BoD Agenda Oct12 by gary bouch

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST PUBLIC MEETING OF THE BOARD OF DIRECTORS 1.00 pm on Tuesday 30 October 2012 to be held in the Large Function Room, St George’s Centre, Leeds LS1 3BR ______________________________________________________________________________ AGENDA

Members of the public will be given the opportunity to ask questions at both the beginning and the end of the meeting. It is preferable if questions could be written down and handed to either the Chair or the Head of Corporate Governance before these points in the meeting. However, the absence of a written comment/question will not preclude members of the public from being allowed to put these to the Board. LEAD 1

Apologies for Absence

Directors’ Interests

Opportunity to receive comments/questions from members of the public in order to inform the discussion on any agenda item

Minutes of Previous Meetings 4.1

Minutes of the Meeting held on 28 September 2012 (enclosure)

Matters Arising

Actions Outstanding from Public Meetings of the Board of Directors (enclosure)

PART A - STRATEGIC ITEMS 7

Leeds and North Yorkshire Transformation Programme Highlight Report October 2012 (enclosure)

7.1

Minutes from the Transformation Programme Board 5 October 2012 (enclosure)

7.2

Transformation Programme Outpatient Project (enclosure)

Quarter 2 Annual Plan progress Report (enclosure)

Organisational Growth Principles and Decision-Making Framework (enclosure)

PART B – GOVERNANCE ITEMS 10

Report from the Chair of the Audit and Assurance Committee for the meeting held on 22 October 2012 (verbal)

Performance, Quality & Use of Resources Report and Quarter 2 Monitoring Return (enclosure)

11.1

Quarter 2 Monitoring Return (enclosure)

11.2

Strategy Progress Report (enclosure)

Equality Act Progress Review (enclosure)

Declaration of Interest Forms (enclosure)

13.1

Independence of Non-executive Directors (enclosure)

Proposed Changes to the Constitution (enclosure)

Discussion paper on the format of agenda papers for the Board of Directors (enclosure)

PART C – FOR INFORMATION ITEMS 16

Chair and Chief Executive’s Report 16.1

Chair’s Report (verbal)

16.2

Chief Executive’s Report (enclosure)

Leeds Safeguarding Adults and Leeds Safeguarding Children Annual Reports for 2011/12 (enclosure)

Minutes from the Infection Control Committee 7 September 2012 (enclosure)

Draft Minutes from the Council of Governors’ meeting held on 13 September 2012 (enclosure)

Draft Minutes from the Nominations Committee meeting held on 28 September 2012 (enclosure)

The Seal of Leeds and York Partnership NHS Foundation Trust (verbal)

Opportunity for any further comments/questions from members of the public

Any Other Business

23.1

NatWest Resolution Indemnity Form (enclosure)

Notice of Motion The Board of Directors resolves that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted; publicity of which would be prejudicial to the public interest.

The next meeting of the Board of Directors will be held at 10.30 on Friday 30 November 2012 in the Morton Suite at the National Railway Museum, York.

AGENDA ITEM 4.1 LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST Minutes of the Public Meeting of the Board of Directors Held on 28 September 2012 at 13:45 in the Millennium Room at the Carriageworks, Leeds Apologies

Board Members Mr C Butler Ms A Choudhry Ms J Copeland Mr F Griffiths Ms D Hanwell Dr J Isherwood Mrs M Moran Mrs L Phipps Mrs N Swan Dr G Taylor Mrs S Tyler Mr A Valks Mr K Woodhouse

Chief Executive Non-executive Director Director of Strategy and Partnerships Chair of the Trust Chief Financial Officer Medical Director Chief Operating Officer & Chief Nurse/Deputy Chief Executive Non-executive Director Non-executive Director Non-executive Director (Deputy Chair of the Trust) Director of Workforce Development Non-executive Director (Senior Independent Director) Non-executive Director

Voting Members

            

In attendance Mrs C Hill Head of Corporate Governance (secretariat and minutes) 4 Members of the public

Action The Chairman opened the meeting at 10:00 and welcomed members of the Board of Directors and the public. In particular Mr Griffiths welcomed Dr Isherwood to his first meeting. 12/166

Apologies for Absence (agenda item 1) There were no apologies for absence.

12/167

Directors’ Interests (agenda item 2) There were no changes to the interests of any director, and no member of the Board of Directors present at the meeting declared a conflict of interest in respect of the agenda items to be discussed.

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Opportunity to Receive Comments / Questions from Members of the Public (agenda item 3) Mr Freeman presented the following question to the Board which was read out in full by the Chair and is reproduced below: The report by the Director of Strategy and Partnerships, dated 17 August 2012 stated that the “NHS Commercial Procurement Collaborative contracts with Veolia Environmental Services (UK) Ltd” paragraph 6.2 contains a statement: “It should also be noted that Veolia Environmental Services (UK) Ltd is only 49% owned by

the Veolia parent company and does not present consolidated accounts with the company” This is at variance with Veolia’s “Report and Financial Statement 2011” which states in paragraph 26: “Veolia Environments S.A. [the ultimate parent and controlling company] . . . is the smallest and largest group for which group financial statements including Veolia Environmental Services (UK) plc are prepared”. This throws into question the legal advice quoted in the Statement on the Trust’s website that “Veolia Environmental Service (UK) Ltd is an independent company to the entity operating in Israel.” Given that there is now serious doubt that the entity operating in Israel countries to assist illegal settlements in the West Bank to the detriment of the Palestinian population, will the board reconsider its belief “that Veolia Environmental Services (UK) Ltd cannot be excluded from the retender on the grounds of grave misconduct”? Ms Copeland acknowledged that this is a complex situation and indicated that this has been looked at by the Board on two previous occasions. Ms Copeland advised the Board that legal advice has been taken which is that the Trust would be open to challenge under procurement law if Veolia (UK) was excluded from the re-tender exercise and that the previous decision of the Board still stands. Ms Copeland indicated that all the relevant reports are on the Trust’s website should any member of the Board wish to look at these. Ms Copeland agreed to respond to Mr Freeman in writing. Mrs Roper, a Mental Health Act manger for the Trust, indicated that she was bringing this question to the Board on behalf of the Mental Health Act Managers (MHAMs) noting that ward visits by MHAMs in Leeds have been suspended pending further evaluation and that this decision had not been communicated properly to either the wards or to the MHAMs. Mrs Roper indicated that the reason for suspending visits was quite spurious and that in the past there had not been a problem with either conflict of interest or the capacity of managers to carry out their statutory duties. Mrs Roper expressed the view that this was not a good step for Leeds and that the statement “Better Together” did not hold true in this case and that it was “Worse Together” for service users. Mr Griffiths indicated that this will be picked up as part of the discussion at agenda item 12. 12/169

Minutes of the Meeting held on 31 August 2012 (agenda item 4.1) Mrs Phipps highlighted a typographical error in minute 12/154 noting that this should have read Out of Area Treatment budget.

With that amendment the minutes of the public meeting held on 31 August 2012 were received and agreed as a true record.

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Actions Outstanding from Public Meetings of the Board of Directors (agenda item 6) Mrs Hill advised the Board that as a result of an action from the Board time-out she had been asked to prepare a list of those actions agreed pertaining to the Board of Directors’ meetings and for those that were still outstanding to come to each meeting. Mrs Hill indicated that the format for the report was that currently used for the Audit and Assurance Committee. The Board considered the items outstanding and directors provided an update on those

that were now completed. It was noted that in future these reports would be presented to the Executive Team meeting prior to them coming to Board. The Board also noted the ongoing nature of this report.

The Board received and noted those actions that had been agreed and were still outstanding and received an update on those that had been completed.

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Matters Arising (agenda item 5) 12/171 – Adult Social Care Section 75 Agreement – Update on Chair’s action (minute 12/155) - Mrs Moran advised the Board that at the August meeting it had discussed the Section 75 Agreement and had asked for two further points of clarification before the document could be signed off. Mrs Moran noted that at that meeting the Board had asked the Chair to arbitrate on the sufficiency of the assurances from the Executive Team on those points requiring further information. It was reported that sufficient assurances had been given to the Chair and the agreement signed on behalf of the Board.

The Board noted the Chair’s action and that the Section 75 Agreement had been signed on behalf of the Board.

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Leeds and North Yorkshire Transformation Programme Highlight Report September 2012 (agenda item 7) Mrs Moran presented the update report for the Transformation Programme and drew attention to the ongoing work to look at some of the issues to come out of tranche one and two; and the progress being made to fill some of the vacancies. With regard to recovery Mrs Moran reported that a paper would be going to the next Transformation Programme Board meeting and that this was being supported by the work in respect of clinical outcomes. With regard to tranche three Mrs Moran indicated that a large amount of work had been done to look at the Leeds inpatient service. Mr Griffiths asked the Board to consider the risk document, noting that there are a number of elements of the risk treatment plans which are showing a red. The Board went through the programme risks in great detail and focussed on those areas showing red, seeking assurance as to the actions in place to address each individual one and the progress is being made in respect of those actions. Mrs Phipps noted that some of the red areas were still showing the same narrative as in previous months and for these wanted assurance on progress or confirmation that the organisation has agreed to hold these risks. Mrs Moran thanked the Board for the observations firstly about the risk treatment plan descriptions, noting that there could be some delay in the Board receiving the most up to date position as the document has to be approved by the Transformation Programme Board before it comes to Board of Directors. Mrs Moran also drew the Bard’s attention to the risk score noting that some of those with red indicators were either high and moderate and were not all extreme risks, and also advised the Board that because an element of the plan was showing red this did not mean that the whole risk was rated red. Mrs Moran explained the governance process for monitoring risks in order to ensure that action plans are being progressed accordingly. Mrs Moran took the Board through each of the elements scored red in the risk treatment plans in detail and assured the Board of the actions being undertaken to mitigate the risk.

With regard to risk 18 (page 31) Mrs Moran noted that this is a high risk and the red areas are linked to the outpatient module and that the elements of the risk treatment plan are rated red due to the non-completion of some of the actions plans in relation to outpatients, but that the Transformation Programme Board is closely monitoring this. Mr Griffiths linked the matter of outpatients to the question raised by a governor at the Annual General Meeting and the problem of the location of services. Mr Valks suggested that a paper should come to the Board on the specific issue of location, the difficulties of travel and the availability of appointments. Mr Griffiths indicated that a written reply was to be provided to the governor who raised the matter. Mr Butler supported a review of this matter. Mrs Swan linked this risk to the issue of the anxiety caused by inappropriate discharge. Mrs Swan also asked about absence levels and what the impact of the forced relocation, caseload and skill mix is having on staff. Mrs Tyler advised the Board that the absence rate is steady, although there are pockets of higher levels which are being looked at to ascertain the reasons for this. With regard to risk 24 (pages 38-39) Mrs Moran indicated that this risk is still an extreme risk despite there having been a lot of work carried out in this area. Mrs Moran indicated that she has requested a full review of this risk and suggested that a full report in respect of this be brought to the Board in October and link this to the issue of location and transport raised under risk 18. Mrs Moran assured that Board that a lot of work has already been undertaken, but that there is still more to be done. The Board discussed this risk in detail. With regard to the comments column which has now been included in the report Dr Taylor observed that the terminology between this and the risk treatment plan does not always match and suggested that attention needs to be paid to ensuring the two sets of information show the same position. Mrs Phipps asked about the implementation of the Single Point of Access, Mrs Moran explained the process of referral noting that there is a review of the triage process to ensure it is still lean and that this is not a major concern. With regard to Mrs Phippsâ&#x20AC;&#x2122; question about the Section 75 Agreement and the integration with Adult social Care Mrs Moran advised the Board that there will be small Project Initiation Document which will go to the Audit and Assurance Committee and also outlined the governance arrangements which are being set up.

The Board of Directors noted the work of the Transformation Programme, identified those areas on which it wanted more information, and also received information and assurance on specific areas identified in the report.

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Minutes from the Transformation Programme Board held on 6 August and 4 September 2012 (agenda item 7.1) Mr Butler noted that the minutes for meetings held on 6 August and 4 September 2012 were before the Board. Mrs Moran sought clarification as to whether the Board wanted both a verbal report as well as the minutes of meetings. Mr Griffiths indicated that the Board should receive only the minutes of meetings and that the format of information as presented at this meeting is sufficient.

The Board received the minutes of the Transformation Programme Board meeting held on 6 August and 4 September 2012 and noted the contents.

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Performance, Quality and Use of Resources Report (agenda item 8) Ms Hanwell presented the performance report for the period ending August 2012 and drew the Board’s attention to a number of issues which had been highlighted in the report. In respect of the non-financial performance Ms Hanwell reported that from a compliance perspective the Trust is compliant with all Monitor targets, however, Ms Hanwell noted that there are some areas of concerns and highlighted delayed transfers of care in the North Yorkshire and York (NY&Y) area and that action is ongoing to address this. Mr Valks asked for an update on the outcome from the York Overview and Scrutiny Committee. Mrs Moran indicated that the committee had accepted the Trust’s paper and that it now wanted there to be a process of consultation, and would report back to the committee in November. With regard to the NY&Y CQC action plan Ms Hanwell indicated that there are two actions that have slipped and that a paper has been presented to the Means Goal 7 Group and assured the Board of the work that is ongoing to complete these areas of work. With regard to the Health and Safety aspect of this plan Mrs Moran indicated that the health and safety PDA usage audit had been completed and was compliant. Ms Hanwell drew attention to the Tier 1 Risks indicating that there are some concerns around the pace of the embeddedness of Payment by Results (PbR) but assured the Board that this is in hand and work is being taken forward. With regard to the number of whole time equivalents Mr Valks observed that the medical and dental staff numbers have increased and asked why this was. Mrs Tyler agreed to confirm this to Mr Valks, but suggested that it might be due to additional junior doctor posts because the number of training posts had been increased in psychiatry. Mr Woodhouse asked what actions were being taken to address the issues of Care Programme Approach (CPA) in York. Mrs Moran assured the Board that she is receiving weekly reports to ensure that the target isn’t breached. Mrs Swan asked about how the voluntary sector representative might be involved in the CPA, Mrs Moran indicated that this was being taken forward in the Standing Support Group tasked with this. On a wider point Ms Hanwell indicated that she was looking to introduce some sensitivity analysis into the report to try and forecast at what point a target might be breached. For trigger to Board events Mrs Phipps asked for the cumulative figures to be circulated. Ms Hanwell agreed to include these and note that she was keen to receive feedback on the report in order to develop it further. Mrs Phipps also noted that at the recent directorate performance reviews staff motivation had been recognised as a key risk and asked for this to be scored as she felt that this may be assessed as a rather high risk. With regard to the financial targets Ms Hanwell reported that income and expenditure was ahead of plan with a surplus of £1.7 million. Ms Hanwell also reported that new to the report was forward risk indicator which provided the Board with a view of the number of days operating cash the Trust is holding, currently 62 days, which is above the Monitor requirement of a minimum of 10 days. Ms Hanwell acknowledged that there needs to be a strategy developed for how that cash will be handled. With regard to Cash Releasing Efficiency Savings (CRES), Ms Hanwell also noted that the report now included a simple summary on the CRES position year to date. Mrs Swan asked what the effect would be if an organisations with whom the Trust has a legally binding contract runs out of available funds and is unable to meet its obligations

under that contract. Ms Hanwell advised the Board that the arbitration process of obtaining the funds due in such a circumstance is not straight forward and very time consuming; and explained that just because there is a legally binding contract in place this is no guarantee that the money will be forthcoming as expected. The Board discussed the reported financial position in respect of NHS NY&Y and the impact this may have on the contract with this Trust for services in that area and it was noted that the Executive Team have meetings arranged the discuss this matter with senior staff at the PCT. Mr Woodhouse asked for a paper to come to the Board that clarifies the exact legal position of the contract with NHS NY&Y. Mr Griffiths asked for this to come the Board in October in the private session.

JC/DH

Mr Valks asked about debtors over 90 days and why this was so high. Ms Hanwell indicated that she had undertaken a review of debts and is looking to reduce this, but assured the Board that they were non-NHS debtors.

The Board received the performance report and considered the position against both non-financial and financial targets and was assured of progress.

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Quality Health Community Service User Survey (agenda item 9) Mrs Moran presented the Quality Health Community Service User Survey noting that this had been presented to the Council of Governors at its September meeting. Mrs Moran noted that this had come to the Board as two separate reports due to the organisations having been separate when the reports were commissioned, but that for next year there would be a combined report. Mrs Moran drew the Boardâ&#x20AC;&#x2122;s attention to the differences between the results in the Leeds area and in the North Yorkshire and York (NY&Y) area, with NY&Y services performing better in many respects than the Leeds services. Mrs Moran outlined some of the reasons as to why this might be. With regard to some of the specific findings Mrs Moran expressed disappointment at areas such as access to crisis services and access to an out of hours number noting that a lot of work has been done to address these. Mrs Moran assured the Board that actions plans are being drawn up to address the weaknesses highlighted in the management report and that these will be monitored through the governance structure. With regard to the action plans Mrs Moran advised the Board that a report has been asked for by the Council of Governors to set out innovative ways in which the actions might be addressed and that this will be going to the Council of Governors in November. Mrs Phipps highlighted the question in the report which asked service users â&#x20AC;&#x2DC;how well does your care co-ordinator organise the care and services you needâ&#x20AC;&#x2122; and asked what the scope of the CPA training is and whether the training includes a module around listening. Mrs Moran acknowledged that more might be done in this area; and also that there needs to be more analysis of why things are different in the York services. Mrs Phipps offered to provide her thoughts on this outside of the meeting. Mrs Phipps also noted the reference to tracking actions and suggested that this could be linked to the work within the COGNOS system. Mrs Moran advised the Board that action plans are monitored and followed through; however, Mrs Moran indicated that even through actions had been devised and completed to address previous weaknesses these did not seem to be having the desired effect.

Mrs Swan noted that many of the actions are about training and asked how many of the weaknesses are about staff not having enough time to carry out their role. Mrs Moran indicated that work was ongoing to look at caseloads to try and understand the perceived time constraints.

Having received the outcome of the Quality Health Service User Survey the Board commented on the findings and supported the need for further discussion and engagement with service users and carers in respect of the area of weakness.

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Andrew Simms Centre (ASC) â&#x20AC;&#x201C; Progress Against Business Plan (agenda item 10) Mrs Tyler presented the annual report for the Andrew Sims Centre, and reported on the objectives identified in the ASC Business Plan. Mrs Tyler reminded the Board that the ASC is entirely self funding and that all coasts, including salary costs, have to be covered and that having done that the centre archived a ÂŁ6k surplus, which Mrs Tyler commented was a significant achievement. With regard to Key Performance Indicators (KPIs) Mrs Tyler noted that one KPI was to increase the number of Trust staff attending and informed the Board that this had increased by 84%. Mrs Tyler also outlined some of the future proposed developments for the centre including the use of new technology for providing training. Mrs Tyler asked the Board to consider the target areas for 2012 and 2013 and to make recommendations as to the future direction of the ASC predominantly as a commercial venture and as a CPD provider both within and outside of the Trust. The Board discussed the report. Dr Taylor noted that she had personal experiences of running such a business, and acknowledged the achievement of the ÂŁ6k surplus. Dr Taylor observed that the core purpose and the strategic focus for the business is not quite clear in the plan and there needs to be more clarity around some of the business drivers. Dr Taylor offered her support to developing the plan further. Mr Woodhouse asked for clarity as to why the Trust was providing such a service, given that it is not core to our business, and suggested there needs to be a more strategic discussion as to whether this is something that the trust would wish to continue to do. Mrs Swan suggested that this was an operational matter and questioned why this had come to the Board. Mr Griffiths supported there being more work on the business plan looking at what else it can do and how it might work in partnership. Mr Griffiths reminded the Board that this is a teaching and learning organisations and as such this is central to what the organisation does, and noted that the ASC provides some specialist areas of learning. Mr Griffiths also offered support in developing the business plan further. Mr Butler outlined some of the many teaching connections and organisations this Trust is involved in and suggested that there may be scope for the Trust to become a hub for mental health learning. Dr Isherwood observed that when lecturing at the centre there had been a large number of people from outside the area suggesting that there may be a gap in the market which the centre could take advantage of. Ms Choudhry suggested that consideration should be given to any employment opportunities there may be for service users.

Having discussed the paper the Board provided some observations as to the direction that the ASC might consider taking and suggested that the business plan be further developed.

In respect of agenda items 11, 12 and 13 the Board noted that Mr Woodhouse, Mrs Phipps, Ms Choudhry and Mrs Swan were trained Mental Health Act Managers and noted their potential interest in these agenda items. 12/177

Re-appointment of the Mental Health Act Managers (MHAMs) (agenda item 11) Dr Isherwood presented to the Board a list of the MHAM for re-appointment, noting that the recommendation to re-appoint for the periods outlined will ensure there are sufficient well trained MHAMs to carry out this important role, particularly during a period when new managers are being appointed and trained. Mrs Phipps questioned the statement in the supporting paper that “Trust Boards must formally delegate this duty” and also suggested that the Board is delegating the power rather than a duty. Dr Isherwood explained the reason for the wording is that in ordered for the duty to be carried out it has to be delegated and this must be done by the Board. In addition to this Mrs Phipps also questioned the statement that MHAMs may not wish to continue due to the “distressing nature” of the role. Mrs Phipps indicated that in her view the role was not distressing and whilst it could be challenging and difficult it was, it was very rewarding, and suggested that this word should not remain in the paper without some form of comment. Dr Taylor asked for clarification as to the length of term of office and whether setting it at three years for all MHAMs would mean they would all come to the end of their term of office at the same time. Dr Isherwood indicated that there would a rolling programme of recruitment, which would ensure a natural difference of when the term of office come to an end. Mr Griffiths assured the Board that he had had several meetings with the lead for MHAMs and had himself been assured of the processes in place to ensure a robust programme of refresh.

Having discussed the matter the Board agreed:    

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The re-appointment of the current MHAMs for a period of three years from 1 October 2012. That any new MHAMs that are recruited will also be appointed for a term of three years staring from the date of the Board meeting at which the appointment was approved. That all MHAMs would be eligible to be re-appointed for a further term of three years subject to satisfactory appraisal and being competent to carry out the role That in exceptional circumstances and at the Trust’s discretion a recommendation of a further term of three years may be made to the Board.

Mental Health Act Managers Governance Arrangements (MHAMs) (agenda item 12) Dr Isherwood introduced the paper which set out the proposed new governance arrangements for the MHAMs, noting the specific references to MHAMs. Dr Isherwood noted that whilst in York there hasn’t been a programme of visits to wards by MHAMs there had been informal visits from time to time and that as a clinician he found these to be helpful; however he noted that the Task and Finish group hadn’t made any recommendation as to how such visits might be addressed in the future, and asked the Board to consider this. Dr Isherwood also advised the Board of his view that the Medical Director should not have a prominent role in the governance of the MHAMs as this could lead to a conflict of interest due to the role of MHAMs to challenge some of the medical decisions and powers from

time to time, and that the role of Medical Director should be advisory. This was supported by the Board. With regard to ward visits Mrs Phipps indicated that she has not undertaken ward visits herself, but acknowledged the value of the learning to come from these visits and asked for consideration to be given as to how such learning might continue to contribute to service user care. With regard to ward visits Mr Butler firstly apologised for any communication issues there may have been with staff and MHAMs. In respect of the learning that came from these Mr Butler indicated that this was very valuable; however, Mr Butler indicated that the organisation has changed since the visits were initiated and that a decision has been taken to focus the work of the MHAMs around their statutory obligations which does not include ward visits. Mr Butler advised the Board of the large range of visits which are now being or will be carried out both from within and the Trust and by external bodies which provide the Trust with many points of learning. Mr Butler also referred to the way in which the Trust has taken the best from the practices in both Leeds and York when the services merged. Mr Griffiths suggested that if anything were to be observed by MHAM during the course of a hearing there would be an expectation that this would be reported to management. With regard to the suspension of ward visits by MHAM Mr Griffiths indicated that this provides clarity in respect of their role and ensures there is no conflict of interest. Mrs Phipps asked when the governance arrangements would come into force. Dr Isherwood confirmed that this would be the date from when the arrangements are approved by the Board. Mrs Phipps also asked what arrangements would be made for carrying out appraisals given that this would move from being once every three years to annually and would present a greater workload. Dr Isherwood indicated that this will bring MHAMs into line with staff and the process for doing this was still to be determined. With regard to the terms of reference Mr Valks asked if both the Director of Operations and the Chief Nurse would be required in the composition of the MHAM Governance Group, and if a non-executive director would be chairing the group would this need to be one trained as a MHAM. Mr Griffiths asked for these points to be addressed outside of the meeting.

Having considered the paper the Board of Directors approved the proposed governance arrangements for MHAMs.

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Mental Health Act Managers â&#x20AC;&#x201C; Scheme of Delegation (agenda item 13) Dr Isherwood presented the proposed change to the Scheme of Delegation and asked the Board to ratify this change.

The Board of Directors ratified the changes to the Scheme of Delegation.

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Transparency of Care (agenda item 14) Mrs Moran noted that the paper is here to inform the Board of the work being undertaken to progress Transparency of Care and to identify a non-executive director (NED) to support the work.

JI/AV

Mrs Moran advised the Board that Transparency of Care is acute biased and that work is ongoing to look at how it can be tailored more to mental health.

The Board received the paper and supported the participation in this project and identified Mrs Phipps as the NED to support the work.

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Ratification of the Procedure for the Development of Procedural Documents (agenda item 15)

The Board of Directors considered and ratified the refreshed procedure for the Development of Procedural Documents.

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Options Appraisal – International Link Work with Chainama Hills College Hospital, Lusaka, Zambia (agenda item 16) Mrs Moran explained the context to this paper, noting that it outlines the international links with the only mental health and learning disability hospital in Lusaka and updates the Board with the progress to date. Mrs Moran asked the Board to consider if it wished to continue to support the work, given that a new Chief Executive has been appointed to the Chainama Hills Hospital and he is keen to continue the links. By way of context Mr Griffiths asked for it to be noted that he and Mr Butler are trustees of a charity called Action Zambia which is totally separate from the work carried out by the Trust. Mr Woodhouse questioned the benefits that the work carried out by the Trust brings to the organisation and its staff. Mr Griffiths advised the Board that this work came out of a government initiative in the year 2000. Ms Copeland indicated that it was not about what Zambia can do for the Trust, but what the Trust can do for Zambia but that the paper doesn’t really set out what the benefits are for Zambia. Mr Valks indicated that the paper doesn’t set out the risks and benefits and as such felt unable to provide a view. Mrs Swan felt that more should be made of this to develop the Trust’s diverse links. Mrs Swan also suggested that this was not a matter for the Board to discuss given the value of the expenditure. Mr Butler indicated that it had been brought to Board due to its novel and previously contentious nature.

It was agreed that this paper should go back to the Executive Team meeting for consideration there.

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Chair’s Report (agenda item 17.1) Mr Griffiths reported on the Annual Members Day noting that despite the weather it had been a great success and paid tribute to the effort all the staff, in particular the communications team, had made to make it such a success. Mr Griffiths remarked on the interview with Frank Bruno as having been powerful and insightful. With regard to the venue Mr Griffiths raised some question as to whether this would be used again and also noted that there were a few points of learning which he would be speaking to directors outside of the meeting.

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Chief Executive’s Report (agenda item 17.2) Mr Butler presented the Chief Executive’s Report, in particular referring to the “Get Me?” campaign; and the nursing development work. Mr Butler also formally advised the Board that Mrs Moran has been successful in being appointed at the Chief Executive of Manchester Mental Health and Social Care NHS Trust and will be leaving at the end of November. On behalf of the Board Mr Butler congratulated Mrs Moran on her appointment and noted that he was considering how the upcoming vacancy will be filled, including acting up arrangements. With regard to the report Dr Taylor offered some comment on how this might be strengthened and improved, and asked what support could be provided to develop the report into something that the NEDs will find more insightful. Mr Butler indicated that he had already changed the report to take account of the previous comments provided by NEDs but that this led to it being of a more discursive nature which it was reported didn’t meet their needs either. Mr Butler suggested that if any member of the Board has any example they forward to it him.

The Board of Directors received the Chief Executive’s report and noted the matters highlighted in the report.

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Dates of Meetings for the Board of Directors for 2013 (agenda item 18)

The dates of the meetings for 2013 were noted by the Board and that venues will be circulated in due course.

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Application of the Seal of Leeds and York Partnership NHS Foundation Trust (agenda item 19) Mr Griffiths advised the Board the seal had not been applied since the last meeting.

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Further Questions or Comments from the Public (agenda item 20) There were no further questions from members of the public.

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Any Other Business (agenda item 21) 12/188.1 – The appropriateness of agenda papers – Mr Woodhouse raised the matter of agenda papers, noting that some had been very well written and some not so well and commented on the overall length of the totality of papers. Mr Woodhouse commented that this had also been raised by a number of governors. Mr Woodhouse suggested that some of the information circulated as Board papers could have been circulated at any time prior to the meeting rather than rolling it into a long Board paper with a paper referring to that documentation being presented at Board at a later date. Mr Woodhouse indicated that some papers were not clear leaving the reader to pick their way through what might be the issue. Ms Copeland supported Mr Woodhouse’s comments and advised the Board that a piece of work is underway, led by Mrs Hill, to work with governors to produce some guidance for paper authors to try and address the issues raised.

ALL

Mr Griffiths asked for a paper on the matter of the production of agenda papers to come back to the next meeting. 12/189.2 â&#x20AC;&#x201C; LYPFT Strategic Clinical IT System â&#x20AC;&#x201C; Ms Hanwell presented a paper which set out the case for a strategic review of PARIS against the clinical and business requirements and asked for the Board to be aware that this is going to take place and to note that a paper detailing the results will be coming back to the Board in January 2013.

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Notice of Motion (agenda item 17)

The Board of Directors resolved that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted; publicity of which would be prejudicial to the public interest.

At the conclusion of business the Chair closed the public meeting of the Board of Directors of Leeds and York Partnerships NHS Foundation Trust at 13:20 and thanked members of the Board and members of the public for attending.

BOARD OF DIRECTORS’ ACTION SUMMARY (PUBLIC MEETING) Meeting held 28 September 2012

MINUTE

ACTION SUMMARY (PUBLIC MEETING – PART A)

12/168

Opportunity to Receive Comments / Questions from Members of the Public (agenda item 3) Ms Copeland acknowledged that this is a complex situation and indicated that this has been looked at by the Board on two previous occasions. Ms Copeland advised the Board that legal advice has been taken which is that the Trust would be open to challenge under procurement law if Veolia (UK) was excluded from the re-tender exercise and that the previous decision of the Board still stands. Ms Copeland indicated that all the relevant reports are on the Trust’s website should any member of the Board wish to look at these. Ms Copeland agreed to respond to Mr Freeman in writing.

12/172

Leeds and North Yorkshire Transformation Programme Highlight Report September 2012 (agenda item 7) With regard to risk 24 (pages 38-39) Mrs Moran indicated that this risk is still an extreme risk despite there having been a lot of work carried out in this area. Mrs Moran indicated that she has requested a full review of this risk and suggested that a full report in respect of this be brought to the Board in October and link this to the issue of location and transport raised under risk 18. Mrs Moran assured that Board that a lot of work has already been undertaken, but that there is still more to be done. The Board discussed this risk in detail.

12/174

LEAD DIRECTOR

Performance, Quality and Use of Resources Report (agenda item 8) With regard to the number of Whole Time Equivalents Mr Valks observed that the medical and dental staff numbers have increased and asked why this was. Mrs Tyler agreed to confirm this to Mr Valks, but suggested that it might be due to additional junior doctor posts because the number of training posts had been increased in psychiatry. Mr Woodhouse asked for a paper to come to the Board that clarifies the exact legal position of the contract with NHS NY&Y. Mr Griffiths asked for this to come the Board in October in the private session.

JC/DH

MINUTE

ACTION SUMMARY (PUBLIC MEETING – PART A)

12/178

Mental Health Act Managers Governance Arrangements (MHAMs) (agenda item 12) With regard to the terms of reference Mr Valks asked if both the Director of Operations and the Chief Nurse would be required in the composition of the MHAM Governance Group, and if a nonexecutive director would be chairing the group would this need to be one trained as a MHAM. Mr Griffiths asked for these points to be addressed outside of the meeting.

12/182

Chief Executive’s Report (agenda item 17.2) With regard to the report Dr Taylor offered some comment on how this might be strengthened and improved, and asked what support could be provided to develop the report into something that the NEDs will find more insightful. Mr Butler indicated that he had already changed the report to take account of the previous comments provided by NEDs but that this led to it being of a more discursive nature which it was reported didn’t meet their needs either. Mr Butler suggested that if any member of the Board has any example they forward to it him.

12/188

Options Appraisal – International Link Work with Chainama Hills College Hospital, Lusaka, Zambia (agenda item 16) It was agreed that this paper should go back to the Executive Team meeting for consideration there.

12/184

LEAD DIRECTOR

ALL

Any Other Business (agenda item 21) 12/188.1 – The appropriateness of agenda papers Mr Griffiths asked for a paper on the matter of the production of agenda papers to come back to the next meeting.

12/189.2 – LYPFT Strategic Clinical IT System – Ms Hanwell presented a paper which set out the case for a strategic review of PARIS against the clinical and business requirements and asked for the Board to be aware that this is going to take place and to note that a paper detailing the results will be coming back to the Board in January 2013.

AGENDA ITEM 6

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Actions Outstanding from Public Meetings of the Board of Directors

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Chris Butler – Chief Executive

PAPER AUTHOR:

Cath Hill – Head of Corporate Governance

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC:

GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

  

IMPACT ON THE TRUST’S S MEANS GOALS (please tick relevant box) MG1 We provide excellent quality, evidence-based, evidence based, safe care that promotes recovery and inclusion MG2 We involve people in planning their care and in improving services MG3 We work with partner organisations to improve health and lives MG4 We value and develop our workforce and those supporting us MG5 We improve our services through learning, research and innovation MG6 We provide efficient and sustainable services MG7 We govern our Trust effectively and meet our regulatory requirements



STATUS OF PAPER



To be taken in the public session (Part A)



To be taken in private session (Part B) - If the paper is to be taken in the private session please indicate which criterion is applicable: Legal advice relating to legal proceedings procee (actual or possible) Negotiations in respect of employee relations where they are of a confidential nature Procurement processes and contract negotiations Information relating to identifiable individuals or groups of individuals Matters exempt under the Freedom of Information Act (quote section number)

SUMMARY: It is considered good practice to formally monitor progress against actions agreed by the Board of Directors, so that undue delay or failure to complete actions is formally challenged. Accordingly, the Board action list is derailed in the attached report and will be updated following each meeting. The Board is asked to note the governance pathway for the action list; not only is it received by the Board of Directors at each of its meetings but is also reported to the Executive Team so that executive directors ectors can review their actions ahead of the Board meeting with the Chief Executive maintaining an overview of the completion and progress of actions.

RECOMMENDATIONS: The Board of Directors is asked to: to ď&#x201A;ˇ

Note the actions outstanding from previous Board meetings and the timescale for completion, seeking clarification as to progress where it considers this necessary.

Cumulative Action Report for the Public Board of Directors’’ Meeting

MINUTE NUMBER AND ORIGINATING MEETING DATE

12/150 (August 2012)

ACTION (INCLUDING THE TITLE OF THE PAPER THAT GE GENERATED THE ACTION)

PERSON LEADING

Leeds and North Yorkshire Transformation Highlight Report August 2012 (agenda item 6)

Michele Moran

Programme

Mr Valks noted that work had been completed in respect of the Cash Efficiency Releasing Savings (CRES) report and suggested that outcome form this work should be shared with members of the Board. Mrs Moran agreed to circulate this to Mr Valks along with any ny other information that members of the Board may wish to have. 4

12/150 (August 2012)

Leeds and North Yorkshire Transformation Highlight Report August 2012 (agenda item 6)

Programme

Mr Griffiths noted that the Internal Audit report indicated that the Board has not been regularly sighted on the financial impact of the project noting that a full financial report would be presented to the Transformation Programme Board and asked for there to be full report to the Board of Directors as to the financial achievements against plan with future reports coming to B Board on a regular basis.

To be progressed by Dawn Hanwell

Michele Moran To be progressed by Dawn Hanwell

BOARD MEETING TO BE BROUGHT BACK TO / DATE TO BE COMPLETED BY

COMMENTS

Management action date ate completed to t be advised

Work is ongoing to ensure that the CRES plans provide the information required by the Board of Directors

September Board meeting and ongoing following this

Linked to above

STATUS

LOG NUMBER

Key to status = Overdue more than 1 month/meeting Overdue 1 month/meeting Still outstanding/awaiting completion Completed

1 BOARD OF DIRECTORS – Cumulative Action Log (public board)

12/168.1 (September 2012)

ACTION (INCLUDING THE TITLE OF THE PAPER THAT GENERATED THE ACTION)

Opportunity to Receive Comments / Questions from Members of the Public (agenda item 3) – Veolia (UK) Limited

PERSON LEADING

12/172 (September 2012)

Leeds and North Yorkshire Transformation Highlight Report September 2012 (agenda item 7)

Programme

Management action date completed to be advised

COMPLETED

Michele Moran

October 2012

COMPLETED Item on the October Board agenda (as a sub item of the Transformation Project)

Susan Tyler

Management action date completed to be advised

COMPLETED

With regard to risk 24 (pages 38-39) Mrs Moran indicated that this risk is still an extreme risk despite there having been a lot of work carried out in this area. Mrs Moran indicated that she has requested a full review of this risk and suggested that a full report in respect of this be brought to the Board in October and link this to the issue of location and transport raised under risk 18. 8

12/174 (September 2012)

COMMENTS

Jill Copeland

Ms Copeland acknowledged that this is a complex situation and indicated that this has been looked at by the Board on two previous occasions. Ms Copeland advised the Board that legal advice has been taken which is that the Trust would be open to challenge under procurement law if Veolia (UK) was excluded from the re-tender exercise and that the previous decision of the Board still stands. Ms Copeland indicated that all the relevant reports are on the Trust’s website should any member of the Board wish to look at these. Ms Copeland agreed to respond to Mr Freeman in writing. 7

BOARD MEETING TO BE BROUGHT BACK TO / DATE TO BE COMPLETED BY

STATUS

LOG NUMBER

MINUTE NUMBER AND ORIGINATING MEETING DATE

2 BOARD OF DIRECTORS – Cumulative Action Log (public board)

12/174 (September 2012)

ACTION (INCLUDING THE TITLE OF THE PAPER THAT GENERATED THE ACTION)

Performance, Quality and Use of Resources Report (agenda item 8)

BOARD MEETING TO BE BROUGHT BACK TO / DATE TO BE COMPLETED BY

COMMENTS

Jill Copeland / Dawn Hanwell

October 2012 (private session)

COMPLETED Agenda item for the October Board meeting

Jim Isherwood /Allan Valks

Management action date completed to be advised

COMPLETED Mr Valks has been contacted by Gillianne Walton

PERSON LEADING

STATUS

LOG NUMBER

MINUTE NUMBER AND ORIGINATING MEETING DATE

Mr Woodhouse asked for a paper to come to the Board that clarifies the exact legal position of the contract with NHS NY&Y. Mr Griffiths asked for this to come the Board in October in the private session. 10

12/178 (September 2012)

Mental Health Act Managers (MHAMs) (agenda item 12)

Governance

Arrangements

With regard to the terms of reference Mr Valks asked if both the Director of Operations and the Chief Nurse would be required in the composition of the MHAM Governance Group, and if a non-executive director would be chairing the group would this need to be one trained as a MHAM. Mr Griffiths asked for these points to be addressed outside of the meeting. 11

12/182 (September 2012)

Options Appraisal – International Link Work with Chainama Hills College Hospital, Lusaka, Zambia (agenda item 16)

Delegated to Gillianne Walton

Michele Moran

Management action date completed to be advised

Chris Butler

Management action date completed to be advised

It was agreed that this paper should go back to the Executive Team meeting for consideration there. 12

12/184 (September 2012)

(All Board members to have the opportunity to contribute with ideas where they feel it is appropriate)

3 BOARD OF DIRECTORS – Cumulative Action Log (public board)

12/188.1 (September 2012)

ACTION (INCLUDING THE TITLE OF THE PAPER THAT GENERATED THE ACTION)

Any Other Business (agenda item 21) – The appropriateness of agenda papers

PERSON LEADING

BOARD MEETING TO BE BROUGHT BACK TO / DATE TO BE COMPLETED BY

Cath Hill

October 2012

Dawn Hanwell

January 2013

STATUS

LOG NUMBER

MINUTE NUMBER AND ORIGINATING MEETING DATE

COMMENTS

COMPLETED Agenda item for the October Board meeting

Mr Griffiths asked for a paper on the matter of the production of agenda papers to come back to the next meeting. 14

12/188.2 (September 2012)

Any Other Business (agenda item 21) – LYPFT Strategic Clinical IT System Ms Hanwell presented a paper which set out the case for a strategic review of PARIS against the clinical and business requirements and asked for the Board to be aware that this is going to take place and to note that a paper detailing the results will be coming back to the Board in January 2013.

4 BOARD OF DIRECTORS – Cumulative Action Log (public board)

AGENDA ITEM 7

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Transformation Programme October Highlight Report

DATE OF MEETING:

30th October 2012

LEAD DIRECTOR:

Michele Moran - Chief Operating Office, Chief Nurse and Deputy Chief Executive Sue Whitworth – Transformation Programme Manager Andrew Jackson - Transformation Governance Lead

PAPER AUTHOR:

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC:



GOVERNANCE:



INFORMATION:



IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

IMPACT ON THE TRUST’S S MEANS GOALS (please tick relevant box) MG1 We provide excellent quality, evidence-based, evidence based, safe care that promotes recovery and inclusion MG2 MG3

We involve people in planning their care and in improving services We work with partner organisations to improve health and lives

MG4 MG5 MG6

We value and develop our workforce and those supporting us We improve our services through learning, research and innovation We provide efficient and sustainable services

MG7

We govern our Trust effectively and meet our regulatory requirements

STATUS OF PAPER To be taken in the public session (Part A) To be taken in private session (Part B) - If the paper is to be taken in the private session please indicate which criterion is applicable: Legal advice relating to legal proceedings procee (actual or possible) Negotiations in respect of employee relations where they are of a confidential nature Procurement processes and contract negotiations Information relating to identifiable individuals or groups of individuals Matters exempt under the Freedom of Information Act (quote section number)

          

SUMMARY: The attached report provides the Board of Directors with an update on the work of the various workstreams and projects of the Transformation Programme. The report gives a more detailed account of the work of the Estates Workstream. At requested at the previous Board of Directors Meeting an additional column has been provided in the risk report giving an update on each risk treatment action. In addition a general commentary is provided on the overall progress with managing each risk.

RECOMMENDATIONS: The board is asked to note the work of the Transformation Programme.

Leeds and North Yorkshire Transformation Pro Programme Highlight Report – October 2012 1

Programme status summary

Over the past month the Care Pathway Team have completed their mapping of York inpatient services and are now analysing the information and will be preparing a report over the next few weeks. Consultation on the Tranche 3 Leeds report has taken place and consideration consideration is currently been given to the project needed to take this work forward and develop the new inpatient service model. Due to a number of reasons the development of the needs based Integrated Care Pathways (ICPs) has been delayed by a few weeks. A review of the new pathway and new team structures for those service that were implemented in June is taking place during October. Leeds City Council and Leeds and York Partnership NHS Foundation Trust have now finalised a Section 75 partnership agreement ment under the National Health Service Act 2006 effective from 30 September 2012. The agreement has now been signed off by both organisations.

Care Pathway Workstream

2.1 Tranche 3 York Inpatient Services The mapping of York inpatient service is now completed. completed Members of the Care Pathways team are meeting rd th Service Managers in York on 3 and 4 October to check final versions of the process mapping information. An initial report on the findings will be provided for the November Transformation Programme Board.

2.2 Integrated Care Pathways athways The Care Pathway team continues with the consultation process for the new Needs Based Integrated Care Pathways.. A final meeting with the authoring teams will take place mid November 2012 to sign the first draft for the build into PARIS.

2.3 Recovery The Recovery and Social Inclusion Team are currently reviewing their work plans against the objectives of the Trust wide Recovery plan. The team have been successful in bidding for funding to implement a one year Peer Support Worker and Recovery Recovery College development project and are currently in the design phase of that project. This will allow the team to realign to the new locality boundaries and further develop recovery focussed across all parts of the city. Jenny Thornton – Care Pathways Lead

Tranche 3 Leeds report consultation

At the September Transformation Programme Board the Summary of the findings of the analysis of services in Tranche 3 of the Transformation Project – Hospital Admission (Leeds) was discussed and supported. 3 sessions were provided for staff to discuss the report. The sessions were mainly attended by managers and senior clinicians. John Clare, Transformation Lead, gave a brief presentation regarding the output from the tranche 3 paper aper but largely the sessions were devoted to questions and discussions Page 1 of 8

around a number of broad theme, ie: admission, working more efficiently and effectively on the ward and discharges. Suggestions for specific tranche 3 projects were also sought from de delegates. A range of helpful comments were made which will be take into account when determining the number and range of projects. A paper outlining the feedback from the sessions will be discussed at the Transformation Programme Group. Proposals for specific fic projects to enable the development of the inpatient service model will be made to the Transformation Programme Board in due course. Sue Whitworth – Transformation Programme Manager

Operational Workstream – Leeds

Since the last report the Leeds Operational Workstream has met on 2 occasions. The group were made aware of a cross boundary issue with GPs referring to Leeds from the Selby and being able to access medical staff following the locality restructure. This issue issue has been addressed in the short term with discussions planned with those practices to encourage their alignment with the Selby CMHT. The planned tranche 1 and 2 review was discussed and comments made of what should be included in the review. The draft project charter for this was presented at the Transformation Programme Board on 5th October 2012. The group received some initial feedback from the staff questionnaires for the mobilising the workforce – a fuller report is given below on those findings. The future role of the group and the need to restructure and refocus it was discussed in some detail. The group proposed that future meetings should focus on operational matters involving a wider range of managers and clinicians. An arm’s length link would would be kept with the transformation team, with a manager being available to attend on request. The group would continue to be lead by the Associate Director who is also a member of the Transformation Programme Group. Sue Whitworth – Transformation Programme Programm Manager

Operational Workstream – York

The York and North Yorkshire Operational Workstream is now well established and meeting monthly. Membership is inclusive of all professional groups and relevant leads. Analysis of all team process maps has been undertaken ertaken and draft findings shared with the Operational Workstream. A design group are now beginning to look at how to incorporate the findings into service development plans. Melanie Hird – Associate Director North Yorkshire and York Services

Tranche 1 and d 2 Review

Consideration has been given to what should be included in the first review of Tranches 1 and 2. A project charter has been drafted and support by the Transformation Programme Board at their last meeting. The review will focus on a number of areas: are  

A review of the new pathway including the Single Point of Access, use of the holistic assessment and the process of formulation Service user feedback on their experience and impact of the changes including impact on travelling to appointments Page 2 of 8

  

Stakeholder feedback including staff and referrers Have the changes had any impact on the Critical to Quality Characteristics Have the financial targets been met

Following the review a report will be compiled for the Transformation Programme Board. Following the review the Local Working Instructions will be updated. Sue Whitworth – Transformation Programme Manager

Estates Workstream

The estates workstream continues to meet on a fortnightly basis. This Th workstream co co-ordinates and oversees the development of business cases where works are required to enable the full implementation of the Hub and Satellite model in locality services. In the West/Northwest Locality, the biggest locality,, business cases are almost completed which describe the work needed including estimated costs, which are required to enable the CMHT in Linden House and the main Satellite at Towngate House to function effectively. This will then enable clinical staff to move out of both Millfield House and Malham House. Millfield Millfield House is in the same geographical locality as Towngate House. To enable Malham House to be no longer used as satellite alternative arrangements need to be made within the same geographical area for service users to be seen and staff to access computers. s. Managers are in the process of identifying the clinical need for the city centre and where those needs could be met e.g. The Mount. In The East/Northeast Locality, covering approximately a third of the demand, the Intensive Community service is temporarily rily located at St Mary’s House and the CMHT at Millside. Asket Croft has now been vacated enabling the Asket Croft refurbishment project to be progressed. It is now anticipated that this major project should be completed by July 2013. When Asket Croft re-opens, opens, staff will be able to be relocated there. This will then enable St Mary’s House (Main House), Moresdale oresdale lane and West Point to be vacated. Millside will continue to be used as a satellite building. Staff are no longer based at Brook House, however the he building continues to be used occasionally to see service users and a service user support group takes place there. There is clearly a need for service users to have access to mental health services in the Garforth Kippax areas. Managers are reviewing the the need and considering the options for alternative venues where service users can be seen e.g. in buildings owned by other organisation e.g. GP practice.. When suitable alternative arrangements have been made for the Garforth Kippax area the building will be fully vacated. Concerns have been raised by service users of the impact of the recent changes on the distance some of them have to travel. This is particularly relevant for those who attend the new Intensive Community Services. Where transport is an issue, sue, this will be assessed as part of their care plan. For service users seen in outpatient clinics there should be minimal disruption. Managers are reviewing service user need across the various geographical areas with a view to identify appropriately loc located venues for service users to be seen, particularly in those areas where consideration is being given to closing trust buildings. Work has begun to develop a tool to measure journey distance options to any given base, based on patient post code. This will in the future help to plan better where services need to be located. Works for the Chronic Fatigue Service will be shortly completed completed enable the service to move from its temporary base on Ward 2 Becklin back to the Newsam Centre. This will then enable changes to be made to improve facilities for the 136 Suite and the Single Point of Access. Page 3 of 8

Sue Whitworth – Transformation Programme Manager

Human Resource and Workforce development Workstream

8.1 Management of Change Band 5 staff in the Localities were written to asking for expressions of interest to move voluntarily across localities due to an imbalance of staffing numbers by 7 September 2012. A small number of staff volunteered to move and where these requests met service needs these moves were facilitated. itated. This still left the band 5 staffing structure over in the South Locality ocality by 2.65fte. 9 staff in the South Locality were interviewed on the 2nd October 2012 and all but two staff were appointed. There has been some additional funding agreed for some some acting up arrangements so the two staff members who are displaced are being offered the backfill on a temporary basis for 6 months. Following attendance at the Transformation time –out out work is being done to establish a more stable staffing structure for senior posts in the Localities. Lindsay Jenson – Human Resources esources and Workforce Development Workstream Lead

8.2 Workforce Development Extensive consultation has occurred in relation to the Organisational Effectiveness and Change Management Programme to ensure it will support the Trust in delivering and sustaining the intended benefits from the Transformation Programme. Feedback from key stakeholders including Transformation Programme Board, Executive Team and senior operational management is currently being considered and some interventions within the programme have commenced. The Clinical nical Competency Development Workstream is due to meet for the first time at the start of October with a remit to identify and map the clinical skills, knowledge and competencies required to deliver the ICPs and then identify and map what relevant skills and and knowledge that exists in the community workforce. This will then enable this workstream to complete an analysis of the skills gap to give the basis for a clinical development plan including internal and external training provision, supervision and support. Dave Gaunt – Workforce Development

Mobilising the Trust through technology

Mobilising the Trust through Technology A questionnaire was sent to staff in community services regarding their opinions, preferences and concerns about mobile technology. The time limit for replies was extended and ultimately 94 replies were received. This amounts to about 27% of the community workforce. Response rates did cover most professional groups though psychology was under-represented under in responses.

Page 4 of 8

Psychology Other professional group anonymous 1% Admin 3% 1% OT 1% 11%

Response by professional group Medical 12% Manager/clinical lead 15%

Nursing 56%

Staff were asked about their willingness to use Trust supplied mobile devices and results were encouraging.

Would you be prepared, or be able to use a Trust supplied mobile device to undertake Trust business by connecting remotely via 3G (mobile phone network) whilst away from base and/or at home using 3G or your home broadband (if you have an internet connecti No 15%

No reply 9%

Yes 76%

The project is rolling out mobile devices to staff in SSE locality. Initially the locality manager has requested that consultants and clinical leads are served first and this will be done by the end of October. Project members are liaising with locality management in SSE to set up focus/drop in sessions to allay any fears and introduce the concepts and guides necessary staff to make best use of mobile technology. These are aimed for the end of October. Andrew Jackson â&#x20AC;&#x201C; Project Lead Page 5 of 8

10 Evaluation of transformation The progress with the programme’s evaluation has been in the following area.  That 2 ‘shaping the evaluation’ sessions have been held one with the SPA and CAS team and one with the West Locality team to shape the questions and measures to evaluate phase 1 and 2  That we are promoting the role of ‘evaluation champions’ for staff to get involved in the evaluation both in terms of design and promoting the evaluation to encourage people to get involved when it is being undertaken (we will be promoting the role of evaluation champions for service users too via the relevant group meetings/discussions). meetings  That we will be attending/sending papers to a number of meetings to share emerging ideas during October to get views and further refine the evaluation questions and measures to be used (SW team meeting, Community CSM/Locality Manager meeting, meeting, PAF etc)  That the notional timeline for the evaluation is August 2012 to January 2014  Higher trainee vacancy was discussed at R&I Standing Support Group and medical opinion was that it would be valuable to have someone in post even if they are not curren currently working in Leeds or York. Expression of interest will therefore be revisited. Jules Beresford-Dent - Evaluation Project Manager (Transformation)

11 Informatics Workstream Current status  Holistic Assessment – awaiting amendments from review/refinement  Holistic Crystal Report – is developed from the UDF so this will be constructed once the holistic has had any amendments applied and signed off  Care Plan – awaiting sign of from care planning SSG & decision on go live date  Care Plan Crystal Report - is developed developed from the UDF so this will be constructed once the holistic has had any amendments applied and signed off  Restructuring of Contract Reports – in progress  Restructuring of Data Warehouse – In progress  ECT – UDF awaiting clinical testing/sign off  Needs based sed pathway UDF’s – awaiting specifications from project  Business-as-usual usual support calls to system management continue to be high in volume.  The Informatics work stream structure is currently being reviewed to support Transformation moving forward. Alison Franklin – Informatics Workstream Lead

12 Communication and Engagement Workstream The communications department on behalf of transformation have communicated the changes to a range of stakeholders prior to go live on 25th June 2012.  Email update to send (6 Sept, 20 Sept)  Develop communications and engagement action plan for tranche 3  Programme Board paper highlighting specific plans for tranche 3 (staff engagement)  Draft questionnaires for service user and GP/referrers for their feedback on tranche 1&2 implementation)  Update the ‘Transformation Story’ on website and leaflet for service users Page 6 of 8



Develop SU/Carer leaflet/communications for tranche 3

Over the next few weeks the workstream plans to complete the following:  Email update to send (10 Oct, 18 Oct)  Draftt service user & carer engagement plan for phase 3 inpatient services Leeds  Begin to draft communications plan for phase 3 York & North Yorkshire  Send out questionnaires for service user and GP/referrers for their feedback on tranche 1&2 implementation)  Meet eet with Workforce workstream to work together on engagement events and communications for phase 3  Go live with updated transformation story on website and leaflet Gary Bouch – Communication and Engagement Workstream Lead

13 Finance Workstream The finance workstream has now:  Completed the Cash Releasing Efficiency Savings report for August 2012 actual savings against plans.  Updated 2012/13 forecast Cash Releasing Efficiency Savings position.  Updated Vacancy management details as at August 2012 for Tranche 3 and report to the Vacancy Management Group.  Full finance report for the Transformation Programme Board meeting on 5th October 2012. The following areas of work will be completed by end of October 2012:  Full finance report for the Transformation Programme Board meeting on 2nd November 2012 incorporating additional workforce details for each CRES scheme.  Updated Vacancy management details as at September 2012 for Tranche 3 report to the Vacancy Management Group.  Cash Releasing Efficiency Savings report for September 2012 showing actual savings compared to plans.  Update 2012/13 forecast Cash Releasing Efficiency Savings position.

14 Adult Social Care Integration As outlined in the previous Highlight report Leeds City Council and Leeds and York Partnership NHS Foundation undation Trust have now finalised a Section 75 partnership agreement under the National Health Service Act 2006 effective from 30 September 2012. The agreement has now been signed off by both organisations. Initial dates have been set for the Partnership Board that will oversee the arrangements for delivery outlined in the agreement. Social care staff are now provisionally aligned to the locality teams, there will continue to be some movement of staff between areas to ensure the optimum skills mix. Recruitment tment of several new staff to fill long standing vacancies is progressing interviews having been held in the first week of October. The locality managers and ASC team managers have been directly aligned. A standardised agreement for the allocation of cases ses for assessment is being developed to ensure that the specialist skills of social workers are best utilised. Currently training needs around Paris usage have been identified. ASC Team managers have identifying current case loads, and determining how to to monitor these on an ongoing Page 7 of 8

basis will be required as a priority this month. Due to funding approval mechanisms all support requiring ASC funding must be evidenced on ESCR the ASC system. Sitting alongside this work is the development of the steering group for the successful transformation fund bid regarding peer support workers and recovery focused self directed support outcomes and the recruitment of staff to posts funded by this bid. Iola Shaw - Project Leader Adult Social Care

15 RSM Tenon Report Following lowing the receipt of the report from RSM Tenon on the governance arrangements for the Transformation Programme, a number of actions have been considered. Overlap with issues identified at a senior staff ‘Transformation timeout’ was recognised and a combined combined action plan and detailed project plan have now been developed. The action plan also took into account the risk register as at 4th September and actions already agreed in the post implementation plan for Tranche 1 and 2 of the programme. The plan was discussed scussed and supported by the Transformation Programme Board on 5th October 2012. This paper will next be considered by the trust’s Audit and Assurance Committee on 22nd October 2012. It is proposed that implementation of the actions will be overseen by the Transformation Programme Board and reported to the Board of Directors or Audit and Assurance Committee through a dashboard summarising the key areas. Richard Clayton – Strategic Change Manager

16 Risk Report The Transformation Programme Risk report is attached as a separate document.

Sue Whitworth Transformation Programme Manager 17th October 2012

Page 8 of 8

Introduction The following pages provide the Trust’s Board of Directors with information on the current registered risks for the Transformation Programme. The risks on the following pages are set out in tiers: Tier 1 – corporate risks; Tier 2 – programme risks; Tier 3 – work stream risks. Risks are first approved then reviewed by the Transformation Programme Group. Changes to the risk report Following comments from the Trust Board of Directors meeting the actions given in each risk’s treatment plan have been colour coded in terms of deadlines: RED

Action is overdue

AMBER

Action is implemented with caveats

GREEN

Action has been carried out

GREY

Action is not yet due or is no longer required (action no longer required will be identified in the comments section for each risk)

In addition, I have added a commentary section to each risk where additional details collated from commentary on the risk register is given which adds some explanation for slippage of actions and any other significant comments from risk leads. The above maintains the preferred format of the report but allows the Transformation Programme Board to be advised, in conjunction with comments, about the status of action plans to mitigate and/or reduce the risks. Headlines 

 



Corporate risk 1 was approved to be moved out of the Transformation risk register at Transformation Programme Group on 11 October following confirmation all actions were complete. This risk relating to achievement of CPA targets will remain a residual risk within operational services risk register. A full list of all current risks and outstanding actions relating to the Transformation risk register was circulated on 5 October to all those identified as the lead for a particular treatment action. All actions will be discussed at the Transformation Programme Group on 11 October. A number of risks have been identified for archiving and following the principle set with corporate risks 2 and 3 these all relate to specific events that have passed. Risks that are residual but describe ongoing risk events will not be archived as the circumstances may change and require reassessment of these risks. Some slippage has occurred on many of the risks linked to IT/informatics, particularly relating to the sensitive issue of PARIS. This is an unusual development, as previously these risks have been managed extremely well by the informatics lead.

Please note: the attached pages represent the risks as they were on the risk register at 12:00 noon on 10 October 2012 and hence recent reports to other committees, Boards and groups compiled before or after this date may have different risks or different risk ratings Page 1 of 73

Andrew Jackson Transformation Governance Lead 10 October 2012 Archived Risks The following risks have been archived following approval at Transformation Programme Board and Transformation Programme Group. The table is included for completeness. Former reference

Risk description

Final Risk Score

Reason for archiving

Corporate Risk 2

The Trust continues to provide services based on current configuration beyond the end of June 2012 with reduced staffing and management arrangements already implemented as part of preparing for the go live process Tranche 1 and 2 implementation goes forward without satisfactory project support structures

4 moderate

The risk event has passed â&#x20AC;&#x201C; the event was linked to the decision to implement tranche 1 and 2 on 25 June 2012.

4 moderate

Programme Risk 7

There are areas of service delivery where quantitative data is not fully available to support the experiences of service users, staff and other stakeholders as described through process mapping and voice of the customer in the analysis and measurement phase of the care pathways work stream.

8 High

Programme Risk 10

Trust fails to meet one or more relevant NICE Guidance

2 Low

The risk event has passed â&#x20AC;&#x201C; the event was linked to the decision to implement tranche 1 and 2 on 25 June 2012. This risk was not properly defined and action to mitigate has remained rather vague and unfocussed in. It was decided at Transformation programme group that a new draft risk should be drafted to replace this risk and this has been inserted in the report (programme risk 31). The new risk awaiting Transformation Programme Group review and subsequent approval to be made live. Risk was given a final review and closed but Programme Risk 15 expands on the subject matter of this risk and is still live and being monitored.

Corporate Risk 3

Page 2 of 73

Corporate Risks (tier 1)

Note The Trust has achieved the required percentage for CPA reviews.

Lead Director

Deputy Chief Executive

Impact score

Risk score

Chief Operating Officer & Chief Nurse

* Delay in having full team structures within PARIS * Reporting team require full and complete structures within PARIS to inform the information team about how they need to configure their reports for performance reporting purposes * Delayed go live date to the last

* data quality issues possible given time limits for reporting * Impact on informatics team and others required to mitigate the risk *increases risk to FT status by red report to Monitor * impact on stakeholders and staff of reporting red * business objectives of transformation predicated on the Trust retaining its risk rating * Impact on risk rating and Monitor’s view of the Trust

4 Moderate

Risk of a red performance report to Monitor

4 Major

Impact of risk

1 rare

Risk description

Likelihood score

These are risks that affect the entire organisation because of the wide extent of their impacts, because of the extent of resources needed to address the risk or both. Summary of existing controls

Risk treatment plan



Meeting to discuss ongoing mitigation of the risk to be held - Ian Burgess, Alison Franklin and Richard Clayton. Clayton GREEN



The reports were run in May 2012 and gave services a partial view of potential non compliance with Monitor requirements Clinical commitment to monitor and ensure adequate performance against a select and prioritised list of key Monitor indices that expose the Trust to greatest risk, eg CPA reviews Reports are going to locality managers

Richard Clayton to discuss monitoring regime with Carrie Rae. GREEN Ensure that all reviews are counted as CPA reviews when they are de facto CPA reviews. reviews GREEN Identify any specific problem areas/ teams or individual clinicians for greater scope of monitoring by locality managers GREEN For those within a month or so of requiring a CPA review - carry this out as soon as possible GREEN

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Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

week in June ď&#x201A;ˇ

giving the latest position. CSMs repeating the need to staff with high levels of overdue CPA reviews to target these and reduce

Risk treatment plan

Locality managers have been given latest compliance reports GREEN

Comments: All actions are now complete â&#x20AC;&#x201C; risk is therefore a residual risk. The risk was approved to be moved out of the Transformation risk register and into the operational risk register for continuing evaluation.

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Programme Risks (tier 2) Programme risks are equivalent to Directorate risks where the objectives of the directorate are at risk and authority of Directors and Associate Directors is required to ensure the success of any risk treatment plan. In the example of Programme risks, the resources and authority ves ted in the Programme Board and, as its day to day agent, the Programme Group are needed to ensure that treatment plans will be suitably robust.

Tasks take longer than anticipated

Approval processes required add to length of time to develop ICPs

 

Risk score

Impact score

Lead Director

Deputy Chief Executive



Tasks not completed to the required standard or are delayed resulting in further delays to the project Frustrated staff affected by the transformation programme, resulting in low morale, resistance to change etc Incomplete pathways that do not fully meet needs of service users Financial targets not met within the

Chief Operating Officer & Chief Nurse

Insufficient resources to complete tasks outlined in the programme plan



9 High

Inability to meet project timescales.

3 Moderate

Impact of risk

3 Possible

Risk description

Likelihood score

Movement between tiers may occur and indeed several risks below were initially identified as tier 3 risks, but because of dif ficulties engaging treatment plans have been upgraded to tier 2. Summary of existing controls

Risk treatment plan

Update regarding risk actions

Regular review of dedicated resources by Associate Directors and actions agreed and implement to address any shortfalls.

Initial meeting with AD’s held and a number of actions identified. GREEN

Completed

Project Resource to be reviewed 3 Monthly via the TPG. TPG GREEN

Completed

Ensure that a comprehensive programme plan is developed and monitored through the Transformation Programme Group. GREEN

Completed

To complete and get approval for the Communication and Stakeholder Action Plan. Action Plan to be monitored through the TPG.GREEN .GREEN

Completed

An agreed project management and governance structure is in place. A stakeholder and Communication Action Plan is currently being developed which will ensure staff are communicated with effectively.

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Timescales set to ensure financial targets are met

required timescales resulting in savings decisions being made outside the project

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

A review of the current process to develop Integrated Care Pathways is currently underway. The resulting process will ensure that ICPs are developed effectively and efficiently. The project senior finance manager provides monthly finance reports to the Transformation Project Group and is also a member of the Care Pathways Work stream.

Risk treatment plan

Update regarding risk actions

Reviewed ICP Development and implementation process to be presented initially to the Care Pathways Work stream, followed by TPG and other groups as necessary for support and approval. approval GREEN

Completed

Progress of each IPC to be monitored by the Care Pathways Work stream and reported to the Programme Group and board by exception.

Completed

GREEN

Project Senior Finance Officer to work with the Care Pathways Work stream to identify the 'cost of poor quality'. GREEN

Completed

Identify, and have approved by Transformation Programme Board, a plan of financial mitigation to allow Inpatient transformation work to be delayed until later in 2013. Green

Complete

Develop and complete a post implementation process for elements of tranches 1 and 2 still to be fully implemented. GREY

Action due by 31 March 2013.

Comments on progress with risk: This risk is assigned to the Transformation Lead ead who has confirmed the view that it needs to remain at a high level despite all action being completed. The final risk treatment action has been agreed by the Transformation Lead Lead.. Additional actions have been included to recognise the need to initiate a post implementation plan for items originally scheduled for tranche 1 and 2.

Page 6 of 73

 

Risk score

Impact score

Likelihood score

Lead Director

Deputy Chief Executive



Resources taken from clinical services may result in a reduction of service provision Possible impact on services’ ability to meet agreed clinical performance standards Failure to meet identified timescales Incomplete /substandard final product / outcome

Chief Operating Officer & Chief Nurse

Insufficient resources/ capacity (people/ time/etc)



6 Moderate

Inadequate Project Resources

2 Minor

Impact of risk

3 Possible

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Transformation Business case outlining required resources for the project has been approved by the Board of Directors.

To take the necessary steps to enable staff to be released to the project. Resource issues/requirements reported at care pathway/other work streams and TPG meetings by exception. Unresolved issues reported to the TPB byy exception. GREEN

Completed

To develop a robust performance framework which demonstrates at an early stage that timescales may not be met. To report on Programme process by exception to the TPB. Where timescales are at risk, an action plan is developed describing actions needed to get the Programme back on track. Action Plan presented to the TPB. GREEN

Completed

Complete review of the ICP development and implementation process. New process to be presented initially to the Care Pathway Work stream, followed by TPG and other groups as necessary for support and approval. Progress of each IPC to be monitored by the Care Pathways Work stream and reported to the Programme Group and Board by exception. GREEN

Completed

AD have met to agree action plan to ensure backfill arrangements are expedited as quickly as possible, releasing people to the Programme. Some dedicated resources are now in place. Additional resources have been identified, but not yet in place, and are awaiting back fill arrangements to be completed. Dedicated resources are

Page 7 of 73

Continued

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

not released from clinical posts until back fill arrangements are in place.

Proposal to minimise the impact of capacity issues and staff with dual roles presented to the Transformation Project Board then monitored through the Transformation Project Group. Group GREEN

Completed

To hold workshop with senior managers to review timetable for work and access to resources. GREEN

Completed

The Transformation Lead to produce a business case for structures to support Transformation beyond March 2013. GREY

Action originally due by 19 October 2012.

An agreed programme management and governance structure is in place. PG monitors the progress of the Programme against the programme plan.

Although work is ongoing on this TPB informed of delays business case to timescales by the dealing for exception completion has been revised to 31 October 2012. Comments on progress with risk: Risk reviewed and given pressure of post implementation of Tranches 1 and 2, transformation of North Yorkshire and York and w ork to initiate tranche 3 in Leeds pressure on resources is becoming more of an issue. Project resources continue to be discussed byy the Transformation programme Board and Transformation programme Group. The final risk treatment listed above was a result of these discussions.

Page 8 of 73



The nature of this risk has changed considerably given the successful culmination of the NY&Y project.

Risk score

Impact score

Likelihood score

Lead Director

Deputy Chief Executive

Note:



Insufficient access to skilled resources within prescribed timescales Process to develop specific ICPs may be lengthened due to specific skills being unavailable Quality of ICP may be affected if skilled resources are not available and timescales cannot be extended.

Chief Operating Officer & Chief Nurse



6 Moderate

The Trust Growth Strategy could impact on the ability of the trust to deliver the Programme within the identified timescales

3 Moderate

Impact of risk

2 Unlikely

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

York and North Yorkshire Programme Group is a standing agenda item on the TPG meeting.

Review Highlight Report Template to ensure that Work streams are able to report workforce pressures on the Transformation Programme as a result of other trust projects taking priority. GREEN Work stream leads to ensure that any resource issues affecting the Transformation Programme as a result of the trust growth strategy and reported to the TPG through their monthly highlight report. report GREEN

Completed

The TPB through the Strategic Change Programme Manager highlight unmanaged resource risks as a result of the growth project to the Programme Board for their consideration and advice. GREEN

Completed

To complete the ICP process review. Care Pathway Work stream with the support of the TPG ensures the process includes adequate governance measure and controls. New Clinical Guideline and ICP lead to be managed by the Care Pathway Work stream Manager. TPG to ensure that ICP development follows the agreed governance and authorisation thorisation processes. processes GREEN

Completed

Appointment of a Programme Manager for the Trust's Strategic Change Programme now in post. Remit to work across key trust projects. AD Regional and In-reach Services is a member of both the TPG and the North Yorkshire and York Project, so is able to act as a conduit across the two projects. Work stream project

Completed

Page 9 of 73

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

plans are monitored by each work stream and delays identified.

Strategic Change Programme Board arrangements continue to operate. Strategic Change programme Manager attends Programme Group meetings for Transformation and North Yorkshire and York integration projects. 1:1 meetings with Exec Directors held in December 2011 to discuss the impact of double running on Transformation - all content with Directorate Arrangements and own support arrangements. GREEN North Yorkshire and York Services have now moved into routine service management structures with an AD appointed to manage these services on a day to day basis. GREEN Transformational elements of NY&Y services agreed to be brought within the Transformation Programme to avoid any potential for conflicting demands on Transformation resources between NY&Y and other services. GREEN

Completed

Concerns are reported to the TPG via the monthly work stream highlight report.

Risks to the Programme are assessed and actions identified to address shortfalls. Unmanaged risks are reported by the TPG to the TPB by exception.

Completed

Comments on progress with risk: All action complete â&#x20AC;&#x201C; risk is a residual risk.

Page 10 of 73



Risk score

Impact score

Likelihood score

Lead Director

Deputy Chief Executive



Lack of support for the proposals by key stakeholder groups including commissioners Failure effectively to promote new ways of working to trust staff groups resulting in difficulties to change working practices Lack of confidence by stakeholder that the proposed changes will deliver the perceived benefits

Chief Operating Officer & Chief Nurse

Failure to engage with stakeholders (internal and external at all levels)



4 Moderate

One or more key stakeholders do not support the Transformation Programme Proposals for change

2 Minor

Impact of risk

2 Unlikely

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Strategic Change Programme Communication and Stakeholder Plan in Place. Ad-hoc communications sessions with some stakeholder groups have already taken place.

Detailed Transformation Programme Communication and Engagement Action Plan to be developed and agreed. To develop a log of all Communication and engagement activities. To log feedback as a result of any communication and engagement. To ensure that feedback reaches the relevant Work stream to be considered and acted upon if appropriate. To report on engagement via the TPG performance rformance score card. GREEN To review the staff road shows in light of the agreed communication action plan. To review the role and membership of the Joint Operational Management meeting to ensure good management involvement in the Programme. Requests for communication and engagement activities to be managed through the Transformation Programme Manager. GREEN

Completed

CTQ measures to be prioritised using NHS Leeds prioritisation tool. Detailed method of monitoring change as a result of the Programme to be developed and agreed by the TPB. GREEN

Completed

Plans to increase roll out of information to external stakeholders via trust website. website GREEN

Completed

Staff Road shows take place on a monthly basis. Joint operational management meeting has been held between Adult and Older People's Services, with plans to extend across all directorates. Ad-hoc update meetings with staff groups across the directorate Measurable Critical to Quality Characteristics have been devised and agreed by the TPB.

Completed

Page 11 of 73

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

4. Initial proposals to develop a transformation score card have identified the need to demonstrate changes as the work of the Programme progresses

Risk treatment plan

Update regarding risk actions

Meeting with ASC and NHS Leeds communications leads on 23 March 2012 to plan steps to raise awareness of the transformation Programme to staff. Action completed. GREEN Generate content for partner organisations communications channels (Leeds Transformation Programme newsletter and Volition newsletter). GREEN Presentation booked for 9 May 2012 at Leeds North CCG implementation group for Integrating Health and Social Care.. Action completed. GREEN NHS Leeds South & East Clinical Commissioning Group - chair and lead GP for engagement to reply with date/appropriate action. action GREEN

Completed

Comments on progress with risk: Risk is a residual risk.

Page 12 of 73

Timescales are challenging for the implementation and full adoption by clinicians of different ways of working to deliver savings

Lead Director

Risk score

Impact score

Likelihood score

PR damage from delayed achievement of previously publicised CRES plans

Deputy Chief Executive

Cash releasing efficiency savings are almost entirely related to the workforce and hence the need to deal with complex HR/employment issues in achieving these savings

Summary of existing controls

Risk treatment plan

Update regarding risk actions



The following course of action was approved at February 2012’s Transformation Programme Board: Board  Implementation of a new operational st model on 1 June 2012 encompassing Tranche 1 and Tranche 2 services.  Delayed implementation of mobile technology resulting in £942k savings being deferred to 2013/14.  Mitigation of the admin skill mix saving following NHS Leeds agreement to provide £352k non recurrent support in 2012/13.  Further mitigation savings following NHS Leeds agreement to provide further non recurrent Transformation project support in 2012/13.

Completed



Chief Operating Officer & Chief Nurse

efficiency savings are not achieved in the prescribed timescales

A delay to the achievement of the CRES will adversely impact on the Income & Expenditure position in 2012/13 and potentially the Monitor risk rating

6 Moderate

Cash releasing

3 Moderate

Impact of risk

2 Unlikely

Risk description



Project leads clearly document CRES targets and sign off timescales in all project plans Developed a detailed financial mitigation plan and regularly report progress to project board and project group to enable corrective action to be taken at the earliest opportunity Project resources secured from NHS Leeds to fund backfill for key individuals to enable project timescales to be achieved. Transformation Project Lead given flexibility to allocate resources to ensure timescales are achieved

Agreed Transformation savings (£3.5m including mitigation) gation) for 2012/13 surpass the Transformation target by £332k. GREEN

Page 13 of 73

Competing demands placed on key individuals leading to Programme timescales not being met

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions



The Trust enjoys a significant margin on the extent its income and expenditure position can deteriorate before the risk rating (currently 4) would be threatened with reduction. This is currently slightly over £2M and hence this exceeds this year’s CRES attributable to Transformation. GREEN GR

Completed

The Trust Vacancy Management Group meets every two weeks and monitors the current staffing levels allocated between permanent and temporary staff. The current status is that the Trust is performing better than plan regarding the numbers of staff in permanent positions, i.e. it has more temporary contracts than plan and hence the risk to the CRES from workforce pressures is being effectively mitigated. GREY Additional contingency plans to provide mitigation to the risk to this year’s CRES are being developed. GREY

Due date is 31 March 2013.



Development of ICPs, ensure ICPs are evidence based, give value for money and include a range of quality measures. ICPs will ensure that clear and realistic workforce plans are developed giving clarity on which skill are required for each type of intervention. Vacancy Management Group control the recruitment process to ensure sufficient workforce flexibility exists to achieve the CRES

Due date 31 October 2012.

Comments on progress with risk: The risk above now represents the risk to the 2012-13 Transformation CRES plan which is largely around the implementation of inpatients service. service Work around the final treatment action is ongoing to mitigate the effects of not securing the 2012 -13 13 CRES and implementing the inpatient phase too quickly and without the full delivery of the post implementation projects.

Page 14 of 73

ICPs are shifting the balance of inputs to clinical care to different grades of staff

Sign off of contracts delayed or needing SHA intervention. Delays or causes significant changes to be required to the Programme. Reduced activity impact on amount of funding. Poor rating due to high reference costs.

Risk score

Impact score

Likelihood score

Lead Director

Deputy Chief Executive

Uncertainty regarding way of working on staff given lack of commissioner’s support. Impact on GPs from reduction in activity (future commissioners).

Summary of existing controls

Risk treatment plan

Update regarding risk actions



Seek contractual agreement in principle to contract changes. GREEN

Completed

Continue to work with other sectors to explain and gain understanding about impacts to their workload. GREEN

Completed

Use output from early implementers to make the case for service quality improvements. GREY Superseded

Though not specifically done subsequent meetings with GPs by senior staff have used quality improvement information. Due date 31 March 2013. Work is ongoing with commissioners

 Chief Operating Officer & Chief Nurse

Transformation work streams are seeking reductions in activity – outpatients

Distress and concern to SUs if new systems are delayed or there is uncertainty over how they will be treated. Conflict re contract lines in Contract Management Board.

8 High

Commissioners do not accept or agree to changes to activity and service provision brought about by Transformation and service changes may reduce contract value or increase reference cost

4 Major

Impact of risk

2 Unlikely

Risk description



Main commissioner support (NHS Leeds) has been obtained for the principles and methodology of the project Regular contract management meetings with Commissioners including sharing service development proposals for comment PR activity regarding objective of making services better not merely concentrating on reducing costs New models to ensure equity of new contract value ICP design is based on MH clusters

Ensure that commissioners continue to be informed and involved and are in agreement to changes. GREY

Potential impact on PbR.

Page 15 of 73

Alternatives to hospital care are potentially signposting service users to other alternative methods of healthcare delivery Localities are being restructured The Trust is shifting to an ageless model for treating service users Activity lines will show significant variation to current contract value

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

To set up quarterly meetings with commissioners. commissioners GREY

Due date is 28 December 2012.

Engagement with GPs by Locality Managers regarding commissioning and service issues. issues AMBER

The action was due by 30 September 2012.The Clinical Support Manager has scheduled this for a discussion with Locality Managers to implement a series of meetings. This is an ongoing process â&#x20AC;&#x201C; meetings have already occurred and will continue. Due date for completing this action is 31 January 2013.

GP visits involving senior staff involved in Transformation and senior Trust clinicians to act as a method of obtaining feedback and suggestions. GREY

Comments on progress with risk: An ongoing engagement with service commissioners is taking place place. Key service charges relating to new models have been shared and this t activity means that the specific action relating to the early implementer has been superseded. Feedback from key staff regarding this risk is that hat commissioners do accept the reasons our Trust is transforming its services.

Page 16 of 73

Trade off between day to day activities and working, at short notice, on transformation requirement

Lead Director

Risk score

Impact score

Likelihood score

Functionality of PARIS could be sub optimal for a period if at the date of implementation reconfiguring structures is still a work in progress Could delay implementation dates

Deputy Chief Executive

Ability to schedule key staff may be compromised - may have implications for staff capacity given other commitments

Chief Operating Officer & Chief Nurse

Extent of changes needed are unknown and hence impact on ICT staff time cannot easily be gauged

Extreme time constraints may impact on the quality of ICT's solution to reconfiguring PARIS

6 Moderate

Delays and uncertainty in finalising team structures could cause delays in reconfiguring PARIS in time for the commencement of implementation dates

3 Moderate

8.1

Impact of risk

2 Unlikely

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Additional resources have been secured by ICT so there are more staff able to respond to change requests

The release of information regarding structures features in the high level el critical path for the Programme ensuring that the impact of delay can be properly identified. GREEN

Completed

Example system structures to be developed in a PARIS test environment for evaluation. (Superseded) GREY

Action regarding example structures being developed was not carried out in the run up to go live although the PARIS test environment was used for testing

Meeting on January 6 2012 involving the Head of Information and Knowledge and other staff have agreed a way forward in dealing with change requests

May need external resourcing Could cause service dislocation and logistical/ service quality issues in the short term

Page 17 of 73

Methods of communicating change requests may not be clear, delivered to the correct person or give sufficient time to undertake work

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Clare Hoppitt and Kim Lacey to meet week of 12/3/12 regarding structures. structures Action completed. GREEN

Completed

Operational group and TPG have set 1 May 2012 as the deadline for receipt of all team/staff information. Action completed. GREEN G

Completed.

Comments on progress with risk: This risk describes a past event and approval for the risk to be archived will be sought via the Transformation Programme Gro up.

Page 18 of 73

Risk score

Impact score

Likelihood score

Lead Director

Summary of existing controls

Risk treatment plan

Update regarding risk actions

LD Obesity ICP has been reviewed and is being implemented in PARIS

Review and map the benefits of the LD ICP pathway and measure against future ICPs to ensure alignment or alert to variance. GREEN

Completed.

Set up a reporting mechanism to provide full details of all ICPs to the PARIS authoring team (IT) as they are developed. GREEN

Completed.

HIS work stream lead and Mobile project lead attempting to meet with ICP authors Deputy Chief Executive

Chief Operating Officer & Chief Nurse

PARIS is being tested to demonstrate and verify that it can effectively support new Integrated Care Pathways.

If the Programme is not able to specify and sign off ICPs until 01/04/2012 full PARIS support to the ICPs will not be available until after this date.

3 Low

The known elements of ICP's are additional forms/checklists to be built in PARIS. This is established technology and has been deployed many times within the Trust's PARIS system. There is a risk that ICPs will require additional technology which has not been articulated by the Programme.

3 Moderate

8.2

Impact of risk

1 Rare

Risk description

Page 19 of 73

As the scale of the change required to PARIS is not known the resource and cost of implementing change is not known and cannot be factored into the Programme.

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Provide details of other ICP components. components Superseded given the system identified in action 2 above. GREY

Action covered in connection with action 2.

Comments on progress with risk: PARIS systems management has confirmed that all requested information for build purposes has been delivered. An interim review has been requested to acknowledge the linkage between ICP development and the IT team. Additional control controls have been identified and will be documented.

Page 20 of 73

Lead Director

Risk score

Impact score

Likelihood score

Negative publicity

Notification not seen as an integral part of systems design and improvement

Deputy Chief Executive

Impact on Programme timescales Chief Operating Officer & Chief Nurse

Unfamiliarity of most staff with CQC reporting and notification requirements

Impact on registration

4 Moderate

Events requiring CQC notification are carried out through transformation and these are not reported to the performance team

4 High

Impact of risk

1 Rare

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Programme plans should disclose any requirement for CQC notification as a result of service changes

Staff to be made aware of requirement to identify potential registration issues as they plan their Programmes. GREEN

Completed.

Review of Programme plans by Programme management staff and as part of the compilation of the critical path to check on any potential registration issues and timelines for notification. notification GREEN

Completed.

The Head of Performance is a member of the Transformation Programme Group

Comments on progress with risk: All action complete â&#x20AC;&#x201C; risk is a residual risk.

Page 21 of 73

Lead Director

Risk score

Impact score

Likelihood score

Programme timescales are not adhered to resulting in efficiencies not met fully

Deputy Chief Executive

Impact of double running during the process of change - see other Programme risks

Chief Operating Officer & Chief Nurse

The complexity of the Programme will be difficult to manage and coordinate

Poor co-ordination and management of Programme resources

6 Moderate

One or more outcomes of the Programme will not be achieved

3 Moderate

11.

Impact of risk

2 Unlikely

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Programme management and governance arrangements in place and relevant documentation produced and maintained.

To review and agree terms of reference for Programme Board, Programme Group and Work streams. GREEN

Completed.

To complete detailed Transformation Programme Plan. GREEN

Completed.

To complete development of Programme performance score card.. GREEN

Completed.

Clear project management systems in place for Programme work streams Detailed Programme Plan currently being developed Plans in place to develop a robust Programme performance scorecard

Comments on progress with risk: All actions are complete - risk remains as a residual risk.

Page 22 of 73

Inability to meet Programme timescales

Remaining services will continue to operate with the same level of inefficiency.

Lead Director

Risk score

Impact score

Likelihood score

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Robust Programme management arrangements and structure

Ensure e that work stream leads and implementation project leads identify any additional risks not covered in those risks identified above. GREEN

Completed.

Programme risks reviewed monthly at Transformation Programme Group and Programme Board Deputy Chief Executive

Reductions in services and access to services for service users when they need them and when these services would add most value.

Chief Operating Officer & Chief Nurse

The transformation Programme could fail to a lesser or greater extent from a number of causes:

The impact of Option 1 The consequences of this are also detailed in the Business Case: Potential loss of skills from within the workforce which will prove detrimental to the delivery of care to service users and which may need future investment to reinstate. 4 Moderate

The Transformation Programme will not achieve its aims of implementing a new, high quality, patient centred pathway across all ages and its ambitious CRES target of ÂŁ5.258M, over 2 years 2012/13 and 2013/14

4 Major

12.

Impact of risk

1 Rare

Risk description

All Work streams and Implementation Projects are developing robust project summaries and project plans/milestone trackers Performance Framework under development to provide comprehensive reports to the Programme Board, Executive Team and Board of Directors

Page 23 of 73

Inadequate Programme resources Failure to meet NICE guidance Lack of stakeholder support Impact of the trust's growth strategy not met

The core business of the LPFT would remain poorly defined meaning that reductions in social care and third sector mental health provision could tacitly become the work of LPFT services. The service user experience is not firmly embedded at the centre of any changes to services which they receive.

Changes to commissioning arrangements

Reductions in resources to meet CRES targets likely to impact in some services more than others

PARIS - Systems Management PARIS â&#x20AC;&#x201C; ICPs

Skills deficits likely to impact in some services more than others

Failure to meet CQC and Monitor requirements

There is insufficient time to ensure that teams have access to the right skills to enable interventions to be provided as prescribed in Integrated Care Pathways

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Workforce and Development work stream led by Associate Director HR with representatives from HR, Staff side and Clinical Leads

Develop and agree a process within the Programme to identify, review and monitor Programme risks. risks GREEN

Completed.

Proposal for an evaluation of the Transformation Programme to include elements of monitoring change in culture and measuring the impact of changes on the identified Critical to Quality characteristics

Page 24 of 73

Staff are unable to change their working practices within the required timescales

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Completion and agreement of Programme performance framework which will include an update on Programme risks.. GREEN

Completed.

