board of directors - Hertfordshire Partnership

Transcription

BOARD OF DIRECTORS
A Public meeting of the
Hertfordshire Partnership University NHS Foundation Trust Board
Will be held on Thursday 28th January 2016 – 11.00 – 13.30
VENUE: The Colonnades, Beaconsfield Road, Hatfield AL10 8YE
Da Vinci B & C
AGENDA
Presentation:- Host Families 1
Apologies for Absence:
2
Declarations of Interest
3
Minutes of Meetings held: 28th October 2015
4
Matters Arising Schedule
5
CEO Brief
QUALITY AND SAFETY
6
Research Activity and Future Plans
7
Report from the Integrated Governance Committee
7.b
Terms of Reference
8
Patient Safety Report
9
Major Incident and Business Continuity Plan
10
Safe Staffing Levels Report
OPERATIONAL AND PERFORMANCE
11
Q3 Annual plan Report
12
Q3 Performance Report
13
Workforce Report:
Workforce Organisational Development KPI’s Q3
14
Cultural Index
15
Report From Finance and Investment Committee
15.b
Terms of Reference
16
Revenue Summary to 31 December 2015
TC
TG & NF*
S Betteley
OS
OS
OS
IE
PL
JK
Attached
Attached
Attached
Presentation
Attached
Attached
Attached
Attached
Attached
Attached
Attached
JK
S Barter
Attached
Attached
Attached
KL
Attached
L Weeks**
Attached
QUESTIONS FROM THE PUBLIC
GOVERNANCE & REGULATORY
17
Report from MHA Managers Committee
18.a
18.b
Governance & Risk
 Board Assurance Framework
 Corporate Risk Register
BS
OS
Attached
Attached
19
Well Led Framework: Board External governance Review
BS
Attached
20
Any Other Business
QUESTIONS FROM THE PUBLIC
21
Date and Time of Next Meeting
- Thursday 28th April 2016, 11.00am – 13.30pm
Chris Lawrence – Chair

**
Prof Tim Gale & Dr Naomi Fineberg in attendance to present the report.
Mary Pedlow and Tina Kavanagh to Attend
Agenda-January28.1.16.doc
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PUBLIC MEETING OF THE BOARD OF DIRECTORS
Trust Head Office, The Colonnades, Hatfield, Hertfordshire
28 OCTOBER 2015
NOTES
Present:
NON-EXECUTIVE DIRECTORS
Mr Chris Lawrence (Chair)
Mr Simon Barter
Mr Peter Baynham
Ms Sarah Betteley
Ms Manjeet Gill
Mr Robbie Burns
Ms Loyola Weeks
Ms Michelle Maynard
EXECUTIVE DIRECTORS
Mr Tom Cahill
Dr Oliver Shanley
Mr Iain Eaves
Mr Keith Loveman
Dr Kaushik Mukhopadhaya
Mrs Jinjer Kandola
Ms Karen Taylor
Mrs Barbara Suggitt
Ms Diane Prescott
Mr Paul Lumsdon
Chief Executive
Deputy CEO / Executive Director Quality & Safety
Executive Director Strategy & Improvement
Executive Director of Finance
Executive Director Quality & Medical Leadership
Executive Director of Workforce & Organisational Development
Executive Director Community Services & Integration
Company Secretary & Head of Corporate Affairs
Interim Director Integration
Interim Director Service Delivery & Customer Experience
OTHER
Mr Thomas Makoni
Ms Lara Harwood
Tara Gouldthorpe
Kate Linhart
Mr Colin Dracott
Mr Tap Bali
Seward Lodge Team Leader
Service Experience Coordinator
Team Manager
Consultant Social Worker
Company Secretary of Nottinghamshire Healthcare
Public Governor Hatfield
MEMBERS OF THE PUBLIC
Ms Jean Brown
Ms Caroline Bowes-Lyons
Mr Stuart Asher
Mr Barry Canterford
Ms Mariejka Maciejewski
Apologies:
NON-EXECUTIVE DIRECTORS
Mr Robbie Burns
Strictly Confidential / BS / CL / njp / Notes – Public Board of Directors – 28.10.15 Page1of9
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142/15
Apologies for Absence
Mr Tom Cahill / Mr Robbie Burns
143/15
Declarations of Interest
None.
144/15
Minutes of Meeting Held 30 July 2015
Approved.
One amendment; Sue Darker to be noted as attending.
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Matters Arising Schedule
Well-Led Framework.
In Summary, the self assessment has begun & will shortly be agreed. An external
reviewer will then be appointed.
Action : BS to bring back to future Public Board Meeting.
BS
CL explained his intention to change the Agenda order given that some Agenda items
had already been discussed in detail at Board Sub Committees.
Therefore Item 21 taken as read as discussed in detail at IGC led by SBe & additionally
covered in Agenda Items 6 – 11.
Item 19 led by SBa to only focus on operational performance matters that have not
already been considered.
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CEO Brief
OS delivered the brief in the absence of TC & highlighted the following :

The National perspective is one of enormous financial pressures & demands,
especially in the acute sector which continues to experience deficits. The picture is
one of Trusts increasingly being stretched financially especially in terms of agency
costs.

Mr Jim Mackey has been appointed CEO to NHS Improvement. He is due to
commence in post on 1.11.15.

The Government has announced nursing immigration restrictions are temporarily
lifted in order to address the massive vacancies. This is positive development.


The West Herts Strategic Review – Your Care – Your Future - is taking shape.
To summarise, this will be documented in a Strategic Outline Case paper to be
published in the early part of November.
Action : Update to be brought to the Public Board Meeting in due course.

The E&N Herts Acute Trust have now had their CQC inspection.

OS confirmed that operationally the Trust remains very busy.
IE
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
Key workforce issues are recruitment & retention. JK added that the BMA have
balloted for strike action with notice having been given for strike action between 4 &
18 November. What impact this could have on the Trust is separately being explored
at the LNC to ensure that service users are not compromised & the Trust continues
to safely deliver its keys services.

Congratulations offered to Award winners :
o
OS has been awarded with Most Inspirational Nursing Leader.
o
Professor Kunle Ashaye who has won the Educator of the Year award in the
Quality in Education Training Awards given by the Health Education East of
England.
o
The Community Eating Disorders Service who have won in the “Specialist
Services” category.
o
Charmaine Newman, Team Leader, The Stewarts who is joint winner of the
Unsung Hero Nursing Award.
o
In addition we have a finalist shortlisted for the Board Leadership Award to be
decided in November, Development Champion Leah Johnson.
CL concluded that although as a Board we know how much good work is being done
within our Trust, it is good to have this confirmed.
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Report from the Integrated Governance Committee (IGC)
SBe reported that the Workforce & OD Group had not managed to hold their meeting.
A further meeting is due on 05.11.15 but further action may need to be taken if the
meeting is under-represented & again cancelled. The IGC will be kept informed.
SBe confirmed those matters escalated to the Board:
Loan Worker devices are not being used enough even though they are a safety
requirement. The current Policy is being reviewed to reflect that the devices “must” be
used.
Action : Changes made will be monitored by IGC on behalf of the Board.
The Risk Register was also discussed in detail at the IGC Meeting at which three issues
were approved for addition & agreement by the Board.
Supervision of safeguarding referrals which was deemed not to have enough
assurance. It was suggested that better use of electronic systems & training be
explored.
DOLS authorisations have been overwhelming for the local authority that has been
unable to deal with them as quickly as they should be. In view of the changes early
next year, it was agreed that although this situation is out of our control, work can be
done to tighten up our own process in the interim. It was also accepted that although
we are doing all that we can, we also need to focus on incorrect referrals being put
through via the MHAA.
Environmental issues at Kingfisher Court were also added.
Board approved the additions of 3 risks & noted other changes.
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148/15
Safe Staffing Levels Report
OS confirmed that the overall picture across the Trust is generally adequate in line with
agreed inpatient levels. Although shifts across the Trust have been adequately covered,
there had been more actual hours than planned for both RNs & HCAs. This is partly
arising from some high levels of aggression & acuity as we have been faced with some
Service Users presenting with high level needs arising from their complex difficulties
Norfolk is struggling with recruitment & retention of staff. The SBU is meeting this week
to explore what else can be done. Actions being undertaken were discussed.
Following a number of staff expressing dissatisfaction about the shift Pattern, a ballot
was held. The outcome of the ballot with a 58% vote was to continue with the current
Shift Pattern. A further vote in six months’ time to be offered given the marginal
difference of views.
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Think Local Act Personal (TLAP) – Making it Real
KLa gave an overview of the above with the view of getting Board approval today to
declare support for the programme.
She spoke briefly about the 26 “I” Statements which are National co-produced outcome
statements & are themed around 6 key areas. Approval will ensure that HPFT will be
signing up to a set of priorities & action plan which will support the Trust in delivering
personalised care & support which not only fits with the CQC recommendations but
provides a response to the National Service User Survey.
Following discussion the Board agreed to sign up to the programme and make a formal
declaration to this effect. The work will be taken forward within the SBUs and the Board
will be kept updated on progress.
Action: KLa to report back to the Board in the future on progress.
CL thanked KLa.
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CQC National Service User Survey
During the week beginning 27th April 2015 the CQC undertook a comprehensive inspection of
the Trust. 95 inspectors visited all our inpatient services and many of our community teams in
their assessment of the quality of service provision. They rated the Trust ‘Good’ overall which
places us on the top 25% of Trusts nationally who have been inspected.
The full report is available on our public website and the CQC website.
Following the publication of the Trusts CQC inspection report on the 8th September 2015, the
recommendations for action have been captured in a high level action plan.
The CQC identified 13 ‘must do’ (MD) actions which are linked to the Trust not meeting certain
requirements of the Health and Social Act Regulations.
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There were also 39 ‘should do’ (SD) actions which were identified during the inspection but not
directly linked to non-compliance with the Health and Social Care Act.
The full action plan has been presented to the Board following publication of the final report.
The report has been submitted to the CQC and Monitor. A meeting will be held with CQC in
November to discuss ongoing monitoring of the implementation of the plan. An update on the
action plan will be provided to Board in 6 months’ time.
151/15
Report from Finance & Investment Committee (FIC)
SB confirmed that the Financial Performance for the Trust, to end September, revealed a
surplus of £90K marginally ahead of the Plan of £83K.
Also the overall CRES position for month 6 has improved.
SB spoke briefly about the 10 to 12% agency workforce which needs to come down to
8% to meet with government expectations. 60% is to provide vacancy cover & safe
staffing levels. Agency usage will be affected with the capping process underway
currently. This will have implications (as the cap increases) on how we manage agency
spend.
We are now recruiting more staff than we lose each month.
Financial planning for 2016 – 17 is underway and a full Financial Plan will be brought to
the next Board meeting.
CL concluded that an important issue is that of staff retention as we are losing
experienced members of staff & there are cost implications to replace these staff. He
particularly thanked JK & her staff for doing an outstanding job.
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Q2 Annual Plan Report
IE confirmed that the Annual Plan comprises of 12 objectives with associated milestones
and objectives across 3 areas – Quality & Service Delivery, Workforce & Sustainability.
These have been RAG rated against planned progress at the end of Q2: Two objectives are rated
Green, six Amber / Green, three Amber, one Amber / Red and one Red.
The four red & amber rated objectives at Q2 are the same as reported for Q1:
-
We will live within our means and secure the financial sustainability of our services
We will successfully embed the significant recent changes to our adult community
and CAMH services for the benefit of service users, carers and staff
We will continue to improve the effectiveness and safety of our acute care pathway
and placements service
We will recruit and retain staff, reducing our reliance on temporary staffing
Points of note:


West Essex IAPT working well following the transfer of services.
The Lambourn Grove refurbishment is on track.

HPFT continues to play a leading role within the integrated care programmes in E&N
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




Herts and Herts Valleys. Both programmes have now reached critical stages in
shaping the future model of care across the county and will require significant
investment of time and energy during Q3.
CAMHS access rates improving.
The new Crisis Service in CAMHS is also functioning really well.
Less reliance on external placements.
Increased acuity on wards.
Social care placements continue to be worked on.
It was noted that we wanted to meet access targets but not to neglect waiting times that
were not subject to targets.
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Q2 Performance Report
Monitor
As projected, all Monitor Targets have been met for Q2 and this will be reported in the
quarterly monitoring return and declaration. However it should be noted that the
performance reported against each of the individual metrics has reduced to some
degree, the main highlights being the continuing increase in the delayed transfers of care
and the reduction in the level of outcomes data recorded.
Trust Performance Framework
The Performance Framework focuses on the three broad areas: Access, Safety &
Effectiveness, and Resources. In the previous quarter we reported a mixed performance
picture and overall this picture has continued into Q2. Of 44 indicators 39% are at or
above target (green) with 45% below target (red).
Access to services
There are 19 targets reportable in the period of which ten have been met or exceeded
(reported green) and seven are reported as red (5 last quarter). The key areas of
pressure are:
Three of the five IAPT contracts remain behind Plan (between 10% and 20% below plan
for people entering treatment) and the remedial actions implemented in the period have
not yet had the projected impact. The routine CAMHs 28 day wait is now 86% which
whilst below the 95% target is a 16% improvement and in line with the trajectory with
further improvement expected in Q4 following additional recruitment.
Safety and effectiveness of services
There are 14 targets reported in the period of which eight are reported as red (5 last
quarter) and six are reported as green (7 last quarter). The red indicators are across
several areas of measurement predominately within IAPT where recovery rates on each
of the Essex services are below the 50% target and on clustering levels. The completion
of risk assessments also remains below target.
Resources
This measures a series of workforce and financial metrics. The workforce indicators
overall remain in line with the previous quarter with some improvement on several
measures but offset by reductions elsewhere. In terms of an overall position staff
turnover has increased marginally with sickness rates improving.
Whilst the financial performance was below the internal target for the quarter there was
an improvement in the quarter. The YTD surplus variance is now (£923K) compared to
(£708K) at Q1. In September a surplus was reported for the first time this year.
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154/15
Workforce Report : Workforce Organisational Development KPIs Q2
JK presented the Report & noted that :
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
Recruitment & retention remain a key focus / activity.

Q2 has seen the launch of a number of recruitment and retention initiatives including the
launch of the ‘Golden Hello’ payment, the first ‘Our People Week’, launching the new bank
pay rates, promoting flexible working and retirement, targeted recruitment campaigns in
specific areas and seeking agreement on overseas recruitment.

Time to hire has gone down to 12 ½ weeks. This transparent & robust system is
now seeing the benefits. There have been more starters than leavers although
turnover remains high.

10% is a healthy turnover & that is what we would aim for.

The Managing Excellence Programme has commenced with its first cohort of 18 candidates
in September.
Cultural Index Q2 2015 / 2016
The index is populated from the quarterly Pulse Survey Data. It tracks seven key areas that can
give an indication of the health of an organisation’s culture, which provides invaluable data in
relation to the employees rating of organisational culture with regards to the following key areas:
 Staff recommending HPFT as a place to work
 Staff Engagement and Motivation
 Staff understanding of contribution
 Access to training and development
 Support from Line Manager
 Understanding of Values and Behaviours
 Not experiencing bullying & harassment
There were 307 respondents to the Q2 Pulse Survey, which is around 12% of Trust staff. There is
a slight decrease in the ratings across 6 of the indicators, in most cases, this was a minor change
and still a good position compared to Q2 last year.
The Report was accepted as noted.
156/15
Revenue Summary to 30 September 2015
KL first reflected on the positive feedback already provided today in terms or our
performance.
He acknowledged the pressures & demands in acuity with associated financial
implications.
KL also referred to the significant work in operational services to achieve a more stable
position in terms of managing agency staff & their transition to permanent staff.
In terms of Forecast to year end, the plan to September has been achieved with £90K
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surplus. KL projects the picture for the remainder of the year as similar with no
significant improvement.
The Q2 Report was accepted & the Board signed off the figures for the return to Monitor.
Action : Board approved submission of Q2 figures to Monitor as part of the
regulatory return.
157/15
Medical Appraisal & Revalidation
KM explained that the medical appraisal & revalidation process is a statutory
responsibility he excises on behalf of HPFT to the GMC. The system is to ensure that all
Doctors are qualified & fit to practice. KM is also the RO for Locums.
KM added that the current practice is very robust & we are only one of a handful of
Trusts that use an electronic anonymised system to manage this process.
HPFT had 144 doctors substantially employed at March 31 2015. HPFT is responsible
for recommending (or deferring) the re-licensing of these doctors every five years based
on completion of comprehensive appraisals covering multi-source feedback, and clinical
governance information such as complaints, serious incidents and other relevant
information including continuing professional development.
The Board noted & accepted the Report.
158/15
Governance & Risk - Board Assurance Framework (BAF) –
Corporate Risk Register
BS confirmed that the IGC had examined both Reports in detail.
CL added that the importance of BAF is that it provides a framework to plot, chart &
debate levels of assurance. He thanked BS for her work & noted the paper.
In terms of the Risk Register, BS clarified the 3 additional items recommended by the
IGC to be added to the Register; DOLS, environment risk & gaps in safeguarding,
CAMHS recruitment as already discussed above.
The Report was approved and Board agreed that the three additional risks be added to
the Register.
159/15
Sign off Lambourn Grove Business Case
KL spoke about the refurbishment particularly pointing out the plans to provide
appropriate ensuite facilities & garden area a part of the overall improvement of the
environment & which meet the dementia standards. The case had been presented to
FIC on 21 October & the Board were asked to approve the Committees’ recommendation
to move to completion of Phase IV.
The Board approved the recommendation.
160/15
Any Other Business
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LW took the opportunity to formally thank Tina Kavanagh for the successful Mental
Health Act Managers Meeting recently. It had seen some 40 to 50 people attend with
staff coming from Herts & Essex. Feedback had been very positive.
CL formally welcomed Mr Colin Draycott (Company Secretary for Nottinghamshire
Healthcare) & stated he was delighted he could be here today. He thanked him also for
supporting his visit in July.
DATE & TIME OF NEXT MEETING
Thursday 28 January 2016 - 11.00 to 13.30 – The Colonnades
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Hertfordshire Partnership University NHS Foundation Trust
Agenda Item 4
MATTERS ARISING FROM BOARD OF DIRECTORS PUBLIC MEETING HELD 28 October 2015
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CEO Brief – Update on west Herts Strategic Care
Iain Eaves
•
The West Herts Strategic Review Apr 2016
Review
– Your Care – Your Future - is taking
shape.
To summarise, this will be documented in
a Strategic Outline Case paper to be
published in the early part of November.
Action : Update to be brought to the
Public Board Meeting in due course
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Think Local Act Personal (TLAP) Making it Real
Kate Linhart
Following discussion the Board agreed to Apr 2016
sign up to the programme and make a
formal declaration to this effect. The
work will be taken forward within the
SBUs and the Board will be kept updated
on progress. KL to report back to the
Board in the future on progress
Action Date not yet reached
AgendaItem4-PublicMeeting
Action Not Completed
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Agenda Item 5
January 2016
Subject:
Agenda Item 5
Chief Executive Brief
External & Strategic
National Update
National Planning
There have been a number of items issued by the centre in respect of planning, both guidance on
action to be taken for the remainder of this financial year and for the year ahead 2016/17. This has
included:
‘Delivering the Forward View: NHS Shared Planning Guidance 2016/17 – 2020/21’.
It is published by NHS England, NHS Improvement (the new body which will bring together
Monitor and the NHS Trust Development Authority), the Care Quality Commission, Public
Health England, Health Education England and NICE – the bodies which developed the
Five Year Forward View in October 2014.
The planning guidance is backed up by funding including a new Sustainability and
Transformation Fund which will support financial balance, the delivery of the Five Year
Forward View, and enable new investment in key priorities.
As part of the planning process, all NHS organisations are asked to produce two separate
but interconnected plans:
1. A local health and care system ‘Sustainability and Transformation Plan’, which will
cover the period October 2016 to March 2021; and
2. A plan by organisation for 2016/17. This will need to reflect the emerging
Sustainability and Transformation Plan.
A joint letter from Jim Mackey and Professor Sir Mike Richards to all trust boards, asking
them to consider quality and finances on equal footing in their planning decisions. This
highlights that in due course Monitor, together with CQC and NHS England, will be
publishing revised National Quality Board staffing guidance and a new metric looking at
care hours per patient day, as part of CQC’s new assessment on the use of resources. We
expect further details on this will be published in the coming months.
Individual letters have been sent by NHS Improvement to trusts highlighting their
indicative share of the £1.8bn sustainability fund. This funding will be dependent on
having:
a. A recovery plan with NHS Improvement and agreed control total for 2016/17 including
capital and revenue limits
b. A plan for maintaining agreed performance trajectories for delivering quality and access
standards
c. Development of sustainability and transformation plans, including adherence to the
planning timetable
d. Compliance with all staff agency rules
e. Tangible progress towards achieving seven-day services
Preliminary recommendations from Lord Carter’s review in to operational productivity,
which will be published at the end of this month or early February. In the letter sent from
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Lord Carter to the Secretary of State, he reemphasises that the NHS will be able to
generate £5bn of efficiency savings by the end of the parliament, but only with some key
support from the centre.
A letter from NHS Improvement outlining additional arrangements to tackle agency costs.
It details the following:
a. The plan to lower the agency price caps for medical and clinical staff on 1 Feb has been
restated.
b. The ban on using agency frameworks not approved by NHS Improvement will be
extended to all staff groups from 1 April. Currently, it only applies to nursing staff.
In the coming weeks, we are expecting the following announcements and publications to
be made:
• Technical guidance to support the planning guidance, in particular the development of
sustainability and transformation plans.
• Details of the targeted element of the £1.8bn sustainability fund.
• The standard contract and CQUIN guidance
• Final report from Lord Carter
How these will affect the Trust are dealt with separately on the agenda.
Junior Doctor Strike Action
ACAS, the conciliation service, recommenced talks on Thursday 14 and Friday 15 January
to try and reach a negotiated settlement. Sir David Dalton, Chief Executive of Salford
Royal NHS Foundation Trust was appointed by the Health Secretary to lead negotiations
on behalf of government and the NHS in new talks with the BMA.
The BMA had previously announced further strike action on the following days:
•8am Tuesday, 26 January to 8am, Thursday 28 January – (48 hours) emergency care only will be
provided - this was suspended.
•8am to 5pm, Wednesday 10 February – full withdrawal of labour
Prime Minister Announcement of Funding for Mental Health
The Prime Minister recently made an announcement concerning funding for mental health
services, plans will include:
•£290 million of new investment over the next 5 years to provide mental healthcare for new
mums
•£247 million to invest in liaison mental health services in emergency departments
•over £400 million to enable 24/7 treatment in communities as a safe and effective
alternative to hospital
•expanded services to help teenagers with eating disorders – as anorexia kills more than
any other mental health condition
Further investment and service expansions will be announced when the mental health
taskforce report is published in the next few weeks.
CQC
Fees Consultation
In a consultation document, the regulator outlines two scenarios for future provider fees, which
help fund the running of the CQC. The first scenario would see the CQC move to “full cost
recovery” over just two years. This would mean an NHS trust with a turnover of £125m-£225m
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would see its fee rise from £78,208 this year, to £136,864 in 2016/17 – a 75% increase – before
increasing further to £215,835 in 2017/18 – a 176% increase on the 2015/16 fees. A more
conservative scenario for the same trust would see its fee rise by 40% next year to £109,491, and
while it would still eventually rise to £215,835, this would be staggered over four years. We will be
responding to the consultation.
Appointment of Dame Eileen Sills, National Guardian
As the National Guardian for the freedom to speak up, Dame Eileen will help to lead a cultural
change, initially within NHS trusts and NHS foundation trusts, so that healthcare staff always feel
confident and supported to raise concerns about patient care.
The need for an independent National Guardian for the NHS was highlighted in Sir Robert
Francis’s Freedom to Speak Up review in February 2015, which found that patients could be put at
risk of harm because vital information about mistakes and concerns was not being raised by NHS
staff routinely. The creation of the National Guardian was one of the key recommendations from
the review – an arrangement which the Secretary of State for Health confirmed last July.
Local Update
CCGs
Finance Allocations
CCGs have recently received notification of their allocations for 2016/17. For
Hertfordshire CCGs, our main commissioners, the settlement is slightly better than
expected (E&NH CCG 5.61% and HV CCG 5.48%) but the detail of how these are made
up and the commitments against them is still awaited. The expectation remains that CCGs
will match expenditure increases on MH/LD to their allocation uplifts and we will work with
CCGs as part of our contract negotiations to ensure appropriate funding is made available
to MH/LD services.
HVCCG
The Accountable Officer, Nicola Bell, has announced her retirement in the spring of this year. She
will remain in post until a new appointment is made and has had their induction.
Herts Valley Strategic Review
All of the sponsoring boards have formally endorsed the direction of travel set out in the Strategic
Outline Case for “Your Care Your Future”. The focus is now on planning for implementation and
translating the SOC into a robust system transformation plan for submission to NHS England in
June.
E+N CCG
Beverley Flowers has been appointed as the new Accountable Officer for the CCG.
West Essex CCG
Clare Morris, the Chief Officer of NHS West Essex CCG is stepping down from her post in the
Spring of 2016. She will continue to work on the integration plans for services in West Essex until
she leaves. The plans will include the future of the Princess Alexandra Hospital on our borders.
West Herts Hospital Trust
No appointment has been made to the substantive Chief Executive post following the recruitment
exercise in December. The interim CEO Jac Kelly will remain with the trust until April this year to
support the organisation.
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Internal & Reputation
Strategy
We have been working with staff and stakeholders to develop our strategy to take the organisation
from “Good to Great “. The strategy has four key themes:
 Great Care Great Outcomes
 The Best People
 Highly Effective Organisation
 Partnerships and System Leadership
Feedback from engagement with staff and governors has been extremely positive and will help
shape the next phase of developing our thinking between now and the end of March.
Quality & Safety
Quality & Safety
Care Quality Commission
Trust Action Plan
The Trust has met with the CQC following the submission of the action plan. They have agreed
that we will report quarterly on progress following submission of updates to the Integrated
Governance Committee. Progress has been made in a number of areas including recruitment to
CAMHS, training across the Trust on MCA/DoLS and MH Act and actions to address the concerns
in relation to Medicines Management. Challenges remain in recruitment of staff at Broadland Clinic.
Patient Safety Quarter 3 Report
The predicted suicide rate per 1,000 service users for 2015/16 is marginally lower than the
predicted rate for 2014/15. However, the number of suspected suicides is higher for the first 3
quarters of the year compared with the same period last year. This may be subject to change in
future as inquests are concluded.
The Trust reported a total of 13 serious incidents in Quarter 3 of 2015/16 compared to 12 in the
previous quarter. The incidents were 7 unexpected deaths, 3 serious self-harm incidents, an
alleged homicide and two serious incidents of violent and disruptive behavior.
Full details are in the report on the agenda.
Well Led Framework Governance Review
The external review of governance and board performance has just begun and will involve all our
key stakeholders. A report on the findings will be presented to the Board for discussion and action
and will be shared with our regulator Monitor.
Finance & Performance
Finance
A surplus of £220k is reported for the month, which is ahead of the Plan of £83k. This
continues the improving trend over the last months, and is the highest reported monthly
surplus in the year. There are two key drivers to this surplus: in relation to income,
settlement of the contract value for Hertfordshire, and for expenditure the continued
reduction in pay costs, and smaller reduction in secondary commissioning costs.
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Year to date there is a reported surplus of £113k against the Plan of £750k surplus (£637k
adverse). The Monitor Risk Rating, the FSRR, has increased to a 4 for the first time this
year, the increase being due to the improvement in the I&E margin.
The financial position for the remainder of the year will be dependent upon the level of
recruitment to the new service investments and the level of additional non recurrent
infrastructure investment planned in the final quarter which has been held back during the
period to end of quarter 3. This is mainly in relation to improving service user
environments. The forecast position remains a deficit of c. £200k, £1.2m below the Plan
for the full year.
Operational Performance
Monitor Targets – The Trust is on target to meet all Q3 Monitor Targets.
Acute Care Pathway
Over the Festive period beds were made available to prevent out of area placements. In the week
preceding Christmas, an anticipated surge of referrals did result in two out of area placements.
The acuity and complexity of patients remains high and this was reflected in an increase in the
PICU placements which is now reduced.
Performance against Key Quality Indicators - Performance against the overall 28-day wait time
target ended Q3 at 97.3%. Teams are testing out alternative text messages and phone call
reminders to improve on DNAs and utilise cancellations to bring forward IA appointments.
CAMHS – Forest House has remained at maximum bed capacity level, the demand of CAMHS
beds has meant that our CAMHS inpatient unit at Forest House is frequently full and at times
unable to take local admissions. Discussion with the Local and National Commissioners about
this issue is on-going
Hertfordshire and North Essex IAPT Services - In Q3, access rate and recovery performance
has dipped in some IAPT services across Hertfordshire and North Essex. Actions are in place to
improve performance in these services to achieve the required access rate and recovery
trajectories during Q4 to ensure that we are supporting the CCGs to meet the access targets
ensuring that Hertfordshire and North Essex residents receive timely access to psychological.
Achieving the required 15% access rate in Mid-Essex IAPT service remains challenging and is
dependent upon recruitment to vacant posts and increased referrals into service.
Allocation of Service User to Care-Coordinators - Unallocated cases awaiting a care coordinator remains a significant risk for the service area. Unallocated cases continue to be closely
monitored with weekly wellbeing checks by duty workers or support workers as required and
systems to prioritise allocation in place. No new referrals on CPA have waited longer than 28
days for allocation.
Staff
Recruitment & Retention
Recruitment and retention remains a key activity for the Trust as turnover levels remain high at
14.8% and the current vacancy rate remains at 14%. It is encouraging to see more staff start with
the Trust than leave,
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The focus on recruitment continues with the overseas recruitment of 25-30 registered general
nurses or registered mental health nurses planned to take place in March 2016. The ‘Golden
Hello’ initiative has been successful in recruiting to nursing posts in the community, CAMHS and
Older People Inpatients with 58 candidates being eligible for the payment. In addition 18 of the 21
student nurses who are due to qualify in February 2016 have accepted a post with the Trust
The focus on retention also continues with the introduction of retention workshops for managers,
the launch of a new exit interview process, and feedback surveys for new employees. In addition
all staff who could retire over the next five years have been written to ascertain when they may be
likely to retire so that the Trust can plan accordingly and to promote the flexible retire options that
are available.
The Staff Survey
The national Staff Survey has been completed and the results will be available from the 8
February. A full report on the results will be shared with the Board in due course.
Recruitment
We are undertaking a number of key recruitment exercises for the following posts:
Company Secretary due to the retirement of the current post holder.
Director of Service Delivery and Customer Experience – to substantively fill this post
Non-executive Director as the Chair of the Audit Committee will be standing down in July at the
end of his term of appointment.
Business Development
Work is progressing in respect of the due diligence process and a full report will be brought
to the Board meeting in the next month.
Awards
Congratulations to:
Dr Oliver Shanley who was awarded an OBE in the Queens New Years’ Honours List. This is a
well-deserved award which reflects his services to mental health and learning disability services
over the years.
Tom Cahill
Chief Executive
.
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BOARD MEETING
Report of the
Integrated Governance Committee
Meeting Date
Agenda Item
7
Presented
By
Sarah Betteley
Non-executive
Director
1. Purpose of the Report:
This paper provides a summary of the items discussed at the Integrated Governance
Committee meeting on the 21 January 2016.
2. Items Discussed:
The following items were on the Agenda:
















Reports from Sub Groups – Q&R Management, Workforce OD Group, Policy Panel
Shortlist of suggested deep dive for the committee
Board Assurance Framework
Trust Risk Register
Patient Safety Quarterly Report
Safeguarding Update Report
Annual Claims Report
Whistleblowing Report
Operational Update
Rapid Tranquilisation
Quality Accounts
CQuin Update
Resus report
CQC Action plan
Review of Terms of Reference of the committee
Friends & Family Test Update
The subgroups each reported on their most recent meetings. Quality & Risk Management
gave a report on the issues discussed regarding the acute services including AWOLS;
implementation of the smoking ban and the issues currently being reviewed in stand alone
units around the difficulties being experienced and action being taken to support staff. The
Workforce & OD group had had a marked improvement in attendance and the group had
discussed recruitment and retention noting a 95% uptake of students coming to work within
HPFT; the management of the Occupational Health Contract following some concerns raised
about performance; the progress being made in preparation for the visit from the Deanery in
the autumn around quality of professional training and a look forward to the impact of the
Apprenticeship levies and student loans.
AgendaItem7ReportforIGCco
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The recent letter from Monitor and TDA concerning the need for Trusts to look at quality and
safety on an equal footing to finance was as it linked with recent guidance about use of
agency staff was discussed by the committee. This had been raised at the Finance &
Investment Committee meeting who asked IGC to consider the impact of the guidance on
the safety and quality of care. The committee agreed that a report should come to the next
meeting to allow a full discussion.
The Policy Panel reported that 93% of policies were currently in date and there was now 90
% compliant with the Care Act. The panel was continuing to improve on the review of
policies and timing of these and had also been asked to consider how the “co-production” of
policies could be implemented.
The committee considered the process and possible subjects for its “deep dives” over the
coming year. It was agreed that the suggested process was good and that the first deep
dive to be undertaken should be around a Health & Safety issue – Fire Safety given the
concerns raised within a recent audit. This deep dive would be used to “pilot” the process
and help inform the scope and subjects of the programme for the rest of the year. More
detailed proposals would be considered at the next meeting ensuring that the dives were
closely linked both with the strategic objectives and the risk register.
The committee discussed the quarterly Patient Safety Report and noted the progress being
made in reducing incidents in certain categories and the work being carried out within the
Trust to review processes in the light of the report on Southern Health. The committee
discussed the suicide data and noted that whilst the comparative data was helpful to some
extent that it was more important to note the actual numbers of suicides given the overall
pledge made by the Trust to reduce these to zero.
A verbal update was given on progress being made around recording and reporting
Safeguarding incidents. There will be an audit undertaken in February to test whether the
changes made have made a difference. The results of this audit will be reported to the
Committee in May and a short update will be provided to the March meeting.
The committee noted the Claims Report which gave an analysis out open claims and the
outcome of those closed in the reporting period. It was noted that claims are decreasing and
the Trust has a good record when defending claims due to the processes and investigations
that are undertaken following incidents.
The Whistleblowing report was discussed by the committee and the recent appointment of
a national guardian for the process was applauded. The committee also discussed the
concern about the fact that staff felt unable to raise bullying and harassment concerns
through the policy process but had raised the issues, often anonymously, through the
whistleblowing process. This had also been discussed at JCNC and a champion was being
sought from the Board. The Chair of the committee, as whistleblowing champion for the
Board, was keen to see this taken forward.
The committee received an Operational Update and noted improvements in performance in
meeting targets in some areas such as CAMHS. The areas of concern were also noted and
will be discussed at the Board when reviewing the quarterly performance of the Trust. The
committee noted the work that had been done to facilitate acute flows during the Christmas
period and also the work done to mitigate the recent action by Junior Doctors.
The committee discussed the work that had been done to ensure that NICE guidance on
Rapid Tranquilisation had been implemented and that issues highlighted by an audit had
been picked up and actioned appropriately. There is a review of the policy underway and
staff training has been strengthened and routine checks by Modern Matrons show some
improvement. It was noted that there will be a national audit in September which will show
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how this has progressed and the committee asked that a pre-audit be carried out in
preparation to give assurance.
The committee received a report on progress in the achievements of the targets set out in
the Quality Accounts and asked that the results be checked prior to them being reported as
part of the performance report to the Board.
The committee also received a report on the achievement of CQUIN targets and noted that
there had been real improvement since the last quarter and thus a real improvement in the
funding received – which should result in an achievement of around 96% of the total
available.
The committee received a report on the work being undertaken in the area of Resuscitation
and the priorities that remain for action and would consider any outstanding items at the next
meeting when members had been able to consider the report more fully.
Progress on the implementation of the CQC Action Plan was noted with the key area of
concern being recruitment of staff in Norfolk. IGC will continue to keep oversight of the
implementation of the plan and also noted that a submission has been made to
commissioners around the funding needed to implement some key improvements.
The committee received a report on the results of the Friends and Family Test which
showed improvements both in the numbers of responses and the number that would
recommend our services. Work continues on finding different ways to obtain feedback.
The committee received the updated Board Assurance Framework and noted the changes
that had been made in the levels of assurance against key objectives. A full report on the
assurance around supervision within the organisation is due to come to the next meeting of
the committee. There were no other issues of concern raised by members.
The committee received and discussed the Trust Risk Register, and in the light of earlier
discussions agreed to recommend to the Board that the two new risks should be added to
the register and that given the safeguarding update this could be downgraded for monitoring
on the Corporate Safeguarding Risk Register.
The committee agreed that future meetings should be extended to run for 2 hours 30
minutes to ensure that fuller detailed discussions can be undertaken in respect of key issues
that may be raised through the deep dives.
3. Matters Escalated to the Board:
There were no matters for formal escalation to the Board.
4. Board to Note:
The committee undertook a review of its Terms of Reference to reflect the new committee
membership and reporting arrangements to the Board. The committee also agreed that the
revised terms should be taken to the Board for approval at their meeting on 28 January.
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The committee wished the Board to note concerns raised by the committee about the risk of
AWOLS and environmental issues at Kingfisher Court and the committee will be receiving a
full report on this at their next meeting.
The committee also asks the Board to note its Deep Dive will be to look at Health and Safety
issues in respect of Fire Safety. A programme of further deep dives will then be developed
in conjunction with other committees to ensure that there is no duplication.
5. Recommendation

Board members are asked to note the summary of items discussed at the meeting.

The committee recommend the changes proposed to the Trust Risk Register for
approval by the Board.

The Board are asked to approve the revised terms of reference of the committee.
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Meeting Date:
Trust Board of Directors
28 January 2016
Agenda Item: 7b
Subject:
Terms of Reference
For Publication: Yes
Author:
Catherine Pelley
/Barbara Suggitt
Approved by:
Oliver Shanley
Presented by:
Sarah Betteley
Purpose of the report:
The purpose of this report is to present updated Terms of Reference, which have been
approved by the Integrated Governance Committee for approval by the Board.
Changes made to the Terms of Reference include the Chair and membership details
reflecting changes within the organisation and have been highlighted for ease of
reference.
Action required:
The Board is asked to agree the changes to the Terms of Reference.
Summary and recommendations to the Board:
Following discussion at the IGC on 21 January the Terms of reference are recommended
to the Board for approval. The Terms of Reference were amended to reflect the agreed
changes to membership of the committee and also to standardise the other elements in
line with other committees.
Relationship with the Business Plan & Assurance Framework (Risks, Controls &
Assurance):
None
Summary of Financial, IT, Staffing & Legal Implications:
None
Equality & Diversity (has an Equality Impact Assessment been completed?) and
Public & Patient Involvement Implications:
N/A
Evidence for S4BH; NHSLA Standards; Information Governance Standards, Social
Care PAF:
N/A
Seen by the following committee(s) on date: Finance & Investment/Integrated
Governance/Executive/Remuneration/Board/Audit
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TERMS OF REFERENCE
Integrated Governance Committee
Status:
The Integrated Governance Committee is a subcommittee of the Trust Board
Chair:
Non – Executive Director
Membership:
The Committee shall be appointed by the Board
primarily from amongst the Executive Directors of the
Trust and shall consist of :
Non-Executive Directors (x4 including Chair)
Executive Director Quality and Safety (or Deputy)
Executive Director Service Delivery and Customer
Experience
Executive Director Quality & Medical Leadership
Executive Director Strategy & Commercial Development
Executive Director Workforce & Organisational
Development
Executive Director Integration & Community Services
In attendance:
Deputy Director Safer Care and Standards
Deputy Director of Nursing and Quality
Other nominated Directors (TBA)
Chair of Medical Staff Committee
Service User representative
Council of Governors representative
Company Secretary
Frequency of Meetings:
6 meetings per annum
Frequency of Attendance:
Members will be expected to attend all meetings. If
members miss two consecutive meetings, membership
will be reconsidered by the Committee Chair (subject to
exceptional circumstances).
Quorum:
A quorum shall be three members including at least
one Executive Director and one Non-Executive
Director
1.
Remit
1.1 The IGC is an executive committee of the Board.
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1.2 The remit of the Group is to:
“To lead on the development and monitoring of quality and risk systems
within the Trust to ensure that quality, patient safety and risk
management are key components of all activities of the Trust.”
2.
Accountability
2.1
A report will be made by the Chair to the Trust Board following each committee
meeting. The report will contain:
A note of all the items discussed by the committee
Matters for noting by the Board
Recommendations to the Board regarding decisions to be taken by the Board on
governance matters
Matters for escalation to the Board from the committee
Any other issues as agreed by the Chair & Company Secretary.
2.2
The minutes of Integrated Governance Committee meetings shall be formally
recorded by the Trust Secretary and submitted to the Board and Audit Committee.
2.3
A six monthly report from the Integrated Governance Committee shall be submitted
to the Audit Committee.
3.
Organisational Relationships
3.1
Reports received from the Executive Director Chairs of the following Sub-groups:
 Quality & Risk Management Committee
 Policy Group
 Workforce & Organisational Development Group
 Whistleblowing Strategy Group
 IMT / Information Governance Committee
3.2
Key Interfaces & Relationships
There is an interface between this Committee and the following:
 Trust Board
 Audit Committee
 Executive operational group
 Transformation Programme Board
 Care Quality Commission
 Hertfordshire County Council
 Others to be advised by membership
4.
Responsibilities & Duties
4.1 To assure adherence to CQC and other relevant regulatory requirements for quality
and safety and receive reports from all relevant quality and safety groups.
4.2 Receive minutes, reports, action plans and risk registers from the following standing
sub-committees of the IGC:
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


Quality & Risk Management Committee
Workforce & Organisational Development
Policy Panel
4.3 As well as reports from the following groups on specific items relating to areas of
regulatory compliance
 Operations Group
 Information Governance Group
4.4 Develop, supervise, monitor and review the annual Governance Plan and Trust-wide
Risk Register
4.5 To scrutinise and provide assurance to the Audit Committee and to the Trust Board
through providing regular reports on governance, quality and risk issues and to
escalate any risks or concerns as appropriate where assurance is not adequate.
4.6 Set standards for the Trust Governance systems in order to meet;
 Performance targets,
 Core and developmental standards
 and manage risks
4.7 To recommend to the Trust Board necessary resources needed for the Governance
Committee to undertake its work
4.8Produce the Annual Governance Statement
4.9 Produce an Assurance Framework for the Trust Board and monitor its ongoing
suitability
4.10
Produce the annual Quality Accounts
4.11
Agree terms of reference and work plan for sub-groups
4.12 Ensure that appropriate risk management processes are in place that provide the
Board with assurance that action is being taken to identify risks; manage identified risks
within the Trust
4.13 To be responsible for developing systems and processes for ensuring that the Trust
implements and monitors compliance with the registration requirements of the Care
Quality Commission
4.14 To oversee the establishment of appropriate systems for ensuring that effective
practice governance arrangements are in place throughout the Trust
4.15 To ensure that the learning from inquiries carried out in respect of SIs is shared
across the Trust and implemented through policies and procedures as necessary
4.16 Ensure that services and treatments provided are appropriate, reflect best practice
and represent value for money
4.17
Ensure that plans are in place to promote the patient experience
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4.18 Ensure that services are accessible and responsive to Service User needs and
reflect local “nuances”
4.19 Ensure that the environments in which services are provided are appropriate and
therapeutic
4.20 Ensure that the organisation is engaged in the public health programme and this is
modelled throughout the services we provide
5.
Other Matters
The Committee shall be supported administratively by the Trust Secretary, whose duties in
this respect will include:
 agreement of agenda with Chairman and attendees and collation of papers
 taking the minutes & keeping a record of matters arising and issues to be carried
forward
 advising the Committee on pertinent areas
6.
Monitoring of Effectiveness
5.1
The group will review its own performance and terms of reference at least once a
year to ensure it is operating at maximum effectiveness.
Terms of Reference ratified by: IGC
Date of Ratification:
January 2016
Date of Review:
January 2017 for review by the Chair with full review
in April 2018
Terms of Reference Version:
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PUBLIC BOARD OF DIRECTORS
Meeting Date:
28th January 2016
Agenda Item: 8
Subject:
Patient Safety Quarterly Report
Quarter 3 2015/16
Bela Da Costa - Legal Services Lead
Nikki Willmott – Patient Safety
Manager
Oliver Shanley – Executive Director
Quality & Safety, Deputy CEO
For Publication: No
Author:
Presented by:
Approved by: Oliver Shanley –
Executive Director Quality & Safety,
Deputy CEO
The purpose of this report is to provide an overview of patient safety related data including Serious
Incidents and associated learning in Quarter 3 of 2015/16. It seeks to provide members with information
on how the Trusts data compares nationally, in order to benchmark HPFT with performance of other
Trusts.
The report provides an overview of the learning from patient safety incidents that has been shared
across the organisation.
Action required:
To consider and discuss the content of this report and consider whether any additional actions may be
required.
Summary and Recommendations to the Committee:
Summary
 The HPFT predicted suicide rate per 1,000 service users for 2015/16 is marginally lower than
the predicted suicide rate for 2014/15. However, the number of suspected service user suicides is
higher for the first 3 quarters of the year compared with the same period in 2014/15 (18
suspected suicides in Quarters 1 to 3 of 2015/16, 15 suspected suicides in Quarters 1-3 of
2014/15). These numbers may be subject to change in future reports as Inquests are concluded.
At the time of this report 13 deaths which occurred between October 2014 and December 2015
are still awaiting the conclusion of the Inquest. The Trust also uses the National Confidential
Inquiry data to benchmark against. Currently our rate is below the NCI rate.

The Organisational Feedback Report will be published by the National Reporting & Learning
System in March 2016, covering Patient Safety Incidents reported between 1 April 2015 and 30
September 2015. A forecast of the Trust’s data is provided in this report based on the provisional
data provided by NRLS, although this should be viewed with caution until the published data is
released.

