Agenda and papers - Cambridgeshire and Peterborough NHS

Transcription

MEETING OF THE
BOARD OF DIRECTORS
IN PUBLIC
Date:
Time:
Venue:
Time
AGENDA
Wednesday 28 November 2012
09.00 – 12.00
Board Room, Elizabeth House, Fulbourn, Cambridge
Item
Questions from the Public
09.00
1
09.15
Patient Story – Crisis Resolution and Home Treatment Service
Welcome
Melanie Coombes, Director of Nursing
2
Apologies for absence
3
Declarations of Interest
To declare any pecuniary or non pecuniary interests
4
Minutes of the meetings held on 31 October 2012, to be confirmed
as an accurate record
5
Matters Arising
6
09.30
Chairman’s Report
David Edwards
For Information
7
09.40
Chief Executives Report
Report of the Chief Executive
For information
Quality, Performance & Finance
8
09.50
Quality and Performance Committee Summary Report and
unconfirmed minutes –
Report of Robert Dixon, Chair of the Quality and Performance Committee
To review
9
09.55
Quality and Safety Report
Report of the Director of Nursing
To review
10
10.10
Performance Report M7
Report of the Director of Service Improvement
To review
Time
11
10.25
Item
Finance Report M7
Report of the Director of Finance
To review
Strategy
12
10.35
Workforce Processes
Report of the Director of People and Business Development
13
10.50
Framework for Quality Governance
Report of the Director of Service Improvement and Chief Information Officer &
Director of Nursing
11.00
BREAK
Governance and Risk
14
11.10
Summary Report and Minutes of the Audit and Assurance
Committee –
8 November 2012
Report of Ashish Dasgupta, Chair of the Audit and Assurance Committee
15
11.15
Corporate Risk Register
Report of the Director of Service Improvement
To review and agree remedial action
16
11.25
Programme Board Report
Report of the Chief Executive
For discussion and information
17
11.35
Charitable Funds Accounts
Report of the Director of Finance
To review
18
11.40
Register of the Use of the Seal
Report of the Trust Secretary
For information
19
Register of Directors Interests
Report of the Trust Secretary
For information only
20
11.45
Any Other Business
21
11.50
Points of Reflection
22
23
Date of next meeting
The next scheduled meeting of the Board to be held in public on Wednesday 19
December 2012, Board Room, Fulbourn at 9.30am
12.00
EXCLUSION OF THE PRESS AND PUBLIC
RESOLUTION
That under the provision of Section 1, Subsection 2 of the Public Bodies
(Admissions to Meetings) Act 1960, the public be excluded from the remainder
of the meeting on the grounds that publicity would be prejudicial to the public
interest by reason of the confidential nature of business to be transacted.
CAMBRIDGESHIRE AND PETERBOROUGH NHS FOUNDATION TRUST
DRAFT Minutes of the meeting of The Cambridgeshire and Peterborough NHS Foundation Trust
Board, held in public, on 31 October 2012, in the Board Room, Elizabeth House, Fulbourn,
Cambridgeshire, commencing at 10.00 and concluding at 13:05.
Members Present
Robert Dixon
Attila Vegh
Non Executive Director (Chair)
Chief Executive
Ashish Dasgupta
Ian Goodyer
Non Executive Director
Tom Abell
Darren Cattell
Chess Denman
Mick Simpson
Keith Spencer
Director of Service Improvement and Chief Information Officer
Director of Finance
Medical Director
Chief Operating Officer
Director of People and Business Development
In attendance
Jil Hall
Paul Burton
Interim Trust Secretary
Committee Secretary
Apologies
David Edwards
Barbara Beal
Terry Holloway
Chairman
Interim Director of Nursing
In the gallery
Bernie Gold
Margaret Johnson
Sir Patrick Sissons
Agenda
Item
Public Governor, Cambridgeshire
Public Governor
Two members of the public
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0.1
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Patient Story
Dementia Services
One member of staff attended – Janet Perks, together with several carers
and relatives of dementia patients. Brian Reynolds spoke of his wife’s dementia, which was onset at an early age and which was diagnosed four
years ago. He described a period of uncertainty when the care team
changed, but since they now have a permanent nurse specialist, Carolyn,
together with Fiona as admin support, they were able to deal with all the
paperwork relating to grants, funding and allowances. They also provided
practical help in other ways. Brian explained that it was not one person
affected by dementia, but two – the patient and the carer.
When asked by Attila Vegh for one thing which could be improved, Brian
replied that he would like the day centre hours to be carefully reviewed.
These have been reduced from being open 13 hours a day to only 6
hours a day and has been a big issue for him. He also cited the speed of
response as an area for improvement and informed the Board that it
seemed to take a crisis situation to trigger any prompt action.
Frank Bailey attended with his daughter and described how his wife was
diagnosed with Alzheimer’s in 2009. She suffered a stroke in February and was admitted to Addenbrookes for a month. He explained that when
his wife had been in Willow for a month, that she had been well treated.
She was then an in - patient in Denbigh when it re-opened. She remained
there until August of this year, when she was admitted to a care home
where she is presently.
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Robert Dixon acknowledged that the challenge was to manage services
to the best for everyone and asked what kind of message the carers
wanted the Board to bear in mind.
Desmond explained that the biggest issue for him was communications.
He felt, as did Frank Bailey’s daughter, that while the care received was very good, the constant change of people affected the smooth path of
communications. Desmond also explained that he found it difficult to
attend all the meetings, as he needed to arrange care for his wife, who
had been suffering from Alzheimer’s for 4 – 5 years.
Brian also expressed concerns about the financial restructure of the
service and how this might affect him in the future.
Ian Goodyer asked if a care plan was held by all and if so whether they
understood its contents. Desmond confirmed that he had a care plan
which had been produced with the help of the CPN; whilst Brian stated
that he had helped prepare his plan, had seen it, but had not been given
a copy.
After noting the comments, Robert Dixon thanked the representatives
form the Dementia service for attending, while Attila Vegh advised Brian
that a copy of the care plan would be issued to him.
The Dementia Services representatives then left the meeting.
1.
1.0
2.
2.0
3.
3.0
4.
4.0
Minutes of previous meeting held on 26 September 2012
It was noted that on page 1, section 0.1, the surname of Megan was
omitted and that with this inclusion, together with the amendment raised
by Bernie Gold that page 5, section 8.7 reflect that while the Board were
happy with improvements, it should be noted that “there was still a long way to go” and that also on page 8 at 13.2, the task and finish group were not in place yet, therefore the statement was vague. Subject to these
amendments the minutes of the meeting of the Trust Board held in public
on 26 September 2012 were approved as an accurate record and signed
by the Chairman.
5.
5.0
Matters Arising
It was noted that at page 2 and 0.6 of the minutes that CLAHRC 2 will be
happening and will have implications for CPFT, due to changes being
considered. There is a research meeting on 12 December 2012 with Tom
Abell present. It was acknowledged that a pre meet with Peter Jones
would be helpful.
See separate Action List document
6.
6.0
Report of the Chair
The Board received and noted the report of the Chairman
Attila Vegh
21/11/12
Attila Vegh
Before
12/12/12
Welcome and Introductions
Robert Dixon welcomed all attendees and also introduced Sir Patrick
Sissons, in the public gallery, who had recently been appointed as NED
and who would be taking up his role officially next year.
Apologies for Absence
Apologies were received from David Edwards, Chairman who was
replaced as Chairman by Robert Dixon for this meeting only; Terry
Holloway, NED and Barbara Beal, Interim Director of Nursing.
Declarations of Interest
There were no declarations of interest.
The Chief Executive noted that there had been a major development in
the appointment of four new Non Executive Directors and he welcomed
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Sir Patrick Sissons as one of those appointed. He also informed the
Board that this was as a result of a high number of high calibre applicants
being appointed.
In relation to the Strategy and Board Development, the Chief Executive
informed the Board that the tender process had been completed and that
the provider should be known by Christmas.
Robert Dixon noted that CUHP was a priority and that these must be
agreed from the list in the papers in order to ensure it is made to work.
Monitor will be talking about the plan over the next four months and it was
important to give this work the priority it needed.
7.
6.1
RESOLVED
That the Board NOTED the report of the Chair.
7.0
Report of The Chief Executive
The Board received and noted the report of the Chief Executive. In
particular the following was highlighted and discussed:
7.1
Appointments
Three critical appointments had been made recently – Fraser
Rogers as Trust Secretary, due to join no later than 2 January
2013, Paul Burton, Committee Secretary who began on 22
October and negotiations were currently on going with a high
calibre individual – Rebecca Moore, for a start date in the role of
Governor and Membership Officer.
The appointment of Director of Social Integration had also been
agreed, this would be a jointly funded post with the Local
Authorities
The position of Chief Operating Officer had still to be filled and
work was being done to accommodate this.
The appointment of Director of Nursing had been made and
Melanie Coombes was due to start with the Trust on 5 November.
7
7.2
Monitor
Discussions had taken place with Monitor with a view to determining a
timeline for the de-escalation process.
7
7.3
Care Quality Commission
It was noted that a further inspection of Cavell was due by the end of
November In relation to outcomes 9 and 16; the evidence had been
submitted, with a 3 month timeline for a further inspection to be carried
out. This would likely be a desktop review with indications that if this was
positive the Trust would be declared compliant.
7
7.4
Jack Cochrane Visit
The Chief Executive outlined the details of the visit of Dr Jack Cochrane,
CEO of Permanente Foundation. This involved meeting with the
Executives and the senior clinical management leaders of CPFT to
discuss “managing change in challenging times”.
7
7.5
Staff Awards Ceremony
The first annual award’s ceremony was scheduled to take place on 22 February 2013 and is in recognition of outstanding staff efforts in carrying
out their work. There will be ten awards given under different categories
and work is on-going to enable the event to be fully sponsored. Attila
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Vegh asked the Board for their interest or if any Board member knows of
any potential sponsors, to inform him.
He also informed the Board that it was his first anniversary of working at
the Trust and he thanked the Board for their support during that time.
8
7.06
RESOLVED
That the Board NOTED and DISCUSSED the report of the Chief
Executive.
8.1
Quality and Performance Committee Summary Report and
Unconfirmed Minutes.
The Board received and noted the report of the Chairman of the Quality
and Performance Committee which provide a summary of the meeting
held on 13 October 2012.
The Board were advised that the minutes would be circulated as
unconfirmed minutes.
8
8.2
In particular the Board noted and discussed the following:
Melanie
Coombes
For December
Board
Darren
Cattell
Next meeting
of the Quality
&
performance
Committee
Children’s Services
It was reported that the committee had commissioned a further report on
children’s services to be presented to the December Board.
8
8.3
8
8.4
9
9.0
Quality & Safety Report
The Board received and noted the report of the interim Director of
Nursing, which in her absence was presented by the interim Chief
Operating Officer.
9
9.1
The Chief Operating Officer (COO) introduced the new style report,
which he had taken as read, proposing that he took the Board through the
report, and then provide an opportunity to discuss the format of the report.
9
9.2
The following points were highlighted:
On page 4 of the report, action is being taken on Medicine
Management and it was anticipated that compliance would be
achieved by mid November
On QRP he reminded the Board that small negatives can have a
4
Finance
The top risks to the financial position were highlighted by Darren Cattell
who cited them as:Agency staff
Tier 4 income
The Director of Finance was tasked with reporting the correlation between
targets and the financial position to the Quality and Performance
committee.
This led to some discussion about whether the Audit and Assurance
committee was the best place for this to be discussed.
The Chair of the Audit and Assurance committee emphasised the need
for clarity and end result between finance and quality and that the forum
or committee at which this was done was not so vital.
The Director of Finance agreed that it would be beneficial to discuss how
and where this particular issue would best sit.
RESOLVED:
The Board NOTED and discussed the report
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longer term impact on the scores.
9
9.3
A non executive director (NED) noted that there were no reds on the QRP
report and commended the work that had gone into achieving this.
The board were advised of the level of weight on Community services
feedback which can also influence the QRP results.
9
9.4
The COO advised the Board that at the time the report was written there
were 6 outstanding peer reviews, which had now all been completed. He
also noted that the average across units was now either unchanged or
improved, with an average of 90%. There were no other points to
highlight from the report, however, under safeguarding children, he
advised the Board that steps were being taken to recruit a lead nurse for
this and that 4 candidates shortlisted were to be interviewed.
9
9.5
Bernie Gold, Public Governor, asked what the top issues were within
Medicine management. In response the Medical Director outlined two
separate issues – the administration in hospitals and the prescription of
medicines to outpatients. She acknowledged that there were difficulties
previously with maintenance of accurate records being kept and nursing
staff not giving medication to patients, however, compliance in this area
was now assured and she acknowledged that the administration of PRN
(“as needed” medicine) was lax and needed improvement. The records
should show why the patient was being given specific medication, the
desired effects and the effect achieved.
9
9.6
RESOLVED:
The Board NOTED and discussed the report
10
10.0
Strategy Development
The Board received the report of the Chief Executive which set out the
development of the strategic plan for the next 5 years.
10
10.1
The main points arising from the report were described as:
The Chief Executive, together with The Director of People and
Business Development and the Chairman, had started to develop a
meaningful plan for the Trust over the next 5 years.
The Director of People and Business Development had put together
a process, which had been inconclusive.
It would be beneficial to involve the Board and the Governors, as well
as staff and the Commissioners.
This will be part of the Board’s development process.
It will start next month with the first workshop and concluding by May
2013, which fits in with the Monitor submission.
There was a requirement for a 3 year plan
10
10.2
Some discussion followed in which it was stressed the importance of
having an integrated system that included the CIP process, the DoF
emphasised that there was a lot which the Trust can do to improve
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November
Meeting
Attila Vegh
and Keith
Spencer
Before
next
assessment
controls, efficiency and productivity. A long term plan needed to be in
place in order to implement long term change, which could be achieved
through an integrated long term financial plan.
10
10.3
The need for simplification of strategies was highlighted by NEDs, as
there appeared to be a large number involved, making it complicated. In
their experience a strategy plan would incorporate seven strategies at
most, enabling a strong focus on those strategies that mattered.
There would be merit in challenging the current portfolio and review what
the Trust is doing at present, as well as what the requirements are for the
future. It was also suggested that it would be helpful to have all the
strategies on the same page for clarity.
10
10.4
The Director of Service Improvement commented that it would be
necessary to think how the Trust can engage with carers and users within
a given timeline. It would be helpful to reflect on what the Board had
heard from the visitors earlier this morning.
10
10.5
The issue of staff morale was also raised by the COO who stated that it
would be important to engage with staff, as it will influence morale.
10
10.6
The Board affirmed that the plan tried to address issues, highlighting
internal integration as well as external integration and needed to find new
ways of working. It would be necessary to look at what can be fixed by
cuts and what can be fixed by changing things. It was also acknowledged
that the timetable was tight and requested that the budget plan was
carried out alongside with this work to avoid a separate budget process.
10
10.7
The Medical Director argued that it was important to provide excellent
care, balance the books as well as looking to the future. In order to do this
it would be beneficial to look at what the Trust is good at and its role as a
mental health provider for the future.
10
10.8
In conclusion, it was stated that this was the most critical plan since the
IBP for foundation trust status had been presented. It was noted there
would be challenges in the future, not least the fact that a simple health
provider will not be enough in the present day economy. The Governors
observation that high numbers of bank and agency staff had an impact on
the quality of service provided. The Board requested that it would like to
see the timeline delivered into dates.
10
10.9
The Board were advised that now it had approved the plan, moves can be
made to implement actions.
10
10.10
10
10.11
The Board expressed a desire to have a full discussion on this matter at
the next meeting, stating that a further, fuller report would be needed in
order to answer questions.
It was noted that there were a number of indicators showing issues and
he made an offer of the NED’s help to discuss these issues with The Director of People and Business Development and the Chief Executive
before the next assessment, which was accepted.
10
10.12
RESOLVED:
That the Board
a. NOTED and discussed the report;
b. APPROVED the plan as presented, and
c. REQUESTED that a further report be submitted to the Board
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NED’s to
provide
feedback
on issues
concerning
the
workforce
review,
before next
assessmen
t
Before
next
assessment
responding to the points raised.
11
11.0
11
11.1
11
11.2
11
11.3
11
11.4
Quarterly Workforce Plan
The Director of People and Business Development introduced his report
and advised the Board that a more detailed report would be available for
them at the November meeting.
The Board affirmed that this would need further detailed discussion at
next month’s Board meeting in order to answer questions.
It was highlighted that work was being carried out on the metrics, in order
to address those staff falling below the range. Staff morale was currently
below 50% and it was acknowledged that this needed to be addressed.
The actions to be taken were given at item 7 of the paper provided to the
Board. Endorsement of those actions was sought from the Board. He also
acknowledged that these actions had previously been agreed at the
September Board meeting.
The Board commented that Item 8 of the paper on process efficiency was
conceptual and that the diagram examples did not make sense and as
such it would be more helpful if the diagrams were removed as it was the
Efficiency measures which were required, not effectiveness measures.
The DoF echoed the need to consider a deeper dive look at these issues
and highlighted section 8 which showed a high number of staff on
suspension, incurring cost implications.
RESOLVED
That the Board received and DISCUSSED the report and that a
further report be submitted to the Board at its meeting in November.
12
12.0
12
12.1
Performance Report M6
The Board received and noted the report of the Director of Service
Improvement and Chief Information Officer which set out the performance
of the Trust for month 6.
In particular a number of improvements were highlighted, notably the 7C’s score, as well as the financial and benefits advice given to patients. Work
is on-going with the County and City Councils to manage further
improvements in this area. There was also improvement in the recording
of rights being read in accordance with the MHA.
12
12.2
The following concerns were outlined:
Food quality – a report will go before the Commissioners looking at
the environment and appearance of presentation as there are
significant differences across the patch. Bank and Agency staff, which
will be brought to the Quality and Performance committee next month.
Sign off of Serious Incidents. It was acknowledged that there were
significant challenges meeting the 10 day and 45 day sign off target
and while there was improvement in these areas the improvement
was not consistent. In this regard it would be necessary to make
improvements to communications with managers and to establish why
there are delays in signing off incident reports. Within CQUINN targets
there is concern about children’s services;; and ADHD
Confirmation was given to the Board that robust actions were put in place
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to address these issues.
12
12.3
also It was also reported that agreement had been reached with
Peterborough children’s services and that there would be focus on two areas:
Waiting times and sustainability
Breast feeding – a baseline is needed as not all details of breast
feeding are being recorded and this is a critical National target.
The COO reassured the Board that there had been a risk assessment in
place for several weeks and that the situation was being monitored.
12
12.4
12
12.5
In discussion it was noted that there were a few areas showing red
consistently, and that they had done so for a while and what actions were
being taken to improve those areas. Particularly the operational and CQC
problems.
12
12.6
In response the Board were advised on those areas of concern:
Mental Health Act compliance was showing a slight improvement
although it was still in the red
HONOS is being reported on
Food – a report was in progress on this
Social Care measures depended on other agencies and needed
more work to improve
Mandatory Training has shown a continuing improvement
IT response times – a detailed survey has been issued to staff in
order to identify the issues which require attention.
12
12.7
Further discussion followed, in which it was agreed that the Executives
would produce a paper for the November Board, commissioning
intentions and which could be passed to the Board in December for sign
off.
12
12.8
The Board followed up on the IT problems and expressed concern about
the IT aspect, noting that there was an expectation around RIO to solve
the problems. In relation to this they asked for an update to be produced
for the Board in November. They also asked if there was any concern
over the KPI for SERCO performance.
The Director of Service Improvement provided verbal assurance that
SERCO were achieving all KPI’s and that there were no concerns, as they were performing within their contractual obligations.
12
12.9
The Board stated that IT for most staff was a considerable issue. They
suggested that CPFT needed to develop a technical workforce, with
experts to help clinicians record correctly. This needed to be part of the
workforce plan.
12
12.10
The Director of Service Improvement confirmed that he would provide an
update on RIO, which will include a forward look and gateways.
13
13.0
Finance Report M6
Received
The Board received and noted the report of The Director of Finance which
set out the financial position for month 6.
13
13.1
The key issues were:
Darren
Cattell
November
Board
Tom Abell
November
Board
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There was further improvement in month
Year to date was almost on target
If the trend continues, there will be further improvement
13
13.2
The concerns outlined within the paper were:
CIP – the shortfall will be covered with other budgetary and
system savings
CIP – the number of Bank and Agency staff currently employed.
This issue is to be re scoped by the Executives, with the
possibility of seeking external expertise to assist. The intention is
to bring this to the Quality and Performance committee in
November.
13
13.3
It will be necessary to re scope the estates project as it was recognised
that the planned savings were unrealistic. Although two properties had
been sold, the money had yet to be realised in the bank.
13
13.4
It was worth noting that the way the Programme Management Office was
working it now provided insight in to those areas which were not
performing.
13
13.5
The Board referred to page 5 of the paper and noted that income was
down in September as it had been since April and that it would be useful
to know what the actual rate is after implementation of the Bank and
Agency staff. They also noted that the CIP plan would improve if this
issue was dealt with.
Looking at the Divisional forecast on page 8 of the papers, it was noted
that Corporate services, although having responsibility for control over
this issue, were actually not performing well and this was shown as red
on the table on page 8.
On the concerns about those areas showing red, the Board referred to
page 24 of the paper and stated that there is a significance between
recurrent and non – recurrent, which might require some mix and match,
some non - recurring will be needed. This required some control and to
have ways and means to transfer from the non – recurrent.
The Director of Finance responded by advising the Board that this can be
clarified and plans can be made for non – recurrent transfers.
13
13.6
Some discussion then followed about the Bank and Agency staff during
which the Board asked which of these was at the highest. In response,
The Chief Executive confirmed that as there were virtually no Agency
staff, it was nearly all Bank staffing.
He outlined the reasons for this being challenging:
There were a large number of vacancies, which presented a risk
if they were not filled. This was being looked into, particularly with
reference to permanent staff and establishment levels.
It was also necessary to tackle the cultural element on Bank staff
employment and look at the ability to earn additional money.
There may be a need to use expertise outside of our own area to
help us with this.
13
13.7
The Director of Finance acknowledged that it will be necessary to look at
staff absences which were due to sickness and suspensions as these are
a major contributor to using Bank staff.
13
13.8
The Board concurred that there were three correlated issues which
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13.9
14
14.0
Action
by
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affected staffing and that those issues – overreaching, understaffing and
use of Bank staff, needed a better understanding in order to act upon
establishment.
There followed some discussion about restrictive practices and shift
patterns, in which it was acknowledged that some work would be needed
to ratify establishments as this is fundamental in solving the problems.
It was also acknowledged that if external expertise were to be used in
order to assist, it would be very important to look at the additional costs
that this process would involve.
Change Programme Governance and PMO Update on Progress
Received:
The Board received and noted the report of The Director of Finance.
14
14.1
The Director Of Finance advised the Board that the revised Governance
process was to enable managing the change programme.
He outlined the four main changes as shown at Paragraph 4.0 of the
paper:
IGAP
CQC/Quality action plan
CIP
TSOM
It was intended that significant projects would be placed under each of
these headings. Each programme has a Task and Finish group, with a
committee structure to monitor and deliver.
14
14.2
The question of chairing the committees was raised by The Board, who
expressed concern that because of the change of NEDs between now
and next March there may be a stuttered approach during this period of
change.
The Director of Finance stated that it was critical for there to be
independence on these committees, to which the Board responded that
even for a temporary period, the incoming NEDs should be given a
primary role on these committees and that the transition should be
minimal.
14
14.3
The Board asked why there was a need to do this and what purpose it
served other than to know how and what we were doing.
The Chief Executive explained the reasoning, informing the Board that
there was a need for clarity and to create Executive and Non – Executive
oversight. This was the reasoning behind the creation of the Programme
Board. It would also provide an oversight and control of the matters to be
dealt with. The structure for the pilot task and finish group developed for
IGAP was used develop the other groups.
The chair of this Board, being a member of the IGAP committee
expressed his support for this approach.
14
14.4
The Board also noted that the plan is detailed and desirable and while the
timetable was tight in December, this must become part of next years
planning process for integration. They also stated that there should be no
gap between what PMO should do and what the plan says PMO will do.
The Board noted that this would provide the architecture for the future,
with clarity helping to define how the structure can be used for other
projects.
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14.5
Action
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When
RESOLVED
The Board agreed and supported the structure as outlined in the
paper.
BREAK
15.
15.0
Quarter 2 Monitor Submission
Received
The Board received and noted the report of The CIO and Director of
Service Improvement.
15
15.1
It was reported that while all required standards were being met, the Trust
was still in breach and it may be necessary to discuss the statement on
Quarter 3 to change and declare compliance.
The Board were asked to review and agree the board statement to be
submitted to Monitor.
15
15.2
RESOLVED
The Board reviewed and agreed the statement to be submitted to
Monitor.
16
16..0
Board Assurance Framework
Received:
The Board received and noted the report of The CIO and Director of
Service Improvement.
16
16.0
It was noted that reporting had returned to quarterly, with the next report
due in January 2013. The four red rated risks were the same as at the
last Board, who were now asked to:
Review the exception reported risks which are outside of the
acceptable thresholds and agree any further actions required or
accept the risk
Note the next steps that are being adopted to further develop and
embed the risk management process within the Trust.
16
16.1
The Chief Executive suggested that it would be an aspiration for the
Board to live with the risk by having conversations and discussions to
further understand what the risks are and identify them.
He went on to state that the recurrent FRF3 is a worrying trend. This was
agreed by the Board who noted that these do not change until the
composition of re-current and non re-current has taken place. It would
also be necessary to gauge the magnitude to decide if this is outside of
the Trust’s tolerance.
16
16.2
It was acknowledged that there was a potential loss of reputation issue
and The Chief Executive noted that despite speaking with Andy Boulus
he was no clearer as to whether the Commissioner’s would want to take any action. He also posed the question as to whether enough was being
done to mitigate. If there was a risk, it would be necessary to do more to
mitigate.
16
16.3
The COO noted that action had been taken as required and also
regarding the SI there were steps in place.
Also in answer to the Board’s observation that ID8 had a spend risk, the
COO noted that although this was currently on a low spend, it can be
variable.
11
Public Minutes
Agenda
Item
Action
by
Whom
Ref No
16
16.4
In relation to a query raised by the Board about the OATES position,
where this was previously a regular item on the Board agenda, they
asked whether it should it be placed back on the agenda again; the COO
was able to reassure the Board that OATES was now in a different place
and if it were to show up as an area of risk, he suggested that this could
be raised as an exception report.
16
16.5
The Board noted that various items had interaction together. There were
issues both with finance and performance and they posed the question
whether having separate reports would affect the Trust or whether having
an overall report would be better.
16
16.6
The CIO and Director of Service Improvement acknowledged the
suggestion and stated that this would need further discussion.
16
16.7
16
16.8
Further discussion followed about the possibility of grouping individual
risks together and how this would need work on correlating liabilities and
establishing an underlying commonality to decide what items could be
grouped together.
The issue of staff morale was raised again. The Chief Executive
commenting that if the staff were unhappy this would reflect adversely on
the patient care.
The Board expressed a need for more dynamic activity as the last
update was in August and it was now October, to which they added that
the multidisciplinary matrix was confusing and until it was triangulated it
was in need of correlation. The report should reflect reality.
16
16.9
16
16.10
16
16.11
The Board highlighted the issue of poor morale of staff, citing reasons for
this as IT and Banking staff. Until these were resolved, there would still
be issues with staff. They also cited the high burden of admin which staff
have to undertake and also noted that the Directors on the Board no
longer carry out ward visits and queried this. They suggested that these
kinds of things which if resolved would help improve morale.
They also noted that staff have complained that they do not see a
Director.
These issues need to be addressed and it was recognised that some of
the plans and strategic events would go some way to assist in this, but
also noted that the estates issue was a large area needing work.
16
16.12
The Board asked if there was something more nebulous in the findings. It
Tom Abell
to look at
Grouping
risks under
headings of
strategic
objectives
Action
by
When
December
Board
The Chief Executive explained that a judgement was necessary as to
what might bring the Trust down and that an improved matrix would
prompt the Trust to look at not being surprised at what is revealed. His
view was that numbers were secondary.
The Board followed this by suggesting that it would be helpful if
qualitative issues were made the priority, then to put the numbers to the
issues.
The suggested priorities were given by the Board as:
People first
Finance second
With the issues being weighted it would prevent being driven by the
numbers metrics.
12
Public Minutes
Agenda
Item
Action
by
Whom
Ref No
Action
by
When
was noticeable that the doctors did not have the same perspective as the
nurses and seemed to be disengaged in a qualitative way.
16
16.13
In response, the Medical Director advised the Board that the consultants
were extremely busy, working more than conditioned hours and were
likely to be too tired to carry out any reflection.
16
16.14
The Board expressed concerns that this was the case, acknowledging
that everyone was working hard. The Medical Director was concerned
that this message would continue in the future.
16
16.15
16
16.16
16
16.17
17
17.0
The Board asked that the Director of People and Business Development
address the people issues in next months report.
The Chief Executive noted that BAF best reflects the perception on risks,
but the Board may be helpful in providing constructive criticism to the
Executives.
The Board expressed further concern regarding the overworking issue
and asked that this be addressed.
The CIO & Director of Service Improvement provided a verbal update.
17
17.1
17
17.2
18.
18.0
18
18.1
The Chairman stated that he took this as read, whilst the Director of
People and Business Development noted that progress is against the ongoing Pwc action plan. He explained that there would be more actions
evolving from the meetings the following day. Assessment would be
against QGF.
19.
19.0
Terms of Reference of the Boards Sub – Committees:
1. Audit and Assurance Committee
2. Quality and Performance Committee
The Board received and noted the report.
19
19.1
The Board confirmed that the terms of reference were agreed and
accepted with minor amendments. They also raised the question of
achieving a quorum in the committees and how many NEDs were to be
on each of the committees. The terms of reference were agreed in
principle with a re - format to be carried out in accordance with the new
PMO terms of reference format.
19
19.2
The Board asked for one change on page 4.6 item 15 where it should
read policy approval, not “ratify”.
19
19.3
The Chairman sought approval for this amendment, which was given.
19
19.4
RESOLVED
That the terms of reference were agreed subject to the aforementioned
amendments.
13
Keith
Spencer
November
Board
Mick
Simpson
November
The “bottom up” approach was now providing feedback from Divisions through the performance meetings. The rapid response actions needed
to be shown and this was being worked on.
The Chief Operating Officer noted that although the adult risk register
was not shown, it was actively being managed and will be in the
November report.
Integrated Governance Action Plan
The Board received and noted the report of The Board Chairman.
Public Minutes
Agenda
Item
Action
by
Whom
Ref No
Action
by
When
Items for Information only (No Discussion)
20
20.0
Monitor update on private patient income cap for NHS Foundation
Trusts
20
20.1
Received
From the Chief Executive
21
21.1
Letter from David Bennett (2
Received
From the Chief Executive
22
22.1
Calendar of Meetings
Received
From the Trust Secretary
22
22.2
It was noted that there would be new timings for the Board meetings
which will take place in the first week in the month from next April.
ND
October 2012)
Any Other Business
23
23.0
No other business discussed.
23
23.1
Points of Reflection
No items were raised.
23
23.0
Date of Next Meeting
The next scheduled meeting of the Board to be held in public is on
Wednesday 19 December 2012.
David Edwards, OBE
Chairman
14
Public Minutes
BOARD OF DIRECTORS (Public Meeting) 31 October 2012
Matters Arising
Agenda Item
Action
Receiving
Committee
Due Date
Lead
8 Quality &
Safety
Report
11
Quarterly
Workforce
Plan
Report addressing children’s services to be made available at December
Board
Non-Executive Directors to provide
feedback to Attila Vegh and Keith
Spencer on those areas which highlight
issues in the report. Details to be in
next paper to be addressed
To submit paper to November Board on
commissioning intentions in order for
sign off at December Board
Status report to be prepared for Board
meeting in December on RIO and IT
issues, to include look forward and
gateways.
Non Executive Directors to carry out
ward visits. Programme to be
developed
Board
December
Mick
Simpson
Board
November
Attila Vegh/
Keith
Simpson
Board
November
Tom Abell
Board
November
Tom Abell
Board
November
Mick
Simpson
Risk register to include adults in
November report
Board
November
Tom Abell
12
Performance
Report
12
Performance
Report
16
Board
Assurance
Framework
17
Corporate
Risk register
Page 1 of 1
Status
Chairman’s Report
Clinical Commissioning Groups
The dialogue with our new CCG is continuing at a number of levels. The recent
meeting between Chairs and Chief Officers was positive and I look forward to
developing that relationship. Apart from a general update we discussed how we
might improve the Quality of Services through transformation, given that the
funding will be challenged in the coming years. There is a real appetite to work with
what the population needs, a care pathways approach across organisational
boundaries.
Cambridge University Health Partners (CUHP)
The Academic Health Science Network (AHSN) process was discussed at a recent
Board meeting. Our presentation and interview takes place before the end of
November. Initial feedback on the paper submitted is encouraging. CUHP is
holding a strategy day in January and in the light of the AHSN development, (which
will hopefully be approved) we will be reflecting on the future role of CUHP. I
welcome the opportunity to contribute and would invite our Board members to let
me have any views.
Quality Heroes Ceremony
I had the privilege of presenting the Quality Heroes Awards this month both to
individuals and teams. With the CEO, I was impressed with the range of different
initiatives that attracted support and with the general enthusiasm for the event. It
showed the importance of recognising our staff for the excellent work being done
on behalf of our population and service users. Long may it continue. I was also
impressed with the level of understanding amongst the staff, for the journey we are
on as an organisation.
DATE
MEETING
29.10.12 to 9.11.12 inc
12.11.12
13.11.12
15.11.12
Annual Leave
CUHP Board Meeting
Quality Heroes Ceremony
Cllr Clarke, Cambridge County
Council
IGAP Task and Finish Meeting
Meeting Maureen Donnelly,
Andy Vowles & Neil Modha, CCG
Meeting with Chris Wilkinson,
Governor
Meeting with Caroline Lea-Cox,
CCG
AAC Interviews, Liaison with SI
Major Trauma
Host Festival of Leadership NLP
Session
CEA Panel
Board Meeting
Monthly NED Meeting
Monitor Progress Review
Meeting
15.11.12
15.11.2
21.11.12
21.11.12
22.11.12
27.11.12
27.11.12
28.11.12
28.11.12
29.11.12
Agenda Item: 7
Report to the meeting of the Cambridgeshire and Peterborough NHS
Foundation Trust Board of Directors
Chief Executive’s Report
28TH November 2012
1.