There could be an impact on safety of patients during the process of transferring from one model to a new one Comments on progress with risk: Risk reviewed in February 2012 when all action identified as complete. The Transformation Programme Board has authorised that Tranche 3 (Leeds inpatient) implementation is rescheduled to October 2013 and that a plan of financial mitigation be developed. The Transformation Lead has therefore asked that the risk be revised for the next report to cover this new factor.

Page 25 of 73

Risk score

Impact score

Likelihood score

Lead Director

Deputy Chief Executive

Chief Operating Officer & Chief Nurse

The Transformation Programme needs to test new systems and new ways of working whilst current systems and ways of working are still in place.

* Impact on staff accommodating new ways of working, change of base. * Impact on service users managers less time to focus on clinical quality issues e.g. clinical supervision. * Some service users will be transferred to new services / workers. * Staff not available to maintain service as a result of mergers * Impact on PARIS configuration and reporting due to timescales around mergers. * Small impact on transformation budget to fund backfill. * Some small scale local disruption to Aire Court and some Acute Community Services.

6 Moderate

Staff having to accommodate more than one way of working at relatively short notice and having to work intensively during the period of transitions from the old ways of working to the new ways of working.

2 Minor

13.

Impact of risk

3 Possible

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Provide additional resources to support the testing and change processes.

To continue to provide resources where needed to support transfer from old to new ways of working. GREY

Action due to complete on 31 December 2012 The action is being pursued by short term temporary staff to assist admin workloads. Completed.

Monitor situation through regular update thought work streams/project, TPG and TPB to identify any significant developing issues. Development of implementation plans which are monitored through the use of project documentation and critical path.

Aire Court earlier implementer site to report to TPG on lessons learned from their process. GREEN

To ensure that service users and carers affected by changes to services are communicated with appropriately. GREY

To develop a process /guidance to Projects to ensure that Informatics are given reasonable notice of any changes to team structures. GREEN

Action due to complete on 31 December 2012. The Transformation Lead has attended Service User forums recently. Completed.

Page 26 of 73

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Short term management changes will be considered on an individual manager basis to assist individual managers to deal with and manage their increased workload due to double running/ having a dual role

A detailed plan for managing transition from current roles to new roles will be developed by the Operational Work stream. GREEN

Completed.

A manager from the Development team has been seconded into the Operational Work stream to assist in developing mechanisms to allow staff to move roles and cope with change. GREEN

Completed.

Ask for periodic sickness rate data relevant to services where double running has been identified as a potential problem. GREY (Superseded)

Ad-hoc arrangements are in place and locality managers are monitoring for any specific issues. Action is due by 31 December 2012. A requirement for this review is contained in the post implementation plan.

Post Implementation Plan to include a review of workforce development needs and skills. GREY

Comments on progress with risk: Action is continuing against the outstanding areas.

Page 27 of 73

Lead Director

Risk score

Impact score

Likelihood score

Complexity of Potential financial impacts of the delay. interdependenci The ability to identify smooth es between transition between service activities in a models, movement to new number of locations etc could affect different work existing services. stream plans. Comments on progress with risk: All action complete â&#x20AC;&#x201C; risk is a residual risk.

Deputy Chief Executive

Poor morale and impact on the Trust if the Programme is delayed due to failure to deliver a key element on the critical path. Implementation of the Programme will be delayed and impaired.

Chief Operating Officer & Chief Nurse

Failure to capture all implementation milestones in the operational plan following merger of the Tranche 1 work streams.

External evaluation criticism of the Programme management process. Potential duplication of effort or staff effort not appropriately prioritised to Programme critical activities.

6 Moderate

The Transformation Programme critical path is not signed off and agreed.

3 Moderate

14.

Impact of risk

2 unlikely

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

The Operational Work stream meetings consider key milestones and identify progress/delays on a weekly basis

Produce a complete critical path using Microsoft Programme. Previous work undertaken has been discussed with NHS. GREEN

Completed

IMAS Programme Management support and through IMAS Action Learning Set. GREEN

Completed

Situation Report system developed and daily reports to Chief Operating Officer & Chief Nurse/Deputy Chief Executive have commenced. GREEN Programme Plan discussed at Programme Group 15/03/12 to ensure consistency with existing plans and targets. GREEN

Completed

Get Transformation Programme Board approval and sign-off. GREEN

Completed

Refine the review techniques to identify risks to activities listed on the critical path. GREEN

Completed

Page 28 of 73

Elements of guidance may have been missed by staff

Risk of adverse publicity if an adverse clinical incident is linked to a systemic absence of relevant NICE guidance. A fundamental quality aspect of the Programme could be impaired. Claims could ensue.

Risk score

Impact score

Likelihood score

Lead Director

Deputy Chief Executive

Impact on staffing professional competence impacts of working in clinical systems where elements of NICE guidance are not present. Risk of adverse external inspection ratings.

Chief Operating Officer & Chief Nurse

Extent that ICPs have been modified may have led to the inadvertent exclusion of guidance by mistake

Potential patient safety element of guidance is not included in the ICPs. Clinical quality affected services will not meet standards.

2 Low

ICPs fail to include all aspects of NICE guidance as they go through development and approval stages.

2 Minor

15.

Impact of risk

1 Rare

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Any potential issues will be flagged up to Performance Team and reported to Medical Director for relevant discussions within Executive Team.

Ensure that all completed ICPs are discussed and evaluated by the Clinical Quality and Risk SSG (and any other relevant MG1/2 G1/2 SSG) Note: This will be an ongoing action as ICPs are developed for future tranches. GREY

Action is due for completion on 31 March 2013. This is an ongoing action taking into account all phases of the transformation work.

ICP authoring teams will include clinical staff and there will be clear links with the trust performance team. Ensure that the ICP development process includes clear clinical governance support and guidance. Appointment of a trust Clinical Guidelines lead and ICP Lead.

Page 29 of 73

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Ensure that the

Ensure ICPs are formally approved by MG1/2 Note: This will be an ongoing action as ICPs I are developed for future tranches. GREY

Action is due for completion on 31 March 2013. This is an ongoing action taking into account all phases of the transformation work.

Programme plan details how ICP implementation ensures that NICE Guidance is adhered to during the process of change from the old system of care delivery to the ICP system.

Comments on progress with risk: Risk expands on Programme risk 10 (now archived).. Both actions in the risk treatment plan are ongoing monitoring actions not due to be completed until March 2013.

Page 30 of 73

Risk score

Impact score

Likelihood score

Lead Director

Deputy Chief Executive

Chief Operating Officer & Chief Nurse

The peer support model is not adopted to embed recovery at the heart of transformed services.

* Best practice and guidance regarding recovery is not being met. * Miss the opportunity to embed recovery at the commencement of new and transformed services. * Services remain medically orientated and do not meet current policy on recovery focussed practice. * Inadvertently encourage a culture of dependence. * Financial efficiencies that can be delivered via recovery focussed care not achieved. * Loss of a valuable method for moving service users through services and out to primary care via discharge. * Loss of opportunity to reduce re-admission rates via

6 Moderate

Recovery will not be embedded at the heart of transformed clinical services at our Trust.

3 Moderate

16.

Impact of risk

3 Unlikely

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Service development workers - recovery and social inclusion team are present in the Trust.

Trust approval of the business plan to introduce peer support worker roles within the Trust. Trust GREEN

Completed. Confirmation from Finance has now been received regarding the success of a bid to the PCT to get one year funding for a pilot. Action is due by 31 October 2012. A meeting was held with staff from the Trust, Adult Social care and Leeds PCT to take this forward on 5 October 2012.

Volunteers in post in the Trust and hence service users can receive advice and support by those with lived experiences. Trialled Recovery practitioners in 201112 and their impact is being evaluated by Leeds M University In house module on

Employment of staff to take up the roles identified in the business case. GREY

Recovery practitioners continue some elements of their role within the new CMHT structure to support discharge. (Superseded) GREY

Action 3 is superseded as these roles are now disbanded

Page 31 of 73

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

recovery approach to care. recovery and social Explore additional funding bids for recovery Completed * Staff may not be working in inclusion module practitioners. GREEN recovery focussed services accredited by Leeds M and may miss valuable University attended by development opportunities. SUs, carers and staff * Staff with recovery and social inclusion training will not have their skills used to best effect. * Potential for redeployment into recovery roles from persons at risk. Comments on progress with risk: Risk treatments are progressing in identifying staff and management arrangements to take up recovery worker posts. Risk has had an interim review and likelihood score now reduced to unlikely given successful funding information.

Page 32 of 73

The single referral form will not be designed or, if designed, will not have been developed and tested prior to implementation of Tranche 1 and 2 in June 2012

Patient information captured at referral inconsistent or incomplete

SPA and SPUR task and finish group have, at the date of the risk being drafted, not yet designed the form

Staff would have to revert to a manual procedure

Lead Director

Risk score

Impact score

Likelihood score

Potentially more labour intensive interim solutions Damaging internally to staff views on implementation of Tranche 1 and 2 from clinical perspective

Deputy Chief Executive

Usability of PARIS compromised

4 Moderate

Impact on clustering

Chief Operating Officer & Chief Nurse

Potential impact of untested form on commissioning data and statutory reporting

4 Major

Impact of risk

1Rare

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Assistance is being provided to work stream lead to allow them to focus on this as a matter of priority

Task and Finish group and Ian Burgess to meet with a block of time dedicated solely olely to form design to ensure this is delivered by 1 May 2012 (this will deliver a form that can be developed for PARIS by 1 June but the form may be still untested). untested) Action completed. GREEN

Completed

Additional business analyst support provided for the T&F group to design in PARIS functionality at the discussion level Capacity will be found by the UDF development individual to aim for development of the form if design is delivered by 1 May 2012

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Significant development and testing time is needed after the form has been designed to produce and quality assure the effectiveness of the form within PARIS

Limits the effective implementation of Tranche 1 and 2 and the introduction of the ICP

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Clinical testing of the component, i.e. the single referral form, to be completed. This allows time for reworking and then re-testing testing. GREEN

Completed

Jeanette Lawson to obtain clinical cli sign off from SPA/SPUR Task and Finish Group. GREEN

Completed

Demands on staff time for manual system as an interim solution could impact other areas of service

From development and testing output potential rework of the design may also be required Comments on progress with risk: All actions complete â&#x20AC;&#x201C; risk refers to an event in the past past, i.e. the implementation of SPA/SPUR. The actions prevented the risk occurring. Approval will be sought from the Transformation programme group for the risk to be archived.

Page 34 of 73

* SU does not wish to be discharged, causes anxiety

Lead Director

Risk score

Impact score

Likelihood score

* SU health suffers * Readmission required – possibly urgent * Impact on GPs and secondary health sector * Publicity/ complaints * Quality of services – CQC impact

Summary of existing controls

Risk treatment plan

Update regarding risk actions



Benchmarking - Individual consultant’s caseloads will be considered against internal benchmarks. Line management supervision/discussion to be carried out by Associate Medical Directors.RED Directors.

Due by 31 July 2012. Some work looking at caseloads was prepared by informatics but has not formally been taken forward and used to identify where action is needed. The work and metrics carried out by informatics is available as a suite of reports within COGNOS – this will be an essential part of caseload review by the new projects.

Deputy Chief Executive

Chief Operating Officer & Chief Nurse



9 High

Risk of inappropriate discharges and SUs disengaging from services as part of changes in structures occurring as part of the transformation of services including reduction in medical activity, changed clinical pathways and geographical changes to where services are based. * Unclear criteria are used to assess risk of discharge to localities

3 Moderate

Impact of risk

3 Possible

Risk description

Part of an ongoing review and rationalisation of caseloads that has been occurring for some time Process to be carried out over an extended period rather than rapidly which will reduce errors

The Deputy Director of Care Services will take this matter up with the AMDs for Older People’s Services and Adult Services

Page 35 of 73

their clinical contacts * Changing teams and relationships * Incomplete data or clinical knowledge regarding SU history particularly when SUs are transferred between clinicians/ teams following changes * SUs disengage as part of changes â&#x20AC;&#x201C; change in teams and clinicians and loss of built up trust/confidence

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

A system of peer review was to be developed to consider complex discharge decisions. RED

Due by 31 July 2012. Meetings took place in April and May 2012 involving medical staff and operational management. The use of recovery workers to work with clinicians with the highest caseloads was seen as a way forward. The use of recovery support workers will feature in the new outpatients project. The Deputy Director of Care Services will take this matter up with the AMDs for Older Peopleâ&#x20AC;&#x2122;s Services and Adult Services

Page 36 of 73

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Urgent communications with SUs regarding changes. changes GREEN

Completed

A guideline,, giving basic principles for communication with service users and their carers regarding the changes brought about by Transformation, will be developed by the clinical T&F group and CSMs for ratification by the Operational Work stream. Learning from rom CTS experience to be used in this piece of work. AMBER

This guide was discussed at Transformation Programme Group and it was decided not to use it. Guidance prepared by Adult Directorate was used instead. Completed

Agreement to be sought that the process regarding discharge will be extended and some flexibility will be available to clinicians in dealing with discharge of service users. GREEN

Page 37 of 73

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Caseload reviews undertaken by consultants will look at specific mechanisms for managing this risk regarding the key group of service users who may move between all clinical and medical professionals but still require to be seen by our services. RED

Due by 31 July 2012. The clinical task and finish group working in the original outpatients project proposed some basic measures. These were not taken further at the time although a protocol developed by the Adult Mental Health directorate was used instead. The Deputy Director of Care Services will take this matter up with the AMDs for Older Peopleâ&#x20AC;&#x2122;s Services and Adult Services

Page 38 of 73

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Develop a protocol for the transfer of service users and ratify via operational processes. processes GREEN

Completed

Comments on progress with risk: Overdue actions above are essential elements of the overall outpatients project â&#x20AC;&#x201C; the delay in recommencing the outpatients project and picking up the actions above is the reason for the failure to implement the three risk treatment actions in red above. The he actions above remain valid and to some degree would need to be included within the tasks of the new outpatients project. Please Note: A separate report regarding the outpatients project is also on the Board of Director Directorâ&#x20AC;&#x2122;s Agenda for the 30 October 2012 meeting. meeting

Page 39 of 73

Lead Director

Risk score

Impact score

Likelihood score

Summary of existing controls

Risk treatment plan

Update regarding risk actions

ď&#x201A;ˇ

Richard Clayton to discuss with Debbie Ward the potential to liaise and obtain commissioner support in delayed contract reporting. reporting GREEN

Completed

Richard Clayton to discuss with Carrie Rae. Rae GREEN

Completed

Ongoing discussions with Commissioners to ensure they continue to appreciate the reasons for problems in reporting.. GREEN

The commissioners have now accepted changes to the transformation contract activity lines. Action completed.

ď&#x201A;ˇ Deputy Chief Executive

Chief Operating Officer & Chief Nurse

* Slippage in implementing tranche 1 and 2 to the last week in June * Workload around transformation, staff movements, change of base, change of team structures, change of referral system used etc will cause delays in data input

* Loss of commissioner goodwill * delays in understanding performance against contract requirements * Less effective performance reporting

6 Moderate

Inability to meet contract reporting timescales

2 Minor

Impact of risk

3 Possible

Risk description

Meeting held to identify potential consequences and required controls held 25/4/2012 At a meeting with NHS Leeds the contract lines not being representative of post transformation service models were discussed. As part of this there was acknowledgment that there may be some variation in the following months as we rewrite and refine the procedures.

Comments on progress with risk: Risk has been interim reviewed and the likelihood of the risk occurring has been reduced from almost certain to possible. The risk is a residual risk but will require monitoring in light of future changes to structures and services services.

Page 40 of 73

Lead Director

Risk score

Impact score

Likelihood score

Summary of existing controls

Deputy Chief Executive

ď&#x201A;ˇ

Chief Operating Officer & Chief Nurse

* Original training sessions allocated for modular training have elapsed without take up by staff * Three month advance notice needed to book new sessions * Build days for supporting material, data sets etc have partially elapsed with no instructions regarding required materials

* Potential delay in entering clinical data * Impact on data quality caused by staff without adequate training * Staff in positions without identified skills to do their jobs * Staff training records and CQC reviews could identify poor or inadequate competencies re PARIS * Incompatible with transformation objectives right staff, right skills maxim * Impact on clinics and caseloads

4 Moderate

Tranche 1 and 2 will go live with some staff not having had all requisite PARIS modular training

4 Major

Impact of risk

1 Rare

Risk description

ď&#x201A;ˇ

Trainers have had demonstration of the functionality of the new holistic assessment and CPA - asking trainers to develop supporting training material for self tuition Supplied OD with full list of all staff trained on PARIS with details of existing training on PARIS elements

Risk treatment plan

Update regarding risk actions

Review by senior clinical management of all committed training on PARIS over May to prioritise those staff needing urgent training based on service commitments (Lynn Parkinson - Gary Hostick). Following discussion at TPG 26/4/12 this action was planned to also involve Ray Wallum and Kim Lacey.. GREY (Superseded)

This action was not implemented and has been superseded by the passage of events.

TNA produced and risk rated for the most urgent PARIS training to be prioritised (Dave Gaunt). Partial TNA done and additional information indicates very low need from admin staff. GREEN

Completed

Review the potential for train the trainer or other rapid rollout solutions (Claire Hoppitt) The view is that admin training needs can be met through mainstream training. training GREY (Superseded)

Following the evaluation of the training needs analysis very few staff were identified as needing additional training thereby making this action superfluous. Completed

Complete TNA for CSU staff and need for modular training. GREEN Develop turbo demo and instructions for holistic assessment rollout. GREEN

Completed

Comments on progress with risk: The risk relates specifically to tranche 1 and 2 and hence deals with an event that has passed. Approval from the Transformation Programme Gro up will be sought to archive this risk.

Page 41 of 73

Risk score

Impact score

Likelihood score

Lead Director

Medical Director

* Unclear terms of reference regarding expected outputs * Timescale required is prohibitive * Insufficient resources made available

* Complaints may increase given inability to assure stakeholders about the robust method used to develop services * Professional groups may be concerned or anxious regarding new pathways without external independent evaluation * CQC and Monitor may comment adversely on a key omission in our intended assurance process around transformation * Adverse publicity and ill conceived or groundless negative comments will be harder to refute

6 Moderate

The evaluation of transformation is not completed

3 Moderate

Impact of risk

2 Unlikely

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

ď&#x201A;ˇ

Obtain external assistance in drafting proposal. proposal Mary Godfrey has contributed to the first proposal and subsequently York University. there has been GREEN

Complete

Meet with University of York staff to discuss evaluation methodology and nature of internal evidence gathering/assurance and governance processes and secure their ongoing involvement in the evaluation. evaluation GREEN

Complete

CTQs and KPIs offer some limited assurance in the absence of external evaluation

Comments on progress with risk: All action complete and risk is a residual risk.

Page 42 of 73

Lead Director

Risk score

Likelihood score Impact score

Summary of existing controls

Risk treatment plan

Update regarding risk actions

ď&#x201A;ˇ

Informatics are asked to identify dedicated time/individualss to input to the process. process GREEN

Complete

Lessons learned from conducting the LTQ baseline are used to minimise impact and any duplication of data collection. GREEN

Complete

A project manager is appointed to coordinate activity and ensure a lean process is adopted for evidence gathering phases of the evaluation. evaluation GREEN

Complete

Funding is secured for the additional LTQ work required to assess staff wellbeing and engagement and service user and carer feedback. RED

The Head of Research and Innovation is still attempting to confirm the receipt of funding.

ď&#x201A;ˇ

Medical Director

* Capacity of staff to provide data or complete questionnaires may lead to reduced feedback * Lack of agreed Trust Patient reported Experience Measures or Patient Reported Outcome Measures * Conflicting demands on informatics staff time means that information may be late or incomplete

* Inability to assure external evaluators * Methodology questioned by staff * False assurance is given leading to wrong decision making * Impact on staff in terms of double running issues and workload * Stakeholder criticism 6 Moderate

The quality of the evaluation of Transformation is compromised

3 Moderate

Impact of risk

2 Unlikely

Risk description

External validation should identify poor quality issues The Leading To Quality (LTQ) work is an external evaluation

Comments on progress with risk: Risk still has confirmation of leadership to quality funding as outstanding. This is being actively followed up.

Page 43 of 73

Lead Director

Risk score

Impact score

Likelihood score

Summary of existing controls

Risk treatment plan

Update regarding risk actions



Contribute to the Out Patient Work stream Task and Finish Groups. AMBER

The Lead Support Service Manager was a member of this group but the group has ceased.



Deputy Chief Executive

 Chief Operating Officer & Chief Nurse

Out-patient work stream does not deliver a 50% reduction in outpatient clinics

Current workload for admin staff continues, therefore no opportunity to reduce the amount of admin support without risking delays in patient information being input or sent out to relevant external parties e.g. GPs.

12 High

Unable to reduce the amount of Admin support, identified as part of the Admin Skill Mix Project

4 Major

Impact of risk

3 Possible

Risk description

Project Milestone Tracker Work stream Action Plan Representation at the Outpatient Work stream meetings

Utilise IT Solutions wherever possible to contribute to lean and efficient working.. GREEN

The Lead Support Service Manager will be a key member of the new project group looking at outpatients. Completed

Management of Change Plan. Plan GREEN

Completed

Ongoing consultation with Consultants and Service Leads regarding local admin support structures. structures GREY

Due by 31 October 2012.

Use of Bank staff to supplement the admin support structures as an interim measure. measure GREY

Due by 31 December 2012.

Implementation of a Digital Dictation System to try Due by 31 and improve the workflow. GREY January 2013. Comments on progress with risk: This risk is linked to the outpatients work stream and d action is being delayed due to limitations in reducing outpatient activity and the decision to end the outpatients task and finish group. This risk remains high because we are relying on bank and agency staff to address operational pressures. Please Note: A separate report regarding the outpatients project is also on the Board of Director ’ss Agenda for the 30 October 2012 meeting.

Page 44 of 73

Risk score

Impact score

Likelihood score

Lead Director

Deputy Chief Executive

Chief Operating Officer & Chief Nurse

* Outpatient and community activity does not diminish or does not diminish as rapidly as required given lead time required for planned discharge * Reducing caseload is time intensive and complex work requiring significant clinical input and is usually done

* Time for appointments lengthen * Pressure on staff leading to stress and low morale * Reduction in time available for face to face service user time * Financial pressure if clinical need forces locum/ bank solutions to meet targets * Service users not seen as frequently as required * Impact on safety of SUs * Cut in care for people with MH problems * Overall quality of outpatients / medical community services service declines

16 Extreme

Clinical staff engaged in outpatient and community based work have same levels of activity to deal with but less resources from 1 June 2012.

4 Major

4 Likely

Impact of risk Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions



Reduce medical outpatient and community work caseload by discharging SUs where there is no further clinical reason for seeing them. Institute discharge planning anning process as soon as possible. RED

Action was due by the 31 July 2012. This process has not formally commenced.

T&F group set up with express objective of reducing outpatient and community based consultant activity

For SUs still requiring to be seen – identify those that can be seen by other members of the clinical team. RED

The Deputy Director of Care Services will take this matter up with the AMDs for Older People’s Services and Adult Services Action was due by the 31 July 2012. As in the above action this has not yet commenced. The Deputy Director of Care Services will take this matter up with the AMDs for Older People’s Services and Adult Services

Page 45 of 73

Risk score

Likelihood score

Update regarding risk actions

over a longer time frame

Standardise appointment times for new referrals and follow ups. GREEN

* Fewer Speciality doctors available following post being taken out of structures * Administration staff resource cut to meet CRES target

Develop and have adopted a protocol forbidding discharge/transfers from CMHTs to outpatient. outpatient GREEN

Complete. However, this has not been possible to implement in PARIS because of the continuing size of medical caseloads. Complete

Lead Director

Risk treatment plan

Impact score

Impact of risk Risk description

Summary of existing controls

Page 46 of 73

Lead Director

Risk score

Impact score

Likelihood score

Impact of risk Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Explore ways of reducing or having routine drug monitoring eg Clozapine and for those on drugs to treat Alzheimerâ&#x20AC;&#x2122;s disease done by other MH professionals or by GPs. Requires high level discussion between the Trust and GP groups in the city. RED

Action due by 30 June 2012. Clozapine monitoring has been transferred from the Citywide Treatment Service to each of the ICSâ&#x20AC;&#x2122;s in the community locality team in order that this is undertaken locally to ensure that the close monitoring required is embedded within the care and treatment plan.

Page 47 of 73

Lead Director

Risk score

Impact score

Likelihood score

Impact of risk Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

continued

Dementia drugs were discussed at the LMC meeting on 14th September it was agreed that when secondary mental health service intervention is not required that discharge should take place. The AMD for Older Peopleâ&#x20AC;&#x2122;s Services has been asked to scope the implications of this.

Page 48 of 73

Lead Director

Risk score

Impact score

Likelihood score

Impact of risk Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Review other documentation/demands on staff time until position improves and case reduction starts making in-roads roads to reducing medical workload, eg audit and who carries out audits, assessments â&#x20AC;&#x201C; discuss with Executive Team. RED

Action due March 2012

Impact of SPA on identifying and redirecting referrals regarding SUs who should not be seen in secondary services ie those not attending 1st outpatient appointments and subsequently discharged without being seen or those discharged after 1st appointment. RED R

Meeting to develop a mechanism of consultant caseload reduction being organised. GREEN

The Trust audit cycle was adjusted to alleviate work load pressures. Monitoring of caseload size in place. Review of case load size and complexity being undertaken by Lead nurse in conjunction with review of Tranche 1 and 2 services Action due by 1 April 2012. This action was affected by the delay in implementing SPA. Initial feedback suggests that there is some reduction in new outpatient caseloads but a more detailed report is awaited. Completed.

Comments on progress with risk: This risk describes the ongoing impact of the failure to impl implement the improving outpatients project properly. properly The overdue actions are significant parts of any successful implementation plan and should be picked up and developed by the new outpatients project. Please Note: A separate report regarding the outpatientss project is also on the Board of Director Directorâ&#x20AC;&#x2122;ss Agenda for the 30 October 2012 meeting.

Page 49 of 73

* Delayed decisions regarding medical structures

Lead Director

Risk score

Impact score

Likelihood score

Summary of existing controls

Risk treatment plan

Update regarding risk actions



Agree additional resources to backfill admin staff with caseload transfer experience. This has been identified bases on the extent of cases and a request to consider funding has been issued. GREEN

Complete

Carry out a full reconciliation on patient lists pre and post transfer to map all service users into new teams or to a discharge/transfer process. process GREEN

Complete

Guidance is being provided from a technical and clinical perspective around case transfer processes to ensure transfers are undertaken as effectively and efficiently as possible. Part of the guidance is to use ‘client transfer request’ action in Paris, thiss automatically mitigates against missing appointments. GREEN

Complete



Deputy Chief Executive

* The pressure on existing admin staff and ICT staff to effect this transfer

Chief Operating Officer & Chief Nurse

* The volume of service user cases that require transfer in relation to community teams and outpatients

* Service users may be lost in the system during the transfer * Data and information may not transfer properly or fully impacting on future records and treatment * Pressure on staff to complete the transfer * Data protection issues possible and Caldicott issues * Missed treatments, appointments etc impact on complaints and reputation * Hinders smooth working of new teams post 25 June potential go live * Possible interruption to provision of services and business as usual actions as staff needed to transfer cases

4 Moderate

Service user cases will not be transferred completely, accurately and promptly into new teams and structures

4 Major

Impact of risk

1 Rare

Risk description



T&F group set up with express objective of reducing outpatient and community based consultant activity Experienced staff well used to caseload transfers exist in the Trust and are engaged in the process A 12 week period for transfers has been agreed and will mean leaving both old and new teams open in PARIS to do this, with admin staff transferring the cases upon agreement with the new team, when a service user is next seen or when it is

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* The mechanism that has to be used within PARIS to effect such changes is cumbersome

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

ď&#x201A;ˇ

clinically safe to do so. PARIS team have agreed to work on the weekend of 23 and 24 June 2012 to undertake the alignment of clinic bookings thereby reducing the risk of double booking clinics

Risk treatment plan

Update regarding risk actions

The band 5 admin staff, locality managers and CSMs will be responsible for monitoring that cases are being transferred from the old teams to mitigate against losing service users. We can easily see through caseload manager on Paris if service users are still under the old teams and this can be used as a cross reference point. RED

Action due by 30 September 2012. This action relates to the adoption of the routine checking for service users allocated to pretransformation teams by operational staff.

The likelihood of service users still remaining on old teams caseloads will rapidly reduce over time as each service user is seen by new teams. New service users cannot be allocated to an old team. Comments on progress with risk: The risk has been reduced to moderate at interim review. Confirmation awaited regarding action 4 and then this risk will be a residual risk within operational services.

Page 51 of 73

Risk score

Impact score

Likelihood score

Lead Director

Deputy Chief Executive

Chief Operating Officer & Chief Nurse

* Not enough process testing involving 1st line staff - 1 day 25th May * Not enough time for any amendment due to late component testing. 1 day 23rd May * Original testing schedule has been reduced

Incorrect decisions or presumptions are made by clinical and admin staff due to lack of understanding of the whole process Inability to fully test all reasonable scenarios

6 Moderate

PARIS may not function in the way anticipated in the period following implementation of tranche 1 and 2

3 Moderate

Impact of risk

2 Unlikely

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

ď&#x201A;ˇ

Full evaluation of output from model office and recommendations to be made. made GREEN

Complete

A day has been arranged for w/c 18 June 2012 with admin staff to demonstrate the holistic assessment and particularly focus on the formulation section of the UDF. UDF Action Completed. GREEN

Complete

ď&#x201A;ˇ

Testing was done on some of the scenarios, it was successful and demonstrated that the assessment and referrals can be passed between teams allowing for the pathway to be followed on Paris as described in the swim lane process map and local working instructions. The functional testing of the holistic assessment has been completed and amendments to the UDF have been made as required. The UDF has passed the functional testing.

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Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions



The functional testing of the new care plan was due to place in July. . Once completed this will be tested by supervised “end to end” testing involving clinical staff. RED

Action due by 14 July 2012. Testing had been re-scheduled to October 2012 but due to loss of data on migration between servers by Civica the testing has again be delayed.



There was significant testing and snagging of the holistic assessment by the pathways team, Jim Woolhouse and systems development staff which identified problems prior to the prescribed testing. A day has been held with the HIS team to demonstrate the holistic assessment. Assessment checked by HIS team finding only one minor fault was found – now corrected.

Comments on progress with risk: The risk has been affected on two occasions by slippage around the testing of the new Care Plan. The loss of data has been identified as the reason why October revised due dates cannot be met. The Care Pathways Lead is working with Informatics staff to identify resources and then timetable the build of the care plan in PARIS. The extent of time required for building the new care plan has been recently specified as 15 days.

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Caseload transference process

Lead Director

Risk score

Impact score

Likelihood score

Service user anxiety Additional time consuming manual systems needed Information quality e.g. DNA rates will suffer initially Re-entry of manual data required Inequalities may arise as some consultants will have new clinics

Deputy Chief Executive

Delay in identifying which sectors within localities consultants will be allocated to

Summary of existing controls

Risk treatment plan

Update regarding risk actions



Endeavour to get information regarding new clinics from consultants as soon as possible. GREEN

Complete

Prioritise the building of clinics for consultants receiving ICS caseloads and the N to SSE switch as soon as possible post 25 June 2012. GREEN

Complete

Consider deploying additional resources to work with consultants in identifying new clinic dates and venues based on caseload inheritance. inheritance (Superseded) GREY

Action not required due to extent new clinics were in place.

Re-allocated service users cannot be formally allocated to new clinics with new consultants Chief Operating Officer & Chief Nurse

Delay in clarifying consultant locations in terms of localities

Service users cannot be given a new clinic date

3 Low

Some service users seen in outpatient clinics from 25 June 2012 will not be able to be booked into a future clinic or given a clinic date via PARIS

1 negligible

Impact of risk

3 possible

Risk description



Data entry error eg double booking future manual clinic slots 

Number of affected consultants has been reduced by the PARIS team – estimated 78% of clinics will be built prior to go live Service users will still be seen – as a contact or via DVs etc Issue affects a minority of consultants – systems in place have built most clinics required Manual system will be used to potentially give service users future slots Risk is a short duration risk –

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Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Functionalising adult consultants in ICS and hence needing to reallocate their displaced community team caseload Re-allocation of a consultant from the North OPS CMHT to the SSE locality

ď&#x201A;ˇ ď&#x201A;ˇ

envisaged that once consultants start working in new teams they will identify new clinics quickly and a 48 hour turnaround from request to build will be done by the PARIS team Build of new clinics now at 96% (20/06/12) ICS clinic issues have been resolved.

Risk treatment plan

Update regarding risk actions

Re-analyse analyse data regarding identified consultants later to determine the nature of the activity. activity Given almost complete build achieved this action is not needed. (Superseded) GREY

Action not required due to extent new clinics were in place.

Ensure all manual records are checked when new PARIS clinics are set up to minimise risk of double bookings and data error. (Superseded) GREY

Action not required due to extent new clinics were in place.

Comments on progress with risk: The risk was originally drafted when delays in receiving information around new clinic builds in PARIS indicated a majority would not be built by the June go live date. Concerted last minute efforts by PARIS system management staff built virtually all the clinics by go live date and this made the mitigating action redundant. The risk now describes a past event and approval to archive this risk will be sought from Transformation Programme Group.

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Lack of a formal mandate requiring the use of PARIS underpinned by a PARIS Operational policy

Lead Director

Risk score

Impact score

Likelihood score

Impact on staff morale Impact on reliability of records Undermines the pathways which are predicated on the use of PARIS in full by all clinical groups Impact on recording activity and hence contractual reporting

Chief Financial Officer

Unmet expectations around the extent transformation would improve the overall performance and utility of PARIS

T1 & T2 perceived as a failure in relation to PARIS.

12 High

PARIS is not used as the sole care record within Leeds based services following transformation of services

4 Major

Impact of risk

3 Possible

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions



Ensure that PARIS development opportunities for T3 and future tranches are analysed by IT/informatics staff for feasibility before being included as objectives. RED

Action due by 30 September 2012.

Ensure all decision making is carried out by a wide range of staff with clinical and IT/Informatics backgrounds. RED

Action due by 31 August 2012.

TPG/communication to outline to staff a process to feed in issues and improvements post go live with T1 and T2 and explain that there is already a working progress improvement plan – if we make the plan public staff can see clearly what’s been logged, who’s leading, when they might expect an improvement i to be made. RED

Action due by 31 August 2012. Discussions with staff still reflect clinical staffs’ anxieties regarding PARIS – this action was designed to assure staff making improvements to PARIS is being worked on by Transformation.

Linking pathways, holistic assessment and LWIs to PARIS clearly demonstrates that PARIS is viewed as the single location for recording activity and care records

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Belief persisting that PARIS is not fit for purpose

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Trust Board to clearly mandate PARIS as the sole care record within Leeds services and endorse an operational policy. AMBER

Action rated as amber as ET rather than the Board mandated the use of PARIS.

Comments on progress with risk: Tranche 1 and 2 suffered from a lack of a dedicated informatics workstream similar to the other support workstream such as HR. The creation o f this workstream is proposed in the new Transformation governance structure and is needed to pick up the first two overdue risk tr eatment actions.

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Recent staff departures have had an impact on skill mix within teams.

Lead Director

Risk score

Impact score

Likelihood score

* possible impact on quality of service provided to service users * impact on the ability to follow pathways of care as closely as required

Deputy Chief Executive

* pressure of work and capacity issues for staff where requisite skills are not present in sufficient depth Chief Operating Officer & Chief Nurse

Management of Change processes have lead to staff being deployed in a way that does not always equate with service needs and hence some teams suffering "skills and experience gaps

*anxiety of staff

9 High

Teams may not have all the requisite skills in sufficient depth and numbers of staff to deal with the requirements of the new pathway

3 Moderate

Impact of risk

3 Possible

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Experience does exist within all teams and can be sought from those staff having requisite knowledge and experience

The creation of an ICP/OD task and finish group to oversee ongoing staff development to meet the needs of the ICPs.. AMBER

Issues exist around governance of this workstream in the new structure.

Greater focus on rebalancing teams in the medium term when vacancy or promotional opportunities arise. GREY

Due date 31 March 2013.

Formulation is multidisciplinary and allows for discussion around the correct care package to be developed. It also offers an educational experience for staff working with and obtaining insights from staff with different professional skill sets and service backgrounds. Adult CMHTs work along the lines that any appropriate clinician can do the bulk of assessments (around 90%), particularly given they have the option of calling in specialist medical opinion(either older people or working age specific)

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Some concerns from staff carrying out assessment about recent experience with service users in specified age groups. Some skills in teams are relatively specialised and held by a relatively Staff are being asked to work outside of established "comfort zones" and find this challenging.

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Operational managers are currently moving staff to deal with immediate experience and skills issues as they are identified. identified GREEN

Due date 30 September 2012. Operational management have identified staff that have previous experience in older peopleâ&#x20AC;&#x2122;s services (although most recently they were in Adult MH Services). These staff are being used to supplement staff in CMHTs who were directly from Older Peopleâ&#x20AC;&#x2122;s services.

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Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Operational fix to address skills gap (Kim Lacey).

Staff have been asked to work flexibly and a letter was sent to band 5 staff to address an imbalance in some areas.

AMBER

Workforce development issues will be addressed through longer term development plans. GREY

Due date 31 March 2013.

Comments on progress with risk: This risk has a short scale mitigation element carried out by operational management and a longer term reduction element requ iring HR and organisational development input. The overall management of this risk will reside within the Clinical Competency Development Workstream This met on 11 October 2012. Meetings to identify the scope of this are taking place between clinical leads and professional leads. An organisational effectiveness programme is also being developed to complement the clinical competency work. Locality management have enabled staff to come forward with any concern that they may lack competency; managers have then worked with those staff to develop a way forward regarding acquiring these skills. skill The situation is one of mutual obligation: managers must not place staff in a situation beyond yond their competencies and all practitioners must alert managers when they feel they are being required to act beyond their competency. In addition, Workforce staff are developing work to ensure that staffing structures for more senior staff in the localities are made more stable.

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F T

The ageing demographic predicts an increase in the need for mental health services for older people. Specific skills are required to provide appropriate assessment and treatment to this population, including a knowledge and understanding of cognitive

Risk score

Impact score

Likelihood score

Lead Director

Deputy Chief Executive

* Older people with mental health problems will not be able to access appropriately skilled, specialist staff, leading to reduced quality of care. * Increased risk of inappropriate admissions to hospital or crisis interventions leading to poor quality care and a negative impact on service delivery.

Chief Operating Officer & Chief Nurse

There is the risk that the needs of older people may not always be met by the new pathways.

12 High

3 Moderate

Impact of risk

4 Likely

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions



The “Needs of Older People” to be included as an item for discussion at forthcoming meetings of the Diversity and Inclusion Forum.

Use of diversity measures within the ICP to identify any negative impact on service users. GREY

Action due by 31 October 2012.

Use of CTQs to identify and suggest a response to any inability to meet service users clinical needs. GREY

Action due by 31 October 2012.



Impaired cognitive function pathway developed.

ICP variance tracking will identify variation in care that may be linked to an inability to meet older person’s clinical need. GREY

Action due by 31 December 2012.



Some services previously difficult for older people to access will now be available eg ICS services

Feedback will be sought as part of outcome measures from all service users to determine their views on the ability of the new pathways to meet their needs. GREY

Action due by 31 December 2012.

Rebalancing work is being developed by Gary Hostick and Kim Lacey.. GREY

Action due by 30 November 2012.

Medium term workforce development and training (Lindsay Jensen/Maria Warner). Warner) GREY

Action due by 28 February 2013.

Further work on Local Working Instructions focussing on the medical role. (Andrew Jackson/Guy Brookes/Tony Dearden). Dearden) GREY

Action due by 31 October 2012.

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assessment, physical comorbidities, pharmacotherapy and psychological issues particular regarding older people.

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Further engagement work with those members of staff expressing concerns. (John Clare/Gary Hostick/Tony Dearden). Dearden) GREY

Action due by 31 October 2012.

Comments on progress with risk: Risk has been debated twice at Transformation Programme Group and has not yet been approved to be made live. At the last Tran sformation Programme Board and at the Operational Workstream meeting the view was tthe risk should be taken out of Transformation and d worked on within the Adult and Older peoples Directorate. Approval will be sought to carry out this transfer at the Transformation Programme Group.

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A F T

Data cleansing as part of Transformation implementation within PARIS Numbers of service users who have moved through all aspects of the pathway

Lead Director

Risk score

Impact score

Likelihood score

Extent of available data limited in some areas to underpin the evaluation Ability to give unequivocal assurance may be lessened Potential that 3rd parties will not be assured by the evaluation

Summary of existing controls

Risk treatment plan

Update regarding risk actions

ď&#x201A;ˇ

Ongoing evaluation of data to support the CTQs is taking place

Action due by 24 December 2012.

ď&#x201A;ˇ

An overall assessment has been carried out reporting that most of the data we need is available in sufficient quantity

The evaluation work stream will be producing a detail evaluation proposal that will confirm questions to be asked/answered, measures and indicators to be used to answer the questions and reports required to support this work. work GREY

Chief Financial Officer

Potential impact on choice of CTQs

6 Moderate

Gaps in the way information has historically been collected may mean ongoing monitoring of the impact on performance of Transformed services is impaired.

3 Moderate

Impact of risk

2 Unlikely

Risk description

Mix of pre and post transformation service user data

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Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Early data completeness and capture within PARIS was not as good as more recent data Changes to CPA within PARIS and in response to national directives reduce comparability of data in this respect. Comments on progress with risk: This draft risk replaces the former programme risk 7. It is currently out for consultation with key stakeholders to add more detail. Additional clarification is being sought from informatics staff regarding current mitigations and the most effective risk treatments before the risk w ill be presented to be made live at Transformation Programme Group.

Page 64 of 73

Work stream Risks (tier 3)

Lead Director

Risk score

Impact score

Summary of existing controls

Risk treatment plan

Update regarding risk actions



Attend the mobile working Seminar. GREEN

Complete

Obtain feedback from the early implementer site regarding impact on Admin staff. staff GREEN

Complete

Task and Finish Group to provide scanning function to reduce data input.. GREEN

Complete

Explore Voice Recognition Systems with IT. IT AMBER

Work is ongoing to identify an appropriate solution. Meetings are being held to evaluate packages.

Attend the Informatics Away Day. Day GREEN

Complete

Continue ontinue to work towards implementation of a digital dictation system. system GREY

Action due by 31 January 2013

  Deputy Chief Executive

Chief Operating Officer & Chief Nurse

IT Solutions are not forthcoming leading to lengthy inputting of data and information requiring more staff rather than less.

Delays in inputting data and inefficient use of staff time.

6 Moderate

Remaining Admin Support Service cannot function efficiently due to IT solutions not being present.

3 Moderate

Impact of risk

2 Unlikely

Risk description

Likelihood score

Work stream risks are the equivalent, from a project perspective, of service level risks. They affect individual work stream objectives but do not in isolation affect the overall success of the project. These risks are the responsibility of the work stream lead and Transformation Programme Group to monitor and ensure that risks are effectively managed.

Project Milestone Tracker Work stream Action Plan Representation at the Reducing Time Through Mobile Technology Work stream

Comments on progress with risk: Significant progress is being made with the remaining actions. The area has some overlap with mobilising community services around dictation servi ces to support nursing staff.

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Lead Director

Risk score

Impact score

Likelihood score

Summary of existing controls

Risk treatment plan

Update regarding risk actions



Arrange meeting with AD and CSMs from all the clinical services.. GREEN

Complete

Develop a Communication Plan. (Superseded) GREY

This action was picked up by adhoc meetings with admin staff.

Work with all services both in and out of the Transformation Project to restructure on an interim basis until the new services are developed. RED

Action due by 31 March 2012. This action describes the continuing use of temporary staff to deal with the continuing volume of outpatient activity.

Clinical Services will provide information to be included in to Service Level Agreements (SLA). (SLA) RED.

Action due by 31 March 2012. The drafting and agreement of an SLA is delayed and will be concluded when activity is at a normal level



Deputy Chief Executive

 Chief Operating Officer & Chief Nurse

Individual clinical services are not clearly defined within the transformation timescale. Cultural changes do not take place to facilitate changes to the way admin support is provided

Unable to deploy the reduced admin support structure effectively to reflect the needs of the clinical services.

9 High

New Admin Skill Mix structures not agreed and in place in the planned timescale

3 Moderate

Impact of risk

3 Possible

Risk description

Project Milestone Tracker Work stream Action Plan Admin Skill Mix Meetings

Page 66 of 73

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Ongoing consultation with Consultants and Service Leads regarding local admin support structures. RED

Action due by 30 September 2012. The Lead Service Support Manager is continuing to manage resources, including temporary staff, to support community services. Their attendance at Estates Workstream meetings also enables rapid redeployment of administration staff when services are relocated.

Comments on progress with risk: The slippage on the overdue actions is also influenced by initially setting the due date to coincide with the first proposed go live date for tra nche 1. Administration management is continuing to work with services ces to provide administrative support based on current service location and configuration, including use of temporary staff to meet service needs. Please Note: A separate report regarding the outpatients project is also on the Board of Director Directorâ&#x20AC;&#x2122;ss Agenda for the 30 October 2012 meeting.

Page 67 of 73

Lead Director

Risk score

Impact score

Likelihood score

Summary of existing controls

Risk treatment plan

Update regarding risk actions



Build feedback and lessons learnt from tranche 1 for future tranches to give staff the best opportunity to be fully informed and engaged with the project.

Complete

 Deputy Chief Executive

Chief Operating Officer & Chief Nurse

Pace of change. Staff ability to access email/managers to disseminate briefings to staff not on PCs.

Staff feel removed from the aims of the project and feel less involved.

6 Moderate

Untimely or unclear communications staff and stakeholders feel disconnected and disengaged from the project.

3 Moderate

Impact of risk

2 Unlikely

Risk description



Communications plan to send out weekly communications update to all staff. Weekly communications meetings with project staff and Staff side representative. Staff have the opportunity to feedback their views on each weekly email and via the StaffNet site. Wider communication and engagement carried out by implementation work stream leads and by other staff who are members of the TPG

GREEN

Carry out an evaluation of communications within the Trust over the past 12 months identifying good practice and also areas where lessons could be learnt. Report to TPG.

Complete

GREEN

Comments on progress with risk: Risk is now a residual risk.

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Lead Director

Risk score

Impact score

Likelihood score

Summary of existing controls

Risk treatment plan

Update regarding risk actions

ď&#x201A;ˇ

Develop and publish extent of support and retraining mechanisms available to help staff adjust to changed roles. roles GREEN

Complete

Use positive outcomes of early implementers to sell benefits to staff.. RED

Action due by 29 February 2012.

Continuing engagement with staff side. side GREY

Action due by 31 March 2013.

Develop resources to assist staff - including interview skills, skills in completing application forms. GREEN

Complete

Cultural integration process - focus on team building, opportunities for progression. progression RED

Action due by 30 April 2012.

Vacancy Management Group - ensure staff are kept up to date regarding other jobs or opportunities.

Complete

ď&#x201A;ˇ

Director of Workforce

* Transformation requires staff to change roles, base and working patterns * Pace of change rapid and ability to give staff relevant information has to follow very tight deadlines * Significant change to clinical practice proposed which may be resisted * Breakup of working relationships and established teams

* Staff anxious about retraining or having to deal with changed roles * Ability to staff teams in new structure hampered * New teams do not bond well * Employment tribunals involved * Grievances increase * Delay in progressing implementation * Claims upheld or out of court settlements occur

6 Moderate

Challenges made by staff to offers of suitable alternative employment

3 Moderate

Impact of risk

2 Possible

Risk description

Management of change process Staff side involvement in consultations

GREEN For alternative job offers HR will obtain advice, agreement and sign-off off from Professional Leads that the posts being offered to individuals do represent suitable alternative employment. This will be an ongoing process. GREEN

Complete

Comments on progress with risk: The risk has management of change and staff/organisational development aspects in its treatment plan. The management of change elements have been completed but feedback regarding organisational development elements has not been received and is being chased by the report author.

Page 69 of 73

Lead Director

Risk score

Impact score

Likelihood score

Summary of existing controls

Risk treatment plan

ď&#x201A;ˇ

Implementation may be paused or the rate of implementation may be slowed to allow greater time to sort out inter-related related issues. issu GREEN

ď&#x201A;ˇ

Director of Workforce

* The division of transformation into tranches for implementation can cut across how teams and individuals operate in practice

* Anxiety from staff if some elements of the workforce are better informed or have a clearer view of their future than others * Potential for complaints * Potential breach of employment law regulations due to timescales not achieved from delay in other workstreams * Inter-staff group dissatisfaction or acrimony * Potential media interest * Delays to overall implementation of projects * Disruption to services as transformation may not be rolled out evenly

3 Low

Interdependencies and inter-relationships between staffing issues in one work stream prevent progress on resolving workforce issues in another

3 Moderate

Impact of risk

1 Unlikely

Risk description

Project planning, particularly the critical path to highlight and delays and "pinch points" Consolidation of implementation work stream into the operational work stream will ensure better management of cross-cutting issues

Update regarding risk actions

* Different staff groups with different consultation and negotiating positions are involved

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* Progress in each workstream is not even

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

Implementation of tranche 1 and 2 simultaneously. simultaneously

Complete

GREEN

* The outcome of one work stream's decisions is needed before another work stream can commence negotiations Comments: All action completed â&#x20AC;&#x201C; risk is a residual risk.

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* Limited resource available as the same resource will be already utilised in other areas of development.

Lead Director

Risk score

Impact score

Likelihood score

Proper structured rollout and response to staff will be impaired. Some impact on project objectives - part of which is selling a better PARIS to end users Potential for some impact on services - particularly on informatics business as usual given resourcing issues

Summary of existing controls

Risk treatment plan

Update regarding risk actions



Develop a new system for all PARIS PAR additional development work.. RED

Action due by 30 September 2012. No progress reported.

Confirm governance path for additional PARIS work requests to be reviewed, modified and ultimately approved or rejected via ET&T SSG and its sub-groups. RED

Action due by 30 September 2012. No progress reported.

 Chief Financial officer

* No identified resource for extra development work has been identified within the time constraints.

A ‘drip feed’ approach for T1 & T2 implementation which may be disjointed for staff that are affected by these tranches of transformation.

9 High

Extra development work specified for PARIS will not be delivered either at all or on time.

3 Moderate

Impact of risk

3 Possible

Risk description



Relevant HIS staff now attending some T&F groups to monitor/advise surrounding PARIS functionality, configuration and reporting requirements Direct feed to the project board via HIS rep (Alison Franklin) Direct working with specific staff outside of the clinical T&F groups

Page 72 of 73

Lead Director

Risk score

Impact score

Impact of risk

Likelihood score

Risk description

Summary of existing controls

Risk treatment plan

Update regarding risk actions

* No realistic evaluation regarding workload around additional developments that will arise when new modules and functionality is used by staff in "real world" situations

Comments on progress with risk: The action regarding this risk deals with developing a suitable governance path for additional PARIS work that deals with bot h the evaluation of the merits of the requested work and the governance path for approval. The new IT/Informatics workstream should address this issue as a priority.

Page 73 of 73

AGENDA ITEM 7.1

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Minutes of the Transformation Programme Board held on 5th October 2012 (Draft)

DATE OF MEETING:

30th October 2012

LEAD DIRECTOR:

Chris Butler Chief Executive Lena Gazey Support Secretary

PAPER AUTHOR:

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC: GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

IMPACT ON THE TRUST’S S MEANS GOALS (please tick relevant box) MG1 We provide excellent quality, evidence-based, evidence based, safe care that promotes recovery and inclusion MG2 MG3

We involve people in planning their care and in improving services We work with partner organisations to improve health and lives

MG4 MG5 MG6

We value and develop our workforce and those supporting us We improve our services through learning, research and innovation We provide efficient and sustainable services

MG7

We govern our Trust effectively and meet our regulatory requirements

STATUS OF PAPER

          

To be taken in the public session (Part A) To be taken in private session (Part B) - If the paper is to be taken in the private session please indicate which criterion is applicable: Legal advice relating to legal proceedings procee (actual or possible) Negotiations in respect of employee relations where they are of a confidential nature Procurement processes and contract negotiations Information relating to identifiable individuals or groups of individuals Matters exempt under the Freedom of Information Act (quote section number)



SUMMARY: Attached are the draft minutes of the Transformation Programme Board meeting held on 5th October 2012.. Items of interest are:are:          

Social Media and Digital Tools within Clinical Pathways Workforce Development Plan Update SPA E-mail Update Combined Action Plan ICT Mobilisation Project Update Recovery Plan Outcomes Plan Staff Engagement Plan Service Review Project Plan Dashboard.

RECOMMENDATIONS: The Board of Directors is asked to receive and note the minutes provided.

Transformation Programme Board Meeting Meeting Room 1and 2 Trust Headquarters 5th October 2012 10.00 â&#x20AC;&#x201C; 12.00 Minutes Present:

Michele Moran (MM) (Chair)

Chief Operating Officer and Chief Nurse/Deputy Chief Executive Director of Workforce & Development Director of Strategy & Partnerships Non Executive Director Chief Financial Officer Strategic Change Manager Head of Information & Knowledge Associate Director of Partnerships & Social Inclusion Governor Transformation Lead Deputy Director of Care Services Chair, Professional Advisory Forum Non Executive Director Head of Information and Knowledge Secretary to Michele Moran (minute taker)

Susan Tyler (ST) Jill Copeland (JC) Keith Woodhouse (KW) Dawn Hanwell (DH) Richard Clayton (RC) Heather Cook (HC) Victoria Betton (VB) Andy Parker (AP) John Clare (JCl) Lynn Parkinson (LP) Don Brechin (DB) Andy Parker (AP) Heather Cook (HC) Lena Gazey (LG)

Item Agenda Description No 1 Apologies

Action

Apologies had been received from Chris Butler. The meeting was to be chaired, in his absence, by Michele Moran. 2

Draft minutes of the meeting held on 4th September 2012 The draft minutes of the meeting held on 4th September were agreed to be an accurate record.

Action Sheet 2.0 Tranche 1 & 2 Update The next Tranche 1 and 2 Review Work Shop was planned for October. RC undertook to identify future critical points for review. 3.1 Transformation Timeout Feedback To be covered on the agenda.

4.0 RMS Tenon Report To be covered on the agenda. 6.0 Dashboard To be covered on the agenda. . 8.0 Recovery Plan To be covered on the agenda. 10.00 Proposed Process for Professional Involvement in Transformation Project The paper had been progressed to the Professional Advisory Forum and Audit & Assurance Committee as agreed. 12.00 Project Initiation Document HC had followed up IT involvement as requested. The main requirements of this piece of work will be the deployment of appropriate IT equipment linked to ensuring appropriate support regarding the infrastructure and software requirements. In order to ensure this progresses with the highest level of support the project lead assigned with Andrew Jackson is Dave Shelley Head of IT services. Items 8 and 6 were taken out of order. 8.

Social Media and Digital Tools within Clinical Pathways VB spoke to the paper previously distributed. She outlined some of the work already being developed in the use of digital tools within clinical pathways and suggested that thought should be given to this in the context of transformation. The group agreed that there was a need to respond to new ways of working in order to reach younger people, and that an area for development should be identified. JC said that he and CB had met someone at Leeds City Council who was working with firms in Leeds and would be prepared to do a â&#x20AC;&#x153;matchmakingâ&#x20AC;? exercise to find a partner. Anything undertaken needed to be clinically led and should link into outpatient work. JC suggested that it could also be linked to Recovery. KW made the caveat that a large percentage of such new ideas fail and that we should be following rather than attempting to lead. AP asked where the liability would lie should bad advice be given via such a social media tool. VB noted that this had been addressed by Berkshire Healthcare FT with regard to their SHaRON programme; they were prepared to come and give us a presentation. 2

It was agreed that a small group should be set up to do some evaluation of projects. HW to be involved. This group should report to the Board in December.

VB via JC

DB asked for more information on the Leeds Drug Clinic work but was told that this was social engagement rather than clinical. It was agreed that Berkshire Healthcare Trust be invited to give a presentation on SHaRON. 6.

VB via JC

Workforce Development Plan Update ST reported that funding had been obtained for cultural integration work to support the merging of Leeds and North Yorkshire and York. This work would develop and be adapted to meet the needs of Transformation as it progressed. Evaluation would be constant and comments would be helpful. AP asked where service users and carers fitted into the context of cultural integration and was told that they were represented in the Trust values and the need for these to be firmly embedded in the overall culture. The need for team interventions and support for clinical leads was discussed and the role of communication stressed. KW felt that there was a need for direct communication in meetings and face to face rather than use of newsletters, blogs and the like. The need for skills based training was emphasised and JC said that skills gaps did exist. LP said that a simple tool to identify these gaps was required and that she had spoken with Neil Wood who would addressing this. MM felt that the work should link to the risk register and show how risks would reduce. It was also important that focus should be kept on the staff time element â&#x20AC;&#x201C; people were already stressed. DH suggested that backfill would be needed and that some of the money should be used for this. The group requested a monthly report. At this point the meeting reverted to the printed Agenda

Matters Arising 3.1 SPA E-mail Update RC spoke to the paper circulated which gave the reasons why the SPA e-mail was not yet in operation.

There was some surprise that the referral form was only just in process of being designed and it was suggested that short term needs should be addressed, and as much information as possible captured on the form at the earliest possible point . DB said that referral forms had a checkered history and not everyone completed them correctly. DH said that it was important that we show slick business operations and perhaps an outside eye should be brought to bear on the design process. It was possible that extra admin support would be needed, if only in the short term. RC/LP to update next the meeting.

RC/LP

3.2 Combined Action Plan RC spoke to the paper and requested comments and advice as to how to present the paper for Audit and Assurance Committee. JC requested clarification as to what was contained in the Plan. RC confirmed that it was a composite of existing and added actions. Completed actions would show as grey, while green would indicate those that were on-going and on-track. It was felt that more detail would be required for the Trust Board. MM had spoken to RC and asked him to talk to KW about the LTHT format which she thought was excellent. DH was asked about the PARIS pathway and replied that a needs analysis was being undertaken of clinical needs in order to establish whether PARIS was the right way forward or whether another system should be considered. Work would however proceed on some PARIS issues as any other system would be a long term solution and it would be necessary in the interim to continue with development of PARIS. RC to meet with DH and KW to discuss. Support for the plan was confirmed and RC was asked to prepare it for submission to Audit and Assurance Committee.

RC/KW

RC/DH/ KW RC

3.3 ICT Mobilisation Project Update RC gave a verbal update. He reported that the post implementation plan had been evaluated. Work was slightly behind plan but proceeding. There was some HR slippage but this had not gone behind the critical path. This item to remain on the agenda for updating. 3.4 Recovery Plan

GC/LG

It was felt that the Recovery Plan needed scoping out, proper project plans preparing and resource requirements identifying

MM pointed out that money had already been put into this, but people should take into account the fact that there are no funds available for Transformation from next April. She suggested that the plan be brought back to the meeting with a PID.

JC said that this may not be a question of money, but a better use of resources. RC explained that the project team had tried to pull together a plan from what was already in place. There was a need to ensure capacity. DH said that this was not primarily a question of new money as we would be doing these things anyway. JC/RC to bring a project plan with PID specifying resources required and available to the meeting on 2nd November.

JC/RC

3.5 Outcomes Plan The meeting expressed support for the paper, but DH made the case for prioritising and pacing in order to achieve payment. Some items are, however, mandatory. It would be necessary to link closely with PbR to avoid duplication and the possibility of having a single project lead for the two areas could be considered. DB, DH and JCl to meet to formulate a plan to bring back to the November meeting noting priority areas.

DB/DH/ JCl

3.6 Staff Engagement Plan It was noted that this did not capture engagement at an operational level. And the group wondered how much this was happening and in what form. Was information being cascaded, and given out at team meetings? It was suggested that there should be a barometer question: Are you having regular briefings? AP asked why service users were not included. He was told that a service user plan existed and would come to the next meeting. 4.

Service Review Project Plan JCl spoke to the paper previously circulated and pointed out that there were two areas which were causing concern. These were holistic assessment and the referral and allocation process. Discussions had already taken place with LP and with PAF. The group looked at the three options outlined in JClâ&#x20AC;&#x2122;s paper. Overall it was considered that the requirement was for training and for simple working instructions to support the inputting of the assessment. Clinicians should be reassured that they were free to use professional judgement, and that they need not fill a field where it was clearly not

applicable. This, hopefully, would cut down the time spent inputting. Of the options proposed, option three appeared to be the most suitable. MM pointed out, however, that this proposed significant changes to the holistic assessment, which was not acceptable as the assessment had been signed off by PAF and incorporates lessons learnt from risks and TIRG. It was agreed that this should go back to PAF and that it should be reviewed again at the next meeting of the Transformation Programme Board. 5.

JCl

Tranche 3 Plans and Mitigation Plans The group received and supported the paper.

ICP Update The group received the paper and noted the content.

Programme Monitoring Items 9.1 Dashboard RC reported that the dashboard was now populated. Issues were out-patient work and ICP development which, as indicated in item 7, would be delayed until January. A paper on out-patient work had been requested by the Trust Board and this would be circulated by e-mail. KW asked why the moving of PARIS had not been on the risk register. HC assured him that it had been, and that the actual delay caused was only the loss of three days data collection. LP was asked to investigate why the time delay had apparently increased from three days to a month. MM to receive an update before the November meeting. RC had supplied MM with a paper on risks and would copy this to KW. It was agreed that the Dashboard would be sent to Audit and Assurance Committee. 9.2 Highlight Report The Highlight Report was received and noted. 9.3 CTQ Report on Tranche 1 & 2 The issues covered in the paper circulated were SPA and referrals, with emphasis on the achievement of deadlines. There had been some pressure on the referrals process particularly due to summer holidays. 6

LP RC MM

It was noted that the number of rejected referrals was reduced as things were getting to the right place. However, follow up activity could be better presented by specifying a benchmark. HC pointed out that increased use of PARIS was significant enough to have prompted a move to a higher user licence band.

It was agreed that the paper should go to PAF.

9.4 Programme Group Minutes The Minutes of the Programme Group meeting of16th and 30th August were received. 9.5 Programme Budget Update DH requested sight of the budget request for the project management office resource for 2013/14.

9.6 Transformation Risk Register The risk register for the project was received and noted. 9.7 Post Implementation Plan Tranches 1 & 2 RC distributed an updated project plan and talked through the front sheet accompanying it. DH agreed to look at bringing forward wifi provision. DH After some discussion it was agreed that a meeting would be arranged between MM, CB, JCl, RC and JI to further consider the plan, which would be brought back to a future meeting. 10

Any Other Business There was no further business. Date and time of next meeting 2nd November 2012, 9.00 â&#x20AC;&#x201C; 11.30 a.m., Trust Headquarters

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AGENDA ITEM 7.2

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Transformation Programme – Outpatients Project

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Michele Moran Chief Operating Officer and Chief Nurse/Deputy Chief Executive Andrew Jackson Transformation Governance Lead

PAPER AUTHOR:

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC:

GOVERNANCE: INFORMATION:



IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

  

IMPACT ON THE TRUST’S S MEANS GOALS (please tick relevant box) MG1 We provide excellent quality, evidence-based, evidence based, safe care that promotes recovery and inclusion



MG2 MG3 MG4 MG5 MG6

We involve people in planning their care and in improving services We work with partner organisations to improve health and lives We value and develop our workforce and those supporting us We improve our services through learning, research and innovation We provide efficient and sustainable services



MG7

We govern our Trust effectively and meet our regulatory requirements

 

SUMMARY: The attached paper describes the original improving outpatient project, work done to date, work in progress, and timelines for all ongoing and additional work work. The implications for existing transformation risks are considered. Following discussions between the Medical Director, Transformation Transformation Lead, Deputy Director of Care Services and the Strategic Change Programme Manager, commitment to refocus this work and improve the engagement with senior clinical staff is described. A revised project plan will be agreed by the Transformation Programme Programme Board on the 28th November 2012.

RECOMMENDATIONS: The Board of Directors are asked to consider the paper and support the suggested way forward regarding revision of the outpatients project.

Transformation Programme

Outpatients Project

Author Date Version

A Jackson 17October 2012 1.4

Transformation Project Improving Outpatients Workstream Introduction The Improving Outpatients Workstream was one of the three implementation projects that made up tranche one of the Transformation project. The other two projects were Access to Care and Mobile Technology. The purpose of this paper is to give some detail to the original improving outpatient project, work done to date, work in progress, and timelines for all ongoing and additional work and implications for existing transformation risks. 1. Objectives       

with AMDs identify where savings can be made by restructuring medical teams with AMDs agree trajectories to reduce outpatient activity using agreed trajectories identify where reductions can be made to administration activities and resulting staffing changes Conduct a qualitative analysis of the current outpatient activity and caseloads Identify and clarify those service users whose needs are better met in an outpatient setting Identify those service users whose needs might be better met in either an alternative setting or by another clinician or who could be discharged Identify where savings can be made as a result of new ways of working following engagement with key stakeholders implement proposed changes resulting in a proposed reduction of approx 50% on current activity Ultimately the target figure was reduced to 40%. 10% of the savings originally earmarked for reinvestment in the care pathways to realise the benefits of medical involvement in assessment and formulation at the start of a service user’s journey were used to achieve this reduction rather than follow the recommendation in the paper - Improving efficiency through reducing non value added activity (community tranche version) 4 June 2011.

The resultant overall objective was to enable greater consultant involvement in “front end” parts of the community pathway by reducing outpatient activity where service users could be seen by others or in primary care.

1.1. Rationale Pathways mapping work identified that about 30% of service users were being seen every three months or less frequently and hence this did not meet CPA criteria (regarding risk and complexity). The inference being that this section of outpatient service users could be seen by non medical staff or by non L&YPFT services. Variation was also identified in practice between individual teams relating to outpatient clinics. While some was demand influenced, some element of this variation was not. Further strength to the approach around caseload reduction and utilising psychiatrists’ expertise in front end formulation and assessment and in managing complex cases came from a paper produced by a medical task and finish group in 2011. The task and finish group comprised: Guy Brookes (acting AMD for Adult Mental Health) (Lead) Tony Dearden (AMD for Older People’s Services) Douglas Fraser (Medical Director) Sharon Nightingale (AMD for Doctors in Training) Alison Stansfield (AMD for Learning Disability Services) Peter Trigwell (AMD for Specialist Services) The task and finish group produced a paper, Psychiatrists in Transformation (May 2011), which highlighted that psychiatrists’ role in teams should be defined and focus on: o Review of complex / high risk service users o Clinical leadership in teams o Multi-professional discussion within teams o Involvement in developing holistic and overarching formulations o Involvement in developing comprehensive management plans o To be available to contribute to reviews of care plans in order to ensure they always meet the needs of the service user 2. Chronology The workstream started in August 2011. In November 2011 a task and finish group was set up to take forward clinical elements of the workstream’s project plan. This task and finish group continued into April 2012.

The initial implementation date was set for April 2012. This, along with all tranche one, was later delayed until June 2012. In February 2012 both Access to Care and Improving Outpatients workstreams were closed down and remaining objectives were moved into the Operational Workstream. Mobile Technology had been paused earlier. The clinical task and finish group had one additional meeting following this which created the two existing risks around outpatients. These risks are: 



Risk of inappropriate discharges and SUs disengaging from services as part of changes in structures occurring as part of the transformation of services including reduction in medical activity, changed clinical pathways and geographical changes to where services are based. Clinical staff engaged in outpatient and community based work have same levels of activity to deal with but less resources from 1 April 2012.

Both risks were initially tier 3 workstream risks but were later redefined as tier 2 risks given the ending of the workstream and following discussion regarding the risks at Transformation programme Group. Both risks are discussed in section 6 of this report. The final meeting of the task and finish group also agreed the terms of reference for two clinical audit projects looking at outpatient clinics. 3. Staff in the Workstream 3.1. Project Group (August 2011- February 2012) From August Workstream Lead: Clinical Lead: Finance Lead: HR Lead: Admin Lead:

Debbie Ward, Associate Director of Specialist Services Dr Tony Dearden, Associate Medical Director, OPS David Brewin, Senior Finance Manager Debra Butterworth, Directorate HR Manager Sue Sheard, Lead Support Services Manager

From November Deputy Workstream Lead:

Andrew Jackson, Project Manager

3.2. Task and Finish Membership (November 2011 – April 2012) Dr Tony Dearden, Associate Medical Director - OPS Dr Amanda Spencer, Consultant Psychiatrist – Learning Disabilities Service Dr Nick Venters, Consultant Psychiatrist – Adult Mental Health Services 3

Dr Wendy Neil, Consultant Psychiatrist – OPS Austin Barnett, CLDT Team Leader - Learning Disabilities Service Vos VanMarken, Team Leader - Adult CMHT Katie Walsh, Team Leader – Memory Services Sue Sheard, Lead Support Services Manager Kerry Playle, Information Analyst Specialist Andrew Jackson, Project Manager 4. Limiting factors 4.1. Workstream leads The workstream leads found the project challenging, especially given other project and managerial commitments. The concept of making Associate Directors and Associate Medical Directors responsible for the actual management of these projects is potentially one that needs consideration as we move into the inpatients phase of transformation. The approach for tranche two projects was different in that project leads were operational line managers. 4.2. Finance savings disconnected from service re-design The project became essentially two separate projects as opportunistic savings were sought to make the CRES reduction. These involved the savings from a consultant retiring and not being replaced and vacant speciality doctor posts. 4.3. Medical engagement Medical engagement and proactive discussion with the bulk of medical staff regarding the implications of the Improving Outpatients workstream’s objectives was inadequate. This had a negative impact on identifying a structured way of reducing activity prior to implementation of tranche one and two in June 2012. Insufficient medical engagement also occurred regarding the management of change around outpatient clinics such as:    

Relocation of some consultants to new bases or venues Admin changes Closure of some venues Accommodation/ availability of office space

Finally, caseload transfer as part of the change to locality boundaries and subsequent impact on how clinics and PARIS operates has been another area where earlier and more substantial medical staff leadership would have been beneficial. 4.4. Confusion between caseload reduction and reducing activity A number of medical staff have reduced their caseloads significantly over the last few years. However, when actual activity data is reviewed, there has not been any significant reduction in activity for most medical staff. Some consultants readily admit that the reduction in caseloads has enabled them to see those remaining service users more often and for longer. The overall assumption underpinning the workstream was that a reduction in activity was needed to ensure that consultants could contribute fully to SPA and formulation. 4.5. Boundary changes for the localities This factor brought with it an urgency regarding reducing activity. However, the extent that, for some clinicians, caseloads were being both transferred to and acquired from other clinicians made caseload reduction more complex. It was noted by both the Adult and OPS AMDs that caseload transfer often presents an opportunity for discharge given that medical staff will have to assess whether they discharge or transfer cases. 4.6. Concentration on medical caseload The project concentrated specifically on medical caseloads. The clinical lead extended the scope to take in all medical activity in the community, eg home visits. However, other clinical professionalsâ&#x20AC;&#x2122; caseloads were not considered. This omission was a significant error and the impact on services both in a community setting and on inpatients is being recognised as a significant problem. 5. Work carried out by the original outpatients project and its clinical task and finish group The following section summarises the work initiated by the outpatients project Workstream and current status. Recommendations are made to carry the work forward into new work around outpatients.

Item 1

Work description Achieve project saving of £760,015

Status Completed

Develop some immediate “quick wins” around processes where medical consensus is that they add little/no value and they have the potential to reduce medical activity:  Stop/abolish core trainee to core trainee transfers on rotation  Stop/abolish “discharge to Outpatients” ie  transfer from a non-medic in CMHT to a medical caseload Stop/abolish “automatic/routine reviews’’ by medics when the service user has another care coordinator/care manager, ie no routine annual/ six monthly reviews. Reviews by medical staff should be on an as indicated basis only.

Develop guidance regarding who needs to be seen by a consultant/ other medic/S12 doctor. Define what types of work needs to be done by these staff and identify tasks medics will no longer do.

Develop a process for caseload reviews against specific criteria and identified grades of staff who should lead.

However, the failure to build the financial savings into a service delivery solution means that the risk exists that these costs could re-emerge. Recommendations went to the Professional Advisory Forum (PAF) in March 2012 and were accepted. These procedural rules have not been developed into a policy/procedural statement, however. This work came from the clinical task and finish group lead by the AMD for Older People’s Services. This operated within the overall outpatient project lead by the AD for Specialist Services. Recommendation These three proposals need adoption in a local working instruction regarding outpatient clinics. This should be done for version 2 of the local working instructions. Still work in progress. Recommendation The development of this guideline should be recommenced and be lead by senior consultants when the outpatient project reconvenes. Never fully developed but was again described in the PAF paper approved by PAF in March 2012. Some pre-existing guidance was cited based on Red, Amber and Green ratings of all community caseloads and subsequent recommended way forward with the case. Recommendation This methodology should be developed more fully by the new outpatient project and endorsed by PAF and the Committee of Leeds Consultant Psychiatrists (CLCP) to ensure it has organisational/ professional recognition.

Item 5

Work description Develop guidance around outpatient clinics specifically around best practice to maximise the benefit of medical review.

Status Never fully developed but an outline was again described in the PAF paper approved by PAF in March 2012. Some elements of the paper’s proposals were made operational – duration of clinic slots in PARIS following implementation in June.

These have had to be withdrawn as medical staff reported inability to manage existing caseloads based on 30 minute follow up slots and one hour new cases. Recommendation The outline guidance should be developed further to be included in local working instructions at the next version. 6

Effective and more sophisticated data analysis to be developed. Develop qualitative review processes.

A member of informatics staff contributed to the clinical task and finish group and supplied reports detailing caseload activity, did not attend data, length on caseload as requested. Analysis of the data did disprove the assumed reduction in activity due to a supposed “Hawthorne effect”. CTQ measures were developed to address post implementation effects of reducing medical activity.

Conduct baseline audit activity regarding service user perceptions of outpatient clinics and a qualitative evaluation of compliance by medical staff with accepted best practice for the conduct of medical outpatient clinics.

Recommendation A dashboard should be developed in consultation with medical staff and informatics that provides key performance information and supports the identified CTQ measures for outpatients These audits were commissioned by the clinical task and finish group and were carried out in April – June 2012. A draft report was issued in September 2012 by the Trust’s Clinical Audit Team. Recommendation The findings from these audits should be used to develop specific parts of the outpatients project looking at service user engagement regarding clinics and in assisting in the development of guidelines for outpatient clinics.

Item 8

Work description The role of recovery workers was also considered at a meeting requested by the Transformation Programme Group earlier in 2012 and specifically the potential to assist medical staff with discharges.

Status The recent successful bid for monies to fund recovery workers for 12 months may also be a useful element in a successful way forward with the new post implementation outpatients project. Recommendation The new outpatients project should include an evaluation of the merits of using recovery workers to assist clinicians in identifying service users who may be able to be discharged.

6. Impact on existing risks The following transformation risks are directly linked to the delay in implementing major parts of the outpatients project. The actions, particularly relating to Programme risks 18 and 24, should form part of the project plan when the outpatients project recommences. Programme risk 23 and workstream risk 2 are still rated as high because of the consequences of not reducing medical outpatient activity and the resultant effect this is having on the ability to fully implement the admin model for community services. The risks and actions detailed below were discussed at Transformation Programme Group on 11 October and staff responsible for outstanding risk treatment actions were asked to report the status of each risk treatment action back to the Transformation Governance Lead by 22 October 2012. Board report No Programme risk 18

Risk

Rating

High

Link to delays in the outpatients project This risk relates to the lack of an agreed process of review of caseloads and discharge assessments involving line management, clinicians and supported by Executive Directors. The intention was to develop an agreed mechanism for caseload review that enabled medical staff to safely reduce their caseloads.

Risk treatment actions affected Benchmarking - Individual consultantâ&#x20AC;&#x2122;s caseloads will be considered against internal benchmarks. Line management supervision/discussion to be carried out by Associate Medical Directors.(Originally due by 31 July 2012, this has been rescheduled to 31 December 2012) The Deputy Director of Care Services will take this matter up with the AMDs for Older Peopleâ&#x20AC;&#x2122;s Services and Adult Services. A system of peer review was to be developed to consider complex discharge decisions. Originally due by 31 July 2012, this has been rescheduled to 31 December 2012) The Deputy Director of Care Services will take this matter up with the AMDs for Older Peopleâ&#x20AC;&#x2122;s Services and Adult Services.

Board report No Programme risk 23

Programme risk 24

Risk

Rating

Unable to reduce the amount of Admin support, identified as part of the Admin Skill Mix Project

High

Clinical staff engaged in outpatient and community based work have same levels of activity to deal with but less resources from 1 April 2012.

Extreme

Link to delays in the outpatients project This risk is affected by the higher than anticipated outpatient activity and clinic numbers that were not factored into the admin model. Hence admin staffs are covering more clinics in more locations than planned.

This risk is affected by the lack of progress on discharging service users to reduce medical outpatient activity. It is also affected by delays in developing agreements with partners that will contribute to removing some of the pressures on medical staff that contribute to high caseloads, e.g. routine anti-dementia drug monitoring. Finally, the risk is linked to developing interim measures to assist all community staff in managing this caseload reduction process in terms of a reduction in routine demands on staff time for a period.

Risk treatment actions affected Ongoing consultation with Consultants and Service Leads regarding local admin support structures. (originally due by 31/10/2012, this has been rescheduled to 31 December 2012) The continuing existence of significant numbers of satellite bases and lack of reduction in outpatient clinics has meant that longer than anticipated discussion is required. Use of Bank staff to supplement the admin support structures as an interim measure. (due by 31/12/2012) Reduce medical outpatient and community work caseload by discharging SUs where there is no further clinical reason for seeing them. Institute discharge planning process as soon as possible. (due by 31 July 2012, this has been rescheduled to 31 December 2012) The Deputy Director of Care Services will take this matter up with the AMDs for Older People’s Services and Adult Services. For SUs still requiring to be seen – identify those that can be seen by other members of the clinical team. (due by 31 July 2012, this has been rescheduled to 31 December 2012) The Deputy Director of Care Services will take this matter up with the AMDs for Older People’s Services and Adult Services.

Board report No

Risk

Rating

Link to delays in the outpatients project

Risk treatment actions affected Explore ways of reducing or having routine drug monitoring, e.g. Clozapine and for those on drugs to treat Alzheimer’s disease done by other MH professionals or by GPs. Requires high level discussion between the Trust and GP groups in the city. (Due by 30 June 2012.The work around anti-dementia drugs and potential ability to discharge has been rescheduled to 30 April 2013 ) Clozapine monitoring has been transferred from the Citywide Treatment Service to each of the ICS’s in the community locality team in order that this is undertaken locally to ensure that the close monitoring required is embedded within the care and treatment plan. This piece of work is now complete. Dementia drugs were discussed at the LMC meeting on 14th September it was agreed that when secondary mental health service intervention is not required that discharge should take place. The AMD for Older People’s Services has been asked to scope the implications of this to ensure that this was achieved in a clinically managed and transparent way. To be reviewed at next LMC meeting. Detailed work undertaken to review and define who should undertake the prescribing, administering and monitoring of Depot medication being led by the AMD for Adults MH Services. Review other documentation/demands on staff time until position improves and case reduction starts making in-roads to reducing medical workload, e.g. audit and who carries out audits, assessments – discuss with Executive Team. (Originally due by 31 March 2012, rescheduled to fit in with Tranche 1 and 2 review to 31 December 2012.) The Trust audit cycle was adjusted to alleviate work load pressures. Monitoring of caseload size in place. Review of case load size and complexity being undertaken by Lead nurse in conjunction with review of Tranche 1 and 2 services

Board report No Workstream risk 2

Risk

Rating

New Admin Skill Mix structures not agreed and in place in the planned timescale

High

Link to delays in the outpatients project Although new structures are in place staff working in them are under significant pressure given the continuing high level of demand for outpatient clinic work. In addition, the ability of admin management to specify acceptable standards of service requires the demands on staff and admin resources to reduce to levels that were envisaged in developing the admin model.

Risk treatment actions affected Work with all services both in and out of the Transformation Project to restructure on an interim basis until the new services are developed. (due by 31 March 2012, revised to 31 December 2012) There is a continuing need to use temporary staffing to cover admin structures. This is envisaged to need to continue to at least December 2012. Clinical Services will provide information to be included in to Service Level Agreements (SLA). (Due by 31 March 2012, this date will be revised to March 2013 to coincide with the end of the post implementation projects) The drafting of the SLA will be carried out when the situation regarding service requirements can be properly assessed. Ongoing consultation with Consultants and Service Leads regarding local admin support structures. (Due by 30 September 2012, this date will be revised to March 2013 to coincide with the end of the post implementation projects) This ongoing consultation will need to continue beyond the anticipated date given that current structures do not equate with the model because of the use of temporary staff.

Conclusion and way forward The report indicates that the delay in implementing service re-design around outpatients is having a significant impact on tranche 1 and 2 services. Much of the work initiated in the improving outpatients clinical task and finish group remains valid and should be included in a new post implementation outpatients project. Way Forward The Transformation Lead, the Strategic Change Programme Manager, the Medical Director and Deputy Director of Care Services have met and discussed the issues raised in this report. Poor progress with implementing the elements of the outpatient project is symptomatic of the wider engagement issues and with new ways of working in some cases; these issues may precede the Transformation programme. A number of concerns, expressed by medical staff have been recognised by the Transformation Programme Board and those particularly related to a recent report from the Deanery have been discussed by the Executive Team. It is clear that there is still some variation in both understanding and implementation of the architecture required to support the new service model. Working with senior clinical staff to enable people to change and work according to the principles of â&#x20AC;&#x153;new ways of workingâ&#x20AC;?, is key to delivering the original objectives of the outpatient project and ensuring effective multidisciplinary team working. The outpatient project has already identified a number of specific actions that can be taken forward. These actions, outlined on Pages 6 and 7, will be discussed with clinicians and managers including consultants nominated by the Committee of Leeds Consultant Psychiatrists (CLCP), the Committee of York Consultant Psychiatrists (CYCP) and other professional groups before being further developed and implemented with local teams in a multidisciplinary context. Whilst engagement with clinical staff is key to successful delivery of the outpatient project, it is important that focus is also maintained on developing the specific actions identified in the project. The Outpatient project will be will revised to describe how the tasks are followed at team level, supported by consistent direction around the principles. The Outpatient project will be led by the Deputy Director of Care Services with executive sponsorship from the Medical Director. A revised project plan will be developed for the Transformation Programme Board on the 28th November. 13

To support the local delivery of the outpatients project the following actions will be taken; 

Medical Director to confirm the central principles of the transformed service model and endorse the principles outlined in the “Psychiatrists in the Transformation Project” paper previously approved by the Programme Board.



Work with senior clinicians and managers to define team structures so that teams are able to function effectively and with common purpose



Enable senior clinicians and managers to define how teams can work to achieve the objectives of Transformation



Support improved team working within the new locality model.



Support “Group Job Planning” within the locality teams and individual job planning for Consultants.



Ensure that dedicated medical time, clinic administration time and project management is available to support local implementation of the actions.

AGENDA ITEM 8

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Progress against our Annual Plan 2012-13 2012

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Jill Copeland - director of strategy & partnerships artnerships Amanda Burgess B - business manager

PAPER AUTHOR:

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC: GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

  



STATUS OF PAPER



To be taken in the public session (Part A) To be taken in private session (Part B) - If the paper is to be taken in the private session please indicate which criteria is applicable: Legal advice relating to legal proceedings procee (actual or possible) Negotiations in respect of employee relations where they are of a confidential nature Procurement processes and contract negotiations Information relating to identifiable individuals or groups of individuals Matters exempt under the Freedom of Information Act (quote section number)



SUMMARY: Foundation trusts rusts must submit their Annual Plans Plan to Monitor by 31 May each year. Th The Annual Plan is a three-year year forward plan which includes strategy, external factors and risks to delivery. As set out in Monitor’s Compliance Framework we are required to report to both our Council of Governors and Board of Directors on our performance against the priorities described within the plan. The attached progress report sets out the progress made against the 2012 2012-13 milestones for the second quarter of this year. Overall, the majority of our plans are rated ‘green, which demonstrates that progress is as expected at quarter 2.. Whilst there is slippage in two areas leading to an ‘amber’ rating (clinical ( information system;; and n new women’s low secure forensic unit at York), this slippage does not present any new risks to the Trust. There are no plans at ‘red’.

RECOMMENDATIONS: Members of the Board of Directors are asked to: 

Consider our position with progress made against our Annual Plan priorities.



Comment on the degree to which they are assured regarding both current performance and future trajectories.

PROGRESS AGAINST OUR ANNUAL PLAN 2012-13 â&#x20AC;&#x201C; QUARTER 2 UPDATE (Jul-Sept) On 31 May 2012 we submitted our three year Annual Plan to Monitor. As set out in Monitorâ&#x20AC;&#x2122;s Compliance Framework, we are required to routinely sight both the Board of Directors and Council of Governors on our progress against our strategic/operational priorities described within our Annual Plan. Progress against the milestones set out for quarter two is shown in the table below. Key: Green =milestones are on track Amber = milestones not met but action plan in place Red = milestones not met

Qtr 2 Progress Report

[Lead: John Clare, Transformation Lead]

 Tranche 1: Community services - implement new service model for community mental health and learning disability teams. (June-Dec 2012)  Tranche 2: Alternatives to hospital admission implement single point of access and single point of urgent referral. Implement new model for clinic and home based treatment services. (June 2012)

KEY MILESTONES 2013-14



Tranche 3: Inpatient services – implement new service models for Trust-wide inpatient services. (April 2013) Tranche 4: Out of scope services – implement new service models for the remaining Trustwide services. (Aug 2013)

KEY MILESTONES 2014-15



Implementation of further transformation schemes for Leeds, York and North Yorkshire. An evaluation of the impact of the whole service transformation programme is being carried out over the next 2-3 years.

GREEN

 New community services comprising of three all age locality based Community Mental Health Teams (CMHT) and three Community Learning Disability Teams were in place as planned on 25 June 2012.  On 25 June 2012 a single point of access for all mental health referrals was launched. In addition a new all age Crisis Assessment Service as well as three (coterminous with the CMHTs) Intensive Community Services (which provide 7 day extended hours building and home based services) began working. On 3 September the Learning Disability Service joined the Single Point of Access.

LEAD DIRECTOR

KEY MILESTONES 2012-13

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

Chief Operating Officer & Chief Nurse

Transformation Programme

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

Qtr 2 Progress Report

KEY MILESTONES 2012-13

 Tranche 3: Inpatient services - complete analysis and commence redesign work for Leeds based inpatient services. (July 2012)  Tranche 4: Out of scope services – commence analysis of the remainder of Trust clinical services. (August 2012)  Commence analysis and redesign work across York and North Yorkshire services using the lean six sigma methodology. Commence implementation of new service models for community services and alternatives to hospital admission. (May 2012)  Complete all outstanding needs based integrated care pathways. (March 2012)

KEY MILESTONES 2013-14



KEY MILESTONES 2014-15

Commence implementation of York and North Yorkshire based redesigned services. Complete transformation programme evaluation.

This will examine changes in service quality, costs and staff engagement from staff and service user and carer perspectives and using clinical and outcome data. 

Academic expertise is being provided as part of the Collaboration for Leadership in Applied Health Research and Care.