The Trust reported a total of 13 Serious Incidents in Quarter 3 of 2015/16, compared to 12
reported in the previous Quarter; these were seven unexpected deaths (suspected suicides),
three serious self-harm incidents/para-suicides, an alleged homicide, and two serious incidents of
violent & disruptive behaviour that met specialist commissioning reporting criteria.
Relationship with the Business Plan & Assurance Framework (Risks, Controls & Assurance):
The Patient Safety Report links with the Risk Register and is central to the Trust’s systems of
management of Patient Safety and Risk
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Summary of Implications for:
1 Finance
N/a
2 IT
N/a
3 Staffing
N/a
4 NHS Constitution
N/a
5 Carbon Footprint
N/a
6 Legal
N/a
Equality & Diversity (has an Equality Impact Assessment been completed?) and Public & Patient
Involvement Implications:
N/A
Evidence for Essential Standards of Quality and Safety; NHSLA Standards; Information
Governance Standards, Social Care PAF:
Patient Safety remains a high priority for the Trust.
Seen by the following committee(s) on date:
Finance & Investment/Integrated Governance/Executive/Remuneration/Board/Audit
IGC 21st January 2016
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HERTFORDSHIRE PARTNERSHIP NHS FOUNDATION TRUST (HPFT)
QUARTERLY UPDATE ON PATIENT SAFETY AND SERIOUS INCIDENTS
QUARTER 3 2015/16
1. PURPOSE OF THE REPORT
This report is intended to provide members with an overview of Serious Incidents which were reported by
the Trust in Quarter 3 of 2015/16 with the use of safety metrics to provide the required assurance. Serious
incidents are an important mechanism for improving quality and safety in the Trust.
The report seeks to provide an element of forecasting in relation to unexpected deaths of service users as
a result of suicide and nationally published incident data via the National Reporting & Learning System, as
well as highlighting work being undertaken within the Trust to improve Patient Safety.
2. INCIDENT DATA ANALYSIS
Incidents
Table 1 below contains a summary of the top 5 incident trends reported on the Trust’s Datix incident
reporting system in Quarter 3, 2015/16 with a comparison to data reported in the previous Quarters. This
enables ongoing monitoring of potential trends, themes or actions required. The personal accident
category includes incidents such as moving and handling, needle stick injury, or slip trip or fall. The practice
category includes incidents such as staff shortages, pressure ulcers, communication and unexplained
injury.
Table 1
VIOLENCE & AGGRESSION
PERSONAL ACCIDENT
PRACTICE/CLINICAL CARE
SELF HARM
MEDICATION
Totals:
Q3 14/15
Q4 14/15
Q1 15/16
Q2 15/16
Q3 15/16
790
407
241
120
107
1665
710
314
313
199
98
1634
803
337
246
199
120
1705
793
317
240
234
130
1714
820
292
213
279
98
1702
There has been a 2% increase in the overall number of incidents reported within the top 5 incident types in
this Quarter when compared with the same Quarter in 2014/15.
The upward trend in the number of self-harm incidents reported since Quarter 3 of 2014/15 has continued,
with the majority of incidents occurring in North Essex Inpatient services. A brief analysis of the incidents
reported by North Essex shows that 85% of the incidents reported in the 15 month period relate to one
individual with known self-harming behaviour. It should be noted that the increase in Self Harm reporting is
not seen across all services.
In contrast, the number of Personal Accident incidents reported over the last 15 month period has fallen by
28%; it is of note that slip, trip and fall incidents have decreased from 287 incidents in Q2 2014/15 to 190
incidents in Quarter 3.
Although the total number of Violence & Aggression incidents (including disruptive behavior, physical and
verbal assaults to/by service users, staff and members of the public) reported across the Trust has
increased this Quarter, as seen in Table 1, the number of Violence & Aggression incidents by service users
against staff has fallen this Quarter. Monitoring, interpretation and analysis of the data is undertaken by the
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Trust’s Making Our Services Safer (MOSS) Group; this decrease may in part suggest that the initiatives
and interventions introduced as part of the Trust’s MOSS strategy are having an effect.
Overview of Trust data on the number of Suicides
Chart 1 below presents data for those deaths subject to an investigation by Her Majesty’s Coroner reported
on the Trust’s incident reporting system Datix, where a 'Suicide' or 'Open verdict' has been recorded by the
Coroner at the conclusion of the Inquest.
To ensure consistent analysis, and allow ongoing monitoring, the data is presented as a rate per 1,000
HPFT service user population. The number of confirmed and probable suicide verdicts has also been
included in the charts for ease of reference. The rate is calculated manually based on the total number of
service users with an open spell of care at the end of each Quarter.
The chart is populated with the National Confidential Inquiry (NCI) into Suicide and Homicide by People
with Mental Illness per 1,000 service users. It is taken from the NCI annual report published in July 2015 to
provide a national benchmark for HPFT data.
A number of deaths which were forecasted in previous Patient Safety reports as deaths likely to receive a
Suicide or Open verdict have since received a verdict of Accidental or Self Harm on conclusion of the
Inquest. It should be noted that these cases are therefore excluded from the data in the charts below.
Chart 1 Suicide and Open Verdicts recorded at the conclusion of the Inquests
Confirmed Suicide and Open Verdicts
1.4
Rate/1000 HPFT service user
1.2
23
NCI Rate/1000 MH population
1.0
22
24
20
0.8
19
0.6
14
17
16
12
20
0.4
0.2
7
0.0
2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
q1-q3
Chart 2 below presents data on cases that have received a confirmed Suicide or Open verdict, in addition
to cases where it is anticipated that a Suicide or Open verdict will be recorded by the Coroner, on
conclusion of the Inquest. This allows an element of forecasting, although a degree of caution must be
exercised prior to confirmation of the verdicts recorded by Her Majesties Coroners.
The rate of probable suicides reported each financial year, prior to those deaths receiving a verdict at
Inquest, is shown in green. This provides a more sophisticated way of comparing the reporting picture year
on year.
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Chart 2 Includes Suicides, Open Verdicts and Predicted Cases Pending Inquest
Confirmed Suicide & Open Verdicts and Predicted cases pending Inquest
Rate/1000 service user
NCI Rate/1000 MH population
Rate/1000 service user (prior to verdict)
1.40
1.20
23
1.00
22
24
20
0.80
19
14
0.60
17
16
12
0.40
22
18
0.20
0.00
2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
q1-q3
ANALYSIS
There have been 21 suspected service user suicides reported in the first three Quarters of 2015/16. Ten of
these cases have since been to Inquest, with three receiving non-Suicide conclusions (formerly known as
verdicts).
Although the rate for 2015/16 to date is lower than the previous year, the actual number of suspected
service user suicides occurring between April 2015 and December 2015 is higher than the same period in
2014 (18 deaths compared with 15 the previous year). The rate for the year will have changed due to
acquiring West Essex IAPT services in July 2015. The Trust rate per 1000 remains below the National
Confidential Inquiry rate.
The numbers and rates in Chart 2 are likely to vary in future reports in line with service user number
changes and actual Inquest conclusions received at Inquest, with the possibility that some deaths reported
in the year may not receive a suicide verdict.
All deaths that are probable suicides are reported to the Care Quality Commission (CQC) via the National
Reporting & Learning System (NRLS). HPFT incident data is published in the Organisational Patient Safety
Incident Reports produced by the NRLS which enables the Trust to benchmark with other similar
Organisations.
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The Trust continues to undertake work to reduce the numbers of suicides. The Trust Clinical Risk strategy
focuses on promoting a culture of positive awareness and responsibility for assessment and management
of risk at all levels within the organisation. The Spot the Signs campaign continues with the aim to
encourage local people to talk openly about suicide in order to reduce suicide rates. The campaign, which
is being run in collaboration with Herts MIND Network, aims to make everyone alert to the signs of suicidal
thoughts and feelings and to challenge the stigma around suicide.
3. PATIENT SAFETY NRLS UPDATE
The next release of the Organisational Patient Safety Incident Report data for NHS organisations in
England and Wales is expected in March 2016. This release will include incident data reported between 1
April 2015 and 30 September 2015.
4. SERIOUS INCIDENTS REPORTED BY THE TRUST IN QTR 3, 2015/16
Chart 3 below reports on the number of Serious Incidents reported by the Trust in Quarter 3 of 2015/16, 13
in total: these were seven unexpected deaths (suspected suicides), three serious self-harm incidents/parasuicides, an alleged homicide, and two serious incidents of violent & disruptive behaviour that met
specialist commissioning reporting criteria.
Southern Health Mazars Report
A recent report into Southern Health NHS Trust identified apparent failings in the management of
investigations into unexpected deaths by the Trust. It is expected that providers will be asked to provide
assurance to commissioners on the management of unexpected deaths as a wider response to the
Southern Health report. An interim review of the Trusts processes for incident reporting and serious
incident management identified no immediate areas of concern.
In response to this initial review, however, the trust has taken the opportunity to further review and
strengthen its processes. The findings of the Southern Health report raised concerns about the apparent
low number of deaths reported as serious incidents. Deaths that are reported to the Trust that are
considered to be unexpected may still have a natural cause and would not meet the threshold for an SI
investigation which is in keeping with the National Serious Incident Framework, March 2015. For those
deaths reported in 2012 the Trust reported 25% of deaths as serious incidents; in 2013 the Trust reported
41% of deaths as serious incidents, in 2014 the Trust reported 43% of deaths as serious incidents and in
2015 year to date the Trust has reported 34% of deaths as serious incidents.
The Trust has established an internal group to review all deaths and report on findings from the review to
the Clinical Risk and Learning Lessons Group. Outcomes of this work will be reported in the Quarterly
Patient Safety Reports.
The Trust is currently updating Datix to provide additional guidance to staff on reporting of deaths; this will
also be reflected in the Incident Reporting Policy which is under review and due to be sent round for
consultation in February 2016.
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Chart 3 Serious Incidents reported in Quarter 3, 2015/16
5
Death
Self Harm
Violence & Aggression
Alleged Homicide
4
3
2
1
0
Oct 2015
Nov 2015
Dec 2015
Serious Incidents are reported to Commissioners in accordance with the requirements of the NHS England
Serious Incident Framework, March 2015. The cases reported by the Trust as Serious Incidents in Quarter
3 are currently subject to internal investigations using the principles of Root Cause Analysis investigation
methodology to establish facts and identify any learning for the teams and the wider Trust.
Chart 4 below shows the number of Serious Incidents reported by the Trust in Quarter 3, 2015/16
compared to the same period in the previous reporting year; this shows a small increase (1) in the number
of Serious Incidents reported in this Quarter when compared to the previous Quarter.
The Trust has a proactive reporting culture and will always err on the side of caution when considering
whether a case may meet Serious Incident reporting criteria as defined in the National Serious Incident
Framework. The Trust is of the view that there are always opportunities for learning and that cases can be
downgraded should other information subsequently come to light.
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Chart 4 Serious Incidents reported by the Trust October 2014 to December 2015
ANALYSIS
The Trust continues to monitor the number and types of incidents and Serious Incidents and analyse any
potential emerging trends or themes quarter on quarter and year on year. Serious Incident data and
associated learning is presented and discussed at relevant Committees and at Operational meetings as
part of the Trust’s robust Clinical Governance structures.
There has been a slight increase in the number of Serious Incidents reported by the Trust in this Quarter
when compared to the number reported in Quarter 3 of 2014/15, with one more incident reported.
However, the number of unexpected deaths (suspected suicides) reported in the two Quarters is the same
(seven deaths). It is of note that there were three serious self-harm/parasuicide cases reported in this
Quarter.
It should also be noted that the Trust has also acquired new services in Essex, so the Serious Incident
reporting figures for previous years cannot be compared like for like for this reason.
There have been no Grade 3 or 4 Pressure Ulcers reported on Datix since Quarter 4 of 2014/15; this
suggests the appointment of the Tissue Viability Nurse, who provides ongoing support and advice when a
pressure ulcer incident is identified and reported on Datix, has been effective in reducing harm from
pressure ulcer incidents. The categories of pressure ulcer incidents on Datix, both those acquired in HPFT
care and those identified on admission to HPFT care, have been reviewed and updated by the Tissue
Viability Nurse which has enabled improved monitoring and reporting on these types of incidents. In
November 2015 over 40 staff attended the Stop the Pressure Ulcer Event which was held as part of the
Trusts commitment to zero tolerance of pressure ulcers.
ADDITIONAL ACTIONS TAKEN
Where learning is identified in a Serious Incident investigation an action plan is put in place; this is
monitored by Operational Leads until recommendations are completed and learning has been
implemented.
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The Patient Safety Team disseminates a serious incident position statement as a way of monitoring where
serious incident cases and associated action plans are in process.
In addition, reflective learning sessions are arranged for the team/s where the serious incident occurred to
allow staff to understand the areas of learning and to engage them in the implementation of learning at a
local level. A summary of the learning is shared more widely across the Trust on completion of all serious
incidents to encourage discussion in local teams. Learning is also discussed in each SBU’s Quality and
Risk meetings and key patient safety messages are then disseminated to Operational leads where
required.
5. AREAS OF LEARNING IN QUARTER 3
The following is a summary of the key areas of identified learning from serious incident investigations that
were completed and submitted to Commissioners in Quarter 3, 2015/16.
Unexpected Deaths

The carer was not provided with an opportunity to have their needs reviewed on, at least, an annual
basis by the service

A review of the Out of Hours information and how to access services in a crisis to be undertaken in
light of feedback from a bereaved family.

A review of the wording of the outpatient appointment letter sent to service users with mental health
needs requiring ongoing support to be undertaken following feedback from a bereaved family to
ensure that it does not contain reference to being discharged if they fail to attend.

Not all details of psychotherapy sessions were recorded on the EPR which would have been of
benefit to other professionals working with the service user.

Service user should have been on CPA and allocated a Care Coordinator due to presentation and
assessed risks and needs

Reasons for variations to NICE guidance must be recorded in the notes.

Risk assessment did not contain all known historical risks.

Service user had disengaged from mental health services prior to their death. There was a missed
opportunity for the care coordinator to make contact with the carer when they were unable to
establish contact.

Whilst details of next of kin were obtained on initial triage, and it was noted that they were
supportive, the fact that the service users parents lived some distance away was not considered as
part of the management plan.

Discharge from both mental health services and SPECTRUM at the same time was not in keeping
with the AMHCS policy; prior to discharge an intensive level of support was being provided and
there had been changes to medication.

Decision making process regarding discharge from the mental health services not clearly recorded
in EPR and not recorded in MDT minutes.

No evidence that his Needs Agreement or Risks Assessment was shared with GP in accordance
with the ‘Transfer and Discharge Policy’ (2015).
Falls resulting in long bone fractures
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
Hospital clinicians concluded that the fall was due to low blood pressure caused by a common side
effect of Furosemide 40mg.
Other

There was a lack of specific diabetes guidelines in place; this led to a plan being put in place that
was based on the service users usual insulin regime.

A carer’s assessment was not carried out to determine the needs of the carer

The young person was not visited by the care co-ordinator or a representative from HPFT whilst an
inpatient in an out of area unit

There was no specific guidance within the discharge/transfer policy on managing discharge from
private psychiatric facilities
ACTIONS TAKEN
Three serious incident investigations completed in this Quarter highlighted that there was no evidence that
a carers assessment had been carried out. The following actions are being taken in response to this area
of learning; carers’ assessments are now an agenda item on the supervision template, new Care Act
assessment forms to made available on Paris; performance report to be developed that show position on
identified and completed carers assessments.
Action plans are put in place for all cases where learning is identified. These are monitored by the Practice
Governance Leads in each Strategic Business Unit with oversight from the Patient Safety Team until all
recommendations are completed. Evidence of implementation of learning is requested and held in the
Serious Incident folder. Completed action plans are shared with Trust Commissioners.
6. CONCLUSION
This report has sought to provide a summary on the numbers and types of Serious Incidents reported in
Quarter 3 of 2015/16, a summary of learning from completed serious incident investigations and an
overview of the Trust’s suicide rate and how this compares nationally.
There has been a small increase in the number of Serious Incidents reported by the Trust in this Quarter
(1), following a downward trend in reporting over the previous two Quarters. However the number of
deaths of service users (suspected suicides) that met serious incident reporting criteria (7) was the same in
both Quarters.
The rate of suspected service user suicides for 2015/16 to date is currently lower than the previous year;
however, the actual number of suspected service user suicides occurring between April 2015 and
December 2015 is higher than the same period in 2014 (18 deaths compared with 15 the previous year).
These figures are subject to change in future reports as the service user population changes and Inquests
are heard, with the possibility that some deaths reported in the year may not receive a suicide verdict. The
Trust continues to work with partners to further reduce the rate of suicides.
Report prepared by:
Bela da Costa, Legal Services Lead and
Nikki Willmott, Patient Safety Manager
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PUBLIC BOARD OF DIRECTORS
Meeting Date:
28th January 2016
Agenda Item: 9
Subject:
Major Incident and Business
Continuity Plan
Statement of readiness
Catherine Pelley
Deputy Director Safer Care and
Standards
Oliver Shanley – Executive Director
Quality & Safety, Deputy CEO
For Publication: No
Author:
Presented by:
Approved by: Oliver Shanley –
Executive Director Quality & Safety,
Deputy CEO
The purpose of this report is present to the Board the Trust Major Incident and Business Continuity Plan.
In response to the recent incident in Paris NHS England has asked all providers to provide a statement
of readiness to a public board. This statement sets out the Trust response to a specific set of questions
which are detailed in this report.
Action required:
The Board is asked to note the updated Major Incident and Business Continuity plan and agree the
statement of readiness.
Summary and Recommendations to the Committee:
The Trust is asked to provide a statement of readiness in relation to a Major Incident. The Trust response
to the 4 specific questions is set out below.
1. The Trust has reviewed and tested its cascade systems to ensure that they can activate support
from all staff groups.
The Trust has several cascading systems in place: SBU’s have their individual contacts for their staff groups which is used/tested daily to call staff in
for cover as required
 The communications department have got all staff email addresses which are used weekly to
pass on relevant information to all staff.
 There is a cascade system for all doctors operated by the Medical Director
 There is a Trust mobile phone directory kept centrally
 There is a proven on call arrangement for 1st on call and the Exec team
 All the above are tested daily/weekly in the day to day operation of Trust business and during
recent industrial action.
2. The Trust has arrangements in place to ensure that staff can still gain access to sites in
circumstances where there may be disruption to the transport infrastructure.
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Our business plan highlights sites that are high risk and need to be kept running at all times and services
that can be altered or stopped if required. The business plan also has a decant plan should one or more
of our sites need to shut for any reason.
Staff not able to get to their usual place of work in the event of disruption to transport links are expected
to attend the nearest HPFT site to assist in that unit or carry out remote working and many staff are able
to work from home.
The Trust has a Transport department with passenger carrying vehicles that can be used to move staff
around as required.
3. The Trust has plans in place to significantly increase critical care capacity and capability.
The Trust Business plan highlights all our critical services and details them in Tiers of importance and
how teams would be distributed to support the provision of these services.
There is also a decant contingency plan in the Business plan.
The Trust does not provide critical care services.
4. The Trust has given due consideration as to how it can gain specialist advice in relation to the
management of a significant number of patients with traumatic blast and ballistic injuries.
Traumatic blast and ballistic injuries are not something the Trust would be able to treat and we would
work with the emergency services to move those injured and use our decant plan together with Mutual
Aide to relocate those not in the need of treatment.
The Major Incident Plan and Business Continuity Plan has been updated and is presented to the Board
for information.
Assurance):
1 Finance
N/a
2 IT
N/a
3 Staffing
N/a
4 NHS Constitution
N/a
5 Carbon Footprint
N/a
6 Legal
N/a
N/A
Evidence for Essential Standards of Quality and Safety; NHSLA Standards;
Information Governance Standards, Social Care PAF:
Patient Safety remains a high priority for the Trust.
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Major Incident and Business
Continuity Plan
And Local Incident Response Team (LIRT) Guidance
Version:
7
Executive Lead:
Lead Author:
Executive Director Quality & Safety
Head of Facilities and Maintenance
Approved Date:
Approved By:
26th November 2014
Health, Safety and Security Strategy Committee
Ratified Date:
Ratified By:
10th March 2015
Policy Panel
Issue Date:
Expiry Date:
30th December 2015
30th December 2018
Target Audience:
This Policy must be understood by

Senior Managers and all staff who are involved in the preparation and
enactment of major incident plans and business continuity.
IF PRINTING – PRINT IN COLOUR
Do not forward or copy data in part or full without explicit permission of a Trust
Director or Trust Emergency Planning Liaison on Officer (EPLO)
AgendaItem9iMajorIncident
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Preface - concerning the Trust Policy Management System (PMS)
P1 - Version Control History:
Below notes the current and previous Version details
Version
Date of
Author
Status
Issue
Comment
V6
Oct 2011
Head of
Facilities and
Estates
Archived
Superseded
V7
30th March
2015
Head of
Facilities and
Estates
Ratified
Current Policy
P2 - Relevant Standards:
Equality and RESPECT: The Trust operates a policy of fairness and RESPECT in relation to
the treatment and care of service users and carers; and support for staff.
.
P3 - The 2012 Policy Management System and the Policy Format:
The PMS requires all Policy documents to follow the relevant Template

Policy Template is the essential format for most Policies. It contains all that staff need
to know to carry out their duties in the area covered by the Policy.

Operational Policies Template provides the format to describe our services ,how
they work and who can access them

Guidance Template is a sub-section of the Policy to guide Staff and provide specific
details of a particular area. An over-arching Policy can contain several Guidance’s
which will need to go back to the Approval Group annually.

Recovery Care Pathways (RCP) are documents that describe a clear route from
assessment, through intervention to recovery.
Symbols used in Policies:
=internally agreed, that this is a rule and must be done the way
RULE
described
STANDARD = a national standard which we must comply with, so must be followed
Managers must bring all relevant policies to the attention of their staff, where possible,
viewing and discussing the contents so that the team is aware of what they need to do.
Individual staff/students/learners are responsible for implementing the requirements
appropriate to their role, through reading the Policy and demonstrating to their manager that
they understand the key points.
All Trust Policies will change to these formats as Policies are reviewed every 3 years, or
when national Policy or legislation or other change prompts a review. All expired &
superseded documents are retained and archived and are accessible through the
Compliance and Risk Facilitator [email protected]
All current Policies can be found on the Trust Policy Website via the Green Button or
http://trustspace/InformationCentre/TrustPolicies/default.aspx
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Major Incident and Business Continuity Plan V7
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Contents Page
PART:
Preface
PART 1
PART 2
Page:
Preface concerning the Trust Policy Management System:
P1 - Version Control History
P2 - Relevant Standards
P3 - The 2012 Policy Management System and Document Formats
Preliminary Issues:
1. Flowchart – Invocation Process
2. Purpose and Scope
3. Key services within scope
4. Definitions
5. Duties and Responsibilities
5
5
6
6
What needs to be done and who by:
6. Major Incident & Business Continuity
7. Major Incident & Business Continuity Strategy
8. Objectives
9. Invocation
10. Incident Management
11. Major Incident Response
12. Business Recovery & Continuity
13. Staff
14. Communication requirements and procedures
15. Recovery
16. Information flow and documentation
17. Actions and activities following debrief
18. Training /Awareness
19. Equality and RESPECT
20. Process for monitoring compliance with this document
PART 3
4
7
7
10
10
12
16
17
18
20
21
21
23
Associated Issues
21. Version Control
22. Archiving Arrangements
23. Associated Documents
24. Supporting References
25. Comments and Feedback
Appendices List
Annex A HPFT Decant Contingency plans
Annex B action sheet giving guidance to all levels of Management in
the event of a Major Incident occurring.
Annex C Trust Daily Situation Report
Annex D Log Sheet
Annex E East of England SITREP form
Annex F is a Decision Log to record decisions & actions taken.
Annex G Aid Memoire
Annex H Run, Hide & Tell – Stay safe firearms weapon attack
Annex I Lockdown Flowchart
Annex J Response for self-presenters as a result of a CBRN
23-25
26 - 47
incident
Annex K Guidelines for Loggists
Local Incident Response Team Guidance
48
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PART 1 – Preliminary Issues:
1. Flow Chart – The following flowchart depicts the invocation process
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The purpose of this plan is to improve the capacity of Hertfordshire Partnership University
NHS Foundation Trust to manage significant disruptions to operations thereby reducing the
impact on stakeholders, damage to the reputation of the Trust and financial losses. This is a
statutory duty under the Civil Contingencies Act (2004) and has now been reinforced by DH
Interim Guidance on Business Continuity Planning (June 2008). A significant incident is
defined as: ‘Any occurrence that presents serious threat to the health of the community,
disruption to the service or causes (or is likely to cause) such numbers or types of casualties
as to require special arrangements to be implemented by hospitals, ambulance trusts or
other acute or community provider organisations.’
This plan also includes the procedures for responding to an externally-declared Major
Incident as required by NHS Guidance on Emergency Planning 2005. ‘To describe an event
or situation that threatens serious damage to human welfare in a place in the UK or to the
environment of a place in the UK, or war or terrorism which threatens serious damage to the
security of the UK?
The term ‘‘major incident’’ is commonly used to describe such emergencies. These may
include multiple casualty incidents, terrorism, severe weather conditions, flood or national
emergencies such as pandemic influenza.’(See Trust Pandemic Flu Plan)
This plan also takes into account the need to lockdown (See Trust Lockdown Plan) a Trust
site if the following occurs:1) A member of the public comes into an HPFT site as a result of a nearby
CBRN/Hazmat incident. (All HPFT sites have the Trust CBRN plan with action cards and are
included in their local plans) See LIRT plan at the back of this document (Annex J)
2) A violent service user or terrorist trying to gain entry into an HPFT building – See Annex H
(Run, Hide & tell).
For Mass casualties or surge/escalation plans HPFT will first use its decant plan (Annexe A)
after which it will invoke collaboration with the Acute Trust in Herts and the HCT
3. Key Services within Scope
The scope of the plan covers all activities at Trust locations in Hertfordshire, North Essex and
Norfolk. Local plans have been developed for use at individual sites, and these dovetail into
this plan. Annex A of this plan details residential sites decant plans (Dec 2015)
3.1 Assumption and Core Principles
As every type of incident or emergency cannot be planned for, when the Trust faces a major
incident, longer term emergency or business continuity challenge, the approach will be based
on ‘core principles’ which support & assist consistent decision making in incident situations.
These are:


Trust Managers and Team leaders will be assisted in preparing & testing local
contingency arrangements and a Local Major Incident and Business Continuity Plan
(MI & BCP) based on this document;
Clear determination of any Major Incident and prompt enactment of this plan by
Managing Director with the Executive Team and the Emergency Planning Liaison
Officer ( EPLO);
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




Our primary aim is to maintain our essential/critical services. To facilitate the staff
flexibility needed, there are ‘Terms & Conditions in Severe Disruption’ agreed in
principle by Human Resources (HR) Policy Group;
Major Incident Response Team Members will be clear about their responsibilities and
the systems to use: guided by this document, the ‘Action Sheets’, their training & links
with the EPLO;
A co-ordinated approach will be taken as key decisions will be made centrally and
communicated to the front line managers to carry out, or to other agencies or the
media etc;
We will make best use of resources/expertise/skills already available in the Trust until
particular expertise may be needed when, ‘Subject Matter Experts’ will be sought; and
There will be an equally co-ordinated recovery phase – i.e. return to normal working
after the Incident when services can also be enabled to reflect on any learning.
NHS Emergency Planning Guidance suggest a minimum requirement of a live exercise to be
conducted every 3 years, a table top exercise every 1 year and a communications cascade
test every 6 months
4. Definitions
STANDARD
A significant incident or emergency is any event that cannot be managed within routine
service arrangements. It requires the implementation of special procedures and involves one
or more of the emergency services, the NHS or a local authority.
The term ‘emergency’ is used as defined in the Civil Contingencies Act 2004:
‘To describe an event or situation that threatens serious damage to human welfare in a place
in the UK or to the environment of a place in the UK, or war or terrorism which threatens
serious damage to the security of the UK? The term ‘‘major incident’’ is commonly used to
describe such emergencies. These may include multiple casualty incidents, terrorism or
national emergencies such as pandemic influenza.’
For the NHS, a significant incident or emergency is defined as: ‘Any occurrence that presents
serious threat to the health of the community, disruption to the service or causes (or is likely
to cause) such numbers or types of casualties as to require special arrangements to be
implemented by hospitals, ambulance trusts or other acute or community provider
organisations.’
Business continuity is defined as the “capability of the organisation to continue delivery of
products or services at acceptable predefined levels following a disruptive incident.” NHS
England.
4.1 Types of Incidents
An external significant incident or emergency -an event meeting the definition within
Hertfordshire, or an incident meeting the same criteria elsewhere that nevertheless affects
the county.
This may arise in a variety of ways:
. Big Bang – a serious transport accident, explosion, or series of smaller incidents
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. Rising Tide – a developing infectious disease epidemic, or a capacity/staffing crisis
. Cloud on the Horizon – a serious threat such as a major chemical or nuclear release
developing elsewhere and needing preparatory action
. Headline News – public or media alarm about a personal threat
. Deliberate release of chemical, biological or nuclear materials
. Pre-planned major events that require planning-demonstrations, sports
. Cyber Security Incident – “Cyber Security Incident” means any malicious or suspicious
event that disrupts, or was an attempt to disrupt, the operation of those programmable
electronic devices and communications networks including hardware, software and data that
are essential to the Reliable Operation of the organisation’s Bulk Power System. All Cyber
Security incidents are managed by our IT Service Provider, HBLICT.
5. Duties and Responsibilities
RULE
See section on Incident Management; roles responsibilities and authorities (Section 10)
PART 2 – What needs to be done and who by
6. Major Incident & Business Continuity
The Trust is committed to implementing best practice in Major Incident Response (MIR) and
Business Continuity Management (BCM) throughout the Trust in order to minimise the effect
of disruptions on service users, staff, members of the public and the reputation of the Trust.
Ultimate responsibility for MIR and BCM within the Trust rests with the Chief Executive, but
specific responsibilities are delegated to the Emergency Planning Lead. The management of
the Major Incident and Business Continuity plans and procedures is maintained in the
Management System.
The Trust will take all reasonable steps to ensure that in the event of service interruption
essential activities will be maintained and normal services restored as soon as possible. The
priority at all time is the safety and well-being of service users, staff and members of the
public.
All activities currently undertaken within the Trust are included within the Business Continuity
Management framework. Where specific processes are outsourced to third parties; the
resilience of these third parties must be considered.
Plans have been developed at various levels within the Trust to facilitate a fully integrated
response and recovery mechanism. All plans are to be reviewed and exercised annually to
maintain and validate the organisation’s capability to respond.
All activities should be supported by a robust communications strategy which identifies
responsibilities and systems to inform service users, staff, operational partners, the press and
the public with timely and accurate information.
Annex A - HPFT Decant Contingency Plans (Dec 2015)
Annex B - is an action sheet giving guidance to all levels of Management in the event of a
Major Incident occurring.
Annex C - is the Trust Daily Situation Report
Annex D - is the Log Sheet to be completed when communications are received or sent.
Annex E -. is the East of England SITREP form to be completed as they request.
Annex F - is a Decision Log to record decisions & actions taken
Annex G - Aide Memoire
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Annex H - Run, Hide & Tell – Stay safe firearms weapon attack
Annex I - Lockdown Flowchart
Annex J - Response for self-presenters as a result of a CBRN incident
Annex K – Guidelines for Loggists
7.1 Major Incident
The Trust will provide support to Hertfordshire County Council for the provision and
coordination of the social care response and other humanitarian issues. This may include
provision of support for Reception Centres, for example, but any support will be coordinated
through the County Council or Health Gold Command, following the arrangements laid out in.
7.2 Business Continuity
The strategy for dealing with generalised disruptions is based upon classifying activities into
3 tiers according to their time-criticality as follows:
TIER 1
Must continue
 Acute Adult Mental
Health
Inpatient
Units/Wards
 Mother & Baby unit (2
Bowlers)
Inpatient
 CAMHS
Services (Forest House) 
 A & E Liaison
 Psychiatric Intensive Care
 MHSOP Assessment and
Continuing Care Services 
 Inpatient Services for
people with Learning
Disabilities
 Low Secure Services
 Medium
Secure
Specialist
Learning
Disability Services, (Eric
Shepherd
Unit
&
Broadlands Clinic)
 CATT Teams
 Adolescent
Outreach
Team
 Acute Day Treatment
Unit
 Mental Health Act Assts
 Single Point of Access

Phones and switchboard;
TIER 2
TIER 3
CLINICAL
Provide differently
Temporarily close
 CMHT
 Wellbeing Service
 SMHTOP
 Day Hospital Services for
Older People
 AOT
 Day services for adults
 Eating Disorder Service
Disordered
 Personality
Disorder  Mentally
Offenders Services
Service

Forensic Liaison Team
Early Intervention in
 Prison In Reach Team
Psychosis
 IOT
 Non urgent/Routine Out
Patients
 IST
Specialist Support Teams  Respite Care for Older
People
for CAMHS
 Specialist
Healthcare
 Mental Health Helpline
Workers and Therapists
 Rehabilitation Services

Bed Management &
Placement Team
 ECT
 Community
Learning
Disability Teams (North
Essex)
 IAPT North Essex

SUPPORT FUNCTIONS
NHS Outpatient Booking

F&PI (other functions)
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




Various IT services;
HR
Estates and Facilities
(emergency/BC
functions)
Informatics
Communications Team






Admissions Booking

Records Management

Medical Secretarial
Executive Team
Finance (eg payment of
staff and suppliers)
Informatics (less critical
functions)
Estates & Facilities (BAU)
Finance other Functions
All time-critical functions within the Trust must ensure that they have manual workarounds in
place that would enable them to maintain services to patients and gather the data required
for subsequent coding and invoicing for up to 24 hours without IT systems.
7.2.1 Tier 1
Tier 1 services are the most time-critical. They are essential services and must continue to
be provided, although some could be consolidated onto fewer sites if circumstances and bed
usage allows, enabling temporary unit closures to maximise staffing resources.
The aim is to maintain all of these activities during a disruption, either by moving staff and
equipment the sites for additional support or, where necessary and possible, consolidating
into fewer sites, as required.
7.2.2 Tier 2
Tier 2 services are important but could be reduced or provided differently. These services
have a BCP detailing the reductions that are possible. As an example:

Maintain risk based service for face to face contacts
o Clozapine clinics
o Depot injections
o Urgent prescriptions
o Safeguarding vulnerable adults procedures

Non-essential activity to temporarily cease or be provided differently:
o Provide phone service to low priority cases from fewer bases
o Other regular but non-urgent visits
o Attendance at inpatient or other routine case conferences
o 7 day follow up visits
o Visits to carers
o Walk-in services
In preparation for managing staff shortages and service reductions, staff will review their
caseloads and flag service users indicating the broad level of risk. The flagging would be:
 Red
High risk
 Amber
Medium risk
 Green
Low risk
Community staff released by these measures can be redeployed into Tier 1 services – skills
and competencies permitting. Alternatively, community teams could manage some service
users from inpatient units on a short term basis if resources/skills allow.
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Tier 2 also consists of some ‘back-office’ functions.
The aim is to restore these activities within 24 – 48 hours of a disruption by moving staff to an
alternative office location. A detailed plan has been prepared to facilitate this.
7.2.3 Tier 3
Tier-3 services can be temporarily suspended or closed (with service users and other
stakeholders being informed appropriately) in the event of needing to release resources for
high priority/essential services:
A number of back-office functions are also Tier 3 activities, and can be ceased during the
initial phase of the incident.
The aim is to restore these activities within a week, as resources allow. It is not possible to
plan the precise sequence of restoring these activities in detail but individual departments
have prepared outline plans highlighting their resource requirements.
place that would enable them to maintain services to patients and gather the data required
for subsequent coding and invoicing for up to 24 hours without IT systems.
7.2.4 IT
In the main, service user records can be accessed in the electronic record system - Paris via
any networked site by authorised staff, facilitating safe treatment. The Wellbeing Service use
PCM is for their electronic patient records and the Child & Adolescent Drug & Alcohol Service
use a system called BOMIC. The Clinical Information Filing Policy on TrustSpace explains
the contingency measures that should be in place if the EPRs were to be unavailable for any
length of time. It is imperative each team has a contingency in place, please refer to the
policy for further information.
7.2.5 Staff Unavailability
It is one of our ‘core principles’ that we will always maintain the critical/essential service,
whatever the circumstances. Therefore, when something has occurred leading to staff not
being available to deliver all our services, we must prioritise where these staff work, focusing
on the Tier system listed above.
8. Objectives
The objectives of this Major Incident and Business Continuity plan are:
 To ensure the safety and well-being of staff and service users;
 To enable an effective response to any major incidents impacting the Trust;
 To co-ordinate and provide mental health support to staff, service users and relatives
in collaboration with Social Services;
 To outline how, when required, Ministry of Justice approval will be gained for an
evacuation;
 To identify locations which service users can be transferred to if there is an incident;
 To support local acute trusts by managing physically unwell inpatients if there is an
infectious disease outbreak;
 To ensure the needs of service users involved in a significant incident or emergency
are met and that they are discharged home with suitable support;
 To work effectively with partner agencies during an incident;
 To continue to run services as determined by their categorisation;
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

To ensure swift and accurate communications with staff, service users and other
stakeholders; and
To enable a swift recovery to service as usual.
9. Invocation
If one or more of the following applies, a Trust response may be required:

A major incident or emergency has been declared by a partner agency (health and
non-health partners)
 An internal Trust incident that cannot be managed within normal resources
 A significant incident that threatens to overwhelm the resources of more than one NHS
organisation in the geographic area
 A significant incident that requires coordination of more than one NHS organisation
within the Hertfordshire and South Midlands geographic area
 An incident where mutual aid is required (countywide or regional)
 An incident that requires the attendance of the NHS at a Strategic Coordinating Group
(SCG)
 A significant internal incident within another NHS organisation adversely affecting the
daily running of the organisation and necessitating special arrangements to be
instigated
 A significant incident that requires media coordination, particularly with partner
organisations
 A significant incident requiring support from the NHS
 An incident affecting large numbers of people or having catastrophic effects on a
smaller number of individuals
Examples could include:



Flood
Severe weather
Declaration of a heatwave


Notification of an External Major Incident by NHS England East and Midlands
CBRN / Hazardous Materials incidents (members of the public attending HPFT sites in
a contaminated condition and the need to lockdown the site.
Adverse media coverage;
Loss of electricity, gas, water or medical gases;
Loss of IT capability;
Supply chain issues.
Local disruption at Remote Site which may impact on delivery of Trust services.
Security/ terrorist incidents (may require a lockdown of the site).






The incident Manager on site who identifies that there has been an incident should follow
Action Sheet 1, and report as follows:
In Normal Working Hours – call an Executive Director at The Colonnades (01707 253851)
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Out of Hours – call PICU for the Executive On Call Rota on 01923-850501.
In accordance with UK Emergency Response procedures, the following definitions apply:
Strategic Management Team (SMT): Gold level team
Incident Control Team (ICT): Silver team
Local Incident Response Team (LIRT): Bronze teams
9.1 Methods of invocation
Specific Incident Management actions are invoked as follows:
Action
Authority*
Method
SMT call-out
Director on Call
Contact PICU Unit Tel No 01923 633501
ICT call-out
Director on Call
Via On Call System
Declaring Major
Incident
Director on Call
Phone call to NHS England Midlands and
East, followed up with completion of NHS
Major Incident Situation Report (SITREP)
Annex B
Relocation of staff to
Director on Call / ICT
Invocation of IT
Disaster Recovery
IT Director / ICT
9.2 Activation criteria and procedure
The immediate steps to take in a disruption must consider:
 Due regard to welfare of individuals
 Strategic, tactical and operational options for responding
 Prevention of further loss or unavailability of prioritised activities
It is critical to assess the nature and extent of incident and the potential impact; the Aide
Memoire will act as a prompt, and should be followed.
10.1 Roles, Responsibilities and Authorities
The following roles and responsibilities apply regardless of whether this is a response to a
Major Incident or Significant incident that requires a BCM response. For the latter, additional
expertise may be brought into the team as required.
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1) Colonnades
2) Harper House
1) Colonnades
2) Harper House
10.1.1 SMT (Gold) (Email address)- [email protected]
The responsible director will choose one of the following locations as a base for the Gold
control dependant on the location of the incident:1) The Colonnades Executive Team Floor
2) Harper House Facilities & Estates Planning Department
3) A Hub suitably placed so as not to get too close to the working of the Silver and
Bronze teams activities.
The SMT consists of the Chief Executive and other Directors and provides the focus for
command and control within the Trust. Specifically they:




Provide the strategic direction and priorities for the Trust;
Identify and resolve wider strategic issues;
Resolve any conflicts or tensions arising between different areas of the Trust that
cannot be decided by the Silver Team; and
Present the outward face of the Trust to the wider NHS, the media and other key
stakeholders.
The SMT will nominate a Director to represent the Trust at the CCG and the Hertfordshire
and South Midlands Area Team Health Coordinating Group / Health Gold, where necessary.
10.1.2 ICT (Silver) (Email address) - [email protected]
OUT OF HOURS, THIS TEAM SHOULD BE CHAIRED BY THE ON-CALL DIRECTOR
UNTIL A SUITABLE ALTERNATIVE HAS BEEN APPOINTED AND A THOROUGH HANDOVER COMPLETED.
The ICT controls and coordinates resources and activities across the Trust; specifically they:
 Convert the strategy from the Gold SMT into plans;
 Communicate decisions, actions and plans to the LIRTs and Bronze Teams;
 Establish measurable objectives;
 Review progress against objectives and update the SMT;
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



Bring strategic issues to the attention of the SMT, as required;
Resolve conflicting requirements for resources;
Coordinate with the Emergency Services, Ministry of Justice, Local Authorities, Other
NHS organisations, and other operational partners as required; and
Liaise with key suppliers.
As an example, the immediate response will be coordinated by the LIRTs, who will have the
ability to use their available resources to ensure that the strategy is being followed. However,
in the circumstances that the LIRT requires additional support from other LIRTs or from
outside the HPFT area, e.g. for bed space or staffing, then this request must be coordinated
by the ICT.
The ICT will also coordinate the back-up functions, ensuring that Facilities and IT support, for
example, is prioritised, and that all LIRTs have up-to-date information regarding the status of
any problems.
10.1.3 LIRT (Bronze) ) (Email address)- [email protected]
The LIRT carry out the activities required to mitigate the effects of a disruptive challenge, as
directed by the Silver Team. This may include, for example:



Supporting service users and staff members affected by the incident;
Recovering IT systems; and
Establishing temporary workspace.
Critically, they must keep the ICT informed of progress on a regular basis.
Thus, the LIRTs will ensure that they manage the services within their local area, redeploying
resources to ensure that the Trust Strategy is being followed, and maintaining the provision
of Tier 1 activities. Back office functions, such as IT and Facilities, will ensure the recovery of
their areas, accordingly to the priorities defined by the ICT and the Business Impact
Analyses. Any requests for additional support, eg from other LIRTs, etc, must be coordinated
by the ICT.
10.1.4 Gold & Silver Command Contents & Set up for MI & BCP
Gold – Chief Executive Room & Chairman’s office plus small meeting rooms on this floor.
Silver – Galileo A & B for this command but breakout rooms available throughout this floor.
Facilities available
- 7 Laptops in the cupboard behind reception
- Spider phone in Chief Executives office and in the cupboard in reception.
- All phones have conference call facility
- Smart boards in Chief Executive office
- Galileo has screen that connects to the laptops.
- Both floors have MFD’s
The Trust Conference Call Lines are:
Telephone Number
01923 633 871
01923 633 872
Exec Team only
Exec Team only
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01923 633 873
01923 633 874
01923 633 875
01923 633 876
01923 633 877
01923 633 878
01923 633 879
01923 633 870
There is an emergency cupboard located on each floor of the Colonnades, with an
information card which explains where to find the equipment.
The cupboard on the ground floor is located in the furniture cupboard next to reception; this
contains a map of Hertfordshire & Essex.
Each Cupboard contains a variety of stationary items and a log book.
The cupboard in reception contains laptops, spider phone and flip chart pens.
10.2 Incident Management Teams
10.2.1 SMT (Gold)
Role
Chair
Primary
Alternate
Responsibilities
Chief Exec
Deputy Chief Exec
Liaising with
Board, NHS
England Midlands
& East, PCT and
other Trusts
Lead SBU
Director
Nominated person
Setting clinical
priorities
Advising on
financial
implications
Finance
Finance
Director
Deputy Finance
Director
Invoking
emergency
expenditure
approval process
Advising on supply
chain issues
Log-keepers
Exec team secretaries
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10.2.2 ICT (Silver) – Core Roles
The following roles will normally be required to be filled as a matter of urgency in any
incident.
Role
Primary
Alternate
On-Call
Responsibilities
Chair
Managing
Director SBU
Nominated
person
On-Call
Director
Liaising with Gold
Team
Service Line
Leads
Operations
Deputy
Service Line
Leads
Allocating clinical
resources in support
of agreed priorities
Allocating non-clinical
Admissions
Emergency Services
Liaison
Head of
Facilities and
Maintenance
(EPLO)
Estates
Director of
Estate
Workspace recovery
Telecoms recovery
Damage assessment
Salvage and
Restoration
ICT
Communications
Head of ICT
Head of
Communications
Nominated
person
Nominated
person
Monitoring availability
of IT services
Implementation of IT
Disaster Recovery
plans as required
Preparing messages
for staff, service users
and their carers, and
the media
Setting up of
emergency cost
code(s).
Procurement
Finance
Deputy Director
of Finance
SBU Finance
manager
Recovery of Finance
operations.
Logging and reporting
of expenditure.
Managing insurance
claim.
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Accounting for staff
HR
Director of HR
Staff welfare
Staff queries
Log-Keepers
SBU secretaries
All contact details are listed at Annex A.
10.2.3 LIRT (Bronze)
LIRT details will be defined in the local plans.
Back Office functions will follow the plans described below, and will liaise with the ICT
through the relevant ICT member.
10.3 Incident Manager
Specific guidance regarding issues to be considered by the SMT and ICT is detailed within
the Aide Memoire.
The ICT will decide the reporting frequency for the receipt of Local Sitreps (Annex B), and all
LIRT must ensure that reporting is completed according to the schedule that has been
decided.
An effective log of all actions and decisions must be maintained.
10.4 Incident Management Locations
Team
SMT
Primary Location
Secondary Location
Colonnades
Facilities & Estate Planning
department, Kingsley Green.
(meeting rooms)
Key available on Kingfisher Court
switchboard
ICT
LIRT
Communications
Staff Enquiries
Switchboard
Colonnades (meeting
rooms)
Hub location nearest the
incident
As Above
Nearest Convenient Hub
Colonnades
“
HR Offices, Colonnades
“
Colonnades
“
The following ways to contact the SMT/ICT Location will be announced when needed:



Mobile Numbers
E mail addresses
Video Conference Numbers
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In the event of a disruption affecting a remote location, the ICT will need to coordinate closely
with the LIRT(or equivalent) but will normally remain at THO.
Both SMT and ICT control rooms will require:






Loggist, with logging books (see Annex K for guidelines for Loggists)
Spider phone
TV
Laptop
Printer
Fax
11. Major Incident Response
In the event of a Major Incident external to HPFT, any requests for support from partner
agencies will be coordinated through the ICT. This may include the provision of staff for
Reception Centres.
12. Business Recovery and Continuity
12.1 Operational / HUBS
The operational aspects of the Trust will follow the strategy defined above, with all effort
directed at maintaining Tier 1 activities. The details for individual services will be detailed in
local Plans, as will the close liaison that will be required between services within each
region/area. Hubs will ensure coordination with local partner agencies, such as Social
Services, but must coordinate wider requests for assistance, such as Ministry of Justice,
through the ICT.
Hubs may also be required to provide staffing to support other agencies and partners, such
as for Reception Centres. Any such requests for external assistance must be coordinated
and approved by the ICT.
12.2 Support Functions
The support functions for the Trust, such as Finance, Estates, IT and Communications, will
follow the procedures laid out in the Waverley Road plan. They will communicate all their
updates through the relevant ICT member.
13. Staff
13.1 Staff Details
Staff contact details are managed at a local level, with Service Line Leaders and Team
Managers maintaining contact details for all their staff. HR have a list of all Corporate staff
who have clinical experience
13.2 Welfare
Enquiries from staff and their families will be handled by the ‘Staff Enquiries’ team run by the
HR Department.
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Staff members who have been involved in an incident should be reminded of the services
that are available from the Employee Assistance Helpline and the means of accessing these
services. Equally, a Critical Incident Debriefing Session can be scheduled. See Annex for
contact details.
13.3 Payroll
If there are problems with processing the payroll in the run-up to pay day, the most recent
daily backup file can be sent to. They can then process the payroll and transmit the BACS
instruction on behalf of the Trust. Any discrepancies will be corrected in the following
month’s pay.
13.4 Allowances
Staff who are temporarily relocated to another location are entitled to claim allowances
Excess Travel if there is any increase in their mileage to the new base.
13.5 Policies and Procedures
For issues relating to home working and lone working which may be of particular relevance in
the event of disruption to normal operations. Advice will be given by HR & Service Line
Managers.
13.6 Unavailability of Key Staff
Specific plans have been prepared to address unavailability of key staff due to fuel problems,
severe weather and Pandemic Flu these would form the basis for responding to other
scenarios involving staff unavailability.
14. Communication Requirements and Procedures
14.1 Communication with Staff
All channels for communication with staff will be exploited fully in the event of a Major
Incident, particularly Trust Space.
14.2 Communication with Service Users, Carers and the Public
The Head of Communications & the Control Director will assess the impact of the Major
Incident and the likely need for information to be available or the likely level enquiries and will
decide, depending on the nature of the incident and those affected, what approach to take.
Possible approaches are:





Broadcast messages through the local and if necessary, national media
Post up to date information on the public website
Display posters etc of the same information in reception areas of all local units
Trust Staff make personal contact by letter, telephone or by visiting.
Identify and publicise a dedicated number for enquiries, where a team of well briefed
staff with good communication skills, deal with the calls on a rota. eg.
- the PALS telephone number or
- a Trust number arranged for this purpose
- an external number such as the NHS Direct free phone number
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14.3 Communication with the Media and VIP’s
It is essential that communications with the media are closely coordinated so staff must not
speak to the Press but must direct them to the Communications team on 01727 804557
The Communications Team will therefore:









Use the agreed co-ordinated approach to Media enquires via the Communications
Office & get them on board
Use the current generic information about the Trust; staff numbers, size etc
Use media trained Managers for any live interviews
Ensure that managers do not speculate on the Incident and how it occurred or
comment on other agencies
Use local support arrangements to call on extra help from neighbouring Trusts etc
Plan for facilities to be available for Press – rooms, telephone lines, refreshments
Ensure plans are linked into local multi agency press briefing which may be run by the
Police or Herts Emergency Services Major Incident Committee (HESMIC)
Ensure all people directly involved or affected have been informed prior to media
Document all information given out and who it was given to
15. Recovery
15.1 Recovery Considerations
Longer-term Recovery should be considered even as Incident Management is underway as
actions taken at an early stage can significantly influence the long-term outcome for the Trust
and its stakeholders. Key issues to address in an effective recovery include:
Issue
Department
Backlog of work
All
Reduced availability of staff
HR
Health problems, fear and
anxiety amongst staff
Occupational Health
Restoration of utilities and
essential services
Estates
Restoration of IT and
telecoms
Comments
IT, Estates
Physical reconstruction of
facilities
Estates
Disposal of hazardous waste
Estates
Replacement of equipment
and consumables
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Impact on finances and
performance targets
Improvement
Rewarding and
acknowledging the efforts of
Trust staff and others
Exec Team,
Communications
15.2 Recovery Strategies
Various strategies may be appropriate during the recovery phase including:

Use of temporary facilities;

Asking part-time staff to increase hours and/or use of temporary staff;

Increased use of home working;

Outsourcing of work; and

Suspending or terminating some activities.
16. Information Flow and Documentation
17.
It is critical throughout the incident that effective log-keeping is maintained to record all
instructions received, decisions taken and any subsequent actions.
16.1 Procedure for Stand-down
The SMT will order a stand-down when it judges that normal operations can be resumed.
This will be communicated to all staff via the switchboard and to key stakeholders directly by
the SMT.
16.2 Post incident review
Post-event learning is an essential aspect of health emergency planning. Because incidents
occur on an infrequent basis, it is particularly important to document any lessons identified
from managing incidents and to change current procedures and plans and provide reasons
for any changes, so that they can be referred to in future incidents. Any necessary
organisational changes or amendments to emergency plans will be clearly agreed with the
Chief Executive and detailed by the EPLO who will be responsible for ensuring that actions
are carried out within a specified time frame. Immediately following an incident it is advisable
to conduct a ‘hot debrief’ in order to capture vital information and sequence of events, a ‘full
debrief’ should be conducted within 14-21 days following the initial incident.
16.3 Trust debriefing guidelines
It is vital that debriefing is carried out in a way that is conducive to promoting organisational
learning and encouraging a ‘no blame’ culture. The group should adhere to the following
ground rules when debriefing:
 conduct the debriefing openly and honestly
 pursue personal, group or organisational understanding and learning
 be consistent with professional responsibilities
 respect the rights of individuals
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

value equally all those concerned
All the above should be linked to the Trust Counselling Service
16.4 Key aspects of a trust debrief
Once normal operations have been resumed, or the Trust is close to this situation, it is
important to conduct a review in order to:







Identify the nature and cause of the incident;
Assess the adequacy of management’s response;
Assess the organization’s effectiveness in meeting its recovery time objectives;
Assess the adequacy of the Business Continuity arrangements in preparing
employees for the incident;
Address organisational issues;
Look for both strengths and weaknesses and ideas for future learning; and
Identify improvements to be made to the Business Continuity arrangements.
18. Actions and activities following debriefing
Once debriefing has been completed, a number of activities need to be undertaken including:
 Written Trust report (summarise the sequence of events, identify individuals involved,
describe actions of staff involved, provide an accurate timeline);
 Lessons identified from the incident, and dissemination of these; and
 Agreed action plan for the trust.
The checklist below gives a recommended process for an effective post-incident review.
Depending on the nature of the disruption, it may also be necessary to follow the SUI
procedure.
Task
Comments
Appoint inquiry leader
Ideally a Director who was not personally
involved in managing the incident.
Set terms of reference
Set out the exact remit and aim of the inquiry.
Set a specific date for the submission of
feedback.
Gather information from those
involved
Includes external stakeholders (eg NHS
England, other Trusts)
Assess impact on staff
Review performance outcome measures from
Counselling.
Review data and produce postincident report
Circulate key findings to all staff.
Update the BCP as required
Inquiry Leader to track agreed actions through
to completion.
19. Training/Awareness
STANDARD

