pro-social meaningful activity. The division anticipate a reduction in episodes of long term segregation over the coming months.

Areas of Performance Focus

• Eating Disorder Service: Treatment commencing within 18 weeks of referralTarget 95% Actual 64.52%

Demand for the service continues to increase and to exceed capacity. The Trust will undertake a detailed review of capacity and demand with the aim of stabilising the service pending confirmation of whether the Business Case has been approved. The Business Case recognises

that since the initial service was commissioned that prevalence and identification of eating disorders in the population has increased.

The position reported in August 2019 is significantly improved when compared with the position reported in May 2019 (19.48%). In August 2019, 93 service users are waiting for treatment, with 33 breaching the 18 week to treatment target. This has reduced from last month's figure of 60 breaching the 18 week to treatment target.

• Improving Falls Management: All adults who have had a fall within the last 12 months to berisk assessed using an appropriate tool (Inpatients Only)Target 98% Actual 96.30%

• Falls Management: Of the patients identified as at risk of falling to have a care plan in place.Target 98% Actual 69.23%

The scope of the metrics have been clarified and relevant divisional improvements plans have been implemented in response to the underperformance and the actions from the improvement plans have been summarised below. Progress has been made in this area from 92.98% to 96.30% for the Falls Risk Assessment Tool Completion and 54.90% to 69.23% for Falls Care Plan Completion compared with last quarter. We are confident that looking at the internal analysis that there will be continued improvement in these metrics when reported for Q2 2019-20.

Actions Being Taken: • The falls management metric have been addressed in the division’s modern matron

meeting, with each matron disseminating the need for Falls Risk Assessment Tool (FRAT) and care plan to their respective ward teams if this has been identified as a need on the patients nursing assessment.

• Adult ward teams to be informed of the need to complete a FRAT and falls care plan if anindividual has sustained a fall in 12 months prior to completion of nursing assessment.

• Modern matron’s are now contacting ward teams to advise around the completion ofFRAT and falls care plans when a datix notification is received.

• Communication - All discharge communication from inpatient episodes are sent to GeneralPractice within 24 hours from discharge.Target 95% Actual 84.80%

Following on from the update provided in June 2019 which detailed actions to improve performance, the service continues to implement their plans for improvement and we have seen that the position has improved from 41.40% in Q4 2018-19 to 84.80% in Q1 2019-20 which is in line with the agreed improvement trajectory.

IMPROVEMENT TRAJECTORY (Quarterly Indicators) Quarter Q4 2018-19 Q1 2019-20 Q2 2019-20 Q3 2019-20 Q4 2019-20 Trajectory 41.40% 78% 82% 88% 95% Actual 41.40% 84.80%

• Communication - Outpatients All clinic/outpatient correspondence/ letters sent to GeneralPractice following the patient’s appointment, including discharge from service within 10working days (excluding weekends and bank holidays).Target 95% Actual 49.13%

Following on from the update provided in June 2019 which detailed actions to improve performance, the service continues to implement their plans for improvement and we have seen that the position has improved from 39.00% in Q4 2018-19 to 49.13% in Q1 2019-20 which is in line with the agreed improvement trajectory.

IMPROVEMENT TRAJECTORY (Quarterly Indicators) Quarter Q4 2018-19 Q1 2019-20 Q2 2019-20 Q3 2019-20 Q4 2019-20 Trajectory 39.00% 40% 55% 70% 95% Actual 39.00% 49.13% Our People Accountable Director: Amanda Oates The Trust is now achieving 25% of the Operational Plan Metrics (16) within Our People. Metrics which have moved from Green to Red in August 2019 are: • Recruitment Time to Hire Target 43 days Actual 53.4 days During the month of August there was increased recruitment activity due to funding from external sources. This additional funding resulted in an increase in conditional offers made including 25 trainee Nursing Associates. Furthermore a cohort of 23 trainee Clinical Psychologists had all checks undertaken in August for a September start as well as 13 Assistant Psychologists also ready to commence in September. Three recruitment events were also coordinated for a variety of disciplines including both Facilities positions and Nursing Assistants with the provision of a further 2 events in the latter planning stage for delivery later this month. Additionally support was provided to an external provider in response to a CQC request to ensure compliance with NHS Recruitment check standards. • Personal Achievement and Contribution Evaluation (PACE) Compliance 2019/20 (Attainment

within Window) - Compliance against Bands and Target Dates Band 6 and above 95% by 1 September 2019 Target 95% Actual 41%

The in-month target for August 2019 is 95% of staff at band 6 and above to have completed their PACE and the actual achieved was 41%. Divisions were requested (by Executive Director of Workforce) at July’s Strategic Workforce Group (SWG) to provide action plans of compliance improvement to the Learning and Development team by end of September 2019 for assurance that the Trust target of 95% PACE compliance by 1st January 2020 will be met. Clinical Supervision completed in line with Trust Policy (every 8 weeks) - All Clinical Staff (Local, Secure and Specialist Learning Divisions Only) Target 90% Actual 89.12% Clinical Supervision completed in line with Trust Policy (every 8 weeks) - All Clinical Professional Staff (Local, Secure and Specialist Learning Divisions Only) Target 90% Actual 89.55% The Trust did not achieve the Clinical Supervision Compliance target of 90% in August 2019 for All Clinical Staff and All Clinical Professional Staff. This is the first time Clinical Supervision Compliance has not been achieved since March 2019. The Secure and Specialist Learning Disability Divisions achieved over 90% in August 2019, with the Local Division performing under the 90% target. The Local Division have requested for teams under the 90% target to supply their mitigation and recovery plans. The division will also now monitor clinical supervision within their weekly safety huddle.

Clinical Supervision completed in line with Trust Policy (every 8 weeks) - All Clinical Staff Community Division Only Target 75.06% Actual 63.95% Clinical Supervision completed in line with Trust Policy (every 8 weeks) - All Clinical Professional Staff Community Division Only Target 75.06% Actual 69.88% Clinical Supervision rates at the end of August 2019 are reported at 64% and 70% for clinical and clinical professional staff respectively. Whilst this is below the Trust trajectory, compliance continues to increase month on month and represents a significant improvement compared to the 30% reported during May 2019. Actions: The following actions are being implemented in order to ensure clinical supervision rates continue to increase and the 90% target is achieved by the end of September 2019:

• Clinical supervision remains as an agenda item at team meetings and safety huddles. • Peer supervision will be implemented as a transitional stage to one to one supervision

within certain service groups such as Integrated Nursing where capacity has been identified as a barrier to accessing supervision.

• Progress against individual Service Group improvement trajectories managed via Divisional Performance Framework.

Our Resources Accountable Director: Neil Smith The Trust is currently achieving 40% of the Operational Plan Metrics (5) within Our ‘Resources’. The exceptions are reported below. 1. Planned Cost Improvement Plan v Actual Cost Improvement Plans £m

Target £10.041m Actual £5.281m

The 2019/20 Cost Improvement Plan (CIP) target for the Trust is £10.041m. There is a £4.211m full year forecast shortfall in corporate CIP delivery at month 5. This position continues to be reported as a key financial risk for the Trust. Of the £4.211m, there are £0.187m of further anticipated plans and a further £0.261m of non-recurrent mitigations. There are no plans at this stage for the remaining £3.763m. Therefore with a risk reserve of £3.100m the Trust requires further plans of £0.663m to ensure delivery of control total. Twelve applications for the Trust Mutually Agreed Resignation Scheme (MARS) have been approved by the Remuneration Committee in July. All staff approved via MARS will exit the Trust by 30th September 2019 with the recurrent saving reducing the unmitigated balance of £0.663m. The Local Division continues to report a £0.548m forecast shortfall in CIP delivery. The division has reported plans through Operational Management Group and the division expects to manage the impact non-recurrently in 2019/20 whilst plans for the recurrent delivery of these targets are agreed Initial CIP plans for 2020/21 have been received following a letter sent to Executive Directors and Chief Operating Officers on 1st July 2019. The plans are currently being reviewed and validated. Following quality impact assessment, plans will be reported to Quality Committee for approval in November.

2. Planned Medical Expenditure v Actual Medical Expenditure £mTarget £9.996m Actual £11.443m

The medical budget for 2019/20 is £23.964m, with a year to date budget of £9.996m. The actual medical expenditure for month 5 is £11.443m, a £1.447m variance from plan. The variance from plan can be split between drugs costs pressures of £0.426m and medical staffing overspend of £1.021m. Most of the overspend in medical staffing relates to locums filling vacancies within the local division.

Based on the current spend, there is a risk that the overspend could be in excess of the financial risk reserve (£2.800m) set. There are mitigations in place to address the medical staffing overspend including appointment to substantive consultant vacancies, use of medical bank and review of Additional Programmed Activity. Additional recovery actions for medical spend are required.

3. Planned Year to Date Drug Expenditure v Actual Drug ExpenditureTarget £0.991m Actual £1.443m

The drugs budget for 2019/20 is £2.332m, with a year to date budget of £0.991m. The actual expenditure on drugs for month 5 is £1.443m which is a £0.452m variance from plan. Most of this expenditure on drugs (£1.054m) is within the Local Division.

Based on the current spend, there is a risk that the overspend could be in excess of the financial risk reserve (£2.800m) set. Recovery actions are required to mitigate this overspend.

Our Future

Accountable Director: Louise Edwards

The review of the Trust’s long-term strategy informed the development of the Operational Plan for 2019/20 which was approved by the Board in March 2019. In summary, our long-term strategy is to continue to improve quality and safely reduce costs within our services and from this strong platform, develop more preventative, integrated community based services. We have agreed some key performance indicators that will help us measure how well our strategy is being implemented over the coming year.

The Trust is designing and delivering new models of integrated care across North Mersey in collaboration with partners and key stakeholders, including patients, staff and non-statutory organisations. Leading Provider Alliances across Liverpool and Sefton, the Trust is supporting partners to come together and work collaboratively to deliver system change and develop place based services, delivering integrated care for neighbourhood populations of 30-50,000. These have been piloted in four neighbourhoods across Liverpool and Sefton (Childwall, Aintree, Crosby and Bootle). Provider Alliance Strategies have been agreed for both Liverpool and Sefton for 2019 and delivery groups have been set up to oversee Alliance plans. Integrated Care Teams will be extended beyond the four initial pilot sites to all 16 neighbourhoods across Liverpool and Sefton by October 2019 and a diagnostic tool is being finalised that will measure the effectiveness of the teams. In addition a further four key priorities have been agreed for 2019; Urgent Care, Outpatients, Digital Technology and Social Prescribing. There is a proposal that this is tested out with three segments of the population – Frailty/dementia, Complex Needs and children/ young people. There has been some allocation of CCG resources to support this work and the Trust is progressing discussions about future requirements to enable the scale up delivery.

Cheshire and Merseyside mental health providers were selected to become a wave 2 site for the New Care Models programme for low and medium secure mental health services. The PROSPECT partnership consists of Mersey Care, North West Boroughs Healthcare NHS

Foundation Trust, Cheshire and Wirral Partnership NHS Foundation Trust and independent sector providers, Elysium Healthcare and Cygnet Healthcare. The Partnership has reached agreements in respect of standardising the clinical model and associated processes and agreeing a future delivery model, which will include development of an enhanced Community Forensic Service. The Partnership is working closely with local commissioning colleagues across local authorities and CCGs to design a community housing and support offer. The PROSPECT business case was approved by the boards of all partners during May and June 2019 and went live as a wave 2 site on 1st July 2019. Work has now begun on implementation of the clinical model supported by a standard operating procedure. We have received formal notification that our bid for the Secure Community Forensic Service pilot has been successful and are now awaiting further guidance from NHSE in order to commence our recruitment process. In May 2019 NHSE announced the next steps in mainstreaming new care models and commenced a Lead Provider Collaborative bidding process. NHSE has stated that the ambition is to have 75% of the current new care models population covered by Lead Provider Collaborative arrangements by April 2020 and 100% by 2022/23. A paper was taken PIFC on 21st June 2019 outlining the responsibilities of the Lead Provider function and Mersey Care subsequently submitted a bid to be the Lead Provider for Cheshire and Merseyside in respect of low and medium secure mental health and learning disability services. We have now been notified that that we have been placed on the fast track to go live as a lead provider with an anticipated time frame of April 2020. We will be meeting NHSE in the coming weeks to discuss our implementation plan towards achievement of this deadline.