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

LEAD DIRECTOR

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

 A presentation on the findings from the Tranche 3 analysis of the inpatient services in Leeds was made to the Transformation Programme Board in September 2012.  A timeout involving senior managers was held on 17 August 2012 which reviewed the work undertaken so far in transformation. The bringing forward of York and North Yorkshire inpatients into transformation has impacted on the timetable for Tranche 4.  Mapping and analysis of York and North Yorkshire inpatient services has now been completed and a report will be given to the Transformation Programme Board in November 2012.  Three needs based integrated care pathways (ICPs) have been developed, staff have been consulted and the ICPs are currently being considered through the Trust’s clinical governance processes. It is anticipated that they will be completed by the end of the year with the implementation phase starting in mid January 2013.

Qtr 2 Progress Report

[Lead: Heather Cook, Head of Information & Knowledge Services]

KEY MILESTONES 2013-14

KEY MILESTONES 2014-15

 Implement PARIS ‘vision’ upgrade.  Roll out PARIS to Y&NY services.  Procure and implement IAPT system.  Replicate data warehouse in wider organisation to produce appropriate reports from existing systems in wider area.  Upgrade/modernise IT infrastructure (PCs, printers, switches) on York sites as identified in due diligence report.

 Commence project for review of PARIS and current contract. For potential procurement of existing or alternative system.  Complete IT upgrade scheme covering York sites.

 Determine future clinical information system requirements, in line with national, regional and Trust requirements.

AMBER

 PARIS ‘vision’ upgrade. Test version released in September 2012. Testing lead appointed and programme commenced. Clinical, medical and admin testing resources being identified.  Rollout PARIS to Y&NY services on hold to allow for system evaluation to take place. Work for Learning Disability Services moving to PARIS still ongoing to ensure swift rollout once review has been completed ie configuration data and training plans.  New IAPT system implemented and in use.

LEAD DIRECTOR

KEY MILESTONES 2012-13

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

Chief Financial Officer

Clinical information system

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

Qtr 2 Progress Report

e-records [Lead: Heather Cook, Head of Information & Knowledge Services]

KEY MILESTONES 2014-15

 The work to mobilise the Trust is underway in determining the future plan for mobile/agile working.  Work with supplier to develop appropriate “apps” suitable for deployment as a mobile solution.

 Continue to implement appropriate mobile solutions.

 Determine future IT requirements of Trust.

 Integrate e-records with current transformation programme for scoping with ICP’s.

 Commence phased implementation of erecords.

GREEN

 To continue with phased implementation of e-records.

GREEN

LEAD DIRECTOR

KEY MILESTONES 2013-14

 New remote access management system installed (July) and rollout commencing in quarter 3.  WIFI being installed in west/north west and east/north east locality offices in quarter 3 and 4.  Mobile devices being deployed to Community Teams commencing in November.  Tablet devices (iPad and W8) being evaluated during quarter 3 and 4G smart-phones during quarter 4 after launch of services in January 2013.  Awaiting deployment of PARIS Vision to enable development of ‘apps’ for mobile devices to be evaluated.

Chief Financial Officer

[Lead: Heather Cook, Head of Information & Knowledge Services]

KEY MILESTONES 2012-13

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

 Integrated care pathway (ICP) implementation from June 2012 should direct move toward e-records. ICP developers need to identify key electronic versus paper use to map a phased approach moving forwards. Document management solutions being assessed at pan-Leeds Informatics Board by three other Leeds area trusts. LYPFT have expressed an interest in this and work ongoing with TEWV. Systems evaluation will identify road map to meet e-record implementation.

Chief Financial Officer

Mobile working

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

Qtr 2 Progress Report

[Lead: Heather Cook, Head of Information & Knowledge Services]

KEY MILESTONES 2013-14

 Implement NHS Mail to York and North Yorkshire services.  Procure and deploy single sign-on (SSO) system across Leeds sites.  Provide smart cards to all York and North Yorkshire based staff.  Negotiate and agree SLA for management of existing systems with York, North Yorkshire and Leeds Teaching Hospitals Trust.  Deployment of hardware as required for PARIS roll out.  Procure and deploy remote power management system to centrally manage PCs.  Continue deployment of Voice Over Internet Protocol (VOIP) infrastructure to replace analogue telephony network.  Deliver appropriate training.

 Continued deployment of hardware and PARIS and deliver the changes required by the transformation programme.  Extend SSO to York sites.

KEY MILESTONES 2014-15

 Complete integration.

GREEN

 Deployment of NHSmail to York based staff completed in July 2012.  Project to procure single sign-on (SSO) to commence in quarter 4.  Smart cards to be issued to all York based staff by March 2013 (included in SLA with York Hospitals).  SLAs with York Hospitals and NYYPCT completed (June). SLA with LTHT to be developed during 2012/13 to commence 2013/14.  Infrastructure for York services being upgraded to support PARIS deployment (learning disability services in 2012/13).  Upgrade of existing management software being evaluated to undertake power management of PCs.  Programme to deploy voice over internet protocol (VOIP) across remaining sites (mainly PFI) underway (to be completed by end of 2014).

LEAD DIRECTOR

KEY MILESTONES 2012-13

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

Chief Financial Officer

Informatics requirements of the wider Trust area

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

Qtr 2 Progress Report

Potential to develop an integrated and shared service approach to IT service provision [Lead: Heather Cook, Head of Information & Knowledge Services]

KEY MILESTONES 2014-15

 Implement changes determined by the programme.  Working with supplier for system redesign where required.  Deploy WIFI infrastructure across main Trust sites. Phase 1 – community hubs and satellites. Phase 2 – PFI sites.  Procure and deploy Trust wide digital dictation/speech recognition system to support Clinical Support Unit operations.

 Continued implementation of changes needed to meet needs of new service model.  Complete WIFI implementation by March 2014.  Evaluate extension of system to York sites.

N/A

 Explore and appraise options for provision of IT support via managed or shared service.

 Implement joint services if agreement to proceed.  Initiate tender for outsourcing of data centre operations (in conjunction with Trust HQ re-development)

 Outsource Data Centre Operations.

GREEN

 WIFI to be installed at locality sites (Linden House, Hawthorn and Asket Croft) during 2012/13.  Installation work for WIFI in PFI sites to be tendered in 2012/13 to commence in 2013.  Project to procure and implement a Trust-wide digital dictation system to commence in June 2012 with the aim of deployment in quarter 4.

 Options for outsourcing of IT Service Desk Services are being progressed with potential providers and a management of change plan is being developed with HR. Business case being prepared with objective of moving service by the end of quarter 4.  Evaluation of options for alternative data centre provision currently on hold pending decision on new Trust HQ/corporate services provision.

LEAD DIRECTOR

KEY MILESTONES 2013-14

Chief Financial Officer

[Lead: Heather Cook, Head of Information & Knowledge Services]

KEY MILESTONES 2012-13

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

Chief Financial Officer

Informatics support to the transformation programme

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

Qtr 2 Progress Report

[Lead: Elaine Weston, Chief Pharmacist]

 Lease contract and service specification with The Retreat being concluded April 2012.  Earliest expected hand over of the new dispensary, July 2012.  Adverts and interviews have taken place to appoint new pharmacy staff (within the funding received from NHS NYY).  Appointees expected to start contracts July and August 2012.

KEY MILESTONES 2013-14

 Consolidation of pharmacy service to York mental health units.

KEY MILESTONES 2014-15

 Identify income generation opportunities, regarding clinical /dispensing services for other agencies in York.

GREEN

 The Retreat dispensary opened on 13 August 2012 and was fully staffed by 1 September 2012.  All work transferred back from York District Hospitals and Healthcare @Home on 1 October 2012, therefore fully operational.

LEAD DIRECTOR

KEY MILESTONES 2012-13

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

Chief Operating Officer & Chief Nurse

Development of the dispensary at the Retreat in York.

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

Qtr 2 Progress Report

[Lead: John Walker, Head of Facilities]

KEY MILESTONES 2013-14

KEY MILESTONES 2014-15

 Consistent implementation of healthcare and domestic waste improvements across all York sites to match that of the Leeds sites.  Continuing implementation of travel plan initiatives for St Mary’s Hospital, many of which will benefit staff across the Trust. Cycle loan and car share schemes will complement existing public transport discount scheme.  100% implementation of Trust wide recycling to include PFI sites.  Contribution into design and plans for any new Trust accommodation to develop BREEAM ‘Excellent’ rated buildings.  Transformation programme will continue to provide opportunities for estates efficiencies and further potential rationalisation, in particular getting more out of the buildings already occupied.

 Carbon Management Plan updated and revised to include York and North Yorkshire sites. New baseline established and targets agreed. These will meet all statutory and NHS targets for carbon reductions.

 Subject to Board approval of business cases, the potential disposal programme for the major sites of St Mary’s Hospital, St Mary’s House and the Trust HQ lease termination will significantly reduce the Trust’s building footprint and hence contribute towards the achievement of the carbon reduction targets.

GREEN

 Healthcare waste collection and disposal across Y&NY has been rationalised to take advantage of segregation opportunities and achieve consistency with Leeds. Cost savings are being realised through this approach.  PEAT action plans developed and implemented following assessment.  Healthcare waste internal bins to aid segregation to be implemented in York to match Leeds in 2012.  Cycle loan scheme now in place. Several order points throughout the year.  Car sharing scheme still to be investigated and introduced.  Trial of electric bikes to take place with a view to introducing a loan/pool scheme.  Permit scheme in place for Metrocard scheme. To be introduced for First buses and for Northern Rail travel.  Ward 5 (Newsam Centre) first Equitix PFI to introduce recycling. Recycling also in place at Towngate House and Millside. Remaining PFIs require agreement with Equitix.  Strategic outline cases being developed for Yorkshire Centre for Psychological Medicine, learning disability services and/or Trust Headquarters.  Transformation programme is ongoing.

LEAD DIRECTOR

KEY MILESTONES 2012-13

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

Chief Operating Officer & Chief Nurse

Carbon Management Plan

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

Qtr 2 Progress Report

[Lead: Gary Hostick, Associate Director of AMH/OPS]

KEY MILESTONES 2013-14

 The new ward is to be fully staffed from the beginning of May, with the new facility to be opened from the beginning of June in a phased approach over a period of 4 -6 weeks.  The annual running cost (direct staffing and nonpay) is £1.5m. Repatriation of 12 service users (from out of area locked rehabilitation private sector placements) will generate savings of £1.6m. The remaining beds will be occupied by service users from within the existing Leeds based secure/locked services.

 Fully embedding the locked rehabilitation service within an effective care pathway may give further scope to repatriate additional Leeds clients still out of area, and/or generate income from non-Leeds clients.

KEY MILESTONES 2014-15

N/A

GREEN

 The ward is now fully staffed and opened to service users on 25 June 2012.  All 12 service users have been repatriated to the new 18 bedded ward and arrangements are currently being made to repatriate a further 5 additional Leeds clients.  Initial meetings have taken place with NHS Leeds who are satisfied with the new service.  Once the new care pathway is embedded, further work will be undertaken in the new year to look at the possibility of generating income from non-Leeds clients.

LEAD DIRECTOR

KEY MILESTONES 2012-13

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

Chief Operating Officer & Chief Nurse

Locked Rehabilitation

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

Qtr 2 Progress Report

Dementia Services [Lead: Gary Hostick, Associate Director of AMH/OPS]

 Integration of Asket Croft into The Mount 1 July 2012.

New women’s low secure forensic unit

 Receive confirmation that the NHS North of England will fund the build.  Commence build (PCT responsibility).

[Lead: Melanie Hird, Associate Director of Y&NY Services]

KEY MILESTONES 2014-15

 Asket Croft refurbished and fully functioning as a community hub by July 2013.

 Complete build.  Agree contract with SCG.  Agree lease with PCT (or successor).  Staff service.  Commence service operations.

GREEN

 Operate service in accordance with contract.  Build to full capacity.

 All remaining service users have been transferred from Asket Croft into The Mount. Asket Croft is now empty  A proposal was presented at the September MG6 Standing Group meeting to refurbish Asket Croft and change its use to provide a hub for the East/North East community based mental health and learning disability services. This would enable the cessation of the leases at Brook House, Moresdale Lane and Westpoint.  Currently awaiting confirmation from NHS North of England that they will fund the build.

AMBER

LEAD DIRECTOR

KEY MILESTONES 2013-14

Chief Operating Officer & Chief Nurse

KEY MILESTONES 2012-13

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

Chief Operating Officer & Chief Nurse

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

Qtr 2 Progress Report

[Lead: Victoria Betton, Deputy Director of Strategy & Partnerships]

KEY MILESTONES 2013-14

 Annual public members’ survey. Approved trajectory to be achieved.

KEY MILESTONES 2014-15

 Annual public members’ survey. Approved trajectory to be achieved. GREEN

 Current ‘What’s your Goal? campaign running for 2012.  2013 Your Stories campaign currently under development to be launched in January  LYPFT responsible for chairing the citywide Time to Change strategic group.  LYPFT co-commissions the Time to Change Project Worker in Leeds.  Scoping work for supporting Time to Change in York and North Yorkshire is currently underway.  2012 Love Arts festival currently being delivered and plans being scoped to create a sister event in York and North Yorkshire.

LEAD DIRECTOR

KEY MILESTONES 2012-13

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

Director of Strategy & Partnerships

Our local Leeds campaign to challenge stigma associated with mental health problems that supports the national Time to Change campaign.

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

Qtr 2 Progress Report

[Lead: Victoria Betton, Deputy Director of Strategy & Partnerships]

 Annual Arts and Minds action plan achieved.

KEY MILESTONES 2013-14

 Annual Arts and Minds action plan achieved.

KEY MILESTONES 2014-15

 Annual Arts and Minds action plan achieved.

GREEN

We have made progress on our annual action plan as follows:  We have engaged with 184 service users and 49 staff members on a range of arts projects in partnership with 9 organisations. These projects have included: - The first of planned monthly acoustic events in partnership with Inkwell - A visual arts project with forensic services run by Artlink - A visual/performing arts project with Parkside Lodge run by Pyramid of Arts (both funded by Arts Council) - An art exhibition at Voodoo Cafe in Headingley - 5 summer community outreach courses run by Leeds College of Art.  31 new members have joined the network as a result of these activities (total membership now 823). Other developments include: - Planning and developing work for the Love Arts Festival programme - Development of the National Network for Arts and Health (NNAH) where we are being cited as a good practice case study for NNAH’s launch.

LEAD DIRECTOR

KEY MILESTONES 2012-13

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

Director of Strategy & Partnerships

Arts and Minds is a city-wide network, coordinated by our Trust, to promote the arts and creativity to people using our services.

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

Qtr 2 Progress Report

[Lead: John Walker, Head of Facilities]

 Refresh Estates Strategy.  Examine further space opportunities within PFI premises and develop plan and timeframe to achieve 80% overall occupancy.  Reconfiguration of The Mount to accommodate inpatients from Asket Croft.  Establish hubs for each operating area as part of the transformation programme. Aire Court (South), Asket Croft (East) and St Mary’s Hospital (West temporary until 2014).  Dispose of 36 Otley Old Road, Peel Court and East Ardsley Health Centre.  Develop programme of works for RRO fire survey and anti-ligature for Y&NY premises. To be completed over 3 year period subject to funding from NHS NYY.  Review Y&NY IAPT estate as possible retraction from GP premises if charging takes place.

KEY MILESTONES 2013-14



 



Move elderly assessment unit from Bootham Park Hospital to a community unit. Relocation of York LD services to Easingwold. Relocation of CAMHS services from Limetrees. Serve notice to break lease on Trust HQ. Continuation of RRO fire works and antiligature works for Y&NY in line with agreed programme. Begin development of new HQ and inpatient facility. Subject to business case. Terminate leases at Brook House and Westpoint as services move to Asket Croft as part of transformation programme.

KEY MILESTONES 2014-15



Complete development. Subject to business case. Terminate leases at Trust HQ and The Exchange. Relocate Bootham Park Hospital services. Complete Women’s Low Secure Unit at Clifton. Develop Parkside Lodge into hub for west Leeds services to replace St Mary’s Hospital. Market St Mary’s House and St Mary’s Hospital sites for planned disposal.

GREEN

 Estates Strategy being developed for approval by Board of Directors. Three consultation workshops held in August and September with non-executive directors, governors, staffside and other key stakeholders for feedback. Strategy to be completed by end Nov.  Major review of PFI premises and draft options prepared for improved use. Potential for re-housing of some corporate/HQ functions. Further work being undertaken with clinical service reprovision being the priority with any additional space for corporate/HQ.  Reconfiguration of The Mount no longer required in accordance with the transformation programme.  Hubs established for services at St Mary’s Hospital/St Mary’s House and brief prepared for Asket Croft. Tender due in near future.  36/38 Otley Old Road/Peel Court being marketed 38 Otley Old Road due to complete sale at the end of October. East Ardsley back on market quarter two of 2012-13.  Funding approved for NHSNYY (circa £5m). Procure21 partner working through specification for delivery during year. This is NYYPCT funded.

LEAD DIRECTOR

KEY MILESTONES 2012-13

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

Chief Operating Officer & Chief Nurse

Estates

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

Qtr 2 Progress Report

KEY MILESTONES 2012-13

 Develop business case for new Trust HQ and inpatient facilities.  Begin plans for the decommissioning of St Mary’s Hospital and St Mary’s House site.

KEY MILESTONES 2013-14

KEY MILESTONES 2014-15



Disposal of Malham House, Southfield House and Millfield House. Terminate lease at Lea House Relocation of St Mary’s Hospital and St Mary’s House services.

PROGRESS AGAINST 2012-13 MILESTONES AT QUARTER 2

LEAD DIRECTOR

ASSOCIATED IMPLEMENTATION PLANS/DELIVERY MILESTONES

PERFORMANC E RATING RED/AMBER/ GREEN

STRATEGIC/ OPERATIONAL PRIORITY

 Ownership of Y&NY estate to transfer to NHS Property Services following Board report in September 2012. LYPFT to remain as tenants.  IAPT estate being reviewed.  Proposed new development including site location being reviewed to consider all options as part of strategic outline case.  Linked to above and eventual strategic outline case approval, scheduled for end of November/December.  St Mary’s Hospital/St Mary’s House decommissioning plans will follow final agreement with strategic outline case for new development.

Qtr 2 Progress Report

AGENDA ITEM 9

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE: DATE OF MEETING:

Organisational Growth G Principles and Decision Decision-Making Framework CATEGORY OF PAPER 30 October 2012 ((please tick relevant box)

LEAD DIRECTOR: PAPER AUTHOR:

Jill ill Copeland Director of Strategy and Partnerships Jill Copeland Director of Strategy and Partnerships

STRATEGIC STRATEGIC:



GOVERNANCE: INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

  



We govern our Trust effectively and meet our regulatory requirements

STATUS OF PAPER To be taken in the public session (Part A) To be taken in private session (Part B) - If the paper is to be taken in the private session please indicate which criteria is applicable: Legal advice relating to legal proceedings procee (actual or possible) Negotiations in respect of employee relations where they are of a confidential nature Procurement processes and contract negotiations Information relating to identifiable individuals or groups of individuals Matters exempt under the Freedom of Information Act (quote section number)



SUMMARY: In late 2009/early 2010 the Board of Directors and Council of Governors agreed some principles and criteria for the assessment of significant organisational growth opportunities. A decision-making making framework was also agreed, which set out clearly the Board of Director’s role in approving such opportunities; and the requirement to ensure that the Council of Governors was fully engaged in the process and supportive of the Board’s decisions. The principles, criteria and decision-making decision framework were fully tested sted during the North Yorkshire and York (NYY) tender process. The organisational growth principles, criteria and decision-making decision making framework have been revised to ensure that they remain fit for purpose (see Appendix 1). They now take account of our new services ervices and geographical coverage; learning from the NYY project project; and the new requirement in the Health and Social Care Act for the Council of Governors to approve significant transactions. To meet this requirement of the Health and Social Care Act, we need ed to define ‘significant transaction’ in our Trust constitution. A proposal for this definition is set out at Appendix 2. (Please note that this covers all significant transactions, not just those that relate to organisational growth.) The e proposed principles, criteria, decision-making framework and definition of significant transaction have all been considered by the Organisational Growth Standing Support Group (which reports to Means Goal 6) and the Governors Growth Sub-Group. Sub Group. Following g approval by the Board of Directors, the next step is to gain the approval of the Council of Governors at the meeting on 13 November 2012.

RECOMMENDATIONS: Members of the Board of Directors are asked to: 

Approve the growth principles, principles criteria and decision-making making framework



Approve the definition of significant transaction

(noting noting that this approval will be subject to approval by the Council of Governors in November).

Appendix 1

ORGANISATIONAL GROWTH PRINCIPLES, CRITERIA AND DECISION-MAKING MAKING FRAMEWORK In LYPFT, organisational nal growth is a means to achieving our strategic end goals, rather than an end in itself. To guide our decision-making decision making on organisational growth opportunities, we have therefore developed a set our principles and criteria which must be followed in all cases. The principles provide a number of tests that must be passed before we proceed with a growth rowth transaction; and the criteria provide a means of further detailed assessment as the transaction progresses and before a final decision to proceed is made made. These principles and criteria are set out below and apply to all growth opportunities opportunities. The majority of growth opportunities fall within the delegated limits of the Executive Team (£500,000 in any one financial year). Larger transactions require the approval of the Board of Directors; and the he Health and Social Care Act requires that (from 1 April 2013) the Council of Governors must approve any significant transaction which is entered into by the Trust. This new role for the Council of Governors does not imply that governors are liable for such decisions; nor that they are acting as ‘shadow’ ‘shadow or de facto directors. The Board of Directors will make an initial decision as to whether the Trust should go ahead with any significant transaction; and, if the Board’s initial view is that it should, this will be subject to the Council of Governors approving proving the transaction. In exercising this power of approval, the Council of Governors will be scrutinising a particular decision of the Board of Directors and holding the Board of Directors to account for that decision. The decision-making making framework below sets out how decisions on organisational growth opportunities are governed in LYPFT. Each opportunity is taken on a case case-by-case basis, applying the growth principles, criteria and decision-making decision making framework rigorously rigorously. The principles, criteria and decision-making decision making framework should be read alongside the definition of a significant transaction which requires the approval of the Council of Governors.

Principles for Organisational Growth These principles apply to any organisational growth opportunity that the Trust is seeking to pursue, whether this be growth in clinical or non-clinical services.

Principle 1 Strategy

Strategic growth is a means to achieving the Trust’s ambition and strategic end goals. Any potential growth opportunity must therefore fit with the Trust’s purpose, values and strategic direction; be consistent with the NHS principles and values set out in the NHS Constitution; and must demonstrably benefit people who use our services, their families and their carers.

 Growth should not be seen as an end in itself, but a means of achieving the Trust’s defined end goals.  Growth must benefit current and/or future service users – with the focus on benefit to service users, not to the organisation.  Growth must not compromise our drive for excellence in existing service provision.  Growth could be pursued for financial benefit alone, provided that the financial benefit could be used to further quality improvement.  Growth could be pursued to counter reductions in services elsewhere, where this is needed to maintain financial stability.  Growth could be pursued to protect the Trust’s competitive position in the market, for example to achieve advantage over competitors or respond to opportunities under Any Qualified Provider (AQP). Does growth project meet principle?

Principle 2 Compliance

Yes/No

Any growth opportunity should have a long-term positive impact on the Trust’s risk ratings for quality, provision of mandatory services, finance and governance.

 We would pursue an acquisition, merger, franchise or joint venture which had a shortterm negative impact on risk ratings where we expected that, over the longer-term, it would have a positive impact on the Trust’s risk ratings.  There may be circumstances where the Trust would need inducement to take on higher risk opportunities, for example by another organisation acting as ‘market manager’.  Whilst the Trust may decide to pursue a growth opportunity, detailed due diligence would always be undertaken to achieve detailed understanding of potential risks prior to final contract agreements. Does growth project meet principle?

Yes/No

Principle 3 Sector

The Trust will work with all partners across all sectors. As with Principle 1, any potential growth opportunity must fit with the Trust’s purpose and values; be consistent with the NHS principles and values set out in the NHS Constitution; and must demonstrably benefit people who use our services, their families and their carers.

 Working with other public sector and voluntary sector partners is likely to be most consistent with our purpose, values and strategy.  We would need to assess the risks of providing services that are subject to different regulatory regimes eg Ofsted.  There may be circumstances in which working with the ‘for profit’ sector is consistent with our purpose, values and strategy.  There may be benefits from working with the ‘for profit’ sector, such as access to new markets, new skills and capital. These benefits must be proportionate to the risk involved – which includes risk to our reputation and to good-will of staff.  The bar may need to be set higher for ‘for profit’ organisations that provide direct care for service users than for organisations providing non-clinical services (such as private finance initiative companies managing our buildings).  Changes to the private patient cap now allow the Trust to derive some private income directly, without the need for joint ventures with the ‘for profit’ sector. Does growth project meet principle?

Principle 4 Services

Yes/No

The Trust will provide services that demonstrably benefit people who use our services, their families and their carers. Where any potential growth opportunity involves services that are not geographically coterminous with our current services, benefits must outweigh the disadvantages of geographical distance.

 Provision of mental health and learning disability services in other geographical locations is consistent with our purpose, values and strategy.  Provision of other health and wellbeing services could also be consistent with our purpose, values and strategy. This could provide opportunities to provide new integrated models of care – for examples with community health services, primary care services or social care services.  Expanding into new services or new geographical areas could benefit people who use our services, their families and their carers by providing access to new clinical services and clinical skills.  Expanding the range and volume of services we offer could achieve competitive advantage, counter reductions in services elsewhere or spread overhead costs.  Expanding into non-clinical services could offer opportunities to make surpluses which would be invested in clinical services.  Provision of local services that are coterminous with our current services or regional or national services from current or adjacent locations is likely to offer significant benefits in terms of ease of governance, management arrangements and relationships with partners.  Where services are geographically distant from our current geographical location, governance, management and relationships with partners are likely to be more difficult. Benefits must clearly outweigh the disadvantages of geographical distance. Does growth project meet principle?

Yes/No 3

Criteria for Organisational Growth Options Appraisal Criteria

Weighting

1. Contribution to the delivery of the Trust’s ambition, strategy and values: a. Extent of alignment with LYPFT existing core business

/10

b. Extent of alignment with LYPFT geographical patch (including regional and national services delivered from LYPFT locations)

/10

c. Positive contribution to strategic end goals:  People achieve their agreed goals for improving health and improving lives  People experience safe care  People have a positive experience of their care and support

/20

d. Positive alignment with external strategic context, including improved outcomes for the local health and social care economy

/15

e. Extent of fit with LYPFT’s (NHS) values

/15

f. Extent of support (known or likely) by all key stakeholders, including LYPFT service users and carers, staff and governors

/15

g. Positive contribution to LYPFT’s market position, as demonstrated by an analysis of the competitor landscape and the growth opportunities of new or existing services into new or existing markets Total

/15

/100

2. Contribution to the Trust’s strategic means goals: (Note: update following strategy refresh) a. We provide excellent quality, evidence-based, safe care that promotes recovery and inclusion

/15

b. We involve people in planning their care and in improving services

/15

We work with partner organisations to improve health and lives

d. We value and develop our workforce and those supporting us

/15

e. We improve our services through learning, research and innovation

/10

/15

We provide efficient and sustainable services

g. We govern our Trust effectively and meet our regulatory requirements Total

/15 /100

3. Contribution to the Trustâ&#x20AC;&#x2122;s viability as a going concern: a. Positive contribution to financial sustainability and required financial thresholds, in particular contribution to EBITDA margin

/35

b. Return on investment: realistic expectation of recovering the costs of acquisition within 3 years

/35

/10

Contribution to Trustâ&#x20AC;&#x2122;s optimum size, also taking account of the competitor landscape

d. Extent of opportunities to access capital

/10

e. Positive contribution to reputation and support from staff, service users and the community

/10

Total

/100

4. Consistency with the Trustâ&#x20AC;&#x2122;s continuing regulatory and compliance requirements: a. Likelihood that registration with the CQC can be achieved in all areas (following implementation of action plan)

/30

b. Likelihood that representative membership and governance can be achieved

/30

/25

Impact on risk ratings for finance, governance and provision of mandatory services

d. Impact on other existing or potential risks

/15

Total

/100

Grand Total

/400 =%

Growth decision-making making framework The flowchart below shows the steps required for a Trust decision on whether to proceed with a growth opportunity and at what level that decision is made. Not all of the steps required are shown, as these will vary by transaction. For example, a tender for a large service will require a number of decision points, such as the price at which to submit the tender; the final price agreed for the transaction; an and the detailed provisions within the business transfer agreement. Other growth opportunities opportunities, such as a decision to develop a new service to compete in the AQP market, may simply require approval of a business case.

Appendix 2

DEFINITION OF A SIGNIFICANT IFICANT TRANSACTION The Health and Social Care Act requires that the Council of Governors must approve any significant transaction which is enter ed into by the Trust. This does not imply that governors are liable for such decisions;; nor that they are acting as ‘shadow’ or de facto directors. The Board of Directors will make an initial decision as to whether the Trust should go ahead with any significant transaction; transaction and, if the Board’s initial view is that it should, this will be subject to the Council of G Governors approving the transaction. In exercising this power of approval, the Council of Governors will be scrutinising a particular decision of the Board of Directors and holding the Board of Directors to account for that decision. Final ratification of the decision will remain the responsibility of the Board of Directors. For LYPFT a significant transaction will be defined in line with Monitor’s Risk Evaluation for Investment Decisions by NHS Foundation Trusts (REID guidance).. The REID guidance covers the following types of transactions: significant ignificant capital expenditure; expenditure acquisitions; joint ventures; equity stakes; major property transactions; mergers and alliances (eg formal o r informal agreements to work with other institutions). The financing of such transactions could be through retained surpluses, equity, debt, sale and leaseback transactions, private fi nance initiative PFI) and other financially engineered transactions. (It should be noted that not all of these transactions concern organisational growth.) Significant transactions fall into two categories: 

Value: the he criteria for value are taken from the REID guidance guidance; except for income, where a lower threshold is used (5% ( and 10% instead of the 7.5% and 15% in the REID guidance).



Materiality: the he criteria for materiality also follow the REID guidance, but include some additional items that are important to LYPFT.

A glossary of terms is provided to help the reader wi with technical financial language; and each criterion includes some notes to help understand what it means for LYPFT.

Glossary

EBITDA

EBITA is an important measure (especially from Monitor’s perspective) of the general health of a foundation trust. It is a measure taken from the private sector, that means: Earnings Surplus income. Before Interest Paid or received. Tax Generally not an issue in the public sector, but could include corporation tax in the future. Depreciation The value of capital assets on a company’s books is reduced (by standard metrics) over time. This affects the book value of a company, but does not necessarily have a cash cost (at least not immediately). Eg a seven year old van may have no value on the books but could still be useful to the business for years to come without spending more money. Amortisation In this context amortisation refers to the writing down of intangible assets (similar to depreciation for tangible assets). EBITDA tells us how much short term cash we have generated to fund the long term future of the organisation, especially capital investments. It is worth noting that, relative to the private sector, foundation trust surplus margins are very small. This means that it can take a long time to recoup investments; which is why the REID guidance is in place to ensure due consideration is given to significant transactions.

Capital

Capital refers to the things we own and utilise to enable us to provide our services eg buildings, medical equipment, vehicles, etc. These items are usually fairly durable, unlike the “stock” items we buy and use to deliver our services (bandages dressings, medicines etc).

Assets

Assets are those things we own that have a value. This includes capital and stock, and also intangible assets.

Intellectual property rights are an example of an intangible asset. Therefore, if we developed a clinical assessment tool we could Intangible licence this to other trusts and generate an income. We can give this a value on our books. Similarly “good will” is an intangible assets asset, so if we invest in branding and advertising we can put a value for this on the books; our reputation as a provider could have a good will value. Equity

For this purpose equity relates to the ownership of shares in another business. This could be shares in public companies but more likely to be in private limited companies or similar community interest companies, including LYPFT setting up new businesses to deliver new services. Although we would own the shares, these companies would not be directly part of LYPFT. 2

1. Value Any transaction meeting the thresholds for reporting to Monitor as set out in the REID guidance (or LYPFT variation of).

Category

Ratio

Description

Assets

The gross assets* subject to the transaction divided by the gross assets of the NHS FT

Profits I

The EBITDA attributable to the assets subject to the transaction divided by the EBITDA of the NHS FT

Income

The income attributable to the assets subject to the > 5% transaction divided by the income of the NHS FT

Size

The gross capital† of the Consideration company or business being to total NHS acquired divided by the total FT capital capital of the NHS FT Profitability Profits II * †

‡

Nonhealthcare/ international

The EBITDA margin attributable to the assets subject to the transaction

UK Explanation of what this means for LYPFT healthcare > 10%

LYPFT total assets = £87m; 10% = £8.7m asset value. This could include the sale of some of our estate if it tripped this threshold.

> 25%

2011/12 turnover = £181m and EBITDA = 7.7%, so EBITDA = £13.9m; 25% of this = £3.5m. A new business transaction would have to project an EBITDA return of £3.5m to trip this threshold.

> 10%

10% of £181m = £18m. This would include tenders for any service with an annual income above £18m. (Note: the REID guidance thresholds are higher than this, at 7.5% and 15%)

> 5%

> 10%

10% of £34m = £3.4m. This would include the purchase of shares in another company above this threshold.

Dilutive‡

This would include any transaction that reduced the EBITDA of LYPFT.

> 5%

> 12.5%

Gross assets is the total of fixed assets and current assets Gross capital equals the market value of the target’s shares and debt securities, plus all other liabilities, plus the excess of current liabilities over current assets Lower EBITDA margin than the NHS FT has reported in the last audited financial year

2. Materiality Any transaction meeting the description for reporting to Monitor as set out in the REID guidance or the description for ‘novel and contentious’ set by LYPFT. Category

Other (as defined by the REID guidance)

Novel and contentious (as defined by LYPFT)

Description

Any investments that may have any one of more of the following characteristics:

Any transactions that may have any one of more of the following characteristics:

Explanation of what this means for LYPFT 

An equity component



Significant reputational risk



The potential to destabilise the core business



The creation of material For instance, a business transaction involving staff transfers under TUPE could attract contingent employer liabilities for pensions, discrimination, etc; contingent liabilities or a land purchase could involve various covenants and liabilities attached to that land.



Non-core business for the Trust

Any services that are not mental health, learning disabilities or substance misuse; or are not related research or training services. For LYPFT, this would include provision of community health services; or ‘hosting’ services such as the Commercial Procurement Collaborative.



Locality-based services outside of our adjacent geographical patch

This would be the whole of the LYPFT patch, which includes those geographical areas adjacent to both Leeds and the whole of North Yorkshire and York.



Services which raise serious ethical issues

For instance, gender Identity services for children, especially involving endocrinology (biochemical elements of gender reassignment). Even if LYPFT were commissioned to provide this service, it would still be likely to trip the reputational risk threshold.

Acquiring a shareholding in another business or providing a shareholding on part of our business to another entity eg a joint venture. For instance, a joint venture with a ‘questionable’ partner. Although this could include any large transaction, such transactions should also trip the financial thresholds set out above. Any Qualified Provider could be considered here, as any loss of service would not be subject to TUPE and could therefore result in significant redundancy costs.

AGENDA ITEM 11 LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Performance, Quality and Use of Resources Report

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Chief Financial Officer

PAPER AUTHOR:

Head of Performance

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC: GOVERNANCE:



INFORMATION: IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

  



STATUS OF PAPER



To be taken in the public session (Part A)



To be taken in private session (Part B) - If the paper is to be taken in the private session please indicate which criteria is applicable: Legal advice relating to legal proceedings procee (actual or possible) Negotiations in respect of employee relations where they are of a confidential nature Procurement processes and contract negotiations Information relating to identifiable individuals or groups of individuals Matters exempt under the Freedom of Information Act (quote section number)

SUMMARY: Non- financial performance        

Compliance with Monitor nitor targets (Pages 3 to 11) Progress against North Yorkshire and York services se vices CQC action plans (Page 13) Mental Health Act Monitoring Visits (Pages 15 to 18) Tier 1 Extreme risks with ith mitigating actions (Pages 23 2 to 27) Trigger to Board Events (Pages (Page 34 to 35) Take up of Compulsory (mandatory) (m Training (Pages 36 to 37) Compliance with and implementation of Mental Health Act Legislation (Pages 39 to 44) Payment By Results (Pages 46 to 47)

Financial performance 

 

At 30th September the Income & Expenditure (I&E) surplus was £2.15m, £ m, £0. £0.61m above plan. This s generates an I&E margin of 2.5%, 2.5 0.9% above plan. Cash balance was £5.72m m above plan The year to date financial risk rating is a 4. The headroom to a risk rating of a 3 is £ £1.15m and to a 2 is £2.31m.

RECOMMENDATIONS: The Trust Board of Directors is asked to: 

Consider the position against both non-financial non financial and financial targets and to comment on the degree to which it feels assured regarding both current performance and future trajectories.

Report on compliance with national and local performance requirements, October 2012 This report shows the Trustâ&#x20AC;&#x2122;s current compliance with national and local performance requirements. Colour coding identifies the source of the requirement, as follows:

Monitor compliance requirements CQC registration requirements 2012/2013 Performance Requirements within contracts with commissioners Tier 1 Extreme Risks Quality Accounts Areas for local reporting Transformation Financial performance Contractual Activity Reporting The table below shows areas where performance is currently of concern. Further detail can be found in the body of the report. Indicator

Compliance implication

Delayed Transfers of Care (Page 3)

Monitor Requirement

NYY Services CQC Action Plans (page 13)

CQC Compliance

Trigger to Board Events (page 34)

Locally determined Trigger to Board Events

Compulsory (mandatory training) (page 36)

Areas for local Reporting

Timescales for Appeal against Detentions to Mental Health Act Managers (Page 39)

Areas for Local Reporting

Comments NYY service delays are showing at 15.8%, demonstrating an improving position. The proposal to reconfigure older people's services includes the development of a Nursing Home Team to reduce admissions from care homes and help to address delayed transfers of care. This is currently the subject of consultation. More information is available on page 3. There are currently 2 outstanding NYY CQC issues that were due to be addressed by the 31st July 2012 and th 30 September 2012 respectively. These have been partially completed. Full completion of these 2 outstanding issues will be by December 2012. More information is available on pages 13. Three Trigger to Board events have been reported in September and one Trigger to Board Event reported in October. Immediate action has been taken and full investigations have been completed. More information is available on page 34. Compulsory (mandatory) training take up below 80% compliance. Provision exists to increase compliance. Procedure for Compulsory (mandatory) training has been revised, which increases clarity of the requirements and operational compliance. Reports are provided to services on a monthly basis. More information is available on pages 36-37. Managers Hearings are being held outside of the Trustâ&#x20AC;&#x2122;s internal quality standard. Work is underway to identify why the local target is not being met and to improve performance. More information is available on pages 39 44.

Contents

Page

1. Monitor Requirements...................................................................................................................................................................................................................................................................... 3 1.1 Delayed Transfers of Care ............................................................................................................................................................................................................................................................ 3 1.2 Crisis Resolution Services ............................................................................................................................................................................................................................................................ 4 1.3 7 Day Follow Up............................................................................................................................................................................................................................................................................ 5 1.4 Care Programme Approach (CPA) Reviews within 12 Months ..................................................................................................................................................................................................... 6 1.5 Data Completeness – Identifiers ................................................................................................................................................................................................................................................... 7 1.6 Data Completeness Indicator for mental health outcomes for CPA patients................................................................................................................................................................................. 8 1.7 Access to Healthcare for People with a Learning Disability – Leeds Services.............................................................................................................................................................................. 9 1.8 Access to Healthcare for People with a Learning Disability – North Yorkshire & York Services ................................................................................................................................................. 10 1.9 Meeting Commitment to Serve New Psychosis Cases by Early Intervention Teams.................................................................................................................................................................. 11 2. Care Quality Commission (CQC) ..................................................................................................................................................................................................................................................... 12 2.1 Care Quality Commission (CQC) Registration Requirements..................................................................................................................................................................................................... 12 2.2 North Yorkshire and York Services CQC Action Plans ............................................................................................................................................................................................................... 13 2.3 Healthcare Associated Infections................................................................................................................................................................................................................................................ 14 2.4. Mental Health Act 1983 Monitoring Visits................................................................................................................................................................................................................................... 15 3. 2012/2013 Contractual Requirements (Excluding Monitor Requirements) ...................................................................................................................................................................................... 19 3.1 Crisis Resolution and Assertive Outreach................................................................................................................................................................................................................................... 19 3.2 Adult Inpatient Services .............................................................................................................................................................................................................................................................. 20 3.3 Prisoner Mental Health................................................................................................................................................................................................................................................................ 21 3.4 Further Contractual Reporting Requirements ............................................................................................................................................................................................................................. 22 4. Tier 1 Extreme Risks........................................................................................................................................................................................................................................................................ 23 5. Quality Accounts 2011/2012– Priority 2: People experience safe care........................................................................................................................................................................................... 28 6. Areas for Local Reporting ................................................................................................................................................................................................................................................................ 33 6.1 “Never” & “Trigger to Board” Events ........................................................................................................................................................................................................................................... 33 6.2 Compulsory (Mandatory) Training 2012/2013............................................................................................................................................................................................................................. 36 6.3 Information Governance.............................................................................................................................................................................................................................................................. 38 6.4 Compliance with and Implementation of Mental Health Legislation ............................................................................................................................................................................................ 39 6.5 Complaints .................................................................................................................................................................................................................................................................................. 45 6.6 Physical Health Assessments ..................................................................................................................................................................................................................................................... 45 6.7 Payment By Results Report ........................................................................................................................................................................................................................................................ 46 7. Transformation................................................................................................................................................................................................................................................................................. 48 8. Year to Date Financial Position........................................................................................................................................................................................................................................................ 49 9. Forecast Financial Position.............................................................................................................................................................................................................................................................. 50 10. Contractual Activity Reporting........................................................................................................................................................................................................................................................ 51 10.1 Planned Activity Monitoring (Leeds Service)............................................................................................................................................................................................................................. 51 10.2 Planned Activity Monitoring (NYY Services) ............................................................................................................................................................................................................................. 52 Glossary of Definitions ......................................................................................................................................................................................................................................................................... 53 Appendix 1: Revenue position Appendix 2: Capital Spending Appendix 3: Balance Sheet Appendix 4: Cash Flow Appendix A: Essence of Care Action Plan 2

1. Monitor Requirements 1.1 Delayed Transfers of Care Monitor measure:

Minimising delayed transfers of care

Compliant

Monitorâ&#x20AC;&#x2122;s construction for the measurement of this target is as follows: Number of patients (aged 18 and over on admission) per day under consultant and non consultant-led care whose transfer of care was delayed during the quarter, divided by the total number of occupied bed days (consultant led and non consultant led) during the quarter. Using this construction Monitor has set a threshold of no more than 7.5% of delays across the year. Monitor now includes delays attributable to social care. The Trust continues to maintain compliance for Quarter 2 2012/13 with a cumulative average of 5.7%. There was a tolerance level of a further 793 delay days for Quarter 2 2012/13 before performance exceeded the 7.5% target. Work to reduce the level of delays within NY&Y services is continuing, and the current delay rate of 15.8% demonstrates an improving position. The proposal to reconfigure older people's services includes the development of a Nursing Home Team to reduce admissions from care homes and help to address delayed transfers of care. This is currently the subject of consultation, and City of York Council Overview and Scrutiny Committee have asked to see the outcomes of the consultation at its December meeting. Our proposals are also going to the North Yorkshire County Council Overview and Scrutiny meeting in November. Leeds & York Partnership NHS Foundation Trust Delayed Transfers of Care 20.00% 18.00% 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00%

NYY Cumulative Delay Rate

Leeds Cumulative Delay Rate

LYPFT Cumulative Delay Rate

Monitor Target

1.2 Crisis Resolution Services Monitor measure:

Admissions to inpatient services had access to crisis resolution home treatment teams

Compliant

This target applies to all admissions of working age adults to psychiatric inpatient care, excluding transfers, patients recalled on Community Treatment Orders, patients on leave under section 17 of the Mental Health Act (MHA) 1983 and planned admissions from Specialist Units. Monitor has increased the threshold for 2012/2013 to 95% for this indicator to be reported on a quarterly basis. Monitor refers to the Guidance Statement on Fidelity and Best Practice for Crisis Services and sets out that the Crisis Resolution Home Treatment Team should be actively involved in all requests for admission. â&#x20AC;&#x2DC;Actively involvedâ&#x20AC;&#x2122; requires face to face contact unless it can be demonstrated that face to face contact was not appropriate or possible. For each case where face to face contact is not deemed appropriate, a selfdeclaration that the face to face contact was not the most appropriate action from a clinical perspective is required. Applying the above Monitor criteria the Board of Directors supported the decision that face to face contact with the Crisis Resolution Home Treatment Team is not the most appropriate action from a clinical perspective in the following two circumstances; 1) where a Mental Health Act assessment has already taken place by the Emergency Duty Team and 2) where service users are under the care of the North Yorkshire & York Assertive Outreach Team. The chart below shows admissions that were gate-kept by Crisis Resolution both excluding Mental Health Act admissions (as per the Monitor construction) and including Mental Health Act admissions. The Trust continues to maintain compliance with the Monitor target for Quarter 2 2012/13 with performance at 98.4%. There was a tolerance level of a further 8 breaches for Quarter 2 2012/13 before performance fell below the 95% target.

Total admissions (Monitor construction)

LYPFT

Total face to face assessments Number of Mental Health Act assessments Total % Compliance (Monitor) Tolerance

Feb 2012

Mar 2012

Apr 2012

May 2012

June 2012

July 2012

Aug 2012

Sept 2012

103

Leeds Services

NYY Services

Nov 2012

Dec 2012

Percentage ofadmissions whohave had aface to face assessment with CRHT 100%

80% 16

91.0%

97.8%

96.1%

100.0%

95.3%

96.5%

100%

98.8%

40%

20%

60%

% By Quarter (Monitor) Total % Compliance (Excluding MHA) Total % Compliance including MHA assessments (NHS Leeds) Total % Compliance (Excluding MHA)

Oct 2012

97.1%

98.4%

Feb-12 92.9%

97.1%

100%

98.5%

97.0%

100%

94.3%

97.7%

100%

98.8%

97.5%

100%

86.4%

100.0%

88.2%

100.0%

85%

94.7%

100%

95.5%

Mar-12

Apr-12

Total%Compliance(Monitor)

May-12

Jun-12

Total%Compliance(includingMHAassessments)

Jul-12

Aug-12

TargetCompliance(Monitor)

Sep-12

1.3 7 Day Follow Up Monitor measure:

Receiving follow-up contact within seven days of discharge

Compliant

LYPFT 7 day follow up rates Dec - 12

Nov - 12

Oct - 12

124

Sept - 12

109

Aug - 12

142

July - 12

116

June â&#x20AC;&#x201C; 12

126

May - 12

113

Apr - 12

Discharges

Mar - 12

Feb - 12

ALL

7 Day Follow Up 100%

109

110

80% Follow up

109

122

112

139

105

119

105

107

% By month

96.5%

96.8%

96.6%

97.9%

96.3%

96%

96.3%

97.3%

60% LYPFT

40% Tolerance

20% % By Quarter (Monitor)

97.0%

96.5%

Feb-12

Leeds Services

% By month

96.6%

96.7%

98.9%

98.1%

96.6%

94.8%

96.6%

96.2%

NYY Services

% By month

96.2%

97.2%

89.3%

97.4%

95.5%

100%

95.2%

100%

Monitor measure:

Mar-12

Apr-12

May-12

Percentage Follow Up (7 Days)

Jun-12

Jul-12

Aug-12

Sep-12

Monitor Threshold

Compliant

Monitor has set a threshold of 95%, to be reported on a quarterly basis. This means that the Trust must achieve 95% follow up of all discharges under adult mental illness specialities on CPA (by phone or face to face contact) within seven days of discharge from psychiatric in-patient care. Trust figures include adult mental health service users (aged 18-65) discharged from in-patient care. Service users allocated to Forensic Services are excluded in line with national codes. The Trust has continued to maintain a position of compliance for Quarter 2 2012/13 with performance above the threshold at 96.5%. There was a tolerance level of a further 4 breaches for Quarter 2 2012/13 before performance fell below the 95% target. Older Adult Services are not required to contribute to this target nationally; however the Trust internally monitors this performance as a quality measure. 7 day follow up figures for Quarter 2 2012/13, including Older Adult Services are at 96.5%. Performance is monitored on a weekly basis to minimise the risk of any breaches and actions are put in place where necessary.

1.4 Care Programme Approach (CPA) Reviews within 12 Months Monitor measure: Patients on CPA having formal review within 12 months Monitorâ&#x20AC;&#x2122;s construction for the measurement of this target is as follows:

Compliant

The number of adult mental health service users on CPA having had at least one formal review with their care coordinator in the past 12 months divided by the total number of adult mental health service users on CPA during the reporting period. This indicator excludes service users allocated to Forensic Services in line with national codes. Using this construction Monitor has set a threshold of at least 95% to be reported on a quarterly basis. The graph below shows LYPFT overall performance for Quarter 2 2012/13 along with performance for both Leeds and North Yorkshire and York Services. The Trust continues to maintain compliance for Quarter 2 2012/13 with performance above the 95% threshold at 95.7%. There was a tolerance level of a further 10 breaches for Q2 2012/2013 before performance fell below the 95% target.

Percentage of Service Users Who Have Been on CPA for 12 Months, with a Review in the Past 12 Months - 2012/2013 96.90%

95.70%

100% 80% 60% 40% 20% 0% Quarter 1 2012/13 LYPFT

Quarter 2 2012/13

Leeds ServIces

NYY Services

Monitor Target

Weekly caseload lists continue to be sent to care coordinators identifying those service users where reviews are required and weekly reporting continues to ensure compliance is maintained.

1.5 Data Completeness â&#x20AC;&#x201C; Identifiers Monitor measure:

Data Completeness â&#x20AC;&#x201C; Identifiers

Compliant

Monitor has set a threshold of 97% for this indicator for 2012-2013 to be reported on a quarterly basis. Monitorâ&#x20AC;&#x2122;s construction for the measurement of this target is as follows: The number of valid entries for each of the data items (listed below) divided by the total number of entries for each data item. As Monitor requires quarterly reporting on this indicator the Trust is required to capture this data through its internal systems rather than through the Mental Health Minimum Dataset (MHMDS). Data is captured for all service users who have had contact with services in the last 3 months and excludes Learning Disability Services in line with how this is captured by the MHMDS. The internal figures reported below demonstrate that the Trust has continued to maintain compliance with this target for Quarter 2 2012/13 with an overall data completeness average of 99.8% against the 97% threshold. There was a tolerance level of a further 448 breaches for Quarter 2 2012/2013 before performance fell below the 97% target. Weekly reporting continues to ensure compliance is maintained. Data Item

Quarter 1 2012/13 Data Completeness

NHS Number

99.8%

99.6%

Date of birth

100%

Postcode of normal residence

99.5%

Current gender

100%

99.9%

Registered General Medical Practice organisation code

99.8%

Commissioner organisation code

99.9%

Total Data Completeness Average

99.8%

Leeds Services

Total Data Completeness Average

99.9%

99.8%

NYY Services

Total Data Completeness Average

99.7%

LYPFT

1.6 Data Completeness Indicator for mental health outcomes for CPA patients Monitor measure: Data Completeness â&#x20AC;&#x201C; Outcomes Compliant Monitor has set an overall threshold of 50% to be reported on a quarterly basis. The construction for the measurement of this target is as follows: The proportion of adults on CPA who have had at least one Health of the Nation Outcome Scale (HoNOS) assessment in the past 12 months and also have valid recordings of employment and accommodation. This indicator includes adult mental health service users (aged 18-69) who are on CPA. This excludes service users allocated to Forensic Services, in line with national codes. As Monitor requires quarterly reporting on this indicator the Trust is required to capture this data through its internal systems rather than through the Mental Health Minimum Dataset (MHMDS). The Trust continues to maintain compliance with this target for Quarter 2 2012/13 with performance above the threshold at 64.6%. There was a tolerance level of a further 316 breaches for Quarter 2 2012/13 before performance fell below the 50% target. Weekly reporting continues to ensure compliance is maintained.

Adult Service Users on CPA with a HoNOS Assessment in the Last 12 Months and with a Valid Employment Status and a Valid Housing Status Recorded 100% 80%

66.10% 64.60%

60% 40% 20% 0% Quarter 1 2012/13 LYPFT

Quarter 2 2012/13

Leeds ServIces

NYY Services

Monitor Target

1.7 Access to Healthcare for People with a Learning Disability – Leeds Services Monitor measure: Access to Healthcare for People with a Learning Disability Compliant Trusts must self certify on a quarterly basis whether they are meeting the 6 criteria set out below based on recommendations set out in Healthcare for All (2008). For the 6 recommendations below 5 are currently assessed as a level ‘4’ (the highest rating) and 1 at a level ‘3’. To ensure the assessed position continues to be maintained the recommendations are monitored through the Learning Disability Quality Care & Effective Services Group which reports to the Learning Disability Standards & Assurance Group.

Recommendation

Assessed Position

1. Does the trust have a mechanism in place to identify and flag patients with learning disabilities and protocols that ensure pathways of care are reasonably adjusted to meet the health needs of these patients?

2. In accordance with the Disability Equality Duty of the Disability Discrimination Act (2005), does the trust provide readily available and comprehensive information (jointly designed and agreed with people with learning disabilities, representative local bodies and/or local advocacy organisations) to patients with learning disabilities about the following criteria:

 

Progress to achieve a level ‘4’

treatment options (including health promotion) complaints procedures, and appointments

3. Does the trust have protocols in place to provide suitable support for family carers who support patients with learning disabilities, including the provision of information regarding learning disabilities, relevant legislation and carers’ rights?

5. Does the trust have protocols in place to encourage representation of people with learning disabilities and their family carers within Trust Boards, local groups and other relevant forums, which seek to incorporate their views and interests in the planning and development of health services?

6. Does the trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findings in routine public reports?

1.8 Access to Healthcare for People with a Learning Disability – North Yorkshire & York Services Monitor measure: Access to Healthcare for People with a Learning Disability Compliant Trusts must self certify on a quarterly basis whether they are meeting the 6 criteria set out below based on recommendations set out in Healthcare for All (2008). The table below shows North Yorkshire and York Learning Disability Services assessed position. For the 6 recommendations below 4 are currently assessed at a level ‘4’ (the highest rating) and 2 at a level ‘3. Performance is monitored through the North Yorkshire & York Operational Management Group meeting to ensure progress is achieved.

Recommendation 1. Does the trust have a mechanism in place to identify and flag patients with learning disabilities and protocols that ensure pathways of care are reasonably adjusted to meet the health needs of these patients? 2. In accordance with the Disability Equality Duty of the Disability Discrimination Act (2005), does the trust provide readily available and comprehensive information (jointly designed and agreed with people with learning disabilities, representative local bodies and/or local advocacy organisations) to patients with learning disabilities about the following criteria:  

Assessed Position 4

Progress to achieve a level ‘4’

treatment options (including health promotion) complaints procedures, and appointments

4. Does the trust have protocols in place to routinely include training on learning disability awareness, relevant legislation, human rights, communication techniques for working with people with learning disabilities and person centred approaches in their staff development and/or induction programmes for all staff? 5. Does the trust have protocols in place to encourage representation of people with learning disabilities and their family carers within Trust Boards, local groups and other relevant forums, which seek to incorporate their views and interests in the planning and development of health services?

6. Does the trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findings in routine public reports?

Assessment remains at a 3. Further dedicated Carers Team support outside of the Directorate is not available to carers within the Learning Disabilities Directorate, as the Trust Carers Team are not commissioned to provide this service. A business case is being submitted to the partnership board in York to access Learning Disabilities Development funding to create a group which include carers and service users. This will be through the health priority group and its key role will be to support individuals with health needs and access to services.

To develop newsletters which will be shared through the Partnership Board, Trust website and services.

1.9 Meeting Commitment to Serve New Psychosis Cases by Early Intervention Teams Monitor measure:

Meeting Commitment to Serve New Psychosis Cases by Early Intervention Teams

Compliant

The Monitor target â&#x20AC;&#x2DC;Meeting Commitment to Serve New Psychosis Cases by Early Interventionâ&#x20AC;&#x2122; is only applicable to NY&Y services as Early Intervention is provided by Aspire within Leeds. This service is provided as a sub contract by Community Links. The Monitor target sets out that Trusts must meet 95% of the commissioner contract value, which is 34 new cases of psychosis supported by Early Intervention Teams for NY&Y services.

Item Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Number of New Cases of Psychosis Supported by Early 6 13 5 4 5 2 Intervention (Actual)

Data provided for September 2012 demonstrates LYPFT have achieved compliance with the Monitor target, with year to date figures showing 35 new cases of psychosis supported by the Early Intervention Team.

Number of New Cases of Psychosis Supported by Early Intervention (cumulative)

Target number of New Cases of Psychosis Supported by 2.8 Early Intervention (cumulative)

5.7

8.5

11.3

14.2

17.0

19.8

22.7

Numberof NewCases of Psychosis Supportedby EarlyIntervention(cumulative)

40 35 30 25 20 15 10 5 0 Apr-12 May-12

Jun-12

Jul-12

Aug-12

Sep-12

Cumulative Figure

Oct-12

Nov-12 Dec-12

Monitor Target

Jan-13

Feb-13 Mar-13

25.5

28.3

31.2

34.0

2. Care Quality Commission (CQC) 2.1 Care Quality Commission (CQC) Registration Requirements To ensure Trust-wide compliance is maintained with CQC registration requirements assessments of compliance are reviewed on a quarterly basis. The table below shows the Trustâ&#x20AC;&#x2122;s assessment of compliance with the 16 CQC registration requirements for Quarter 2 2012/2013.

Registration Regulation

Lead Director

Assessment of Compliance

Director of Strategy and Partnerships

Compliant

Consent to care and treatment

Medical Director

Compliant

Care and welfare of people who use services

Medical Director

Compliant

Meeting nutritional needs

Chief Operating Officer and Chief Nurse

Compliant

Cooperating with other providers

Chief Operating Officer and Chief Nurse

Compliant

Safeguarding people who use services from abuse

Chief Operating Officer and Chief Nurse

Compliant

Cleanliness and infection control

Chief Operating Officer and Chief Nurse

Compliant

Medical Director

Compliant

Safety and suitability of premises

Chief Operating Officer and Chief Nurse

Compliant

Safety, availability and suitability of equipment

Chief Operating Officer and Chief Nurse

Compliant

Requirements relating to workers

Director of Workforce Development

Compliant

Staffing

Director of Workforce Development

Compliant

Supporting workers

Director of Workforce Development

Compliant

Assessing and monitoring the quality of service provision

Medical Director

Compliant

Complaints

Chief Executive

Compliant

Chief Financial Officer

Compliant

Respecting and involving people who use services

Management of medicines

Records

2.2 North Yorkshire and York Services CQC Action Plans Action plan No 1

Description Involvement – Reg 17

Structured activity – Reg 17

Accessible information – Reg 17

Advanced decisions – Reg 18

CAMHS consent – Reg 18

Nutritional screening – Reg 14

Safeguarding training – Reg 11

Equipment and reusable devices – Reg 12

9 10, 11,12

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Infection control governance – Reg 12 Pharmacy – Reg 13

Estates – Reg 15

Training records – Reg 15

Oxygen storage – Reg 16

Peppermill Court Oxygen – Reg 16

CAMHS bedrails – Reg 16

CRB compliance – Reg 21

Training resources – Reg 23

Supervision – Reg 23

Governance – Reg 10

Professional leadership – Reg 10

Clinical audit – Reg 10

Risk management policies – Reg 10

Health and safety audits – Reg 10

Complaints – Reg 19 All issues addressed and signed off by responsible Director On track Issues partially addressed

Since the September Board Report Regulation 10 (inconsistencies were found across North Yorkshire & York in relation to Health and Safety inspections/audits) has been addressed. Of the remaining 3 issues, 1 is on track for completion by the specified timescales. Action regarding the 2 outstanding issues is as follows: 

Risk Management Policies – Over half of the procedural documents in relation to risk management have completed the full consultation process and all documents will be presented to the November 2012 Means Goal 7 meeting for approval. Lack of robust independent professional advisory route to the Trust Board:–

Allied Health Professional Lead – interviews have taken place and an appointment has been made. Preferred candidate will commence role in December 2012. Psychology Lead – interviews to be held October/November. It is anticipated that someone will be in post at the end of November 2012. 13

2.3 Healthcare Associated Infections 2.3.1 C.difficile

2.3.4 Meticillin resistant Staphylococcus aureus (MRSA) MRSA Bacteraemias

Numberof toxin positivepatients

Clostridium difficile infections 2012/13 4

1 1

0 Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-12

New Infections

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Re-infections

Leeds Services 2012/2013 C.difficile contract target is not to exceed 8 new cases of Leeds services expected level of MRSA bacteraemia cases is zero with a tolerance C.difficile infections. No contract target has currently been set for North Yorkshire and level of 1 over the total 2012/2013 contract period. York Services. The chart above demonstrates that since April 2012 there have been zero cases of C.difficile reported within Leeds and North Yorkshire and York services. To date there have been zero cases of MRSA, MSSA (Methicillin-sensitive Staphylococcus aureus) or E.Coli bacteraemia within Leeds and North Yorkshire and York Services. The IPCT closely monitor MRSA colonisation results, feeding back to 2.3.2. Outbreaks and Incidents both the Infection Prevention and Control Committee and the Professional Nursing Advisory Forum on a monthly basis. The IPCT is working closely with the Pharmacy An outbreak of infection is defined as an incident in which two or more people, thought to Department to ensure that treatment is completed in order to further reduce the risk of have common exposure, experience a similar illness or proven infection. There were no MRSA in all of the Trust inpatient areas. reported outbreaks of infection within Leeds or North Yorkshire and York Services in September 2012. Individual cases have been identified and controlled to prevent 2.3.5. Audit outbreaks developing, Infection Control Environmental audits continue to be carried out by the IPCT, with results fed back to the relevant Clinical Team Manager with timescales for rectification. 2.3.3 Training Progress against actions is monitored by the IPCT with common themes of audit findings fed back to the Infection Prevention and Control Committee on a quarterly The Infection Prevention and Control Team (IPCT) have concentrated on providing basis. mandatory ‘Infection Control’ sessions throughout the year to individual teams at manager’s requests and at main sites across the Trust. Compliance for Leeds Services The IPCT now undertake audits as part of a simulated internal CQC inspection team to at the end of September is at 62%, with clinical staff attendance at 56%. An action plan ensure that standards of Infection Control consistently remain high within their clinical has been implemented to increase training figures and more training dates have been areas of responsibility. The results of these are fed back to the Clinical Team offered. Targeted focus on North Yorkshire and York staff has improved on last month’s Managers and their teams Further inspections will be carried out across both Leeds position with an 2% increase in the numbers of clinical staff trained. and York sites. From July 2012 training capacity has increased to meet demand with the recruitment of an infection prevention and control nurse.

2.4. Mental Health Act 1983 Monitoring Visits By law the Care Quality Commission (CQC) is required to monitor the use of the Mental Health Act 1983 (MHA) to provide a safeguard for individual patients whose rights are restricted under the Act. This is undertaken by looking across the whole patient pathway experience from admission to discharge. Mental Health Act Commissioners do this on behalf of the CQC, by interviewing detained patients or those who have their rights restricted under the Act and discussing their experience. They also talk to relatives, carers, staff, advocates and managers and review records and documents. Reports have recently been received from the CQC as a result of visits to:     

Towngate House Ward 1, Becklin Centre Ward 4, Becklin Centre Ward 5, Becklin Centre Ward 3, Newsam Centre Ward 4, Newsam Centre

Towngate House, Leeds An unannounced visit was undertaken by a Mental Health Act commissioner on 24 August 2012 to Towngate House. Towngate House is a community based in-patient unit which provides care for service users focused on rehabilitation and recovery, aiming to enable them to return to their own accommodation or appropriate longer term care in a residential setting. On the day of the visit the unit was full (18 bedded) and seven patients were detained. The CQC met with three patients in private and scrutinised three sets of case notes. All of the patients the CQC met with were generally positive about the way they were treated by staff, the ward facilities and the activities available to them. All patients were found to be legally detained and had been reviewed by the first tier tribunal as required by the MHA. The ward has adopted the recovery star assessment tool and clinical decisions are made at a weekly multi-disciplinary ward review meeting. The ward standard is for each patient to be assessed and to have had a Care Programme Approach (CPA) meeting within four weeks of their admission. The activities available to the patients include groups for staying well, creative writing, out and about and music. A “you and your views” meeting is also held each week. All of the bedrooms are of a good size and have en suite facilities. The door blinds can be operated from inside the room and each patient has their own room key. There are several lounges, two kitchens, a large internal courtyard and rooms for games, music and craftwork. All areas were very clean and in a good state of decoration and furnishing. There are a range of notice boards throughout the ward containing information on the activities available, healthy eating, the assessment model, independent mental health advocacy services, the CQC and other mental health related matters. An action plan has been developed to address the following areas.       

Ward staffing establishment Access to General practitioner services Patients involvement in care planning Reducing or eliminating environmental risks Improving the consistency of recording of patient’s leave Improving the recording of consent to treatment Improving the recording of patients being informed of their rights.

Ward 1 - Becklin Centre, Leeds An unannounced visit was undertaken by a Mental Health Act commissioner on 28 June 2012 to Ward 1 at the Becklin Centre. Ward 1 is a 22 bedded unit for female inpatients and on the day of the visit 11 patients were detained. Hospital managers visit the ward on a pro-active and regular basis and will see any patients who would like to meet with them to discuss their detention. The ward has a wide range of activities for all patients; these are available both on the ward and off the ward. One detained patient accepted an interview with the CQC and two informal patients requested a meeting in private. The informal patients were both very positive about the care they were receiving on the ward, with comments including “brilliant care”, “staff always make time to talk to you” and “staff have really helped me”. One comment raised by the detained patient was access to a phone where they could have a private conversation. This was discussed with staff during the visit, who agreed the individual could use the ward telephone in a private room. The CQC did not identify any required actions as a result of their visit to Ward 1, Becklin Centre.

Ward 4 – Becklin Centre, Leeds An unannounced visit was undertaken by a Mental Health Act commissioner on 13 September 2012 to Ward 4 at the Becklin Centre. Ward 4 is a 22 bedded unit for male patients. On the day of the visit the ward was full and 13 of the patients were detained. The CQC spoke with six patients in private (four detained and two informal) and scrutinised three sets of case notes. All patients have their own bedrooms with toilets and bathrooms being located on the two bedroom corridors. There are also two lounges, a large dining room and several smaller rooms for activities and interviewing. The ward was very clean and was in the process of being decorated. The ward manager is taking the opportunity to change the functions of several rooms. There was a large group timetable on one of the ward notice boards and other boards held information on ward and mental health related issues. Leaflets on advocacy and other support services were also available on the reception desk. The ward door was locked but all informal patients and detained patients with the appropriate leave arrangements are given an entry card. All patients also have the key to their bedrooms. The ward is on the first floor and patients have access to a large courtyard garden. Although the ward was full it was calm and the interactions observed between the staff and patients were very appropriate. All of the patients who spoke to the CQC were complimentary about the attitude of the staff and how they were treated. All the patients were legally detained and the prescribed medication was being given under the appropriate legal authority. An action plan has been developed to address the following areas.    

Patients involvement in care planning Improving the recording of patients being informed of their rights. Improving the consistency of recording of patient’s leave Improving the recording of consent to treatment

Ward 5 – Becklin Centre, Leeds An unannounced visit was undertaken by a Mental Health Act commissioner on 28 June 2012 to Ward 5 at the Becklin Centre. Ward 5 is a 22 bedded unit for female inpatients. On the day of the visit there were 22 patients, 11 of which were detained. The ward is locked and operates controlled access and all patients are assessed for the provision of a swipe card for access to the ward. Hospital managers visit the ward on a pro-active and regular basis and will see any patients who would like to meet with them to discuss their detention. Documents relating to detention were available and all of the papers reviewed were found to be in order. A wide range of activities were available and advertised on the notice board as well as several other services and activities that were available in the local community. Patients are encouraged to take part in as many activities as they feel able to. The CQC were introduced to several detained and informal patients whilst looking around the ward environment, the patients were offered the opportunity to have a private meeting. This was declined in all cases with the exception of one patient who agreed to a private meeting. One patient had been refusing to communicate with staff, she agreed to a meeting with the Mental Health Act Commissioner and her detention and rights were discussed. She had been informed by staff about her detention and rights but had refused to discuss these further. After discussion with the Mental Health Act Commissioner she agreed to discuss her rights with staff. The CQC did not identify any required actions as a result of their visit to Ward 5, Becklin Centre.

Ward 3 – Newsam Centre, Leeds An unannounced visit was undertaken by a Mental Health Act commissioner on 16 July 2012 to Ward 3 at the Newsam Centre. Ward 3 provides 17 low secure treatment and recovery beds for males and is a locked unit. All of the 17 beds were occupied on the day of the visit. All patients were detained, with one patient on section 17 leave. The CQC met with two patients in private and spoke to several other patients who declined a private meeting. Hospital managers visit this ward regularly on a pro-active basis and will meet with any patients to discuss their detention and this is viewed as a very positive use of the manager’s time. Several patients were taking advantage of activities that were taking place, including access to the gym. There is a wide programme of activities available for patients and this is publicised on the ward notice board, with several other notices of support available to patients. The ward has access to two enclosed garden areas. All the Mental Health Act paperwork that was reviewed was found to be in good order, with evidence of patients being reminded of their rights on a regular basis. Individual care plans were available and evidence was found of the patients being involved and circulated with copies of their Care Programme Approach (CPA) care plans. An action plan has been developed to address the following area: 

Access to the on call doctors out of hours and at weekends.

Ward 4 – Newsam Centre, Leeds An unannounced visit was undertaken by a Mental Health Act commissioner on 28 August 2012 to Ward 4 at the Newsam Centre. Ward 4 is a 21 bedded acute admission ward for male patients. On the day of the visit the ward was full and 11 of the patients were detained. The CQC interviewed five patients in private and they reviewed three sets of case notes. The patients met with were generally positive about their care and treatment and about the ward facilities. All patients were found to be legally detained and had been reviewed by the first tier tribunal as required by the MHA. Some activities were found to be available to the patients which include groups for art, walking and the use of a local gym. The ward was clean and well decorated and comprised of sitting areas, and rooms for craft, visitors, dining/pool, relaxation and de-escalation. The door viewing panels could be operated from the bedroom side and each patient had a key to their room. The ward is located on the first floor and the patients have the use of a central courtyard which is accessed by the central staircase. An action plan has been developed to address the following areas:     

Patients involvement in care planning Reducing or eliminating environmental risks Improving the consistency of recording of patient’s leave Improving the recording of consent to treatment Improving the recording of patients being informed of their rights.

3. 2012/2013 Contractual Requirements (Excluding Monitor Requirements) 3.1 Crisis Resolution and Assertive Outreach 3.1.1 Crisis Resolution Home Treatment Episodes:

3.1.2 Assertive Outreach Caseload:

CRISIS RESOLUTION EPISODES Apr 2012 - Mar 2013

Crisis Resolution Episodes Count of Patients Monthly Figure Cumulative Figure Cumulative Target

Apr-12 187 175 187 187 138

May-12 172 158 172 359 275

Jun-12 119 112 119 478 413

Jul-12 166 160 166 644 551

Aug-12 183 178 183 827 688

Sep-12 132 132 132 959 826

Oct-12

138 1097 964

ASSERTIVE OUTREACH CASELOAD Apr 2012 - Mar 2013

Nov-12

138 1235 1101

Dec-12

Jan-13

138 1373 1239

138 1511 1377

Crisis Resolution Episodes - Forecast vs. Agreed Target

Feb-13

138 1649 1514

Cumulative Figure

Mar-13

Assertive Outreach Team Forensic Community Team Total Unique Service Users Target

138 1787 1652

Apr-12 177 127 304 237

May-12 176 125 301 237

Jun-12 169 127 295 237

Jul-12 168 127 294 237

Aug-12 169 131 299 237

Sep-12 165 134 298 237

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

237

Total Unique Service Users

Assertive Outreach - Caseload vs Agreed Target

Target

350

2000 1800

300

1600 250

1400 1200

200

1000 150

800 600

100

400 50

200

Target requirements:

M a r-1 3

F e b -1 3

J a n -1 3

D e c -1 2

N o v -1 2

O c t- 1 2

S e p -1 2

A u g -1 2

J u l- 1 2

J u n -1 2

A p r-1 2

Compliant

M a y -1 2

M a r -1 3

F e b -1 3

J a n -1 3

D e c -1 2

N o v -1 2

O c t-1 2

S e p -1 2

A u g -1 2

J u l- 1 2

J u n -1 2

M a y -1 2

A p r -1 2

Compliant

Leeds Services contribution to the target in 2012/2013 is 1652 treatment The Mental Health Policy Implementation Guidance (PIG) assumes an assertive episodes by year end. Estimated monthly figures in grey show Trust trajectories outreach team with a caseload of 90 service users will cover a population of for 2012/2013. Performance continues to exceed the trajectories. 250,000. Based on this, Leeds total city-wide caseload target is 330, of which: As part of the trust’s Transformation programme, the Crisis Resolution team,  Leeds Services target is 237 (180 from Assertive Outreach Team and 57 Acute Community Services teams and Older People’s MH ICT team have ceased from Community Forensic Outreach Team) to exist. These have been replaced with the new Single Point of Access /Single  Touchstone has been commissioned to provide the remaining caseload Point of Urgent Referral, Crisis Assessment Service, and three Intensive proportion of 93. Community Services Teams. The Trust continues to achieve the target caseload for 2012/2013.

3.2 Adult Inpatient Services The Trust’s contract with NHS Leeds requires us to report against the following measures: 3.2.1 Rate of readmissions to adult inpatient beds within 28 days of discharge 3.2.2 Adult Inpatient out of area placements

12% 10%

8% 6 6% 4 2

Adult Inpatient Out of Area Placements

Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Readmissions

Readmission Rate

Cumulative Readmission Rate

The graph above shows the monthly readmission rates for adult mental health inpatients (Leeds Services) for October 2011 – September 2012. Readmission rates are for those services with a 710 speciality code which includes adult mental health service users (aged 18-65), excluding service users allocated to Forensic Services in line with national codes. For October 2011 – September 2012 the cumulative readmission rate is 4.71%. In September 2012 there were 93 discharges from Adult inpatient wards, 4 of whom were readmitted within 28 days. Each readmission is flagged with the appropriate clinical teams and consultants to fully understand the cause of the readmission and implement any necessary actions as required.

400

257

345 180

223

161

350 300

230

250

200

10 26

150

100

5 5

Totallengthofstayindays

Requires monthly reporting on the number of patients placed out of area and length of stay. The graph below shows the number of out of area placements and total length of stay in days for October 2011 –September 2012 for Leeds Services.

Numberofserviceusersplacedoutof area

14%

Readmission Rate, Cumulative Readmission Rate

Readmissions

Readmissions 12

0 Oct-11Nov-11Dec-11 Jan-12Feb-12 Mar-12 Apr-12May-12Jun-12 Jul-12 Aug-12Sep-12 Total New Out of Area Admissions

Total Length of Stay in Days

During September there has continued to be high demand for admissions for female service users and a low level of discharges. The Crisis Assessment Team has recently ring fenced time for senior staff to more actively manage service users who are placed out of area. The initial focus of this work has been to manage the discharge of service users placed out of area to community alternatives or return to Leeds. In the past two weeks 12 service users have left out of area treatment and there are now 3 service users placed out of area. As the numbers of service users placed out of area decreases there continues to be an increased focus on ensuring that service users are effectively managed across the acute care pathway making best use of all resources available.

3.2.3 Bed Occupancy Rates Cumulative Adult Inpatient Bed Occupancy 100% 80% 60% 40% 20% 0% Apr

May

Jun

Jul

Aug

Sep

2011/2012

Oct

Nov

Dec

Jan

Feb

Mar

2012/2013

The contract sets out a requirement for monthly reporting on bed occupancy rates in adult acute inpatient care, with exception reporting if bed occupancy rates exceed 98%. Figures reported exclude PICU and include home leave. The graph above shows the cumulative bed occupancy rates for 2011/12 and 2012/2013. Leeds Services continue to remain below the maximum set threshold as of September 2012 with bed occupancy rates at 97.5%. 20

3.3 Prisoner Mental Health The Trust’s contract with NHS Leeds requires quarterly reporting on the following three areas relating to Prisoner Mental health 3.3.1 Prisoners with a mental health disorder including Learning Disabilities or 3.3.3 Prisoners who need access to an NHS bed for specialist mental health Autistic Spectrum Condition should receive appropriate input from specialist should be transferred as soon as possible services post release The Trust’s contract with NHS Leeds requires us to report that prison mental health in- The Trust’s contract with NHS Leeds requires us to report the time from referral to reach services cover arrangements for follow up post release. The contract specifies that acceptance of a prisoner for care to actual transfer to an NHS bed. local targets should be agreed for follow up times post release, as with follow up post The target for transfer set out in Lord Bradley’s recommendations are that acutely discharge from hospital. mentally ill prisoners should be transferred to an appropriate mental health hospital It is the role of Leeds Mental Health In-reach Team (MHIRT) to ensure that the service within 14 days. The service uses this target as its primary measure. users they work with move on to appropriate clinical services on release from prison. In Quarter 2, 8 service-users were transferred to hospital from prison. Of these: Leeds service users will usually be referred into the Community Forensic Team (CFT) or a Community Mental Health Team (CMHT) which allows for continuity of care. Many  2 service users were from Huddersfield with 1 service user under Section 47, which took 25 days (went to Humber Centre PD Unit) and 1 service user under service users seen by the Mental Health In-reach Team are moved to other prisons or are Section 48 which took 11 days not from Leeds. In these cases the team will link into services at the new prison or refer to  1 service users was from Sheffield under Section 47, which took 27 days services in the service user’s home location.  3 service users were from Halifax, with 1 service user under Section 48 which took In Quarter 2, 21 service users were released from Leeds prison. Of these, 1 service user 39 days, 1 service user under Section 48 which took 83 days, and 1 service user was linked back into CFT, 9 were linked back into CMHT/AOT in Leeds and there was 1 under Section 35 which took 26 days new referral to a Leeds CMHT. The Team also referred 2 service users to Huddersfield  1 service user was from Wakefield under Section 47 which took 24 days mental health services, 1 to Bradford, 2 were linked into Wakefield services and 2 to  1 service user was from Leeds under Section 37 which took 89 days Halifax. In addition, 1 service user was linked in to housing services in the Wakefield area and 2 referrals were made to GP’s, 1 to Halifax and 1 to Bradford areas. In addition the contract requires the recording of remittance to prison and recording of section 117/CPA pre-discharge meetings prior to remittance. 4 service users were released from HMP Wealstun. Of these 1 service user was linked to Leeds CMHT, 1 to CFT, 1 to LD Services in Halifax and 1 to Bradford Substance Misuse There were no cases of remittance to prison during Quarter 2 from Newsam Centre. It Service. would be a rare occurrence for the Trust to return someone to prison on a Section117 3.3.2 People with a mental health disorder should have their needs assessed and as this is more likely to occur from a medium secure unit. should be diverted from the Criminal Justice System whenever appropriate The Trust’s contract with NHS Leeds requires us to report that there is comprehensive coverage of the population by timely and appropriate Criminal Justice System assessment and diversion services. The Leeds Mental Health In-Reach Team (MHIRT) was developed for this purpose. The team work in the prison, four Approved Premises’ (Probation Hostels) and Leeds Magistrate Court. A member of the team attends the courts daily to provide assessment and advice. In Quarter 2, the MHIRT saw 40 service users as part of the court assessment/diversion scheme. As a result 1 referral was made to a CMHT in Leeds, there were 2 cases where the clinician liaised with the Leeds CMHT, 2 liaisons were made with PD Network and 1 liaison was made with Housing Services. 2 service users were remanded into custody with follow up from MHIRT. 3 service users were discussed with the prison primary care mental health team prior to coming into custody. Liaison also took place with CRT service in Leeds in respect of 1 service user. In Quarter 2, 24 service-users were seen in the Approved Premises, of which 4 were referred to CMHT’s, 3 referred to the CFT and 2 referrals were made to Single Point of Access (SPA).

3.4 Further Contractual Reporting Requirements 3.4.1 Nutritional Screening

TOTAL

The contract sets out a requirement to report against the following measures on nutritional screening:

Jul-12

Admission

1. Number of patients with admission duration of 48 hours or more who were screened during the quarter using the appropriate assessment tool. 2. Number of patients with an admission > 7 days who were screened at discharge during the quarter 3. Number of patients admitted who were at 'high' nutritional risk during the qtr (>6) 4. Plans are in place for effective clinical management for those identified at risk on discharge.

Discharge

HR on admission HR on discharge

Performance is monitored on a weekly basis and an action plan is in place and attached at Appendix A which demonstrates how Essence of Care indicators on nutrition will continue to be met to best practice standards.

CCP

Aug-12

116 111 95.7% 110 103 93.6% 4 3.4% 6 5.5% 6 100.0%

130 129 99.2% 97 91 93.8% 6 4.6% 6 6.2% 6 100.0%

Sep-12

TOTAL

115 115 100.0% 105 100 95.2% 10 8.7% 6 5.7% 6 100.0%

361 355 98.3% 312 294 94.2% 20 5.5% 18 5.8% 18 100.0%

3.4.2 Referral to Treatment Referral to Treatment

The contract sets out a requirement to report quarterly on Referral to Treatment waiting times for consultant led teams. Within the Trust this includes the Perinatal Service and the majority of Liaison Psychiatry teams. Agreement has been made for the purpose of mental health that treatment begins at first contact with the clinician. The data in the table below shows the numbers of referrals and number that were over the 18 week target for Quarter 2 2012/13.

100% 99% 98% 97% 96%

Referrals

95%

Over 18 weeks

94%

July 2012

319

93% 92%

August 2012

286

91%

90%

September 2012

289

Quarter 2 2012/13

894

July

August % referrals seen in 18 weeks

September

4. Tier 1 Extreme Risks Information has been taken from the Trust’s electronic risk register and is correct as of 9 th October 2012. Mitigating actions are in place to control and reduce each of the risks. Below are the risks on the system identified as extreme Tier 1 risks. Tier 1 risks are risks that affect the entire organisation because of the wide extent of their impacts, because of the extent of resources needed to address the risk or both. Key for risk treatment plan timescales

LTHT not re-providing Ward 40 within LGI, when Brotherton wing closes.

Comments Strategic outline case is being worked up looking at all potential options available.

Lead Director

Risk score

Impact score

Service will not be able to operate effectively, having a significant and damaging impact on income generation for LPFT.

Chief Operating Officer & Chief Nurse/Deputy Chief Executive

LTHT considering ‘exit strategy’ for Brotherton Wing at LGI (which currently houses Ward 40, the liaison psychiatry inpatient unit) by 2011. Possible threat to the continuation of the service which needs to stay where it is or be re-provided within LGI. If this was not secured the service would not be able to operate effectively, and this would have a significant and damaging impact on income generation for LYPFT.

Impact of risk

Extreme

Specialist Services

Risk description

Directorate

Likelihood score

Action is overdue Action not on track for milestones projected Action is on track

RED AMBER GREEN

Summary of existing controls

Risk treatment plan

LYPFT Chief Executive and Chief Operating Officer/Chief Nurse addressing with counterparts in NHS Leeds and LTHT.

Senior colleagues actively exploring alternative options for accommodation, including Leeds, York and other potential solutions.

income

Inability to expenditure

reduce

Risk score

Impact score

Lead Director Director of Strategy & Partnership

Insufficient generation.

Impact on overall Trust financial position of circa £200k

Extreme

CPC fails to achieve endyear surplus of £142,795 and LYPFT management fee of £150k. At the end of May 2012 risk of up to £200k shortfall in total

Impact of risk

Strategy Partnership

Risk description

Likelihood score

Directorate

Summary of existing controls

Risk treatment plan

Plans in place to generate more measured new income Invoices issued to all existing CPC customers Monthly senior performance management group meetings attended by Executive Director Governance through Means Goal 6 Standing/ Standing Support Groups Vacancy freeze Monthly finance meetings between Executive Director, Commercial Director and finance staff

Staff being moved from non-incoming generating to income generating service lines Targeted approach to generating new customers Active marketing of CPC Drive and reprofiling of resources to divert resource to this area Development of a robust marketing strategy for all products Develop a revised staffing structure for CPC to take out cost in-year Development of key performance indicators to monitor income generation and cost reduction at a more granular level Updating and consolidating pricing policies to increase income per transaction Implement a revised staffing structure for CPC to take out cost in-year

Comments: 13/06/12 The impact on the Trust financial position is now circa £300k 17/08/12 Timescales extended for KPI action to enable further work to be completed

Risk score

Impact score

Lead Director Chief Financial Officer

NYY do not mandate data capture where systems are in place. NYY do not develop CPD system to capture mandatory data

Trust unable to gain satisfactory assurance on performance specifically: MHMDS; PbR; and statutory returns. Trust Board will not have appropriate information to determine performance/ activity of NYY services

Extreme

Data reporting systems Lack of robust Information systems in place at NYY to support the recording of appropriate regulatory information

Impact of risk

Finance Directorate

Risk description

Likelihood score

Directorate

Summary of existing controls

Risk treatment plan

Detailed gaps analysis undertaken with actions plans being worked up Proposed solutions for some information and services Early implementation of PARIS to services with no systems Continuance of manual systems and CPD system Potential for interim systems to be utilised Request to NYY to develop current system to at least meet national requirements for PbR and MHMDS Working closely with performance team to ensure highest priorities are met first

Develop initial reports to obtain key information requirements from the York CPD system Manual reporting systems in place where key data cannot be obtained from the initial York CPD system reports above Request that York Hospitals Trust develop the CPD system to incorporate collection of key data not previously supported by the system Implement programme of data quality improvement work for York services Implement information systems to fill any gaps in data collection identified Implement new data extract from York CPD system to Trust data warehouse and make Cognos reports available for key data Establish regular information and performance meetings with York service to ensure actions required are progressed

Comments: 08/08/12 York Hospitals Trust incorporated the facility to collect cluster data to support PbR into the CPD system. The Data Quality Policy was updated to include the York CPD system for 31/1/2012 and disseminated to staff. Work has progressed re data quality work but has been hindered by vacancies for data quality staff (separate risk logged). The IAPTUS system was implemented into the IAPT service in July 2012. Work is underway to implement PARIS for York PLD service and further implementation is planned for the autumn. York Hospitals Trust have made good progress in making the CPD system available in a form from which it can be downloaded to the Trust data warehouse. Our work on this has been delayed by the requirements of transformation.