Trust Events
I have had the pleasure of attending the following events during November.
Opening of Recovery College
I officially opened the Recovery College East on Wednesday 7th November. The
opening was attended by more than 160 service users, prospective students, staff
and partners. We are proud to be the first to open in the East of England and fifth
nationally.
This exciting initiative, run by CPFT, is a collaborative, educational learning
environment that will enable people who use or have used secondary services from
the Trust to develop new skills or increase their understanding of the mental health
challenges they have. It will offer a range of interesting and aspiring courses to
promote recovery and wellbeing for us all. I am very pleased that CPFT is working
alongside partner organisations to help deliver the prospectus and host venues for
this to happen.
Opening of DeNDRoN Dementia Research Unit
Also on 7th November I attended and officially opened the Dementia and
Neurodegenerative Diseases Research Network (DeNDRoN) research unit which is
situated in the newly refurbished Windsor House. The unit offers facilities for
clinicians to carry out assessments on site and develop their own research skills and
projects.
This is an important initiative that will raise awareness about everyday care of people
with dementia and provide more opportunities for people with the disease to take part
in research that could lead to new treatments.
Friends of Fulbourn AGM
On 14th November I attended the Friends of Fulbourn Hospital and the Community
AGM where I was pleased to give a presentation on the future of the Trust.
Undoubtedly this charity are passionate about our future and provide support in so
many ways.
2.
New Operating Service Model
Following the successful appointment of the new GMs and CDs, an initial workshop
was run to set out the expectations to ensure a smooth transition into the new
divisional structures on 7th January 2013. They were tasked to prepare a number of
documents including :
Divisional Quality Priorities
Divisional Quality Diamond
Divisional Cost Improvement Plans
Divisional Accountability and Governance Agreement
Our new senior leadership team were asked to present the above to the Trust Board
at an Authorisation Workshop to be held on the 19th December. Invitations have
been sent to Board members and also to governors.
3.
Board Development
The Board has gone through many changes over the last year including the
appointment of a new Chairman and recently the appointment of 4 new Nonexecutive Directors and Executive Directors. To support these changes and to
address concerns raised by our regulators which subsequently led to the Trust being
in breach of its authorisation, a programme of board development has been
established to cover seven key areas:
Establishing a Unified Board
Board Competencies
Governance
Risk management
Ward-to-Board-Ward information tracking
Strategic development
Governor Engagement
The plan for the first phase of this programme is attached to this report for
information.
The first workshop will be held on 28th November and is the first of three sessions on
strategy. External support has been secured for the Governance sessions from
PwC.
4.
PCT to CCG
The CCG has recently completed its authorisation process and the results are due to
be published in January. Early feedback is positive.
The Chairman and I met with Maureen Donnelly, Andy Vowles and Neil Modha to
discuss and set out how we would work together and also discuss future plans for
both CPFT and the CCG.
5.
Cambridgeshire Community Services
Following the recent announcement that Cambridgeshire Community Services (CCS)
would not become a Foundation Trust, discussions have begun on their future.
David Edwards and myself have a meeting scheduled with Heather Peck, Chair and
Matthew Winn, CEO to discuss how we can support future developments.
5.
NHS Confederation Mental Health Network
On 8th November I attended the annual NHS Confederation Conference.
This gave me an opportunity to meet with Chief Executive colleagues within the
Mental Health network.
I also had opportunity to speak briefly with Norman Lamb. Norman Lamb, Minister of
Care Services is a very senior member of the new team of Jeremy Hunt, Secretary of
State for Health. He is passionate about bringing the mental health agenda to
physical health and integration of services. He has accepted an invitation to spend
time with us during the afternoon of the 14th December.
In the New Year we would also like Norman to play a role in the integration agenda
for the local health economy and attend our planned set of workshops on integration.
6. Quality Diamond
We are due to launch our Quality Diamond throughout the organisation. This is a
communications piece of work describing the priorities for quality improvement Trust
wide.
The document clearly outlines the Trust’s quality priorities:
To become top five in patient safety
To become top five in patient experience
To become top five for staff engagement
To become top five on value for money
For each of these objectives we have identified four initiatives to provide regulators
(bi-weekly) updates on the progress made on each of the priority areas. We will also
be using the document to regularly update our staff and partners.
7. Government’s First Mandate to the NHS Commissioning Board
The Government published its first Mandate to the NHS Commissioning Board on the 13th
November 2012. The Mandate sets out a series of priorities for the period April 2013 to
March 2015, by which the Government will hold the NHS Commissioning Board to
account. Alongside the Mandate, the Government have also published a revised version of
the NHS Outcomes Framework.
Under the changes set out in the Health and Social Care Act, the Mandate, along with the
NHS Outcomes Framework, forms the central part of how the Government will set
strategic priorities for the NHS in future. This first Mandate puts mental health in a
prominent position, which is very much welcome. As the Commissioning Board is
established and begins to set out its priorities, the Mandate therefore sets out a clear
platform upon which to move forward.
We welcome the focus given to improving employment outcomes for people with mental
health problems, and championing the Time to Change campaign. We also welcome the
focus on mental health and criminal justice, including the development of liaison and
diversion services.
Board Development Programme
Date
Facilitated
Topic
Strategy Workshop 1
28 November 2011
Understanding the context
recent developments (CCs, GPs, CBC)
Market Analysis
Business Plan cycle and Monitor relationship
Current priorities
Our strengths and weaknesses
Opportunities
Strategic option development
Internal
facilitation
Governance Workshop 1
13 December 2012
DAGA and Governance Structure & Annual Planner
QGF – where we are against best practice
Escalation reports
John Morris
PwC
Governance Workshop 2
16 January 2013
Understanding risks of the organisation
How to use the CRR and BAF
Use of the dashboard
Use of the Annual Audit Plan
John Morris
PwC
De Escalation Workshop
14 February 2013
Team building
Workshop
March 2013
Strategy Workshop 2
3 April 2013
Board Competency
Workshop
May 2013
Governor Engagement
Workshop
June 2013
De escalation planning
QGF Review
CIP Planning Review
Board roles and responsibilities
United Board
Working principles
Strategy and relationships
(Workshop would also provide the Steering Committee for
the CPFT 2020 Strategy Project)
Roles & responsibilities as individuals and a whole
Exploring challenge
What is assurance?
Interaction and engagement
Roles and responsibilities
Attila Vegh
PWC
(tbc)
Michael
Cawkwell,
Sporting Edge
External
Support
External
Support
Foundation
Trust
Governors
Association
Agenda Item: 8
BOARD OF
DIRECTORS
MEETING
Date:
Subject:
Prepared by:
FOIA Status
REPORT
28th November 2012
Report of the Chair of Quality & Performance Committee
Robert Dixon
Public
Links to the Business and Risks
Strategic Priorities (please mark in bold)
Our services will be recognised as
world class
We will develop service plans that
achieve financial stability
We will deliver care through engaged
and empowered people
We will develop strong relationships
based on trust and mutual respect
with key stakeholders
We will develop our built environment
and technology infrastructure to
deliver our vision
Corporate Risk Register priorities (please mark in bold)
Details of additional risks associated
with this paper:
Links to the CQC Essential Standards
regulations
Links to the NHS Constitution
(relevant staff/patient rights)
All NHS organisations are required by
law to take account of the NHS
Constitution in performing their NHS
functions
Financial implications/impact
Legal implications/impact
Partnership working and public
engagement implications/impact
All CQC standards
3. The NHS aspires to the highest
standards of excellence and
professionalism.
4. NHS services must reflect the
needs and preferences of patients,
their families and carers.
6. The NHS is committed to providing
best value for taxpayers’ money and
the most effective, fair and
sustainable use of finite resources.
None identified
None identified
None identified
Other
Committees/groups where this
item has been presented before
Other options available and their
pros and cons
Progress monitoring and review
Background papers
Report provides summary of Quality &
Performance Meeting held on
14/11/12.
Report presented monthly
RECOMMENDATION
The Board is asked to:
Note this report which highlights issues discussed at the October meeting of
the Committee which it is felt should be drawn to the Board’s attention.
1.0
INTRODUCTION
The purpose of this report is to highlight issues discussed at the October
meeting of the Committee which it is felt should be drawn to the Board’s
attention.
2.0
ISSUE
Cycle of Business
The Committee discussed the proposed Cycle of Business and approved this
subject to some minor changes whilst recognising that this would evolve and
change over time as the organisation moves forward.
In particular, a key change requested by the Committee was for additional
focus and scrutiny to be placed on the Research and Development activities
of the Trust and it was agreed that a report would now be received quarterly
on these activities rather than annually as proposed.
Quality & Safety
The Committee had an extensive discussion regarding the Quality and Safety
report, much of which will be considered by the Board today. It was
recognised that a number of changes were required within the report in order
to better assure the Committee of the actions being taken by the organisation
to resolve concerns that were being identified rather than the identification of
the issues themselves.
We also discussed the need to gain better assurance on the operation of the
complaints and PALS arrangements that are in place within the organisation,
building on the learning from recent national reports and a need to ensure
that we maintain an open culture within which people who use services are
comfortable with raising complaints and queries.
The Committee drew specific attention to Springbank Ward which is a high
reporter of Serious Incidents, a lack of achievement of variable income
against target and an indication that staffing levels are causing concern. It
was noted that the Medical Director was commissioning an External Review
of the ward and requested that this be undertaken as promptly as possible in
order for any issues to be understood and actions taken to rectify these.
The Committee also highlighted the need to ensure that there was active
Executive level engagement in the on-going policy review and updating
process and it was noted that the Chair of the Audit & Assurance Committee
had offered to chair a task and finish group in this area.
Mental Health Act (MHA, ‘the Act’)
The Committee received a report on the operation of the Mental Health Act
within the Trust, in particular it was noted that a greater understanding was
required of how the Act was being used in different parts of the organisation,
particular in respect to areas such as home leave.
The Committee also highlighted the importance of ensuring Non-Executive
Director focus in this area and agreed to recommend to Board that a NonExecutive Director is given lead responsibility for understanding and focusing
on Trust compliance against and use of the Act.
The Committee also approved amendments to the following policies in
relation to the Act:
S132/132a and 133 (Provision of information under the MHA) – updates in
relation to a schedule for the reminding of patients of their rights as well as a
detailed process to be followed and supporting monitoring arrangements.
S25 (The rights and role of the Nearest Relative) – updates to strengthen
the rights and role of the Nearest Relative as defined under the Act.
S114 (Appointment of Mental Health Approved Professionals (AMHP) –
updates to reflect a revised procedures for the approval process of new
members of staff whose previous employer authorised them under s114,
those who have completed their AMHP training and are yet to be approved
and those whose approval is due for renewal on a one, three or five year
cycle.
Clinical Audit Plan
The Committee was disappointed that the detail of the Clinical Audit Plan was
unavailable to be presented at the November meeting, and that the plan
would be scheduled again for approval in December. The Committee
believes that it is important to establish the areas of assurance that clinical
audit will provide to the organisation and any outstanding gaps for
consideration.
The Committee also highlighted the urgency in agreeing the terms of
reference for reporting groups, notably the Clinical Executive and have
requested this to be presented for approval at the December meeting.
Finance
The Committee welcomed the continued improved financial performance of
the Trust, particularly with the achievement of a Financial Risk Rating of 3 in
Month 7 for the first time this financial year.
However, the Committee remains concerned about the deliverability of the
Cost Improvement Plan this year and the resulting impact this may have on
the financial plan and CIP in FY14. In particular, the Committee identified that
a substantial risk remains in the delivery of the planned CIP for Bank and
Agency staffing and the need for a more sophisticated approach to this area
to be developed with urgency.
Performance
The Committee had the opportunity to review benchmarked performance
information for the Trust against that of other Mental Health and Community
Providers across the Midlands and East Region. A number of areas were
noted which require further investigation, in particular our performance
against the crisis resolution home treatment gatekeeping measure and the
key staffing metrics of staff turnover and sickness. A further report will be
received on these areas in December.
The Committee also highlighted the need to develop a more integrated
approach to the reporting of key measures, in particular moving to a single
page of measures upon which individual Executive Directors could be held to
account for.
Risk Register
The Committee considered the risks identified by Divisions which are
currently rated above the Trust risk threshold. In particular issues in regard to
staffing and bank and agency have emerged as a key theme across all
Divisions with the Executive providing updates to the on-going work to agree
appropriate ward establishments and the implementation of the new Trust
Service Operating Model to resolve these issues. The Committee requested
that further detail on the actions being taken in this area be presented in
December.
The Committee also discussed the concerns raised in regard to a gap in
forensic services in Peterborough. Whilst it was recognised that this gap has
arisen as a result of historic commissioning differences between
Cambridgeshire and Peterborough there still remains significant reputational
risk to the organisation whilst this issue remains unresolved.
Policies
The Committee received a number of policies for approval. The decision of
the Committee is outlined below:
Policy Title
Committee Decision
Estates Policy
Approved, subject to minor
changes agreed at
meeting.
Mandatory Training Policy
Rejected, further work
required to ensure policy
was fit for purpose.
Risk Management Strategy Policy
Approved
Risk Assessment Policy
Rejected, further work
required to ensure policy
was fit for purpose.
The Committee highlighted the importance of every aspect of the organisation
operating in a high quality manner, and it was felt that in the case of the two
policies that were rejected further attention to detail was required.
3.0
SUMMARY AND CONCLUSIONS
Note this report which highlights issues discussed at the October meeting of
the Committee which it is felt should be drawn to the Board’s attention.
Agenda Item:9
REPORT
Date:
Subject:
Prepared by:
21st November 2012
Quality & Safety Report
Melanie Coombes. Director of Nursing
world class
based on trust and mutual respect with
key stakeholders
and technology infrastructure to deliver
our vision
BAF/Corporate Risk Register priorities (please mark in bold)
with this paper:
regulations
Links to the NHSLA Standard
Reference
functions
ALL
ALL
N/A
Other
pros and cons
Quality and Performance Committee
Background papers
QUALITY AND SAFETY REPORT
1. Executive Summary
The purpose of this report is to provide a summary of the performance of the Trust
against a range of quality and safety metrics.
This month’s report is the second in the new format which is still in a
developmental stage.
The November Quality and Performance Committee made several
recommendations which are detailed below.
The Board is requested to receive and approve the report and associated actions.
2. Recommendations from Quality and Performance Committee
i)
Format of the report
The report requires more narrative to support the information given and to
provide assurance that issues are being dealt with appropriately.
Incidence report to be broken down into severity and timeliness of reporting
Details of complaints received, actions and recommendations from
investigations are to be included
More detailed information on serious incidents, timeliness of closure, action
plans, and lessons learnt
Merge duplicate information contained in the performance report into the
Quality and Safety report
To include a summary of key issues
The above recommendations will be demonstrated in the December report.
ii)
Other actions;
InCA tool compliance to be monitored though Matron meeting, commencing in
December
Chair of Quality and Performance committee to conduct a deep dive into
serious incidents – date to be confirmed
QUALITY & SAFETY REPORT
NOVEMBER 2012
Quality & Performance Committee
Contents
•Acknowledgements
•Introduction
•CQC Compliance
•Medicines Management
•Integrated Compliance Assessment
•Patient Safety Incidents
•Serious Incidents/Never Events
•Inquests
•Claims
•Safety Thermometer
•Infection Prevention and Control
•Pressure Ulcers
•Policy Development and Review
•PALS & Complaints
•Care Planning
•Adult Safeguarding
Mel Coombes
Director of Nursing
Judy Dean
Head of Nursing and Practice Development
Acknowledgements
Thanks to the following who have contributed to this report:
Clare Mundell
Wendy Llaneza
Tommie Kilbride and Julie Cook
Judy Dean
Nicola Sharp
Marie McKearney and Maureen Broadbent
Tim Simmance
Paul Collin
Thanks to the hard work and commitment of:
Modern Matrons, Ward Managers and front-line clinicians for
contributing to assuring quality through undertaking the INCA,
REV, Medicines Management and Care Planning in the
Community Assessments reported on here.
Introduction
Purpose of this document
The purpose of this document is to provide a summary of the
performance of the Trust against a range of quality and safety
metrics
Overview and commentary
This month’s report is the second in the new format for discussion in terms of content and presentation.
The intention of the report is to increasingly focus on highlights, key
issues and potential risks to bring to the attention of the Board.
Recommendation
The Q & P committee is recommendation to review, discuss and
comment upon the contents, style and presentation of the quality
and safety report
Future Developments
It is proposed that this report will develop during the coming months
to broaden the scope of the metrics and also begin reporting
on/drawing upon themes arising from quality and safety metrics.
CQC Essential Standards Compliance
Context
The Trust continues to make good progress in improving its compliance with the Essential Standards of Quality & Safety as set out in the Care
Quality Commission (Registration) Regulations 2009. The Trust is currently registered across 7 core service delivery locations.
Developments
The Trust is expecting a visit from the CQC in November.
Registered Location
Risk
Action Taken
Gaps / Residual Concerns
Cavell Centre
Outcome 1 ( Moderate)
Respecting & Involving People
who use services
Trust has declared compliance
with Outcome 1 and is currently
awaiting the return of the CQC to
inspect the Trust against this
outcome
None
Fulbourn Hospital
Outcome 9 (Minor)
Management 0f Medicines
Action plans are being
implemented following the CQC
review. An evidence base for each
outcome is present.
Residual actions identified to
support compliance. The Trust
plans to declare compliance by
mid November
Divisional Risk registers being
monitored through monthly
Divisional quality and performance
triangulation meetings.
Outcome 16 evidence reliant upon
Q&S strategy approval (currently
out to staff for consultation).
Outcome 16 (Moderate)
Assessing & monitoring the quality
of service provision
Medicines Management
% Completed Medicines Administration Records
% No Harm Administration Errors
100.00%
100%
90.00%
90%
80.00%
80%
70.00%
70%
60.00%
50.00%
2012/13
40.00%
Target
60%
30.00%
40%
20.00%
30%
10.00%
20%
0.00%
2012/13
50%
Target
10%
June
July
Aug
Sept
Oct
Apr
May
June
Jul
Aug
Sept
Oct
Risk
Action Taken
Failure to sustain improvement may
compromise compliance with Outcome 9 of
CQC standards and impact upon patient safety
Medicines Administration Records
• Monthly monitoring by the pharmacy team
will continue on an ongoing basis.
Priority areas for further improvement are:
• Medicines governance in prisons and
children’s services
• Systematic learning from medicine incidents
• Implement clinical audit action plans
• Implement medicines reconciliation process
fully
• Improved practice of communication with
patient s on side effects of medication
6
Ou
tco
me
s
Integrated Compliance Assessment (InCA)
1
2
4
5
6
7
8
9
10
11
12
13
14
16
17
21
Ave
Oct
Self
95%
91%
94%
93%
96%
96%
94%
93%
98%
96%
97%
94%
89%
100%
100%
99%
95%
Adults
Sep Aug
Peer Self
94% 90%
86% 87%
92% 90%
89% 88%
95% 100%
93% 79%
92% 92%
82% 90%
97% 98%
95% 87%
85% 100%
98% 100%
90% 79%
93% 100%
100% 100%
85% 90%
92% 92%
Jul
Self
66%
75%
82%
79%
100%
55%
65%
57%
66%
69%
82%
81%
68%
75%
88%
68%
86%
Spec Services
Oct Sep Aug Jul
Self Peer Self Self
95% 97% 96% 87%
90% 89% 72% 61%
93% 93% 89% 85%
91% 89% 97% 87%
100% 100% 100% 100%
96% 100% 89% 78%
100% 100% 92% 96%
95% 99% 89% 79%
99% 98% 95% 82%
95% 100% 88% 84%
100% 100% 100% 100%
100% 100% 100% 83%
83% 93% 87% 75%
100% 100% 89% 89%
100% 100% 100% 100%
94% 100% 81% 75%
94% 97% 92% 85%
Oct
Self
98%
91%
96%
98%
94%
90%
100%
89%
99%
98%
100%
100%
91%
100%
100%
100%
96%
Childrens
Sep Aug
Peer Self
92% 92%
100% 98%
87% 93%
91% 95%
100% 100%
96% 55%
94% 92%
86% 86%
97% 97%
92% 88%
100% 88%
100% 100%
85% 73%
100% 92%
88% 100%
100% 86%
90% 90%
Jul
Self
84%
96%
84%
81%
100%
53%
88%
72%
82%
90%
94%
75%
72%
100%
100%
85%
83%
Oct
Self
88%
90%
95%
97%
100%
91%
97%
98%
97%
100%
88%
100%
94%
100%
88%
90%
94%
Older People
Sep Aug
Peer Self
90% 97%
46% 100%
94% 90%
93% 92%
100% 100%
79% 72%
90% 95%
95% 88%
97% 94%
94% 98%
100% 100%
88% 100%
87% 84%
92% 100%
100% 100%
100% 93%
90% 94%
Jul
Self
82%
87%
89%
90%
92%
80%
93%
68%
78%
94%
100%
100%
76%
100%
50%
87%
85%
Context
The second round of the self
assessments commenced in October
with compliance rates continuing to
improve significantly. The Modern
Matrons have been actively engaged in
the process and the wards have reported
that the process have helped them to
improve their standards of practice.
Corporate actions have been identified
which include the need to update of the
Business Continuity Plan and
development of consistent guidelines in
certain areas. These actions will be led
by the Nursing Directorate.
Points to note
•Springbank has not been able to submit a self assessment in October due to work pressures.
•Results of the October self assessment appear to generally match the Peer Reviews apart from Outcomes 2 and 7 in the Older
People’s service whereby the self-assessment scores are higher than the peer review scores.
•Most wards are now using the iPad version of the tool apart from two wards (GMH and Denbigh) who have stated they will use the
iPad in November
•The InCA tool has been reviewed with a group of Modern Matrons. The revised tool is around a third shorter than the first version, and
was signed off on 6th November. The changes will be implemented in the iPad in time for the December Peer Review.
•Work will start to develop the Community version of the InCA tool in November with a planned roll out in January/February 2012.
Risk
Action Taken
Impact of the assessment process on resources
and workload of clinical staff
Review of InCA and rationalisation of standards
Challenges in meeting reporting deadlines.
9
Integrated Compliance Assessment (InCA) Tool returns
Inpatient Units -September Peer Review Results & Comparative Results for July/August/September/October 2012
Outcomes
Teams
CNs
1
2
4
5
6
7
8
9
10
11
12
13
14
16
17
21
Ave%
Adults
Adrian
95%
100%
100%
92%
85%
100%
100%
86%
93%
98%
93%
100%
100%
78%
100%
100%
100%
95%
Cedars
100%
100%
100%
98%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Friends
67%
80%
40%
70%
92%
100%
80%
71%
68%
96%
77%
75%
100%
89%
100%
100%
90%
83%
LVG
96%
100%
100%
98%
93%
100%
100%
86%
100%
100%
100%
100%
100%
78%
100%
100%
100%
97%
Oak1
94%
97%
100%
96%
100%
100%
100%
100%
100%
100%
100%
100%
50%
88%
100%
100%
100%
96%
Oak2
95%
97%
100%
98%
100%
67%
83%
100%
92%
100%
93%
100%
100%
89%
100%
100%
100%
95%
96%
NA
98%
100%
100%
100%
100%
90%
97%
100%
100%
100%
100%
100%
100%
100%
99%
Oak 3 / Cavell AU
Poplar
98%
100%
100%
100%
92%
100%
100%
100%
100%
98%
100%
100%
100%
100%
100%
100%
100%
99%
S3
91%
86%
NA
96%
75%
100%
100%
100%
95%
95%
100%
100%
100%
78%
100%
100%
100%
95%
97% 94%
85% 98%
100% 100%
82% 81%
89%
90%
79%
68%
100% 100%
93% 100%
100% 100%
75% 88%
99%
85%
90%
68%
95%
92%
92%
86%
did not submit
Springbank
ave - October
ave - September
ave - August
ave - July
89%
95%
94%
90%
66%
91%
86%
87%
75%
94%
92%
90%
82%
93%
89%
88%
79%
96%
95%
100%
100%
96%
93%
79%
93%
80%
96%
NA
93%
82%
90%
55%
94%
92%
92%
65%
57%
98%
97%
98%
66%
96%
95%
87%
69%
98%
93%
89%
100%
100%
100%
100%
87%
100%
96%
98%
100%
100%
100%
89%
100%
100%
100%
97%
100%
90%
98%
86%
100%
100%
71%
100%
100%
100%
89%
100%
100%
100%
100%
100%
100%
88%
100%
100%
83%
100% 96% 100%
100% 100% 100%
100% 89% 92%
100% 78% 96%
100%
100%
95%
99%
89%
79%
99%
98%
95%
82%
95%
100%
88%
84%
100% 100%
100% 100%
100% 100%
100% 83%
83%
93%
87%
75%
100%
100%
89%
89%
100%
100%
100%
89%
Key:
1 Involvement & respect
2 Consent
4 Care & welfare
5 Nutrition
6 Cooperating with other providers
7 Safeguarding & safety
8 Infection control
9 Medicines management
10 Safety & suitability of premises
11 Safety, availability & suitability of equipment
12 Requirements for workers
13 Staffing
14 Supporting workers
16 Monitoring quality of services
17 Complaints
21 Records
Spec Services
IASS
Hollies
89%
GMH
86%
97%
100%
93%
79%
90%
89%
72%
94%
95%
97%
96%
87%
93%
93%
89%
85%
91%
89%
97%
87%
100%
92%
100%
96%
100%
100%
100%
100%
89%
100%
Phoenix
96%
100%
83%
94%
100%
100%
71%
100%
81%
100%
92%
100%
100%
Darwin
98%
100%
80%
96%
92%
100%
87%
100%
95%
98%
100%
100%
100%
Croft
98%
100%
100%
98%
100%
75%
100%
100%
92%
98%
100%
100%
95%
98%
92%
92%
84%
91%
100%
98%
96%
96%
87%
93%
84%
98%
91%
95%
81%
94%
100%
100%
100%
90% 100% 89%
96% 94% 86%
55%
92% 86%
53%
88% 72%
99%
97%
97%
82%
98%
92%
88%
90%
Denbigh
86%
75%
83%
89%
87%
100%
62%
88%
93%
98%
100%
100%
100%
88%
100%
50%
100%
88%
Willow
97%
87%
75%
96%
100%
100%
100%
100%
100%
89%
100%
75%
100%
86%
100%
100%
71%
92%
Maple 1
98%
89%
100%
98%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
99%
Maple 2
98%
100%
100%
98%
100%
100%
100%
100%
100%
100%
100%
75%
100%
100%
100%
100%
87%
90%
95%
46%
94%
100% 90%
87% 89%
97%
93%
92%
90%
100%
100%
100%
92%
91%
95%
88%
90%
97%
82%
97%
90%
95%
93%
98%
95%
88%
68%
97%
97%
94%
78%
100% 88% 100%
94% 100% 88%
98% 100% 100%
94% 100% 100%
94%
87%
84%
76%
ave - October
ave - September
ave - August
ave - July
61%
96%
100% 94%
100% 100%
100% 81%
100% 75%
94%
97%
92%
85%
100%
100%
100%
98%
87%
100%
100%
100%
94%
89%
100%
100%
100%
96%
100%
100%
100%
100%
100%
98%
100% 100%
100% 100%
88% 100%
94% 75%
91%
85%
73%
72%
100% 100% 100%
100% 88% 100%
92% 100% 86%
100% 100% 85%
96%
90%
90%
83%
Children's
Otters
ave - October
ave - September
ave - August
ave - July
Older People
ave - October
ave - September
ave - August
ave - July
79%
72%
80%
100% 88% 90%
92% 100% 100%
100% 100% 93%
100% 50% 87%
98%
94%
90%
94%
85%
Thresholds
G
A
R
75%
< 74%
< 60%
85%
< 84%
<70%
95%
<94%
<80%
Incidents
Incidents
2012/13
604
538
523
439
Apr
May
599
611
575
493
Jun
Jul
“Top 5” Reporters 2011/12
606
533
650
511
454
Aug
Sept
“Top 5” Type
1.
2.
3.
4.
5.
Service User Issues
Accident
Behavioural Issues
Medication
Security Issues
138
60
54
28
26
568
Oct
1.
2.
3.
4.
5.
Springbank
Learning Disabilities
Denbigh
Lucille Van Geest
Cavell Centre – Maple 1
75
68
26
25
22
Serious Incidents - Open
Open SI's
In October 2012 there have been a total of 3 SIs
reported to CQC/PCT
1
2
3
2012/13
SI 398/2012 OPMH – Level 1 Death in
Community
SI 399/2012 Adult – Level 1 Death in
Community
SI 400/2012 Adult – Level 1 Inpatient
Death – Elderly Ward
3
4
5
4
2011/12
6
5
2
2
3
2
5
4
0
Apr
May
Jun
Jul
Aug
Sept
Serious Incidents - Closed
COMPLETED:
In October 2012 4 SI Reports were formally completed.
SI 376/2012 (SB) – Inpatient death, Springbank.
This report was completed was completed and sent to PCT and family on 4 October 2012.
SI 379/2012 (GH) – Death of patient whilst on home leave from Adrian House.
The report failed to meets its September deadline due to staff sickness. Completed report was sent to PCT on
4 October 2012.
SI 382/2012 (MT) - Death in the Community
SI 388 (HJ) – Death in Community
PENDING FOR COMPLETION:
In October 2012 1 SI Report was due for completion but has been held over until 9 November 2012.
SI 386/2012 (HK) – Death in the Community
6
Oct
Inquests Cases Open
During October 2012 5 new
inquest cases were opened
and adjourned.
9
8
7
6
5
4
3
2
1
0
2012/13
2011/12
Apr
May
Jun
Jul
Aug
Sept
Oct
Inquest Cases Closed
During
5 Inquest
Cases
_____ October
______ 2012 ______
____
were
____ closed.
______
Inquest Cases Closed
298/2011
Inquest
date: 11/10/12.
______
____
Open Verdict recorded.
___ ______ ________
2012/13
2011/12
5
326/2011
Inquest
date: 16-18/10/12.
______
____
Accidental
______ Verdict:
_________
____ Death
4
3
364/2011
Inquest
date: 8/10/12
______
____
Open _________
Verdict, 3 witnesses
___ ______
______ called.
372/2012
Inquest
date: 31/10/12
______
____
Verdict
yet received.
______ ___
___ not
________
3
2
1
1
0
Apr
1
0
May
2
2
1
0
Jun
Jul
Aug
Sept
Oct
375/2012
Inquest
date: 17/10/12
______
____
his own life.
______ Verdict:
___ ___Took
___ ____
6
Claims
Claims Opened
2012/13
2011/12
There was 1 claim opened in October 2012
3
• 1 Clinical Negligence.
There were 4 claims closed in October 2012
2
1
3
2
1
1
1
0
Apr
3
May
Jun
1
0
Jul
1
0
Aug
Sept
Oct
7
Safety Thermometer
Context: The NHS Thermometer national CQUIN incentivises the collection of data on patient harm. The tool was
developed as part of the QIPP Safe Care national work stream to survey relevant patients in NHS providers. It has
been agreed with commissioners that we survey our inpatient learning disability and older peoples wards on a monthly
basis. The Safety Thermometer provides a snapshot survey for the four harms of pressure ulcers, falls, Urinary Tract
Infections (UTIs) and catheters, and Venous thrombo-embolism (VTE).
Issue
Risk
Action Taken
Slight upward trend in ‘no harm’ falls
Detailed analysis of falls reported via datix being
undertaken within the Older Peoples Division
None
Infection Prevention & Control
Context
• MRSA screening is a requirement of the Health and Social Care Act
and allow for adequate precautions and treatment to take place.
Reported 1 month in arrears
• Issues
• Demonstrable improvement from last year is shown, however target
still not met every month.
Context
• Essential Steps is the audit tool to demonstrate good practice within
infection prevention and control.
• Issues
• Continued non-compliance in regard to returns from in-patient areas.
Risk
Action Taken
Non compliance with legalisation
Monthly reminders to non responders and their
matrons. Reported at Infection Control
Committee.
Lack of engagement from some areas
Non compliance with audit
Monthly reminders to non-responders. Further
guidance provided regarding completion of audit
As above
Infection Prevention & Control
Context
• Low risk is the National Standard for out patient sites
• Significant risk is the National Standard for in-patient areas
Issues
• The Trust remains above the National Standards
Area
Results April 2012- October 2012
MRSA bacteraemia
No cases
Clostridium difficile
No cases
Pressure Ulcers
1 case not acquired within the
Trust
Context
• Targets set by PCT
Issues
• Continue to be below target in all three areas.
Risk
Action Taken
Perception of low standards of cleanliness
Cleaning standards monitored by contractors
and Serco
None
Breach of targets for any category
Audits of infection prevention and control
standards. MRSA Screening
As above
Pressure Ulcers –www.stopthepressure.com
Context
CPFT has engaged with the McKinsey project. This relates to the SHA’s Ambition: ‘eliminating avoidable grade 2,3 and 4 pressure ulcers by December 2012’
•Nicola Sharp Matron for Infection Prevention and Control has been designated as the lead for CPFT and attends the
Midlands and East ‘Stop the Pressure’ seminars on our behalf, encouraging Trusts to produce action plans and for members to act as change agents within their organisation.
Work to date
•Produced a Pressure Ulcer webpage for staff with links to the ‘Stop the Pressure’ campaign
•Using the Safety Thermometer in learning disability and care of the older persons mental health in-patient units.
•All service users are assessed for the risk of acquiring pressure-related damage as part of their physical health
assessment on admission. The Waterlow scoring system is used.
•Supported the Stop the Pressure week by visiting wards & providing credit card guides to staff. These promote SSKIN and
can be attached to name badges.
•Monitor and investigate rare incidences of pressure ulcers within our service
Policy Development and Review
Policy development & review process
In August 2012, the arrangements for the
management of Trust policies was reviewed. The
responsibility for overseeing this process now rests
with the Audit & Assurance Committee, while the
Quality & Performance Committee will be responsible
for the final ratification of policies on behalf of the
Trust Board. The appropriate responsible committees
will take a stronger lead on the development and
review of policies that fall under their terms of
reference.
The overall governance arrangements around the
development and review of policies will be updated to
take account of the new Trust governance structure by
the end of the year.
Clinical Executive Group
The newly formed Clinical Executive Group has overarching responsibility for the development, review and formal approval of
clinical, patient safety, medicines management and research & development policies. A plan for updating out of date policies
was agreed at the October meeting – leads have been identified and completion dates will be agreed.