Specific training to be provided on request
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
20.
Training linked to regional/local and national exercises
Embedding a culture of Equality & RESPECT
STANDARD
The Trust promotes fairness and RESPECT in relation to the treatment, care and support of
service users, carers and staff.
RESPECT means ensuring that the particular needs of ‘protected groups’ are upheld at all
times and individually assessed on entry to the service. This includes the needs of people
based on their age, disability, ethnicity, gender, gender reassignment status, relationship
status, religion or belief, sexual orientation and in some instances, pregnancy and maternity.
Working in this way builds a culture where service users can flourish and be fully involved in
their care and where staff and carers receive appropriate support. Where discrimination,
inappropriate behaviour or some other barrier occurs, the Trust expects the full cooperation
of staff in addressing and recording these issues through appropriate Trust processes.
RULE: Access to and provision of services must therefore take full account of needs
relating to all protected groups listed above and care and support for service users, carers
and staff should be planned that takes into account individual needs. Where staff need
further information regarding these groups, they should speak to their manager or a member
of the Trust Inclusion & Engagement team.
Where service users and carers experience barriers to accessing services, the Trust is
required to take appropriate remedial action.
Process for monitoring compliance with this document
RULE: This section should identify how the organisation plans to monitor compliance with
the process/system being described, presented in a table.
Action:
Major Incident
Exercises
Lead
Method
Head of
Live Tests
Facilities
and
Maintenance
Frequency
As required
Report to:
Health Safety
and Security
Committee
PART 3 – Associated Issues
21. Version Control
STANDARD
Version
V6
Date of Issue
Oct 2011
V7
March 2015
Author
Head of
Facilities and
Estates
Head of
Facilities and
Estates
Status
Archived
Comment
Superseded
Ratified
Current Policy
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22. Archiving Arrangements
STANDARD: All policy documents when no longer in use must be retained for a period
of 10 years from the date the document is superseded as set out in the Trust Business and
Corporate (Non-Health) Records Retention Schedule available on the Trust Intranet
A database of archived policies is kept as an electronic archive administered by the
Compliance and Risk Facilitator. This archive is held on a central server and copies of these
archived documents can be obtained from the Compliance and Risk Facilitator on request.
23. Associated Documents
STANDARD
Trust Policies Relevant to Major Incidents
 Major Incident and Business Continuity Aide Memoire
 Local Incident Response Team Plan
 Emergency Plan for Fuel Shortages
 Extreme Weather Plan (hot and cold weather)
 Business Continuity Plan Summary for IT
 Physical Security Policy
 Business Continuity Plan Pandemic Flu
 Lockdown plan
 Trust CBRNE plan
24. Supporting References
STANDARD
Local Health Economy Documents
 NHS England Hertfordshire and South Midlands Area Team Command, Control &
Coordination (C3) Framework
 HPFT Flu Pandemic Communications Plan
 Interserve MI & BCP
 HCC Health & Community Services Incident Response Plan
 Herts Primary Care Trusts Emergency Plan
 Memorandum of Understanding Herts PCTs and Trusts in Hertfordshire
 NHS Herts Response to a Chemical, Biological, Radiological or Nuclear Incident
 Hertfordshire Influenza Pandemic Phased Response Workforce & Organisational Plan
 Herts Informatics Services BCP Risk Assessment Management Summary
 Herts PCTs ICT Business Continuity Plan
 Hertfordshire County Council Incident Response Plan
 Hertfordshire Resilience Multi Agency Emergency Response Plan
 Hertfordshire Resilience Multi-Agency Fuel Plan V1.21
 Major Accident Hazard Pipeline Plan V3.0
 Hertfordshire Resilience Care of People Plan – Humanitarian Assistance
Arrangements & Documentation Pack
 North Herts DistrICT Council Response to an Emergency
 East of England Pandemic Influenza Forum Data User Name and Password
 East of England Mass Casualty Plan
 East of England Mutual Aid Agreement for Emergency Planning
National Guidance Documents (also available)
 NHS Security Management Service – Lockdown Guidance
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









DoH NHS Emergency Planning Guidance (evacuation & shelter)
DoH NHS Emergency Planning Guidance (advanced medical care)
DoH NHS Resilience & Business Continuity Management Guidance
DoH NHS Recovery Information Pack
DoH Pandemic Influenza Guidance on Preparing Mental Health Services
DoH Pandemic Flu Communications Plan
DoH Pandemic Flu: A Summary of Guidance for Infection Control in Healthcare
Settings
DoH– The use of Face Masks During an Influenza Pandemic
NHS Pandemic Flu: Guidance for the Hospitality Industry
DoH Pandemic Influenza: Guidance for Primary Care Trusts and Primary Care
Professionals on the Provision of Healthcare in a Community Setting in England
25. Comments and Feedback – List people/ groups involved in developing the Policy.
STANDARD
Example list of people/groups involved in the consultation.
Executive Director Quality & Safety
RCN representative
Health Safety and Security Manager
Director of Operations
Risk and Compliance Manager
Delegated Health, Safety and Security
Officers for SBUs
Specialist Fire Prevention Officer
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Annex A
HPFT decant contingency plans December 2015
The purpose of this document is to set out how HPFT would manage the need to fully decant an inpatient area in the event of a major incident. The document is an appendix to the Trust Major Incident
and Business Continuity plan. The decant plan is supported by local unit MI and BCP. It is an
expectation that staff in each unit is aware of the local plans. All staff will be up to date with fire
training and understand the local evacuation procedures. This is particularly important in units where
service users are likely to be in beds and chairs and require support to leave a unit.
It is recognised that in the event of a major incident final decisions regarding decant will be managed
by the incident control centre and take into consideration the following:




The unit requiring decant
The availability of beds across the trust
The support available to the Trust in the event of a major incident
The current risk status of service users to be moved
Bed stock to support decant
The trust will have a stock of 18 beds available to support decant. 6 will be in Kingsley Green (6
Forest Lane) and 12 will be at Fairlands Ward, at the Lister Hospital. In addition pressure relieving
mattresses will be available at sites across the Trust. The trust transport service can be mobilised to
move beds in stock to the decant area as required. Out of hours the transport service can be
contacted as required.
MH Act status
In the event of having to move service users subject to the MH Act it is recognised that the immediate
safety of the service users would be paramount. All legal issues would be resolved within 1 working
day of a unit decant.
Partial decant
All units would be expected to manage short term loss of beds by moving and creating space within
communal areas in each unit. The on call manager would be coordinating this and with the unit
determine if the scale of damage required a full decant and declaration of an internal major incident.
Full decant
The management of a full decant of a unit would be via the incident control centre. The specifics of
each move would be managed at that level and include access to consultant on call to assess the
needs of service users to be moved. Beds across the Trust would be utilised and community teams
would be mobilised to support discharge where it was considered safe to do so.
Kingfisher Court
The ward specific plans set out below work on the assumption that the risk all the beds at Kingfisher
Court require decant is extremely low. The layout of the unit means that the wards affected can be
isolated and evacuation of the whole site would only be an extreme action. If the whole of Kingfisher
Court was needing to be decanted the Trust would require the support of other providers and services
and would declare a full major incident. CCGs and NHS England would be expected to support the
Trust in accessing beds to meet the needs of the large number of service users whose beds were
unavailable.
Bed management
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During working hours the bed management service (currently 9-9 Mon to Fri and 9-5 Saturday and
Sunday) would be used to support a decant. They would be able to advise where beds were available
in the trust. Outside of working hours clinical leads would support the incident control centre until the
bed management service could be operational in the case of a major incident.
Staffing
If a unit is to be decanted staff would be directed to the unit where service users are relocated to.
Additional staff needs would be determined by the incident control centre. It is recognised that
additional staff may be required. Clinical staff in support services would be redirected to support the
relocation of service users and communication with carers and families.
External communication
The on call director would agree communication plans including contact with media in the event of a
unit decant. Restrictions on visitors may be put in place during the decant process to effectively
manage the process.
Should there be a incident on any of our residential sites and service users beds need to be moved
within the site or service users moved to another building contact with the relevant relatives or carers
should be made as soon as reasonably practical.
Thus contact should be made by the 1st on call if out of hours or by community leads during normal
working hours (assuming staff in the unit are involved in the practicability of moving service users) The responsible Service Line Lead for the moving service should arrange this.
East and North SBU decant plans
Forest house
adolescent unit
Victoria Court
Elizabeth Court
The Stewarts
Partial Damage –
Major Incident –
Full Evacuation
Major Incident –
Full Evacuation –
High Risk S/U
Vacate affected part
of ward and work
with NHS England
and C-CATT to
facilitate transfer/
supported discharge
home
of ward and work
across all OP wards
to create capacity to
enable transfer
Forest House school
Use of section 136
suit
Use of adult beds
NHS England to find
alternative services
Full decant to
Fairlands, 6 Forest
Lane
High risk likely to
relate to physical
frailty therefore work
with HCT/Acute
partners to create
capacity in extremis
of ward and work
across all OP wards
enable transfer
Holding day space
lounge space on
Elizabeth Court or
ADTU at Lister
Full decant to
Fairlands, 6 Forest
Lane
Holding day space
lounge space on
Victoria Court or
Lister ADTU
Full decant to
High risk likely to
relate to physical
with HCT/Acute
partners to create
High risk likely to
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of ward and work
across all OP wards
enable transfer
Fairlands, 6 Forest
Lane
of ward and work
across all OP wards
enable transfer
Full decant to
Fairlands, 6 Forest
Lane.
The Meadows
Ward layout would
enable affected wing
to be closed off
Full decant to
Fairlands, 6 Forest
Lane
Logandene
Ward Layout would
enable affected area
to be closed off
Full decant to
Fairlands, 6 Forest
Lane
Prospect House
Holding day space in
CHESS day hospital
Holding day space
ADTU on site
Full decant to
Fairlands, 6 Forest
Lane and Dove
would be used if
Fairlands was also
out of use.
Edenbrook
relate to physical
with HCT/Acute
partners to create
High risk likely to
relate to physical
with HCT/Acute
partners to create
High risk likely to
relate to physical
with HCT/Acute
partners to create
High risk likely to
relate to physical
with HCT/Acute
partners to create
West SBU decant plans
Partial Damage –
Major Incident –
Full Evacuation
Major Incident –
Full Evacuation –
High Risk S/U
Thumbswood
Ward Layout would
to be closed off if
damage was to
bedrooms only (2
bedrooms not in
use). Liaison with
NHSE to find
alternative resource
Full decant to 6
Forest Lane.
Discussions would
take place to ask
families to take
babies home short
term where this was
possible.
Oak
Ward Layout would
to be closed off if
damage was to
bedrooms only (5
bedrooms not in use)
Service users would
be evacuated to 6
Forest Lane whilst
decisions were made
on suitable areas to
move based on the
current needs and
risk status of the
service user. Spare
beds in Dove would
High risk likely to
relate to high
numbers of
Safeguarding
children concerns.
Partner organisations
to be involved and
informed of decant
plans and alternative
plans for babies
High risk likely to
relate to high levels
of aggression to
others, AWOL risks
and self-harm. MHA
issues apply which
can include Hospital
orders and MOJ
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be used to manage
those most suitable.
4 Bowlers Green
would be used to
manage those higher
risk service users.
Bed management
and commissioners
would need to
support the Trust in
accessing external
PICU beds.
Gainsford House
Sovereign
The Beacon
Hampden House
Albany Lodge
136 Suite
Ward Layout would
to be closed and use
of communal area for
short term solution.
Consider discharge
to community
services
Very limited capacity
within unit. Consider
admisisonm to other
rehab / acute
vacancies short term
Full decant to
Fairlands and
overspill to 6 Forest
Lane
High risk likely to
of AWOL, Self-harm,
increased access to
drug & alcohol
substances and
detention under MHA
Full decant to
Fairlands and
Lane
Ward Layout would
of communal area
and use of
communal space in
The Beacon ‘House’
for short term
solution. Consider
discharge to
community services
Ward Layout would
Consider discharge
to community
services
Ward Layout would
to be closed. Other
Acute wards to
consider capacity.
Expedite discharge
in conjunction with
carers/ CATT/ ADTU
As per major incident
Full decant to
Fairlands and
Lane
High risk likely to
of AWOL, Self-harm,
increased access to
drug & alcohol
substances and
detention under MHA
High risk likely to
of AWOL, Self-harm
increased access to
drug & alcohol
substances, and
detention under MHA
Full decant to
Fairlands and
Lane
High risk likely to
of AWOL, Self-harm
increased access to
drug & alcohol
substances, and
detention under MHA
Full decant to
Fairlands and
Lane
High risk likely to
relate to possible
increased risk to
others, AWOL risks
and self-harm. MHA
issues apply
If the 136 on Oak
was out if use then
the 136 at KC would
High risk likely to
relate to possible
increased risk to
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be used.
If the 136 on KC was
out of use the 136 on
Oak would be used.
If more than 1 136
was required in such
circumstances a
place of safety would
be designated based
on risk on site.
others, AWOL risks
and self-harm/
neglect. MHA issues
apply
ADTU
Unit layout would
to be closed
Service users would
be sent home and
supported by
community teams.
High risk likely to
relate to possible
increased risk of selfharm/ neglect
Aston ward
Ward Layout would
to be closed. Other
Acute wards to
consider capacity.
Expedite discharge
in conjunction with
carers/ CATT/ ADTU
Full decant to
Fairlands, 6 Forest
Lane and Dove
would be used if
Fairlands was also
out of use.
High risk likely to
relate to possible
increased risk to
others, AWOL risks
and self-harm/
neglect. MHA issues
apply
LD and F SBU decant plans
Warren
Court
Broadland
Clinic
Partial Damage –
Remain within secure
perimeter
 Ward Layout
would enable
affected area to
be closed and
use of communal
area for short
term solution.
 Move affected s/u
to designated
house or
therapeutic
activity area
within secure
perimeter
 Ward Layout
would enable
affected area to
be closed and
use of communal
area for short
term solution.
 Move affected s/u
Major Incident – Full
Evacuation






Ensure MOJ aware
of transfers
Police Presence as
required
Move Beech / 4BG
– liaise NHSE re
secure placements
elsewhere if unable
return within an
agreed EoE
Contingency Plan.
Ensure MOJ aware
of transfers
Police Presence as
required
Willowbank if total
evacuation. There is
an agreed plan with
the Norfolk
Evacuation – High
Risk S/U
Memorandum with
police for high risk s/u
temporary use police
custody whilst
alternative secure
accommodation found
Memorandum with
police for high risk s/u
custody whilst
alternative secure
accommodation found
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to other unit or
therapeutic
activity area
(Wherries) within
secure perimeter


Constabulary and
emergency services
within Contingency
Plan 515
Reciprocal
Agreement in place
with nearby Norvic
Clinic (NSFT)
Liaise NHSE re
secure placements
elsewhere if
required (within an
agreed EoE
Contingency Plan)
Astley
Court

Ward Layout
would enable
affected area to
be closed and
use of communal
area for short
term solution.

Willowbank within
Little Plumstead site
Not applicable
Beech Unit

Ward Layout
would enable
affected area to
be closed and
use of communal
area for short
term solution.

Ensure MOJ aware
of transfers
Police Presence as
required
Move Warren Court
/ 4BG – liaise NHSE
re secure
placements
elsewhere if unable
return
n/a
Ward Layout
would enable
affected area to
be closed and
use of communal
area for short
term solution.

Ensure MOJ aware
of transfers
Police Presence as
required
Move Warren Court
/ Beech – liaise
NHSE re secure
placements
elsewhere if unable
return
n/a
Ward Layout
would enable
affected area to
be closed and
use of communal
area for short
term solution.

Use 6FL / Dove
dependent on
service user
population within
affected unit
N/a
4 Bowlers
Green
SRS






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Dove

Ward Layout
would enable
affected area to
be closed and
use of communal
area for short
term solution.

N/a
Use 6FL – deploy
beds within SRS if
KF Court required to
be evacuated
Lexden

Ward Layout
would enable
affected area to
be closed and
use of communal
area for short
term solution.

If Rehab unit –
move to A&T unit
(additional capacity
in mothballed area)
If A&T unit – move
to Elizabeth House
on Lexden site

N/a
Plan subject to annual review
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Annex B
ACTION SHEET 1
INCIDENT MANAGER ON SITE
OBJECTIVE – To report the Major Incident promptly & clearly to an Executive Director
or other appropriately senior person, & to be the on site manager, co-ordinating the
response/action as needed by the Hub Major Incident & Business Continuity Plan and
as planned by the ICT.
REPORT THE INCIDENT
In Normal Working Hours – call an Executive Director at The Colonnades-01707 253800
Summarise the Incident clearly & succinctly: SBAR is useful
 Situation (S)- what has happened (& the severity); where did it happen (exact
location); the date and time it happened; & the people & organisations involved and
their status give your details: Name, Job Title, Service, location & contact numbers
 Background (B)- what led up to it and any other key details
 Assessment (A)- is this a Major Internal or a Multi-Agency, Major Incident? And what
is the situation now/the outcome & if you need immediate support
 Recommendation (R) – what do you advise is the immediate practical action needed
Make a note of the date and time of the call & who you spoke to & the details of your contact
point in the Incident Team & keep in touch
NB
Make sure the reporting manager at scene of incident completes the Trust
Serious Untoward Incident Form and sends the completed form to the Risk
Management Department at 99 Waverley Road immediately.
If necessary the Exec Director will call in the Incident Command Team via the PICU
switchboard (see out of hours number above), to assist with the Out of Hours/On Site
management of the Major Incident.
MANAGE THE ON SITE ASPECTS OF THE INCIDENT:
 Manage the immediate situation ensuring relevant safety & security considerations
 Activate the Hub Major Incident Plan/BCP if necessary
 Arrange phone lines + conference call facilities for Incident Communications
 Keep a timed log of all events (see Log Sheet, Annex C)
 Discuss /seek authorisation service closure/adaptation as per the Prioritisation Plans.
 Inform relevant staff of any relevant decisions and action needed by them
ALSO CONSIDER IF NECESSARY :
 Evacuation/working with Bed Management/Estates for alternative accommodation
 Victims/Casualty clearance/ Parking for emergency services
 Preservation of forensic evidence
 Mortuary arrangements & liaison with chaplains, social services and voluntary sector
 Support for staff & for relatives and carers
 Designate Press liaison points
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MAJOR INCIDENT REPORT RECORD
REPORTING
MANAGER
ANYONE RECEIVING THE INITIAL CALL REPORTING A MAJOR INCIDENT:
must record as much information as possible below
Name of
Informant
Designation
Contact No.
Tel:
Fax:
Call Received
Date:
E-mail:
Time:
DETAILS OF MAJOR INCIDENT
Description of
the Incident
Date/time of
Date:
Time:
incident
Location of
incident
(Any access
issues?)
Multi-Agency Incident or Internal Incident? Delete as appropriate
Current
Situation
(and do you need
immediate
support?)
Potential
Complications
Casualties
Estimated
Number
Severity
Type
Hospitals/ other
health services
involved
Name of person
receiving call
Title
Signature
NB: Copy this Form to the Director, EPLO & Risk Mgt – to be recorded on Datix
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Annex C
Annex C - Daily Situation Report
To be sent to HPFT ICT daily by fax or email:
1.0 Hub
__________________________________________________________________
2.0 Staff Rostered to be on duty now
Staff Group
Consultant staff (or equivalent)
Medical Staff – please specify
Nurses
HCA
Administrative Staff
3.0 Staffing Levels Today
Staff Group
WTE
WTE
WTE Sick / Absent
Reason for Absence
4.0 Anticipated / Actual Difficulties with Staff
___________________________________________________________________
5.0 Anticipated / Actual Loss of Facilities
___________________________________________________________________
6.0 Anticipated / Actual Unavailability of Essential Supplies
___________________________________________________________________
7.0 Contingency Plans Already in Place
___________________________________________________________________
8.0 Anticipated Difficulties with Routine Service Delivery
Yes/No
9.0 If “Yes” Anticipated Duration and Numbers of Service Users Affected
___________________________________________________________________
Signed: ____________________________ Date: _________________________
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Annex D – HPFT Log Sheet
Team:
Name:
Date /Time
From
To
Contact No:
Message
Page:
Action / Decision
of
Signature
This log is to be used to record all messages received and sent during an incident. Once completed, this form must not be destroyed, and should be returned to the EPLO.
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Annex E
Annex D - NHS ENGLAND MAJOR INCIDENT SITUATION REPORT - SITREP
Note: Please complete all fields. If there is nothing to report, or the information request is not applicable, please insert NIL or N/A.
Organisation:
Date:
Name (completed
by):
Time:
Telephone number:
Email address:
Authorised for
release by (name &
title):
Type of Incident
(Name)
Organisations
reporting serious
operational
difficulties
Impact/potential
impact of incident
on services / critical
functions and
patients
Impact on other
service providers
Mitigating actions
for the above
impacts
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Impact of business
continuity
arrangements
Media interest
expected/received
Mutual Aid Request
Made (Y/N) and
agreed with?
Additional
comments
Other issues
NHS ENGLAND
Regional Incident
Coordination Centre
contact details:
Name:
Telephone number:
Email:
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Annex F
Annex E – Decision Log
Date: …………………………………………… Time: ………………………………
Team: …………………….
PROBLEM FACED:
OPTION 1:
Agreed to use?
Time agreed:
Agreed by who:
OPTION 2:
Agreed to use?
Time agreed:
Agreed by who:
OPTION 3:
Agreed to use?
Time agreed:
Agreed by who:
Name: …………………………
(Decision maker)
Signed: ……………………………………
Date: …………………………………………Time: ……………………………………
Once completed, this form must not be destroyed, and should be returned to the EPLO.
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Annex G
HPFT Incident Management
Location
Resources required
 The Colonnades Hatfield
 Stationery
 Harper House Facilities &
Estates
 Telephony
 Hub nearest the incident
 White Board
 Flip-charts
 W eb access/Email
Mobilisation
 Have all team members
been notified?
 Has the Trust been
informed that the
ICT/SMT have been
mobilised?
 Have relevant contact
numbers been circulated?
 Have future meetings
been scheduled?
 Have the Incident Meeting
Rooms been established?
Background Information








 Have conference call lines
been opened?
 Has a log been
commenced?
Service Users
 Are the service users
accounted for?
 Have service users/carers
been notified of a
disruption to services ?
 Are there any transport
implications?
 Do we need any
additional
support/supplies/staff

W hat is the situation?
What has occurred?
W here and when?
What is the scale of the
event?
Is the event likely to
escalate?
W hich facilities/services may
be affected?
W hat is the current Trust
situation?
W hat is the current impact
on:
Staff
Service Users
Premises
What is the potential
impact?
Facilities
 What facilities have been
impacted?
 W hat functions within the
facility are Tier 1l?
 Can those functions be
transferred?
 What is the potential impact
on the Trust?
 Are there any other likely
issues that will have an
impact, eg air conditioning,
utilities failure?
 What are the H&S
implications?
Roles & Responsibilities
 Update staff information line/release updates for staff
 Release press release
 Coordinate business response to incident
IT
 What areas are impacted?
 What is Trust critical?
 W hat needs to stay running/be switched off?
 Do staff need to avoid usage?
 Are there any manual workarounds?
 What is the potential impact to the Trust?
 What is the potential timescale for return to BAU?
Communications:
Service Users
Return to BAU
Staff
 Do Carers need to know?
 Who will lead on the recovery?
 Are all staff accounted for?
Media
 Has a press statement been
released?
 W hat reporting/checking structure will be applied?
 Do they know the situation?
 Can they be notified/updated?
Liaison
 Do they know ICT has been
activated?
 Is there regular coordination
with:
 What is the long-term impact on:
Staff
 Has the Staff Helpline been
updated?
Emergency services
 Have the staff been reminded
the counselling service?
Regulators
Partner agencies
Neighbours
Service Users
Facilities
Technology
 How frequently will the ICT meet?
of
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Annex G
January 2016
INCIDENT MANAGEMENT
HPFT
Mobile
Name
Name
Strategic Management Team
ICT
Role
Name
Stakeholders
Data Protection
These telephones numbers have
been supplied in confidence, and
are to be used for purposes of
Incident Management only. The
data is collated by the EPLO,
and questions regarding
management of the data should
be forwarded to the EPLO
Project Management
 Outstanding tasks
 Specialist advice requirements
 Legal perspectives
 Insurance perspectives
 Other?
Shift Management for next Planning
Group
HPFT
 Need for stand-by resources
Other Issues
January 2016
Agenda Items
 Situation
 What has happened?
 Impact analysis
 Growth potential
 Update
 Objectives
 Stakeholders
 Who needs to know?
 Service Users/Carers
 3rd parties
 Staff
 Media
 etc
 Allocate responsibility
INCIDENT MANAGEMENT
Crisis Leadership
Team Conference Call
Facilities
 Who will do next shift
Next meeting
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Annex H
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Annex I
Service identifies
need to lock down
due to an incident
Decision to lockdown made
by GM/Director on-call with
advice from the
Start recording all decision made
and actions taken
emergency services
GM/Director on-call.
Informed of decision
Lockdown activation.
Lockdown deployment
Lockdown Maintenance
Carry a risk assessment of
the potential risk to staff and
patients of locking down the
site. Agree extent of lockdown
e.g which doors to be secured,
who will be allowed access.
Notify the emergency services
Advise staff of the situation
and task accordingly to secure
All entrances and exits
Included in the lockdown
Ensure regular security checks
Are made to all secure entrances
And exits
Appoint a communications lead
to communicate with staff,
Patients and public.
Continually review the situation
Reporting to Locality Manager
And GM as appropriate
Lockdown Stand down
Notify Locality Manager, GM and
Police of the reopening of the
Building.
Advice staff and task with reopening entrances and exits
Carry out a complete check of
the building contacting Estates
/Maintenance for assistance if
Required.
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Annex J
Response for Self-Presenters contaminated as a result of a Chemical Incident
(Guidance for HPFT Staff)
This guidance uses the research and results from a number of projects including the ORCHIDS
project and the IOR to Chemical Biological Radiological Nuclear (CBRN), sometimes referred to as
CBRNe where the ‘e’ stands for ‘explosive’, and Hazardous Materials (HAZMAT) Incidents.
It should be noted that:
 Not all potentially contaminated people will require follow-on treatment or evaluation at a
health care facility;
 Some people will leave the incident scene prior to responders arriving;
 Some people, who were not at risk of contamination and do not require any medical
assistance, may still present for evaluation and treatment, including requesting
decontamination.
Patient disrobe and dry decontamination is an important mitigation process that:
 Is a ‘first aid’ measure that is proven to reduce exposure
 reduces adverse health effects in the patient;
 permits faster access to medical care;
 protects the health, safety and wellbeing of staff;
 protects the integrity of the health care infrastructure
Improvised Decontamination
Improvised emergency decontamination is the use of an immediately available method
of decontamination prior to the use of specialised resources. This should be performed on
all disrobed people as a priority.
Dry decontamination, which should be considered the default process for non- caustic
chemical incidents, is the use of dry absorbent material such as paper tissue or cloth to
blot the exposed skin.
Unless casualties are demonstrating signs or symptoms of exposure to caustic or irritant
substances, for example, redness, itching and burning of the eyes or skin, exposed skin
surfaces should be blotted and rubbed with any available dry, absorbent material such
as paper tissues (e.g. blue roll). All waste material arising from disrobing and
decontamination should be double bagged in clinical waste bags (or equivalent) and tied
for disposal at a later stage.
Existing local procedures should be followed for processes including re-robing,
handling of personal items, and management of hazardous waste.
Wet decontamination – only to be used if there signs and symptoms of caustic
chemical substance – is the use of water from any available source such as taps,
showers, hose-reels, sprinklers. Paragraph 76 and following below give more detail
of wet decontamination.
Emergency decontamination would be performed on all disrobed casualties,
unless medical advice is given to the contrary.
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Interim Wet Decontamination
Water should not be used for decontamination unless casualty signs and symptoms are
consistent with exposure to caustic substances such as acids and alkalis, or the
contamination has been identified as biological or radiological in nature. Interim wet
decontamination is the use of standard equipment to provide a planned and structured
decontamination process prior to the availability of purpose-designed decontamination
equipment. There is no national standard for interim decontamination though the option of
applying this method could be from any available source of water such as taps, showers,
hose reels, sprinklers, etc. When using water, it is important to try and limit the duration of
decontamination to between 45 and 90 seconds and ideally, to use a washing aid such as a
cloth. This change is indicated by the ORCHIDS research. Existing local processes for the
management of contaminated waste should be followed.
Dry decontamination
Use of dry decontaminants is generally safer than wet decontamination.
NB – If a self-Presenter attends a unit – Dail 999. They should be put into a room & isolated.
Anyone coming in contact with this person will be potentially contaminated. If Staff come in
contact they must stay in the room with the presenter until the ambulance/fire brigade attend.
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Annex K
BEST PRACTICE FOR USING LOG BOOKS
Best practice in record keeping is the 'gold standard' towards which all Logglsts should aim. Judges expect
that Loggists will comply with this standard as do enquiry Chairs and Coroners.
A comprehensive record must be kept of all events, Information received, .decisions, reasoning behind those
decisions and action taken. Each responsible manager should also keep his/her own records, either
personally, or assisted by a Loggist.
It Is Important that a nominated Information manager be made responsible for overseeing the keeping and
storage of the records and files created during the response and also for ensuring the retention of those
records that existed before the emergency Incident occurred and Immediately afterwards.
This also applies to Emergency Incident Record Books© (EIRB)©) used by on-call managers to record issues,
Information received and action taken In an Incident or Emergency Pocket Log Books© (EPLB©).
Your entries must be C IA - Clear Intelligible Accurate.
Relevant Information should always be recorded in official Log Books.
Write In permanent black Ink. Write legibly. Avoid blue Ink.
Your record must be contemporaneous.
Use a new Log Book for each Incident.
Ensure you note dates, times (use the 24 hour clock) places and people concerned.
Record any non-verbal communication. Do not put your own Interpretation on that non-verbal
communication.
Only note down facts. Do not assume anything, give your own comment or give your own opinion.
Entries in the record must be in chronological order.
NO
Erasures
Leaves must be torn out of the Log Book
Blank spaces - rule them through
0verwrltlng
Writlng above or below lined area
Unused space at end of a page must be ruled through with a diagonal line, Initialed by you, dated and
timed.
Record all questions and answers in direct speech.
Unused spaces at the end of lines must be ruled out by you with a single line. Mistakes
must be ruled through with a single line and initialed by you.
Any mistake you make which you notice at the time of writing must be ruled through by you with a single
line, Initialed and the correct word(s) added after the mistake.
Overwriting or writing above the ruled through error must not be made.
Correction fluid must not be used in any circumstances
If you notice a mistake or an omission in the record later, during the debrief or at any other time, you must
tell your senior manager and the mistake must be corrected or the omission made good. Cross reference
the mistake (in red ink) to the corrected entry on the next available page using letters from the alphabet,
consecutively.
Make clear references to exhibits (such as maps, flip chart pages, etc) and other documents so that It Is
clear In the record which particular exhibit Is being referred to.
Each series of entries must be signed off, dated and timed at their close.
Logglsts should sign off their notes at the end of their shift to ensure the Integrity of the record.
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Local Incident Response
Team (LIRT)
Guidance
Version:
2
Approved Date:
Approved By:
26th November 2014
Health, Safety and Security Strategy Committee
Issue Date:
Review Date:
30th December 2015
30th December 2018
Related Policy: Major Incident and Business Continuity Plan
Target Audience:
This Guidance must be understood by staff working in their specific unit or team
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CONTENTS
PAGE:
PART 1
1. Purpose and scope
36
2. Key services within scope
36
3. BCM Policy
37
37
5. Objectives
6. Invocation
8. Business Continuity
9. Staff
40
40
43
46
46
10. Communication requirements and procedures
47
48
11. Recovery
49
12. Information flow and documentation
13. Process for Stand-down
14. Monitoring
15. Related Documents
16. Version Control
49
50
50
50
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The purpose of this plan is to improve the capacity of Hertfordshire Partnership University NHS
Foundation Trust to manage significant disruptions to operations thereby reducing the impact
on stakeholders, damage to the reputation of the Trust and financial losses. This is a statutory
duty under the Civil Contingencies Act (2004) and has now been reinforced by DH Interim
Guidance on Business Continuity Planning (June 2008). A significant incident is defined as:
‘Any occurrence that presents serious threat to the health of the community, disruption to the
service or causes (or is likely to cause) such numbers or types of casualties as to require
special arrangements to be implemented by hospitals, ambulance trusts or other acute or
community provider organisations.’
This plan also includes the procedures for responding to an externally-declared Major Incident
as required by NHS Guidance on Emergency Planning 2005. ‘To describe an event or
situation that threatens serious damage to human welfare in a place in the UK or to the
environment of a place in the UK, or war or terrorism which threatens serious damage to the
security of the UK?
The term ‘‘major incident’’ is commonly used to describe such emergencies. These may
include multiple casualty incidents, terrorism, severe weather conditions, flood or national
emergencies such as pandemic influenza.’(See Trust Pandemic Flu Plan)
This plan also takes into account the need to lockdown (See Trust Lockdown Plan) a Trust site
if the following occurs:CBRN/Hazmat
1) A member of the public comes into an HPFT site as a result of a nearby
incident. (All HPFT sites have the Trust CBRN plan with action cards and are included in their
local plans)
2) A violent service user or terrorist trying to gain entry into an HPFT building.
For Mass casualties or surge/escalation plans HPFT will first use it’s decant plan (Annexe A)
after which it will invoke collaboration with the Acute Trust in Herts and the HCT
2. Key Services within Scope
The scope of the plan covers all HPFT activities within enter hub/location. Local plans have
been developed for use at individual sites, and these dovetail into this plan.
- Annexe A of this plan details Residential Sites decant Plans (Dec 2015)
2.1 Assumption and Core Principles
As every type of incident or emergency cannot be planned for, when the Trust faces a major
incident, longer term emergency or business continuity challenge, the approach will be based
on ‘core principles’ which support & assist consistent decision making in incident situations.
These are:


Trust Managers and Team leaders will be assisted in preparing & testing local
contingency arrangements and a Local MI & BC Plan based on this document;
Clear determination of any Major Incident and prompt enactment of this plan by
Managing Director with the Executive Team and the EPLO;
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




Our primary aim is to maintain our essential/critical services. To facilitate the staff
flexibility needed, there are ‘Terms & Conditions in Severe Disruption’ agreed in
principle by HR Policy Grp;
Major Incident Response Team Members will be clear about their responsibilities and
the systems to use: guided by this document, the ‘Action Sheets’, their training & links
with the EPLO;
A co-ordinated approach will be taken as key decisions will be made centrally and
communicated to the front line managers to carry out, or to other agencies or the media
etc;
We will make best use of resources/expertise/skills already available in the Trust until
particular expertise may be needed when, ‘Subject Matter Experts’ will be sought; and
There will be an equally co-ordinated recovery phase – i.e. return to normal working
after the Incident when services can also be enabled to reflect on any learning.
NHS Emergency Planning Guidance suggest a minimum requirement of a live exercise to be
conducted every 3 years, a table top exercise every 1 year and a communications cascade
test every 6 months
3. BCM Policy
Hertfordshire Partnership NHS Foundation Trust is committed to implementing best practice in
Major Incident Response (MIR) and Business Continuity Management (BCM) throughout the
Trust in order to minimise the effect of disruptions on patients, staff, members of the public and
the reputation of the Trust. Ultimate responsibility for MIR and BCM within the Trust rests with
the Chief Executive, but specific responsibilities are delegated to the Emergency Planning
Lead. The management of the Major Incident and Business Continuity plans and procedures
is maintained in the Management System.
Hertfordshire Partnership NHS Foundation Trust will take all reasonable steps to ensure that in
the event of service interruption essential activities will be maintained and normal services
restored as soon as possible. The priority at all time is the safety and well-being of patients,
staff and members of the public.
All activities currently undertaken within Hertfordshire Foundation NHS Foundation Trust are
included within the Business Continuity Management framework. Where specific processes
are outsourced to third parties; the resilience of these third parties must be considered.
Plans have been developed at various levels within the Trust to facilitate a fully integrated
response and recovery mechanism. All plans are to be reviewed and exercised annually to
maintain and validate the organisation’s capability to respond.
All activities should be supported by a robust communications strategy which identifies
responsibilities and systems to inform patients, staff, operational partners, the press and the
public with timely and accurate information.
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4. Major Incident and Business Continuity Strategy
4.1 Major Incident
The Trust will provide support to Herts County Council for the provision and coordination of the
social care response and other humanitarian issues. This may include provision of support for
Reception Centres, for example, but any support will be coordinated through the ICT and SMT.
4.2 Business Continuity
The strategy for dealing with generalised disruptions is based upon classifying activities into 3
tiers according to their time-criticality as follows:
TIER 1
Must continue
 Acute Adult Mental
Health
Inpatient
Units/Wards
 Thumbswood Mother &
Baby unit
 CAMHS
Inpatient
Services
(Forest 
House)
 A & E Liaison
 Psychiatric
Intensive
Care
 MHSOP Assessment
and Continuing Care 
Services
 Inpatient Services for
people with Learning
Disabilities
 Low Secure Services
 Medium
Secure
Specialist
Learning
Disability
Services,
(Eric Shepherd Unit &
Broadlands Clinic)
 CATT Teams
 Adolescent Outreach
Team
 Acute Day Treatment
Unit
 Mental
Health
Act
Assts
 Single Point of Access




TIER 2
TIER 3
CLINICAL
Provide differently
Temporarily close
 CMHT
 Wellbeing Service
 SMHTOP
 Day Hospital Services
for Older People
 AOT

Day
services
for
 Eating Disorder Service
adults
 Personality
Disorder
 Mentally Disordered
Service
Offenders Services
Early Intervention in
 Forensic
Liaison
Psychosis
Team
and
Baby
 Mother
 Prison In Reach Team
Services
 Non
urgent/Routine
 IOT
Out Patients
 IST

Respite Care for Older
Specialist
Support
People
Teams for CAMHS
 Specialist Healthcare
 Mental Health Helpline
Workers
and
 Rehabilitation Services
Therapists
 Bed Mgt & Placement
Team
 ECT
 Community
Learning
Disability teams (North
Essex)
 IAPT North Essex
SUPPORT FUNCTIONS
Phones
and  NHS
Outpatient 
switchboard;
Booking

Various IT services;
 Admissions Booking
HR
 Records Management
Estates and Facilities  Medical Secretarial
(emergency/BC
 Executive Team
F&PI (other functions)
Estates & Facilities
(BAU)
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


functions)
Informatics
Communications Team

F&PI (eg payment of
staff and suppliers)
Informatics (less critical
functions)
place that would enable them to maintain services to patients and gather the data required for
subsequent coding and invoicing for up to 24 hours without IT systems.
4.2.1 Tier 1
Tier 1 services are the most time-critical. They are essential services and must continue to be
provided, although some could be consolidated onto fewer sites if circumstances and bed
usage allows, enabling temporary unit closures to maximise staffing resources.
The aim is to maintain all of these activities during a disruption, either by moving staff and
equipment the sites for additional support or, where necessary and possible, consolidating into
fewer sites, as required.
4.2.2 Tier 2
Tier 2 services are important but could be reduced or provided differently. These services
have a BCP detailing the reductions that are possible. As an example:
Maintain risk based service for face to face contacts
o Clozapine clinics
o Depot injections
o Urgent prescriptions
o Safeguarding vulnerable adults procedures
Non essential activity to temporarily cease or be provided differently:
o Provide phone service to low priority cases from fewer bases
o Other regular but non-urgent visits
o Attendance at inpatient or other routine case conferences
o 7 day follow up visits
o Visits to carers
o Walk-in services
In preparation for managing staff shortages & service reductions, staff will review their
caseloads and flag service users indicating the broad level of risk. The flagging would be:



Red
Amber
Green
-
High risk
Medium risk
Low risk
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Community staff released by these measures can be redeployed into Level 1 services – skills
and competencies permitting. Alternatively, Community teams could manage some service
users from inpatient units on a short term basis if resources/skills allow.
Tier 2 also consists of some ‘back-office’ functions.
The aim is to restore these activities within 24 – 48 hours of a disruption by moving staff to an
alternative office location. A detailed plan has been prepared to facilitate this.
4.2.3 Tier 3
Tier-3 services can be temporarily suspended or closed (with Service Users and other
stakeholders being informed appropriately) in the event of needing to release resources for
high priority/essential services:
A number of back-office functions are also Tier 3 activities, and can be ceased during the initial
phase of the incident.
The aim is to restore these activities within a week, as resources allow. It is not possible to
plan the precise sequence of restoring these activities in detail but individual departments have
prepared outline plans highlighting their resource requirements.
place that would enable them to maintain services to patients and gather the data required for
subsequent coding and invoicing for up to 24 hours without IT systems.
4.2.4 IT
Paris has been developed as a high-availability system. However, in the event of a loss of
Paris, manual records will be maintained.
4.2.5 Staff Unavailability
It is one of our ‘core principles’ that we will always maintain the critical/essential service,
whatever the circumstances. Therefore, when something has occurred leading to staff not
being available to deliver all our services, we must prioritise where these staff work, focusing
on the Tier system listed above.
5. Objectives
The objectives of this Major Incident and Business Continuity plan are:







To ensure the safety and well-being of staff and service users;
To enable an effective response to any major incidents impacting HPFT;
To co-ordinate and provide mental health support to staff, patients and relatives in
collaboration with Social Services;
To outline how, when required, Ministry of Justice approval will be gained for an
evacuation;
To identify locations which patients can be transferred to if there is an incident;
support local acute trusts by managing physically unwell inpatients if there is an
infectious disease outbreak;
To ensure the needs of mental health patients involved in a significant incident or
emergency are met and that they are discharged home with suitable support;
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



To work effectively with partner agencies during an incident;
To continue to run services as determined by their categorisation;
To ensure swift and accurate communications with staff, service users and other
stakeholders; and
To enable a swift recovery to service as usual.
6. Invocation
If one or more of the following applies, the incident could require a HPFT response:

A major incident or emergency has been declared by a partner agency (health and non
health partners)
 This is an internal HPFT incident that cannot be managed within normal resources
 This is a significant incident that threatens to overwhelm the resources of more than
one NHS organisation in the geographic area
 This is a significant incident that requires coordination of more than one NHS
organisation within the Herts and South Midlands geographic area
 This is an incident where mutual aid is required (countywide or regional)
 This is an incident that requires the attendance of the NHS at a Strategic Coordinating
Group (SCG)
 This is a significant internal incident within another NHS organisation adversely
affecting the daily running of the organisation and necessitating special arrangements to
be instigated
 This is a significant incident that requires media coordination, particularly with partner
organisations
 This is a significant incident requiring support from the NHS
 This is an incident affecting large numbers of people or having catastrophic effects on a
smaller number of individuals
Examples could include:

Flood




Severe weather
Declaration of a heatwave
Notification of an External Major Incident by NHS England East and Midlands
CBRNE / Hazardous Materials incidents (a member of the public entering an HPFT site
in a contaminated condition that would require the site to lockdown.
Adverse media coverage;
Loss of electricity, gas, water or medical gases;
Loss of IT capability;
Supply chain issues; and
Local disruption at Remote Site which may impact on delivery of HPFT services.
Security/terrorist incidents (may require lockdown)






The Incident Manager on site who identifies that there has been an incident should follow
Action Sheet 1, and report as follows:
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In Normal Working Hours – call an Executive Director at Trust Head Office
The following flowchart depicts the invocation process:
In accordance with UK Emergency Response procedures, the following definitions apply:
Local Incident Response Team (LIRT): Bronze teams
Incident Control Team (ICT): Silver team
Strategic Management Team (SMT): Gold level team
6.1 Methods of invocation
Specific Incident Management actions are invoked as follows:
Action
SMT call-out
Authority*
Director on Call
Method
PICU
Tel No 01923 633501
ICT call-out
Director on Call
On Call System
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Declaring Major
Incident
Director on Call
Relocation of staff to
Director on Call / ICT
Invocation of IT
Disaster Recovery
IT Director / ICT
Phone call to NHS
England Midlands and
East, followed up with
completion of NHS Major
Incident Situation Report
(SITREP) Annex D of the
Trust MI&BC Plan
6.2 Activation criteria and procedures
The immediate steps to take in a disruption must consider:
 Due regard to welfare of individuals
 Strategic, tactical and operational options for responding
 Prevention of further loss or unavailability of prioritised activities
It is critical to assess the nature and extent of incident and the potential impact; the Aide
Memoire (Ref A) will act as a prompt, and should be followed.7. Incident Management
7.1 Roles, Responsibilities and Authorities
The following roles and responsibilities apply regardless of whether this is a response to a
Major Incident or Significant incident that requires a BCM response. For the latter, additional
expertise may be brought into the team as required.
1) Colonnades
2) Harper House
1) Colonnades
2) Harper House
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7.1.1 SMT (Gold)
The SMT consists of the Chief Executive and other Directors and provides the focus for
command and control within the Trust. Specifically they:

Provide the strategic direction and priorities for the Trust;

Identify and resolve wider strategic issues;

Resolve any conflicts or tensions arising between different areas of the Trust that
cannot be decided by the Silver Team; and

Present the outward face of the Trust to the wider NHS, the media and other key
stakeholders.
7.1.2 ICT (Silver)
OUT OF HOURS, THIS TEAM SHOULD BE CHAIRED BY THE ON-CALL DIRECTOR
UNTIL A SUITABLE ALTERNATIVE HAS BEEN APPOINTED AND A THOROUGH HANDOVER COMPLETED.
The ICT controls and coordinates resources and activities across the Trust; specifically they:

Convert the strategy from the Gold SMT into plans;

Communicate decisions, actions and plans to the LIRTs and Bronze Teams;

Establish measurable objectives;

Review progress against objectives and update the SMT;

Bring strategic issues to the attention of the SMT, as required;

Resolve conflicting requirements for resources;

Coordinate with the Emergency Services and other operational partners as required;
and

Liaise with key suppliers.
As an example, the immediate response will be coordinated by the LIRTs, who will have the
ability to use their available resources to ensure that the strategy is being followed. However,
in the circumstances that the LIRT requires additional support from other LIRTs or from
outside the HPFT area, eg for bedspace or staffing, then this request must be coordinated by
the ICT.
The ICT will also coordinate the back-up functions, ensuring that Facilities and IT support, for
example, is prioritised, and that all LIRTs have up-to-date information regarding the status of
any problems.
7.1.3 LIRT (Bronze)
The LIRT carry out the activities required to mitigate the effects of a disruptive challenge, as
directed by the Silver Team. This may include, for example:

Supporting patients and staff members affected by the incident;
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
Recovering IT systems; and

Establishing temporary workspace.
Critically, they must keep the ICT informed of progress on a regular basis.
Thus, the LIRTs will ensure that they manage the services within their local area, redeploying
resources to ensure that the Trust Strategy is being followed, and maintaining the provision of
Tier 1 activities. Back office functions, such as IT and Facilities, will ensure the recovery of
their areas, accordingly to the priorities defined by the ICT and the Business Impact Analyses.
Any requests for additional support, eg from other LIRTs, etc, must be coordinated by
the ICT.
7.2 Hub Incident Management Team
The following roles will normally be required as a matter of urgency:
Role
Primary
Alternate
Chair
Hub Manager
On-Call
Responsibilities
Liaising with ICT
Allocating clinical
Operations
Allocating non-clinical
Admissions
Emergency Services
Liaison
Liaison with
Estates/Facilities for:

Estates



Log-Keepers
Workspace
recovery
Telecoms
recovery
Damage
assessment
Salvage and
Restoration
See Annex A
7.3 Incident Management
Specific guidance regarding issues to be considered by the LIRT is detailed within the Aide
Memoire.
The ICT will decide the reporting frequency for the Sitrep at Annex B. This MUST be
forwarded to the ICT in a timely fashion.
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An effective log of all Actions and Decisions must be maintained.
7.4 Incident Management Locations
The LIRT will be based at the nearest Hub to the incident. Alternate locations could include
used, but any change in location will be notified when a suitable location had been identified.
The location chosen will need access to:
Telephone, laptop, whiteboard/flipchart, stationery, mobiles, MFD (Printer scanner)
The SMT and ICT locations will be notified when the event has occurred, but their location is
likely to be:
The Colonnades, Beaconsfield Close, Hatfield, Herts, AL10 8YE
Curie, Grey Thompson and the Mandela rooms will be used.
(should this not be possible then the training rooms in Kingfisher court will be used)
The following ways to contact the SMT/ICT Location will be announced when needed:
 Mobile Numbers
 E mail addresses
 Video Conference Numbers
In the event of a disruption affecting a remote location, the ICT will need to coordinate closely
with the LIRT(or equivalent) but will normally remain at THO.
8. Business Continuity
8.1 Operational/HUBS
The operational aspects of the Trust will follow the strategy defined above, with all effort
directed at maintaining Tier 1 activities. The details for individual services will be detailed in
local Plans, as will the close liaison that will be required between services within each
region/area.
In the event of the hub/location requiring support from other Hubs, this MUST be coordinated
through the ICT.
Hubs may also be required to provide staffing to support other agencies and partners, such as
for Reception Centres. Any such requests for external assistance MUST be coordinated and
approved by the ICT.
8.1.1 Acute
8.1.2 LD & Forensics
8.1.3 Older People
8.1.4 SPA
8.1.5 Community
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8.1.6 CAMHS
9. Staff
9.1 Staff Details
Staff contact details are managed at a local level, with Service Line Leaders and Team
Managers maintaining contact details for all their staff. HR have a list of all Corporate staff
who have clinical experience.
9.2 Welfare
Enquiries from staff and their families will be handled by the ‘Staff Enquiries’ team run by the
HR Department.
Staff members who have been involved in an incident should be reminded of the services that
are available from the Employee Assistance Helpline and the means of accessing these
services. Equally, a Critical Incident Debriefing Session can be scheduled. See Annex … for
contact details.
9.3 Payroll
If there are problems with processing the payroll in the run-up to pay day, the most recent daily
backup file can be sent. They can then process the payroll and transmit the BACS instruction
on behalf of the Trust. Any discrepancies will be corrected in the following month’s pay.
9.4 Allowances
Staff who are temporarily relocated to another location are entitled to excess travel allowances
if applicable.
9.5 Policies and Procedures
For issues relating to home working and lone working which may be of particular relevance in
the event of disruption to normal operations. Advice will be given by HR and Service Line
Leads
9.6 Unavailability of Key Staff
Specific plans have been prepared to address unavailability of key staff due to fuel problems
severe weather and Pandemic Flu, these would form the basis for responding to other
scenarios involving staff unavailability.
10. Communications Requirements and Procedures
10.1 Communication with Staff
All channels for communication with staff will be exploited fully in the event of a Major Incident,
particularly Trust Space.
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10.1.4 Gold & Silver Command Contents & Set up for MI & BCP
Entry to the Colonnades; Entrance fobs are held by Executive Team Members or on reception
during working hours.
Gold – Chief Executive Room & Chairman’s office plus small meeting rooms on this floor.
Silver – Galileo A & B for this command but breakout rooms available throughout this floor.
Facilities available
- 7 Laptops in the cupboard behind reception
- Spider phone in Chief Executives office
- All phones have conference call facility
- Smart boards in Chief Executive office
- Galileo has screen that connects to the laptops.
- Both floors have MFD’s
The Trust Conference Call Lines are:
Telephone Number
01923 633 871
01923 633 872
01923 633 873
01923 633 874
01923 633 875
01923 633 876
01923 633 877
01923 633 878
01923 633 879
01923 633 870
Exec Team only
Exec Team only
10.2 Communication with Service Users, Carers and the Public
The Head of Communications & the ICT will assess the impact of the Major Incident and the
likely need for information to be available or the likely level enquiries and will decide,
depending on the nature of the incident and those affected, what approach to take. Possible
approaches are:





Broadcast messages through the local and if necessary, national media
Post up to date information on the public website
Display posters etc. of the same information in reception areas of all local units
Trust Staff make personal contact by letter, telephone or by visiting.
Identify and publicise a dedicated number for enquiries, where a Team of well briefed
staff with good communication skills, deal with the calls on a rota. eg.
- the PALS telephone number or
- a Trust number arranged for this purpose
- an external number such as the NHS Direct free phone number
10.3 Communications with the Media
It is essential that communications with the media are closely coordinated so staff must not
speak to the Press but must direct them to the Communications Lead on 01727 804557
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11. Recovery
11.1 Recovery Considerations
Longer-term Recovery should be considered even as Incident Management is underway as
actions taken at an early stage can significantly influence the long-term outcome for the Trust
and its stakeholders. Key issues to address in an effective recovery will be managed by the
ICT, and will include:
Issue
Department
Backlog of work
All
Reduced availability of staff
HR
Health problems, fear and
anxiety amongst staff
Occupational Health
Restoration of utilities and
essential services
Estates
Restoration of IT and
telecoms
Comments
IT, Estates
Physical reconstruction of
facilities
Estates
Disposal of hazardous waste
Estates
Replacement of equipment
and consumables
Impact on finances and
performance targets
Improvement
Rewarding and
acknowledging the efforts of
Trust staff and others
Exec Team,
Communications
11.2 Recovery Strategies
Various strategies may be appropriate during the recovery phase including:

Use of temporary facilities;

Asking part-time staff to increase hours and/or use of temporary staff;

Increased use of home working;

Outsourcing of work; and

Suspending or terminating some activities.
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12. Information Flow and Documentation
It is critical throughout the incident that effective log-keeping is maintained to record all
instructions received, decisions taken and any subsequent actions.
13. Process for Standing Down
13.1 Procedure for Stand-down
The SMT will order a stand-down when it judges that normal operations can be resumed. This
will be communicated to all staff via the switchboard and to key stakeholders directly by the
SMT.
13.2 Post-incident review
Post-event learning is an essential aspect of health emergency planning. Because incidents
occur on an infrequent basis, it is particularly important to document any lessons identified
from managing incidents and to change current procedures and plans and provide reasons for
any changes, so that they can be referred to in future incidents. Any necessary organisational
changes or amendments to emergency plans will be clearly agreed with the Managing Director
and detailed by the EPLO who will be responsible for ensuring that actions are carried out
within a specified time frame. Immediately following an incident it is advisable to conduct a
‘hot debrief’ in order to capture vital information and sequence of events, a ‘full debrief’ should
be conducted within 14-21 days following the initial incident.
13.3 Trust debriefing guidelines
It is vital that debriefing is carried out in a way that is conducive to promoting organisational
learning and encouraging a ‘no blame’ culture. The group should adhere to the following
ground rules when debriefing:





conduct the debriefing openly and honestly
pursue personal, group or organisational understanding and learning
be consistent with professional responsibilities
respect the rights of individuals
value equally all those concerned
13.4 Key aspects of a trust debrief
Once normal operations have been resumed, or the Trust is close to this situation, it is
important to conduct a review in order to:







Identify the nature and cause of the incident;
Assess the adequacy of management’s response;
Assess the organization’s effectiveness in meeting its recovery time objectives;
Assess the adequacy of the Business Continuity arrangements in preparing employees
for the incident;
Address organisational issues;
Look for both strengths and weaknesses and ideas for future learning; and
Identify improvements to be made to the Business Continuity arrangements.
14. Monitoring of this Guidance
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This Guidance will be reviewed Annually
Action:
Lead
Method
Frequency
Report to:
15.
Rel
ate
d Documents
A. HPFT Major Incident and Business Continuity Aide Memoire
B. HPFT Local Incident Response Team Plan
C. HPFT Exec On Call Major Incident Emergency Guide
D. HPFT Emergency Plan for Fuel Shortages
E. HPFT Emergency Procedure in case of Heating or Water provision Breakdown
F. HPFT Extreme Weather Plan (hot and cold weather)
G. HPFT Business Continuity Plan Summary for IT
H. HPFT Suspect Package and Substance Plan
I. HPFT Business Continuity Plan Pandemic Flu
J. HPFT Response to a Chemical, Biological, Radiological or Nuclear(CBRNE) Incident
K. HPFT Lockdown plan
16. Version Control
Version
Date of Issue
Author
Status
Comment
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Annexe A
HPFT decant contingency plans December 2015
The purpose of this document is to set out how HPFT would manage the need to fully decant an inpatient area in the event of a major incident. The document is an appendix to the Trust Major Incident
and Business Continuity plan. The decant plan is supported by local unit MI and BCP. It is an
expectation that staff in each unit is aware of the local plans. All staff will be up to date with fire training
and understand the local evacuation procedures. This is particularly important in units where service
users are likely to be in beds and chairs and require support to leave a unit.
It is recognised that in the event of a major incident final decisions regarding decant will be managed by
the incident control centre and take into consideration the following:




The unit requiring decant
The availability of beds across the trust
The support available to the Trust in the event of a major incident
The current risk status of service users to be moved
Bed stock to support decant
The trust will have a stock of 18 beds available to support decant. 6 will be in Kingsley Green (6 Forest
Lane) and 12 will be at Fairlands Ward, at the Lister Hospital . In addition pressure relieving mattresses
will be available at sites across the Trust. The trust transport service can be mobilised to move beds in
stock to the decant area as required. Out of hours the transport service can be contacted as required.
MH Act status
In the event of having to move service users subject to the MH Act it is recognised that the immediate
safety of the service users would be paramount. All legal issues would be resolved within 1 working day
of a unit decant.
Partial decant
All units would be expected to manage short term loss of beds by moving and creating space within
communal areas in each unit. The on call manager would be coordinating this and with the unit
determine if the scale of damage required a full decant and declaration of an internal major incident.
Full decant
The management of a full decant of a unit would be via the incident control centre. The specifics of
each move would be managed at that level and include access to consultant on call to assess the
needs of service users to be moved. Beds across the Trust would be utilised and community teams
would be mobilised to support discharge where it was considered safe to do so.
Kingfisher Court
The ward specific plans set out below work on the assumption that the risk all the beds at Kingfisher
Court require decant is extremely low. The layout of the unit means that the wards affected can be
isolated and evacuation of the whole site would only be an extreme action. If the whole of Kingfisher
Court was needing to be decanted the Trust would require the support of other providers and services
and would declare a full major incident. CCGs and NHS England would be expected to support the
Trust in accessing beds to meet the needs of the large number of service users whose beds were
unavailable.
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Bed management
During working hours the bed management service (currently 9-9 mon to Fri and 9-5 Saturday and
Sunday) would be used to support a decant. They would be able to advise where beds were available
in the trust. Outside of working hours clinical leads would support the incident control centre until the
bed management service could be operational in the case of a major incident.
Staffing
If a unit is to be decanted staff would be directed to the unit where service users are relocated to.
Additional staff needs would be determined by the incident control centre. It is recognised that
additional staff may be required. Clinical staff in support services would be redirected to support the
relocation of service users and communication with carers and families.
External communication
The on call director would agree communication plans including contact with media in the event of a
unit decant. Restrictions on visitors may be put in place during the decant process to effectively
manage the process.
Should there be a incident on any of our residential sites and service users beds need to be moved
within the site or service users moved to another building contact with the relevant relatives or carers
should be made as soon as reasonably practical.
Thus contact should be made by the 1st on call if out of hours or by community leads during normal
working hours (assuming staff in the unit are involved in the practicability of moving service users) The responsible Service Line Lead for the moving service should arrange this.
East and North SBU decant plans
Forest house
adolescent unit
Victoria Court
Elizabeth Court
The Stewarts
Partial Damage –
Major Incident –
Full Evacuation
Evacuation – High Risk S/U
of ward and work
with NHS England
and C-CATT to
facilitate transfer/
supported discharge
home
of ward and work
across all OP wards
enable transfer
Forest House school
Use of section 136 suit
Use of adult beds
NHS England to find
alternative services
Full decant to
Fairlands, 6 Forest
Lane
High risk likely to relate to
physical frailty therefore work
with HCT/Acute partners to
create capacity in extremis
of ward and work
across all OP wards
enable transfer
of ward and work
across all OP wards
Holding day space
lounge space on
Elizabeth Court or
ADTU at Lister
Full decant to
Fairlands, 6 Forest
Lane
Holding day space
lounge space on
Victoria Court or
Lister ADTU
Full decant to
Fairlands, 6 Forest
Lane
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enable transfer
of ward and work
across all OP wards
enable transfer
Full decant to
Fairlands, 6 Forest
Lane.
The Meadows
Ward layout would
enable affected wing
to be closed off
Full decant to
Fairlands, 6 Forest
Lane
Logandene
Ward Layout would
to be closed off
Full decant to
Fairlands, 6 Forest
Lane
Prospect House
Holding day space in
CHESS day hospital
Holding day space
ADTU on site
Full decant to
Fairlands, 6 Forest
Lane and Dove
would be used if
Fairlands was also
out of use.
Edenbrook
West SBU decant plans
Thumbswood
Oak
Partial Damage –
Major Incident –
Full Evacuation
Evacuation – High Risk S/U
Ward Layout would
to be closed off if
damage was to
bedrooms only (2
bedrooms not in
use). Liaison with
NHSE to find
alternative resource
Ward Layout would
to be closed off if
damage was to
bedrooms only (5
bedrooms not in use)
Full decant to 6
Forest Lane.
Discussions would
take place to ask
families to take
babies home short
term where this was
possible.
High risk likely to relate to high
numbers of Safeguarding
children concerns. Partner
organisations to be involved
and informed of decant plans
and alternative plans for
babies
Service users would
be evacuated to 6
Forest Lane whilst
decisions were made
on suitable areas to
move based on the
current needs and
risk status of the
service user. Spare
beds in Dove would
be used to manage
those most suitable.
4 Bowlers Green
would be used to
manage those higher
risk service users.
Bed management
and commissioners
levels of aggression to others,
AWOL risks and self-harm.
MHA issues apply which can
include Hospital orders and
MOJ
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would need to
support the Trust in
accessing external
PICU beds.
Gainsford House
Sovereign
The Beacon
Hampden House
Albany Lodge
136 Suite
Ward Layout would
Consider discharge
to community
services
Very limited capacity
within unit. Consider
admisisonm to other
rehab / acute
vacancies short term
Ward Layout would
of communal area
and use of
communal space in
The Beacon ‘House’
for short term
solution. Consider
discharge to
community services
Ward Layout would
Consider discharge
to community
services
Ward Layout would
to be closed. Other
Acute wards to
consider capacity.
Expedite discharge
in conjunction with
carers/ CATT/ ADTU
As per major incident
Full decant to
Fairlands and
Lane
levels of AWOL, Self-harm,
increased access to drug &
alcohol substances and
detention under MHA
Full decant to
Fairlands and
Lane
levels of AWOL, Self-harm,
alcohol substances and
detention under MHA
levels of AWOL, Self-harm
alcohol substances, and
detention under MHA
Full decant to
Fairlands and
Lane
Full decant to
Fairlands and
Lane
levels of AWOL, Self-harm
alcohol substances, and
detention under MHA
Full decant to
Fairlands and
Lane
possible increased risk to
others, AWOL risks and selfharm. MHA issues apply
If the 136 on Oak
was out if use then
the 136 at KC would
be used.
If the 136 on KC was
out of use the 136 on
Oak would be used.
If more than 1 136
was required in such
circumstances a
place of safety would
be designated based
on risk on site.
others, AWOL risks and selfharm/ neglect. MHA issues
apply
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ADTU
Unit layout would
to be closed
Service users would
be sent home and
supported by
community teams.
possible increased risk of selfharm/ neglect
Aston ward
Ward Layout would
to be closed. Other
Acute wards to
consider capacity.
Expedite discharge
in conjunction with
carers/ CATT/ ADTU
Full decant to
Fairlands, 6 Forest
Lane and Dove
would be used if
Fairlands was also
out of use.
others, AWOL risks and selfharm/ neglect. MHA issues
apply
LD and F SBU decant plans
Partial Damage – Remain
within secure perimeter
Warren
Court


Broadland
Clinic


Evacuation
Ward Layout would
enable affected area to
be closed and use of
communal area for
short term solution
Move affected s/u to
designated house or
therapeutic activity
area within secure
perimeter

Ward Layout would
communal area for
short term solution
Move affected s/u to
other unit or
therapeutic activity
area (Wherries) within
secure perimeter







Astley Court

Ward Layout would

Ensure MOJ aware
of transfers
Police Presence as
required
Move Beech / 4BG
– liaise NHSE re
secure placements
elsewhere if unable
return within an
agreed EoE
Contingency Plan
Ensure MOJ aware
of transfers
Police Presence as
required
Willowbank if total
evacuation. There
is an agreed plan
with the Norfolk
Constabulary and
emergency services
within Contingency
Plan 515
Reciprocal
Agreement in place
with nearby Norvic
Clinic (NSFT)
Liaise NHSW re
secure placements
elsewhere if
required (within an
agreed EoE
Contingency Plan
Evacuation – High Risk
S/U
Memorandum with police
for high risk s/u
custody whilst alternative
secure accommodation
found
Memorandum with police
for high risk s/u
custody whilst alternative
secure accommodation
found
Not applicable
Willowbank within
Little Plumstead site
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communal area for
short term solution
Beech Unit
4 Bowlers
Green


Ward Layout would
communal area for
short term solution

Ward Layout would
communal area for
short term solution





Ensure MOJ aware
of transfers
Police Presence as
required
Move Warren Court
/ 4BG – liaise
NHSE re secure
placements
elsewhere if unable
return
n/a
Ensure MOJ aware
of transfers
Police Presence as
required
Move Warren Court
/ Beech – liaise
NHSE re secure
placements
elsewhere if unable
return
n/a
SRS

Ward Layout would
communal area for
short term solution

Use 6FL / Dove
dependent on
service user
population within
affected unit
N/a
Dove

Ward Layout would
communal area for
short term solution

Use 6FL – deploy
beds within SRS if
KF Court required
to be evacuated
N/a
Lexden

N/a Ward Layout
would enable affected
area to be closed and
use of communal area
for short term solution

If Rehab unit –
move to A&T unit
(additional capacity
in mothballed area)
If A&T unit – move
to Elizabeth House
on Lexden site
N/a

Plan subject to annual review
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Board of Directors Meeting
Meeting Date:
Subject:
Author:
Presented by:
28th January 2016
Safe Staffing Update
Jaya Hopkins, Head of Nursing
Learning Disability & Forensic and
Dr Jane Padmore, Deputy Director
of Nursing and Quality
Dr Oliver Shanley, Deputy Chief
Executive
Agenda Item: 10
Approved by:
Dr Oliver Shanley, Deputy Chief
Executive
This report provides the quarterly update on nursing staffing report for the Board in line
with the requirements set out by the National Quality Board (NQB). This report contains
summary details of direct care staff fill rates for Registered Nurses (RN) and Health Care
Assistants (HCA) for the months of October, November and December 2015, broken
down by day and night shifts in addition to setting some context on the published data.
The current actions by the Trust are included in this report, to ensure safe staffing level
and mix on the in-patient services.
The report provides information on recruitment and retention of nurses in view of the
national shortage of nurses as well as information on the recent increase in scrutiny on
the use of agency nursing staff. The purpose of this report is to provide the Board with the
information to enable them to determine that they are assured of the governance process
for rostering of nursing staff.
Action required:
The Board is asked to:
 Consider and note the contents of the report and discuss any point of clarification
 Confirm that the Board is assured of the governance process for rostering.
Summary and recommendations to the Committee:
Nurse staffing data for direct care nursing staff on duty for each shift during the month of
October, November and December 2015 were collected and coded according to planned
number of staff required on any given shift, in comparison to those who actually worked.
The data was analysed according to total hours worked per ward for RN and for HCA,
divided into day and night time hours. The data included additional duties such as for
observations and planned escorts.
In summary, the data collection and analysis for quarter 3 showed:
 The overall picture is one of adequate staffing and shift cover in response to
unexpected demand and levels of acuity and dependency on the wards. The Trust
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used in total, more actual hours than planned for both RNs and HCAs.
Despite the challenges with recruitment and retention of registered nurses in
Norfolk services, the service was adequately covered during quarter 3. In effect, in
November 2015 the actual staffing level in the services was for the first time 90% or
above.
In most of the services where there were gaps in staffing, this was covered by an
increase in the opposite staff band group or from co-located services.
Higher than usual fill rates were subject to scrutiny to ensure that there is a
legitimate need for this level of staffing.
Recruitment of staff is ongoing; where there are particular challenges, new
initiatives have being considered to attract nurses to the Trust.
There has been a recent increase in the scrutiny of Agency Nursing staff. All Trusts
are required to complete a weekly data collection template and submit it to Monitor.
The percentage cap for agency spend for the Trust has been set at 8%. The
average performance of the Trust since October 2015 has been 13%, 5% higher
than the target.






Relationship with the Business Plan & Assurance Framework
(Risks, Controls & Assurance):
Adequacy of a balanced skill mix for nursing workforce has an impact on clinical
outcomes, patient safety and experience.
1
2
3
4
5
6
Finance
n/a
IT
n/a
Staffing
there is a need for regular review of staffing establishment.
NHS Constitution n/a
Carbon Footprint n/a
Legal
n/a
Equality & Diversity (has an Equality Impact Assessment been
completed?) and Public & Patient Involvement Implications:
n/a
Evidence for Essential Standards of Quality and Safety; NHSLA
Standards; Information Governance Standards, Social Care PAF:
Potentially all of the above
Finance & Investment/Integrated
Governance/Executive/Remuneration/
Board/Audit
2
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Report to:
Date:
Report by:
Subject:
Nature of Report
Board Meeting
28th January 2016
Jaya Hopkins (Head of Nursing, Learning
Disability & Forensic SBU) and Dr Jane
Padmore, Deputy Director of Nursing and
Quality
Safer Nurse Staffing Update
Open
Introduction
This report provides the quarterly nursing staffing report for the Board in line
with the requirements set out by the National Quality Board (NQB) guidance
‘How to ensure the right people, with the rights skills, in the right place at the
right time’. The publication followed recommendations from the Francis
Report and other high profile national reviews such as those by Professor Sir
Bruce Keogh, The Cavendish Review and Don Berwick’s review into patient
safety in England.
The Trust continues to collate and submit staffing data according to planned
number of staff required on any given shift, in comparison to those who
actually worked. The data together with any board papers on nursing staffing
are published on the Trust website which is linked to NHS Choices website.
Trust expectations in relation inpatient nurse staffing levels
The Trust’s expectation is that the planned number of staff (Appendix 1) to
cover the ward demand and acuity level would closely match with the actual
number of staff who work as this should reflect the complexity of the needs of
the service users. Where the skill mix and the numbers of staff who actually
work is lower than planned, this may indicate a safety concern. There is an
agreed escalation process for reporting any safety concerns associated with
nurse staffing. The nurse in charge escalates the concerns through the
operational, nursing management line and explores all the options that are
available to cover the shifts.
In the event that a shift remained unfilled, this is reported to the Heads of
Nursing and recorded as a safety incident on Datix. These incidents are then
reviewed at the Safe Staffing meeting, chaired by the Deputy Director of
Nursing and Quality, in order to learn lessons and share good practice across
the Trust. Staffing cover is often mitigated by an increase of staff from a
different band, cross cover from co-located services and by the Team Leaders
and Matrons, who are supernumerary on the ward. Although all efforts are
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made to ensure the right skill mix, staff sometimes prefer to work with a
regular HCA to ensure continuity of care rather than seek a Registered Nurse
(RN) through the Bank office or Agency.
Outliers, i.e. wards with fill rates below 80% and in excess of 120% are
subject to scrutiny at the Safe Staffing meeting and SBU governance
meetings in order to understand the rationale for low or increased staffing.
This additional scrutiny ensures that there are no safety issues as a result of
low staff numbers and also no inefficiencies in the system and that extra
staffing reflects the clinical need of the service users.
Summary of findings for quarter 3 staffing data collection
The analysis from the safe staffing returns has been broken down by months
to provide detailed information about the services. In the absence of nationally
agreed RAG rating (red, amber and green) for safe staffing, detailed analysis
is provided on services with fill rate under 80% in red and those over 120% in
purple.
On the whole, there was adequate staffing across all services during quarter
3. Many services used extra hours to ensure the delivery of safe and quality
services. Team Leaders review their nurse staffing level daily, on a shift by
shift basis, in response to the changing clinical needs of services. There is a
clear process for escalation when staffing falls below the minimum safe level.
October 2015
Service Area
Sovereign House
Gainsford House
Hampden House
Elizabeth Court
Victoria Court
Warren Court
Owl
Wren
Robin
Swift
Oak
Beech
Dove
4 Bowlers Green
Forest House
Thumbswood
SRS
Lexden in –patient
Astley Court
Day RN fill
rate
101.7%
97.6%
101.6%
101.1%
100.0%
104.8%
118.5%
98.4%
115.3%
94.1%
89.7%
104.8%
145.9%
116.2%
111.4%
130.5%
99.6%
96.8%
87.0%
Day HCA
fill rate
100.0%
106.3%
104.8%
99.4%
113.2%
98.6%
153.6%
107.8%
203.3%
154.3%
134.9%
97.6%
158.0%
100.7%
76.9%
64.5%
98.5%
103.5%
97.8%
Night RN
Night HCA
100.0%
100.0%
100.0%
96.8%
100.0%
92.5%
98.3%
93.5%
100.0%
99.0%
101.6%
93.5%
151.7%
100.0%
98.3%
103.4%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
99.3%
149.9%
101.8%
140.2%
114.0%
232.2%
125.7%
103.2%
141.9%
188.6%
100.0%
85.5%
106.5%
99.4%
123.1%
97.8%
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Broadland Clinic
Logandene
Albany Lodge
Aston
Edenbrook/Lambourn
Grove
Seward Lodge
The Meadows
Prospect House
The Beacon
The Stewarts
75.5%
96.7%
102.1%
110.7%
107.3%
141.9%
160.4%
147.6%
86.0%
100.0%
101.6%
106.3%
117.2%
112.9%
137.6%
96.8%
99.2%
105.6%
100.0%
138.6%
98.4%
105.6%
97.6%
100.8%
100.0%
119.7%
135.4%
115.7%
96.7%
87.9%
101.6%
100.0%
100.0%
103.1%
93.5%
102.2%
159.7%
174.0%
93.5%
106.3%
Overall, the picture is of adequate staffing in all Trust services. In 13 services,
staffing has been over the establishment due to
 an increase in acuity,
 dependency
 observation levels.
Three services had a day fill rate in one group of staff below 80%; however all
these 3 services were partially compensated with a higher fill rate in the other
group of staff, resulting in an overall day fill rate over 90%.
November 2015
Services
Sovereign House
Gainsford House
Hampden House
Elizabeth Court
Victoria Court
Warren Court
Dove
Forest House
SRS
4 Bowlers Green
% RN
Day
101.5%
99.1%
100.9%
106.7%
95.0%
101.4%
121.7%
97.7%
102.9%
% HCA Day
% RN Night
% HCA Night
100.0%
101.5%
111.5%
116.7%
111.1%
104.0%
129.4%
113.4%
102.1%
100.0%
100.0%
100.0%
100.0%
100.0%
104.4%
149.9%
98.3%
103.4%
100.0%
100.0%
100.0%
173.3%
150.0%
100.3%
158.3%
105.5%
103.0%
90.0%
102.5%
103.2%
98.3%
Oak
Beech
Swift
Owl
Robin
Wren
Thumbswood
Edenbrook/
Lambourn Grove
92.2%
112.5%
150.9%
115.9%
121.7%
100.9%
82.5%
115.5%
94.2%
150.7%
173.4%
124.6%
110.7%
173.3%
96.6%
96.6%
143.3%
96.6%
101.6%
98.3%
163.3%
109.1%
103.4%
222.4%
155.0%
203.3%
122.4%
80.0%
102.5%
97.4%
100.0%
105.0%
Lexden in-patient
Astley Court
97.2%
112.5%
98.3%
97.3%
100.0%
100.0%
101.6%
100.0%
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Broadland Clinic
Logandene
Albany Lodge
Aston
The Meadows
Prospect House
Seward Lodge
The Beacon
The Stewarts
95.2%
100.0%
92.2%
110.5%
97.9%
105.9%
100.0%
101.7%
100.0%
100.4%
106.3%
155.8%
101.1%
170.9%
133.9%
103.4%
105.0%
103.3%
90.0%
91.7%
100.0%
96.6%
100.0%
100.0%
96.6%
100.0%
91.7%
117.8%
111.1%
139.9%
100.0%
188.3%
163.3%
138.3%
116.6%
109.9%
November 2015 was the first month where no services had a fill rate below
80%. Overall, the picture is one of adequate staffing in all Trust services
although more staff was used than their establishment. The reasons for this
included:
 Increased observation
 Supporting service users to access and stay in the general hospital
 Increased dependency
December 2015
Services
Sovereign House
Gainsford House
Hampden House
Elizabeth Court
Victoria Court
Warren Court
Owl
Swift
Robin
Wren
Dove
Forest House
Beech
4 Bowlers Green
SRS
Thumbswood
Oak
Lexden in-patient
Astley Court
Broadland Clinic
Logandene
Albany Lodge
RN
Day (%)
98.30%
100.00%
97.60%
103.10%
95.90%
105.10%
104.00%
91.90%
119.40%
102.40%
130.60%
87.10%
120.10%
110.10%
99.60%
166.10%
89.30%
85.50%
101.60%
91.8%
100.00%
104.80%
HCA Day (%)
103.1%
100.00%
116.00%
112.90%
108.60%
108.30%
147.10%
167.80%
204.60%
109.00%
126.90%
122.00%
103.00%
109.70%
99.50%
78.20%
193.00%
77.40%
96.80%
90.1%
145.10%
117.70%
RN Night
(%)
100.00%
98.30%
98.30%
100.00%
100.00%
111.90%
100.00%
95.70%
100.00%
100.00%
151.70%
96.80%
96.80%
100.00%
100.00%
135.60%
98.30%
96.60%
100.00%
95.7%
95.10%
100.00%
HCA Night
(%)
100.00%
103.40%
100.00%
133.30%
127.40%
98.90%
141.90%
174.00%
209.60%
133.40%
116.10%
88.10%
117.60%
106.30%
100.00%
135.60%
136.30%
92.70%
99.00%
116.1%
102.20%
121.50%
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Edenbrook/
Lambourn Grove
Aston
The Meadows
Prospect House
Seward Lodge
The Beacon
The Stewarts
99.20%
100.00%
104.00%
106.40%
97.60%
97.20%
102.40%
97.80%
77.00%
115.40%
141.90%
97.90%
87.90%
92.30%
98.30%
84.00%
98.30%
104.80%
96.80%
96.80%
96.80%
114.40%
97.30%
135.50%
167.70%
111.30%
96.90%
111.30%
Overall, there was adequate staffing in all Trust services. More staff than the
establishment was used, mainly due to an increase observations due to
service users’ acuity and dependency levels. There were 3 services with a fill
rate below 80%:
 Thumbswood – the HCA fill rate during the day which was
compensated with a higher RN fill rate
 Lexden – the HCA fill rate during the day. There was a fluctuating bed
occupancy rate during the month and therefore the service had
adequate staff to meet the clinical needs of the service users.
 Aston – the HCA day fill was low. This was as a result of the closure of
the 136 suite at the Lister and therefore a reduction in the requirement
for this staffing level.
Recruitment and Retention of nursing staff
The national shortage of nurses is having an impact on the Trust, however
proactive actions are being implemented to ensure high calibre staff are
recruited and retained. The recruitment and retention group oversees this
work and meets on a monthly basis. A range of recruitment and retention
strategies are being implemented. For example:
 Where the Trust biggest challenge is, (our medium secure service in
Norfolk) new Mental Health Practitioner (MHP) and band 4 Health Care
Assistant (HCA) posts have been developed and recruited to. 1 MHP
from an Occupational Therapy background is in post which is working
well. An additional MHP has been re-advertised. Two band 4 HCA
have been appointed. These posts will be reviewed to assess the
impact on service delivery.
 The Trust has a plan for the recruitment of overseas Mental Health
nurses. Working with a recruitment agency and a visit to the Philippines
has been organised for the end of February/early March 2016.
 The Trust has been actively recruiting newly qualified nurses. This has
resulted in a significant increase in the number of students from the
University of Hertfordshire that are recruited into posts in the Trust
once they register. The success rate is currently 79% for Learning
Disability nurses and 95% for Mental Health nurses.
Staff working in 24/7 services are encouraged to apply for flexible
working and to ensure a consistent process, all flexible working
requests are discussed and reviewed by the Heads of Nursing, Deputy
Service Line Lead and Human Resources Business Partner on a
monthly basis. If the request cannot be met locally in the staff
7
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member’s team, this group will explore options in alternative services
across the Strategic Business Unit.
Agency monitoring
There has been a recent increase in the scrutiny of the high level of agency
staff use-age within the NHS and the implications that this has for both patient
safety and Trusts’ finances
(i)
Agency price cap and off-framework agency
Monitor has set price caps on the maximum hourly rate that Trusts should
pay for agency staff. This price cap is set so that the hourly cost of agency
staff is reduced incrementally until 1st April 2016:
Price caps as a percentage above basic substantive hourly rates
Max.
charge Max.
charge Max.
charge
from 23 Nov from 1 Feb 2016 from 1 Apr 2016
2015
Junior doctors
150% above
100% above
55% above basic
basic
basic
Other medical
100% above
75% above basic 55% above basic
staff
basic
All other clinical
100% above
75% above basic 55% above basic
staff
basic
Non-clinical staff
55% above basic
All trusts are required to complete a weekly data collection template and
submit it to Monitor. A shift is reported if:
a) the total amount a trust pays pay per hour for an agency worker (all
types of staff) is higher than the capped rates; or
b) a trust uses an agency worker through a non-approved framework or
off-framework, unless this agency has been pre-approved by Monitor
and TDA; or
c) a trust uses an agency worker through an approved framework, but the
price paid is escalated above the maximum specified rate for that
agency through the framework.
The Trust has been submitting weekly returns to Monitor since the week
commencing 23rd November 2015. The number of shifts worked where the
hourly rate paid was higher than the price cap or where an agency shift was
commissioned off-framework are shown in the table below
Number of shifts
Week commencing
Staff group
Control
Medical & dental
Nursing, midwifery & health visiting
Nursing, midwifery & health visiting
Scientific, therapeutic & technical (AHPs)
Administration & estates
Other
Price cap
Framework only
Price cap only
Price cap
Price cap
Price cap
23-Nov-15 30-Nov-15 07-Dec-15 14-Dec-15 21-Dec-15 28-Dec-15 04-Jan-16
0
0
13.5
18
22.5
0
0
1
22
15
25
0
0
0
22
10
25
0
5
0
25
10
25
0
0
0
22
8
18
4
3
0
3
3
12
0
5
0
16
5
23
0
Extract from Monitor returns submitted
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In the return the Trust also has to confirm if there has been any impact on
quality and safety resulting from the imposition of the agency caps. The Trust
has confirmed that there has been no impact to date. It should be noted that
for most of the above weeks 10 of the agency nursing shifts that have
exceeded the price cap are for safeguarding roles which the Trust are
commissioning on behalf of (and being reimbursed by) Hertfordshire County
Council.
(ii)
Agency nursing spend cap
Since October 2015, Monitor has also imposed a cap on the level of agency
nursing spend (registered nursing only). The level is expressed as the
percentage of agency nursing spend compared to the total combined level of
nursing spend (substantive, bank and agency staff). The percentage cap for
the Trust has been set at 8%. The average performance of the Trust since
October 2015 has been 13%, 5% higher than the target.
Conclusion
This report sets out to brief the Board about the current position in relation to
the safe nursing staffing within in-patient services. In addition, the paper sets
out the work the Trust is currently undertaking in order to be compliant with
the requirements, including the reporting requirements, to ensure the Trust
has the right staff, in the right place, with the right skills, at the right time.
The Board are asked to note this report and discuss any point of clarification.
The Board is also asked to confirm that they are assured of the governance
process for rostering.
Jaya Hopkins (Head of Nursing, Learning Disability & Forensic SBU)
Dr Jane Padmore, Deputy Director of Nursing and Quality
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Appendix 1 Current Shift Levels
SBU
LD&F
West
E&N
Ward
SRS
Dove
Broadland
Astley Court
Warren
4 Bowlers Green
Lexden in-patient
Early
RN
4
2
5
1
6
2
3
12
3
8
4
7
2
6
late
RN
4
2
5
1
6
2
3
HCA
12
3
8
4
7
2
6
night
RN
2
1
3
1
3
1
2
HCA
HCA
10
2
6
3
9
2
4 + 1 twilight
Beech
Robin
Owl
Thumbswood
Weekends
Thumbswood
Week days
Oak weekends
Oak week days
Aston
Swift
Albany
Sovereign
Gainsford
Beacon
Hampden
Elizabeth
Victoria
Lambourn/Edenbrook
Logandene
Seward Lodge
Meadows
2
2
2
1
4
3
3
2
2
2
2
1
4
2
2
2
2
2
2
1
2
1.5
1.5
1
1
1.5
1
2
1
1
2
3
3
3
3
1
2
2
2
2
2
2
2
2
2
3
2
2
3
2
1
1
2
1
7
6
5
5
4
5
2
3
3
3
3
1
2
2
2
2
2
2
2
2
2
3
2
2
2
2
1
1
2
1
7
6
4
4
4
4
2
2
3
3
3
1
2
2
2
2
2
2
2
2
2
3
3
2
2
2
1
1
1
1
3
2
2
3
2
3
Prospect
Wren
Forest
Stewarts
2
2
3
2
3
3
5
4
2
2
3
2
3
2
5
3
2
2
2
2
2
1.5
3
2
10
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Trust Board
Meeting Date:
28th January 2015
Agenda Item: 11
Subject:
Annual Plan Report Q3 2015/16
Author:
Iain Eaves
Executive Director of Strategy and
Improvement
Approved by:
Iain Eaves
Executive Director of
Strategy and Improvement
Presented by:
Present the Trust’s performance against the Annual Plan for Q3
Action required:
Note and discuss Q3 performance and outlook for Q4
Summary and recommendations:
The Annual plan comprises of 12 objectives with associated milestones and outcomes.
These have been RAG rated against planned progress at the end of Q3: 2 objectives are
rated Green, 5 Amber / Green, 3 Amber, 1 Amber / Red, and 1 Red.
Despite significant progress on a number of areas four of the five red and amber rated
objectives at Q3 are the same as reported for Q2:
- We will live within our means and secure the financial sustainability of our services
- We will successfully embed the significant recent changes to our adult community
and CAMH services for the benefit of service users, carers and staff
- We will continue to improve the effectiveness and safety of our acute care pathway
and placements service
- We will recruit and retain staff, reducing our reliance on temporary staffing
A fifth objective has also been rated amber this quarter (downgraded from amber/green).
- We will complete ongoing transformation projects, including developing information
systems and tools that support staff to work productively, and deliver the highest
quality care
The attached paper summarises progress against each of the 12 objectives.
Relationship with the Strategy (objective no.), Business Plan (priority) & Assurance
Framework (Risks, Controls & Assurance):
Summarises Progress against Annual Plan
Summary of Financial, Staffing, and IT & Legal Implications:
Equality & Diversity and Public & Patient Involvement Implications:
Evidence for Registration; CNST/RPST; Information Governance Standards, other key
targets/standards:
-
AgendaItem11Q3AnnualPlan
Page
1
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1. Summary
The Annual plan comprises of 12 objectives with associated milestones and outcomes
across three areas. Each objective has been RAG rated against planned progress at the
end of Q3. The overall picture is shown in the table below (the Q2 position is shown in
brackets where different from Q3.
Amber /
Green
Amber
Amber /
Red
Red
Total
2 (2)
3 (2)
-
-
5
2 (1)
1 (2)
-
1
-
4
-
2
-
-
1
3
2 (2)
5 (6)
3 (2)
1
1
12
Green
Quality &
Service Dev.
Workforce
Sustainability
Total
-
(1)
Summary commentary for each of the objectives is set out below. Further detail on each
objective is set out in the Appendix
Objective
Q3 RAG Q2 RAG Summary Comments
Quality and Service Development
We will successfully embed the
significant recent changes to
our adult community and
1
CAMH services for the benefit
of service users, carers and
staff
We will continue to improve the
effectiveness and safety of our
2
acute care pathway and
placements service
We will complete ongoing
transformation projects,
including developing
3 information systems and tools
that support staff to work
productively, and deliver the
highest quality care
Amber
Amber
Amber
Amber
Continued pressures on adult community and
CAMHS teams whilst work to recruit to
vacancies continues. CAMHS vacancies in
particular have fallen significantly since the
beginning of the year.
Amber
Acute external placements came down to
zero at the end of Q3 due to a huge amount
of hard work. The wards remain very busy
and the rate of inpatients reporting feeling
safe remains below the target. The
placement panel and review processes are
now much more robust and the health
placements work is progressing well.
However, the work on social care placements
is proving challenging.
Amber/
Green
Page
2
The key service transformation and estates
programmes are on track, with the exception
of the new Hemel hub. Development of the
business intelligence system has progressed
slower than originally planned due to the
need to stabilise the informatics team and
review the overall BI framework to ensure it is
fit for purpose. Additional capacity to support
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this was agreed during Q3 and key
dashboards are planned for roll out during the
next two quarters.
We will play a leading role
working with our partners
across Hertfordshire and
4
Essex in developing and rolling
out new, integrated models of
care
We will successfully mobilise
5 and deliver IAPT services in
West Essex
Amber/
Green
HPFT continues to play a leading role within
the integrated care programmes in E&N
Herts and Herts Valleys. Both programmes
Amber/ have now reached critical stages in shaping
Green the future model of care across the county
with the requirement to submit concrete
System Transformation Plans at the end of
June.
Amber/
Green
The transition to business as usual has been
well managed and feedback from staff has
been positive and engagement levels high.
Access and recovery rates have come under
pressure in Q3, but are expected to be back
on track by end Q4.
Green
Workforce
We will recruit and retain staff,
6 reducing our reliance on
temporary staffing
7
We will improve staff
engagement and motivation
Leaders and line managers will
be better equipped with core
8
management and leadership
skills
9
We will embed a culture that
promotes our values
Amber /
Red
Turnover fell slightly in the quarter. The
overall vacancy rate remains high but has
Amber / fallen on a like for like basis compared to the
Red
start of the year. Agency use has continued
to fall but remains high. A further reduction in
the use of agency is expected in Q4.
Amber /
Green
The key indicators including the staff FFT
have improved following a dip in Q2,
however, the number of respondents was
Amber /
very low this quarter. Qualitative feedback
Green
suggests that there are some hotspots of
poor performance that remain to be
addressed.
Green
Green
Green
Q1 had the best score over the last two years
in staff reporting feeling supported by their
line manager. This has been sustained into
Q2 and Q3. The Managing Services
Excellence programme has been well
received and is expected to support this
going forward.
Over 90% of staff have now had values
focused workshops and 82% of staff reported
Amber /
that they know how the Trust values apply to
Green
their role in line with rate in above the end of
year target of 80%.
Sustainability
We will live within our means
10 and secure the financial
sustainability of our services
Red
Red
Page
3
The overall financial position has improved at
the end of Q3 however agency and
secondary commissioning continue to put
pressure on the overall position
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We will remain the
Amber /
11 commissioners’ provider of
Green
choice for our existing services
Commissioner relationships and dialogue
Amber / remain strong, however, a number of
Green contractual performance targets remain
under pressure.
We will continue to develop our
relationships with primary care,
Amber /
12 partner providers and
Green
commissioners across
Hertfordshire and Essex
Relationships with commissioners remain
strong and we are now beginning to develop
Amber / stronger links with local primary and urgent
Green care providers. Further work is required to
build on this at both strategic and operational
levels.
Page
4
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Appendix
Priority
Key Actions / Milestones
Key Outcomes
We will successfully
embed the significant
recent changes to our
adult community and
CAMH services for the
benefit of service users,
carers and staff
Issue
 Adult Community: Implement actions from demand and
capacity work and embed discharge planning to ensure
effective throughput
 CAMHS: Funding for C-CATT secured following
successful trial
 Both: Delivery of targeted plans to improve recruitment
and retention

Commentary:
Commentary:
Adult Community: The Demand and Capacity project
continues with oversight by the Managing Director. Capacity
to provide care coordination remains a key challenge.
Service user reviews as part of the work on embedding
discharge planning was ongoing through Q3.
Adult Community: The average number of service users
waiting for allocation of a care co-ordinator remains a
challenge and continues to be affected by the reliance on
agency staff to cover vacancies.
Following a period of major
transformational change and new
ways of working, there is still
more work to do in order to
establish consistent high quality
care and stabilise the workforce.
Staff morale, care coordinator
capacity and the high use of
temporary staff to cover
vacancies require a particular
continued focus.
CAMHS: Funding for C-CATT service has been agreed to
extend hours of functioning to 9am – 9pm, 7 days per week.
This new service has proved invaluable this year in managing
the levels of high acuity, psychiatric and emotional distress
experienced in both our A&E departments as well as
supporting young people remain in their communities as an
alternative to hospital admission.
Summary


CAMHS: Sustained improvement in access waiting times
performance to see routine referrals within 28-days (89% in
Q3 vs 85% in Q2). Further resourcing is needed to achieve
the Commissioner target of 95%, with recruitment ongoing to
achieve it in Q1 2016/17.
Both: Overall vacancy levels have fallen significantly in
CAMHS since the beginning of the year and have fallen
slightly in adult community services, but remain high. Staff
experience remains below target levels.
Q2 Rating
Amber rating reflects ongoing pressures on adult community and CAMHS teams whilst work to
recruit to vacancies continues.

Adult Community: Fewer service users waiting for
allocation of a care co-ordination
CAMHS: Improved access times in line with contractual
targets
Both: Lower vacancy rate
Both: Improved staff experience
Page
5

Q3 Rating

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Priority
We will continue to
improve the effectiveness
and safety of our acute
care pathway and
placements service
Issue
The Acute Care Pathway has
been under strain throughout
2014-15 with delays in discharge
and a high level of external
placements. This is placing
additional demand on our
community teams and the care
coordinators on whom the acute
pathway depends
There remains a high demand for
both health and social care
placements. A recent review
identified opportunities within the
placement pathway to improve
both service user outcomes and
value for money.
Key Outcomes






Acute Pathway: Test and evaluate solutions to priority
improvement actions across the pathway
Placements: Service user reviews completed and shift to
more appropriate placements on track.
Commentary:
Commentary:
Acute Pathway: The impact of investment to improve 24/7
services and the centralisation of services at Kingfisher Court
have supported increased patient flow, improved assessment
and efficiency. The key area of focus from the pathway
review has been embedding of the AAU model on Swift ward
and seeking ways of improving efficiency and effectiveness.
Placements: Programme commenced six weeks behind
original schedule in Q1. This has been recovered for health
placements and individual plans are in place. The focus on
health placements resulted in a further delay to the review of
social care placements which were completed during Q3.
The social care reviews have identified fewer individuals than
expected who are ready to step down and this work will now
continue into 2016/17.
Summary
 Use of acute non-HPFT beds has decreased significantly
month on month from a peak at the end of Q1 and
reached zero by the end of Q3.
 The rate of inpatients reporting feeling safe has
remained unchanged at 68% in Q3, well below the target
of 80% for the year end. Work is underway supported by
Peer Listeners including safewards interventions that
continue to be implemented as part of the MoSS
strategy. A series of focus groups are being held across
the 6 acute inpatient areas as well as separate ones for
the Modern Matrons and the Team Leaders
 Pre-placement procedures were fully completed for all
external placements in the quarter
 The placement review process has led to a number of
individuals in health and social care placements who
moving on to alternative (step down) placements where
this was identified as clinically beneficial
Q3 Rating
Acute external placements came down to zero at the end of Q3 due to a huge amount of hard
work. The wards remain very busy and the rate of inpatients reporting feeling safe has fallen. The
placement panel and review processes are now much more robust and the health placements
work is progressing well. However, the work on social care placements is proving challenging.
More inpatients feel safe (year average ≥80%)
Reduction in external acute placements
Full compliance with pre-placement procedures
Reduced length of stay for health and social care
placements
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Priority
Key Outcomes
We will complete ongoing
transformation projects,
including developing
information systems and
tools that support staff to
work productively, and
deliver the highest quality
care
 Estate: Commence Lambourne Grove construction
 EPR and Business Intelligence: Roll out team-level dashboards within
CAMHS and Adult Community Mental Health services.

Issue
Commentary:
Commentary:
Key projects to modernise our
estate, improve services for older
people and remodel rehabilitation
services continue to be priorities
for 2015/16.
We have rolled out a new
Electronic Patient Record (EPR)
and Business Intelligence (BI)
system over the last 24 months
and need to begin to more fully
realise the potential benefits.

Estate: Construction work has commenced at Lambourn Grove and detailed
design has commenced for Logandene. The new Hemel hub design has
delayed as a result of joint work with HCT. Cheshunt and Hitchin hub
refurbishments remain on track.
EPR and Business Intelligence (BI): Team dashboards have been developed
in partnership with the service for Adult Community Mental Health services and
will be rolled out in February. Work on the CAMHS dashboards has been
delayed with an expected roll out in Q1 2016/17.
The service at Seward Lodge has received
very positive feedback from service users,
carers, and staff regarding the benefits of
the new environment since opening in Q1.
The team dashboards have been well
received but there remains a long way to
go to fully realise the potential of the OMNI
Business Intelligence System.
The delays relate to the need to stabilise the informatics team and review the
overall BI framework to ensure it is fit for purpose. To support this and
accelerate further development of the Business Intelligence system the
informatics function has now been aligned to performance.
Summary
Q2 Rating
The key service transformation and estates programmes are on track, with the exception of the new Hemel hub.
Development of the business intelligence system has progressed slower than originally planned due to the need to
stabilise the informatics team and review the overall BI framework to ensure it is fit for purpose. Additional capacity
to support this was agreed during Q3 and key dashboards are planned for roll out during the next two quarters.

Improved quality of care and service
user experience
Better environments for service users
and staff
More relevant and timely information
available at all levels
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Priority
Key Outcomes
We will play a leading role  Work in partnership with HCT and HCC to roll out Home
working with our partners
First (including mental health component) to remaining
across Hertfordshire and
localities for E&N CCG
 Sign off Your Care, Your Future (YCYF) Strategic Outline
Essex in developing and
Case and play leading role in the development of the
rolling out new, integrated
programmes implementation
models of care
 Improved quality of care and service user experience as
a result of more joined up care
Issue
Commentary:
Commentary:
Home 1st has now been operating as a fully functioning
integrated service in North Herts and Lower Lee Valley with
positive feedback. The first of the additional Rapid Response
teams for the remaining 4 localities in the E&N Herts CCG
area commenced in December 2015 in Stort Valley and
Upper Lee Valley.
Specific performance and outcome measures for integrated
care have yet to be agreed. A generic set of indicators is
currently being developed building on work commissioned
from the Policy Innovation Research Unit (PIRU) by the
DOH
The recent publication of the NHS
Five Year Forward View and the
response of our CCG
commissioners has added further
momentum towards more joined
up care across mental health,
physical health and social care.
We are committed to playing a
leading role in this area.
The whole system vision for out of hospital care continues to
be developed through the Herts Valley Your Care, Your
Future (YCYF) process. HPFT continues to be actively
involved in influencing and shaping thinking with in YCYF and
its implementation.
Summary
Q2 Rating
HPFT continues to play a leading role within the integrated care programmes in E&N Herts and
Herts Valleys. Both programmes have now reached critical stages in shaping the future model of
care across the county with the requirement to submit concrete System Transformation Plans at
the end of June.
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Priority
Key Outcomes
We will successfully
mobilise and deliver IAPT
services in West Essex




Issue
Commentary:
During 2014/15 we were
appointed as preferred bidder for
IAPT services in West Essex.
The transition to business as usual has been well managed and feedback from staff has been positive and engagement
levels high. Nonetheless the access target has fallen marginally behind target for Q3. This is expected to be recovered
during Q4.
We expect to take on these
services by the beginning of Q2
2015/16.
Recovery rates have also fallen to 44%, below the 50% target. A corrective action plan is in place with target levels expected
to be reached by the end of Q4.
Successful transition from delivery of 100 day plan to
business as usual
Commentary:
Summary
Q2 Rating
The transition to business as usual has been well managed and feedback from staff has been
positive and engagement levels high. Access and recovery rates have come under pressure in
Q3.
Safe and effective transfer of services
Staff morale maintained or improved
Delivery of contractual KPIs
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2.
Workforce
Priority
Key Actions Planned / Milestones
Retention
 Promotion of flexible retirement
We will recruit and retain
staff, reducing our
reliance on temporary
staffing
Issue
Even though our recruitment
activity was 67% higher in
2014/15 than over the previous
12 months, the number of staff
leaving has been greater than the
number of staff recruited.
As a result, spend on temporary
staffing has risen placing
pressure on services as well as
the Trust’s financial position.
Recruitment
 Deliver reduced time to hire as a result of implementation of the TRAC
recruitment system
 Targeted recruitment drives
Key Planned Outcomes
 Turnover Rate reduced from
15.7% at end of 2014/15
 Vacancy Rate reduced from
13.6% at the end of 2014/15
 Agency Usage reduced
Commentary:
Commentary:
Retention
Promotion of flexible working and retirement has continued and letters have been
sent to all staff who could currently retire or who could retire within the next five years
to ascertain when they may be planning to retire and if they would be interested in
returing to the Trust on a flexible basis.
Overall agency costs fell to 7.4% of
total pay in December but remain
above the Monitor target rate for
nursing.
Recruitment
There continues to be a significant level of recruitment activity undertaken within Q3,
which is demonstrated by 96 new starters in the quarter and there are currently 126
offers of employment made to candidates. Targeted recruitment drives for CAMHS,
Older People, the CATT Team and Norfolk have also taken place, and our drive to
retain student nurses has resulted in 18 out of the 21 nurses accepting positions with
the Trust.
On a like for like basis the vacancy
rate has fallen to 11.0% in Q3 from
13.6% at the beginning of the year.
The overall vacancy rate remains
high at 14.3% due to the creation of
a significant number of new posts
over the period that remain to be
filled.
Turnover Rate fell back to 14.9% in
Q3 from 15.3% in Q2
The time taken to hire staff currently remains at 13 weeks which is 0.5 weeks higher
than the time reported in Q2, but significantly lower than the 16-18 weeks previously.
Summary
Q2 Rating
Turnover fell slightly in the quarter. The overall vacancy rate remains high but has fallen on a like for like basis compared
to the start of the year. Agency use has continued to fall but remains high. A further reduction in the use of agency is
expected in Q4.
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Priority
We will improve staff
engagement and
motivation
Issue
Our workforce is undergoing
significant change placing
pressure on staff engagement
and motivation.
This was borne out in the 2014
national staff survey results, with
an increased number of scores in
the bottom 20% of comparator
trusts, including staff feeling able
to contribute towards
improvements at work
Key Outcomes
 Ongoing delivery of OD programme
 Increased rate of staff recommending HPFT as a place to work (Staff Friends
and Family Test (FFT)) to work 55% by EOY
 Increased rate of staff reporting feeling engaged and motivated
Commentary:
Commentary:
Work as part of the extensive ongoing
OD programme continued during Q3.
There were only 165 respondents to the Q3 Pulse Survey compared to over 300
in Q2. Q3 return rates are commonly the lowest during the year as it co-incides
with the Christmas period and also the national staff survey. Within this context
there was an improvement in the ratings across the key indicators:
There were the highest number of
nominations received so far for the staff
awards in December 2015

The senior leaders forum in Q3 focused
on the introduction of the Trust Strategy
‘Good to Great’.