Lead Director

Risk score

Summary of existing controls

Chief Financial Officer



15 Extreme

Risk that future income will become unstable for Adult and Older People's services if not sufficiently tested to timescales (approx 68% of organisational income). Current DH timescales is 2012-13 when the clusters (with local prices) become mandatory for

Highest Impact score

The Payment by Results (PbR) currency model will not be sufficiently developed to allow it to be tested in shadow form from September 2011 onwards

5 Catastrophic

Impact of risk

3 Possible

Finance Directorate

Risk description

Likelihood score

Directorate



LYPFT is a member of the Care Pathways & Packages regional consortium and is working in partnership to develop "criteria for successful pilot" for the PbR currency model. Care Pathways & Packages (PbR) Standing Support Group reports into Means Goal 6 Group Review of project status with Chief Finance Officer

Risk treatment plan

Review of reporting requirements with Data Lead and increased priority for the CPP Project - Data Lead to report back to Standing Support Group on earliest timescales for completion Cluster coverage to be increased on medic only caseloads through a process of engagement with the PbR Programme Board and work to develop performance management dashboards. A fixed term post is being recruited to support engagement and the whole project. Plan for commissioner engagement has been developed. A memorandum of understanding has been signed by NHS Leeds and NHS NY&Y to offset any potential financial risk during the shadow contract period (extended to 2012-13). Ongoing discussion and performance review of PbR tariff development will take place at the activity and finance contract meetings with commissioners

Comments Work is ongoing to clarify and implement all requirements of PbR and to minimise any potential impact on the Trust through the national roll out of PbR for mental health. A signed memorandum of understanding is in place with all key commissioners.

Lead Director

Summary of existing controls



Inadequate information given to the patient, reduced adherence, relapse. Litigation against the trust may ensue and damage to reputation may result

Litigation against the trust may ensue and damage to reputation may result.

Medical Director



15 Extreme

Reduced continuity and follow up of patients can result in not detecting and responding to potentially serious side effects which could lead to injury/death to a service user.

Risk score

Clozapine is the most dangerous anti-psychotic and can result in death if not properly monitored.

Highest Impact score

Clozapine is a high risk treatment requiring mandatory ongoing blood monitoring and physical health monitoring. Removal of central hub to coordinate overall management of clozapine, now sits between 5 areas – 3x ICSs, pharmacy, prescribers.

Likelihood score

Impact of risk

5 Catastrophic

Medical Directorate

Risk description

3 Possible

Directorate



Acute Community Service's with onsite pharmacy will maintain mandatory framework however remote sites risk will need to be managed by (yet to be produced ) protocol. Side effects will be enquired about in clinic, but limited knowledge to address with current staff. Disclosure of side effects at pharmacy hatch (where more specialist knowledge is held) but less likely due to non confidential environment. PARIS used to record pertinent issues to provide continuity.

Risk treatment plan

The new staff involved with the service have been trained and on how the clinic should be run on a weekly basis Pharmacy technicians have spent up to 14 weeks (and in one area ongoing) ensuring staff are trained with the issues relating to clozapine and the complications with the drug The pharmacy technicians during the 14 week training programme, have updated all the patients medication histories and ensured their current medication list are up to date. Any drug-drug interactions have been identified and s/e have been monitored. Patient records have been updated. All nursing and Health Support Workers involved with the clinic have been trained to do phlebotomy Staff are aware they can contact CPMS (Clozapine Patient Monitoring Service) if they have any issues relating to the patients bloods Development of service specification and Local Working Instructions/ Service Operational Policies needed.

Comments 24/05/2012 Following an increase in clozapine related incidents, this was added to the risk register. This risk will be discussed at the Clinical Interventions Standing Support Group on 19 September 2012. The future plan for the pharmacy service is to merge the four Leeds dispensaries into one which would free up staff to support the Clozapine clinics and the ICS’s. Until this plan comes to fruition a temporary appointment of 1.5wte pharmacy technicians would allow full technician support to the clinics, which would reduce the risk rating.

5. Quality Accounts 2011/2012â&#x20AC;&#x201C; Priority 2: People experience safe care Monitor and the Department of Health require Trusts to publish comprehensive Quality Accounts, which set out their priorities for quality improvement. Our 2011/2012 Quality Accounts have been developed and are available on our Trust website and on NHS Choices website. Progress against one of our three Quality Accounts priorities and measures will be detailed in this section each month. This month the focus is on Priority 2: People experience safe care. The Trust has identified initiatives for implementation in 2012/2013 with regard to Priority 2. These are detailed below along with updates on progress

Initiatives for implementation in 2012/2013 Initiatives Within the 2012 Nursing Strategy work plan focused work will take place on both records review and audit and Mental Health Act training development. Objectives will build upon the successful work carried out over the previous three years in relation to Essence of Care benchmarks, Medication Management, Infection Control standards and Safeguarding awareness and knowledge.

Comments/Updates

Infection Control The Infection Prevention and Control environmental audit and Performance Monitoring Framework is fully established in Leeds services, with information now being received from North Yorkshire and York services. The audits and framework support a continual process of improvement across all areas leading to improved service user experience. Outbreaks have been controlled, monitoring of trends occurs and advice is provided where infection control input will minimise risks to patients, staff and visitors. Safeguarding A specific safeguarding section in PARIS has been written and will go live in early November. This requires staff to give a prĂŠcis of incidents which may relate to a service user or their family. Guidance has been generated for staff and a desktop banner will publicise the changes. The governance agenda has been updated to incorporate a standing support group and supporting operational groups covering both Leeds and NYY services. This group will continue to build on the efficacy of safeguarding work and ensure continued assurance and monitoring of safeguarding issues. Trust representation to the 2 Local Safeguarding Children Boards within the NYY area has been established Record keeping is a priority and work has taken place to improve safeguarding information and consideration of the children of service users on PARIS, including information on the children and information on the care pathway/holistic assessment specific to children The Safeguarding Board in Leeds is undergoing a review with a view to merging Safeguarding Boards and protocols for the West Yorkshire region. Consideration is also being given to the upcoming Care and Support Bill currently progressing through parliament. The new Act will put the Boards on a statutory footing and any implications for the Trust with regard to safeguarding will need to be reviewed once the Act had been passed. Domestic violence awareness remains a priority and the Trust safeguarding team now replicate the MARAC attendance established in Leeds to the NYY localities. A draft policy has been written in preparation for achieving the level 2 Quality mark. Essence of Care The Essence of Care Steering Group continues to lead on this work. Following a Trust-wide audit in 2011, specific action plans have been developed at a team, service and Directorate level to address areas for further improvement, as well as to support the sustainability of good practice. The Steering Group is planning a re-audit of the 12 benchmarks in November 2012 across all inpatient areas within the Trust. 28

Initiatives

Comments/Updates Medicines Management All nursing staff within Leeds Care Services have successfully completed the Biennial Support Framework for the Safe Administration of Medicines and work is being progressed to ensure nursing staff remain up-to-date with this requirement. The framework has been introduced to services in North Yorkshire and York and this is being progressed within each team with oversight from the newly established Lead Nurse for North Yorkshire and York.

Development and extension of the Section 136 service in Leeds is aimed to increase both the physical space and capacity of the Section 136 service and also to provide a flexible care environment which will allow a greater range of therapeutic activities to take place. The suite will include bedrooms to allow service users who are not fit to be assessed when they are first brought to the unit to be nursed until assessment is possible The suite will also allow service users requiring assessment by the Crisis Resolution Service to come to the Becklin Centre in Leeds and receive care whilst they are waiting for assessment. This may be for short periods and will be beneficial for service users who may struggle to maintain their safety during this period. Narrowing of the Board to Ward Experience: Expansion of the “Quality Walk Arounds” program for Board Members to include North Yorkshire and York services. As in 2011/2012 an additional 12 “walk arounds” will be scheduled across the Trust and reported to our Board of Directors. Further enhancement to the role of the Patient Safety Champion from Doctors in Training in the pursuit of safer care delivery. Expansion of our previous benchmarking for Patient Safety on a local, regional and national level to include North Yorkshire & York services.

The monitoring of medicines management related matters is undertaken on a monthly basis through the Professional Nurse Advisory Forum, as well as the Multi-professional Medicines Management Sub-Group. Medicines Talks for Nurses continue to be delivered by the Lead Nurses in collaboration with pharmacy colleagues to support the ongoing developments in medicines management. Bespoke training has been delivered within the Community hubs to address training needs relating to medicines management following Transformation. The expansion of the Section 136 suite was paused in order for the Chronic Fatigue Service to be temporarily relocated into this area whilst work was undertaken on Ward 5 at Newsam Centre. This work is now complete and plans are in place for the Chronic Fatigue Service to move back to the Newsam Centre by the end of October 2012. Given the changes to the Trust’s Single Point of Access, previous plans for the Section 136 suite will be revisited to ensure the whole of the expansion is fit for purpose.

Since the “Quality Walkarounds” began in September 2011, ten visits have taken place across a variety of Leeds clinical services. A further “Quality Walkaround” within Leeds Adult services is planned for the end of October 2012. Future “Quality Walkarounds” will include North Yorkshire and York clinical services. All of the “Quality Walkarounds” are open to all Non Executive Directors and Executive Directors to participate in.

A new Patient Safety Champion from Doctors in Training has been appointed for 2012-2013 and will take up the post at the end of October 2012. We continue to use and enhance a variety of national and locally generated benchmark indicators for quality and patient safety, which includes:  

NPSA “How do you compare to your peers” national and regional statistics of patient safety incidents. Statistical Process Control on unexpected deaths of service users in receipt of Trust services. 29

Initiatives  

Continued expansion of proactive Patient Safety initiatives across the Trust.

Comments/Updates Incorporation of the extended NPSA “Never Events” into Board reporting. Continuation of monthly reporting of the Trust’s “Trigger to Board” events.

The North Yorkshire and York services data sets are currently being integrated into the Trust’s benchmarkers. Patient Safety remains a top priority within the Trust. In order to continue advancing patient safety, a number of initiatives have commenced on an individual team, directorate and Trust wide basis. These initiatives are based around the following work streams and are monitored through Risk Management, the Trust’s Means Goal 1 & 2 Standing Group and Means Goal 5 Standing Group: 1. Promotion of Best Practice. 2. Benchmarking standard of care. 3. Striving to be “An Organisation with a Memory”, through the lessons learned process

Performance of Trust against selected measures Selected Measures People who use our services report that they experienced safe care

2011/2012 Baseline to be set at end of June 2012 from local survey results

Source: Strategy Measure

Current Status A pilot commenced in July using the Psychological Therapies Service questionnaire in order to fully ensure that the process works. The pilot will be completed in October 2012. A phased roll out across services will commence in November 2012 and roll out across all services with access to the electronic records system PARIS will be completed by January 2013. People who use our services report that they experienced safe care 2012 100% 80% 60% 40% 20% 0%

LPFT

NYY

Nat Av

Results from the 2012 Mental Health Inpatient Service User Survey

Number of ‘no harm’ or ‘low harm’ incidents increases as % of total:  

% where ‘no harm’ has occurred (National Patient Safety Agency score 1). % where ‘low harm’ has occurred (National Patient Safety Agency score 2).

Source: Strategy Measure

Number of ‘no harm’ or ‘low harm’ incidents increases as % of total 100%

The graph below shows the number of ‘no harm’ or ‘low harm’ incidents from July 2012 – September 2012 as % of total: Number of ‘no harm’ or ‘low harm’ incidents increases as % of total

80%

July 2012 - September 2012

60%

100%

40%

80% 60%

20%

40%

0% % where "no harm" has occurred (NPSA score 1) 2009-2010

% where "low harm" has occurred (NPSA score 2)

2010-2011

2011-2012

20% 0% % where "no harm" has occurred (NPSA score 1)

All service user incidents – inpatient & community

% where "low harm" has occurred (NPSA score 2)

Selected Measures Staff views of the fairness and effectiveness of incident reporting procedures Source: Strategy Measure from National NHS Staff Survey

Evidence that we meet national guidelines for clinical care and treatment relevant to our Trust within 2 years of publication Source: Strategy Measure NHS Safety Thermometer: Improve the collection of data in relation to pressure ulcers, falls, urinary tract infection in those with a catheter and Venous thromboembolism (VTE) Source: Commissioning Innovation Measure

for

Effective procedures 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Ineffective/ unfair procedures

Staff views of the fairness and effectiveness of incident reporting procedures

2009

2010 LPFT

Current Status This measure has been discussed at the Trust Security Management Committee. It was agreed that further work will be undertaken to understand staffâ&#x20AC;&#x2122;s perceptions regarding this question through either a short survey question or through a barometer survey.

2011

Nat Av.

Trust score is based on 425 staff (Leeds) who took part in the 2011 National NHS Staff Survey In 2011-2012 the Trust achieved this target for 100% of newly published clinical guidelines.

To be determined by end of July 2012 in line with national requirements.

Quality and

Improving the implementation of action plan goals following a serious untoward incident which relates to a community patient suspected suicide Source: Commissioning Innovation Measure

2011/2012

70% of community suspected suicides for Leeds Services reported to NHS Leeds within 1 working day of the incident being reported to the Trust and the initial action plan submitted within 5 working days, which describes the immediate action taken.

Quality and

The Trust continues to achieve this target for 100% of newly published clinical guidelines.

Processes are in place to ensure that the required data is collected on a monthly basis and reported to the Information Centre on a quarterly basis. Data has been collected relating to July, August and September in the relevant areas. Information is presented to the Professional Nurse Advisory Forum and to the Clinical Quality and Risk Standing Support Group. A 6 monthly update will be provided to the Trust Board. One community suspected suicide was reported to NHS Airedale, Bradford & Leeds in Quarter 2 for Leeds Services. This was reported within one working day of the incident being reported to the Trust and the initial action plan was submitted within five working days, which describes the immediate action taken. Performance for Quarter 2 is therefore at 100% for both measures and above the Quarter 2 trajectory.

6. Areas for Local Reporting 6.1 “Never” & “Trigger to Board” Events In March 2012 the Department of Health and National Patient Safety Agency revised the “Never Events” list. “Never Events” are also included in our contract with our commissioners. “Never Events” and “Trigger to Board Events” are reported to the Trust Board of Directors on a monthly basis. Trust performance for Never Events for September 2012 is reported below as of 12 October 2012. Please note that data may change as IR1 forms for September are still being processed by the Risk Management Department. Any changes will be reported in future performance reports.

Never Events

September 2012

Inpatient suicide using non-collapsible rails (Contract and NHS The Never Events List) – Death or severe harm to a mental health inpatient as a result of a suicide attempt using non-collapsible curtain or shower rails

Misplaced naso or orogastric tube (Contract and NHS The Never Events List) – Death or severe harm as a result of a naso- or orogastric tube being misplaced in the respiratory tract

Opioid overdose of an opioid-naïve patient (Contract and NHS The Never Events List) – Death or severe harm as a result of an overdose of an opioid given to a patient who was opioid naïve

Wrong route administration of oral/enteral treatment (Contract and NHS The Never Events List) – Death or severe harm as a result of oral/enteral medication, feed or flush administered by any parenteral route

Maladministration of Insulin (Contract and NHS The Never Events List) – Death or severe harm as a result of maladministration of insulin by a health professional

Falls from unrestricted windows (Contract and NHS The Never Events List) – Death or severe harm as a result of a patient falling from an unrestricted window

Entrapment in bedrails (Contract and NHS The Never Events List) – Death or severe harm as a result of entrapment of an adult in bedrails that do not comply with Medicines and Healthcare products Regulatory Agency (MHRA) dimensional guidance

Air embolism (Contract and NHS The Never Events List) – Death or severe harm as a result of intravascular air embolism introduced during intravascular infusion/bolus administration or through haemodialysis circuit Wrong gas administered (Contract and NHS The Never Events List) – Death or severe harm as a result of the administration of the wrong gas, or failure to administer any gas, through a line designated for Medical Gas Pipeline Systems (MGPS) or through a line connected directly to a portable gas cylinder Failure to monitor and respond to oxygen saturation (Contract and NHS The Never Events List) – Death or severe harm as a result of failure to monitor or respond to oxygen saturation levels in a patient undergoing general or regional anaesthesia, or conscious sedation for a healthcare procedure (eg endoscopy) Severe scalding of patients (Contract and NHS The Never Events List) – Death or severe harm as a result of a patient being scalded by water used for washing/bathing Misidentification of patients (Contract and NHS The Never Events List) – Death or severe harm as a result of administration of the wrong treatment following inpatient misidentification due to a failure to use standard wristband (or identify band) identification process Overdose of midazolam during conscious sedation (Contract and NHS The Never Events List) – Death or severe harm as a result of overdose of midazolam injection following use of high strength midazolam

0 0

0 0 0 N/A

September 2012 Maladministration potassium-containing solutions (Contract and NHS The Never Events List) – Death or severe harm as a result of maladministration of a potassium-containing solution

N/A

Wrongly prepared high-risk injectable medication (Contract and NHS The Never Events List) – Death or severe harm as a result of a wrongly prepared high-risk injectable medication Inappropriate administration of daily oral methotrexate (Contract and NHS The Never Events List) – Prescription, supply or administration of daily oral methotrexate to a patient for non-cancer treatment including supply to the patient with the instruction to take daily Escape of a transferred prisoner (Contract and NHS The Never Events List) – A patient who is transferred prisoner escaping from medium or high secure mental health services where they have been placed for treatment subject to Ministry of Justice restriction directions

N/A N/A

N/A

Trigger to Board Events Trust performance for Trigger to Board events for September and October 2012 is reported below as of 12 October 2012. Immediate action has been taken and full investigations have been completed for each trigger to board event. Please note that data may change as IR1 forms for September and October are still being processed by the Risk Management Department. Any changes will be reported in future performance reports.

September 2012 Leeds NYY Services Services Service user suicide whilst an inpatient

October 2012 Leeds NYY Services Services

Medication prescribed, dispensed or administered to a service user to which an allergy to this medication is documented:-

Level 0 – Non completion of the allergy box

Level 1 – Those incidents where medication has been prescribed

Level 2 – Those incidents where medication has been prescribed and dispensed

Level 3 – Those incidents where medication has been prescribed, dispensed and administered Level 4 – Those incidents where medication has been prescribed, dispensed and administered and harm has been caused

Non completion of Patient Safety Alerts within the designated timescale

Any reported incident where a female catheter has been used to catheterise a male service user

Cumulative Trigger to Board Events (September 2011 to October 2012)

Trigger to Board Events (September 2011 to October 2012) 45

7 40

10 5

Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

In-patientSuicide

Medication incident Level 0

Medication incident Level 1

Cumulative Inpatient Suicide

Cumulative Medication Incident level 0

Cumulative Medication incident level 1

Medication incident Level 2

Medication incident Level 3

Medication incident Level 4

Cumulative Medication incident level 2

Cumulative Medication incident level 3

Cumulative Medication incident level 4

The graph above shows the number of “trigger to board” events that have been reported since September 2011 to October 2012.

The graph above shows the cumulative “trigger to board events” from September 2011 to October 2012.

A clear mechanism has been established for the Associate Medical Directors for Doctors in Training and the Doctor's Educational Supervisor (ie the Consultant Psychiatrist), in collaboration with the School of Psychiatry to ensure that any Junior Doctor who has made a drug error is closely supervised to reduce the likelihood that further similar prescribing errors will occur. Following discussions at the Executive Team and Trust Board of Directors it has been agreed that electronic prescribing options will be fully explored as there is some evidence that electronic prescribing solutions may reduce prescribing errors in relation to allergy status. Research has shown that an organisation with a high rate of reporting indicates a mature safety culture where reporting incidents is encouraged and treated fairly. This maturity enhances openness and provides a truer reflection of current practice which allows more robust action planning.

6.2 Compulsory (Mandatory) Training 2012/2013 This report demonstrates compliance against the Procedure for Mandatory Training version 5.0 for Leeds Services and compliance against the former NYY Statutory and Mandatory Training Policy for NYY Services for Quarter 2 2012/13. Work has commenced to standardise the procedure and reporting processes across Leeds and York services. Standardisation was expected to be completed by the end of FY12/13 Q2 however this is now planned for FY12/13 Q3 due to some additional benchmarking activity of the procedure against other Trusts.

Planned Headcount Requiring Training in 12/13 to Achieve 80% Compliance

Total Number of Training Places Scheduled to be Provided 12/13

% Compliance 12/13 Q1

% Compliance 12/13 Q2

2033

1547

2316

659

63%

64%

Amber

Provision continues to exist to deliver 100% compliance across FY.

2428

43%

2275

1789

2112

648

46%

Amber

Fire Safety

2428

75%

2428

1942

2500

938

75%

69%

Amber

Increased provision in FY12/13 through increased capacity – ET paper presented 9.10.12 specifying investment required to increase compliance and achieve cost saving on agency staff spend. Provision continues to exists to deliver 100% compliance.

1800

504

64%

56%

Amber

700

150

70%

64%

Amber

556

71%

62%

Amber

67%

55%

Compliance Status*

Planned Headcount Requiring Training in 12/13 to Achieve 100% Compliance

58%

% Compliance 12/13 Q4

% Compliance 11/12 Q4

2428

% Compliance 12/13 Q3

Total Headcount Requiring Training Start 12/13 Q1

Moving and Handling PMVA

Total Number of Training Places Utilised in 12/13

Mandatory Training Product

Green = 80%+ compliance / Amber = 40-79% compliance / Red = less than 40% compliance

ACTION PLAN

exceeded

Resuscitation

1671

57%

1671

1337

Food Safety

1176

77%

637

402

exceeded

Infection Control Equality and Diversity Health and Safety Safeguarding Adults Trust Induction

2428

75%

1770 (C)

72%

658 (NC)

82%

2428

71%

1490

2500 exceeded

815

329

82%

79%

267

75%

76%

Amber

370

55%

62%

Amber

262

74%

75%

Amber

432

68%

61%

Amber

800

110

75%

77%

Amber

2000

335

77%

72%

Amber

Provision continues to exists to deliver 100% compliance which is on an upward trajectory. Provision continues to exists to deliver 100% compliance which is on an upward trajectory. Provision continues to exists to deliver 100% compliance which is on an upward trajectory. Compliance reduced due to service driven need of recruitment of staff prior to induction – compliance will increase in FY12/13 Q3-4. Compliance reports are being utilised to direct provision at the non compliant workforce. Provision continues to exists to deliver 100% compliance.

758

74%

68%

Amber

Provision continues to exists to deliver 100% compliance.

5621

68%

66%

Amber

Sustain the increase in compliance levels through the above action plans and continued compliance reporting.

1000 exceeded

2428

49%

1634

1148

2000 exceeded

2428

68%

1013

527

1100 exceeded

360

77%

estimate

Clinical Risk Management Safeguarding Children Information Governance Performance Summary

1975

360

288

estimate

1090

74%

344

126

2428

78%

1859

1373

Challenges in service delivery occurred in Q2 – increased provision now scheduled in Q3-4 to address reduction in compliance. Current TNA and provision has been reviewed with new approach in MT Procedure V5.0. Provision continues to exists to deliver 100% compliance – the decrease relates to the high training activity that occurred in FY11/12 Q2.

exceeded

2428

67%

2428

1942

2500 exceeded

26149

65%

19472

14240

21760

North Yorkshire and York Services:

Mandatory Training Product

Headcount Requiring Training Start 12/13 Q1

% Compliance 12/13 Q1

% Compliance 12/13 Q2

Moving and Handling (Group 1,2,3)

Compliance Status*

ACTION PLAN

Red

797

16%

13%

980

55%

54%

Equality and Diversity (Group 1)

980

79%

74%

Amber

Group 1 training remains in place and available through CBLS. A suitable training space has now been secured at BPH Ward 3 and appropriate beds and hoists are being transported to enable Group 2/3 training to be scheduled in Q3/4. Operational compliance reporting has been implemented with NYY SMT and this will assist with compliance. Provision continues although infrastructure for provision is to be reviewed after procedure standardisation across the Trust. A specific exercise had been agreed with NYY SMT to validate the TNA data to ensure that compliance is being accurately calculated and that it is not being under reported. Face to face training has commenced and practice will be formalised through Procedure standardisation. A suitable training space has now been secured at BPH Ward 3 and appropriate resuscitation equipment is in place. Training has been scheduled for Q3/4 and the volume of supply is being increased through external commissioning to meet the demand. Operational compliance reporting has been implemented with NYY SMT and this will assist with compliance. Face to face training has commenced and practice will be formalised through Procedure standardisation. Provision continues which will also be reviewed in light of the MT Procedure standardisation.

Health and Safety (Group 1)

980

81%

73%

Amber

Provision continues which will also be reviewed in light of the MT Procedure standardisation.

Safeguarding Adults (Group 1)

980

82%

76%

Amber

Provision continues which will also be reviewed in light of the MT Procedure standardisation.

Information Governance (Group 1)

980

63%

55%

Amber

Provision continues which will also be reviewed in light of the MT Procedure standardisation.

Safeguarding Children (Group 1&2)

980

86%

82%

Green

Provision continues which will also be reviewed in light of the MT Procedure standardisation.

980

44%

38%

PMVA (Group 2&3)

Fire Safety (Group 1)

Red 902

31%

26%

980

58%

Resuscitation (Group 1 & 2)

Infection Control (Group 1 & 2)

Amber Red

Amber

6.3 Information Governance The Government Public Sector Data Handling Review contained a number of recommendations that are mandatory to government and, with some exceptions, the wider public sector. The Trust continues to monitor NHS, Department of Health, Connecting for Health and Government Information governance initiatives and implement as required. 6.3.1 Connecting for Health Information Governance Toolkit v10

6.3.2 Information Governance (IG) Training (Connecting for Health IG Training Tool/North Yorkshire & York Computer Based Learning Solution)

The Information Governance (IG) Toolkit version 10 was released in late May 2012, with minimal changes. The IG team has now commenced working with requirement owners to agree target performance levels and refresh our evidence base ahead of final submission st by 31 March 2013. Our baseline submission was completed by 31st July 2012 (67%) and we are now working towards our interim submission in October 2012.

Information Governance (IG) training is mandatory and is required to be completed annually by all staff. Trust compliance rates are based on the percentage of staff who have completed IG training using any appropriate tool in the last 12 months. Current training figures are at 60%. This includes training figures for North Yorkshire & York services.

Performance will be monitored throughout the year by the Information Governance Standing Support Group, with regular updates provided to the Trust’s Governance and Regulatory Requirements Standing Group (Means Goal 7). Action plans will be completed st to ensure compliance by 31 March 2013. It is expected that a marginal improvement over our 2011-2012 score of 79.5% will be possible, whilst a ‘satisfactory’ overall performance will be maintained.

The IG team are pro-actively directly informing staff whose training has lapsed. North Yorkshire & York services will migrate to training via Connecting for Health IG Training Tool later this year, aligning with Leeds services. A strong communications approach is now underway to increase compliance.

6.3.3 Information Governance Incident Reports & Serious Untoward Incidents

6.3.4 Freedom of Information Act (FoIA) Exemptions & Performance Freedom of Information Act Performance & Exemptions April 2012 to September 2012

Information Governance Incident Reports & Serious Untoward Incidents April 2012 to September 2012

11%

100 90 80 70 60 50 40 30 20 10 0 Level 0

Level 1

89% In Progress

Level 2

To date, the Trust has had no IG Serious Untoward Incidents (level 3 or higher) reported to the Information Governance Standing Support Group. This is based on the grading scale advised by the NHS Chief Executive and matches the Trust’s Annual Report. Trustwide communications have been distributed to highlight the most common incident themes.

On Time

Void/Withdrawn

To date, the Trust has received 61 requests. 54 were completed on time, with 7 in progress and no void requests at the time of writing. 10 requests had exemptions to disclosure applied, with all exemptions reported in detail to the IG Standing Support Group for oversight. The majority of requests remain commercial in nature, although service changes are an emerging theme among FoIA requestors, with requests from journalists frequently apparent.

6.4 Compliance with and Implementation of Mental Health Legislation 6.4.1 Leeds Services The following information shows the Trust’s performance against requirements of the Mental Capacity Act 2005 and the implementation and monitoring of the Mental Health Act 1983 (which are within the Trust’s sphere of responsibility). Compliance with the requirements of the Mental Capacity Act (MCA) 2005 NHS Leeds commissioned the Trust to develop a further practical based e-learning package on MCA and Deprivation of Liberty Safeguards (DoLs). The Mental Health Legislation department are working with the Trust’s e-Learning manager to develop the design and operation of the package to consider how it will be used in the overall training plans. It is expected that the package will be completed by December 2012 with training rolled out from January 2013. Deprivation of Liberty Safeguards (DoLS) activity During quarter 2, 7 enquiries under DoLS have been made, resulting in no new applications for a DoL. There are currently no DoLs within the Trust. Independent Mental Capacity Advocate (IMCA) st

The graph below indicates the number of referral enquiries per Quarter from the Trust since 1 April 2007 (data provided by Leeds Advocacy).

During the period 1 July 2012 to 30 September 2012 there were 74 enquiries from the Trust to the Leeds IMCA service. The graph below indicates the IMCA referrals by decision type.

IMCA Referrals Per Quarter

IMCA Referral (per decision type) 12 months ending 30 September 2012 (Qtr 4 2011 and Qtr 1, 2, 3 2012)

30 40

30 25

15 10

0 07,2

07,3

07,4

08,1

08,2

08,3

08,4

09,1

09,2

Enquiries

09,3

09,4

10,1

10,2

10,3

10,4

11,1

11,2

11,3

11,4

12,1

12,2

Serious Medical Treatment

IMCAin role

Safeguarding

Not IMCA reason

Change of Accommodation

Care Review

Implementation and monitoring of the requirements of the Mental Health Act (MHA) 1983 The governance arrangements for Mental Health Act Managers (MHAMs) was agreed by the Board of Directors in September 2012 and recruitment has now commenced with the expectation that at least ten new MHAMs will be appointed. The new meeting arrangements for MHAMs and other governance arrangements (honorary contract, job description, appraisal, training) will be taken forward by the Corporate Mental Health Legislation Manager. To complete the harmonisation of protocols across LYPFT, the S132 protocol and the protocol for the hospital manager’s review of detention will go through the Trust governance process with the aim of ratification by the Executive Team by December 2012. Information relating to patients detained by the Trust under the Mental Health Act is now accessible, on PARIS by clinical staff on a read only basis. This also includes Mental Health Act detention papers which are now scanned into PARIS. 39

Mental Health Legislation Training Mental Health Law training is now included in the Trust compulsory (mandatory) training procedure as an essential training requirement for all relevant clinical staff. The Corporate Mental Health Legislation Manager is conducting a training needs analysis for mental health law training and a Trust wide training strategy will be developed. An additional band 7 post within the Mental Health Legislation department has been appointed and the primary duty will be to assist in the development and implementation of training on mental health legislation. Total number of Mental Health Act section occurrences Independent Mental Health Advocate (IMHA) activity for qualifying patients (non Learning Disability as provided by Advocacy for Mental Health & Dementia) Jul-12 Aug-12 Sep-12 TOTAL April-June 2012 175 Section 136 67 74 34 IMHA referrals allocated 38 158 Section 136 Discharge 61 68 29 134 Section 2 51 38 45 New clients to service 40 43 Section 2 Discharge 10 18 15 Previously assessed 17 70 Section 3 20 32 18 Service declined 2 31 Section 3 Discharge 17 11 3 Clients on active caseload at end of quarter 52 22 Section 3 Renewal 9 5 8 2 Section 37 Renewal 1 1 0 Clients discharged 33 47 Section 5(2) 18 14 15 21 Section 5(2) Discharge 5 4 12 Advocacy for Mental Health & Dementia (Leeds) continue to liaise with Cloverleaf 6 Section 5(4) 1 1 4 (York) to review the IMHA engagement protocols within Leeds and York in order to 21 Community Treatment Order 3 10 8 harmonise both protocols with consideration to better provision for those patients 1 Community Treatment Order Discharge 1 0 0 without capacity. Due to demand from number of referrals the IMHA service (Leeds) The table above shows the total number of occurences of unrestricted Mental Health Act sections during Quarter 2. The total number of current and active Community Treatment Orders (CTO) to date is 97.

continues to have a waiting list of service users awaiting IMHA allocation.

Managers Hearings by Section - July 2012 to September 2012

Managers Hearings Outcomes - July 2012 to September 2012

14 12

2 0

0 Jul-12 Section 2 - Application

Aug-12 Section 2 - Hearing

Section 3 - Application

Sep-12 Section 3 - Hearing

Application Withdrawn Discharged from section Discharged from section prior to hearing

CTO - Application CTO - Hearing

The chart above shows the total number of patients appealing against their detentions to Mental Health Act (MHA) Managers during Quarter 2. 40

Section 3

CTO

Not specified

Remains on section

Transferred out of area

Section 2

The above chart shows the total number of outcomes for patients appealing against their detentions to Mental Health Act (MHA) Managers during Quarter 2.

Local Standards for Managers Hearings The Trust’s internal standard for Managers Hearings for Leeds Services: 5 working days for section 2. 10 working days for section 3 and equivalent. CTO is a 15 working day standard. The chart below shows the number of days taken to hold an appeal against detentions to Mental Health Act (MHA) Managers during Quarter 2. Local Standards for Hearings - July 2012 to September 2012 10 8 6 4 2 0 2

Section 3

Section 2

The following are reasons why 10 out of the 13 hearings were held outside of the Trust’s internal standard: 2 due to Responsible Clinician availability  8 due to solicitor availability Managers Hearing outcomes by ethnicity

White British

Mixed White/ Black Caribbean

White Irish

Mixed Other

Black African

Black Caribbean

Asian Pakistani

Asian Indian

Not Known

TOTAL

Remained on Section

Application withdrawn

Discharged prior to hearing

Transferred out of area

Discharged from Section

Not Specified*

TOTAL

* due to hearings being scheduled after the end of the quarter

Section 136 applications (gender and ethnicity) The chart below shows the number of Section 136 applications by gender and ethnicity during Quarter 2.

Section 136 Applications (gender & ethnicity) - July 2012 to September 2012 40 35 30 25

Jul-12

20 Aug-12 15 Sep-12

10 5 0 Male

Female

Male

Female

Asian/Asian British Black/Black British

Male

Female

Male

Mixed

Female

Not Known

Male

Female

Other

Male

Female

White

Mental Health Tribunal (MHT) Hearings Applications received

Applications withdrawn

Discharged prior to hearing

Tribunals adjourned

Detention upheld

Detention discharged

Transferred prior to hearing

Outstanding Tribunals

Unknown

July-12

August-12

September-12

TOTAL

129

6.4.2. North Yorkshire and York Services Total number of Mental Health Act section occurrences

Section 136 Section 136 Discharge Section 2* Section 2 Discharge* Section 3* Section 3 Discharge* Section 3 Renewal Section 37 Renewal Section 5(2) Section 5(2) Discharge Section 5(4) Community Treatment Order Community Treatment Order Discharge

Independent Mental Health Advocate (IMHA) activity for qualifying patients

Jul-12

Aug-12

Sep-12

TOTAL

0 0 5 9 10 5 3 1 3 1 2 1 0

0 0 11 4 4 4 2 0 3 0 1 0 1

0 0 5 9 6 4 2 1 1 1 2 1 0

0 0 21 22 20 13 7 2 7 2 5 2 1

July-September 2012 IMHA referrals received

New IMHA clients allocated

Cases closed

Total IMHA clients

Dementia patients receiving IMHA support

Young people receiving IMHA support

CTO patients receiving IMHA support

* These figures include Section 19 transfers in and out The table above shows the total number of occurences of Mental Health Act sections during Quarter 2. The total number of new CTOs is 2 and the locality has a running total of 12 active CTOs. In addition, there was one Section 37/41 admission during July and one S47/49 admission during August. There was one Section 37 admission in September. There were four CTO extensions during August. Managers Appeal Hearings by Section

Managers Hearings by Outcome

Managers Appeal Hearings by Section - July 2012 to September 2012

Managers Hearings Outcomes - July 2012 to September 2012

16 14

12 10

8 4

6 4

2 0

0 Jul-12 Section 2 - Application Section 2 - Hearing

Aug-12 Section 3 - Application Section 3 - Hearing

Application Withdrawn

Sep-12 CTO - Application CTO - Hearing

Section 23 RC

Discharged Section 3

The above chart shows the total number of patients appealing against their detentions to Mental Health Act (MHA) Managers during Quarter 2.

Adjourned CTO

Section 2

Not Specified

Not Discharged

Transfer out before hearing

Section 37

The above chart shows the total number of outcomes for patients appealing against their detentions to Mental Health Act (MHA) Managers during Quarter 2. This also includes renewal and CTO extension hearings.

Section 136 Assessments (gender)

Local Standards for Appeal Hearings

The chart below shows the number of Section 136 applications by gender during Quarter 2.

The Trustâ&#x20AC;&#x2122;s internal standard for Managers Hearings for North Yorkshire & York Services: 21 calendar days for section 3 and CTO appeals from receipt of application. The chart below shows the number of days taken to hold an appeal against detentions to Mental Health Act (MHA) Managers during Quarter 2.

Section 136 Assessments (gender) - July 2012 to September 2012 16

Local Standards for Hearings - July 2012 to September 2012

12 10

8 6

2 0

2 Jul-12

Aug-12 Male

Sep-12 Female

0 16

Section 3

CTO

First Tier Tribunal (Mental Health) Hearings. The table below shows the number of First Tier Tribunal hearings during Quarter 2. Applications received

Applications withdrawn

Discharged before hearing

FTTs adjourned

Detention upheld

Detention discharged

Transferred before hearing

Outstanding FTTs *

Unknown

July-12

August-12

September-12

TOTAL

* Hearings with no date arranged

6.5 Complaints Requires quarterly reporting on number and type of complaints together with identified trends and action plans. Complaints are to be responded to within specified timescales (performance threshold 95%, with exception reports if full resolution takes longer than 30 working days). Complaints reports are presented to the Trustâ&#x20AC;&#x2122;s Audit & Assurance Committee on a quarterly basis. The following information highlights key areas of the report covering the period 1 July 2012 to 30 September 2012. Complaints Received - The Trust received 29 formal written complaints between 1 July 2012 and 30 September 2012. All were acknowledged within the NHS regulation timescale of 3 working days. The main subject of complaints received during this period are summarised below:Subject

Number Of Complaints

All aspects of clinical care & treatment (medical & nursing)

Attitude of staff

Discharge arrangements

Delay in appointments

Trust policy decisions

Confidentiality

Other

Total

Complaints Responded to - 26 complaints received a response following investigation in this period, 21 of which were achieved within the agreed 30 day timescale. Of the 26 complaints responded to, 1 was upheld, 4 were partially upheld and 21 were not upheld. Appropriate actions were taken to address the issues raised in the complaints that were either upheld or partially upheld. Work is being undertaken to obtain benchmarking information from similar Trusts to assess how we compare with regards to complaints.

6.6 Physical Health Assessments Requires reporting on the number of service users who have been in hospital/long-term health care for more than one year and who have had a physical health check on at least an annual basis.

Annual Physical Health Check 100%

89.00%

90.60%

86.40% 78.70%

80%

As of 2nd October 2012, 86.4% of patients who had a continuous inpatient stay for a year or longer have had an annual physical health check recorded on PARIS. This is above the Trustâ&#x20AC;&#x2122;s baseline of 82%.

61.90% 60%

40%

Information is sent out to ward teams prior to the check being due to ensure 100% compliance with this target and correct recording on PARIS.

20%

0% Quarter 2 2011/12

Quarter 3 2011/12

Quarter 4 2011/12

% Received Annual Physical Health Check

Quarter 1 2012/13

Quarter 2 2012/13

Trust Baseline

6.7 Payment By Results Report st

Mental health services are nationally mandated to implement Payment by Results from 1 April 2013 for Older Peoples and Adult Services with some exclusions. LYPFT is a member of the Regional Care Pathways and Packages Project consortium which is made up of Trusts from Yorkshire, Humber and the North East of England. In order to achieve the national requirement LYPFT must improve cluster accuracy and coverage to enable the development of contracts. Equally, there is a need to develop local and influence national outcome measures which align with the cluster based pathways. This requires a whole Trust response supported by the Payment by Results project team. North Yorkshire and York services joined the project in February 2012 and at that time commenced training and clustering. The data below relates to Leeds service only. Table 1. Trajectories and Progress - In March 2012 a number of project performance trajectories were set for Leeds Services

Coverage Reviews in date Rare and unlikely transitions

Q2 Target 80% 90% 20%

Q2 Achieved 78% 44.8% 41.7%

Table 2: Project and Workstream status Project Status

Amber Guidance - Operational guidance awaiting ratification.

Clinical & Training Workstream

Costing Workstream

Amber

Data Workstream

Amber

Commissioner Engagement

Green

Staffing 1. New full time post being recruited. Training -Training Strategy written and in the process of being scoped. -Strategy will bring uniformity of approach to training across the whole Trust in scope services. -Training of locality teams agreed -Re-training continues across Leeds services. -Manager and super users per team targeted for training currently.

Assurance of accuracy -work underway to identify critical aspects of accuracy and evidence to measure those aspects.

Benchmarking - we continue to produce and submit cluster costs to CPPP for benchmarking purposes. - the costs produced are dependent on the quality of the activity and cluster information and so cannot be assured. Capture of Information - Reports need to be written to provide service managers and individual clinicians with more detail on which patients require cluster assessments/cluster reviews. This piece of work will be linked in with the new Trustwide Performance and Information Group, to consolidate the amount of information being sent out to clinical staff via the COGNOS reporting system.

Assessments - Work is ongoing to develop a suitable methodology for costing initial assessments. -We are currently unable to cost initial assessments separately as they cannot be extracted from the activity information.

North Yorkshire & York - We are unable to include NYY services within the costing work as the activity data that is required is not available.

Recording of Assessment - Develop reports based on guidance set out by the finance and training and Clinical Engagement Leads, to analyse the costs of assessment activity recorded on PARIS.

Reporting - Development of Cube reports and enhancements to the trust data warehouse to support trend analysis of clustering coverage and training effectiveness, and costing. This item is currently overrunning due to unforeseen technical complications. It is expected that trend reports will be available before the end of October 2012.

Memorandum of Understanding signed

Regular Communication with Commissioners

Supporting Commissioners to develop an understanding of the Clustering process

Outcome measures - The outcome measures work is aligned but out with this project and is now part of transformation.

NY&Y Data -NY&Y data is currently available. A presentation was delivered to York services in September, showing current cluster data. This dataset will be enhanced during October and November, enabling creation of more detailed reports for NY&Y services. It is expected that a trust-wide position for cluster coverage will be available in early 2013.

Coverage - no significant change

7. Transformation

Project Sponsor

M ilesto n es o n track (R/G )

KP I's o n track (RAG )

S takeh o ld ers m g t (R/G )

P ro ject team assessm en t (RAG )

Risk M an ag em en t

High Level Critical Path

Overall progress of the Transformation Project. (Measured against agreed key milestones and timescales.)

Michele Moran

Care Pathway Workstream

Work undertaken with clinical teams to identify how and where services can improve to make them better, simpler and more efficient.

Michele Moran

N/A

Integrated Care Pathway (ICP) Development

Work with clinical teams to ensure that appropriate care is delivered in the right place, at the right time by the right clinician.

Michele Moran

N/A

Releasing Time to Care

Using the latest technology to spend more time with service users and their carers.

Michele Moran

Human Resources/Workforce

Ensuring Staffing and employment issues arising from the transformation projects are properly supported and managed.

Susan Tyler

N/A

Informatics

Ensuring Information systems, processes and technology supports newly designed services.

Dawn Hanwell

N/A

Operational Delivery Workstream

Implementing internal changes to support the newly designed services.

Michele Moran

Finance Workstream

Delivery of savings associated with transsformation.

Dawn Hanwell

Communications and Engagement

Responsible for briefing and engaging with staff, service users, carers and other stakeholders about our services, throughout the Transformation project.

Jill Copelend

N/A

Research and Evaluation

Evaluation of the Transformation project. This workstream will cover service quality outcomes, Impact of Integrated Care Pathways, leadership and team working.

Jim Isherwood

N/A

Project/Workstream Title

RAG Commentary O verall P ro ject Assessm en t

Description

F in an cial Ben efits o n track (R/G )

The Transformation Project is our plan to find better ways of providing care, treatment and support for the people who use our services, whilst making financial savings. We are working with people to find out what works best for them. Our aim is to make sure that people have a positive experience of using our services and achieve their goals for improving their health and lives. The following dashboard describes the progress of the Transformation Project. The overall project plan and individual implementation projects are reviewed along with the supporting work-streams. Each month the Project Board will assess the overall rating for the project and each individual element contributing to its success. Any concerns are explored by the Project Board and referenced in the comments field. Project risks will be monitored through the Trustâ&#x20AC;&#x2122;s electronic risk register.

The outpatient project has not progressed to the original plan. Some slippage against implementation plans for the new CPA care plan and needs based ICPs has occurred.

Awaiting the report on York inpatient analysis.

New CPA care plan cannot be implemented until hard copy facility is completed.

g a

some delay in developing the User Guide and and with OD involvement due to capacity - now resolved

Medical job planning to be completed on a group basis.

New pathway implemented. Ongoing issues and risks managed by Operational workstream.

The Trusts is working with external partners to finalise the revised proposal for the Novemer 2012 Programme Board meeting .

8. Year to Date Financial Position Income and Expenditure

Statement of Comprehensive Income (Appendix 1) Month Ending: 30th September 2012

Year to Date Plan £'000s

Actual £'000s

Variance £'000s

Clinical Income Other Operating Income

75,600 10,542

76,743 11,003

1,143 462

Total Income

86,141

87,746

1,605

Pay Non Pay

(63,736) (17,024)

(63,686) (17,987)

50 (964)

Total Expenses (exc financing)

(80,760)

(81,673)

(913)

Overall Operating Income was above plan in September by £1.61m.

EBITDA

5,381

6,073

692

Financing / Other Income & Costs

(3,841)

(3,923)

(82)

I&E Surplus / (Deficit)

1,540

2,149

610

% 6.2 1.6

% 6.9 2.5

% 0.6 0.9

(23,444) (1,911) (3,701) (14,746) (1,678)

(23,353) (1,563) (3,652) (15,083) (1,583)

91 347 49 (336) 95

47,020

47,382

362

1,541

2,149

608

September Actual Rating 112.9 6.9 6.3 2.5 27.9

Plan Yr END Rating 5 3 5 3 3

September Actual Rating 5 3 5 4 4

EDITDA Margin Net I&E Margin YTD Surplus Variance by Directorate Adult & Older Services Specialist Services Learning Disabilities & Supported Living NYY Services Clinical Support Unit Corporate Services (inc CPC, capital charges, block clinical income) I&E Surplus / (Deficit)

£0.55m of the additional income relates to NYY as a result of extra Liaison, CAMHS & Low Secure income, the bulk of which is non recurrent and is currently offsetting unachieved CRES. £0.66m relates to additional contracted income in Adult & Older, Learning Disabilities & Specialist Services. £0.66m relates to additional ILM, R&D, Junior Doctors & Pharmacy income. The bulk of which has offsetting costs. Other corporate income is currently £0.26m below plan. Overall Operating Expenditure was above plan in September by £0.91m; of which there are a number of offsetting variances. Pay expenditure under-spend (permanent plus agency spend) was £0.05m (£0.82m under-spend on permanent pay expenditure and £0.77m over-spend on agency pay expenditure). NYY pay is over-spent due to the timing of CRES delivery. This is offset by under-spend in Specialist services (development slippage) and Adult & Older services (delayed opening of Newsam ward 5). Non Pay expenditure is currently over-spent due Out of Area Treatment (OATs) expenditure being £0.53m above plan at the end of September. This was due to the delay in the opening of Newsam Ward 5 and the high level of adult acute out of area clients (this is partly offset by pay under-spending on the Newsam Ward 5) . Additional over-spend due to NYY services £0.29m (offsetting NYY income to cover the extra spend). Additional R&D and ILM expenditure £0.29m (offsetting income). Other non pay is under-spent by £0.15m due to non utilisation of redundancy, early retirement & personal injury provisions and timing of expenditure on corporate contracts & estates maintenance. Financing / Other Income & Costs is currently above plan due to the sale of Peel Court having not been completed. This had been assumed to be completed by June. An offer has now been accepted.

Financial Risk Ratings & Headroom

Indicators of Forward Financial Risk (as per Compliance Framework)

Month Ending: 30th September 2012 EBITDA achievement of plan EBITDA Margin Return on Assets Employed I&E Margin Liquidity Ratio

% % % % Days

Overall Financial Risk Rating

September Headroom (£'000s)

FRR 4 to a 3

FRR 4 to a 2

1,145

2,305

Cash (Appendix 3) Month Ending: 30th September 2012

u u u p p u

Capital (Appendix 4) Year to Date Plan £'000s

Actual £'000s

Variance £'000s

Opening Cash and Cash Equivalents Operating Surplus Other Non-Cash flows Working Capital Investing Activities Financing Activities

23,497 1,540 3,795 36 (968) (2,939)

23,497 2,149 3,878 5,280 (1,309) (2,812)

0 610 82 5,244 (342) 126

Estates PFI IT Service Strategy Other

Closing Cash and Cash Equivalents

24,962

30,682

5,721

Total Capital Expenditure

The cash position was above plan by £5.72m at the end of September with a value of

Response FALSE FALSE FALSE TRUE FALSE FALSE FALSE FALSE FALSE FALSE

Value

Year to Date Plan £'000s

Actual £'000s

Variance £'000s

Unplanned decrease in (quarterly) Trust is unable to certify that Board Working capital facility (WCF) was Debtors > 90 days past due account Creditors > 90 days past due account Two or more changes in Finance Interim Finance Director in place over Quarter end cash balance <10 days Capital expenditure < 75% of plan for for the year to date

8% 2%

68.6 87% 87%

CRES

Month Ending: 30th September 2012

Year to date capital expenditure is £1.02m, with commitments of £1.39m.

Year to Date Plan £'000s

Month Ending: 30th September 2012

Actual £'000s

Variance £'000s

59 76 430 620 22

118 169 139 589 1

58 94 (291) (31) (20)

Adult & Older Services Specialist Services Learning Disabilities & Supported Living NYY Services Corporate Services

1,505 183 257 1,016 435

1,662 183 270 715 170

158 0 13 (301) (265)

1,206

1,016

(190)

Total CRES

3,396

3,000

(395)

Year to date CRES is currently £0.4m below plan. This is predominantly due to

9. Forecast Financial Position Income and Expenditure

Statement of Comprehensive Income (Appendix 1) Month Ending: 30th September 2012

Overall Operating Income is was forecast above to plan be in above August plan byby £1.10m. £4.02m.

Plan £'000s

Forecast Actual £'000s

Variance £'000s

151,199 21,083 172,282

153,365 22,938 176,303

2,166 1,855 4,021

(127,290) (33,917) (161,207)

(127,799) (36,354) (164,153)

(509) (2,437) (2,946)

EBITDA

11,075

12,150

1,074

Financing / Other Income & Costs

(7,910)

(7,843)

I&E Surplus / (Deficit)

3,165

4,306

1,141

Recurrent Non Recurrent

2,877 288

2,817 1,490

(61) 1,201

EDITDA Margin Net I&E Margin

% 6.4 1.8

% 6.9 2.4

% 0.4 0.6

(46,708) (3,821) (7,402) (29,403) (3,356)

(46,504) (3,394) (7,429) (29,680) (3,232)

204 427 (27) (277) 124

Range Forecast A range forecast has been prepared for month 6 – best case forecasts an I&E surplus of £5.53m & down side an I&E surplus of £2.65m. The downside forecast assumes the following adjustments to the base case forecast variance: - Impairment of Seacroft fees £0.32m - Delayed repatriation of rehab OATs & increased adult OATs spend £0.22m - Eating Disorders beds reduction £0.10m - Deterioration of corporate position £0.29m - NYY reduced CRES achievement & income reduction £0.51m - LD wards spend increase & reduced SSL income £0.21m

93,856 3,165

94,545 4,306

690 1,141

Underlying (recurrent) position The forecast recurrent surplus at month 6 is £2.82m, which is a £0.06m deterioration from plan.

3,165 3,165

5,528 2,652

2,363 (513)

September Forecast Rating 109.7 6.9 6.1 2.4 31.3

Plan Yr END Rating 5 3 5 3 3 4

September Forecast Rating 5 3 5 4 4 4

Clinical Income Other Operating Income Total Income Pay Non Pay Total Expenses (exc financing)

Forecast Surplus Variance by Directorate Adult & Older Services Specialist Services Learning Disabilities & Supported Living NYY Services Clinical Support Unit Corporate Services (inc CPC, capital charges, block clinical income) I&E Surplus / (Deficit) Best Case Forecast Downside Forecast

£1.85m of the additional income relates to NYY as a result of extra Liaison, CAMHS & Low Secure income, the bulk of which is non recurrent and is currently offsetting unachieved CRES £0.59m CRES.and additional non pay spend. £0.58m relates to additional contracted income in Adult & Older, Learning Disabilities & Specialist Services. £1.26m relates to additional contracted income in Adult & Older, Learning Disabilities & Specialist Services. £0.18m relates to additional Junior Doctors & Pharmacy income. £1.33m relates to additional ILM, R&D, Junior Doctors & Pharmacy income. The bulk of which has offsetting costs. NHS CPC income remains a concern and is currently £0.25m below plan (largely CPC Plus & Bespoke income). Other corporate income is forecast to be £0.42m below plan. Overall Operating Expenditure was above plan in August by £0.54m; of which there are a number of offsetting variances. Overall Operating Expenditure is forecast to be above plan by £2.95m. Pay expenditure over-spend (permanent plus agency spend) was £0.10m (£0.53m under-spend on permanent pay expenditure and £0.63m over-spend Pay expenditure on agency over-spend pay expenditure). (permanentNYY pluspay agency is over-spent spend) forecast due to the £0.51m timing (£0.72m of CRES under-spend delivery. This on permanent is offset by pay under-spend expenditure in Specialist and £1.23m services over-spend (development on agency slippage) pay expenditure). and Adult &NYY Older pay services is over(delayed spent dueopening to CRES of slippage. Newsam The wardcurrent 5). run rate under spend on permanent pay is forecast to reduce due to pharmacy and specialist services development spend being incurred. This is offset by additional contracted income being received. Non Pay expenditure is currently under-spent due to non utilisation of redundancy, early retirement & personal injury provisions and timing of expenditure on corporate contracts & estates maintenance. Out of Area Non Pay Treatment expenditure (OATs) forecast expenditure over-spend was £0.49m due to NYY above services plan at£1.25m the end(there of August. is additional This was NYY due income to the to delay cover in the the opening extra spend) of Newsam & Adultward / Older 5 and services the high £0.26m. level of This adult is partially acute out offset of area by under clients.spend This is on partly off-set corporate contracts by pay £0.08m. under-spending on the ward. Additional R&D and ILM expenditure £0.54m (offsetting income). Financing Out of Area/ Treatment Other Income (OATs) & Costs expenditure is currently forecast below £0.47m plan due above to plan. the sale This of is Peel dueCourt to thehaving delay in notthe been opening completed. of Newsam This had ward been 5 and assumed the hightolevel be completed of adult acute by June. out ofAn area offer clients. has now been accepted.

Financial Risk Ratings & Headroom

CRES

Month Ending: 30th September 2012 EBITDA achievement of plan EBITDA Margin Return on Assets Employed I&E Margin Liquidity Ratio Overall Financial Risk Rating

August Forecast Headroom (£'000s)

% % % % Days

FRR 4 to a 3

FRR 4 to a 2

2,415

4,395

Month Ending: 30th September 2012 u u u p p u

Cash (Appendix 3) Month Ending: 30th September 2012

Opening Cash and Cash Equivalents Operating Surplus Other Non-Cash flows Working Capital Investing Activities Financing Activities Closing Cash and Cash Equivalents

Forecast Actual £'000s

Variance £'000s

23,497 3,165 7,864 (3,170) (5,727) (5,834) 19,795

23,497 4,306 7,798 (1,098) (2,690) (5,752) 26,060

0 1,141 (66) 2,072 3,036 82 6,265

Month Ending: 30th September 2012

Estates PFI IT Service Strategy Other Total Capital Expenditure

25,000 20,000

3,178 366 514 2,031 640 6,730

3,306 366 533 1,813 493 6,512

Plan £'000s

Forecast Actual £'000s

Variance £'000s

313 0 1,342 5,609 51 7,315

355 278 1,048 1,708 90 3,479

41 278 (294) (3,901) 40 (3,836)

CRES is forecast to be £0.2m under achieved. This is predominantly due to a delay in achieving CRES in NYY, partially offset by early delivery of Transformation savings. The Forecast assumes the sales of Peel Court, Otley Old Road & Ardsley House will proceed as planned.

Variance £'000s

128 0 19 (218) (147) (218)

Forecast expenditure is £3.48m which represents £3.84m slippage from planned levels of capital expenditure. Expenditure analysed into the main categories of capital expenditure in the table on the left. A significant element of the forecast £3.48m annual capital expenditure plan relates to Service Strategy spend (£1.71m):- Asket Croft £1.25m - New accommodation £0.32m - NYY IT £0.10m. - Newsam rehabilitation unit £0.15m. - The Mount sensory garden £0.14m (brought forward from 2011/12).

Capital Expenditure (with Forecast) against Approved Funding

8,000

7,315

7,000

Cashflow (with Forecast) against Annual Plan 30,000

Forecast Actual £'000s

Capital (Appendix 4) Plan £'000s

The yearend forecast is for cash to be £6.27m above plan at £26.06m. This assumes an operating cash flow improvement of £1.07m, an improvement in working capital of £2.07m and a reduction against investing activities of £3.04m, predominantly reduced capital spend for the scheme for new accommodation £1.75m & Asket Croft £1.50m.

35,000

Adult & Older Services Specialist Services Learning Disabilities & Supported Living NYY Services Corporate Services Total CRES

Plan £'000s

6,000

30,682 26,060 24,962 19,795

15,000

5,000 4,000 3,479

3,000

10,000 5,000

2,000

1,000

1,206 1,016

0 Apr-12 Actual (+ Forec ast)

May-12

Annual Plan

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Actual (including Forec ast)

Approved Funding

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

10. Contractual Activity Reporting 10.1 Planned Activity Monitoring (Leeds Service) Board Report: Planned Activity Monitoring: 2012/September Adult Services Contract Line

Contract Line Code Currency

YTD Leeds Activity

Planned YTD Leeds Activity

Variance

YTD NonLeeds Activity

Planned YTD Contracted Non-Leeds and other Leeds Activity

Variance

YTD SCG Activity

Planned YTD SCG Activity

Variance

Total YTD Activity

Planned YTD Activity

Variance

Day Care - Acute Community (Day) Services

ASD02

Attendances

4974

4000

24.3%

4974

4000

24.3%

ICS Day Attendances

NCL02

Attendances

5683

6858

-17.1%

5734

6858

-16.4%

9195

9477

Inpatients - Rehab Units (Long Stay)

Bed Days

8853

9477

-6.6%

342

Inpatients - Acute Adult

ASI02

Bed Days

19196

18497

3.8%

225

19421

18711

Home Based Teatment

NCL01

ASI01

Contacts

3785

5806

-34.8%

3838

5806

Crisis Assessment Service

NCL03

Contacts

2476

2327

6.4%

2554

2327

9.7%

3085

2630

17.3%

3182

2630

21.0%

Crisis Resolution

ASC01

Contacts

Section 136 Service

ASC02

Referrals

458

428

7.0%

215

4.9%

496

428

-3.0% 3.8% -33.9%

15.8%

Assertive Outreach Team

ASC03

Contacts

8904

5601

59.0%

8941

5601

59.6%

CMHT's - Other Adult

ASC04

Contacts

30088

35051

-14.2%

180

30268

35051

-13.6%

Outpatients - Adult- New

ASO01

Attendances

761

1068

-28.7%

37.9%

765

1071

-28.6%

Outpatients - Adult - Follow up

ASO02

Attendances

6471

7105

-8.9%

-1.0%

6523

7158

Adult Psychological Therapies

ASC05

Attendances

8164

8088

0.9%

124

200

-37.9%

8288

Attention Deficit Disorder

ASO06

Attendances

130

105.8%

134

1653

0.9%

142

1809

1775

1.9%

6888

5751

19.8%

-8.9% 0.0% 112.1%

Inpatients - Intensive Care

SSI05

Bed Days

1667

Inpatients - Low Secure

SSI02

Bed Days

Inpatients - The Beeches

SSI04

Bed Days

1452

1463

-0.8%

1452

1463

Community Forensics Team

SSC03

Contacts

1423

1358

4.8%

1462

1358

7.7%

Outpatients - Forensics - New

SSO07

Attendances

14.3%

16.8%

455

Outpatients - Forensics - Follow up

SSO08

123

15.6%

6888

5751

19.8%

-0.8%

Attendances

440

453

-2.9%

453

0.4%

Psychological Therapies Services - Forensics

SSC06

Attendances

249

360

-30.8%

249

360

-30.8%

Locked Rehab Ward 5

ASI04

Bed Days

600

2956

-79.7%

690

2956

-76.7%

108906

115282

-5.5%

1572

593

165.3%

19.8%

117366

121626

YTD Leeds Activity

Planned YTD Leeds Activity

Variance

YTD NonLeeds Activity

Planned YTD Contracted Non-Leeds and other Leeds Activity

Variance

Total YTD Activity

Planned YTD Activity

Variance

Total

6888

5751

-3.5%

Learning Disability Services Contract Line

Contract Line Code Currency

YTD SCG Activity

Planned YTD SCG Activity

Inpatients - Assessment and Treatment

LDI01

Bed Days

1310

1727

-24.1%

270

124

118.0%

1580

1851

-14.6%

Inpatients - Rehabilitation

LDI02

Bed Days

692

1152

-39.9%

183

0.0%

875

1335

-34.5%

Day Care (Ventures)

LDD01

Attendances

3531

3042

16.1%

3561

3042

Inpatients - Respite

LDI03

Bed Days

1268

1296

-2.1%

1343

1296

3.7%

Social Care

LDC04

Bed Days

16587

17202

-3.6%

16587

17202

-3.6%

17.0%

ATCs (Day Service Nursing Team)

LDC01

Attendances

3548

5128

-30.8%

3580

5128

-30.2%

CLDT

LDC02

Contacts

6837

6033

13.3%

199

7036

6033

16.6%

Psychology

LDC03

Attendances

802

528

51.8%

839

528

58.8%

Outpatients - New

LDO01

Attendances

109

101

7.6%

113

101

11.6%

Outpatients - Follow up

LDO02

Attendances

1037

755

37.3%

1058

755

19134

19763

-3.2%

17438

17509

-0.4%

36572

37272

YTD Leeds Activity

Planned YTD Leeds Activity

Variance

YTD NonLeeds Activity

Planned YTD Contracted Non-Leeds and other Leeds Activity

Variance

488

Total

40.1% -1.9%

Older Peoples Services Contract Line

Inpatients - Functional- acute mental health

Contract Line Code Currency

OPI01

YTD SCG Activity

Planned YTD SCG Activity

Variance

Total YTD Activity

Planned YTD Activity

Variance

Bed Days

6360

6954

-8.5%

6954

-1.5%

Liaison Psychiatry (combined nursing & outpatients)

OPC10

Contacts

1909

1257

51.8%

1961

1257

56.0%

Cityw ide treatment

SSC11

Contacts

2315

2256

2.6%

135

2450

2256

8.6%

Memory Services

OPC02

Contacts

6151

3738

64.5%

6213

3738

66.2%

296

64.0%

6848

Young Peoples Dementia Team

OPC03

Contacts

473

296

59.9%

485

Physiotherapy

OPC09

Contacts

516

567

-8.9%

518

567

Psychological Therapies and Counselling Services

OPC06

Attendances

949

1026

-7.5%

958

1026

-6.6%

OPS - MH ICT

OPC07

Contacts

1808

2573

-29.7%

105

1913

2573

-25.6%

3778

3806

-8.6%

Outpatients - Follow up

OPO02

Attendances

4849

-22.1%

4849

-21.5%

Outpatients - New

OPO01

Attendances

723

1611

-55.1%

728

1611

-54.8%

CMHT Care Home Team

OPC05

Contacts

2260

1258

79.6%

2293

1258

82.2%

CMHTs

OPC01

Contacts

12083

16690

-27.6%

167

12250

16690

-26.6%

Inpatients - Organic

OPI03

Bed Days

Total

6298

7815

-19.4%

716

45623

50890

-10.4%

1814

YTD Leeds Activity

Planned YTD Leeds Activity

Variance

YTD NonLeeds Activity

Planned YTD Contracted Non-Leeds and other Leeds Activity

10573

10557

0.1%

0 Planned YTD Contracted Non-Leeds and other Leeds Activity

7014

7815

47437

50890

-10.2% -6.8%

Leeds Addictions Unit Contract Line

Contract Line Code Currency

Total

Variance

YTD SCG Activity

Planned YTD SCG Activity

Variance

Total YTD Activity

10670

Planned YTD Activity

10557

Variance

1.1%

Specialist Services Contract Line

Contract Line Code Currency

YTD Leeds Activity

Planned YTD Leeds Activity

Variance

YTD NonLeeds Activity

4489

3520

27.5%

119

22.3%

Personality Disorder Service

SSC01

Contacts

Day Care - Perinatal

SSD01

Attendances

Inpatients - Eating Disorders

SSI01

Bed Days

0 343

Variance

YTD SCG Activity

Planned YTD SCG Activity

Variance

2182

2631

-17.1%

903

Total YTD Activity

4534

Planned YTD Activity

3520

Variance

28.8%

131

34.7%

2182

2631

-17.1%

1011

1177

-14.1%

903

805

12.2% -35.5%

Inpatients - Liaison Psychiatry

SSI06

Bed Days

Inpatients - Perinatal

SSI07

Bed Days

805

12.2%

Eating Disorders Outpatients - New

SSO01

Attendances

-35.5%

Eating Disorders Outpatients - Follow up

SSO03

Attendances

873

867

0.7%

873

867

Perinatal Outpatients - New

SSO05

Attendances

-13.9%

302

-17.5%

660

-48.1%

668

-15.3%

516

29.4%

0.7%

Perinatal Outpatients - Follow up

SSO06

Attendances

302

-19.5%

Community Perinatal Team

SSC02

Contacts

272

302

-9.9%

277

302

Prison Psychiatric Inreach Services

SSC04

Attendances

2115

2052

3.1%

2122

2052

3.4%

A & E Liaison Services and self harm

SSC09

Contacts

2477

1710

44.9%

152

2629

1710

53.8%

Liaison Inreach Team

SSC10

Contacts

618

503

22.8%

Psychiatric Liaison Services Total

SSC12

Attendances

4590

3866

Eating Disorders Service - Outreach Team

SSC21

Hours

Total

243

458

503

-9.0%

160

3042

2632

15.6%

1548

358 13978

249

1233

25.5%

0 11851

17.9%

2604

1750

48.8%

3998

4365

-8.4%

20222

17966

-8.2%

18.7% 12.6%

10.2 Planned Activity Monitoring (NYY Services) September 2012 activity against contract is shown below.

54,304

September 12 YTD Contract 27152

September 12 YTD Activity 27165

4,623

2311

900

-61.06%

Contacts

31,149

15574

14305

-8.15%

Adult Psychology

Contacts

3,645

1822

1416

-22.28%

Assertive Outreach

Contacts

8,137

4068

4560

12.09%

CAMHS

Contacts

8,380

4190

5990

42.96%

Crisis Res

Contacts

6,017

3008

2833

-5.82%

Early Intervention

Contacts

3,635

1817

2265

24.66%

Forensic Community

Contacts

915

457

293

-35.89%

IAPT

Contacts

8,272

4136

7406

79.06%

Contacts

2,741

1370

1598

16.64%

Older People's CMHT Older People's Psychology Prison Inreach

Contacts

28,715

14357

15450

7.61%

Contacts

361

180

403

123.89%

Contacts

1,292

646

221

-99.69%

Other NHS activity

Contacts

18,233

9116

11073

21.47%

180419

90204

95659

6.05%

Activity – Mental Health

Line

12/13 Contract

Inpatients

OBDs

Addictions

Contacts

Adult CMHT

TOTAL

Variance 0.05%

The 2012/13 activity plan included in the Mental Health/Learning Disability contract with NHS North Yorkshire & York should be treated as indicative only. The previous clinical contract for these services did not include activity and the activity information provided as part of the tender was inaccurate and incomplete. Activity projections were therefore developed by extrapolating from comparable Leeds services, pro-rated to population. This has resulted in projections which are highly inaccurate for a number of services, because of differences in service models. Within the Mental Health/Learning Disability contract we have undertaken to develop systems to accurately capture activity in all teams, and agreed that an activity-based contract will be in place from 2013/14 onwards. York and North Yorkshire services and the Trust information team are undertaking work to validate the reported figures against reported activity in teams. This work indicates that the monthly activity reports for inpatient, addictions, assertive outreach, CAMHS, crisis resolution, early intervention and older people’s CMHT services are becoming accurate. However, further work is required to validate the activity for adult CMHT and forensic community services as the validation work has identified discrepancies between the extracts provided by York FT and the reports available to York and North Yorkshire services. Some examples of reasons for significant variance between actual and contracted activity are as follows: Addictions activity was based on Leeds activity applied to York population; in reality this team consists of only two individuals, therefore actual activity shows a variance of -61.1% against plan. Assertive Outreach Team and Crisis Resolution Team operate different service models to Leeds. IAPT services Data is included for the first time from the recently purchased IAPTUS system. Much work has been undertaken to address data quality issues although a smaller number remain outstanding. Older People’s Psychology Services The reasons why activity is over plan are being investigated but may be associated with a restructuring of the service. Prison in-reach services currently record activity on System1 in Northallerton. The data reported is recorded within the service. Arrangements are being made to also record this activity on CPD. Reporting of activity within CPD is currently completed with the use of a weekly extract of data provided by York FT. The extract specification remains the same as prior to the transfer of services in February 2012, except for the addition of Mental Health Clustering data. The extract was developed to provide the PCT with data to submit the MHMDS and does not contain information that was not required within the MHMDS. Investigations into differences between activity figures reported from the extract and those generated via CPD report indicate that some contact types, such as those via telephone and carer contacts, are not included in the extract. LYPFT is now able to undertake a nightly download of data from CPD. Work is underway to map this data to a replica of the PARIS data warehouse. This will allow a comparable level of information provision to that currently provided from PARIS services and issues such as those identified with activity will be resolved. Testing and the quality of the data provided in the nightly download is being undertaken by LYPFT’s Information Department. A further development will then be required to integrate IAPT data from IAPTUS into the data warehouse. There are no comments to report from commissioners. 52

Glossary of Definitions 7 Day Follow-Up

Ensures people discharged from in-patient care are contacted within 7 days of leaving hospital in order to reduce risk.

Assertive Outreach Team

Help people who have been diagnosed with a mental illness but find it hard to engage with mental health services.

Bed occupancy

The number of beds occupied by service users, shown as a percentage of all the beds in the hospital

Better code

payment

practice A requirement to pay 95% of invoices that the Trust receives within a set timeframe.

C.difficle

Clostridium difficile - a bacterium that is one of the most common causes of infection.

Capital Expenditure

A capital expenditure is incurred when a business spends money either to buy fixed assets or to add to the value of an existing fixed asset.

Care Programme Approach The approach used to assess, plan, review and co-ordinate the range of treatment, care and support needs for people in (CPA) contact with secondary mental health services who have complex needs. Care Quality Commission The independent regulator of health and social care in England. (CQC) Cashflow

Is the movement of cash into or out of a business.

Compliance

Used to describe if something is meeting established guidelines/national targets.

CQUIN

The Commissioning for Quality and Innovation (CQUIN) payment framework which allows commissioners to reward excellence by linking a proportion of providers’ income to the achievement of local quality improvement goals.

Crisis Resolution Service

Assesses people in mental health crises and, where appropriate, provides intensive support for them in their own home

EBITDA

Earnings Before Interest, Taxes, Depreciation and Amortization. An approximate measure of a company’s operating cash flow based on data from the company’s income statement.

Forecast position

A forecast of the expected financial position based on expected conditions.

HoNOS

Health of the Nation Outcome Scale (HoNOS) is a clinical outcome measure to improve the health and social functioning of people with mental health problems.

I&E

Income and Expenditure. 53

Mental Health Act 1983

Is an Act of Parliament which applies to people in England and Wales. It covers the assessment, treatment and rights of people with a mental health condition.

Mental Health Minimum Dataset (MHMDS)

Contains data about NHS services delivered to people with mental health problems.

Monitor

Authorises and regulates NHS foundation trusts and supports their development, ensuring they are well-governed and financially robust.

MRSA

Methicillin Resistant Staphylococcus aureus, a type of bacteria that has become resistant to many antibiotics.

National Drug Treatment Provides access to national statistics about Drug and Alcohol Misuse Treatment Program (NDTMS) Never Events

Very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place.

National Institute for Health An independent organisation responsible for providing national guidance on promoting good health and preventing and and Clinical Excellence treating ill health (NICE) Non-operating expenditure

Expense incurred not directly related to the main business.

Non-pay

This relates to expenditure incurred by the Trust whilst providing our services that does not directly relate to any member of staffâ&#x20AC;&#x2122;s pay.

Normalised surplus

A statement of the Trusts financial position excluding Non-Recurrent items.

Operating expenditure

Expenditure that a business incurs as a result of performing its normal business operations.

PARIS

The Trustâ&#x20AC;&#x2122;s electronic care record system.

Planned surplus

A situation where there is more revenue than was planned for in the budget

Procurement

A process for buying goods, works and services from third parties or in-house providers. E-Procurement is the process for doing this over the Internet.

Quality Accounts

A report about the quality of services written each year by each NHS healthcare provider and made available to the public.

Trigger to Board Events

Incidents which the Trust Board of Directors consider to be preventable. 54

Appendix A

Essence of Care - Nutrition Action Plan Goal LPFT aims Factor 1 : Promoting Health People are All wards actively encouraged to promote healthy eating eat and drink in at appropriate a way that opportunities promotes health

Action required

Lead

Timescale

Progress/Evidence

1. All staff in collaboration with dieticians (where available) promote healthy eating

Clinical Team Managers & Directorate Lead Dieticians

IN PLACE AS AT JULY 2011

All inpatient areas in Leeds gave their practice an A or B rating when benchmarking this factor as part of the Essence of Care audit. Progress is monitored via the Essence of Care Steering Group and Directorate Implementation Groups. Reviews of individual assessments and care plans evidence that this is taking place and is monitored through ongoing clinical supervision.

Service users are advised and encouraged to make healthy choices

Education and information is available for staff in the promotion of healthy eating

A re-audit of the Essence of Care benchmarks is scheduled within all inpatient areas in November, which will give inpatient services in North Yorkshire and York the opportunity to participate in this piece of work for the first time and areas in Leeds the opportunity to re-audit their practice.

2. Healthy eating and nutrition to be included in health promotion training for staff

Nutrition task & finish group

IN PLACE AT SEPTEMBER 2011

All staff are able to access the following e-learning modules produced by the NHS Core Learning Unit:  

Food, nutrition & hydration Obesity

These short courses provide a basic introduction to the pertinent issues in these areas. Information for staff about how this training can be accessed is located on the Nursing/Essence of Care Staffnet pages. Nutrition task & finish group

IN PLACE AT JULY 2011

Modules produced as part of the ‘Harm Free Care’ initiative relating to nutrition and hydration have also recently been developed and are available to staff as part of the drive to improve standards of care in this area. Diabetes Awareness training continues to be delivered within the Trust. The nutrition task & finish group have added Diabetes to their workplan and the group will explore a range of issues including the identification of training needs across the whole organisation.

Essence of Care - Nutrition Action Plan Goal

LPFT aims

Factor 2: Information People and User-friendly carers have information is readily sufficient available in a range of information to different formats that enable them to informs service users obtain their food how they can obtain and drink food, the ordering process and food/snack/drink availability outside of mealtimes

Menus are clear and self-explanatory

Action required

Lead

Timescale

3. Healthy Living Team to continue to provide information, advice and resources on healthy eating to both staff and service users

Healthy Living Team

IN PLACE AT JULY 2011

1. All wards to ensure service user information packs include information about arrangements for obtaining food and drink

Clinical Team/Unit/ward Managers

IN PLACE AS AT SEPT 2011

Lead Nurses

IN PLACE AS AT DEC 2011

2. All wards to review processes and mealtimes as part of the Releasing Time to Care ‘Meals’ module

3. Menus and ordering systems to be reviewed with PFI providers to establish a consistent service across the Trust, ensuring menus and systems are more userfriendly

Jim Merrick (Catering task & finish group)

IN PLACE AS AT APRIL 2012

Progress/Evidence Dietetic staff continue to support staff and service users by providing further assessment and support in relation to nutritional needs. The Healthy Living Team comprise of Healthy Living Advisors able to offer advice and support to staff and service users across all service areas within LYPFT.

Information is provided to all service users regarding meal provision and food/drink/snack availability on admission. Work has taken place on the dementia inpatient wards to ensure information is user friendly for service users and carers. Any preferences/requirements are recorded as part each service user’s holistic assessment.

All inpatient wards are actively engaged in the Releasing Time to Care programme, as well as other service improvement programmes such as Star Wards and AIMS. This work is supported by the Lead Nurses. Wards are working towards implementation of all modules, including the mealtime module, in line with the QIPP target of every patient receiving ‘productive care’ by 2013. Monthly reports are collated by the Lead Nurses and progress is reported on a quarterly basis to the SHA & NHS Institute. As work relating to the improvement cycle is never ‘complete’ ongoing evaluation of work is key to this initiative. This is monitored through pyramid visits and lead nurse reports. The Catering Task and Finish group aim to develop a consistent service for all service users across PFI and non-PFI sites. Changes implemented as part of this group’s work have evaluated well with service users ensuring greater choice, availability and adequate portion size.

Essence of Care - Nutrition Action Plan Goal

LPFT aims Where appropriate, service users are offered assistance to order food, based on their needs and preferences

Factor 3 : Availability People can A range of snacks are access food and available to all drink at anytime inpatient service users according to their 24 hours a day needs and Hot and cold drinks preferences. are drinks are available 24 hours a day. Arrangements are in place for accessing meals outside of set mealtimes.

Action required

Lead

Timescale

4. Service users needs and preferences to be discussed as part of the admission process with their primary nurse and built into their care plan

Clinical Team/Unit/ward Managers

IN PLACE AS AT JULY 2011

1. All wards to ensure continued access to snacks and drinks 24 hours a day

Clinical Team/Unit/Ward Managers

TARGET COMPLETETION NOV 2012

Further work is required in this area to ensure consistent practice across the wider organisation. The Essence of Care Steering Group and Nutrition Task and Finish Group have an identified member from services in North Yorkshire & York as a member of the group, as well as a Directorate Lead Nurse in post. This will ensure necessary work in this area is taken forward.

IN PLACE AS AT JULY 2011

CTM’s/Ward & Unit Managers ensure all staff are aware of meal facilities as part of localised induction

2. All staff to be aware of facilities available for accessing meals outside of usual times and storing patient’s own food

Progress/Evidence

In line with local and national guidance all service users receive a holistic assessment that incorporates their needs and preferences in relation to information about food and drink. Wards are asked to self-assess their ability to meet this indicator as part of the Essence of Care Audit. Reviews of individual assessments and care plans evidence that this is taking place and is monitored by ongoing clinical supervision.

All wards have appropriate facilities to store food brought in, for example, by carers and friends Factor 4 : Provision People are Service users are provided with provided with the food food and drink they ordered in the that meets their appropriate portion individual needs size and preferences

A choice of food is available that meets people’s needs and

1. All wards to review meal provision as part of the Releasing Time to Care ‘Meals’ module. This will include consideration of service user experience.

Lead nurses

2. Choice of food available/portion size to be reviewed in collaboration with PFI/non-PFI catering

Jim Merrick (Catering task & finish group)

IN PLACE AS AT SEPT 2011

IN PLACE AS AT JULY 2011

In response to changes implemented as part of the Productive Mental Health Ward (PMHW) initiative positive feedback has been received from service users in relation to portion size and meal choice. Several teams presented work relating to the meals module of the PMHW Regional Sharing Network hosted by the SHA. Meals was the focus of good practice discussions at the Trust-wide PMHW forum and teams shared their experience of meal provision with a particular focus on

Essence of Care - Nutrition Action Plan Goal

LPFT aims preferences e.g. special diet and cultural options Nutritional supplements are provided for those service users that require them following further assessment by a dietician

Factor 5 : Presentation People’s food Food is served at an and drink is appropriate presented in a temperature to ensure way that is safety and to meet appealing to people’s needs and them preferences

A range of suitable crockery is available

Meals are served promptly

Action required providers

Lead

Timescale

3. All services users to undergo nutritional screening on admission. Those identified as at risk of malnutrition may be prescribed nutritional supplements following further assessment by a dietician, if deemed necessary but only after considering food first approach.

Senior dieticians, Modern Matrons & Clinical Operations Managers

1. Specific needs or preferences are identified on initial assessment and built into an individualised care plan

Lead Nurses

2. Concerns regarding quality of PFI service provision are communicated to Service Support Managers

Clinical Team Managers

3. Service users assessed as requiring specialist equipment have this available at mealtimes

Clinical Team Managers/Lead OTs

4. All wards to review meal provision as part of the Releasing Time to Care ‘Meals’ module. This will include consideration of service user experience.

Lead Nurses

Progress/Evidence supporting self-catering with the rehabilitation and recovery units. A review of food choice formed part of the catering task and finish group’s work-stream, as detailed in Factor 2 actions above.

All service users considered ‘high risk’ following a nutritional screening assessment are referred for further assessment by a dietician. A food first approach is promoted by dietetic staff, however, where recommended nutritional supplements are provided and their use continually reviewed as part of the service user’s plan of care. Guidance related to the prescription of supplements is currently being developed by the nutrition task and finish group to be incorporated into a nutritional care pathway.

IN PLACE AS AT JULY 2011

TARGET COMPLETION SEPTEMBER 2012

IN PLACE AS AT JULY 2011

Performance is monitored through monthly meetings with PFI providers, Clinical Team Manager’s and Service Support Managers. Any concerns raised are fed into this group to address. As indicated previously further work is required to ensure this process is replicated in services within North Yorkshire and York.

Monthly performance monitoring is in place for reviewing progress against the Releasing Time to Care Programme

In line with the LYPFT Procedure for Therapeutic Mealtimes all service users are assessed for any needs or difficulties by an appropriate health professional. This may include an assessment of the need for specialist equipment conducted by Occupational Therapy staff.

Essence of Care - Nutrition Action Plan Goal

LPFT aims

Action required

Lead

Timescale IN PLACE AS AT JULY 2011

Progress/Evidence Service user experience is collected as part of the Releasing Time to Care project and monitored on a monthly basis as part of the ‘Knowing How We Are Doing’ module. Feedback received informs process modules.

1. Service users identified as requiring specialist equipment to eat and/or drink have this available at mealtimes

Lead OTs/CTM’s

IN PLACE AS AT JULY 2011

Monitored by Clinical Team/Ward/Unit Manager’s in line with LYPFT Procedure for Therapeutic Mealtimes.

Handwashing facilities are available to all service users prior to mealtimes and assistance is given, where necessary

2. All wards to ensure that hand washing information is visible and up-to-date

Infection Control Lead

IN PLACE AS AT JULY 2011

Monitored as part of the PEAT audit and infection control environmental audit

Protected mealtimes are in place on all wards to ensure inappropriate activity is curtailed at mealtimes

3. Staff to remain in dining areas at mealtimes in line with LYPFT Therapeutic Mealtime Procedure and non-interrupted mealtimes

Clinical Team/Unit/Ward Managers

IN PLACE AS AT JULY 2011

Monitored by Clinical Team/Ward/Unit Manager’s in line with LPFT Procedure for Therapeutic Mealtimes.

1. Monthly performance reports are circulated to all area 100% compliance to be addressed.

Lead Nurses, Modern Matrons and Clinical Operations Managers / Essence of Care Steering Group

Factor 6 : Environment People feel the Specialist utensils are environment is available as required conducive to eating and drinking

Factor 7 : Screening & assessment People who are All service users in screened on inpatient areas are initial contact screened on and identified as admission and at risk receive a discharge using the full nutritional LPFT nutrition assessment screening tool

2. Training on use of screening tool to be provided, where required

EXPECTED TO COMMENCE DEC 2012

IN PLACE AS AT SEPT 2011

The mental health toolkit for the 15 Step Challenge was launched in October 2012. A pilot of this initiative is planned in the Becklin Centre which will support work relating to PMHW and prepare teams for CQC, PEAT inspections. The focus of this work will be on the care environment from the patient/carer perspective. Processes are in place for monthly monitoring of number of service users screened on admission and discharge. Process in place to report performance monthly to Chief Operating Officer and Chief Nurse through monthly directorate reports. Systems are in place on the electronic clinical records system (PARIS) to prompt an electronic referral to dietetics, should a nutritional screen identify a service user as ‘high risk’.

Essence of Care - Nutrition Action Plan Goal

LPFT aims Nutritional screening progresses to further assessment for all service users identified as at risk

Action required 3. LYPFT protocol for management of nutrition in adults to be reviewed and updated

Lead Lead nurses/lead dieticians

Timescale IN PLACE AS AT JULY 2011

TARGET COMPLETION NOVEMBER 2013

Lead Nurses

Lead Nurses/ dietetic representative

IN PLACE AS AT NOV 2011

IN PLACE AS AT SEPT 2011

IN PLACE AS AT JULY 2011 Performance Improvement Manager

Services in North Yorkshire & York continue to use the MUST nutritional screening tool. In Leeds the existing nutritional screening tool has been evaluated. The recommendations of this review have been communicated to the Lead Dieticians and amendments to the tool on PARIS are currently being considered, to be finalised by the Clinical Interventions Standing Support Group.

Nutrition Task & Finish Group

Factor 8: Planning, implementation, evaluation & revision of care People’s care is All service users 1. A system for the planned, identified as at risk monitoring of implemented, have individualised individualised care plans continuously care plans in place in line with best practice evaluated and based on ongoing standards to be revised to meet nutritional assessment developed needs and preferences for All services users 2. Discharge planning to food and drink identified on the consider the ongoing screening tool as at needs of service users ‘high’ risk on discharge identified by the screening have continuing plans tool as ‘high’ risk in place or are referred to appropriate services

Progress/Evidence

The Nutrition Task and Finish group is currently working on a Nutrition Care Pathway incorporating a review of existing policies and procedures both in NYY and Leeds. The pathway will link with Physical Health Care pathway for the organisation and incorporate work currently being progressed in relation to refeeding, nutritional supplements, enteral feeding, diabetes and documentation.

All inpatient services in Leeds gave their practice an A or B rating when benchmarking this factor as part of the Essence of Care audit. Action plans identify how this practice may be maintained by ensuring nutritional care plans are in place where required. A re-audit of this practice will take place in November The quality of care plans and frequency of review are monitored through ongoing clinical supervision

Monthly performance monitoring is in place and results are discussed at the Clinical Interventions Standing Support Group. Lead Nurses/Modern Matrons are responsible for following up any underperforming areas within their Directorate and liaising with operational managers.

Essence of Care - Nutrition Action Plan Goal LPFT aims Factor 9: Assistance People receive On each ward a system the care and is in place to ensure assistance they that service users who require with require assistance to eating and eat and drink receive it drinking

Action required 1. Specific needs or preferences are to be identified on initial assessment and these built in to each service user’s care plan

Privacy and dignity is maintained at all times

2. Primary nurses to request advice and support from dieticians/Occupational Therapist’s, where required

Service users with special needs have their needs assessed and the correct facilities, resources and support is available to meet their individual needs, whilst maintaining their independence

3. Staff providing assistance and support to service users during mealtimes to have the correct knowledge, equipment and resources to do so 4. A system is to be developed for monitoring of the LYPFT Therapeutic Mealtime procedure

Lead

Timescale

Progress/Evidence

Clinical Team/Ward/Unit Managers/Lead OTs/Lead Dieticians

IN PLACE AS AT JULY 2011

All service users have their needs assessed as part of the holistic assessment and nutritional assessment. Where required, referral to dietetics or OT staff for specific resources or equipment is made and care planned appropriately. This is evidenced through reviews/evaluation of care plans and MDT reviews.