Ref Monthly Metrics SPC Trust/ National Median Target

Latest Peer Position* Jun-19 Jul-19 Aug-19 Trend Line

C.1 Mental Health Friends and Family Test: (% positive)* _ 90.10% 89.50% 88.43% 90.11% 90.89%

C.2 Community Friends and Family Test: (% Positive) _ 95.96% 97.50% 94.93% 95.90%

E.3 Care Programme Approach 7 day Follow Up* _ 95.00%/ 96.93% 96.43% 96.36% 93.68% 96.49%

E.4 % clients in settled accommodation* _ 61.00% 61.50% 68.63% 67.79% (Internal)

66.10% (Internal)

E.6 % clients in employment* _ 8.00% 6.50% 5.23% 5.19% (Internal)

4.95% (Internal)

S.8 Patient Safety Alerts not completed by deadline _ 0 0 0 0

S.9 Occurrence of any Never Event (Rolling 6 Month) _ 0 0 0 0

S.10 Admissions to adult facilities of patients who are under 16 years old _ 0 0 0 0

W.11 Sickness (In-month)* - Click Here for SPC Chart 5.06% 6.17% 6.80% 7.07% 6.86%

W.12 Turnover (In-month)* _ 0.89% 0.77% 0.64% 0.92% 0.91%

W.13 Proportion of Temporary Staff* _ 4.17% 3.24% 3.61% 3.81% 4.03%

R.14 First episode of psychosis begin treatment with a NICE-recommended package of care within 2 weeks of referral (Part A - Unify2 Dataset) (three-month rolling)* _ 56% from June 2019 71.00% 61.18% 63.41% 67.42%

R.15 First episode of psychosis begin treatment with a NICE-recommended package of care within 2 weeks of referral (Part B - MHSDS Dataset)* _ 56% from June 2019 74.00% 59% 61%

(Provisional)Due Oct

2019

R.16 Accident and Emergency Maximum waiting time of four hours from arrival to admission/ transfer/ discharge _ 95.00% 100.00% 100.00% 100.00%

E.17 IAPT - Proportion of people completing treatment who move to recovery (Internal Reporting)* - Monthly - Click Here for SPC Chart 50.00% 52.00% 44.77% 47.29% 50.38%

R.18 IAPT - Waiting time to begin treatment (from IAPT minimum dataset) within 6 weeks* - Click Here for SPC Chart 75.00% 87.00% 99.51% 98.94% 96.85%

R.19 IAPT - Waiting time to begin treatment (from IAPT minimum dataset) within 18 weeks* - Click Here for SPC Chart 95.00% 99.00% 100.00% 100.00% 100.00%

S.20 Inappropriate Out of Area Placement (In-Month) _ Q2 - 121 days 0 0 0

S.21 Potential under-reporting of patient safety incidents* _ 42.79 32.77

E.37 Data Quality Maturity Index (DQMI) - MHSDS Dataset Score - 36 items - Click Here for Breakdown by Datafields _ 95%

National Average:71.53% 84.33% 84.50%

W.22 Capital Services Capacity _ Year End Plan - 2In-Month Plan - 2 3 2 2

W.23 Liquidity Days _ Year End Plan - 1In-Month Plan - 1 1 1 1

W.24 Income and Expenditure Margin _ Year End Plan - 1In-Month Plan - 2 3 3 2

W.25 Income and Expenditure Margin Variance (based on original plan) _ Year End Plan - 1In-Month Plan - 1 1 1 1

W.26 Agency Spend _ Year End Plan - 2In-Month Plan - 2 2 2 2

Ref Quarterly Metrics Trust/ National Median Target

Latest Peer Position* Q3 18-19 Q4 18-19 Q1 19-20 Trend Line

E.34 IAPT - Proportion of people completing treatment who move to recovery (from IAPT minimum dataset) - Quarterly* _ 50.00% 52.00% 47.42% 50.54% 39.82%

C.35 Staff friends and family test % recommended - care _ 75.60% 72.50% Staff Survey 76.95% 74.39%

C.36 Written complaints per 1,000 staff – rate* _ 15.19 27.05 6.75 8.06 Due 5 Sept 2019

Ref Annual Metrics SPC Trust/ National Median Target

Latest Peer Position 2016/17 2017/18 2018/19 Trend Line

W.38 Staff Survey - Staff recommendation of the organisation as a place to work or receive treatment (Key Findings 1) _ 3.74 3.63 3.67 3.77

C.39 Care Quality Commission - Community Mental Health Survey _ Lower Limit Range - 6.37 Upper Limit Range - 7.30 7.37 7.47 7.05

R.40 Cardio-metabolic assessment and treatment for people with psychosis - inpatients _ 90.00% 66.00% 46.24% 74.00%

R.41 Cardio-metabolic assessment and treatment for people with psychosis - Early Intervention in Psychosis _ 90.00% Not Available 15.00% 91.75%

R.42 Cardio-metabolic assessment and treatment for people with psychosis Community Mental Health Team (CPA) _ 65.00% 8.00% 19.80% 20.00%

KeyMetrics for which a judgement of performance is not appropriateMetrics which are being achieved or where performance is better than the national median.Metrics which are not being achieved at the target or where performance is worse than the national median.

Domain Reference KeyS = Safe, E=Effective, C=Caring, R=Responsive, W=Well-Led

The data provided on the above metric is extracted from the NHS Improvement Model Hospital and relates to May 2018.

The data provided on the above metric has a three-month timelag due to national publishing timescales for the Mental Health Services Data Set and the data above relates to January 2019.

Mersey Care NHS Foundation Trust - Single Oversight Framework 2019/20

Latest data relates to May 2018.

Latest data relates to May 2019

The five finance metrics above are scored on a scale of 1(best) to 4 by NHS Improvement using their RAG System of 1 = Green, 2 = Yellow, 3 = Amber and 4 = Red.

* The peer position represents the latest peer position available from NHS Improvement, Model Hospital and does not necessarily represent the latest data position reported. The peers included are:Cheshire and Wirral Partnership NHS Foundation Trust, Cumbria Partnerships, North West Boroughs Healthcare NHS Foundation Trust, Greater Manchester Mental Health NHS Foundation Trust,

Lancashire Care NHS Foundation Trust, Pennine Care NHS Foundation Trust, Bridgewater Community Healthcare NHS Foundation Trust and Wirral Community NHS Foundation Trust.

The metrics above use national data where available, however, if this is unavailable for the latter months of reporting internal data is used until such time that the national data becomes available. The national median is the latest data available within NHS Improvement, Model Hospital. The change in data/national median could result in a different Red, Amber, Green rating being reported.

New Metric Ref SPC Trust Target Jun-19 Jul-19 Aug-19 Trend Line

NEW TBC _ 95.00% 89.90% 88.08% 88.39%

NEW TBC _ 0 0 0 0

S.50 In-Month Target: 74 145 118 48

S.51 In-Month Target: 57 61 26 29

S.49 _ 0 2 2

NEW TBC _ 1 2 1

R.48 _ 95.00% 87.10% 87.85% 84.55%

R.48a _ 95.00% 87.18% 87.25% 84.55%

R.48b _ 95.00% 83.33% 100.00% Not Applicable

R.48c _ 95.00% 100.00% 100.00% Not Applicable

NEW TBC _ 95% by January 2020In-Month Target: 55% 42.46% 46.52% 48.48%

NEW TBC _ 65% by March 2020In-Month Target: 20% 15.55% 20.23%

NEW TBC _ 0 1 1 1

NEW TBC _ 0 0 0 0

E.5 _ 85.00% 88.33% 87.38% 85.46%

E.7 _ 85.00% 85.66% 84.45% 82.69%

TBC _ 31 days 45.95 40.46 34.89

TBC _ 46 days 13.50 33.78 42.29

NEW TBC _ 74 days 120.50 95.48 75.26

E.89 _ 1.78 years 2.00 2.00 2.00

E.90 _ 1.95 years 1.57 3.17 3.49

R.85 _ 10.47% 7.27% 4.00% 5.13%

NEW TBC _ 7.50% 4.81% 4.53% 4.61%

NEW TBC _ 995 968 993

NEW TBC _ 618 523 507

NEW TBC _ 247 328 299

NEW TBC _ 130 117 187

NEW TBC _ TBC

NEW TBC _ TBC

NEW TBC _ TBC

NEW TBC _ TBC

R.59 8 weeks Commissioner Target 11 10






R.59.1 18 weeks Commissioner Target 13 10





New Metric Ref SPC Trust Target Q3 18-19 Q4 18-19 Q1 19-20 Trend Line

C.53 _ 90.00% 86.40% 86.00% 86.40%

NEW TBC _ 100.00% 100.00%

NEW TBC _ 95.00% 94.99% 96.27% 96.58%

* The report used to measure this metric is a real time report and the data for August 2019 was extracted on the 17.09.2019.

Podiatry Waiting Times - Liverpool Community - Click Here for SPC Chart

Dietetics Waiting Times - Sefton Community - Click Here for SPC Chart

Dietetics Waiting Times - Liverpool Community - Click Here for SPC Chart

Speech and Language Therapy Waiting Times - Sefton Community - Click Here for SPC Chart

Physiotherapy Waiting Times - Sefton Community - Click Here for SPC Chart

Occupational Therapy Waiting Times - Sefton Community - Click Here for SPC Chart

Podiatry Waiting Times - Sefton Community - Click Here for SPC Chart

Patient Experience - Involvement in the Development of your Care Plan (excluding Community Division).

100% of Clinical Inpatient Areas to have an Environmental Suicide Risk Assessment in place which is reviewed annually and an associated action plan.

Triangle of Care - % Self-Assessed as "Green" (of applicable criteria)

% of Service Users on the Adult Community Mental Health Team Caseload for more than 12 months on CPA with a diagnosis of Psychosis and with a Cluster 10-14,16 and 17 with an Annual Physical Health Check completed. This includes all screening and intervention requirements. *

Speech and Language Therapy Waiting Times - Liverpool Community - Click Here for SPC Chart

Fall Services Waiting Times - Liverpool Community - Click Here for SPC Chart

Physiotherapy Waiting Times - Liverpool Community - Click Here for SPC Chart

Occupational Therapy Waiting Times - Liverpool Community - Click Here for SPC Chart

Delayed Transfer of Care - Occupied Bed Days Lost by Responsible Organisation - Joint

Category 2 Pressure Ulcers developed on the Mersey Care caseload that have deteriorated to Category 3*Category 3 Pressure Ulcers developed on the Mersey Care caseload that have deteriorated to Category 4*

Service Users will have full protected characteristics demographic data recorded to enable effective analysis: Sexual Orientation Status - Local, Secure and Specialist Learning Disability Division Only.

Employment Status (Data Completeness) - MHSDS Reporting. All patients who are on CPA, aged between 18 and 69 who have had an Employment Status reported within the last 12 months as at the end of the reporting period.

By December 2019 CMHT Service Users who have received an initial assessment for Psychological treatment will wait no longer than 30 weeks for the start of Psychological Interventions

By December 2019 CMHT Service Users referred and accepted for assessment to Community Psychology will wait no longer than 10 weeks for their initial assessment

Service Users will have full protected characteristics demographic data recorded to enable effective analysis: Disability Status - Local, Secure and Specialist Learning Disability Division Only.

Hospital Re-admissions within 28 days - Adult Mental Health Services (excluding Rathbone Rehab)

Monthly Metrics

All staff to Complete Level 1 Suicide Training*

Number of Inpatient Suicides

Number of All Ligature Incidents - 20% Reduction by March 2020 - Click Here for SPC Chart

Mersey Care NHS Foundation Trust - Long-Term Quality Improvement MetricsOperational Plan 2019/20 Our Services

Number of Prone Restraints associated with Rapid Tranquilisation

Number of physical restraints associated with self-harm. 20% reduction by March 2020 - Click Here for SPC Chart

Number of Prone Restraints associated with Intramuscular Injection

Quarterly Metrics

% of New Admissions who have had physical health screening completed (National Audit of Schizophrenia Standard) - Local Division

% of New Admissions who have had physical health screening completed (National Audit of Schizophrenia Standard) - Secure Division

% of New Admissions who have had physical health screening completed (National Audit of Schizophrenia Standard) - Specialist Learning Disability Division

Cumulative Average Length of Stay in Medium Secure Unit - Discharged Patients (years) (Excluding Leave)

Delayed Transfer of Care - Quarter (In-Month)

% of New Admissions who have had physical health screening completed (National Audit of Schizophrenia Standard)

Average Length of Stay for Discharged Patients - Adult Acute Ward (excluding PICU and Rathbone Rehab) - Local Division Only (days) (Excluding Leave)*Average Length of Stay for Discharged Patients - Psychiatric Intensive Care Unit - Local Division Only (days) (Excluding Leave)*Average Length of Stay for Discharged Patients - Complex Care (Older Adult Wards) - Local Division Only (days) (Excluding Leave)*Cumulative Average Length of Stay in Low Secure Unit - Discharged Patients (years) (Excluding Leave)

Settled Accommodation Status (Data Completeness) - MHSDS Reporting. All patients who are on CPA, aged between 18 and 69 who have had an Settled Accommodation Status reported within the last 12 months as at the end of the reporting period.

% of Service Users on the Early Intervention in Psychosis Caseload with a diagnosis of First Episode of Psychosis and have a cluster of 10-14,16 and 17 with an Annual Physical Health Check completed. This includes all screening and intervention requirements.

Delayed Transfer of Care - Occupied Bed Days Lost

Delayed Transfer of Care - Occupied Bed Days Lost by Responsible Organisation - NHS

Delayed Transfer of Care - Occupied Bed Days Lost by Responsible Organisation - Social Care

Metric is in development. To be reported on in Q3 2019-20

Metric is in development. To be reported on in Q3 2019-20

Reported one month in arrears

These metrics were discussed at the Equality Trust meeting and it was agreed that the latest data would be provided to support

development of a trajectory with the aim for reporting to commence following this.