Arrangements for the responsibility over Mental Health Act (MHA) policies are still under review pending agreement of the
governance arrangement for the MHA committee. Out of date policies have been reviewed and are ready for approval.
Other Policies
HR policies will be managed by the Human Resources department, with approval resting with the Staff Consultative Forum.
An overall lead for the management of Corporate policies needs to be identified. This includes policies around finance,
information governance and other general corporate policies and procedures.
Risk
Action Taken
Staff working to out of date policies and
procedures which may impact on standards of
practice.
Responsible leads and committees are required
to report actions taken and progress to the
Audit & Assurance Committee
Challenges in meeting review deadlines.
Complaints
20
Complaints Comparative data
18
Context
Total complaints for October 2012 (n = 6), a slight decrease compared
with September 2012 (n = 7).
16
14
October 2012 shows an increase compared with the same period last
year (n = 4).
12
10
Categorisation
Of the 6 complaints recorded in October:
8
6
4
2
0
Januar Februar
March
y
y
April
May
June
July
August
Septem
October
ber
2011/2012
7
3
13
9
9
4
7
9
13
4
2012/2013
19
7
15
8
3
2
0
3
7
6
• 2 graded at level 1 (relatively low level complaint with only a few issues
and relatively uncomplicated)
• 3 graded at level 2 (more complex in nature requiring mediation and
more comprehensive investigation and response)
• 1 graded at level 3 (very complex in nature which may have
implications on patient safety, possible media interest and or litigation
processes).
Risk
Action Taken
All complaints related to outpatient settings.
•Complaints team have contacted relevant
commissioning bodies to produce joint responses to
concerns raised which will aid cross agency learning
and action planning.
•Complaints staff have made contact with the
Quality & Clinical Effectiveness Manager to discuss
how to manage quality of information issues.
None
Themes include:
•
Ineffective multi agency working including
commissioner providers
•
Delays in access to services
•
Quality and accuracy of written
information taken during clinical
assessments.
PALs
90
80
PALS Comparative data
70
Context
Total number of PALS for October (n=43.), an increase in contacts when
compared with September 2012 (n = 40)
60
50
Themes
There appears to be a theme of where family members (either with or
without consent) are contacting PALs raising concerns about the
care/treatment of the cared for person. This poses an issue with
confidentiality and ‘sharing’ information. There have been a few cases where parents /family want/need to be included and cannot either by lack
of consent or divulging information would cause a breach in
confidentiality.
40
30
20
10
0
Januar Februar
March
y
y
April
May
June
July
August
Septem
October
ber
2011/2012
81
48
51
49
28
59
33
59
44
41
2012/2013
67
53
40
57
47
29
41
75
40
43
Risk
Action Taken
Reputational risk to Trust regarding a lack of
understanding by carers as to why staff are not able
to provide the information requested without
breaching legal requirements regarding patient
confidentiality.
PALS have spoken with Communications about the
possibility of producing a leaflet regarding
confidentiality specifically for carers.
None
Compliments
Compliments by Division and Subject
Compliments Comparative data
Care and Communication
Adult MH North
9
Older Peoples MH North
4
Totals:
13
Context
There were 13 compliments received in October, an increase when
compared with September ( n = 8).
Issue
Compliments received offer valuable feedback in terms of what is
important to patients and their families and where the Trust is getting
this right for them. Themes included: patients feeling listened to and
supported, being well cared for and kindness being shown to carers
and patients alike.
Risk
Action Taken
Missed opportunity for learning and service
improvement to enhance patient experience
Learning from compliments will form part of
complaints review and staff training
None
REV (Respect, Empower, Value)
Context
The REV scale was developed by
clinicians as a response to CQC
moderate concerns around
Outcome 1. It involves
predominantly senior nurses
observing a range of interactions
and care processes on the wards
and lasts approx 1 hour, including
feedback to ward managers.
Since end of October this project
has moved to the DoN portfolio
Outcomes
Wards are consistently scoring
100%.
Issues
The scheduling of REV
assessments from a dwindling pool
of assessors and administrator
capacity for scheduling and data
entry is being addressed.
Care planning in Community Teams
•28 out of 37 Teams hitting 95% target
•9 teams missing target (range 79%-94%)
•4 teams overdue an assessment
Risk
Action Taken
Failure of teams to sustain 95% Target and embed
improvements over time.
•Refocusing of assessor/practice development
support to struggling teams
•Learning event planned for January 2012
•Non CPA Assessment criteria developed and
communicated
Sufficient capacity for
focused practice
development within new
service models and
embedding practice in a
changing landscape
Implementation of Trust’s new service model could detract from focus on care planning.
Adult Safeguarding
Context
• Compliance with CQC Standard 7 re adult safeguarding
Issues
• The Trust is compliant with CQC Standard 7
• The Trust has not been involved in any Serious Case Reviews this year and actions from previous reviews are
complete.
• Compliance with adult safeguarding training is currently above target, at 98%.
• Safeguarding referrals continue to increase
Developments
• The Trust was recently required by the SHA to complete a self assessment framework (SAFF)
Compliance measure
Risk
Action Taken
Gaps / Residual
Concerns
SHA SAFF
Absence of overall CPFT
safeguarding strategy.
CPFT to develop adults
safeguarding strategy based on
strategic objectives of SABs
Need to dovetail
strategy with two
SABs
Need to develop processes to
govern the use of restriction and
restraint & where DoLS should
be considered.
Review DoLS guidance.
Staff levels of
understanding of
MCA / DoLS is
variable
Roll out of WRAP (Workshop to
raise awareness of prevent)
training to target identified key
risk areas.
WRAP training is
not mandatory and
is not prioritised.
The organisation has a robust
strategic plan for the
implementation of PREVENT.
Which is supported by a strategy
for training and local policies
and procedures
Agenda Item: 10
BOARD OF
DIRECTORS
MEETING
Date:
Subject:
Prepared by:
FOIA Status
REPORT
28th November 2012
Performance Report
Tom Abell, CIO / DSI
Public
world class
key stakeholders
deliver our vision
with this paper:
regulations
functions
All CQC standards
professionalism.
None identified
None identified
None identified
Other
pros and cons
Background papers
See ‘Quality Dashboard’ available
online.
RECOMMENDATION
Note and discuss the report, including the risks regarding current
performance against standards.
1.0
INTRODUCTION
The purpose of this document is to provide a summary of the performance of
the Trust during October and reported upon in November against the
standards we have set ourselves and that which are expected from our
stakeholders.
2.0
This month’s report includes:
Quarter 2 Initial assessment of performance against the Commissioning for
Quality & Innovation (CQUIN) measures outlined within this years contract
Presentation of activity metrics
An update to the Quality Diamond
Continued reporting of Peterborough Children’s Services.
ISSUE
Key themes within the report include:
Areas of concern
• % patients who had been offered support with financial advice or benefits
• % Incidents signed off by managers within 10 working days
• % staff sickness
Areas of improvement
• % Compliance with 7 Cs has improved during October
• % Patients describe food as good, v good or excellent
• % MHA Rights being read has improved.
• % patients with a HoNOS assessment minor improvement from last
month
3.0
o
Note and discuss the report, including the risks regarding current
performance against standards.
Performance Report
NOVEMBER BOARD 2012
Contents
Introduction:
Activity:
Commissioning for Quality & Innovation
Quality Diamond:
Patient Experience:
Staff Experience:
Safe and Effective Care:
Peterborough Children’s Serv:
2
3
4
5
6
7
8
10
Tom Abell
Director of Service Improvement
Nicola Brookes-Jones
AD, Performance Information and Audit
1
Introduction
Purpose of this document
The purpose of this document is to provide a summary of the performance
of the Trust during October and reported upon in November against the
standards we have set ourselves and that which are expected from our
stakeholders.
More information is available in the full quality dashboard which is
available on the Trusts’ intranet.
Overview
This month’s report includes:
-
Quarter 2 Initial assessment of performance against the
Commissioning for Quality & Innovation (CQUIN) measures outlined
within this years contract
-
Presentation of activity metrics
-
An update to the Quality Diamond
-
Continued reporting of Peterborough Children’s Services.
Key themes within the report include:
Areas of concern
• % patients who had been offered support with financial advice or
benefits
• % Incidents signed off by managers within 10 working days
• % staff sickness
Areas of improvement
• % Compliance with 7 Cs has improved during October
• % Patients describe food as good, v good or excellent
• % MHA Rights being read has improved.
• % patients with a HoNOS assessment minor improvement from last
month
2
Activity
Key Performance Indicator
Adult
Target
Last Month
This Month
External Referrals
1152
Internal Referrals
OPMH
Trend
Last Month
This Month
1265
337
418
390
Total Active Caseload
8506
Distinct Patients on Caseload
CAMH
Trend
Last Month
This Month
367
202
172
216
8207
2510
4439
4215
Number of First Appointments
875
Number of Contacts
Specialist Services
Trend
Last Month
This Month
270
14
16
39
44
6
4
2523
2396
2336
526
544
2236
2312
1878
1870
406
416
908
460
408
136
70
11
16
10040
9553
4636
4124
1505
937
888
809
Number of DNA's
775
706
110
122
136
83
144
121
Contact Hours
6301
6209
2563
2701
1003
905
634
601
Admissions
116
129
15
19
45
16
5
1
Discharges
144
135
17
25
53
15
4
4
Available Beds
5040
5208
1560
1612
1320
1364
1110
1147
Bed Occupancy (Percentage)
80.46%
82.07%
102.68%
94.85%
75.08%
71.41%
90.00%
91.54%
Treated within 18 Weeks
94.47%
97.15%
92.83%
94.32%
92.00%
92.86%
90.00%
87.50%
Trend
Commissioning for Quality and
Innovation (CQUIN)
The CQUIN agreed between the Trust and its Commissioners is a series of measures and metrics to
support quality improvement. The Trust submits evidence against each of the themes on a quarterly basis.
Based upon Q2 evidence the initial feedback indicated insufficient assurance has been received across a
number of themes. These elements have been picked up with the relevant lead and divisions as part of the
Performance meetings and additional assurance will be provided for consideration by our Commissioners at
the next quality review meeting in December 12..
Theme
Dementia
Submission
Timetable
Quarterly
Commissioner Assessment
Red
National Thermometer
Quarterly
Green
Patient Experience
Quarterly
Red
Frail Elderly
Quarterly
NA
Making every contact count
Quarterly
Red
Measuring Outcomes
Quarterly
Green
Perinatal mental health
Quarterly
Green
Learning disabilities
Quarterly
Red
ADHD
Quarterly
Amber
Patient Experience
Staff Experience
Measure
Oct
Sept
24.% patients felt
listened to
93
93
04.% patients
involved
86
25.% Food
satisfaction
29.% Financial
Advice
Change
Measure
Oct
Sept
n/a
12.% staff sickness
5.0
3.9
n/a
83
n/a
14.% staff
recommend
46
46
1/4ly
(July)
50
43
Pg. 6
54.% Staff turnover
10.6
10.1
n/a
39
66
Pg. 6
11.% bank / agency
20.3
21.1
Pg.7
16.% mandatory
training
91
96
Safe and Effective Care
Measure
71.% REV score
Excep
t Rpt
Oct
100
Sept
100
Change
Net
Promoter
Score
Finance and Infrastructure
Excep
t Rpt
Measure
Oct
Sept
Except
Rpt
n/a
Change
n/a
06.% 5 Stars
100
Change
58.% MHA Section
58
100
n/a
21.% MHA Rights
Read
90
01.% 7Cs
94
88
n/a
02.% With a Care
Plan
90
91
n/a
70.% HoNOS
81
80
Pg.8
19.% Incident Sign
off
43
51
Pg.9
18.% SI 45 days
66
4.0
4.2
Report
ReferSee
to Finance
Finance
Report
CIP
89
See finance report for full details
Pg.8
FRR2
Key:
Performance Improving:
No change in performance:
Performance worsening:
55
Pg. 9
Except
Rpt
n/a
Patient Experience
Issue
The overall satisfaction with food has improved above our trajectory.
Issue
Patient survey feedback shows improvement in provision of financial
advice. Trajectory to be developed following information review.
Risk
Action Taken
Poor levels of satisfaction with the food
provided on our inpatient wards could impact
upon nutritional intake of patients and may
delay recovery.
Diagnosis work with each ward now complete.
None subject to work programme being
complete
Risk regarding the delivery of the social care
indicators which form part of our contract with
the Local Authorities.
Ambassadors have undertaken a preliminary
review of ward information and identified gaps
in the accessibility of promotional material.
Booklets from the local authority (LA) have
been ordered and will be distributed to all
wards when received.
Options for arrangements and types of food
has been developed but further work required
to define a key sets of proposals for agreement
by the Executive.
Level of promotional literature variable on
wards. Trust is still awaiting the booklets from
the LA.
Staff Experience
There continues to be variability in the use of bank and
agency staff. The highest reported use this month was in
Adults South at 31.60% and Specialist Services at 30.30%
Risk
Action Taken
Reliance on bank and agency staff may impact
adversely upon quality of care, patient safety
and reduce patient satisfaction with care
delivery.
Chief Operating Officer is holding regular
conference calls with locality teams to review
resource allocations across wards.
Timescales for completion of recruitment
processes
General Managers or Directors continue to
authorise all agency usage.
Recruitment continues to substantively fill
permanent posts which are currently being
filled by bank staff.
Following implementation of action plan performance has slightly improved
from last month and a revised trajectory is now in place.
Adults and Specialist Services Divisions both report improvement in
compliance this month.
Risk
Action Taken
The lack of HoNOS assessment inhibits the
ability to understand the effectiveness of
services for our patients and will impact upon
future commissioning.
A significant data cleansing exercise is
underway in order to target areas of concern
None subject to work programme being
complete
Risk regarding compliance with CQC Outcome 1
and breach of legislation.
Continued engagement with modern matrons
and ward managers to address any compliance
issues arising from the application of the Act.
The set target for this new area is 95% of
appropriate service users have a clinically
validated HONOS cluster by March 2013.
Performance improvement reliant upon practice
and culture change by nursing staff
Safe and Effective
There remains ongoing variability in the performance of the Trust in
meeting the 45 day national standard for investigation of serious
incidents. Note: Small numbers of incidents.
There remains significant variation in the timeliness of incident sign-off
across the Trust against the Trust standard of 10 working days.
Risk
Action Taken
Risk to patient safety and quality of care if the
Trust does not promptly investigate and learn
lessons from serious incidents
Patient Safety Manager, Head of Nursing and
Director of Nursing to meet to review
underlying issues with meeting this target and
develop an action plan to deliver improvements
Further patient safety incidents may continue
as learning processes are not in place
Risk is that the Trust is non-compliant with
Outcome 20 due to the Trust not delivering on
the requirement to report incidents to the NPSA
in a timely fashion and patient safety maybe
compromised.
Patient Safety Manager, Head of Nursing and
Director of Nursing to meet to review
underlying issues with meeting this target and
develop an action plan to deliver improvements
Further patient safety incidents may continue
as learning processes are not in place
Peterborough Children’s Services
Background
This report provides an update to performance for Peterborough
Children’s Services (PCS) to the Board of Directors.
Key Exception Themes are :
Exception area 1: Pledge 2 18 Weeks Referral to Treatment
There was one breach recorded in October for SALT
Exception area 2: Breastfeeding prevalence at 6-8 weeks from birth
and breastfeeding recording
The percentage breastfeed in October is up slightly on previous months,
but more noticeably the percentage of infants for whom we have a
recorded status has increased, showing an improvement in recording.
Benchmarking our performance against the region demonstrates
improvement across both measures during the last quarter although this
still falls short against the regional overall performance.
6
Trust wide dashboard appended
October 2012
17
Agenda Item: 11
BOARD OF
DIRECTORS
MEETING – PUBLIC
Date:
Subject:
Prepared by:
FOIA Status
REPORT
28th November 2012
Finance Report Month 7 – 2012-13
Darren Cattell, Interim Director of Finance
Public document
Our services will be recognised as world
class
We will deliver care through engaged and
empowered people
We will develop strong relationships based
on trust and mutual respect with key
stakeholders
We will develop our built environment and
technology infrastructure to deliver our
vision
with this paper:
regulations
All NHS organisations are required by law
to take account of the NHS Constitution in
performing their NHS functions
Refer to paper
-
Achievement of Financial Plan to
enable the Trust to maintain or improve
service quality
Other
pros and cons
Background papers
Quality and Performance Committee
Executive Directors
Finance Report to 31 October 2012
Trust Board
28 November 2012
Contents
1.
Highlight Report
2.
Exception Report
3.
Key Actions
4.
Forward Financial Risks
5.
Financial and CIP Planning update
Appendices – Financial Statements
Darren Cattell
Director of Finance
1
Section 1: Highlight report
- Key Financial Performance Indicators
- Income Statement Summary
- Run Rate Analysis
- Forecast Outturn
- Divisional Forecast
- Use of Enabling Fund
2
Key Financial Performance Indicators
Indicator
EBITDA %
Operational Surplus / (Deficit)
CIP Savings Performance
Performance as at
Month 7
Target
Actual
5.05%
5.30%
(£0.230m)
£4.317m
(£0.068m)
£3.627m
Year to
date
Rating
Report
Reference
G
App 1
Actual at month 7 is ahead of target by £0.162m. Target
and actual includes a further £0.110m utilisation of
Enabling Fund in the period.
G
App 1
Actual at month 7 is behind target by £0.690m.
R
Narrative
Key
EBITDA margin is ahead of plan at month 7.
Green = On target or above
Amber = 0 to 5% below target
App 6
Red =
Liquidity Position (Cash Balance)
Capital Expenditure
Financial Risk Rating
£8.700m
£4.760m
2
£7.900m
£4.689m
3
Cash balance at 31 October is £7.9m
Ytd position is £0.071m behind plan at the end of month 7
.
Actual Risk Rating at month 7 is a 3
R
App 7
G
App 8
> 5.0% below target
Green = On target or underspend
G
App 9
Amber =
Red =
Green =
Amber =
Red =
0 to 5% above target
> 5.0% above target
Plan or above
N/a
Behind plan
3
Income Statement Summary
Month 7 Results – Trust wide
Summary
- Continuing Improvement in Month 7
Position (£172k above plan)
- Achievement of Monitor FRR 3 –
better than plan
- £162k better than plan YTD
- CIP Delivery behind target, although
being offset by budget and reserve
underspends
Key Actions (see section 3)
- continued focus on income recovery,
now includes Springbank
- PMO focus on CIP delivery (Red
Action meetings *4)
- Re-scoping failing CIPs (*2)
- Divisional Compliance Statements on
forecast outturn
- Implementation of Financial
Governance Action Plan following
PwC independent review.
Month 7
£m
Year to Date
Month 7
£m
Plan
73
(230)
Actual
245
(68)
Relative Risk
Rating
Month 7 Results
Improving
162
Month 7 Budget
Plan
Actual
73
392
(230)
634
Improving
864
Month 7 CIP
Plan
Actual
0
0
(147)
(702)
Worsening
Note – CIP plan delivery is at 80% of net ytd target despite worsening position
4
Monthly Run rate Analysis
Monthly Expenditure
11.10
11.10
11.00
11.00
10.90
10.90
10.80
10.80
£m
£m
Monthly Income
10.70
10.70
10.60
10.60
10.50
10.50
10.40
10.40
10.30
Actual Income
April
10.61
May
10.79
June
10.78
July
10.91
Aug
11.02
Sep
10.93
Oct
10.98
10.30
Actual Expenditure
April
10.79
May
11.01
June
10.90
July
10.94
Aug
10.96
Sep
10.74
Oct
10.73
Summary
Overall the financial position at the end of Month 7 is a deficit of £0.068m against a planned deficit of £0.230m, representing an improvement of
£0.246m in the month since September.
This is a continuing improvement in the underlying run rate in the period.
Monthly Surplus / (Deficit)
Overall Surplus / (Deficit)
£000s
300
200
(68)
£'000s
100
0
(182)
(100)
(314)
(200)
(300)
Actual Surplus / (Deficit)
Green = On target or above
(401)
April
(182)
May
(219)
June
(117)
July
(33)
Aug
53
Sep
188
Oct
245
Amber = 0 to 5% below target
(518)
April
May
June
(551)
July
(498)
Aug
Red = > 5.0% below target
Sep
Oct
5
Forecast Outturn
Most Likely Forecast at the end of Month 7 is a deficit of £0.250m,
against planned deficit of £0.592m. FRR 3 in month and forecast.
Income Statement
Community Services Income
Community Services Income
Protected/ M andatory Clinical income
High Cost Low Vol Activity - Cost & Vol Contract Income
Annual
Budget
£
7.572
Forecast Expenditure FY13
Best
Worst
Case
Case
£m
£m
Most Likely
£m
7.572
7.572
Key Assumptions and Sensitivities
3.137
3.207
2.922
1.014
21.522
0.670
21.522
0.690
21.522
0.600
21.472
50.211
11.105
17.883
105.156
50.211
11.010
17.400
103.950
50.211
11.010
17.400
104.040
49.711
11.010
17.400
103.115
0.000
2.536
2.536
0.014
2.173
2.187
0.014
2.173
2.187
0.014
2.173
2.187
5.170
7.511
4.775
7.241
4.775
7.241
4.775
7.241
4.409
17.090
4.952
16.968
5.002
17.018
4.876
16.892
132.354
130.678
130.818
129.767
Employee Benefit Expenses (Pay) - Substantive
(84.255)
(77.062)
(76.956)
(77.725)
Employee Benefit Expenses (Pay) - Agency
Employee Benefit Expenses (Pay) - Bank
Subtotal Employee Benefit Expenses (Pay)
Drug Costs
Clinical supplies
Non-Clinical Supplies
(0.535)
(0.137)
(84.927)
(1.187)
(0.258)
(0.291)
(3.115)
(3.757)
(83.934)
(1.069)
(0.378)
(0.420)
(2.969)
(3.557)
(83.482)
(1.069)
(0.378)
(0.420)
(3.290)
(3.907)
(84.922)
(1.069)
(0.378)
(0.420)
(1.356)
(4.880)
(4.713)
(1.186)
(4.425)
(4.433)
(1.018)
(4.425)
(4.433)
(1.580)
(4.425)
(4.433)
Block Contract - 2: Cambs PCT
Block Contract - 3: Other PCT's
Clinical Partnerships Income (incl.s75 agreements)
Total
Non Protected/ Non Mandatory Clinical income
Private patient income
Other non-protected clinical income
Total
Other income
Research and Development
Education and Training
Other income*
Total
Total income
Expenses
Secondary Commissioning Costs
Research & Development Costs
Education & Training Costs
Other Costs (excl. depreciation)
Reserves
PFI specific costs
PFI - Unitary payment
Total costs
The forecast uses year to date income and expenditure and projects forward,
taking into account planned changes and using trend analysis. The best and
worst case scenarios capture the potential impact of changes in the most volatile
areas of income or expenditure and take into account the potential influence of
external factors.
7.572
3.420
Other - Cost and Volume Contract Income
Block Contract - 1: Peterborough PCT
Summary
(25.695)
(0.531)
(1.931)
(125.767)
(25.930) (25.930) (26.335)
0.000
0.000
0.000
0.000
0.000
0.000
(1.923)
(1.923)
(1.953)
(123.697) (123.077) (125.514)
EBITDA
Profit / loss on asset disposals
Total Depreciation
Total interest receivable/ (payable)
Interest Expense on PFI lease
Total interest payable on Loans and leases
PDC Dividend
Impairment
6.587
0.000
(3.679)
0.100
(1.289)
(0.062)
(2.250)
0.000
6.981
(0.049)
(3.679)
0.097
(1.289)
(0.062)
(2.250)
0.000
7.741
(0.049)
(3.679)
0.097
(1.289)
(0.062)
(2.250)
0.000
4.253
(0.049)
(3.679)
0.097
(1.289)
(0.062)
(2.250)
0.000
Net Surplus/(deficit)
EBITDA %
(0.592)
4.98%
(0.250)
5.34%
0.510
5.92%
(2.978)
3.28%
The most likely forecast outturn is based on the following key assumptions:Income: Tier 4 variable income is on plan for the remainder of the year; other
variable income streams continue at current levels; there are no changes to
block contract arrangements.
Pay: Recruitment to inpatient vacancies impacts favourably on bank spend
(offset by an increase in substantive spend); MARs settlement costs are offset
by savings made from resultant vacancies.
Non-pay: Out of Area Treatment contingencies are partly released to reflect
current expenditure trends. Other Non pay expenditure levels are assumed to
remain constant
Other: non operating costs are forecast to continue at current levels.
The best case and worst case scenarios have been developed to incorporate:Income: movements in variable income and risk in relation to CQUIN funding
element of block contracts. Springbank income now a risk to forecast
Pay: volatility of temporary staffing expenditure, potential impact of further
settlement costs as a result of Trust Service Model
Non-pay: volatility of out of area treatment costs and potential impact of
further external support to the Trust.
Risks
Key risks to delivering the forecast position include:Block Income: CQUIN Income target of £1.3m is not fully recoverable
Variable Income: Tier 4/Sprinbank income performance is depend ant on
continued focus within the Division and through marketing support to maintain
demand.
Pay: costs incurred in implementing the Trust Service Model may exceed the
in-year savings, which would be managed through release of balance sheet
contingencies.
City Care Centre : reaching financial resolution with the PCT regarding inyear rent costs;
OAT’s costs: a contingency remains within FOT for additional placements.
6
Divisional Forecast
Summary
-
-
Divisions continuing to perform well with
all Divisions forecast to be better than
plan, with the exception of Older
Peoples and Children’s Services. No
overall movement between month 6 and
month 7.
Corporate Services position includes
non recurrent costs pressures for
temporary staff and recruitment.
Actions
-
All Divisions completing Compliance
Statement on forecast.
-
Children’s Services review underway,
with divisional leadership currently
preparing report on actions for Trust
Executive.
-
Agreement on devolvement of Medical
CIP.
-
Performance reviews to be extended to
Corporate Teams.
-
Plan being developed to restructure
Budgets in line with revised Trust
Management Structure.
-
Review of budgets within General
Services as part of Trust Service Model
budget changes.
Division / Service
Annual Forecast
Budget (estimate)
£m
£m
Variance
Favourable /
(Adverse)
£m
Clinical Divisions
Out of Area Treatments (OATs)
(1.356)
Adult Services
(26.948)
Older People's Services
(12.168)
Specialist Services
(3.603)
Children's Services
(16.079)
Primary Care & Liaison Services (4.387)
Supported Living Services
(0.565)
(1.255) 0.101
(26.431) 0.517
(12.204) (0.036)
(3.445) 0.158
(16.475) (0.396)
(4.387) 0.000
(0.452) 0.113
Total Clinical Divisions
(64.649)
Corporate Services
General Services
(65.106)
(6.650)
(21.562)
RAG
Indicator
%
7.5%
1.9%
(0.3%)
4.4%
(2.5%)
0.0%
20.0%
G
G
A
G
R
G
G
0.457
0.7%
G
(7.236) (0.586)
(8.8%)
R
1.3%
G
(21.275)
0.287
7
Use of Enabling Fund
Scheme Description
MARs Settlements
PWC Turnaround Costs
Total Enabling Fund Commitments - Month 7
Costs to
Date
Additional
Anticipated
Costs
TOTAL
COSTS
£000
£000
£000
213
363
576
115
0
115
328
363
691
Enabling Fund
The Financial Plan for FY13 included the establishment of
an Enabling Fund to support the costs of service changes.
As part of the financial governance process for the year the
Trust Board must approve all expenditure to be charged
against the Enabling Fund.
At the end of Month 7 costs of £0.328m have been charged
against the fund, with approval given for an additional
£0.363m.
Risk
Action Taken
The CIP plans do not deliver to a sufficient level
to establish full £2m Enabling Fund.
CIP plans reviewed and PMO monitoring of
CIP delivery.
None.
Financial forecast updated on monthly basis to
ensure any spend to be charged to Enabling
Fund is affordable.
Costs chargeable to the Enabling Fund exceed
the funds available.
All costs to be charged to Enabling Fund must
have Trust Board approval.
Schedule of costs charged to Enabling Fund
provided to Quality & Performance Committee
on a monthly basis.
None.
8
Section 2: Exception report
- Cost Improvement Plans
- Variable Income Analysis
9
Cost Improvement Plans
Cost Improvement Programme
£m
£000s
1,000
900
800
700
600
500
400
300
200
overall
100
The
cost improvement plan is behind plan by £0.555m at the end of Month 6. The main areas of underperformance relate to reductions in
temporary staffing spend, and in estates savings costs. The target increases from Month 7 onwards as a result of implementation of the new Trust
April
May
June
July
August
September
October
November December
January
February
March
Service Model. Plans
are in place
to deliver
this, and
have been
reviewed635
by the Trust
Board. 746
Planned Savings
556
557
557
633
633
746
746
894
894
894
Actual Savings
502
502
502
504
503
514
599
Risk
Action Taken
Pay CIPs
Consultation on Trust Restructure complete. GM
and CD posts recruited
Temporary Staffing and Estates projects to be rescoped.
Travel and Mobile ‘phones savings start in Nov.
Red Action Meetings for all CIPs behind target.
Impact and delivery of re-scoped projects.
Commissioner sign up of CIP projects and the
impact on quality.
Further mitigation of red CIPs being planned
Non-pay CIPs
Estates Rationalisation – reviewed deliverability
of current CIP plans and further ideas being
developed.
CCC issue
Cost Improvement Programme
£m
Planned Savings
0.56
0.50
April
1.11
1.00
May
1.67
July
Actual Savings
3.57
3.03
2.01
1.51
June
2.94
2.30
8.49
4.32
3.63
Forecast Savings
5.81
5.06
5.09
4.36
6.70
5.98
7.60
7.76
6.87
2.51
August
September
October
November December
January
February
March
10
Variable Income Analysis
Category
Actual
Total to
Q2
£000
Plan
Actual Variance
Narrative
Variable Income
M7
£000
YTD
£000
YTD
£000
YTD
£000
Summary
Overall variable income is £0.157m
behind plan at the end of Month 7.
High Cost Low Vol Activity - Cost & Vol Contract Income
CAMH Tier 4 variable Income
354
94
618
522
(95) Lower than planned occupancy at the Croft for out of area patients
Currently only 1 out of area patient. Delays in recording
102 discharges resulted in backdated credits for September
Springbank Unit Income
242
19
422
523
Adult Eat Disorder variable Income
365
157
734
786
TOTAL
961
271
1,774
1,832
The unit continues to have high occupancy levels with higher than
52 planned out of area patients.
58
Other Cost & Volume Contract Income
Non contracted activity
56
11
225
114
Performance reflects activity captured across all services for
PCTs with which the Trust has no contract. This income is highly
(111) volatile and currently behind budgetted level.
Ministry of Defence income
30
19
139
100
59 occupied bed days for the 4 MoD beds in October represents
(39) 48% occupancy which is significantly higher than last month.
ABI Income
52
18
228
163
(65) Reduced number of referrals, limited capacity within the team.
137
48
592
376
(215)
1,098
318
2,365
2,208
(157)
TOTAL
TOTAL VARIABLE INCOME
Tier 4 Income is behind plan by £0.095m.
There is a project plan in place to manage
the recovery of income in this service
which is being monitored by the PMO.
Adult EDS Services variable income is
performing well against target. Variable
income in the Springbank Unit has
historically performed well in the year to
date, however in Month 7 Springbank had
only 1 Out of Area patient against a target
of 4 resulting in under-recovery of Income
by £92k. If this trend continues there is a
risk to the income forecast. Mitigation
work has started.
Risk
Action Taken
CAMH Tier 4 Income is not recovered to planned
levels in year.
Project established, led by Children's Division,
and being monitored by PMO. Regular Red
Action Meetings have driven improvements.
None.
Other Costs & Volume Income is not recovered
to planned levels in year.
Issues raised with Divisional leads through
Performance Review meetings. Springbank risk
being mitigated as per Childrens Tier 4 approach
None.
11
Section 3: Key Actions
- Update
12
Key Actions - Update
Actions to Deliver Financial Plan
Update – October 2012
Further ACTIONS
Continue current actions to reduce Temporary staffing
costs
Inpatient wards completed. Corporate
staff reviewed
Temporary staffing CIP project being rescoped to encompass all aspects of
Temporary staffing, including Medical
staff. Red Action Meetings continuing.
Review level of flexible reserves/non recurrent funding
Some non recurrent funding has been
identified and confirmed by PwC
review.
Critically assess income expectation
Income briefing prepared. Financial
risk could be £250k fye particularly in
Springbank
CQUIN Income recovery to be
monitored through PMO project.
Mitigating actions for financial risk
Refocus CIPs and/or budgetary savings
Recurrent/non recurrent savings
analysis undertaken.
Continue to review CIP achievement
and consider impact on FY14 financial
planning.
Re-energise and Refocus CIP and PMO requirement –
Board leadership
Formal Board approval at October
meeting to new process. CIP savings
included as separate programme in
new Programme Management
Framework.
CIP Planning framework for FY14 being
developed and shared with Clinical
Leaders.
Revise PMO governance – Exec Directors
Formal Board approval at October
meeting to revised framework and
project approach.
New framework being implemented.
Develop accountability structure
Functional Programme Board and Red
Action meetings
See above
Review and refresh plans in certain work streams
Recurrent/non recurrent savings
analysis undertaken. CIP Planning
framework for FY14 being developed.
Implement Financial Governance Action
Plan following PwC review.
13
Section 4: Forward Financial Risks
- Monitor Metrics
14
Forward Financial Risks (Monitor Metrics)
Indicator
Unplanned decrease in (quarterly) EBITDA
margin in two consecutive quarters against
Monitor submitted plan.
Trust is unable to certify that Board anticipates
that the Quarterly FRR will be at least 3 over
the next 12 months (from Governance
Statement)
Working capital facility (WCF) was used at any
point in the period to date
Planned
Actual
Comments
Action
Increase against plan reflects
Q1: £1.147m Q1: £1.226m revised phasing of enabling fund
Q2: £1.344m Q2: £1.956m in budget, compared to Monitor
Plan.
Yes
Yes
Planned financial risk rating of 2
for FY13
No
No
No plans to utilise the facility in the
foreseeable future
Following PwC review, Trust
plans to move to an FRR 3.