Clinical Team Managers

IN PLACE AS AT JULY 2011

Lead Nurse, OPS

IN PLACE AS AT JULY 2011

Clinical Standards Development Nurse & AD Nursing

SCHEDULED COMPLETION APRIL 2013

Where possible service users are encouraged to maintain their independence, however, when assistance is required this is provided by appropriate staff members. Carers are also encouraged and supported to assist where this has been deemed appropriate. This is evidenced in individual care plans.

Actions supported by the LYPFT Procedure for Therapeutic Mealtimes are monitored via the Essence of Care Steering Group and local Essence of Care/Dignity Implementation Groups. All inpatient areas in Leeds, with the exception of Ward 2 The Mount, gave their practice an A rating when benchmarking this factor as part of the Essence of Care audit. Directorate Essence of Care action plans have been developed to maintain these standards. Ward 2 The Mount have chosen to explore mealtimes using the Productive Mental Health Ward framework to make further improvements to current practice. The LYPFT Therapeutic Mealtime Procedure is currently being reviewed. Due to the acquisition of additional services in York, Selby & Tadcaster from st February 1 2012, harmonisation of this procedure and NYY’s existing nutritional policy is required. Existing procedures will be updated to reflect Therapeutic Mealtimes across the whole organisation and will include details for the monitoring of compliance and effectiveness of the procedure. Whilst this review takes place both current procedures remain relevant to practice.

Essence of Care - Nutrition Action Plan Goal

LPFT aims

Factor 10 : Monitoring People’s food Where monitoring of and drink intake dietary/ fluid intake is monitored forms part of the and recorded service user’s care plan, a standard format is used. People recording dietary/fluid intake should be have the necessary skills and knowledge to do so.

Action required

Lead

Timescale

Progress/Evidence Privacy & dignity is an ongoing focus of the Essence of Care Steering Group. The Clinical Standards Development Nurse & Associate Director of Nursing have been successful in accessing funding to support this area of work within the Trust. Part of this work will focus on ensuring privacy and dignity is maintained in all areas through the use of dignity champions.

1. Standardised documentation to be developed & implemented across the Trust

Nutrition Task & Finish Group

COMPLETED MARCH 2012

A collaborative review of existing documentation and practice in relation to the monitoring of dietary and fluid intake across all inpatient areas has taken place. Standardised documentation for inpatient areas has been developed by members of the multi-professional nutrition Task and Finish Group. This work is currently being piloted in three areas of the Trust with a review of this work planned for November.

SCHEDULED COMPLETION NOV 2012

Guidance notes on how to complete documentation has also been produced, rather than developing specific training.

2. Standardised training to be provided for those people completing documentation and monitoring intake

New documentation will be approved by the Clinical Interventions Standing Support Group prior to full implementation across the Trust. This documentation will be incorporated into the updated LYPFT procedure for the management of nutrition in adults (as per the action detailed in Factor 7)

Where a service user’s intake of food and/or drink raises cause for concern this leads to appropriate action.

Appendix 1

Leeds and York Partnership NHS Foundation Trust Income & Expenditure Performance Against LTFM Plan as at September 2012 2012/13

2012/13

Annual Forecast Variance Plan Full Year Full Year FOT £'000 £'000 £'000 Operating NHS Mental Health activity Income Other - Cost and Volume Contract Income Block Contract - Leeds PCTs Block Contract - NYY PCT Block Contract - Other Clinical Partnerships providing mandatory services (including S31 agreements) Other clinical income from mandatory services NHS Mental Health activity Income, Total Other Operating income Research and Development income Education and Training income Grants received in cash & to fund Operating Expenses Parking revenue Catering revenue Revenue from non-patient services to other bodies Misc. Other Operating Income Other Operating income, Total Operating Income, Total Operating Expenses Raw Materials and Consumables Used Drugs Clinical supplies Non-clinical supplies Raw Materials and Consumables Used, Total Cost of Secondary Commissioning of mandatory services Employee Benefits Expenses, permanent staff Employee Benefits Expenses, agency & contract staff Employee Benefits Expenses, Total Research and Development expense Education and training expense Consultancy Expense Misc. Other Operating expense PFI operating expenses Operating Expenses, Total Profit (Loss) from Operations Non Operating Non-Operating income Interest Income Profit/Loss on Asset Disposal Non-Operating income, Total Non-Operating expenses Finance Costs [for non-financial activities] Interest Expense Interest Expense on Finance leases (non-PFI) Interest Expense on PFI leases & liabilities Interest Expense, Total Depreciation and Amortisation Depreciation and Amortisation - owned assets Depreciation and Amortisation - assets held under finance leases Depreciation and Amortisation - PFI assets Depreciation and Amortisation, Total PDC dividend expense Other Finance Expenses Finance Costs [for non-financial activities], Total Impairment (Losses) / Reversals net Non-Operating PFI Costs (e.g. Contingent Rent) Non-Operating expenses, Total Surplus (Deficit) before Tax Income Tax (expense)/ income Surplus (Deficit) After Tax Total Income Total Expenses EBITDA Net I & E Margin Net I & E Margin risk rating EBITDA EBITDA MARGIN EBITDA Margin risk rating Revenue Available for debt service

Annual Plan YTD £'000

Actual

Variance

YTD £'000

5,422 95,168 34,267 7,337 7,289 1,717 151,199

6,252 95,922 30,814 11,471 7,328 1,578 153,365

830 755 -3,453 4,134 39 -139 2,166

2,711 47,584 17,133 3,669 3,645 859 75,600

3,271 47,855 15,407 5,745 3,669 796 76,743

560 271 -1,726 2,076 24 -62 1,143

685 3,356 47 0 53 5,033 11,909 21,083

1,165 3,630 69 0 73 4,787 13,215 22,938

480 274 22 0 20 -246 1,306 1,855

343 1,678 24 0 27 2,517 5,955 10,542

531 1,818 27 0 36 2,388 6,203 11,003

189 140 3 0 10 -128 248 462

172,282

176,303

4,021

86,141

87,746

1,605

-2,678 -1,021 -1,672 -5,371 -3,588 -123,407 -3,883 -127,290 -808 -704 -77 -17,082 -6,287 -161,207

-2,546 -1,604 -1,632 -5,782 -4,060 -122,686 -5,114 -127,799 -1,275 -1,030 -121 -17,896 -6,191 -164,153

132 -583 40 -411 -472 721 -1,231 -509 -467 -326 -44 -814 96 -2,946

-1,339 -511 -836 -2,686 -1,794 -61,792 -1,944 -63,736 -404 -352 -39 -8,606 -3,144 -80,760

-1,298 -842 -810 -2,950 -2,325 -60,973 -2,713 -63,686 -587 -495 -24 -8,553 -3,055 -81,673

41 -331 26 -264 -531 819 -769 50 -183 -143 15 53 89 -913

11,075

12,150

1,074

5,381

6,073

692

450 130 580

454 124 578

4 -6 -2

245 180 425

282 -6 277

37 -186 -149

-333 -2,664 -2,997

-282 -2,483 -2,764

51 181 233

-167 -1,332 -1,499

-141 -1,242 -1,382

26 90 116

-2,179 -150 -1,384 -3,713 -520 -46 -7,276 0 -1,214 -8,490

-2,124 -151 -1,379 -3,654 -448 -46 -6,912 0 -1,509 -8,421

55 -1 5 59 72 0 364 0 -295 69

-1,090 -75 -690 -1,855 -260 -46 -3,659 0 -608 -4,267

-1,029 -75 -690 -1,793 -224 -46 -3,446 0 -755 -4,200

61 0 0 61 36 0 213 0 -147 67

3,165 0 3,165

4,306 0 4,306

1,141 0 1,141

1,540 0 1,540

2,149 0 2,149

610 0 610

172,862

176,881

4,018

86,567

88,023

1,456

-169,697

-172,574

-2,877

-85,027

-85,874

-846

11,075

12,150

1,074

5,381

6,073

692

1.8%

2.4% 4

1.6%

2.5% 4

11,075 6.4%

12,150 6.9% 3

5,381 6.2%

6,073 6.9% 3

5,807

6,349

11,655

12,727

Appendix 2

Leeds and York Partnership NHS Foundation Trust Statement of Financial Position at September 2012

Annual Plan Closing £'000

Assets Assets, Non-Current Intangible Assets, Net Property, Plant and Equipment, Net PFI: Property, Plant and Equipment, Net Other Receivables, Non-Current Prepayments, Non-Current Assets, Non-Current, Total

277 36,182 21,096 2 2,669 60,226

2012/13 Forecast

Variance

Closing £'000

£'000

Annual Plan May £'000

2012/13 Actual

Variance

May £'000

£'000

276 32,395 21,101 0 2,673 56,445

-1 -3,786 5 -2 4 -3,781

314 31,181 21,790 4 2,561 55,848

316 31,044 21,790 0 2,565 55,715

2 -137 0 -4 4 -134

Assets, Current Inventories 73 Trade and Other Receivables, Net, Current NHS Trade Receivables, Current, Gross 750 Non NHS Trade Receivables, Current, Gross 1,117 Other Receivables, Current, Gross 2,000 Impairment of Receivables, Current ( for bad & doubtful debts ) -117 Trade and Other Receivables, Net, Current, Total 3,750 Accrued Income 1,250 Prepayments, Current 1,000 Cash 19,795 Non-Current Assets held for sale 0 Assets, Current, Total 25,869

750 2,000 2,000 -267 4,483 1,250 1,000 26,060 0 32,867

0 883 0 -150 733 0 0 6,265 0 6,998

1,000 1,127 2,000 -127 4,000 1,250 1,000 24,962 350 31,635

1,036 2,121 2,065 -267 4,955 1,365 1,309 30,682 1,015 39,400

36 994 65 -140 955 115 309 5,721 665 7,765

Total Assets

86,094

89,311

3,217

87,483

95,114

7,631

-1,658 -279

-2,680 -212

-1,022 67

-5,308 -280

-9,287 -193

-3,979 88

-2,567 -4,700 -1,350 -8,617

-3,067 -4,700 -550 -8,317

-500 0 800 300

-2,567 -4,700 -300 -7,567

-3,696 -4,605 -614 -8,915

-1,129 96 -314 -1,347

-4,800 -214 -1,163 0 -6,177 -16,732

-6,120 -214 -1,164 0 -7,498 -18,707

-1,320 0 -1 0 -1,321 -1,975

-4,500 -214 -1,163 0 -5,877 -19,033

-6,203 -179 -1,074 0 -7,456 -25,850

-1,703 35 89 0 -1,579 -6,817

9,137

14,159

5,023

12,602

13,549

947

-1,403

-1,505

-102

-1,508

-1,575

-67

-1,994 -28,858 -30,852 -32,255

-1,994 -28,858 -30,851 -32,356

1 0 1 -101

-2,085 -29,397 -31,481 -32,989

-2,123 -29,495 -31,618 -33,193

-39 -99 -137 -204

TOTAL ASSETS EMPLOYED

37,107

38,248

1,141

35,461

36,071

610

Taxpayers' and Others' Equity Public dividend capital Retained Earnings (Accumulated Losses) Revaluation Reserve Miscellaneous Other Reserves TAXPAYERS EQUITY, TOTAL

19,119 12,070 6,569 -651 37,107

19,119 13,211 6,569 -651 38,248

0 1,141 -1 0 1,141

19,119 10,444 6,549 -651 35,461

19,119 11,054 6,549 -651 36,071

0 610 -1 0 610

TOTAL ASSETS EMPLOYED

37,107

38,248

1,141

35,461

36,071

610

Liabilities Liabilities, Current Deferred Income, Current Provisions, Current Trade and Other Payables, Current Trade Payables, Current Other Payables, Current Capital Payables, Current Trade and Other Payables, Current, Total Other Financial Liabilities, Current Accruals, Current Finance Leases, Current PFI leases, Current PDC dividend payable, Current Other Financial Liabilities, Current, Total Liabilities, Current, Total NET CURRENT ASSETS (LIABILITIES) Liabilities, Non-Current Provisions, Non-Current Other Financial Liabilities, Non-Current Finance Leases, Non-current PFI leases, Non-Current Other Financial Liabilities, Non-Current, Total Liabilities, Non-Current, Total

Appendix 3

Leeds Partnerships NHS Foundation Trust Cashflow Analysis as at September Annual Plan 2012/13

Forecast

Variance

2012/13

£'000

Surplus/(deficit) after tax 3,165 non-cash flows in operating surplus/(deficit) Finance income/charges 3,761 Other operating non-cash movements 0 Depreciation and amortisation, total 3,713 Impairment losses/(reversals) 0 Gain/(loss) on disposal of property plant and equipment -130 Gain/(loss) on disposal of intangible assets 0 PDC dividend expense 520 Other increases/(decreases) to reconcile to profit/(loss) from operations 0 Non-cash flows in operating surplus/(deficit), Total 7,864

Actual

Variance

2012/13

Annual Plan YTD

YTD

£'000

4,306

1,141

1,540

2,149

610

3,820 0 3,654 0 -124 0 448 0 7,798

59 0 -59 0 6 0 -72 0 -66

1,861 0 1,855 0 -180 0 260 0 3,795

1,855 0 1,793 0 6 0 224 0 3,878

-6 0 -61 0 186 0 -36 0 82

11,029

12,104

1,074

5,335

6,027

692

0 563 1,144 82 -1,250 -162 0 -1,299 -125 0 -3,472 1,041 308 -3,170

0 492 364 129 -1,250 -162 0 -277 -91 0 -2,972 1,041 1,628 -1,098

0 -71 -780 47 0 0 0 1,022 34 0 500 0 1,320 2,072

0 313 1,144 82 -1,250 -162 0 2,351 -19 0 -3,472 1,041 8 36

0 207 243 64 -1,365 -471 0 6,330 -40 0 -2,343 945 1,710 5,280

0 -107 -901 -18 -115 -309 0 3,979 -21 0 1,129 -96 1,703 5,244

7,859

11,006

3,146

5,371

11,307

5,936

-6,872 1,145 -5,727

-3,835 1,145 -2,690

3,036 0 3,036

-1,813 845 -968

-1,309 0 -1,309

503 -845 -342

2,133

8,315

6,183

4,403

9,998

5,594

Net cash inflow/(outflow) from financing activities Public Dividend Capital received 0 Public Dividend Capital repaid 0 PDC Dividends paid -520 Interest element of finance lease rental payments - other -385 Interest element of finance lease rental payments - On-balance sheet PFI -3,826 Capital element of finance lease rental payments - other -168 Capital element of finance lease rental payments - On-balance sheet PFI -1,085 Interest received on cash and cash equivalents 450 Movement in Other grants/Capital received 0 (Increase)/decrease in non-current receivables -300 Increase/(decrease) in non-current payables 0 Other cash flows from financing activities 0 Net cash inflow/(outflow) from financing activities, Total -5,834

0 0 -377 -307 -3,966 -179 -1,074 454 0 -302 0 0 -5,752

0 0 143 78 -140 -11 11 4 0 -2 0 0 82

0 0 -260 -193 -1,913 -168 -456 245 0 -194 0 0 -2,939

0 0 -153 -141 -1,996 -85 -526 282 0 -194 0 0 -2,812

0 0 107 53 -83 83 -70 37 0 0 0 0 126

Operating Cash flows before movements in working capital Increase/(Decrease) in working capital (Increase)/decrease in inventories (Increase)/decrease in NHS Trade Receivables (Increase)/decrease in Non NHS Trade Receivables (Increase)/decrease in other receivables (Increase)/decrease in accrued income (Increase)/decrease in prepayments (Increase)/decrease in other assets Increase/(decrease) in Deferred Income Increase/(decrease) in provisions Increase/(decrease) in post-employment benefit obligations Increase/(decrease) in Trade Payables Increase/(decrease) in Other Payables Increase/(decrease) in accruals Increase/(Decrease) in workling capital, Total Net cash inflow/(outflow) from operating activities Net cash inflow/(outflow) from investing activities Property, plant and equipment expenditure Proceeds on disposal of property, plant and equipment Net cash inflow/(outflow) from investing activities, Total Net cash inflow/(outflow) before financing

Net increase/(decrease) in cash and cash equivalents

-3,702

2,563

6,265

1,465

7,185

5,721

Opening cash and cash equivalents

23,497

19,795

26,060

6,265

24,962

30,682

5,721

Effect of exchange rates Closing cash and cash equivalents

Appendix 4

2012/13 Capital Programme as at end of September 2012

Ref

Original Capital Programme £'000

Schemes

ESTATES E12/01 Health & Safety / Peat , EHO E12/02 RRO Fire Works & Self Harm Doors E12/03 Planned Annual Commitments E12/04 NIFES Brought Forward E11/05 NIFES E11/06 Backlog Maintenance E09/08 Maple House Car Park Total Estates

Allocated Funding £'000

Approvals since last meeting £'000

Committed Expenditure £'000

Actual Spend £'000

Forecast at Year End £'000

Forecast Variance £'000

75.0 30.0 130.0 45.0

45.0 30.0 149.3 34.4

17.0 0.0 141.4 34.4

1.1 0.0 41.7 0.0

45.0 30.0 141.4 34.4

30.0 0.0 -11.4 10.6

33.1

16.1 20.0 64.7

7.0 19.0 67.8

1.5 5.6 67.8

16.1 20.0 67.8

-16.1 -20.0 -34.6

313.1

359.5

0.0

286.5

117.7

354.6

-41.5

90.0

0.0

90.0

-90.0

101.5 24.2 18.8 44.0

84.3 24.2 18.8 41.8

101.5 24.2 18.8 44.0

-101.5 -24.2 -18.8 -44.0

188.5

169.1

278.5

-278.5

1.0 0.0 53.9 0.0 10.8 0.0 70.8

121.0 20.0 314.0 32.4 47.7 0.0 206.7 60.0

-71.0 0.0 -114.0 -2.4 -24.2 300.0 -146.7 0.0

0.0 30.0 80.0 40.0 0.0 89.1 0.0 0.0 0.0 6.8 0.0 0.0 0.0 0.0

144.8 0.0 0.0 -1.8 149.2 -39.1 0.0 0.0 0.0 -6.8 5.5 55.4 45.2 0.0

PFI P12/01 Chronic Fatigue Service Brought Forward P11/01 PFI Cooling Air-Conditioning P11/02 Becklin Centre Reception P10/02 Becklin overnight ward 2 P09/01 PFI Cooling Phase 2

104.1 24.5 0.0 44.0 Total PFI

0.0

262.6

90.0

50.0 20.0 200.0 30.0 23.5 300.0 60.0 60.0

263.8 20.0 314.0 32.4 47.7 0.0 206.7 60.0

1.0 0.0 60.0 0.0 19.1 0.0 91.7 0.0

144.8 30.0 80.0 38.2 149.2 50.0

0.0 30.0 80.0 45.2 0.0 89.1 0.0 0.0 0.0 6.8 5.5 0.0 0.0 0.0

0.0 0.0 0.0 6.9 0.0 5.0 0.0 0.0 0.0 6.8 0.0 0.0 0.0 0.0

IT I12/01 I12/02 I12/03 I12/04 I12/05 I12/06 I12/07 I12/08

Paris Enhancements Videoconferencing PC Replacement Programme Additional IT Infrastructure Additional Server/Storage Capacity NCRS- N3 Infrastructure deferred to 13/14 Mobility (Inc Wireless N/Ws) Trustwide EDMS

Brought Forward I11/01 Paris Enhancements I11/02 PC Power & Patch Management System I11/03 Single Sign-On System I11/04 Additional Cognos Licences + Server I11/05 PC Replacement Programme I11/06 Expansion Of VOIP To Additional Sites I11/07 Additional Server/Storage Capacity I11/08 Key Systems & Infrastructure Resilience I11/09 Network Intrusion Protection Server I11/10 Occupational Health IT I11/11 Observer Suite Network Analysis Software I11/13 Transformation Project IT I10/02 Expansion of VOIP to other sites I10/07 Vmware systems and infrastructure Total IT

5.5 55.4 45.2

1,341.9

1,201.0

2,500.0 2,075.0 266.0 264.0

0.0

2.9

190.5

139.5

1,047.6

294.4

2,500.0 2,125.0 0.0 264.0

150.1 273.7 0.0 0.0

150.1 273.7

1,000.0 323.7 0.0 100.0

76.2 427.9

135.2 148.7

118.1 148.7

118.1 46.9

135.2 148.7

1,500.0 1,751.3 266.0 164.0 0.0 0.0 -59.0 279.3

5,609.1

5,172.9

690.5

588.8

1,707.6

3,901.5

18.5 18.5 5.5 8.0

18.5 0.0 5.5 0.0

0.0 0.0 0.0 0.0

18.5 0.0 0.0 0.0

0.0 18.5 5.5 8.0

48.0 40.0

30.6 0.0

30.6 40.0

-30.6 -40.0

SERVICE STRATEGY S12/01 S12/02 S12/03 S12/04

East Leeds Services To Asket Croft New Accommodation (incl £125k b/f) Mobile Technology (Transformation) NYY IT

Brought Forward S11/01 Sensory Garden For The Mount S11/02 Rehab Unit Newsam Ward 5 Total Service Strategy

0.0

OTHER O12/01 O12/02 O12/03 O12/04

Physio Equipment Newsam Security Grills & Bars 4 Woodland Sq-Hoist 550 LAU Security

Brought Forward O11/02 ECT Machines O11/03 ECG Monitors Replacement Total Other

50.5

112.0

0.0

Contingency 2011/12 Completed Schemes Grand Total

7,314.7

7,108.0

90.0

30.6

0.0

89.1

-38.6

0.0 1.3

1.3

0.0 1.3

0.0 -1.3

1,387.9

1,016.4

3,478.6

3,836.1

AGENDA ITEM 11.1

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Quarter 2 2012/2013 monitoring returns and self self-certification

DATE OF MEETING:

30th October 2012

LEAD DIRECTOR:

Chief Financial Officer

PAPER AUTHOR:

Head of Performance

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC: GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

  



STATUS OF PAPER



To be taken in the public session (Part A)



SUMMARY: 1.

NHS Foundation Trusts are required to provide in-year in year reports for Monitor on a quarterly basis. This paper relates to Quarter 2 2012/13 The financial position remains strong, with a maintained financial Risk Rating of ‘4’. No breach has been identified in any national target and the Trust has no CQC compliance actions, therefore the governance risk rating remains at ‘Green’. For 2012/2013 the Board of Directors are also asked to confirm there are no matters requiring an exception report which have not already been reported to Monitor.

2. 3.

RECOMMENDATIONS: The Trust Board of Directors is asked to:   



Receive and approve the 2012/2013 Quarter 2 Monitoring Return which will be submitted to Monitor by the 31st October 2012. Confirm that the board anticipates that the trust will continue to maintain a financial risk rating of at least 3 over the next 12 months and sign the attached declaration. Confirm that the board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix B of the Compliance Framework; and a commitment to comply with all kknown targets going forwards and sign the attached declaration. Confirm that there are no matters arising in the quarter requiring an exception report to Monitor (per Compliance Framework) which have not already been reported and sign the attached declaration.

Contents

Page number

Introduction

Financial commentary

Governance declaration

Reports on any changes to the Board of Directors or Council 8 of Governors

Exception reports.

Introduction

Prior to 2010/2011 for both annual risk assessment and in-year monitoring, Monitor assigned a risk rating in three areas - finance, governance and mandatory goods and services. From 2010 onwards the provision of mandatory goods and services is included in the governance risk rating. Monitor uses these risk ratings to guide the intensity of its monitoring and to signal to the NHS Foundation Trust its degree of concern with the specific issues identified and evaluated. The table below shows the Trustâ&#x20AC;&#x2122;s risk ratings to date. The previous amber-red risk ratings have been due to compliance actions received by the Care Quality Commission as a result of inspections. All compliance actions have been addressed in a timely and effective manner. Risk ratings

At authorisation

At Q2 2007/08

At Q3 2007/08

At Q4 2007/08

Financial Governance Mandatory services

3 Green Green

4 Green Green

Risk ratings

At Q1 2008/09

At Q2 2008/09

At Q3 2008/09

At Q4 2008/09

Financial Governance Mandatory services

3 Green Green

3 Amber Green

Risk ratings

At Q1 2009/10

At Q2 2009/10

At Q3 2009/10

Financial Governance Mandatory services

4 Green Green

Risk ratings

At Q1 2010/11

At Q2 2010/11

At Q3 2010/11

At Q4 2010/2011

Financial Governance

4 Green

5 Green

4 Green

Risk ratings

At Q1 2011/12

At Q2 2011/2012

At Q3 2011/2012

At Q4 2011/2012

Financial Governance

4 Amber Red

Risk ratings

At Q1 2012/13 4 Green

At Q2 2012/2013 4 Green

Financial Governance

At Q4 2009/10

4 Green

Risk rating at 2007/08 year end 4 Green Green

Risk rating at 2008/09 year end 3 Amber Green

Risk rating at 2009/10 year end 4 Green Green

Risk rating at 2010/11 year end 4 Green Risk rating at 2011/2012 year end 4 Green

2. Financial Commentary period 1st April 2012 to 30th September 2012 Introduction This report addresses the financial position of the Trust for the period 1st April to 30th September 2012. It also provides assurance to support confirmation that the Trust anticipates maintaining a Financial Risk Rating (FRR) of at least 3 over the next 12 months, as required by Monitor. Year to Date Financial Position The year to date financial position remains strong, with higher than planned EBITDA and Income Statement surplus (Income and Expenditure). The FRR Trust continues to be a ‘4’ as planned, with two indicators showing an improvement from plan. Financial Risk Ratings Month Ending 30th September 2012

September Actual Rating

Plan Yr END Rating

September Actual Rating

EBITDA achievement of plan

112.9



EBITDA margin

6.9



Net return after financing

6.3



IS margin

2.5



Days

27.9





Liquidity Ratio Overall FFR

The EBITDA year to date is £6.07m against a plan of £5.38m, yielding a margin of 6.9% against a plan of 6.2%. In terms of income and expenditure on revenue headings (i.e. day to day expenses), the Trust’s I & E surplus was £2.15m against a planned surplus of £1.54m, a variance of £0.61m at 30th September 2012. The £0.61m surplus variance is explained by the following:          

Additional clinical income ILM, Pharmacy & Junior Doctors income Other operating income NYY pay overspends (Delayed CRES) Locked Rehab pay slippage Development pay slippage Rehab & adult OATs overspend Additional ILM and R&D spend Delayed sale of Peel Court Other over spend

£1.14m £0.66m -£0.19m -£0.59m £0.34m £0.30m -£0.53m -£0.29m -£0.15m -£0.08m

Income At 30th September overall operating income is £1.61m above plan.

Clinical Income was £1.14m above plan. This was due to additional NYY CAHMS, Liaison & Low Secure income and additional Leeds Low Secure, Specialist & LD cost per case income. Other Operating Income was £0.46m above plan. A £0.27m Corporate income deficit was offset by a £0.07m over-recovery on across service directorates and £0.66m additional corporate income for ILM, Pharmacy and Junior Doctors. Pay At 30th September pay expenditure is £0.05m below plan. Pay over-spends due to delayed implementation of NYY CRES (£0.59m) and delayed closure of Asket Croft Dementia Inpatient Unit (£0.31m) are currently being offset by underspends due to delayed implementation of the new Eating Disorders community team (£0.15m), delayed opening of the new Locked Rehab unit (£0.34m), early achievement of Transformation CRES (£0.31m) and other development slippage / vacancies (£0.15m). In order to facilitate service transformation a number of vacancies have been filled with temporary staff. This has been predominantly in ward settings. Over the course of the next 2 years it is anticipated that the use of temporary staff will reduce. Non Pay At 30th September non pay operating expenditure is £0.96m above plan. Adult OATs and Rehab OATs were £0.53m over-spent in the period due to the delayed opening of the new Rehab inpatient unit and a general increase in adult OATs expenditure. There was also £0.29m additional corporate spend due to R&D and ILM. This is partially offset by unutilised provisions, PFI benefit and slippage on corporate contracts of £0.15m. There is also £0.29m additional NYY spend, however this is offset by additional NYY income. Non Operating Income / Expenditure At 30th September Non Operating Income / Expenditure is £0.08m below plan due to the assumed June sale of Peel Court having not been completed. An offer has now been accepted. Cash Releasing Efficiency Savings Cash releasing efficiency savings are currently £0.40m below plan. This is predominantly due to the delayed sale of Peel Court and Otley Old Road properties within Corporate. CRES across care services as a whole is below plan, however early achievement of Transformation CRES is partially offsetting delayed CRES in NYY. Cash The cash position is above plan by £5.72m at the end of September with a value of £30.68m. This is due to a £5.24m improvement in working capital (of which £3.98m is deferred income) and £0.69m in operating cash flows, offset by £0.34m reduction in investing activities due to the delayed sale of Peel Court and Otley Old Road properties. Liquidity increased from 26.9 days worth of operating expenses at the end of August to 27.9 days at the end of September.

Capital Expenditure Year to date capital expenditure is £1.02m, with commitments of £1.39m. Expenditure was predominantly on the scheme for new accommodation £0.27m, Asket Croft £0.15m, PFI £0.17m and IT capital schemes £0.14m. £0.12m has been committed against the Mount sensory garden scheme, £0.14m brought forward from 2011/12. Forecast Financial Performance Over The Next 12 Months The Trust is required to confirm that it anticipates maintaining a FRR of at least 3 over the next 12 months. To support this declaration a 12 month forward look including cash flow is produced. The table below shows a forecast strong FRR of 4 in the next 12 months with EBITDA and IS forecast above current plans. th

Forecast Financial Risk Rating as at 30 September 2013:

September Forecast Position

September Forecast Rating

EBITDA achievement of plan

100



EBITDA margin

7.7



Net return after financing

5.3



IS margin

2.3



Days

36.1



Liquidity Ratio Overall FFR

The financial risk rating of ‘4’ as at 30th September 2013 is based on the following assumptions:    

Achieving a £4.3m I&E surplus for 2012/13 2013/14 I&E surplus (£1.9m) at end of quarter 2 , as per current plan Reduced capital expenditure plans reflecting the updated strategic review of accommodation. (£1.8m reduction in 2012/13 and £5.9m reduction in 2013/14) Cash balance of £25.5m as at 30th September 2013 (£8.5m more than planned, reflecting reduced capital expenditure)

In terms of sensitivity analysis this forecast position could deteriorate by £0.9m before the financial risk rating would reduce to a ‘3’, and could deteriorate by £2.0m before the financial risk rating reduced to a ‘2’. This is a reasonable tolerance to mitigate unplanned risks. Summary The Trusts financial position as at quarter 2 is robust, with an FRR of 4. With regard to the 12 month forecast, the key is to maintain a good surplus margin and sufficient cash balances. The key risk going forward will be the deliverability of sustainable CRES targets. Processes are in place to support this. The cash balance is forecast to be significantly above plan throughout the next 12 months, due to an improved I&E surplus position and slippage on capital investment schemes. The spending expectations on capital schemes remain under constant review. If capital spending increased the Trust would need to explore the utilisation of a working capital facility to support the liquidity metric. The underlying position is in line with plan and an overall financial risk rating of ‘4’ will be maintained throughout the next 12 months.

The Board of Directors is asked to confirm that the board anticipates that the trust will continue to maintain a financial risk rating of at least 3 over the next 12 months and sign the attached declaration.

Governance Declaration

NHS Foundation Trust Boards must confirm that the board is satisfied that plans in place are sufficient to ensure; ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix B of the Compliance Framework; and a commitment to comply with all known targets going forwards. No breach has been identified in any national target during Quarter 2 2012/2013, for Leeds and York Partnership NHS Foundation Trust where thresholds have been published by Monitor. Plans are in place to ensure continued compliance with all existing targets and all known targets going forward. The Trust received formal notification in May 2012 that the compliance actions received for Ward 3 Newsam Centre have been removed. The Trust received a visit from the CQC to Becklin Centre in August 2012 as part of the national older peoples review. The report and findings from this review are still being awaited from the CQC. Plans are in place to continue to respond to the Care Quality Commission’s regulatory framework and the Trust remains compliant with existing registration requirements.

Full details of performance in relation to national targets and CQC Registration are given in the Performance Quality and Use of Resources report to the Board of Directors (agenda item 11).

Monitor’s Quality Governance Framework:

NHS Foundation Trust Boards must confirm that they are satisfied that, to the best of their knowledge and using their own processes and having assessed against Monitor’s Quality Governance Framework (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), its NHS Foundation Trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients. An internal audit has been undertaken of the Trust’s Quality Governance Framework. The audit concluded that taking account of the issues identified the Board can take substantial assurance that the controls upon which the organisation relies to manage this area are suitably designed, consistently applied and effective. No recommendations were made as part of the review. A review was also undertaken by Deloitte on the Trust’s Quality Governance Framework, as part of the NYY transaction. This review found evidence to support the opinion that the Trust had a high level of compliance when assessed both subjectively and objectively against the Monitor Quality Governance Framework. Quality governance arrangements have been implemented across NYY Services. To further strengthen compliance and assurance improvement plans have also been put in place across NYY services around the following areas -

Performance Strategy

Risk Governance IT and information

Progress against improvement plans is monitored by the Executive Team. The performance, strategy and governance improvement plans have been signed off as complete.

The Board of Directors is asked to approve the signing of the in year Governance Declaration which is attached.

Reports on any changes to the Board of Directors and Council of Governors

CHANGES TO THE BOARD OF DIRECTORS Executive Directors Chief Financial Officer On the 1 August 2012 Ms Dawn Hanwell took over the role of Chief Financial Officer. Prior to her appointment Ms Hanwell was the Director of Finance of Barnsley Hospital NHS Foundation Trust. Ms Hanwell was appointed to the post of Chief Financial Officer substantively following a competitive interview process. Medical Director On the 1 September 2012 Dr Jim Isherwood took over the role of Medical Director from Dr Douglas Fraser who had been seconded into this role since September 2010. Prior to his appointment as Medical Director of the Leeds and York Partnership NHS Foundation Trust Dr Isherwood was the Medical Director of the services formerly provided by the NHS North Yorkshire and York. Dr Isherwood was appointed to the post of Medical Director substantively following a competitive interview process. Chief Operating Officer / Chief Nurse / Deputy Chief Executive On 25 September 2012 it was announced that Mrs Michele Moran has been appointed as the Chief Executive of the Manchester Mental Health and Social Care NHS Trust. The Nominations Committee met on the 28 September 2012 to look at the options for filling this forthcoming vacant post both on a temporary and substantive basis. It is expected that the process will commence in Quarter 3. Non-Executive Directors (NEDs) During Quarter 2 work has continued to make three appointments to the non-executive director team. The Council of Governorsâ&#x20AC;&#x2122; Appointment and Remuneration Committee, supported by the Board of Directorsâ&#x20AC;&#x2122; Nominations Committee agreed with the Council of Governors a process for the appointment of three NEDs to fill the impending vacant posts that will be left when Niccola Swan, Linda Phipps and eventually Allan Valks come to the end of their terms of office on 30 November 2012, 31 January 2012 and 31 May 2013 respectively. The Council of Governors is working towards appointing to the first two posts substantively and for the third to be filled by a NED-designate post until Allan Valks comes to the end of his term of appointment on the 31 May 2013 at which point the NED-designate appointment will become substantive. It is expected that the process will be completed during Quarter 3.

CHANGES TO THE COUNCIL OF GOVERNORS Elected Governors During the second quarter the following governors came to the end of their terms of office:    

Jenny Roper (Public Leeds North West) – ended on 16 July 2012 Alec Hudson (Public Morley and Outwood) – ended on 17 August 2012 Andy Parker (Service User Leeds) – ended on 17 August 2012 Tricia Thorpe (Service User Leeds) – ended 17 August 2012

In addition to this Mr Bill Boland stepped down as governor (Carer Leeds constituency) on the 15 September 2012. On the 4 September 2012 the elections to these and other vacant seats commenced. The following seats were included in the elections:

CONSTITUENCY Public: Morley & Outwood Public: Pudsey Public: Leeds North West Public: Leeds West Public: York Central Public: North Yorkshire &York Countywide Carer: Leeds (Learning Disability) Carer: York and Selby Service user: North Yorkshire &York Countywide Service user and carer: Rest of UK Service user: Leeds resident

At the end of the Nominations phase on the 20 September there had been 5 nominations made, two for Public Leeds North West and three for Service User Leeds. Voting for these two seats will conclude in Quarter 3 and the outcome advised to the Trust on the 1 November 2012. With regard to the other still vacant seats the Council of Governors’ Membership Committee will be meeting in Quarter 3 to agree when the next round of elections will be held.

Appointed Governors During Quarter 2 the following appointed governors came to the end of their term of office or stepped down:  

Cllr Lucinda Yeadon – Leeds City Council Kate Langan – Tenfold

Also during Quarter 2 the following governors were appointed to the Council of Governors by our partner organisations:    

Councillor Simpson-Laing – City of York Council Councillor Cllr Christine Macniven – Leeds City Council John Dossey – Tenfold Nigel Gray – NHS Leeds.

Exception reports

NHS Foundation Trusts must report risks to compliance with the Authorisation on an exception basis. Examples of these include:       

Unplanned significant reductions in income or significant increases in costs Failure to comply with the NHS Foundation Trust Annual reporting Manual Significant third party investigations that suggest material issues with governance Performance penalties to commissioners Outcomes or findings of Care Quality Commission responsive or planned reviews. Patient Safety issues which may impact the Authorisation Enforcement notices from other bodies implying potential or actual significant breach of any other requirement in the Authorisation

No matters have arisen in Quarter 2 which require an exception report to Monitor.

The Board of Directors is asked to confirm that there are no matters arising in the quarter requiring an exception report to Monitor (per Compliance Framework) which have not already been reported and sign the attached declaration.

AGENDA ITEM 11.2

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Trust Strategy Progress Report

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Jill Copeland - director of strategy & partnerships artnerships Dawn Hanwell – chief financial officer Carrie Rae - head of performance Amanda Bennett - business manager

PAPER AUTHOR:

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC:

GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

IMPACT ON THE TRUST’S S MEANS GOALS (please tick relevant box) MG1 We provide excellent quality, evidence-based, evidence based, safe care that promotes recovery and inclusion MG2 MG3

We involve people in planning their care and in improving services We work with partner organisations to improve health and lives

MG4 MG5 MG6

We value and develop our workforce and those supporting us We improve our services through learning, research and innovation We provide efficient and sustainable services

MG7

We govern our Trust effectively and meet our regulatory requirements

          



SUMMARY: Performance against strategy measures: measures The attached progress report sets out our performance against each of the strategy measures and details any action plans in place to improve performance. The areas of amber or red performance are largely those that the Board of Directors has already discussed in the context of the results of our service user and staff surveys. There is still no robust performance data to demonstrate performance against Development of strategy measures: easures: The clinical outcomes measure remains red for development, although progress is being made in this area. The following has been agreed greed by Means Goal 4 Standing Group for ratification by the Board of Directors: 

Means goal al 4, measure 5c (Number (Number of temporary staff who believe that the Trust values their contribution)

We e are currently undertaking a full strategy refresh. Each means goal standing group has been asked to review their basket of measures and agree different measures measures where these would better contribute to the achievement of the means goals. The refreshed strategy will be published in April 2013.

RECOMMENDATIONS: Members of the Board of Directors are asked to: to 

Comment on the degree to which they feel assured that actions are being taken to improve performance against strategy measures.



Ratify the new measure for means m goal 4: measure 5c

OUR TRUST STRATEGY PROPOSED STRATEGY MEASURES â&#x20AC;&#x201C; baselines and milestones Baselines and milestones have now been developed for the following strategy measures and have been approved at the relevant Means Goal Standing Group. The Trust Board of Directors is asked to receive and ratify the below proposed baselines and milestones. Measure

Baseline

2011 2012 2013 milestone milestone milestone Means goal 4: We value and develop our workforce and those supporting us 5c Number of temporary staff who 42% 50% 50% 50% believe that the trust values their (Apr â&#x20AC;&#x201C; contribution Mar 12)

2014 milestone

2015 standard

Lead director

55%

60%

Director of Workforce & Development

Measure was approved by Means Goal 4 Standing Group in June 2012. The Board of Directors are asked to ratify the proposed milestones.

The Board of Directors is asked to ratify the proposed baseline and milestones.

OUR TRUST STRATEGY - PROGRESS AGAINST OUR STRATEGY MEASURES In September 2010 the Trust formally launched the 5 year Trust Strategy, ‘improving health, improving lives’. Progress on implementation of the strategy is reported to Monitor on an annual basis, via the Trust’s Annual Plan. The Trust also produces a mid-year review of the Annual Plan for presentation to the Board of Directors and the Council of Governors. In addition a quarterly update on performance against the Strategy measures is included in the Performance Report to the Board of Directors. Oversight of progress against the Strategy measures is via the Means Goal 7 Standing Group which is chaired by the Chief Executive. The Strategic Development Team is responsible for development of strategy and measures, milestones and baselines. The Performance Team is responsible for performance monitoring and performance management of strategy delivery (where measures are set) and for determining any actions required to improve performance.

Green =measure agreed / milestone met Amber = milestone not met but action plan in place Red = measure not agreed / milestone not met

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

Measures agreed Y/N

2012 Milestone (To be st met by 31 March 2013) 2015 Standard st (To be met by 31 March 2016)

2011 Milestone st (To be met by 31 March 2012)

Current Performance

Measure

Baseline

End Goal 1: People achieve their agreed goals for improving health and improving lives

People report that the services they receive definitely help them to achieve their goals: A. People using mental health

43% (2010)

39% Leeds (2012)

50%

55%.

80%

Ratified measures in place.

AMBER

ACTION PLANS TO IMPROVE PERFORMANCE

To enable us to collect this information on a more frequent basis an automated postal survey generated from the PARIS information system is being rolled out across the Trust. Due to software difficulties a phased roll out process is implemented and timescales are as follows:  October 12- Pilot with PTS to be completed  November 12- Phased roll out across services to commence

services

 January 13 – Roll out completed for all services with access to PARIS

53% Y&NY (2012)

GREEN

The Trust’s Planning Care cross directorate action plan identifies actions to be taken to support clinicians in agreeing goals with service users and planning care, support and treatment to facilitate this. Actions include:  

B. People using learning disability services Lead Director: Chief Operating Officer/ Chief Nurse

73%

50%

75%

90% Y

Ratified measures in place

(Local Survey) GREEN

Quality of care planning to be monitored via case load management. Post review questionnaire (CQUIN) is to be repeated this year and will include all Community Mental Health Teams.

Agreed clinical outcomes have been achieved for people who use our services. Lead Director: Medical Director

To be set

To be set N

ACTION PLANS TO DEVELOP MEASURES

A suite of clinical outcomes for this measure, drawing on HoNOS, CORE and TOMs is being developed. The aim is for the measure to be two pronged: outcome measures collected for service users receiving treatment in the Trust and service users maintaining, functioning, improving and recovering. The overarching timeline is as follows:  Information reports to be produced (June 2012)  Disseminate information reports and directorates to review performance (JunSep2012)  T&F/outcomes workstream to review data with directorates (Jun-Sep 2012)  Outcomes workstream to source national benchmarking date (Jun-Sep 2012)  Outcomes workstream to set targets (OctNov 2012)

PERFORMANCE RATING RED/AMBER/ GREEN

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

2012 Milestone (To be met by st 31 March 2013

2011 Milestone (To be met by st 31 March 2012)

Current Performance

Measure

Baseline

End Goal 1: People achieve their agreed goals for improving health and improving lives

ACTION PLANS TO IMPROVE PERFORMANCE

Carers report that their own health needs are recognised and they are supported to maintain their physical, mental and emotional health and well-being. Lead Director: Chief Operating Officer/ Chief Nurse

64%

70%

80%

Ratified measures in place.

A revised method(s) for collection was presented to the Planning Care Standing Support Group (PCSSG) in September 2012 to improve the collection of carers experience against this end goal. A meeting with service leads will be held to identify an appropriate long term data collection method for all services and a report will be provide to the PCSSG in November 2012. In the interim period carers questionnaires are being issued via the automated postal survey system generated from the PARIS information system. Due to software difficulties a phased roll out is being implemented and timescales are as follows:  October 12 - Pilot with PTS to be completed  November 12 - Phased roll out across services to commence  January 13 – Rollout completed for all services with access to PARIS

70%

80% Y

Lead Director: Medical Director and Chief Operating Officer/ Chief Nurse

ACTION PLANS TO DEVELOP MEASURES

Ratified measures in place – agreed at June meeting of the Board of Directors. The baseline will be determined at the end of June 2012, after 3 months data collection from the local questionnaire. The automated postal survey generated from the PARIS information system is being rolled out across the Trust. Due to software difficulties a phased rollout process is implemented and timescales are as follows:  October 12 - Pilot with PTS to be completed  November 12 - Phased rollout across services to commence  January 13 – Rollout completed for all services with access to PARIS

PERFORMANCE RATING RED/AMBER/ GREEN

Measures agreed Y/N

2015 Standard st (To be met by 31 March 2016)

To be set

2012 Milestone st (To be met by 31 March 2013)

People who use our services report that they experienced safe care.

2011 Milestone (To be met by st 31 March 2012)

Current Performance

Measure

Baseline

End Goal 2: People experience safe care

ACTION PLANS TO IMPROVE PERFORMANCE

Number of ‘no harm’ or ‘low harm’ incidents increases as % of total: % where ‘no harm’ has occurred (NPSA score 1). % where ‘low harm’ has occurred (NPSA score 2). Total % ‘no harm’ and ‘low harm’. % where ‘no harm’ has occurred (NPSA score 1). % where ‘low harm’ has occurred (NPSA score 2). Total % ‘no harm’ and ‘low harm’.

76%*

LYPFT 73%**

78%

80%

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

Measures agreed Y/N

2015 Standard (To be met by st 31 March 2016)

2012 Milestone (To be met by st 31 March 2013)

2011 Milestone (To be met by st 31 March 2012)

Current Performance

Measure

Baseline

End Goal 2: People experience safe care

86% Y

20%*

24%**

18%

16%

11%

96%*

97%**

96%

97%

* NPSA data – inpatients only (AprSept 2009)

(Apr 2011 – Mar 2012) Leeds Services

Ratified measures in place

AMBER

ACTION PLANS TO IMPROVE PERFORMANCE

Work continues on the following:  Production of reports identifying trends/ hotspots  Thematic analysis of incidents including serious incidents  Monthly incident data to clinical directorates  Medication incident data analysed by MMMP  Integrated report containing PALS, complaints, claims, incidents including serious incidents  Agree actions needed to achieve further reductions in the number of incidents where harm has occurred. The data for Leeds services for quarter 1 is based on a small sample size as not all forms have been received and processed. NYY service data is not included for quarter 1 as they record incidents on a separate system. Plans are in place to report onto a sole system.

58%**

37%**

95%** ** All service user incidents – inpatient & community (April 2012 – June 2012) 7

 Trigger to Board events Lead Director: Medical Director and Chief Operating Officer/ Chief Nurse

Zero

Zero ((Apr 2012 – July 2012)

Zero

15 trigger to board events (Apr 2012 – July 2012)

Zero

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

15 trigger to board events (Apr 2012 – July 2012)

Measures agreed Y/N

2015 Standard (To be met by st 31 March 2016)

 Never events

Zero

2012 Milestone (To be met by st 31 March 2013)

There are no nationally set ‘never events’ or ‘Trigger to Board’ events

2011 Milestone (To be met by st 31 March 2012)

Current Performance

Measure

Baseline

End Goal 2: People experience safe care

ACTION PLANS TO IMPROVE PERFORMANCE

In the main the trigger to board events are due to the noncompletion of the allergy box in the patients records.

Ratified measures in place AMBER

Zero

GREEN

Zero

AMBER

A clear mechanism is in place through the Medical Professional Leadership Group for the Educational Supervisor (ie the Consultant Psychiatrist) to ensure that any junior doctor who has made a drug error is closely supervised to ensure that no further prescribing errors will occur. This is in addition to the robust approach being taken by the Associate Medical Director for Doctors in Training.

People using our mental health services; A. report overall rating of care in last 12 months as very good/ excellent

B. report being definitely treated with respect and dignity by staff providing care

64% (2010)

58% Leeds (2012)

65%

68%

80%

67% Y&NY (2012)

91% (2010)

85% Leeds (2012)

ACTION PLANS TO DEVELOP MEASURES

Ratified measures in place

PERFORMANCE RATING RED/AMBER/ GREEN

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

2012 Milestone (To be met by st 31 March 2013)

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

End Goal 3: People have a positive experience of their care and support

AMBER

GREEN

91%

92%

95% AMBER

93% Y&NY (2012)

GREEN

ACTION PLANS TO IMPROVE PERFORMANCE

An automated postal survey generated from the PARIS information system is being rolled out across the Trust. Due to software difficulties a phased rollout process is implemented and timescales are as follows :  October 12 - Pilot with PTS to be completed  November 12 - Phased rollout across services to commence  January 13 – Rollout completed for all services with access to PARIS LYPFT has recently been allocated funding by the Yorkshire & Humber Local Education Board to improve privacy and dignity in care. It is proposed this funding will be used to support dignity champions to work with service users and carers to challenge poor practice, as well as identify areas of good practice within our Trust. A key role of the dignity champion will be to produce an educational package for staff based on service user/carer experience. A respect and dignity conference for staff, service users and carers is planned later next year to celebrate achievements in this area. Respect and dignity remains high on the agenda as one of the Department of Health’s Essence of Care benchmarks. The Essence of Care Steering Group will continue to monitor progress in this area and ensure the delivery of targeted actions plans in relation to respect and dignity.

People using learning disability services.

Ratified measures in place . GREEN

C. report overall rating of care in last 12 months as very good/ excellent D. report being definitely treated with respect and dignity by staff providing care Lead Director: Chief Operating Officer/ Chief Nurse 3

Carers report that they are recognised, identified and valued for their caring role and treated with dignity and respect.

88%

79%

88%

79%

88%

91%

90%

92%

95%

The directorate developed a service user questionnaire to in cooperate the measures in the Trust’s strategy.

95%

Plans are in place to ensure all questionnaires included this question. AMBER

49%

70%

80% Y

Lead Director: Chief Operating Officer/ Chief Nurse

Ratified measures in place

A revised method(s) for collection was presented to the Planning Care Standing Support Group (PCSSG) in September 2012 to improve the collection of carers experience against this end goal. A meeting with service leads will be held to identify an appropriate long term data collection method for all services and a report will be provide to the PCSSG in November 2012. In the interim period carers questionnaires are being issued via the automated postal survey system generated from the PARIS information system. Due to software difficulties a phased rollout is being implemented and timescales are as follows:  October 12 - Pilot with PTS to be completed  November 12 - Phased rollout across services to commence  January 13 – Rollout completed for all services with access to PARIS

Lead Director: Medical Director

85%

100%  16 Guidelin es assesse d as Complia nt Agreed – Full  0 Guidelin es assesse d as Complia nt Agreed – Partial  2 Guidelin es assesse d as Working Towards Complia nce  23 Guidelin es are Under Review)

100%

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

100%

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

Evidence that we meet national guidelines for clinical care and treatment relevant to our Trust within two years of publication.

2012 Milestone (To be met by st 31 March 2013)

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

Means Goal 1: We provide excellent quality, evidence-based, safe care that promotes recovery and inclusion

The Trust has achieved this target for 100% of guidelines. All guidelines that are less than 2 years old are in the process of:  Being baselined  Have been baselined and declared compliant  Have been audited and declared compliant  One guideline has been baselined and declared ‘working towards compliance’. Action plan is being implemented.

Y Ratified measures in place

GREEN

ACTION PLANS TO IMPROVE PERFORMANCE

For those guidelines that are more than 2 years old, guidelines have either been declared as compliant or are under review to establish or reassess compliance. This includes York services. One guideline has been reassessed and the declaration modified to “working towards compliance”. Action plans are in place to ensure compliance when reassessed. A retrospective review of all NICE guidance has been undertaken to ascertain the relevance for York services. Many of those identified as relevant are now under review to declare a position on compliance. Maintain current performance by continuing to receive national guidance through the Clinical Guidelines and Clinical Outcomes Standing Support Group which considers relevance and assesses compliance with the guideline (including consideration of the evidence to support compliance). Continue to audit NICE Guidelines as part of the Trust Priority Clinical Audit Plan.

2 a

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

2012 Milestone (To be met by st 31 March 2013)

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

Means Goal 1: We provide excellent quality, evidence-based, safe care that promotes recovery and inclusion

To enable us to collect this information on a more frequent basis an automated postal survey generated from the PARIS information system is currently being put in place. Due to software difficulties a phased rollout process is implemented and timescales are as follows:

Support towards recovery and inclusion: Percentage of those mental health service users who would have liked help from our services who received such help in the last 12 months: A. With finding or keeping work. B. In finding and/or keeping their accommodation.

C. In getting financial advice or benefits.

ACTION PLANS TO IMPROVE PERFORMANCE

49% (2010)

59% (2010)

53% (2010)

41% Leeds (2012)

55%

60%

50% Y&NY (2012) 54% Leeds (2012)

65%

70%

80%

63% Y&NY (2012) 52% Leeds (2012)

AMBER

80% Ratified measures in place

AMBER AMBER AMBER

60%

65%

80%

64% Y&NY (2012)

AMBER GREEN

 October 12 - Pilot with PTS to be completed  November 12 - Phased rollout across services to commence  January 13 – Rollout completed for all services with access to PARIS Actions in place include; revised CPA documentation, CPA training for staff, the citywide CPA policy and the introduction of integrated care pathways. Progress against the action plan is monitored by the Planning Care Standing Support Group.

Percentage of learning disability service users who have: A.

A person-centred care plan (PCP).

Completed ‘My Yearly Healthcheck’ and/or a health action plan

Staff report they agree or strongly agree that if a friend or relative needed treatment, they would be happy with the standard of care provided by our Trust. Lead Director: Chief Operating Officer/ Chief Nurse Evidence of recovery oriented services  Changing the nature of day-to-day interactions with people who use services and their relatives, friends and carers and the quality of their experience of using services  Establishing a ‘Recovery Education Centre’ to drive the training programmes forward  Transforming the workforce to include the expertise of lived experience in the form of new peer support workers

. Y

95%

Ratified measures in place

95% GREEN

95%

(Local Survey)

55% (2009 Staff Survey)

55% (2011 Staff survey)

56%

58%

80%

AMBER

Y Level 1

A staff survey task and finish group has been established to focus on and prioritise those key findings in the 2011 Staff Survey which requires improvement and action.

Ratified measures in place.

Level 1

Level 3

Level 1

Level 1-2

Level 1

Level 3

Level 1

Level 2

Level 1

Level 3

The areas in the action plan are being addressed through established workstreams.

The levels incorporate the four organisational challenges that were identified as key priorities for the organisation as making the most impact on developing recovery orientated services. The levels set out are level 1 – engagement, level 2 – development and level 3 – transformation.

Ratified measures in place

GREEN

After a one day workshop which took place on 5 July 2012 to re-audit using the IMROC tool. It was determined that the levels identified at the previous audit had improved in some areas. Where current performance, states level 1-2 this is due to the criteria having improved but not fully meeting the criteria for the next stage A new action plan following the audit, is currently being developed. This plan links to the changes the Trust has made within Transformation Programme and will be completed by November 2012.

 Increasing opportunities for building ‘a life beyond illness’ (ordinary housing, open employment, community integration, social inclusion) Lead Director: Chief Operating Officer / Chief Nurse

Level 2

Level 3

Maintaining diversity of our workforce so that it reflects diversity of Leeds. Lead Director: Director of Human Resources

Achieved (2010)

Achieved (Leeds Services)

Maintain

Achievement of Essence of Care ‘getting the basics right’ Standards.

Ratified measures in place. GREEN

Amber (2009)

Amber (August 2012)

Green

An action plan is in place to meet the workforce requirements of the Equality Act (2010) Public Sector Equality Duty and workforce equality objectives for 2012/13. Evidence to meet the reporting requirements and future governance arrangements were approved by the Means Goal 7 Standing Support Group and the Board of Directors in March 2012. Our last Trust-wide Essence of Care audit took place in August 2011. Following this all teams and services developed action plans to address areas for improvement. Work has taken place over the last 12 months in line with agreed action plans.

Ratified measures in place.

Lead Director: Chief Operating Officer/ Chief Nurse

AMBER

The next Trust-wide audit is planned for November 2012. For many areas this will be a baseline audit as new services have since joined the Trust and many teams have been restructured as part of the Transformation Programme. As a result of organisational changes the membership of the Essence of Care Steering Group will be strengthened to include a range of professionals from across the Trust. The group are currently establishing key objectives for the next year and will focus on a number of Trust wide initiatives such as the NHS Safety Thermometer and Transparency of Care project to ensure that standards of care are monitored and actioned appropriately.

Attainment of good or excellent Patient Environment Action Team ratings across all assessed Trust locations.  ‘Good’ scores  ‘Excellent’ scores Lead Director: Chief Operating Officer/ Chief Nurse

Number of patients admitted and remaining for more than 48 hours who were screened using a nutritional screening tool and recorded on PARIS Lead Director: Chief Operating Officer/ Chief Nurse

Y 100%

100%

Following the 2012 inspections, as a combined Trust we scored: 53% 47% (2010)

16.5% (2010)

24% 76% (2012) (Leeds Services)

45% 55%

98.6% (Qtr 1 2012)

75%

35% 65%

10% 90%

GREEN

 

Excellent – 48% Good 39%

Actions are in place to Improve performance across Y&NY services to ensure we meet the 2013 milestone. 95%

95%

Ratified measures in place.

GREEN

Achievement of standards for access to and responsiveness of services: a. Improving access to assessment for adults of working age experiencing acute mental health problems (4 hour CRHT assessment )

The current performance is for Leeds services and has improved on last year’s PEAT inspection results.

Ratified measures in place.

50% (Apr-Jun 2010)

64% (July 2012)

75%

77%

83%

Ratified measures in place.

Performance is being looked at on a regular basis and where breaches are identified the relevant action is taken.

AMBER

b. Improving access for adults of working age experiencing non acute mental health problems (assessment & treatment )

Assess: 30% Treat: 46% (Apr-Jun 10)

c. Meeting the needs of people with a learning disability (Green-light Framework)

Audit 2010/11

Assess: 65.8% Treat: 84.3% (July 2012)

Assess: 65% Treat: 65%

70%

Assess: 85% Treat: 85% GREEN

Leeds Services

Improved audit results

Improved audit results GREEN

The CPA audit results show that the proportion of people recorded as meeting the Green Light criteria remained about the same as 2010 and that there was an increase in evidence of joint working from 42% in 2010 to 56% in 2011. The Green Light e-learning module is available for staff, with the aim of raising awareness. The next stage of training is being developed during 2012.

d. Development and implementation of integrated dementia pathway across mental health and learning disability community and acute sectors Lead Director: Chief Operating Officer/ Chief Nurse

Audit 2010/11

Improved audit results

It has been agreed not to proceed with any further work to set a measure for this, pending the refresh of the strategy measures commencing from 1 April 2013.

1 a

Involvement in care planning: People who use our mental health services report that: A. Staff definitely listened carefully

82% (2010)

76% (2012) Leeds Services

84%

ACTION PLANS TO DEVELOP MEASURES

Ratified measures in place.

90%

AMBER

51% (2010)

70% (2012) Leeds Services

GREEN

People using our learning disability services report that: A. They had accessible

60%

80% GREEN

80% (2012) NYY Services

Y 82%

82%

 

60%

GREEN

1 b

ACTION PLANS TO IMPROVE PERFORMANCE



86% (2012) NYY Services

B. Their views were definitely taken into account when deciding what was in their care plan. Lead Director: Chief Operating Officer/ Chief Nurse

PERFORMANCE RATING RED/AMBER/ GREEN

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

2012 Milestone (To be met by st 31 March 2013)

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

Means Goal 2: We involve people in planning their care and in improving services

82%

84%

90% 17

Ratified measures in place

GREEN

October 12 - Pilot with PTS to be completed November 12 - Phased rollout across services to commence January 13 – Rollout completed for all services with access to PARIS

Action plans have been developed by service directorates as a result of the most recent community service user survey. A task and finish group has been established to review information provided to people who use our services, their families and carers to ensure it meets best practice and supports people to take an active part in making decisions about their care, treatment and support.

information to support their care. B. Staff providing care definitely listened carefully. C. Their views were definitely taken into account when deciding what was in their care plan. 1 c

Carers report that they felt satisfied or very satisfied that they were included as a valued partner in the planning and delivery of treatment and care, and in particular in discharge planning.

90%

100%

69%

69% (Local Survey)

60%

69%

90%

80%

85%

81%

Ratified measures in place.

A revised method(s) for collection was presented to the Planning Care Standing Support Group (PCSSG) in September 2012 to improve the collection of carers experience against this end goal. A meeting with service leads will be held to identify an appropriate long term data collection method for all services and a report will be provided to the PCSSG in November 2012. In the interim period carers questionnaires are being issued via the automated postal survey system generated from the PARIS information system. Due to software difficulties a phased rollout is being implemented and timescales are as follows:  October 12 - Pilot with PTS to be completed  November 12 - Phased rollout across services to commence  January 13 – Rollout completed for all services with access to PARIS.

Evidence that service user and carer involvement in service improvement is inclusive and effective.  Data collected from CPA questionnaire  Data from Trust wide Involvement activity feedback forms  Evaluations from Diversity and Social Inclusion Forum  Evaluations from Building your Trust Events  Evaluation from Trust Board around Stories to the Board  Evidence folder around CQC involvement requirements always kept up to date. Lead Director: Chief Operating Officer/ Chief Nurse

Measure met

Measure Met

Measure met

Measure continues to be met

Ratified measures in place.

(qualitative evidence)

GREEN

3 a

Evidence that engagement with Governors is inclusive and effective.  Annual questionnaire to governors conducted and report presented to MG3  Data collected from Annual Governor appraisals  Evaluation of governor development programme  Evaluation of Governor involvement through projects and groups  Data produced on Governor page of trust website is always up to date Lead Director: Director of Strategy and Partnerships

Measure met

Measure continues to be met

ACTION PLANS TO DEVELOP MEASURES

PERFORMANC E RATING RED/AMBER/ GREEN

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

2012 Milestone (To be met by st 31 March 2013)

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

Means Goal 2: We involve people in planning their care and in improving services

Ratified measures in place.

An evidence file and minutes of meetings presented annually to MG3SG.

(qualitative evidence)

GREEN

ACTION PLANS TO IMPROVE PERFORMANCE

Measure met

Measure continues to be met

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

Measure met

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

Evidence that engagement with members is inclusive and effective.  Annual membership survey conducted and report presented to MG3  Evaluations from ‘Everything you need to know about...’ events.  Evaluation from Annual Members day  Membership data Reports presented to membership Committee Lead Director: Director of Strategy and Partnerships

2012 Milestone (To be met by st 31 March 2013)

3 b

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

Means Goal 2: We involve people in planning their care and in improving services

Ratified measures in place.

An evidence file and minutes of meetings presented annually to MG3SG.

(qualitative evidence)

GREEN

ACTION PLANS TO IMPROVE PERFORMANCE

3 c

Evidence that engagement with the wider public is inclusive and effective.  Annual attitude survey conducted and report presented to MG3  Evaluations from engagement and recruitment events  Membership recruitment report presented to membership committee always meets its trajectory

Measure met

Measure continues to be met

 

mental health service users learning disability service users carers.

Ratified measures in place.

An evidence file and minutes of meetings presented annually to MG3SG.

(qualitative evidence)

GREEN

People report definitely having the information they need to support their care: 

To be set

71%

70%

75%

80%

71%

70%

75%

80%

To be set

71%

70%

75%

80%

Ratified measures in place

GREEN

To enable us to collect mental health service user and carer information an automated postal survey generated from the PARIS information system is being rolled out across the Trust. Due to software difficulties a phased rollout process is implemented and timescales are as follows: 

Lead Director: Chief Operating Officer/ Chief Nurse

(Local Survey)

 

October 12 - Pilot with PTS to be completed November 12 - Phased rollout across services to commence January 13 – Rollout completed for all services with access to PARIS

Partners report that the Trust demonstrates successful partnership working, including commitment to the Compact for Leeds and the ability to influence partners’ priorities.

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

2012 Milestone (To be met by st 31 March 2013)

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

Means Goal 3: We work with partner organisations to improve health and lives

This has been raised as a risk on the Trust risk register as a ‘moderate’ tier 1 risk.

Y Ratified measures in place.



Trust

90%

71%

80%

80% min



Control Mutuality

88%

78%

80%

80% min



Commitment

88%

87%

80%

80% min



Satisfaction

94%

90%

80%

80% min



Communal relationships

77%

67%

80%

80% min



Exchange relationships

50%

39%

60%

80% min



Commitment to the Compact

100%

42%

80%

80% min

Lead Director: Director of Strategy and Partnerships

ACTION PLANS TO IMPROVE PERFORMANCE

An action plan has been developed to address the current performance and the actions will be monitored by the deputy director of strategy & partnerships.

AMBER

Qualitative evidence

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

Qualitative evidence

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

Evidence that we are working with our partnerships to reduce mental health and learning disability stigma in Leeds

2012 Milestone (To be met by st 31 March 2013)

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

Means Goal 3: We work with partner organisations to improve health and lives

Ratified measures in place.

 Time to Change reports  Love Arts evaluation  Get Me reports  Public attitudes survey

ACTION PLANS TO IMPROVE PERFORMANCE

Love Arts Festival has now taken place. Evaluation of the event showed that 80% of respondents would now feel more confident talking about mental health. It is estimated that over the 7 week festival contact was made with 10,000 people through our events and exhibitions.

GREEN

Our second public attitudes survey was undertaken and the results are currently been collated and will be available shortly.

Lead Director: Director of Strategy and Partnerships 3

Evidence of meeting agreed national and local standards for adult and child safeguarding.

Standards Met

Standards Maintained

Standards Met

Standards continue to be maintained through the Adult and Child Clinical Governance Councils.

Ratified measures in place. GREEN

Lead Director: Chief Operating Officer/ Chief Nurse

72%

78%

B. Feeling valued by work colleagues.

82%

C. Quality of job design.

3.45

80%

90% Y

80%

83%

84%

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

87%

Measures Agreed Y/N

2011 Milestone (To be met by st 31 March 2012)

2015 Standard (To be met by st 31 March 2016)

Current Performance (2011 Staff Survey)

A. Feeling satisfied with the quality of work and patient care delivered.

Measure

2012 Milestone (To be met by st 31 March 2013)

Baseline (2009 Staff Survey)

Means Goal 4: We value and develop our workforce and those supporting us

90%

Ratified measures in place.

AMBER

D. Working in a well structured team environment. Lead Director: Director of Workforce Development

43%

86%

Receiving job-relevant training, learning or development in the last 12 months

B. Appraised with personal development plans in the last 12 months Lead Director: Director of Workforce Development 3

A. Reporting good communication between senior management and staff. Lead Director: Director of Workforce Development

A staff survey task and finish group has been established to focus on and prioritise those key findings in the 2011 staff survey which require improvement and action.

AMBER 3.37

3.46

3.47

3.5 AMBER

ACTION PLANS TO IMPROVE PERFORMANCE

3.77

46%

49%

58% Non Compar -able

79%

87%

88%

90%

79%

72%

80%

82%

90%

29%

24%

40%

50%

80%

Ratified measures in place.

AMBER

Ratified measures in place.

AMBER

The areas in the action plan are being addressed through established workstreams

A. Suffering work-related injury in the last 12 months

30%

28%

26%

20%

Ratified measures in place.

B. Fairness and effectiveness of incident reporting procedures.

3.47

3.48

3.5

3.53

3.6

Ratified measures in place.

C. Perceptions of effective action from employer towards violence and harassment.

3.55

D. Impact of health and well-being on ability to perform work or daily activities. Lead Director: Director of Workforce Development

1.66

A. Staff job satisfaction.

3.57

3.54

3.6

3.65

AMBER

3.8 AMBER

1.59

1.5

1.4

1 GREEN

3.51

3.6

3.62

3.7

Lead Director: Director of Workforce Development B. Number of volunteers who believe that the Trust values their contribution Lead Director: Director of Strategy and Partnerships

GREEN

63% (May 11)

79% (2011 local Volunteer Survey)

70%

85%

Ratified measures in place.

AMBER

GREEN

The 2012 survey will measure job satisfaction to see whether improvements have been made.

C. Number of temporary staff who believe that the trust values their contribution Lead Director: Director of Workforce Development

A. Believing the Trust provides equal opportunities for career progression or promotion.

42%

94% (2009 Staff Survey)

50%

88% (2011 Staff Survey)

50%

95%

50%

95%

60%

98%

Y Yes â&#x20AC;&#x201C; subj ect to Boar d appr oval in Octo ber Y

Measure was approved by Means Goal 4 Standing Group in June 2012. The Board of Directors are asked to ratify the proposed milestones.

GREEN

Ratified measures in place. AMBER

Lead Director: Director of Workforce Development

This survey is a good barometer of whether our Trust principles and values are working and it is important to work with these results which are to be taken to Professional Advisory Forum (PAF) for their recommendation as to a way forward.

A staff survey task and finish group has been established to focus on and prioritise those key findings in the 2011 staff survey which require improvement and action. As part of the new appraisal process, links will be made to a Trust succession plan.

B. Our Trust can demonstrate mechanisms for learning, for example evidence of learning from incidents. Lead Director: Director of Workforce Development

50% (July 2012)

90%

ACTION PLANS TO DEVELOP MEASURES

Baseline and current performance currently sourced from appraisals. Performance indicators to be established and work to take place to revise baseline

PERFORMANCE RATING RED/AMBER/ GREEN

90%

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

61%

2012 Milestone (To be met by st 31 March 2013)

Evidence of learning: A. Our staff can identify what learning is relevant to their work and can demonstrate participation in at least one learning activity per year. Lead Director: Director of Workforce Development

2011 Milestone (To be met by st 31 March 2012)

Current Performance

Measure

Baseline

Means Goal 5: We improve our service through learning, research and innovation

AMBER

ACTION PLANS TO IMPROVE PERFORMANCE

Review of measure being undertaken alongside a refresh and re-launch of the appraisal process. A task and finish group has been established under the Director of Workforce Development and work will align with the current strategy refresh. Appropriate recommendations and approval will be made and sought via the standard governance route.

To be Agreed

A paper was taken to MG5SG in March 2012. The paper set out how the current strategy measure needed to be revised as part of the strategy refresh. In the interim a thematic review of learning from incidents and untoward occurrences will be conducted on a 6 monthly basis with the outcomes communicated via the relevant means goal meeting.

Lead Director: Medical Director We can demonstrate that we have initiated at least one innovative project in each service directorate per year, evaluated its benefits and shared the learning.

1582 (2010/11)

800

1200

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

682

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

161 (2009/ 10)

2012 Milestone (To be met by st 31 March 2013)

Evidence of commitment to service improvement through research by increasing the total number of people (service users/staff/carers) participating in research studies.

2011 Milestone (To be met by st 31 March 2012)

Current Performance

Measure

Baseline

Means Goal 5: We improve our service through learning, research and innovation

Ratified measures in place.

ACTION PLANS TO IMPROVE PERFORMANCE

A re-audit will take place between January â&#x20AC;&#x201C; March 2013 which will report into the quality accounts.

GREEN

Ratified measures in place.

RED

Lead Director: Medical Director

No current performance provided to the Performance Team on whether this measure has been met. An innovation task and finish group has been set up to progress the innovation agenda within LYPFT. Innovations are collected by service directorates and reported as part of the performance review process.

£818k

MPET funding £2.75m

£818k

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

£818k

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

We will maintain or increase the investment we attract through the MPET (Multiprofessional Education and Training) and SIFT (Service Increment for Training) funding streams.

2012 Milestone (To be met by st 31 March 2013)

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

Means Goal 5: We improve our service through learning, research and innovation

ACTION PLANS TO IMPROVE PERFORMANCE

Figures based on Trust’s finance information system are as follows:  MPET £2.75m  SIFT £616k  NSCAP £1.9m

Y Ratified measures in place.

GREEN

Measure to be reviewed as part of strategy refresh and linked to succession planning.

Lead Director: Medical Director 5

Evidence of commitment to service improvement through research by increasing the number of participants in National Institute for Health Research portfolio studies.

18 (2009/10)

155 (Apr – Aug)

300

400

600

Maintenance of staffing to facilitate this participation through successful bid for funding from WYCLRN for Oct 2012 – 2013.

Ratified measures in place.

AMBER

Lead Director: Medical Director

FRR4 (2010)

FRR4 (Quarter 1 2012/2013)

FPR4

FRR4

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

FRR4

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

Maintain optimum financial headroom possible to allow for flexible planning over 3-year planning period.

2012 Milestone (To be met by st 31 March 2013)

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

Means Goal 6: We provide efficient and sustainable services

Ratified measures in place.

GREEN

Lead Director: Chief Financial Officer

ACTION PLANS TO IMPROVE PERFORMANCE

The Trust has a good track record in achieving plan FFR whilst still accommodating unexpected events. The current 3 year annual planning assumptions have been set to facilitate a FRR of 4 with a minimum headroom of circa £1m (to a 2). The FRR assessments have been revised to incorporate York and North Yorkshire although this initially reduces the headroom capacity the overall FRR will be maintained. The Trust stress tests its financial metrics and re-forecasts on a monthly basis to ensure ongoing maintenance of FRR required trajectory.

Workforce productivity: A. Sickness absence rate

5.4%

B. Relative pay efficiency

0.98

C. Average labour costs Lead Director: Chief Financial Officer

£30k (2010)

4.7% (July 2012)

£33,000 (LYPFT) (Regional average £30,775)

4.0%

3.9%

3.6%

Maintain at comparator average

Maintain at comparator or average

Ratified measures in place.

AMBER

Regular updates are provided to the Board on sickness absence rates and work has been undertaken to improve performance.

The SHA no longer collect information on relative pay efficiency. This was collected for 2010 QUIPP. Average labour costs continue to be reviewed annually against regional QUIPP workforce information. AMBER

Environmental sustainability: we meet carbon reduction targets as set out in our carbon management plan, which is approved by the Carbon Trust.

Y 5,364 tonnes 2 CO (2007/08)

4,790.63 2 tonnes CO (Leeds Services)

5,050 tonnes 2 CO

4,900 tonnes 2 CO

4,023 tonnes 2 CO

Lead Director: Chief Financial Officer

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

2012 Milestone (To be met by st 31 March 2013)

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

Means Goal 6: We provide efficient and sustainable services

Current focus is upon estates rationalisation being driven by the transformation programme. The situation is currently still quite fluid, with several buildings having a reduced occupancy, but not yet completely vacated and other buildings being made to ‘work harder’ with more staff occupying the same space. This will have a significant further positive impact on carbon emissions although it is still too soon to measure and evaluate.

Ratified measures in place.

GREEN

ACTION PLANS TO IMPROVE PERFORMANCE

Ownership and overall facilities management responsibilities for the occupied buildings in York is still not clear (Trust ownership v’s Propco ownership) and looks likely to remain so for the next couple of months meaning that the Trust is not yet in a position to either measure consumption or devise and communicate a strategy for reducing such. The situation will become more clearer within the coming weeks.

Maintaining our positive reputation: the number of positive or neutral mentions in all media including local, regional and national press, broadcast and online media is significantly greater than the number of negative mentions. A. Positive B. Neutral C. Negative

We have exceeded our milestones for positive media coverage so far this year 2012.

GREEN 75% 25%

69% (22) 19% (6) 12%(4)

77%

79%

85%

23%

21%

15%

22%

30%

(Apr 12 â&#x20AC;&#x201C; July 12)

Lead Director: Director of Strategy and Partnerships 5

Ratified measures in place.

Measure of effectiveness of succession planning: Number of staff achieving promotion following attendance on Institute for Leadership & Management (ILM) Programmes. Lead Director: Director of Workforce Development

17%

Robust business continuity plans in place for all areas of Trust business.

80% (2009/10)

17%

Ratified measures in place.

GREEN

100%

An Organisational Development Strategy has been developed. The strategy aims to consider amongst other things succession planning and talent management and will naturally review the measures of success. It is unlikely that the current measure will be retained however it will be developed in accordance with the Trust strategy refresh and the Workforce Development Strategy development.

Directorate business continuity plans are in place. A process of peer review commenced in October 2011 and it is planned to review and update plans in September 2012.

Ratified measures in place. GREEN

Lead Director: Chief Financial Officer

The Trust-wide Major Incident & Business Continuity Plan has been revised as an LYPFT document and has now been approved and ratified. 33

Achieved (2010)

Compliance maintained (August 2012)

Maintain complianc e

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

Maintain complianc e

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

Compliance with requirements of: A. Care Quality Commission B. Monitor C. West Yorkshire Fire and Rescue Service D. Health and Safety Executive E. Environment Agency

2012 Milestone (To be met by st 31 March 2013)

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

Means Goal 7: We govern our Trust effectively and meet our regulatory requirements

ACTION PLANS TO IMPROVE PERFORMANCE

Ratified measures in place.

GREEN

Lead Director: Chief Financial Officer 2

Timely provision of information to support â&#x20AC;&#x2DC;real timeâ&#x20AC;&#x2122; measurement of outcomes and performance. Lead Director: Chief Financial Officer

97% of info available within 30 days (2010)

93.7% of data input within 15 days (July 2012)

97% of info available within 21 days

97% of info available within 15 days

97% of info available within 12 hours

The figure of 93.7% is below target and represents a reduction on the 96.2% previously reported.

Ratified measures in place.

AMBER Leeds Services

This reflects problems with data entry during the implementation of transformation. Care services undertook work to ensure that missing data was input to provide accurate contract monitoring data.

Level 1

Level 2

Level 3

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

Level 1

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

Achievement and maintenance of Risk Management Standards for Trusts requirements.

2012 Milestone (To be met by st 31 March 2013)

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

Means Goal 7: We govern our Trust effectively and meet our regulatory requirements

ACTION PLANS TO IMPROVE PERFORMANCE

Ratified measures in place. GREEN

Lead Director: Medical Director 4a

Effectiveness of Board of Directors. Lead Director: Director of Strategy and Partnerships

Evidence that Board of Directors is effective (2010)

Board of Directors is effective as evidenced by results of Board Developme nt Tool

Evidence that Board of Directors is effective

Ratified measures in place.

GREEN

The Board Development Plan has been updated to take account of further Board workshops. Areas have been identified for further development which do not adversely impact on this assurance category, but demonstrate the Boardâ&#x20AC;&#x2122;s commitment to continuous improvement. The Board is currently undergoing an external assessment of performance by Real World Group.

80%

Data Quality Improvement Plan: contract data provided to commissioners is consistent with data available to commissioners through the Secondary Users Service (SUS). Lead Director: Medical Director

+/-4% maximum variation (2010)

82%

90%

ACTION PLANS TO DEVELOP MEASURES

+/-4% maximum variation (proposed )

+/-3% maximum variation

+/-1% maximum variation

GREEN

The Trust is currently operating well within the 2012 milestone of +/- 3%

Ratified measures in place.

+/-1.5% (Outpatient s/ Community , Apr - July â&#x20AC;&#x2DC;12)

ACTION PLANS TO IMPROVE PERFORMANCE

The Governors Training and Development Task and Finish group will develop an action plan for agreement at the Council of Governors meeting.

Ratified measures in place.

+/-1.4% (Inpatients, Apr - July â&#x20AC;&#x2DC;12)

PERFORMANCE RATING RED/AMBER/ GREEN

80%

Measures Agreed Y/N

80%

2015 Standard (To be met by st 31 March 2016)

2011 Milestone (To be met by st 31 March 2012)

Effectiveness of the Council of Governors: percentage of governors completing an annual effectiveness questionnaire who indicate that they believe the Council to be effective. Lead Director: Director of Strategy and Partnerships

Measure

2012 Milestone (To be met by st 31 March 2013)

Baseline

Current Performance

Means Goal 7: We govern our Trust effectively and meet our regulatory requirements

GREEN

Meeting the pledges within the NHS Constitution: demonstrating that we are using Trust values in a way which is meaningful to staff and service users. Percentage of Trust staff who responded positively to the following questions via the Trust barometer poll; A. Are the Trust values important to your work? B. In your experience, do staff you have contact with behave in ways that reflect our values? Lead Director: Director of Strategy and Partnerships

ACTION PLANS TO DEVELOP MEASURES

PERFORMANCE RATING RED/AMBER/ GREEN

Measures Agreed Y/N

2015 Standard (To be met by st 31 March 2016)

2012 Milestone (To be met by st 31 March 2013)

Baseline

2011 Milestone (To be met by st 31 March 2012)

Measure

Current Performance

Means Goal 7: We govern our Trust effectively and meet our regulatory requirements

ACTION PLANS TO IMPROVE PERFORMANCE

As part of our Trust strategy refresh we will be further embedding our Trust values across LYPFT in a number of ways:

Ratified measures in place.

 

Disagree/ strongly disagree: 14%

Disagree/ strongly disagree: 13%

Agree/ strongly agree: 86%

Agree/ strongly agree: 87%



10%

AMBER

  91%

94%

90%

We are also looking at the way in which we communicate with each other in a valuesbased way, including reviewing standardised Trust letters to ensure that they are respectful and reflective of our values.

Leeds Services Disagree/ strongly disagree: 51%

Disagree/ strongly disagree: 37%

Agree/ strongly agree: 49%

Agree/ strongly agree: 63% Leeds Services



49%

40%

20%

Our strategy refresh launch will now take place in April 2013, at the same time we will be promoting our values. GREEN

51%

Displaying our values charter across Y&NY sites Holding values awareness stands across Y&NY Holding BYT events in Leeds and York on our strategy refresh and values Encouraging new staff to become values champions Embedding our values in recruitment, PDP and appraisal processes. Holding a stand at this year’s Annual Members’ Day

60%

80%

AGENDA ITEM 12

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Equality Objectives Progress Report

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Jill ill Copeland Director of Strategy and Partnerships Caroline Bamford Head of Strategy & Inclusion

PAPER AUTHOR:

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC: GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

IMPACT ON THE TRUST’S S MEANS GOALS (please tick relevant box) MG1 We provide excellent quality, evidence-based, evidence based, safe care that promotes recovery and inclusion MG2 MG3

We involve people in planning their care and in improving services We work with partner organisations to improve health and lives

MG4 MG5 MG6 MG7

We value and develop our workforce and those supporting us We improve our services through learning, research and innovation We provide efficient and sustainable services We govern our Trust effectively and meet our regulatory requirements

       



SUMMARY: The attached paper sets out mid-year year progress against our organisational equality objectives for 2012/13. The Public Sector Equality Duty under the Act (2010) requires public sector organisations as of 6 April to: 

Publish ublish one or more equality objectives which are evidence based and embedded within business planning, at least every four years



Publish information ion to show their compliance with the Equality Duty, at least annually

The DH Equality Delivery System (EDS) has been used as the framework to identify our equality objectives and to monitor progress through consultation with our stakeholders and local interests under the following four EDS goals: 1. Better health outcomes for all 2. Improved patient access and experience 3. Empowered, engaged and well-supported well staff 4. Inclusive leadership at all levels At this mid-year year stage, progress is on track to achieve all priority actions by March 2013. We have also completed an analysis of workforce and service user data for this mid-year period and identified areas for further work. work

RECOMMENDATIONS: Board members are asked to: 

Confirm that they are assured that sufficient progress is being made against our 2012/13 equality objectives detailed within Appendix A.



Confirm that they support the priorities for further work identified at section 4 of the main paper,, which are based on the mid-year mid year equalities data repor reporting detailed at Appendix B.

Equality Objectives Progress Report 1.

Purpose 1.1

Background 2.1

The aim of this paper is to inform the Board of Directors of mid-year progress against our published organisational equality objectives for 2012/13.

The Public Sector Equality Duty under the Equality Act (2010) requires public sector organisations as of 6 April 2012 to: 

Publish one or more equality objective which are evidence based and embedded within business planning, at least every four years



Publish information to show their compliance with the Equality Duty, at least annually

2.2

In February 2012 the Means Goal 7 Group approved the use of the DH Equality Delivery System (EDS) as the framework to self-assess our equality performance and to identify our equality objectives through consultation with our local stakeholders and local interests. This was achieved through a joint approach with NHS equality leads in Leeds and through consultation with local interest organisations within the York and North Yorkshire area.

2.3

During February 2012 four panels were held with local stakeholders, where our equality progress was assessed against the 18 outcomes under the four main EDS goals: 1.

Better health outcomes for all

Improved patient access and experience

Empowered, engaged and well-supported staff

Inclusive leadership at all levels

2.4

Through this consultation process with our local stakeholders and local interests, equality objectives were identified for 2012/13. It should be noted that our stakeholders identified a number of process-orientated priorities, with the view that these would support the identification and implementation of outcomes-focused objectives, aligned to the Trust Strategy from 2013 onwards.

2.5

In April 2012 the Means Goal 7 Group approved our organisational equality objectives, identified through the EDS consultation process: 

To improve the collection, analysis and use of equality data and monitoring for protected groups



To develop a consistent approach across the local NHS economy in respect of equality leadership, staff empowerment and access to development opportunities

To further develop the involvement and engagement of protected groups and “local interests” including service users, carers, staff, third sector, clinical commissioning groups and the local authority



To improve access and service user experience and choice for protected groups.

Progress 3.1

Since April 2012 systems have been implemented to improve the analysis of our workforce and for people who use our services. This includes, for example: the conversion rates for people who apply and are appointed to posts within the Trust; and length of stay for people using our mental health services within inpatient settings.

3.2

Further engagement and partnership work has been undertaken within our Leeds and York and North Yorkshire geographical areas to support the development and implementation of our equality objectives. For example, the development of project work through York Mind to improve access to and experience of mental health services within York and North Yorkshire for BME communities.

3.3

At this mid-year stage, progress is on track to achieve all priority actions by March 2013. Full details of our equality objectives for 2012/13 and progress as of September 2012 is attached at appendix A.

Analysis of Findings 4.1



An analysis report of workforce and service user data for this period is attached at Appendix B. Areas identified for further work are as follows: 

In line with national NHS workforce profiles, staff from BME backgrounds are underrepresented at bands 6 to 8



Appointment rates for people who are Black or Black British are lower than for other groups (0% for the reporting period)



The mean length of stay within Leeds inpatient wards is most concentrated for Asian or Asian British males averaging 1,020 days out of the total 4,827 days for the reporting period



Service user ethnicity data completeness was 81.1% for York and North Yorkshire services and 93.5% for Leeds services for the reporting period.

Next Steps 5.1

Further work will be undertaken to address the findings detailed within section 4.

5.2

Engagement events with our local interest organisations in Leeds and York and North Yorkshire are taking place in October and November 2012. This will provide an opportunity to share progress to date and to identify future equality priorities aligned to our Strategy refresh.

Recommendation 6.1

Board members are asked to: ď&#x201A;ˇ

Confirm that they are assured that sufficient progress is being made against our 2012/13 equality objectives detailed within Appendix A.

ď&#x201A;ˇ

Confirm that they support the priorities for further work identified at section 4, which are based on the midyear equalities data reporting detailed at Appendix B.