New Metric Ref Target Jun-19 Jul-19 Aug-19 Trend Line

S.43 TBC

S.44 TBC

R.45 90.00% 88.06% 90.09% 93.18%

R.46 95.00% 91.76% 93.75% 91.79%

R.124 0 0 0 0

NEW TBC Year End Target <= 875 In-Month Target: 365 229 317 370

NEW TBC Year End Target <= 261In-Month Target: 109 61 82 97



C.1.1 90.00% 91.70% 92.58% 91.06%

E.47 95.00% 93.02% 98.70% 98.86%

NEW (CCG) TBC 95.00% 41.46% 52.00% 64.52%

NEW (CCG) TBC 95.00% 100.00% 82.35% 100.00%

New Metric Ref Target Q3 18-19 Q4 18-19 Q1 19-20 Trend Line

NEW (CCG) TBC Q1: 4.75% Q2: 4.75%

Q3: 4.75% Q4: 5.50% 3.71% 4.06% 3.74%

NEW (CCG) TBC 98.00% 92.86% 92.98% 96.30%

NEW (CCG) TBC 98.00% 57.69% 54.90% 69.23%

NEW (CCG) TBC 95.00% 40.90% 41.40% 84.80%

NEW (CCG) TBC 95.00% 31.50% 39.00% 49.13%

NEW (CCG) TBC 95.00%

NEW (CCG) TBC 97.00%


S.56 8 10 2

C.57 1 5 1

NEW TBC TBC

NEW TBC 5.7 8.13 3.15 0.00

NEW TBC 0 0 0 0

NEW TBC 0 0 1 0

E.32 <5% 0.92% 1.00% 0.60%

E.33 <5% 1.97% 2.70% 2.30%

NEW TBC TBC

NEW TBCFor Information - Baseline

to come from 2019/20 positions

709 919 1096



264 362 440



45 61 75



3 4 5

S.99For Information - Baseline


36.96% 35.04% 33.17%

C.2 95.00% 97.50% 94.93% 95.90%

Number of StEIS Incidents reported

Number of formal Complaints reported

% of Incidents that Result in Harm (All incidents)

Walk In Centre Unplanned Re-attendance within 7 days

Walk In Centre Left Without Being Seen

Percentage of Carers Offered Assessment

Number of Patient Related Incidents that result in Harm: Severity Low (Cumulative Position)

Number of Patient Related Incidents that result in Harm: Severity Moderate (Cumulative Position)

Number of Patient Related Incidents that result in Harm: Severity Severe (Cumulative Position)

Number of Patient Related Incidents that result in Harm: Severity Catastrophic/ Death (Cumulative Position)

Community Friends and Family Test: (% positive) - Internal Reporting - Community Division

Mersey Care NHS Foundation Trust Continuous Improvement 2019/20 Our Services

Local Division - Continuous Improvement

Community Division - Continuous Improvement

Mental Health Friends and Family Test: (% positive) - Internal Reporting - Local Division

95% of Service Users receiving best practice gate keeping assessment



Communication - All discharge communication from inpatient episodes are sent to General Practice within 24 hours from discharge.Communication - Outpatients All clinic/outpatient correspondence/ letters sent to General Practice following the patient’s appointment, including discharge from service within 10 working days (excluding weekends and bank holidays). Carers of people with newly diagnosed dementia will have a preliminary assessment of their needs when seen for the first time by secondary care mental health services and referred for a detailed assessment by relevant agencies where appropriate

A statement of carers` needs (those caring for someone with dementia) will be part of all new service user assessments and follow up letters will include similar statements when carers needs have changed

The division are working with Centre for Perfect care in ensuring all inpatient and community managers are trained to deliver safety planning and will then

cascade this to their teams. Once this has been completed a trajectory will be developed and reporting will commence. No timescales at present.

Metric is in development and will be reported upon once reporting has been approved.



Eating Disorder Service: Treatment commencing within 18 weeks of referral

CPA Follow up 2 days (48 hours) for higher risk groups are defined as individuals requiring follow up within 2 days (48 hours) by appropriate Teams.

IAPT: The number of people who have entered psychological therapies (at the end of the reporting quarter) as a proportion of prevalence Falls Management: All adults who have had a fall within the last 12 months to be risk assessed using an appropriate tool (Inpatients Only)

Falls Management: Of the patients identified as at risk of falling to have a care plan in place

Quarterly Metrics

Metric to be developed and confirmed.

Metric to be developed and confirmed.

Metrics

Within the local division, all adult mental health services inpatients to be offered the opportunity of completing a safety plan.

Within the local division, 50% of discharged patients will be discharged with a safety plan in place by March 2020.

Liaison Response Times (all contacts) of 24 hours on acute wards.

Liaison Response Times (all contacts) of 1 hour in Accident and Emergency.

Number of incidents where a service user has waited 12 hours or more from the decision to admit within an A&E department to be admitted to their agreed bed.

Metrics

Medication Errors Resulting in Major Harm

Catheter Acquired Urine Tract Infections

Percentage of identified staff compliant with de-escalation/ breakaway training

Falls: Number per 1,000 Occupied Bed Days


NEW TBC 95% by March 2020

NEW TBC 95% by October 2019



S.8815878 days by Mar 2020In-Month Target: 17002

days18273 18736 19552

NEW TBC 22 by March 2020In-Month Target: 25 23 25 31

NEW TBC 13 by March 2020In-Month Target: 15 15 15 15

NEW TBC 100% by September 2019In-Month Target: 90% 92.00% 96.00% 92.00%

NEW TBC108 planned sessions per

month by March 2020In-Month Target: 85

79 92 92

NEW TBC To ensure every service user nursed in long term segregation is provided the opportunity to have a monthly physical health check

100% by August 2019In-Month Target: 100% 100% 100% 100%

NEW TBC 100% by August 2019In-Month Target: 100% 100% 88% 100%


NEW TBC 95% by March 2020In-Month Target: 83% 84.08% 85.85% 83.84%




NEW TBC Year End Target: 0In-Month Target: 0 0 0 0

NEW TBC Year End <= 138In-Month Target: 58 10 11 20

C.1 81.00% 82.42% 78.79% 90.91%

C.1 81.00% 87.36% 85.71% 86.67%


NEW TBC 95% by October 2019 100.00%







S.91 90.00% 99.79% 99.80% 99.80%

S.92 95% by March 2020In-Month Target: 70% 63.89% 63.89%

New Metric Ref Target Q3 18-19 Q4 18-19 Q1 2019-20 Trend Line

C.1.1 81.00% 57.45% 62.90% 77.14%

Specialist Learning Disability Division - Continuous Improvement

To ensure a ‘Barriers to Change Checklist’ is completed and regularly reviewed for all service users nursed in long term segregation by September 2019

To increase opportunities for service users nursed in long term segregation to engage in ‘off ward’ meaningful activity sessions within the Rehabilitation Service by 50% by March 2020

To ensure every service user nursed in long term segregation has the opportunity to attend all physical health care appointments.



Mental Health Friends and Family Test: (% positive) - Internal Reporting - Secure Division (In-Month)


95% of Patients offered 3x30mins of moderate exercise per week (High Secure Services Only)


Quarterly Metrics

Patient Experience Friends and Family Test: (% positive) - Quarterly

Metrics

% of Admissions to Hospital Prevented from the Specialist Support Team Caseload

95% of Inpatients to be assigned a Specialist Support Team Link by March 2020

95% of Service Users who are identified as not a risk of suicide to have a safety plan in place by March 2020.


95% of Service Users who are identified as risk of suicide to have a safety plan in place by October 2019




20% reduction of T-Supine restraints by March 2020

Mental Health Friends and Family Test: (% positive) - Internal Reporting - Secure Division (Cumulative)

95% of mental health inpatients at HMP Liverpool and within the Psychology Service at Beacon to have a safety plan by March 2020.

95% of Service Users who are identified as risk of suicide to have a safety plan in place by October 2019

95% of Service Users who are identified as not a risk of suicide to have a safety plan in place by March 2020.

Metrics

Targeted Roll out of Level 2 Suicide Training to Band 6 Inpatient Charge Nurses between July and March 2020.

Mersey Care NHS Foundation Trust Continuous Improvement 2019/20 Our Services

10% Reduction of Self-Harm incidents from June 2019 to March 2020 - HMP Beacon (Cumulative Position)

Secure Division - Continuous Improvement

Reporting to be confirmed.

Reporting to commence in December 2019 (November 2019 data)

Reporting to commence in Q3 2019-20

Reporting to be confirmed.

Reporting to commence in December 2019 (November 2019 data)

Hope Programme train the trainer rolled out by June 2019, with training for 95% of Charges Nurses / Ward Mangers (Inpatients only) staff complete by March 2020.

To reduce the amount of time (cumulative days) services users are nursed in long term segregation by 10% by March 2020

To reduce the number of service users nursed in long term segregation (using baseline of March 2019) by 20% by March 2020To reduce the number of service users who have been nursed in long term segregation for over 12 months by 20% by March 2020

Training is being launched in Sept 19. Shadow reporting to commence in Q4 2019-20. Targeted reporting to commence in April 2020.

New Metric Ref Trust Target Jun-19 Jul-19 Aug-19 Trend Line

W.65 <=6% 6.80% 7.07% 6.86%

W.68 45 Days 43.4 44.69 53.4

W.69 95.00% 97.08% 96.72% 96.94%

NEW TBC 95% by June 2020

NEW TBC 90% by March 2020In-Month Target: 85% 87.56% 88.68% 88.76%

NEW W.71 14.00% 22.42% 21.04% 22.49%

W.72 11.00% 4.62% 6.48% 6.52%

W.73 7.00% 6.10% 7.41% 7.54%

W.74 95%In-Month Target: 55% 42.34% 52.40% 62.07%

W.152 95.00% 90.53% 88.82% 88.29%

W.75 95% by 31.12.2019 18.27% 25.49% 33.52%

NEW TBC 95% by set target dates 29.43% 41.00%

W.76 95.00% 55.28% 36.84% 40.53%

NEW TBC 95.00% 91.15% 91.22% 91.30%

W.78 90.00% 86.47% 91.88% 89.12%

W.79 90.00% 88.27% 91.79% 89.55%

NEW W.78 49.66% 60.38% 63.95%

NEW W.79 54.69% 66.67% 69.88%


W.116 Month 5 Plan - £1,107,417 £431,352 £755,818 £730,522

W.119 2019/20 Plan - £10,041 £5.054 £5.118 £5.281

NEW TBC Month 5 - £9,996 £6,733 £9,095 £11,443

NEW TBC Month 5 - £991,000 £855,000 £1,138,000 £1,443,000

NEW TBC Month 5 - £125,431 £93,533 £125,407 £156,883

NEW TBC TBC

New Metric Ref Trust Target Q3 2018-19 Q4 2018-19 Q1 2019-20 Trend Line

NEW TBC End of Year Target: 70% 51% 57%

NEW TBC End of Year Target: 85% 86% 86%


NEW TBC

End of Oct 2019 Target: 16

Trajectory to be confirmed

NEW TBC

End of March 2020 Target: 16

Trajectory to be confirmed

NEW TBC TBC

NEW TBC TBC

NEW TBC TBC

NEW TBC TBC

Reporting to commence in Q3 2019-20

Metric to be confirmed - PROSPECT Secure New Care Model Length of Stay in Medium and Low Secure Services

Planned Year to Date Drug Expenditure v Actual Drug Expenditure

Planned Year to Date Spend v Actual Year to Date Spend

All community teams will be expected to reach 70% or above effectiveness according to the associated definitions by end of March 2020.

Metric to be confirmed (Provider Alliance) - Dying in Place of Choice

Metric to be confirmed (Provider Alliance) - Hospital Re-admissions

Our Future Metrics

All 16 neighbourhood teams (12 in Liverpool and 4 in South Sefton) achieving 20% improvement from their baseline position by end of October 2019

Mersey Care NHS Foundation Trust - Operational Plan 2019/20 Our Future

Metric to be confirmed (Provider Alliance) - Delayed Transfer of Care

Planned Cost Improvement Plan v Actual Cost Improvement Plans £m

Increase from 59% (2018/19 baseline) of facilities in acceptable condition/ satisfactory performance to 100% ( Single Sex, Single Room Accommodation) by March 2024

Planned Medical Expenditure v Actual Medical Expenditure £000's

Personal Achievement and Contribution Evaluation (PACE) Compliance 2019/20 (Attainment within Window)

90% by Sept 2019In-Month Target:

75.06%

Mersey Care NHS Foundation Trust - Operational Plan 2019/20 Our People

Clinical Supervision completed in line with Trust Policy (every 8 weeks) - All Clinical Staff (Local, Secure and Specialist Learning Divisions Only)Clinical Supervision completed in line with Trust Policy (every 8 weeks - Professional Staff Only (Local, Secure and Specialist Learning Divisions Only)

Personal Achievement and Contribution Evaluation (PACE) Compliance 2019/20 (Attainment within Window) - Compliance against Bands and Target DatesBand 8D and above 95% by 1 May 2019 Band 8A and above 95% by 1 July 2019Band 6 and above 95% by 1 September 2019

Our People Metrics

Staff Sickness (In-Month) - Internal Reporting

Recruitment Time to Hire (days) (inclusive of Bank Staff)

Vacancy Rate for Qualified Nursing %

Overall Vacancy Rate %

Information Governance Training Compliance (Attainment within 2019/20)

The National Target for Information Governance Compliance of 95% has to be achieved by 31 March 2020 but internally we have set a target to achieve 95% by 31 December 2019.

Information Governance Training Compliance Completed within last 12 months

Completion of Core Mandatory Training (Reported by Subject)

Completion of Role Specific Mandated Training (Reported by Subject)

Completion of Prevent Level 3 Training

Vacancy Rate for Consultants %

Clinical Supervision completed in line with Trust Policy (every 8 weeks) - All Clinical Staff (Community Division Only)Clinical Supervision completed in line with Trust Policy (every 8 weeks - Professional Staff Only (Community Division Only)

Technology that helps us provide better care - total spend on Global Digital Exemplar

Our Resources Metric- Monthly Metrics

Personal Achievement and Contribution Evaluation (PACE) Compliance 2018/19 Completed within last 12 months (Excludes Liverpool Community )

Staff Protected Characteristics - Disability Status

Mersey Care NHS Foundation Trust - Operational Plan 2019/20 Our Resources

Metric in development with Estates Department

Metric in development. Trajectory to be confirmed with reporting to commence following

this.

The new Care Model was approved on the 1 July 2019 by all partnerships. Data flows and reporting are currently being identfied and

confirmed.