The Staff FFT saw a 7ppt improvement in the rate of staff recommending
HPFT as place to work since last quarter, from 49% to 56%, above the
target rate of 55%.
Staff also reported feeling more engaged and motivated. This is
measured through the responses to three questions including the Staff
FFT. For the remaining two:
o The rate of staff feeling listened to and that their opinions count
remained stable at 490% (50% in Q2)
o The rate of staff saying they enjoy coming to work increased by
10ppts to 65% from 55%
Qualitative feedback suggests that there are some hotspots of poor staff
experience. The HR Business Partners are continuing to work with their Core
Management Teams to identify areas for intensive HR and OD support.
Summary
Q2 Rating

The key indicators including the staff FFT have improved following a dip in
Q2, however, the number of respondents was very low this quarter.
Qualitative feedback suggests that there are some hotspots of poor
performance that remain to be addressed.
Q3 Rating
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Priority
Leaders and line
managers will be better
equipped with core
management and
leadership skills


Key Outcomes
Managing Service Excellence Programme being
delivered
Collective Leadership work with King’s Fund
progressing
Issue
Commentary:
The 2014 staff survey results
place the trust in the bottom 20%
of mental health trusts for staff
feeling supported by their
immediate managers and
effective team working
A key OD objective this year is to drive a culture of
collective ownership and we continued with our work
with the King’s Fund this quarter. We have a group of
‘lead ambassadors (who are staff representatives from
across the organisation), working under the guidance
of the Kings Fund and using their evidence based tools
to undertake a cultural assessment. The findings of the
cultural assessment are due to be completed by the
July Board. The findings will then inform the leadership
strategy for next year. The desk based research has
commenced in Q3
 More staff report feeling supported by their line manager
 Improved staff engagement, motivation and retention
Commentary:
74% of staff reported feeling supported by their line manager
maintaining the improvement seen of in the previous quarter two
quarters compared to 2014/15.
Qualitative feedback continues to show some comments
expressing dissatisfaction with their manager. The Managing
Service Excellence has been developed to help address these
shortcomings.
As noted above staff also reported feeling more engaged and
motivated than both last quarter and this time last year
The managing service excellence programme has
been well received. It is anticipated that all new
managers will attend this programme as well as those
identified through personal development planning.
Summary
Q2 Rating
Q1 had the best score over the last two years in staff reporting feeling supported by their
line manager. This has been sustained into Q2 and Q3. The Managing Services Excellence
programme has been well received and is expected to support this going forward.
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Priority
We will embed a culture
that promotes our values
Issue
In October 2013 we launched our
values – welcoming, kind,
positive, respectful and
professional – along with a set of
customer care standards.
Since then we have been on a
journey to embed them across
the Trust and create an
organisation we are all proud to
be part of.
Key Outcomes


 Rate of staff reporting a clear understanding of the Trust’s
values and behaviours
 Improved staff engagement, motivation and retention
Continued delivery Living Our Values Sessions
Deliver the next phase of the living our values
programme aligned to the work on Collective
Leadership with the King’s Fund
Commentary:
Commentary:
The team continue to roll out the Living Our Values
Training sessions and have a standing slot at the Trust
induction. Over 90% of staff have had values focused
workshops
82% of staff reported that they know how the Trust values apply
to their role, above the end of year target rate of 80%
As part of embedding the culture, the organisation has
introduced values based recruitment and the OD team are
involved in delivering specific training on how to use the
scenarios and use behavioural questions
The next phase of the living our values programme is
being developed which is aligned to the work on Collective
Leadership with the King’s Fund. As noted above this
includes a cultural assessment which will inform the
leadership strategy for next year. The desk based
research for this has commenced in Q3
Summary
Q2 Rating
Over 90% of staff have now had values focused workshops and 82% of staff reported that they
know how the Trust values apply to their role in line with rate in above the EOY target of 80%.
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3.
Sustainability
Priority
We will live within our
means and secure the
financial sustainability of
our services

Key Outcomes
Deliver the CRES programme in line with the plan
Issue
Commentary:
2014/15 has been a challenging
year in financial terms with a
forecast underlying break even
position at year end, £2m below
plan.
As a result of robust control measures and additional
measure taken to manage costs the Trust’s financial position
has continued to improve during Q3. However the overall
position is still £637k behind plan with agency and secondary
commissioning costs continuing to put pressure on budgets.
Commentary:
Despite the expected investment
into mental health services
2015/16 will be equally
challenging with further a 3.5%
efficiency requirement.
The Monitor Risk Rating, the FSRR, increased from a 3 to a 4
in month 9 due to a continued improvement in the I&E margin
ratio.
The overall plan is to save circa £8.0m in 2015/16.
Progress to date continues to indicate both a shortfall within
year and an underlying recurrent shortfall
The large majority (96%) of eligible service users have been
clustered and there has been a significant reduction in those
that are overdue a PbR cluster review (a 13ppt improvement
on Q2 down to 17%). Addressing the remaining gap will
continue to be a key focus during Q4.
Summary
Q2 Rating
The overall financial position has improved at the end of Q3 however agency and secondary
commissioning continue to put pressure on the overall position
 Financial Sustainability Risk Rating of 4 maintained
 Recurrent delivery of CRES target
 Improvement in clustering data
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Priority
We will remain the
commissioners’ provider of
choice for our existing
services
Issue
National and local commissioners are
expected to re-procure or revise the
nature of service provision across a
range of services for 2016/17.
This includes national tenders for
forensic services, Tier 4 CAMHS, as
well as the local re-procurement of LD
services across North Essex.

Key Outcomes
Move towards agreement on the key terms of core
CCG contracts for 2016/17 and beyond
Commentary:
Ongoing positive conversations with Hertfordshire CCGs around a new contract demonstrate their continued
commitment to partnership working with HPFT.
Planned procurements by NHSE for forensic and CAMHS Tier 4 services have been delayed.
Performance against contractual performance targets is detailed in the Q3 Performance Report (also on the Board
agenda) with continued pressure on IAPT targets in particular. These are subject to ongoing dialogue with
commissioners and plans are in place to bring these indicators back in line with targets.
Summary
Q2 Rating
Commissioner relationships and dialogue remain strong, however, a number of contractual
performance targets remain under pressure.
 Deliver on contractual performance targets
 Successful negotiation of core CCG contracts for
2016/17 and beyond
 Retention of NHS England contracts for forensic and
CAMHS Tier 4 services
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Priority
We will continue to develop our
relationships with primary care,
partner providers and
commissioners across
Hertfordshire and Essex
Issue
The emergence of new more joined up
models of care means that we need to
develop different relationships across the
health and social care system.
Strong relationships with individual GP
clusters will become increasingly important
as locality based models of care begin to
emerge.
Key Outcomes



Develop approach to emerging GP Federations
Develop at least one partnership to support the
delivery of more joined up care
Commentary:
Stakeholder map updated to reflect the ongoing development of the GP federations across Hertfordshire.
Conversations have been initiated with some of the more established groups and we will continue to build on this
during Q4.
Hertfordshire CCG commissioner relationships remain strong and are supporting positive contract conversations,
as well as our leading role in supporting the integrated care agenda. Strong relationships established with West
Essex commissioners following new IAPT contract.
Relationship with Herts Urgent Care continues to develop around jointly identified opportunities for partnership
working.
Summary
Q2 Rating
Relationships with commissioners remain strong and we are now beginning to develop stronger
links with local primary and urgent care providers. Further work is required to build on this at both
strategic and operational levels.

Profile and reputation with commissioners, GPs and our
key partners will continue to improve
Successful negotiation of core CCG contracts for
2016/17 and beyond
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
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Trust Board
Meeting Date:
27th January 2016
Agenda Item: 12
Subject:
Performance Report Q3 2015/16
Author:
Performance Team
Presented by:
Paul Lumsdon
Director Service Delivery &
Customer Experience
Approved by:
Ian Eaves
Director of Strategy and
Improvement
1. To inform the Trust Board on the Trust’s performance against both the Monitor
Targets and Trust KPIs for Q3 2015/16 and to present the performance within the
wider context of the Trust’s current environment.
2. To assess the likely future performance projections based upon a review of
current trends, management actions and any variations in future targets
3. To provide an overview of the Trust’s performance on the wider quality agenda as
at Q3 2015/16
Action required:
1. Review and assess the Trust’s Performance against the Monitor targets, the
published KPIs, the reported Service Line Activity and the other selected quality
measures provided.
2. To consider whether any further information is required to adequately assess the
performance reported and make any required enquiries
3. Approve the submission of the performance declaration based on the Quarter 3
Monitor indicators.
4. Approve the submission of the Access to Healthcare Declaration for people with
a learning disability.
Summary and recommendations:
Monitor
As projected in previous reports all Monitor Targets have been met for Q3 and this will be
reported in the quarterly monitoring return and declaration submitted to Monitor. Access to
Healthcare for People with Learning Disabilities remains fully compliant with five out of the
six indicators and partially compliant for the sixth indicator with plans in place to achieve full
compliance by the end of Q4.
Trust Performance Framework
The Performance Framework focuses on the three broad areas: Access, Safety &
Effectiveness, and Resources. There has been a positive shift in performance between Q2
and Q3. In Q3 49% of indicators were rated as fully compliant (green) against 39% in Q2.
Red indicators had decreased to 35% of the total (45% in Q3).
Access to services
There are 20 targets reportable in the period of which ten have been met or exceeded
(reported green) and seven are reported as red. The key area of pressure remains access
Agendaitem12BoardQ3Perfor
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into IAPT services with the remainder of targets being missed due to waiting time breaches
within services with relatively low service populations. Other areas below target; CAMHS 28
day waits and EMDASS 6 week waits are due to recognised problems with capacity that
have agreed action plans for improvement.
Safety and effectiveness of services
There are 14 targets reported in the period of which seven are reported as green (6 last
quarter) and five are reported as red (8 last quarter). The red indicators are across several
areas of measurement predominately within IAPT where recovery rates on each of the
Essex services are below the 50% target and on clustering levels. The completion of risk
assessments also remains below target.
Resources
This measures a series of workforce and financial metrics. The workforce indicators show an
improvement over the previous quarter with a significant improvement on several measures
within the period. In particular very strong increases have been recorded in the
understanding of values and behaviours, workforce engagement and the staff Friends and
Family Test score.
The financial performance should a continued improvement in the quarter with a surplus
above Plan. This is part due to cost reductions particularly through better control of agency
spend. In addition there remains vacancies within several of the new Hertfordshire service
developments funded mid-year. The YTD surplus is £113K compared to a Plan of £750K
variance is now (£637K) compared to (£923K) at Q1. In September a surplus was reported
for the first time this year.
Relationship with the Strategy (objective no.), Business Plan (priority) & Assurance
Framework (Risks, Controls & Assurance):
Annual Plan
SBU Business Plans
Assurance Framework
Summary of Financial, Staffing, and IT & Legal Implications (please show £/No’s
associated):
N/A
Equality & Diversity and Public & Patient Involvement Implications:
N/A
Evidence for Registration; CNST/RPST; Information Governance Standards, other key
targets/standards:
All targets
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Contents
Dashboard Summary
Page 4
Performance against Monitor Indicators
Page 5
Access to Healthcare Declaration
Page 5
Performance on Quality
Page 5
Quality Account
Page 6
CQUIN
Page 6
Performance against Trust KPIs
Page 7 - 12
Activity
Page 13
Appendix 1 – Performance against Monitor Targets
Page 14 - 16
Appendix 2 – Declaration of Access to Healthcare for People with a Learning Disability
Page 17 - 19
Appendix 3 – Quality Performance
Page 20 - 23
Appendix 4 – KPI Dashboards
Page 24 - 33
Appendix 5 – KPI Dashboards
Page 34
Appendix 6 – CQUIN Goals
Page 35 - 37
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1. Quarter Three 2015/16 Dashboard summary
Access (20 measures)
Monitor (9 measures)
0%
35%
Red
Amber
Green
No Target
Red
Amber
Green
50%
15%
100%
Safe & Effective (14 measures)
36%
50%
14%
Red
Amber
Green
No Target
Resources - Workforce (9
measures)
22%
33%
22%
22%
Resources - Finance (2
measures)
Red
Red
Amber
Green
No
Target
50%
50%
Amber
Green
0%
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Target
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2 Performances against Monitor Targets
All Monitor Targets have been achieved in Quarter 3 and the Board is asked to approve this is as the basis for the quarterly return to the regulator. It is forecast
that the targets will continue to be met in Q4. See Appendix 1 for detail.
3 Accesses to Healthcare for People with a Learning Disability Board Declaration Q3 2015/16
The Board is required to review the evidence and agree the rating for submission to Monitor. The Trust is fully compliant for 5 out of the 6 indicators and
partially compliant for the sixth. This partial compliance relates to ‘Does the trust have protocols in place to regularly audit its practices for patients with learning
disabilities and to demonstrate the findings in routine public reports?’ There is a programme of audit involving service users with learning disabilities in
assessing services across the Trust. Results are shared widely within the Trust and with Commissioners and Service User Groups. The Trust is progressing
how this information is then shared on the Public Web-site to allow wider access to this information and it is expected that full compliance will be achieved by
the end of Q4. The key evidence is set out in Appendix 2.
4. Quality Visits and Wider Measures of Quality and Safety
In addition to our performance against the KPIs for ‘Access’ and ‘Safe and Effective Services’ summarised in this report we also:
 Undertake a programme of quality visits; and
 Employ a wider range of qualitative and quantitative measures to assess the safety and quality of services in relation to serious incidents, safeguarding,
health and safety, infection prevention and control, and compliments and complaints.
The key highlights for Q3 in relation to these areas are summarised below:
 Quality visits – In this quarter all SBUs have returned to their pre-CQC approach of operating a programme of quality visits throughout the year, with
action plans for each and findings shared at their quality and risk management groups by Practice Governance leads.
 Serious Incidents – The Board is presented with a separate Patient Safety Report detailing the Q3 activity.
 Safeguarding- The Safeguarding Team have finalised in partnership with HCC the Making Safeguarding Personal (MSP) leaflet which will be distributed
in February 2016. A recent internal audit on cases where the decision was not to proceed to an Enquiry established that in 75% of the cases this
decision was appropriate and clearly recorded within the case notes. The Trust has now commenced the delivery of the PREVENT training to its staff
and via its 4 qualified trainers. The new procedure on reporting historic abuse beginning to work well.
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 Health and Safety- The Trust has reported a total of 13 RIDDOR incidents in this quarter compared to 18 in the previous quarter. There has been a
slight increase in the amount of recorded ligature incidents this quarter; 35 compared to 34 in the previous quarter. None of these incidents resulted in
any serious harm or a fatality,
 Service Experience: Due to the timing of the meeting the Q3 complaints data is not available. A full Q3 Complaints and Patient Experience report will be
presented to the next Board meeting. Data on Friends and Family test is available. Response rates remain consistent overall with significant
improvements in CAMHS response rates. The overall score remains high with SPA rating at 100% of service users who would recommend the service.
Further detail is set out in Appendix 3
5. Quality Account
The Quality Account priorities this year have been set to ensure that they cover a wide range of services delivered by the Trust, with a strong emphasis on
access. There are 11 indicators of which 3 have 2 elements giving a total of 14 scores. The position at the end of Q3 is one which has improved from Q2 with 4
indicators still to be reported
A detailed report on progress against the Quality Account measures for Q3 has been reviewed at IGC and all but one of the indicators (which relates to lengths
of stay on older peoples inpatient units) align with the indicators and CQUIN targets covered in this report. The full set of Quality Account indicators and
performance against them is set out in Appendix 5.
6.
Herts CCGs CQUIN Goals 2015/16
For Q2 the Trust secured 86.5% of the avialble CQUIN funding a significant improvement on Q1 (53%). With the improved performance in Q2, this
means the Trust has achieved a total of 85.8% overall so far and are on track to achieve at least 96% by year end (payments are weighted towards
quarters 3 and 4). A summary of progress against each of the CQUN goals is shown in Appendix 6.
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7. Performances against Trust KPIs
The Trust monitors and reports on performance at an individual KPI level. This is summarised below against three broad areas.
 Access Indicators
 Safe and Effective Care Indicators
 Resource Indicators
The Resource indicator section has been split out with a separate area focussed upon specific areas of workforce. The Trust-wide dashboards can be found in
Appendix 4.
A) Access Indicators
There are 20 rated indicators reportable in the quarter (compared to 19 indicators at Q2.) Ten indicators are green and therefore the percentage of access
indicators fully met has fallen slightly to 50% in Q3 compared to 53% in Q2. Red indicators have decreased by 2% from 37% to 35%, whilst amber indicators
have risen slightly from 10% to 15%.
Table 1
Access Indicators 2015/16
10
5
0
Q1
Q2
Q3
Red
5
7
7
Amber
3
2
3
Page
7
Green
7
10
10
Page7of39
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The 7 red rated indicators relate to EIP 14 day waits, CAMHS 28 day waits, urgent community waits and the remaining four all relate to IAPT access volumes
which have been a significant challenge throughout the year
Red/Amber Rated Indicators:
EIP 14 day waits
31/39 new EIP cases were seen within the current 14 day target parameters in Q3. The people that were not seen within this time were cases that were
identified retrospectively and added to the First Episode of Psychosis pathway. This meant that the normal tracking procedures to ensure timely appointments
had not happened. Additional work is being undertaken to ensure compliance against 2016/17 NICE guidelines, (50% service users engaged with an EIP care
co-ordinator within 2-weeks of referral is the national target).
Urgent Community Referrals
There were two breaches of the urgent 24 hour wait time in December. Both were due to the service users not being contactable despite numerous attempts.
The risks were appropriately considered and documented in SPA including liaison with Police Services.
CAMHS 28 day waits
CAMHS are currently working to an internal target of 85% while newly allocated resourcing is being put in place, and this was achieved in Q3. Actions and
trajectory are in place to achieve 95% by Q1 2016/17, addressing the current backlog and increasing capacity for choice appointments. The actions include
substantive recruitment and the targeted use of agency staff to address partnership waits funded by new transformation funds.
IAPT
IAPT access targets have been met in N.E Essex but have not been achieved in the other four areas: ENCCG, HVCCG, Mid Essex and West Essex CCGs.
There is a significant level of management focus on each of these areas to recover this position and meet the targets including:
 targeted promotional activity to generate the most appropriate referrals
 detailed work on the initial assessment process which will reduce DNA rates and speed up access
 further workforce development work on areas such as supervision and clinical training
Each area re has a recovery plan in place which continue to be tested and refined . Whilst last year saw a significant uplift in Q4 activity which saw the full year
targets being exceeded, this cannot be assumed for this year. Meeting the end of year targets will be particularly challenging for Mid Essex where
commissioner s have issued a contract performance notice and for HVCCG.
Routine Referrals to Eating Disorder Services
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There were two breaches in November (both were seen just outside of threshold) due to administrative errors that have now been identified and systems put in
place to prevent them recurring.
Routine Referrals to Community Services
Breaches in the quarter were due to capacity issues in the North of the county because of increase in referrals and difficulties with sourcing locum medical staff.
A substantive consultant has now been appointed and additional slots identified on a short term basis to clear any backlog.
B) Safe and Effective Services Indicators
Performance on Safe and Effective Indicators has improved in Q3. Indicators that are fully met have increased from 43% to 50% in Q3, whilst red rated
indicators have decreased from 57% to 36%. Additionally two indicators are rated as amber. Three of the red indicators relate to IAPT recovery rates in Essex.
The additional indicator relates to improvements in Pulse Survey Results.
Table 3
Safe and Effective Indicators 2015/16
10
5
0
Q1
Q2
Q3
Red
5
8
5
Amber
1
0
2
Green
7
6
7
Red/Amber Rated Indicators:

IAPT recovery rates have fallen in Mid-Essex, NE Essex and West Essex for the second consecutive quarter and remain below the 50% target.
Hertfordshire CCG
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IAPT services continue to exceed target. As advised above there is a significant level of management focus on each of these areas to recover this
position and meet the targets. Detailed analysis of the non-recovery cases has been completed to identify areas for action including further work in
relation to group work, the differential in rates amongst different client groups and the need for further clinical training.
 Risk assessment rates continue to improve with a further 3.3% improvement in the month. The overall rate is now 91.4% against a target of 95% with
table 4 showing all care groups have improved in quarter 3 but all remain below threshold other than Adult Acute. The current process of notifications of
assessments falling due and targeted work with those teams and individuals with below average performance will continue as well as work on caseload
supervision. There are a number of teams now achieving above target levels. And LD&F as a directorate is above 95% currently.
Table 4
Percentage Valid Risk Assessment by
Service Area
100%
80%
60%
40%
20%
F
LD
&
P
HS
O
M
HS
M
CA
Co
A
m dul
m t
un
ity
Ad
ul
tA
cu
te
0%
Sep
Oct
Nov
Dec
Target
 The rate of acute inpatients feeling safe has fallen slightly from 68.7% in Q2 to 68.2% against a target of 80%. The Making our Services Safer (MoSS)
strategy has been in place since the summer 2015, using the Safewards interventions as a methodology. Additional training has been provided to the
service areas by the Practice Development & Patient Safety Lead. Looking at feeling safe has also been explored with the Peer Experience Listeners
(PEL) & the Practice Audit & Clinical Effective (PACE) team. There a now a series of focus groups being held across the 6 acute inpatient areas as well
as separate ones for the Modern Matrons and the Team Leaders.
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
C)
Service users with a PbR cluster were rated as amber in Q3, with a 2.2% improvement to 96.2% which is now marginally below the plan of 97%. Cluster
reviews have also increased, with a significant 13% increase over the three months since Q2, but remain rated as red at 83% against a 99% target.
Further improvements will be made during the next months as work is undertaken within teams and with individuals to provide the relevant training and
to target those areas with below average performance. The area of most risk currently is where there are large caseloads with individual clinicians;
further bespoke work is needed in this area to remedy this.
Resource Indicators
Workforce:
Quarter 3 has seen improvements in all of the indicators, with the exception of 2 indicators which have remained relatively stable. Three of the indicators – staff
recommending the Trust as a place to work, staff feeling engaged and motivated at work, and staff having a clear understanding of the Trust’s values and
behaviours have moved from either red or amber into green and one indicator, staff having a current PDP or appraisal has moved from red to amber.
In this quarter’s pulse survey, staff saying they would recommend the Trust as a place to work has increased by 6.8% from 49.6% in Q2 to 56.4% in Q3, which is
above the Trust target of 55%. This is the highest rate since Q1 2014/15. Staff reporting that they feel engaged and motivated at work has also increased by
5.6% this quarter from 53.4% in Q2 to 59% in Q3. Staff reporting that they experience physical violence from service users has significantly decreased from 14%
in Q2 to 7.1% in Q3. Whilst the percentage of staff reporting that they have access to the relevant training and development has increased from 56.9% in Q2 to
61.8% in Q3 it is still below the target of 72%.
The sickness absence rate in Q3 remains similar to the rate in Q2 and still remains above the Trust target of 4%. Both LD&F and East and North SBUs have had
high sickness absence rates in Q3, 5.5% and 4.98% respectively; however it should be noted that due to the focussed efforts being made in relation to sickness
absence in LD&F the sickness absence rates have improved significantly over the last two months. The Workforce Team are working closely with managers to
address areas with high sickness absence.
The turnover rate in Q3 also remains similar to that in Q2 at 15%. Similar to Q2, Q3 has also seen more new starters in comparison to the number of leavers.
Staff with a current PDP and appraisal has increased by 1.5% this quarter from 85.1% in Q2 to 86.6% in Q3. There have been improvements since Q2 in the
PDP rates within LD&F and East and North due to the focus being given to the completion of PDPs, whilst the rates within the West SBU and Corporate have
declined.
The mandatory training rate has decreased slightly from 88% in Q2 to 87.1% in Q3. Compliance rates and reminders continue to be circulated to manager by the
HR Business Partners.
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Staff reporting a clear understanding of the Trust’s values and behaviours has significantly increased by over 20% from 61.5% in Q2 to 81.6% in Q3 based on the
responses received in this quarter’s pulse survey. This indicator is now above the Trust target of 80%. This increase will be due to the work that has been
undertaken focussing on values statements through the ‘having your say’ feedback at a local level and the collective leadership work that is currently being
undertaken by the Kings Fund.
Table 5
Resources - Workforce Indicators 2015/16
5
0
Q1
Q2
Q3
Red
2
2
2
Amber
4
4
2
Green
1
1
3
Finance:
A surplus of £220k is reported for the month, which is ahead of the Plan of £83k. This continues the improving trend over the last months. There are two key
drivers to this surplus; the settlement of the contract value for Hertfordshire which is £2.8m above Plan for the year and, the reduction in pay and secondary
commissioning costs.
The reported position reflects that some of the newly funded service developments are not yet fully operational. There has also been a reduction in the level of
agency cost
YTD there is a reported surplus of £113k against the Plan of £750k surplus (£637k adverse). The Monitor Risk Rating, the FSRR, is reported as a 4, for the first
time this year.
The financial position for the full year will be dependent upon the level of incremental pay cost referred to above. The forecast position is a small loss for the full
year. This reflects the fact that there will be additional costs in Q4 on estates refurbishment and I.T investment
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£,000; bars show in month; lines cumulative
900
400
-100
A
M
J
J
A
S
O
N
D
J
F
M
-600
8. Activity
This section summarises recorded activity levels against plan. Improving the quality and completeness of activity recording remains a key priority. Data quality
will continue to improve as we work closely with services, particularly those delivering community based care. The overall activity headlines are:


Community
December has seen an overall 9% decline in recorded attended contacts, compared to the previous month of November, although the decline was to be
expected based on 2014/15 seasonal trends. However, 2015/16 records remain a 21% increase against 2014/15 recorded contacts and are 17% above the
2015/16 planned contractual targets.
It is expected that the last quarter will have further activity increases, based on 2014/15 trends showing a 4% increase for Q4 compared to Q1-3; the increased
recording awareness and capacity planning should also result in higher figures for future reports; this is partly supported by the pilot sites receiving regular staff
drill reports to assist local managers in analysing individual staff member’s productivity.
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
The Adult community teams continue to have the highest ‘DNA’ rates ranging from 12-15% across all quadrants; whilst both the MHSOP / Children’s services
have 8-9% DNAs.
Inpatient
Overall Occupancy rates remain above the contractual arrangements (where recommended occupancy levels of 80%-93% were used), apart from the Adult –
Low Secure beds remaining around 81% against the contracted level of 88%. December overall shows an minor decline from 98% to 96% occupancy, mainly
due to reduced LD / MHSOP bed activity.
Monitor Inpatient Categories
Adult - (excluding High/Medium/Low Secure)
Adult - Low Secure
CAMHS
Learning Disability
Older People
Grand Total
UNIT
Occup %
Occup %
OCCUPIED
CAPACITY Incl. Leave
Excl. Leave
4979
159
105%
101%
378.5
15
82%
81%
494
16
100%
100%
3484
127
88%
88%
5557
181
99%
99%
14892.5
498
98%
96%
.
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Appendix 1 Performance against Monitor Targets
Further detail in relation to individual targets is:
 CPA reviews within 12 months have remained stable at 96.7% (drop of 0.1% on Q2) and are still comfortably above the 95% target.
 Gate-kept admissions have improved by 1.1% on Q2 and are now at 99.3% for the quarter.
 The new cases of FEP in the period are 46 against the target requirement of 37.5. This figure includes some cases in the HVCCG area that have been
retrospectively identified as FEP and added to the pathway. The Trust has completed a considerable amount of work to be in a state of readiness for
shadow reporting of the new National FEP target from January 2016 and formal introduction from April 2016. Compliance with the 50% target for new
cases beginning therapeutic interventions within 14 days of identification/referral is expected. Work continues to ensure that the Trust meets NICE
compliance with treatment options and methods of recording and auditing this are currently being implemented.
 Delayed transfers of care have risen by 0.5% on last quarter, but remain below the 7.5% limit at 7.1%. Work in elderly units and adult acute units to
reduce delays have resulted in a significant reduction in December (from 9.27% to 6.34% in elderly and 9.28% to 6.99% in acute – the latter being the
lowest number of delays year to date).
 99% of people discharged from acute care on CPA were followed up within the mandated 7 day period. There were a total of two breaches in the
quarter; one person left the country immediately after discharge and the other was of no fixed abode and could not be contacted despite numerous
attempts to do so.
 As predicted at the end of Q2 performance on the MHLDDS outcomes indicator has begun to improve at 58.34% - a 4 % increase on Q2. This is due to
an increased focus by teams on recording accommodation and employment information. Currently the employment and accommodation statuses are
not flagged on Paris as being due for review – this should be rectified when the Trust moves to a later version of the EPR in 2016.
 Performance on the IAPT targets introduced from Q3 and reported to monitor for the first time this quarter, remains very strong at 99.9% against a target
of 95% for 18 week wait and 96.49% against a target of 75% for 6 week wait.
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Appendix 1 – Trust Performance Monitor
Ref
Indicator (Monitor/Contractual/Internal)
Target
12 month Trend
Current Period
Numbers
(Q3)
Current Period
Performance
(Q3)
Previous Period
Performance
(Q2)
Change on
previous period
1312
1357
96.7%
96.8%
-0.1%
↔
287/289
99.3%
98.3%
1.1%
↔
7.10%
7.10%
6.55%
0.5%
↔
200/202
99.01%
98.8%
0.2%
↔
46
46
42
4
↔
Comments
Forecast for next
period
(Q4)
100%
M1
The proportion of those on Care Programme
Approach (CPA) for at least 12 months who had a CPA
review within the last 12 months (Monitor)
>=95%
95%
90%
J
F
M
A
M
J
J
A
S
O
N
D
100%
M2
Percentage of inpatient admissions that have been
gate-kept by crisis resolution/ home treatment team
(Monitor)
>=95%
95%
90%
J
8%
Delayed transfers of care to the maintained at a
minimal level (Monitor)
<=7.5%
M
A
M
J
J
A
S
O
N
D
CEILING
6%
M3
F
4%
2%
0%
J
F
M
A
M
J
J
A
S
O
N
D
100%
M4
Care Programme Approach (CPA): The percentage of
people under adult mental illness specialties on CPA
>=95%
who were followed up within 7 days of discharge from
psychiatric in-patient care (Monitor)
95%
90%
J
F
M
A
M
J
J
A
S
O
N
D
150
M5
150 per
The number of new cases of psychosis served by early
year
interventions teams year to date - Target 150 per
(100 as at
year, 12.5 per month) (Monitor)
month 8)
100
50
0
A
M
J
J
A
S
O
N
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Appendix 1 – Trust Performance Monitor
Ref
Target
Current Period
Numbers
(Q3)
12 month Trend
Current Period
Performance
(Q3)
Previous Period
Performance
(Q2)
Change on
previous period
Comments
Forecast for next
period
(Q4)
0.0%
Includes: NHS Number, DOB,
Postcode, Gender, Registered
General Medical Pracice
organisation code, Commissioner
Organisation Code;
For all service users
↔
↑
100%
99%
M6
Data Completeness MHMDS - Identifiers (Monitor)
>=98%
119,928
120,320
98%
97%
99.67%
99.67%
96%
J
F
M
A
M
J
J
A
S
O
N
D
70%
M7
Data Completeness MHMDS - Outcomes (Monitor)
>=50%
50%
4421
7578
58.34%
54.33%
4.0%
Includes: Employment status,
accomodation status, HoNOS;
For total number of adults aged
18-69 who have received
secondary mental health servcies
and were on CPA at any point in
quarter
8280
8288
99.90%
99.95%
-0.05%
West Essex figures included from
July 2015
↔
7997
8288
96.49%
96.5%
-0.02%
West Essex figures included from
July 2016
↔
30%
J
M8
IAPT 18 week RTT (Monitor from Q4)
>=95%
F
M
A
M
J
J
A
S
O
N
D
100.0%
4000
95.0%
2000
90.0%
0
A
M
J
J
A
S
O
N
D
100.0%
4000
90.0%
M9
IAPT 6 week RTT (Monitor from Q4)
>=75%
2000
80.0%
70.0%
0
A
M
J
J
A
S
O
N
D
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Appendix 2 - Access to Healthcare for People with a Learning Disability
Evidence for Board Declaration Q3 2015/16
Indicator
Evidence
Score31
/12/15
1. Does the trust have a mechanism in place to identify
and flag patients with learning disabilities and
protocols that ensure that pathways of care are
reasonably adjusted to meet the health needs of
these patients?









Mechanisms are in place to flag and identify people with a learning disability
on the Electronic Record System, Paris.
All people with a learning disability are asked if they have a Health Action
Plan (Purple Folder) on admission and offered one if not. This is recorded on
the Electronic Patient Record System, Paris.
All people with a learning disability have a physical health examination within
24 hours of admission, highlighting any physical health issues to be
addressed; this is recorded on the Electronic Patient Record system, Paris.
All care pathways include working with people with learning disabilities,
making reasonable adjustments as required, appropriate to individual needs.
All operational policies include the importance of making reasonable
adjustments to support people with Learning disabilities accessing
mainstream services. The Operational Policies Group is responsible for
making sure the needs of people with learning disabilities is fully considered,
included and monitored on an ongoing basis.
All learning from specific audits in relation to people with learning disability
accessing and experiencing mental health services have been incorporated
into the redesigned community services.
Work is ongoing to ensure all electronic systems highlight people with
learning disabilities and their needs
Greenlight Toolkit Steering Group has been re launched, to monitor progress
against indicators across all adult and older adult mental health services
Every team in adult/older adult mental health services has completed the
Greenlight Toolkit “basic audit” to provide evidence of above being in place
and identify areas for further development
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

2. In accordance with the Disability Equality Duty of the
Disability Discrimination Act (2005), does the trust
provide readily available and comprehensible
information (jointly designed and agreed with people
with learning disabilities, representative local bodies
and/or local advocacy organisations) to patients with
learning disabilities about the following criteria:
1. Treatment options (including health promotion)
2. Complaints procedures, and
3. Appointments









3. Does the trust have protocols in place to provide
support for family carers who support patients with
learning disabilities, including the provision of
information regarding learning disabilities, relevant
legislation and carers’ rights?

4.

Does the trust have protocols in place to routinely
include training on learning disability awareness,
relevant legislation, human rights, communication
techniques for working with people with learning
disabilities and person centred approaches in their
staff development and/or induction programmes for
all staff?




The Basic Audits have been analysed to better understand the progress that
has been made against the indicators and identify where further work needs
to be done
The pilot sites who undertook the “Basic Audit” earlier in 2015 have all
completed the “Better Audit”
The Web site/internet has been updated with the use of word bank to
facilitate easy read material for both people who use the service and staff to
use
There are a wide range of easy-read leaflets available on the Web
site/internet for both people who use the service and staff to use – includes
signposting to further information.
Easy read complaints leaflets have been sent to all services to use
Easy-read appointment letters are available on Trust-space for all staff to
use.
In liaison with Trust employed Health Access Champions (experts by
experience), accessible leaflets are being developed which will be in the
welcome packs for inpatient mental health services.
LD & F Making Services Better Group is in place to review information.
Includes people with mental health issues on the membership.
Easy Read Appointment cards are available to use with service users
Mental Health inpatient welcome packs have been rewritten in easy read;
one set includes pictures and one set without.
Every team in adult/older adult mental health services has completed the
Greenlight Toolkit “basic audit” to provide evidence of above being in place
and identify areas for further development
The Trust’s Carer’s Policy is included in the Carer’s Packs. The charter has
also been circulated to managers, team leaders, carer practitioners, carer
leads and members of the Carer Strategy Group. Copies were also included
in the information pack for Carers’ Conference.
The Carers’ Strategy includes carers of people with a learning disability.
The Trust is in the process of working towards AIMS accreditation for all
learning disability assessment and treatment units. Accreditation will provide
evidence of appropriate carer support.
People with learning disability are employed as Health Access Champions
supporting services and involved in service development. Two further Health
Access Champions have been employed to support the Community Learning
disability services
There is an accessible information e-learning package for all staff to access.
Each adult/older adult team has an appointed LD champion to support the
implementation of the Greenlight Toolkit project plan and to promote learning
disability awareness. Staff within LD services will support the champions.
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4
4
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


5.
Does the trust have protocols in place to encourage
representation of people with learning disabilities and
their family carers within Trust Boards, local groups
and other relevant forums, which seek to incorporate
their views and interests in the planning and
development of health services?



Key to
3,4,5,6
(1) =
6. Does the trust have protocols in place to regularly
audit its practices for patients with learning disabilities
and to demonstrate the findings in routine public
reports?

Champions have attended training to support them in their role. The
Greenlight Toolkit steering group is also working to pull together material to
support increased awareness and devise an e-learning package to support
the access to mental health services for people with a learning disability.
Top Tips for Communication’ cards have been introduced across the Trust.
The Involvement Guide is being rolled out across the organisation.
The service user stories report has been delivered developed and shared –
use as and when necessary
The Board of Governors, Involvement Steering Group, Service User and
Carer Councils and the Partnership Board all include membership of people
with a lived experience and carers.
Learning Disability Services have active service user forums in each service,
supported by Health Access Champions with oversight by the Making
Services Better Group.
The Making Services Better Group consists of Health Access Champions,
carers and service users and is supported to provide a key oversight function
on service user and carer experience within services, making
recommendations for improvements within services.
Health Access Champions, Carers and people with learning disabilities are
actively involved in a schedule of Quality Visits across services to provide
feedback on positive practice and highlight where improvements can be
made. People with a learning disability and carers are actively involved in
Patient Lead Assessment Care Environment Audits. Quality visits in adult
services to be amended to include access for people with a learning
disability. Reports currently are shared with service user and carer groups
within the Trust. Trust Practice in relation to services for people with a
learning disability, are reported in public reports e.g., Quality Account.
Further work is required to ensure that work specifically related to monitoring
of the Greenlight Toolkit indicators is required.
4
Scoring:
Q’s 1,
3
Protocols/mechanisms are not in place.
(2) = Protocols/mechanisms are in place buy have not yet been implemented.
(3) = Protocols/mechanisms are in place but are only partially implemented.
(4) = Protocols/mechanisms are in place and are fully implemented.
Q2
(1)
(2)
(3)
(4)
= Accessible information not provided
= Accessible information provided for one of the criteria
= Accessible information provided for two of the criteria
= Accessible information provided for all three of the criteria
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Appendix 3 Quality Performance
This section of the report summarises the Trust’s performance against internally selected quality related considerations. For each of these areas a narrative
summary is provided covering the quarter period which identifies the progress in the period and priorities for the subsequent period.
Safeguarding
As indicated below the training and reporting culture within the Trust remains of a high calibre. Decision making by investigating managers remains of a consistent
and appropriate nature. A more planned approach is required to identify real time spent within investigating teams on managing and dealing with safeguarding
issues. The Trust retains a positive culture of reporting which is evident via the high rate of Concerns that are raised by staff.
The Safeguarding Team have finalised in partnership with HCC the Making Safeguarding Personal (MSP) leaflet which will be distributed in February 2016. This
will provide staff with key guidance on the principles of MSP.
A recent internal audit on cases where the decision was not to proceed to an Enquiry established that in 75% of the cases this decision was appropriate and
clearly recorded within the case notes.
The Trust has now commenced it delivery of the PREVENT training to its staff and via its 4 qualified trainers.
Changes to Datix to make safeguarding reporting more effective have been activated and series of meetings now in place with investigating managers, acute
managers, and medical leads to embed recent changes to procedures.
Discussions held with SPA to agree more effective screening of referrals badged as safeguarding by external agencies.
New procedure on reporting historic abuse beginning to work well.
Training and Performance Data
Level
% Compliance
Safeguarding Adults
94%
Safeguarding Children
94%
Level 2
Safeguarding Children
92%
Level 3
Level
PREVENT TRAINING
No of staff trained
42
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A recent exercise to establish the amount of time that investigating managers spend managing safeguarding issues identified an average of 1.5 days is spent per
week by individuals.
Inconsistent recording within Datix reports, mainly from in-patient services where incidents are incorrectly classified as safeguarding which they should not; and
do not classify things as safeguarding which they should. The Safeguarding team is working closely with Datix Manager to address this with the specific service
areas.
Very uneven safeguarding workload between different investigating teams with some overloaded. The SG team is working with the Investigating managers to
embed a system which is equitable across the teams
Service Experience
The level of responses to Having your Say (HYS) and the Friends and Family test (FFT) remains consistent from Q2 to Q3. FFT responses received from CAMHS
clinics has increased by 37% compared to Q2.
In December the Single Point of Access service scored 100% for FFT.
Trust-wide 68.2% of service users giving feedback through an inpatient HYS survey answered that “Yes” they felt safe on the unit compared to 68.7% in Q2.
The number of HYS Carers surveys received has dropped again in Q3 to 80 from 109 (Q2), a fall of 27%.
The team is working on several pilot projects to encourage different methods of feeding back including iPads, kiosks and SMS.
Page
22
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FFT Score
100
80
60
40
20
0
Would Recommend
Would Not Recommend
Jan
72
7
Feb
77
9
Mar April May June
79
88
78
85
8
3
12
7
Would Recommend
July
83
11
Aug
84
8
Sept
80
13
Oct
83
10
Nov
90
6
Dec
86
8
Would Not Recommend
Health and Safety
RIDDOR’s Reported to the HSE
The Trust has reported a total of 13 RIDDOR incidents this quarter compared to 18 incidents in the previous quarter and 5 in the same period last year. All
incidents involve injuries sustained by staff. There were no incidents involving injuries to service users in this quarter.
Incident type
Physical Assault
Slip, Trip or Fall
Injury sustained whilst undertaking RESPECT
technique
Road Traffic Accident
Service Users
Q2
9
3
1
Q3
6
2
4
0
5
1
0
Of the 13 incidents 2 were reported as a major injury (Fractured bones to a member of staff’s hand as a result of a Slip, Trip or fall incident and Fractured Bones
to a member of staff’s foot who was involved in the Road Traffic Accident). The other 11 incidents resulted in staff being absent from work for more than 7 days.
Ligature Incidents
35 ligature incidents were reported in Q3 compared to 34 in Q2. None of these incidents resulted in any serious harm or a fatality. 32 of the 35 incidents did not
involve the use of a ligature anchor point.
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The 3 incidents involving potential ligature anchor points were shoelaces being tied together and tied to a light fitting, a dressing gown cord being tied to a soap
dish and shoelaces being plaited and tied to a door hinge. Observations were increased and Care Plans were reviewed and updated.
The majority of the incidents involved personal items of clothing other items included a bandage, head set phone leads and a handle from a handbag.
13 of the incidents were undertaken by the same two service users.
The Trust continues to be compliant with the Department of Health National Alerts regarding ligature anchor points.
Infection Prevention and Control
The total number of infection prevention and control incidents reported in quarter 3 was 37 (compared to 21 in Q2 and 30 in Q1).
Alert organism/condition surveillance continues to be collated. Points of note are:
 There have been no confirmed reported cases of either MRSA, MSSA, E-coli bacteraemia.
 There are no reported cases of Clostridium difficile in the period (None in the previous quarter )
 There have been no suspected/confirmed Norovirus outbreaks reported. One period of increase in incidence of gastro intestinal illness was reported and
investigated at Forest House. Two members of staff initially reported with symptoms of vomiting. No service users reported with symptoms. On
investigation, one member of staff vomited once but also had other flu like symptoms. The other member of staff just felt nauseas after a period of night
shifts which is common for that member of staff.
The Norovirus guidance has been updated and distributed to staff along with the Public Health England Norovirus poster.
Infection prevention and control training programmes continue to be implemented. Up to the end of December 2015, the overall compliance percentage was
recorded at 85%. This is a slight decrease from last quarter which reported 89% compliance.
The Infection Prevention and Control Team celebrated the 2015 International Infection Prevention and Control Awareness Week, at the Colonnades. The
Infection Prevention and Control Link Practitioners also celebrated this event locally in their units. The overall standards of cleanliness remain a concern in certain
areas. The focus remains on continuing to work with Interserve managers, to ensure that high standards of cleanliness are consistently implemented and
maintained.
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Appendix 4 – Trust Performance KPIs – Access
Ref
Target
12 month Trend
Current Period
Numbers
(Q3)
Current Period
Performance
(Q3)
Previous Period
Performance
(Q2)
6/6
100.0%
100.0%
0.0%
Chart - if there is a height gap
between blue and red bars, that
month is below 98 threshold.
↔
60/62
96.8%
98.2%
-1.4%
↑
31/39
79.5%
85.7%
-6.2%
1222
1256
97.3%
97.7%
-0.4%
22 service users not seen within
28 days due to patient choice and
excluded from the figures (4 Oct;
9 Nov; 9 Dec)
↔
7/9
77.8%
87.5%
-9.7%
↑
Change on
Data Quality
previous period
Issues
Forecast for next
period
(Q4)
Comments
4
Urgent Refs
3
A1
Urgent referrals to community eating disorder
services meeting 96 hour wait (Contractual)
>=98%
Within 96 hrs
2
1
0
J
F
M
A
M
J
J
A
S
O
N
D
30
Routine Refs
A2
Routine referrals to community eating disorder
services meeting 28 day wait (Contractual)
Within 28 days
20
>=98%
10
0
J
F
M
A
M
J
J
A
S
O
N
D
100%
20
15
A3
Routine referrals to early intervention in psychosis
service meeting 14 day wait (Contractual)
>=98%
50%
10
↑
5
0%
0
J
F
M
A
M
J
J
A
S
O
N
D
100%
A4
Routine referrals to community mental health team
meeting 28 day wait (Contractual)
>=98%
95%
90%
J
F
M
A
M
J
J
A
Urgent referrals to community mental health team
meeting 24 hour wait (Contractual)
O
N
D
Urgent Refs
40
A5
S
Within 24hrs
>=98%
20
0
J
F
M
A
M
J
J
A
S
O
N
D
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25
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Ref
Target
12 month Trend
Current Period
Numbers
(Q3)
Current Period
Performance
(Q3)
Previous Period
Performance
(Q2)
1188
1188
100.0%
100.0%
0.0%
78/81
96.3%
96.5%
-0.2%
3 service users not seen within 28
days due to patient choice and
excluded from the figures (2 Dec;
1 Nov)
1/1
100.0%
100.0%
0.0%
672/1248
53.8%
52.2%
1.6%
Change on
Data Quality
previous period
Issues
Forecast for next
period
(Q4)
Comments
100%
400
95%
A6
CATT referrals meeting 4 hour wait (Contractual)
>=98%
200
90%
0
J
F
M
A
M
J
J
A
S
O
N
D
100%
60
90%
A7
Routine referrals to Specialist Community Learning
Disability Services meeting 28 day wait (Contractual)
40
80%
20
70%
>=98%
↔
60%
0
J
F
M
A
M
J
J
A
S
O
N
D
↑
3
Urgent Refs
A8
Urgent referrals to Specialist Community Learning
Disability Services meeting 24 hour wait (Contractual)
Within 24hrs
2
>=98%
1
↔
0
J
F
M
A
M
J
J
A
S
O
N
D
100%
A9
EMDASS Referrals meeting 6 week wait (Contractual)
>=90%
50%
↑
0%
J
F
M
A
M
J
J
A
S
O
N
D
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26
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27
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Ref
Target
12 month Trend
Current Period
Numbers
(Q3)
Current Period
Performance
(Q3)
Previous Period
Performance
(Q2)
169/173
97.7%
96.9%
0.8%
↔
50/60
83.3%
85.7%
-2.4%
↔
58/59
98.3%
83.3%
15.0%
↔
39/40
97.5%
66.7%
30.8%
↔
358/401
89.3%
85.5%
3.8%
5743
5896
97.4%
99.3%
-1.9%
Change on
Data Quality
previous period
Issues
Comments
Forecast for next
period
(Q4)
100%
A10
CAMHS referrals meeting assessment waiting time
standards - CRISIS (4 hours) (Contractual)
90%
>=90%
80%
70%
J
F
M
A
M
J
J
A
S
O
N
D
100%
A11
standards - URGENT (P1 - 7 DAYS) (Contractual)
>=75%
75%
50%
J
A12
CAMHS referrals meeting social worker contact
waiting time standards - TARGETED SERVICE 14 DAYS
(Contractual)
>=75%
F
M
A
M
J
J
A
S
O
N
D
100%
25
90%
20
15
80%
10
70%
5
60%
0
A
A13
standards - TARGETED SERVICE 28 DAYS(Contractual)
>=75%
M
J
J
A
S
O
N
D
100%
20
90%
15
80%
10
70%
5
60%
0
A
M
J
J
A
S
O
N
D
100%
80%
A14
standards - ROUTINE (28 DAYS) (Contractual)
60%
>=95%
40%
20%
1 person not seen within 28 days
due to paitent choice
↑
0%
J
F
M
A
M
J
J
A
S
O
N
D
100%
90%
A15
SPA referrals with an outcome within 14 days
(Internal)
>=95%
80%
70%
↔
60%
J
F
M
A
M
J
J
A
S
O
N
D
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28
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Ref
Target
12 month Trend
100%
Rate of referrals meeting maximum 18 week wait time
A16 from referral to treatment for all mental health and
learning disability services (Contractual)
95%
1000
90%
Q3 2217
(739 per
month)
F
M
A
M
J
J
A
S
O
N
8000
800
6000
600
4000
400
2000
200
Number of people entering IAPT treatment (HVCCG)
(Contractual)
M
J
J
A
S
O
N
D
J
F
8000
1000
6000
800
98.8%
-0.2%
↔
2083
2083
1942
141
↑
2493
2493
2293
200
↑
1193
1193
1334
-141
↔
1178
1178
1240
-62
1341
1341
1339
2
600
4000
400
2000
200
0
A
Q3 1473
(491 per
month)
Forecast for next
period
(Q4)
M
0
Number of people entering IAPT treatment (Mid
A19 Essex)
(Contractual)
98.6%
Comments
0
A
A18
6498
6589
Change on
Data Quality
previous period
Issues
D
0
Q3 2871
(957 per
month)
Previous Period
Performance
(Q2)
0
J
Number of people entering IAPT treatment (ENCCG)
A17
(Contractual)
Current Period
Performance
(Q3)
3000
2000
>=98%
Current Period
Numbers
(Q3)
M
J
J
A
S
O
N
D
J
F
M
5000
600
4000
500
400
3000
300
2000
200
1000
100
0
0
A
M
J
J
A
S
O
N
D
J
F
M
3000
600
500
A20
Number of people entering IAPT treatment (West
Essex) (Contractual)
Q3 1233
(411 per
month)
2000
400
300
1000
200
0
A21
Number of people entering IAPT treatment (NE Essex)
(Contractual)
M
J
J
A
S
O
N
D
J
F
M
5000
600
4000
500
400
3000
300
2000
200
1000
↔
100
0
0
A
↑
0
A
Q3 1332
(444 per
month)
Contract started 1st July 2015
100
M
J
J
A
S
O
N
D
J
F
M
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29
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Appendix 4 – Trust Performance KPIs – Safe & Effective
Ref
Target
12 month Trend
Current Period
Numbers
(Q3)
Current Period
Performance
(Q3)
Previous Period
Performance
(Q2)
478/918
52.1%
53.8%
-1.7%
↔
Change on
Data Quality
previous period
Issues
Comments
Forecast for next
period
(Q4)
80%
SE1
IAPT % clients moving towards recovery (ENCCG)
>=50%
SE2
IAPT % clients moving towards recovery (HVCCG)
>=50% 60%
735/1157
63.5%
57.4%
6.1%
↔
SE3
IAPT % clients moving towards recovery (Mid Essex)
>=50%
255/569
44.8%
47.4%
-2.6%
↑
210/555
37.8%
44.4%
-6.5%
↑
211/478
44.1%
48.8%
-4.6%
IAPT Recovery Rate by CCG
40%
SE4
SE5
IAPT % clients moving towards recovery (NE Essex)
IAPT % of clients moving towards recovery (W Essex)
(From 1st July 2015)
>=50%
ENCCG
Target
HVCCG
Mid Essex
NE Essex
W Essex
>=50% 20%
A
M
J
J
A
S
O
N
Data starts from August as there
were no discharges in July
↑
D
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30
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Ref
Target
Current Period
Numbers
(Q3)
12 month Trend
Current Period
Performance
(Q3)
Previous Period
Performance
(Q2)
Change on
Data Quality
previous period
Issues
Comments
Forecast for next
period
(Q4)
Since November data, this no longer
matches the quality Schedule, as we
have been able to separate Herts from
non-Herts CCGs' data and improve the
relevance of the QS.
↑
100%
SE6
Rate of service users with a completed up to date risk
assessment (inc LD&F & CAMHS from Apr 2015) Seen >=95%
Only
90%
15480
16944
91.4%
88.1%
3.3%
90/132
68.2%
68.7%
-0.5%
↑
116/164
70.7%
62.3%
8.4%
↔
408/475
85.9%
81.4%
4.5%
↔
80%
J
F
M
A
M
J
J
A
S
O
N
D
100%
SE7
Rate of acute Inpatients reporting feeling safe (rolling
3 month basis)
>=80%
80%
60%
J
F
M
A
M
J
J
A
S
O
N
D
80%
SE8
Staff Friends and Family Test (FFT) - recommending
Trust services to family and friends if they need them
>=70%
60%
40%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
100%
SE9
Rate of service users that would recommend the
Trust's services to friends and family if they needed
them (rolling 3 month basis)
>=70%
80%
60%
J
F
M
A
M
J
J
A
S
O
N
D
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31
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Ref
Target
12 month Trend
Current Period
Numbers
(Q3)
Current Period
Performance
(Q3)
Previous Period
Performance
(Q2)
281/319
88.1%
90.9%
-2.8%
↔
280/385
72.7%
75.7%
-3.0%
↔
57/71
80.3%
76.2%
4.0%
↔
11608
12067
96.2%
94.0%
2.2%
↑
9631
11607
83.0%
70.0%
13.0%
↑
Change on
Data Quality
previous period
Issues
Comments
Forecast for next
period (Dec 2015)
100%
SE10
Rate of service users saying they are treated in a way
that reflects the Trust's values (rolling 3 month basis)
>=75%
80%
60%
A
M
J
J
A
S
O
N
D
100%
Rate of Community service users saying the services
SE11 they receive have helped them look to the future more >=60%
confidently (rolling 3 month basis)
75%
50%
A
M
J
J
A
S
O
N
D
100%
SE12
Rate of carers that feel valued by staff (rolling 3
month basis)
>=75%
80%
60%
A
SE13 Percentage of eligible service users with a PbR cluster
Percentage of eligible service users with a completed
SE14
PbR cluster review
90% at
end Q1;
95% at
end Q2;
97% at
end Q3
80% at
end Q1;
90% at
end Q2;
99% at
end Q3
M
J
J
A
S
O
N
D
100%
90%
80%
J
J
A
S
O
N
D
90%
70%
50%
J
J
A
S
O
N
D
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32
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Appendix 4 – Trust Performance KPIs – Resources – Workforce
Ref
Target
12 month Trend
Current Period
Numbers
(Q3)
Current Period
Performance
(Q3)
Previous Period
Performance
(Q2)
Change on
previous period
Comments
Forecast for next
period
(Q4)
93/165
56.4%
49.6%
6.8%
Total responses in the quarterly
Pulse survey
↔
292/495
59.0%
53.4%
5.6%
Pulse survey
↔
11/154
7.1%
14.0%
-6.9%
Pulse survey
102/165
61.8%
56.9%
4.9%
Pulse survey
Data Quality
Issues
70%
W1
Staff Friends and Family Test (FFT) - Staff saying they
would recommend the Trust as a place to work
>=55%
50%
30%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
90%
W2
Rate of staff reporting feeling engaged and motivated
at work
>=55%
60%
30%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
20%
15%
W3
Rate of staff that report experiencing physical violence
from service users
N/A
10%
5%
0%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
80%
60%
W4
Rate of staff that report having access to relevant
training and development
>=72%
40%
20%
↑
0%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
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33
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Appendix 4– Trust Performance KPIs – Resources – Workforce
Ref
Target
12 month Trend
100%
W5
Rate of staff with a current PDP and appraisal
>=90%
2014-15
Current Period
Numbers
(Dec-15)
Current Period
Performance
(Dec-15)
Previous Period
Performance
(Sep-15)
Change on
previous period
Comments
Forecast for next
period
(Q4)
2058
2376
86.6%
85.1%
1.5%
Status as at quarter end
↑
87.1%
88.0%
-0.9%
Status as at quarter end
↑
4.76%
4.63%
0.1%
Average taken for the 3 months in
each quarter
↔
14.9%
15.2%
-0.3%
Average taken for the 3 months in
each quarter
81.8%
61.5%
20.3%
Pulse survey
Data Quality
Issues
2015-16
90%
80%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
100%
W6
Rate of mandatory training completed and up to date
>=90%
90%
80%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
8%
6%
W7
Sickness rate
<=4%
4%
CEILING
2%
J
F
M
A
M
J
J
A
S
O
N
D
20%
15%
W8
Turnover rate
N/A
10%
5%
J
F
M
A
M
J
J
A
S
O
N
D
100%
W9
Rate of staff reporting a clear understanding of the
Trust's values and behaviours
>=80%
75%
↔
50%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
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34
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Appendix 4 – Trust Performance KPIs – Resources - Finance
Ref
Target
Current Period
Numbers
(Q3)
12 month Trend
1000
Year to Date
Performance
(Dec-15)
Previous Period
YTD Performance
(Sep-15)
Change on
previous
period
400
To Achieve Surplus of £1million in
year
750k at
month 9
Forecast for next
period
(Year end)
Chart:
600
F1
Comments
£,000; bars show in month; lines cumulative
800
83k per
month
Data
Quality
Issues
536k
Surplus in
Q3
200
0
A
-200
M
J
J
A
S
O
N
D
J
F
113k
Surplus
423k
Deficit
Red line = Cumulative target to
£1m surplus
536k
M
↑
Blue bars - in month
surplus/deficit
Blue line = cumulative
surplus/deficit
-400
-600
4
F2
Continuity of Service Risk Rating
(CoSRR)
3
4
2
4
1
1
↔
0
A
3
M
J
J
A
S
O
N
D
J
F
M
Page
35
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Appendix 5 – Quality Account Indicators
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Indicator
Achievement of MOSS CQUIN Goal
Achievement of Reducing Acute MH Pressures CQUIN Goal
Completion of risk assessments at least annually
CAMHS 28 day waiting time target for routine referrals
Maintenance of baseline rate of average Lengths of Stay on MHSOP
inpatient units
Functional
Organic
Specialist Community LD Teams:
28 waiting time target for routine referrals
24 hours for urgent
All Essex IAPT services – access to treatment targets met
18 week
6 week
Achievement of Physical Health CQUIN Goal
Friends and Family Test - Service Users
Friends and Family (as a place to receive care) – Staff
Staff reporting feeling engaged and motivated at work
Page
36
EOY target
Yes/No/Partial
Yes/No/Partial
95%
95%
Q2
Fully achieved
Fully achieved
88.1%
85.5%
Q3
tbc
tbc
91.4%
89.7%
30
45
39 days
66 days
30 days
53 days
98%
98%
96.5%
100%
96.3%
100%
95%
75%
Yes/No/Partial
To be set
70%
55%
99.3%
94.5%
Partial
80.9%
49.6%
60.7%
99.8%
96%
tbc
tbc
56.4%
57.0%
Page36of39
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Appendix 6 – CQUIN Goals
numb
er
name
1.
MoSS (Year 2)
local
weighting
£
Achieved Q2
End of
Year
predictio
n
comment
14%
£430,780
100%
100%
We need to
maintain focus on
the details of the
CQUIN – reducing
incidents, rolling
out Safe Wards,
enabling acute
inpatients to feel
safe.
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37
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2.
Strengthening AMH
Community Services
local
14%
£430,780
100%
100%
This has been
difficult to achieve
so far but we are
working hard to
ensure we achieve
100% overall. We
have provided
additional evidence
to satisfy the
requirements.
3.
Improved service user
flow in Acute Mental
Health Services
local
14%
£430,780
100%
100%
This is on track.
4.
Communication with GPs
local
14%
£430,780
50%
(To be paid in
full when
clinical lead is
identified)
100%
Agreed full payment
on identification of
Clinical Lead for
this CQUIN. This is
in process and we
will be able to
provide assurance
to commissioners
on this for Q3.
5.
Improving physical
healthcare in SMI
national
20%
Overall
£615,400
(broken
down as
below)
80%
80%
Indicator a
£492,320
Indicator
100% for
indicator a
We are negotiating
with commissioners
to establish % we
can achieve for
indicator b if we fulfil
additional
requirements. Worst
case scenario is we
0% for
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b
£123080
indicator b
(see
comments)
achieve 80%
overall but we
expect to achieve
the full amount.
6.
Improving diagnoses and
reducing readmission rates
for mental health in A and
E
national
10%
£307,700
(Commences
Q3)
100%
This goal was revised
during Q2 as we did
not fulfil national
audit criteria.
Currently indications
are that we will
achieve the full
amount.
7.
Green Light Toolkit (Year
2)
local
10%
£430,780
100%
100%
This goal is on
track
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BOARD MEETING
Meeting Date:
28th January 2016
Agenda Item: 13
Subject:
Workforce & OD Key Performance
Indicators – Q3 Results
Mariejke Maciejewski – Deputy
Director of Workforce
Jinjer Kandola – Director of Workforce
& Organisational Development
Author:
Presented by:
Approved by: Jinjer Kandola
To update the Trust Board on the Q3 performance against the key workforce metrics and
organisational development activity agreed in the Annual Plan.
Action required:
To note the report and recommend any additional measures required.