Caroline Bamford Head of Strategy and Inclusion October 2012

Appendix 1 Key Actions completed Actions on track but not completed Actions not on track

Objectives

Timescale

Priority Actions

Progress Review Sept 2012

To improve the collection analysis and use of equality data and monitoring for protected groups.

Oct. 2012

1.1 Identify good practice in collecting equality monitoring data for complaints. Implement recommendations to address current gaps.

Scoping completed to identify best practice in collecting equality monitoring data for complaints. Initial meeting with complaints managers across the 4 participating trusts held. On track to implement system by March 2013. Complaints received in 2011 – 52 Complaints upheld in 2011 – 4 Complaints partially upheld in 2011 – 15 Complaints not upheld in 2011 – 24

Mar 2013

Jun 2012

From Sep 2012

1.2 Disaggregate and critically analyse Community Mental Health Service User results by protected characteristics to identify any variations in satisfaction rates and common themes 1.3 Disaggregate and analyse service user and carer postal survey results by protected characteristics to identify any variations in satisfaction rates and common themes.

CMHSU 2012 survey results analysed by ethnicity, age and gender. No specific variations in satisfaction rates identified. Due to the small sample size for the national survey information will be triangulated against the LYPFT postal satisfaction survey results.

Carer survey disseminated over a period of 19 months from September 2010 until March 2012. Overall, in total 42 responses as at 31/8/12. Analysis of demographic data is consistent with the national profile of a carer ie predominately white British female aged 40 to 60 years of age (census 2001). To enable service user and carer satisfaction data to be collected on a more frequent basis an automated postal survey from the PARIS information system is being rolled out across the Trust. Due to software difficulties a phased roll out process is being implemented and timescales are as follows:  October 12- pilot phase  November 12- phased roll out across services to commence  January 2013- roll out across all services with access to PARIS.

Objectives

Timescale

Priority Actions

Progress Review Sept 2012

Oct 2012

1.4 Replace current Equality Impact Assessment (EIA) processes with a simplified Equality Analysis Process. Strengthen governance and monitoring processes through the implementation of a centralised audit and quality assurance system. Develop and monitor implementation for policies and procedures via the Policies & Procedures Standing Support Group

EIA processes replaced with simplified equality analysis process based on DH guidelines to be implemented for all policies and procedures from October 2012. Governance and audit processes have been agreed and will be monitored via the Policies and Procedures Standing Support Group.

April 2012

1.5 Disaggregate and analyse 2011 staff survey results by protected characteristics to identify any variations in satisfaction rates and common themes.

Analysis completed; variation in satisfaction rate in relation to flexible working opportunities for staff with a disability or long term health condition. Please see section 1.6 for details of further actions to address this.

Oct 2012

1.6. Investigate and implement methods to improve collection and analysis of workforce data by protected groups to include the following areas: A) Applications for flexible working B) Reasons for leaving

A) Applications for flexible working No consistent method of recording or availability of data on flexible working (application/approval) held centrally although capacity within ESR to record this. A reporting and monitoring process will be implemented as part of the review of the Flexible Working Procedure due to be completed by December 2012. B) - Reasons for leaving Process for analysing reasons for leaving now in place. Initial analysis undertaken for the period 1/4/12 to 31/08/12. Please see data report at Appendix B, section 4.

Objectives

Timescale

Priority Actions

Progress Review Sept 2012

C) Access to health and wellbeing programmes

C) Workforce Wellbeing: (i) Occupational Health For the period 1/4/12 - 31/8/12: Number of referrals to Counselling service – 50 Number of counselling sessions – 265 Demographic data collection commenced in August 2012 and reported in next reporting period. (ii) Global Corporate Challenge 427 participants in 2012 cohort. 52 members of staff participated for the second consecutive year. Demographic profiles are not collected. If LYPFT participates in the programme in 2013/14, demographic data will be collected as part of the application process. (iii) Have Fun Feel Good 12.2% of Have Fun Feel Good members are LYPFT staff. This equates to 151 staff as at 31st August 2012. Demographic profiles are not currently collected, scoping is currently being undertaken to enable demographic data to be collected. (iv) What’s Your Goal 718 staff members have registered with the campaign since its launch in February 2012. Demographic profiles are not collected.

Sep 2012

1.7. To scope and implement Process for analysing recruitment conversion rates now in place. Initial analysis processes for analysing undertaken for the period 1/4/12 to 31/08/12. Please see data report at Appendix conversion rates i.e. the B, section 3. number of people who people apply compared to the number of people appointed, at application and appointment stage by protected characteristics.

Objectives

Timescale

Priority Actions

Progress Review Sept 2012

To develop a consistent approach across the local NHS economy in respect of equality leadership, staff empowerment and access to development opportunities.

March 2013

2.1 To develop and implement an Innov8 Charter action plan to support the development of “different leaders” at all levels within the organisation. To undertake a review with “Race for Opportunity” to establish a current base line and to support the development of improvement targets for 2012/13.

Action plan developed in May 2012, bi-monthly joint meetings with SHA Innov8 team and the four trusts within the region signed up to the charter. Current priority work includes:  Development of pilot one day inclusive leadership programme to be delivered by “Race for Opportunity” in November 2012.  Development and implementation of inclusive leadership workshop for Board members, governors and non-executive directors in January 2013.  Baseline analysis of uptake of leadership development and long course applications undertaken. Please see the data report at Appendix B, section 2.

Sept 2012

2.2 Review diversity training and explore better use of local interest expertise. Work with Equality Advisory Panel members to support with the content and delivery.

LYPFT diversity training is reviewed on an ongoing basis and input sourced from internal services and external partners for example learning disability services, Recovery and Social Inclusion workers, Gender Identity Service, older age services, local faith representatives and carers services to ensure that training is relevant and adheres to current best practice.

March 2013

2.3. Develop staff networks and agree TOR. Produce options appraisal for advisory panel.

To be reviewed and staff consultation process to be agreed at October NHS Equality Leads meeting.

March 2013

2.4 To scope the integration of the “Competency Framework for Equality and Diversity Leadership” within leadership and development programmes, developing a framework for inclusive leadership across management structures which support the organisation to advance equality outcomes.

Development of pilot one day inclusive leadership programme with SHA Innov8 team to be delivered by “Race for Opportunity” within LYPFT in November 2012.

Objectives

Timescale

Priority Actions

Progress Review Sept 2012

To further develop the involvement and engagement of protected groups and ‘local interests’ including service users, carers, staff, third sector, Clinical Commissionin g Groups and the local authority.

Sept 2012

3.1 To develop and implement an engagement plan to pick up on priority gap areas from the assessment process e.g. trans gender and disability.

Engagement plan developed in July 2012 achievements to date include:  Consultation work with service users from Leeds Gender Identity service to inform work to improve the experience of transgender people within NHS services (primary and secondary).  Extending membership of LYPFT Diversity and Inclusion Forum to include a wider representation of people from protected groups and “local interest” organisations across Leeds and York and North Yorkshire.  LYPFT equalities partnership work to be showcased at DH Equality and Diversity Summit in Leeds in November 2012 to inform CCGs and the local authority of best practice within health and social care.

To improve access and service user experience and choice for protected groups

March 2013

4.1 Implement joint action plan with Touchstone Community Development Service to address access and outcomes inequalities for service users from BME communities.

Support from 6 Community Development Workers (CDWs) located on inpatient wards with priorities for actions mutually agreed with Clinical Team Managers. Overall objectives include: ‘Improving the quality of inpatient stays for BME clients’ and ‘Increasing race, ethnicity and cultural awareness amongst staff and service users’. Action areas include service improvement and developing inclusive literature, facilitating discussions around ethnic care needs, facilitating in regular discussion forums with staff/service users around cultural and diversity awareness, developing vocational support and awareness/access to other community and culturally appropriate services. Timescales for review and evaluation set at December 2012.

March 2013

4.2 Critically analyse service user surveys to identify variations in service user satisfaction and access.

CMHSU 2012 survey results analysed by ethnicity, age and gender. No specific variations in satisfaction rates identified. Due to small sample size for the national survey, information will be triangulated against the LYPFT postal satisfaction survey results.

Appendix B Equality and Diversity Data Analysis Report

1.0 LYPFT WORKFORCE PROFILE As of 1 April 2012 workforce, membership and service user equality data is produced bi-annually and published annually, to meet the requirements of the Equality Act Public Sector Equality Duty. Since merging with mental health and learning disability services in York and North Yorkshire from 1 February 2012, our workforce has increased by approximately 27.6%, therefore any comparisons made in this report against previous data is shown in real time.

1.1 Ethnic Profile of Staff by Agenda for Change Pay Banding

Ethnicity by Banding as at 31st August 2012

Current activities to address Ethnic profile inequalities

120.0%

11.9% of Leeds & York NHS PFT staff are from a BME background.

100.0% 94.7% 94.8% 94.3% 100.0% 92.6% 94.1% 94.1% 90.0% 90.0% 88.0% 88.1% 86.8%

80.0% 60.0%

% White %BME

40.0% 20.0%

10.0% 5.7%

11.9% 12.0% 10.0%13.2% 7.4% 5.2% 5.9% 5.3% 5.9% 0.0%

0.0%

Staff from an Ethnic Background by Bandings

Figure 7.3.1 illustrates that by banding, BME staff are under-represented in comparison to the local population (census 2001; Leeds 8.2%, York 2.1%, North Yorkshire 1.1%) across Agenda for Change bandings 1, 6, 7, 8b, 8c and 9. The following activities aim to support the development of a more balanced workforce:

ď&#x201A;ˇ

Institute of Leadership and Management (ILM) development programmes Fit For the Future, ILM levels 4, 5 and 7. 9% of participants in the 2011-12 cohort were from BME background. This is slightly higher than the BME demographic figure for Leeds of 8.2%. 8% of BME staff undertook long course development opportunities during this period also. The Trust is participating in the regional Innov8 Alliance action plan development and implementation to build more diverse leadership.

1.2 LYPFT Staff: Ethnic Origin as at 31st August 2012 st

Ethnic Origin White Mixed Background Asian Background Black Background Other Backgrounds Not Stated Total

LYPFT: 31 August 2012 Headcount % 2932 87.2 43 1.3 146 4.7 185 5.5 15 0.4 30 0.9 100.0% 3362

1.3 Number & Percentage of staff who have declared a disability

Trust Disability Profile - 31st August 2012 4% (146)

23% (753)

No Not Declared 73% (2463)

As at 31 August 2012, 4% of Trust staff declared themselves as having a disability compared to 5% in January 2012. However the number of staff with a disability has increased in real terms from 112 to 146.

Yes

Disabled No Not Declared Yes Total

LYPFT: 31 August 2012 Headcount % 2463 73 753 23 146 4 3362 100.0%

1.4 Religion or Belief staff profile

Current activities to Promote Faith and Spirituality st

LYPFT Staff - 31 August 2012 Religion or Belief

Headcount

Atheism

359

10.7%

Buddhism

0.4%

Christianity

1650

49.1%

Hinduism

1.4%

I do not wish to disclose my religion/belief

924

27.5%

Islam

1.61%

Jainism

0.0%

Judaism

0.4%

Other

284

8.5%

Sikhism

0.4%

3362

100.0%

Total

 Quarterly Mental Health & Healing Forums provide an opportunity for staff, service users and carers to explore and discuss the spiritual and religious aspects of mental health within a faith and with a senior faith leader. Each Forum focuses on themes around how the culture or faith understands and defines mental health and the support structures available for someone of the same faith who may be experiencing mental health difficulties.  Community Faith Volunteers from a number of religious and spiritual backgrounds provide support to Leeds & York PFT staff, service users and carers around faith needs and provide links with appropriate services. The provision is being reviewed and further developed.  The Trust’s Spiritual Assessment Tool is a framework which integrates an individual’s spiritual dimension in daily mental health care provision. The Tool and associated guidance have now been incorporated within the CPA process.

1.5 Sexual Orientation staff profile st

LYPFT Staff - 31 August 2012 Sexual Orientation

Headcount

Bisexual

0.4%

Gay

1.3%

Heterosexual

2416

71.9%

I do not wish to disclose my sexual orientation

857

25.5%

Lesbian

0.9%

3362

100.0%

Total

Currently 74.5% of Trust staff have declared their sexual orientation, of which 2.6% have declared themselves as lesbian, gay or bisexual (LGB). The Government estimate 5-7% of the population is LGB.

1.6 Staff Age profile â&#x20AC;&#x201C; 31st August 2012 (Excludes Bank Staff) st

Age Band 16 - 20 21 - 25 26 - 30 31 - 35 36 - 40 41 - 45 46 - 50 51 - 55 56 - 60 61 - 65 66 - 70 71 & above Total

LYPFT: 31 August 2012 Headcount % 7 0.2% 170 5.1% 332 9.9% 445 13.2% 410 12.2% 494 14.7% 556 16.5% 510 15.2% 280 8.3% 130 3.9% 27 0.8% 1 0.0% 3362 100.0%

Actions to Address Age inequalities In January 2012, 25.3% of Trust staff were aged over 50, in August 2012 this figure had increased to 28.2%. As at August 2012, 7 members of staff were aged 20 or under. Targeted work is being undertaken to promote opportunities within the Trust to younger people through student and school placements.

2.0 LYPFT WORKFORCE TRAINING UPTAKE BY DEMOGRAPHIC PROFILE: INSTITUTE OF LEADERSHIP & MANAGEMENT PROGRAMMES (Fit for the Future, ILM 4, 5 & 7) AND LONG COURSES 2011 2011-12 During 2011-12, 87 members of staff participated in ILM programmes and 47 staff undertook long courses as personal and professional development. 2.1 50.5% of staff undertaking ILM programmes in the 2011 -12 cohort 2.2 represented those from ages 41-50years.

ILM uptake by Age 2011-12 1.1% 3.4%

ILM uptake by Gender 2011-12 2011

21-25 26-30

3.4% 1.1% 8.0%

11.5%

1.1%

31-35 33.3%

36-40

9.2%

41-45

11.5%

Male 65.5%

46-50

28.7% 21.8%

Female Do not wish to disclose

51-55 56-60 61-65 Do not wish to disclose

2.3 9.2% of participants were from a BME background, 88.5% white and 2.3% did not wish to disclose their ethnicity.

2.4

ILM uptake by Ethnicity 2011 2011-12

2.3%

2.3% 2.3% 2.3% 2.3%

2.3% 2.3%

10.3%

White

Heterosexual

Black

Gay

Mixed 88.5%

Asian Other Do not wish to disclose

85.1%

Do not wish to disclose Lesbian

2.5

2.6

ILM uptake by Disability 2011-12 2011 5.7%

1.1%

2.3%

Atheism 21.8%

Christianity

21.8%

2.1.1 Long course uptake by Age 2011-12 10.6%

10.6%

None

Yes Do not wish to disclose

96.6%

Hindusim

2.1.2 Long course uptake by Gender 2011-12 2011

26-30 31-35 36-40

10.6%

41-45

8.5%

46-50

19.1%

51-55 56-60 61-65

2.1.3 Long couse uptake by Ethnicity 2011-12

2.1.4 Long course uptake by Sexual Orientation 2011-12

21-25

6.4% 4.3%

25.5%

Do not wish to disclose Other

47.1%

4.3%

2.3%

2.1% 4.3% 2.1%

17.0%

White

Female 83.0%

25.5%

Heterosexual

Mixed

Male

Asian 91.5%

Black

74.5%

Do not wish to disclose

2.1.5 Long course uptake by Disability 2011-12 0.0% Yes

14.9%

No 85.1%

Not Declared

3.0 LYPFT â&#x20AC;&#x201C; Recruitment & Selection The following data illustrates recruitment conversion between 1 April 2012 to 31 August 2012 and it should be noted that this data cannot be correlated against existing Trust workforce demographic profiles since this data only captures recruitment activity between these reporting periods.

3.1 Age Applications Age band Under 20 Age 20-24 Age 25-29 Age 30-34 Age 35-39 Age 40-44 Age 45-49 Age 50-54 Age 55-59 Age 60-64 Age 65-69 Age 70+ Undisclosed

Headcount

Totals

179 1165 987 597 406 368 343 188 77 24 7 1 3 4345

Shortlisted

Headcount

4.1% 26.8% 22.7% 13.7% 9.3% 8.5% 7.9% 4.3% 1.8% 0.6% 0.2% 0.0% 0.1% 100.0%

22 164 192 120 92 93 79 61 29 11 1 0 1 865

Appointed

Headcount

2.5% 19.0% 22.2% 13.9% 10.6% 10.8% 9.1% 7.1% 3.4% 1.3% 0.1% 0.0% 0.1% 100.0%

3 36 36 32 26 16 19 12 6 1 1 0 0 188

1.6% 19.1% 19.1% 17.0% 13.8% 8.5% 10.1% 6.4% 3.2% 0.5% 0.5% 0.0% 0.0% 100.0%

The highest numbers of applications received were from age groups 20-29 at a collective 49.5%. 41.2% were shortlisted and 38.2% of appointments made across all bandings were from these age categories. This was closely followed by 23% of applications made by those in the 30-39 groups and appointments at 30.8%. Overall, most age groups had an appointment rate that was similar or better than the application rate, however there was a marked difference in the Under 20 category with only 1.6% of overall appointments. Although the current workforce constitutes 28.2% of staff over the age of 50, appointments from the over 50 age bands during this reporting period equated to only 10.6%.

3.2 Disability Applications Disability Disabled Not Disabled Not declared Totals

Shortlisted

Appointed

Headcount

234 4074 39 4347

5.4% 93.7% 0.9% 100.0%

70 778 17 865

8.1% 89.9% 2.0% 100.0%

13 169 6 188

6.9% 89.9% 3.2% 100.0%

5.4% of applications made to the Trust came from those who declared a disability. In the 2001 census, 18% of the population in Leeds indicated they had a long term ilness, health problem or disability. The Trust’s ‘Two Ticks’ accreditation enables ongoing commitment in employment activities. One of the requirements of this is that disabled applicants meeting the essential criteria for a role are automatically given an interview. The similarity in the applications and shortlisted figures for disabled applicants indicate that the Trust’s interview guarantee scheme for disabled applicants is working effectively. The conversion rate from being shortlisted to appointment was lower for disabled applicants with 1.2% difference. This can be explained by the interview guarantee scheme. Those not disabled would need to demonstrate that they meet desirable as well as essential criteria in order to be interviewed. In these cases, they would be better placed to be successful at interview.

3.3 Ethnic Origin Applicants Ethnicity Headcount Asian or Asian British Indian 275 Asian or Asian British Pakistani 473 Black or Black British – Caribbean 48 Black or Black British – African 754 White 2677 Undisclosed 61 Totals 4288 17

Shortlisted

Appointed

Headcount

6.4%

5.2%

3.3%

11.0%

7.0%

8.3%

1.1%

0.6%

0.0%

17.6% 62.4% 1.4% 100.0%

79 638 9 832

9.5% 76.8% 1.1% 100.0%

14 144 2 181

7.7% 79.5% 1.1% 100.0%

36.1% of overall applications and 22.3% of all those shortlisted were from Black Ethnic Minority (BME) communities during this reporting period. 19.3% of those appointed were from Black Ethnic Minority (BME) backgrounds which can be compared to the local BME populations (Census 2001: 8.2% Leeds, 2.1% York and 1.1% North Yorkshire).

3.4 Gender Applications Gender Male Female Totals

Shortlisted

Appointed

Headcount

1343 2997 4340

30.9% 69.1% 100.0%

224 640 864

25.9% 74.1% 100.0%

55 133 188

29.3% 70.7% 100.0%

During this period there were more female applicants than male. 70.7% of those appointed were female in comparison to 29.3% male.

3.5 Religion or belief Religion or Belief

Applications

Shortlisted

Appointed

Headcount

610 2081 110 628 7 428 400 4264

14.3% 48.8% 2.6% 14.7% 0.2% 10.0% 9.4% 100.0%

126 433 14 74 3 96 108 854

14.8% 50.7% 1.6% 8.7% 0.4% 11.2% 12.6% 100.0%

36 92 4 16 0 15 24 187

19.3% 49.2% 2.1% 8.6% 0.0% 8.0% 12.8% 100.0%

Atheism Christianity Hinduism Islam Judaism Other Do not wish to disclose Totals

The Trust attracts applicants from a wide range of faiths and beliefs. The percentage of those appointed from each group varies in comparison to the local demographic data for that particular group. Appointment rates of those of a Hindu and Islamic faith exceed the figures for local areas. Hinduism (Leeds 0.6%, York 0.19%), Islam (Leeds 3%, York 0.57%).

3.6 Sexual orientation Sexual Orientation Gay man Gay woman/lesbian Bisexual LGB total Heterosexual/straight Do not wish to disclose Totals

Applications

Shortlisted

Appointed

Headcount

57 42 45

1.3% 1.0% 1.0%

14 9 7

1.6% 1.0% 0.8%

3 1 2

1.6% 0.5% 1.1%

144

3.3

3.4

3.2

3915

90.1%

761

88.0%

170

90.4%

286 4345

6.6% 100.0%

74 865

8.6% 100.0%

12 188

6.4% 100.0%

3.3% of applicants declared themselves lesbian, gay or bisexual (LGB) and 3.2% of those appointed were LGB. Government estimations are that around 5-7% of the population is LGB which illustrates an under-representation against national trends.

4.0 Reasons for Leaving Demographic analysis for the period 1st April 2012 to 31st August 2012 highlights overall the most common leaving reasons for the Trust as: 

End of Contract, Voluntary Resignation (Other), Retirement due to Age or Ill Health, Voluntary Resignation due to Relocation.

However ‘reasons for leaving’ amongst demographic groups varies as explained below. It should be noted that due to small numbers within some of the categories, a statistical assessment is unable to provide an accurate indicator against that particular reason. The overall analysis identifies that 68.3% of staff who left the Trust between this period were male and 31.7% female and the main reasons cited were end of contract and retirement for this group. The percentage of Black Minority Ethnic people leaving the Trust during this period was 18.3% and most activity is within the following categories: voluntary resignation – promotion, voluntary resignation – relocation, voluntary resignation – other/not known, end of contract and retirement. As highlighted in section 3.3, in terms of recruitment conversion, this can measured against the number of appointments made of BME staff (19.3%) during the same period. 6.25% of those who left declared disability with the main reasons for leaving as: voluntary resignation – other/not known, voluntary resignation – health, retirement and end of contract.

5.0 Equality and Diversity – MEMBERSHIP 1 Public Membership Ethnicity Profile – 31st August 2012

Not Stated

164

Other

338

Asian or Asian British

186

  

703

Black or Black British

On 31 August 2012 the Trust membership base was 16,413 with an ethnicity breakdown as follows:-

272

Staff Service User

457

Public Mixed

White

3,236 0%

195

950

20%

9,611 40%

60%

80%

100%

85% White 8.8% BME 6.2% Not stated

Overall membership has increased by 834 since the last reporting period. There has been a percentage decrease of Trust members from BME communities from 10.3% on 31 January 2012 to 8.8% on 31 August 2012. This difference reflects membership recruitment in the new geographical patch in North Yorkshire and York (NYY). The ethnicity spread in this patch is very different to the Leeds community. An example of this would be in York Central BME representation in the local population is the equivalent to 2% whereas in Leeds Central BME representation in the local population is 12%. Membership recruitment is currently very NYY-driven therefore we can expect to see the membership base change considerably to represent our new patch. In the membership base as a whole, our lowest representation in regards to ethnicity is White (British; Irish; any other White background) with 0.66% of the local population recruited. Our highest representation is Black or Black British (British; Irish; any other White background) with 2.4% of the local population recruited. The ethnicity, gender and age profiles of current membership continue to fall broadly in line with that of the constituencies that they serve, with no significant deficit. These balances will continue to be closely monitored as membership develops. Demographic data around sexual orientation: Gay/lesbian 168 Bisexual 63 Heterosexual 1267 Asexual 2

5.2 NHS North Yorkshire and York Membership Trajectory

The government estimates that 5-7% of the general population are LGBT. Currently Leeds & York PFT membership shows a 15.6% average LGBT representation of those that have disclosed sexual orientation. Since February 2011, data collection on disability was introduced. The figures to date for declaration of disability or long term health condition are; Yes 293 No 865 19% of U.K working age population is registered disabled (www.dlf.org.uk). Currently Trust membership illustrates that since collecting disability demographics (February 2011), of those that have disclosed, 25.3% have declared a disability or long term health condition North Yorkshire and York update The target membership in table 5.2 includes staff members. Service User and Carer groups The membership base in North Yorkshire and York currently stands at 644 (579 public members and 65 service users/carers members). Service users and carer representation currently stands at 10% of the membership base in North Yorkshire and York. When compared with the service user and carer base in Leeds, there is very slight shortfall against the average of 10.7%. In order to increase this average to the proportionate ratio to Leeds, a further 500 service users and carer members will be recruited over the next six years. Table 1 highlights service user/carers support groups throughout North Yorkshire and York which will be targeted as recruitment opportunities.

Table 1 York Carers Forum North Yorkshire & York Families & Carers Service Recovery after psychosis Alzheimer's Society Carers Support Group Contact a Family Groups for carers in York York & District Mind Harrogate & Area-charities and volunteers Craven Mind Harrogate & Ripon Mind Patient Advice and Liaison Service Mental Health First Aid (MHFA)

Location York central York central York central York central York central York central York central North Yorkshire North Yorkshire North Yorkshire North Yorkshire North Yorkshire

The forthcoming events for this year in North Yorkshire and York are listed in Table 2. Table 2 Date

Event

Constituency

Sep 2012

York Peace Festival

Central York

Sep 2012

York 50+

Central York

Sep 2012

St John's University Fresherâ&#x20AC;&#x2122;s fair

Central York

Sep 2012

Nidderdale Show

Central York

Partnerships with York Council of Voluntary Services, York Older Peopleâ&#x20AC;&#x2122;s Assembly, York and North Yorkshire Local Involvement Networks, and York Mental Health Forum have been developed. These groups will further assist in a rigorous membership campaign via their strategic contacts.

6.0 Equality and Diversity – SERVICE USER PROFILE 6.1 Ethnicity Analysis of service users by Directorate 1 April – 31 August 2012 From the 2001 Census 91.8% of the population of Leeds, 97.9% of York and 98.9% of North Yorkshire gave their ethnic origin as ‘white’ (this includes “white British”, “white Irish” and “white other”). Using this definition the overall percentage of service users in contact with the Trust, by ethnicity, as at 31st August 2012 was 79.7% “white” and 8.4% from BME communities (11.9% of service users declined to answer or ethnicity was not known). BME service users are over represented in comparison to the current known BME population for Leeds. The BME ethnicity breakdown by directorate is as follows:Directorate August 2012 Adult & Older People Services 8.6% Learning Disability Services 8.2% Specialist Services 7.7% 6.2 The chart below shows service user contact with Trust services from 1 April – 31 August 2012 by age. 31.4% of people who had face to face contact with Trust services during this period were over 65 years of age and 68.6% between 18-64 years.

Current activities to address ethnic profile inequalities The following work streams are underway to identify and address potential inequalities: Innov8 project engaging BME health professionals to improve the physical and mental health wellbeing needs of BME communities accessing mental health services within the Trust.  Partnership project with community development workers from Touchstone carrying out in-reach work into adult inpatient wards. The project is supporting the development of the workforce through cultural competence training and developing a deeper understanding of service users’ experiences.  Project to improve access to and knowledge of Psychological Services for people from BME communities. 6.3 The below chart shows service user contact with Trust services from 1 April – 31 August 2012 by gender Women were slightly over-represented at 55.6% against a gender split close to 50:50 as per census data for Leeds, York and North Yorkshire & York.

Specialist Services Specialist Services

Learning Disabilities

Adult and Older People's

Learning Disabilities

0% 0-17

20%

40% 18-64

60% 65+

80%

100% Adult and Older People's

0.0%

20.0%

40.0%

FEMALE

60.0% MALE

80.0%

100.0%

6.4 LYPFT National Community Mental Health Service User Survey Results 2012 Between February-June 2012, Quality Health was commissioned to undertake a survey analysis on service user experiences of using community mental health services. The following charts capture the demographic profile of 250 respondents (sample size 30%) and exclude responses where data was missing. Of these, 61% of respondents were Female and 39% Male. 6.4.1 6.4.2 No Religion

Age

25-34 2.0% 11.1% 16.4%

21.3%

35-44

10.2% 13.9% 13.9% 11.1%

45-54 55-64

Buddhist

Religion or Belief

16-24

23.5%

0.4% 3.7% 0.4% 2.9% 4.1%

65.0%

20%

40%

60%

80%

100%

6.4.3

20%

40%

60%

80%

100%

Other

65% of service users were Christian, 24% had No Religion and 4% preferred not to state their religion. Other religions make up the remaining 7%. 6.4.4

Hetrosexual/Straight 90.4%

1.3% 2.5%

2.1%

Gay/Lesbian

3.8%

Bisexual

Ethnicity

Sexual Orientation

White British

89.1%

0.4% 0.8% 0.8% 1.7% 1.7%1.7%0.8%0.8% 0.4% 1.3% 0.4%

Other Prefer not to say 85%

90%

95%

100%

90% of those surveyed were from a Heterosexual orientation, 4% were LGB and 4% preferred not to disclose their sexual orientation. 2% were classified in the Other category.

Jewish Sikh

75-84

Responses from the 35-44 and 45-54 years age groups were the most prevalent. The 16-24 years age group accounted for just 2% of service users.

Hindu Muslim

65-74 0%

Christian

White Irish Other White Mixed Indian

80%

85%

90%

95%

100%

Pakistani

92% of respondents to the survey were from a White background and 8% from a BME background. Local population data: (Census 2001; Leeds 8.2%, York 2.1%, North Yorkshire 1.1%).

6.5 LYPFT Inpatient Stay and Care Spells for Period (1st April â&#x20AC;&#x201C; 31st August 2012) The following charts illustrate service user/inpatient ethnicity and gender demographics under the following areas: Number of (distinct) service users - a distinct count for each ward type, i.e where a service user may have had two spells of inpatient stay for adult male they would be counted once against adult male (and once against each ward type they received care from). Number of (distinct) care spells - a distinct count of the care spell by ward type (each care spells is counted once against the ward type the service user received care from). Mean LOS (Length of Stay) â&#x20AC;&#x201C; ward stays and not inpatient care spell. Service Users on CPA - service users who were active in inpatient services for the period specified and on CPA at some point during the period. 6.5.1 Leeds Services Distinct Service Users

Service Users in Period (distinct)

250

200 Asian or Asian British Black or Black British

150

Mixed Not known Not stated

100

Other Ethnic Groups White

0 Adult Adult Male, Adult Male, Adult Female, FEMALE MALE Mixed, FEMALE FEMALE

Adult Mixed, MALE

Forensic, FEMALE

Forensic, MALE

LD, LD, MALE FEMALE

Older Female, FEMALE

Ward Type, Sex Desc

Older Male, MALE

Older Mixed, FEMALE

Older Mixed, MALE

PICU, FEMALE

PICU, MALE

Specialist, Specialist, FEMALE MALE

BME groups were 16.9% of service users across all services, 76.6% were White, 6.5% and were not known/not stated. The highest numbers of BME service users on the Forensics wards were from Black or Black British groups and accounted for 18% of the overall total for this ward area.

Care Spells in Period (distinct)

6.5.2 Leeds Services Care Spells 250 200 150 Asian or Asian British

100

Black or Black British

Mixed

Not known Not stated Other Ethnic Groups White

Ward Type, Sex Desc

BME service users made up 16.6% of those under care during this period, 77.2% were white and 6.2% were Not known/ Not stated 6.2%

Mean LOS

6.5.3 Leeds Inpatients Services Mean Length of Stay 700.000 600.000 500.000 400.000 300.000 200.000 100.000 0.000

Asian or Asian British Black or Black British Mixed Not known Not stated Other Ethnic Groups White

Ward Type, Sex Desc

Asian or Asian British males had the most highly concentrated mean length of stay (LOS) across all ethnic groups, averaging 1,020 days out of the total 4,827 days during the reported period. BME service users are mostly concentrated in the adult wards. Mean length of stay in the Forensic wards is marked for Asian or Asian British with this being 370.33 days for males and 247 for females.

Service Users on CPA in period

6.5.4 Leeds Service Users on CPA 250 200 150 Asian or Asian British

100

Black or Black British

Mixed

Not known Not stated Other Ethnic Groups White

Ward Type, Sex Desc

Of all service users on CPA, 17.5% were from BME backgrounds, 75.9% White and 6.6% were Not known/Not Stated. For North Yorkshire and York services there is high prevalence of data in ‘unknown’ in terms of ethnicity whilst conversely no BME ethnicity data recorded across a number of services e.g. Forensic, LD, Older People (incl male, female, mixed) and Specialist. Around 18.9% of distinct service users ethnicity is unknown. ‘Unknown’: Distinct Service Users - 18.9% Distinct Care Spells – 17.5% Service users on CPA – 11.%

Service Users in Period (distinct)

6.5.5 North Yorkshire and York Services Distinct Service Users 70 60 50 40 30 20 10 0

Asian or Asian British Black or Black British Mixed Adult Female, Female

Adult Male, Female

Adult Male, Adult Mixed, Adult Mixed, Male Female Male

Forensic, Male

LD, Female

LD, Male

Older Male, Older Mixed, Older Mixed, Specialist, Male Female Male Female

Not known Other Ethnic Groups White

Ward Type, PERSON_GENDER_CURRENT

BME service users made up 2.3% of across all wards, 78.8% White, and 18.9% were Not known/ Not stated.

Specialist, Male

Care Spells in Period (distinct)

6.5.6 North Yorkshire and York Services Care Spells 90 80 70 60 50

Asian or Asian British

Black or Black British

Mixed

Not known

Other Ethnic Groups

White Adult Female, Female

Adult Male, Adult Male, Adult Mixed, Adult Mixed, Female Male Female Male

Forensic, Male

LD, Female

LD, Male

Older Male, Older Mixed, Older Mixed, Specialist, Male Female Male Female

Specialist, Male

Ward Type, PERSON_GENDER_CURRENT

BME service users made up 2.5% of those under care during this period, 80.0% were white and 17.5% were not known/not stated.

Service Users on CPA in Period

6.5.8 North Yorkshire and York Service Users on CPA 45 40 35 30

Asian or Asian British

Black or Black British

Mixed

Not known

Other Ethnic Groups

5 0

White Adult Female, Adult Male, Female Female

Adult Male, Male

Adult Mixed, Adult Mixed, Female Male

Forensic, Male

LD, Female

LD, Male

Older Male, Older Mixed, Older Mixed, Male Female Male

Specialist, Female

Ward Type, PERSON_GENDER_CURRENT

Of those service users on CPA in North Yorkshire and York 3.4% were from BME groups, 85.5% and 11.1%.White and Not known/ Not stated.

AGENDA ITEM 13

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Declaration of Interest forms for members of the Board of Directors

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Chris Butler – Chief Executive

PAPER AUTHOR:

Cath Hill – Head of Corporate Governance

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC:

GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

  



STATUS OF PAPER



To be taken in the public session (Part A)



SUMMARY: All members of the Board of Directors are required to complete a Declaration of Interest form annually. Declaration forms were sent out to all Board members and all have been completed and received back.. Completed forms are held on file in the Chief Executiveâ&#x20AC;&#x2122;s Office, and are available for public inspection should such a request be made. Whilstt these forms are completed as part of an annual declaration process, Board members are reminded that should any change occur they are required to submit an updated form to the Head of Corporate Governance, and inform the Board of Directors at its next mee meeting.

RECOMMENDATIONS: The Board of Directors is asked to receive the Declaration of Interest forms for members of the Board, and to note the declarations made by each director.

AGENDA ITEM 13.1

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Independence of Non-Executive Non Directors

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Chris Butler – Chief Executive

PAPER AUTHOR:

Cath Hill – Head of Corporate Governance

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC:

GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

  



STATUS OF PAPER



To be taken in the public session (Part A)



SUMMARY: The NHS Foundation Trust Code of Governance paragraph A.3.1 requires the Board of Directors to “determine whether a Non-executive Non executive Director is independent in character and judgement and whether there are relationships or circumstances which are likely to affect or could appear to affect the director’s judgement”. In order to allow the Board to determine the independence of all Non Non-Executive Directors (including the Chairman), declaration forms were completed and are attached for consideration at Appendix 1. It is for the Board to consider each Non-Executive Non Director ctor (including the Chairman) in turn and to record itss decision in respect of each. Information regarding whether NEDs are independent will be published in the Annual Report.

RECOMMENDATIONS: The Board of Directors is asked to: 

In turn consider the independence of each of the non-executive executive directors of the Leeds and York Partnership NHS Foundation Trust in accordance with paragraph A.3.1 of the Code of Governance, taking account of each of their the declarations made on the forms attached at Appendix 1.

AGENDA ITEM 14

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Proposed Changes to the Constitution

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Chris Butler – Chief Executive

PAPER AUTHOR:

Cath Hill – Head of Corporate Governance

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC:

GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

  



STATUS OF PAPER



To be taken in the public session (Part A)



SUMMARY: On the 1 October 2012 some of the provisions rovisions of Part 4 of the Health and Socia Social Care Act 2012 (the 2012 Act) came into force. These related to:      

The continuation of the body corporate known as Monitor A change in the terminology from the ‘Board of Governors’ to ‘Council Council of Governors Governors’ A requirement for the principal purpose (i.e. i.e. the provision of goods and services for the health service in England) to be stated in the constitution The introduction of the new legal duty to ensure that income of NHS funded goods and services is greater than income from other sources An introduction of additional oversight and scrutiny by the Council of Governors over activities generating ating non-NHS non income Replacement of ‘HM HM Treasury’ Treasury with ‘Secretary of State’ in regard to giving guidance over FT accounts.

Monitor has requested that the constitutions of all FTs be amended to take account of these changes; that hat they go through their necessary nece approval process; and be submitted to Monitor for approval (approval approval will be given “en masse” for FTs). Monitor has also advised that where the constitution has not been en authorised that the FT abides by the changes that came into force on 1 October 2012 as if they were in their constitutions. The attached document shows the tracked changes to the constitution which takes account of the above changes,, with the exception of a change to moving to using the term “Council of Governors” which has already been adopted by this organisation. It should also be noted that because constitutions will be authorise “en masse” no other changes is to be made to it at this time. Work is ongoing to look at the other necessary changes to meet the future commencement order order that will come into force on the 1 April 2013, and any other changes the Trust may wish to administer internally.

RECOMMENDATIONS: The Board of Directors is asked to approve the changes to the Constitution set out in the attached tracked document, as required as a result of the 1 October 2012 commencement order for Part 4 of the 2012 Act. Act

AGENDA ITEM 15

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Discussion paper on the format of agenda papers to the Board of Directors

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Chris Butler – Chief Executive

PAPER AUTHOR:

Cath Hill – Head of Corporate Governance

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC:

GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

  



STATUS OF PAPER



To be taken in the public session (Part A)



SUMMARY: PURPOSE OF THE PAPER The purpose of this paper is to ask the Board of Directors to discuss and agree a set of standards and principles for the production of Board of Directors’ and Council of Governors’ agenda papers, which will be drawn together into in guidance and be issues to paper leads and authors of agenda papers. EXECUTIVE SUMMARY There is a recognition that this organisation produces some very good agenda papers which ensures the Board of Directors and the Council of Governors are able to discharge their duties duties, including any legal duties.. However, because this is not consistently the case this paper seeks agreement for a set of standards and principles to be disseminated to paper authors in the form of guidelines that will facilitate the production of fit for purpose agenda papers. BACKGROUND Members of the Board of Directors, in particular particula the non-executive executive directors, have expressed concern at the quality of some agenda papers presented to Board of Directors’ meetings meetings; and similar concerns have to some extent been raised by governors in respect of the papers received at their Council meetings. ngs. The Head of Corporate Governance has drafted a set of guidelines uidelines for the production of agenda papers for all formal meetings in the Trust (including the Board of Directors’ s’ and Council of Governors’ meetings). These guidelines have been commented on by two members of the Board thus far who have made some very helpful observations which will be incorporated into the next iteration of the guidelines.. These guidelines will be consulted on more widely within the or organisation including with governors. If agreed, the standards and principles set out below and in the attached will form the substance of the e guidelines for paper authors, authors, with there being very specific guidance for Council of Governors’ papers. PROPOSED D STANDARDS AND PRINCIPLES FOR THE PRODUCTION OF BOARD OF DIRECTORS’ AND COUNCIL OF GOVERNORS’ AGENDA PAPERS The Board is asked to consider and support the following being used as the principles and standards for the guidelines: 1. Cover sheets should ideally ideall be no longer than 2 sides of A4,, and should be in the agreed template. 2. Any supporting upporting papers should ideally be no longer the 4 sides of A4 3. All papers must be seen and approved by the lead director / paper lead before being issued as an agenda paper. 4. No acronyms cronyms should be used without first being written in full. 5. Plain English must always be used and unnecessary jargon removed or explained. 6. Papers must be written in an accessible way, way tailored to the reader taking account where necessary of any disabilities. disabilities

7. Cover sheets to the Council of Governors (in particular) must provide enough detail to allow a decision to be made by those governors who do not wish to delve into greater detail. 8. Where a paper is to note serious consideration should be made as to whether it is appropriate to bring this to a meeting or if it can be circulated in some other way. In addition to the above principles the the Board is also asked to agree the attached as a minimum for the headings to be included in any supporting paper(i.e. paper(i.e. a paper produced to support the cover sheet). See Appendix 1. RISKS AND BENEFITS Much time and effort is spent in the organisation writing agenda papers for meetings. The benefits of agreeing principles and standards for the production of such pape paper is that it will:   

Ensure the Board of Directors and Council of Governors can carry out their role effectively; that decision are based on the right information; and challenge is properly formulated Ensure resources are properly spent producing ‘fit for purpose’ agenda papers Ensure information is presented in a consistent way that is suitable for and can be easily understood by the target audience

The risks of not having an agreed and well communicated set of standards and principles is that agenda papers ers are not fit for purpose; purpose; discussion in not focussed on the key priority issues; and the Board of Directors and Council of Governors may be unable to discharge their respective responsibilities, with any potential legal implications this may have. NEXT STEPS If agreed the principles and standards will be incorporated into a set of guidelines which will be produced in accordance with the NHS Litigation Authority (NHSLA) risk management standard for procedural documents as agreed by the Board of Directors Directors at the October 2012 meeting meeting. These guidelines will cover the production of all agenda papers in the organisation, not just those for the Board and Council,, but will facilitate the production of Board and Council papers papers. It is anticipated that these guidelines will be ready for launch into the organisation by the end of November 2012.

RECOMMENDATIONS: The Board of Directors is asked to: 1. Consider and agree the standards and principles for the production of Board of Directors and Council of Governors’ agenda papers. 2. Support these standards and principles being applied to all agenda papers produced in the organisation and for these to form the substance of guidelines which will be produced in the NHSLA agreed format.

Appendix 1 Proposed Sections to be included in a Board of Directors / Council of Governors agenda paper The following information may be included in the template cover sheet or it may be used for the supporting paper to the cover sheet. If it is produced as a supporting paper to a cover sheet it must have page numbers on it and must have the document’s author/s name and title and the date at the end of the paper. Paragraphs should be numbered in a consistent way to help with identification of discussion points during the meeting. The T use of bullets or flow charts within these paragraphs should be considered as a way of getting across complex issues in easy ‘bite-size’ ‘bite size’ pieces of information. A supporting paper should ideally be no longer than four sides of A4 to ensure it remains clear and succinct for the reader and gets the message across quickly and efficiently. 1

Purpose This section will give a clear indication of what the paper is about ideally in only one or two sentences. This sets the scene for the rest of the paper. For example “this paper is to seek approval to spend £XX to upgrade the computer system”. It is a bit like the recommendation, but is an opening statement used to hook in the audience so they read the rest of the paper paper in the context of what they are ultimately being asked to do.

Executive Summary Briefly explain what the paper is about and what it is endeavouring to achieve. It should set out the highlights of the ‘must know’ information, setting out what the issue is, what caused it and what action is needed. This section will set the scene a bit more and drill down a bit further than the purpose of the paper, but not be as detailed as the background or issues sections.

Background Outline the background to what is being considered. This should include a very brief outline of the historical al context, for example, the steps taken before it came to the meeting, who has been involved, what previous engagement/approval has been undertaken, or the reason for the paper coming to the meeting. A clear outline of the background will help the reader, reader, who has not been involved in the day-to-day day management of the issue, understand better the matter being presented and how the current position has been arrived at.

The Issue/s This may take more than one paragraph or heading, but the informat information in these headings/paragraphs must be concise, clear, relevant and unambiguous. This section should clearly set out the problem, concern or opportunity and only where it is necessary to convey a complex issue, which cannot easily be covered in a few paragraphs ragraphs or headings, should further attachments (or appendices) be provided (see below), but this should be the exception and not the rule.

Benefits and risks You should always consider if this is relevant to your subject matter. Having such a section on would strengthen a paper and provide the reader with a deeper understanding of the subject matter and the considerations the reader is being asked to make. Areas that may need to be addressed might include financial, HR, reputational implications. This s may be in the format of a risk / benefit analysis or just a list of the risks and / or benefits.

Options appraisal It may be necessary to include a short section on options appraisals. This should describe any options that may be available along with the pros and cons of each.

Next steps By including the next steps it is clear to the reader what the future stages in the governance process are. his helps to put the work into context and helps the reader and the admin support for the meeting to be clear as to what if anything is expected of them or others in the organisation.

Recommendation Outline the recommendation and set out clearly what action act ion is required for example ‘ratification’, ‘approval’, ‘agreement’, ‘discussion’, ‘support’, ‘information’ etc.

Name of author/s Title/s Date paper written

Further attachments or appendices (if necessary) As a rule the supporting paper should give all the information necessary and attachments/appendices should only be there so that those who are interested in the detail of the subject can read further into the matter. Should it be necessary to provide further attachments/appendices to the supporting pa paper these should be pertinent to the subject of the paper and not be made up of copious

amounts of irrelevant information which the reader has to wade through. They should support the content of the paper and not introduce new ideas or concepts. If the quantity uantity or complexity of the attachments/appendices is unavoidable they should be supported by a key to draw the reader to the relevant information, this will ensure that the paper can be easily comprehended by the reader who may not be as familiar with th the issues and detail as the paper author / paper lead.

AGENDA ITEM 16.2

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Chief Executive’s Report

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Chris Butler

PAPER AUTHOR:

Chris Butler

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC: GOVERNANCE: INFORMATION:



IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1

People achieve their agreed goals for improving health and improving lives

EG2 EG3

People experience safe care People have a positive experience of their care and support

  

IMPACT ON THE TRUST’S S MEANS GOALS (please tick relevant box) MG1 MG2

We provide excellent quality, evidence-based, evidence safe care that promotes recovery and inclusion We involve people in planning their care and in improving services

MG3 MG4 MG5

We work with partner organisations to improve health and lives We value and develop our workforce and those supporting us We improve our services through learning, research and innovation

MG6 MG7

We provide efficient and sustainable services We govern our Trust effectively and meet our regulatory requirements

       



SUMMARY: This paper summarises topics of interest to the Board of Directors and information internal to our Trust.

RECOMMENDATIONS: The Board of Directors is asked if it has sufficient assurance concerning our Trustâ&#x20AC;&#x2122;s response to the issues highlighted in the report.

Chief Executive’s Report to the Board of Directors October 2012 What’s on my mind? At the previous Board meeting I announced the departure of Michele Moran to be the Chief Executive of the Manchester Mental Health and Social Care NHS Trust. Michele’s last day with us will be the 30th of November with her last “official duty” being the meeting of the Board of Directors on that day. I want to take a moment to thank Michele for the enormous contribution she has made to the development of our Trust and its nurses. Michele will be missed by very many people, myself included. Our loss is very much Manchester’s gain. In the interim Lynn Parkinson, the Deputy Director of Care Services, has kindly agreed to be the Acting Chief Operating Officer and Chief Nurse. During this period Dawn Hanwell, in addition to her current responsibilities, will provide management oversight of Estates and Facilities, also Contracting. My view is that the current distribution of the work of Directors has, albeit with stresses and strains, served us well given that we are a successful and now a significantly larger organisation. However we still have much work to do, at the heart of which is delivering our strategy of: “Working in partnerships, we aspire to provide excellent mental health and learning disability care that supports people to achieve their goals for improving health and improving lives” Allied to this strategic intent there is a lot going on. A few examples include:  

 



Working to develop positive and forward looking relationships with our commissioners and other partners in Leeds and the York; Continuing to positively respond to early lessons learnt from the implementation to date of our Transformation programme at the heart of which “better, simpler, efficient” services; Progressing a “recovery” focus to the work we do; Securing the delivery of services for service users and carers by developing and implementing our long term financial model, including preparing for payment by results in mental health services; Extending the boundaries of knowledge with regard to mental health and learning disability services through participation in major developments such as the Yorkshire and Humber wide bid to become an Academic Health Science Network (AHSN); Delivering a broader public benefit through campaigns and awareness raising through “Time to Change” and “Get Me? Page 1

With Michele’s departure, over the coming weeks I am taking the opportunity to think through the portfolios of Directors. This is not the first time this has been done during my time as your Chief Executive. Over the past few years the Executive Director team (excluding the role of Chief Executive) has gone from six to five despite the extra demands on our Trust and the NHS. Portfolios have also changed, for example the bringing together the role of Chief Nurse with responsibility for service provision, the “abolition” of what was then described as Corporate Development with the creation of Strategy and Partnerships. More recently the role of Medical Director is now part-time. Looking to the future there are a number of factors to consider. These include, inter alia:     

Ensuring, as far as is possible in a complex organisation, a rational alignment of work areas; Ensuring an equitable distribution of responsibilities – including that people have “doable” jobs; Having a Director structure that is adaptable to future requirements and new initiatives; A need to take account of the personal and career development of Directors, complementary to succession planning which ensures “business continuity”; Not creating new posts which would increase our management costs.

I have commenced conversations with key stakeholder and, not surprisingly, people have different views. I do view the conclusion of this work as being urgent and it is my intention to determine the future work areas of existing Directors before the next meeting of the Board. Complementary to this, I will take to the Nominations Committee the job description and person specification for the Registered Nurse member of our Board of Directors. In the interim I positively welcome any views people may have about this topic. As a reminder, my email address is christopherbutler@nhs.net

Operational and People Matters Yorkshire and Humber AHSN Prospectus The Government intends that AHSN’s will improve patient and population health outcomes by translating research into practice and developing and implementing integrated health care systems. Also intended is that AHSNs will, though broader collaborations with industry, ensure that the NHS plays a role in developing the regional and national economy http://www.dh.gov.uk/health/2012/06/ahcn/ To take the work forward a business plan for the AHSN has been developed and was submitted to the Department of Health (DH) on the 28th of September. The coordinating organisations are the Sheffield Hospitals NHS Foundation Trust, the Page 2

Leeds Teaching Hospitals NHS Trust and the Hull and East Yorkshire Hospitals NHS Trust. I have been party to the development of the prospectus. The next stage of the process is for a panel of experts, convened by the DH, to review the prospectus and, if successful, they will invite the Yorkshire and the Humber project team to an interview later in October or early November. Contact:

Chris Butler

NHS Leadership Recognition Awards 2012 NHS Quality Champion of the Year I am pleased to inform the Board that Lyndsey Charles, our Allied Health Professional Lead for Learning Disability Services has been shortlisted for a national NHS Leadership Recognition Award for her work around the introduction of the Therapy Outcome Measure (TOM). Getting as far as the shortlist is an outstanding achievement for Lyndsey. The Awards Ceremony and Dinner will take place in the Great Hall at Barts on 10th December 2012. Congratulations Lyndsey and the best of luck! Contact: Michele Moran NHS North Yorkshire and York (NHS NYY) The health economy in North Yorkshire and York is forecasting a year-end deficit of £40m. In order to achieve financial balance in the medium term, the health economy will work together to develop a series of options that could be taken forward that change the clinical models for how healthcare is delivered in the future. One approach is remodelling the NHS in North Yorkshire and York based not on current expenditure but on the actual resources available. With regard to mental health and learning disability services, both ourselves and commissioners are bound to what is contained in the legally binding “business transfer agreement” which was signed by both ourselves and our colleagues in NHS NYY. However I am clear that we do have a duty to help as much as is feasible, one example could be bringing back into local services service users being treated “out of area”. I will keep the Board up to date with developments as they emerge. Contact:

Chris Butler

Page 3

Specialised Supported Living Service: Annual Report 2012 - 2013 The Board has received a hard copy of the annual report for the Specialised Supported Living Service. This report outlines what has been happening across the service and what the plans are for the future to continue to try and improve things for service users and carers. This report is now widely available on our website: http://www.leedspft.nhs.uk/_documentbank/SSLS_Annual_Report_2012.pdf

Contact:

Michele Moran

Conclusion I hope this briefing is helpful to the Board.

Chris Butler Chief Executive October 2012

Page 4

AGENDA ITEM 17

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE: DATE OF MEETING:

Leeds Safeguarding Children Annual Report 2011/12 Leeds Safeguarding Adults Annual Report 2011/12 CATEGORY OF PAPER 30th October 2012 ((please tick relevant box)

LEAD DIRECTOR:

PAPER AUTHOR:

Michele Moran Chief Operating Officer and Chief Nurse/Deputy Chief Executive Leeds Safeguarding Children Board Leeds Safeguarding Adults Board

STRATEGIC STRATEGIC:



GOVERNANCE: INFORMATION:



IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

IMPACT ON THE TRUST’S S MEANS GOALS (please tick relevant box) MG1 We provide excellent quality, evidence-based, evidence based, safe care that promotes recovery and inclusion MG2 MG3

We involve people in planning their care and in improving services We work with partner organisations to improve health and lives

MG4 MG5 MG6

We value and develop our workforce and those supporting us We improve our services through learning, research and innovation We provide efficient and sustainable services

MG7

We govern our Trust effectively and meet our regulatory requirements

         

STATUS OF PAPER



To be taken in the public session (Part A)



SUMMARY: Attached are the annual reports for the Leeds Safeguarding Children Board and Leeds Safeguarding Adults Board.

RECOMMENDATIONS: The Board of Directors is asked to receive and note the annual a reports eports provided.

Annual Report 2011/12

Important Contact Details: If any person needs to make a safeguarding adult referral they should ring: •

Adult Social Care: Contact Centre: 0113 222 4401 (Minicom 0113 222 4410) (Mon-Fri 8am – 6pm; except Bank Holidays)

•

Adult Social Care: Emergency Duty Team: 0113 240 9536 (Outside of the Contact Centre opening times)

If any person needs to report a crime: •

Non-emergency police number: 101

•

In an emergency, dial 999

If any person would like advice in relation to a safeguarding concern, they may ring: •

Safeguarding Adult Partnership Support Unit Advice Line: 0113 224 3511 (Office Hours, Mon-Fri)

If any person needs advice about a Deprivation of Liberty Safeguards (DoLS) concern, they may ring: •

Deprivation of Liberty Safeguards helpline: (0113) 295 2347 (Office Hours, Mon-Fri)

If any person needs more information about Safeguarding Adults, Mental Capacity Act or Deprivation of Liberty Safeguards (DoLS) they can obtain further information from the Leeds Safeguarding Adults Partnership website:

•

www.leedssafeguardingadults.org.uk

Foreword Each year, the Annual Report provides the Leeds Safeguarding Adults Board with the opportunity to reflect on our achievements and plan for the subsequent year. Over the last 12 months the Boardâ&#x20AC;&#x2122;s achievements have been considerable and reflect the quality of relationships and the strength of commitment across the partnership. We have achieved important milestones in each area of our identified work streams reflecting significant efforts on the part of both individuals and organisations across our city. The Annual Report provides an overview of all that has been achieved in relation to safeguarding adults, mental capacity and deprivation of liberty safeguards (DoLS). Amongst these achievements I am particularly pleased with our increasing engagement with those who have experienced abuse or neglect and the subsequent safeguarding work, enabling our future development to be shaped by their personal experiences. The seriousness of these issues means that despite our achievements we can never be complacent. We see the number of people requiring support to safeguard themselves continuing to increase each year, and our developments strengthen our ability to safeguard the rights and safety of those in need of our support. We have set ourselves ambitious targets for 2012/13, as we remain committed to safeguarding the rights and safety of our citizens. We recognise that we must continue to raise the profile of these issues with members of the public, so that we are alerted to all those who need help to protect themselves.

Dr. Paul Kingston, Independent Chair of the Board

Message from the Director of Adult Social Services The Director of Adult Social Services (DASS) is responsible for ensuring that the partnership overseen by the Leeds Safeguarding Adults Board is effective in reducing harm from abuse and neglect. In this annual report, the Board has shown its continued commitment to working with adults who are at risk of harm, developing and improving services to investigate and protect people. The Board’s intention is to raise the profile of every person’s right to live a life free from abuse and to feel safe and is committed to raising public awareness about safeguarding adults and what to do if somebody has a safeguarding concern. The Board recognises that some people find it difficult to protect themselves from harm without some support, and is committed to driving up standards and to ensure that when concerns arise, individuals get the most supportive and skilled response. I am delighted that during the last year, the Board published the Leeds Safeguarding Adults Charter, to confirm its commitments to responding fairly and effectively to safeguarding adults concerns, on behalf of the people of Leeds. During the year the Board held its first Community Engagement Event called “Have Your Say about Safeguarding”, which was attended by 100 people who have experienced the safeguarding process, as adults at risk of harm, carers, providers of services or other professionals. We have learnt a tremendous amount about what people value and what works well to help them manage the risks they face. We have revised our procedures based on what people have told us, and our training has been adapted to emphasise this learning too. Plans for the next year include work to seek feedback from those who experience safeguarding on an ongoing basis, to ensure we keep well-informed about what works best for those who need our services, and what we need to achieve to meet their expectations and aspirations. We also need to ensure that our responses to concerns raised are just and fair for all involved. I would like to offer my thanks and appreciation to the Independent Chair of the Safeguarding Adults Board, Dr. Paul Kingston, for steering the Board through the last year. I would also like to extend my thanks to Board members and everyone across the city who have helped us to achieve all that we have in the last 12 months, and will, I am sure, help us to achieve our plans for the next 12 months.

Sandie Keene Director of Adult Social Services

Contents Foreword.......................................................................................................................................i Message from the Director of Adult Social Services....................................................................ii 1. Executive Summary ................................................................................................................ 1 2. Leeds Safeguarding Adults Partnership Board 2011/12 ........................................................ 2 2.1 Leeds Safeguarding Adult Board structure and governance ........................................... 2 2.1.1 Board Sub-groups ....................................................................................................... 2 2.1.2 Leeds Safeguarding Adult Partnership Support Unit (LSAPSU) ................................ 3 2.1.3 Funding Arrangements................................................................................................ 3 3. Our Work & Achievements...................................................................................................... 4 3.1 Safeguarding Adults ......................................................................................................... 4 3.1.1 Governance, Leadership and Partnership .................................................................. 4 3.1.2 Policy, Protocols and Procedures ............................................................................... 5 3.1.3 Training and Workforce Development ........................................................................ 5 3.1.4 Serious Case Review and Professional Practice........................................................ 6 3.1.5 Communication and Community Engagement ........................................................... 7 3.1.6 Performance, Audit and Quality Assurance ................................................................ 9 3.2 Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) ............................... 9 3.2.1 Mental Capacity Act Local Implementation Network (LIN)........................................ 10 4. Activity Reports ..................................................................................................................... 11 4.1 Safeguarding Adults ....................................................................................................... 11 4.1.1 Safeguarding Referrals ............................................................................................. 11 4.1.2 Investigated Safeguarding Referrals........................................................................ 13 4.1.3 Completed Investigations......................................................................................... 15 4.2 Deprivation of Liberty Safeguards (DoLS) ..................................................................... 18 4.3 Independent Mental Capacity Advocates (IMCAs) ........................................................ 21 5. Annual Statements of Board Member Organisations ........................................................... 24 5.1 Leeds City Council: Adult Social Care............................................................................ 24 5.2 NHS Airedale, Bradford and Leeds (NHS ABL) ............................................................. 25 5.3 Leeds Teaching Hospitals NHS Trust (LTHT)................................................................ 25 5.4 Leeds and York Partnership NHS Foundation Trust (LYPFT) ....................................... 26 5.5 Leeds Community Healthcare NHS Trust (LCH) ........................................................... 27 5.7 The Leeds ALMOs ......................................................................................................... 28 5.8 Leeds City Council: Domestic Violence Team ............................................................... 29 5.9 West Yorkshire Fire and Rescue Service (WYFRS) ..................................................... 29 5.10 Care Quality Commission (CQC) ................................................................................. 30 6. Going Forward ...................................................................................................................... 32 6.2 Board Business Plan 2012/13 ........................................................................................ 34 Appendix A: Representation and attendance of Member Organisations.................................. 35

iii

1. Executive Summary The Leeds Safeguarding Adult Partnership Board Annual Report 2011/12 provides an overview of the Board’s achievements over the last 12 months and its objectives for 2012/13. The board is a voluntary arrangement of statutory and non-statutory agencies that work together to safeguard adults at risk of abuse or neglect and both promote and safeguard people’s rights under the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). The ambitious work programme for 2011/12 has resulted in significant achievements in developing continuous step wise improvements in how such issues are provided for within Leeds. Amongst the most notable achievements are the following: •

Increased awareness of safeguarding adult issues as illustrated by a 24.3% year on year increase in the number of safeguarding adult referrals.

•

Review and revision of the multi-agency safeguarding adult policy and procedure, and the development of a range of complementary practice guidance.

•

The undertaking of the first ever ‘Have Your Say’ Community Engagement Event in order to learn from those individuals and organisations who have had experience of the safeguarding adult procedures.

•

Provision of safeguarding training by Adult Social Care and NHS partners to approximately 8552 across Level 1 and Level 2. In addition 425 training places at Level 3 and Level 4, provided by Safeguarding Adult Partnership Support Unit, were attended.

•

Identifying learning through the completion of a Serious Case Review and the completion of four ‘Learning the Lesson Reviews’.

•

Independent Mental Capacity Advocates (IMCAs) support people without mental capacity in relation to decision making on specific important issues. Use of IMCA services increased during 2010/11 – 2011/12 by 39%. The highest rate of increase related to Care Reviews and Serious Medical Treatment decisions.

•

Deprivation of Liberty Safeguards (DoLS) are legal safeguards for people without the mental capacity to consent to care or treatment in hospital or care homes and a particularly restrictive care plan is required in their best interests. Applications for Deprivation of Liberty Safeguards (DoLS) have increased in Leeds from 55 to 97 (an increase of 76%) during 2011/12. This reflects an increasing awareness amongst managing authorities (hospitals and care homes) as to their responsibilities.

Based upon the Board’s learning and ongoing work programme, the Annual Report also sets out priorities for the next 12 months. More detailed information about how these priorities are taken forward is recorded within the Board Business Plan 2012/13, published on the Leeds Safeguarding Adults Partnership website: www.leedssafeguardingadults.org.uk .

2. Leeds Safeguarding Adults Partnership Board 2011/12 2.1 Leeds Safeguarding Adult Board structure and governance The current government has announced its intention to introduce legislation placing safeguarding boards on a statutory footing with clear guidance on their role and function. Currently however, the Leeds Safeguarding Adults Partnership Board is a voluntary arrangement of statutory and non-statutory organisations that work together to: • • •

safeguard adults at risk from abuse or neglect promote best practice in the use of the Mental Capacity Act 2005 promote use of Deprivation of Liberty Safeguards (DoLS)

The Board includes senior representatives from Adult Social Care, NHS partners, Police, Probation, Community Safety and Fire Service, Service User and Carer organisations, Housing and Regulatory organisations amongst others. A full list of current member organisations and representatives can be found on the Leeds Safeguarding Adult Partnership website www.leedssafeguardingadults.org.uk. The Board has appointed Dr. Paul Kingston, as the Independent Chair to the Board, providing for independent perspective, challenge and support to the Board in achieving continuous development. The Board is overseen by the Director of Adult Social Services. The Board meets bi-monthly, its governance arrangements and functions are set out in full within the Board ‘Memorandum of Understanding’ available to everyone on the Leeds Safeguarding Adult Partnership website. The vision of the Safeguarding Adults Board is that “all the citizens of Leeds, irrespective of age, race, gender, culture, religion, disability or sexual orientation can be free from abuse or the fear of abuse”. This vision is central to all the Board’s functions and work programmes. The Boards Vision is detailed in full within the Board ‘Memorandum of Understanding’.

2.1.1 Board Sub-groups The Board work programme is supported by its sub-groups, each comprising multi-agency representation across statutory and non-statutory services as well as health and social care organisations. Each is accountable to the Board in relation to achievements against the business plan. There are six sub-groups addressing the various work steams required to drive forward the Board’s agenda: • • • • • •

Policy, Protocols and Procedures sub-group Training and Workforce Development sub-group Serious Case Review and Professional Practice sub-group Performance, Audit and Quality Assurance sub-group Communications and Community Engagement sub-group Mental Capacity Act Local Implementation Network sub-group

The Chairs of each sub-group form the sub-group chairs group which coordinates the work of the sub-groups, and supports the Board in respect of effective governance, leadership and partnership arrangements.

2.1.2 Leeds Safeguarding Adult Partnership Support Unit (LSAPSU) The Board is also supported by the Leeds Safeguarding Adult Partnership Support Unit (LSAPSU) that is hosted within the Leeds City Council, Adult Social Care Directorate. The Safeguarding Adults Partnership Support Unit provides an Advice Service in relation to safeguarding adult concerns and practice. The advice line: 0113 224 3511 can be used by professionals and members of the public to access advice and information. The Head of Safeguarding fulfils various functions in supporting the development of board, partner and partnership processes. Other posts within the unit fulfil specific roles in relation to facilitating serious case and learning lesson reviews, training and workforce development, or the development of multi-agency policies and procedures in order to support the Board in achieving its objectives. The unit also includes three Independent Safeguarding and Risk Managers and an administrative team in order to facilitate independently chaired Case Conferences.

2.1.3 Funding Arrangements The costs of the Leeds Safeguarding Adults Board and its support unit are jointly funded (50/50) by Leeds City Council Adult Social Care and NHS Airedale, Bradford and Leeds 1 . Other partners provide significant contributions in a range of ways, not least in terms of providing support, expertise and leadership in respect to the various areas of the Board’s business plan as well as providing training/meeting venues and resources. The following is the budget statement for the year 2011/12. 2011/12 Budget

Employees Premises Supplies and Services Transport TOTAL EXPENDITURE Income from training Contribution from Funding Partners (Adult Social Care and NHS) TOTAL INCOME

2011/12 Expenditure/ (Income)

2012/13 Budget

£ 443,950 0 35,960 1,230 481,140 (6,000) (475,140)

£ 446,528 0 33,249 1,627 481,404 (4,515) (476,889)

£ 455,990 0 35,960 1,230 493,180 (6,000) (487,180)

(481,140)

(481,404)

(493,180)

NHS Airedale, Bradford and Leeds pays 50% of the Board’s budget, on behalf of the whole Leeds Health Community.

3. Our Work & Achievements 3.1 Safeguarding Adults Abuse is “a violation of an individual’s human and civil rights by any other person or persons” (No Secrets, 2000) Safeguarding adults is a term used to describe “all the work which enables an adult [at risk] to retain independence, wellbeing and choice and to access their human right to live a life that is free from abuse and neglect” (ADASS: Safeguarding Adults 2005:05). Safeguarding adults involves: • • •

organisations working together and with people to prevent abuse or neglect from occurring providing people with mental capacity the support needed to end abuse or neglect protecting those people from abuse who do not have the mental capacity to decide about their own safety

The role of the safeguarding board is to achieve continual improvements in how issues of abuse or neglect are managed within Leeds. The various work streams of the Board are highlighted below, alongside a summary of their achievements over the last 12 months.

3.1.1 Governance, Leadership and Partnership A priority for the board during 2011/12 has been to engage more closely with certain key agencies in order to improve how organisations work together to achieve the best possible outcomes for adults at risk. This has included establishing closer working relationships with the Crown Prosecution Service (CPS), Trading Standards Service, the Leeds Safeguarding Children Board and the Safer Leeds Executive (the Community Safety Partnership for Leeds). There is shared representation on the adults and children’s safeguarding boards, and the independent chairs of the two safeguarding boards have made it a priority to be in communication with each other, to discuss shared issues and solutions for safeguarding both adults and children on an ongoing basis, and to develop joint board development events. In addition, there is now shared representation from the Safeguarding Adults Board and Safer Leeds. This ensures that criminal justice agencies are able to consider safeguarding adults issues alongside services dealing with domestic violence, hate crime, anti-social behaviour and honour-based violence. There is ongoing work local and regionally to develop closer working relationships with the Department of Work and Pensions. NHS Airedale, Bradford and Leeds is actively engaged in seeking to secure medical expertise within the board and is advising on developments in relation to Clinical Commissioning Group arrangements and how to include appropriate representation within the Board. In addition to the bi-monthly Board meetings, the Leeds Safeguarding Adult Partnership Board has held two ‘Development Days’ in order to focus on setting the Board’s strategic direction. The first in July 2011 focused on the subject of Safeguarding Thresholds in order to inform ongoing policy development work. The second during March 2012 focused on identifying and prioritising actions for the Board Business Plan in 2012/13.

3.1.2 Policy, Protocols and Procedures The Leeds Safeguarding Adult Partnership Board produces the multi-agency safeguarding policy, procedures and guidance for all organisations to follow. The Board has placed a strong emphasis on the continual development of safeguarding practices. During 2011/12 significant work has been undertaken in relation to policy and procedures in order to provide for continuing improvements in practice. This has involved a full review and revision of the Leeds Safeguarding Adult Partnership MultiAgency Safeguarding Adults Policy, Procedure and forms as well as providing additional specific guidance on: • • • • •

coordination of safeguarding investigations (with other investigations) reporting an unauthorised deprivation of liberty safeguards and considerations in making a safeguarding adult referral involving the person alleged to have caused harm in the safeguarding process legal powers to intervene in safeguarding cases developing safeguarding policies and procedures for organisations

As part of these reviews of policy and procedures, the safeguarding board took the decision to use the term ‘adult at risk’ rather than vulnerable adult. The term ‘vulnerable adult’ has become increasingly criticised in recent years as it is felt that term implies that the problem of abuse lies with the person themselves, rather than their circumstances or the person that caused the abuse or neglect. The term adult at risk is generally felt to be more respectful to those to whom it refers.

3.1.3 Training and Workforce Development A key focus of the Board’s work is to ensure that training is provided that enables staff (and volunteers) to understand their responsibilities to safeguard adults at risk. During 2011/12 the Training & Workforce Development Framework has been reviewed and updated, ensuring courses have been adapted to include amendments to the safeguarding procedures, new guidance, and fully include Mental Capacity and Deprivation of Liberty Safeguard (DoLS) issues. Training materials and content across partner organisations have been endorsed, assuring the quality of training provided. Training charging options have been reviewed and partner training objective achievements monitored. This work has been completed alongside reviewing partner staff induction programmes and making training available to carers. Training is provided at 4 levels within the Board’s Training & Workforce Development Framework, reflecting the various roles that staff (and volunteers) may fulfil within the safeguarding adult procedures. Level 1: Level 2: Level 3: Level 4:

Alerter – recognising and responding to abuse Referrer – when and how to refer abuse into the multi-agency safeguarding process Investigator – how to undertake an investigation into abuse or neglect Safeguarding Coordinator (and other specialist roles) – specialist training for people fulfilling other key roles

Level 1 and Level 2 are provided by Adult Social Care to independent sector organisations free of charge, the Adult Social Care: Business Support Centre can be contacted on 0113 247 5570 for information about available courses. In addition, NHS and other partners will provide such

training on an in-house basis. Across Adult Social Care and NHS partners alone, 8552 people have received training across Level 1 and Level 2 during 2011/12. Level 3 and Level 4 training courses are provided by the Safeguarding Adults Partnership Support Unit. New courses, Writing the Investigation Officers Report, Safeguarding Adults and Domestic Violence were introduced during 2011/12 in response to demand. During 2011/12, 425 Level 3 and Level 4 training places were attended across the following courses below: Level 3 courses provided:

Level 4 courses provided:

Investigating Allegations and Disclosures

Coordinating safeguarding Investigations

Writing the Investigation Officerâ&#x20AC;&#x2122;s Report

Safeguarding Coordinators Procedure Review

The Process for Social Workers and Joint Care Managers

LSAPB Partnership Training for Trainer

Safeguarding, Capacity and the IMCA service

Safeguarding Adults and Domestic Violence

3.1.4 Serious Case Review and Professional Practice Serious Case Reviews: Where alleged abuse is serious and safeguarding practice gives rise to potential concerns about how agencies have worked together, the Leeds Safeguarding Adult Partnership Board will consider conducting a Serious Case Review. A Serious Case Review provides an opportunity to identify how safeguarding practice can be improved across the partnership. Each agency involved with the adult at risk, as well as the views of the adult at risk and or their family/representatives would be included within the review. An independent author is commissioned to ensure the learning is objective and focused on the experience of the adult at risk. The Executive Report is published and the actions plans in relation to recommendations are monitored to ensure key lessons are carried forward into practice. During 2011/12 a Serious Case Review was completed in relation to an older person with dementia who lived in a care home with nursing before she died (VA1). The Executive Report was presented by the independent author to the Safeguarding Adult Board during April 2011. This report is available on the Safeguarding Adult Partnership Website (www.leedssafeguardingadults.org.uk). A further Serious Case Review is currently being undertaken in relation to a young woman residing in a care setting. The Executive Report will be made available on the Board website in due course. A number of independent authors were recruited during 2011/12 in order to facilitate Serious Case Reviews as required and provide for a consistent approach. The Serious Case Review procedures are currently being revised so as to integrate experiential learning from undertaking these reviews.

Learning Lesson Reviews: In the event that identified concerns are less complex and do not require a Serious Case Review but there is significant learning for the partnership, a Learning the Lessons Review will be considered. During 2011/12, four Learning the Lesson Reviews were completed and a further 4 are currently being undertaken. Learning the Lesson Reviews are conducted by the individual agencies but their findings and the learning is shared with the partnership through the Serious Case Review and Professional Practice sub-group.

3.1.5 Communication and Community Engagement A key priority for 2011/12 was to ensure the Board learnt from the experiences of people involved within the safeguarding adult process. The first ever ‘Have Your Say, Community Engagement Event was held during November 2011, and included adults at risk, family carers, voluntary sector organisations and service providers. The focus of the event was to capture people’s experiences of the safeguarding adult process and consult on questionnaires that can be used routinely to capture these experiences. Learning from the event is being used into influence the Board’s ongoing work programme.

The document above is part of the graphic record used to record issues raised during the ‘Have Your Say’ event. Future events will be held to continue this learning. A process of mapping safeguarding adult stakeholders has also been undertaken in order to provide for effective communication and community engagement going forward.

The Board provides a range of information about safeguarding adults. In order to improve understanding of the safeguarding procedures a series of fact sheets, aimed at adults at risk and their relatives/friends was developed during 2011/12. These fact sheets provide information about various aspects of the safeguarding adult procedures so that people know what to expect. The Leeds Safeguarding Adults Partnership website was also redesigned in order to provide more information and make it more accessible to adults at risk, the public and professionals. In addition, the Leeds Safeguarding Adults Charter (below) was finalised and published by the Board in June 2011, reflecting the Boardâ&#x20AC;&#x2122;s commitment to improving outcomes to adults at risk.

3.1.6 Performance, Audit and Quality Assurance A priority for the board during 2011/12 has been to continue developing ways to effectively monitor standards of practice being carried out within the safeguarding procedures. During 2011/12 work has been undertaken and is ongoing to develop the ‘balanced scorecard’, a series of standards that measure the quality of the safeguarding process being undertaken. This includes ‘customer perceptions’, ‘workforce capability and capacity’, ‘business processes’ and ‘value for money’. Following from the ‘Have Your Say – Community Engagement Event’ a task and finish group has been established to consider the design of questionnaires that capture ‘customer perceptions’ of safeguarding. Work is also ongoing to identified measurable indicators in relation to ‘value for money’. Quarterly reports are produced in relation to safeguarding activity. Alongside this work, considerable time has been spent mapping out the standards expected at each stage of the safeguarding process, and providing clear guidance within all the safeguarding forms to help these standards be achieved. This Quality Assurance Framework is in the final stages of development and a plan for implementation is being devised. Ensuring that the Board learns from individual experiences of the safeguarding procedures and ensuring standards are maintained will be an ongoing priority and area of development during 2012/13.

3.2 Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) The Mental Capacity Act 2005 was introduced to cover situations where someone is unable to make a decision because of the way their mind or brain works or is affected, for instance by illness or disability or the effects of drugs or alcohol. The Mental Capacity Act establishes the definition of mental capacity, determines how decisions should be made if a person lacks mental capacity and establishes statutory guiding principles for practice. The Mental Capacity Act relates to everyday decisions as well as major decisions about someone's property, financial affairs, health and welfare. It is an important safeguard, protecting the rights of people who lack mental capacity. Through Lasting Powers of Attorney, Advance Decisions and Advance Statements, the Act also provides the means by which people can plan for a time when they no longer have mental capacity to make decisions. The Mental Capacity Act introduced Independent Mental Capacity Advocates (IMCAs) to represent and safeguard people’s best interests when certain important decisions are made as described in the IMCA Activity Report on page 21. The Act also introduced a specialist court, the Court of Protection, for all issues relation to people who lack mental capacity in relation to specific decisions. The Deprivation of Liberty Safeguards, often referred to as DoLS, were also introduced by the Mental Capacity Act. DoLS are a legal safeguard for people who cannot make decisions about their care and treatment when they need to be cared for in a particularly restrictive way. They set out a process that hospitals and care homes must follow if they believe it will be necessary to deprive a person of their liberty, in order to deliver a particular care plan in the person's best interests. The DoLS Activity Report is provided on page 18.

More information about mental capacity and Deprivation of Liberty Safeguards (DoLS) can be located on the Safeguarding Adult Partnership website: www.leedssafeguardingadults.org.uk Mental Capacity Act In Practice Sometimes it is the simple things that are important. The daughter of a patient with dementia wanted to be able to access confidential information about her father's health and treatment in order to be able know how to support him. Her father was assessed as no longer having the mental capacity to consent to his information being shared with someone else. The hospital needed to make sure they were not breaching his confidentiality and data protection laws. In circumstances where a person does not have the mental capacity to make a particular decision for themselves, the Mental Capacity Act allows for the decision to be made in the their best interests. As sharing the information would improve care the patient would receive and enable him to be better supported during medical appointments, it was decided that it was in the patient’s best interests for relevant information to be shared. With this information the daughter was able to work closely with the hospital to provide her father with the support he needed.

3.2.1 Mental Capacity Act Local Implementation Network (LIN) The Mental Capacity Act Local Implementation Network (Mental Capacity Act LIN) is a multiagency group that provides strategic direction in relation to the implementation of the Mental Capacity Act and DoLS across the city of Leeds. Since April 2009 the Mental Capacity Act LIN has carried out this role as a sub-group of the safeguarding adults board. The achievements of the sub-group over the last 12 months are wide ranging, and include: In relation to Mental Capacity Act: • • •

maintaining an overview of partner organisation Mental Capacity Act audits, performance and activity measures disseminating lessons from national learning, such as new case law monitoring use of Independent Mental Capacity Advocacy (IMCAs) across the partnership

In relation to Deprivation of Liberty Safeguards (DoLS): • • • • •

supporting the development of guidance as to how to respond, when there are concerns that a person is being deprived of their liberty without the authorisation process being followed monitoring provider activity in relation to DoLS improving recording of DoLS assessments undertaken ensuring appropriate training and refresher training is available for best interest assessors and mental health assessors that undertake DoLS assessments monitoring the numbers of Best Interest and Mental Health Assessors to ensure there is sufficient resource to meet statutory responsibilities

4. Activity Reports 4.1 Safeguarding Adults This activity report provides a summary of key information about safeguarding adults activity during 2011/12. It includes information about: •

Safeguarding referrals – these are the reports of incidents, allegations or concerns received into the multi-agency safeguarding process during 2011/12. A process of decision making is undertaken to decide the most appropriate response to these concerns. Only a proportion of these safeguarding referrals result in a safeguarding investigation.

•

Investigated referrals – these are those referrals that do require a safeguarding investigation. The information provided here is about those investigations commenced during 2011/12. Work will also have taken place on other investigations that have continued from the previous year.

•

Completed investigations – these are those investigations that have been actually completed during 2011/12, regardless of when they started.

4.1.1 Safeguarding Referrals Safeguarding referrals are incidents, concerns or allegations that are reported into the multiagency safeguarding process as potentially requiring a safeguarding investigation. Safeguarding referral numbers There were 3,449 safeguarding referrals during 2011/12. This is an increase of 24.3% from 2010/11 and an increase of 68% from 2009/10 as illustrated in Figure 1. In 19 of these cases, the gender, age, or client group was unknown, so in subsequent sections about referrals, the number included in the analysis is 3430. Safeguarding Adult Referrals 2009/10 - 2011/12 4000 3449

3500 2774

3000 2500

2049

2000 1500 1000 500 0 2009/10

2010/11

2011/12

Figure 1: Safeguarding Adult referrals (2009/10 – 2011/12 (Source – ESCR database)

Rising referral numbers indicate that awareness of safeguarding issues and how to report and respond to abuse continues to increase. The rate of increase, however, has slowed slightly: the increase from 2009/10 - 2010/11 was 35.4%.

Safeguarding Referrals by Source Of 3430 referrals made, the largest proportion came from Social Care Staff (37%), followed by Health Staff (23%) and Housing (13%). Social care staff includes referrals from staff working in care management or social work, residential, domiciliary or day care services or personal assistants. Health staff includes primary/community health staff, secondary health staff and mental health staff. A significant number referrals fall into the Other category, this includes 176 referrals (5%) made by staff in the voluntary sector. Figure 2 illustrates that referrals are received from a broad and diverse range of sources, indicating the range of individuals and organisations actively engaged in safeguarding adults. Safeguarding Referrals by Source 2011/12 Family Member, 205

Friend/Neighbour, 42

CQC, 10 Health Staff, 792

Education/Training/ Work Place, 10 Social Care Staff, 1252

Housing, 431 Not Known, 1

Self Referral, 44 Police, 230

Other, 413

Figure 2: Safeguarding Referrals by Source (2009/10 – 2011/12 (Source – ESCR database)

Safeguarding Referrals By Referral Outcome From 3,430 safeguarding adult referrals received, 1222 (36%) were taken forward to a safeguarding investigation as illustrated in Figure 3.

Safeguarding Referrals By Outcome 2011/12 Community Care Asssessment, 169 Other Outcome, 91

Referred to health professional, 73

Signposting/info /advice, 230

Safeguarding Investigation, 1222

Unspecified, 67

Log details of enquiry only, 1210

Unscheduled Review, 218 LYPFT Safeguarding, 150

Figure 3: Safeguarding Referrals By Outcome (2011/12 (Source – ESCR database)

150 referrals (4.4%) were taken forward for safeguarding investigation by Leeds and York Partnership Foundation NHS Trust. This information is recorded separately from the ESCR database and is therefore not included within subsequent activity data recorded in this report. Systems are currently in the process of review so as to be able to include such information in future Annual Reports. Although a safeguarding investigation is not always required, other forms of support may be, such as signposting/offering information and advice (7%), and unscheduled review with (6.0%) or a community care assessment (5%).

4.1.2 Investigated Safeguarding Referrals The investigated safeguarding referrals reported here are those started during 2011/12. Work will also have been undertaken on investigations started but not completed during the 2010/11. Investigated Referrals by Client Group

Investigated Referrals by Client Group 2011/12

Other Vulnerable People 5% Physical Disability / Frailty 41% Sensory Impairment 1%

Substance Misuse 1% Learning Disability 27%

Dementia 20% Mental Health 5%

Figure 4: Investigated Referrals By Client Group 2011/12 (Source â&#x20AC;&#x201C; ESCR database)

The highest proportion of investigations have involved a person with physical disability or frailty (41%). This is followed by those involving a person with a learning disability (27%) and those involving a person with dementia (20%). Investigated Referrals by Age and Gender Figure 5 illustrates the distribution of investigations according to both age and gender. This year for working age adults (those aged 18 â&#x20AC;&#x201C; 64), the gender balance is very close, with marginally more males than females (184 females and 191 males). The majority of safeguarding referrals concern females and this is most marked in the 85+ age group, but is reflected in all the over 65 age ranges. This pattern is consistent with 2009/10 and is most likely explained by differences in mortality rates and the resulting differences in population size. Overall, investigations involving females amounts to 63% of all investigations.

Investigated Referrals by Age and Gender 2011/12 25

Percentage

20 15

Female Male

10 5 0 Age 18-64

Age 65-74

Age 75-84

Age 85+

Figure 5: Investigated Referrals By Age And Gender 2011/12 (Source – ESCR database)

Investigated Referrals by Ethnicity The following table illustrates the proportion of investigations according to the ethnic background of the adult at risk. Ethnicity

White

92%

Mixed

Asian/ Asian British

Black or Black British

Other Ethnic Group

<1%

Not Stated

Table 1: Investigated Referrals By Ethnicity 2011/12 (Source – ESCR database)

Approximately 8% of investigated referrals concern people from black and minority ethnic communities. Investigated Referrals by abuse Type

Investigated Referrals by Type of Abuse

Discriminatory <1% Neglect 29%

Physical 40%

Sexual 4% Emotional/ Psychological Financial 9% 17%

Institutional 1%

Figure 6: Investigated Referrals By Type Of Abuse Type (2011/12 (Source – ESCR database)

Figure 6 illustrates that the most frequent form of abuse investigated is physical abuse (41%) , followed by Neglect (29%) and Financial Abuse (17%). On many occasions however an investigation may concern more than one incident of abuse and more than one form of abuse. Investigated Safeguarding Referrals – Type of Investigation The Leeds Multi-Agency Safeguarding Adult Procedures provide 4 different types of safeguarding investigation. Having 4 types of investigation provides for a proportionate response according to the nature of the alleged abuse and the circumstances within which it has arisen. Safeguarding Investigations by Type 2011/12

Ty pe 3 17%

Type 4 4%

Type 1 53% Type 2 26%

Figure 7: Safeguarding Investigations By Type (2011/12 (Source – ESCR database)

Type 1 investigations are coordinated by Adult Social Care or an NHS body but investigated by the provider service. The majority of investigations are undertaken as Type 1 (53%). Type 2 investigations are undertaken by an investigating officer from Adult Social Care or an NHS body focusing on the review of care needs relating to the allegation/concern of abuse. These are the next most frequent form of investigations undertaken (26%). Type 3 and Type 4 investigations are more serious or complex investigations requiring an independently-chaired, multi-agency case conference to conclude them. These are the least frequent investigation types. Type 3 relate to a single adult at risk (17%), Type 4 relate to investigations concerning more than one adult at risk (4%).

4.1.3 Completed Investigations Completed investigations are those completed during 2011/12. Some investigations will have commenced during 2011/12 that will not be completed until 2012/12, and will therefore be included within next year’s Annual Report. Case Conclusions A safeguarding investigation will gather evidence about the incident, allegation or concern. The decision based on this evidence, as to whether abuse has occurred, is called the case conclusion. Case conclusions are decided ‘on the balance of probabilities’. Figure 8 illustrates the four possible outcomes as established by the National AVA data recording requirements.