Increase current levels to a minimum of 85% maturity achieved in relation to clinical records by 2020/21

Our Resources Metrics - Quarterly Metrics

Increase current levels to a minimum of 70% overall digital maturity by March 2020/21

Appendix 1 - SPC GraphsSingle Oversight Framework - Staff Sickness - Click Here to return to Single Oversight Framework

3%

4%

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Chart Title

Mean % Staff Sickness Process limits - 3σHigh or low point 7 points above or below mean Rising or falling trendTarget

Single Oversight Framework Sickness (In-Month) - Local Division- starting 01/04/17

3%

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Chart Title


Single Oversight Framework Sickness (In-Month) - Trust Position- starting 01/04/17

3%

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Chart Title


Single Oversight Framework Sickness (In-Month) - Community Division- starting 01/04/18

3%

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Chart Title


Single Oversight Framework Sickness (In-Month) - Secure Division-Sickness (In-Month) starting 01/04/17

Appendix 1 - SPC GraphsSingle Oversight Framework - Staff Sickness/ IAPT - Click Here to return to Single Oversight Framework

3%

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Chart Title


Single Oversight Framework Sickness (In-Month) - Specialist Learning Disability Division- starting 01/04/17

70%

75%

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90%

95%

100%

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Chart Title

Mean IAPT - 6 Weeks Process limits - 3σHigh or low point 7 points above or below mean Rising or falling trend

IAPT - Waiting time to begin treatment (from IAPT minimum dataset) within 6 weeks- starting 01/04/17

20%

25%

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70%

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Chart Title

Mean IAPT - Recovery Process limits - 3σHigh or low point 7 points above or below mean Rising or falling trendTarget

IAPT - Proportion of people completing treatment who move to recovery - Monthly- starting 01/04/17

92%

94%

96%

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104%

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Mean IAPT - 18 Weeks Process limits - 3σHigh or low point 7 points above or below mean Rising or falling trendTarget

IAPT - Waiting time to begin treatment (from IAPT minimum dataset) within 18 weeks- starting 01/04/17

Appendix 1 - SPC GraphsAll Ligature Incidents - Click Here to return to Long-Term Quality Improvement

Mean Average Changes Here

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Mean Ligature Incidents Process limits - 3σHigh or low point 7 points above or below mean Rising or falling trendTarget

All Ligature Incidents - Specialist Learning Disability Division- starting 01/04/17

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Mean No. of Ligatures Process limits - 3σHigh or low point 7 points above or below mean Rising or falling trendTarget

All Ligature Incidents - Secure Division- starting 01/04/17


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Chart Title


All Ligature Incidents - Local Division- starting 01/04/17



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Chart Title


All Ligature Incidents - Trust Position- starting 01/04/17

Appendix 1 - SPC GraphsAll Physical Restraint Incidents Associated with Self-Harm - Click Here to return to Long-Term Quality Improvement


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Mean No. of Physical Restraints Associated with Self-HarmProcess limits - 3σ High or low point7 points above or below mean Rising or falling trend

Physical Restraint Incidents Associated with Self-Harm - Local Division- starting 01/04/17


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Mean No. of Physical Restraints Associated with Self-HarmProcess limits - 3σ High or low point7 points above or below mean Rising or falling trend

Physical Restraint Incidents Associated with Self-Harm - Secure Division- starting 01/04/17



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Mean No. of Physical Restraints associated with Self-HarmProcess limits - 3σ High or low point7 points above or below mean Rising or falling trend

Physical Restraint Incidents Associated with Self-Harm - Specialist Learning Disability Division- starting 01/04/17


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Mean No. of Physical Restraint associated with Self-HarmProcess limits - 3σ High or low point7 points above or below mean Rising or falling trend

Physical Restraint Incidents Associated with Self-Harm - Trust Position- starting 01/04/17

Appendix 1 - SPC GraphsLiverpool Community Waiting Times - Click Here to return to Long-Term Quality Improvement

Appendix 1 - SPC GraphsLiverpool and Sefton Community Waiting Times - Click Here to return to Long-Term Quality Improvement

Appendix 1 - SPC GraphsSefton Community Waiting Times - Click Here to return to Long-Term Quality Improvement

Appendix 2 - DQMI Breakdown No. Field Name Mar-19 Apr-19 May-19 Current Status

77.9% 79.0% 84.5% The DQMI is an overall score calculated for each provider by a defined algorithm 1 ETHNIC CATEGORY 84% 86% 87% Data Captured and reported within MHSDS Submission2 GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) 99% 99% 100% Data Captured and reported within MHSDS Submission3 NHS NUMBER 100% 100% 100% Data Captured and reported within MHSDS Submission4 ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) 96% 98% 98% Data Captured and reported within MHSDS Submission5 PERSON STATED GENDER CODE 100% 100% 100% Data Captured and reported within MHSDS Submission6 POSTCODE OF USUAL ADDRESS 95% 100% 100% Data Captured and reported within MHSDS Submission7 MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE 97% 97% 97% Data Captured and reported within MHSDS Submission

8 PRIMARY REASON FOR REFERRAL (MENTAL HEALTH) (REFERRAL RECEIVED ON OR AFTER 1ST JAN 2016) 20% 23% 22% Data Captured and reported within MHSDS Submission

9 SERVICE OR TEAM TYPE REFERRED TO (MENTAL HEALTH) 100% 100% 100% Data Captured and reported within MHSDS Submission

10 CARE PROFESSIONAL SERVICE OR TEAM TYPE ASSOCIATION (MENTAL HEALTH) 78% 70% 71% Data Captured and reported within MHSDS Submission

11 CLINICAL RESPONSE PRIORITY TYPE 100% 100% 100% Data Captured and reported within MHSDS Submission12 EX-BRITISH ARMED FORCES INDICATOR - 0% 4% *Data is now being captured and reported on within MHSDS Submission13 HOSPITAL BED TYPE (MENTAL HEALTH) 96% 100% 100% Data Captured and reported within MHSDS Submission14 ORGANISATION SITE IDENTIFIER (OF TREATMENT) 73% 67% 64% Data Captured and reported within MHSDS Submission15 PERSON BIRTH DATE 100% 100% 100% Data Captured and reported within MHSDS Submission

16 REFERRED OUT OF AREA REASON (ADULT ACUTE MENTAL HEALTH) - - -

System configuration and process development required - currently not reported on17 TREATMENT FUNCTION CODE (MENTAL HEALTH) 90% 89% 88% Data Captured and reported within MHSDS Submission18 ACTIVITY LOCATION TYPE CODE 96% 96% 96% Data Captured and reported within MHSDS Submission19 ATTENDED OR DID NOT ATTEND 96% 96% 97% Data Captured and reported within MHSDS Submission20 CARE PLAN TYPE - - 100% Data Captured and reported within MHSDS Submission21 CONSULTATION MEDIUM USED 96% 96% 96% Data Captured and reported within MHSDS Submission22 DELAYED DISCHARGE ATTRIBUTABLE TO 31% 11% 71% Data Captured and reported within MHSDS Submission23 DELAYED DISCHARGE REASON 31% 11% 77% Data Captured and reported within MHSDS Submission24 ESTIMATED DISCHARGE DATE - - - *Data is now being captured and reported on within MHSDS Submission25 PRIMARY DIAGNOSIS DATE 98% 97% 98% Data Captured and reported within MHSDS Submission26 PROVISIONAL DIAGNOSIS DATE - - - *Data is now being captured and reported on within MHSDS Submission27 REFERRAL CLOSURE REASON 79% 85% 80% Data Captured and reported within MHSDS Submission28 SECONDARY DIAGNOSIS DATE 98% 98% 99% Data Captured and reported within MHSDS Submission29 SOURCE OF REFERRAL 72% 68% 67% Data Captured and reported within MHSDS Submission

79.4% The DQMI is an overall score calculated for each provider by a defined algorithm 1 SPECIALISED MENTAL HEALTH SERVICE CODE - WARD STAY - - - Process to be developed - currently not reported on2 CARE CONTACT TIME (HOUR) 100% 100% 100% Data Captured and reported within MHSDS Submission3 REFERRAL REQUEST RECEIVED TIME (HOUR) 60% 61% 62% Data Captured and reported within MHSDS Submission4 ONWARD REFERRAL TIME (HOUR) - - - *Data is now being captured and reported on within MHSDS Submission5 INDIRECT ACTIVITY TIME (HOUR) 100% 100% 100% Data Captured and reported within MHSDS Submission6 DISCHARGE PLAN CREATION TIME (HOUR) - - - *Data is now being captured and reported on within MHSDS Submission7 SERVICE DISCHARGE TIME (HOUR) 98% 100% 99% Data Captured and reported within MHSDS Submission

A hyphen is used to indicate that data was not submitted for these data fields for the reporting period. *Areas identified as data now being captured will begin to show within the national publications over the coming months.

DQMI MHSDS SCORE (%) with additional data items

DQMI MHSDS Score (%)

NHS Oversight Framework 2019/20 ASIM PATEL| Joint Chief Information Officer

Appendix 3

• To provide an overview of the NHS Oversight Framework 2019/20 published in August 2019

• To summarise the oversight approach for providers

• To outline the provider oversight metrics relevant to the trust and highlight where these differ from the metrics previously looked at through the NHS Improvement Single Oversight Framework.

Aim

I

NHS Oversight Framework 2019/20

• New approach to oversight will set out how regional teams review performance and identify support needs across sustainability transformation partnerships (STPs) and integrated care systems (ICSs).

• Framework summarises how this new approach will work from 2019/20 and the work that will be done during this financial year for a new integrated approach from 2020/21

• Existing statutory roles and responsibilities of NHS Improvement and NHS England in relation to providers and commissioners remain unchanged.

I

Oversight Principles

• NHS England and NHS Improvement speaking with a single voice

• Greater emphasis on system performance alongside contribution by providers and commissioners to system goals

• Working with and through system leaders to tackle problems

• Matching accountability for results with improvement support

• Greater autonomy for systems with evidenced capability for collective working and successful delivery of NHS priorities

I

Oversight Arrangements

• System review meetings (default quarterly) informed by shared information covering:

– Performance against a core set of national requirements at system and / or organisational level including quality of care, population health, financial performance and sustainability and delivery of national standards

– Emerging organisational health issues

– Implementation of transformation objectives in the NHS Long Term Plan

• Focused engagement with the system and relevant organisations where specific issues emerge outside of these meetings

• Organisational-level information flows with reporting and dashboards made available to organisations, systems, regional and national teams – ‘single version of the trust’

• Commissioner and provider metrics, aggregated to system level where appropriate and complemented by purpose-built system metrics. In 2020 these will include Long-Term Plan Implementation Framework measures.

I

Provider Oversight Approach

• Potential support needs will be identified under five themes – Quality of care (safe, effective, caring, responsive)

– Finance and use of resources

– Operational performance

– Strategic change

– Leadership and improvement capability (well-led)

• Does not give a performance assessment or rating of individual providers

• Information collected and reviewed includes annual plans and reports, regular financial and operational information and other significant data including relevant third-party material.

• Information can be collected / reviewed in-year, annually and by exception.

• Providers are expected to notify regional teams of actual or prospective changes in performance.

I

Identifying support needs and organisation segmentation Regional teams will use metric data as well as local information and insight to identify where support may be needed and what level of support is required. Once assessment of support needs has been completed the region will allocate to a support ‘segment’ or category. This is determined by the level of support required (universal, targeted or mandated). Segmentation is 1 to 4 (as now).

Segment / catgory Description of support needs Level of support offered

1 (Maximum autonomy)

No actual support needs identified across the five themes. Maximum autonomy and lowest level of oversight appropriate. Expectation that provider supports providers in other segments.

Universal (voluntary)

2 (Targeted support)

Support needed in one or more of the five themes, but not in breach of licence (or equivalent for NHS trusts) and/or formal action is not considered needed.

Universal + targeted (not mandatory) support as agreed with the provider to address issues identified and help move the provider to segment 1.

3 (Mandated support)

The provider has significant support needs and is in actual or suspected breach of the licence (or equivalent for NHS trusts) but is not in special measures.

Universal targeted + mandated support as determined by the regional team to address specific issues and help move the provider to segment 2 or 1.

4 (Special measures for providers)

The provider is in actual or suspected breach of its licence (or equivalent for NHS trusts) with very serious/complex issues that mean it is in special measures.

Universal targeted + mandated support as determined to minimise the time the provider is in special measures.

I

Provider oversight metrics (1)

Measure Description Standard In single oversight framework?

New service models

A&E maximum waiting time of four hours from arrival to admission/transfer/ discharge

The percentage of attendances at an A&E department that were discharged, admitted or transferred within four hours of arrival.

95% Y

Quality of care and outcomes ALL PROVIDERS (metrics used as quality ‘proxies’ to identify potential concerns)

CQC rating Most recent CQC inspection rating, as published on CQC website

N/A N

Written complaints – rate Written complaints – rate N/A

Staff Friends and Family Test % recommended – care

Count of those categorised as extremely likely or likely to recommend/count of all responders

N/A Y

Occurrence of any Never Event Count of Never Events in rolling six-month period

N/A Y

Patient Safety Alerts not completed by deadline

Number of NHS England or NHS Improvement Patient Safety Alerts outstanding in most recent monthly snapshot

N/A Y

I



Quality of care and outcomes - Community providers

Community scores from Friends and Family Test – % positive

Count of those categorised as extremely likely or likely to recommend/Count of all responders

N/A Y

Quality of care and outcomes – Mental health providers

CQC community mental health survey

Findings from the CQC survey which gathered information from people who received community mental health services

N/A Y

Mental health scores from Friends and Family Test – % positive

Count of those categorised as extremely likely or likely to recommend/count of all responders

N/A Y

Admissions to adult facilities of patients under 16 years old

Number of children and young persons under 16 who are admitted to adult wards

N/A Y

Care programme approach (CPA) follow-up – proportion of discharges from hospital followed up within seven days (MHSDS)

Proportion of discharges from hospital followed up within 7 days

N/A Y

I



Quality of care and outcomes – Mental health providers cont/d…

% clients in settled accommodation

Percentage of people aged 18 to 69 in contact with mental health services in settled accommodation

N/A Y

% clients in employment Percentage of people aged 18 to 69 period in contact with mental health services in employment

N/A Y

Potential under-reporting of patient safety incidents

Count of reported incidents (no harm, low harm, moderate harm, severe harm, death)/estimated total person bed days for rolling six months shown as rate per 1000 bed days

N/A Y

People with a first episode of psychosis begin treatment with a NICE-recommended care package within two weeks of referral (UNIFY2, moving to Mental Health Services Data Set – MHSDS)

Percentage of people with a first episode of psychosis beginning treatment with a NICE-recommended care package within two weeks of referral

50% (inconsistent with 5YFVMH

standard – 56% in 2019/20)

Y

I



Quality of care and outcomes – Mental health providers cont/d…

Data Quality Maturity Index (DQMI) – MHSDS dataset score

MHSDS quarterly score in DQMI 95% Y

Improving Access to Psychological Therapies (IAPT)/talking therapies: a. proportion of people

completing treatment who move to recovery (from IAPT minimum dataset)

a. b. waiting time to begin

treatment (from IAPT minimum dataset): i) within 6 weeks ii) within 18 weeks

a. Percentage of people completing a course of IAPT treatment moving to recovery

b. Percentage of people waiting i) six weeks or less from

referral to entering a course of talking treatment under Improving Access to Psychological Therapies (IAPT)

ii) 18 weeks or less from referral to entering a course of talking treatment under IAPT

50%

75%

95%

Y

Y

Y

Inappropriate out-of-area placements for adult mental health services.