Regular dialogue and current
The major old debts are with East
disputes have been resolved with
of England SHA and relate to
settlement expected in
Regional Psychology Invoices
November
Debtors > 90 days past due account for more
than 5% of total debtor balances
Yes
12.80%
Creditors > 90 days past due account for more
than 5% of total creditor balances
No
2.69%
Two or more changes in Finance Director in a
twelve month period
No
Yes
Interim arrangement in place
pending appointment to
substantive role.
No
Yes
Interim Finance Director currently
Recruit substantive Director of
in post, supported and agreed by
Finance in Jan 13.
Trust Board and Monitor.
No
19.52 days
No
98.51%
No
98.51%
Interim Finance Director in place over more
than one quarter end
Quarter end cash balance <10 days of
(annualised) operating expenses
Capital expenditure < 75% of plan for the year
to date
Capital expenditure > 125% of plan for the year
to date
Recruit substantive Director of
Finance in Jan 13.
15
Section 5: Financial Planning Framework
-
Financial Planning Timetable
CIP Framework
16
Development of Financial Plan FY14-16
Activity
Timeframe
Responsible
Officer
Update – November 2012
Further ACTIONS
Keep under review as
commissioning discussions
progress and NHS Operating
Framework for FY14 is
finalised.
Agree key financial assumptions for next 3
years
Mid-Oct
Director of
Finance
Assumptions agreed at Directors Meeting
in October
Develop 3 year Financial Framework
Mid-Nov
Director of
Finance
Initial draft developed
Develop 3 year CIP Framework
End-Nov
Director of
Finance
Outline CIP Planning framework for FY14
developed and shared with Clinical
Leaders. Exec agreement 27-11-12.
Divisional workshops
planned for early Dec to
progress detailed CIP
planning
Authorisation Workshop
19-12-12
COO
First cut CIP plans expected as part of
Authorisation
Guidance to be issued to
Divisions
End Nov to
31 January
COO
End January
2013
Director of
Finance
Divisions present final divisional business
plans to Executive Team inc 3 year CIP
plan
Early
February
2013
Director of
People and
Business
Development
Board development day : draft CPFT
Strategy and business plan inc budget for
2013/14
End
February
2013
Director of
People and
Business
Development
March 2013
Director of
Finance
Divisions engage with staff regarding new
vision, forward plans and detailed CIP
development
Draft CIP Plans for FY14 shared with
Commissioners
Board approves draft annual budget
To be updated as planning
assumptions crystallise.
17
CIP Framework
New domain framework – Control,
Efficiency and Change
“Control” focuses largely on
non-pay initially, and then into
staff-based controls
“Efficiency”
focuses on
doing things
better.
Initially in
non-pay but
then into
staffing
8.3% of
non pay
could be
our target
for controls
and
efficiency
Some
initiatives
will span
each of the
three
domains
2.4%
could be
our target
for
change
“Change” is over to divisional teams where some generic
examples are listed. This is your chance to innovate!
18
Finance Report to 31 October 2012
Appendices
1.
2.
3.
4.
5.
CIP Performance
Statement of Position and Cash Flow
Debtor Report
Capital Expenditure
Monitor Risk Rating
19
Appendix 1 - CIP Performance
PMO
Workbook Workstream
Reference
Scheme
Year to
Year to
Date
Date
Year to Date Year to Date
YTD
Variance
Variance Variance
Plan @ Month Actual @
RAG
Month 7
@ Month 7 @ Month
7
Month 7
7%
£000
Planned
Value FY13
£000
Plan
Month 7
Actual
Month 7
1,709
142
142
0
997
997
0
0.0%
G
Savings delivered - fye of ward closures
1,924
160
160
-0
1,122
1,139
17
1.5%
G
An element of savings are being delivered nonrecurrently. Work continues with Divisional Heads to
identify savings on a recurrent basis.
900
100
59
-41
400
104
-296
(74.1%)
R
Saving reflects reduction in overall spend on temporary
staffing in the month. Expenditure has reduced in all
areas with the exception of Admin within Social Care.
Recurrent budgetary savings cannot be achieved
Comments
CIP workstream - Full Year Effect Savings
Workforce and non401
workforce CIPs
In-patient Reconfiguration
CIP workstream - to deliver in-year
121 - 402
Workforce CIP
403 Workforce CIP
Savings - Community Services
Reduction in temporary staffing spend (bank
and agency)
121 - 404
Workforce CIP
Trust Service Model
1,100
183
26
-157
183
26
-157
(85.8%)
R
MARs scheme savings have largely been achieved.
Further savings will accrue once the new structure is
recruited to.
121 - 405
Workforce CIP
Recruitment Control
800
67
60
-6
467
410
-57
(12.2%)
R
Target being achieved in Clinical Services; shortfall in
Corporate and General services
406 Workforce CIP
Savings - Medical staffing (including job
planning)
400
51
8
-42
148
77
-70
(47.7%)
R
Junior Doctors savings are being achieved. CIP for
medical establishment is under review for allocation to
Divisions but has not yet been achieved
407 Workforce CIP
Savings - Nursing and other groups
400
67
0
-67
67
0
-67
(100.0%)
R
Shift Pattern review underway - challenges around
balancing quality with financial savings.
(100.0%)
136 Workforce CIP
Performance management savings
200
22
0
-22
89
0
-89
R
Incorporated into Trust Service Model planned savings
409 Workforce CIP
Savings - Deighton Unit
150
25
25
0
25
25
0
0.0%
G
Change in Service Model from October - detailed plans
are in place.
Sub-total: Workforce savings
5,874
675
339
-336
2,500
1,781
-720
(28.8%)
R
410 Non-workforce CIP
Estates rationalisation projects
685
21
0
-21
135
0
-135
(100.0%)
R
Current detailed plans follow short of CIP target; risk in
City Care Centre exit and delay in other areas.
Support Service Savings
650
54
54
0
379
379
0
0.0%
G
Savings delivered - outsourcing of ASP
Procurement - Reduction in non-pay spend
770
64
64
0
449
449
0
0.0%
G
Realignment of non-pay budgets and procurement
efficiencies across a range of cost headings
Reduce travel expenses
250
42
0
-42
42
0
-42
(100.0%)
R
Reduce legal fees
100
8
0
-8
58
21
-37
(63.7%)
R
75
8
0
-8
33
0
-33
(100.0%)
R
415
416
Non-workforce CIP
Printing
Non-workforce CIP
Reduce Mobile bills
10
1
0
-1
4
0
-4
(100.0%)
R
Sub-total: Non-workforce savings
2,540
199
118
-81
1,101
849
(251)
(22.8%)
R
Total CIP savings
Year 1 Risk Adjustment
10,123
1,016
599
-417
4,598
3,627
(971)
(21.1%)
R
(1,622)
(270)
0
270
(270)
0
270
Trust Board approved Revised Scheme - Staff
Consultation underway
Management controls on Legal costs are being
adhered to, although demand means savings not being
delivered.
Plans to reduce ratio of Printers to Staff to Industry
Standard, reduction in consumables maintenance and
energy - now underway
Decommission inactive devices, enhanced control over
issue, and scrutiny of high users
Net CIP savings
8,501
746
599
-146
4,328
3,627
(701)
(16.2%)
R
310 Revenue Generation
Scheme
Variable income recovery
1,100
167
134
-33
367
305
-61
(16.8%)
R
Reduction in income in M7 due to low occupancy of out
of area patients at the Croft
312 Service Devpts /
Other
Service Devpts / Other
436
36
31
-5
244
232
-12
(5.0%)
R
Partial shortfall in Family Nurse Partnership overhead
contribution managed within division
10,037
949
764
-185
4,939
4,164
-775
(15.7%)
R
Total savings
20
Appendix 2 – Summarised Statement of
Financial Position and Cash Flow
Cashflow Statement - Month 7
Statement of Financial Position - Month 7
As per Final
Accounts
2011/12
Plan
Actual Variance
This Month This Month from Plan
£'m
As per Final
Accounts
2011/12
£'m
8.1
£'m
£'m
£'m
102.2
105.4
3.1
6.6
22.3
20.0
(2.3)
(7.7)
(1.5)
Plan YTD Actual YTD
Month 7
Month 7
£'m
Variance from
Plan
£'m
£'m
EBITDA
3.1
4.2
1.0
Movement in working capital
1.1
2.8
1.7
CF from Operations
4.2
7.0
2.8
Net capital Expenditure
(1.3)
(4.9)
(3.6)
3.0
2.1
(0.9)
(2.4)
(2.3)
0.0
(0.3)
(0.8)
104.5
Property, Plant and Equipment
20.4
Assets Current
(20.8)
Liabilties, Current
(23.0)
(23.0)
0.0
(1.1)
CF before Financing
(31.1)
Liabilities, Non-Current
(29.6)
(29.5)
0.0
(4.1)
Financing
73.0
TOTAL ASSETS EMPLOYED
71.9
72.8
0.9
(5.2)
Net cash outflow/inflow
0.6
13.3
Opening Cash Balance
8.1
8.1
0.0
73.0
TOTAL TAXPAYERS EQUITY
71.9
72.8
0.9
8.1
Closing Cash Balance
8.7
7.9
(0.8)
SoFP is broadly in line with Plan
Cashflow is behind plan which reflects the delays to the disposal of the Cobwebs site
which is currently scheduled for completion on 23rd November.
21
Appendix 3 – Debtor Reporting
Risk
Action Taken
Debtor levels impact on Trusts Cash position
and ability to generate investment income
Contras agreed with PSHFT, and agreement
from SHA to settle Regional Psychology
invoices
None.
22
Appendix 4 - Capital Expenditure
Locality
Scheme Name
Site
Description
Annual
Budget
Budget at
month 7
Actual
Month 7
Annual
Forecast
£'000
£'000
£'000
£'000
Cambridge
Rationalisation of Admin space
Fulbourn
Rationalisation of Admin space
300
175
0
0
Cambridge
Provision of space for Dendron
Fulbourn
Provision of space for Dendron
150
150
73
150
Cambridge
GMH - internal reconfiguration
Fulbourn
Internal reconfiguration work at GMH
240
160
208
240
45
45
162
383
735
530
443
773
Schemes less than £100k
Development
Trustwide
Ligature Risk
Trustwide
Carry out ligature risk reduction work
600
350
571
600
Cambridge
Springbank
Fulbourn
Changes to design requirments
150
150
2
150
Fenland
Wicken Ward Refurb
Cost of refurbishing ward at Croyland team
100
100
14
100
Cambridge
Denbeigh Ward Refurbishment
Fulbourn
Ely
Denbeigh Ward Refurbishment
283
283
278
283
Cambridge
Willow ward Refurbishment
Fulbourn
Willow ward Refurbishment
180
180
136
180
Cambridge
GMH Windows
Fulbourn
GMH Windows
150
150
2
150
770
556
584
1,083
2,546
Maintenance
2,233
1,769
1,587
Peterborough
Reprovision for Peterborough Hub
500
292
0
500
Ida Darwin
Preperation for sale of Ida Darwin
300
167
200
200
192
192
212
298
Other
992
650
413
998
2,278
960
928
1,398
Peterborough
Reprovide for Peterborough Hub
Cambridge
Ida Darwin site
Information Technology
Strategic IM&T
Trust wide
Development of IT Stategy solutions
Respond
Trust wide
Capital costs associated with ABIC project
378
378
203
378
Equipment Replacement Plan
Trust wide
Ensure our IT equipment is fit for purpose
500
292
373
500
COIN move from St Johns to Cavell
Trust wide
To identify solutions and business case to enable procurement
220
73
4
200
OASIS
Trust wide
Patient facing web enabled Services
0
0
119
150
Open Ward Scheme
Trust wide
Project Management Costs
100
58
134
150
50
50
491
750
3,526
1,811
2,252
3,526
Information, Communication and Technology Category Subtotal
Anglia Support Partnership
0
0
(6)
0
7,486
4,760
4,689
7,843
Annual
Budget
Budget at
month 7
Actual
Month 7
Annual
Forecast
Depreciation
3,694
2,077
2,038
3,694
Disposals
4,710
3,350
1,100
3,960
Charitable Donation
0
0
0
250
Cash
0
0
1,551
0
8,404
5,427
4,689
7,904
Grand Totals
Funded by
Funding total
• Capital plan
behind schedule
by £0.07m
(1.5%) at the end
of M7.
• Forecast for
year-end is
currently above
plan and the IDG
is currently
reviewing options
for managing this
down to planned
levels.
• The Trust has
planned to
secure £250k of
charitable
funding towards
the works at the
Gatehouse
23
Appendix 5 - Monitor Financial Risk Rating
FRR at Month 7 = 3 ahead of plan
Weight
5
4
3
2
1
Annual
Plan
rating
FY13
EBITDA margin %
25%
11
9
5
1
<1
2
5.2%
3
Achievement
of plan
EBITDA achieved %
10%
100
85
70
50
<50
5
130.0%
5
Financial
efficiency
Return on assets %
20%
6
5
3
2
<-2
2
2.9%
2
I&E surplus margin %
20%
3
2
1
-2
<-2
2
-0.09%
2
Liquid ratio days
25%
60
25
15
10
<10
4
21.3
3
Criteria
Metric
Underlying
performance
Liquidity
Average
Overriding
rules
Overriding rules
Overall rating
Overall rating
At least one criteria is rated as 1 or 2
Score
FY13
Risk
rating
YTD
FY13
2.8
2.8
2
3
2
3
24
Agenda Item: 12
BOARD OF
DIRECTORS
MEETING
Date:
Subject:
Prepared by:
FOIA Status
REPORT
28 November 2012
Workforce Process Review
Keith Spencer, Director of People and Business Development
No restrictions
To provide safe and effective care and an
excellent patient experience
To provide services through empowered staff who have
the right skills, attitudes and behaviours
Details of additional risks associated with
this paper:
None
regulations
Essential standards: 12,13 and 14
Links to NHS constitution staff pledges:
Pledge 1: To provide all staff with clear roles, responsibilities
and rewarding jobs.
All NHS organisations are required by law to
take account of the NHS Constitution in
Pledge 2: To provide all staff with personal development,
access to appropriate training for their jobs and line
management support to succeed.
Pledge 3: To provide support and opportunities for staff to
maintain their health, well being and safety.
Pledge 4: To engage staff in decisions that affect them, the
services they provide and empower them to put forward
ways to deliver better and safer services.
The remedial programme of action resulting from this paper
may have associated financial implications. These will be
addressed on a case by case basis in line with the Trusts
scheme of delegation
None
WORKFORCE PROCESSES
AGENDA ITEM
To be reported to Board in January 2013 and through
Quality Dashboard on quarterly basis
1. EXECUTIVE SUMMARY
The specific focus of this Board report is the work that has been undertaken as part of the preparation for
the new Workforce Strategy, to review a number of key workforce processes specifically Recruitment and
Discipline following feedback from a range of internal stakeholders that these may not be functioning as
effectively as possible. This review involved an online survey of 83 managers and focus groups with a small
sub set of managers and representatives from SERCO who manage recruitment processes on behalf of CPFT.
The key improvement actions are:
Recruitment
• Changes to and adoption of a new standard operating process for recruitment will reduce ‘fill time’ from
the current 16 weeks (80 working days) to a maximum of 12 weeks (60 working days) from 1 December
2012. From 1 April 2013, we will work with SERCO to further reduce this to 50 working days (10 weeks).
Performance against this will be monitored through Divisional Performance meetings and through the
Workforce Dashboard (see appendix 1).
•
The trust is currently undertaking a targeted recruitment campaign to fill a significant number of nursing
vacancies. A key component of this will be regular recruitment fairs in Cambridge and Peterborough for
nursing staff from January 2013. This is a joint initiative between Divisions, the Nursing and People
Services teams. This will also enable us to publicise the CPFT brand to potential employees.
Discipline
• A streamlined policy, procure and standard operating procedure has been agreed with the trade unions.
• The revised standard operating procedure is as follows:
Each disciplinary case will be fully scoped at the start of the process including investigation and
hearing timelines and an end date of the complete process identified.
A standard of 63 days from start to process completion (disciplinary hearing) will be adopted
(current is 113 Days). This may be varied for complex cases
A performance management process for case management will be implemented. Line Managers
will be required to seek formal approval from the Director of People and Business Development
to break the 63 day standard. Cases moving beyond this will be subject to ‘Red Action’ meetings
to ensure timely completion
Performance reports will be produced for the monthly divisional performance/Board meetings
to include recruitment time to hire, disciplinary cycle time and sickness management cycle time
Managers and HR will be held accountable for the relevant steps within the process and overall
management of the process.
• As part of the much wider restructuring of People Services, a specialist team will be set up called the
People Performance Team dedicated to working assertively with managers to tackle discipline,
performance and absence issues amongst the workforce.
General HR
As part of the survey of 83 CPFT managers, Managers were also asked generally for their views on HR.
71% either agreed or strongly agreed with the statement that HR’s advice enables them to address the issues
at hand whereas 12% either disagreed or strongly disagreed with this statement.
WORKFORCE PROCESSES
AGENDA ITEM
2. RECOMMENDATIONS
The Board is asked to endorse the enclosed report and proposed actions
3. INTRODUCTION
There are four emerging workforce priorities that will form the basis of the new Trust workforce strategy
2013 – 2016 which will be presented for approval at the February 2013 Board Meeting.
These priorities known collectively as the ‘Working at PaCE Priorities1’ have emerged consistently through
the turnaround process over the last 12 months whether through discussions with the Board of Directors,
the Senior Operational Leadership of the organisation or with staff themselves at the recent Town Hall
events as being vital to the future success of CPFT. They are:
Definition
Productivity
engAgement
Capability
Efficiency
1
Target Outcome over three years
Example initiatives
Maximising the
contribution of
every CPFT staff
member to
patient care
75% of our substantive staff
productively deployed at any
one time
Safe establishments on Ward
and Community Teams at 2
3% less cost per annum
Focus on Performance
Management:
Discipline, Absence,
Capability
Setting Safe
establishment at less
cost through workforce
redesign and skill mix:
Every member of
staff will be
involved with,
committed to and
satisfied with their
work for CPFT
80% of staff to recommend
CPFT to family and friends
80% of staff state they have
the ability to make the
changes necessary for
excellent patient care
New Communication
mechanisms
Involvement in
decision making at the
front line
Employee Health,
Safety and Wellbeing
strategy
Every CPFT staff
member will have
the knowledge
skills and attitudes
to perform to the
required
performance
standards
Vacancy rates across CPFT are
less than 5%
95% of staff will be receive
appropriate training relevant
to their job role including
Governance
All Band 7 and 8A’s will have
completed an appropriate
Leadership Development
Programme
Strategic recruitment
and Induction
Delivering great
management and
leadership
development
Delivering personal
development and
training for all staff
Our key workforce
processes will be
slick and efficient
Recruitment ‘Time to Fill’ <
12 weeks currently 16 weeks
Discipline Cycle Time < 63
Performance
Management of
workforce processes
From the key letters in the words Productivity, engAgement, Capability and Efficiency
WORKFORCE PROCESSES
AGENDA ITEM
days currently 113 days
Implementation of NHS
Sickness and Capability cycle
Jobs 2
time will be reduced by 20%
Our current performance against some of these key metrics is reproduced from the Quarterly Workforce
Review from the October Board Meeting at appendix 1.
The specific focus of this Board report is the work that has been undertaken as part of the preparation for
the new Workforce Strategy, to review a number of key workforce processes specifically Recruitment and
Discipline following feedback from a range of internal stakeholders including board members that these may
not be functioning as effectively as possible. This review involved an online survey of 83 managers and focus
groups with a small sub set of managers and representatives from SERCO who manage recruitment
processes on behalf of CPFT.
4. RECRUITMENT
Current Process
Along with all other SERCO partners, CPFT’s end to end Recruitment processes from advert to contract issue
following appointment are run on behalf of the Trust by SERCO. CPFT Managers determine shortlists, select
interview dates, conduct interviews and decide who to appoint. They interact with SERCO directly in relation
to these key stages. Current recruitment ‘time to fill’2 is 16 weeks (80 working days).
To gather some qualitative feedback, we surveyed 83 CPFT Managers regarding a range of workforce
processes. Their feedback on current recruitment processes within the Trust is as follows:
Serco Employment Services does a good job in administering the
Grand total, Agree, Recruitment
25
process
Strongly Agree
Grand total, Disagree,
Agree
16
Neither agree nor disagree
Grand total, Neither
agree nor disagree, 8
Grand total, Strongly
Agree, 3
Disagree
Strongly Disagree
Grand total, Strongly
Disagree, 5
2 The time to fill metric represents the number of days from when the job plan was opened until the offer was
accepted by the candidate.
WORKFORCE PROCESSES
AGENDA ITEM
Of the 57 respondents to this particular question, 49% (28) either strongly agreed or agreed that Serco
Employment Services does a good job in administering the recruitment process whilst 37% disagreed or
strongly disagreed.
When asked whether they were satisfied with the length of time it takes to fill open positions, CPFT
Managers responded:
I am satisfied with the length of time itTotal,
takes
to fill open
Disagree, 31
positions
Total, Strongly
Strongly Agree
Disagree, 21
Agree
Total, Agree, 9
Total, Neither agree
nor disagree, 9
Disagree
Strongly Disagree
Total, Strongly Agree,
3
73 Managers responded to this question. 71% (52) either strongly disagreed or disagreed with the statement
that ‘I am satisfied with the length of time it takes to fill open positions.’
Challenges and Solutions
There is clearly widespread concern regarding recruitment ‘fill times’ across the Trust. We have therefore
recently run a ‘hire to retire’ workshop with a cross section of Team/Ward Managers, SERCO staff and Senior
CPFT HR Staff to identify problems and propose solutions. The current process ‘pinch points’ include:
•
•
•
•
Managers perceptions of the current flexibility within the recruitment process (e.g. there is a
misconception that the current post holder must have left the trust before the recruitment process for a
replacement can be started)
Recruitment controls put in place as part of the CIP programme have lengthened recruitment timelines
Lack of standardisation in the time that it takes CPFT appointing officers to provide key information, e.g.
managers are notifying Serco of the successful candidate on average within 10 working days following
interview (range 0 22 days)
Lack of proactive organisation by CPFT appointing officers e.g. the elapsed time between application
closing date to interview date is an average 19 working days (range 10 27 days)
The workshop came up with a range of solutions which the Executive Team has agreed to work with division
to implement:
•
Devolve vacancy control to Divisions following implementation of a new, streamlined establishment
control process (from mid December 2012)
WORKFORCE PROCESSES
AGENDA ITEM
•
•
•
•
•
Setting key dates such as short listing and interview dates in advance will be made mandatory on
ERICa/NHS jobs 2 when a recruitment plan is set up (January 2013)
Implement quality at source by getting things right first time – P forms (starter, leaver and amendment
forms) to be emailed to Employment Services (from Dec 2012) rather than sent by post.
Clarify flexibilities available to appointment officer regarding the recruitment processes. This has been
completed.
Implement greater online self service functionality for managers through the implementation of NHS
Jobs 2 when it is available in 2013.
HR will performance manage the new recruitment process both with SERCO and with Divisions through
regular performance metrics at Trust and Divisional level from December 2012.
The changes and adoption of a new standard operating process for recruitment will reduce ‘fill time from 16
weeks (80 working days) to a maximum of 12 weeks (60 working days) from 1 December 2012. From 1 April
2013, we will work with SERCO to further reduce this to 50 working days (10 weeks). Performance against
this will be monitored through Divisional Performance meetings and through the Workforce Dashboard (see
appendix 1).
The trust is currently undertaking a targeted recruitment campaign to fill a significant number of nursing
vacancies. A key component of this will be regular recruitment fairs in Cambridge and Peterborough for
nursing staff from January 2013. This is a joint initiative between Divisions, the Nursing and People Services
teams. This will also enable us to publicise the CPFT brand to potential employees.
5. DISCIPLINARY, PERFORAMCNE AND SICKNESS PROCESSES
Current Process
The disciplinary process aims to manage cases, fairly and equitably whilst ensuring the Trust appropriately
manages risk. The process commences with the raising of allegations and/or concerns about an individual
member of staff, their formal investigation and then completion of the subsequent disciplinary hearing. The
process is management led with support and advice from CPFT HR. The current average cycle time for the
process described above is 113 days.
The recent survey of 83 CPFT Manager regarding a range of workforce processes also provided feedback on
disciplinary processes within the Trust. When asked whether they were satisfied with the length of time it
takes them to complete disciplinary processes, CPFT Managers responded:
WORKFORCE PROCESSES
AGENDA ITEM
I am satisfied with the length of time that it takes me to complete
Total , Disagree, 26
my Team's disciplinary processes
Strongly Agree
Agree
Total , Neither agree
nor disagree, 11
Disagree
Total , Agree, 9
Total , Strongly
Strongly Disagree
Disagree, 7
Total , Strongly Agree,
2
55 managers responded to this question. 60% (33) either strongly disagreed or disagreed with the statement
that ‘I am satisfied with the length of time it takes me to complete my Team’s disciplinary processes. 20%
either agreed or strongly agreed with the statement.
There are clearly concerns regarding the length of time that completion of disciplinary cases is taking. This
was endorsed by the findings of a recent Internal Audit Report into this matter. A clue as to why the process
is currently taking so long is given by managers in response to the question:
I don't always have the time to handle disciplinary, capability
Total , Agree, 35
and sickness issues as quickly or as effectively as I would like
Strongly Agree
Agree
Total , Strongly
Agree, 8
Total , Neither agree
Disagree
Total , Disagree, 12
nor disagree, 12
Strongly Disagree
Total , Strongly
Disagree, 3
70 managers responded to this question. 61% (43) either agreed or strongly agreed with the statement that
‘I don’t always have the time to handle disciplinary, capability and sickness issues as quickly or as effectively
as I would like’. Capacity is clearly a problem in handling these cases but manages state that they
nevertheless feel they have the skills to have these ‘courageous conversations’
WORKFORCE PROCESSES
AGENDA ITEM
I feel confident handling employee capability and disciplinary
related issues
Strongly Agree
Agree
Disagree
Strongly Disagree
Of the 70 managers who responded to this question, 63% (44) either agreed or strongly agreed that they feel
confident handling employee capability (including sickness) and disciplinary related issues. 16% (11)
disagreed or strongly disagreed with the statement.
Managers views in terms of the fitness for purpose of HR policies and procedure in relation to discipline and
capability vary. 40% agree with the statement below that HR policies and procedures are fit for purpose in
handling employee performance and disciplinary issues, 30% disagree or strongly disagree.
HR policies and procedures are fit for purpose in handling
Total, Agree, 26
employee performance and disciplinary issues
Total, Neither agree
nor disagree, 18
Total, Disagree, 20
Strongly Agree
Agree
Disagree
Strongly Disagree
Total, Strongly Agree,
0
Total, Strongly
Disagree, 1
As a footnote to this discussion, when asked whether they felt that HR provides them with the support that
they need to handle discipline, performance and sickness issues, 56% of managers (39) in the survey either
agreed or strongly agreed with the statement, 13% either disagreed or strongly disagreed.
Challenges and Solutions
WORKFORCE PROCESSES
AGENDA ITEM
The Trust wishes to ensure that its workforce processes are as efficient as possible to maximise patient facing
time for staff. Disciplinary processes are clearly taking longer than they should. The length of time it takes to
complete the process from start to finish is currently 113 days. This is unacceptable. The key pinch points in
the process are the time taken to diarise investigations and disciplinary hearings in Managers, Trade Unions
and HR schedules.
Following an intensive review the following remedial actions have been agreed with the Trust Audit and
Assurance Committee:
•
•
•
•
A streamlined policy, procure and standard operating procedure has been agreed with the trade unions.
The revised standard operating procedure is as follows:
Each case will be fully scoped at the start of the process including investigation and hearing
timelines and an end date of the complete process identified. This will include liaising
appropriately with trade union colleagues.
A standard of 63 days from start to process completion (disciplinary hearing) will be adopted
(current is 113 Days). This may be varied for complex cases
A performance management process for case management will be implemented. Line Managers
will be required to seek formal approval from the Director of People and Business Development
to break the 63 day standard. Cases moving beyond this will be subject to ‘Red Action’ meetings
to ensure timely completion
Performance reports will be produced for the monthly divisional performance/Board meetings
to include recruitment time to hire, disciplinary cycle time and sickness management cycle time
Managers and HR will be held accountable for the relevant steps within the process and overall
management of the process.
Ensure managers understand the importance of tackling and managing a disciplinary process and that it
is appropriately prioritised.
As part of the much wider restructuring of People Services, a specialist team will be set up called the
People Performance Team dedicated to working assertively with managers to tackle discipline,
performance and absence issues.
6. GENERAL VIEWS ON HR
As part of the survey of 83 CPFT managers, Managers were also asked generally for their views on HR. The
chart below describes the responses of this cohort of 83.
71% (59) either agreed or strongly agreed with the statement that HR’s advice enables me to address the
issues at hand whereas 12% either disagreed or strongly disagreed with this statement.
WORKFORCE PROCESSES
AGENDA ITEM
HR's advice enables me to address the issues at hand
Strongly Agree
Agree
Disagree
Strongly Disagree
It is planned to undertake this survey on a quarterly basis.
7. RECOMMENDATIONS
The Board is asked to endorse the enclosed report and proposed actions
.
WORKFORCE PROCESSES
AGENDA ITEM
APPENDICES
APPENDIX 1: TRUSTWIDE POSITION
Productivity
As at end of As at end of
QTR2
QTR1
Engagement
Target/
Budget Trajectory
% Sickness Rate
4.22%
3.57%
<4.35%
% Turnover Rate
9.97%
8.49%
10.50%
% Vacancy Level
13.11%
11.27%
5%
Establishment (WTE)
1900.25
1908.34
2186.99
Bank and Agency Rate (WTE)
186.75
199.06
17.44
Target/
Budget Trajectory
Jul 12
Apr 12
% Recommending CPFT as a place to work
46%
57%
85%
% feeling able to make changes necessary
for excellent patient care
49%
57%
85%
Trustwide Workforce
Scorecard
Process Efficiency
As at end of As at end of
QTR2
QTR1
Target/
Budget Trajectory
Capability
As at end As at end
of QTR2 of QTR1
Target/
Budget Trajectory
Average Recruitment 'Time to fill' (Weeks)*
16
N/A
12
% of staff compliant with Mandatory
Training Gateway Modules
96%
84.25%
95%
Average Disciplinary Cycle Time (Days)
113
N/A
63
% of staff compliant with Mandatory
Training Clinical/Physical Skills Modules
78%
71%
95%
% of staff having an Appraisal*
34.16%
0%
95%
Average Capability Cycle Time
Monitoring process is currently being developed
which will be included next quarter.
Manager Satisfaction with HR
Evaluation process being developed which will be
included next quarter.
*plus notice period which can range from 4 12 weeks depending on seniority
*This includes staff who have started their appraisal but not yet completed it.
Agenda Item: 13
BOARD OF
DIRECTORS
MEETING
Date:
Subject:
Prepared by:
FOIA Status
REPORT
28th November 2012
Framework for Quality Governance
Mel Coombes / Tom Abell
Public
world class
deliver our vision
with this paper:
regulations
functions
All CQC standards
professionalism.
None identified
None identified
None identified
Other
pros and cons
The consultation draft of this
document was considered by the BoD
in September 2012
The actions included within this report
will be reported as part of the Quality
& Safety report in the future.
Background papers
RECOMMENDATION
Approve the Framework for Quality Governance
1.0
INTRODUCTION
It was agreed by the Board that the Framework for Quality Governance would
be amended and returned to the Board for final approval following comments
being received from key stakeholder groups in November. The attached
Framework reflects the comments received by the Trust in response to us
sending out the Framework.
The development of this Framework was a key recommendation from the
Quality Governance Review that was commissioned by the Trust with the
purpose of this Framework being to:
Define what quality means to the organisation and the associated quality
goals and expectations of staff.
Provide the framework within which systematic quality improvement can be
achieved and the mechanisms and approaches by which the Trust would
secure this and how the Board will be assured that progress is being made.
Provide a vehicle to communicate to staff, service users and stakeholders on
how the Trust approaches and views quality.
2.0
ISSUE
Feedback was principally received from Governors and LiNKS across which
they was much commonality in general consensus on how the Framework
could be strengthened. These key themes, alongside changes to the
Framework (or proposed alternative steps) are detailed below:
Theme
Response
Length of document and therefore
accessibility for staff and service
users.
It is considered important to have a
comprehensive document as recommended
by the Quality Governance Review, however
Theme
Response
the Trust recognises that most staff and
service users do not need to access such an
lengthy document. It is therefore proposed
that:
Greater reference and focus on carers
should be evident within the
document.
Raise the profile of CPFT with a
programme of clinically led seminars
for the public.
In addition to clinical effectiveness,
continually assess service provision
from a patients’ and families’
perspective.
Encourage the voluntary sector to
work more closely with the Trust
The Trust should better tell staff how
the Trust is performing and set up
arrangements to share best practice.
-
A ‘easy read’ short document for staff
and service users which focuses on
headline quality priorities.
-
Critical governance requirements for
teams and divisions as outlined within
the Framework will be covered as part of
the Governance Training within the
CPFT academy. The first iteration of this
training will be held between December
2012 and February 2013 for staff to
grades 7 and above.
The Trust recognises and agrees with this
comments and therefore it is proposed that a
key action arising from the Framework is the
development of a Patient and carer
engagement strategy which should include
how the profile of CPFT is raised within the
community and how we will seek to assess
service provision from a patients’ and
families’ perspective.
In addition this strategy should include how
we will work more effectively with the
voluntary sector.
Again, the Trust agrees with this comment
and has committed through the Quality
Diamond document (which is now
referenced more strongly within the
document) to providing better information to
teams on how they are doing. This will
include team and divisional level dashboards
and the procurement of a Business
Intelligence system.
In addition, following internal review and comments from staff a number of
changes have been made to the Framework, particularly focusing on the
overarching approach to improvement within the Trust and some of the
specific improvement measures to make them more manageable and
systematic.
A further key change within the document is ensuring a greater consistency of
this document and that of the Quality Diamond, this has included:
Structuring the delivery plan (section 6) principally by the key areas of the
quality diamond relating to Quality.
Clearly articulating the measures that will be used by the Trust to assess
whether progress is being made in these areas.
Simplifying the approach and techniques which it is proposed to be used by
the Trust to support the implementation of the Framework.
Simplification of section 4 (Defining quality) and section 5 (Improving quality)
by focusing more on a single improvement technique and approach rather
than multiple approaches as proposed in the previous document.