Safeguarding Case Conclusions 2011/12

Inconclusive/Not Determined 24%

Substantiated 48%

Not Substantiated 18% Partly Substantiated 10%

Figure 8: Safeguarding Case Conclusions 2011/12 (Source – ESCR database)

In 58% of occasions during 2011/12, the safeguarding investigation has led to the abuse being ‘substantiated’ or ‘partly substantiated’. Outcomes for the adult at risk Outcomes for the adult at risk are those recorded at the conclusion of the investigation according to the criteria established by the National AVA data recording requirements. The most frequent outcome was ‘no further action’ in 44% of occasions. Outcomes also included monitoring (33%), move to increase/different care (7%), restriction / management of access to the person alleged to have caused harm (2%) and management of access to finances (2%). Outcomes for the person alleged to have caused harm Outcomes for the person alleged to have caused harm those recorded at the conclusion of the investigation according to the criteria established by the National AVA data recording requirements. In 38% of occasions the outcome was recorded as continued monitoring, in 30% of occasions the outcome was recorded ‘no further action. Outcomes also included disciplinary action (5%), management of access to the adult at risk (5%), removal from property or service (2%) and criminal / formal caution (1%).

Safeguarding Adults In Practice Mr Taylor has dementia and lived at home with his wife. Over time Mr Taylor had become increasing dependent upon his wife, who was having difficulty understanding and coping with his changing needs. Other family members became increasingly concerned as they became aware of incidents when Mr Taylor had been pushed, hit and been shouted at by his wife. They made a safeguarding adult referral because they wanted to make sure he was safe. Whilst the issues were fully understood everyone was in agreement that Mr Taylor should receive respite care to keep him safe and provide his wife with a rest. Without the constant care demands, Mrs Taylor was able to recognise how serious the incidents had become. The investigation found that Mr Taylor was being abused by his wife. Whilst in respite care, assessments revealed that Mr Taylor did not have mental capacity to decide about this own care arrangements and that he had significant needs that could not be fully met at home. Everyone was in agreement that it was in his best interests to make this move permanent. Mrs Taylor had found her husbandâ&#x20AC;&#x2122;s dementia hard to accept and was unable to cope with the demands on her. Mrs Taylor felt that her husbandâ&#x20AC;&#x2122;s move into a residential care was a difficult decision, but the right one to be made. Mrs Taylor now feels she has quality time with her husband without the constant pressure and strain of struggling to cope with his care needs. Mr Taylor is happy in his new home. The wider family provide Mrs Taylor with support to visit and for them to both go out together

4.2 Deprivation of Liberty Safeguards (DoLS) The Deprivations of Liberty Safeguards, often referred to as DoLS came into effect in 2009. They are part of the legal framework set out in the Mental Capacity Act 2005 to safeguard the rights of people who lack the mental capacity to make decisions for themselves. The European Court of Human Rights established in the principle that ‘no one should be deprived on their liberty unless it is prescribed by law’. The Deprivation of Liberty Safeguards was subsequently introduced to ensure, that in circumstances where a hospital or care home believe it will be necessary to deprive a person of their liberty in order to deliver a particular care plan, that any deprivation of liberty: • • •

is in the person’s best interests is with representation and rights of appeal is reviewed, monitored and continues no longer than necessary

What amounts to a deprivation of liberty depends on the specific circumstances of each individual case. As a result, there is no single definition or a standard checklist that can be used. However, the following indicators have been established through court judgments: • • • • • • • •

restraint was used to admit a person to a hospital or care home when the person is resisting admission medication was given forcibly, against a patient's will staff exercised complete control over the care and movements of a person for a long period of time staff took all decisions on a person's behalf, including choices relating to assessments, treatments, visitors and where they can live hospital or care home staff took responsibility for deciding if a person can be released into the care of others or allowed to live elsewhere when carers requested that a person be discharged to their care, the hospital or care home staff refused the person was prevented from seeing friends or family because the hospital or care home has restricted access to them the person was unable to make choices about what they wanted to do and how they wanted to live, because the hospital or care home staff exercised continuous supervision and control over them. (Extract DH (2009) Deprivation of liberty safeguards: A guide for hospitals and care homes)

Anyone can request a deprivation of liberty assessment but in general terms it will be the responsibility of the managing authority (the hospital or care home) to alert the supervisory body (Leeds City Council: Adult Social Care or NHS Airedale, Bradford and Leeds). The supervisory body will then coordinate six separate assessments to ensure it is in the person’s best interests. If the authorisation is declined the hospital or care home must find alternative less restrictive ways to provide the treatment or care needed. Leeds Deprivation of Liberty Safeguards Co-ordination Service In Leeds a DoLS Co-ordination Service is provided, that allows for a single point of contact in relation to DoLS issues. This means that whether the concerns relate to someone in hospital or in a care home, the reporting process is the same. All DoLS referrals are made through this service, which also co-ordinates the assessment process. The DoLS Co-ordination service also provides a helpline providing advice to organisations, professionals and members of the public.

The DoLS helpline can be contacted on (0113) 295 2347 (9am-5pm, Monday-Thursday; 9am4.30pm Fridays (excluding Bank Holidays).

DoLS Advice Line Enquiries 250

226

200

168

150 Number of enquiries 100 52 50 0 2009/10

2010/11

2011/12

Figure 9: DoLS Advice Line Enquiries 2011/2 (Source: DoLS Coordination Service)

The DoLS Co-ordination Service received a total of 226 enquiries regarding Deprivation of Liberty Safeguards during 2011/12. This is a 35% increase from the previous year. The majority of these were from care professionals working in a variety of fields including social work, hospital inpatient care, private sector care homes and from voluntary sector providers. A small number were from informal carers or other members of the public. Use of Deprivation of Liberty Safeguards in Leeds The table below details the number of Deprivations of Liberty Safeguard referrals from 2009/10 to 2011/12.

DoLS Referrals & Authorisations 120 97

100 80

Referrals

60 42

40 20

Authorisations

28 17

0 2009/10

2010/11

2011/12

Figure 10: DoLS Referrals and Authorisations 2011/12 (Source: DoLS Coordination Service)

Referrals for Deprivation of Liberty Safeguards in Leeds have increased year on year since they were introduced in 2009. There has been a substantial increase (76%) over the last 12 months from the previous year. This indicates an increasing awareness of Deprivation of Liberty

Safeguards (DoLS) and their importance in safeguarding people’s rights. Of these referrals 28 were for people within a hospital setting and 69 were made for people residing in a care home. The table also illustrates the actual number of DoLS authorisations approved in Leeds which have also increased year on year. During 2011/12 authorisations increased significantly by 46% from 2010/11. National Comparison National comparison data for 2011/12 is not yet available. However, during 2010/11 the national increase in DoLS referrals was 25% and for authorisations 50% from the previous year. Within Leeds during the same period the increase was above the national trend with an increase of 31% in respect to referrals and an increase of 65% in respect of authorisations. The numbers of referrals and authorisations have continued to increase during 2011/12.

Deprivation of Liberty Safeguards (DoLS) In Practice Mr Taylor moved into a care home when he was no longer able to live independently and safely in his home as a consequence of dementia. After a number of months concerns arose when Mr Taylor became unhappy to stay at the home Several incidents occurred when Mr Taylor started leaving the premises without the knowledge of staff. During these occasions it became apparent that Mr Taylor was unable to negotiate traffic safely and unable to recognise that he was placing himself at risk. Mr Taylor was returned reluctantly by the police on these occasions. The care home undertook an assessment and concluded that Mr Taylor lacked mental capacity in relation to decisions about where he resided and the risk of going out on his own. The care home wanted to make sure Mr Taylor was safe. The care home drew up a new care plan that meant that Mr Taylor could not go out on his own despite his wishes. The care home manager applied for a DoLS because the staff team were concerned that the care plan might be depriving Mr Taylor of his liberty, especially as he did not always want to be at the home. Leeds Adult Social Care facilitated a series of assessments. An IMCA was involved to represent Mr Taylor in the decision making. The DoLS was authorised as the care plan was felt to deprive Mr Taylor of his liberty and was assessed to be in Mr Taylor’s best interests. Mr Taylor’s needs and placement were also reviewed and additional support provided in response. It is hoped that these new care arrangements will help to make Mr Taylor happier at the home. The authorisation of the DoLS provides Mr Taylor with legal safeguards that ensure the deprivation of liberty is kept under review, continues only so long as necessary, can be appealed, and ensures he has representation in decision making. The DoLs also provide the care home with the legal authority to follow the agreed care plan, in order to provide for Mr Taylor’s needs and best interests.

Additional information about DoLS can also be accessed from the Leeds Safeguarding Adult Partnership website www.leedssafeguardingadults.org.uk Please note, the Deprivation of Liberty Safeguards (DoLS) relate to a person receiving care and treatment within a hospital or care home (or nursing home). They do not apply to a person subject to compulsory powers under the Mental Health Act.

4.3 Independent Mental Capacity Advocates (IMCAs) Independent Mental Capacity Advocates (known as IMCAs) were established by the Mental Capacity Act 2005. The role of the Independent Mental Capacity Advocate is to help people who lack the mental capacity in relation to certain important decisions, when they have no-one else (other than paid staff) to support or represent them. An IMCA can only be appointed by an NHS body or the local authority; and only in very specific circumstances that have been established in law. These are: • • • • •

an NHS body is proposing to provide serious medical treatment an NHS body or local authority is proposing to arrange accommodation (or change of accommodation) in certain circumstances a care review (in relation to the accommodation arranged above) an application for Deprivation of Liberty Safeguards (DoLS) is being made safeguarding adults (this may be possible in some circumstances, even if family, friends or others are already involved)

The role of an IMCA is not to decide what is in the person’s best interests but rather to support the decision making process. It includes: • • • • •

finding out the views, feelings, wishes, beliefs and values of the person, using whichever communication method is preferred by the client and ensuring that those views are communicated to, and considered by, the decision maker asking questions on behalf of the person and representing them; making sure that the person’s rights are upheld and that they are kept involved and at the centre of the decision-making process gathering and evaluating information from relevant professionals and people who know the person well checking that the decision-maker(s) are acting in accordance with the Mental Capacity Act and the decision is in the person’s best interests challenging decisions that are not reached in adherence with the Mental Capacity Act and Code of Practice

The national findings of the 4th Year of the IMCA Service published by the Department of Health in 2012 highlighted the value of including IMCAs within decision making. “The research found that IMCA involvement could make a significant difference in some 52% of cases… IMCAs were thought to ensure that decisions were timely and based on thorough assessments of options…. IMCAs played a role in bringing a holistic, person centred angle to the clinical decision making process. In particular IMCAs helped to broaden clinical thinking about how adjustments could be made to treatment to reflect a person’s needs and wishes… In safeguarding cases, IMCAs reported their involvement led to additional personalised outcomes for clients, and assisted in clarifying misunderstandings...” “...the research identified that the IMCA role brought about wider benefits: IMCAs were regular and visible visitors to a range of health and social care settings. Their awareness of the rights of people under the Mental Capacity Act, coupled with their specialist knowledge about poor practice, meant they were in a strong position to provide additional assistance, not just for their individual client, but for other people using services at the same settings...” The tables below illustrate the significant improvements made within Leeds in promoting use of IMCA services.

Use of IMCAs in Leeds The table below details the frequency of IMCA involvement from 2009/10 to 2011/12. LEEDS 09/10 Number Serious medical Treatment Accommodation DoLS Care Reviews Safeguarding Unknown Total

LEEDS 10/11 Number

LEEDS 11/12 Number

Comparison Increase from 2010/11 – 2011/12

+ 74%

92 18 16 48 5 205

126 26 20 62 5 277

162 34 62 66 5 386

+ 29% + 31% + 210% + 6% + 39%

Table 2: Use of IMCA’s In Leeds 2009/10-2011/12 (Source – Articulate Advocacy)

Use of IMCAs have increased year on year for each kind of decisions where IMCAs may be involved. The percentage increase from 2010/11 to 2011/12 is significant at 39%; the rate of increase is highest in relation to care reviews (210%) and serious medical treatment (74%). National Comparison National information provided by the Department of Health is not yet available for 2011/12. The table below compares the use of IMCAs in Leeds during 2010/11 with the national average. NATIONAL 10/11 % of all % Increase from involvement previous year Serious medical Treatment Accommodation DoLS Care Reviews Safeguarding Unknown Total

LEEDS 10/11 % of all involvement

% increase from previous year

15%

22%

14%

46%

42% 16% 7% 14% 6%

8% 33% 20% 13%

45% 9% 7% 22% 2%

37% 44% 25% 29%

15%

35%

Table 3: National Comparison for Leeds 2010/11 (Source – Department of Health and Articulate Advocacy)

This table shows that the use of IMCAs in Leeds during 2010/11 increased by 35%, this is more than twice the national average (15%). For each of the IMCA decision areas, the increase in Leeds is greater than the national trend. In Leeds use of IMCAs in safeguarding adult cases was highest in the country and second highest within accommodation decisions. There was a lower percentage use of IMCAs in DoLS than the national average, but this is one of the highest area of increased use (44% increase from 2009/10 – 2010/11). As noted in the previous table, this has increased again by 31% from 2010/11 – 2011/12. This figure will be influenced by the number of DoLS assessments undertaken. Findings The IMCA service has a very important role in representing and protecting people’s rights when certain key decisions are made for them. In Leeds use of IMCAs is increasing year on year, meaning that more and more people are being provided with this additional support to ensure their ‘best interests’ care carefully considered when they are unable to make important decisions for themselves.

The IMCA service in Leeds is provided by Articulate Advocacy. The Articulate Advocacy Annual report contains additional useful information. It can be accessed on the Articulate Advocacy website www.leedsadvocacy.co.uk/annual_report.html The Mental Capacity Act Code of Practice provides information about the role of an IMCA. This can be obtained from the Leeds Safeguarding Adult Partnership Board website www.leedssafeguardingadults.org.uk

Independent Mental Capacity Advocacy In Practice Mrs Aldwick was discharged from hospital into a residential care home whilst she was recuperating from a period of illness. A care planning meeting was arranged to consider how best to meet Mrs Aldwick’s needs in the future. At the meeting it was clear that there were differences of opinion as to what should happen. Mrs Aldwick wanted to go home and her son agreed this was the right thing to do. However, Mrs Aldwick’s daughter was very concerned about whether this was safe for her, and wanted her to move permanently into the residential home. She was concerned her mother would no longer be able to live safely on her own at home. Mrs Aldwick was assessed as lacking mental capacity to make an informed decision about where she lived and how her care needs should be met, and so a decision would be needed in her best interests. The assessment of Mrs Aldwick’s needs revealed that she required 24 hour supervision and support to meet her care needs and maintain her safety. An IMCA was appointed to represent Mrs Aldwick in the decision making about where she lived. The IMCA took time to understand Mrs Aldwick views and circumstances and produced a report that took into account her wishes, preferences, beliefs and values. This helped focus everyone on what was best for Mrs Aldwick. The son and other family members offered to work with the home care agency to provide 24 hour support. It was decided that it was in Mrs Aldwick’s best interests for this support to be provided at home rather than in a care home. Mrs Aldwick returned home and has coped better than everyone expected. This has meant that the amount of support provided could be reduced and Mrs Aldwick has been able to maintain more independence. The use of an IMCA helped in focusing everyone on Mrs Aldwick’s best interests, keeping her needs and wishes at the heart of the decision making.

5. Annual Statements of Board Member Organisations 5.1 Leeds City Council: Adult Social Care Throughout 2011/12 adult social care has continued to promote awareness and develop practice in relation to safeguarding adults and mental capacity issues. A focus during 2011/12 has been on learning and improving safeguarding practice. The adult social care safeguarding meeting provides a forum to reflect on and develop good practice and share learning with partners through the various sub-groups of the board. This has included, for example, supporting the development of guidance in relation to involving the person alleged to have caused harm, ensuring the safeguarding process is fair to all concerned. Learning has also taken the form of a number of Learning the Lesson Reviews. These reviews have involved frontline practitioners and their managers and have resulted in improved practice arrangements in a number of areas including: o Joint training between Adult Social Care and West Yorkshire Police around Mental Capacity Act matters o Changes in mental health provider service procedures to address risk o Enhanced involvement of carers in reviews o Guidance provided to all staff about the need for medical checks when emergency protection action is taken o Training for investigation staff giving greater emphasis investigation planning in order to achieve efficient timescales Independent and other quality assurance audits have led to the development of a multiagency quality assurance framework that includes practitioner guidance, practice standards and revised safeguarding templates. These were developed initially through a series of development sessions with the senior practitioners. Safeguarding training has been reviewed during 2011/12 taking into account changes in the revised multi-agency safeguarding adult policy and procedures. As a result, improvements to both approach and content have been identified and commissioned. This includes the development of existing courses, workbooks, e-learning resources and new courses such as refresher training for managers of Older People Services and a course called Protecting Yourself and Others for staff with learning disabilities. Training continues to be provided free to independent sector organisations. Improvements have also been made in relation to electronic recording systems, enabling more effective recording of concerns in relation to a service provider. Protocols have also been developed to ensure safe internal transfer of information where the referral concerns a unnamed person or numerous individuals. One of the most significant achievements in 2011/12 has been adult social careâ&#x20AC;&#x2122;s involvement in ground breaking case law in respect of the Mental Capacity Act and the concept of inherent jurisdiction to protect adults at risk of harm. This has provided significant protection for the adults at risk concerned but has also opened up a new source of protection for others in similar situations.

5.2 NHS Airedale, Bradford and Leeds (NHS ABL) The structural changes to the NHS mean that the team have spent a significant amount of time preparing to hand over our safeguarding commissioning function to Clinical Commissioning groups. In times of such change and uncertainty the team have been acutely aware of the risks involved and have worked closely with colleagues within NHS ABL and across the health economy to ensure the people of Leeds are protected from abuse. Some of the specific achievements during 2011-12 are listed below: Safeguarding Quality Assurance: • New Adult Safeguarding Commissioning Policy agreed and inserted in all provider contracts for 2012-13. This document clearly sets out the safeguarding adult standards expected from all providers that NHS ABL commission with. The policy also clearly describes the process by which NHS ABL will ensure services protect patients from abuse. • Following the uncovering of abuse at Winterbourne, NHS ABL have reviewed all Leeds residents in out of area placements to ensure they are receiving high quality and safe care. Safeguarding Training: • Over 1000 staff in primary care (GP practices, pharmacies, dental practices and opticians) have received face to face adult safeguarding training from the NHS ABL (Leeds) safeguarding team. Approximately 75% of GPs and 85% of dentists have received safeguarding adults training. • NHS ABL (Leeds) has further developed its training evaluation to be able to demonstrate the impact of training. • Updated the safeguarding adults e-learning package. • The production of various resources e.g. a GP resource pack for safeguarding. Safeguarding Partnership working: • Development and dissemination of Safeguarding and Serious Case Review Newsletters • Considerably increased the amount of clinical safeguarding advice and information given to primary care staff MCA / DoLS: • Commissioned NHS Trusts to increase training, policy development and audit in relation to MCA / DoLS. • Development of a DoLS database to monitor DoLS activity levels. • A significant increase in the number of DoLS applications from hospitals, helping to ensure that those that need to be detained in hospital for care and treatment receive the appropriate safeguards. • The development and wide distribution of MCA resources such as MCA flowcharts and Deprivation of Liberty application process flowcharts.

5.3 Leeds Teaching Hospitals NHS Trust (LTHT) Over the past year LTHT made progress in a number of areas. We continue to grow and develop the service and with this continue to see a rise in referrals to the Adult Safeguarding team. Over 11000 staff have been provided with Level 1 Adult Safeguarding training since April 2009.). Training has been incorporated into the Trust Induction programme which captures all

new staff who join the organisation and the Trust Mandatory Training Programme which captures existing staff. There is also additional training being delivered to managers (Level 2) Over the last year safeguarding alerts to the Trust Adult Safeguarding team have risen to an average of 40 a month. Ongoing audit of Adult Safeguarding, Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). This has been strengthened over the last year with the appointment of a Mental Capacity Act Co-ordinator . LTHT have been active in the Serious Case Review process having now participated in 3 Serious Case Reviews. Action planning following these are underway and on target. LTHT has full engagement with the multi-agency process and as such contributes to all stages of relevant safeguarding investigations and all the sub-groups of the safeguarding board. A trainer for Safeguarding Adults and Children was appointed in June 2011. This has allowed the existing team to focus more on clinical support and higher level training. A Part-time Co-ordinator (with responsibility for MCA & DoLS training, policy development and audit) was appointed in August 2011 in order to ensure that all our staff are confident in using the Act. Other developments across the Trust include working closely with the LTHT Children's safeguarding team to develop a safeguarding web page on the LTHT intranet. This was activated in August 2011 and enables staff to locate resources and information relating to safeguarding easily including appropriate external links from these pages.

5.4 Leeds and York Partnership NHS Foundation Trust (LYPFT) This last year has seen a greater need for Leeds and York Partnership Foundation Trust (LYPFT) to focus on the administrative and data processing aspect of safeguarding within our Trust and across the city. We have developed considerable knowledge and skill on the delivery of safeguarding practice within the Trust and there is a now heightened scrutiny as to how rigorously individual agencies respond internally to all safeguarding issues, especially regarding accountability. National developments and influences have been managed via action plans and we have developed an interim means of capturing the audit trail by careful monitoring and recording of email traffic but a more sophisticated data management system has been identified as the ultimate solution. Key Developments • • • • •

There is now a generic “drop box” for all safeguarding information SafeguardingAdults.LYPFT@nhs.net, this is monitored daily to ensure all referrals are acknowledged within 24 hours. All email content is archived. The number of safeguarding coordinators is currently being increased to 28 Leeds services have now merged with North Yorkshire and York mental health and learning disability services to form LYPFT. A Trust wide MCA audit has been conducted. Supplementary guidance has been produced to support and promote the principles of the MCA when completing a care plan.

• • • •

The Trust has reviewed, amended, approved, ratified and monitors protocols for consent to care and treatment, Advanced Decisions and Deprivation of Liberty Safeguards. The Trust is currently reviewing care pathways for service users within the transformation project. The care pathways will reflect and incorporate the guiding principles of the MCA. PARIS data recording has been developed to include the identification and involvement of relevant others including carer, family, Independent Mental Capacity Advocate and Independent Mental Health Advocate (if applicable) The Trust has further developed the commission by the Strategic Health Authority to produce e-learning on the Mental Capacity Act and the e-learning is accessible to all clinical teams on the Trust e-learning site. Level 1 Safeguarding Adults Training is also provided on this site.

5.5 Leeds Community Healthcare NHS Trust (LCH) During the last twelve months there have been many significant changes for Leeds Community Healthcare (LCH). From 1 April 2011 the organisation became an independent NHS Trust and now continues on its journey to become a Community Foundation Trust. New safeguarding structures and services have been developed as we drive forward the integration agenda, and a key part of this has been the ongoing commitment to strengthening work around safeguard adults at risk. The ‘new’ Leeds Multi-Agency Policies and Procedures prompted a review of LCH operational policy with the introduction of a reporting and recording flowchart. In September 2011; a specialist nurse was identified to take a lead role in MCA and DoLS and has worked closely with NHS Leeds to develop a training and support programme for “champions” from clinical teams across the organisation. Also in the summer two clinicians successfully completed the Best Interest Assessors training and now attend regular updates. LCH has a mandatory training programme for clinicians which now includes Safeguarding Alerter and MCA training. Compliance is achieved through e-learning packages, which have been reviewed and agreed across health organisations. As an organisation we are working hard to achieve a standard of 90% compliance. With this increased awareness we have noticed an increase in reporting and number of referrals made. In October 2011 LCH agreed to pilot a model of Adult Protection Supervision by offering monthly sessions to clinicians. The sessions are aimed at clinical staff that have concerns about safeguarding issues, and to support these individuals in their safeguarding work. These are open sessions at venues across the city, lasting approximately 2 hours and will run as a pilot until June 2012, when this will be evaluated. In this twelve month period, the organisation saw the development of a vision statement and strategy for adult safeguarding for the next three years with the production of an annual work plan identifying priorities for 2011-2012 to deliver the vision. This work plan consisting of 10 separate work streams and a monthly operational group, reporting to the LCH adult Safeguarding Committee, has been established to embed the strategy and monitor performance across all work streams.

Moving into 2012 Leeds Community Healthcare has taken the opportunity to integrate adult and child safeguarding by creating a safeguarding team with one Head of Service. In recognition of the growing needs of adults at risk LCH has increased resources assigned to adult safeguarding, which mirror structures and roles within child safeguarding, bringing 27

Mental Capacity Act and Deprivations of Liberty Safeguards under the same umbrella . The next 12 months will be both exciting and challenging as we move to an integrated team, sharing learning and working in a more effective way to safeguard the most vulnerable in the city. We still have a way to go in the field of adult safeguarding, but we hope we can learn from our colleagues in child safeguarding and explore new and innovative ways of working. There is clear evidence of how far we have come during the past 12 months, which places the organisation in an excellent position for moving forward. 5.6 West Yorkshire Police The work of the Leeds West Yorkshire Police Safeguarding team has been enhanced over the last year through the co-location of staff and appointment of dedicated vulnerable adult coordinators within the unit. New comprehensive policies and procedures have been adopted based on ACPO guidance and a forum introduced for the Police and Local Authority Safeguarding Managers from across West Yorkshire to meet and share good practice West Yorkshire Police has developed a bespoke training package for all front line and specialist resources. The training includes a series of case studies involving vulnerable adults aimed at ensuring all staff understand safeguarding principles and are able to recognise vulnerability and identify abuse. Local safeguarding staff have provided training to operational officers in relation to the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). During the year, West Yorkshire Police hosted a multi-agency conference on 'Understanding and Supporting our Vulnerable Adultsâ&#x20AC;&#x2122;. The event was well supported by partners from the five Adult Safeguarding Boards, Health and Regional Police Forces. The day included presentations about a wide range of initiatives and operations. The day concluded with a moving video of a vulnerable adult who told his own story, successfully highlighting the paramount importance of a multi-agency approach towards safeguarding the vulnerable. Externally, West Yorkshire Police has established much closer working relationships with a host of partners and are actively engaged with senior practitioners within Adult Social Care, Mental Health Trust, LTHT and nurse consultants. New meeting structures provide a regular opportunity for key staff to share good practice and has resulted in the development of a referral pathway between the mental health and the police safeguarding unit. 5.7 The Leeds ALMOs Aire Valley Homes, East North East Homes and West North West Homes, referred to as ALMOâ&#x20AC;&#x2122;s are Arms Length Management Organisations that provide housing on behalf of Leeds City Council. All three of the Leeds ALMOs, which provide housing management services for the Council, now have specialist internal teams in place supporting tenants at risk through robust internal safeguarding procedures that include needs and risk assessments linked to support packages and a referral process to Adult Social Care. The procedures for safeguarding underpin internal Safeguarding Policies agreed by the ALMO Boards, that apply the Leeds Safeguarding Adults Partnership policy at a local level.

Mandatory e-learning modules have been introduced for staff and safeguarding training is delivered for all new starters at staff Induction. In addition internal safeguarding training has been delivered to staff and external repair and improvement contractors who work for the ALMOs. So far 35 sessions have taken place with Contractors with a plan to complete the training by May 2012. On the back of this training almost 1000 alerts have been made by housing staff and contractors to the ALMOs specialist teams in 2011/12, with around 50 of these becoming full safeguarding referrals to Adult Social Care. Of the remainder, the majority are supported within the ALMOs through a series of interventions coordinated with other support agencies. These are aimed at supporting people to remain living independently in their own tenancies. Around one third of ALMO alerts arise at the initial allocation of a property stage, which assists us to be proactive in identifying support needed at tenancy commencement. This helps to sustain tenancies and independent living. Nearly half of referrals come through Tenancy Management teams when tenants are identified as being in need of help or are in crisis and/or at risk of losing their tenancies. The remaining referrals are made from partners such as the Leeds Anti Social Behaviour Team and our repair and improvement Contractors. We also have a small number of tenants who have self referred due to the articles that we have published in our tenants magazines outlining the support that our teams provide. The last twelve months has seen further development of a common cross ALMO approach to safeguarding and assessing risk. Joint working and shared training has been developed and 2012/13 will see more sharing and joint working together in managing risk, delivering support and safeguarding to ensure that people who move across ALMO boundaries remain within scope.

5.8 Leeds City Council: Domestic Violence Team The safeguarding agenda is addressed by the Councilâ&#x20AC;&#x2122;s Domestic Violence Team in a range of ways. All domestic violence training includes references to or full case studies on the additional issues facing disabled women experiencing domestic violence, encouraging the use of the social model of disability to improve access to services. Safeguarding adults is addressed in monthly domestic violence multi agency risk assessment conferences (MARACs) where information is shared among key agencies about high risk victims and safety plans are developed to address risk. Consent is sought among all victims being discussed at MARACs and the Leeds MARAC Operating Protocol highlights mental capacity as an issue to be considered in the consent seeking process. The team work closely with the partnership unit Training and Development Officer to support the integration of domestic violence in Safeguarding Training and have agreed protocols in cases where domestic violence has featured in Serious Case Reviewsâ&#x20AC;&#x2122;.

5.9 West Yorkshire Fire and Rescue Service (WYFRS) WYFRS Safeguarding Children & Vulnerable Adults Policy was implemented in Dec 2010. The policy put in place a clear structure for reporting concerns of potential cases of abuse, raised by WYFRS personnel, into the multi-agency safeguarding process. The agreed reporting structure as set out in the policy is for quarterly activity reports to be presented to the Corporate Driving Diversity Board, and an annual report presented to Management

Board. Since the new policy went live, forty one safeguarding cases have been referred through to the safeguarding units. The policy includes the identification of designated officers with clearly defined responsibilities to ensure the efficient delivery of safeguarding procedures. West Yorkshire Fire and Rescue Service have developed a safeguarding e-learning module on ‘recognising and responding to abuse’. This was launched in February 2012 for all staff to complete.

5.10 Care Quality Commission (CQC) The Care Quality Commission’s (CQC) responsibility regarding safeguarding is to ensure that CQC uses its regulatory powers to ensure that risks to people, who receive services that are regulated by CQC, are minimised. The CQC powers will be used promptly and in accordance with CQC frameworks for judging compliance with the regulations outlined in the Health and Social Care Act 2008 and the Commission’s enforcement policy. In Leeds this works in three ways. Firstly, CQC meets regularly with the commissioning and safeguarding officers of the Leeds City Council and NHS Leeds. The purpose of the meetings is to share information about services which may pose risks to people’s safety. Secondly, outside of these meetings partnership agencies may refer concerns brought to their notice to CQC. Commission inspectors will respond as appropriate by undertaking inspections in order to ascertain whether or not the service is complying with government regulations and if not, determine the action that needs to be taken to ensure the safety of the individuals concerned. In addition, there are occasions when inspectors identify incidents that mean people may be at risk. In these circumstances inspectors will make a safeguarding adult referral. Thirdly, inspectors are also involved in meetings convened within the safeguarding adult procedures to consider actions necessary to either investigate concerns raised and/or to ensure the safety of vulnerable people who receive services that are regulated by CQC. Since the reporting of the incidents at Winterbourne View in the South West Region, CQC has strengthened the way it responds to alert calls from members of the public and people who report their concerns as “whistleblowers”. A dedicated central team was established to ensure the appropriate responses as the regulator of health and social care services. CQC records the exchange of information between agencies. For Leeds the level of recorded activity is significant and shows increasing awareness amongst partner agencies and the public about safeguarding vulnerable people. The Commission reviewed and consulted partners on its policies and guidance with respect to judging compliance and taking enforcement action against providers that are not compliant with the regulations. The result of this work is now available on the Commission’s website www.cqc.org.uk or by following the direct website links: CQC Judgement Framework, April 2012 CQC Enforcement Policy, April 2012 The new judgement framework and enforcement policy gives clear guidance to providers about their responsibilities. These documents show that the Commission’s judgements will be clear to the public and providers. Providers either comply or do not comply with the regulations. When providers do not comply with the regulations then CQC must consider the action it will take under its enforcement policy.

It has also been recognised that in order to be an effective regulator of health and social care that the Commission should be better resourced to carry out this function. Nationally this has meant that more inspectors are being recruited and this also has been the case for the Leeds area. More inspectors were recruited in latter part of 2011 and this process continues. The Commissionâ&#x20AC;&#x2122;s priorities are to: 1. 2. 3.

Respond swiftly to concerns that suggest providers are not complying with the regulations. Ensure that all social care providers, independent health care providers and NHS trusts will be inspected frequently. All inspections will continue to be unannounced. Review from a national perspective health and social care issues of public concern.

6. Going Forward 6.1 Board Priorities for 2012/13 The board’s priorities for 2012/13 are set out here, aligned with the various work streams of the board. Governance, Leadership and Partnership: • • •

Strengthen the board’s relationship with key agencies important to achieving positive outcomes for adults at risk, specifically the Department of Work and Pensions and Clinical Commissioning Consortiums Strengthen the board’s expertise by securing a medical representative on the board Explore with partner boards within West Yorkshire, the possibility of adopting West Yorkshire Safeguarding Adult Procedures

Policies, Protocols and Procedures: Continue the ongoing programme of policy and procedure development, including: • • • • • • • • •

Developing a multi-agency approach to risk management, in relation to adults at risk with mental capacity that make decisions that place themselves at risk of harm Undertake an Equality Impact Screening in relation to the multi-agency policy and procedures Review the Contesting Decisions Procedure Review arrangements for organisations acting as safeguarding coordinator when investigations involve their own services Develop fact sheets aimed at informing people alleged to have caused harm of the safeguarding procedures Develop good practice guidance in relation to financial abuse Produce guidance on service user towards service user abuse Review investigating institutional abuse guidance Facilitate a process of learning within the partnership in relation to restraint policies

Training and Workforce Development: • • • • • • • • •

Agree a common evaluation process to measure impact of training on learning and practice Ensure attendance levels are maintained within the training and workforce development sub-group Produce of directory of approved safeguarding adult training programmes Agree targets for completion of alerter and referrer training, DoLS and MCA training within statutory agencies Develop a new Board member induction programme Agree minimum criteria for trainers, including frequency of refresher training and numbers required Agree training priorities in light of Board performance targets Introduce and explore the concept of a staff competency framework in relation to safeguarding adults Support the integration of safeguarding learning into wider subject materials

•

Ensure learning from the partnership is included within safeguarding training programmes and trainers are kept updated of changing practice

Serious Case Review and Professional Practice: • • • • • • •

Review policies and procedures in relation to establishing serious case reviews Devise a bulletin to share findings from serious case reviews Develop clear criteria, procedures and templates for learning the lesson reviews Develop a framework for regular monitoring of agreed outcomes from serious case reviews Provide training relevant to those participating in serious case reviews Develop a protocol with the Leeds Safeguarding Children’s Board for serious case reviews / learning the lesson reviews, that cover both adult and children’s safeguarding Develop other processes for learning from safeguarding cases e.g. root cause analysis in order to widen learning opportunities.

Performance, Audit and Quality Assurance: • • • • • •

Work with partners agencies to ensure effective data capture and recording across agencies Explore potential to develop measures in relation to ‘value for money’ and work with the Communications and Community Engagement sub-group in order agree measures that capture ‘customer perceptions’ of safeguarding adults Undertake a review of data collected on referrals and analyse the differences in conversion from referral to investigation for different client groups Review quality assurance measures to ensure performance activity is being captured Facilitate an Annual Partner Agency Self Assessment in relation to Board partner organisations Finalise and implement the Quality Assurance Framework and evaluate the findings

Communications and Community Engagement: • • • • • • • • • •

Work with other Board sub-groups to set up processes to incorporate the learning from community engagement events Evaluate current leaflets, publicity and methods of communication, considering accessibility for adults at risk of abuse or neglect Explore and develop new communication media Devise and implement a prevention of abuse campaign Support the development of evaluation tools to capture customer perceptions of safeguarding Ensure a process is in place for stakeholder views/experiences to influence revisions of safeguarding procedures Review the Leeds Safeguarding Adults Charter, building in plain English and easy read principles Support the development of publicity information about Lasting Powers of Attorney and other similar measures that enable people to plan for their future Organise further two-way engagement exercises with stakeholders, including an event specifically for carers Work with Adult Social Care and NHS partners to ensure advocacy needs within safeguarding are reflected in commissioning strategy / service specifications

Mental Capacity Act LIN: • • • • • • •

Produce a Deprivation of Liberty Safeguards (DoLS) Annual Report Work with children services to identify priority development needs in relation to the Mental Capacity Act Monitor the transition arrangements to transfer supervisory body functions in relation to DoLS from NHS Airedale, Bradford and Leeds to Adult Social Care Maintain an overview of partner audits, performance and activity measures Develop a leaflet advising on safeguards, such as Last Powers of Attorney, Advance Decisions and Advance Statements, advising on how people can plan for their future Audit the quality of best interest assessments within Deprivation of Liberty Safeguard (DoLS) processes. Advise the board of the implications of forthcoming court judgements in relation to mental capacity and management of tenancies

6.2 Board Business Plan 2012/13 The Board Business Plan sets out the detail of the Board’s continuous work programme. This includes more detailed information about how these identified priorities will be taken forward during 2012/13. It includes additional detail including supporting actions and target timescales. The Board Business Plan 2012/13 is available on the Safeguarding Adult Partnership Board website: www.leedssafeguardingadults.org.uk

Appendix A: Representation and attendance of Member Organisations April 2010 to March 2011 Organisation

Invitee

Leeds Adult Social Care

Sandie Keene, Director of Adult Social Care

Independent

Leeds Adult Social Care

NHS Airedale, Bradford and Leeds

Leeds Teaching Hospitals NHS Trust NHS Leeds Community Healthcare NHS Trust

Leeds and York Partnership NHS Foundation Trust

Dr. Paul Kingston, Independent Chair Dennis Holmes, Deputy Director, Strategic Commissioning (also previous MCA LIN sub-group chair) Michele Tynan, Chief Officer, Learning Disability Maxine Naismith, Head of Service, Learning Disability (also MCA LIN subgroup chair) John Lennon, Chief Officer, Access & Inclusion Julia Suddick, Head of Service, Access & Inclusion Matt Ward, Associate Director of Commissioning (also previous PA&QA sub-group chair) Jo Coombes, Director of Quality and Nursing Diane Hampshire, Head of Service (also SCR&PP sub-group vice chair) Al Sheward, Divisional Nurse Manager Sally Mansfield, Nurse Consultant Paul Morrin, Director of Operations, Care Services Sam Prince, Director of Operations Andrea North, General Manager Susan Lines, Safeguarding Facilitator Michele Moran, Chief Operating Officer and Chief Nurse, Deputy Chief Executive Norman McClelland, Associate Director of Nursing Steve Wilcox, Lead Clinician for Safeguarding Adults

Membership April Status 2011 Ex-Officio Accountable Officer 9

Chair

June 2011

Aug. 2011

Oct. 2011

Dec. 2011

9 9 9

Full member

9 9

Deputy

Full member

Feb. 2012

9 9

Deputy

Full member

Full member Deputy

Full member

Deputy

9 9 9 9

Full member

9 9

Full member Deputy

Deputy

Full member

Deputy Deputy

9 9

Organisation

Invitee

Richard Jackson, Chief Superintendent West Julie Sykes, Yorkshire Detective Chief Inspector (also Police SCR&PP sub-group chair) Andrew Eaton, Detective Inspector Neil Moloney, Assistant Chief Officer West Yorkshire Kevin Ball, Probation Assistance Chief Officer Service Marianne Ward, Probation Manager Bridget Emery, Head of Housing Strategy and Leeds City Solutions Council Liz Cook, Environment Chief Officer, Statutory and Neighbourhoods Housing John Statham, Strategic Landlord Manager Leeds City Martyn Stenton, Council: Head of localities and Community safeguarding Safety Graham Heath, West Area District Manager Yorkshire Fire & Rescue Nigel Kirk, Service Assistant District Manager Policies, Protocols and Chair: Kieron Smith, Procedures LSAPSU sub-group (PP&P) Chair: Wendy Kelvin, Training and NHS Airedale, Bradford and Workforce Leeds Development Vice Chair: sub-group Norman Sterling-Baxter, (TWFD) LSAPSU Serious Case Chair: Keith Lawrance, Review & Community Safety Professional Practice subChair: Julie Sykes, group West Yorkshire Police (SCR&PP) (also organisation deputy) Chair: Matt Ward, NHS Airedale, Bradford and Performance, Leeds Audit and (also organisation member) Quality Chair: Rachel Gregson, Assurance Leeds and York Partnership sub-group Foundation NHS Trust (PA&QA) Marcus Beacham, LSAPSU

Membership April Status 2011 Full member

Deputy

June 2011

Aug. 2011

Oct. 2011

Dec. 2011

Feb. 2012

Deputy Full member

Full member

Deputy

Deputy Full member

Full member Deputy

Full member

Full Member

Deputy

Full Member

Full member

9 9

Full Member

Deputy

Full Member

Full Member Deputy

Organisation

Invitee

Communication and Community Engagement sub-group (C&CE)

Chair: Hilary Paxton, LSAPSU (also organisation member)

Mental Capacity Local Implementation network subgroup (MCA LIN) Leeds ALMOs Leeds Safeguarding Children Board LCC: Childrenâ&#x20AC;&#x2122;s Services Leeds Voice

Advonet Link / The Alliance of Service Experts Care Quality Commission Crown Prosecution Service (CPS) Trading Standards Service Leeds City Council Legal Services Leeds Safeguarding Adults Partnership Support Unit (LSAPSU)

Chair: Dennis Holmes, Leeds Adult Social Care (also organisation member) Vice Chair: Dave Shields, Leeds Adult Social Care Chair: Maxine Naismith, Leeds Adult Social Care (also organisation deputy) Steve Hunt, Chief Executive, ENE Homes Bryan Gocke, LSCB Manager

Membership April Status 2011 Full Member 9

Full Member

June 2011

Aug. 2011

Oct. 2011

Dec. 2011

Feb. 2012

9 9

Deputy Full Member Associate member

Deputy

Chair

Associate member

Sarah Sinclair, Deputy Director Associate Commissioning member Julia Preston, Director (Gipsil) Tim Whaley, Co-opted Representative Pammi Sahota, Manager Joy Fisher, Alliance Chair

Associate member Co-opted member Co-opted member Co-opted member

Emma Stewart

Deputy

Rod Hamilton, CQC Compliance Manager Lizzy Mills, Equality, Diversity & Community Engagement Manager

Co-opted member

Caroline Dollins, Trading Standards Officer

Co-opted member

Gerry Gillen, Corporate Lawyer,

Ex-officio member

Ex-officio & Associate Member

Ex-officio member

Hilary Paxton, Head of Safeguarding Partnership Unit (also C&CE sub-group chair) Emma Mortimer, Safeguarding Adults Partnership Manager Jayne Ogier, Board Minute Taker

9 9

Co-opted member

9 9

LSCB ANNUAL REPORT 2011/12 20 July 2012 David Radford - Independent Advisor to the Board Highlights from this Report: In October 2011 Ofsted published their report of the outcome of their announced re-inspection of Safeguarding in Leeds. The Report recognised significant improvements made across the City. Taken together with their unannounced inspection of contact, referral and assessment arrangements in January 2011 - when Ofsted noted ‘remarkable and impressive improvements’ - this report is a strong endorsement of the progress being made in Leeds. Within the key statutory agencies services are being re-organised in line with strategic plans. During 2011/12 a new Directorate within Leeds City Council was created for services to children and young people. Teams that previously worked within Education Leeds, Early Years and the Integrated Youth Support Service, Children and Young People’s Social Care, and the Director of Children’s Services Unit, became an integrated service that is better placed to respond to the needs of children and young people growing up in Leeds. The LSCB and Children’s Services jointly commissioned an updated review of processes and decisions made in response to requests for service and referrals made to the ‘front door’ duty system for children and young people and their families by Professor David Thorpe. As a result restructuring the Children’s Services duty system is viewed as a key task in contributing to the ‘rebalancing’ of the safeguarding system in Leeds and a new dedicated multiagency Duty and Advice Team is being established in the Contact Centre from May 2012. Changes taking place in ‘Early Start‘ Health Service provision to families in Leeds are also aligned to the priorities of the Children and Young People’s Plan. The development of an Early Start service bringing together Health Visitors and Children’s Centre staff working together in localities and teams linked to the local ‘Clusters’ of other professionals is part of the further development of preventative early help. In order to ensure that the significance of the pattern of usage of the Common Assessment Framework (CAF) was fully understood and that the CAF process was being effectively used as part of the ‘rebalancing’ of services towards increased use of prevention, the Children’s Trust Board supported a

major review of the Common Assessment in Leeds and Mark Peel from Leicester University was commissioned to support this work. The work highlighted that in fact in 2010/11 the number of CAFs being instigated had compared well with other similar local authority areas. In July 2011 the LSCB commissioned an independent assessment of the extent to which it was effectively carrying out the functions ascribed to it under statutory guidance. Overall, there was evidence at that time that almost all of the functions were being addressed to a satisfactory level or better and that clear plans were in place for further development where needed. This assessment was endorsed by an Ofsted inspection report published in October 2011 Overall good progress has been made against the objectives set for the year in an ambitious LSCB Business Plan. The LSCB has inputted into the Children and Young People Plan (CYPP) 2011-15 and set challenges to the CTB for 2011/12 to further improve safeguarding arrangements and outcomes for children and young people. The LSCB Chair is co-sponsor of one of the 5 key CYPP outcomes: that children and young people are safe from harm. The new LSCB Performance Management System (PMS), based on an Outcomes Based Accountability approach, was developed in 2010/11 for gradual implementation in 2011/12. There is evidence of improvements in both the effectiveness and efficiency of child protection (CP) processes and in outcomes for Children and Young People at risk of or suffering significant harm:



A new approach to child protection conferences has received overwhelming positive feedback from parents and professionals as a much more effective way of exploring risk, developing plans and engaging families.



The number of Initial Child Protection Conferences held over the year has fallen steadily from a peak in July 2011.



The number of Children and Young People subject to a Child Protection Plan has decreased from 1019 in April 2011 to 924 in March 2012. The further reduction in April 2012 to 893 suggests that this downward trend is continuing.

1.0

Introduction: The LSCB has a key role in achieving high standards in safeguarding and promoting welfare, not just through co-ordinating but by evaluation and continuous improvement.’ Working Together to Safeguard Children, 2010, page 93.

1.1

Leeds Safeguarding Children Board (LSCB) is a statutory body established under the Children Act 2004 and ‘Working Together to Safeguard Children (2010)’. It is independently chaired and consists of senior representatives of all the principle stakeholders working together to safeguard children and young people in the City.

1.2

Its statutory objectives are to:  Co-ordinate local work to safeguard and promote the welfare of children  To ensure the effectiveness of that work

1.3

The full Board currently meets bi-monthly and an Executive Group meets on the alternate months in order to maintain the momentum that the completion the Board’s significant workload requires. The Board has a series of sub-groups, each with its own business plan, focused on key elements of the Board’s work. The Board Manager is supported by a Business Unit which, complemented by recent additions to the establishment, is able to effectively support the varied elements of the Board’s work. (See Appendix 1, Structure of the LSCB)

1.4

This report of the work of Leeds Safeguarding Children Board covers a year that has been characterised by the consolidation of significant changes and development in the governance, structure, membership, and operation of the Board that took place during the previous year. At the same time the national Safeguarding agenda, through a series of proposed reforms and developments, is driving significant change and this is reflected in the further changes that have been initiated during this year in how local child protection services are organised and provided.

1.5

The LSCB works closely with the Leeds Children’s Trust Board (CTB). The CTB is specifically accountable for overseeing the development and delivery of the Children & Young people’s Plan (CYPP).

1.6

This Report identifies challenges for both the LSCB and for the Children’s Trust Board. The CTB must consider the report in preparing and refreshing the Children & Young People’s Plan. The Munro Review, a review of the national Child Protection system, recommended that once published the Annual Report should also be submitted to the Chief Executive and Leader of the Council, the local Police and Crime Commissioner (when in place) and the Chair of the Health and Wellbeing Board. It is envisaged that the update of Working Together guidance, the publication of which is expected in the latter part of 2012, will support this recommendation. There is also a local agreement to submit it to the governance bodies of all partner organisations to support their governance of safeguarding practice in Leeds.

1.7

In order to achieve a level of consistency the format adopted for this report is similar to the one used last year. This is a structure that is recommended in current national guidance.

2.0

LSCB Vision, Values and Principles

2.1

Children, their welfare, protection and the promotion of their best interests are at the heart of everything the LSCB does. The existence and continued prominence of what the Board stands for and the commitment to how it carries out its work remains crucial.

2.2

The following was agreed through the LSCB members working together at Development sessions as part of the creation of the LSCB Strategic Plan 2011-15.

2.3

Our Vision Is for Leeds to be a child friendly city in which children and young people are safe from harm in their families, their communities and their neighbourhoods.

2.4

Our Values We will promote these values in order to influence our behaviours jointly with the Children’s Trust Board     

2.5

Celebrating diversity Engaging citizens locally Being open and honest Working as a team for Leeds Spending money wisely

Our principles We are as a Board:  Committed to putting the child / young person at the centre of all that we do  Focused on getting safeguarding right for children, young people and their families  Clear about what we expect of safeguarding services  Informed about how well protected children and young people are in Leeds  Open about what we do and why  Co-operative and collaborative with each other  Challenging of each other and of the safeguarding services each partner provides  Effective and providing value for money  Accountable to the people of Leeds for how we invest our resources  Accessible to and informed by children, young people and their families, the communities they live in, the staff in our organisations that serve them, and the priorities of the Children’s Trust  Learning from everything we do and changing as a result  Improving practice and outcomes for children and young people

2.51

All our work is underpinned by an agreed set of approaches, shared with the Children’s Trust Board, so that we all work together to deliver improved outcomes for children and young people –         

The child IS the client Talking a common language Using ‘outcomes based accountability’ to improve outcomes in each locality across Leeds Doing things WITH children and families, not TO or FOR them Doing the simple things better – never doing nothing Supporting strong schools, settings, families and communities Involving everyone who has a part to play – a whole city approach Improving assessment and intervention Targeting resources to make the biggest impact on our priorities

3.0

The Safeguarding Context

3.1

Leeds is the second largest city council in England. The population of the city has increased rapidly in recent years. The latest population estimate is 798,800 representing a 12% increase over the last 10 years, which is higher than the average regionally and nationally. The population of children and young people aged 0-19 is almost 180,000. Within this, the number of very young children (0-4 year olds) has increased faster with over 10,000 children born in Leeds in 2009/10. Leeds has a significantly higher proportion of 15–25 year olds compared to both the regional and national averages, with a total population of 289,000 0-25 year olds living in the city.

3.2

Leeds is a very diverse city, with over 130 nationalities included in a minority ethnic population of just less than 17.4%. The proportion of pupils in Leeds schools that are of minority ethnic heritage has increased by more than six percentage points since 2005 to 22.5% of pupils in 2011. A higher proportion of primary than secondary pupils are of minority ethnic heritage. Some 14% of pupils have English as an additional language and over 170 languages are recorded as spoken in Leeds schools. The largest minority ethnic groups in the city are the Indian and Pakistani communities but more recently there has also been a significant increase in economic migration, mainly from Eastern Europe.

3.3

The local authority area includes some rural communities, as well as densely populated inner city areas where people can face multiple challenges.

3.4

The Indices of Multiple Deprivation indicate that 19%, or over 150,000 people in Leeds, live in areas that are ranked amongst the most deprived 10% nationally. Around 30,000 children and young people, 23% of all those aged 0-16, live in poverty.

4.0

Effectiveness of Safeguarding Arrangements in Leeds.

4.01

This section of the Report draws together evidence from a range of sources to provide an overall picture of effectiveness. However, at the present time there is insufficient consistency in the methodology used to collect and interpret the data. This is a common picture around the Country. As a

result of recent national developments in how services are inspected there will, in the immediate future, need to be a significant move towards greater separation of the quantity of activity (how much are we doing?) the quality of the work (how well are we doing it?) and the outcomes for children and young people (what difference are we making?) This will rightly give an emphasis and greater focus on improving outcomes for children and young people – and on being able to evidence this. Both the CTB and the LSCB have during 2011/12 made significant moves in this direction with the adoption of the Outcomes Based Accountability (OBA) Quality Assurance Framework. 4.02

The Leeds Children’s Trust Board is responsible, through the implementation of the CYPP, for the strategic development of effective Safeguarding services in the City. The Leeds Children and Young People’s Plan 2011-15, which was agreed by the Children’s Trust Board in April 2011, has been refreshed following a review of the first year of implementation. The CTB has agreed the following four guiding principles to inform all work with children, young people and their families. These are predicated on a ‘restorative approach’ built on the basic premise that people are happier, more co-operative, productive and more likely to make positive changes when those in positions of authority do things with them rather to them or for them. This represents a commitment to a fundamental renegotiation of the relationship between Children’s Trust and Local Government Partners and local citizens. 1) The default behavior of Children’s Trust and Local Government Partners in all dealings with local citizens / partners / organisations should be a restorative one, combining high support with high challenge. 2) Children’s Trust and Local Government Partners should ensure that families, whose children might otherwise be removed from their homes, are supported to meet and develop a safe alternative plan before such action is taken. 3) For all other families where a plan or decision needs to be made to help safeguard and promote the welfare of a child, or children, the family should be supported to help decide what needs to happen. Conditions must be created to enable families to safely help themselves. 4) Children’s Trust and Local Government Partners must see all local schools as community assets and have a clear role in holding those institutions to account for the contribution they make to the wellbeing of the local population, regardless of the governance arrangements in place. The use of the CAF and Family Group Conferences are seen as key approaches in underpinning these guiding principles.

4.03

Safeguarding children in Leeds is a significant component of the plan: ‘that children and young people are safe from harm’ is one of 5 outcomes sought; and of 11 priorities ‘help children to live in safe and supportive families’ is one of 3 that is seen as a key starting point. Of 16 key indicators of progress ‘the number of looked after children’ is one of 3 “obsessions” that are seen as key to the successful implementation of the plan.

4.04

Leeds Safeguarding Children Board has an important but distinctive role with the Children’s Trust Board in keeping children safe. Whilst the CTB is specifically accountable for overseeing the development and delivery of the Children & Young People’s Plan. The LSCB is responsible in turn for challenging the CTB on their success in keeping children and young people safe. The two Boards have established an ongoing and direct relationship, with regular communications, seeking to ensure there is no duplication of activity and no unhelpful gaps in strategic or operational policies, protocols, services or practice. The LSCB has a separate identity and independent voice from the Children’s Trust; it is not subordinate to or subsumed within the CTB.

4.05

The membership of each Board includes the Chair of the other Board to support close communication and a good working relationship. Agendas for each meeting routinely provide an opportunity for updates on key matters discussed at the other Board meeting.

4.06

The Chairs of the two Boards meet periodically to discuss the issues arising from meetings and to support close working between the two Boards. The Director of Children’s Services facilitates these meetings. The LSCB Strategic Plan and Business Plan were presented to the CTB in June 2011. The LSCB Annual Report 2010/11was accepted by the CTB in July 2011. LSCB Policy and Procedures and Learning and Development sub groups are contributing to the CTB workforce reform sub work on developing common values, attitudes and behaviours to underpin improved multi-agency working.

4.07

The LSCB has inputted into the Children and Young People Plan 2011-15 and set challenges to the CTB for 2011/12 to improve safeguarding arrangements and outcomes for children and young people. The LSCB Chair is co-sponsor of one of the 5 key CYPP outcomes: that children and young people are safe from harm.

4.08

Within the key statutory agencies services are being re-organised in line with strategic plans. During 2011/12 a new Directorate within Leeds City Council was created for services to children and young people. This brought together teams and services that previously worked within: Education Leeds; Early Years and the Integrated Youth Support Service: Children and Young People’s Social Care: and the Director of Children’s Services Unit, to create a new integrated services that is better placed to respond to the needs of children and young people growing up in Leeds.

4.09

A significant restructure has taken place within the directorate relating to:   

social work services delivered to children in need children subject to child protection plans children subject to care proceedings and children looked after by Leeds City Council.

4.010

These services will be delivered under the title of Children’s Social Work Services (CSWS). Under the new structure children’s social work teams are locally based in the same localities as other Council Services, using the cluster model already in place for groups of schools so they can work more closely with schools, health visiting teams and other professionals

4.011

The new teams include:  Looked after children teams - all three areas of the city have dedicated provision for two different age groups, age 12 and under and 13 plus. These teams focus on the specific needs of looked after children implementing plans to ensure that more children experience permanence through adoption, special guardianship, return to their family or independence.  Social work teams - social work teams work with children who have high levels of need, children subject to child protection plans and those children subject to care proceedings. Locality-based social work teams now work very closely with local targeted and universal services to help reduce the number of schools, health visiting teams and other professionals that social workers and their managers work with. The aim is to ensure more in-depth professional liaison and sharing of information, for the benefit of children and young people.

4.012

There are a number of strands to this strategy:   

Improving prevention and early identification services to vulnerable and potentially vulnerable children to reduce family breakdown, in particular the redesign of the Common Assessment for Leeds and developing multi-agency ‘front door’ arrangements (referrals to and assessments by CSWS); Increasing evidence based services that prevent family breakdown and support children to remain within their family underpinned by Restorative Practice, Family Group Conferencing and Multi Systemic Therapy; Strengthening care planning for looked after children through the creation of specialist looked after children’s teams.

4.013

The LSCB and Children’s Services jointly commissioned an updated review of processes and decisions made in response to requests for service and referrals made to the ‘front door’ duty system for children and young people and their families by Professor David Thorpe. Professor Thorpe’s research identified a significant increase in investigative and assessment work undertaken by, the then, Children and Young People’s Social Care in response to ‘requests for service’ and referrals from across the partnership. However, this increase in workload was not matched by a proportionate increase in the level of support services provided to children and young people and their families. Moreover, the research identified a number of procedural and professional issues in the operation of the Council’s Contact Centre and Children’s Services Duty Room.

4.014

As a result restructuring the Children’s Services duty system is viewed as a key task in contributing to the ‘rebalancing’ of the safeguarding system in Leeds and a new dedicated multi-agency Duty and Advice Team is being established in the Contact Centre from May 2012. The team will include education, police and health staff.

4.015

Changes taking place in ‘Early Start‘ Health Service provision to families in Leeds are also aligned to the priorities of the CYPP. The development of an Early Start service bringing together Health Visitors and Children’s Centre staff working together in localities and teams linked to the local ‘Clusters’ of other professionals is part of the further development of preventative early intervention.

4.1

External Inspection

4.11

In October 2011 Ofsted published their report of the outcome of their announced re-inspection of Safeguarding in Leeds. The Report recognised significant improvements made across the city. Overall, five of the nine categories that Ofsted assessed were rated as ‘good’ and four were rated as ‘adequate’ - there were no categories rated as inadequate. The key judgments of ‘overall effectiveness’ of Safeguarding in the City were rated as ‘adequate’ and the ‘capacity to improve’ was rated as ‘good’.

4.12

Taken together with their unannounced inspection of contact, referral and assessment arrangements in January 2011 - when Ofsted noted ‘remarkable and impressive improvements’ - this latest inspection report is another strong endorsement of the progress being made in Leeds.

4.13

The report endorsed the view that developments in Safeguarding are making a significant difference to the well being and safety of children in Leeds. The inspection found that ‘arrangements to ensure children are safeguarded are now secure’. It highlighted ‘significant progress in improving

outcomes’. The inspectors did not identify any children left at potential risk of harm, and none of the cases reviewed were deemed to be inadequate. 4.14

4.15

Amongst the other areas that the inspectors highlighted were: · The development of more child centred approaches, for example through the way that children are increasingly involved in child protection conferences so that their wishes and views are fully taken into account. · Improvements in the way partnership between different services to safeguard children works, especially in terms of shared responsibility, vision and priorities, and the overall understanding that in Leeds, ‘safeguarding is everyone’s business’. · That the Leeds Safeguarding Children Board is much improved. The Report noted areas in which further development needs to take place: ·

The need to improve the electronic social care record system (ESCR) – used by the Children’s Social Work Service.

Continuing to improve the timescales for initial children protection conferences.

Improving the quality of assessments to help achieve a consistent standard across the service.

Information sharing between partner agencies in relation to domestic violence.

4.16

As a result of the significant amount of progress made and the finding of this inspection that supported this view, the Government removed the Improvement Notice that had been placed on the City Council in 2009 in relation to its Safeguarding Services.

4.17

In order to maintain progress the CTB have agreed to continue with the model of external challenge provided by the Improvement Board that was established following the Inspection of 2009 and has agreed to set up a Bi-Annual Challenge Board of external experts. The Chair of the LSCB will sit on that Board.

4.2

Performance Management and Quality Assurance of Safeguarding Services

4.21

As described above, in order to progress the first desired Outcome of the CYPP; that ‘Children and Young People are Safe from Harm’, there are two key priorities against which progress is captured, tracked and regularly reported to the CTB. For the key priority, ‘help children to live in safe and supportive families’ the measure is the number of children who are Looked After by the Local Authority. For the second priority ‘ensure that the most vulnerable are protected’ the measure is ‘the number of children subject to a child protection plan.

4.22

The new LSCB Performance Management System (PMS), based on an Outcomes Based Accountability approach, was developed in 2010/11 for gradual implementation in 2011/12. Key to judging safeguarding performance in Leeds is comparison with data from other Local Authority areas. The LSCB uses as comparators average data from ‘Core Cities’ (CC) and ‘Statistical Neighbours.’(SN). It is noteworthy that the CTB, as part of its commitment to supporting Leeds becoming a ‘Child Friendly City’ has chosen a higher standard; that of comparing Leeds’ performance against the average in other Local Authority areas, aiming to perform in the top 50%.

4.23

Key data relating to these two priorities was presented in detail to the LSCB through the Annual Performance Report. In the current climate of improvement and with the need to address some key pressure points within the safeguarding system, a small number of further scorecards have been maintained to report on key operational processes. These concentrate on three areas: 1. Entry to the Child Protection system (Numbers of referrals and CPPs, CAFs, Number of S47s, speed of assessment and conferences) 2. Participation and engagement (Numbers of children/parents participating in conferences and reviews) 3. Referrals and request for service to the Children’s Social Work Service

4.24

It is planned that these measures will only be required for a transitional period. Once reporting against strategic priorities and vulnerable groups are well established there should be no requirement for additional process measures.

4.25

Analysis of the measures for priority areas in the CYPP that contribute to an understanding of the current effectiveness of safeguarding is as follows:

4.26

Children and Young People with a Child Protection Plan (CPP): 

The number of Initial Child Protection Conferences (ICPCs) initiated over the year has fallen steadily from a peak in July and 1241 children ended a CPP which is a 14.7% increase from 2010/11 when 1082 children ended a CPP.



The number of C&YP subject to a CPP has decreased from 1019 (67.1/10,000) in April 2011 to 924 (58.0/10,000) by year end in March 2012 which is a decrease of 95 (9.3%). This is also less than the 2010/11 out turn number of 984 (64.8/10,000) C&YP subject to a CPP, marking a decrease of 60 or 6.0% over the year. Comparison with CCs (58.5 / 10,000) and SNs (39.0 / 10,000) suggests that this downward trend is appropriate.



Provisional data for the number of CP Plans in April 2012 suggests that this downward trend is continuing (893, 56.0/10,000).



These performance trends are a vindication of the introduction in August 2011 of the ‘Strengthening Families’ approach to CP Conferences and a more rigorous process for reviewing CP Plans.



The previous steady increase in CP Plan numbers through 2009/10 and the beginning of 2011/12 can be viewed as the result of an adjustment and more consistent application of thresholds for statutory intervention in response to the finding of the Ofsted unannounced inspection in 2009.

4.27

A breakdown of the reasons children were on CPP between June 2011 and March 2012 shows that on average 67.9% were due to multiple reasons, 2.8% sexual abuse, 11.6% neglect, 11.6% emotional abuse and 5.8% physical abuse. The prevalence of ‘multiple categorisation’ has a limiting impact on the analysis of why C&YP become subject to CP plans. Single, primary categorisation will be introduced for 2012/13.

4.28

The number of C&YP subject to CP plans from black minority ethnic (BME) backgrounds fluctuated throughout the year from 16 – 20% -, averaging

19%. This remains broadly in line with the proportion of the BME population on the rolls of Leeds schools (21.4%) and BME representation in the all age population (16%). 4.29

There is evidence of improvements in both the effectiveness and efficiency of CP processes and in outcomes for C&YP at risk of or suffering significant harm from:  

The continuing increase in the timeliness of ICPCs completed from 31.9% in 2010/11 to 54.0 in 2011/12; however this figure is still below the statistical neighbour (SN) comparator at 70%. The reduction in the overall CPP rate by 6.8/10,000 over the year from 64.8/10,000 in (year end) 2010/11 to 58.0/10,000 in ((year end) 2011/12. This is in line with the Core Cities (CC) comparator 2010/11 figure of 58.5/10,000 and significantly higher than SN 2010/11 figure of 39.0/10,000.

4.210

The introduction in August 2011 of the ‘Strengthening Families’ model for child protection conferences focuses on risk analysis, shared responsibility for the child protection planning process and timely improvements for children. Better engagement with C&YP and their families through a ‘restorative approach’ and improved multi-agency planning will ensure that intervention is more effective and where plans are not working this is identified and corrected at an early point. The new approach to child protection conferences has received overwhelming positive feedback from parents and professionals as a much more effective way of exploring risk, developing plans and engaging families.

4.211

In 2012/13 the LSCB Audit programme will provide more qualitative information about the effectiveness of Child Protection Plans through two strands:  

4.212

(S1) To quality assure and audit the impact and outcomes for C&YP subject to CP Plans (S2) To audit compliance with timescales for calling CP Conferences, reviews and core groups and identifying reasons for delays.

Children and Young People who are Looked After (LAC): Over 2011/12 there has been a small increase in the number of LAC (by 1.8% to 1474 on the 31 March). The rate of looked after children, 96.9/10,000, is above that of statistical neighbours of 74/10,000 but it is in line with the figure for Core Cities 95/10,000, which have similar demographics to Leeds. It should also be noted that these comparator figures are for 2010/11. However regional data indicates that the rate of increase across the region for 2011/12 was 4.4%. Had Leeds had a similar rate of increase there would have been 1550 looked after children. Indications from the first 2 months 2012/13, although outside of the timescale for this report, are that the number of looked after children has since reduced to that in April 2011.

4.213

The increase in the number of LAC occurred between January – March 2012 during a major restructure of the CSWS. During this period 103 children became looked after. Of these 47 children were aged under one and 70 were 5 or under. This may indicate a shift in the make up of the looked after children population in Leeds and highlights the importance of early intervention initiatives for families with young children, such as Early Start and the Family Nurse Partnership.

4.214

Children and young people from a mixed heritage background are over-represented in care making up 12% of the cohort, whereas those from an Asian background are under-represented comprising 4% of the cohort. Those from a Black background also make up 4% of the Looked after children population.

4.215

Leeds has maintained a high level of allocation of social workers to LAC (99 – 100%) over the year. Almost 14% of looked after children are being supported to remain within their extended families through placement with a family network carer. This is consistent with the principles of the Children Act 1989 and research findings that demonstrate that children that are appropriately supported within their family achieve better outcomes. 9% are ‘placed with parents’ and work is on going with CAFCASS to promote, where appropriate, the revocation of care orders.

4.216

2011/12 has seen a 31% increase in the use of independent fostering agency (IFA) placements from 206 to 270 and of external residential placements from 76 to 89; a 17% increase. Indications are that this is consistent with an increase in the use of agency foster care across the region. The budgetary implications of this trend will be a matter of interest to the LSCB as it seeks to monitor the ‘value for money’ of safeguarding services from 2012/13.

4.217

There has been a downward trend in the percentage of LAC reviews within statutory timescales, 95.1% of reviews in April 2011 were within timescales, reducing to 81.1% in March 2012 although this is still higher than the 2010/11 result of 75.7%. The percentage of LAC who participate in their reviews has decreased over a rolling 12 month period from 92.0% in April to 81.0% in March which is lower than 2010/11 result of 82.2%.

4.218

The introduction within the CYPP of an ‘obsession’ focussed on reducing the number of C&YP who need to be accommodated by the Local Authority has underpinned the analysis of the effectiveness of the safeguarding system in Leeds and laid the groundwork for its ‘rebalancing’ to increase preventative services and reduce the need for statutory intervention.

4.219

There is evidence that ‘turning the curve’ has started with much work being undertaken to maintain the relative stability of overall LAC numbers during 2011/12. The indication of a trend of increasing numbers of LAC Jan – Mar 2012 will be monitored in 2012/13. Provisional figures for April 2012 of 1463 LAC would suggest that this is being stabilised.

4.220

The performance of key LAC processes remains a concern. LAC reviews and Health Assessments will have a significant impact on outcomes for looked after children and may be identified as a particular challenge for 2012/13 given the capacity pressures of servicing such a high level of looked after children and in the context of an appropriate focus on reducing the number of children and young people who need to be looked after. Implementation of LSCB Audit strand 3 (to quality assure and audit the impact and outcomes of child care plans for looked after children, including the quality of C&YP’s participation in their statutory reviews) will provide a fuller picture of progress in these areas in the coming period.

4.221

Children Missing and Child Sexual Exploitation:

4.222

This is the third category of vulnerable children and young people that the LSCB is currently focusing attention on. Data has been collated on this combined grouping of vulnerable C&YP since September 2011 and reflects an increasing focus on this vulnerable group across the partnership.

4.223

Between 14/09/2011 and May 2012 there have been 643 recorded incidents of children and young people under 18 going missing, from these 285 went missing from residential units, 53 from foster care, 315 missing from home (in care of parents) and 2 were missing from other residences.

4.224

Return interviews for children and young people missing from both home and care are a crucial element of exploring the reasons they ran away and in responding appropriately through CAFs, referrals to CSWS, or linking into care planning as appropriate. Every child and young person who is

reported missing to the police has a return home interview by the police and those details are forwarded to the CS Independent Safeguarding Unit (ISU). If a case is open and has an allocated social worker then they are responsible for undertaking the return home interview. Information sharing following return interviews will be monitored in 2012/13. 4.225

The collection of information has enabled greater transparency of the frequency with which children in residential units have or are going missing and for how long. This monitoring allows the Integrated Safeguarding Unit to ensure that strategy meetings are arranged if a young person meets the criteria of four times in a month or six times in a two month period. A number of these meeting have already taken place and pro active plans put in the system both with social care and the safeguarding police.

4.226

Links have been set up between the city centre youth teams who assist in monitoring those at high risk and they have also been involved in undertaking return home interviews. This ensures that links are made within the community area that the child or young person lives and follow up work can be done with that child or young person.

4.227

At the end of March 2012 West Yorkshire Police had flagged 98 C&YP as being potentially at risk from sexual exploitation. The Children’s Services Integrated Safeguarding Unit identified 31 C&YP believed to be at risk and 21 believed to have been exploited. Concerns about 4 C&YP previously identified as at risk were no longer held. Work is being undertaken at the beginning of 2012/13 to share relevant data about child sexual exploitation between West Yorkshire Police, Children’s Services Integrated Safeguarding Unit, Genesis and Blast.

4.228

The data collected in Q3 & Q4 of 2011/12 represents the establishment of a baseline against which progress to address the issues posed by these vulnerable groups of C&YP can be gauged in 2012/13.

4.229

Operational Performance: Referrals and requests for service:

4.230

A total of 13,754 referrals were made to CSWS in 2011/12 compared to 13,643 in 2010/11 an increase of 111 (0.8%). The first three quarters of 2011/12 saw a decrease in the number of referrals from 3691 in Q1 to 3229 in quarter 3. Quarter 4 saw a slight increase in referrals to 3359 although this was still a 9.8% decrease from Q1.

4.231

Referrals made between December 2011 and March 2012 show that on average 33% of referrals came from Police, 17% health, 17% education and 33% other referral sources. Over that time period some of the referrals made have resulted in no further action (5.0% December, 2.6% January, 6.1% February and 7.7% in March)

4.232

Given the concerns in 2010/11 about the steadily rising number of referrals being accepted by Social Care it is reassuring that this trend was stabilised in 2011/12. The impact of the implementation of the new Duty and Advice ‘front door’ team will be monitored in 2012/13.

4.233

During 2011/12 there have been 864 CAFs instigated compared with 1098 in 2010/11. The fact that the number of CAFs initiated in 2011/12 was lower than in 2010/11 is, on the face of it, a cause for concern. Increasing the use of CAFs was included in the challenges to the CTB in the LSCB Annual Report July 2011. However, between August 2011 and March 2012 there were 621 CAFs instigated, which is an encouraging indicator that the trend is now showing the sought after increase in CAF usage.

4.234

In order to ensure that the significance of the pattern of usage of the CAF was fully understood and that the CAF process was being effectively used as part of the ‘rebalancing’ of services towards increased use of prevention, the Children’s Trust Board supported a major review of the Common Assessment in Leeds and Mark Peel from Leicester University was commissioned to support this work.

4.235

The work highlighted that in fact in 2010/11 the number of CAFs being instigated had compared well with other similar local authority areas. What appeared to be continuing poor performance in the first part of the year reflected some local uncertainty about the future of the Common Assessment Framework following the decision nationally not to proceed with the e CAF and concerns across the partnership about the over complicated and time consuming nature of the existing process.

4.236

The common assessment record used in Leeds has been considerably simplified in response to feedback and the process has been revised. The CAF process is being re-launched in Leeds in the Summer of 2012 and will be integrated into the replacement for the current LCC ESCR system (due in 2013/14). This is designed to embed the centrality of CAF processes in the safeguarding system in Leeds and help to ensure that C&YP receive ‘the right help at the right time.’

4.237

The number of Initial Child Protection Conferences held in 2011/12 was 1191 which is a reduction of 492 (29%) from 2010/11 when 1683 ICPCs were held. ICPCs held each quarter have reduced from 356 in Quarter 1 to 238 in quarter 4 (327 in Quarter 2 and 270 in quarter 4). This reduction would suggest that the ‘curve is being turned’ in the identification of whether C&YP are likely to be suffering or at risk of suffering significant harm.

4.3

‘Section 11 Duty to Safeguard’ Compliance

4.31

The Children Act 2004 is the legislative framework for safeguarding and promoting the welfare of children and s.11 places a duty on a range of organisations to make arrangements for ensuring that their functions, and services provided on their behalf, are discharged having regard to the need to safeguard and promote the welfare of children. Services they contract out to others should be provided having regard to that need and the application of this duty will vary according to the nature of each agency and its functions.

4.32

Following the completion and analysis of the 2010/11 s.11 Self Assessment Tool (SAT), distributed to partner agencies by the LSCB, a sample audit of recruitment, selection and supervision of staff was undertaken with four partner agencies. As a result recommendations were made as follows to improve practice in a number of areas and agencies asked to submit action plans. Examples of areas for improvement identified were:  Ensure that websites are regularly reviewed from a user’s perspective and that their commitment to safeguarding is more transparent.  Ensure that safeguarding responsibilities are explicit on all job descriptions and/or contracts within a service working with children and young people.  Consider frequency of training for recruitment panel members and how the panel’s performance can be reviewed as part of the recruitment culture rather than if there are identified problems.  Review their new employee induction process in terms of the quality of the mentoring and ensure that it meets new employee’s needs.

4.33

For 2011/12 the LSCB used the West Yorkshire Safeguarding Children Consortium s.11 self- assessment tool. This has had an impact on the extent to which comparisons can be made between 2010 and 2011 data due to differences in the wording of the documents. In addition the scoring system adopts a different format so it has only been possible to make general rather than specific comparisons.

4.34

Twenty partner agencies were asked to submit their s.11 documents. Nineteen were returned on time.

4.35

The results of self-assessment were reported to the LSCB. Overall the picture emerging through this self-assessment process was very positive. No safeguarding concerns were identified in key areas of practice and the following strengths were identified:  ‘Senior management commitment to the importance of safeguarding and promoting children’s welfare’:  ‘There is a clear statement of the agencies responsibilities towards children available to all staff’:  ‘A clear line of accountability exists within the organisation for work on safeguarding and promoting the welfare of children’:  ‘Service development takes account of the need to safeguard and promote the welfare of children and is informed where appropriate, by the views of children and families’:  ‘Staff training and development is available on safeguarding and promoting the welfare of children for all staff working with or in contact with children and families’:

4.36

Where issues were identified these have been discussed with the agencies involved with a view to implementing changes and improving practice.

4.37

Areas for improvement were identified in the following areas: 

Potential safeguarding concerns were identified within Education as a result of a discrepancy between guidance issued to schools (‘Safeguarding Children and Safer Recruitment in Education Jan 2007) and s(11) of the Children Act 2004 with respect to CRB checks being undertaken on staff. This is being considered by the Children’s Services Leadership Team in order to harmonise expectations across children’s services.



Following the audit, clarification was sought and received from a small number of partners about the identity of their senior officer who is responsible for ensuring that allegations received against staff are passed to the Local Authority Designated Officer (LADO)

4.38

Overall it is felt that the S11 audit process is very helpful to individual agencies, but also the sharing of the outcomes across the partnership makes an important contribution to partnership working.

4.4

Serious Case Reviews and Learning Lessons Reviews

4.41

The LSCB is responsible for initiating a Serious Case Review (SCR) in circumstances where there has been a death of a child and abuse or neglect is suspected, or where there has been a serious injury and there are concerns about interagency working. The purpose of such a review is to:  Establish whether there are any lessons to be learnt from the case and from the way in which local professionals and organisations worked together to safeguard and promote the welfare of children.  Identify clearly what those lessons are, how they will be acted on, what is expected to change as a result and within what timescale and  as a consequence, improve inter-agency working to better safeguard and promote the welfare of children

4.42

Three SCR were completed during the year. There were recurring issues regarding training, communication, multi agency working and LAC policies in all three SCRs. In two of the cases there were specific issues related to LAC reviews, training and practice and SCR guidance. The identification of these lessons will inform the refreshing of the Business Plan for 2012/13. The Board is incorporating the auditing of the action plans from these SCRs into the newly established audit programme.

4.43

Of the three completed SCRs, Ofsted judged one to be ‘adequate’, one to be ‘satisfactory’ (following remedial work) and one received positive feedback (following a change in the way Ofsted undertakes evaluations of SCRs

4.5

Managing Allegations Against Professionals

4.51

Dealing with allegations made against professionals is the role of an employing agency. However, the Local Authority is required to provide a coordinating role through the provision of a Local Authority Designated Officer, or ‘LADO’. Individual agencies are required to notify the LADO of any allegations made.

4.52

The role of the LADO is to provide advice and guidance to employers and voluntary organisations, to liaise with the police and other agencies and to monitor the progress of cases to ensure that they are dealt with as quickly as possible consistent with a thorough and fair process.

4.53

An annual report has been provided to the LSCB on activity by the LADO during 2011/12. This report provides statistical information for the period, development work this year and plans for future development for the year 2012-2013.

4.54

There has been agreement for funding for a second LADO post within the structure of the Children’s Services Integrated Safeguarding Unit, but at the time of writing the recruitment process has still to be completed. In the structure, those LADO posts will also have line management responsibility for some existing and new posts within the ISU.

4.55

The existence of the post of LADO has continued to improve the timeliness of responses to referrals, but comes under some strain when the LADO is on leave. That should improve when the recruitment process for the additional post is complete and has been greatly assisted by the provision of administrative support.

4.56

Since 2006-2007 the number of referrals to the LADO service has been growing with a significant increase, particularly in the last two years: 2006-2007 - 63 2007-2008 - 80 2008-2009 - 119 2009-2010 - 126 2010-2011 249 2011-2012 405

4.57

304 of the referrals were about specific children possibly being harmed by professionals, of which just under a third (94) were Looked After Children. Not all of them are Leeds children; several are placed by other Local Authorities in Independent Fostering Agency (IFA) or Private Residential units within the city area.

4.58

Only about a third of referrals led to the convening of an inter agency allegations management strategy meeting, which is similar to the proportion in the previous year. Again, the vast majority of all referrals involved employers taking action using their own codes of conduct for employees, following consultation with the LADO. Criteria for convening a strategy meeting are when there is a judgment either that a child may be at risk of significant harm or the behaviour of a professional may pose a risk of significant harm to children.

4.59

46 referrals to the LADO in the year led to Police investigations. These figures are low but similar to previous years and reflect the evidential difficulties in allegations made by children that are denied by those who may be responsible without corroborating information.

4.510

There has been a significant (over threefold) increase in referrals from Wetherby YOI. This is in part related to good practice and liaison developed between the YOI safeguarding committees and the LADO. The LADO is now contacted routinely by the Safeguarding Team at Wetherby whenever a trainee makes an allegation of ill treatment, whenever an officer uses restraint that is unwarranted and when a trainee sustains an injury in restraint. There is a similar positive relationship with Eastmoor Secure Children’s Centre.

4.511

The number of referrals from the police and from health remains low. Of the 11 referrals, none were about a health care professional harming a child whilst at work, but were about the implications for their work given safeguarding concerns in their family life (own children subject to child protection plans and domestic violence being examples). This feature of the health referrals is also seen in the 101 referrals to the LADO which were not about specific children. Working Together (2010) is very clear that there should always be consideration of a person’s suitability to work with children if there are safeguarding concerns outside of that person’s workplace or contact with children.

4.512

An important part of the LADO role, which will be extended further with the introduction of the second post, is development work. The LADO is currently engaged in discussions with the LSCB on work around safer recruitment of staff, selection of carers and maintaining a culture of vigilance. Briefings for agencies on the LADO role and the management of allegations against staff are provided to many agencies including: Social Care Management, Child Protection Conference Chairs, Independent Reviewing Officers, Fostering Officers, the Early Years Partnership Service and a monthly programme of meetings with foster care support groups.

4.513

The LADO activity is part of the overall commitment to making Leeds a safer city for children, and future work will focus on how best to enable the child’s voice to be heard in the work of the LADO, particularly around how children are supported and communicated with when they make referrals.

4.6

Single and Multi-agency Auditing Activity.

4.61

A LSCB multi-agency audit programme has been initiated during 2011/12 designed to check the embedding of changes resulting from lessons identified in SCRs and LLLRs. Six strands were agreed as subjects for quality assurance audits which will provide the LSCB Partnership with evidence of the effectiveness of aspects of safeguarding and the promotion of children and young people’s welfare in Leeds:



(S1)To quality assure and audit the impact and outcomes for children and young people subject to child protection plans.



(S2) To audit compliance with timescales for calling child protection conferences, reviews and core groups and identifying any reasons for delay.



(S3) To quality assure and audit the impact and outcomes of Child Care Plans for Looked After Children, including the quality of participation in LAC Reviews.



(S4) To audit the effectiveness of the practice against policy on safeguarding outcomes for the children of teenage parents who have been referred to the Leeds Teenage and Pregnancy Pathway.



(S5) To audit (a) the effectiveness of revised care and control policies in Special Inclusion Learning Centres (SILCs) and (b) when brought to the local authority’s attention, the outcomes for children where independent advocates are provided when complaints are made by parents and children.



(S6) To audit the extent to which the views of children and families inform agencies’ service development regarding the safeguarding and promotion of children and young people’s welfare.

4.62

Strand (1): to quality assure and audit the impact and outcomes for children and young people subject to child protection plans has been set up and initiated and will be ongoing through 2012/13. Emerging issues will be reported in September 2012.

4.63

Developmental work has been completed for strands (4) & (5) and the audits will commence in the first 6 months of 2012/13.

4.64

Audit tools have been developed for strands (2) & (3). These audits will commence in 2012/13.

4.65

Progressing strand (6): to audit the extent to which the views of children and families inform agencies’ service development regarding the safeguarding and promotion of children and young people’s welfare.is awaiting the development of the LSCB C&YP’s Voice and Engagement Strategy.

4.7 4.71

Evidence from Safeguarding in Schools Ofsted’s inspections of schools include a specific focus on how the school addresses safeguarding issues, proactively and, when necessary, in a responsive way.

4.72

The following information demonstrates a very positive picture amongst those schools in the City that received an inspection during the year.

Primary Secondary PRU Total

Inspections under new Ofsted Framework

Inspections under old Ofsted Framework

Total number of Inspections

18 3 1 22

33 4 1 38

51 7 2 60

Safeguarding/Behaviour Judgements - Primary Schools Number Percent Outstanding 5 10% Good 35 69% Satisfactory 11 22% Unsatisfactory 0 0% Safeguarding/Behaviour Judgements - Secondary Schools Number Percent Outstanding 1 14% Good 3 43% Satisfactory 3 43% Unsatisfactory 0 0% Safeguarding/Behaviour Judgements - PRUs Number Outstanding 0 Good 2 Satisfactory 0 Unsatisfactory 0

Percent 0% 100% 0% 0%

(The above figures use "The Effectiveness of Safeguarding Procedures" judgement from inspections under the old framework, and the "Behaviour and Safety" judgement from inspections under the new framework.)

4.8

Learning from Complaints

4.81

Complaints received about services for C&YP can also contribute to our understanding of the effectiveness of safeguarding arrangements and activity in Leeds. There is a well established complaints and representations process as part of the Council’s services for children and young people.

4.82

The following information about complaints is drawn from all complaints dealt with by Children’s Services. This service is in the process of developing relevant performance information.

4.83

Number of complaints during year 2011/2012

4.84

Who made the complaint How Involved Adoptive Parent Other Agency / Professional Parent Relative Solicitor Total

– 13

Number 1 3 6 1 2 13

4.85

Number of children/young people requiring and provided with advocacy support - 0

4.86

Type of complaint Type of Complaint Challenge Assessment Outcome Staff Attitude / Conduct Breach of Confidentiality Alleged Child Abuse Neglect Process Quality of Service Total

Number 2 2 1 1 1 3 3 13

4.87

Outcome of complaint Outcome Locally Resolved Stage 1 Inconclusive Not Upheld Ongoing Partially Upheld

Number 1 2 5 1 4

4.88

Number of complaints progressed to stage two – 1 The complaint is against the area office and the child protection team

4.89

Number of complaints progressed to stage three – 1 The complaint is about the way the safeguarding concerns were dealt with.

4.810

Number of complaints progressed to the ombudsman - 0

4.811

Customer satisfaction surveys are conducted with parents and carers whose children receive a social work service. Responses are analysed and presented to the management team along with outcomes from formal complaints in order to identify strengths in practice as well as any shortfalls. Following three separate complaints and findings by the Local Authority Ombudsman, the local authority has taken appropriate and robust action to drive service improvement, including an inquiry by the council’s scrutiny board into services for children with disabilities and special educational needs and additional health needs.

4.9

Private Fostering

4.91

Working Together to Safeguard Children 2010 sets out a policy and procedural function for the LSCB in relation to private fostering. The LSCB role includes monitoring and quality assurance, and to ensure that public awareness is raised about private fostering.

4.92

It is the duty of local authorities to promote public awareness of the requirement for those considering undertaking private fostering arrangements to notify the local authority. The local authority has a duty to satisfy themselves that the welfare of children or young people who may be privately fostered within their area will be satisfactorily safeguarded and promoted. It is a requirement of the Private Fostering Regulations, 2005 that an annual report is presented to the LSCB.

4.93

There has been an increase in overall numbers with 15 children being identified as privately fostered during this financial year compared to 10 children in the previous 2 years and 7 in 2008. Six of the children are aged 15 or over, 5 are between 10 and 14 years old, 3 are aged 5 to 9 and one child is aged 2 years. Comparator statistics are only available for year ending 2010. In 2010 comparison with Core Cities (the nearest neighbours in terms of size) indicates that Sheffield and Birmingham had identified 20 private fostering arrangements and Manchester 15. In the same year Leeds had identified 10. This compares to the 15 identified cases in Leeds at the year end March 2012.