Total number of bed days patients have spent out of area in last quarter

Progress in line with trajectory

Y

I



Leadership and workforce

Staff sickness Level of staff absenteeism through illness in the period Numerator = number of days sickness reporting within the month. Denominator = number of days available within the month

N/A Y

Staff turnover Number of staff leavers reported within the period /average of number of total employees at end of the month and total employees at end of the month for previous 12-month period Numerator = number of leavers within the report period. Denominator = staff in post at the start of the reporting period

N/A Y

NHS Staff Survey Staff recommendation of the organisation as a place to work or receive treatment

N/A Y

I



Leadership and workforce (cont/d…)

Proportion of temporary staff Agency staff costs (as defined in measuring performance against the provider's cap) as a proportion of total staff costs. Calculated by dividing total agency spend over total pay bill.

N/A Y

Support and compassion Average rating of: • % experiencing harassment, bullying or abuse from staff in the last 12 months • % not experiencing harassment, bullying or abuse at work from managers in the last 12 months • % not experiencing harassment, bullying or abuse at work from managers in the last 12 months

N/A N - NEW

Teamwork Average of: • % agreeing that their team has a set of shared objectives • % agreeing that their team often meets to discuss the team’s effectiveness

Trusts in lowest third across the

sector will represent a

concern

N - NEW

I



Leadership and workforce (cont/d…)

Inclusion (1) Average of • % staff believing the trust provides equal opportunities for career progression or promotion • % experiencing discrimination from their manager/team leader or other colleagues in the last 12 months



concern

N - NEW

Inclusion (2) The BME leadership ambition (WRES) re executive appointments.



concern

N - NEW

Finance and use of resources (see following slides)

I

Provider oversight metrics (8) – Finance and Use of Resources

I


• In 2019/20 very little change in terms of the provider oversight metrics from those included in the single oversight framework.

• Cardio-metabolic assessment and interventions for people with psychosis indicators are no longer part of the framework.

• There are new leadership and workforce indicators drawing from the staff survey and WRES.

• The main oversight framework document includes the following measures which would be of relevance to the trust. These are not detailed in the provider metrics annex so it currently unclear how these will be measured: – injuries from falls in people aged 65 and over

– percentage of patients admitted, transferred or discharged from A&E within four hours

Links to further information

This link takes you to the page with all publications: https://www.england.nhs.uk/publication/nhs-oversight-framework-for-2019-20/ Overarching document: https://www.england.nhs.uk/wp-content/uploads/2019/08/nhs-oversight-framework-19-20.pdf Provider oversight approach: https://www.england.nhs.uk/wp-content/uploads/2019/08/nhs-oversight-framework-a1-provider-oversight-approach-aug-19.pdf Provider oversight metrics: https://www.england.nhs.uk/wp-content/uploads/2019/08/nhs-oversight-framework-a2-provider-oversight-metrics-aug-19.pdf CCG oversight metrics: https://www.england.nhs.uk/wp-content/uploads/2019/08/nhs-oversight-framework-a3-ccg-technical-annex-aug-19.pdf

https://www.england.nhs.uk/publication/nhs-oversight-framework-for-2019-20/

https://www.england.nhs.uk/wp-content/uploads/2019/08/nhs-oversight-framework-19-20.pdf



https://www.england.nhs.uk/wp-content/uploads/2019/08/nhs-oversight-framework-a1-provider-oversight-approach-aug-19.pdf

https://www.england.nhs.uk/wp-content/uploads/2019/08/nhs-oversight-framework-a1-provider-oversight-approach-aug-19.pdf

https://www.england.nhs.uk/wp-content/uploads/2019/08/nhs-oversight-framework-a2-provider-oversight-metrics-aug-19.pdf



















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COUNCIL OF GOVERNORS

Report provided (check necessary boxes): Report to: Council of Governors

To Note: ☒ For Assurance: ☐


Process for the development of the Trust Clinical Strategy

Accountable Director(s): Trish Bennett, Executive Director of Nursing & Operations Arun Chidambaram, Acting Executive Medical Director

Report Author(s): Tina Wilkins, Clinical Senate Consultant

Purpose of Report • describe the underlying principles, time frame and process for developing the clinical strategy;

• set out the engagement process that will be conducted; • inform Governors of the opportunities for them to become

involved in the engagement process. Summary of Key Issues for Consideration of Governors :

• That an engagement process will: o be conducted in order to inform the development of the

strategy; o be undertaken through a number of activities with a

range of stakeholders; o enable people to express their views and opinions of our

services; o help to identify the priorities and themes for the clinical

strategy. • Governors will be sent invitations to attend engagement events

that will run between 7th October and 7th December 2019.

Recommendation:

The Council of Governors is asked to: 1) Note the contents of the report. 2) Note the timetable for the development of the clinical strategy.

Next Steps: (Subject to recommendation being accepted)



Trust Board 25.09.2019 Process for the development of the Trust Clinical Strategy and update on the development of the Trust Clinical Service Model

1. Agreed 2. Noted

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PURPOSE

1. The clinical strategy will support the achievement of the Trust’s long term strategy by providing more detail about how we will work more effectively across the diverse services we provide to best support patients live well in their community. The clinical strategy will be developed following an engagement process with staff, service users and carers.

2. A clear process and a timeframe have been proposed and agreed, for the development of the clinical strategy. The clinical strategy will reflect the emerging clinical models developing in local mental health and community services and secure/specialist learning disability services.

BACKGROUND AND CONTEXT

3. Mersey Care’s five year Strategy describes our vision to provide “Perfect Care that enables people with physical health and mental health conditions, learning disabilities and addictions to live longer, healthier lives”. The long term Strategy to develop more preventative and integrated services for children, young people and adults, which will enable them to take a more active role in their own health and wellbeing, will necessitate the development of new workforce models, whilst realising the potential benefits of digital technology. The Strategy also sets out the intention to achieve an ‘Outstanding’ CQC rating within the next five years through the development of new clinical models that will, prevent crisis in community settings, enable people to take more control of their own health and integrate services around the patient.

4. The importance of the role held by clinical staff in finding new opportunities to improve clinical services whilst at the same time saving money is emphasised throughout the Trust Strategy. Improvement will be achieved over the lifetime of the Strategy, through a process of building on the basics of good care and continually setting our own stretch goals for improvements in care.

5. The improvement process will be strengthened by the availability of a number of quality improvement tools and methodology, supported by the Centre for Perfect Care. This will ensure improvement programmes produce the changes we want by being patient focussed, measurable and effective. This will accelerate the learning cycle, so that we are testing out improvements, learning from our mistakes and applying successful improvements and innovation faster.

6. The Trust’s long term Strategy sets out Mersey Care’s focus on the integration of community physical and mental health services to best support those patients in community settings who have multiple, complex health needs and depend on many health and social care services to meet these needs. The model of care will ensure that patients will receive care that factors in their physical, mental health and social needs and how these needs will be met, for example, using non-medical services such

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as the Life Rooms effectively. The wider aspiration is to have an integrated model of care across all providers. Mersey Care’s operating plan 2019/20 sets out how it is working to help local providers to operate within an all-age ‘One Team’ ethos for out of hospital care, uniting primary care, social care, community physical and mental health services and the voluntary sector.

ISSUES FOR CONSIDERATION

7. The engagement events will ask people to consider a number of overarching areas including: a) How we organise services b) The role of the patient c) Workforce d) How we use our buildings and estate e) The quality of our clinical services

8. We will also have focus on specific subjects including

a) Integrated care b) Delivering outstanding safe care c) Self-care d) Specialist services e) Where we deliver care f) Working with partner organisations

9. The Engagement process is designed to ensure we work side by side putting people at

the heart of how we develop the strategy by engaging fully with, governors, staff, service users, carers and stakeholders. This will be through the provision of clear and accessible information, holding conversations, providing regular feedback and making sure that everyone has the opportunity to be involved directly and indirectly. The process of working side by side will ensure that people get ample opportunity to have a conversation and engage fully with us about our aims and will guide how we work together to co-produce a clinical strategy that will set out how we will achieve ‘Outstanding’ safe care.

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NEXT STEPS

10. It is proposed that the finalised clinical strategy is presented for approval at the Board due to be held on 29th January 2020. To achieve this date a timetable has been set out in Table 1.

Date Action Date to be completed

7 October 2019 Commence clinical strategy engagement process with the Clinical Senate

7 October 2019

7 October 2019 Working side by side disseminate publicity material and conduct a range of events and engagement sessions with, professional and leadership groups, staff, service users, carers and stakeholders.

9 December 2019

15 October 2019 Members Event 15 October 2019

17 October 2019 Council of Governors 17 October 2019

13 November 2019 Quality Assurance Committee 13 November 2019

18 December 2019 Board Development Session 18 December 2019

15 January 2020 Quality Assurance Committee 15 January 2020

29 January 2020 Board of Directors 29 January 2020

Table one: Timetable

RECOMMENDATIONS

11. The Council of Governors is asked to: a) Note the contents of the report. b) Note the timetable for the development of the clinical strategy.

Trish Bennett, Executive Director of Nursing & Operations Arun Chidambaram, Acting Executive Medical Director

17th October 2019

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To Note: ☐ For Assurance: ☐

For Decision: ☒ For Consent: ☐ Meeting Date: 17 October 2019

Governance Update

Accountable Director(s): Elaine Darbyshire, Executive Director of Communications and Corporate Governance

Report Author(s): Sarah Jennings, Deputy Trust Secretary Andy Meadows, Trust Secretary

Purpose of Report The purpose of this report is to update Governors on a series of developments in respect of governance.


• In August 2019, Mr Paul Taylor, Lead Governor, resigned fromhis role following two issues raised in which Mr Taylor did notfeel supported;

• It has been recognised that the Lead Governor may not alwaysbe available to attend Council of Governors meetings. Usuallythe Lead Governor would chair a pre-meeting of the Council, inorder to allow Governors to coordinate their questions andagree approaches to issues they would like to raise. In light ofthis, an amendment to the Constitution is proposed to allow thecreation of a Deputy Lead Governor;

• The review of Chairman and Non-Executive Directorremuneration has been deferred following the publication ofGuidance from NHS Improvement which will impact on theconsiderations of Governors regarding this matter. This will nowbe considered in January 2020;

• It is good practice for a Council of Governors to produce areport to update its members on its recent activities. An AnnualReport has therefore been prepared to provide a brief overviewof the activities undertaken by our Council of Governors over2018/19;

• The existing Governor Induction, Training and DevelopmentPlan has been updated for 2019 – 2020 to further ableGovernors to undertake their role.

Recommendation: The Council of Governors is asked to: 1) note the resignation of the Lead Governor2) consider and approve a proposal to create a Deputy Lead

Governor role and amend the Trust’s Constitution (subject tothe approval also of the Council of Governors);

3) note the update in respect of the delayed review of chairmanand Non-Executive Director remuneration;

4) consider and approve the Council of Governors Annual Report2018/19

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5) Consider and approve the draft Governors Induction, Trainingand Development Plan for 2019 and 2020;

6) Note the update in respect of the membership.


1) The Constitution published on the Trust website will be updatingand Governors will be contacted to seek nominations for the roleof Deputy Lead Governor;

2) The Council of Governors’ Nominations and RemunerationCommittee will be asked to meeting in late 2019/ early 2020 toconsider the remuneration and terms of Chairman and Non-Executive Directors to allow a recommendation to be made tothe full Council in January 2020;

3) The Council of Governors Annual Report 2018/19 will bepublished on the Trust website to ensure this is accessible to themembership;

4) The Corporate Governance Team will commence makingarrangements for training and development in line with the Planat Appendix B.



Board of Directors 25/9/19 Board Governance Report Amendment to Constitution approved

PURPOSE

1. This paper informs the Board of Directors of the resignation of the Lead Governor (MrPaul Taylor) and outlines the lessons that need to be learnt from his resignation, so asto continue to develop communication with the Trust’s Council of Governors.

2. The second part of this paper proposes a number of amendments to the Trust’sConstitution to allow the election of a Deputy Lead Governor by Governors. Ifapproved by the Board this will than be taken for consideration by the Council ofGovernors at their next meeting on 17 October 2019.

RESIGNATION OF THE LEAD GOVERNOR

3. On 5 August 2019 the Chairman received a letter of resignation from Mr Paul Taylor, aGovernor representing the service user / carer constituency and also the LeadGovernor. Mr Taylor’s resignation letter is as follows:

It is with deep regret to inform you that as from Monday 5th August 2019, I have decided to resign my voluntary governors seat that I held on MerseyCare Trust Council of Governors.

Like many Trust’s throughout, there will always be some disputes, and while holding the position of Lead Governor, two instances occurred that I had issues with, whereas I felt I wasn’t supported, leaving me with no option but to resign my position.

I want to thank all the Governors I have worked with in the past and to further say good luck to all the new governors

Kind Regards

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Paul Taylor

4. Following private discussions between the Chair and Mr Taylor upon receipt of hisresignation letter, Mr Taylor agreed to reflect on his decision. However on Monday 12August 2019 the Chair informed the Trust Secretary (Andy Meadows) that Mr Taylorwished that his letter still stand. Following discussion with the Trust Chair and MrMeadows, it was agreed that Mr Meadows should contact Mr Taylor to see if he wouldbe prepared to discuss the issues raised in his resignation letter. Mr Meadowscontacted Mr Taylor who agreed to meet, subsequently a meeting was held on 5September 2019 at Walton Life Rooms.