The overall delivery plan outlined within Section 6 of the document is
deliberately high level and the detailed plans, timescales and owners will be
available through the Trusts’ Quality Diamond document and delivery
monitored via the existing programme management arrangements which will
be regularly reported to the Board of Directors.
Next steps
If approved it is proposed that the following next steps are instigated:
3.0
-
Development of ‘easy read’ version of the framework for staff, patients
and carers.
-
Development of a detailed implementation plan for the actions arising
from the Quality Framework, progress on which will be reported through
the Quality & Safety report.
-
Particular focus is placed on the development of the Patient and Carer
Engagement Strategy as a key next step deliverable arising from the
Framework.
Approve the Framework for Quality Governance and next steps as outlined
within this document.
!
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!
!
!
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!
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!
Framework for quality governance
Final
November 2012
!!
1
!
Foreword
The delivery of high quality care is the core
commitment of this Trust and as such this
document is a vital step in explaining not
only how quality is integral to the mission of
the people who work at the Trust, but the
framework within which quality
improvement will be made over the next
three years.
This framework represents the first time
that the Trust has brought together all of
the excellent quality initiatives and good
practices that have been introduced over
the years, alongside our learning over
recent years from where we have failed to
provide the quality of care that we would
expect into a single document, based on
our organisational values.
This framework sets out a need for us to
better define quality at a level of detail that
is appropriate and tailored to the people
that we serve and those who care for them,
for example an appropriate definition of
quality for a patient who is being cared for
by our dementia services will be very
different from that of a new mother who is
under the care of our health visiting
services.
Given that we provide care to some of the
most vunerable people in our society, we
need to always consider the balance which
needs to be achieved between managing
risk, measuring harm and providing a high
quality service and it should be recognised
that at times that our people will at times
take well-managed risks in order to provide
a quality service that promotes recovery and
well-being for our people who use our
services.
However, at the core of this framework is a
focus on relationships based on values. This
particularly concerns the therapeutic
relationship that our people create with
those that use our services and the wider
partnerships we help that person build with
services that support them. This partnership
between our people, our service users and
those that care for them alongside partner
organisations is the foundation of a quality
service.
2
!
This framework sets out a challenging
agenda for the Trust over the coming three
year period as we look to not only
strengthen our internal processes and
systems to ensure that people who use our
services are safe but equally how we
support our people to develop partnerships
with patients and carers which result in
positive outcomes for them and help them
develop the relationships they need with
other agencies to achieve the outcomes
they seek.
Through the annual quality account process
we will tell you not only how we have done
in delivering improvements in quality over
the previous 12 months but equally our key
priorities for improvement for the following
year. Therefore this document should be
read alongside the quality account.
On behalf of the Board we hope that our
people, service users, carers and all the
other stakeholders in Mental Health,
Learning Disability and Children’s Services
will read this framework and refer to it
often. Our quality mission is a never ending
one and therefore if you have ideas on how
we can improve services, or this guide, we
want to hear from you.
David Edwards
Chair
Attila Vegh
Chief Executive
Executive summary
Quality is at the core of what we do, it is
inherent within our values, our mission and
our vision. It is what service users and
carers want and it is what motivates staff at
their best.
our services, and those who care for them
which identified a number of themes for
quality improvement which included:
•
Providing better information about
medicines and more involvement in
making decisions about their care.
This document sets out, for the first time, to
all of us who work at the Trust, to the
people who use our services and care for
those people and to our stakeholders what
we mean when we say we want to deliver a
quality service and how we will go about
delivering, measuring and assuring
ourselves that this is what people who use
services receive. We have defined quality
as:
•
Communication, particularly who to talk
to if they have a problem.
•
Ensuring that we adequate involve
service users, carers, friends and
advocates in the care review process.
“Health and social care that is service user
centred, safe, effective and promotes
recovery”
•
Focusing our services on recovery and
working better across teams and
partner agencies to provide service user
centred care.
•
Providing better support to our people
so they understand how they are doing
and giving them more freedom and
accountability to improve services.
•
Focusing on the therapeutic relationship
that our people create with people who
use our services to improve care.
To deliver this mission we need to work on
a number of key areas, based around the
themes of our Quality Diamond:
We also have tried to reflect what our
people have said to us about quality over
the past few months, which has included:
We have also considered and reflected the
views of stakeholders such as those who
buy services from us; and the organisations
who regulate what we do as an
organisation.
We are improving services, but we
recognise that we have a lot more to do
We have listened to what people say about
quality at the Trust
In developing this document we started by
listening to the views of the people who use
3
!
The Trust has worked hard since the end of
2011 to improve the quality of services
following the findings of inspections that
were undertaken by the Care Quality
Commission. Since then we have
significantly improved the quality of our
services in a number of areas but recognise
that there is much more to do.
Key themes identified within this document
from our work for quality improvement
include:
•
Understanding the cause of variation in
incidents involving self-harm,
absconding and other areas and how to
reduce these.
•
Developing a better understanding of
the relationship between staffing levels,
skill mix and the processes and
outcomes for people who use our
services.
•
Improving our arrangements for the
monitoring of quality and managing risk
across all services, particularly those
provided within the community.
We will focus on patient safety
A fundamental element of the approach
outlined within this Framework is ensuring
that everyone who works at the Trust is
focused on patient safety, and we are
proposing to adopt the “7 steps to patient
safety in mental health” which is published
by the National Patient Safety Agency to do
this. The seven steps are:
1.
2.
3.
4.
5.
Build a safety culture
Lead and support your staff
Integrate your risk management activity
Strengthen reporting
Involve and communicate with service
users and the public
6. Learn and share the safety lessons
7. Implement solutions to prevent harm.
To support this further, we recognise the
need to strengthen nursing and allied
health professional leadership throughout
our organisation and intend to embed the
principles arising from ‘Developing the
Culture of Compassionate Care’ which will
shortly be published by the NHS
Commissioning Board
4
!
A clear approach to quality improvement
This Framework proposes that the Trust
adopts the seven steps to quality
improvement as outlined within “High
quality care for all” as the mechanism
within which we will seek to improve the
quality of our services.
This framework also sets out what we
expect of all levels of the organisation, from
individual clinicians to what is expected of
the Board and the Framework sets out
standards for governance at Team,
Divisional and Trust level and how we will
use our reinvigorated risk management
arrangements as the back-bone for assuring
quality and identifying problems and how
we will put those problems right.
Finally, we recognise that in order to do
these things there are some things that the
Trust needs to do in order to support staff
to be able to deliver a quality service, these
include:
Develop diagnosis,
problem and needbased pathways. In
each pathway the
treatment will be on
a clear evidence
base.
Provide all teams
and divisions with a
‘quality dashboard’
Making sure that
our staffing levels
are based on
international
research into patient
care and staff
requirements.
Introduce new
systems to assess
how we are doing
against quality
standards.
Introduce new ways
to listen to patients’
and carers
comments about our
services.
Promote and
increase our focus
on recovery and
integration of our
services.
Improve the way we
investigate and learn
from incidents.
Introduce a ‘stop the
line’ initiative.
Implement our new
electronic patient
record system
Create a CPFT
Academy to support
staff development.
Introduce new ways
of recognising and
rewarding success.
Putting this into practice
Whilst this Framework sets out what quality
means and the processes and systems we
will use to make sure we continuously
improve quality – it does not detail
individual quality improvements which we
will pursue during the life of this
Framework.
To identify these individual quality
improvements we will work on these in
partnership with our people, our service
users, carers and stakeholders to generate
these and will publish them on an annual
basis through the Trusts’ Business Plan and
Quality Account. Both of these documents
are public so that we can be held to
account to deliver these.
The differences between these two key
roles is defined below:
7
The Framework for Quality
Governance will state:
•
•
Where we want to be;
The approach we will take in
order to deliver quality
improvement.
!
The Business Plan and
Quality Account will state:
•
•
•
5
!
How we are doing against our
definition of quality;
The things we will do each
year to get to where we need
to be;
The risks that we face as an
organisation to deliver what
we aspire to.
Index
Section
1.
2.
3.
4.
5.
6.
6
!
Title
Foreword
Executive summary
Putting this into practice
The vision
What do people say about quality
Our quality journey
Defining quality
Improving quality
The plan for quality
Page
2
3
5
7
8
13
15
21
27
1. The vision
Every NHS Trust and everyone who works within it have a duty of quality, first defined in the
1999 Health Act and renewed and reinvigorated in the 2008 Darzi report ‘High Quality Care for
all’.
The duty of quality has two parts: to meet standards and maintain high standards of care; and
to strive to improve the quality of services
Darwin Nurseries provides horticultural day
placements to people with learning
disabilies and mental health issues.
Quality is at the heart of the NHS. Quality,
together with safety is paramount. It is
what service users and carers want and it is
what motivates staff at their besti.
The heart of a quality service lies in the
relationship between a member of staff and
a service user. Quality comes when this
relationship is based on values of trust,
respect, and mutual endeavor to improve
the service user’s health, well-being and
quality of life. This is supported by the
requirement for everyone who works at the
Trust to:
•
Do their job well; and,
•
To improve their job.
Quality is central for Cambridgeshire &
Peterborough NHS Foundation Trust. The
Trust’s vision is:
We become a top five mental and
community healthcare provider delivering
best-in-class care, research and education.
This vision is underpinned by 4 key values.
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The
Trust’s
key values: by four key
This
visionfour
is underpinned
values.
1. Patient First - We focus on the needs of
the whole person, we aim to consistently
exceed the expectations of our service
users and their carers by making every
interaction with them count.
2. Only the best - we have high standards in
all that we do, we are uncompromising in
our pursuit of excellence, we only do
what is known to work, we evaluate
everything that we do and share the data
with others to allow them to hold us to
account.
3. Staff matter - we trust, value and develop
each other, we build a great place to
work, where people are inspired to be the
best they can be, where they are engaged
in decisions that affect them and where
they are empowered to deliver better and
safer services.
4. Together, as one - we value our teams
and our partners and believe we can
achieve more by working together for the
benefit of the people we serve.
2. What do people say about quality?
A town hall event in June 2012 which were attended by over 2,000 of our people.
What service users and carers say
The Care Quality Commission (CQC)
undertakes an annual survey of community
service users which provides us with a
report about the experience of people who
use our services and compares these with
similar organisations across England. The
results from the 2012 surveyii highlight a
number of thematic areas for improvement
in comparison to other mental health and
community providers, these themes are:
•
•
•
Information about medicines and
involvement in the decision making
process about their care.
8
!
•
How we ensure that the quality of food
we provide to people who are
inpatients is of high enough quality.
Our other work with service users and
carers has shown there to be a number of
further priorities for them when assessing
the quality of our services, these include:
•
Communication, particularly
understanding who to talk to if they
have a problem.
Communicating in a way that our
service users and their carers
understand their care, and what to do if
they have problems.
•
Ensuring that we adequately involve
service users, carers, friends and
advocates in the care review process.
Seeing people as individuals and giving
them some choice and control over the
treatment they receive.
•
Feeling safe and secure when people
use our services.
•
Providing a good quality and
therapeutic environment.
In addition, to support our understanding of
the experience of service users and carers in
the decision making process we have
introduced regular surveys across all of our
services. These surveys have highlighted
further issues which require tackling in
relation to:
•
support to help improve their care, for
instance in relation to finding
accommodation, obtaining benefits or
support around employment.
How the Trust supports people who use
our services to access third party
What our people say
The Trust undertook a series of meetings
with over 2,000 of our people in town hall
events during June 2012 to understand
what quality means to them, a number of
key themes arose from these events:
•
Service users and carers should be
actively involved in their care and that
the Trust should actively listen and
change things based on this feedback.
•
The Trust should take steps to improve
the quality of the environment in which
we provide our services, in particular the
food we provide on wards.
•
Our services should be focused on
recovery and we should work better
across teams and with partner agencies
in providing holistic care.
•
We should ensure that we provide care
that is based on evidence and that is
known to work.
•
We need to better support our people
to understand how they are doing and
give them more responsibility and
accountability to improve services.
•
Focusing on the development of our
people, recognising good performance
and promoting staff wellbeing.
Together, as one, we build strong
relationships that improve the quality of
care that people who use our services
receive.
What government policy and the health and
social care regulators say
Given the diversity of the services we
currently provide there are a number of key
areas of government policy which are
relevant to our services, primarily in respect
to mental health and learning disability
services and in the area of children’s
services.
The NHS Constitution
The NHS Constitution sets out in one place
what staff, people who use NHS services
and the public can expect from the National
Health Service. It also explains what people
can do to support the NHS, help it work
effectively and help ensure that its resources
are used responsibly.
The Constitution sets out seven principles
that guide the NHS and which should be
reflected by the Trust in all that it does:
•
The NHS provides a comprehensive
service, available to all.
•
Access to NHS services is based on
clinical need, not an individual’s ability
to pay.
What the Board of Directors says
•
The Board of Directors has set out within
the Quality Account, values statement and
quality diamond it’s vision for the outcomes
for people who use our services.
The NHS aspires to the highest
professionalism.
•
NHS services must reflect the needs and
preferences of patients, their families
and their carers.
•
The NHS works across organisational
boundaries and in partnership with
other organisations in the interest of
patients, local communities and the
wider population.
•
The NHS is committed to providing best
value for taxpayers’ money and the
most effective, fair and sustainable use
of finite resources.
•
The NHS is accountable to the public,
communities and patients that it serves.
•
Improving and strengthening the
relationships between our people and
service users to improve care and
putting in place mechanisms which give
them more time to care.
These values are focused on:
9
•
•
Putting people who use services first,
taking their views into account and
involving them in their care.
•
Only the best, we provide safe and
effective services.
•
Staff matter, we develop our staff and
support them to do the right thing and
to improve their practice.
!
No health without mental healthiii
In February 2011 the Government published
No Health Without Mental Health which is a
cross-government, all-age strategy for
mental health in England. The strategy sets
our six objectives for improving mental
health and wellbeing, all of which are
related directly to quality:
•
More people have better mental health
•
More people will recover
•
Better physical health
•
Positive experience of care and support
•
Fewer people suffer avoidable harm
•
Fewer people experience stigma and
discrimination.
The strategy focuses on improving
outcomes for mental health service users
and promoting positive mental health and
wellbeing amongst the whole population.
A call to actioniv – health visiting
In February 2011 the Department of Health
published ‘A call to action – health visitor
implementation plan 2011-15’ which sets
out ambitious goals to strengthen the role
of health visiting services across England.
This plan sets out a number of areas of
focus for quality in respect to health visiting
services:
•
Building capacity and using that
capacity to improve health outcomes.
•
Building strong relationships in
pregnancy and early weeks to
strengthen universal services for all
families.
•
Providing holistic care for any family and
for more vulnerable families –
intervening early to prevent problems
developing or worsening.
•
Working well with other agencies
where there are safeguarding and child
protection concerns.
Alongside A call to action is the four
principles of Health Visitingv many of which
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can be usefully extended to other areas of
our services which consider the broader
societal factors that affect health and
contribute to wellbeing. These principles
are:
•
The search for health needs.
•
Stimulation of an awareness of health
needs.
•
The influence on policies affecting
health.
•
The facilitation of health enhancing
activities.
The essential standards of quality and
safetyvi
The Care Quality Commission (CQC) is the
independent regulator of health and adult
social care in England. They also protect
the interests of people whose rights are
restricted under the Mental Health Act. The
CQC have been asked by Government to
ensuring that people receive care that
meets essential standards of quality and
safety and encourage ongoing
improvements by those who commission or
provide care.
Every provider of health and adult social
care in England is required to be registered
by the CQC which is governed by the
Health and Social Care Act (Regulated
Activities) Regulations 2010 and the Care
Quality Commission (Registration)
Regulations 2009.
These pieces of legislation set out a series of
requirements that health and social care
providers are required to meet when they
provide care to people. The CQC have
codified these into 28 Outcomes which are
known as the ‘Essential standards of quality
and safety’. The CQC have themed these
outcomes into 6 areas:
•
Involvement and information which
focuses on ensuring providers involve
people who use services are involved in
making decisions about their care,
treatment and support.
•
Personalised care, treatment and
support which focuses on ensuring that
providers make sure that people who
use services get effective, safe and
appropriate care and treatment and
support that meets their individual
need.
•
•
Safeguarding and safety which focuses
on making sure that people who use
services, workers and others that visit
are as safe as they can be and that risks
are managed. This includes respecting
human rights and dignity of people and
how providers should respond when
people are in vulnerable situations.
Suitability of staffing which focuses on
ensuring that providers have the right
staff with the right skills, qualifications
and experience and knowledge to
support people. It also looks at training
needs for staff and how they should be
supported to carry out their role.
•
Quality and management which focuses
on how providers manage risk to ensure
that the essential standards are
maintained and information which
providers should give to the CQC about
important events.
•
Suitability of management which
focuses on what providers and
managers need to do to show they are
suitable to run the service and keep the
CQC informed about relevant changes.
Although there are 28 standards in total, 16
of these directly relate to the provision of
care and therefore are of primary focus of
this Framework.
Children’s services
In addition to the role played by the CQC
the Trust also has a role to play in working
with partner agencies in ensuring that our
services meet the requirements as set out by
the Office for Standards in Education,
Children’s Services and Skills (Ofsted).
Ofsted regulates and inspects childcare and
children’s social care and in particular
services for looked after children,
safeguarding and child protection.
The principle requirements in relation to
quality as outlined by Ofstedvii for providers
are:
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•
Protecting children and young people
from maltreatment.
•
Preventing impairment of children and
young people’s health or development.
•
Ensuring that children and young
people are growing up in circumstances
consistent with the provision of safe
and effective care.
•
Undertaking that role so as to enable
those children and young people to
have optimum life chances and to enter
adulthood successfully.
Monitor
Monitor is the organisation that regulates
the Trust as a Foundation Trust and it too
expects the Trust to meet quality standards
and requires the Board of Directors to self
certify that it has effective arrangements in
place to monitor and continually improve
the quality of healthcare provided to service
users. A key tool which Monitor expects
NHS Foundation Trusts to use in
undertaking these assessments is the
Quality Governance Frameworkviii which
describes quality governance as:
“the combination of structures and
processes at and below board level to lead
on trust-wide quality performance
including:
•
Ensuring required standards are
achieved;
•
Investigating and taking action on substandard performance;
•
Planning and driving continuous
improvement;
•
Identifying, sharing and ensuring
delivery of best-practice; and
•
Identifying and managing risks to
quality of care.”
Monitor frames this description of quality
governance around four areas: strategy,
capabilities and culture, processes and
structure and measurement.
•
Building the capability and capacity of
our people to build high quality
therapeutic relationships with people
who use services which are based on
trust and where service users are
actively involved in their care.
•
Putting in place the systems, processes
and tools for our people to do their jobs
effectively and so we can ensure
standards are met and risks to the
quality of care are identified and
managed.
•
Being a more outward facing
organisation which engages more in the
communities it serves and forging
strong partnerships with others which
support the provision of high quality
care.
What our commissioners and stakeholders
say
As part of the process of publication of our
Quality Accountix for 2011/12 we invited
statements for inclusion from the Trust’s
principle commissioners; NHS
Cambridgeshire & Peterborough,
Cambridgeshire County Council Adults
Wellbeing and Health Overview and
Scrutiny Committee and the Local
Involvement Networks (LINks) for
Cambridgeshire and Peterborough.
A number of key themes arose from these
statements, these were:
•
Resolving the challenges faced by the
Trust with respect to the Essential
Standards of Quality and Safety as
inspected by the Care Quality
Commission.
•
Concerns regarding the capacity of the
trust to deliver the intended
improvements in quality outlined within
the quality account.
•
The pressures that our people are
currently under in undertaking the level
and amount of care currently required
by our service users.
•
The need to ensure culture change,
alongside better integration of Trust
services within the wider health and
social care community.
•
Strengthening the role and involvement
of service users and carers in shaping
the future of Trust services and in
tackling some of the quality issues we
face.
•
Reviewing and improving our
arrangements of clinical risk assessment.
Drawing together the views of people
Our analysis of the various feedback and
information we have from all the different
groups that we need to listen to in order to
provide a quality service, we believe a
number of themes are emerging, these are:
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3. Our quality journey
Cambridgeshire & Peterborough NHS Foundation Trust has faced many challenges over the last
few years with respect to quality, although many improvements have been made, we know
there is much more to be done in order to achieve our mission.
Denbigh ward in Cambridge had a total refurbishment in
spring 2012 as part of our environment improvement project
Regulatory action
In February 2011 the CQC found that the
Trust failed to achieve five of the essential
standards and following a period of noncompliance with some of these standards
the Trust received two warning notices from
the CQC in January 2012 in respect to the
environment and care planning on our
wards.
Following these findings the Trust
implemented a turnaround programme
designed to address these shortcoming
which involved a significant investment in
our ward buildings and introducing new
mechanisms for monitoring the quality of
care planning.
However, despite significant improvements
which have been noted by the CQC there
remains a number of concerns regarding
certain aspects of Trust services for which
an extensive programme of work is now
underway.
Due to the time it took for the Trust to
resolve these concerns the Trust was found
to be in significant breach of its Terms of
Authorisation by Monitor for failing to
delivery its governance duty.
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To understand the governance challenge
faced by the Trust we commissioned an
independent review of the quality
governance arrangements within the Trust
which noted a number of areas requiring
significant improvement for which the Trust
has developed and implemented an
Integrated Governance Action Plan.
Areas for improvement
The Trust has undertaken a comprehensive
‘heat mapping’ exercise across all Trust
services to understand some of the key
quality issues which it faces. Key known
issues include:
•
Understanding the cause of and how to
reduce the levels of variation in
incidents involving self harm,
absconding, violence, behavioural
disturbance and rapid tranquilisation.
•
A need to better understand the
relationship between staffing levels, skill
mix and the processes and outcomes of
care.
•
A recurring theme within serious
incidents and complaints associated
with communication, care planning,
assessment, risk assessment and the
sharing of information between teams.
Understanding the impact of areas of
partial compliance with NICE guidance
and the impact this has on Trust
services.
•
Top 5 themes arising from root cause
analyses
•
Risk assessment
•
Clinical assessment
•
Communication between services
•
Care planning
•
Clinical notes / record keeping
•
Observations: handover/policy/criteria
We also know from our own systems and
processes that we have more work to do in
a number of further areas:
•
Improving our arrangements for
monitoring quality and managing risk
across all services, particularly for
services provided within the community.
•
Ensuring that care planning in the
community is fit for purpose.
This document provides the framework
within which these issues will be addressed,
and also outlines specific projects we will
implement to improve the quality of care
we provide.
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4. Defining quality
The Trust’s definition of quality has been developed from the views of service users and carers,
of staff and of the Board. It is informed by NHS policy and health and social care regulation.
Quality in Cambridgeshire & Peterborough NHS Foundation Trust is defined as health and social
care that is service user centred, safe, effective and promotes recovery.
As part of the town hall events we have
held with our people, we have introduced a
‘quality diamond’ which has four key
domains focused on:
•
Net Promoter Score
•
Complaints / PALS enquiries
1. Patient experience
•
Percentage of patients reporting that
their care plan sets out their goals and
that we have helped them start
achieving these.
2. Staff experience
3. Safe and effective care
4. Cost of delivering care
This section of the framework explains how
we as a Trust defines quality under these
four domains.
What do we plan to do about
experience?
•
We will change the way we work
and develop diagnosis, problem and
need-based pathways. In each
pathway the treatment will be based
on the best evidence and delivered
by specialists in that area.
•
We will make sure our staffing levels
on all teams are based on
international research into patient
care and staff requirements.
•
Develop a patient and carer
engagement strategy.
Patient experience
Service user and carer experience
The experience of the people who use our
services is central importance to the Trust,
our stated mission is that we delivery care
that we are proud to recommend to our
family and friends.
It is proposed that the Trust sets ambitious
targets agains the following key areas to
assess service user and carer experience:
!
15
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stakeholders belonging to protected
characteristics.
What do we plan to do about
experience?
•
We will develop and implement a
new social care strategy.
!
The Board of Governors includes service
users and carers and provides an important
voice within the Trust. It has a key role in
ensuring that the Trust focuses on
improving the experience of service users
and carers and the Board of Directors
commits to working closely with them to
understand how their voice is heard
throughout our organisation, and to
strengthen this.
The Trust proposed to set ambitious targets
against the following key areas to assess
safety and effectiveness:
•
Harmful incident rates
•
InCA compliance
•
HONOS improvement and NICE
compliance
Equality and inclusion
Reducing inequalities and promoting social
cohesion and inclusion are vital aspects of
all Trust services and everyone who works
at the Trust need to be aware of the wider
social context in which they operate.
Under the Equality Act 2010, every public
sector organisation has a duty to promote
equity in employment and service delivery, a
specific requirement was the publication of
equality objectives by 2012/13. Based on
the analysis undertaken by the Trust and
local engagement groups 5 objectives have
been established for delivery in 2012/13:
16
•
Develop a central resource to provide
detailed equality data on people who
use our services, the communities we
serve and our people to inform the
design and delivery of an inclusive and
equitable environment for all.
•
Formulate an engagement plan for
service users, our people and relevant
!
•
Review and develop an equality and
diversity training strategy that supports
and underpins other relevant training
•
Improve translation and communication
services.
Support and establish a range of staff
networks for protected characteristics.
Outcomes, effectiveness and evidence
based care
The Trust will clearly articulate and establish
the structured way in which it will measure
the safety and effectiveness of our services
through the implementation of a
redesigned internal governance process (see
section 5). We will also clearly explain what
our people are accountable and responsible
for. The Patient Safety Group will be
responsible for considering and challenging
the safety and effectiveness of our services
and reporting this to the Clinical Executive.
Alongside assessing effectiveness the Trust
will also introduce a way to assess the
evidence base of care that people who use
services recieve and will oversee the
development of protocol driven treatment
across our services, this will be overseen by
the Clinical Effectiveness Group which will
also report to the Clinical Executive.
What are we doing about outcomes,
effectiveness and evidence based care?
•
•
•
We will change the way we work
and develop diagnosis, problem and
need-based pathways. In each
pathway the treatment will be based
on the best evidence and delivered
by specialists in that area.
We have rolled out the recording of
Health of the Nations Outcome Scale
(HONOS) recording across adults and
older people services and have a
target for all adults and older people
to have a HONOS cluster by April
2013.
We have agreed with our
commissioners as part of an
incentive scheme to roll out other
outcome measures during 2012/13.
!
As part of the development of diagnosis
based care pathways we anticipate that
there will be areas we identify where to
provide fully evidence based care pathways
will require additional investment in
services. We commit to an open debate
with our commissioners on these issues.
Managing risk and safety
Improving patient safety is a great challenge
to our people and we propose to improve
and strengthen our processes, systems and
practices to better support staff to ensure
they effectively manage risk and improve
the safety of our services to service users.
The Trust will adopt the framework outlined
within the ‘7 steps to patient safety in
mental health’x published by the National
Patient Safety Agency (NPSA)
Where are we now against the 7 steps?
We know that we have made
considerable improvements in a number
of aspects of care, most notably in
relation to issues identified around
specific CQC outcome areas.
Our challenge now is how we create a
continuously maturing safety culture
which we recognise will require work
against all seven of the steps outlined by
the NPSA here.
The seven steps and proposed outcomes is
outlined below.
Step 1: Build a safety culture
We will build a culture where our people
have a constant and active awareness of the
potential for things to go wrong, and both
our people and the organisation is able to
acknoledge mistakes, learn from them and
take action to put things right.
A key aspect to building this culture will
initally be using The Manchester Patient
Safety Framework to baseline our current
position and to measure our progress in
developing a safety culture.
The Manchester Patient Safety
Framework
This framework has been developed for
NHS organisations to assess their
progress in developing a safety culture.
It helps identify areas of particular
strength or weakness, and will inform
how we direct our resources to improve
the safety culture across the
organisation.
Step 2: Lead and support your staff
We will demonstrate strong leadership and
develop clear policies in relation to safety,
and a willingness to implement best
practice at a service level.
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A clear role for the Executive
We believe that demonstrating
leadership from the Executive is key to
creating a safety culture.
•
Preoccupation with failure
•
Commitment to resilience,
proactively seeking out potential
hazards and containing them before
they cause harm.
•
A culture of safety in which
individuals are able to speak up and
are listened to.
Medical Director
•
The Medical Director has overall
responsibility and accountability for
clinical effectiveness and ensuring
evidence based practice. The role also
has responsibility for professional
leadership of all medical and pharmacy
staff.
High reporting culture and an expert
led process of investigation which
focuses on the underlying structural
or process mechanisms.
•
Interventions which target the
system, leading to longer-lasting
impact on the delivery of safe, high
quality care.
Director of Nursing
The Director of Nursing will have overall
responsibility and accountability for
patient safety and the professional
leadership for nursing and other allied
health professionals.
The Director of Service Improvement has
responsibility for ensuring there are
robust mechanisms in place to monitor
and report performance and risk
throughout the organisation. The role
is also expected to lead the delivery of
trust wide improvement initiatives.
Step 3: Integrate your risk management
activity
We will refresh our risk management
system with the goal of integrating and
actively managing risk across the
organisation in order for us to become a
‘high reliability organisation’.
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Characteristics of a high reliability
organisation
Step 4: Strengthen reporting
Our goal is for all incidents to be identified,
recorded and reported within the
organisation with teams getting feedback
on these. We will proactively analyse
incidents and use the learning to identify
risks and manage these throughout the
Trust.
Step 5: Involve and communicate with
service users and the public
Our goal under step 5 is the same as that
outlined within Service user and carer
experience identified earlier in this section.
This goal is:
Everyone who uses our services is treated
with dignity and respect, in accordance with
their human rights. People who use our
services have a voice in the care they receive
and are supported to do this.
Guiding principles for solutions
Key areas where we will involve service
users and carers in safety
•
We will recognise service users as
experts in their own condition and
will use this expertise to help identify
risks and devise solutions to safety
problems.
•
We will involve service users in their
own care and treatment.
•
We will say sorry when things go
wrong and encourage an open, twoway dialogue between health
professionals and service users when
this happens.
Step 6: Learn and share the safety lessons
Reporting when things go wrong is
essential in healthcare, but is only part of
the process of improving patient safety. It is
equally important that we look at the
underlying causes of patient safety incidents
and learn how to prevent them from
happening again.
We will use the Root Cause Analysis process
to ask ‘how and why did this incident
occur?’ to pinpoint areas for change and to
develop recommendations for sustainable
solutions that will reduce the chances of the
incident happening again.
Step 7: Implement solutions to prevent
harm
Over two million articles are published
annually on medical issues and staying on
top and using this information is very
challenging for any NHS organisation,
including the Trust.
We will change practice quickly and reliably
based on the clinical prioritisation of
solutions to safety issues; be they designing
out the potential for harm, designing
systems for people to do the right thing or
raising awareness and understanding.
19
!
•
Solutions should be simple and lowcost.
•
They should be developed in a stepby-step approach.
•
They should require little training
and effort and be measurable.
Evaluate what we do and share the findings
Integral to our strengthened governance
arrangements (see section 5) will be
ensuring that we are consistently evaluating
what we are doing and we are sharing this
with people who use services, carers and
key stakeholders.
Staff engagement
To measure the impact we are having on
staff engagement we propose to set
ambitious targets in the following areas:
•
Friends and family test
•
Training compliance
•
Deployment rate
Excellence in all that we do
The Trust recognises that in order for our
people to be able to do a number of the
things we have outlined within this
document, they need to be supported by
the whole organisation to do this.
Key aspects of supporting staff
•
High standard, safe and fit for
purpose estates and information
technology infrastructure.
•
Giving our people the information
and intelligence they need to do
their job and to understand how
they are doing.
•
Supporting staff through high quality
specialist support in human
resources, finance, risk management
and staffing support.
Inspired to be the best they can be
Quality can only be delivered by skilled,
effective and motivated people, working in
partnership with service users and carers,
with their colleagues and with the wider
health and social care community.
Therefore, a key priority arising from this
Framework is the need to ensure that all
our people have the necessary skills and are
supported and empowered to make the
changes that improve quality, which is
codified in the following goal:
We will support leaders by giving them
tools and feedback on areas for
improvement and will put in place the
training and support they need to become
better leaders and inspire everyone who
works for them.
Engagement in decision making
The Trust recognises that in order to provide
high quality care it needs to listen more to
its people and act on this feedback, our
goal in this area is for:
Everyone who works at the Trust will feel
involved in setting our priorities for the
future, being informed about these
priorities and get regular feedback on how
both they individuals and we as an
organisation are doing.
Empowerment to deliver better and
effective services.
We recognise that in order for our people
to understand what is expected of them
and their responsibilities, they need to work
in an environment where they are
respected, valued and their well-being is
promoted. This has been summarised
within the following goal:
Our people will understand the values of
the organisation and the behaviours
expected of the organisation, of them and
of their colleagues to support these values.
We are good people to do business with
Working together with partners
In order to deliver high quality care, we
need to build strong and effective working
relationships with a significant array of
different partners from the third sector,
20
!
social care, housing, education and other
NHS organisations. As part of our work to
establish these relationships we intend to
build in these areas and requirements for
joint working within each of our diagnosis
based pathways in order to have an
informed debate with partners on how best
these needs are met.
We will also actively participate with
partners through the strategic engagement
networks and arrangements we have in
place.
5. Improving quality
This section describes the systems, processes and approach that the Trust will establish to make
sure it can both meet the standards and maintain a high quality of care, and innovate and
improve the quality of services.
Bring
to
clarity
y
qualit
ur e
Meas
y
qualit
h
Publis
y
t
quali
ce
rman
pe r f o
nise
Recog
a nd
d
r e wa r
y
t
li
a
qu
The seven steps
The Trust proposes to adopt the approach
to quality improvement as outlined in ‘High
Quality Care for All’ and described within
seven steps to improving quality, we believe
these to be consistent with and support our
values. The seven steps are described
below.
uard
Safeg
y
qualit
incentives are in place to support quality
improvement.
Step 5: Raise standards
Quality is improved by empowered patients
and empowered professionals. There must
be a stronger role for clinical leadership and
management throughout the NHS.
Step 1: Bring clarity to quality
Step 6: Safeguard quality
This means being clear about what high
quality care looks like in all specialities and
reflecting this in a coherent approach to the
setting of standards.
Patients and the public need to be
reassured that the NHS everywhere is
providing high quality care. Regulation – of
professions and of services – has a key role
to play in ensuring this is the case
Step 2: Measure quality
In order to work out how to improve we
need to measure and understand exactly
what we do. The NHS needs a quality
measurement framework at every level.