A number of the key performance indicators for workforce have either improved or
remained static in Q3.

Recruitment and retention remains a key activity for the Trust as turnover levels remain
high at 14.8% and the current vacancy rate remains at 14%. We continue to see more staff
start with the Trust than leave, however the number of leavers is still high. The focus on
recruitment has continued this quarter and the ‘Golden Hello’ initiative has seen positive
results with 58 candidates being eligible for the payment.

Retention also remains a key focus and a number of initiatives such as writing to staff who
could retire within the next five years to understand when they may be likely to retire and to
promote flexible retirement, and a retention workshop have been undertaken.

The desk based research for Collective leadership commenced in Q3 with ‘lead
ambassadors’ working under the guidance of the Kings Fund and using their evidence
based tools to undertake a cultural assessment of the organisation. This will inform the
strategy moving forward. The national staff survey was also undertaken in Q3 and the
results will be made available during Q4.

Q3 also saw the annual staff awards ceremony. 204 nominations were received, which is
the highest number ever and 16 awards were presented. The Trust also recognised and
presented 121 staff development awards.

Since October the Trust has been holding flu clinics at numerous sites to vaccinate staff
against the flu virus. To date 27% of our frontline staff have been vaccinated which is a
10% increase on last year.
AgendaItem13FrontSheetfor
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Relationship with the Business Plan & Assurance Framework (Risks,
Controls & Assurance):
1 Finance
2 IT
3 Staffing
4 NHS Constitution
5 Carbon Footprint
6 Legal
Evidence for S4BH; NHSLA Standards; Information Governance
Standards, Social Care PAF:
Finance & Investment/Integrated Governance/Executive/Remuneration/
Board/Audit
2
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Workforce and Organisational Development Report
Quarter Three October – December 2015
Agenda Item 13
1. Introduction
The purpose of this report is to appraise the Trust Board on the Q3 performance of
the key workforce metrics and organisational development activity as agreed in the
Annual Plan. The report summarises the activities undertaken to improve
performance against the agreed targets and outlines the planned activities for the
next period. Detailed below is the Q3 summary position.
2. Summary
KPI Summary Position
Vacancy Rate %
Q3, 14.32%
Q2, 14.28%
0.00%
2.00%
4.00%
6.00%
Annualised Sickness Rate %
8.00%
10.00%
12.00%
14.00%
16.00%
Q3, 4.74%
Q2, 4.67%
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
Annualised Turnover Rate %
Q3, 14.79%
Q2, 15.26%
0.00%
5.00%
Appraisal Rate %
10.00%
15.00%
20.00%
25.00%
Q3, 86.61%
Q2, 85.11%
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00%100.00%
Mandatory Training Rate %
Q3, 87.14%
Q2, 87.99%
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00%100.00%
1
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A number of the key performance indicators for workforce have either improved or
remained static in Q3.
Recruitment and retention remains a key activity for the Trust. On a like for like
basis the vacancy rate has fallen to 11.0% in Q3 from 13.6% (there has been an
increase in establishment due to new services and creation of new posts which
remain unfilled). However the overall vacancy rate remains high at 14.3% and
turnover levels remain high at 14.8%. Encouragingly we continue to see more staff
joining the Trust than leaving, although the number of leavers is still higher than we
would want. The focus on recruitment has continued this quarter and the ‘Golden
Hello’ initiative has seen positive results with 58 candidates being eligible for the
payment.
Retention also remains a key focus and a number of initiatives such as writing to staff
who could retire within the next five years to understand when they may be likely to
retire and to promote flexible retirement and a retention workshop have been
undertaken.
The desk based research for Collective leadership commenced in Q3 with ‘lead
ambassadors’ working under the guidance of the Kings Fund and using their
evidence based tools to undertake a cultural assessment of the organisation. This
will inform the strategy moving forward. The national staff survey was also
undertaken in Q3 and the results will be made available during Q4.
Q3 also saw the annual staff awards ceremony. 204 nominations were received,
which is the highest number ever and 16 awards were presented. The Trust also
recognised and presented 121 staff development awards. Feedback from attendees
and winners
Since October the Trust has been holding flu clinics at numerous sites to vaccinate
staff against the flu virus. To date 27% of our frontline staff have been vaccinated
which is a 10% increase on last year.
3. Key Workforce Metrics
3.1 Sickness Absence
The Trust has set a target for the reduction of sickness absence to 4% or less. The
annualised sickness absence rate has remained the same at 4.7% in Q3 as in Q2.
There was an increase in the sickness absence levels in October but this has been
followed by a reduction in sickness absence levels over the last two months.
Corporate has a sickness absence rate which is below target at 3.1% whilst the West
SBU is just above the target at 4.3%. Both LD&F, and East and North SBUs have
had high sickness absence rates in Q3, 5.5% and 4.98% respectively, however it
should be noted that due to the focussed efforts being made in relation to sickness
absence in LD&F the sickness absence rates have improved significantly over the
last two months. The Workforce Team are working closely with managers to address
areas with high sickness absence.
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The top five reasons given for absence in the Trust are as follows:
1.
2.
3.
4.
5.
Cold, Cough, Flu
Gastrointestinal problems
Other known causes – not classified elsewhere
Anxiety/stress/depression/other psychiatric illnesses
Back problems
The top reasons for sickness remain relatively the same and there still continues to
be a large number of sickness episodes that have no reason assigned to them. We
will continue to work with payroll and managers to improve the reporting of sickness.
The estimated costs to the Trust of sickness absence for Q3 has been caluclated at
£926k, which is the same as Q2. A breakdown of the sickness absence costs can be
found in appendix 1, section 4.
There are currently 17 short term sickness absence cases and 51 long term sickness
absence cases being formally managed through the employee relations team.
Tables and graphs showing the breakdown of sickness absence data can be
found in appendix 1, section 4 – Information on sickness absence.
3.1.2
Flu Campaign
This year’s flu campaign continues with 789 staff having been vaccinated.
Guidelines produced by NHS` England advises that 100% of frontline staff should be
offered the flu vaccine, with a target of 75% of frontline staff being vaccinated. Only
17% of HPFT staff were vaccinated last year, against a national average of 55%, so
the Trust has set a target of 40% of frontline staff to be vaccinated in winter 2015/16.
To date 27% of our workforce with direct service user care (683 staff) have been
vaccinated, which is an increase on last year’s performance. The breakdown is
shown in the table below:
Frontline Staff Vaccinated against Flu by Staff Group
Staff Group
HCWs involved
with direct
patient care
HCWs involved with direct
patient care vaccinated
since 1st Sep 2015
%
Vaccinated
All Doctors
Qualified Nurses
169
723
60
171
36%
24%
All Other Professional
Clinal Staff (AHP,
ST&T, Pharmacy)
548
167
30%
1090
285
26%
2530
683
27%
Support To Clinical
Staff (HCAs, OT
Techs, Ass Psyc,
Admin in Clinical
Areas, etc)
Total
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To date 58 flu clinics have taken place at numerous Trust sites throughout
Hertfordshire, Norfolk and Essex, between 15th October 2015 and 22nd December
2015. Further clinics will take place throughout January and February.
The workforce team have been working closely with the new Occupational Health
provider regarding the flu campaign and a review of the campaign will take place in
quarter 4 to address lessons learnt, what worked well and what did not work well,
and to plan for next year’s campaign.
3.2 PDP Rates
The PDP rates have increased from 85% at the end of Q2 to 87% at the end of Q3.
Whilst this is positive news unfortunately the Trust has not achieved it’s target of
95%. It should be highlighted that there has been an improvement in the PDP rate
for East and North, and LD&F, with LD&F increasing their rate from 84% in Q2 to
91% in Q3. However, there has been a reduction in the PDP rate in Corporate and
the West. It should also be noted that the increased numbers of new starters and
and the high turnover rate may be affecting PDP rates. Further work has been
undertaken by the department to look at an abridged PDP form Service line leads
will continue to be supported to ensure that all their staff are appraised. The PDP
rates for each SBU are as follows:
SBU
Q1%
Q2%
Q3%
LD&F
90.0
84.0
91.0
East
North
West
and 82.0
85.0
86.0
83.0
87.0
85.0
Corporate
77.0
84.0
81
Trust
84.0
85.0
87.0
3.3 Mandatory Training Rates
The mandatory training rates have decreased slightly to 87% in Q3 from 88% in Q2.
It is recognised that this is below the Trust target of 92% but it should be noted that
the mandatory training rates have remained relatively static in Q2 and Q3 even
though a decision was made to temporarily suspend training over the six weeks of
the summer holidays to make time to care. Compliance rates and reminders
continue to be circulated to team leaders through the HR Business Partners.
However, a further piece of work needs to be undertaken to understand why this
figure is remaining static as feedback from the pulse survey shows that access to
training and development is rated low.
Further tables and graphs showing the PDP and mandatory training
compliance can be found in appendix 1, section 7 – Staff Development.
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4. Establishment and Resourcing Data
4.1 Establishment Data
The establishment data as at 31st December 2015 is as follows:






Funded Establishment =
Staff in post
=
=
Vacant posts
Vacancy rate
=
=
Turnover rate
Stability rate
=
3006.62
2575.92
430.64
14.32%
14.79%
89.39%
4.2 Turnover Index
The turnover rate has decreased slightly from 15.26% in Q2 to 14.79%. Significant
work is being undertaken to address the turnover. Since Q2, the trend for more
starters than leavers remains, and in Q3 there was a net gain of 9 staff. There were
96 new starters and 87 leavers. It has been recognised that there is a need to focus
on retention as well as recruitment. The retention plan continues to be worked on
and a number of initiatives including promotion of flexible working, flexible retirement,
succession planning and development of staff and managers are currently underway.
A retention workshop for managers has taken place and will be rolled out within all
SBUs.
4.2.1 Analysing the leavers data
There were 87 leavers during Q3 which is an decrease from Q2. The largest group
of leavers were again additional clinical services, admin and clerical staff, and
nurses. A new exit interview process, with an external organisation to obtain more in
depth information as to why staff are choosing to leave and what we could do to
retain staff has commenced in Q4. A number of activities around retention are
focused on within the retention project plan which includes the promotion of flexible
working, flexible retirement, career progression and succession planning.
Details of those staff who could retire now from the Trust is shown in Appendix 1,
Section 3, table 4. To address this issue and to try and plan accordingly letters have
been sent to all staff who could currently retire or who could retire within the next five
years to ascertain when they may be planning to retire and if they would be
interested in returing to the Trust on a flexible basis
4.2.2 Reasons for leaving
On analysing the reasons for leaving in Q3, the highest were: retirement, relocation,
work life balance, and promotion. This supports the need to focus on flexible
working, flexible retirement, and career and succession planning.
Further tables and graphs showing the turnover information can be found in
appendix 1, section 3 – Turnover.
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4.3 Stability Index
This data shows the number of staff with more than one year’s experience at two
points in time, usually a year apart. These results are compared to give a reflection of
the increase or decrease in experience in the organisation. A target of 75% - 85%
represents a good balance of new ideas and organistional memory. The stability
index at the end of Q3 has remained at 89% which is outside the target but higher
than recommended which is really positive and shows that experience is being
retained in the organisation.
4.4 Recruitment and Retention Group
This group continues to meet on a regular basis and is chaired by the Director of
Workforce and Organisational Development working with Operations colleagues to
scope ideas for recruitment and to improve retention rates within the organisation as
well as review initiatives that have been undertaken.
Overseas recruitment for registered mental health nurses and registered general
nurses has been agreed
The Trust will be recruiting 25-30 registered general
nurses and registered mental health nurses from the Philippines at the end of
February or beginning of March. Members of the Trust will be travelling to the
Philippines to undertake final interviews with candidates. A welfare package is
currently being devised to support these candidates upon arrival at the Trust.
Marketing and branding to support recruitment and retention is also being developed.
The Trust has asked a number of marketing agencies to submit proposals and once
received a preferred supplier will be chosen. This will include the development of a
recruitment microsite incorporating ‘a day in the life’ videos and improvements in
social media presence. The Trust is also trying to improve current recruitment
through social media such as linkedin and twitter.
Recruitment initiatives including the ‘refer a friend’ scheme and ‘Golden Hello’
scheme continued in Q3. The ‘Golden Hello’ scheme was also extended to
candidates appointed into Band 5 nursing roles in Older People’s Inpatients, the
CATT Team, and on Broadlands Clinic in Norfolk. The ‘Golden Hello’ scheme ended
at the end of December. A review of these initiatives has shown that no one was
referred under the ‘refer a friend’ scheme. However, the ‘Golden Hello’ scheme has
been successful with 58 candidates being eligible for the payment within Community,
CAMHS and Older People Inpatients.
Bank pay incentives also continued in Q3 and more detail on this can be found in
section 4.8 on temporary staffing.
Focused work continues to be undertaken with regards to retention. A number of
retention activities have been devised which include the following:

Following discussions with an external company and agreement during Q3 a
revised exit interview process has been implemented in January so that more
specific information is collated about the reasons employees are leaving e.g.
what specifically about work life balance is making staff leave – is it the
number of additional hours they work or have they had a flexible working
request refused, so that specific action can be taken to address this. Data on
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the feedback received from these exit interviews will be received on a
quarterly basis and analysed.

A new employee survey has also been launched in Q3. Candidates who
have been offered a role with the Trust are contacted once they have
completed their pre employment checks to gain feedback on their recruitment
experience. Feedback and analysis of this information should be available at
the end of Q4.

A further survey is also undertaken with new employees who have completed
90 days employment with the Trust to ascertain how their employment is
going and if the role is living up to expectations. Again feedback and analysis
of responses should be available at the end of Q4.

A significant number of pensions surgeries have been held throughout Q3 for
staff which have proved extremely popular.

Promotion of flexible working within the SBUs, demonstrating the type of
options on offer and converting staff onto these contracts who may otherwise
leave.

Promotion of flexible retirement options continues. All staff who could retire
now or within the next five years have been sent a letter by the Executive
Director of Workforce and OD asking staff when they currently plan to retire
and advising that flexible retirement options are available and would they be
interested in returning to the Trust either on the bank, part time, or on a fixed
term contract. Once more responses have been received more detailed
forward planning can take place.

Establish career pathways and succession planning, so staff know that there
are opportunities to progress e.g. the Band 5 to 6 nurse progression
programme, and establishing career pathways for Bands 1-4. Talent mapping
is currently taking place which should also aid with the retention of staff.

Providing managers with the tools so that consistent leadership is provided
throughout the Trust. Examples are including people management objectives
in all managers’ performance reviews and by launching the managing
excellence programme.
4.5 Key Recruitment Activity
There continues to be a significant level of recruitment activity undertaken within Q3,
which is demonstrated by 96 new starters in the quarter and there are currently 126
offers of employment made to candidates, of which 42 candidates have a start date
between now and April 2016. Targeted recruitment drives for CAMHS, Older People,
the CATT Team and Norfolk have also taken place during Q3. During Q3 there has
also been another drive to retain student nurses who are due to qualify in February
2106 which has resulted in 18 out of the 21 nurses accepting positions with the Trust.
The time taken to hire staff currently remains at 13 weeks which is 0.5 weeks higher
than the time reported in Q2. Further work is being undertaken to reduce the time
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taken in the authorisation stage to see if this has a positive impact on the overall time
to hire. The time to hire may also have been affected by a delay in receipt of
references especially from the university with regards to the student nurses.
As part of the East of England streamlining programme approval has been received
to implement factual references. Moving forward all reference requests will be
received by the recruitment team and a factual reference will be provided. If this
process is implemented by all Trusts throughout the East of England it will assist in
reducing the time to hire even further.
Recruitment, Selection and Values Based workshops are due to launch on the 1st
February 2016 for all staff groups. All staff in the Trust are encouraged to book onto
the workshops. Communication has gone out via HPFT news, a screensaver and
through direct individual invitations from the recruitment team to book the training via
the OLM system. The Trust template job description, person specification, guides,
value based screener and panel packs have been created to support the new values
based process. There is currently a total of 21 staff members booked on the
workshop.
4.6 Number of starters
There were 96 new starters in Q3 which means that between Q1 and Q3 there have
been 339 new starters within the Trust. The breakdown of new starters by staff
group is shown in appendix 1, section 3, Graph 5 – starters and leavers by staff
group. Recruitment has been successful for additional clinical service; professional,
scientific and technical staff and nursing staff during the quarter. The ‘Golden Hello’
scheme has assisted in attracting nursing staff over the last quarter.
4.7 Vacancy Trend
The number of vacancies has increased slightly from 425.26wte in Q2 to 430.64wte
in Q3. Since Q1 there has been an increase in the establishment within each SBU
and Corporate. This increase in establishment has resulted in additional vacancies
and as a result has had an effect on the overall vacancy rate. The table below
shows what the current vacancy rate is in each SBU and what the vacancy rate
would be if the establishment had not increased.
SBU
Corporate
SBU LD & Forensic
SBU MH East & North
Herts
SBU MH West Herts
Total
Current Vacancy %
12.47%
13.97%
14.37%
15.51%
14.32%
Vacancy % if establishment
as at April 2015
6.37%
10.15%
12.76%
11.28%
11.02%
The vacancy level is still high so ongoing recruitment activity and a continued focus
on driving down the time to hire and initiatives to retain staff continue.
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4.7.1 Vacancy Analysis by Staff Group
The vacancy analysis shows that most of the vacancies are within nursing, followed
by professional, scientific and technical posts. However, in Q3 there has been a
reduction in the percentage of nursing vacancies. There is a national shortage of
nursing staff and all local trusts in the area are competing to recruit nursing staff. This
continues to remain a challenge for the organisation and as part of the workforce
planning process we need to think about adopting new ways of working and
considering alternative job roles. Focused activity to attract nurses to HPFT in Q3
included the continuation of the ‘Golden Hello’ for nursing staff in community,
CAMHS, Older People, the CATT Team and Norfolk and social workers in
community as well as targeted recruitment campaigns.
4.7.2 Vacancy analysis by SBU.
The largest level of vacancies remains in East and North SBU and in particular for
Band 5 and Band 6 nurses. A contributing factor to this is the fact that this SBU has
the highest funded establishment. However, it should be noted that the SBU has
made 83 offers of employment of which 33 are to nursing staff. Recruitment
campaigns for CAMHS and Older People have been successful especially with the
introduction of the ‘Golden Hello’.
The workforce team have undertaken analysis of the vacancies within their SBUs
taking into consideration the recruitment pipeline, the retirement profile and turnover
rates. All of this information is being collated so that decisions can be made with
regards to holding recruitment fairs for certain staff groups or continuing with targeted
recruitment.
Tables and graphs showing recruitment and vacancy information can be found
in appendix 1, section 2 – Recruitment.
4.8 Temporary Staffing
During Q3 bank and agency fill rates have remained stable at 95%. The nursing fill
rate increased slightly to 94% in Q3. Bank and agency fill rates for all other staff
groups are 100%. There was a decrease of over 3200 shifts requested to be filled in
Q3 in comparison to Q2. 68.2% of temporary staffing shifts requested are filled by
bank staff and 16% of the shifts are filled by agency staff. There has been a
decrease in the percentage of shifts filled by agency staff from 25% in Q2 to 16% in
Q3.
In Q3, 9% of the pay bill was spent on bank staff and 8% of the pay bill was spent on
agency which is the same as in Q2. Graph 8 in appendix 1, section 5 shows agency
and bank pay since April 2015.
To reduce the cost of agency the bank incentives continued in Q3 to encourage staff
to work on the bank and not go and work agency, and to increase the number of
shifts filled by bank staff. The incentives included paying a loyalty bonus to all bank
staff when they work additional shifts, paying bank staff at their substantive pay band
and pay point, and paying a premium for specialist skills and hard to fill posts. The
uptake of the bank incentive scheme including the number of people who have
qualified and the costs is shown in the table below:
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Bank Incentives
Recruitment
Incentive
Number
Total
Qualifying to Date
Date
£200 Bonus
184
£36,800
£400 Bonus
50
£20,000
20%
7
£2,020
Totals
241
£58,820
Cost
To
Q3 has also seen the introduction of the first phase of the agency cap, with the
second phase due to be implemented with effect from the 1st February 2016. The
Trust is having to report any agency shifts that are breaching the cap plus any
occasions where the Trust goes off framework to Monitor on a weekly basis.
Members of the workforce team are working with colleagues from other Trusts within
Hertfordshire and Bedfordshire so that a collaborative way of working is being
demonstrated to the agencies to enforce the agency cap.
Further tables and graphs showing bank and agency information can be found
in appendix 1, section 5 – Temporary Staffing.
4.9 Further recruitment and retention activities planned for Q3
The Recruitment and Retention task group has a comprehensive work programme
for the remainder of Q4 and the next financial year focusing on new and innovative
ways of addressing this agenda.
4.10 Junior Doctors Strike
The first Junior Doctor’s Strike took place on the 12th January 2016. 41 of the 72
junior doctors we have went on strike. Generally all of our services under the junior
doctors management were well covered by the Consultants and some the trainees
who did not strike.
5. Organisational Development Activity
The OD and Learning Teams work closely with the Workforce Team to deliver the
workforce and OD Strategy. The high level deliverables in the Organisational
Development Activity Plan are outlined below with associated activity detailed for Q3.
5.1 To develop a culture that supports quality, continuous improvement and
compassionate care through collective leadership
A culture of collective leadership is one where formal and informal leaders pull
together to deliver the goals of the organisation and where everyone takes
responsibility for the success of the organisation as a whole, taking accountability for
quality, innovation and improvements. This is a key part of delivering the
organisational strategy. We have a group of ‘lead ambassadors (who are staff
representatives from across the organisation), working under the guidance of the
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Kings Fund and using their evidence based tools to undertake a cultural assessment.
The findings of the cultural assessment are due to be completed by the July Board.
The findings will then inform the leadership strategy for next year. The desk based
research has commenced in Q3.
5.2 To measure and analyse workforce satisfaction levels and make
recommendations on the information provided
The staff survey was live during Q3 and the results will be received in
February/March and be presented at the public board in April. We had a response
rate of 40.1% which was average for mental health trusts. Results will be published
towards the end of February 2016.
The Q3 pulse survey was live in December and we had 165 returns this quarter. The
cultural index paper details the outcomes of the Q3 pulse survey, which were
positive, compared to last quarter and the same period last year. (The Cultural Index
presented to The Board, provides a breakdown of the pulse survey results)
The OD Team have worked as part of the bullying and harassment focus groups
and have been providing training sessions on giving feedback effectively using a
structured model and approach. These sessions will continue (for e.g. at the big
listen)
5.3 To deliver a programme of talent management, leadership and skills
development
Supporting the WRES programme we offer coaching and interview skills training
and support for BME staff (and other employees who lack confidence at interviews).
We are investing in additional skills training for our coaching network to maintain
competence and quality. An Executive Mentoring Programme for BME Staff has
been initiated.
Managing Service Excellence Programme The first cohort of managing service
excellence has completed and the second commences in January 2016. This
programme is focused on middle managers, support is being targeted to those
areas with the most challenging people agenda. 14 individuals have gone through
the programme, which evaluated well and are also receiving coaching to help
facilitate the transfer of learning back to the workplace. The programme is pragmatic
in nature and focuses on real scenarios and how to utilise Trust policy and be
proactive to improve the workplace culture and take collective ownership for
employee satisfaction. This programme will becoming mandatory for individuals who
want to progress their career in management roles. We have already received
nominations for the next 3 cohorts of this programme.
Leadership Academy The emerging leaders programme is live and there are 10
individuals on this cohort (C6) and C7 is about to commence. 27 people are taking
emerging and the higher-level leaders programme. We are completing a review of
the leadership academy in light of the strategy and new OD Plan and the content will
be updated to align with organisational priorities and the results of the cultural
assessment activity.
Talent Management and Succession Planning A Talent Mapping exercise has been
undertaken during December and January to support the workforce planning,
development planning and sustainability of the organisation. The process identifies
critical posts and skills enabling focused plans to mitigate against highlighted risks.
11
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A succession plan will inform the investment in development activities. As part of
this process, we will be working with other organisations in the region to widen the
talent pool and provide a wider variety of development opportunities. The data will
be used to identify a pipeline of staff who would benefit from the internal and
external management and leadership programmes provided.
5.4 Develop deliver and evaluate a plan of employee engagement
Q3 has been an active quarter with regards to engagement activity:
Staff Awards There were the highest number of nominations received so far for the
staff awards in December 2015. As part of this reward and recognition event, we
received 204 nominations and presented 16 awards. We also recognised and
presented 121 staff development awards (certification and receipt of qualifications).
Senior Leaders Forum. The senior leaders forum in Q3 focused on the introduction of
the Trust Strategy ‘Good to Great’. The Senior Leaders Forum will develop through
next year providing targeted development opportunities for this group of staff and
active planning, involvement and discussion in the delivery of the strategy and
operational business plans.
Chief Executive Breakfast Meetings. There is a rolling programme of meetings, the
CEO has recently met with a group of senior leaders and team leaders in an informal
engagement session. These breakfast meetings form a valuable part of the
engagement process for the Trust and drive actions for continuous improvement.
This forum provides further opportunity for the triangulation of feedback.
5.5 To deliver the health and wellbeing strategy for the organisation
The OD Team is providing a development day for preceptorship nurses that focuses
on patterns of behaviour and how they impact on others.
Health and Well-being Co-ordinator a health and wellbeing co-ordinator is in post to
drive elements of the health and wellbeing strategy and wider workforce strategy.
They will support health campaigns such as the flu and promote healthy lifestyles
and will work closely with the Strategic Business Units and Corporate Teams to
support wellbeing of our staff and encourage work life balance. We have developed a
staff health and social committee who will inform the agenda and field the requests
for activities funded via the staff lottery scheme. Workshops are being created for roll
out in Q4 focusing on positivity, personal resilience and mindfulness.
5.6 Embedding the Trust values Welcoming, Kind, Positive, Respectful and
Professional supporting the customer care strategy
The team continue to roll out the Living Our Values Training sessions and have a
standing slot at the Trust induction. Over 90% of staff have had values focused
workshops.
As part of embedding the culture, the organisation has introduced values based
recruitment and the OD team are involved in delivering specific training on how to
use the scenarios and use behavioural questions. The values based screener is now
launched in all new episodes of recruitment.
5.7 To support strategy, transformation and improvement areas of the
organisation to be the choice provider of mental health and learning disability
services
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Team Based Learning The OD Team provide a service to teams in the organisation
where improvement action is identified (this is in conjunction with operational
managers and HR Business Partners) and includes team development sessions and
away days to develop service improvements, build relationships, improve productivity
and time to care and focus on workplace culture. These bespoke sessions include
skills development and behavioural change
6. Learning Education and Development
Provision of Education As a Trust we have a role as a provider of education for
Health Education East of England. As a result we undergo a series of quality visits
where we are assessed against a set of standards for medical education, nonmedical education library quality standards and the regional band 1-4 programme
‘Talent for Care’. We also have to meet standards for the provision of QCF
programmes (formally NVQ) as an accredited centre.
Quality Visits We have had three quality visits during Q3 and the organisation
received positive feedback at each. The library achieved 94% in their quality visit in
December. The Trust has a formal Quality Improvement Performance Framework
Visit (Health Education East of England) in September 2016. A project plan has been
developed in preparation for this and evidence of quality is being collated.
Talent for Care - The organisation is mapped against set criteria in the regional
Talent for Care Programme. This focuses on band 1-4 staff development and
includes criteria to attract, onboard and develop this group of individuals. As part of
this we recruited a cohort of apprentices last year and to maximise success of the
programme, we have put a support network in place to mentor the apprentices and
also to develop managers of apprentices. The Trust has rated high in the progress
visit by Health Education East of England. Continued plans will be delivered in the
implementation of the Workforce Strategy.
Pathways of Development – working with the Deputy Director of Nursing, we are
scoping pathways into nursing and investigating apprenticeships in care. This
agenda is developing with the recent spending review and the changing national
funding streams for nursing.
Training - During Q3, 3616 staff have attended a range of classroom based training
sessions. (NB this is sessions not days training and includes induction). Over this
period, 353 classes took place. There has been a continued drive to reduce the
number of did not attends (DNAs). During Q3 the number of DNAs was 278. In Q3
there were 98 staff who attended induction.
Apprenticeships – We have 45 individuals currently undertaking apprenticeship
programmes as part of their continuing professional development. The team also
support with the care certificate qualification (essential for all new health support
workers). We have 74 individuals undertaking the care certificate.
Training Needs Analysis Process The training needs analysis (TNA) process is
currently underway. The Strategic Business Units (SBUs) and Corporate Services
were asked to consider workforce development requirements as part of their
business planning meetings to ensure alignment of training needs with strategic
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priorities. The populated training needs analysis templates have now been submitted
and will be considered by the Strategic Workforce Development Group (SWDG).
Streamlining Statutory and Mandatory Training
We are working on streamlining our statutory and mandatory training. In conjunction
with our subject matter experts, the Learning and Development Team have been
reviewing the competency requirements for different staff groups and adjusting the
training delivered (medium and duration) to align to best practice without
compromising national safety standards and statutory guidance. This piece of work is
50% complete and has already resulted in a saving of 7,800 hours of training
annually for the organisation.
6. Recommendations
The Board is asked to note the Q3 position and the level of activity that is being
undertaken to support delivery of the Workforce and Organisational Development
metrics as well as the actions being identified to improve the position moving
forward.
Mariejke Maciejewski
Deputy Director of Workforce
January 2016
14
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December 2015 - Based on Q3
HPFT Workforce
Information Report
Summary
Agendaitem13Appendix1Q3W
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WORKFORCE INFORMATION REPORT SUMMARY
Workforce Report December 2015 (Based on data for Q3 2015/2016)
Section 1: KPI summary position
Vacancy Rate %
Table 1: Establishment Data
Q3, 14.32%
Q2, 14.28%
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
Annualised Sickness Rate %
Q3, 4.74%
Q2, 4.67%
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
Funded Establishment =
3006.62
Staff in post =
2575.92
Vacant posts =
430.64
% Vacancy rate =
14.32
% Turnover rate =
14.79
% Stability rate =
89.39
Annualised Turnover Rate %
Q3, 14.79%
Graph 1 : % Stability
Q2, 15.26%
10.00%
15.00%
20.00%
94
25.00%
93
Appraisal Rate %
92
91
%
Q3, 86.61%
Q2, 85.11%
90
2015/2016
89
88
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00%100.00%
87
Mandatory Training Rate %
86
85
Ap
ril
Q3, 87.14%
Q2, 87.99%
ay
Ju
ne
Ju
Au ly
Se gu
pt st
em
Oc ber
No tob
ve er
De mb
ce er
m
b
Ja er
nu
Fe ary
br
ua
r
M y
ar
ch
5.00%
M
0.00%
95
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00%100.00%
1
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Section 2: Recruitment
Table 2: Recruitment Summary by SBU
Vacancy Stage
Corporate FTE
SBU LD&F FTE
Authorisation
SBU East & North FTE
19.5
Vacancy Stage
Corporate FTE
SBU LD&F FTE
SBU West FTE
18.1
SBU East & North FTE
Total FTE
16.52
SBU West FTE
54.12
Total FTE
Longlisting
4.6
17
27.9
15.51
65.01
Shortlisting
2.6
14.1
15.5
6
38.2
10.5
9.5
23.6
12.43
56.03
Interview
Vacancy Stage
Corporate Headcount
Offer
Starting
SBU LD&F Headcount
SBU East & North Headcount
19.51%
17.06%
42
65
37
155
5
13
17
9
44
Graph 3: Vacancies (fte) by Staff Group
Add Prof Scientific and Technic
Add Prof Scientific and Technic
Additional Clinical Services
Additional Clinical Services
77.94
Administrative and Clerical
9.58%
Allied Health Professionals
11.08%
7.28%
Allied Health Professionals
70.02
Healthcare Scientists
15.59%
Medical and Dental
26.68
Nursing and Midwifery
Registered
0.49 3.20 16.23
Students
Estates and Ancillary
Healthcare Scientists
Medical and Dental
11.43%
Administrative and Clerical
165.11
13.94%
Total Headcount
11
Graph 2: Vacancies (%) by Staff Group
0.00%
SBU West Headcount
2
70.95
Nursing and Midwifery Registered
Students
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Section 3: Turnover
Graph 4 : % Turnover
Table 3: Q3 2015-2016 Leavers by Leaving Reason
No of Leavers
20
Voluntary Resignation - Relocation
Retirement Age
Voluntary Resignation - Work Life Balance
Voluntary Resignation - Promotion
Voluntary Early Retirement - with Actuarial Reduction
Voluntary Resignation - Other/Not Known
End of Fixed Term Contract
Voluntary Early Retirement - no Actuarial Reduction
Voluntary Resignation - Child Dependants
Voluntary Resignation - Health
Voluntary Resignation - Lack of Opportunities
Dismissal - Capability
Employee Transfer
Redundancy - Compulsory
Voluntary Resignation - Adult Dependants
Voluntary Resignation - Better Reward Package
Dismissal - Conduct
End of Fixed Term Contract - Completion of Training Scheme
Has Not Worked
Mutually Agreed Resignation - Local Scheme with Repayment
Retirement - Ill Health
Voluntary Resignation - Incompatible Working Relationships
Voluntary Resignation - To undertake further education or training
12
11
11
8
6
5
4
4
3
3
3
2
2
2
2
2
1
1
1
1
1
1
1
18
Grand Total
87
14
Target
2014/2015
12
Ap
ril
M
ay
Ju
ne
Ju
A ly
Se ugu
pt st
em
Oc ber
No tob
ve er
De mb
ce er
m
b
Ja er
nu
Fe ary
br
ua
r
M y
ar
ch
10
Graph 5: Starters & Leavers by Staff Group Q3
60
40
20
26
2730
19
15
13
1817
5 3
4 5
1
3
Starters
Leavers
Students
Nursing and Midwifery
Registered
Medical and Dental
Allied Health
Professionals
65+
12
14
44
10
80
Administrative and
Clerical
25
37
93
36
191
Additional Clinical
Services
55-59
41
80
145
58
324
Age
60-64
Add Prof Scientific and
Technic
0
Table 4: Retirement Profile
Retirement profile
367 Corporate
367 SBU Learning Disability & Forensic
367 SBU MH East & North Herts
367 SBU MH West Herts
Grand Total
2015/2016
16
%
Leaving Reason
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Section 4: Sickness Absence
Graph 6: % Sickness Absence
Table 5: Q3 2015-2016 Top 10 Reasons for Sickness Absence
6
No Of
Episodes
5
290
209
127
114
78
65
62
55
40
37
4.5
Target
4
3.5
Ju
Au ly
Se gu
pt st
em
Oc ber
No tob
ve er
De mb
ce er
m
b
Ja er
nu
Fe ary
br
ua
r
M y
ar
ch
ay
ne
Ju
M
ril
3
Graph 7: % Sickness Absence by SBU for Q3
Table 6: Sickness Cost
SBU
2015/2016
Ap
S13 Cold, Cough, Flu - Influenza
S99 Unknown causes / Not specified
S25 Gastrointestinal problems
S98 Other known causes - not elsewhere classified
S10 Anxiety/stress/depression/other psychiatric illnesses
S11 Back Problems
S12 Other musculoskeletal problems
S16 Headache / migraine
S28 Injury, fracture
S15 Chest & respiratory problems
5.5
%
Sickness Absence Reason
Estimated Cost of
sickness Q3
Corporate
£82,571
LD & F
£284,137
MH E&N Herts
£352,366
MH W Herts
£206,435
Trust
£925,509
3.12%
5.50%
LD & F
MH E&N Herts
MH W Herts
Corporate
4.28%
4.98%
4
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Section 5: Temporary Staffing
Graph 8: Bank & Agency Spend
Table 7: Q3 2015-2016 Bank, Agency & Substantive Spend
#,##0;[Re11](#,##0)
#,##0;[Re26](#,##0)
2015- 2016
#,##0;[Re11](#,##0)
Q3
YTD
Bank
#,##0;[Re26](#,##0)
Agency
£
Total spend
£
%
£
%
Agency
2,725,757
7.04%
9,277,403
7.83%
Bank
3,551,042
9.17%
10,585,723
8.93%
Substantive
32,446,996
83.79%
98,645,030
83.24%
#,##0;[Re11](#,##0)
#,##0;[Re27](#,##0)
38,723,795
Total
#,##0;[Re13](#,##0)
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
118,508,156
Graph 9: % FTE of Workforce by Assignment Category
Table 8: Q3 2015-2016 Bank and Agency Usage
Number of
Shifts
requested
minus the
cancellations
Number of
Bank
Shifts
Filled
21,934
16,474
2,884
Social Workers
OT/AHP
Staff
Nursing
Qualified
Unqualified
and
Admin
Total
2.97%
Number of
Agency
Shifts
Filled
Agency Fill
Rate
75.11%
4,104
18.71%
93.82%
2,669
92.55%
215
7.45%
100.00%
858
466
54.31%
392
45.69%
100.00%
824
669
81.19%
155
18.81%
100.00%
26,500
20,278
76.52%
4,866
18.36%
94.88%
Bank Fill
Rate
Total Fill
Rate
3.73%
5
11.79%
Permanent
Fixed Term
Bank
Agency
81.52%
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Section 6: Employee Relations
Table 9: Total Number of Live Employee Relations Cases in Progress by Staff Group
Additional
Clinical
Services
Admin and
Clerical
Number of Disciplinary Cases
8
3
Number of Grievances
1
Live ER Cases
Add Prof
Scientific
and Technic
Number of Capability cases
Allied Health
Professionals
Medical and
Dental
Nursing and
Midwifery
Registered
Total
7
18
1
2
1
1
Number of Bullying & Harassment cases
Number of Whistleblowing cases
Total number of cases in progress
1
1
9
4
9
22
Number of suspensions/restricted duties
5
1
5
11
Number of appeals
2
1
3
Number of Mediation sessions
6
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Section 7: Staff Development
Graph 10: % PDP Compliance
PDP Rate %
100
90
240
296
81%
565
622
91%
777
899
86%
476
559
85%
2058
2376
87%
85
2015/2016
Target 2015/2016
80
75
Ap
ril
M
ay
Ju
ne
Ju
A ly
Se ugu
pt st
em
Oc ber
No tob
ve er
De mb
ce er
m
b
Ja er
nu
Fe ary
br
ua
r
M y
ar
ch
367 Corporate
Grand Total
95
%
Number of Staff
SBU
Number of completed
appraisals
Table 10: Appraisal Compliance
Table 11: Mandatory Training Compliance
5469
88%
1345
535
7539
86%
706
358
4752
88%
2995
1330
18962
87%
Grand Total
75
7
Ju
A ly
Se ug
pt ust
em
Oc ber
No tob
ve er
De mb
ce er
m
b
Ja er
nu
Fe ary
br
ua
M ry
ar
ch
295
ne
763
Target 2015/2016
ay
80
Ju
88%
2015/2016
ril
1202
85
M
142
90
Ap
181
95
%
367 Corporate
100
% Compliance
Meets
Requirement
Due to expire
SBU
Does not meet
requirement
Graph 11: % Mandatory Training Compliance
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TRUST BOARD MEETING
Meeting Date:
January 2016
Agenda Item: 14
Subject:
Cultural Index Q3 2015/16
For Publication:
Author:
Lindsey Holman Interim Associate
Director Organisational Development
and Learning
Jinjer Kandola – Director of Workforce
& Organisational Development
Approved by: Jinjer Kandola
Presented by:
To present the Q3 cultural index data and recommendations to the Board
Action required:
To note and comment on the report
The index is populated from our quarterly pulse survey data. It tracks seven key areas that can
give an indication of the health of an organisation’s culture, these are:
 Staff engagement and motivation
 Support from line manager
 Understanding of values and behaviours
There were 165 respondents to the Q3 Pulse Survey, which is around 6.5% of Trust staff. Q3
return rates are commonly the lowest during the year as it co-incides with the Christmas period
and also the national staff survey. The return rate the same time last year was 215. There is a
general increase in the ratings across the indicators, and a good position compared to Q3 last
year.
The detailed data and SBU / corporate comparison are detailed in the report which also outlines
the activity being undertaken through the on-going Workforce and Organisational Development
activities.
Pulse Survey , Staff Satisfaction Survey, Retention plan
AgendaItem14WorkforceCultu
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Evidence for S4BH; NHSLA Standards; Information Governance
Standards, Social Care PAF:
CQC, NHS Constitution
Board/Audit
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Workforce and Organisational Development
Cultural Index – Quarter Three 2015/16
1. Introduction
1.1. This report provides an update to the Trust Board on the Quarter Three Workforce
Cultural Index. The index is populated from the response to our quarterly pulse
survey. The cultural index tracks the following seven key areas that can give an
indication of the health of an organisation’s culture:
 Staff engagement and motivation
 Support from Line Manager
 Understanding of values and behaviours
1.2. There were 165 respondents to the Q2 Pulse Survey, which is around 6.5% of
Trust staff. Q3 return rates are commonly the lowest during the year as it coincides with the Christmas period and also the national staff survey. The return
rate the same time last year was 215.
1.3. The culture index is not the sole measurement of organisational culture; however,
it provides the Trust with a picture of our employee viewpoints and provides us
with data to evaluate the impact of the ongoing actions being driven as a result of
the 2014 national staff survey, previous pulse surveys and other engagement
events.
1.4. True engagement ensures that there is a feedback loop recognising that the
organisation has listened to feedback from their employees and what it has done
in response. We are keeping a live record of the themes arising through staff
engagement processes (such as the Big Listen and pulse survey) and outlining
the activity undertaken by the organisation in response to these themes. This
engagement record is hosted on the intranet and updated quarterly. It also invites
staff to provide further comments or submit ideas for continuous improvements.
1.5. We are reviewing the engagement activities in the next quarter to evaluate and
plan for 2016/17 activities. We will consider the results of our staff survey 2015
results as we do this evaluation and also the results of the collective leadership
diagnostic process, which commences in Q4.
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2. Organisational Context
2.1. The quarter three pulse survey went live within the Trust from 7th – 31st December
This co-incided with the national staff survey and this may have had an impact on
the response rate.
2.2. The vacancy level for this period was 14.32% and sickness at 4.5%
2.3. We held our annual staff awards during December and recognised 121 learning
and development awards and 10 individual and 6 team awards. The number of
nominations received for the staff awards was 204, which is an increase of 34%
on last year. This suggests that the event is valued and recognised as a way of
rewarding staff and teams for their contribution.
2.4. There are remaining financial pressures for the Trust although in an improved
position from Q2. There has been a national agency cap introduced nationally
which the organisation is reporting compliance on weekly.
2.5. This context does represent a challenge for services to maintain staff rosters and
is likely to make access to off the job learning and development increasingly
difficult. In recognition of this, the Organisational Development and Learning Team
are taking more of their activities out to the services.
3. Summary of Findings
3.1. There is an increase in the ratings across 5 of the indicators, no change in the
percentage of staff reporting an understanding of contribution and a 1% decrease
in the 7th indicator (support from my line manager) which is still at 74% compared
to 59% at the same time last year. This is a good position; all indicators have
shown increases between at least 4% and up to 15% compared to the same time
last year.
3.2. The corporate area has the strongest cultural index although they report the
lowest access to training and development compared to other areas of the Trust.
3.3. 56% of respondents in Q3 would recommend the Trust as a place to work (an
increase of 6% compared to the last quarter. Of people who responded from the
corporate area, 81% said that they would recommend the Trust as a place to work
(compared to 71% in Q2)
3.4. The percentage of responders who agreed that they have an understanding of the
Trust values has increased this quarter to 82%, which is the highest score this
year and an increase of 13% compared to the same quarter last year. East and
North SBU rate the highest in this indicator at 85%.
3.5. As well as having the highest response rate for an understanding of the values,
East and North SBU also have the highest motivation levels from within the SBU
responders and are the SBU most likely to recommend the Trust as a place to
work at 56% (this is compared to 31% at Q1 this year).
3.6. LD & Forensic SBU and West SBU are both above average for the dimension of
‘contribution to the organisation’. West SBU is also above average for staff
reporting sufficient access to training and development. LD & Forensic SBU
reported the lowest experience of bullying and harassment this quarter.
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4. Q3 Results
4.1. The graph below shows the trend for response rates to the pulse survey. Q4
responses co-incide with the national staff survey and the Christmas period. There
was a good response rate from E&N SBU where 71 people responded to the
survey. This compared to 37 in West, 35 in LD&F and 21 in corporate services.
Q2 2011/12
Q3 2011/12
Q4 2011/12
Q1 2012/13
Q2 2012/13
Q3 2012/13
Q4 2012/13
Q1 2013/14
Q2 2013/14
Q3 2013/14
Q4 2013/14
Q1 2014/15
Q2 2014/15
Q3 2014/15
Q4 2014/15
Q1 2015/16
Q2 2015/16
Q3 2014/15
0
100
200
300
400
500
600
4.2. The trend analysis in the graph below, shows the trends since first reporting the
cultural index at Q1 2013/14. Since the last quarter, there has been an increase across
five of the key areas, one no change and a 1% dip in staff reporting support from their
Line Manager.
Cultural Index Trend - Q3 2015/16
90%
Recommending HPFT as a place to
work
80%
70%
Staff Engagement and Motivation
60%
50%
Understanding of contribution
40%
30%
Access to training and
development
20%
Support from Line Manager
10%
/1
6
/1
6
01
5
-2
Q3
/1
6
01
5
-2
Q2
/1
5
01
5
-2
Q1
/1
5
01
4
-2
Q4
/1
5
01
4
-2
Q3
/1
5
01
4
-2
Q2
/1
4
01
4
-2
Q1
/1
4
01
3
-2
Q4
/1
4
01
3
Q3
-2
01
3
/1
4
01
3
-2
Q2
Q1
-2
0%
Understanding of Values and
Behaviours
Not experiencing bullying &
harassment
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4.3. Looking at the trends in the previous graph, there has been a significant decrease
over the two years in the access staff has to training and development relevant to
their role (although an improving trend year on year). Staff engagement and
motivation does show a general increase over the two years. Support from line
manager has shown an improvement since a dip in 2014/15 (which was a time
when there was still significant transformation taking place).
4.4. Cultural Index by SBU and Corporate Areas
Cultural Index by SBU - Q3 2015/16
Recommending
HPFT as a place to
work
100%
Not experiencing
bullying &
harassment
80%
60%
Staff Engagement
and Motivation
40%
20%
Understanding of
Values and
Behaviours
Support from Line
Manager
0%
Understanding of
contribution
Corporate
East & North
LD&Forensic
West
Access to training
and development
4.5 Comparison by individual areas – The spider graph above shows pictorially that
the cultural index in the corporate area is in the best position and that in the other
areas, their scores are closer. The position for the following elements of the cultural
index is strong:



Understanding the Trust values and behaviours
Not experiencing bullying and harassment
Support from Line Manager
Within the operational areas (SBUs) the following elements of the index are weaker:



Understanding of contribution
Staff engagement and motivation
Recommending the Trust as a place to work
4.6 Staff recommendation of the Trust as a place to work: This is a dimension often
referred to as one of the ‘litmus test’ questions. In Q3, this dimension has seen a 6%
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increase as a Trust compared to the last quarter and the highest position since Q1
2014-15. There is a variance in the response to this question across the areas.
Corporate area remains the highest area where staff would recommend the Trust as a
place to work is at 81% (increased since Q2). In the SBUs the range is 46% in West,
53% in LD&F and 56% in East and North. We will continue to seek feedback and
acknowledge what staff are saying in the qualitative statements in the pulse survey. In
the summer of 2015, we introduced the concept of collective ownership, recognising
that an individual’s immediate ‘workplace’ culture is heavily influenced by the local
managers. This model is a key component of the managing service excellence
programme and other leadership development courses. A Health and Wellbeing coordinator post has been created to work with local teams focusing on their wellbeing.
4.7 Staff engagement and motivation levels This score is made up of responses to
three questions; I feel that I am listened to and that my opinions count; I enjoy coming
to work; and staff recommendation of the Trust as a place to work. Within this
dimension, the number of staff reporting that they enjoy coming to work was 65% this
quarter, which is a 12% increase year on year. 49% staff say that they feel listened to
and opinions count. This will be considered in the review of engagement activities to
improve this rating (which is still 16% increase from Q3 last year). The introduction of
the staff health and social committee will also provide further opportunities for staff to
have their ideas considered in the health and wellbeing agenda
4.8 Understanding of how individuals and their teams performance contributes to the
Trust – this score is made up of responses to three questions; feedback at an
individual level regarding how well people are doing in their role; understanding how
the team contributes to the Trust and lastly feedback in relation to how well the team is
doing. The scores for the first two questions are over 70%. it is the question regarding
how likely the organisation is to provide feedback on the team that scores lowest at
49% reducing the average collated results for this dimension. Although this is a 9%
increase since Q3 last year, we aim to improve this rating. We will be raising
awareness of the inspire awards and encouraging specific feedback from senior
managers during team visits. The HPFT news letter is also an opportunity to promote
good work of our teams
4.9 Staff access to training and development – Although this has increased in the last
quarter, it has significantly reduced since the cultural index monitoring began. Training
was postponed in the summer of 2015 (Q2) and this is likely to have had an impact on
the forthcoming staff survey. In addition, it is recognised that being released from
services is difficult (balancing ‘time to care’). As a result, the OD and Learning Team
are working more closely across different sites and are streamlining the statutory and
mandatory training programmes. It is also noted that for this quarter, the corporate
staff responding, rate this dimension the lowest. In the current training needs analysis,
the learning and development team will look to further promote non-clinical training
opportunities.
4.10 Support from line managers – The support from line managers is rated highly
(74% Trust wide). Every area of the Trust score above 69% on this dimension. The
supervision policy is being reviewed during Q4 as there are some managers who have
a high number of direct reports (which could dilute the quality of supervision). In
addition, we have provided guidance for managers on how to approach performance
and development reviews for new starters.
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4.11 Harassment and bullying – 86% of responders state that they are not
experiencing harassment and bullying, which is an improvement of 7% on this time last
year. There is focused activity planned to improve this rating further. A ban bullying
campaign took place in November to raise awareness across the organisation and
focus groups provided information on what our staff perceive as ‘harassment’ at work.
The OD Team are providing short workshops on a model of feedback that is respectful
and professional and these have evaluated well.
4.12 Values and behaviours – There has been an increase in this dimension since the
last quarter and an increase of 4% against Q4 last year. Further activity to continue to
embed the values will be ongoing through 15/16 and the collective leadership
diagnostic phase will provide us with further data for the next phase of living our values
and ‘going from good to great’.
5. Planned Actions
5.1 Engagement Points. There will be a review of the evaluation activities for the
organisation during Q4 to finalise the programme of engagement for 16/17. We will
continue to respond to feedback and ensure that staff know what the organisation has
done as a result of these engagement events. To truly understand the staff
experience, we are looking beyond the quantitative data of our surveys to the
qualitative verbatim statements and communicating these to managers to raise
awareness. We are developing the terms of reference for a staff health and social
committee who will work with the health and wellbeing co-ordinator to create a sense
of community across the organisation and inform the wellbeing agenda.
5.2 Delivery Model. The OD and HR team are re-focusing ways of working to be closer
to the services; delivering training, team development and coaching support locally in
the place of work and supporting managers through their live challenges.
5.3 Training Needs Analysis. The learning and development team will analyse the
training needs for the organisation to commission appropriate programmes of learning
for staff. We are developing pathways of development (for nursing initially, but aim to
develop this across other professional groups and administrative/ managerial routes).
5.4 Talent Mapping. During December and January, the organisation has undertaken a
talent mapping exercise to ensure stability and continuity across services now and
considering the future. Additional training and development opportunities (particularly
‘on-the-job’ training will be recommended once the analysis is undertaken. We will also
have a pipeline of participants for the internal and external management leadership
development programmes.
5.5 Collective Leadership Cultural Diagnostic Exercise. The Trust is working with the
Kings Fund and Professor Michael West to undertake an assessment of the Trust’s
Culture against the characteristics of collective leadership (which through their
evidence based research is shown to create a sustainable leadership culture to
provide safe, integrated and compassionate care within budget. This is a culture where
formal and informal leaders pull together to deliver the goals of the organisation and
individuals take responsibility and accountability for quality as part of this.
5.6 Communication of Trust Strategy. As the Trust strategy develops further, there will
be a series of planned engagement and communication activities to enable people to
understand their contribution. A revised Organisational Development Plan will be
developed to support the delivery of the Strategy.
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6. Conclusion
The results for Q3 have increased in the main and represent a good improvement
since the same quarter last year. We anticipate a greater response rate in the next
pulse survey in line with historic trends.
Next quarter we will also receive the Trust results in the national staff survey and we
will be commencing the collective leadership cultural diagnostic assessment both of
which will provide us with additional data of employee satisfaction and experience at
work informing our organisational development plan and activities for 2016-17.
The Trust Board is asked to note the findings of the Workforce Cultural Index and
make any additional recommendations and comments.
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TRUST BOARD OF DIRECTORS
Report of the
Finance & Investment
Committee
Meeting Date
January 2016
Agenda Item
15
Presented
By
Simon Barter
1. Purpose of the Report:
This paper provides a summary report of the items discussed at the Finance & Investment
Committee meeting on the 20 January 2016.
2. Items Discussed:
The Agenda for the meeting included:
 Financial Summary to end of December 2015 and recent guidance from Monitor on
Q4 actions needed.
 2016/17 National Planning Guidance
 2016/17 Financial Planning Update
 MH Payment Systems
 Updates on Contract negotiations; Buckinghamshire LD Services; elements of the
Strategic Investment Programme.
 Operational Capital Programme
 A review of the committee Terms of Reference and a draft work programme for the
committee.
The committee received a presentation regarding recent guidance received from Monitor
which had suggested actions for FT’s in respect of their end of year accounting and
efficiencies that could be made to ensure the overall out-turn target for the NHS was
reached. The committee noted the action that was being proposed in relation to the
guidance and supported these.
Discussions were held by the committee on the financial report for the period to 31
December 2015 and noted that the Monitor Risk Rating had increased to a 4 for the first time
in this financial year. The committee noted that the position built on the improving trend in
Q2, which confirmed that the control measures implemented around secondary
commissioning and agency spend have been sustained. The latest forecast for outturn was
a deficit of £200k for the full year.
The committee noted the National Planning Guidance for 2016/17 which required production
of two plans: a five year sustainability plan for all local health systems and a one year
operational plan for each health provider. The national “must do’s” outlined in the guidance
include the achievement of the two new mental health access standards and the delivery of
actions in local plans to transform care for those with learning disabilities. The National Tariff
shows a 2% efficiency factor which is predicated on providers meeting a deficit position of
AgendaItem15FICReport20.
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£1.8bn at the end of 2015/16 and a 3.1% uplift (including a one-off adjustment in respect of
the changes to pensions.) The committee noted the changes in the planning arrangements
and supported the planning approach – noting that the guidance was issued on 22
December with the requirement that first draft of the plan be submitted by 8 February. The
committee asked for further consideration to be given to the surplus figure to be planned
given the “control total” that Monitor was a surplus of £0.6m.
The committee discussed the national proposals to develop new payment systems which
Monitor consulted on last year. Two key options are being considered – developing an
episodic/year of care approach and developing a capitated payment approach. The
committee noted that whilst the episode of care approach would appear to best fit HPFT it
may provide a more limited framework for the development of an integrated care approach.
A key issue is to continue to develop appropriate baseline data and information in relation to
activity and resources and to develop, jointly with commissioners, potential outcomes based
definitions. The committee agreed that the internal “Service Line Reporting Board” should
continue its work on developing an implementation plan and the trust would continue to
explore the transition to a revised payment approach within the current contract negotiations
and into 2016/17 as part of the service development plan supporting the three year contract.
Contract negotiations are progressing with discussions on the form of future contracts
underway. In respect of Hertfordshire that committee noted that two significant areas have
emerged: one regarding the move away from the block contract to a contract based on
activity and outcomes for IAPT and a capitated plus outcomes approach for the balance
effective from 1 April 2016. The committee supported the Trust position around the ensuring
that the move to the new approaches was a balanced one in terms of risks to the
organisation; and the second that the Section 75 agreement requires a fundamental review
as under the Care Act it is not possible for the Council to delegate its safeguarding duties but
it can instruct others to help it discharge those duties. Discussions are underway to reach
an understanding of the options. Final agreement is likely to take until end of March 2016.
Other contract negotiations in respect of LD services in N Essex and Norfolk are progressing
well. The committee noted that the N Essex contract was likely to be an extension of the
current contract prior to a full tender exercise across Essex in the coming year. The IAPT
services challenges were discussed and it was noted that if we fail to hit the planned
trajectories agreed following the issue of a Contract Performance Notice the Trust would be
subject to a financial sanction of 10% of the monthly contract value for each CPN.
The committee noted that due diligence is progressing in relation to the Buckinghamshire LD
services and a final business case will be presented to the Board next month. The
committee asked that the “stop/go” criteria be clarified to inform the Board’s decision.
The committee discussed the updated Capital Plan which had been amended to reflect
overall affordability. The operational priorities for funding are being finalised and any key
changes will be reported to the committee. A draft detailed plan for the spending of
operational capital (ligature, fire, backlog maintenance) had been compiled to address items
highlighted in the 5 facet survey and the fire safety compliance survey. The committee
agreed that they wished to receive regular reports on the achievement of the plans timeline.
The committee discussed changes to the current Capital Plan and noted the renewed
interest in the purchase of Shrodells Unit.
In respect of Seward Lodge – the committee noted that the construction final account of
£2,088,172 had been agreed with Interserve on 13 January 2016. The proposed final
settlement exceeds the project expenditure approved by £22,442 due to final agreement with
HMRC of reclaimable VAT being at a lower percentage than the original assessment by the
Trust’s VAT advisors. The committee recognised the Final Account.
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The Operational Capital Plan allocations for the next five years were reported to the
committee with a prioritisation plan to manage the expenditure across the 5 year
programme. The committee noted the prioritisation in respect of the risks identified and ..
The committee discussed its terms of reference which had been revised to reflect the Board
review of its committees and reporting arrangements. They asked that consideration be
given to ensuring standardisation across the terms of reference for all committees and asked
the Company Secretary to revise as necessary concerning attendance at meetings and a
section on escalation of risk. With these provisos the terms of reference were approved to
be taken to the Board for final ratification.
The committee also discussed a draft work programme for agreement at the next meeting.
3. Matters for escalation to the Board:
There were no matters for escalation to the Board.
4. Committee decisions for Board to note:
The committee approved the amended Terms of Reference to be submitted to the Board.
5. Decisions for Board approval
There were no decisions for Board approval as the Board will be receiving full reports in
respect of the guidance and planning process for 2016/17 for separate approval.
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Meeting Date:
28 January 2016
Agenda Item: 15b
Subject:
Review of Terms of Reference
For Publication: yes
Author:
Barbara Suggitt
Presented by:
Simon Barter
Approved by:
Keith Loveman
To put forward Terms of Reference of the committee, following the annual review process, for
approval by the Board.
Action required:
The Board to approve approval.
The Board reviewed the working of its committees last year and agreed changes to the
membership of the committee and the reporting requirements to the Board. The Terms of
Reference have been reviewed to reflect the changes:
Membership has been reduced from the full Board to 5 Non-executive and 4 Executive Directors
The Chair of the committee is now required to report to the Board following each committee
meeting and the detailed requirements are set out in the terms of reference.
Recommendations
The FIC reviewed the terms of reference at their meeting on 20 January and the Board is not
asked for their approval.
Assurance):
Part of the code of governance for Board.
No financial or legal implications.
n/a
Evidence for Essential Standards of Quality and Safety; NHSLA Standards;
n/a
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TERMS OF REFERENCE
Finance and Investment Committee
Status:
The Finance & Investment Committee is a subcommittee of the Trust Board
Chair:
Non – Executive Director
Membership:
The Committee shall be appointed by the Board
and shall consist of:
Non-Executive Directors (x5 including committee
Chair)
Executive Director Finance
Executive Director Quality and Safety/Executive
Director Quality & Medical Leadership
Executive Director Service Delivery and Customer
Experience
Executive Director Strategy & Commercial
Development
Executive Director Integration & Community
Services
Frequency of Meetings:
6 meetings per annum
Frequency of Attendance:
Members will be expected to attend all meetings.
If members miss two consecutive meetings,
membership will be reconsidered by the
Committee
Chair (subject to exceptional
circumstances).
Quorum:
A quorum shall be three members including at
least one Executive Director and two NonExecutive Directors
1.
Remit
1.1 The Finance & investment Committee is a Standing Committee of the Board.
1.2 The remit of the Group is to:
“To conduct an independent and objective review of financial and
investment policy and performance issues including the
assessment and monitoring of risk in respect of financial issues”.
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2.
Accountability
2.1
A report will be made by the Chair to the Trust Board following each
committee meeting. The report will contain:
A note of all the items discussed by the committee
Matters for noting by the Board
Recommendations to the Board regarding decisions to be taken by the Board
Escalation of matters from the committee to the Board
Any other issues as agreed by the Chair & Company Secretary.
2.2
The minutes of the Finance & Investment Committee meetings shall be
formally recorded by the Trust Secretary and submitted to the Board and
Audit Committee.
2.3
A six monthly report from the Finance & Investment Committee shall be
submitted to the Audit Committee.
3.
3.1
Responsibilities & Duties
Financial Policy, Management and Reporting
3.1.1 To consider the Trust’s financial strategy, in relation to both revenue and
capital.
3.1.2 To consider the Trust’s annual financial targets and performance against
them.
3.1.3 To review the annual budget, before submission to the Trust Board of
Directors.
3.1.4 To consider the Trust’s financial performance, in terms of the relationship
between underlying activity, income and expenditure, and the respective budgets.
3.1.5 To review proposals for major business cases and their respective funding
sources.
3.1.6 To commission and receive the results of in-depth reviews of key financial
issues affecting the Trust.
3.1.7 To maintain an oversight of, and receive assurances on, the robustness of the
Trust’s key income sources and contractual safeguards.
3.1.8 To oversee and receive assurance on the financial plans of significant
programmes.
3.1.9 To consider the Trust’s tax strategy.
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3.1.10 To annually review the financial and accounting policies of the Trust and
make appropriate recommendations to the Board of Directors.
3.2
Investment Policy, Management and Reporting
3.2.1 To approve and keep under review, on behalf of the Board of Directors, the
Trust’s investment strategy and policy.
3.2.2 To maintain an oversight of the Trust’s investments, ensuring compliance with
the Trust’s policy and Monitor’s requirements.
3.3
Other
3.3.1 To make arrangements as necessary to ensure that all Board of Directors
members maintain an appropriate level of knowledge and understanding of key
financial issues affecting the Trust.
3.3.2 To examine any other matter referred to the Committee by the Board of
Directors.
3.3.3 To review performance indicators relevant to the remit of the Committee.
3.3.4 To monitor the risk register and other risk processes in relation to the above.
4.
Other Matters
The Committee shall be supported administratively by the Company Secretary,
whose duties in this respect will include:
 agreement of agenda with Chairman and attendees and collation of papers
 taking the minutes & keeping a record of matters arising and issues to be
carried forward
 advising the Committee on pertinent areas
5.
Monitoring of Effectiveness
5.1
The group will review its own performance and terms of reference at least
once a year to ensure it is operating at maximum effectiveness.
Terms of Reference ratified by: FIC
Date of Ratification:
January 2016
Date of Review:
January 2017
Terms of Reference Version:
4
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Trust Board
Meeting Date:
28th January 2016
Agenda Item: 16
Subject:
Finance Report for the period to 31st
December 2015
Sam Garrett, Head of Financial
Planning & Reporting
For Publication: No
Author:
Presented by:
Keith Loveman, Executive Director of
Finance
Approved by: Paul Ronald, Deputy
Director of Finance and Performance
Improvement
To inform the Board of the current financial position, the forecast position for the financial year
and any likely short term financial risks.
Action required:
To review the financial position set out in this report, and consider whether any additional action is
necessary, or any further information or explanation is required.
The overall Trust position is a surplus of £220k for the month, which is ahead of the Plan of £83k;
and a surplus of £113k for the year to date, behind the Plan. This continues the improving trend
over the last months; it is largely due to the continued reduction in Pay Costs, smaller reduction in
Secondary Commissioning costs particularly private sector Acute placements, and non-recurrent
benefit against income.
The Monitor Risk Rating, the FSRR, has increased to a 4 for the first time this year, the increase
being due to the improvement in the I&E margin. The financial position for the remainder of the
year will be dependent upon the level of recruitment and the level of additional non recurrent
infrastructure investment planned in the final quarter which has been held back during the period
to end of quarter 3. The forecast position remains a deficit of c. £200k, £1.2m below the Plan for
the full year.
Effective use of resources, in particular to meet the continuing financial requirements of the
organisation.
Finance – achievement of the 2015/16 planned surplus
AgendaItem16PublicBoardFi
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Seen by the following committee(s) on date: Finance & Investment / Integrated Governance /
Executive / Remuneration / Board / Audit
FIC 20th January 2016
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1. Background to Financial Plan 2015/16
1.1 The Financial Plan for 2015/16 assumes achievement of a surplus of £1.0m, (lower than the
2014/15 Plan which was £2.0m, but compares to a break-even position achieved in 2014/15);
and a Monitor CoSRR of 4 (again, in line with 2014/15). 4 is the highest rating, and is very
dependent upon a return to surplus. The key risks to its achievement are:
1.1.1
1.1.2
1.1.3
Securing our planned income from commissioners, including the successful conclusion of
current discussions with commissioners on additional investment.
The achievement of a stretching CRES target of £8.0m, particularly reductions in agency pay
spend and in external placements.
Management of the capital estates programme within the available capital funding.
2. Performance Summary and Risk Rating
2.1 The overall Trust position is a surplus of £220k for the month, ahead of the Plan of £83k by
£137k; and a surplus of £113k for the year to date, behind the Plan of £750k surplus by £637k.
This is shown in Fig. 2a below:
2.2 The Trust’s overall Monitor risk rating, the Financial Sustainability Risk Rating (FSRR), increased
to a 4 in month 9, due to the continued improvement in the I&E Margin ratio.
2.3 Performance against the Monitor Agency Cap (calculated as the proportion of overall nursing
pay filled by agency) was 14% in December, and 13% average from October, against a target of
8% (to be achieved as the average over the six month period).
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3. Trading Position
3.1
Appendix F1 Statement of Comprehensive Income, (SOCI), gives the full position and
comparison to the Plan.
3.2
Employee Pay Costs totalled £10.7m in December; below Plan of £10.8m for the first time in
year, and a decrease in total spend of £132k from November. For the year to date they
totalled £98.7m, above Plan by £1.8m. Of the overall total spend in the month, £8.7m (82%)
was on Substantive Staff, £789k (7%) on Agency, and £1.2m (11%) on Bank.
3.3
Fig. 3a below shows overall actual against planned pay spend for the last 12 months, with pay
better than Plan for the first time. Agency staff pay costs remain high, due to high levels of
vacancies, but have reduced in recent months, with significant focus applied to recruitment of
substantive staff.
3.4
The most significant area of non-pay spend above Plan remains Secondary Commissioning,
which totalled £2.25m in December, above Plan by £210k. Areas of most concern remain
Acute and PICU placements, which have reduced from a peak in 2014/15, but remain high.
4. Income and Major Contracts
4.1 Total income planned for the year is £198.8m, with Block income of £188.6m. Additional
funding has been received from Hertfordshire Commissioners in respect of “Parity of Esteem”.
5. CRES
5.1 The CRES requirement for 2015/16 is c. £8.0m. To date schemes totalling £3.2m have been
fully delivered, £3.5m are in progress and forecast for delivery, and a gap of £1.3m remains.
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6. Forecast 2015/16
6.1
As noted above the forecast position is a deficit of £200k. It includes income significantly
above Plan and expected savings on financing costs due to lower interest and capital charges. This is
offset by Pay costs and secondary commissioning costs being above Plan and some additional
overhead spend. The detail of planned and potential movements across the final quarter are
reviewed on an ongoing basis, including consideration of areas of uncertainty presented at the Audit
Committee in December.
6.2
There is additional committed non recurrent spend to meet PLACE requirements in relation
to service user environments, and support to Performance Improvement and IM&T to ensure
services have necessary equipment and information.
6.3
All NHS Trusts have received details from NHS Improvement of areas for potentially
improving the financial position in-year. The majority of these are already factored into the yearend
forecast, but opportunities to further improve cost control and efficiency will continue to be
explored where these do not compromise service quality or safety.
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Current Trading - Income Statement for Period Ended 31-December-201
Actual in
month Dec14
Actual YTD
to 31-Dec14
Description
Number of Calendar Days
APPENDIX F1
2015/16
Plan
Month
Actual
Dec - 15
Plan
Year to Date
Actual
Dec - 15
Plan
365
31
31
275
275
152,704
18,467
9,061
2,020
6,364
188,616
12,705
1,525
755
168
562
15,715
12,725
1,539
755
168
569
15,756
(20)
(14)
0
(0)
(6)
(41)
115,015
13,743
6,796
1,515
4,600
141,668
114,528
13,850
6,796
1,515
4,658
141,347
487
(107)
0
(0)
(59)
321
554
2,111
1,646
5,088
803
23
198,841
46
231
219
416
127
39
16,793
46
176
137
424
67
2
16,609
(0)
55
81
(8)
60
37
184
366
1,764
3,422
4,013
749
344
152,326
416
1,583
1,235
3,816
602
17
149,016
(50)
181
2,187
197
147
327
3,310
(124,613)
(4,670)
(387)
(8,709)
(1,969)
(54)
(10,415)
(389)
(32)
1,705
(1,580)
(21)
(78,837)
(19,862)
(488)
(93,369)
(3,502)
(290)
14,532
(16,359)
(198)
(24,119)
(2,725)
(2,250)
(166)
(2,039)
(227)
(210)
61
(20,474)
(1,899)
(18,119)
(2,044)
(2,355)
145
(45)
(121,560)
(117,325)
(4,235)
30,767
20.20%
31,691
21.27%
Variance
Variance
31
0
12,636
1,547
767
164
436
15,550
31
0
111,499
13,916
6,901
1,478
3,920
137,714
66
273
455
464
56
27
16,890
614
1,788
3,365
3,881
814
352
148,529
(8,725)
(2,012)
(40)
(77,883)
(17,939)
(353)
(2,434)
(235)
(19,944)
(1,985)
Employee expenses, permanent staff
Employee expenses, agency & contract staff
Clinical supplies
Cost of Secondary Commissioning of mandatory
services
Drugs
(13,445)
(118,104)
Total Direct Costs
(156,514)
(13,148)
(13,102)
3,445
20.40%
30,425
20.48%
Gross Profit
Gross Profit Margin
42,326
21.29%
3,645
21.71%
3,506
21.11%
(148)
(128)
(338)
(0)
(1,459)
(93)
(243)
(263)
(2,672)
(824)
(714)
(2,833)
(0)
(13,742)
(802)
(2,005)
(2,518)
(23,438)
Overheads
Consultancy expense
Education and training expense
Information & Communication Technology
Hard & Soft FM Contract
Misc. other Operating expenses
Non-clinical supplies
Rents
Travel, Subsistence & other Transport Services
Total overhead expenses
(15)
(402)
(3,504)
(5,658)
(13,942)
(694)
(2,717)
(3,021)
(29,953)
(37)
(106)
(379)
(435)
(1,086)
(41)
(236)
(258)
(2,579)
(1)
(33)
(292)
(472)
(1,141)
(58)
(226)
(252)
(2,475)
(36)
(73)
(87)
36
55
17
(10)
(6)
(104)
(422)
(723)
(3,456)
(4,017)
(9,264)
(526)
(2,186)
(2,503)
(23,097)
(11)
(301)
(2,628)
(4,244)
(10,403)
(520)
(2,038)
(2,266)
(22,412)
(411)
(422)
(828)
227
1,139
(5)
(148)
(237)
(686)
773
4.57%
6,987
4.70%
EBITDA
EBITDA Margin
12,373
6.22%
1,066
6.34%
1,031
6.20%
35
7,669
5.03%
9,280
6.22%
(1,610)
(370)
(21)
(0)
8
(389)
(3,222)
(267)
(7)
71
(3,509)
Depreciation and Amortisation
Other Finance Costs inc Leases
Gain/(loss) on asset disposals
Interest Income
PDC dividend expense
(5,961)
(600)
(0)
96
(4,908)
(437)
(43)
(0)
11
(378)
(497)
(50)
(0)
8
(409)
60
7
(0)
3
31
(3,906)
(367)
(23)
91
(3,351)
(4,471)
(450)
(0)
72
(3,681)
564
83
(23)
19
330
(0)
52
1,000
220
83
136
113
750
(637)
0.50%
1.31%
0.50%
Block contract #1 Hertfordshire JCT
Block contract #2 East Anglia LAT
Block contract #3 North Essex (West Essex CCG)
Block contract #4 Norfolk (Astley Court)
Block contract #5 IAPT Essex
Block Contracts
Clinical Partnerships providing mandatory svcs (inc
S31 agrmnts)
Education and training revenue
Misc. other operating revenue
Other - Cost & Volume Contract revenue
Other clinical income from mandatory services
Research and development revenue
Total Operating Income
Net Surplus / (Deficit)
Net Surplus margin
0.00%
0.04%
0.07%
0.50%Page6of6
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BOARD OF DIRECTORS
Meeting Date:
28th January 2016
Agenda Item: 17
Subject:
MHAM Committee Annual Report
to the Board
Mary Pedlow/Tina Kavanagh
Loyola Weeks and Mary Pedlow
For Publication:
Author:
Presented by:
Approved by:
To report on the activity of Mental Health Act Mangers during 2015 and for the board to
support changes to TOR of the MHAM Subcommittee which extends membership to all
NEDs.
Action required:
As required by the Terms of Reference of the MHAM Subcommittee meeting an
annual report is to be presented to the Board for information about MHAM activity.
For information only.
All MHA legislation is integrated into the Business Plan. Board, to gain agreement that
the report provides assurance that all statutory responsibilities are undertaken and
agreement to changes to the TOR
MHAM are not employees of the Trust. There is a legal requirement for the Board to
authorise individuals to exercise the power of discharge (S26 (3) MHA) and to ensure
that there is a scheme of delegation in place to ensure all other responsibilities of the
Trust are met in respect of the MHA.
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1)
Introduction
This report covers activity in respect of the Mental Health Act Manager
Service as required by the MHA Code of Practice (2015) and also by the
Terms of Reference for the MHA Manager Committee, which is reviewed
and reapproved by the Board for Hertfordshire Partnership University NHS
Foundation Trust.
The report focuses on 2015 and the ongoing development of processes,
guidance, training requirements in respect of the Mental Health Act and the
evolving implications of the Mental Capacity Act 2005 (and Deprivation of
Liberty Safeguards).
2)
Responsibilities of the Trust Board
NHS Trusts are defined as Hospital Managers for the purposes of the Mental
Health Act 1983, (as amended by the MHA 2007), in effect this is the Board
of Directors made up of executive and non-executive members. It is the
Hospital Managers who have the authority to detain patients under the Act
and they have the primary responsibility for ensuring that the requirements of
the Act are followed, in particular:



They must ensure that patients are detained only as the Act allows;
That treatment and care accord fully with the provisions of the Act;
That patients are fully informed of, and are supported in exercising
their statutory rights.
Hospital Managers have various powers and duties which include:




The power of discharge from compulsory powers (detention and
Community Treatment Orders).
Receipt and Scrutiny of Mental Health Act Documents.
Provision for access to the First Tier Tribunal Service (Mental Health)
Provision of information to patients and their nearest relatives.
In practice, the decisions and actions of the hospital managers are actually
taken by individuals (or groups of individuals) authorised by the Board to act
on their behalf, in particular, decisions about discharge. Section 26(3) of the
Act states that any three or more persons authorised by the Board, that are
not Executive Directors of the Board or an employee of the Trust can exercise
the power of discharge from compulsory powers:



Only non-executive directors or other non-employees appointed for the
purpose can exercise this power.
These other non-employees are referred to in HPFT as Mental Health
Act Managers (MHAM).
MHAM may be paid a fee for their role, but their role and activity within
the organisation must not be such that it would amount to the MHAM
being classed as an employee.
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The Mental Health Act Managers Committee is a sub-committee of the Trust
Board for these purposes.
Information in relation to the use of the Mental Health Act within HPFT:
The data for 2014/15 from the Health and Social Care Information Centre
show that nationally there has been a 6.7% increase in the number of
patients subject to detention or CTO restrictions compared to the 31st March
2014, and an increase of 20% compared to the 31st March 2011 snapshot
count. Although there was a decrease of 17.5% in the number of patients
subject to the MHA as at 31st March 2015 (295) compared to 31st March
2014 (358), the number of detentions within HPFT continue to rise. There
were 1321 detentions 2014/15 compared to 1053 detentions 2013/14, an
increase of 25.5%.
The following graph shows the increase in the number of detention
orders over the years within HPFT.
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3)
MHA Managers Subcommittee Meeting Structure:
There is an annual Trustwide Committee meeting for all HPFT MHA
Managers which is the official Subcommittee of the Board and membership
of all NEDs is now included in Terms of Reference; This event also
combines an all-day training, development and discussion event and
includes formal minutes of the meeting. 20 of the MHA Managers attended
the annual meeting in October 2015 at Newmarket.
As well as the combined annual Board Subcommittee meeting there were
also Hertfordshire, Essex and Norfolk MHAM Committee meetings
throughout the year.
These individual county specific Committee meetings complement the
annual meeting with an opportunity to discuss aspects of Hearings specific
to their area.
4)
The Team of MHA Managers
In 2014 a new NED lead for MHA Managers was appointed along with a new
Manager of the Mental Health Act Manager service in October 2014. These
appointments continue to ensure a clear line of responsibility and
accountability to the Board.
MHA Managers have a yearly appraisal to review the previous year with the
Chair of the Mental Health Act Managers Committee and the Manager of the
MHA Manager Service. The Code of Practice states that appointments to
MHA Managers’ Panels should be made for a fixed period and that any
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reappointment should not be automatic and should be preceded by a review
of the person’s continued suitability. These review meetings are also used as
an opportunity to identify potential new Panel Chairs and to inform the
training/discussion group programme and development of the Service.
Hertfordshire Partnership University NHS Foundation Trust has 41 MHAM as
follows:
Location
Hertfordshire
Norfolk
N.Essex
Total Number of Active
MHAM
31
5
5
Chairs
13
2
4
The team of MHA Managers is relatively stable in Hertfordshire and 2 new
MHA managers have recently been approved by the board, 1 in
Hertfordshire and 1 in Norfolk and a further 3 prospective MHA Managers
interviewed for Herts. Any shortfall in availability of MHAM for Norfolk has
been covered by N.Essex MHAM.
There is an expectation that MHAM (Herts) will attend 10-22 Hearings per
year to ensure that there is an equitable distribution.
5)
MHA Managers Hearings
Patients subject to compulsion orders under the MHA that can be renewed
or extended must have the renewal/extension reviewed by the MHAM,
(patients subject to compulsion can also appeal against their section to the
MHAM). The figures for 2015 have shown a decrease in appeals and
reviews.
Location
Appeals and
Reviews Req
Herts
182
Norfolk
16
N.Essex
10
Total
208
*Excludes CTO Paper Reviews
Number
Reviewed*
2015
132
16
10
158
Difference
from 2014
Discharged by
MHAM
- 13
0
+6
-7
4
0
1
5
5
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The following chart shows reasons, where known, why hearings were not
held.
Reasons for cancelled hearings
15
16
14
12
10
8
6
4
2
0
13
8
5
2
2
1
1
1
1
1
* Prior to March 2015 reasons for cancellations were not recorded.
The MHAM Committee, following much debate, agreed that the review of
extensions for uncontested Community Treatment Orders, where the patient
has capacity to make this decision, can be held as a “paper review”, (this is
in accordance with the Code of Practice). This means that Responsible
Clinicians (RC) and Care Coordinators (CC) do not have to physically attend
a hearing however should be available by phone when the review hearing is
held. Paper reviews for uncontested Hertfordshire CTO extensions were
piloted at Little Plumstead Hospital during 2013 and from May 2014 were
also being held at Lexden. During 2015 30 CTO extension reviews were held
at Lexden and 1 at Little Plumstead Hospital, there were no discharges
resulting from these reviews.
6)
First Tier Tribunals (FTT)
All patients subject to the MHA have the right to appeal to the FTT for a
review of their section and the MHAM have a duty to refer a patient at
specific intervals during their compulsion.
Location
Appeals and
Referrals Req
Herts
Norfolk
N.Essex
Total
405
21
7
433
Number
Reviewed
2015
204
20
7
231
Difference
from 2014
Discharged by
FTT
+21
+8
+4
+33
13
1
0
14
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7)
Responsible Clinicians
There was an invitation for Loyola Weeks, (Lead NED for the MHAM) and
Mary Pedlow (Manager of MHAM), along with Tina Kavanagh to attend a
MSC meeting in Little Plumstead to confirm the role of the MHA Managers
and the responsibilities of the MDT in respect of attendance at MHAM
hearings. This proved to be a constructive meeting where it was agreed that
members of the clinical team could leave before the end of the hearing where
other pressing clinical matters needed to be addressed. This was agreed
subject to them being contactable if required by the MHAM.
An annual meeting with the Consultants in Hertfordshire is due to take place
in 2016.
8)
Discussion Groups and Training 2015
There was a programme of discussion groups and training in place for 2015
this included an essential update of the changes to the MHA Code of Practice
by Bevan Solicitors.
All MHAM have been given a copy of the new MHA Code of Practice that
came into force on 1st April 2015.
The HPFT MHAM Annual Committee Meeting included presentations and
discussions on:






Trust update - Christopher Lawrence (Chair).
MHA Legal Update (Tina Kavanagh, Directorate Manager MH
Legislation) which included changes to the MHA Code of Practice.
How risk averse are MHAM, a presentation by Chris Wright, MHAM
General feedback on MHA Hearings and CTO paper reviews (all
attendees).
Nursing Reports, problems and possible resolution presented by Andy
Cashmore (Practice Development & Patient Safety Lead).
RCs and risk – Kaushik Mukhopadhaya (Executive Director - Quality
& Medical Leadership).
Key themes from Annual Reviews and updates (Mary Pedlow
MHAMM).
The MHA Managers Information Packs, which includes guidance on Hearings,
Competencies Framework, complaints and the MHA Managers Standards
amongst other information is being updated on a continuous basis and will be
available to all MHAM via the Trust Internet site on a “secure” part of the
website.
The county specific MHA committee meetings have focused on development
of services within each county with updates delivered by relevant service
managers.
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9)
Service User Feedback Form
Although a service user feedback form in respect of how they felt during and
after a MHAM hearing was introduced during 2014 there was minimal
response. The MHA dept revised the form and continue to send the feedback
form to all those Service Users that attend a hearing, work with the IMHA
service will continue to try to encourage completion of the form to help
improve the MHAM service.
10) Achievements and Acknowledgements for 2015
The year has continued to provide challenges particularly around
implementing amendments to the Mental Health Act and the testing
challenges that have been thrown up at Hearings.
The guidance on structure and contents of Responsible Clinician, Nursing and
Social Care Reports was completed and implemented across Little
Plumstead, Hertfordshire and North Essex which has supported the
production of more focused and, on the whole, shorter joined up reports. We
have had fruitful discussions with the Director of Nursing in respect of
strengthening nursing input at Hearings and there is an ongoing piece of work
taking place to improve the quality of the nursing reports.
We would welcome endorsement from the Board of the significant and
remarkable input during a period of increased demand in volume and
complexity in MH Legislation made by the MHA Legal Team and recognition
of the continued challenges of the MHA Manager role for Chairs and Panel
Members.
11) 2016 Discussion Groups and Training
There is a duty (Mental Health Act Code of Practice) that MHA Managers
should properly understand their role and the working of the Act and that the
Board ensures that they “receive suitable training to equip them to understand
the law, work with patients and professionals, reach sound judgements and
properly record their decisions.
A programme is currently being drawn up for the forthcoming year.
There will be on going focus on:




Standards of Hearings in terms of meeting the criteria for detention
and discharge.
Achieving consistency in recording of panel decisions, in an evidence
based manner.
Updating knowledge and understanding in light of the changes in the
Code of Practice.
Identifying gaps in understanding/requirements and actively
addressing these both with individuals and at group training sessions.
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

Developing high performing panels through use of group best practice
experience sharing.
Acknowledging specific training needs for Little Plumstead, N Essex
and Hertfordshire including those identified by MHAMs locally.
Priorities for 2016
12)
There are a number of priorities for the forthcoming year for the MHA
Manager Service (including continuation of many 2015 priorities)












Ongoing training and MH legal updates in respect of the MHA and its
interface with MCA and DOLS.
Further development work to try to gain feedback from Service Users
about their experiences of MHAM Hearings and to actively take
account of this feedback.
On-going support to all MHA Managers to ensure a consistent and
integrated service across all sites.
To ensure that learning resources for guidance on the MHA and MCA
is available electronically for the MHAM, including access to elearning.
To continue CTO Paper Reviews by LPH & N Essex MHA Managers.
Continuing the progress being made towards achieving greater
diversity in the pool of MHA Managers, particularly around ethnicity.
Continue to contribute to the London Mental Health Act Network’s
quarterly meetings and training strategy group to maintain good
practice within our Trust and help to develop better practice.
To ensure that the training programme for MHAM addresses the
requirements of the Code of Practice overall and specifically in
respect of understanding risk.
To reinforce the need for clarity and conciseness in reports from all
disciplines and in decision making and that standards in respect of
recording decisions are consistent and show the necessary evidence
for either ongoing detention or discharge.
Ensure MHAM are aware of the changes to the MHA Code of Practice
and all policies relevant to this are updated.
All MHAM to have current DBS checks.
Communication/circulation of information to Managers.
13) Future Annual Reports on the Service
A future report will be submitted to the Trust Board in 6 months in line with
other Sub Committees of the Board.
Report produced by Mary Pedlow /Tina Kavanagh
on behalf of Loyola Weeks
January 2016
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Meeting Date:
28th January 2016
Agenda Item: 18a
Subject:
Author:
Board Assurance Framework
(BAF) Oct – Dec 2015
Nick Egginton
Presented by:
Barbara Suggitt
Barbara Suggitt
Approved by:
The Board Assurance Framework (BAF) is reviewed quarterly and presented to the Audit
Committee for their overview as a key assurance process for the Board.
Action required:
The Board is asked to review the Board Assurance Framework. The framework has been seen
and discussed at the Integrated Governance Committee.
Summary and recommendations to the Audit Committee:
1. Introduction to the Board Assurance Framework (BAF).
The Board Assurance Framework (BAF) identifies the principle risks of the Trust not achieving
its Strategic Goals, the systems and controls in place to manage and mitigate those risks and
assurances about the effectiveness of these systems and controls.
2.The BAF Review & Assurance Cycle
The Board Assurance Framework is reviewed each quarter. The four review cycles per year
comprise two full reviews and 2 routine reviews, alternating between the two types. The full
review includes a scrutiny by the Audit Committee between the IGCs review and the Board.
3. Changes to the BAF since the last report
A full review of the BAF with the leads took place in November and December 2015; the review
took place to ensure that the BAF reflected the current assurances and controls.
4. Low / Medium Assurance against Strategic Objectives
 Supervision
- The assurance required is about supervision in general for all disciplines as well as
community and the need for assurance for all in a systematic way.
- From a nursing perspective we are currently undertaking a qualitative and quantitative
audit of RN and HCA supervision across the Trust. The data collection was
throughout November and has been extended to ensure full participation. The results
will be analysed and a report available by the end of January 2016 with an action
plan.
- Nursing supervision structure trees are available in each SBU.
- The Heads of Nursing monitor the frequency of supervision for the services in their
SBU
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- E-rostering and ESR are two long term options but both require additional resources
The results of the audit will be taken to the IGC for review.
 The Trust Quality Account has been to the external quality review meeting and a Q2
report was presented at the Integrated Governance Committee. Framework will be
amended to reflect this.
 The overarching 2015/2016 Corporate Communications and Engagement Strategy is
linked to the Trusts Strategic Objective to develop a strong relationship with
commissioners, GPs, and key partners. The Communications and Engagement Strategy
includes guidance on the following:
- Public Engagement and Consultation
- Media Relations
- Stakeholder Roles and Framework
- Membership Strategy (sign off is with Trust Governors)
- Written Communication and Public Information (sign off is with the co-production
group)
- Media Crisis Plan
The overarching strategy is now with the Executive Director for Workforce and
Organisational Development for review.
5. Conclusion
The Board is asked to note the updated BAF and note the areas of low assurance and the
action that is being taken to improve this.
N/A
N/A
Equality & Diversity (has an Equality Impact Assessment been completed?) and Public & Patient
Involvement Implications:
N/A
Evidence for Essential Standards of Quality and Safety; NHSLA Standards; Information
Governance Standards, Social Care PAF:
CQC Fundamental Standards – Regulation 17 Good Governance
Board/Audit
Integrated Governance Committee 21st January 2016
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Board Assurance Framework (BAF)
1st October - 31st December 2015
To be reviewed by:

Integrated Governance Committee: 21.01.2016

Audit Committee: TBC

Trust Board: 28.01.2016
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Introduction
This Board Assurance Framework brings together the principal risks potentially threatening the Trust’s Strategic Goals and outlines
specific controls measures that the Trust has put in place to manage the identified risks and the independent assurances relied
upon by the Board to demonstrate that these are operating effectively.
Explanation of Assurance types and levels
Assurance Type - The identified source of assurance that the Trusts receives can be broken down into a three line model (1st, 2nd
and 3rd line assurances)
1st Line
Assurance from the service that
performs the day to day activity
E.g. Reports from the department that
performs the day to day activity,
Departmental Meetings, Departmental
Performance Information
2nd Line
Assurance provided from within the
Trust - Internal assurance
E.g. Internal Audit, Management
Dashboards, Monthly monitoring
meetings with key managers
3rd Line
Assurance provided from outside the
Trust - Independent assurance
E.g. External Audit, Peer Review,
External Inspection, Independent
Benchmarking
Assurance Level - For each source of assurance that is identified you can rate what it tells you about the effectiveness of the
controls
High
Effective controls are in place and the
Trust Board are satisfied that
appropriate assurances are available
Medium
Effective controls in place but
assurances are uncertain and/or
possibly insufficient
Low
Effective controls may not be in place
and/or appropriate assurances are not
available to the Board
Substantial assurance provided over the
effectiveness of controls
Some assurances in place, or
substantial assurance in place, but
controls are still maturing so
effectiveness cannot be fully assessed
at this time.
Assurance indicates poor effectiveness
of controls
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Strategic
Objective
Principal Risk
Risk Controls
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Assurance
Date
Gaps in Assurance
Action for Gaps
in Assurance
What the
Trust aims
to deliver
Principal risks are
those that threaten
the achievement of
the Trusts strategic
objectives.
The Trust should ensure that
key controls are in place which
is designed to manage the
principal risks.
What sources of
assurance are there?
It is essential
that Board and
Board sub
committees
receive regular
reports about
the assurances
on the
management of
their principal
risks and are
proactive in
addressing
issues that
arise.
The
assurances
that the
Trust
receives can
be broken
down into a
three line
model
Each source
of assurance
that is
identified you
can rate what
it tells you
about the
effectiveness
of the
controls
The date of
the assurance
There is a lack of
assurance, either
positive or negative,
about the
effectiveness of one
or more of the key
controls.
The date which
the assurance
was published
High
QIA report to
IGC
22.07.2015
This may be as a
result of lack of
relevant reviews,
concerns about the
scope or depth of
reviews that have
taken place or the
length of time since
the last review.
1. Deliver
safe and
effective
services
Service users
unable to access
the right service in
a timely way
Quality Impact Assessments
Procedure for CRES
QIA sign off meetings
every six weeks with
the Executive Directors
for Quality and Medical
Leadership and Quality
and Safety
IGC
2st Line
CRES
Performance
Assurance
Board
CRES Board
Nov 2015
QIA Quarterly Reports
Performance Monitoring
(Access Indicators)
Performance Report
(Q2)
Trust Board
2nd Line
High
Lull in QIA
process as
majority of
QIA’s linked to
CRES
completed for
15.16
Meeting with
the directors
responsible –
6 weekly
28.10.2015
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Strategic
Objective
Principal Risk
Service users are
not able to
progress positively
through our
services, feel safe
and be protected
from avoidable
harm
Risk Controls
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Assurance
Date
Annual Business Plan
2014.2015
Report / KPIs (Q2)
Trust Board
2nd Line
High
28.10.2015
Quality Account 2015 – 2016
(Making Our Services Safer /
Risk Assessments )
Quality Report - Key
Performance Indicators
Trust Board
2nd Line
Medium
21.01.2016
Quarterly
Commissioner Meetings
Quarterly Reports
Quality Review
Meeting
Trust Board
3rd Line
High
18.11.2015
2st Line
High
30.07.2015
1 page
summary
report to TB
in Jan 2016
18.11.2015
CQUIN 2015 – 2016 (Making
our Services Safer / Acute
Mental Health Services –
Improved Service User Flow)
Annual Programme of Clinical
Audit (Practice Audit and
Clinical Effectiveness)
Quarterly
Performance Reports /
Dashboards
Quality Review
Meeting
Ops Committee
3rd Line
High
2nd Line
High
24.09.2015 /
10.10.2015
Regular reports on
progress against the
plan
QRMC
2nd Line
High
11.11.2015
Audit
Committee
2nd Line
High
23.09.2015
PAIG
1St Line
Medium
Need a report
for PAIG
meeting on
20.01.2016
NICE Progress Reports
Gaps in Assurance
Action for Gaps
in Assurance
Quality Account has
been to the external
quality review
meeting but has not
been to our IGC or
Board since sign off in
July – Q2 report to be
presented at IGC / TB
in January 2016
Some gaps in closing
the audit loop around
receipt of action plans
and evidence of
implementation
Difficulty in
measuring
compliance and gaps /
Reporting on progress
is informal
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Strategic
Objective
Principal Risk
Risk Controls
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Assurance
Date
Safer Care and Standards
Processes
Whistleblowing /
Freedom to Speak up
Whistleblowing
IGC reports
2nd Line
High
Next Report
for IGC
21.01.2016
CCG Quality
Contract
Meeting
3rd Line
High
18.11.2015
Service User / Carer
concerns raised with
the Trust via the CQC
(CQC Concerns)
Whistleblowing
Group
2nd Line
High
26.11.2015
Quarterly Patient Safety
Report
Trust Board
Review of Serious
Incidents
2nd Line
High
28.10.2015
3rd Line
High
22.10.2015
18.11.2015
ENHCCG
2nd Dec 2015
HVCCG
Planned for
March 2016
CQC Assurance Process
Internal Audit Review
CQC Intelligence
Monitoring Tool
CQC Planned Inspection
27.04.2015 Report /
Action Plan
Action for Gaps
in Assurance
Next Report
for IGC
21.01.2016
IGC
IGC
Clinical
Commissioning
Groups
Gaps in Assurance
IGC
IGC
3rd Line
3rd Line
Medium
High
Last report
22.07.2015
Next report to
be published
25.02.2016
22.10.2015
Next update
planned for
21.01.2016
7
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Strategic
Objective
Principal Risk
Risk Controls
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Assurance
Date
Gaps in Assurance
Trust Board
3rd Line
High
28.10.2015
CQC MHA Inspections
Mental Health
Act Quality
Managers
Meeting
3rd Line
High
Regularly
Routine unannounced
visit as part of the
HVCCG and the
Integrated Health and
Social Care Team’s
Quality Assurance Visit
Programme
Reported at
Quality
Contracts
Meeting
3rd Line
Medium
Adult Eating
Disorder
Service
08.08.2015
Limited in scope,
infrequent and
limited selected
locations
Risk, BAF and
Governance Internal
Audit Review
Audit
Committee
2nd Line
High
Completed
Green Rating
01.09.2015
Action plan to be
completed and
presented
CQC - Review of Health
Services for Children
Looked After and
Safeguarding in
Hertfordshire – Action
Plan
Safeguarding
Strategy Group
3rd Line
High
08.12.2015
Health, Safety and
Security Report
(Quarterly & Annual)
HSSC
2nd Line
High
25.11.2015
Making Our Services
Safer (MOSS) Strategy
and Report
CRLLG
2nd Line
Medium
19.11.2015
Action for Gaps
in Assurance
Action Plan in
place linked to
the MOSS
Strategy
Safer Wards
initiative
8
Page8of18
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Strategic
Objective
Principal Risk
Risk Controls
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Assurance
Date
Gaps in Assurance
Action for Gaps
in Assurance
Emergency Planning
and Business Continuity
Local Health
Resilience
Partnership
Peer Reviews
3rd Line
High
06.10.2015
Verbal feedback
confirmed as fully
assured.
Further work
on on-call packs
and updating
decant plans
National Quality Board (NQB)
Staffing Report
Safe Staffing Levels
report
Trust Board &
Standing
agenda item at
Commissioners
Meeting
2nd Line
High
28.10.2015
Medicines Management
Safe and Secure
Handling of Medicines
QRMC
2nd Line
Medium
11.11.2015
Further report
at QRMC
31.01.2016
Staff report that
they are not able to
deliver safe and
effective services
2. Service
users,
carers,
referrers
and
commission
ers will have
a positive
experience
of our
Service users
unable to report
that they would
recommend our
services to friends
and family if they
needed them
Systems for Staff Feedback
(FFT)
2014 National Staff
Survey
Trust Board
3rd Line
High
29.04.2015
Pulse Survey (Cultural
Index Report Q2)
Trust Board
2nd Line
High
28.10.2015
Trust Board
2nd Line
Medium
21.01.2016
Most units have
received safe and
secure handling
audits in last 3 years,
there is a gap in
assurance around
action plans from
these visits
Deputy Director
for Quality and
Nursing is
addressing the
action plan via
the SBU Heads
of Nursing
2015 National
Staff Survey
launched in
October 2015 –
results available
late January
2016
Quality Account has
quality review
meeting but has not
been to our IGC or
in January 2016
9
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Strategic
Objective
Principal Risk
Risk Controls
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Assurance
Date
Quarterly
Quality Review
Meeting
3rd Line
High
18.11.2015
Complaints and Service
Experience
Quarterly Report
QRMC
2nd Line
High
11.11.2015
Carers Strategy 2013 - 2018
Carer Strategy Action
Plan 15.16
SUCEG
2nd Line
Medium
19.11.2015
(FFT)
Trust Board
2nd Line
Medium
21.01.2016
High
18.11.2015
(Access Indicators)
Quality Review
Meeting
Trust Board
3rd Line
GP’s will feed back
that they are
unable to access
services and clinical
expertise when
they need it and
experience poor
communication
with HPFT staff
Quarterly
Performance Report
(Q2)
2nd Line
High
28.10.2015
Failure to deliver
on contractual
targets
(all Quality Account Priorities)
Trust Board
2nd Line
Medium
21.01.2016
services
Carers unable to
report feeling
supported and
valued in their role
Gaps in Assurance
Action for Gaps
in Assurance
Due for sign off
by SUCEG on
19.11.2015
Quality Account has
quality review
meeting but has not
been to our IGC or
in January 2016
Quality Account has
quality review
meeting but has not
been to our IGC or
10
Page10of18
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Strategic
Objective
Principal Risk
Risk Controls
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Assurance
Date
Gaps in Assurance
Action for Gaps
in Assurance
in January 2016
CQUIN 2015 – 2016 (all CQUIN
targets)
3. We will
transform
services,
putting the
needs of
service
users and
carers at
the centre
Failure to deliver a
consistent service
and experience in
line with best
practice
Quarterly
Quarterly Reports
Quality Review
Meeting
Trust Board
3rd Line
High
18.11.2015
2st Line
High
30.07.2015
1 page
summary
report to TB
in Jan 2016
18.11.2015
Quarterly
Performance Reports /
Dashboards
Quality Review
Meeting
Ops Committee
3rd Line
High
2nd Line
High
24.09.2015 /
10.10.2015
(Monitor Targets)
Performance Report
Trust Board
2nd Line
High
28.10.2015
Public Sector Equality Duty &
EDS 2
Assurance Report
Trust Board
2nd Line
High
29.04.2015
NHS Workforce Race Equality
Standard (WRES)
Assurance Report
Trust Board
2nd Line
High
30.07.2015
Service User Feedback
2015 Community
Mental Health Survey /
National Service User
Trust Board
3rd Line
High
28.10.2015
In process of
recruiting
maternity cover
for Equality
Lead to
progress
stakeholder
engagement in
EDS2
11
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Strategic
Objective
Principal Risk
Risk Controls
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Assurance
Date
Carer Strategy Action
Plan 15.16
SUCEG
2nd Line
Medium
19.11.2015
Service User & Carer
Engagement Group
QRMC
1st Line
High
19.11.2015
Triangle of Care
East of England
Carers Trust
Committee
3rd Line
High
24.04.2015
QRMC
2nd Line
High
11.11.2015
Annual Plan Report Q2
Trust Board
2nd Line
High
28.10.2015
Finance and Investment
Committee (FIC)
Update Reports
FIC
Gaps in Assurance
Action for Gaps
in Assurance
Survey
Failure to work in
partnership to
deliver support and
treatment that is
joined up across
mental health,
physical health and
social care services
Failure to invest in
modern, state of
the art
environment that
promotes recovery
and deliver the
highest quality care
Carers Strategy (2013-2018)
Transformation Programme
Due for sign off
by SUCEG on
19.11.2015
Currently in process
of working toward
Level 2 of
accreditation across
all community teams.
Due for
completion by
end of
December 2015
for submission
to carers Trust
Feb 16.
21.10.2015
Workforce
4. Staff will
have a
positive
experience
of work
Staff do not report
feeling engaged
and motivated and
do not recommend
the Trust as a place
to work
Provider of Medical Education
for Health Education East of
England
Multi Professional Quality
Improvement Performance
Framework
Deanery Inspection
WODG
3rd Line
High
Informal visit
took place
26.03.2015
Formal
Inspection
September
2016
12
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Strategic
Objective
Principal Risk
Risk Controls
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Assurance
Date
Gaps in Assurance
Action for Gaps
in Assurance
Annual visit on nonmedical training
provision.
WODG
3rd Line
High
2015
No concerns (some
recommendations for
continuous
improvement)
Follow up visit
January 2016
Library Quality Visit
Inspection
WODG
3rd Line
High
Scheduled
visit Dec 2015
by Library
Quality
Assurance
Framework
Workforce Health and
Wellbeing Strategy 2015-2017
KPI’s Report against
Strategy Aims (Q2
Report)
Quarterly Workforce
and Organisational
Development KPI
Report
Quarterly Workforce
Cultural Index Report
WODG
2nd Line
High
05.11.2015
Trust Board
Trust Board
2nd Line
High
28.10.2015
28.10.2015
Trust Board &
Exec quarterly
2nd Line
High
28.10.2015
Recruitment and
Retention Group
Workforce
Organisational
Development
Group
Trust Board
1st Line
High
Every 4 – 6
Weeks
2nd Line
High
28.10.2015
Recruitment and Retention
Strategy and Policy
Failure to achieve
reduced levels of
bullying,
harassment and
physical violence
Pulse Survey
Workforce Race Equality
Standard (NHS Contract 15.16)
Dashboard for
improving race equality
Trust Board
2nd Line
High
30.07.2015
Pulse Survey
Trust Board
2nd Line
High
28.10.2015
2015 National Staff
Trust Board
3rd Line
High
TBC
94% compliance
Workforce Race
Equality Standard as
currently not part of
our quality schedule
WRES project
lead in place
2015 National
13
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Strategic
Objective
Principal Risk
Risk Controls
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Assurance
Date
Survey
MOSS Strategy
Making Our Services
Safer (MOSS) Strategy
and Report
(Links to positive and
safe (DH, 2014)
CRLLG
2nd Line
Medium
19.11.2015
Gaps in Assurance
Action for Gaps
in Assurance
Staff Survey
launched in
October 2015
results in Jan
2016
Action Plan in
place linked to
the MOSS
Strategy
Safer Wards
Initiative
5. We will
have a
productive
and high
performing
workforce
Failure of staff to
develop strong
core competencies
Workforce and Organisational
Development Strategy and
Plan 2014 - 2016
Quarterly Workforce
and Organisational
Development KPI
Report
WODG
3 Year Organisational
Development Plan ( OD
Activity Reporting)
WODG
2nd Line
High
Trust Board
05.11.2015
28.10.2015
1st Line
High
Trust Board
05.11.2015
28.10.2015
OD Activity in
place for
2015.2016
To be reviewed
before 2016 –
commission of
Michael West
from Kings Fund
to undertake
cultural audit
Leaders not
equipped with core
management and
leadership skills
Failure to
demonstrate
efficient ways of
working across our
Workforce and Organisational
Development Strategy and
Plan 2014 - 2016
OD Work plan 15-16
(OD Activity Reporting)
Trust Board
2nd Line
High
28.10.2015
14
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Strategic
Objective
6. We will
embed a
culture that
promotes
our values
Principal Risk
services
Failure of staff to
understand how
the Trusts values
relate to their
specific roles and
provide evidence
through
supervision and
appraisal of how
they are putting
the aligned
behaviours into
practice
Risk Controls
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Assurance
Date
Gaps in Assurance
Action for Gaps
in Assurance
Supervision
Supervision Records
Line Manager
1st Line
Low
N/A
No central assurance
process for
monitoring
compliance,
assurance provided
through Heads of
Nursing monitoring at
a local level (Only for
inpatient nurses)
PACE nursing
supervision
audit
completed and
being finalised.
Likely review of
supervision
policy (working
group) in near
future.
Appraisal / PDP
Monthly Dashboard
Reporting
Trust Board
2nd Line
High
28.10.2015
Mandatory Training
Programme
Sustainability
7. We will
secure the
financial
sustainabilit
y of our
services
Failure to maintain
a solvent financial
position that
supports the
continuity of
services provided
by the Trust
Financial Plan 15.16
Monitor Continuity of
Service Risk Rating
(CoSRR) and
Governance Rating
Trust Board
(CEO Brief)
3rd Line
High
28.10.2015
Finance Reports
Revenue Summary
Report (to 30.09.2015)
Finance and
Investment
Committee /
Trust Board
2nd Line
High
28.10.2015
Quarterly Financial
Summary Reports
Monitor
3rd Line
High
Quarterly
Treasury Management Policy
Annual Report 14.15
2nd Line
High
21.05.2015
External Audit
Deloitte External Audit
2014.2015
Audit
Committee /
Trust Board
Trust Board
3rd Line
High
21.05.2015
15
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Strategic
Objective
8. We will
develop an
enviable
reputation
for quality
and
innovation,
and strong
relationship
with
commission
ers, GPs and
our key
partners
Principal Risk
Failure to deliver
on the efficiency
savings required by
our commissioners
and maintain a
surplus
Failure to secure
existing income
streams and
continue to seek
out new
opportunities for
growth
Failure to continue
to improve our
profile and
relationships with
commissioners,
GP’s and our
partners
Risk Controls
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Assurance
Date
Losses and Special Payments
Annual Report
2nd Line
High
21.05.2015
CRES
Part of Financial
Summary Report
Audit
Committee /
Trust Board
Trust Board
2nd Line
High
28.10.2015
Regular Reports /
Quarterly contract
meetings with CCG’s
Finance and
Investment
Committee
2nd Line
High
21.10.2015
Trust Board
Gaps in Assurance
Action for Gaps
in Assurance
28.10.2015
University Partnership
Annual Report to Trust
Board on University
Partnership
Trust Board
2nd Line
High
23.10.2014
Quality Assurance Framework
Report - University Partnership
Annual Report to Trust
Board
Trust Board
2nd Line
High
23.10.2014
Communication, Marketing
and Engagement Strategy and
Plans
(Including Stakeholders,
Members and Social Media)
Reports against
Strategy, plans and
KPI’s
Trust Board
1st Line
Medium
TBC
The overarching
2015/2016 Corporate
Communications and
Engagement Strategy
is with the Executive
Director for
Workforce and
Organisational
Development.
16
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Strategic
Objective
Principal Risk
Risk Controls
Meetings with key
Stakeholders
Failure to develop
and sustain
strategic
partnerships to
support the
delivery of more
joined up,
integrated services
Continuously engage with
commissioners, DoH, Monitor,
review / reflect on intelligence
amending plans in year as
necessary
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Assurance
Date
Governors engagement
groups
Trust Board
2nd Line
High
Quarterly
Service User Council /
Carer Council / Youth
Council (regular reports
to SUCEG)
Service User
and Carer
Engagement
Group (SUCEG)
3rd Line
High
On -going
Council of Governors
working groups /
Council of Governors
Trust Board
2nd Line
High
November
2015
Clinical Commissioning
Group
Contract
Meetings
3rd Line
High
On-going
Quality Review
Meetings
3rd Line
High
On-going
Monitor Updates
Quarterly
Telephone
conversations
on Risk Ratings
3rd Line
High
On-going
Meetings with CQC
Local Inspector
Meeting
1st Line
Medium
Deloitte Audit (Findings
and recommendations
from the 2014.2015
NHS Quality Report
External Assurance
Review)
Trust Board
3rd Line
High
Meeting held
10.11.2015 ,
further
meetings to
be planned for
2016
21.05.2015
Gaps in Assurance
Action for Gaps
in Assurance
17
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Strategic
Objective
Principal Risk
Risk Controls
Assurance Source
Reported to
Assurance
Type
Assurance
Level
Failure to achieve
recognition
regionally and
nationally for the
achievements of
our staff and the
areas of good
practice across our
services
The Trust has achieved regionally and nationally over the last 12 months

CQC Good Rating

HSJ Trust Board of the Year Award

Positive Practice in MH Team and Individual awards

Director of Quality and Safety honoured in Nursing Times inspirational nursing leaders in 2015
Assurance
Date
Gaps in Assurance
Action for Gaps
in Assurance
18
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Trust Board
Meeting Date:
28th January 2016
Agenda Item: 18b
Subject:
Trust Risk Register December
2015
Nick Egginton
Compliance & Risk Manager
Catherine Pelley / Oliver Shanley
Author:
Presented by:
Approved by:
Catherine Pelley
A quarterly review of the current Trust Risk Register (TRR)
Action required:
The Trust Board is asked to:
 Review the Trust Risk Register
 Note the risks escalated to the Trust Risk Register by the Integrated Governance
Committee
1. Introduction / Background
The Trust Risk Register (TRR) outlines the current risks of all types facing the organisation and
summaries the mitigating actions being taken to control and minimise them.
There are 10 risks currently on the Trust Risk Register
Where a risk links to an identified CQC action then this has been noted, although the work to
match risks on the risk registers to CQC actions continues.
2. Escalated Risks to Trust Risk Register by the Integrated Governance Committee
ID Risk 366 Approved Mental Health Practitioner (AMHP) Staffing Levels
There are not enough AMHPs to provide a robust service across Hertfordshire, which means
that the Trust is at risk of not delivering delegated duties under section 75 of the MHA, meet
locally agreed timescales and with a potential patient safety risk for service users / carers.
This risk was reviewed at the Safeguarding Strategy Group on 08.12.2015, the funding agreed
for additional AMHPs is in place and interviews were taking place in December. However HCC
have recently said that these posts cannot solely be recruited to provide AMHP cover as this is a
1
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function of the local authority (AMHP cover is provide by HPFT staff who undertake it as a
secondary role). This recent development might pose a barrier to recruitment.
ID Risk 488 Timely Step up from PICU to Medium Secure Services
This risk covers a number of areas however the prime reason for escalation is the risk to staff
which is a health and safety issue.
Specifically Oak ward are holding a service user in long term segregation for months due to a
resourcing issue of which the SBU have virtually no control but hold all the risks and will
continue to do seemingly for a number of months to come. In addition it has/ is affecting the
SBU’s ability to admit to PICU which has financial and quality implications on a number of levels.
3. Risks downgraded from Trust Risk Register
ID Risk 430 Gaps in the Safeguarding referral process leading to referrals not being completed
This risk was reviewed at the Safeguarding Strategy Group on 08.12.2015. A recent meeting
hosted by the HPFT safeguarding team with HPFT patient safety teams has clarified the
process and mandatory fields have been included on Datix to assist with the process. The risk
has been downgraded to a score of 8. It will remain on the Corporate Safeguarding Risk
Register.
4. Risk Updates
ID 116 Financial Challenges
 Cost pressures due to lack of capacity for specialist services like CAMHS inpatient beds
and service users with Personality Disorders with a gap in CCG / Specialised
Commissioning funding.
 Monitor and Trust Development Authority national cap in place – Nursing cap of 8% with
reducing trajectory
 Cap on agency rate 55% above agenda for change rates
 Currently behind financial plan – forecasted a 200k deficit
 Reduced over establishment of Adult Community Agency Staff
 Funding of placements not commissioned for (Placement Service)
ID 215 Workforce Recruitment and Retention
 Risk is about impact on finance, quality and safety, and staff morale
 Recruitment and Retention Group continues monthly
 Values based recruitment is starting shortly
 New exit interview process to start shortly
 Recruitment is locally driven with HR support
 Net gain of 15 staff in Q2
 HR Business Partners developing a recruitment calendar for 2016
 40 new starters have been eligible for the golden hello scheme but the refer a friend
scheme has been less successful
 25% of the workforce have or are reaching retirement age, letters have been sent to
those asking what their short to medium term plans are.
 The Trust currently has 15 agency staff whose current hourly rate exceeds the price cap
that will need to be reported to monitor.
 This risk is linked to the CQC action MD2 that the Trust must recruit to fill vacancies,
2
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decrease the number of agency staff and increase permanent staff across each core
service.
ID 120 Business Risk – Loss of Income
 Herts - Contract negotiations underway with commissioners, memorandum of
understanding has been drafted, positive response from commissioners for 3 year
contract, although with new payment system.
 North Essex - On-Going discussions with Essex commissioners re intentions. Expectation
of 1 year extension to current contract with further clarity anticipated in December 2015.
 Specialist Medium and Low Secure services - Expectation of a further 1 year contract
ID 167 Continuing Healthcare Strategy
 Update paper is being presented to the Exec on this risk.
 The financial implications of double running costs remain.
 The risk has been linked to risk ID 486 added by Estates Planning about failure to deliver
the older people transformation programme to budget / time.
ID Risk 427 DOLS Authorisations not in place
 Since the Cheshire West ruling Supervisory Bodies have been inundated with DOLS
applications and then subsequent reviews. The Trust is left in a position that most of the
DOLs follow up applications are being considered as low priority. Nationally this is an
issue and we as the Managing Authority have done all we can in that we are constantly
chasing them up.
 The Trust is currently awaiting outcomes on 112 Dols applications; including applications
that have gone past the 21 days expect outcome date.
 This risk is linked to the CQC action MD4 to ensure that each patient under DOLS has a
current authorisation.
5. SBU Risk Register Summary
Risks scoring Moderate and above – excluding those risks escalated to the Trust Risk Register
West SBU Risk Register
Risk ID
488
324
412
157
146
428
403
320
West SBU Risk Register
Title
Timely Step up from PICU to medium secure
Albany Lodge Ligature risks (linked to CQC action MD5)
Swift Ward Staffing (linked to CQC action MD3)
Staffing of the S136 Suite
Albany Lodge Staffing (linked to CQC action MD3)
Managing Acuity Levels on Robin Ward
Internal doors locking at Kingfisher Court
Access Target Rates for Wellbeing Teams
Risk Rating
16
15
12
12
12
12
12
12
East and North SBU Risk Register
East and North SBU Risk Register
Risk ID
Title
Risk Rating
3
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303
301
470
305
304
302
299
SBU Financial Position
SBU Recruitment and Retention
DOLS authorisations not in place within Inpatient Units
Maintaining Quality and Safety within Older Peoples
services
SBU use of bank and agency (linked to MD action MD2)
MHSOP consistent GP and physical health medical cover
CAMHS waiting times and partnerships
16
15
12
12
12
12
12
LD&F SBU Risk Register
Risk ID
379
273
145
124
LD&F SBU Risk Register
Title
Astley Court & Broadland Clinic Recruitment and Retention
(linked to CQC Action MD2)
Continuing Care and Placement sustainability/delivery of
savings
Mid Essex IAPT – contractual performance
Ligature risks at Warren Court and Broadland Clinic (linked
to CQC Action MD5 and SD23)
Risk Rating
12
12
12
12
6. Corporate Risk Register Summary
Risks scoring Moderate and above – excluding those risks escalated to the Trust Risk Register
Risk ID
137
367
430
Safeguarding
Title
Risk to the safety of service users, their families and to
AMHPs due to long waits for conveyance
Corporate Safeguarding Staffing Resources
Gaps in the Safeguarding referral process leading to
referrals not completed
Medicines Management Team
Title
Ascribe IT Software has restricted functionality and long
term future unclear
380
Pharmacy Capacity in MMT to provide support for Rehab
and Older People Inpatient Units (linked to CQC Action
MD7)
382
Risk of secondary dispensing
381
Pharmacy capacity to provide clinical pharmacy support to
community teams
495
Safe and Secure Handling of Medicines Audits
383
Impact of AAU Swift beds on pharmacy and kingfisher court
dispensary
*funding recently agreed for solution so risk score will be reduced
Risk ID
384
Risk ID
454
386
Infection Control
Title
Legionella Prevention / Management
Unable to fully meet the requirements of Criteria 3 of the
Risk Rating
12
9
8
Risk Rating
12*
12
9
9
9
9
Risk Rating
12
12
4
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Health and Social Care Act (antibiotic use)
Failure to achieve DoH flu vaccination targets
Inconsistent Infection Control Service level agreements
364
362
12
12
HR and Organisational Development
Risk ID
490
444
442
335
443
Title
Occupational Health, not performing to the contract level
Accreditation temporarily suspended for QCF delivery
Capacity and capability in operational teams to deliver
workforce agenda
Compliance with pre-employment checks
Outliers in NTS Survey (Medical Education)
Risk Rating
12
12
12
12
10
Estates Planning*
Risk ID
486
Title
Failure to deliver the Older People Inpatient Transformation
programme to budget / time
485
Failure to deliver the Hubs programme on budget
487
Unable to find an affordable solution for 305 Ware Road
*Risks awaiting approval from Head of Estates Planning
Risk Rating
12
12
9
Assurance):
Risks linked to Board Assurance Framework
N/A
Equality & Diversity (has an Equality Impact Assessment been completed?) and Public
& Patient Involvement Implications:
N/A
Evidence for S4BH; NHSLA Standards; Information Governance Standards, Social
Care PAF:
CQC Fundamental Standards – Regulation 17 Good Governance
Board/Audit
Reviewed by IGC 21.01.2016
5
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Trust Risk Register
December 2015
To be reviewed by: Integrated Governance Committee:
21.01.2016
Audit Committee: TBC
Trust Board: TBC
6
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Risk Scoring Matrix (Risk = Likelihood x Consequence)
Step 1 Choose the most appropriate row for the risk issue and estimate the potential consequence
Consequence score (severity levels) and examples of descriptors
1
2
3
4
5
Domains
Negligible
Minor
Moderate
Major
Catastrophic
Impact on the
safety of
patients, staff or
public
(physical/psychol
ogical harm)
Minimal injury
requiring no/minimal
intervention or
treatment.
Minor injury or illness, requiring
minor intervention
Moderate injury requiring professional
intervention
Major injury leading to long-term
incapacity/disability
Incident leading to death
Requiring time off work for >3
days
Requiring time off work for 4-14 days
Requiring time off work for >14 days
Multiple permanent injuries or irreversible health
effects
Increase in length of hospital stay by 4-15 days
Increase in length of hospital stay by >15
days
An event which impacts on a large number of
patients
No time off work
Increase in length of hospital stay
by 1-3 days
RIDDOR/agency reportable incident
An event which impacts on a small number of
patients
Quality/complain
ts/audit
Peripheral element of
treatment or service
suboptimal
Informal
complaint/inquiry
Mismanagement of patient care with longterm effects
Overall treatment or service
suboptimal
Treatment or service has significantly reduced
effectiveness
Non-compliance with national standards
with significant risk to patients if unresolved
Totally unacceptable level or quality of
treatment/service
Formal complaint (stage 1)
Formal complaint (stage 2) complaint
Multiple complaints/ independent review
Gross failure of patient safety if findings not acted
on
Local resolution
Local resolution (with potential to go to
independent review)
Low performance rating
Single failure to meet internal
standards
Repeated failure to meet internal standards
Minor implications for patient
safety if unresolved
Major patient safety implications if findings are
not acted on
Inquest/ombudsman inquiry
Critical report
Gross failure to meet national standards
Reduced performance rating if
unresolved
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Human
resources/
organisational
development/sta
ffing/
competence
Short-term low
staffing level that
temporarily reduces
service quality (< 1
day)
Low staffing level that reduces
the service quality
Late delivery of key objective/ service due to lack
of staff
Uncertain delivery of key objective/service
due to lack of staff
Non-delivery of key objective/service due to lack of
staff
Unsafe staffing level or competence (>1 day)
Unsafe staffing level or competence (>5
days)
Ongoing unsafe staffing levels or competence
Low staff morale
Loss of several key staff
Loss of key staff
Statutory duty/
inspections
Adverse
publicity/
reputation
No or minimal impact
or breech of guidance/
statutory duty
Rumours
Potential for public
concern
Poor staff attendance for mandatory/key
training
Very low staff morale
No staff attending mandatory training /key
training on an ongoing basis
Breech of statutory legislation
Single breech in statutory duty
No staff attending mandatory/ key training
Enforcement action
Multiple breeches in statutory duty
Reduced performance rating if
unresolved
Challenging external recommendations/
improvement notice
Multiple breeches in statutory duty
Prosecution
Improvement notices
Complete systems change required
Low performance rating
Zero performance rating
Critical report
National media coverage with <3 days
service well below reasonable public
expectation
Severely critical report
National media coverage with >3 days service well
below reasonable public expectation. MP
concerned (questions in the House)
Local media coverage –
short-term reduction in public
confidence
Local media coverage –
long-term reduction in public confidence
Elements of public expectation
not being met
Business
objectives/
projects
Insignificant cost
increase/ schedule
slippage
Total loss of public confidence
<5 per cent over project budget
5–10 per cent over project budget
Schedule slippage
Schedule slippage
Non-compliance with national 10–25 per
cent over project budget
Incident leading >25 per cent over project budget
Schedule slippage
Schedule slippage
Key objectives not met
Finance including
claims
Small loss Risk of claim
remote
Loss of 0.1–0.25 per cent of
budget
Loss of 0.25–0.5 per cent of budget
Key objectives not met
Uncertain delivery of key objective/Loss of
0.5–1.0 per cent of budget
Non-delivery of key objective/ Loss of >1 per cent
of budget
Claim(s) between £100,000 and £1 million
Failure to meet specification/ slippage
Purchasers failing to pay on time
Loss of contract / payment by results
Claim(s) between £10,000 and £100,000
Claim less than £10,000
Service/business
interruption
Environmental
impact
Loss/interruption of >1
hour
Loss/interruption of >8 hours
Loss/interruption of >1 day
Loss/interruption of >1 week
Claim(s) >£1 million
Permanent loss of service or facility
Minor impact on environment
Moderate impact on environment
Major impact on environment
Catastrophic impact on environment
Minimal or no impact
on the environment
8
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Step 2 Estimate the likelihood
Step 3 Complete the Risk Grading Matrix
Step 4 Escalation Process
9
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ID
Title
Description
Rating
(initial)
Controls in place
TRR
Rating
Early warning indicators
Current Position
Executive Lead
142
Acute Bed
Pressures
Failure to meet demand
for inpatient beds within
HPFT leading to a quality
and financial risk.
16
Alternatives to
admission in place
16
Monitor of bed stats on a twice
daily basis
Decrease in pressures but continue
to be escalated as appropriate.
Paul Lumsdon
Proactive monitoring of
care and discharge
planning of service
users in non HPFT beds
via the bed
management team.
High level of DTCs resulting in
being unable to respond to
demands on acute services and
users placed in inappropriate
care settings awaiting
discharge.
Situation constantly monitored by
SBU Senior Management team and
Bed Manager and On call
managers.
Daily reviews of all
HPFT in patient service
users by senior nurse
and Consultant
Increase in DTCs
Last updated
05.01.2016
Centralised Bed
Management Model
now agreed with Pro
Active recruitment
Weekly DTC
teleconference
including placement
team and community
input to agree actions
to facilitate discharge.
Escalation process is in
place re DTCs
x2 weekly senior
management acute
pressures meetings
Predicted Date of
Discharge agreed
within 72 hours of
Long delays in service users
awaiting admission in A&E and
CTO's awaiting readmission.
x2 Weekly acute pressures
meetings held, Chaired by MD.
Bed manager works closely with
Centralised AMHP duty system.
Out of Hours Clinical Leads are now
in place
Admissions to non HPFT beds
Temporary reduction in
medical cover
Length of stay data
Increased lack of numbers of
Care Co-Ordinators in the
Community and lack of follow
up.
Lack of continuity in Care CoOrdination.
Newly set up centralised bed
management team - whole systems
approach. Dashboard will look a
bed pressures across the Trust inc
daily bed stats, demand capacity
inc ADTU, CATT and Community.
Additional CCG investment is being
used to further enhance 24/7
services.
Street Triage now being funded.
Increase in the admission of
service users with Personality
Disorder diagnosis.
Failure to allocate Care Co-
10
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ID
Title
Description
Rating
(initial)
Controls in place
TRR
Rating
admission
Ordinators in a timely fashion.
ADTU and AAU
operational across
county
Service Users missing
medication and not being
picked up quickly in the
Community.
Admission checklist
implemented
Out of Hours Clinical
Leads are now in post
and will go operational
in December.
Current Position
Executive Lead
Increased CTO recalls
Reduction in AMHP availability
prevents effective planning of
discharges and admissions.
Reviewing the
escalation process
around the bed
capacity and position.
11
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ID
Title
Description
Rating
(initial)
Controls in place
TRR
Rating
Current Position
Executive Lead
411
Kingfisher
Court
Environmental
Issues
Serious Incidents /
AWOLs due to
environmental issues
identified across the site
- ligature points
- en-suite doors
- design of fences
16
All en-suite doors have
been removed and
alternatively designed
doors are now on
order.
16
Increase in AWOLs and
attempted AWOLs
Action Plan is being implemented
and reviewed and monitored by the
Operations Committee.
Oliver Shanley
(Director
Quality &
Safety, Dpty
CEO)
Last updated
05.01.2016
Increase in use of ligature
points
All ensuite doors to be replaced
with revised hinge mechanism
Action Plan has been
agreed following the
Independent Review of
environmental issues at
Kingfisher Court.
Staff have been made
aware of the risks and
Datix is being used to
records all incidents
12
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ID
Title
Description
Rating
(initial)
Controls in place
TRR
Rating
Current Position
Executive Lead
116
Financial
challenges
Continued financial
challenges over the next
five years and risk of
failure to meet financial
plans.
16
Strengthened CRES,
Programme Assurance
Board monitor delivery
- raised emphasis on
corporate services
16
Quarterly Review / Horizon
Scanning
Regular Reports are made to the
Trust Board, Finance & Investment
Committee and the Executive
Team.
Keith Loveman
(Director
Finance &
Performance
Improvement)
Last updated
30.11.2015
Agreed income tariff uplifts
Increased agency spend
Specifically, failure to
achieve financial targets
through:
Planning for 2016/17
CRES requirements
underway
Double running costs
incurred as
transformational changes
are implemented and
embedded
Raised authorisation of
spend to more senior
levels
Cost pressures due to
lack of capacity
(FHAU/Personality
Disorders) and gap in
CCG / Specialised
Commissioning funding
Regular update
meetings with SCG
commissioners
Information sharing
with JCT in relation to
contract changes
National Tariff as a % for
MH services is decreasing
Working with other
providers on integrated
services
Ongoing £8.0 million of
Cash Releasing Efficiency
Savings (CRES) are
required.
Non – recurrent
measures in relation to
staffing expenditure /
vacancy management.
Sustainability risk
identified in outer years
of five year plan
Frozen non-emergency
maintenance works.
Placement of Service
Increased number of
placements outside HPFT
CRES plans for 2015/16 have
identified savings however a
financial risk remains
Demography funding confirmed
and growth investment being
negotiated with commissioners
External support on efficiency
savings from CAPITA review being
taken forward
Target 15.16 is £1 million surplus currently behind plan with forecast
200k deficit.
Disparity of CCG funding due to the
financial position of Herts Valleys
CCG expected 3.5 million
investment into MH services is
likely only to be 2 million. E&N CCG
expected to meet the 3.5 million
funding
Monitor and TDA national agency
cap in place
Reduced over establishment of
Adult Community Agency staff
Letter to Budget
holders
13
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ID
Title
Description
Users outside of the Trust
£3 million expense
Agency overspend with
Adult Community
Services - established
posts
Rating
(initial)
Controls in place
TRR
Rating
Current Position
Executive Lead
Monitor and TDA
national cap in place on
agency spend. Nursing
cap 8% with reduced
trajectory.
Potential financial
implications based on
CQC report and
recommendations
14
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ID
Title
Description
Rating
(initial)
Controls in place
TRR
Rating
Current Position
Executive Lead
215
Workforce
Recruitment
and Retention
Risk to Patient Safety,
Quality, Staff Morale and
Financial Risk.
15
Recruitment
monitoring plan for
forecasting and
recruitment reports
15
Failure to attract quality
candidates
Recruitment drives moving forward
locally with HR support provided.
Last updated
01.12.2015
Recruitment
There is a risk that the
organisation is not able
to recruit and select the
best staff and that timely
recruitment to vacancies
does not occur leading to
increased operational
pressures and a
reduction in quality of
care
Long standing number of
vacancies and hotspots
HR Business Partners looking at
recruitment hot spots and devising
a recruitment calendar for 2016.
Jinjer Kandola
(Director
Workforce &
Organisational
Development)
Retention
There is a risk that a
higher number of existing
staff choose to exit the
organisation leading to
increased and unplanned
vacancies and a drain of
knowledge and
experience from the
organisation
SBU review regular
data – HR Performance
Dashboards
HR systems maintained
to enable accurate
establishment and
vacancy information to
be accessed at all times
Increased temp/agency costs
Lack of clarity to plan
recruitment campaigns
High turnover
Exit interviews feedback forms
OD plan for Talent and
succession planning
Lack of quality PDPs and staff
training
Recruitment to
vacancies of candidates
who bring with them
correct competencies ,
skills and knowledge.
Inconsistent and ad hoc
supervision
Recruitment and
Retention Group
continues to meet
monthly.
New anonymised exit interview
process about to launch
The ‘Golden Hello’ scheme and the
refer a friend scheme have been
launched, although the latter has
had minimal effect. 40 staff
recruited are eligible for the golden
hello and the scheme remains in
place for Adult Community (CPNs
and Social Workers), Older People
Inpatient (Band 5 Qualified), Albany
Lodge, CATT Teams and Norfolk
Services.
The incentive for additional bank
hour being worked has resulted in
30/40 staff doing additional bank
shifts although its estimated
around half may have ready been
doing these. This scheme is being
monitored and likely to be changed
slightly to prevent this scenario.
There has been a net gain of 15
staff in Q2 the first time in several
months.
Values based recruitment and
15
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ID
Title
Description
Rating
(initial)
Controls in place
TRR
Rating
Current Position
Executive Lead
selection to be launched
Retention now needs to be the
focus and a retention activity plan
has now been put in place to
address this as part of the
corporate plan. There is a
significant number of staff (approx.
25% or workforce) that are 55 and
over and could retire with minimal
notice, mainly with nursing and
within East and North SBU. Letters
are being sent to these staff to try
and identify their short to medium
plans.
16
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ID
Title
Description
Rating
(initial)
Controls in place
TRR
Rating
Current Position
Executive Lead
120
Business Risk
– Loss of
income
This risk is an inherent
feature of the
environment the Trust
now operates in;
however, the specific
service areas at risk and
overall risk profile are
very live issues that are
subject to continuous
change.
12
Already in place:
12
Performance report monitoring
on beds and reducing referrals
SBU plans reflect a focus on further
improving the quality and safety of
services
Iain Eaves
(Director
Strategy &
Commercial
Development)
Last updated
30.11.2015
Key current threats relate
to:
The end of the three year
contract with Herts
commissioners combined
with new service delivery
models envisaged by the
Five Year Forward View.
National commissioners
have signalled their
intention to run a
procurement for
medium and Low Secure
Forensic Service
North Essex
Commissioners are
looking to develop
integrated learning
Disability Services
Robust Financial Mgt.
System and Strategic
and Operational
Business Plan
Steering Group to
oversee all business
development and
retention in place
support aligned to
service streams
Dedicated Executive
leadership in place for
service Integration
Proposed / Under
Development:
Retention plan nearing
approval and an
evolving approach to
CCG relationship
building and
engagement in all the
areas where we
provide services
Feedback through formal and
informal engagement with
commissioners
After significant Business
Development Activity the focus is
on retaining our existing and new
business. Plans are being
developed to address each of the
identified threats.
Herts
Contract negotiations underway
with commissioners, memorandum
of understanding has been drafted,
positive response from
commissioners for 3 year contract,
although with new payment
system.
North Essex
On-Going discussions with Essex
commissioners re intentions.
Expectation of 1 year extension to
current contract with further clarity
anticipated in December 2015.
Specialist Medium and Low Secure
services
Expectation of a further 1 year
contract
Contract Negotiating
Group set up chaired by
Exec Director of
Finance
17
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ID
Title
Description
Rating
(initial)
Controls in place
TRR
Rating
Current Position
Executive Lead
128
Adult
Community
Mental Health
Risk of:
- Lack of care coordinator
capacity within teams to
allocate all cases
- High number of
vacancies and turnover
rate/failure to recruit to
posts
- Having insufficient staff
to allow for safe
allocation of cases.
9
Recruitment continues
to teams
12
Increased sickness
Processes in place in ll quadrants to
review cases awaiting allocation via
welfare phone calls.
Paul Lumsdon
Last updated
01.12.2015
Which could lead to:
- Increased patient safety
risks
- Delays in treatment
- Staff Morale
Professional leadership
has been strengthened
to support staff
Increased operational
services oversight.
Weekly dashboards and
weekly service line lead
meetings with
managing director to
manage risk.
Rolling adverts to
recruit to all remaining
vacancies.
Demand & Capacity
projects in place to:
review activity in
community teams
make best use of
existing resources
review discharge plans
to increase throughput
review effectiveness of
intital assessment
processes
Increased number of
unallocated cases.
Reduction in staff feeling
satisfied at work
Negative feedback in the staff
survey
Increase in the number of
Serious Incidents reported
Increase in complaints into the
service
Slippage or missing Key
Increased turnover of staff
Weekly community dashboards
tracking performance and issues
escalated to Exec
Community Team vacancies
covered by bank/agency and
managed on a weekly basis.
QIA completed on reduction of
agency posts signed off.
Supervision tool being developed
to be used in supervision sessions
to support throughput.
Changes beings made on PARIS to
enable better staff activity data to
be pulled off
Unallocated cases approx. 120
18
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ID
Title
Description
Rating
(initial)
Controls in place
TRR
Rating
Current Position
Executive Lead
167
Continuing
Healthcare
Strategy
Independent sector
capacity for continuing
healthcare beds still not
available at the end of
the refurbishment
programme leading to:
- Continued requirement
for Edenbrook &
Stewarts ‘holding plan’
- Stewarts & Meadows
remaining open
(programme risk)
- Continued additional
cost (financial risk)
16
Engagement with HCC
and CCG to take a
whole system approach
to market development
12
General knowledge of
placements / market
availability
Capacity still not widely available in
the private sector
Paul Lumsdon
Last updated
01.12.2015
Early engagement with
independent sector and
partners to build
capacity giving enough
time for construction if
required
Giving independent
sector providers clarity
over what and how
many beds are required
Providing independent
sector providers with
assurance around use
to give them
confidence to invest in
building capacity
Level / intensity of engagement
from partners
Level of interest from market in
increasing capacity
Seeking to work with partners to
look for system wide solutions HCC
to take the lead role and are
providing project management
resource
Progress made with partners and
providers to increase CHC capacity
has slowed
Long term plan for the Stewarts
and The Meadows will be consulted
upon.
Lambourn works commenced.
Indicators show sufficient capacity
in sector to deliver 2016
requirements challenges are 2017
onwards bur engagement has
slowed.
Paper to be presented at Exec to
update on risk
19
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ID
Title
Description
Rating
(initial)
Controls in place
TRR
Rating
Current Position
Executive Lead
366
Approved
Mental Health
Practitioner
(AMHP)
Staffing Levels
There are not enough
AMHPs to provide a
robust service across
Hertfordshire
12
AMHP waiting times
and staffing being
monitored
12
Increase in AMHP waiting times
Current AMHPs are asking to come
off the AMHP duty register due to
the pressures - current AMHP list
includes 32 staff
Oliver Shanley
(Director
Quality &
Safety, Dpty
CEO)
Last updated
30.10.2015
Risk of not delivering
delegated duties under
section 75 of the MHA
Inability to consistently
meet locally agreed
timescales
Potential risk to Service
Users / Carers
Increase in reported incidents
Not enough staff identified for
future AMHP training
Head of Social Care and
Safeguarding meeting with
previous AMHP staff and asking if
they would consider going back
onto the AMHP rota
Start and Finish Group is working
on three AMHP workstreams:
- Recruitment and Retention
- Training
- Alternative model of AMHP
working / service provision
Considering agency staff as an
interim solution although at
present the Trust has not been able
to appoint to these posts (funding
provided by HCC)
Data on the gaps in the AMHP rota
are being monitored by the Head of
Safeguarding and Social Care and
escalated to the Interim Director of
Service Delivery.
20
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ID
Title
Description
Rating
(initial)
Controls in place
TRR
Rating
Current Position
Executive Lead
427
DOLS
Authorisations
not in place
Since the Cheshire West
ruling Supervisory Bodies
have been inundated
with DOLS applications
and then subsequent
reviews.
16
Continual dialogue with
supervisory body to
request assessments
12
Increasing number of
applications pending
Individual DOLS applications are
being escalated 2 months prior to
DOLS expiry.
Oliver Shanley
(Director
Quality &
Safety, Dpty
CEO)
Last updated
09.10.2015
The Trust is left in a
position that most of the
DOLs follow up
applications are being
considered as low
priority. Nationally this
is an issue and we as the
Managing Authority have
done all we can in that
we are constantly chasing
them up.
Supervisory body
accept that they hold
the risk
Monitor individual
DOLS applications
centrally and ensure
teams are aware
Family / Solicitors could
challenge the Trust for
depriving patients of their
liberty without authorisation.
External regulatory visits (CQC)
will highlight the non-compliant
DOLS
Most affected locations are SRS and
Older People Inpatient Services.
At present there are 49 DOLS
applications pending where
patients are deprived of their
liberty without authorisation.
The Trust does have an option to
make Court of Protection
applications for these people which
I believe is a disproportionate
response and would waste public
money.
The risk however remains
that we do not have
current DOLS
authorisations in place
for some patients.
We do have an option to
make Court of Protection
applications for these
people which is a
disproportionate
response and would
waste public money.
The national picture is
the same and current
academic legal thinking is
21
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ID
Title
Description
Rating
(initial)
Controls in place
TRR
Rating
Current Position
Executive Lead
that if the Managing
Authority have done all
they can then that is
sufficient, however, this
remains to be challenged.
22
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ID
Title
Description
Rating
(initial)
Controls in place
TRR
Rating
Current Position
Executive Lead
488
Timely Step
up from PICU
to Medium
Secure
Services
Inability to access a
Medium Secure Unit for a
service user, due to
capacity issues within
Nationally Commissioned
Services.
20
Service User is being
cared for under the
Long Term Segregation
Policy
12
Increased use of bank and
agency staff on Oak Ward
Service User remains in Long term
segregation and Oak Ward
continues to use significant amount
of bank and agency staff
Paul Lumsdon
Last updated
04.01.2016
Service User is being
supported on 2:1
supported observations
and increases to 4:1
staffing when certain
interventions are
required.
Agreed process for
weekly escalation to
NHS England on
concerns regarding wait
and reduced quality of
treatment for Medium
Secure
Increased violence towards
staff and other service users
and increased reporting of
RIDDORs
Reduced capacity to admit
other service users to PICU
Reduced ability to meet Section
136 commitments
Clinical team are raising concerns
within the SBU
Agreed process for weekly
escalation to NHS England on
concerns regarding wait and
reduced quality of treatment for
Medium Secure
Increased and/or low morale of
the staff team
Potential for service user
and/or carer complaints
Review of the Long
Term Segregation
position as per Policy
23
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BOARD OF DIRECTORS
Meeting Date:
28 January 2016
Agenda Item: 19
Subject:
Author:
Well – Led Framework Review of
Board Performance
Barbara Suggitt, Company Secretary
Presented by:
Barbara Suggitt
Approved by:
Name of Exec Director
This report sets out an update on progress in respect of the review which is now underway.
Action required:
For information.
Relationship with the Business Plan & Assurance Framework (Risks, Controls
& Assurance):
Summary
Four firms responded to our tender proposal to undertake this PWC; EY; Grant Thornton;
Foresight Centre for Governance (part of GE Healthcare Finnemore). The contract was
awarded to the Foresight Centre for Governance following a review of the tenders by a
panel of members of the Board.
A scoping meeting was held with the project lead from Foresight about the areas that the
Board had highlighted from their self-assessment exercise and the timetable of the review
was agreed.
The review will be undertaken through a combination of interviews, focus groups and a
survey of key stakeholders as well as a document review. Board members will complete an
individual survey as well as being interviewed. Focus groups are being convened for
Governors, Service Users and Carers and senior staff and external stakeholders, including
commissioners, will be asked to respond to a survey. In addition to the document review
representatives from the company will observe key meetings of the Board and its
committees and the Council of Governors.
A final report will be presented to the Board at a workshop in March. The report will be
shared with Monitor as required under the framework.
Financial Implications of overall review : cost will be £40k
Equality & Diversity (has an Equality Impact Assessment been completed?)
and Public & Patient Involvement Implications:
NA
Agendaitem19FrontSheetW
Page1of2
OverallPage274of275
Evidence for Essential Standards for Quality and Safety; NHSLA Standards;
Good governance and reported in Annual Report as part of Monitor requirements.
Board/Audit
N/A
Agendaitem19FrontSheetW
Page2of2
OverallPage275of275

board of directors - Hertfordshire Partnership

Transcription

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