Meeting and Lessons to be Learnt

5. At this meeting Mr Taylor drew attention to the two specific instances which he hadreferenced in his letter of resignation:a) expense claim – specifically the way in which an expense claim was managed by

the Trust following a request to participate in an interview panel in April 2019;b) Twitter post – the response of the Trust to a tweet that had purportedly been made

from Mr Taylor’s account at the end of July 2019.

6. In his meeting with Mr Meadows, Mr Taylor explained that he was indignant with theresponse from the Trust in respect of these matters. In the first matter (expenses) hebelieves his trustworthiness in claiming expenses was being questioned whilst in thesecond matter (Twitter) he believes the Trust was wrong to assume that the tweet hadcome from him, especially given his record of supporting the Trust and its work.

7. In responding to the first issue Mr Meadows recognised that in processing the claimthe Trust, incorrectly, had asked Mr Taylor to resubmit the claim to another team. Thiswas the Trust’s error and not a mistake by Mr Taylor. Mr Meadows assured Mr Taylorthat it was never the intention of the Trust to question his trustworthiness andapologised unreservedly that that was Mr Taylor’s belief. In future the Trust willmanage internally between teams the payment of expense claims and will not askpeople to resubmit claims.

8. In responding to the second issue Mr Meadows noted that Governors were asked tobe critical friends of the Trust. Therefore the tweet that had been posted was not seenin any way negatively; indeed as can be seen below the tweet did not use languagethat was in any way offensive or could be seen to cause upset:

“So; after reading MCT Board papers today ,am I correct to assume ,side by side working within Merseycare is shelved because of no time available by staff to include it ? (Guidance please)”

Tweet dated 31 July 2019, not posted by Mr Taylor

9. Noting the text, Elaine Darbyshire, as Executive lead for side by side working, askedthat the Trust contact Mr Taylor offering, if he had any concerns, would he like to meetwith her. In responding, Mr Taylor informed the Trust that he had not the author of thistweet and that his account had been compromised. When subsequently speaking toMr Meadows, Mr Taylor expressed his disappointment that when contacting him, theTrust had made the assumption that he was the author had not, especially given hispositive support for the Trust, first asked him if he was the author.

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10. In discussing this matter with Mr Taylor, Mr Meadows countered that if he had beenasked to contact Mr Taylor, he also would not have thought to assume that theaccount had been compromised. Mr Meadows agreed that should the Trust in futurerespond to such messages by contacting people, the Trust should first ask if theperson was the author instead of making the assumption they were. Mr Taylorinformed Mr Meadows that he has raised the compromise of his Twitter account withthe police.

CREATION OF A DEPUTY LEAD GOVERNOR

11. It has been recognised that the Lead Governor may not always be available to attendCouncil of Governors meetings. Usually the Lead Governor would chair a pre-meetingof the Council, in order to allow Governors to coordinate their questions and agreeapproaches to issues they would like to raise.

12. As such Governors have requested consideration be given to creation of a DeputyLead Governor post. It is not unusual for other trusts to have such a Deputy LeadGovernor post. It is therefore proposed to amend the Trust’s Constitution to create therole of Deputy Lead Governor, with similar roles and responsibilities as the LeadGovernor when deputising for the Lead Governor (i.e., when they are unavailable orhave resigned during their term of office).

13. The role of Deputy Lead Governor should also be subject to election by their fellowGovernors and the term of office should be for 1 year. It is proposed that the electionof the Deputy Lead Governor should normally take place at the Council meetingfollowing the meeting electing the Lead Governor. This will allow Governors toconsider the candidates for Deputy Lead Governor knowing who has been electedLead Governor and also provide some overlap between Lead Governor and DeputyLead Governor elections.

14. However the election cannot proceed unless both the Board of Directors and theCouncil of Governors consent to the proposal to create a Deputy Lead Governor postby approving the following amendments to the Trust’s Constitution:

a) in paragraph 1.2 in the main body of the document, a definition needs to be addedas follows – “Deputy Lead Governor means the Governor appointed by theGovernors to fulfil the role described at Paragraph 12 of Annex 6 below” (NB –“below” meaning in the Constitution);

b) in Annex 6 of the Constitution, the following changes:• replace the existing Paragraph 12 (Communications with Governors) with a

new Paragraph 12 called Deputy Lead Governor – described in paragraph 17 ofthis paper below,

• renumber the existing Paragraph 12 (Communications with Governors) asParagraph 13,

• make any changes deemed necessary by the Trust Secretary to account forthis new Paragraph 12 and a re-numbered Paragraph 13 (i.e., ensuring anycross-references and content pages are updated as necessary in light of thischange).

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15. In respect of the new Paragraph 12 (Deputy Lead Governor) in Annex 6, the followingtext is proposed to be added:

“12.1 The Council of Governors shall appoint one of the governors as the Deputy Lead Governor. Subject to paragraphs 12.2 and 12.3 below, such governor shall fulfil the role of the Deputy Lead Governor for a period of 12 months.

12.2 The Council of Governors may reappoint a governor to the position of Deputy Lead Governor at the end of any 12 month period, if he/she wishes to be so reappointed.

12.3 If the Deputy Lead Governor notifies the Council of Governors, prior to the end of his term in office, that he/she no longer wishes to be the Deputy Lead Governor then the Council of Governors shall appoint another governor as the Deputy Lead Governor.

12.4 Whilst the Deputy Lead Governor is absent, or following the resignation of the Lead Governor, undertake the duties of the Lead Governor as described in paragraphs 11.4 to 11.6 of Annex 6 of the Constitution until such time as the Lead Governor is not absent or a new Lead Governor has been appointed.”

16. This proposal was approved by the Board of Directors on 25 September 2019,therefore, subject to the Council of Governors approval; nominations for the DeputyLead Governor will be sought so that the election can take place at the Council’smeeting in January 2020.

REVIEW OF CHAIRMAN AND NON-EXECUTIVE DIRECTOR REMUNERATION

17. As Governors will be aware, a review of Chairman and Non-Executive Directorremuneration (pay and terms) is due and this is one of the key roles of the Council ofGovernors.

18. When reviewing and approving the Chairman and Non-Executive Directorremuneration in 2016, the Council of Governors agreed that a further review ofChairman and NED’s remuneration would be undertaken in 2019.

19. As reported to the last meeting of the Council of Governor (August 2019), a meeting ofthe Governors Nomination and Remuneration Committee had been arranged (on 2October 2019) to undertake this review make a recommendation to the Council ofGovernors at their meeting on 17th October 2019. A report outlining benchmarkinginformation and options for consideration of Governors had been prepared for thismeeting, however, on 26th September, NHS Improvement issued new guidance inrespect of Chairs and NEDs remuneration.

20. The covering letter from Dido Harding, Chair of NHS Improvement, includes thefollowing statement – ‘We ask foundation trust chairs to share and review theframework with their lead governors and discuss any potential changes they wish tomake with their remuneration committee”.

21. The guidance will impact upon the decision of Governors regarding remuneration andtherefore will need to be taken into account and reflected in any supporting paperworkto the Nomination and Remuneration Committee and Council of Governors. There wasinsufficient opportunity to do so in time for the meeting on 2nd October. In addition,

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given Paul Taylor’s resignation, a new Lead Governor will not be elected until the 17 October and this Governor will also need to be given time to consider this matter and consult with their fellow Governors.

22. In light of this, a decision was made to defer this matter until the Council of Governorsmeeting in January 2020. We will arrange a meeting of the Nominations andRemuneration Committee prior to this in order to consider and make arecommendation to the full Council. We will consult with the Lead Governor in respectof these arrangements prior to arranging the Nominations and RemunerationCommittee meeting.

COUNCIL OF GOVERNORS ANNUAL REPORT

23. It is good practice for a Council of Governors to produce a report to update itsmembers (service users, staff and the public) on its recent activities. The report(Appendix A) has therefore been prepared to provide a brief overview of the activitiesundertaken by our Council of Governors over 2018/19 including meetings held andCommittee’s established, news and decisions over the past 12 months, Governortraining and development and an update on the Trust’s membership.

24. Subject to the Council of Governor’s approval, this Annual Report will be published onthe Trust website to ensure it is accessible to the membership.

COUNCIL OF GOVERNORS TRAINING AND DEVELOPMENT PLAN

25. The role and responsibilities of Governors are set out in the Trust’s Constitution andinclude:

a) holding Non-Executive Directors to account for performance of the Board;b) representing the interests of members and the public;c) the appointment and removal of the chairman and Non-Executive Directors;d) approving the appointment of the Chief Executive;e) appointing and removing the Trust’s External Auditors;f) receipt of the Annual Report and Accounts;g) being consulted on the Annual Operating Plan;h) taking decisions on significant transactions;i) taking decisions on non-NHS income.

26. In order to continue to support Governors in undertaking their duties, the existinginduction, training and development plan has been refreshed for 2019 – 2020 and canbe found at Appendix B.

27. This plan incorporates:a) Mandatory training sessions for new Governors;b) Core development modules (optional)c) Annual/ bi-annual Training Sessions (optional)d) Ad hoc development sessions either requested by Governors or proposed by the

Executive Team/ Board (optional).

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MEMBERSHIP UPDATE

28. As at end of September 2019, we have 13,463 members. This is broken down asfollows:

Member Numbers

Public 4,458 Service User/Carer 2,078 Staff 6,927 Total members 13,463

29. The age, gender and ethnicity of our members has been analysed against externalpopulation data (2014 population projections data and 2011 census from the Office ofNational Statistics). The findings as at October 2018 are consistent with those reportedto the previous meetings and are as follows:

a) Age• We are under-represented with members aged 16 to 21;• We have sufficient representation across age groups 30-39, 40-49, 50-59 and

60-74;• We continue to be under-represented with regards members aged 22-29 and

74+;• We have 89 members who have not completed their date of birth.

b) Gender• The majority of our members are female 67%;• We continue to be under-presented in terms of male members• We have 168 members who have not stated their gender.

c) Ethnicity• We have 828 members who have not completed their ethnic group information• We continue to be over-represented with regard the following ethnic groups:

- White – other;- White – Irish;- Asian or Asian British – other;- Black or black British – other.

d) We continue to be significantly under-represented in the following ethnic groups:• Asian or Asian British – Bangladeshi;• Asian or Asian British - Chinese;• Other Ethnic Group – Arab;• White – Gypsy or Irish Traveller.

30. The Membership and Engagement Committee will continue to monitor ourmembership profile and will look at ways in which we can improve representativeness.

NEXT STEPS

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31. Subject to the Council of Governors approval of the recommendations laid out withinthis report, the following actions will be taken:

a) The Constitution published on the Trust website will be updating and Governorswill be contacted to seek nominations for the role of Deputy Lead Governor;

b) The Council of Governors’ Nominations and Remuneration Committee will beasked to meeting in late 2019/ early 2020 to consider the remuneration and termsof Chairman and Non-Executive Directors to allow a recommendation to be madeto the full Council in January 2020;

c) The Council of Governors Annual Report 2018/19 will be published on the Trustwebsite to ensure this is accessible to the membership;

d) The Corporate Governance Team will commence making arrangements fortraining and development in line with the Plan at Appendix B.

RECOMMENDATIONS

32. The Council of Governors is asked to:

a) note the resignation of the Lead Governorb) consider and approve a proposal to create a Deputy Lead Governor role and

amend the Trust’s Constitution (subject to the approval also of the Council ofGovernors);

c) note the update in respect of the delayed review of chairman and Non-ExecutiveDirector remuneration;

d) consider and approve the Council of Governors Annual Report 2018/19e) Consider and approve the draft Governors Induction, Training and Development

Plan for 2019 and 2020;f) Note the update in respect of the membership.

SARAH JENNINGS

October 20179

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1

ANNUAL REPORT OF THE COUNCIL OF GOVERNORS 2018/19

an overview of the activities undertaken by our Council of Governors over the past year for members, staff and public.

Striving for Perfect Care and a Just Culture

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2

WHO ARE WE…

Mersey Care NHS Foundation Trust provides specialist mental health services in North West England and beyond. We provide specialist inpatient and community mental health, learning disabilities, addiction services and acquired brain injury services for the people of Liverpool, Sefton and Kirkby and community physical health services to South Sefton. We also provide secure mental health services for the North West of England, the West Midlands and Wales and specialist learning disability services across Lancashire, Greater Manchester, Cheshire and Merseyside.

Mersey Care’s Council of Governors is made up of 29 Governors, the majority (24) of which are elected by our membership including public, service user, carer and staff Governors.

Other Governors are appointed from our partner organisations such as Sefton Council and Edge Hill University to name a few.

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3

WHAT WE DO… OUR MEETINGS…

Governors are an important group of people within the Trust, who represent the views of our membership by being the “voice” of local people and surrounding communities.

Governors play a key role in the governance of the Trust and work hard to ensure that the interests of all members are taken into account whenever key decisions are made.

Governors also play an essential role in holding the Board of Directors to account, through the nonexecutive directors, for the performance of the Board. Through the performance of our statutory duties and other engagement activities, Governors help to ensure that the Trust lives its core values.

Duties of the Council of Governors include:

Appoint and if appropriate, remove the Chair and the othernon-executive directors

Decide the remuneration and allowances of the chair andthe other non-executive directors

Approve (or not) the appointment of a new chief executive Approve changes to the Trust’s constitution Represent the interests of the members of the Trust as a

whole and the interests of the public Receive the Trust’s annual report and accounts Hold the non-executive directors to account, for the

performance of the board of directors

The Council of Governors met on occasions in 2018/19 and all its meeting were quorate.

A revised Constitution was approved by the Council of Governors and Board of Directors in March 2018. Elections to the Council of Governors took place in Autumn 2018and Spring 2019 with 18 Governors commencing during2018/19.