Step 3: Publish quality performance
Making data available on how well we are
doing widely available to staff, people who
use services and the public will help us
understand variation and best practice and
focus on improvement.
Step 4: Recognise and reward quality
The system should recognise and reward
improvement in the quality of care and
service. This means ensuring that the right
21
e
Provid
rship
leade
ality
f or q u
S ta y
a he a d
!
Step 7: Staying ahead
New treatments are constantly redefining
what high quality care looks like. We must
support innovation to foster a pioneering
NHS.
What methodologies will we use to deliver
high quality care?
Leading Improvement in Patient Safety
(LIPS) programme
It is proposed that the Trust reinvigorates
the LIPS programme provided by the NHS
Institute for Innovation and Improvement.
The programme is designed to build
capacity and capability within the
organisation to improve patient safety. The
programme aims to help NHS organisations
to develop organisational plans for patient
safety improvements and to build teams
responsible for driving improvements across
their organisation.
1. Decide Aim
2. Choose
measures
Building organisational capability
The Trust also recognises that a key
foundation of achieving sustainable
improvement in services will be through
providing our people with the support and
tools they need to improve services.
To achieve this it is proposed that the Trust
developes a ‘CPFT Academy’ which will
focus on leaders throughout the
organisation to ensure they have the right
skills and competencies to do a great job.
Strengthening nursing and allied health
professional leadership
The Trust recognises that a key component
of strengthening quality within the Trust is
to put in place the systems, mechanisms
and processes to strengthen nursing and
allied health professional (AHP) leadership.
To do this we propose to develop a plan to
strengthen this leadership which will be
build from the Chief Nursing Officer’s vision
contained within ‘Developing the culture of
compassionate care’ which will be shortly
issued by the NHS Commissioning Board.
The principles behind this are shown in the
diagram below:
3. Define
measure
6.
Review
measur
Clinical audit
7.
Repeat
steps 4-
4.
Collect
data
5.
Analyse
and
Clinical audit is defined as ‘the systematic
critical analysis of the quality of health and
social care, including the procedures used
for the diagnosis and treatment, the use of
resources and the resulting quality of life for
the service user’.
Clinical audit is a well established tool for
assessing the quality and effectiveness of
care and services. Many professional staff
are required to participate in audit as part
of their training and professional practice,
and the Trust has clinical audit facilitators to
support and co-ordinate this work.
The Trust recognises that over recent years
the clinical audit programme has been
driven mostly by national and regional
‘must-dos’ and it is proposed that greater
oversight and direction is provided to
clinical audit through the Patient Safety
Group which will directly link the clinical
audit programme to our informed analysis
of complaints and incidents.
Measuring quality
The Trust will continue to develop the ways
and methods it uses to measure service
quality and will deploy the following
methodology to the development and
review of measures.
22
!
Another key aspect of the role which will be
fulfulled by the Patient Safety Group will be
to ensure that the results of clinical audit
always go to teams and are disseminated
widely across the Trust. Clinical audit will
also be reported to the Trust’s Audit and
Assurance Committee so that clinical quality
issues have the same standing as financial
and corporate issues.
Clinical and integrated governance
Defining clinical and integrated governance
Clinical governance ‘provides a framework
through which NHS organisations are
accountable for continually improving the
quality of their services and safeguarding
high standards of care by creating an
environment in which excellence in clinical
care can flourish’. (Scally and Donaldson,
1998).
More recently, the focus in health and social
care organisations has been on integrated
governance. Proper integration can only
take place where there is a clear
understanding of the system and process
for the clinical aspects of governance –
those related to the delivery of high quality
health and social care. The quality, safety
and effectiveness of care should be the
dominant component in integrated
governance systems with the majority of
time taken up by these aspects.
The NHS Integrated Governance Handbook
(2006) defines intergrated governance as:
‘Systems, processes and behaviours by
which trusts lead, direct and control their
functions in order to achieve organisational
objectives, safety and quality of service, and
in which they relate to patients and carers ,
the wider community and partner
organisations.’
The handbook stresses the importance of
behaviours, quoting the sixth Shipman
report:
‘sound structures and processes are not, on
their own, enough to secure good
governance. A complaints system is of no
value unless those intended o use it
(customers, clients, patients, etc) know of
its existence and are trained to operate it
effectively. A whistle blowing policy will
not be used unless staff are made aware of
it and are confident that, if they voice their
concerns, those concerns will be taken
seriously and the organisation will deal with
them fairly.’
The purpose of clinical and integrated
governance within the Trust
23
!
The purpose of governance in the Trust is to
ensure that we consistently deliver the
Trust’s values, these being:
•
Focus on the needs of the whole person
•
We have high standards in all that we
do
•
We trust, value and develop each other
•
We are good people to do business
with.
In doing this, governance will:
•
Identify good practice and celebrate
quality improvements and innovation.
•
Highlight problem areas.
•
Set targets for improving quality and
measure progress towards meeting
those targets.
•
Report back to stakeholders including
service users, carers and our people on
whether it has met the improvement
targets and the impact this has had.
The process for clinical and integrated
governance
Governance is delivered in the Trust
through a process of team and directorate
governance meetings, reports and
processes. Making sure these systems are
embedded is a key area of focus for the
Trust at present.
The process for clinical and integrated
governance is shown below:
Step 1: The starting point
•
What are service users and carers telling
us about the quality of services we
provide?
Step 2: Other essential information for
governance
•
Evidence base for clinical effectiveness
•
Staff views and feedback
•
Risk logs
•
•
Analysis of reports based on our
measures, incidents and other local
databases.
Analysis and learning from national
reports and guidance.
Step 3: Two key questions to set direction
This Framework sets out a set of proposed
quality standards for team governance,
which will be known as ‘how are we
doing?’ meetings against which teams can
be assessed:
•
What do we need to improve?
Proposed standards for team governance
•
What do we want to improve?
1. The purpose of team governance is to
ensure and improve the quality of service
user and carer experience, service user
safety and to identify, mitigate or
escalate the risks to the delivery of this.
Step 4: Set SMART targets for improvement
•
Specific.
•
Measureable.
•
Achieveable.
•
Resourced.
•
Timely.
Step 5: Monitor, review and report back
•
Monitor progress.
•
Review impact.
•
Report back to stakeholders and
through the Trust’s governance systems.
The structures for delivering clinical and
operational governance in the Trust
The operational governance structures
which provide assurance and monitoring
are described in this section and through
the terms of reference which will be
developed for the various groups identified
within here.
Clinical and integrated governance is based
on governance in teams, so that it is close
to the service user and staff contact which
lies at the heart of improving quality.
Governance can be seen as a pyramid,
based on the interaction between staff and
service users.
Team governance
The Trust is aware that at present there is
some inconsistency in the delivery of team
governance and it is proposed that support
24
teams to ensure that their practice reflects
that of the best.
!
2. Team governance will follow the five
steps of the governance process, from
service user experience through to
monitoring progress.
3. Team governance should take place in a
spirit of openness, constructive challenge
and willingness to reflect and learn.
They shouldn’t be afraid to raise risks
and issues if they don’t believe they can
manage these.
4. Teams must produce a governance
report at least once a year.
5. Team governance meetings should take
place at least monthly and can either be
stand alone meetings or form part of
multi-disciplinary team meetings with
protected time for governance.
6. Team governance processes should be
multi-disciplinary and include
representatives of all staff groups, this
includes administrative and
housekeepers as well as health and
social care professionals.
7. Teams should discuss and agree how
service users and carers are involved in
their governance processes.
In order for teams to be able to effectively
undertake these meetings, the Trust
recognises that it needs to put in place
training, support and practical tools. This
support will include:
•
The development of training and
support to teams in undertaking these
regular meetings.
•
The provision of information to teams in
order for them to fulfill steps 1, 2 and 5
of the governance process.
•
Self assessment and peer review tools
such as the Integrated Compliance
Assessment (INCA) which provides
teams with a basis from which they can
consider their compliance with the
CQC’s essential standards.
•
A new process and system of risk
management which it is proposed will
form the back bone of governance
within the of the organisation.
The supporting process for management
and escalation of issues through the risk
management processes
At team level we need to:
•
•
•
Ask ourselves at our governance
meetings what does the information
we’re discussing say about the risks
to service users or the organisation.
Based on this we need to update our
risk register, and where we can
manage them safely ensure we have
put SMART mitigating actions in
place.
Alongside team governance, our divisions
also have governance processes and
systems in place.
The Trust has recently introduced ‘Divisonal
Accountability Governance Agreements’
(DAGA) which are designed to clearly set
out the expectations of the Board of
Directors in regard to both quality, safety
and risk management arrangements as well
as financial performance.
!
Divisions will also be required to consider
quality issues in internal governance
meetings which will look at team
governance and specific safety, quality and
effectiveness issues. This could include
reports from the CQC, incident reports and
complaints and must require consider risks
being identified by teams and any further
risks emerging from the divisional oversight
of a number of teams.
It is proposed that the standards for team
governance equally apply to divisional
governance and similarly the risk
management system is used as the
backbone for managing problems.
The supporting process for management
and escalation of issues through the risk
management processes
At divisional level we need to:
•
Ask ourselves at our governance
meetings what does the information
we’re discussing say about the risks
to service users or the organisation,
including those that have been
escalated to us by teams.
•
Based on this we need to update our
risk register, and where we can
manage them safely ensure we have
put SMART mitigating actions in
place.
•
Where we don’t have the ability to
manage these risks, we need to
escalate this to the Executive and
Board.
Where we don’t have the ability to
manage these risks, we need to
escalate this to the division.
Divisional governance
25
To support this each Division has a monthly
review through the Performance and Risk
Executive which all aspects of performance,
risk management and service planning are
considered.
As with team governance, the corporate
directorates will provide support with data
and advice for directorate governance
processes.
Key roles to support governance
within the Trust
Team leaders and managers
Trust-wide governance
Will be responsible for ensuring that
meetings are undertaken on a
monthly basis and are in line with the
principles outlined within this
framework and Trust policy.
As part of the Integrated Goverance Action Plan the Trust
has begun to implement a new committee structure based
around the Board of Directors and two committees, the
Audit and Assurance Committee and the Quality and
Performance Committee.
Divisional modern matrons
In order to support these new arrangements it is proposed
that the following overall structure is implemented within
the Trust based on fullfilling the four vital aspects to
effectively running the organisation:
Will have responsibility for providing
oversight, advice, monitoring and
challenge of divisional risks and that of
the teams which make up the
divisions.
Clinical directors
divisional meetings are undertaken on
a monthly basis and are in line with
the principles outlined within this
framework and Trust policy.
Patient safety leads
Based within the corporate nursing
function will have responsibility for
providing oversight, monitoring,
challenge and advice of divisional risks
and will work with modern matrons to
ensure consistency in approach.
the processes and tools in place to
support these arrangements are in
place. They will also be responsible
for ensuring that risk is considered at
the divisional performance meetings
and mitigated actions are tracked
through the Trusts’ performance
management processes.
This role is also responsible for
ensuring the flow of information
through the Trusts’ corporate
governance arrangements.
Director of Nursing and Medical
Director
Will ensure that they jointly undertake
at least a monthly review of divisional
risks and those that have been
escalated, supported by the Executive
Team.
26
!
•
Thinking, planning and assuring
•
Initiating and controlling action
•
Informing and monitoring
•
Relating and reporting
The proposed organisational map is overleaf.
Mechanisms to support assurance across divisions of safe,
effective, evidence based and professional clinical care
across the Trust
It is proposed that to support the need for the Trust to have
in place mechanisms to support cross divisional and trust
wide mechanisms that three new groups are formed which
will replace existing Trust infrastructure and overseen by the
Clinical Executive in order to provide clarity on how
business is done within the Trust and equally provide a clear
line of sight to the Board of Directors.
The role of the Board of Directors
The Board of Directors has clear responsibilities for clinical
and integrated governance, defined by the Monitor
Compliance Framework and Quality Governance
Framework and Department of Health guidance. Service
quality and safety issues must be its top priority, and time at
Board meetings allocated accordingly.
In addition, the Board must set strategic objectives for
quality improvement over the medium to long term. It
must set annual quality improvement objectives and
monitor and report on these through the annual Quality
Account process.
6. The plan for quality
Delivery of the seven steps to improve quality and our goals
At Cambridgeshire & Peterborough NHS Foundation, the seven steps and other goals outlined
within this document will be delivered over the next three years. The table below is an outline
delivery plan for the next 12 months that will be reviewed on an annual basis and developed
further to form the plan to implement this framework.
No.
Goal / Step
Delivery plan
1
Equality and inclusion
Deliver the single equality action plan.
2
Patient experience
Develop diagnosis, problem and need-based
pathways.
Measured by:
- Net promoter score
- Complaints/PALS enquiries
- Recovery score
Make sure our staffing levels on all teams are
based on international research into patient care
and staff requirements.
Develop and launch a patient and carer
engagement and involvement strategy.
Develop and implement a social care strategy.
3
Patient safety
Measured by:
- Harmful incident rates
- InCA compliance
- HONOS and NICE compliance
Provide all teams and divisions with a ‘quality
dashboard’.
Improve how we investigate serious incidents
and share learning from them.
Implement the InCA tool to assess compliance
against basic standards to care.
Implement a ‘stop the line’ initiative so that our
people can take action if they are concerned
about care being provided.
4
Staff engagement
Measured by:
- Friends and family test
- Mandatory training
compliance
- Deployment rate
27
!
Implement the new electronic patient record
systems and roll-out mobile working.
Create the CPFT academy
Recognise and reward outstanding achievement
Continue the town hall events and the guiding
coalition.
No.
Goal / Step
Delivery plan
5
Supporting initiatives
Implement the Manchester Patient Safety
Framework
Implement the new trust service operating
model, notably identifying patient safety
champions within each division.
Run dedicated governance training for staff from
band 7 upwards on governance, information
and risk management.
Implement a process for thematic analysis of
incidents, complaints and other data to provide
greater qualitative evaluation of issues facing the
Trust.
Develop an Estates, IT and Informatics Plan to
support the implementation of the Trusts’
Strategy (once this has been completed).
Develop a Nursing and Allied Health Professional
Leadership plan.
This plan is deliberately high level and the detail supporting these actions is available within the Trust’s
Quality Diamond document and plans which are being developed and monitored through the Trust
Programme Board. Progress on the implementation of these areas will be reported via Programme Board
to the Trusts’ Board of Directors on a regular basis.
28
!
References
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
i
!(High%quality%care%for%all,%2008)!
!CQC!community!survey!
iii
!No!health!without!mental!health!
iv
!A!call!to!action!
v
!Principles!of!HV!
vi
!CQC!essential!standards!
vii
!Ofsted!safeguarding!framework!
viii
!Monitor!QGF!
ix
!Quality!account!
x
!7!steps!to!patient!safety!on!mental!health!
ii
29
!
Agenda Item: 14
BOARD OF
DIRECTORS
MEETING – PUBLIC
Date:
Subject:
Prepared by:
FOIA Status
REPORT
28th November 2012
Audit and Assurance Committee update based on the
meeting of 8th November 2012
Darren Cattell, Interim Director of Finance
Public document
class
We will deliver care through engaged and
empowered people
We will develop strong relationships based
on trust and mutual respect with key
stakeholders
We will develop our built environment and
technology infrastructure to deliver our
vision
with this paper:
regulations
All NHS organisations are required by law
to take account of the NHS Constitution in
Refer to paper
-
Achievement of Financial Plan to
enable the Trust to maintain or improve
service quality
Other
pros and cons
Background papers
Summarised activities of the Audit and
Assurance Committee
Summary of the meeting held on 8th November 2012
1)
Summary of Content
Subject – Limited Assurance Internal Audit Report on Human Resources
The September Committee meeting received an internal audit report from Parkhill that had
been commissioned by the Director of People and Business Development into Disciplinary
procedures within the Trust. This report indicated Limited Assurance (weaknesses in the
design or inconsistent application of controls put the achievement of objectives at risk).
The audit was focussed around the Trusts performance against disciplinary procedures
and to review progress against the implementation of previous recommendations
regarding sickness absence processes.
The Committee were keen to understand the wider context of the reasons for the
Commissioning of the review and the findings of it and invited the Director of People and
Business Development to the November meeting.
The Director of People and Business Development provided a very useful update to the
Committee outlining that the findings from the review were indeed expected and that
provided information on both the reasons for the review and confirmed that an
improvement action plan to address the findings was already in place. In addition the
Committee noted that work had already started in improving certain control weaknesses
identified during the review but it was recognised that there was much more to do.
The Committee asked for regular updates to be presented to the Quality and Performance
Committee on the action plan through the Director of People and Business Development.
Subject – External Audit Independence of Consultancy Services
The Committee received an update from Julian Ricketts, Partner PwC, outlining the work
done under a review of the independence of the Consultancy services work recently
provided to the Trust from PwC in regards to the External Audit work over the final
accounts. The Audit and Assurance Committee were assured by this process.
Subject – Receipt of the Charitable Funds Accounts and ISA260 from PwC, External
Auditors
The Committee received a presentation from the finance department recommending the
approval of the Charitable Funds accounts for the year ended 31st March 2012 and the
ISA 260 management letter from PwC. The Committee supported the recommendation for
the Accounts and the Auditors Opinion to be presented to the Trustees (Trust Board) for
approval at the November meeting.
Subject – Internal Audit Recommendations
The Committee received an update from Parkhill on the completion of previous audit
recommendations. This showed the expected considerable improvement on the last report
received at the September Committee and Executives were congratulated on the
improvement. It is expected that this progress is sustained.
A specific report on the use of credit cards was presented and following discussion the
Internal Auditors were asked to ensure clarity of messages within their reports to ensure
appropriate action could be directed through the Audit Committee.
Subject – Internal Audit and Counter Fraud service procurement
The Committee received an update on the procurement for replacement Internal Auditors
and Counter Fraud Specialists. In summary this was progressing well, to the agreed
timeframe for the new Providers to commence on the 1st January 2013.
Subject – Committee Terms of reference and cycle of business
The Committee noted the Board approved terms of reference. The Committee also
reviewed the revised Governance arrangements approved by the Board and noted the
close working relationships between the Audit and Assurance Committee and the Quality
and Performance Committee. At present this was helped by the good and close working
relationships between the two NED chairs.
Subject – Policy update
Following discussion and some dissatisfaction at the September Committee the meeting
received an updated presentation from the Trust Secretary.
Following further discussion it was agreed that the Executive Directors did not appear to
be giving this high enough priority. It was strongly felt that the Audit and Assurance
Committee still did not receive sufficient assurance from this paper on the progress made
to date in improving the situation as expected following the September meeting.
It was agreed that this would be reported to the Trust Board as an escalation issue.
2)
Decisions made
The Committee approved the updated cycle of business, special losses and payments
report, as well as the waivers of SFI’s for procurement.
3)
Points requiring Board approval
None
Next meeting – Monday 14th January 2013 at 10:00 AM
Agenda Item: 15
BOARD OF
DIRECTORS
MEETING
Date:
Subject:
Prepared by:
FOIA Status
REPORT
28th November 2012
Tom Abell
Public
world class
deliver our vision
with this paper:
regulations
functions
All CQC standards
professionalism.
None identified
None identified
None identified
Other
pros and cons
Background papers
Report was presented and discussed
at Quality & Performance Committee
on 14th November 2012.
RECOMMENDATION
Note and discuss the report, including the risks above threshold as identified
by Divisions.
Identify areas for further challenge / action.
1.0
INTRODUCTION
The purpose of this document is to provide an update to the Board of
Directors of the risks identified by Divisions during October 2012, reported in
November.
2.0
ISSUE
The attached paper presents a total list of all risks identified by Divisions
which are above the agreed risk threshold as set by the Board of Directors.
There are 18 risks that have been identified as above threshold.
Key themes arising from the risk register are risks in relation to staffing, bank
and agency and the operation of PSS. These have been identified in the
following risks by Divisions:
Children’s: Risk IDs 3, 7
Specialist: Risk IDs 0, 1
Adults: Risk ID 4
Older People: Risk IDs 5, 7, 9
These issues were discussed at the Quality & Performance Committee at
great length (see item 8 of the agenda) where it was noted that the following
actions were currently underway to tackle these issues:
The Trust is undertaking an establishment review of all inpatient wards to
establish the basic staffing requirements of each ward to improve safety
and quality, alongside reducing reliance on bank staffing. This work
would report at the end of December.
As part of the new Trust Service Operating Model, the new divisional
leadership of the Community Division is currently developing plans for the
implementation of both the primary care and diagnosis based pathways
and the staffing requirements of these teams.
In addition, two risks have been identified in relation to gaps in service, both
of which are currently scored as being at high risk, these are:
Specialist ID 84: “Unmet need regarding forensic community provision within
Peterborough”
Adult ID 4: “High level of inpatient care need incurring spend above budget”
A number of ongoing service change proposals are also highlighted within the
risk register by divisions, these include:
Children’s risk ID 2: “Failure to implement Cambridgeshire Community
CAMHS Transformation”
Adults risk ID 3: “Implementing the 3,3,3 model in the South”
All identified risks above threshold will be discussed with Divisions at their
next Performance and Risk Review meetings on the 21st November and the
Board is encouraged to identify any areas for further probing and discussion.
3.0
Note and discuss the report, including the risks above threshold as identified
by Divisions.
Identify areas for further challenge / action.
Corporate Risk Register - Risks over threshold
Ref
Risk cause
Risk consequence
Risk Indicators (how you know whether the risk is materialising)
1
Failure to have agreed
service specifications with
Commissioners
Reduced clinical safety and
quality. Failure to provide a
responsive service. Non
compliance with quality
standards
Not meeting targets on community performance dashboards. Increased waiting times. Negative
patient experience feedback and negative feedback from commissioners and partner agencies.
increased numbers of complaints/ PALS issues
2
quality. Failure to provide a
Failure to implement
Cambridgeshire Community responsive service. Non
CAMHS Transformation
standards
3
Accountable Manager
Strategic objective the risk links
Division
to
Negotiation with commissioners with Business
Development Team
Rachel Gomm/Venkat Reddy/Naomi
Elton/Stephen Legood
To provide safe and effective
care which provides an excellent
customer experience
To Childrens
meet our financial obligations as
an NHS Foundation Trust
Rachel Gomm/Venkat Reddy/Naomi Elton
customer experience
To Childrens
Gaps in Control
16
Relationship management with
commissioners and partner agencies
Vacancy management
service specifications
Not meeting targets on community performance dashboards. Increased waiting times. Negative
increased numbers of complaints/ PALS issues
16
Relationship management with
commissioners and partner agencies
Vacant clinical posts used to offset
against CIP
Bank and Agency staffing
usage
Impact on budget and quality of
Overspend on staffing. Potential increase in incidents and adverse impact on patient experience
care
12
Senior Managers addressing vacancy
factor and sickness absence
4
Requirements to meet
community KPIs & CIP
targets whilst sustaining
responsive clinical care.
quality . Failure to provide a
responsive service.Non
standards
16
Recruitment to vacancies
Vacant clinical posts used to offset
against CIP
9
7
PSS and nursing agencies
unable to prove adequate
staff to cover ward shifts
Shifts not covered, patient care
not adequately provided,
Activity data incident reports, numbers of shifts uncovered.
increased risk of incidents
12
Units are flexibly using resources across
with each other
Division not able to influence PSS or
agencies ability to provide staff.
9
Robust management of staffing across the units.
General Manager authorisation for any bank and Kim Masson/Jill Hudson
agency usage.
To provide a safe and effective
care and an excellent patient
experience
Childrens
84
Unmet need regarding
forensic community
provision in Peterborough
unmett need for high risk group
who pose danger to the public
Presentation within the Criminal Justice System in Peterborough i.e. Police Station and disposal at Court
therefore also posing reputational and/or serious offence against member of public
risk
16
Redevelopment of business case to
Commissioners in support of funding a
new service
Commissioners supported the
original business case in principle
but no money
12
draft completed and sent to Steve LeGood for
approval
Wendy Scott Earl/Mark Hall
experience
Specialist
101
Service is outside Trust
Business model and poses
governce risk (LDP)
Continue to provide services that
are not best suited to Trust
portfolio and poses goevernance
risk
12
Absence of contractual
arrangement with Commissioners
Negotiating with Commissioners regarding
to facilitate transfer options
transfer options
compounded by loss of senior
management capacity
9
Continue to press the case with commissioners
Maggie Romjon/Mark Hall
experience
Specialist
Bank and Agency staffing
usage increasing at George
Mackenzie House
Both budget control and quality of
Overspend on staffing budgets and potentia lincrease in incidents
care compromised
15
Senior Managers addressing vacancy
factor and sickness absence
9
Recruitment to existing vacancies at the earliest
opportunity and daily monitoring of staffing usage
Wendy Scott Earl/Mike Bell
experience
Specialist
Significant gaps in adult
community teams as a
consequence of delivering
cost improvements
programmes and freezing
posts to maintain the "run
rate"
Loss of key posts such as psychology
impact on the ability to deliver NICE
compliant interventions. Lack of
clinicians affect ability to carry out
planned care (number 5 of the 7c).
Reputational risk due to pathways
Findings from NICE audit, KPI information, staff survey feedback, patient experience feedback
(interventions identified) not being
delivered. A number of smaller teams
have insufficient critical mass to be
sustained. Staff morale low, increased
stress and sickness levels.
15
Identify where resource can be shared
across teams. Attempt to gain approval
for key posts e.g. psychology in fenland.
Clinical teams to prioritise tasks including
clinical risk management. Use of waiting
lists for routine referrals.
8
New operational model
COO
experience
Adults
1
Failure to hand back business to commissioners
Residual Risk Rates
Comments/Action Plans
Management Controls
Not meeting targets on community performance dashboards. Increased waiting times, Negative
increased nos of complaints/ PALS issues
Initial Risk Score.
Review of
9
9
9
Recruitment process
Recruitment to existing vacancies agreement
by Execs and full implementation of
Cambridgeshire Community CAMHS
transformation
Robust management of staffing across the units.
General Manager authorisation for any bank and Rachel Gomm/Kim Masson
agency usage.
Recruitment to existing vacancies agreement
by Execs and full implementation of
Cambridgeshire Community CAMHS
transformation
General Manager, Team Managers, Clinical
Directors and PMO
customer experience
To Childrens
customer experience. To meet
Childrens
our financial obligations as a
Foundation Trust.
Ref
Risk cause
Risk consequence
3
Implementing 3,3,3 model
in the South
increased risk of out of area admission
due to further reductions in bed
Bed occupancy figures and impact on the OAT Budget
capacity.
4
Version three of the
inpatient staffing model
and its impact on the Oak
wards and Poplar at the
Cavell. Current funded
establishment is insufficient
to meet the roster demand.
The night coordinator rota
isn't fully funded
Increased use of temporary staffing
and overspend. Patient experience
affected. Staff morale and
dissatisfaction will increase.
16
There are no forensic
services for Peterborough
and Fenland.
The Trust can't particpate adequately
in the MAPPA arrangements for
individuals on level three in
Peterborough and Fenland
Increased use of temporary staffing. Increase in stress and sickens levels. Increase in staff turnover. Overspend on
budget. Key targets and standards such as 7C's and patient experience won't be maintained.
Initial Risk Score.
Management Controls
Lack of dedicated peri natal what is a potentially high risk patient
group as highlighted in recent high
mental health nurse in
profile media story following death of
peterborough
5
Trust/Division do not meet
High level of in patient care finance performance target.
need incurring spend above Incresased staff sickness
budget.
absence, complaints and datix
incident reports.
Reduction of quality, not
Failure to provide B7 and B6 meeting quality & governance
leadership on OPMH wards standards, increased staff
sickness / absence
bank/agency staff useage, finance reports, intensive observation data, sickness absence,incident
reports
Increased staff sickness, poor team morale, poor patient experience feedback.
Accountable Manager
Division
to
New operational model
Clinical Director and general manager
experience
Adults
15
9
15
modern matrons and ward mangers meet
every morning to plan the staffing
requirements each day with PSS across the
Cavell. Use less staff at quiet times e.g.
early in the morning. Deployment of staff
flexibly across the inpatient system at the
Cavell. Ward managers acting down to
make up the numbers during shifts.
Deployment of deputy ward managers to
support the night practitioner role
9
experience
Adults
15
Pursue the development of
appropriate forensic services with
commisioners and as a priority
within the new Trust operating
model
9
experience
Adults
16
Utilise staff with a special interest
and ensure Peterborough Teams are
represented at the Trust wide
perinatal mental health group.
Work closely with the existing
teams to ensure standard operating
procedures are understood and
applied within the constraints
locally. Develop realtionships with
local stakeholders to make best use
of expertise eg specialist midwife.
Identify funding stream for
development of a new post in
Peterborough (cost pressure)
12
experience
Adults
16
Recruit to all vacant posts. Identify those
Control of use of bank / agency
patients requiring level of care above ward
staff. A number of vacant posts held
establishment. MM liaison and integrtaed
for staff re deployment
working with OPMH crisis teams
12
Local plans in place that include; robust
scrutinising of rotas, determining clinical needs
on daily basis,re arranging of leave booked,
Lynda Tickell (Maples) Joe Lynch (Denbigh
swapping shifts, utilising staff resources from
and Willow)
other wards on site. Ward running at/close to
budget overall for 3/12 but possible impact on
other KPIs sickness in particular
To meet our financial obligations
Older People
as a foundation trust
12
Ward manager posts:
Maple 1
recruited, starts 5 Dec 12.
Maple 2 B7 post out to advert. 2xB6 to cover
with MM support until resolved
Willow B7 vacant. MM covering B7 duties. B7 Lynda Tickell (Maples) Joe Lynch (Denbigh
approved for advert.. 2x acting B6 in place fixed and Willow)
term.
Denbigh B7 being re advertised, B6 acting up,
x2B6 in post (1 fixed term). Good clinical
lead/medical support to all 4 OPMH wards.
To provide servcies through
empowered staff with the right
skills, attitudes and behaviours
a baby in Cambridge
4
Residual Risk Rates
introduction of the 333 model didn't lead
to an increase in bed usage when it was
implemented in the North.
Implementation group will meet regularly
to monitor impact of changes and work to
ensure that the model is adopted fully and
that clinical staff are fully prepared to
make the changes required
leaves a gap in service provision for
23
Gaps in Control
16
Trust recruitment process
Delays caused by approval process.
Inability to attract high quality B6
and B7 staff.
Older People
Ref
Risk cause
Risk consequence
7
Adverse impact on patient
safety and well being.
Failure to provide adequate
Increased complaints,
medical staffing
performance & quality targets
not met/breached
9
PSS and nurinsg agencies
unable to prove adequate
staff to cover ward shifts
11
16 week wait for memory
services in P'boro
Gaps in Control
16
Flexible use of existing medical staffing
and adjustment of job plans until posts
recruited to
Approval process not in Division's
control. Inability to attract suitable
candidates
12
Posts currently being re advertised approval to
appoint to 2.8wte vacant consultant posts.
Sue Green
Interviews Nov. Locum cover arranged for
Hunts and P'boro to start Nov 12.
care which provides an excellent Older People
customer experience
Shifts not covered, patient care
not adequately provided,
Activity data incident reports, numbers of shifts uncovered.
increased risk of incidents
16
Division is flexibly using resources across
wards/teams and in conjunction with
pother Divisions.
Dsivision not able to influence PSS
or agencies ability to provide staff.
9
Local plans in place that include; robust
scrutinising of rotas, determining clinical needs
on daily basis,re arranging of leave booked,
Jill Hudson
swapping shifts, utilising staff resources from
other wards on site before PSS/agency are
called.
experience
Older People
Patient not accesssing
teatment within reasonable
timescales. GPs expressing
unhappiness
12
Appointment to vacant medical posts.
Division not in control of approval
and AC process
9
Locum consultant appointed to P'boro memory
clinic to address backlog/waiting list. Starts
Sue Green
early Nov.
experience
Older People
Activity data waiting times
Residual Risk Rates
Accountable Manager
Division
to
Management Controls
posts not filled, increased waiting times
Initial Risk Score.
Agenda Item: 16
BOARD OF
DIRECTORS
MEETING
Date:
Subject:
Prepared by:
FOIA Status
REPORT
28th November 2012
Programme Board Update Report
Attila Vegh, Chief Executive on behalf of Programme
Board
Not Applicable
world class
deliver our vision
with this paper:
None
regulations
All standards
All NHS organisations are required by law to
take account of the NHS Constitution in
All Rights
FRR is potentially impacted if PMO
Governance is not adhered to. The PMO
Governance is to ensure that all Strategic
Programmes and projects (including
CIP’s) are delivered within the Portfolio Ceiling.
Delivery of the Governance Programme
is essential to the Trust returning to
compliance with its terms of authorisation
as a FT.
SHA, CCG’s, Monitor and CQC
Programme Board
1.0 INTRODUCTION
This paper provides an update on progress against the Trust’s key strategic programmes and projects. It is written on behalf of the Programme Board in-line with
the programme and project governance arrangements agreed at the Trust Board in
October. The PMO provides the independent assessment of these programmes to
assure the Trust Board that the Trust is delivering against its strategic priorities.
The PMO operates a Red, Amber, Green (RAG) assessment criteria. All projects
and programmes are measured against delivery on the following areas:
Critical Path (project plan)
KPI’s
Red Risks
Amber Risks
Total Risks
Issues
A RAG rating is applied to these areas individually and also provides each of the
projects with a total RAG rating. The Programme is rated as whole in relation to the
total number of projects in Red, Amber and Green.
2.0 SUMMARY
In summary, the Trust’s key strategic programmes are experiencing a number of issues. The governance process is highlighting areas of concern and as such
appropriate mitigations are being put into place to manage exceptions and ensure
that the programmes and projects are delivering as needed.
The Programme Board is aware of all of the issues and has initiated remedial actions
which are being managed appropriately by the individual Programme’s Director and Programme Manager.
3.0 PROGRAMME OVERVIEWS
This month’s rating has the four programmes assessed at two amber and two red.
All Task and Finish Group’s have now been set-up and have their own TOR. Task
and Finish Group’s are managing by exception. Programme Managers are
responsible for keeping their programme on track, and ensuring that exception
reporting is provided to their Task and Finish Group.
The paper is intended to be high level, the Board can request, where required, further
information or clarity and more detailed reports can be provided.
3.1 Governance Programme
The Governance Programme is rated this month as Amber.
The IGAP project had a number of red risks identified at the beginning of November;
however mitigations are in place which has reduced these risks to amber. There are
currently two red risks and one increasing amber risk these are currently being
reviewed for mitigations. Risks are being managed on an exception basis through
the Governance Task and Finish Group.