4.94

Private fostering arrangements in Leeds were inspected in September 2008 and were judged to be inadequate. In January 2011, the service was independently reviewed and a further action plan developed. Some progress was made in all aspects of the plan. However, further internal auditing of the service indicated a significant lack of compliance with requirements. There is also a continuation of a low rate of reporting of private fostering arrangements albeit with year on year increase.

4.95

As a result management of the private fostering service has been transferred to the Council’s head of service for looked after children and immediate and robust actions have been taken to address the issues identified. Additional specialist resources have been created and a restructuring of responsibilities has taken place so that those with expert knowledge of private fostering are directly involved in assessments. A updated action plan has been created which will address the issues and will be monitored by the new management accountability. One of the challenges to the LSCB, arising from this Annual Report is to monitor the progress required and privately fostered children and young people have been identified as an LSCB priority vulnerable group for 2012/13. Monitoring will be undertaken through a follow up report to the Board in November 2012 which will include the findings of a scrutiny enquiry.

5.0

Assessment of the Extent to which LSCB Functions are being Effectively Discharged

5.01

This section of the Report reviews on the way in which the LSCB has carried out its defined functions, intended to ensure that partner agencies work effectively together, and that the LSCB makes a significant contribution to progress on improving outcomes for children and young people.

5.02

In July 2011 the LSCB commissioned an independent assessment of the extent to which it was effectively carrying out the functions ascribed to it under statutory guidance. Overall, there was evidence at that time that almost all of the functions were being addressed to a satisfactory level or better and that clear plans were in place for further development where needed.

5.03

Two areas were lacking adequate plans which would address a shortfall:  ‘LSCBs should ensure appropriate links with any secure setting in its area and be able to scrutinise restraint techniques, the policies and protocols which surround the use of restraint, and incidences and injuries’  ‘The LSCB as the ‘responsible authority’ for ‘matters relating to the protection of children from harm’ under the Licensing Act 2003’

5.04

As a result action has since taken place in both of these areas and the LSCB’s contribution is proving beneficial. Further details are provided in the relevant section elsewhere in this report.

5.05

This work formed part of a broader Review of the LSCB activity, which was considered as part of a development session by the full Board in September 2011. The session involved Board members giving active consideration in a small group format to specific themes that emerged from each of the tools used as part of the Review work. The tools were;   

Conclusions from the LSCB Annual Report to the CTB 2010-11 on how effective the Board has been in undertaking core responsibilities. Conclusions of the LSCB Governance Review. The completion of a self - assessment ‘Challenge and Improvement’ tool by Board members.

  

5.06

LSCB Sub-group Chairs’ Reports evaluating performance during the year Independent Chair 360 degree evaluation. A feedback questionnaire with a range of LSCB stakeholders.

The overall conclusions from the information from each of these components confirmed the progress that the Board has made and which was independently confirmed in the Ofsted inspection, undertaken at that time and published in October 2011 which stated: “The LSCB is adequate and meets its statutory responsibilities. It has an independent chair who provides effective leadership. She has worked hard to secure the effective engagement of all members and is beginning to challenge agencies on their contribution to safeguarding. The LSCB has appropriate senior manager representation. Partners have valued direct contact with the chair in their service locations. Attendance by some agencies is poor but this is being monitored and addressed and will be reported annually. A more focused Business Plan Oct 2010 - March 2011 with clear strategic objectives has been agreed. The LSCB annual report 2010/2011 is good; it takes a selfcritical review of the board’s performance both in terms of its achievements and challenges. The LSCB has reviewed and improved its multiagency training programme and access to this high quality training is good. It has secured resources to establish new posts to support the business of the board in 2011-2012 and will use these to improve communication, consultation, quality assurance, performance monitoring and the participation of children and young people”. Ofsted Oct 2011

5.07

5.08

The themes chosen for the workshop were those that focused attention on the ‘process’ of how the Board undertakes it’s work, rather than on what the Board does, which is primarily dealt with in the ‘business’ part of meetings, because evidence suggests that successful LSCBs pay attention to how members of the Board work together. This creates more engagement for all members and models co-operative working. The themes worked on were:     

5.09

‘How can the LSCB enable children and young people to participate in the work of the Board so that their contribution assists the Board in carrying out its responsibilities?’ ‘What steps can the LSCB take to ensure active participation and involvement of all members of the Board and to promote inclusivity?’ ‘What further steps can the LSCB take to ensure that communication and co-ordination between the LSCB and the Executive Group is most effective.’ ‘If it is true that how LSCB members work together is crucial, because it is potentially mirrored at all levels of inter-agency working and will influence how practitioners work with the public, what steps can the LSCB take to take control of this process? How can the LSCB ensure that Board members work effectively together and take control of what is mirrored?’ ‘How can the LSCB ensure that it remains child focused in all the work that it does?

Work undertaken on these themes has contributed to progress made by the LSCB during the year.

5.1

Work of the LSCB – Realising the Strategic Plan 2011-15 through implementing the Annual Business Plans.

5.11

Strategic Plan 2011-15 Initial feedback from the Annual Review process is that the existing strategic priorities and priority areas remain fit for purpose and that no significant changes should be made. On 20.04.12. the LSCB decided to change the status of ‘Effective Governance’ from a ‘strategic priority’ to a ‘business priority.’ This was in recognition of the progress that the Board has made in the past two years on its governance arrangements. Performance will continue to be monitored through the existing scorecard.

5.12

The Annual Business Plan 2011/12 Overall good progress has been made against the objectives set for the year in an ambitious business plan. 98% of tasks have been progressed, although slippage against timescales is evident in 37%. A more detailed summary of progress against business plan objectives is attached as Appendix 3 and updated Strategic and Business Plans are attached as Appendix 3.

5.13

A Report on the LSCB’s income and expenditure for the year is available. (attached as Appendix 4). This shows a budgetted shortfall in income, which has been addressed by further use of the LSCB strategic reserve. A ‘standstill’ base budget has been set for 2012/13, again with a projected income deficit of £21,560.

5.14

In order to address this situation the Board have agreed to undertake a review of funding and value for money which will inform budget setting for 2013/14.

5.2

Development of Effective Inter-Agency Procedures

5.21

Leeds is part of a consortium of five West Yorkshire local authorities that contracts with a specialist company to produce the agreed Inter-Agency Safeguarding Procedures. During the course of the year Leeds has supported this arrangement and contributed to updates, which are undertaken on a six monthly basis.

5.22

The procedures are available on the LSCB website and updates are flagged to partner agencies so that practitioners are kept up to date.

5.3

Assessment of Single and Multi-Agency Training

5.31

Detailed information about the LSCB training programme 2011/12 has been included for the first time in the revised Performance Management and Quality Assurance System using the Outcomes Based Accountibility (OBA) framework. Significant activity has been undertaken through the LSCB Learning & Development sub group to disseminate learning to support the effectiveness of multi-agency safeguarding practices and hence improve outcomes for Children and Young People.

5.32

A total of 117 training sessions were run in 2011-12, with a total of 2501 places booked. Of those sessions 38 were level 1 courses (for Third Sector agencies), providing 832 places and 34 sessions were Level 2 courses which provided 769 places. The remaining 45 sessions were “Additional and Specialist” courses, and provided 900 places. Of those places booked 2133 (85%) participants attended, 212 (8%) sent apologies, 143 (6%) did not attend and 13 (1%) attended but were either sent away for arriving late or left early. This exceeds the expected overall attendance rate of 75%,

5.33

In addition to the standing training programme of the LSCB a series of city-wide events were held for practitioners, which included:    

5.34

10 briefings on the introduction of the Strengthening Families Framework approach to Child Protection Conferences. A West Yorkshire Masterclass Four SCR briefings A conference to launch the updated CSE and Missing Children procedures

Reactive evaluation sheets are issued at the end of every training session through which participants are asked to evaluate the following aspects of the course:      

Have the learning outcomes been met Whether the participants have increased knowledge, understanding and skills If issues of equality and anti-discriminatory practice have been appropriately addressed The methods used and the approach of the trainers If the course met the participants expectations The venue and its facilities

5.35

For the core courses Level 1 and Level 2 there was a response rate of 97%. For all questions the target of 90% or higher of the responses indicating that the training had been a positive and useful experience was achieved.

5.36

In addition qualitative data was collected in relation to what participants found the most useful, how the course could be improved, and how it would impact on their work practice.

5.37

The responses indicate that a high proportion of participants felt that the courses met their needs, that they found all of it useful and that they did not identify anything which required improving or changing. Although relatively small in numbers, suggestions were made as to how courses could be improved.

5.38

When considering potential impact on practice, participants predominantly identified that attending the course provided them with better awareness and increased knowledge. They also identified that it would improve their practice, and that they would share their learning with colleagues.

5.39

For the additional and specialist courses there was an 88% response rate, and it again hit the same identified target; with 95% of responses indicating that the training had been a positive and useful experience. The qualitative feedback again showed a similar pattern, with the same trends being identified.

5.310

Identifying how improvements in practice, multi-agency working and outcomes for children and young people had resulted from attending the training is captured through three monthly follow up questionnaires to participants and first line managers. Common reoccurring themes included; a better understanding, updated knowledge, increased awareness, improved knowledge of policies and procedures and more confidence. These outputs will have a significant impact on outcomes for children and young people in relation to appropriate and timely responses to concerns or identified need.

5.4

Lessons about Preventing Child Deaths (CDOP)

5.41

Under statutory national guidance contained in Chapter 7 of Working Together to Safeguarding Children, Leeds has both a Sudden Unexpected Death in Childhood (SUDIC) process, and a Child Death Overview Panel (CDOP) process. The two are separate processes, but are closely linked.

5.42

The Leeds Child Death Overview Panel (CDOP) was established from 1st April 2008 under guidance issued in Chapter 7 of Working Together to Safeguard Children 2006. The aim of the CDOP, (as required by the Local Safeguarding Children Boards Regulations 2006) is to undertake a comprehensive and multidisciplinary review of all deaths of children normally resident in Leeds aged under 18 years, in order to understand better how and why they die, and to use the findings to take action to prevent other deaths and improve the health, wellbeing and safety of children and young people.

5.43

The SUDIC process involves early notification of the unexpected death of a child, and a prompt process of investigation, led by the SUDIC Paediatrician. This may involve discussion with clinicians at the hospital, Police, Social Care and others. Sometimes a visit to the place of death is undertaken. A meeting is held with professionals involved with the child, to learn lessons. A report into the circumstances of the child’s death is produced, which is shared with the Coroner, and with the CDOP.

5.44

The CDOP considers the death of each child, and is required to complete a national proforma regarding its findings for each child. The proforma include factors relating to the child and family, and service provision; categorization of the cause of death; a judgment regarding preventability of the death; learning points and recommendations; immediate follow up actions for the family; and whether the case should be referred to the LSCB Chair for consideration of a Serious Case Review. In addition, during the past year, the Leeds CDOP has piloted a West Yorkshire form to collect specific information about preventable factors from a public health perspective. In Leeds, a decision was taken to hold two separate Panels – one to review the deaths of younger babies who were never discharged from hospital (“Neonatal Panel”), and a second panel to consider the deaths of older babies and children (“Older Children Panel”). This approach has enabled the right sort of experts to attend each Panel, and to use their expertise most efficiently to consider those cases where they have an effective contribution to make.

5.45

The Chair of the Child Death Overview Panel prepared an Annual Report for the LSCB on activity during the calendar year, in this instance 2011, and provides a review of progress on previous recommendations, data on cases referred over the financial year, learning from examination of those cases, and recommendations for improving practice in the future.

5.46

The CDOP panel is concerned with prevention. It aims to identify those factors in the course of a child’s life, and leading to the child’s death, which might have been amenable to modification, and to make recommendations which will help to prevent similar deaths occurring in the future. With this in mind, the Leeds CDOP has made a small number of key strategic recommendations to the Leeds Safeguarding Children Board, building upon the cumulative understanding of child deaths acquired over this and preceding years. Both these new recommendations, and an update on progress towards previous recommendations, are included in the latest report.

5.47

As in previous years, there remain some persistent challenges in running the CDOP, and there is a continuing backlog of cases. At the end of March 2012, there were 94 outstanding cases awaiting review. The reasons for the backlog include continuing delays in receiving completed Agency Report Forms from various agencies and administrative issues in the Business Unit. Most recently, an agreement has been reached with Leeds Teaching Hospitals NHS Trust, on which the heaviest demand falls, to utilize discharge letters as a primary source of information for the CDOP. It is anticipated that this will alleviate considerably the delays in compiling the panel information.

5.48

The Chair undertook a further review early in 2012, making further recommendations to improve the efficiency of the Leeds CDOP, drawing on different approaches used in Birmingham and other local areas. However, it was agreed to delay implementation of these proposals until after the publication of the updated version of Working Together, due in Spring/Summer 2012, in order to ensure that changes take account of new guidance.

5.49

Notifications and CDOP Activity (April 2008 to 30 March 2012) Year

Notifications to CDOP Administrator

2008-9 2009-10 2010-11

34 30 26

Older child 32 41 33

2011-12

Neonatal

Number of Cases Reviewed by CDOP

Number of Cases Outstanding for CDOP Review

Total

Neonatal

Older child

Total

Neonatal

Older child

Total

66 71 59

34 28 17

30 29 13

64 57 30

0 2 9

2 12 20

2 14 29 49

5.410

As in previous years, the Panel has highlighted several issues arising from individual cases, which were recorded to be considered in the overall context of the Panel’s findings. Some of the same issues arose in more than one case, and some have been highlighted in previous reports but are again prominent among cases considered this year. The following issues were highlighted during the period covered by this report: The risks of sudden unexpected, unexplained death among babies associated with co-sleeping, sleeping on sofas, inappropriate bedding, and parental smoking, alcohol and substance use. Consanguinity (cousin marriage) as a risk factor for serious genetic conditions. The importance of protective equipment and clothing in road traffic accidents. The role of chicken pox (Varicella zoster) in 2 deaths, in light of a national policy not to provide routine childhood immunization for chicken pox. The processes in Leeds for obtaining timely support from Social Care for families with children with very complex disabilities. The high standard of care available to Leeds children with complex needs and at the end of life, from a range of agencies. The importance of ensuring that routine childhood immunizations are made available to children who move to the UK from other countries.

5.411

Detailed recommendations are made to the LSCB which when implemented will potentially contribute to children and young people being safer in the future. (The full CDOP Annual Report 2011 is attached as Appendix 5)

5.5

Progress on Priority Issues/Groups of Children and Young People.

5.51

During the course of the year the LSCB has continued its role in monitoring and coordinating activity and supporting continuous improvement in work with those groups of children and young people that are seen as particularly vulnerable, and in need of the highest priority, those involved in ‘front door processes’ (requests for service, referrals responses and actions); those subject to a Child Protection Plan; and those who are ‘Looked After’.

5.52

This year this has been extended to include children missing and those at risk or subject to child sexual exploitation. The LSCB & The Children’s Society held a multi-agency city-wide conference in February 2012 to raise awareness of C&YP who go missing and are at risk of sexual exploitation and to launch revised procedures. Following the conference briefing sessions have been held to ensure that staff from across the partnership are clear about their responsibilities in this area.

5.53

Work is on going to develop good sound practice in this area. Work is also underway around domestic violence, drugs and alcohol, and mental health and their impact on parenting capacity. The LSCB is mindful of the need to broaden this approach to other vulnerable groups as progress is made with the current target groups.

5.6

Undertaking Serious Case Reviews

5.61

There are six SCRs and three LLLR sets of action plans currently in the process of implementation. A composite database held by the LSCB Business Support Team contains details of evidenced SCR/LLLR action plan progress in the last three years. . . . .

5.62

Good progress is being made on implementation of all six SCR action plans. One is in the early stages of implementation. There are currently 10 actions being progressed, 4 of which relate to SCRs completed prior to 2011. These are due to be completed by September 2012. All outstanding ‘historical’ out of area SCRs involving Leeds SCB or partner agencies have been implemented. Monitoring is ongoing on implementing SCR action plans from 3 SCR undertaken in other area that Leeds contributed to. 15 Actions from the three LLLRs are being progressed and monitored.

The LSCB Quality Assurance & Audit Programme includes 4 strands which test out the implementation and impact on outcomes for C&YP of actions from completed SCRs and LLLRs:    

S1)To quality assure and audit the impact and outcomes for children and young people subject to child protection plans. S2) To audit compliance with timescales for calling child protection conferences, reviews and core groups and identifying reasons for delay. (S4) To audit the effectiveness of the practice against policy on safeguarding outcomes for the children of teenage parents who have been referred to the Leeds Teenage and Pregnancy Pathway. (S5) To audit (a) the effectiveness of revised care and control policies in Special Inclusion Learning Centres (SILCs) and (b) when brought to the local authority’s attention, the outcomes for children where independent advocates are provided when complaints are made by parents and children.

5.63

The LSCB Performance Management Sub Group, as part of its annual review process, in July 2012, reviewed and refreshed the audit programme in the light of emerging lessons from SCRs and LLLRs. Information from the monitoring of compliance with policy and procedural changes will also be considered.

5.7

Engagement with the Community, Communicating and Raising Awareness

5.71

The LSCB has approved the establishment of a Communications Task and Finish group that will lead on developing proactive and reactive communication systems, participation by families, children and young people, and community engagement. The LSCB agreed a Communication Strategy on 22.06.12.which will steer how effective communication can be integrated into all aspects of the Board’s work.

5.72

Increased capacity in the LSCB Business Unit will support communication of key safeguarding messages across both the professional and wider communities and the engagement of children and young people in the work of the Board.

5.73

Redesign of the LSCB branding is now completed and work to redesign the website is being undertaken.This will strengthen the LSCB’s ability to deliver effective professional and community leadership.

5.74

The recruitment of lay members has not been progressed during the year as planned. Although the reasons for this are complex there is a determination to start a recruitment process early in 2012/13 so that by the end of year lay members are properly inducted into the work of the Board and can make the valuable contribution envisaged for community representatives.

5.75

There has also been insufficient progress in establishing consistent ways of obtaining the views of children and young people to assist the Board in its work. Although there is a firm commitment from all agencies to this work, the delay has centred on identifying a dedicated resource with specialist skills to support this initiative at a time of reorganisation. A high priority is being given by the Board to resolving these issues in the early part of 2012/13.

5.8

Children and Young People in Secure Settings

5.81

An independent review was undertaken in 2011/12 on the use of restraint in the secure estate for children and young people. Leeds City Council has two juvenile secure establishments within its jurisdiction – HMYOI Wetherby and East Moor Secure Children’s Home (SCH).

5.82

The first Annual Review of the use of Restraint in secure Settings identified overall good practice across both East Moor Secure Children’s Centre and HM YOI Wetherby. Nevertheless a number of areas for improvement were identified. 1. The differences between the two establishments in recording and reporting restraint incidents and in the data provided to the LSCB makes it difficult to make any overall comments – we would like to see a more standardised form of reporting to the LSCB. 2. The LSCB would welcome more commentary from the establishments on the month by month restraint numbers and whether there are particular explanations for this – for example specific children being accommodated, issues around gangs etc. – and what measures the establishments take to counter the effects of these.

3. While both establishments provide data on injuries to children, we are concerned that the classification is different in each setting. 4. There is insufficient data provided for the LSCB to comment on incidents of inappropriate use of restraint, or use of unauthorised (and untrained) methods. 5. Details of the different techniques and positions used during restraint incidents are insufficient to allow the LSCB to make any judgements in relation to risk and safety’ 5.83

The following actions are being progressed as a result of an audit of restraint practices. 1. Leeds LSCB will work with East Moor and HM YOI Wetherby to achieve more consistency and common ground in their reporting to the LSCB. It should be noted that both Wetherby and East Moor have expressed their willingness to cooperate in this and have already put forward suggestions as to the data that would meet the LSCB needs. 2. Leeds LSCB will work with both establishments to find ways of sharing information on month by month restraint numbers and whether there are particular explanations for this and what measures the establishments take to counter the effects of these 3. Taking into account any changes to recording in YOIs as a result of the new restraint system, work will be undertaken with both establishments to ensure more consistency in relation to classification of injuries sustained as a result of restraint. 4. Leeds LSCB will work with both establishments to ensure that data is shared on inappropriate use of restraint, or use of unauthorised (and untrained) methods. 5. Leeds LSCB will work with both establishments to establish a mechanism for sharing this information.

5.9

The Licensing Act 2003

5.91

As a result of the introduction of the Licensing Act 2003 all licensing functions are carried out by the local authority. The LSCB is specified as a “Responsible Authority” in matters relating to the protection of children from harm.

5.92

Following liaison with the Leeds Licensing Authority and Safer Leeds, the LSCB contributes to the evaluation of applications by focusing on how the applicant demonstrates in their operating schedule how they intend to protect children from harm. As a responsible authority the Safeguarding Children Board can make representation to the Licensing Committee in relation to an application that raises concern in relation to the safeguarding of children. The LSCB Business Unit receives, on average, 20 applications per month.

6.0

Summary of Achievements in 2011/12

6.01

Building on the good working relationship being established between the LSCB & CTB the second LSCB Annual Report on the effectiveness of safeguarding arrangements in Leeds will hold the CTB to account for progress made in 2011/12 and identify new challenges for 2012/13.

6.02

The CTB has responded to the key challenge posed by the LSCB Annual report (July 2011) to ‘rebalance the safeguarding system’ to ensure that C&YP receive the right service at the right time through the CYPP 2011-15; confirming an outcome priority of ‘keeping C&YP safe from harm’ and initiating an ‘obsession’ on reducing the number of C&YP who require to be ‘looked after.’ This has generated a series of reviews of central components of the ‘safeguarding system’ (e.g. Front Door processes and decision making in response to referrals to CSWS; CAF processes; the operation of the CP Conference system) which have resulted in significant planned change in safeguarding arrangements for 2012/13.

6.03

LSCB learning and improvement activity has been maintained and expanded during 2011/12 to include regular partnership briefings and conferences addressing emerging safeguarding themes. Completion and implementation of the LSCB Professional Development Strategy will help to ensure an overview of safeguarding learning across the partnership can be established and its impact on practice and outcomes for C&YP evaluated. Links established with the LSCB Communication & Engagement task group will enable learning to be more widely disseminated.

6.04

The gradual implementation of the LSCB Performance Management System throughout 2011/12 provides the basis for a more sophisticated understanding of performance issues in 2012/13 and agreement reached in 2011/12 about how information is collected, collated and analysed will facilitate more effective and robust challenge to partners.

6.05

The involvement of the two secure children’s establishments in Leeds in the annual review of the use of restraint has resulted in a small working group to pool safeguarding experience and approaches to this particularly vulnerable group of C&YP.

6.06

Progress against the LSCB Strategic Priority (4) ‘Effective Governance’ has been sufficient for this to be re designated as a ‘Business Priority’ for 2012/13; to be reported on through the Annual Review process. The LSCB BU will be fully staffed for the first time from July 2012, which will enable more consistent support to be provided to sub, task and reference groups.

7.0

Review of Challenges to the Children’s Trust Board made in last year’s Annual Report

7.1

The CTB accepted the LSCB Annual Review and the challenges made to the CTB on 7th July 2011 and asked for updates on progress re the challenges throughout the year. At the Sept CTB meeting it was agreed that the cluster Performance Framework needed to reflect the CTB and the LSCB reporting to one another on key indicators. It was agreed the performance management sub groups of both bodies should link up to ensure this takes place.

7.11

Significant work has been progressed, consistent with the challenges made to the CTB and also with the CTB Obsession (one of three) to ‘Reduce the need for children to be Looked After (help children to live in safe and supportive families). Challenge 1) Rebalance safeguarding interventions across the continuum of need to ensure preventative work is undertaken appropriately and in a timely manner. To involve: 

Improved multi agency working at locality levels to ensure that children and young people receive the right service at the right time and that the Common Assessment Framework

Performance 

Consistency in the CTB overseeing the LAC ‘obsession’

 

Reduction in number of CAF 2011/12 Plateau then reduction in no. of CP Plans

Story behind the Data

   

Introduction of a ‘restorative approach’ Implementation of cluster working Restructure CSWS Development of CS targeted services

(CAF) is used appropriately to facilitate a “team around the child” approach.

   



A change in the pattern of referrals and other processes used to communicate concerns between agencies that children and young people are at risk of harm.



Reducing the number of children and young people who need to be “looked after”.



 

2) Ensure all partners are able to attend and/or provide input in a timely manner to Initial Child Protection Conferences enabling them to be held within timescales laid down in statutory guidance.



Static no. of referrals to CSWS 2010/11 – 2011/12

No. of LAC stabilised over 2011/12 (1.8% increase at year end, subsequently reduced in 1st 2 months 12/13)

 

Increasing timeliness ICPCs Reduction in timeliness RCPCs



(eg FGCs) to underpin all processes Development of multi-agency operational handbook Review of Early Start teams implemented in one cluster. Review and re-launch of CAF Intro ‘strengthening families’ approach to CP Conferences D Thorpe updated review of patterns of referrals and subsequent decision making Re-design of CSWS duty and advice team implemented from March 2012. CYPP LAC obsession 2011-15 Integrated Social work and LAC services introduced March 2012. Legal ring fence of time to support revocation of care orders re placement with parents. LSCB Audit (S2) will examine this in 2012/13

3) Consider how the performance improvements made to date are sustained and built upon within the context of increasing demand for child protection services.

Evidence of ‘turning the curve’ in a number of key components of safeguarding system:  No. CP Plans  Timeliness ICPCs  Stabilisation LAC numbers

LSCB Annual performance Report Analysis:  2010/11 identification of key Areas For improvement  2011/12 planning changes and implementing changes  2012/13 impact of changes to be reflected in improved outcomes for C&YP

4) Ensure that partners are able to demonstrate how they meet their safeguarding

 



Initiation LSCB QA & Audit Programme S(11) audit

Increase pace of audit programme for 2012/13

 

responsibilities, through internal audit processes and by contributing to the LSCB multi agency auditing programme.

5) Prepare to respond to the local implementation of recommendations provided by the ‘Munro Review of Child Protection’

 

Ongoing developments planned within the ‘context of ‘Munro. Allocation of CWDC funding to CSWS/LSCB to prepare for Munro implementation.

Increase net for S(11) audit for 2012/13 To request more meta analyses from partners internal reviews and audits 2012/13

   

Issuing of revised Working Together for consultation July 2012 Pilot authorities trialling proposed changes. Work detailed in section 1-4 consistent with Munro implementation. LSCB Practitioner conference held May 2012

8.0

Challenges to the CTB for 2012/13

8.01

Arising from this evaluation of 2011/12 there are a number of new challenges for the CTB (accepted on 9 July 2012)



To embed changes being implemented to the safeguarding system and be able to evidence the development of a more ‘balanced’ system (towards earlier intervention,) with improving outcomes for vulnerable children and young people.



To ensure that high quality services are provided to C&YP within the statutory system (C&YP subject to CP Plans and LAC)



To ensure that risk is appropriately considered as services delivery is developed in response to the Munro Review of Child Protection, so that children’s safety is not jeopardised as a result.



To lead the development within partner agencies of complementary quality assurance frameworks consistent with the ‘The Children’s Safeguarding Performance Information Framework’ published by the Government in June 2012.



To ensure that the potential risks to safe practice, as changes to how Health Services are provided are implemented, are kept under consideration.



To provide the LSCB with a year end report for 2012/13 directly addressing progress made against challenges set.

9.0

Review of Challenges to the LSCB made in last year’s Annual Report

Challenge 1) To consolidate and develop further the progress that has been made in providing effective leadership and challenge to the safeguarding system in Leeds, engaging with both the professional partnership and the wider community of children, young people and their families.

Performance 

Story behind the Data

Annual report to CTB July 2011 (incl. challenges) Updates on safeguarding issues to CTB provided by LSCB Chair Presentation of Annual Report to strategic bodies across the partnership

Increasing LSCB profile.



Quarterly performance reports received by LSCB with a particular focus on 2 vulnerable groups (CP Plans, LAC)

Increasing comprehensiveness of data collection and sophistication of analyses.



Slow progress in developing C&YP voice and influence strategy



Delay in appointing lay members

2) To implement the work plans generated within the Business Plan 2011/12 to meet the objectives and outcomes set.

 

Progress made on 98% of tasks Slippage against timescales in 37%

Strategic & Business plans being refreshed in the light of the Annual Review process, the consultation on the re write of Working Together in 2012 and the proposed local framework for learning and improvement.

3) To develop and implement a communications strategy that undertakes campaigning and raising awareness activity of safeguarding issues

 

Communication task group established. Communications strategy accepted by LSCB 22.06.12.

Campaigns planned for 2012/13 incl. raising awareness about CSE and general safeguarding issues.

 

CTB response through refreshing CYPP (more specific response to challenges requested for 2012/13.)

Care has been taken to ensure sufficient resources are available to support the agreed strategy.

4) To implement the new Performance Management System (PMS) in 2011/12 in order to receive improved information and more rounded intelligence about the effectiveness of safeguarding services, the impact of lessons learnt from reviews and audits and outcomes for C&YP.

    

New PMS implemented 2 score cards reported on quarterly (CP Plans, LAC) 4 Strategic priority score cards completed at year end Score card on operational performance completed at year end Score card re C&YP who are missing / at risk CSE introduced for last 6m of the year

Gradual increase in data collection for PM framework Quarterly reports to LSCB based on analysis of information by Performance Management sub group (PMSG). To increase data collection from across the partnership in 2012/13. To refresh PMF & Audit programme in light of Annual Review and the Children’s Safeguarding Performance Information Framework.

5) To set up and implement the LSCB multiagency quality assurance and audit programme, particularly in relation to child protection, children in need, and early intervention processes and practice. This will include the impact of SCR action plans, and compliance with s(11) requirements.



6) Audit of the arrangements for paediatric medicals is also included in this plan following some issues raised with the LSCB about current practice.



Cohort for auditing agreed

7) To undertake the annual s.(11) self assessment audit with partner agencies seeking improvements in the following areas:  Understanding when and how to initiate a CAF  Ensuring C&YP are made aware of their right to be safe from abuse



S(11) audit completed for Board members

CAF process revised in 2011/12

Additional area for focus in 2012/13 S11 Audits

 

Audit programme set up with 6 strands (drawn from SCRs, LLLRs, s11 audit). Strand (1) initiated – impact and outcomes for C&YP subject to CP Plans. Audit tools developed for 4 other strands

 

Pace of audit programme to be increased during 2012/13 Early learning from strand (1) to be reported in September 2012



S(11) audit 2012/13 to include 3 Sector agencies



To be progressed in 2012/13



More consistent engagement with the self-audit process.

Refined audit tool to be used 2012/13

Areas for Improvement identified:  More consistent application of CRB checks across the partnership  Ensuring more consistent engagement with CAF processes  Information sharing Common, user friendly s(11) audit tool developed. LCC CS Commissioners to use tool as part of tendering and contract compliance processes.



New tool to be used in 2012/13 – to include third sector agencies and a wider spread of statutory agencies.



Slow progress in developing C&YP voice and influence strategy



C&YP were engaged in rebranding of LSCB



CS restructuring delayed the identification of a dedicated resource to support the work A Board workshop is planned for Autumn 2012 to build on contact made with Redcar and Cleveland Junior LSCB

10) To continue to develop QA processes to ensure safeguarding training undertaken by partner agencies and through the LSCB are of a consistently high standard.



Partner agency Level 1 training materials QA’d and amended as appropriate.

To be developed as part of the Professional Development strategy 2012/13.

11) To undertake more effective evaluation of the impact on practice of training and development opportunities provided by the LSCB and partner agencies.



Impact on practice questionnaires (3m after training event) disseminated to all attendees throughout year.



8) To develop a consistent approach to s.(11) audit and commissioning standards requirements that takes account of the challenges faced by small Third sector organisations.



9) To effectively engage C&YP in the work of the LSCB



Increased response rate to be targeted in 2012/13

12) To improve the process for responding to, collecting, collating and analysing information about child deaths in order to identify in a timely manner lessons that may contribute to the prevention of deaths in the future.



13) To prepare to respond to the local implementation of recommendations provided by the ‘Munro Review of Child Protection’



 



Reviews of process undertaken at 6m and 12m. Revisions made to process to simplify data collection and analysis and to improve timescales. Gradual improvement of timeliness over the year.

CDOP process to be reviewed and revised in the light of re write WT 2012.

All sub groups have considered the implication of the Govt’s response to Munro. LSCB PMS was designed to incorporate Munro recommendations



P&P sub to lead on responding to the WT consultation LSCB Strategic Plan & Business being refreshed in the light of WT Consultation.

10.0

Challenges to the LSCB for 2012/13 – structured under the LSCB Strategic Plan priorities.

10.01

Arising from this evaluation of 2011/12 there are a number of new challenges for the LSCB (accepted on 20 July 2012).

10.02

Strategic Priority 1: Lead, Listen, Advise Exercise strategic leadership across all stakeholders: to support a child friendly city Through the Annual Report to the CTB, to promote consolidation of improvements in service provision across the partnership and maintain the pace of change in the coming period. To develop productive relationships with the Health & Wellbeing Board, and other appropriate strategic bodies To support the transition in the NHS to a new framework of commissioning and delivering health services and ensure all the new organisations have strong safeguarding governance arrangements

Support the professional community to keep children and young people safe Contribute to continuing development of safeguarding arrangements in schools. Implement the policy and procedural changes resulting from the re-write of Working Together. To develop the working relationship with Leeds Safeguarding Adult Board.

Influence the wider community to keep children and young people safe Progress work to agree and establish a LSCB Voice & Engagement strategy for C&YP. Increase engagement with faith groups To undertake a community campaign to raise awareness of Child Sexual Exploitation (CSE) and ‘what to do if you are worried.’

10.03

Strategic Priority 2: Learn and Improve Promote child-centred practice To engage more effectively with operational managers and practitioners to ensure the direct impact of learning and development opportunities on multi-agency practice and improving outcomes for vulnerable C&YP.

Promote Professional Judgement Complete work to produce and agree a Professional Development Strategy for safeguarding

Promote an “adaptive” safeguarding system To review and revise the current SUDIC arrangements To review and revise CDOP processes To contribute to the local implementation of the Munro Review of Child Protection, including responding to the associated rewrite of ‘Working Together’ guidance. 10.04

Strategic Priority 3: Know the Story, Challenge the Practice Agree what we need to know Review and refresh the Performance Management Framework to ensure that appropriate multi-agency data is collected which is consistent with the development of a local framework for learning and improvement. To monitor the progress in making the improvements required to the City’s private fostering service through a further progress report to be presented to the Board in November 2012.

Understand the responsiveness of the local safeguarding system Understand the quality of the local safeguarding system To increase the scope and pace of delivery of the LSCB QA & Audit Programme To complete the process of establishing a truly multi-agency basis for the Performance Management System (PMS); by including more information and data from across the wider partnership. To obtain a greater understanding of the quality of services provided to children and young people through the LSCB Audit Programme. To develop a comprehensive understanding of S(11) compliance across the whole partnership. To promote the adoption of the OBA approach to quality assurance across all partner agencies in relation to safeguarding services, so as to create greater consistency in data so that interpretation is more effective in its contribution to understanding effectiveness. To require partner agencies to provide an annual report to the LSCB on how governance and accountability for safeguarding services have been undertaken.

Use the knowledge gained about the safeguarding system to make a difference To increase the timeliness of PMS reporting to the LSCB to ensure the understanding of safeguarding issues / concerns is up to date and that action is taken appropriately to improve services and outcomes for C&YP. Business Priorities 10.05 Demonstrate accountability To ensure that sufficient progress is made in implementing plans for greater Community and Children and Young People engagement and awareness raising

Â Â Â

Develop the capacity of the LSCB and its infrastructure to deliver core functions Progress process to appoint lay members to the Board

Identify and manage risks to the delivery of the core functions Undertake a funding and value for money review to inform budget setting for 2013/14. 11.00

Conclusion

11.01

This is a report of a year in which significant progress has been made, both in how child protection services in Leeds have been improved and in how the LSCB has progressed in undertaking its responsibilities. The LSCB’s achievement has been to consolidate significant changes and development in the governance, structure, membership, and operation of the Board that took place during the previous year. For those agencies providing child protection services, the changes introduced in 2010/11 to how services are organised and provided have been built upon. The ‘rebalancing’ of services towards increasing the availability and the effective use of Early Help services to reduce the need for statutory intervention has been further progressed.

11.02

The positive endorsement from the unannounced Ofsted inspection in January 2011, which stated that areas of priority action had been addressed and that contact, referral and assessment processes, a significant part of effective Safeguarding, now met statutory guidance was encouraging.

11.03

There is, however, no room for complacency. The challenges to the Children’s Trust Board for the coming year, detailed in section 9 of this report, make it clear that there is still much to do to ensure that these significant changes provide improvements to the lives of children and young people. The challenges for the LSCB, detailed in section 10 of this report, particularly highlight the need for the Board in the coming year to be able to gather and make use of detailed evidence of whether improvements in children’s lives are being made.

12.0

Next Steps

12.01

This Annual Report will be presented to the CTB in September 2012. The Children’s Trust Board in turn will want to give consideration to this report, how they respond to the findings, particularly to the challenges the LSCB is bringing to the CTB’s attention, and will want to take them into consideration when reviewing the Children and Young People’s Plan.

12.02

The Annual Report will also be submitted to the Chief Executive and Leader of the Council, the Council Executive, the Police Authority (in lieu of the local Police and Crime Commissioner) and the Chair of the Health and Wellbeing Board (HWB). It will be presented to the Safer Leeds Partnership, as well as the HWB. It will also be sent to the Chief Executives of all partner organisations with a request that it is reported to their governance body.

13.0

Appendices: 1. LSCB Structure Chart 2. Summary of progress against LSCB business plan objectives (2011/12) 3. Strategic and Business Plans 2012/13 4. LSCB end of year Financial Report 5. CDOP Annual Report date 2011

AGENDA ITEM 18

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE: DATE OF MEETING:

Draft Infection Control Committee meeting minutes held 7th September 2012 CATEGORY OF PAPER 30th October 2012 ((please tick relevant box)

LEAD DIRECTOR:

PAPER AUTHOR:

Michele Moran Chief Operating Officer and Chief Nurse/Deputy Chief Executive Ann Foster Administrator

STRATEGIC STRATEGIC:

GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

IMPACT ON THE TRUST’S S MEANS GOALS (please tick relevant box) MG1 We provide excellent quality, evidence-based, evidence based, safe care that promotes recovery and inclusion MG2 MG3

We involve people in planning their care and in improving services We work with partner organisations to improve health and lives

MG4 MG5 MG6

We value and develop our workforce and those supporting us We improve our services through learning, research and innovation We provide efficient and sustainable services

MG7

We govern our Trust effectively and meet our regulatory requirements

          



SUMMARY: Attached are the draft minutes of the Infection Control Committee meeting held on 7th September 2012. Items of interest are:are:     

HCAI statistics and screening including outbreaks Waste Management Incident NHS Leeds/LYPFT Flu Vaccination Update PEAT Feedback from Lead Nurses/ADs

RECOMMENDATIONS: The Board of Directors is asked to receive and note the minutes provided.

Infection Prevention and Control Committee 7th September 2012 09.00am – 11.00am Old Canteen Meeting Room, North Wing St Mary’s House

Minutes of Meeting Present:

Kavita Sethi (KS) (Chair) Michele Moran (MM) Stanley Cutcliffe (SC) Leslie Munemo (LM) Gugu Ncube (GN) Norman McClelland (NM) Nicky Needham (NN) Trisha Prouse (TP) Gill Johnson (GJ) Vanessa Garrity (VG) Jim Merrick (JM) Gail Evans (GE)

In attendance:

Ann Foster (AF)

Apologies:

Douglas Fraser (DF) Linda Rose (LR) Caroline Dada (CD) Aqila Choudhry (NED of Trust) (AC) Elaine McAleese Christine Woodward (CW) Robert Mann (RM)

Agenda Item Apologies

Action

Apologies were received from the above. 2.

Minutes of the meeting held on 15th June 2012 Page 4 paragraph 5 should read ‘alcohol free standing alternative’. VG queried the fact of there being no report submitted at the last meeting from Specialist Services even though a representative was sent in her absence. It was confirmed that no feedback was received.

Matters arising 1

Clarification was received regarding the service users laundry facilities and that they are staffed as such. JM commented that in certain areas of the Trust there is a standing agreement with Interserve that laundry provision is provided for the service users clothing. The Mount has provision for laundry facilities which are staffed by Trust staff. SC clarified that in this instance only the Trust has accepted responsibility for the service users clothing whilst in the laundry room. In Towngate, Millside and Ward 5 the laundries available are therapeutic and are not staffed, but it is the responsibility of the R&R services to encourage service users to make use of the facilities. Asket Croft has been designed to hold a laundry service for therapeutic purposes also. KS requested that if for any reason an action cannot be fed back to the group, that the responsible member send a representative or arrange for another member of the group to feed back and a report be sent in order that the action is not constantly being carried forward.

All

JM reported to the group regarding a 3 year rolling replacement sink programme. The work will commence within the next few weeks for this year. Funding of ÂŁ50k this year, ÂŁ40k next and ÂŁ30+k the following has been allocated for replacement of sanitary wear. JM reaffirmed that work will be ongoing as buildings are structurally progressed. JM stated that there were no major Infection Control issues raised on PEAT. The only issues which have been raised are regarding shortages of hand gels and these were actioned as soon as the issues were raised. Please see attached report regarding Asket Croft outbreak. MM asked that NN follow up on the actions, as Asket has now moved location and preventative measures regarding the learning points need to be in place for the future.

Asket croft.docx

The location of the baby changing equipment at The Mount has been identified. The funding for this has been agreed and the ordering of the equipment is being progressed via Interserve. SC reported that the identified locations have been taken forward to CQ&R and are in the process of being progressed and approved. SC stated that after the re-audit of the ECT suite, himself and NN have sat down with staff to detail the action plan together. Many of the issues have been actioned. NN is to revisit the ECT suite to ensure that ownership has taken place of the actions outlined. SC

NN 2

commented that avenues of communication between the Infection Control team and theirs need to be kept open. SC reported that the MRSA screening training in York has been completed and the fact that 3 negatives must have occurred has been reiterated. SC commented that PEG feed and Catheter training have as not yet been actioned. The training will be delivered via LCH following a request being received from the unit requiring the training. Where the LYPFT Infection Control team could help is with the auditing of the procedure as part of the Essential Steps which GN is to take up with RM.

SC confirmed that the C.diff toxin site testing protocol for NYY is through GDH, EIA and PCR. SC reported that the risk assessment has been looked at and there have been no incidents within the Trust in the past 4 years. Foam alcohol dispensers are in use. Distribution points are in observed points. The revised risk assessment is in place. SC stated that it was felt that the MRSA decolonisation stickers was a stigma for the service user on the wards, i.e. having the sticker on their drug chart and so the use of the stickers was rejected. SC reported that the NHS Leeds meeting was cancelled and so the issues surrounding the community bed screening were unable to be discussed. This will be taken forward to the next NHS Leeds meeting and SC will feed back.

SC confirmed that the policy has now been amended to include the source isolation of GDH POS toxin negative C.diff. SC confirmed that the CDI document needs no amendments. KS and SC stated that as yet there are no identified amendments required for the algorithm. CW has supplied a standard for the blood pressure cuffs, and the auditing tool should pick out any areas requiring replacement. It is up to individual areas to have a rolling replacement programme in place. LM commented that there is a new audit tool in progress to capture the CMHT and day centres. Evidence shows that the green stickers are being used more widely. NM reported that the Interhealth Transfer form went forward to MG1 as part of the discharge and transfer procedure and has been returned to him to move into a new template to move forward and progress. NM reported that there are no problems foreseen. SC confirmed to the group that the majority of the areas within the 3

prison area are the ownership of the LCH and therefore they are to complete the audits and responsibilities. GE reported that many of the issues raised have now been resolved and that LCH have accepted the responsibility. SC confirmed that the breach of hygiene notice is awaiting publication. 4.

Standard business items 4.1 HCAI statistics and screening including outbreaks LM fed back the HCAI statistics. LM reported that there have been 2 outbreaks, one on ward 1 Becklin and one at The Mount, both tests came back as negative. Screening tests for MRSA were sent and 3 positives were returned. The next data report will include York after the creation of a new form. There was nil response from some units and the team will chase this up. SC stated that some of the information from York is end of month data and will be collated ready for PNAF on 25th September to report on, and this information will be distributed with the minutes to IPCC. MM requested that the Lead Nurse for York be invited to following IPCC meetings and present the report on behalf of York. LM stated that the data for Leeds has improved. LM stated that contact with CTMs is ongoing with regards to Infection Control training. There has also been an uptake for Link Champions. A reason for the recent drop in uptake of training being undertaken from the link champions is that a rumour was circulated that the champions were not allowed to complete training which is incorrect. This has now been rectified and training is again ongoing. NM requested a push from the Lead nurses to emphasise the necessity of Infection Control training. 4.2

Performance Report

(a)

NYY No update provided

(b)

Leeds No update provided

4.3

Board Report No update provided

4.4

Incidents (i)

SC/LM/GN

SC AF

Lead Nurses

Waste Management Incident

SC reported back on the incident regarding waste management whereby sharps were found to be disposed of in a general waste bin at St Maryâ&#x20AC;&#x2122;s House. The sharps were 4

contained within a plastic pop bottle. This occurred after bins were moved around the premises. An audit has been completed and fed back with an action plan. There has also been an agreement with Jason Mitchell to monitor the bins at St Maryâ&#x20AC;&#x2122;s House. KS queried the fact that a regular sharps audit is in place. SC affirmed that an audit and a walk around audit undertake the sharps aspect also. MM requested that the Lead Nurses check and complete a walk around. TP raised an issue with bins at Millside and SC confirmed that he has recently sent an email to Jason Mitchell to ensure that wherever there is a sink in place a bin must be provided for paper towels and cost does not reflect the issues.

4.5

Lead Nurses

Training activities (i) Hand Hygiene and Train the Trainer statistics Training has dropped off slightly, but this could be due to the above issue with the Link Champions. The link champions meetings are now in place to pick up data and share information. An action plan is in place and is being picked up at the Link Champion meetings. (ii) Leaflets No update provided

4.6

Audit No update provided

4.7

Essential Steps Update No update provided

Specific agenda items: 5.1 NHS Leeds/LYPFT Flu Vaccination Update SC fed back that this is very much in the hands of occupational health and a meeting has been held with them to organise this yearâ&#x20AC;&#x2122;s inoculations from October onwards. Locations are to be set across the Trust as opposed to wards and will be published on COMMs. ID is required to receive the inoculation. The target set externally is 75%. GE stated that the GP information is now being produced. SC to email SC Beryl Bleasby to obtain a copy of the form in order to capture the statistics. NM requested that SC email John Clare a short SC brief of the flu campaign. 5.2

Estates PFI issues 5

(i)

PEAT JM commented that he has revisited the PEAT action plan several times and is now in possession of a final format. It is now on the agenda for SMT and will be able to start monitoring it shortly, November or December. JM reported back on an initial proposal for a patient led pilot for next year. JM stated that there are significant changes and will be producing a briefing paper which will be produced shortly. JM requested that the IPCC dates for next year be sent to him as soon as possible to enable him to schedule the Joint Catering and Cleaning Support Group. AF

(ii)

Waste Management As previous. Nothing to report from NY&Y

(iii)

Sinks/Handwashing As previous

(iv)

Laundry Issues As Previous

5.3

Feedback from Lead Nurses/ADs Adult and Older persons: TP fed back that after a potential complaint, a walk around took place which highlighted some issues particularly with dress code, mainly involving students, wearing nail varnish or false nails. Also some issues were identified surrounding Interhealth transfer forms. TP mentioned that she is currently working on creating links with performance monitoring regarding issues with cleanliness of wards, and TP is working with the Modern Matrons to provide consistency and accuracy of reports. TP believes that many of the issues surrounding consistency of cleanliness are attributable to Interserve as there have been numerous reports regarding issues of staffing. MM requested that JM pick this up and feed back. JM JM stated that he has had a meeting with the regional director for Interserve and that it was agreed that weekly audits would occur in all areas and inputting them into an immediate action plan, but for some reason this has not happened at Newsam. Interserve have increased staffing across the board by 75 hours, but at present they are currently carrying 6 vacancies. However from next week Asket Croft closes and therefore 3 members of domestic staff will be carried over to concentrate on areas with specific issues and act as a â&#x20AC;&#x2DC;hit teamâ&#x20AC;&#x2122;. JM felt that Interserve were responding but there was a need to keep up the pressure on them to maintain standards. Older Peoples Services: NN reported that in addition to the Modern Matrons walk through she also completes her own walk through bi-monthly 6

and actions any point arising from that. NN stated that in addition they distribute the satisfaction surveys across the four areas to gain feedback regarding comfort and cleanliness, and these results are always available in the specific areas. NN reported that she is not aware of any poor standards at the Mount regarding Interserve. The only issue is with the ECT suite and an audit has been arranged together with a member of the Interserve staff and the results of this will be fed back to SC when completed. JM reported that he has an action plan in place whereby the lower ground floor of the Mount looks more like a goods entrance and the ambiance is not acceptable for service user usage.

Specialist Services: VG reported that the main issues were within the eating disorders service regarding NG feeding and veno puncture. SC stated that the training is delivered externally and Infection Control monitor the training through Essential Steps but do not deliver it. NM suggested that the ward manager contact Laura Scott, the Clinical Standards Development Nurse, who has completed work surrounding these issues and will be able to advise on approved training. VG fed back that there were no particular concerns regarding the mother and baby unitâ&#x20AC;&#x2122;s cleanliness, but she is aware that staff do complete additional cleaning with the play equipment etc. The main issue picked up was that there was no evidence of the use of the Interhealth Transfer form for two mothers. VG commented that the YCPM, Ward 40 have the problems of sitting within the LTHT and requested that the care plan that they use is of a standard that our IC team require. VG commented that the staff on YCPM had completed extra training such as critical care and catheter training and suggested that these skills could be utilised in other areas. MM suggested that Laura Scott be the conduit for these suggestions. VG had nothing to report from LAU and MM requested that this service not be VG/LS forgotten as it was a potential high risk area. Learning Difficulties: RM had sent in a report and SC commented that there has been a drop off in the delivery of training. GN reported that she has arranged an amount of training to be delivered to the outlying areas and that she is focussing on this with RM. NM requested that GN and RM produce specific monthly targets and report back at the December IPCC. SC commented that the drop off in the training percentage was probably as a result of staff concentrating on other areas to do with transformation and that this was where the slippage had occurred, but targets were to be set primarily for September and October and November to bring the target level back up to standard.

GN/RM

York: No report received on this occasion. NM reported that he had not been requested to send a report and apologised for the lack of a report on this occasion. However, he indicated that Terri Sanders had recently taken up post as Lead Nurse in York and would be supplying a report and attending the next meeting. 6.

Information Items:

None Updates from Committees/Groups:

7.1

NHS Leeds IPCC minutes – (No further meeting held since last IPCC) No update provided

7.2

Joint Cleaning Strategy Group Minutes Out of synchronisation with IPCC. Meeting to be held next week.

7.3

North Yorkshire District Control of Infection Committee SC reported that this committee use a catheter passport book and SC is looking into the use of this within our network. SC will liaise with Laura Scott. SC to circulate to the group for comments.

Policies and Procedures for approval/ratification 8.1

NM/York Lead Nurse

Policies all presently being harmonised. SC fed back on minor changes and commented on the fact that they all need to be placed on to the correct template. SC explained that they will then go to MG1 and be passed through September or October.

Any other business: GJ explained the revised work book produced for North Yorkshire which is circulated to the community groups. SC commented that this would be a useful tool for induction. KS requested for GJ to bring a report to the IPCC to show if the booklet has made any impact on results and to show improvements.

The dates and time of the next year’s IPCC meetings as follows: 04 March 2013, 03 June 2013, 09 September 2013, 02 December 2013,

2pm – 4.30pm, 2pm – 4.30pm, 2pm – 4.30pm, 2pm – 4.30pm,

Meeting Room 1 THQ Meeting Room 1 THQ Meeting Room 1 THQ Meeting Room 1 THQ 8

Please place in your diaries as appropriate. 10

Date and time of next meeting: 14th December 2012 – 09.00am – 11.00am – Old Canteen Meeting Room, North Wing, St Mary’s House

AGENDA ITEM 19

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Draft Minutes from the Council of Governors’ meeting held 13 September 2012

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Frank Griffiths – Chair of the Trust

PAPER AUTHOR:

Cath Hill – Head of Corporate Governance

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC:

GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

  



STATUS OF PAPER



To be taken in the public session (Part A)



SUMMARY:

The draft minutes of the meeting of the Council of Governors held on 13 September 2012 are presented to the Board of Directors for information.

RECOMMENDATIONS: The Board of Directors is asked to receive and note the draft minutes from the Council of Governorsâ&#x20AC;&#x2122; meeting held on 13 September 2012.

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST Minutes of the 25th Public Meeting of the Council of Governors Held on 13 September 2012 in the Morton Suite at the National Railway Museum, York PRESENT: Frank Griffiths (Chair) Public Governors Keith Wilson Andrew Marran Amit Bhagwat Graham Purdy Colin Rhodes

Service User Governors Jonathan Butler Roy Goddard Fiona Walker Maria Trainer Staff Governors Stephen Wright Heather Simpson Paul Cockcroft Pamela Morris Jonathan King

Carer Governors Bill Boland Julia Raven Annie Dransfield Janette Howlett Appointed Governors Pip Goff Colin Clark

IN ATTENDANCE: Chris Butler – Chief Executive Michele Moran – Chief Nurse / Chief Operating Officer / Deputy Chief Executive Dawn Hanwell – Chief Financial Officer Jill Copeland – Director of Strategy and Partnership Dr Jim Isherwood – Medical Director Susan Tyler – Director of Workforce Development Linda Phipps – Non-executive Director Allan Valks – Non-executive Director Cath Hill – Head of Corporate Governance (secretariat and minutes) 4 Members of the public

Action 12/076

Welcome and Introductions (agenda item 1) The Chair opened the public meeting at 13:00 and welcomed governors and members of the public to the Council of Governors’ meeting. 1

Mr Griffiths noted that there were three non-executive directors who had not been able to be in attendance at the meeting, namely Mr Woodhouse, Mrs Swan, Ms Choudhry and Dr Taylor. 12/077

Apologies (agenda item 2) Apologies were received from: Barry Tebb, elected governor for Public Rest of England and Wales; Mark Willis, elected governor for staff clinical; Mahesh Jayaram, elected governor for staff clinical; Ann Shuter, elected governor for service user learning disability Leeds; Julie Bolus appointed governor for NHS North Yorkshire and York; Pamela Dolan, elected governor for service user Leeds; Cllr Tracy Simpson Laing, appointed governor for City of York Council; Grace Mangwanya, elected governor for Public Leeds East; Andrew Bottomley, elected governor for carer Leeds; Cllr Christine Macniven, appointed governor for Leeds City Council; and John Dossey appointed governor for Tenfold.

12/078

Governorsâ&#x20AC;&#x2122; Declaration of Interests (agenda item 3) There were no changes to the Declarations of Interest for any governor, and no governor present at the meeting declared an interest in any item to be discussed.

12/079

Opportunity to Receive Comments or Questions from Members of the Public (agenda item 4) There were no questions raised by members of the public.

12/080

Minutes of the Public Meeting held on 12 July 2012 (agenda item 5)

The minutes of the public Council of Governorsâ&#x20AC;&#x2122; meeting held on the 12 July 2012 were agreed as an accurate record.

12/081

Matters Arising (agenda item 6) 12/081.1 – NHS Mail Accounts for Governors (Minute 12/074.2) – Ms Copeland advised the Council that Mr Howorth would be assisting any governor who wished to have an NHSmail account set up and that forms to facilitate this process are available from him. Ms Copeland also advised the Council that work was underway to develop the staff intranet and that as part of that this there would be the development of an area where discussion forums can be set up and accessed by any governor with an NHSmail account. Ms Goff asked if there were any drawbacks to having an NHSmail account. Ms Copeland indicated that once the intranet upgrade was completed it would be possible to ensure that governors didn’t receive the numerous Trustwide emails and would only get those relevant to their role. With regard to those governors who do not opt for NHSmail Ms Copeland assured them that they would still be communicated with in the normal way.

The Council of Governors noted the progress with setting up NHSmail accounts for governors and the continuing work to develop the staff intranet.

12/081.2 – “Get Me?” Campaign (minute 12/072) – Ms Goff asked to draw attention to this very important campaign and suggested that governors receive more information. Mr Griffiths supported this and asked for a full report and possibly a presentation to come to the November meeting. Ms Betton agreed that it would be appropriate to show the film at the next meeting.

It was agreed that a paper and presentation by way of the film would come to the next meeting.

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12/082

Changes to the Council of Governors (agenda item 7.1) Mrs Hill drew attention to the changes to the membership of the Council of Governors, which had occurred since the last meeting, namely that Mr Alec Hudson, Mr Andy Parker, Ms Tricia Thorpe and Mrs Jenny Roper had come to the end of their term of office. Mrs Hill also drew attention to the ongoing process of elections that were taking place, noting that these were due to conclude on the 30 October and that a further report would be made to the next meeting in respect of the outcome. Mr Griffiths noted that in addition to the changes notified in the agenda paper Mr John Dossey had been appointed as the governor to represent Tenfold, and was to replace Kate Langan. Mr Griffiths advised the Council that Mr Dossey had unfortunately not been able to attend this meeting due to a previous commitment.

The Council of Governors noted the changes to its membership.

12/083

Changes to the Board of Directors (agenda item 7.2) Mr Griffiths advised the Council of the changes to the Board of Directors, which had occurred since the last meeting and introduced to the Council Ms Dawn Hanwell, who had taken up post as Chief Financial Officer on the 1 August 2012, and Dr Jim Isherwood, who had taken up post as Medical Director on the 1 September 2012.

The Council of Governors noted the changes to the membership of the Board of Directors and welcomed Ms Hanwell and Dr Isherwood to the Trust.

12/084

Chairâ&#x20AC;&#x2122;s Communication (agenda item 8)

12/084.1 – The “Get Me?” Campaign – Mr Griffiths advised the Council that he, along with other members of the Board, had attended the launch of the “Get Me?” campaign and that this has featured some of our service users, carers and people more widely in Leeds. Mr Griffiths pointed out that there is a major issue with recognising the needs of people with learning disabilities and who they are as individuals including the contribution they can make to the well-being of society as a whole. Mr Griffiths drew attention to the film which was shown at the launch and the contribution that our governors had made to that film, noting that this will be shown at the Annual Members Day and also at the next meeting. Mr Bhagwat asked for the film to be uploaded to the Trust’s website and for all members to be made aware that it is there. Ms Betton indicated that the film was already there; that there was a separate website which was www.getmecmpaign.co.uk and agreed to send a link to governors via Mrs Hill.

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12/084.2 – Role of Governors – Mr Griffiths reminded the Council that whilst the Council has a number of statutory duties to perform one of which is to ensure that the Board of Directors complies with the Trust’s Terms of Authorisation, a governor’s role was also to be an ambassador for the Trust and champion the causes it serves, namely mental health and learning disabilities, and stated that this needs to be more strongly injected into work of the Council, and also taken forward by individual governors when they carry out their role on an individual basis. Mr Griffiths suggested that this ambassadorial role should be outward looking and celebratory of the things we do, along with there being searching discussions about what the Trust is doing. 12/084.3 – Task and Finish group to look at the review and appraisal process for individual governors and also the review of effectiveness of the Council – Mr Griffiths asked Governors governors to notify Mrs Hill if they wished to join a short life task and finish group to look at these matters.

12/084.4 – Update on the process for the appointment of three non-executive directors – Mr Griffiths advised the Council that the closing date for applications had now passed. Mr Griffiths noted that the Appointments and Remuneration Committee had met briefly before the Council meeting to review the process and that shortlisting would take place on 24 September 2012, with the process being completed in the near future. Jonathan King joined the meeting at 13:35. 12/085

Quality Health results from the community service user survey (agenda item 9) Mrs Moran presented to the Council of Governors the results from the Quality Health National NHS Community Mental Health Service User Survey for the service users in both the Leeds and the North Yorkshire and York areas who are on the ‘old’ enhanced Care Programme Approach (CPA). Mrs Moran noted that for this year there are two separate surveys but that from next year there will be a combined report. Mrs Moran also explained the governance pathway for the surveys, noting that the comments received from the Council would be fed into a report that is to go to the Board of Directors on the 28 September 2012. Mrs Moran also drew attention to a supplementary report which outlines work within the Trust to address some of the issues highlighted in respect of CPA. Mrs Moran took the Council of Governors through the findings and results of the survey in some detail. Mrs Moran focussed firstly on the results for the Leeds area and drew attention to the issues for action as identified by Quality Health. Mr Bhagwat observed that the statistics for North Yorkshire and York were in many respects better than for Leeds and asked what the statistical significance of this was, and what the sample size related to total service users was. Mrs Moran noted that it was 33% for Leeds and 30% for North Yorkshire and York, and that the survey is sent out to a sample of service users on CPA. 6

Mrs Morris asked why there has been a downward shift between the current results and those for 2011. Mrs Moran indicated that this is sometimes difficult to determine due in part to the sample being a different cohort of people each time. Mrs Moran indicated that each time a survey is carried out by Quality Health areas of weakness are addressed, but acknowledged that the focus of the work may not always be right. With regard to the North Yorkshire and York survey Mrs Moran noted that overall the results were better than for Leeds and there needs to be more work to understand why this might be. Having completed the presentation slides Mrs Moran invited governors to ask questions. Ms Goff asked about the CPA report and changes to third sector funding and asked how this had made an impact. Also with regard to the report Ms Goff asked if the recommendations are strong enough and wondered if anything more radical could be done to address these. Ms Goff also suggested that by drilling down to individual teams to look at any specific issues; also whether actions could be part of the stretch targets in the strategy. Ms Goff also highlighted the differences in staff attitudes and the lower score for Leeds, noting that there is a lot of learning to be shared across the new organisation. With regard to service users in crisis and out of hours arrangements Ms Goff noted that a paper would be going to the Joint Strategic Commissioning Group in Leeds which would look at citywide actions. Dr Wright supported Ms Goff in respect of the discrepancy between Leeds and North Yorkshire & York and observed that the more factual and bureaucratic elements had been carried out well in Leeds but the personal communications elements were maybe not so well performed. Dr Wright asked if time could be a factor in this, and whether case loads could be very different. Dr Wirght also suggested that this work could be linked into the NICE audits, which Mrs 7

Moran supported. Mr Purdy asked if there are any similar Trusts who have good practice and learning to share. Mrs Moran indicated that it is not as straight forward as changing practice to mirror Trusts with better scores, but that sharing good practice is always a good thing to do. Mrs Simpson observed that money has been allocated to organisations in the Yorkshire and Humber area to look at the evidence for learning and improving on respect and dignity and asked if this could be tied into the membership campaign for next year around telling stories. Mrs Moran outlined some of the work that would be undertaken to establish champions. Mrs Dransfield asked if would be possible to look at the comments box to look at examples and understand some of the context of what the respondents are saying. Mrs Moran agreed to look at using the comments box in the survey to better effect, to pick up examples cited and use these as a point of learning, and would work with Ms Betton and Mr Howorth to extract these. With regard to care reviews Mr Wilson noted that in the Leeds Quality Health survey it showed a figure of 42% carried out whereas in the performance report CPA was reported as being at 90% and asked why these two figures were so different. Mrs Moran indicated that this is due to the differences between data collection and an individualâ&#x20AC;&#x2122;s perception and understanding of the question. Mrs Moran assured the Council that the Trust is compliant with the Monitor target. Mr Marran expressed concern at the some of the results and suggested that there is a bigger piece of work around the culture of the Leeds services to understand how this can be improved. Mr Marran also indicated that he supported Ms Goffâ&#x20AC;&#x2122;s comments about the action plans detailed in the CPA paper suggesting that they were wordy and imprecise and that they need to be more meaningful about what is going to happen. Mrs Moran agreed that there are two different cultures in the organisation and that there needs to be a mix of the best of both service areas and that work is 8

ongoing to address this. Mr Griffiths asked when the Trust would receive one integrated report. Mrs Moran indicated that the next Quality Health report would be an integrated one and that when presented to the Council of Governors and Board of Directors Mrs Moran agreed to drill down to team level to get a better understanding of the issues in more detail.

Having received a detailed report from Mrs Moran in respect of the overall findings from the Quality Health Community Service User Survey, and from an internal report focussing on CPA and Care Co-ordination, it was agreed that the Council of Governors would receive a paper at the November Council meeting which looks at creative and innovative ways of addressing the differences between the culture in the Leeds and the North Yorkshire and York areas and other key actions outlined in the reports.

12/086

Trust strategy progress update (agenda item 10) Ms Copeland presented an update on the progress with the development and refresh of the Trustâ&#x20AC;&#x2122;s strategy. Ms Copeland indicated that governors had been informed, via Mrs Hill, that the Board of Directors had taken a decision to delay the completion of the Trustâ&#x20AC;&#x2122;s strategy until the Department of Health dashboard of mental health indicators has been issued and until the next section of the Francis Report is issued in the Autumn. Ms Copeland drew attention to the new strategy refresh timeline, with the strategy being launched in April 2013. Ms Copeland also drew attention to the strategy measures noting that these are still work in progress and the Governors strategy Sub-group has met to look at these on a number of occasions.

Having discussed the matter the Council of Governors agreed the new timeline for publication of the refreshed strategy and agreed the direction of travel with the strategy measures.

12/087

How we comply with our Terms of Authorisation and quarter 1 monitoring return (agenda item 11) 1:19:25 â&#x20AC;&#x201C; 1:42.45 Ms Hanwell presented the paper which set out the Trustâ&#x20AC;&#x2122;s compliance with its Terms of Authorisation. Ms Hanwell outlined the different sections of the report noting that this report contained the Quarter 1 monitoring information for the period April to June, which had been submitted to Monitor at the end of July. Ms Hanwell advised the Council that this Trust is a high performing Trust and as such only has to report on a quarterly basis and assured the Council that for Quarter 1 the Trust is meeting all the Monitor compliance standards with a financial risk rating of 4. With regard to the non-financial information for the period ending July 2012 Ms Hanwell drew the Councilâ&#x20AC;&#x2122;s attention to some areas of importance. Ms Hanwell reported that the Trust is green in all nine areas of the Monitor standards and targets; however, she noted that there is still some concern about the target for delayed discharges in the North Yorkshire & York area indicating that this is being looked at with partners in the area. With regard to seven day follow-up Ms Hanwell indicated that there were five breaches in the Leeds service and that to address this monitoring processes have been escalated. Ms Hanwell drew attention to the White Horse View CQC inspection where minor concerns were raised, noting that the action plan to address these has been included in the report which demonstrates that all actions have been completed and that the Trust is awaiting notification that this concern has been lifted.

Ms Hanwell drew attention to the CQUIN targets noting that these are set by the commissioners to stretch the organisation in terms of delivery of quality services. Ms Hanwell advised the Council that for this financial year £3 million of income is reliant on achieving these targets. Mrs Morris asked about the Transformation Programme and highlighted some concerns that she has about the way in which the budget is being used, in particular with regard to the transfer of staff from one base to another. It was agreed that this matter would be picked up with Mrs Morris outside of the meeting by Ms Hanwell and Mrs Moran. Mr Griffiths also asked for this to be picked up as a matter arising at the November meeting.

MM/DH MM/DH

With regard to the Trust’s financial performance headlines Ms Hanwell reported that: the Trust is slightly ahead of the income and expenditure plan as at month four, and explained the reasons for this; the capital plan is slightly behind plan, with a forecast to still be behind plan at the end of the year, but that work is underway to look at the linkages with the Estates Strategy to ensure the capital plan is still appropriate; and the Trust is ahead of the cash position which means that the Trust will be able to meet its financial obligations. Mr Bhagwat asked about the plans the Trust has for the surplus it makes. Ms Hanwell advised that one of the freedoms and FT has is to make and retain any surplus it makes to invest back into our services, and that there is an expectation by Monitor that FTs will in fact make a surplus. With regard to this Trust’s plans for its surplus Ms Hanwell indicated that this is linked to the Trust’s priorities as set out in the strategy and the Annual Plan. Ms Hanwell also indicated that surplus cash is largely invested in one off capital items and there is a plan for this set out in the report. Mr Goddard observed that some of the format and presentation of the information in the report is illegible. Ms Hanwell indicated that she was looking at the way in which the report is structured with a view to simplifying it. Mr Rhodes asked about the NHS Commercial procurement Collaborative and whether the report was showing a loss 11

overall or just a loss of income. Ms Hanwell indicated that this would be picked up in more detail in agenda item 12, but there is an expectation that the service will make an overall loss in this financial year.

Having reviewed the report the Council of Governors confirmed that it was assured that the Trust is meeting its Terms of Authorisation.

12/088

Progress against the Annual Plan 2012/13 (agenda item 11.1) Ms Copeland advised the Council of Governors that Monitor requires the Trust to report to the Council of Governors and the Board of Directors on performance against the priorities as set out in the Annual Plan and that this report provides progress against the 2012/13 milestones for the first quarter of the year. Ms Copeland indicated that overall the majority of the plans are rated ‘green’ which demonstrates that progress is as expected at quarter 1; with slippage in two areas leading to an ‘amber’ rating. Ms Copeland assured the Council that this does not present any new risks to the Trust.

Having reviewed the progress against the Annual Plan the Council of Governors confirmed that it was assured that the Trust is making sufficient progress against the milestones.

12/089

The NHS Commercial Procurement Collaborative (CPC) financial performance (agenda item 12) Ms Copeland set out the background to the CPC and described the service they provide. Ms Copeland advised the Council that whilst the CPC did not provide a service which is core to the Trust (i.e. the provision of mental health and learning disability care), it did provide a valuable service to other NHS organisations which ultimately saves them a lot of money to be invested back into their care services. 12

Ms Copeland outlined the historical context to the financial position which the CPC now finds itself in, including the external changes to the NHS structure and the changes in the cash available in the system brought about by the economic climate and the changes in legislation. Ms Copeland also outlined some of the actions that have been put in place to improve the financial position and reduce the level of risk to the Trust, which includes increasing income and reducing costs. Ms Copeland assured the Council that the actions identified in the financial plan should allow the service to achieve its forecast targets in the following financial year, and that the service is being closely managed by herself and a senior member of the finance team. Mr Cockcroft noted that the CPC is made up of a relatively small number of people specialising in financial savings, and that given the nature of the service they provide it is disappointing that the financial performance has been so poor to date. Mr Cockcroft also asked about the current employment status of two senior members of CPC and asked how this has affected productivity and what the cost has been to the organisation and what the ongoing costs are. Mr Cockcroft also asked if this has affected the direction of this organisation. With regard to the actions Ms Copeland reported that some of these should have been in place and that work is progressing at a pace to ensure this is now the case. With regard to the HR process which is in place Ms Copeland indicated that she is not able to address these in a public meeting and would take advice as to what information if any can be released in a private meeting.

Ms Goff asked what the overall turnover of the organisation is. Ms Copeland indicated that the turnover is in the region of ÂŁ3 m and is expected to be around ÂŁ2.5 m in the next financial year. Mr Marran indicated that the report has been very helpful to 13

understand the CPC and how it has been managed. Mr Marran expressed some caution noting that the business and the way it operates is very different from the way the Trust operates. With regard to the financial plan Mr Marran sought assurance that the business plan is flexible enough to be responsive to recruiting the right people at the right time. Ms Copeland acknowledged that the business is very different from that of the Trust and that there needs to be a flexible approach to solutions. Mr Rhodes noted that at the Board meeting in 2010 it was reported that it was expected to provide a return of 10%, and asked if the loss reported is a real loss or a hypothetical loss. Ms Copeland indicated that the target for the year has been set at a net 10% in order to make a surplus for the Trust. Mr Griffiths suggested that Mr Marran gives support to Ms Copeland in respect of the business plans. Mr Marran agreed to do this.

The Council of Governors considered the report and gained assurance that all the necessary actions are being taken to manage the financial performance.

12/090

Minutes of the Membership Committee Meeting held on 7 August 2012 (agenda item 13) Mr Goddard presented the minutes from the Membership Committee meeting held on 7 August 2012 With regard to the membership stall at York Hospitals NHS Foundation Trust Mrs Simpson advised the Council that 47 new members had been recruited including the Mayor of York. Mr Griffiths noted that the committee had discussed the film archive, and on a related matter he advised the Council that a number of historical items from an old psychiatric facility in Leeds had been brought to the attention of himself and the Chief Executive. Mr Butler speculated at the amount of material that may be in the possession of services in Leeds and York and suggested that this should be archived if only to show how far mental health and learning disability care 14

JC/AM

has come. There was some support for looking at the possibility to establish an archive. Ms Copeland suggested that this could be linked into the membership campaign for the coming year which is about sharing stories.

The Council received and noted the minutes from the Membership committee held on 7 August 2012.

12/091

Update on the appointments to the forthcoming vacant non-executive director posts (agenda item 14) Mr Griffiths noted that this item had been covered in agenda item 8.

12/092

Induction training â&#x20AC;&#x201C; progress (agenda item 15)

The Council of Governors noted the future dates for induction training.

12/093

Dates of Council of Governorsâ&#x20AC;&#x2122; meetings for 2013 (agenda item 16)

The Council of Governors noted the future dates for Council meetings in 2013.

12/094

Information Item Previously Circulated to Governors (agenda item 17)

The Council of Governors received the paper and noted the items previously circulated.

12/095

Minutes of the Meeting of the Board of Directors held on 30 June and 27 July 2012 (agenda item 18) 15

The Council of Governors received the report and noted the content.

12/096

The Annual Members Day (agenda item 19)

The Council of Governors received information about the Annual Members Day.

12/097

Questions and Comments from Members of the Public (agenda item 20) There were no further questions for the Council from members of the public.

12/098

Any Other Business (agenda item 21) 12/098.1 – Governors Growth Sub-Group – Ms Copeland advised the Council that governors had been advised via Mrs Hill that the sub-group will be reconvening to look at the principles, criteria and framework for assessing growth opportunities and also to look at defining significant transactions which will go forward into the refreshed Constitution. Ms Copeland advised governors of the date and noted that there was an open invitation to attend. Ms Copeland indicated that the outcome of the discussion at the meeting would be brought back to the Council in November.

Ms Copeland agreed to arrange for those governors who wished to join the meeting by conference call, and asked Governors governors to let Mrs Batley (Ms Copeland’s PA) have their details. 12/098.2 – External assessment of the Board of Directors – Ms Copeland noted that the Board of Directors in conjunction with the Real World Group is about to undertake an external assessment of their performance. Ms Copeland outlined the arrangements for governors feeding into the external assessment, indicating that full details of the 16

arrangements would be circulated to governors shortly. Ms Copeland also indicated that there could be an opportunity for the Real World Group to carry out an assessment of the Council of Governors’ effectiveness in 2013. 12/098.3 – Refresh of the Constitution – Ms Copeland indicated that there are three areas of focus for this refresh, these being to better define the role of governors; to look at defining significant transactions; and to look at the membership of the Council of Governors and refresh this in the light of the abolition of PCTs and emerging Clinical Commissioning Groups, the need to ensure quoracy, and to look at the geographical areas of the constituencies and where governors live in relation to those they represent. 12/098.4 – Governors’ email addresses – Mrs Hill noted that she now has a list of governors who would like their addresses sharing and that she will be circulating these. 12/099

Motion to Move to a Private Session of the Council of Governors’ Meeting The Council of Governors’ resolved that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest.

The Chair closed the public meeting of the Council of Governors of Leeds and York Partnership NHS Foundation Trust at 15:25 and thanked governors and members of the public for their attendance.

COUNCIL OF GOVERNORS’ ACTION SUMMARY (PUBLIC MEETING) Meeting held 13 September 2012

MINUTE

ACTION SUMMARY (PUBLIC MEETING)

12/081.2

“Get Me?” Campaign (minute 12/072) It was agreed that a paper and presentation by way of a film would come to the next meeting.

12/082

JC/VB

Changes to the Council of Governors (agenda item 7.1) Mrs Hill also drew attention to the ongoing process of elections that were taking place, noting that these were due to conclude on the 30 October and that a further report would be made to the next meeting in respect of the outcome.

12/084

LEAD

12/084.1 Chair’s Communication – “Get Me?” Campaign (agenda item 8) Mr Bhagwat asked for the film to be uploaded to the Trust’s website and for all members to be made aware that it is there. Ms Betton indicated that the film was already there; that there was a separate website which was www.getmecmpaign.co.uk and agreed to send a link to governors via Mrs Hill.

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12/084.3 Chair’s Communication – Task and Finish group to look at the review and appraisal process for individual governors and also the review of effectiveness of the Council Mr Griffiths asked governors to notify Mrs Hill if they wished to join a short life task and finish group to look at these matters.

Governors

MINUTE

ACTION SUMMARY (PUBLIC MEETING)

12/085

Quality Health results from the community service user survey (agenda item 9) Mrs Dransfield asked if would be possible to look at the comments box to look at examples and understand some of the context of what the respondents are saying. Mrs Moran agreed to look at using the comments box in the survey to better effect, to pick up examples cited and use these as a point of learning, and would work with Ms Betton and Mr Howorth to extract these. Having received a detailed report from Mrs Moran in respect of the overall findings from the Quality Health Community Service User Survey, and from an internal report focussing on CPA and Care Coordination, it was agreed that the Council of Governors would receive a paper at the November Council meeting which looks at creative and innovative ways of addressing the differences between the culture in the Leeds and the North Yorkshire and York areas and other key actions outlined in the reports.

12/087

LEAD

How we comply with our Terms of Authorisation and quarter 1 monitoring return (agenda item 11) Mrs Morris asked about the Transformation Programme and highlighted some concerns that she has about the way in which the budget is being used, in particular with regard to the transfer of staff from one base to another. It was agreed that this matter would be picked up with Mrs Morris outside of the meeting by Ms Hanwell and Mrs Moran. Mr Griffiths also asked for this to be picked up as a matter arising at the November meeting.

MM/DH

Mr Goddard observed that some of the format and presentation of the information in the report is illegible. Ms Hanwell indicated that she was looking at the way in which the report is structured with a view to simplifying it.

MM/DH

MINUTE

ACTION SUMMARY (PUBLIC MEETING)

12/089

The NHS Commercial Collaborative (CPC) financial (agenda item 12)

Procurement performance

With regard to the actions Ms Copeland reported that some of these should have been in place and that work is progressing at a pace to ensure this is now the case. With regard to the HR process which is in place Ms Copeland indicated that she is not able to address these in a public meeting and would take advice as to what information if any can be released in a private meeting. Mr Griffiths suggested that Mr Marran gives support to Ms Copeland in respect of the business plans. Mr Marran agreed to do this. 12/098

LEAD

JC/AM

Any Other Business (agenda item 21) 12/098.1 – Governors Growth Sub-Group Ms Copeland advised the Council that governors had been advised via Mrs Hill that the sub-group will be reconvening to look at the principles, criteria and framework for assessing growth opportunities and also to look at defining significant transactions which will go forward into the refreshed Constitution. Ms Copeland advised governors of the date and noted that there was an open invitation to attend. Ms Copeland indicated that the outcome of the discussion at the meeting would be brought back to the Council in November. Ms Copeland agreed to arrange for those governors who wished to join the meeting by conference call, and asked governors to let Mrs Batley (Ms Copeland’s PA) have their details. 12/098.2 – External assessment of the Board of Directors Ms Copeland noted that the Board of Directors in conjunction with the Real World Group is about to undertake an external assessment of their 20

Governors

MINUTE

ACTION SUMMARY (PUBLIC MEETING) performance. Ms Copeland outlined the arrangements for governors feeding into the external assessment, indicating that full details of the arrangements would be circulated to governors shortly. 12/098.4 â&#x20AC;&#x201C; Governorsâ&#x20AC;&#x2122; email addresses Mrs Hill noted that she now has a list of governors who would like their addresses sharing and that she will be circulating these.

LEAD JC

AGENDA ITEM 20

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

Draft Minutes from the Nomination Committee for the Meeting held on 28 September 2012

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Frank Griffiths – Chair of the Trust

PAPER AUTHOR:

Cath Hill – Head of Corporate Governance

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC:

GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

  



STATUS OF PAPER



To be taken in the public session (Part A)



SUMMARY: The draft minutes of the meeting of the Nominations Committee held on 28 September 2012 are presented to the Board of Directors for information.

RECOMMENDATIONS: The Board of Directors is asked to receive and note the draft minutes from the Nominations Committee held on 28 September 2012.

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST Minutes of the Nominations Committee held on 28 September 2012 in the Millennium Room at the Carriageworks, Leeds Present:

Mr F Griffiths Mrs N Swan Mr A Valks Dr G Taylor Mr C Butler Mrs S Tyler

Chair of the Trust (Chair of the Committee) Non-executive Director Non-executive Director Non-executive Director Chief Executive Director of Workforce Development

In attendance:

Mrs C Hill

Head of Corporate Governance (secretariat support and minutes)

Mr Griffiths opened the meeting at 14:30 and welcomed everyone to the meeting. Action 12/019

Apologies (agenda item 1) There were no apologies.

12/020

Directors Interests (agenda item 2) Mr Griffiths declared an interest in agenda item 7 noting that for that item he would hand the chairing of the meeting over to Dr Taylor and that he would leave the meeting at that point. This proposal was agreed by the committee. There were no other interests declared in respect of any of the agenda items being discussed.

12/021

Minutes of the Meeting held 26 April 2012

The minutes of the meeting held on 26 April 2012 were considered by the committee and approved as a true record.

12/022

Matters Arising There were no matters arising that were not already covered on the agenda.

12/023

Upcoming Vacant Post of Chief Nurse / Chief Operating Officer / Deputy Chief Executive (agenda item 5) Mr Butler advised the committee that Mrs Moran would be 1

leaving the Trust at the end of November 2012 to take up the post of Chief Executive at Manchester Mental Health and Social Care NHS Trust. Mr Butler outlined the potential options for the way in which this upcoming vacancy and the related portfolio might be covered in the interim; and what the potential options are for managing the portfolio in the longer term. Having discussed the potential options the committee supported Mr Butler reviewing directorsâ&#x20AC;&#x2122; portfolios and looking at different ways in which these might be covered within the Executive Team. To inform Mr Butlerâ&#x20AC;&#x2122;s considerations he invited members of the committee to email any thoughts they may have on how these might be stratified, which will be added to the views already received from the Executive Team.

ALL

Mr Griffiths advised the committee of the need to expedite the work to develop the future structure of the Executive Team and their individual portfolios, as the Chief Nurse post was a statutory requirement on the Board. The committee discussed timescales. With regard to the advert for this post Mrs Tyler suggested that this should be placed either before the end of November or in the New Year in order to avoid the Christmas period.

The committee was assured that there were solutions to covering the vacancy in the short-term. It was agreed that the matter would be discussed again at the meeting on 30 October 2012, having particular regard to the options for the Executive Team structure and portfolios.

12/024

Update on the Process for the Appointment of Three Nonexecutive Directors (agenda item 5) Mr Griffiths updated the committee on the position with regard to the appointment process for three upcoming NED vacancies. Mr Griffiths advised the committee that interviews would take place on the 4 October 2012, noting that a further update would be brought back to the committee on 30 October 2012.

Having received an update on the process it was agreed that a further report would be brought back to the Nominations Committee on 30 October 2012.

Mr Griffiths let the meeting at 14:55 and the chair was taken by Dr Taylor. 2

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Process and Documentation for the Appointment of the Chair of the Trust Mrs Hill presented the timetable of key dates, the proposed advert and the role description / person specification. Mrs Hill noted that the documentation presented at the meeting was that used previously for the process of appointing to the chair position, which had been updated to take account of the organisational changes that had occurred since April 2010. The committee discussed the key dates and the proposed process. The committee asked if the only option for of appointment was through competitive interview and asked Mrs Hill to check the Constitution and advise the committee by email as to the options for the process to appoint a chair so the committee can consider these and make a proposal to the Appointments and Remuneration Committee as to how it might consider taking this forward. The committee also noted that the next step was to convene a meeting of the Appointments and Remuneration Committee before the next Council of Governorsâ&#x20AC;&#x2122; meeting in order to consider the documentation and options for the process of appointment of the chair.

It was agreed that Mrs Hill would advise the committee of the potential options for the appointment process of the Chair of the Trust and would arrange for there to be a meeting of the Appointments and Remuneration Committee before the next Council of Governorsâ&#x20AC;&#x2122; meeting.

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Any Other Business There were no items of other business.

The meeting closed at 15:10 and the chair thanked members for attending.

NOMINATIONS COMMITTEE – ACTION SUMMARY Meeting held 28 September 2012

MINUTE

ACTION SUMMARY (NOMINATIONS COMMITTEE)

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Upcoming Vacant Post of Chief Nurse / Chief Operating Officer / Deputy Chief Executive (agenda item 5) Having discussed the potential options the committee supported Mr Butler reviewing directors’ portfolios and looking at different ways in which these might be covered within the Executive Team. To inform Mr Butler’s considerations he invited members of the committee to email any thoughts they may have on how these might be stratified, which will be added to the views already received from the Executive Team. It was agreed that the matter would be discussed again at the meeting on 30 October 2012, having particular regard to the options for the Executive Team structure and portfolios.

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ALL

Update on the Process for the Appointment of Three Non-executive Directors (agenda item 5) Having received an update on the process it was agreed that a further report would be brought back to the Nominations Committee in October 2012.

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LEAD DIRECTOR

Process and Documentation for the Appointment of the Chair of the Trust The committee discussed the key dates and the proposed process. The committee asked if the only option for of appointment was through competitive interview and asked Mrs Hill to check the Constitution and advise the committee by email as to the options for the process to appoint a chair so the committee can consider these and make a proposal to the Appointments and Remuneration Committee as to how it might consider taking this forward. The committee also noted that the next step was to convene a meeting of the Appointments and Remuneration Committee before the next Council of Governors’ meeting in order to consider the documentation and options for the process of appointment of the chair.

AGENDA ITEM AOB

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST MEETING OF THE BOARD OF DIRECTORS PAPER TITLE:

NatWest Resolution Indemnity Form

DATE OF MEETING:

30 October 2012

LEAD DIRECTOR:

Dawn Hanwell, Chief Financial Officer

PAPER AUTHOR:

Joanne Brayshaw, Brayshaw Finance

CATEGORY OF PAPER ((please tick relevant box) STRATEGIC STRATEGIC: GOVERNANCE:



INFORMATION:

IMPACT ON THE TRUST’S STRATEGIC END GOALS (please tick relevant box) EG1 EG2

People achieve their agreed goals for improving health and improving lives People experience safe care

EG3

People have a positive experience of their care and support

  



SUMMARY: The purpose of the Indemnity form is to have this resolution in place with the bank to enable all cheques received in new or old Trust names to be banked into the Trust’s Trust s bank accounts.

RECOMMENDATIONS: The Chairman is asked to sign the “NHS Trust Resolution Indemnity” form and Dawn Hanwell is asked to sign the “Deposit of Third Party Payee Cheques” form to enable all future cheques to be banked into the Trust’s bankk accounts, whether in the Trust’s new or old name.