In 2016/17 the Council of Governors set up the following Groups & Committees and these continued to meet as required in 2018/19

Nominations & Remuneration Committee – is responsible for organising and participating in the recruitment and selection process for appointing the Trust Chairman and non-executive directors. The committee receives reports on the performance of these individuals and is responsible for determining the appropriate remuneration for such posts.

Membership & Engagement Group – a formal group set up to review and implement the Trust’s Membership Strategy and advice on mechanisms to improvement engagement with our members.

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4

NEWS AND DECISIONS FROM THE PAST 12 MONTHS… HOLDING THE BOARD TO ACCOUNT…

Governors sought assurance of the quality and safety of

Community Services following the acquisition of

Liverpool Community Health

Governors approved the process for the Chairman and

Non Executive Director appraisals and received the

outcomes of these

Governors received the Trust Annual Report 2018/19 and

External Audit Opinion

Governors have provided input into the review of the Trust’s

Strategy and Operational Plan in addition to the Quality

Priorities

Governors scrutinised the performance of the Trust

Governors monitored the retraction of Specialist LD

Services at Whalley

Governors elected a Lead

Governor

Governors approved a series of appointments including the re-appointment of the Chairman and a Non-Executive Director

and appointed a new Non Executive Director

Governors participated in Quality Review Visits

Approved changes to the Trusts

Constitution

Our Council of Governors use a number of different ways to ensure they hold the Board to account for the performance of the Trust; these include:

Considering performance reports from the Board of Directors, presented by Non Executive Directors

Receiving the Trust’s Annual Report and Annual Accounts

Considering issues raised by Trust members and the general public.

Appraising the performance of the Chairman and Non Executive Directors.

Reviewing minutes and reports from the Board of Directors.

Evaluating reports received from our regulators and our auditors.

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5

GOVERNOR TRAINING AND DEVELOPMENT… OUR MEMBERSHIP…

Participation in Quality Review Visits

Events open to all our members

Board of Directors Meetings

Visits to services

Annual General Meeting & Annual Members Meetings

Groups and Committees established by the Council of Governors

All our governors receive training and opportunities for development to carry out their duties with confidence. This starts with an induction process to equip them for their role and is supplemented with an on-going programme of additional training to meet Governor’s needs.

In 2018/19, Governors were offered the following training:

The Role of the Council of Governors, the Board of Directors and Foundation Trust

An introduction to our Clinical Divisions The Trusts Strategy and Operational Plan Performance and Finance Quality of Services Striving for Perfect Care Quality Review Visit training NHS Providers Training

As at end of March 2019 we had 13,730 members which included:

2151 service user / carer members

4639 public members

6940 staff members

We actively recruit members by providing information to our service users and carers and through meeting the general public at a variety of events. We also recruit members through the Trust’s website and as a result of reporting our activities through the local press, in our Trust magazine, MC Magazine and through social networking sites.

Becoming a member is simple! If you are aged 14 or over and want to join our trust please call us on 0151 471 2303 and we will send you an application form.

Being a member is free and does not commit you to anything.

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6

REPORTING TO OUR MEMBERS… MORE INFORMATION…

To ensure our members and the wider public are aware of the work of the Council of Governors, we report all their activities through:

our Annual Members’ Meeting and Annual General Meeting

Our bi-annual Members Events The quarterly MC Magazine Our website: http://www.merseycare.nhs.uk/about-

us/council-of-governors/ holding our Council of Governors’ meetings in public the Trust’s Annual Report attendance at events internal communications

For more information about our Council of Governors please contact us on [email protected] or telephone 0151 473 2778.

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http://www.merseycare.nhs.uk/about-us/council-of-governors/

http://www.merseycare.nhs.uk/about-us/council-of-governors/

mailto:[email protected]

Appendix B

COUNCIL OF GOVERNORS INDUCTION, TRAINING AND DEVELOPMENT PLAN 2019 - 2020

AREA PURPOSE ATTENDANCE DATE &TIME VENUE MANDATORY

Induction Module

To provide Governors with an overview of Mersey Care including the structure of the organisation, services provided and priorities, in addition to the role of the Board and Council of Governors including their statutory duties.

New Governors [any existing Governors wishing to refresh their knowledge]

October 2020 Internal venue

GovernorWell Training Programme

A one-day training delivered by NHS Providers which covers:

• A re-cap of the role of Governors • Holding Non-Executive Directors to

Account; • How to effectively question and

challenge • Membership engagement

All Governors January 2021 Quaker Meeting House School Lane Liverpool

CORE DEVELOPMENT MODULES Trusts Strategy and

Operational Plan The Trust’s Strategy and Annual Operational Plan sets out our direction and objectives in improving quality whilst safely reducing costs. Governors will be provided with an overview of the Trusts key objectives and how these are being delivered.

All Governors October – December 2020

Internal venue

Striving for Perfect Care This session will focus on what we mean by perfect care, how this translates across our strategy and how we are working with others – particularly colleagues at Stanford University – through our Centre for Perfect Care & Wellbeing to embed perfect care in the way we deliver services.


Internal venue

Quality of Services The session will focus on how the trust undertakes quality surveillance and provides assurance to the Board of Directors, the Council


Internal venue

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Appendix B

of Governors, its commissioners and regulators on the quality and safety of the services the trust provides;

Performance and Finance The trust measures its performance against a range of indicators and targets, some of these are set nationally by regulators, some locally by our commissioners and some by the trust itself to ensure the successful delivery and implementation of the trust’s strategy. The session will provide governors with an understanding of the key performance issues and financial pressures facing the trust.


Internal venue

Overview of Specialist Learning Disabilities

Division & Secure Division

This session will allow for an overview of the SLD Division and Secure Division with an update on the transformation to be delivered.


Internal venue

Overview of Local Services Division &

Community Services Division

This session will allow for an overview of the Local Division and Liverpool and South Sefton Community Services Division with an update on the transformation to be delivered.


Internal venue

ANNUAL/ BI-ANNUAL TRAINING SESSIONS Role of the External

Auditor This session will provide an overview to governors on the role of the External Auditor, the important of audit and the Council of Governors role in the annual audit.

All Governors May/ June 2020 Internal venue

Quality Review Visits The session will outline the purpose of Quality Review Visits, how these fit into the Trusts Quality assurance Process and the role of Governors in such visits.

Those Governors wishing to participate in visits.

Training sessions bi-annually

Internal venue

ADD HOC DEVELOPMENT SESSIONS*

Workforce

This development session will explore the workforce issues outlined in the performance report including staff sickness and recruitment and the actions being taken to address these. [Requested at April 2019 CoG Meeting]

All Governors Nov 2019

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Appendix B

Integration

This session will build upon the Integration update provided to the Council of Governors in August 2019 to outline to Governors the plans for the integration of physical and mental health services in the organisation. [Requested at Aug 2019 CoG Meeting]

All Governors End of 2019 Internal venue

Repetitive Transcranial Magnetic Stimulation

(RTMS)

Specific request following a visit by Governors to the Broadoak Unit (Electro-Convulsive Therapy Suite). [Requested at Aug 2019 CoG Meeting]

Mark McCarthy and any interested Governors

To be confirmed with M McCarthy

Internal venue

Developments with North West Boroughs

Development sessions to keep Governors updating on developments with north West Boroughs to be arranged as and when required.

All Governors As required To be confirmed

*These are items either requested through a Council of Governors meeting or pertain to a specific piece of work.

Agenda Item E2

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Report provided (check necessary boxes): Report to: Council of Governors To Note: ☒ For

Assurance: ☒

For Decision:

☐ For Consent: ☐ Meeting Date: October 2019

Specialist Learning Disabilities Division Retraction Update Accountable Director(s): Trish Bennett, Executive Director of Nursing and Operations

Report Author(s): Susan Wrathall, Deputy Chief Operating Officer Lisa Rens, Strategic Operations Manager

Purpose of Report To allow members of the Council of Governors to:

• be updated on the transformation programme progress for the Specialist Learning Disability Division


• On the 31st August 2019 there were 95 (25F, 70M) resident service users on the Whalley site.

• A key focus for the service is to close 15 Enhanced Support Service) beds and to reduce the LSU male beds from 26 to 20.

• The Quality of Life recommendations have been considered, actions agreed and implementation has commenced.

• Organisational change has commenced for over 700 staff on the Whalley and Scott Clinic sites as part of the staffing plan for Rowan View.

Recommendation:

The Council of Governors is asked to: 1) To note progress to date 2) To note the content of the report




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PURPOSE 1. To allow members of the Council of Governors to be updated on developments

within the Specialist Learning Disability Division. EXECUTIVE SUMMARY BACKGROUND/ CONTEXT 2. The national transformation plan ‘Building the Right Support’ (NHSE 2015),

outlines the requirement to move people with learning disabilities (LD) into ‘more appropriate community settings’ with less reliance on in-patient beds. The report also signalled a 50% reduction in low secure learning disability beds and 25% reduction in Medium Secure Unit (MSU) beds. In addition, NHS England advised following the consultation (28th March 2017) that all hospital beds on the Whalley site will close and be re-provided over the next three years on a case by case basis for each service user, in the community or in new state of the art units elsewhere in the North West.

ISSUES FOR CONSIDERATION 3. On the 31st August 2019 there were 95 (25F, 70M) resident service users on

the Whalley site.

4. A key focus for the service is to close 15 ESS (Enhanced Support Service) and to reduce the LSU male beds from 26 to 20.

5. Demand for services is ongoing, at the end of August 2019 there were 6

service users awaiting admission to our services, 2 are internal for Service Users requiring to transfer from medium to low secure services and 4 are external to the Trust.

6. There are currently four Service Users with Individual Packages of Care (IPC)

on the Whalley site and Lancashire CCG Commissioners are leading on the options and agreement of the final plan for the services.

7. The Specialist Support Teams now have a full caseload of over 450 service

users and they continue to provide a full range of services including out of hours support and attendance at urgent meetings preventing hospital admissions.

8. Funding for the new LSU has recently been confirmed by NHS England, a

communication to staff explains it will be approximately 3 years before the new low secure unit will be open in Maghull.

9. Work on the Rowan View MSU build is progressing well and without delay and

organisational change for Rowan View commenced in July 2019.

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OUR SERVICES - Whalley Site Bed Numbers

10. On the 31st August 2019 there were 95 (25F, 70M) resident service users on the Whalley site in the following services.

• IPC 4 • ESS 15 (incl. 2 NHSE funded service users) • LSU 48 (26M, 22F incl. 1 CCG funded service user) • MSU 28 (25M, 3F)

Admissions and Waiting Lists 11. There was 1 admission to the site in August 2019; 1 male admission to MSU.

12. The MSU bed numbers remain within planned commission number of 40.

Normal business continues, there are 2 pending female admissions (repatriation from Out of Area) and three pending referrals for the MSU.

13. Waiting lists remain in place, as at the 31st August 2019 there were 7 service

users awaiting admission to the following onsite services: Transfer/Discharge Planning MSU

14. The MSU is currently running slightly under contracted numbers and a plan is

progressing to repatriate 2 further female patients who are currently in an MSU out of area. There are also 3 pending referrals for MSU (male).

ESS 15. A key focus for accelerated discharges remains on the 15 service users within

the ESS service. Collaborative working continues with CCG Commissioners for Lancashire, Greater Manchester and Cheshire & Merseyside planning the discharges that are likely to take place during the next year.

Male LSU 16. A key focus remains on the contraction of the service. As of 31st August 2019

there were 18 (2 reside in ESS) male LSU service users currently in the transfer/discharge process.

Individual Packages of Care 17. There are currently four service users with individual packages of care (IPC) on

the Whalley site. There have been several meetings held regarding the future of the services provided in the periphery housing and Lancashire CCG Commissioners are leading on the options and agreement of the final plan, they continue to work closely with the Trust and NHS England Commissioners and importantly the service users and their families.

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Specialist Support Services – Lancashire and Greater Manchester 18. Both teams have been in place for a year and CCG commissioners have

notified the intention to review both services. The Lancashire review has commenced and is being undertaken by Moorhouse and is part of a wider review of Lancashire Services. Greater Manchester have agreed the review process and it is expected to commence shortly.

Quality of Life Report 19. The NHS England Quality of Life Report recommendations are detailed

below:

• Explore ways to share experiences of community to help people feel safe about moving on

• Explore ways to develop the positive reputation of people in and leaving hospital setting to expedite discharge

• Explore sessions and other methods of allowing people to express their experience without having the validity of their story questioned

• Consider a mechanism to highlight to MOJ when their requirements are dehumanising that put people at risk of delaying discharge

• Consider investment in assisting people to develop the skills to establish and maintain friendships to make them healthier and more successful in the community

• Consider investment in counselling and therapy for people who experienced trauma that could reduce risk on readmission

• The barriers to accessing people to request their consent to participate in projects about their experiences be explored further

20. Following on from considering the recommendations, actions have been agreed

and are now being implemented; this work is overseen by the Divisional Service User and Carer forum.

OUR PEOPLE Staffing 21. The Division is currently budgeted for 708 WTE staff. At the end of August

2019 there were a total of 59 vacancies (8.3%) excluding transition. The majority of vacancies relate to the Whalley site including 6 registered nurse vacancies and 31 nursing assistant vacancies. A recruitment plan remains in place and is linked to the Rowan View Plan.

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OUR FUTURE Low Secure New Build 22. Funding for the new LSU has recently been confirmed by NHS England, a

communication to staff explains it will be approximately 3 years before the new low secure unit will be open in Maghull.

Rowan View MSU 23. Work on the build is progressing well and without delay. The workforce plan

is in place and potentially 199 new staff are required, to support this a recruitment plan is in place and the first cohort of 70 staff have been recruited in line with the plan. These staff are working on the Maghull and Whalley sites filling vacancies until late summer 2020.