There are two high issues in relation to IGAP, one is the increasing number of
policies that have passed their review date, the Task and Finish Group has asked for
a detailed action plan on how this is being managed, and priority has been given to
getting these policies reviewed and updated. The other issue is in relation to the total
cost of this programme, it is currently showing a negative variance of -£142,500
against its allocated budget, there are a number of changes taking place that may
incur additional costs, these will be worked through and the total variance will be
reported at the next Task and Finish Group in December.
The Finance Action Plan project is in place and is being progressed, a number of
actions have been completed and the project is currently on track for delivering. The
workbook has been developed; there are a number of actions that need to be
completed before it receives final sign off from the executive sponsor before going to
Programme Board in December. The process for developing the CIP’s for FY13/14
is underway.
The Governance Capability Building project is progressing; a number of tasks are
currently being actioned. The Workbook for this project has still not been developed
in full; the deadline for all workbooks to be completed is 30th November 2012. If
workbooks have not been completed in time, the Programme Board will take
appropriate action with individuals accountable and responsible.
3.2 CIP’s Programme
The CIP’s Programme is rated this month as Red.
There are four projects being re-scoped, these are Estates, Reduction in Temporary
Staffing, Medical Savings and Savings – Nursing (Shift and Establishment Review).
None of these projects have delivered against their initial plans.
The Variable Income Recovery project is -£95,000 off track YTD or 8.6%. In month 7
there was a variance of -£66,581, this was due to a low occupancy of out of area
patients at the Croft.
There are three projects currently behind savings targets; Legal Fees, Printing and
Mobile Bills, mitigating actions are being put in place to correct this performance.
The total variance at month 7 of the CIP’s programme is -£775,000. The Director of
Finance along with the Programme Manager are undertaking an assessment of the
variance and ensuring mitigations are put into place to manage the impact of nondelivery. The impact of this is reflected in the finance report elsewhere on this
agenda.
3.3 CQC Standards Programme
The CQC Standards Programme is rated this month as Amber.
The Care Planning project, has a missed KPI in relation to community care plans
being 100% compliant, it is measured at 71%. A critical path was missed this was in
relation to fortnightly assessments, assessments did not take place w/c 5th
November and were rolled over to w/c 19th November this means only one
assessment took place in the month. The DoN and COO have been tasked with
advising all staff that assessments are mandatory not optional.
Medicines Management has a new high issue in relation to an increase in dispensing
errors, due to increased service requirements and pressures on pharmacy staff.
Mitigations are being put into place to manage this; it has been raised with the
Executive sponsor of the project and at programme level.
Patient Safety and SI’s Management project has three missed critical path
milestones, all tasks have been re-scheduled. There is one high issue in that the
Trust still does not have a formal policy in place for learning from SI’s. There are
also two new issues in relation to a couple of committee’s and group meetings being cancelled in November, delaying decisions. There are also two new changes which
require approval from the Executive sponsor. This project needs Executive focus if it
is to deliver. It needs to be picked up by the Programme Director (DoN) and
Programme Manager.
3.4 CPFT Re-Organisation Programme
The CPFT Re-Organisation Programme this month is rated as Red.
The TSOM project has a variance of -£180,209 or 16.3% against its savings; all other
areas of assessment are on track. The PMO has questioned how a project can be
on track for delivery with such a large negative variance, there is an immediate
review being undertaken, it is currently assumed that triple counting could be causing
the negative variance, however this has not been confirmed. The TSOM workbook
needs to be split into the three agreed projects, 3 Divisions, Community Pathways
and Admin Hub, the date for these workbooks to be completed and submitted for
sign off is 30th November. Programme Board will take necessary action with
individuals responsible and accountable if workbooks are not completed by the
deadline.
Acute Care has one increasing red risk, this is in relation to the cost of the staffing
model may be higher than the available divisional budget. This has now become an
issue with a gap of -£62,000. Project Lead and Finance to meet to discuss
mitigations to ensure delivery of project.
RIO has one red risk and twenty one increasing amber risks, mitigations are being
put into place and these are being managed. There is a pre go-live meeting
scheduled with Executives w/c 26th November, set criteria or go live has been
defined and final go-live sign off process will be agreed at this meeting. Rollback
options to be in place, should they be required.
ARC has been successfully implemented in Peterborough; it is currently being
scoped for Fenland, Huntingdon and Cambridge. The Programme Board has asked
for costs to be brought to December’s Programme Board for final sign off before implementation in Fenland and Huntingdon.
The Children’s Business Unit project is currently being scoped, and a workbook is in
development. Deadline for completion of workbook is 30th November ready for sign
off by Executive Sponsor and Programme Board.
Appendix A shows the programme dashboards; these are a visual representation
that show on quick review current status of the individual programmes and projects.
These dashboards are used to inform Programme Managers of the PMO’s assessment against delivery of their programme. In next months report the Trust
Board will receive a portfolio dashboard which will highlight overall programme and
project delivery.
4.0 SUMMARY AND CONCLUSIONS
In summary, the Trust’s key strategic programmes are experiencing a number of issues. The governance process is highlighting areas of concern and as such
appropriate mitigations are being put into place to manage exceptions and ensure
that the programmes and projects are delivering as needed.
The Programme Board is aware of all of the issues and has initiated remedial actions
which are being managed appropriately by the individual Programme’s Director and
Programme Manager.
BOARD ACTION
The Board is not required to take any further action at this stage.
Appendix A
Governance Programme Implementation Dashboard
Based on
Project Status
Project metrics for Programme over time
What
8
submissions
Who
Date
Confirm cost of individual projects, which will populate Forecast savings chart
7
2
16/11/2012
Next Steps
Check High issues are stable
6
Confirm date when Governance Capability Building project workbook will be completed
5
1
4
3
2
0
1
0
08/10/2012
19/10/2012
02/11/2012
16/11/2012
Sum of KPIs missed
Sum of # Missed Critical Path Milestones
Sum of # Current Red Risks
Sum of # High Issues
Programme Risk Breakdown for
current period
Forecast savings for rest of year
against RAG status
Implemented
Finance (PWC) Action Plan
Governance Capability
Building Project
On track
Sum of No
Change
Red Ri sks,
1
Sum of
Increasi ng
Red Ri sks,
1
Implementation RAG
Total 'Red'
Total 'Amber'
Total 'Green'
At risk
KPI
Red Risk
Red
Critical
Path
Green
Green
Red
Amber
Risk
Red
Amber
Green
Green
Green
Green
Overall
Project name
IGAP
Issues
Financials
Red
Red
Unknown
Green
Green
Unknown
1
0
1
0
0
0
No data as awaiting workbook
Red
2
1
0
Risk
0
0
2
0
0
2
1
0
1
1
0
1
1
0
1
Not on track
Unplanned
£-
£1
£1
Total Value 2012/13 (£ 000's)
Programme Timeline
IGAP-Trust quality Framework,Division &
Corporate Risk Register in use,QIA Reviewed
& in use,Divisional Leadership Governance
Training Started,2 new NEDS in post
Nov-12
IGAP-Change story distributed to staff,Team
leadership governance training
started,Monthly Pulse implemented,Revised
DAGA,Governance Structures & Policy in
place
Dec-12
IGAP-Divisional & Team Integrated
Dashboard, Division Quality and Safety
Strategy, Stop The Line mechanism in place,
Heat Map system in place, Commence Board
Development Programme, Lessons Learnt …
IGAP-Governance Training Programme
Developed,Board Assesment
Jan-13
Feb-13
IGAP-Substantive COO and DoSI in
post,Authorisation Breach lifted
Mar-13
CIP Programme Implementation Dashboard
Based on
Project Status
16/11/2012
submissions
Next Steps
What
12
Who
Date
Confirm date when Deighton will be closed down
9
0
10
Confirm date when Medical savings workbook will be submitted
Confirm what actions are being taken to resolve financial issues of red rated projects
8
6
4
1
2
0
08/10/2012
19/10/2012
02/11/2012
16/11/2012
Sum of KPIs missed
current period
against RAG status
Sum of
Reducing
Red Risks,
1
Implemented
On track
At risk
Estates rationalisation
Procurement
Reduce Travel Expenses
Reduce Legal Fees
Reduce Mobile bills
Printing
Unplanned
-£5,000
-£4,000
-£3,000
-£2,000
-£1,000
Project name
Variable Income Recovery
Reduction in temporary
staffing spend
Medical Savings &
Psychology (329)
Savings - Nursing and other
groups (8-12 hour shifts)
and establishments
Savings - Deighton Unit
Not on track
Sum of No
Change
Red Risks,
6
Implementation RAG
£-
£1,000
Total Value 2012/13 (£ 000's)
Total 'Red'
Total 'Amber'
Total 'Green'
KPI
Red Risk
Issues
Financials
Green
Green
Amber
Risk
Green
Risk
Red
Critical
Path
Green
Green
Green
Red
Red
Green
Red
Red
Green
Red
Red
Red
Overall
Red
Red
Close
down
Red
Red
Green
Red
Red
Red
9
0
1
Rated red as no workbook submitted to review
Red
Green
Green
Red
Green
Red
Red
Red
Green
Green
Green
Green
Green
Green
Green
Green
Green
Green
Green
Red
Green
Green
Green
Green
Green
Amber
Green
Green
Red
Green
Green
Green
Green
Green
Green
Green
Green
Green
Green
Green
Red
Green
Green
Green
Green
Green
Green
Green
Green
Green
Green
Red
Red
Green
Red
Red
Red
1
0
6
1
1
5
3
0
3
0
0
6
3
0
3
2
0
4
9
0
1
Programme Timeline
Implementation to start achieving saving
targets month 1-Temporary
staffing,Medical staffing savings,Estates
rationalisation,Procurement,Legal fees
Apr-12
May-12
targets month 7-Nursing Savings,
Deighton Savings, Travel Expenses
FYE 4m savings achieved for all CIPS
targets month 4-Variable income, Printing,
Mobile Bills
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
CQC standards Programme Implementation Dashboard
Based on
Project Status
What
45
Who
Date
40
1
submissions
16/11/2012
Next Steps
Check with Project lead and PMO about the progress on InCa and whether the 2 week for
the Incubation period is sufficient time to review the project
Check what actions are being taken for the Patient safety and Serious Incident
management project to bring the project back on track
35
30
25
3
20
15
10
0
5
0
08/10/2012
19/10/2012
02/11/2012
16/11/2012
Sum of KPIs missed
current period
Implementation RAG
against RAG status
Project name
InCa
Implemented
NO HIGH
RISKS TO
REPORT
Care planning (7Cs)
(Outcome 4)
Medicines management
Patient safety and Serious
Incident management
Review and implement new
mandatory training
programme
On track
At risk
Overall
Critical
Path
KPI
Red Risk
Amber
Risk
Risk
Issues
Financials
Incubation
Red
Red
Red Risk
Green
Red
Red
Unknown
Amber
Red
Amber
Green
Red
Amber
Green
Unknown
Amber
Green
Green
Green
Green
Green
Red
Unknown
Red
Red
Green
Green
Green
Green
Red
Unknown
Amber
Green
Green
Green
Green
Green
Red
Unknown
1
3
0
3
0
2
1
1
3
0
0
4
1
0
4
1
1
3
4
0
1
0
0
0
Not on track
Total 'Red'
Total 'Amber'
Total 'Green'
Unplanned
£-
£1
£1
Total Value 2012/13 (£ 000's)
Programme Timeline
Care planning-All care plans meeting 95%
compliance. Mar 31st (inpatients) &Dec 31st
(community)
-Transition to InCA
Medicines Management-Develop initiatives to
address gaps
REV-Trust complaince at 100% across all
themes
SI's-All incidents investigated effectively
(against national framework) & develop
InCa-Inpatient & community tool developed
learning outcomes.
Medicines Management-Complete PCA's
SI's Management-Develop & update SI
Policies and Procedures
& Mandatory training-Update policy
Medicines Management-Identify Gaps in
Outcome 9
Care planning-Launch community roll out
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
CPFT Re-Organisation Programme Implementation Dashboard
Based on
Project Status
What
7
Check what actions are being taken for the
back on track
back on track
project back on track
back on track
Confirm when Implement ARC - Cambridge
5
4
1
submissions
Who
Date
6
3
16/11/2012
Next Steps
3
2
Trust Service model project to bring the project
Trust Service model project to bring the project
333 South Implementation project to bring the
RiO Implementation project to bring the project
will be in progress
1
0
0
08/10/2012
19/10/2012
16/11/2012
current period
Sum of
Reducing
Red Risks,
1
02/11/2012
Sum of KPIs missed
against RAG status
Sum of
Increasing
Red Risks,
1
Develop Trust Service Model
and Develop the Trust new
service delivery processes
Implemented
333 South Implementation
Implement ARC Cambridge
RiO implementation
Childrens Business Unit
Turnaround
Health Visiting Sustain call
to action
On track
At risk
Not on track
Sum of No
Change
Red Risks,
2
Sum of
New Red
Risks, 2
Unplanned
-£1,500
-£1,000
-£500
Implementation RAG
Project name
£-
Overall
Critical
Path
KPI
Red Risk
Amber
Risk
Risk
Issues
Financials
Red
Green
Green
Green
Green
Green
Green
Red
Red
Not in
progress
Red
Not in
progress
Green
Green
Red
Green
Red
Red
Unknown
Green
n/a
Red
Red
Red
Red
Amber
Red
Green
Red
Green
Red
Green
Unknown
3
1
0
1
0
3
0
0
3
3
0
1
1
0
3
3
0
1
2
0
2
1
0
0
Total 'Red'
Total 'Amber'
Total 'Green'
Unknown
Unknown
Unknown
Total Value 2012/13 (£ 000's)
Programme Timeline
RIO-Contract Awarded
Jun-12
RIO-Clinical Portal operationalise & Specialist
Services Go Live
333-Finalis e and cos t s taffing m odel & Develop
new operational procedures
333-Staff Training Events & Development of Patient
Inform ation
RIO-CDL Upgrade & Pilot - IAPT
333-Recruit to B7 roles and below
RIO-OPMH Go Live
333-Staff consultation
TSOM-FYE 3.8m savings achieved
ARC-Post Im plem entation Review & Phase 2
Business Case and Project Plan Developed
ARC-Phase 1 P'boro Im plem entation
333-Launch m odel and 24/7 m erged CRHT
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
RIO-Adult Go Live
May-13
Jun-13
RIO-Children, IAPT, Prim ary Go Live
Jul-13
Aug-13
Sep-13
Agenda Item:17
BOARD OF
DIRECTORS
MEETING
Date:
Subject:
Prepared by:
FOIA Status
REPORT
20 November 2012
Charitable Funds Accounts for the year ending 31 March
2012
Darren Cattell
Public
class
key stakeholders
our vision
with this paper:
regulations
functions
Completion of the accounts is a legal
requirement
-
Other
pros and cons
The Accounts have been received and
approved for submission to the Board
of Directors by the Audit and
Assurance Committee.
EXECUTIVE SUMMARY
The Cambridgeshire Mental Health and Primary Care Trusts Charitable Fund is registered with the
Charity Commission (registration number 1099485) and includes funds in respect of all the
Cambridgeshire and Peterborough NHS Foundation Trust (formerly Cambridgeshire and
Peterborough Mental Health Partnership NHS Trust) services and the services of the following
Primary Care Trusts:
Cambridgeshire Community Services NHS Trust
NHS Cambridgeshire
NHS Peterborough
The main purpose of the charitable funds held on trust is to apply income for any charitable
purposes relating to the National Health Service wholly or mainly for the services provided by the
Cambridgeshire and Peterborough NHS Foundation Trust and the other Trusts set out above.
THE AUDITED ACCOUNTS
The Audited accounts are included as Appendix 1.
The Accounts were first presented to the Audit and Assurance Committee in draft form in July
2012. Since then PWC have carried out the required audit and identified a number of changes that
are summarised below;
The transfer of funds from NHS Luton has been adjusted and accounted for as
incoming resources and not a “transfer in” at the bottom of the Statement of Financial
Activities.
The £17,500 expenditure in relation to Cambridgeshire Community Services for a
contribution towards nursing services for the period January - March 2012 has been
reflected in 2011/12 and not 2012/13.
There were also a small number of presentational amendments made, none of which affected the
substance of the financial position reported.
The Accounts were re-presented to the Audit and Assurance Committee on Thursday 8th
November 2012 and were approved following assurance from PwC, External Auditors that
everything was in order, specifically;
That the Trust had produced the Accounts within the appropriate accounting
conventions and standards
The Auditors had issued an unqualified Audit Opinion on their audit of the Accounts
REPORT OF THE AUDITORS
The Auditors have issued an unqualified audit report and only minor recommendations were
identified in relation to allocation of income balances, and in relation to the accruals of interest
receivable, all of which the Trust will act upon. The auditors’ letter to those charged with
Governance of the charitable funds has been reviewed by the Audit and Assurance Committee in
November 2012.
The Auditors have also provided a pro-forma letter of representation for the Corporate Trustee to
sign at Appendix 2, this is a standard part of the audit process.
RECOMMENDATIONS
The Board of Directors is asked to:
Review the audited accounts of the Charitable Fund for the year ended 31 March 2012 and
approve the Trust Chair, Chief Executive and Director of Finance and Performance to sign the
accounts on behalf of the Trust.
Review the report of the auditors (PWC) and approve the Chief Executive to sign the letter of
representation to the auditors (Appendix 2 of the report).
Darren Cattell
DIRECTOR OF FINANCE AND PERFORMANCE
NOVEMBER 2012
www.pwc.co.uk
Year ended 31st March
2012
Cambridgeshire
Mental Health and
Primary Care Trusts
Charitable Fund
Report to those charged
with governance (ISA 260
(UK&I))
Contents
1
Introduction
1.1
Audit status
1.2
Audit overview and conclusions
1.3
Misstatements and deficiencies in internal control
1.4
Other areas of feedback
2
Audit Findings
3
Other matters
3.1
Required communications:
4
External developments
Appendices
5
Appendix 1 – Deficiencies in internal control
6
Appendix 2 – Representation letter
8
The matters raised in this and other reports that flow from the audit are only those which have come to our attention
arising from or relevant to our audit that we believe need to be brought to your attention. They are not a comprehensive
record of all matters arising and in particular we cannot be held responsible for reporting all risks in your business. This
report has been prepared for and only for Cambridgeshire Mental Health and Primary Care Trusts Charitable Fund in
accordance with the terms of our engagement letter 9 December 2010 and for no other purpose. We do not accept or
assume any liability or duty of care for any other purpose or to any other person to whom this report is shown or into
whose hands it may come save where expressly agreed by our prior consent in writing.
PwC Contents
1 Introduction
We have pleasure in presenting this report relating to our audit of the financial statements of Cambridgeshire
Mental Health and Primary Care Trusts Charitable Fund for the year ended 31st March 2012.
We have discussed this report with management as part of our audit process. The purpose of this report is to
update the members of the Committee on the progress of the audit and of any significant matters that have
arisen during the course of our work.
1.1 Audit status
We have completed our audit, subject to the following outstanding matters:
Final partner review of the financial statements;
Approval of the financial statements and letters of representation; and
Completion procedures including subsequent events review.
1.2 Audit overview and conclusions
Subject to the satisfactory resolution of these matters, the finalisation of the financial statements and their
approval by the Trustee we expect to issue an unqualified audit opinion for Cambridgeshire Mental Health and
Primary Care Trusts Charitable Fund.
1.3 Misstatements and deficiencies in internal control
A summary of control deficiencies identified is included in Appendix 1 as well as an update on those raised in
previous years. There are no uncorrected misstatements to report.
1.4 Other areas of feedback
Section 3 contains other matters for the attention of those charged with governance, including elements of
communication required under International Standard on Auditing “Communication with those charged with
governance”.
Section 4 contains details of those external developments in the sector that we believe are relevant for the
Charity and your consideration.
The final draft of the representation letter that we are requesting management and those charged with
governance to sign is attached in Appendix 2. This comprises our standard letter for Charities.
We look forward to the opportunity to discuss the points raised in the report with you at the Audit and
Assurance Committee meeting on 8 November 2012.
We would also like to take this opportunity to express our thanks for the co-operation and assistance we have
received from the management and staff of the Charity throughout our work.
PwC 1
2 Audit Findings
Our audit followed the strategy set out in our Audit Plan document presented to you on 20 October 2011. Our
initial assessment was that amounts in excess of 2% of the total fund balances would be material. Following our
assessment of the balances at year end and our internal guidance, we determined that amounts in excess of 2%
of total assets would be material. We confirm that there has been no further cause for us to vary the planned
scope of our work.
We have included a summary of our findings below.
Our response to the areas of audit focus identified in the audit plan:
Risk identified/area of audit focus
Override of normal financial control processes
In common with all audits, there is the risk that transactions
or adjustments that have a material impact on the financial
statements could be processed outside of the normal financial
control systems through management override of the control
systems.
Completeness of income
The Charity receives its voluntary income in the form of
donations and legacies. As with other charities, there is a need
to implement sufficient arrangements to mitigate the risk that
donated income may be lost or misappropriated after initial
handover. Typically these arrangements include steps to
advise potential donors on how to make a donation and the
issue of receipts for any monies handed over that can be fully
accounted for.
Audit Response
We have performed testing on journals processed during
the year. We have also performed testing on samples of
income and expenditure items designed to confirm their
validity.
There are no matters which we wish to draw to your
attention.
We have reviewed and assessed the Charity’s
arrangements for the receipt and recording of donated
income as a basis for ensuring the completeness of
voluntary income. We have identified one control
deficiency in relation to evidence of donations, see
Appendix 1.
Ensuring the completeness of income is made more complex
for the Charity because that income may be donated to a
number of different NHS bodies.
PwC 2
3 Other matters
3.1 Required communications:
The following table contains communication required under ISA 260 (revised and re-drafted) “Communication
with those charged with governance”.
Requirement
Delivery of requirement
Uncorrected and corrected misstatements There are no uncorrected misstatements to report. One significant corrected misstatement
which we believe should be brought to your attention is set out below.
During the year, funds were transferred from NHS Luton totalling £105,000. These were
initially recognised as a transfer of Trusteeship in the lower section of the Statement of
Financial Activities, however the correct treatment set out by the Charity Commission is to treat
the transfer as incoming resources within Voluntary Income in the upper section of the SoFA.
This has been corrected in the financial statements.
Significant accounting principles and
policies
Significant accounting principles and policies are disclosed in the notes to the financial
statements. We will ask the Corporate Trustee to represent to us that they have considered the
accounting policies and that here have not been any material changes in the accounting
principles and policies used during the year.
Significant qualitative aspects of the
Charity’s accounting practices and
financial reporting , management’s
judgments and accounting estimates
No significant judgements or accounting estimates were required in the preparation of the
financial statements.
Deficiencies in the internal control
environment
The purpose of the audit was to express an opinion on the financial statements. The audit
included consideration of internal control relevant to the preparation of the financial
statements in order to design audit procedures that were appropriate in the circumstances, but
not for the purpose of expressing an opinion on the effectiveness of internal control. The
matters being reported are limited to those deficiencies that we have identified during the audit
and that we have concluded are of sufficient importance to merit being reported to you.
Such deficiencies in internal controls are included in Appendix 1 to this report.
Details of material uncertainties related to We have not identified any such matters.
events and conditions that may cast
significant doubt on the entity's ability to
continue as a going concern
Significant difficulties encountered during We have not identified any such matters.
the audit
Confirmation of audit independence
We confirm that, in our professional judgment, as at the date of this document, we are
independent auditors with respect to the Charity and its related entities, within the meaning of
UK regulatory and professional requirements and that the objectivity of the audit engagement
leader and the audit staff is not impaired. We have presented separate papers to the Audit and
Assurance Committee regarding our assessment of appropriate threats and safeguards to our
independence in relation to non-audit work provided to the Corporate Trustee. There are no
further matters to raise in this regard.
PwC 3
4 External developments
Key issue
Response
Charities Act 2011
The Charities Act 2011 received Royal Assent on 14 December 2011
and came into force in March 2012. The new Act repealed and
replaced the Recreational Charities Act 1958, the Charities Act 1993
and many of the provisions of the Charities Act 2006.
The new Act simply consolidates existing legislation. It does mean
that references to the Charities Act will need to be amended to refer
to the new Act.
Future of UK GAAP
Update on proposals to change UK GAAP
The Accounting Council (AC) (and its predecessor, the Accounting
Standards Board (ASB) have been discussing comments on the
following exposure drafts: :
FRED 46, ‘Application of financial reporting requirements’;
FRED 47, ‘Reduced disclosure framework’; and
FRED 48, ‘The financial reporting standard applicable in the
UK and Republic of Ireland’.
All entities reporting under UK GAAP will be affected, as they will
have to decide whether to apply IFRS, the new FRS or, if eligible,
the FRSSE. Qualifying entities will need to consider whether they
wish to use the reduced disclosure framework. It is currently
unclear whether charities would be able to apply IFRS.
The proposals in FREDs 46, 47 and 48 are intended to apply for
accounting periods beginning on or after 1 January 2015.
The changes will affect charities. This is a fast moving area but we
now expect that the landscape will be much clearer next year.
We have previously provided details of the progress of these
discussions. Feedback has been received on a number of issues
relating to public benefit entities, including:
definitions of restrictions and performance conditions;
the boundary between grants and donations;
classification as public benefit entities;
concessionary loans;
funding commitments; and
donated services.
The AC tentatively agreed to recommend the following to the FRC:
There should be revised definitions of performance-related
conditions and restrictions in relation to receipts of resources
from non-exchange transactions.
The accrual method of accounting for grants should only be
available for government grants (rather than all grants),
consistent with EU-adopted IFRS.
The other issues are to be considered further. The current suite of
UK accounting standards will be withdrawn when the new
accounting standards are implemented.
Public Benefit Entity SORPs
The three existing PBE Statements of Recommended Practice
(SORPs) - charities, education and housing - will be updated to
reflect the ASB's convergence agenda.
PwC 4
Appendices
PwC 5
Appendix 1 – Deficiencies in
internal control
Current year recommendations
The following points detail our internal control recommendations based on the results of our current year audit.
We have graded our recommendations according to their possible impact.
(H)
High
Serious matters which should be addressed as a matter of urgency
(M)
Medium Areas where attention is required
(L)
Low
Best practice recommendations
Evidence of Donations
Medium
Finding
Recommendation
For a sample of 15 donations, supporting documentation/donation
receipts were not available for three items. Two of these items were
received via ‘Just Giving’ and one item was received for research, all
three have therefore been allocated based on knowledge within the
accounts team.
It is recommended that when donations are received receipts are
issued and a copy retained, to ensure the correct allocation of funds.
There is a risk that without the supporting documentation donations
could be misallocated and this could result in the use of funds
against the original purpose of the donation.
Management response
Owner:
Action:
Timescale:
Interest accrual
Medium
Finding
Recommendation
Interest is recognised on a cash basis rather than on an accruals
basis. This is not the appropriate accounting convention, however
there is not a material impact on the accounts as a full year’s interest
has been accounted for in 2011/12 (from Jan 2011 to Dec 2012).
Interest should be recognised on an accruals basis.
Management response
Owner:
Action:
Timescale:
PwC 6
Status of prior year recommendations
The following table details the outstanding internal control recommendations identified during our 2010/11
audit together with a current year update.
Deficiency
Recommendation
2011/2012 update
For a sample of 15 items of fundraising
income, one item was allocated to the wrong
fund.
It is recommended that allocation of income
to funds is reviewed and authorised, at least
for larger accounts, to ensure the correct
allocation.
No exceptions noted through testing
completed, other than in relation to
supporting documentation.
All funds are restricted and therefore
misallocation of income could result in the
use of funds against the original purpose of
the income.
Recommendation implemented.
It should be noted that no such matters arose
in the prior year.
Our testing identified four funds which are in
deficit.
Funds should not be allowed to fall into
No exceptions noted through testing
deficit. There should be a process in place to completed.
monitor and identify when funds are likely to
All funds are restricted and therefore another fall into deficit/have fallen into deficit.
fund cannot be used to compensate for the
deficit.
From nine petty cash balances, one was not
confirmed with the float holder as at the year
end.
All petty cash balances should be agreed with No exceptions noted through testing
float holders
completed.
PwC 7
Appendix 2 – Representation
letter
To be prepared on the Charity’s letterhead
[Date]
To: PricewaterhouseCoopers LLP
The Atrium
St George's Street
Norwich
NR3 1AG
Dear Sirs
This representation letter is provided in connection with your audit of the financial statements of
Cambridgeshire Mental Health and Primary Care Trusts Charitable Fund (the “charity”) for the year ended 31
March 2012 for the purpose of expressing an opinion as to whether the financial statements give a true and fair
view, have been properly prepared in accordance with United Kingdom Generally Accepted Accounting Practice
(UK GAAP), and have been prepared in accordance with the Charities Act 2011 and Regulation 8 of The
Charities (Accounts and Reports) Regulations 2008.
Financial Statements
We have fulfilled our responsibilities, as set out in the terms of the audit engagement letter dated 9
December 2010, for the preparation of the financial statements in accordance with UK GAAP and the
Charities Act 2011 and The Charities (Accounts and Reports) Regulations 2008; in particular the
financial statements give a true and fair view in accordance therewith.
All transactions have been recorded in the accounting records and are reflected in the financial
statements.
All grants, donations and other income have been notified to you and where the receipt is subject to
specific terms or conditions, we confirm that they have been recorded in restricted funds. There have
been no breaches of terms or conditions during the period in the application of such income.
We confirm that to the best of our knowledge all income receivable by the charity and the group during
the accounting period has been included in the financial statements. Where material, gifts in kind and
intangible income have been included at a reasonable estimate of their value to the charity and the
group or at the amount actually realised.
Significant assumptions used by us in making accounting estimates, including those surrounding
measurement at fair value, are reasonable.
All events subsequent to the date of the financial statements for which UK GAAP requires adjustment
or disclosure have been adjusted or disclosed.
The effects of uncorrected misstatements are immaterial, both individually and in the aggregate, to the
financial statements as a whole. A list of the uncorrected misstatements is attached to this letter.
Information Provided
Each trustee has taken all the steps that he or she ought to have taken as a trustee in order to make
himself or herself aware of any relevant audit information and to establish that you (the charity’s
auditors) are aware of that information.
PwC 8
We have provided you with:
Access to all information of which we are aware that is relevant to the preparation of the financial
statements such as records, documentation and other matters;
Additional information that you have requested from us for the purpose of the audit; and
Unrestricted access to persons within the charity from whom you determined it necessary to obtain
audit evidence.
So far as each trustee is aware, there is no relevant audit information of which you are unaware.
Fraud and non-compliance with laws and regulations
We acknowledge our responsibility for the design, implementation and maintenance of internal control
to prevent and detect fraud.
We have disclosed to you the results of our assessment of the risk that the financial statements may be
materially misstated as a result of fraud.
We have disclosed to you all information in relation to fraud or suspected fraud that we are aware of
and that affects the charity and involves:
–
–
–
Management;
Employees who have significant roles in internal control; or
Others where the fraud could have a material effect on the financial statements.
We have disclosed to you all information in relation to allegations of fraud, or suspected fraud, affecting
the charity’s financial statements communicated by employees, former employees, analysts, regulators
or others.
We have disclosed to you all known instances of non-compliance or suspected non-compliance with
laws and regulations whose effects should be considered when preparing financial statements.
Related party transactions
We have disclosed to you the identity of the charity’s related parties and all the related party relationships and
transactions of which we are aware.
Related party relationships and transactions have been appropriately accounted for and disclosed in accordance
with the requirements of FRS 8, “Accounting and Reporting by Charities: Statement of Recommended Practice”
or other requirements, the Charities Act 2011 and The Charities (Accounts and Reports) Regulations 2008.
We confirm that we have identified to you all employees with emoluments over £60,000, as defined by
“Accounting and Reporting by Charities: Statement of Recommended Practice”, and included their emoluments
in the financial statement disclosures.
Employee Benefits
We confirm that we have made you aware of all employee benefit schemes in which employees of the charity
participate.
Contractual arrangements/agreements
All contractual arrangements (including side-letters to agreements) entered into by the charity have been
properly reflected in the accounting records or, where material (or potentially material) to the financial
statements, have been disclosed to you.
PwC 9
Litigation and claims
We have disclosed to you all known actual or possible litigation and claims whose effects should be considered
when preparing the financial statements and such matters have been appropriately accounted for and disclosed
in accordance with UK GAAP.
Taxation
We have complied with the taxation requirements of all countries within which we operate and have brought to
account all liabilities for taxation due to the relevant tax authorities whether in respect of any corporation or
other direct tax or any indirect taxes. We are not aware of any non-compliance that would give rise to
additional liabilities by way of penalty or interest and we have made full disclosure regarding any Revenue
Authority queries or investigations that we are aware of or that are ongoing.
In managing the tax affairs of the charity, we have taken into account any special provisions such as transfer
pricing, debt cap, tax avoidance disclosure and controlled foreign companies legislation as applied in different
tax jurisdictions.
We confirm that to the best of our knowledge, throughout the year, the charity has acted within its charitable
objectives and therefore there are no activities on which the charity should be accounting for direct taxes.
As minuted by the Board of Cambridgeshire and Peterborough NHS Foundation Trust Board as Corporate
Trustee at its meeting on [date]
................................................................................
(Board Member of the Corporate Trustee)
For and on behalf of Cambridgeshire Mental Health and Primary Care Trusts Charitable Fund
Date…………………………………………………
PwC 10
This document has been prepared for the intended recipients only. To the extent permitted by law, PricewaterhouseCoopers LLP does not accept or
assume any liability, responsibility or duty of care for any use of or reliance on this document by anyone, other than (i) the intended recipient to the
extent agreed in the relevant contract for the matter to which this document relates (if any), or (ii) as expressly agreed by PricewaterhouseCoopers
LLP at its sole discretion in writing in advance.
© 2012 PricewaterhouseCoopers LLP. All rights reserved. 'PricewaterhouseCoopers' refers to PricewaterhouseCoopers LLP (a limited liability
partnership in the United Kingdom) or, as the context requires, other member firms of PricewaterhouseCoopers International Limited, each of
which is a separate and independent legal entity.
Appendix 1
The Audited Accounts
of the
Cambridgeshire Mental Health and Primary Care Trusts
Charitable Fund
Charity No: 1099485
Year to 31 March 2012
Elizabeth House, Fulbourn Hospital, Fulbourn, Cambridge CB21 5EF Tel: 01223 726789
Fax: 01480 398501
The accounts of the Cambridgeshire Mental Health and Primary Care Trusts Charitable Fund
Statement of Trustee's Responsibilities
The Trustee is responsible for:
keeping proper accounting records which disclose with reasonable accuracy at any time the
financial position of the funds held on trust and to enable them to ensure that the accounts
comply with requirements in the Charities Act 2011 and those outlined in the directions issued
by the Secretary of State;
establishing and monitoring a system of internal control; and
establishing arrangements for the prevention and detection of fraud and corruption.
The Trustee is required under the Charities Act 2011 and the National Health Service Act 2006 to
prepare accounts for each financial year. The Secretary of State, with the approval of the
Treasury, directs that these accounts give a true and fair view of the financial position of the funds
held on trust, in accordance with the Charities Act 2011. In preparing those accounts, the Trustee
is required to:
apply on a consistent basis accounting policies laid down by the Secretary of State with the
approval of the Treasury
make judgements and estimates which are reasonable and prudent
state whether applicable accounting standards have been followed, subject to any material
departures disclosed and explained in the accounts.
The Trustee confirms that it has met the responsibilities set out above and complied with the
requirements for preparing the accounts. The financial statements set out on pages 12 to 20
attached have been compiled from and are in accordance with the financial records maintained by
the Trustee.
as far as the trustee is aware, there is no relevant audit information of which the charity’s
auditors are unaware
the trustee has taken all the steps that ought to have been taken as trustee in order to make
themselves aware of any relevant audit information and to establish that the charity’s auditors
are aware of that information
the trustee prepares the financial statements on the going concern basis, unless it is
inappropriate to do so.
By order of the Trustee on
Chair
DAVID EDWARDS
…………………………………………
Chief Executive
ATTILA VEGH
…………………………………………
Interim Director of Finance
DARREN CATTELL
…………………………………………
Audited Accounts of the Cambridgeshire Mental Health And Primary Care Trusts Charitable Fund Year to 31 March 2012
2
Independent Auditors’ Report to the Trustee of Cambridgeshire Mental Health and Primary
Care Trusts Charitable Fund
We have audited the financial statements of Cambridgeshire Mental Health and Primary Care
Trusts Charitable Fund for the year ended 31 March 2012 which comprise the Statement of
Financial Activities, the Balance Sheet and the related notes. The financial reporting framework
that has been applied in their preparation is applicable law and United Kingdom Accounting
Standards (United Kingdom Generally Accepted Accounting Practice).
Respective responsibilities of trustees and auditors
As explained more fully in the Trustee’s Responsibilities Statement, set out on page 2, the trustee
is responsible for the preparation of financial statements which give a true and fair view.
Our responsibility is to audit and express an opinion on the financial statements in accordance with
applicable law and International Standards on Auditing (UK and Ireland). Those standards require
us to comply with the Auditing Practices Board’s Ethical Standards for Auditors.
This report, including the opinions, has been prepared for and only for the charity’s trustees as a
body in accordance with section 144 of the Charities Act 2011 and regulations made under section
154 of that Act (Regulation 27 of The Charities (Accounts and Reports) Regulations 2008) and for
no other purpose. We do not, in giving these opinions, accept or assume responsibility for any
other purpose or to any other person to whom this report is shown or into whose hands it may
come save where expressly agreed by our prior consent in writing.
Scope of the audit of the financial statements
An audit involves obtaining evidence about the amounts and disclosures in the financial statements
sufficient to give reasonable assurance that the financial statements are free from material
misstatement, whether caused by fraud or error. This includes an assessment of: whether the
accounting policies are appropriate to the charity’s circumstances and have been consistently
applied and adequately disclosed; the reasonableness of significant accounting estimates made by
the trustees; and the overall presentation of the financial statements. In addition, we read all the
financial and non financial information in the Annual Report to identify material inconsistencies with
the audited financial statements. If we become aware of any apparent material misstatements or
inconsistencies we consider the implications for our report.
Opinion on financial statements
In our opinion the financial statements:
give a true and fair view of the state of the charity’s affairs as at 31 March 2012, and of its
incoming resources and application of resources and cash flows, for the year then ended;
have been properly prepared in accordance with United Kingdom Generally
Accepted Accounting Practice; and
have been prepared in accordance with the requirements of the Charities Act 2011 and
Regulation 8 of The Charities (Accounts and Reports) Regulations 2008.
Matters on which we are required to report by exception
We have nothing to report in respect of the following matters where the Charities Act 2011
requires us to report to you if, in our opinion:
3
the information given in the Trustees’ Annual Report is inconsistent in any material respect
with the financial statements; or
sufficient accounting records have not been kept; or
the financial statements are not in agreement with the accounting records and returns; or
we have not received all the information and explanations we require for our audit.
PricewaterhouseCoopers LLP
Chartered Accountants and Statutory Auditors
Norwich
PricewaterhouseCoopers LLP is eligible to act, and has been appointed, as auditor under section
144(2) of the Charities Act 2011
The maintenance and integrity of the Cambridgeshire Mental Health and Primary Care Trusts
Charitable Fund website is the responsibility of the trustee; the work carried out by the auditors
does not involve consideration of these matters and, accordingly, the auditors accept no
responsibility for any changes that may have occurred to the financial statements since they were
initially presented on the website.
Legislation in the United Kingdom governing the preparation and dissemination of financial
statements may differ from legislation in other jurisdictions.
4
Foreword to the Accounts
The Charity’s annual report and accounts for the year ended 31 March 2012 have been prepared
by the Trustee in accordance with Part 8 of the Charities Act 2011 and the Charities (Account and
Reports) Regulations 2008.
The Cambridgeshire Mental Health and Primary Care Trusts Charitable Fund is registered with the
Charity Commission (registration number 1099485) and includes funds in respect of all the
Cambridgeshire and Peterborough NHS Foundation Trust (formerly Cambridgeshire and
Peterborough Mental Health Partnership NHS Trust) services and the services of the following
Trusts:
NHS Cambridgeshire
NHS Peterborough
The main purpose of the charitable funds held on trust is to apply income for any charitable
purposes relating to the National Health Service wholly or mainly for the services provided by the
Cambridgeshire and Peterborough NHS Foundation Trust and the Trusts set out above.
5
Trustee's Annual Report
The Trustee presents its Report and Accounts for the year ended 31 March 2012.
Charity Registration
The Umbrella Charity, the Cambridgeshire Mental Health and Primary Care Trusts Charitable Fund
is registered with the Charity Commission, and the registration number is 1099485.
The 'Group' charity name entered into the Charity Commission Register is:
'Cambridgeshire and Peterborough Mental Health and Primary Care Trusts Charitable Fund and
Other Related Charities'.
The principal address of the charity is
Trust Headquarters, Elizabeth House, Fulbourn Hospital, Fulbourn, Cambridge CB21 5EF.
Structure, Governance and Management
The charitable trust constituted by the Trust Deed is administered and managed by the Trustee of
the Charity which is the Cambridgeshire and Peterborough NHS Foundation Trust. The overall
responsibility, therefore, rests collectively with the Board. The Board consists of a Chairman and
six other Non Executive Directors who are each appointed by the Appointments Commission,
together with a Chief Executive and six other Executive Directors.
Directors during the financial year ended the 31 March 2012 and at the date the Annual report and
Accounts were approved were as follows:
Anne Campbell
Chairman (to 31 August 2012)
David Edwards
Chairman (from 1 September 2012)
Ashish Dasgupta
Robert Dixon
Terry Holloway
Howard Nelson
Non Executive Director (to 1 September 2011)
Lucy O'Brien
Ian Goodyer
University of Cambridge nominated Non-Executive Director
Rebecca Stephens
Non Executive Director (to 1 February 2012)
Jenny Raine
Chief Executive (from 1 September 2010 to 30 October 2011)
Attila Vegh
Chief Executive (from 31 October 2011)
Derek McNally
Director of Finance and Performance (from 1 September 2010 to 30
October 2011)
Jenny Raine
Director of Finance and Performance (from 31 October 2011 to 30 April
2012)
Derek McNally
Director of Finance and Performance (from 1 May 2012 to 3 July 2012)
Darren Cattell
Interim Director of Finance (from 4 July 2012)
6
Dr Tom Dening
Medical Director (to 31 December 2011)
Dr Chess Denman
Medical Director (from 1 January 2012)
Annette Newton
Director of Operations (to 31 January 2012)
Barbara McLean
Chief Operating Officer (from 16 January 2012 to 16 April 2012)
Tim Bryson
Director of Nursing and Quality (to 31 January 2012)
Mick Simpson
Interim Chief Operating Officer (from 17 April 2012) and Director of
Nursing (from 1 February 2012)
Keith Spencer
Director of People and Business Development
Tom Abell
Chief Information Officer and Director of Service Improvement
The Charity has policies and procedures in place for the induction and training of the Board. This
induction includes an introduction to the objectives, scope and policies of the charitable funds,
Charity Commission information on Trustee Responsibilities and copies of the previous year's
Annual Report and Accounts.
Throughout the year, the Board received and considered accounts and also received reports on
investments prepared by a sub-committee consisting of the Chairman, Director of Finance and
Performance and one Non - Executive Director from the Cambridgeshire and Peterborough NHS
Foundation Trust and a representative from each of the Trusts.
The Charity has identified and examined all major risks to which it is exposed and systems have
been established to mitigate these risks. The area of significant risk to the Charity is that of the
investment of surplus funds.
7
Special Trusts
The following Special Trusts are registered with the Charity Commission:
Cambridgeshire and Peterborough NHS Foundation Trust Fund
Cambridge Primary Care Trust Charitable Fund
Peterborough Primary Care Trust Charitable Fund
Community Nursing Services For Fenland Fund
Cambridge Psychiatric Rehabilitation Service Research
Cambridge Mental Health Psychotherapy
Occupational Therapy Study Fund Cambridge Mental Health
Doddington Hospital Fund
Community Resource Team City South
Child Health Services Fund
Hospital at Home Service Fund
Continence Services Fund
Cambridge Day Clinic
Chapel, Fulbourn
David Clark House
Mitchell Ward Fulbourn
General Fund Fulbourn
North West Anglia Health Authority - Paediatric Hospital at Home
Advisors and Auditors
The names and addresses of principal advisors are as follows:
Barclays Bank
28 Chesterton Road
Cambridge
CB4 3AZ
Mills & Reeve, Solicitors
112 Hills Road
Cambridge
CB2 1PH
and the External Auditors are:
PricewaterhouseCoopers LLP
Abacus House
Castle Park
Cambridge
CB3 0AN
Objectives and Activities
The objective of the Cambridgeshire Mental Health and Primary Care Trusts Charitable Fund is for
the Trustee to hold the funds upon trust to apply the income, and at its discretion, so far as may be
permissible, the capital, for any charitable purpose or purposes relating to the National Health
Service. The main policy followed is that the majority of the expenditure is incurred for the support
and improvement of patient services and to provide further comforts for patients which cannot be
afforded through public funding.
Achievements and Performance
Total incoming resources for the year totalled £462,000 compared with £395,000 for the previous
year, of which 80% was from voluntary income (57% donations and 23% legacies), 10% from
investment income and 10% from activities for generating funds. Expenditure for the year totalled
£276,000 compared with £387,000 for the previous year, of which 63% was for the benefit of
8
patients' welfare and amenities either directly or through contributions to the National Health
Service, 29% was for the benefit of staff welfare and amenities and 8% was for governance costs
and management and administration of the charity.
Major items of expenditure included specialist mattresses, chairs and an integrated listening
system.
Financial Review
Balances were held during the year in a Charities Official Investment Fund (COIF) Deposit
account, Epworth Affirmative Deposit Fund and a CAFCash Account.
Investments are made within common investment funds in the UK, which are established
exclusively for charities, and authorised Unit Trusts. Investments during the year were held with
the following organisations:
Organisation
Managed By:
COIF property funds
CCLA Investment Management Limited
Epworth Affirmative Fixed Interest Fund
Epworth Investment Management Limited
F&C Investments
The Stewardship International Fund is managed by
F&C Fund Management Limited which is a subsidiary
of F&C Asset Management Plc. The Stewardship
International Fund is an open ended investment
company.
The performance of all investments is compared regularly with those of similar funds.
9
Investment Policy
The aim of the Investment Policy is to give clear guidelines to the Trustee in the managing of the
Charity's funds and to ensure proper and timely monitoring and review of investment performance.
The objectives of the Investment Policy is to:
invest money not immediately required, or place it on deposit to accrue interest if expenditure
is anticipated in the near future
invest the funds in such a manner which will both preserve their capital value and produce a
proper return consistent with prudent investment
not place the funds at risk by speculative investment
diversify investment to reduce risk
invest money in Common Investment Funds or an authorised Unit Trust, split between equity
and non-equity. With the agreement of the Trustee, the typical split of funds will be based on
expert advice from suitably qualified investment managers
where possible, the Trustee should not invest funds in a particular company if the company's
activities are directly contrary to the Charity's purpose and, therefore, against its interests and
those of the beneficiaries, e.g. tobacco companies.
At 31 March 2012 restricted funds totalled £1,525,000 (2011: £1,327,000) and endowment funds
totalled £39,000 (2011: £38,000) (see note 8). The restricted funds will be mainly used to support
and improve patient services and also to provide further comforts for patients that cannot be
afforded through public funding.
Reserves Policy
The Trustee has a duty to manage the cash reserves of the Charity efficiently. This requires
keeping cash held at the bank to a minimum and investing prudently. Charity reserves, as defined
by the Charity Commission, are ‘funds freely available for its general purpose’ and this definition
excludes investment assets.
The Trustee of the Charity is under a general legal duty to ‘apply’ (in practice this means ‘expend’)
and not accumulate income. Charity Commission guidance on this issue determines that the
income of a charity should be applied to specified purposes within a ‘reasonable period of receipt’
(currently 6 months to 2 years). Levels of future income flows are never guaranteed and it is
prudent to retain reserves that enable the Charity to continue to meet its regular commitments.
Income may be retained beyond this ‘reasonable period’ if, in the considered opinion of the trustee,
it is implementing an action necessary for the Charity to function properly ie the holding of specified
income reserve balances.
Investment assets are shown on the balance sheet at market value. Subject to the above it is the
intention that the Charity will spend available funds generally over a 2 year period, but with a
maximum of 3 years and the Trustee will ensure that resources are maintained in a fashion that
achieves this objective.
10
Relationship with Related Parties/External Bodies
The Cambridgeshire Mental Health and Primary Care Trusts Charitable Fund works closely with its
related NHS organisations. The related NHS organisations include:
Cambridgeshire and Peterborough NHS Foundation Trust
NHS Cambridgeshire
NHS Peterborough
The majority of its grants are provided to its related NHS organisations and to individuals within
these organisations. Staff within these organisations identify and advise the Cambridgeshire
Mental Health and Primary Care Trusts Charitable Fund on local priorities and assist the corporate
Trustee in monitoring the use of the charitable funds.
The Cambridgeshire Mental Health and Primary Care Trusts Charitable Fund maintains close links
with staff and patients within the related organisations and their hospitals and community. The
strong relationship with members of staff is particularly valued and enables the charitable funds to
be directed to ensure an effective contribution is made in support of these organisations.
Close links are also maintained with individual hospital voluntary organisations.
Grant Making Policy
In making grants, the Trustee requires that the activity falls within the objects of the Charity and
that the funds are available to meet the requirement.
Plans for Future Periods
The Charity will continue to follow the main policy that the majority of expenditure is incurred for the
support and improvement of patient services and to provide further comforts for patients which
cannot be afforded through public funding.
Approved by the Trustee on
and signed on behalf by
Chair
DAVID EDWARDS
…………………………………………
Chief Executive
ATTILA VEGH
…………………………………………
DARREN CATTELL
…………………………………………
11
Statement of Financial Activities for the Year Ended 31 March 2012
Restricted
Funds
Endowment
Funds
Total
Funds
2012
Total
Funds
2011
£'000
£'000
£'000
£'000
264
107
-
264
107
206
72
Investment income
Activities for generating funds
45
45
___
1
___
46
45
___
40
77
___
Total Incoming Resources
461
___
1
___
462
___
395
___
270
6
___
___
270
6
___
6
375
6
___
276
___
___
276
___
387
___
185
1
186
8
13
-
13
37
___
___
___
___
198
1
199
45
1,327
38
1,365
1,320
___
___
___
___
1,525
39
1,564
1,365
___
___
___
___
See
Note
Incoming Resources
Voluntary income:
Donations
Legacies
11
Resources Expended
Costs of Generating Funds:
Investment Management Costs
Charitable activities
Governance costs
2
3
Total Resources Expended
Net Income for the year before other recognised gains
Other Recognised Gains
Realised and Unrealised gains on Investment
assets
Net Movement in Funds
Fund Balances Brought
Forward at 31 March 2011
Fund Balances Carried Forward at
31 March 2012
The notes on pages 14 to 20 form part of these accounts.
12
Balance Sheet as at 31 March 2012
Restricted
Funds
Endowment
Funds
£'000
4
5
6
See
Note
£'000
Total
Funds
2012
£'000
Total
Funds
2011
£'000
1,038
30
1,068
1,055
103
-
103
178
426
9
435
258
___
___
___
___
529
9
538
436
42
-
42
126
___
___
___
___
487
9
496
310
___
___
___
___
___
___
___
___
1,525
___
39
___
1,564
___
1,365
___
1,525
-
1,525
1,327
___
39
___
39
___
38
___
1,525
___
39
___
1,564
___
1,365
___
Fixed Assets
Investments
Current Assets
Debtors
Cash at bank and in
hand
Total Current Assets
Current Liabilities
Creditors amounts falling due within one
year
7
Net Current Assets
Net Assets
8
Funds of the Charity
Income Funds:
Restricted
Capital Funds:
Endowment
Total Funds
Approved by the Trustee on
10
and signed on behalf by
Chair
DAVID EDWARDS
…………………………………………
Chief Executive
ATTILA VEGH
…………………………………………
DARREN CATTELL
…………………………………………
The notes on pages 14 to 20 form part of these accounts.
13
NOTES TO THE ACCOUNTS
1
Accounting policies
1.1
Accounting convention
These accounts have been prepared in accordance with the Statement of Recommended
Practice (revised) 2005 'Accounting and Reporting by Charities' and with accounting standards
and policies for the NHS approved by the Secretary of State, and on the historic cost basis of
accounting, except for investments that have been included at revalued amount.
1.2
Incoming resources from generated funds
a
all incoming resources are included in full in the Statement of Financial Activities as
soon as the following three factors can be met:
i
entitlement - arises when there is control over the rights or other access to the
resources, enabling the charity to determine its future application
ii certainty - when it is virtually certain that the incoming resources will be received
iii measurement - when the monetary value of the incoming resources can be
measured with sufficient reliability.
b
Gifts in kind
i
Assets given for distribution by the funds are included in the Statement of Financial
Activities only when distributed.
ii Assets given for use by the funds (e.g. property for its own occupation) are included
in the Statement of Financial Activities as incoming resources when receivable.
iii Gifts made in kind but on trust for conversion into cash and subsequent application
by the funds are included in the accounting period in which the gift is sold.
In all cases the amount at which gifts in kind are brought into account is either a
reasonable estimate of their value to the funds or the amount actually realised. The
basis of the valuation is disclosed in the annual report.
c
Legacies
Legacies are accounted for as incoming resources once the receipt of the legacy
becomes virtually certain. This will be once confirmation has been received from the
representatives of the estate that payment of the legacy will be made or property
transferred and once all conditions attached to the legacy have been fulfilled.
14
1.3
Resources expended
The Funds Held on Trust accounts are prepared in accordance with the accruals concept.
A liability (and consequently, expenditure) is recognised in the accounts as resources
expended as soon as there is a legal or constructive obligation committing the Charity to
the expenditure as described in Financial Reporting Standards 5 and 12.
Resources expended are split into three main activity categories being the costs of
generating funds, the costs of charitable activities and the governance costs.
The costs of generating funds are the costs associated with generating income resources
from all sources other than from undertaking charitable activities. Resources expended on
charitable activities comprise all the resources applied by the charity in undertaking its work
to meet its charitable objectives as opposed to the cost of raising the funds to finance these
activities and governance costs. Charitable activities are all the resources expended by the
Charity in the delivery of goods and services, including its programme and project work that
is directed at the achievement of its charitable aims and objectives. Such costs include the
direct costs of the charitable activities together with those support costs incurred that
enable these activities to be undertaken.
Grants are only made to related or third party NHS bodies and non-NHS bodies in
furtherance of the charitable objects of the funds. A liability for such grants is recognised
when approval has been given by the Trustee.
Governance costs include the costs of governance arrangements which relate to the
general running of the Charity as opposed to the direct management functions inherent in
generating funds, service delivery and programme or project work. They are apportioned
on the basis of the average monthly fund balances.
1.4
1.5
Investment fixed assets
i
Profits realised on the sale of investments are included in the Statement of Financial
Activities.
ii
All investments are included in the Balance Sheet at market value. Market value is
deemed to be the mid market value which is the average of the bid price and the offer
price.
Fixed assets
These funds have no retained fixed assets.
1.6
Structure of funds
Where there is a legal restriction on the purposes to which a fund may be put, the fund is
classified in the accounts as a restricted fund. Funds where the capital is held to generate
income for charitable purposes and cannot itself be spent are accounted for as endowment
funds. Other funds are classified as unrestricted funds. Funds which are not legally
restricted but which the Trustee has chosen to earmark for set purposes are classified as
designated funds.
15
1.7 Realised and unrealised gains and losses
All gains and losses are taken to the Statement of Financial Activities as they arise. Realised
gains and losses on investments are calculated as the difference between sales proceeds and
opening market value (or date of purchase if later). Unrealised gains and losses are
calculated as the difference between market value at the year end and opening market value
(or date of purchase if later).
1.8 Value Added Tax
Most of the activities of the trust are outside the scope of VAT and, in general, output tax does
not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the
relevant expenditure category or included in the capitalised purchase cost of fixed assets.
Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.
2
Charitable activities
Restricted
Funds
£'000
Patient's welfare and amenities
Endowment
Funds
£'000
Total
2012
£'000
Total
2011
£'000
12
-
12
19
160
-
160
255
80
-
80
87
-
-
-
(5)
18
___
___
18
___
19
___
270
___
___
270
___
375
___
Restricted
Funds
£'000
Endowment
Funds
£'000
Total
2012
£'000
Total
2011
£'000
Friends of Fulbourn Hospital and the Community
_____
_____
_____
(5)
_____
Total grants made
_____
_____
_____
(5)
_____
Contributions to NHS towards patient's welfare and
amenities
Staff welfare and amenities
Grants made to other organisations*
Management and administration of the Charity
* Grants made to other organisations
Name of Recipient
The allocation of the management and administration costs of the Charity are based on the
average monthly balance of the funds.
3
Governance costs
Governance costs include the fee payable to the external auditor of £5,000 (2011: £5,000) which
have been apportioned between the funds on the average monthly balance of the funds.
16
4
Fixed asset investments
Equity
Based
Fixed
Interest
Property
Fund
Stewardship
International
Fund
Epworth
COIF
Total
2012
Total
2011
£'000
£'000
£'000
£'000
£'000
364
148
543
1,055
999
Purchase of investments at cost
-
-
-
-
329
Sale of investments at cost
-
-
-
-
(310)
Realised gain/(loss)
-
-
-
-
14
Net unrealised gain/(loss)
9
___
14
___
(10)
___
13
___
23
___
Market value 31 March 2012
373
___
287
___
162
___
143
___
533
___
504
___
1,068
___
934
___
1,055
___
934
___
Market value 1 April 2011
Historical cost as at 31 March 2012
Investments are made within common investment funds and authorised Unit Trusts in the UK
which are established exclusively for charities.
COIF charity funds are managed by CCLA Investment Management Limited, a leading
investment management company serving charities and local authorities.
The Stewardship International Fund is managed by F&C Fund Management Limited which is a
subsidiary of F&C Asset Management Plc. The Stewardship International Fund is an open
ended investment company.
Epworth Affirmative Fixed Interest Fund is managed by Epworth Investment Management
Limited.
The performance of all investments is compared regularly with those of similar funds.
Gross income from the above investments amounted to £44,000 (2011: £39,000).
17
Appendix 1
5
Debtors: amounts falling due within one year
Trade debtors
Other debtors
Accrued income
6
3
100
___
7
130
41
___
103
178
___
___
2012
£'000
2011
£'000
220
85
125
90
___
124
49
___
435
___
258
___
2012
£'000
2011
£'000
42
___
33
93
___
42
___
126
___
Total
2012
£'000
Total
2011
£'000
Creditors: amounts falling due within one year
Amounts due to associated undertakings
Accruals
8
2011
£'000
Cash at Bank and in Hand
Cash at Barclays and in Hand
Other Institutions:
Epworth Affirmative
COIF
CAF
7
2012
£'000
Analysis of net assets between funds
Restricted
Funds
£’000
Investments
Current assets
Current liabilities
Endowment
Funds
£'000
1,038
529
(42)
___
30
9
___
1,068
538
(42)
___
1,055
436
(126)
___
1,525
___
39
___
1,564
___
1,365
___
18
9
Related party transactions
The Cambridgeshire Mental Health and Primary Care Trusts Charitable Fund works closely
with its related NHS organisations. The related NHS organisations include:
Cambridgeshire and Peterborough NHS Foundation Trust
NHS Cambridgeshire
NHS Peterborough
During the year, certain members of the Charitable Funds Investment Panel, which is
empowered by the Trustee to act on its behalf in the day-to-day administration of all Funds
Held on Trust, were also members of the above organisations.
During the year, the Charity had a number of material transactions with these organisations in
furtherance of the objectives of the charity totalling £276,000 (2011: £387,000),which includes
administration charges. Other than these payments there have been no transactions between
the Charity and the listed NHS bodies.
Board Members of the Cambridgeshire and Peterborough NHS Foundation Trust, the
Corporate Trustee and members of the Charitable Funds Investment Panel ensure that the
business of the charity is dealt with separately from the associated Exchequer Funds for which
they are also responsible.
Declarations of personal interest are made where appropriate, and these declarations pertaining
to the Funds Held on Trust are available for public inspection by application through the Trust
Secretary of the Cambridgeshire and Peterborough NHS Foundation Trust.
The Corporate Trustee did not pay expenses to any member of the Cambridgeshire and
Peterborough NHS Foundation Trust Board of Directors’ nor to any member of the Charitable
Funds Investment Panel and members did not receive any honoraria or emoluments from
charitable funds in the year.
19
10 Summary of Total Funds
Balance at Transfer of
31-Mar 2011
Funds
Income
Expenditure
Realised Balance at
and
31-Mar 2012
Unrealised
Gains
£'000
£'000
£'000
£'000
£'000
£'000
Cambridgeshire and Peterborough
NHS Foundation Trust
447
28
65
(113)
3
430
NHS Trust
693
-
302
(82)
9
922
3
-
-
-
-
3
184
(28)
94
(81)
1
170
___
___
___
___
___
___
1,327
-
461
(276)
13
1,525
___
___
___
___
___
___
38
-
1
-
-
39
___
___
___
___
___
___
Restricted Funds:
NHS Cambridgeshire
NHS Peterborough
Total Restricted Funds
Endowment Funds
NHS Trust
Total Endowment Funds
TOTAL FUNDS
38
-
1
-
-
39
___
___
___
___
___
___
1,365
-
462
(276)
13
1,564
___
___
___
___
___
___
11 Voluntary Income: Donations
Donations of £264,000 include funds of £105,000 which were transferred from NHS Luton
during the year.
20
Agenda Item: 18
BOARD OF
DIRECTORS
MEETING
Date:
Subject:
Prepared by:
FOIA Status
REPORT
28 November 2012
Use of the Trust Seal
J Hall, Interim Trust Secretary
Public
class
key stakeholders
our vision
with this paper:
regulations
Reference
functions
Other
N/A
N/A
N/A
N/A
N/A
N/A
pros and cons
N/A
Background papers
Quarterly reporting to Trust Board
Register of Trust Seal
Purpose
1. The purpose of this paper is to inform the Board of the use of the Trust Seal in
accordance with Standing Orders (Sealing of Documents paragraph 8.3). The use
of the Trust Seal will be reported to the Board on a quarterly basis.
2. The Board is asked to note the use of the Trust Seal on the following documents
under delegated powers:
Sealed Documents April 2012 – October 2012.
Date
sealed
2nd May
2012
Details
Signature
CPFT and Rockwell Automation LTD –
Tenancy
Attila Vegh, Chief Executive
Anne Campbell, Chair
13th July
2012
License for underletting first floor south wing,
Winchester Place
Tom Abell, Director of Service
Improvement
Keith Spencer, Director of People &
Business Development
1st August
2012
Deed of Ratification of project agreement
Anne Campbell, Chair
2nd August
2012
Crawford Adjusters Limited – 1st floor, South
Wing Winchester Place
Mick Simpson, Interim Chief
Operating Officer
8th August
2012
Deed of variation with National grid – Ida
Darwin Hospital
Darren Cattell, Director of Finance
26th
September
2012
27th
September
2012
Sale of Cobwebs
David Edwards, Chairman
Headway lease relating to Block 10 Ida Darwin
David Edwards, Chairman
Tom Abell, Director of Service
Improvement
3rd
October
2012
National Grid Gas – Ida Darwin Hospital
Keith Spencer, Director of People &
Business Development
Agenda Item: 19
BOARD OF
DIRECTORS
MEETING
Date:
Subject:
Prepared by:
FOIA Status
REPORT
26 November 2012
Declaration and Register of Interests
J Hall, interim Trust Secretary
Public
class
our vision
with this paper:
regulations
Reference
functions
N/A
N/A
It is a legal requirement for Board
Members to declare any personal
interests.
N/A
Other
pros and cons
Annually and each Board and Board
Committee meeting
Background papers
Standards of Business Conduct for NHS
Staff
Monitor Code of Governance
Executive Summary
1.
The Trust’s Standing Orders require members of the Board to declare any
personal interests that bear on their discharge of public duties as Directors of
the Trust.
2.
The declarations of Board members for the year 2012/13 are attached for
noting. These will be included in the Annual Report.
3.
In addition, the paper also outlines the arrangements for collection and collation
of the declarations of interests, gifts, hospitality and sponsorship from across
the Trust.
Declarations and Register of Interest
4.
The Trusts Standing Orders require members of the Board to declare any
personal interests that bear on their discharge of public duties as Directors of
the Trust. This is achieved individually by requiring Board members to declare
interests on appointment, and subsequently each year, or ad hoc if their
personal position changes during the year. Declared interests are retained for
public scrutiny and published in the Annual Report.
5.
Moreover, the opportunity is offered at the start of each meeting of the Board,
and of its Committees, to declare any interests deriving from the agenda at that
meeting.
6.
Relevant and material declarations are depicted as:
a) Directorships, including Non-executive Directorships held in private
companies or PLCs (with the exception of those dormant companies);
b) Ownership or part-ownership of private companies, businesses or
consultancies likely or possibly seeking to do business with the NHS;
c) Majority or controlling share holdings in organisations likely or possibly
seeking to do business with the NHS;
d) A position of Authority in a charity or voluntary organisation in the field of
health and social care;
e) Any connection with a voluntary or other organisation contracting for NHS
services;
f) Research funding/grants that may be received by an individual or their
department;
g) Interests in pooled funds that are under separate management.
7.
Board members should also declare in relation to gifts and hospitality as
required and any returns will be included in the register.
8.
Two declaration forms are used covering the declarations of interests (which
includes the requirement for nil returns) and the declaration of gifts and
hospitality. These forms are retained in the formal register which is available
for public inspection.
9.
Between May and October no returns have been received for gifts and
hospitality from Board members of other staff members.
10.
Awareness will be raised amongst divisions and Corporate Directorates of the
governance requirements with respect to declarations of interest and gifts and
hospitality and associated matters, who will be asked to remind staff within their
areas of the requirement to declare each year.
Recommendations
11.
The Board is asked to note the declaration of interests of Board members.
REGISTER OF DECLARATION OF DIRECTORS’ INTERESTS NOVEMBER 2012
Name
Designation
Other
employment
Relevant and material
interests in business firms,
partnerships, limited
companies
Membership of voluntary and
charitable organisations
Non-Executive Directors
David Edwards,
Chairman
OBE
Ashish Dasgupta
Non-Executive
Director
Director, ABD
Management
Services Limited
None
Robert Dixon
Non-Executive
Director
Self employed
business
consultant T/A
MH Consult
Shareholder and Director
(Chairman): Medilec Limited
Shareholder and Director: The
Gables Fenstanton Limited
Senior Business Associate:
YTKO Limited
Trustee/Director: Papworth Trust
Trustee/Director: Varrier Jones
Foundation
Trustee: Pye Foundation
Member of Medical Marketing
Group, The Chartered Institute of
Marketing
Other
Vice-Chairman – University of
East Anglia (UEA Council)
Chairman – Norfolk & Suffolk
Dementia Alliance
Board Member – University
Campus Suffolk
None
Ian Goodyer
Non-Executive
Director (University
Nominated)
University of
Cambridge
None
None
Wife:
Clinical Specialist: Women’s
Health, Fitzwilliam Hospital,
Peterborough
Director/Trustee/Treasurer:
Bladder and Bowel
Foundation (registered
charity)
Nephew (Godson):Director of
Consulting (Healthcare),Tribal
Group plc
None
Terry Holloway
Non-Executive
Director
Group Support
Executive,
Marshall of
Cambridge
Board member:
Cambridgeshire Chamber of
Commerce
Vice Chairman: The Air League
None
Business interests: have
relationships with both professional
and patient advocacy organisations
involved in urology
/continence/heart disease
Name
Designation
Other
employment
Relevant and material
interests in business firms,
partnerships, limited
companies
Membership of voluntary and
charitable organisations
Other
Executive Directors
Attila Vegh
Chief Executive
None
None
None
None
Executive Director of
People and Business
Development
Service Improvement
None
None
None
None
None
None
None
Executive Medical
Director
Chief Operating
Officer
Nursing
None
None
None
None
Trustee: Denman Charity Trust
Trustee: Talisman Charity Trust
None
Partner employee of
Cambridgeshire University
Hospitals NHS FT
None
None
None
None
Keith Spencer
Tom Abell
Chess Denman
Mick Simpson
Melanie Coombes
None
None

Agenda and papers - Cambridgeshire and Peterborough NHS

Transcription

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