24. An organisational change process was launched on the 15th July 2019 for just

over 700 staff on the Whalley and Scott Clinic sites. As at the 23 September 2019 165 one to one organisational change interviews have taken place and 17 staff from the Whalley site have expressed an interest to move to Rowan View when it opens. Consultation meetings will continue until the 15 December 2019.

NEXT STEPS 25. The Division will continue to progress the retraction of services in

collaboration with commissioners. RECOMMENDATIONS 26. The Council of Governors is asked to:

• To note progress to date • To note the content of the report

Trish Bennett Executive Director of Nursing and Operations October 2019

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End of report

Agenda Item No: F2

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Report provided (check necessary boxes):

To Note: ☒ For Assurance: ☐ Report to: Council of Governors


Community Services Improvement Programme Update

Accountable Director(s): Trish Bennett, Executive Director of Nursing and Operations Report Author(s): Chris Lyons, Director of Transformation and Service Delivery

Purpose of Report To provide members of the Council with: • an overview of progress against the 44 issues within the

Community Services Improvement Programme. Summary of Key Issues for Consideration of Governors :

• It is important that the Council of Governors are provided with assurance that a structured and comprehensive approach to the improvement of community services is in place.

Recommendation:

The Council of Governors is asked to: 1) note the continued progress within the programme based on

this high level overview report. Next Steps: (Subject to recommendation being accepted)

None identified.



Liverpool Community Services Transition Sub-Committee

30 September 2019

Community Services Improvement Programme Update

Update was noted by the Sub Committee.

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EXECUTIVE SUMMARY/ BACKGROUND

1. The improvement programme for Community Services continues to be implemented across 44 identified issues. 37 of the 44 issues are now rated as ‘green’, indicating that they are complete and/or have moved to ‘business as usual’, with the remaining seven rated ‘amber’.

PROGRESS REPORT

2. This report is based upon a report submitted to the Community Services Transition Sub Committee meeting on Monday 30 September 2019. There were no concerns raised at this meeting that need to be addressed by the Council of Governors.

3. The improvement programme for Community Services continues to be implemented across 44 identified issues. 37 of the 44 issues were rated as ‘green’ in the September report, indicating that they are complete and/or have moved to ‘business as usual’.

4. At the Transition Sub Committee meeting on 30 September a report was provided on OP14a, Special Schools, and it was determined by the Sub Committee that this issue should now also be considered ‘business as usual’ and its status changed to ‘green’ on the next report.

5. Six of the 44 issues therefore currently remain ‘amber’, including:

• QA2 – Quality Improvement • OP11 – Engaging with Patients About Quality of Services • OP14c – Safeguarding • OP14e – Child Health Information Systems (CHIS) • OP17 – Children’s Services • OP18 – Reliance on Hybrid Records

6. It should be noted that the planned milestones for OP14c, Safeguarding, have now been superseded by the announcement of an independent inquiry led by Dr Bill Kirkup.

7. The final meeting of the Transition Sub Committee is due to be held on 29 November 2019. Final reports for outstanding issues (those which remain ‘amber’) will be submitted to the Sub Committee at this final meeting. It is expected that these issues will then be considered to be either complete or ‘business as usual’ within the Community Division.

8. Any issues which the Sub Committee feel require additional assurance after November 2019 will be referred to the Quality Assurance Committee for oversight.

RECOMMENDATIONS

9. The Council of Governors is asked to:

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a) note the continued progress within the programme based on this high level overview report.

TRISH BENNETT EXECUTIVE DIRECTOR OF NURSING & OPERATIONS

October 2019

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Agenda Item No: F3

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To Note: ☐ For Assurance: ☒


Mersey Care Winter Plan 2019-20

Accountable Director(s): Trish Bennett, Executive Director of Nursing and Operations Lee Taylor, Chief Operating Officer, Community Division Donna Robinson, Chief Operating Officer, Local Division

Report Author(s): Michelle Fanning, Head of Service, Intermediate and Urgent Care, Community Division Dave Jones, Deputy Chief Operating Officer, Community Division Andrew Jones, Winter Support, Community Services

Purpose of Report To allow Council of Governors to: 1) Be assured Mersey Care have further learned from the

experiences of winter 2018-19 and developed an even more robust plan across its community and local division’s’ services.

2) Be assured that Mersey Care are taking a much more focused approach as a system leader to maximise impact on the number of attendances to ED, the average length of stay, help reduce admissions and avoidable re-admissions into acute care and support flow [discharges] daily.

3) Be assured the impact of the plan and winter initiatives on the delivery of clinical services and corresponding activity is recognised and will be operationally managed.

4) Be assured that a proactive dashboard will be in place and used as an operational tool throughout winter to demonstrate impact.

5) Be assured that the Mersey Care daily SitRep out to the wider system has been further developed by listening to partners and includes the number of “Ready for Discharge” [RFD] patients to help focus the Mersey Care decision making.


• The Mersey Care winter offer for 2018-19 resulted in 3893 extra bed days saved compared to 2017-19. The 2019-20 winter offer has identified:

o A further 2326 potential extra bed days saved

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compared to 2018/19. This equates to another 60% increase on the extra 3893 the Trust contributed to the system during winter 2018/19.

o 461 potential additional admissions saved and; o A further 1480 ED attendances avoided. The majority

of this would also equate to the same reduction in ambulance conveyance numbers.

The key approach of the Mersey Care winter plan for 2019-20 include: • Getting all services, for the first time ever, to report through

EMS; • Using the action cards within EMS as a way of driving change

and increasing responsiveness from services; • Building and putting in place an operational governance that

has more grip and control that responds to staff needs and pressures;

• Attempting to recruit into new capacity initiatives or fill rotas sooner than in previous years;

• Articulating the offer from core services so that the wider system and partners recognise Mersey Care as a key player within the system’s winter planning;

• Developing an impact dashboard, that will inform ongoing decisions throughout winter, that will be used as an operational tool not just a planning tool.

Recommendation:

The Council of Governors is asked to: 1) Note the updates and improvements from the 2018-19 winter

plan. 2) Receive assurance of the delivery of the winter plan and note

the emphasis on significant operational, financial and quality metrics to be achieved and communicated to the wider system.


1) Support the Mersey Care winter plan 2019-20 and agree to promote its intent within the local community.



Community Division Senior Leadership Team Meeting

4th Sept 2019 Mersey Care Winter Plan 2019-20

Agreement to progress through Mersey Care Governance structure

QAC 11th Sept 2019

Mersey Care Winter Plan 2019-20 Accepted

Operational Management Group

17th Sept 2019

Mersey Care Winter Plan 2019-20 Accepted

Executive Committee

19th Sept 2019

Mersey Care Winter Plan 2019-20

Accepted and Recommended to Trust Board

Trust Board 25th Sept 2019

Mersey Care Winter Plan 2019-20 Accepted and signed off

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PURPOSE

1. To be prepared to cope with the ever increasing demands over winter and build a Mersey Care winter plan, incorporating the combined mental and physical health offer to the wider health and social care system. A plan that is built upon the experiences and learning from winter 2018-19. A plan that has identified further impact on saving extra bed days whilst ensuring our patients have the best possible experience and care is maximised.

BACKGROUND/ CONTEXT

2. The 2019/20 Mersey Care winter plan [Figure 1.0] will again focus on an approach that: • Looks to create more unplanned care capacity within its core services;

• Identifies and advocates investment in key initiatives that would further increase

capacity; • Includes a combined mental and physical health operational hub that will co-

ordinate resources and make decisions based on real time information that contributes to Opel levels and will respond to Opel levels and escalation triggers;

• Will impact on and reduce pressures at our local acute hospitals and;

• Will further strengthen its relationships with key system partners including the

Acute Trusts [adult and children], Local Authority and Primary Care to offer a “step up” and “step down” approach.

3. The plan will focus on core services differently over the winter period to ensure they were more ready to create further capacity in the system to respond to the unplanned care demand.

The emphasis will be on making sure there is impact for the wider system and contributions towards:

a) reduced ED attendances; b) reduced admissions; c) reduced average length of stay and; d) reduced re-admissions and ultimately demonstrate extra bed days saved during

winter 2019/20 compared to the same period 2018/19.

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Figure 1.0 Winter Plan – Summary Approach and Impact

ISSUES FOR CONSIDERATION

Key parts of the offer that are an enhancement from 2018/19 winter plan 4. One SPC number and one SPC Team across Liverpool, Sefton and Knowsley. Working

towards a re-branding of the Single Point of Contact [SPC] to be known going forward as the Mersey Care Clinical Contact Centre and an increase in patients being monitored through Telehealth with LTC from 1200 to 1700.

5. One ICRAS team with two bases and one ICRAS Lead Co-ordinator for the day. Daily on-site presence (RLBUH & UHA) of a Therapist and Nurse [2018/19 there was only one professional skill set on site] to increase the step down capability. In addition to the Mental Health Liaison Officer who will also join the daily safety huddle meetings.

6. The on-site co-ordination will take more ownership for the Ready for Discharge patient cohort [RFD] to help optimise patients and get them into their next onward place of safety as quickly as possible helping to reduce AloS and the total numbers in this cohort.

7. The weekly stranded and super stranded patients [a sub-set of the RFD list] will also be the responsibility of the co-ordinators to attend and significantly contribute providing the community intelligence of service provision and patient risk thresholds.

8. A significant development this year will see the proposed neighbourhood model for the ICRAS Liverpool & South Sefton taking shape for winter 2019/20. The teams will be

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built around the geography of neighbourhoods and primary care networks and will include ward 35. It will see more robust service delivery support in the following areas:

• GP/ANP/ACP across the neighbourhoods 7 days a week (5days GP);

• All ICRAS band 7 co-ordinators brought together with the amalgamation of ICCT & ERT, working alongside as one team of co-ordinators;

• Each neighbourhood ICRAS Teams will be under a team leader, with the team made up of band 6 nursing caseload holders, HPA’s / AHP’s.

9. Home First+ [Care Provision by the Local Authority] - Co-location, improved pathway alignment and increased capacity will release capacity with care calls provided by ICRAS.

10. 7 day working - A daily MDT approach at weekends using ANP’s/Matrons [Masters Level Practitioner] to lead the MDT, have the competencies to undertake a comprehensive geriatric assessment, allocate referrals and co-ordinate care. Using the ICRAS infrastructure, general Nursing staff and Therapists will respond to the immediate need as decided by the MDT. The single point of contact [SPC] will be used as the clinical platform.

11. Ward 35 – More focus on the reasons for NHS delays [evidence collected from 2018/19 winter period], Continue with “Red” to Green” methodology and focused MDT’s and goals attainment care plans to reduce LoS, maximise occupancy at 95% and reduce the levels of DTOC’s compared to 2018/19 levels.

12. WICs – More focussed marketing of the services and diversion of non-complex DVT patients away from ED at RLBUH and UHA by extending the pathway offer to Garston and the City WIC’s. Currently it is just offered at Old Swan. Core 24 and/or triage car to create stronger links with the WICs and have agreed ways of being responsive to patients with Mental Health needs. The aim will be to avoid unnecessary attendances and/or admissions through ED.

13. NWAS – Electronic Referral Information Sharing System [ERIS]. Having access to this daily by the ICRAS team will ensure outcomes like simple falls requiring therapy intervention will be addressed within 24hrs rather than 3-4 days. In time for winter 2019/20 it is expected that the skin tear pathway will also be in place and another way, alongside NWAS, where ICRAS can support “step up” options rather than a direct conveyance to ED.

14. Integrated Nursing - MDT’s will be in place for all neighbourhood teams taking ownership for the most vulnerable and complex patients. The roll out of “Red to Green” philosophy for 40-50% of our District Nursing Teams will help manage patients more effectively on and off caseloads. Roll out to at least 50% of teams the alignment of Community Matrons into daily safety huddles to maximise their clinical competencies and knowledge across all relevant patients and not just their restricted caseload.

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15. Improved ICRAS and appropriate District Nurse support into the intermediate care/Dementia hubs.

16. Pharmacy - This year consideration will also be given to how the team can also support patients discharged to the community with ICRAS or domiciliary care packages to avoid any complications caused by patients having differing medication regimes pre and post hospital stay.

17. CEDAS – Same day [4hr] response and allocate a selection of static PAC mattresses (standard and bariatric) to each of the Local Authority Intermediate Care Hubs to hold in stock.

18. Mental Health – includes triage car, support to WICs, A&E diversion scheme, medial support, bed flow co-ordinator and weekend management cover. All of these are subject to gaining the appropriate funding. In total it equates to approximately £365K. a) The Mersey Care offer from the older people’s Mental Health inpatient beds will be

stepped up this year. The Community Division, who have the physical health expertise, will be used in a more systematic way in 19/20 to ensure a more holistic and preventative approach is embedded. It is anticipated that alongside better patient care and more knowledgeable MH staff, this offer will save a further 53 ED attends and acute admissions giving a bed days saving of circa 100.

19. Flu Campaign – 80% target compared to 75% in 2018/19. Over 200 immunisers being trained compared to 130 in 2018/19 to ensure the expected level of patients and staff are immunised during winter 2019/20.

20. Operational Hub – Tested in September. Twice weekly in October and 5 days per week from 1st November. MH colleagues [silver] part of the daily meeting for 2019/20 and the Community Bronze on call will input this year.

21. SitRep – Matured in 2019/20 to include the RFD numbers from UHA and RLBUH to engender shared ownership. MH metrics included for 2019/20 for the first time to include:

o DTOCs o 12-hour breaches o Demand – expected planned discharged v expected planned admissions.

NEXT STEPS

22. Mobilise services and prepare for the implementation phase of the plan and initiate the communication plan.

RECOMMENDATIONS

23. The Council of Governors is asked to: a) Note the updates and improvements from the 2018-19 winter plan.

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b) Receive assurance of the delivery of the winter plan and note the emphasis on significant operational, financial and quality metrics to be achieved and communicated to the wider system.

Trish Bennett - Executive Director of Nursing and Operations

October 2019

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End of Report

part 1 – formal meeting in public · 2019-10-04 · page 1 . agenda for . council of governors...

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